All Washington & Alaska Employees

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Welcome to PeaceHealth Employee Health Care Plans

Introduction

PeaceHealth is please to provide you with this comprehensive program of medical and prescription drug card coverage. Our goal is to help improve the health status of the communities in which we serve.

This booklet contains important information about the health plans PeaceHealth offers to its Corporate Center (Washington & Alaska Employees), Southeast Alaska Region, Lower Columbia Region and Whatcom Region employees. Healthcare Management Administrators, Inc. (HMA) serves as the Plan Supervisor for these Plans.

Please read this booklet carefully and particularly note the special requirements you must follow prior to having surgery or being admitted to a medical facility - this is explained in the "Prior Authorization" section.

If you have any questions regarding either your Plan's benefits or the procedures necessary to receive these benefits, please call HMA at 425/974-3886 (Seattle Metro Area) and toll free nationwide at 866/206-7786.

With this plan you may receive covered services from Preferred Providers through what is called your "In-Network" benefit. You also have the option to receive covered services from non-Preferred Providers through what is called your "Out-of-Network" benefit. Information on using your Out-of-Network benefit is listed under "Using Your Plans Out-of-Network Benefit."

About this handbook

This handbook is an explanation of your PeaceHealth Plan benefits.

It is important to carefully read this handbook. It will help you understand your benefits and responsibilities. If you don’t understand a term that is used, you may find it in the "Definitions" section. If you need additional help understanding anything in this handbook, please call your Customer Service Team at HMA at 425/974-3886 (Seattle Metro Area) and toll free nationwide toll free at 866/206-7786.

This handbook is not complete without your Online Preferred Provider Directory for Open Network Plan Plus members. Preferred Providers for the in-network benefit for the Open Network Plus Plan are listed online at www.regence.com. Providers must participate in the Regence Washington and Oregon PPO panel to be considered a Preferred Provider. You will need this directory to be able to access covered services. We also have a list of Preferred Providers in a paper directory. To obtain a paper directory, call your Customer Service Team or check with your employer’s human resource department.

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Benefit Summary

This is a summary of benefits only. Please consult your Member Handbook or PeaceHealth's Plan Document for detailed information on Plan use and benefit coverage. Benefits are provided for medically necessary services when provided by a participating physician or provider.

* Deductible does not apply

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Mental Health & chemical Dependency

All mental health and chemical dependency treatment, inpatient and outpatient, must be pre-authorized. Failure to pre-authorize may result in the denial of your claim.

For employees working in Southeast Alaska Region, Corporate Office or Lower Columbia Region, contact Mental Health Match at 1-800-457-3798 for pre-authorization.

For employees working in the Whatcom Region, contact Health Promotion Network at 1-800-244-6142 or 360/715-6575 for pre-authorization.

	Mental Health			Chemical Dependency Combined Inpatient and Outpatient limited to $10,000 every two calendar years
	You Pay		Limits	You Pay
	In-Network	Open Network		In-Network	Open Network
Inpatient	20%	30%	30 days every 24 months	20%	30%
Outpatient**	20%	30%	20 visits per calendar year	20%	30%

**Does not apply to the out-of-pocket maximum.

Prescription Drugs

Retail and Mail Order Prescription Co-Pays
	Retail (30 day supply)	Mail Order (90 day supply)
Generic	$7 copay	$14 copay
Formulary Drugs	$12 copay	$24 copay
Non-Formulary Drugs	50% coinsurance	50% coinsurance
Combined retail and mail order $1,000 out-of-pocket maximum. $18 minimum for non-formulary drugs.

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Customer Service

We want you to understand how to use your PeaceHealth Plan benefits. We also want you to be satisfied with your health plan. We are here to help and are always glad to answer any questions you have about using your health plan.

How to contact your Customer Service Team

Your HMA Customer Service Team will handle all your needs including claims, enrollment and customer service issues. Here’s all you need to do to get in touch with your Customer Service Team:

Have your HMA member identification card ready when you call. Your card lists your member number.

• If you live in:

  • The Seattle Metro Area: Call 425/974-3886.

  • All other areas: Call 1-866-206-7786.

Your HMA Customer Service Team is available from 8:00 a.m. to 5:00 p.m., Monday through Friday.

For your information

Your Customer Service Team is available to help you understand your benefits and resolve any problems. Your team will handle:

• Specific benefit or claim questions.

• Questions or concerns about adding or dropping a dependent.

• Enrollment issues.

• Questions or concerns about your health care or service.

When contacting the HMA Customer Service Department, answers for benefits and eligibility will be provided to any participant and to providers of service. The benefits quoted by HMA are not a guarantee of claim payment. Claim payment will be dependent upon eligibility at the time of service and all terms and conditions of the Plan. This disclaimer will be provided to the caller when benefits are quoted over the telephone.

For a written pre-estimate of benefits, a provider of service must submit to the Plan Supervisor his or her proposed course of treatment, including diagnosis, procedure codes, place of service and proposed cost of treatment. In some cases, medical records or additional information may be necessary to complete the pre-estimate.

When the Medical Review Coordinator at HMA pre-authorizes any confinement, procedure, service or supply, it is only for the purpose of reviewing whether the service is determined to be medically necessary for the care of the treatment or illness. Pre-authorization does not guarantee payment of benefits. All charges submitted for payment are subject to all other terms and conditions of the Plan, regardless of authorization by the Medical Review Coordinator whether by telephone or in writing.

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General Information

Prior authorization

Prior authorization is required for the following services:

• All inpatient admissions, including admission to a hospital, skilled nursing facility or a rehabilitation facility and maternity delivery. For emergency hospitalizations, you, or a relative, need to notify the Plan within 48 hours, or as soon as reasonably possible.

• All outpatient surgical procedures.

• All non-emergency mental health and chemical dependency services must be prior authorized by:

  • Mental Health Match at 1-800-457-3798
    (Corporate Office, Southeast Alaska Region, Lower Columbia Region and Corporate employees located in Southeast Alaska and Lower Columbia Region).

  • Health Promotion Network at 1-800-244-6142 or 360/715-6575 (for Whatcom Region employees, Corporate employees located in the Whatcom region).

• All human organ/tissue transplant related services.

• All hospice services.

• Medical supplies, durable medical equipment, appliances and prosthetic devices in excess of $500.

• Temporomandibular joint syndrome (TMJ) services (surgical procedures only).

• All outpatient hospitalization and anesthesia for covered dental services.

Failure to call for pre-authorization five days prior to an outpatient surgery or an admission into a medical facility or, in the case of an emergency admission, failure to obtain authorization either within 48 hours after the emergency admission or on the next business day, if later, will result in the denial of your claim. These penalty amounts do not apply to your out-of-pocket maximums or deductibles.

Getting services prior authorized

For all services (except non-emergency mental health and chemical dependency services), call HMA’s Medical Review Department at 866/206-7786 to obtain prior authorization.

When you call to request prior authorization, please be prepared to give the following information:

• Member’s name.

• Member’s health plan identification number and group number (these numbers are listed on your PeaceHealth Plan member identification card).

• Member’s date of birth.

• Medical Facility name and address.

• Scheduled date of admission, or date services are to begin.

• Treatment or procedure to be performed.

The Medical Review Coordinator will send written confirmation of the approved admission to the patient once authorized.

Pre-authorization does not guarantee payment of benefits.

Member identification card

Each member of the PeaceHealth Plan receives a member identification card. You must have this card to identify you as a Plan member. Your member identification card lists your member number, your health plan and important phone numbers.

When scheduling an appointment or receiving Plan services, identify yourself as a PeaceHealth Plan member, present your member identification card and pay your copayment or coinsurance.

Please keep your health plan member card with you and use it when you:

• Have appointments with your personal physician/provider or other Preferred Provider. If you are an enrolled Out-of-Area Dependent, or an Open Network Plus Plan member, please present your card to any non-Preferred Providers you are seeing.

• Call for mental health/chemical dependency customer service.

• Call or write your HMA Customer Service Team.

• Receive urgent or emergency health care.

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Using Your Plans In-Network Benefits

Introduction

This section summarizes basic information you need to know to take advantage of the benefits offered by your PeaceHealth health plans.

Preferred Providers

PeaceHealth has contracted for arrangements with certain physicians/providers. These providers are called "Preferred Providers." The agreements with these providers enable you to receive quality health care for a reasonable cost. For in-network benefits to be covered, you must receive health care services from Preferred Providers. Your Preferred Provider will work with the Plan and HMA to arrange for any Plan prior authorization requirements that may be required for certain covered services.

Open Network Plus Plan  members also have an additional out-of-network benefit that gives them access to non-Preferred Providers, see "Using Your Plans Out-of-Network Benefit," section.

Open Network Plus Plan  members designated as Out-of-Area Dependents have a special Out-of-Area benefit allowing them to use non-Preferred Providers. For further information, see "Enrolled Out-of-Area Dependent Benefits," section.

To encourage optimum health, we promote wellness and preventive care. We also believe wellness and overall health is enhanced by working closely with one physician or provider – your personal physician/provider. He or she can provide most of your care and can track all of your medical care to avoid unneeded or conflicting treatment. To encourage this relationship, your out-of-pocket costs for office visits with a participating personal physician/provider are generally lower. You can, however, see any Preferred Provider you want for covered medical services. When you do this, your out-of-pocket costs will generally be higher. The choice is up to you.

If you are unsure about a provider’s, hospital’s or other facility’s participation in PeaceHealth Plan visit the Online Regence Preferred Provider Directory at www.regence.com before you make an appointment. You also can call your HMA Customer Service Team to get information about a provider’s participation with PeaceHealth Plan.

We encourage our members to use the Online Preferred Provider Directory for Preferred Provider and hospital information. The online directory is updated on a frequent basis and includes additional information on each provider.

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Personal physicians/providers

We recommend that upon enrolling in the Plan you and each of your family members choose a preferred personal physician/provider from the Regence Preferred Provider Directory as soon as possible. If you live in the Seattle Metro area, you can call HMA at 425/974-3886 or 866/206-7786 for help in choosing a physician or provider.

In most cases, personal physicians/providers specialize in one or more of the following areas of medicine: family practice, internal medicine, pediatrics, general practice or nurse practitioner practice. In some instances, physicians or providers who specialize in obstetrics/gynecology also may be personal physicians/providers. Your personal physician/provider can provide most of your care and, when necessary, coordinate care with other providers in a convenient and cost-effective manner. Personal physicians/providers provide preventive care and health screening, medical management of many chronic conditions, allergy shots, treatment of some breaks and sprains, and care for many major illnesses and nearly all minor illnesses and conditions. Many personal physicians/providers offer maternity care and minor outpatient surgery as well.

Established patients with personal physicians/providers

If you and your family already see a pediatrician, family practitioner and/or internist regularly, check the preferred provider directory to see if your provider is a preferred physician/provider for the PeaceHealth Plans.

Selecting a new personal physician/provider

If you don’t have a regular personal physician/provider or your provider is not a preferred provider, we recommend you choose one from the Regence Preferred Provider Directory for each covered member of your family. Call the provider’s office to make sure he or she is accepting new patients.

Soon after you select your personal physician/provider, it is a good idea to have your previous physician or provider transfer your medical records to your new personal physician/provider. On your first visit make a list of questions or information you would like to discuss with your new personal physician/provider, including the following:

• What are the office hours?

• How can I get medical advice after hours?

• What do I do in an emergency?

• Let your personal physician/provider know if you are under a specialist’s care.

• Inform your personal physician/provider of any ongoing prescription medications you are currently taking.

Some women’s health care providers may be approved to serve as personal physicians/providers. These women’s health care providers include physicians specializing in obstetrics or gynecology, nurse practitioners, certified nurse midwives, or physician’s assistants specializing in women’s health care.

Changing your personal physician/provider

You are encouraged to establish an ongoing relationship with your personal physician/provider. We understand, however, how important it is for you and your family to feel confident in your choice of providers. If you decide to change your personal physician/provider or your personal physician/provider is no longer participating with the Plan, simply choose a new one from the Preferred Provider Directory and begin seeing him or her the next time you need medical care. Please remember to have your medical records transferred to your new personal physician/provider.

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Personal physician/provider office visits

We recommend you see your personal physician/provider for all routine care and call your personal physician/provider first for urgent or specialty care. If you need medical care when your personal physician/provider is not available, the personal physician/provider on call may treat you and/or recommend that you see another Preferred Provider who specializes in treatment for your condition.

.Whenever you visit your personal physician’s/provider’s office:

• Bring your HMA member identification card with you.

• Make your copayment before you leave your personal physician’s/provider’s office.

Office visits to other Preferred Providers (specialists)

When your personal physician/provider decides you need diagnostic tests or other specialist services, he or she will discuss it with you. Your personal physician/provider may recommend you see a participating specialist for your condition.

You also may decide to see a participating specialist without consulting your personal physician/provider. Check our Online Regence Preferred Provider Directory at www.regence.com to make sure the provider you choose is a Preferred Provider with the Plan. You also can contact your HMA Customer Service Team to verify whether or not a provider is participating with the Plan.

If you decide to see a preferred specialist on your own, we recommend you let your personal physician/provider know about your decision. Your personal physician/provider will then be able to coordinate your care and share important medical information with your specialist. In addition, we recommend you let your specialist know the name and contact information of your personal physician/provider.

Whenever you visit a preferred specialist:

• Bring your HMA member identification card with you.

• Since in most cases your out-of-pocket costs will be a percent of billed services, you will most likely not be able to pay for what you owe at the time of your visit. Your provider’s office will send you a bill for what you owe later. Some providers, however, may ask you to pay for an estimate of what you may owe at the time you receive services and bill or credit you for the balance later.

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Claims payment

All participating physicians, providers and hospitals submit claims directly to the address listed on your HMA medical identification card. If you receive services from a preferred personal physician/provider and have already paid all of your out-of-pocket costs to that provider, he or she may send you an informational statement after billing HMA. If you receive services from other preferred providers, you most likely will receive a bill from your provider’s office for the percentage of coinsurance that you owe unless you paid this when you were in the provider’s office. Pay your provider’s office the amount you owe. Do not pay this amount to HMA.

Explanation of Benefits (EOB). You will receive an EOB after your claim has been processed. An EOB is not a bill. An EOB explains how your claim was processed, and will assist you in paying the appropriate member responsibility to your provider. Copayment or coinsurance amounts, services or amounts not covered and general information about our processing of your claim are explained on an EOB.

If you see a non-Preferred Provider for a covered service, please send an itemized statement directly to:

HEALTHCARE MANAGEMENT ADMINISTRATORS, INC.

PO Box 85008

Bellevue, WA 98015

All claims for reimbursement must be submitted within one year of the date incurred or they will be denied.

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Annual Out-of-Pocket Maximums & Deductibles

Annual out-of-pocket maximums

Your Open Network Plus Plan  has both a per person and per  family annual (calendar year) out-of-pocket maximum. 

The Open Network Plus Plan  has two different sets of per person/per family maximums: one for payments you make for covered services when you use the in-network benefit and one for payments you make for covered services when you use the out-of-network benefit. In-network and out-of-network maximums accumulate separately and are not combined. Your maximums are listed on your Open Network Summary of Benefit.

Your maximums are the total amount you or your covered dependents will pay out-of-pocket in any calendar year for covered services. The family maximum combines out-of-pocket costs made by all family members. Once you or your family have paid the maximum amounts listed on your Summary of Benefits, you will have no additional out-of-pocket costs for covered services for the remainder of the calendar year.

Plan calendar year Out-of-Network deductible

The Open Network Plus plan has a per person and per family out-of-network deductible . For out-of-network benefits only, the deductible must be met each year before the Plan will begin paying for covered services. Deductible amounts should be paid directly to your providers. A per person deductible needs to be met by each individual family member . If three individual family members meet this deductible, then the family deductible will apply. No further per person deductibles will need to be met by any other family members . Payments toward meeting your deductible do not apply to your out-of-pocket maximums.

Deductible carryover: Applicable charges used to meet any portion of the deductible during the fourth quarter of a calendar year will be applied toward the next year’s deductible.

Out-of-pocket costs that do not apply to deductibles or maximums

For all plans, the following out-of-pocket costs do not apply toward your annual out-of-pocket maximum or any applicable deductibles:

• Services not covered under the Plan.

• Services in excess of any maximum benefit limit.

• Fees in excess of the usual, customary and reasonable (UCR) charges.

• Durable medical equipment and medical supplies and devices.

• Services relating to the diagnosis of infertility.

• Any penalties you must pay if you do not follow the Plan’s prior authorization requirements.

• Payments you make toward meeting any applicable calendar year deductibles.

• Services related to outpatient mental health treatment.

• Services related to smoking cessation treatment.

• Copayments or coinsurance for any supplemental benefits your plan may have such as alternative care or chiropractic care.

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Enrolled Out-of-Area Dependent Benefits

Introduction

Dependents who live outside the Regence Preferred Provider service area (including dependents who are away at school) are eligible to become Out-of-Area Dependent members. See the "Definitions," section for the Plan’s definition of "dependent" and "Out-of-Area dependent."

This section discusses how enrolled Out-of-Area Dependents can obtain covered services through the Plan’s Out-of-Area benefit.

Enrollment

Out of Area Dependents - To apply for Out-of-Area Dependent benefits, complete an Out-of-Area Dependent Enrollment form, available from your Human Resources Department. If you do not complete an Out-of-Area Dependent Enrollment form, your Out-of-Area Dependent will not be covered for Out-of-Area Dependent benefits.

Coverage

When you enroll for Out-of-Area coverage, we will send you an Out-of-Area Summary of Benefits. As stated on your Summary of Benefits, a member with Out-of-Area benefits may see any provider, in or out of the service area. The Plan will pay up to 80 percent of covered charges, with no deductible for eligible benefit services. The Plan’s payment is based on usual, customary and reasonable charges (UCR). Charges which exceed UCR are the member’s responsibility and are not applied to the member’s annual $1000 out-of-pocket maximum. For a more thorough explanation on UCR charges, see the "How the Plan Pays for Non-Preferred Provider Covered Services (UCR)," section.

Additional Information:

• See "Approved Non-Preferred Provider Categories," for information regarding Plan-approved non-Preferred Providers.

• See "Submitting Claims for Non-Preferred Providers," for information on payment of non-Preferred Provider claims.

• See the Out-of-Area Summary of Benefits for specific coverage information.

Prior authorization

Prior authorization is required for certain covered services enrolled Out-of-Area members receive. For a list of these services and how to obtain prior authorization, see the "Prior Authorization," section.

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Change of status

Enrolled Out-of-Area Dependents
These members may change to the subscriber’s In-Area plan benefits when they return to our service area. If they do so, they will receive In-Area benefits. They also must follow Plan procedures for the In-Area plan.

Members who change their status must wait at least 30 days before switching again. For example, if your dependent child returned to our service area for summer vacation, you would need to contact your Human Resources Department to change the child back to In-Area coverage. Then, to be eligible for Out-of-Area coverage again, your child would need to have been covered under the In-Area benefit plan for at least 30 days.

If your dependent comes home for a short visit that is less than 30 days (for example, during Christmas vacation), coverage will remain at the 80 percent Out-of-Area benefit level. Please call your Human Resources Department if you have any questions on a change of status for dependents.

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Using Your Plans Out-of-Network Benefit

Introduction

This section summarizes basic information you need to know for taking advantage of the non-Preferred Provider or out-of-network benefit offered by your Open Network Plus Plan  Plan. For information on your in-network benefits, see the "Using Your Plans In-Network Benefits," section.

Out-of-Network benefits

As an Open Network Plus Plan  member, you may choose to seek care through preferred providers using your in-network benefit or seek care through non-Preferred Providers by using your out-of-network benefit. (Some services are covered only when you use your in-network benefit, see your Summary of Benefits for details.) Generally, when you use your out-of-network benefits your member coinsurance payments will be higher than when you use in-network benefits. It is usually to your advantage to use your in-network benefits whenever you can. Your out-of-network benefits are described in the "Out-of-Network" column on your Summary of Benefits.

After you meet your Plan’s deductible, out-of-network benefits are paid according to usual, customary and reasonable (UCR) charges. Amounts charged by a non-Preferred Provider in excess of UCR are your responsibility and do not apply to your out-of-pocket maximums or deductibles. For a more thorough explanation on UCR charges, see the "How the Plan Pays for Non-Preferred Provider Covered Services (UCR)," section.

Additional Information:

• See "Approved Non-Preferred Provider Categories," for information regarding Plan-approved non-Preferred Providers.

• See "Submitting Claims for Non-Preferred Providers," for information on payment of non-Preferred Provider claims.

The following services are not covered under your out-of-network benefit. These services are only covered under your in-network benefit:

• Diabetic education and counseling.

• Infertility/fertility services.

• Alternative Care.

• Chiropractic.

• Smoking cessation services.

Prior authorization

Prior authorization is required for certain services. For a list of these services and how to obtain prior authorization, see the "Prior Authorization," section.

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Non-Preferred Providers

Introduction

This section summarizes basic information for Open Network Plus Plan  enrolled Out-of-Area Dependents, and Open Network Plus Plan  members using the out-of-network benefit on obtaining covered services from non-Preferred Providers.

Prior authorization

Prior authorization is required for inpatient admissions and outpatient surgeries received the services from a non-Preferred Provider. Please see the "Prior Authorization" section (under General Information) for specific information on requirements and penalties.

Approved non-Preferred Provider categories

When you use non-Preferred Providers, the Plan provides benefits for covered medically necessary care only when it is received from providers or facilities in approved categories, and when the provider is practicing within the scope of his or her license.

The Plan has approved and may provide reimbursement for non-participating qualified practitioners and facilities. Qualified practitioners are defined as a physician, women’s health care provider, nurse practitioner, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or illness and who provides services covered by the Plan within the scope of that license. A qualified facility is defined as a facility, institution or clinic duly licensed by the appropriate state agency, which is primarily established and operating within the lawful scope of its license.

Important Note: While the Plan will provide reimbursement for covered services received by any of the Plan approved providers listed above, for benefits to be paid you must receive medically necessary covered services as listed in this handbook. All treatment, supplies, and medications excluded by the Plan are not covered no matter what type of approved category of provider you see.

How the Plan pays for non-Preferred Provider covered services (UCR)

The Plan’s payment to non-Preferred Providers is based on usual, customary and reasonable charges (UCR). Charges which exceed UCR are the member’s responsibility and are not applied to the out-of-pocket maximum.

Example on how UCR charges and your coinsurance for non-Preferred Providers is calculated.

You see a non-participating provider and you are charged $100 for an office visit.	$100
The UCR charge determined for the service is $80.	$80
Your benefit plan has a 20% member coinsurance so the Plan pays 80% of $80,not $100.	(80% of $80 = $64)
Your coinsurance payment for the $80 is $16.	($80 - $64 = $16)
You also may owe the non-participating provider the $20 difference between the amount the provider charged and the calculated UCR charge.	($100 - $80 = $20)
Consequently the total amount you may owe to the non-participating provider would be $36.	($16 + $20 = $36)

UCR calculations are complicated and vary by type of service and where the service is received. There is no precise method for determining the UCR amount until after the provider bills HMA for the services you receive.

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Submitting claims for non-Preferred Providers

Many health care providers will submit the bill for you. Please be sure to show your member identification card to your provider. If your provider does not bill directly, request an itemized bill suitable for insurance purposes. Send this information with your member identification number on it to:

HEALTHCARE MANAGEMENT ADMINISTRATORS, INC.

PO Box 85008

Bellevue, WA 98015

To ensure timely processing of claims, you are encouraged to submit a claim for treatment within 60 days of the date of services. The Plan will not pay claims received more than 12 months after the date of service.

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Emergency and Urgent Care

Definition of an emergency or urgent care situation

A medical emergency is a sudden unexpected illness or injury that you believe would place your life in danger or cause serious damage to your health if you do not seek immediate medical treatment. Medical emergencies include, but are not limited to:

• Heart Attack

• Acute abdominal pain

• Stroke

• Severe chest pain

• Poisoning

• Serious burn

• Loss of consciousness

• Bleeding that does not stop

• Medically necessary detoxification

The definition of an "Emergency medical condition" is a medical condition that manifests itself by symptoms of sufficient severity that a prudent lay person, possessing an average knowledge of health and medicine, would reasonably expect that failure to receive immediate medical attention would place the health of a person (or a fetus in the case of a pregnant woman) in serious jeopardy.

"Emergency Services" are those health care items and services furnished in an emergency department. Services include all ancillary services routinely available to an emergency department to the extent they are required for the stabilization of the patient.

"Emergency Medical Screening Exams" include medical history, examination, ancillary tests and medical determinations required to ascertain the nature and extent of an emergency medical condition.

Your health plan benefits cover emergency services in the emergency room of any hospital in or outside the Plan service area. Emergency room services are covered when your medical condition meets the guidelines for emergency care as stated above. Coverage includes services to stabilize an emergency medical condition and emergency medical screening exams.

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What to do if you have an emergency

If you or a family member believe that immediate assistance is needed for an emergency medical condition, call 9-1-1 or go to the nearest emergency room. Tell the emergency personnel the name of your personal physician/provider and show them your HMA member identification card.

If you’re not sure it’s an emergency

Call your personal physician/provider any time, any day of the week. Your personal physician/provider, or the personal physician/provider on call, will tell you what to do and where to go for the most appropriate care. You also may call HMA at 866/206-7786, if you’re not sure whether to call your personal physician/provider or go to the emergency room. If you believe that taking time to call your personal physician/provider or HMA would threaten your life or cause serious damage to your health, call 9-1-1 or go to the nearest emergency room.

Emergency care in the service area and outside the service area

If you are in the Plan’s service area and need emergency services, try to go to the nearest participating hospital. If additional travel time to a participating hospital would endanger your life, or if you are more than 30 miles away from a participating hospital, go directly to the nearest hospital.

If you are outside the Plan’s service area and need emergency services, go to the nearest hospital.

Emergency room co-payment

You are responsible for your plan’s copayment/coinsurance whenever you receive services in an emergency room, unless you are admitted to a hospital within 24 hours. Please be prepared to pay your copayment/coinsurance at the time you receive care. You are responsible for your plan’s copayment/ coinsurance for each hospital emergency room visit. Please refer to your Summary of Benefits for your copayment/coinsurance amounts and any applicable deductibles.

Services not covered

The Plan does not pay for emergency room treatment for medical conditions that are not medical emergencies. Do not go to the emergency room for care that should take place in your provider’s office. Routine care for sore throats, common colds, follow-up care, and prescription drug requests are not considered to be emergencies.

Eye emergencies

If you have an emergency medical condition involving injury or illness to your eye(s), you may receive services directly from an optometrist or ophthalmologist or a hospital emergency room.

Psychiatric emergency

Emergency services are provided for psychiatric, mental health and chemical dependency conditions that in the reasonable judgment of a prudent layperson would place your life in danger or cause serious damage to your health if immediate care is not received. If you have a psychiatric emergency or crisis and receive emergency treatment at a specialized mental health facility that handles emergency care, the emergency room copayment/coinsurance will apply.

What to do if you are admitted to a non-participating hospital

If you are admitted to a non-participating hospital, you, or a relative, should call HMA within 48 hours or as soon as reasonably possible. All approved services will be covered at usual, customary and reasonable (UCR) charges. You will be responsible for any copayments and all amounts above the UCR charges.

You will need to submit a claim for a non-participating hospital service if the provider does not submit it for you. For information on how to submit a claim, see "Additional Information," on the next page.

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Urgent/immediate and after-hours care

Urgent care is treatment you need right away for an illness or injury that is not life threatening. This includes, but is not limited to, minor sprains, minor cuts and burns, and ear, nose, and throat infections. Routine care that can be delayed until you can be seen by a physician or provider in his or her office is not urgent care.

Whenever you need urgent care, call your personal physician/provider first. You also may call HMA at 866/206-7786, if you’re not sure whether to call your personal physician/provider or go to the urgent care center. Your personal physician/provider or personal physician/provider on call is always available, day or night. He or she may either suggest that you come to the office, or go to an emergency room or urgent care facility. If you can be treated in your provider’s office or participating urgent care facility, your copayment/coinsurance usually will be lower. You are responsible for your plan’s copayment/coinsurance whenever you receive services in an urgent care clinic, unless you are admitted to a hospital within 24 hours. Please be prepared to pay the copayment/coinsurance at the time you receive care.

If you are admitted to a non-participating hospital, you, or a relative, should call the Plan within 48 hours or as soon as reasonably possible.

The Plan pays for urgent care wherever you are. If you are injured or seriously ill while you are away from the Plan service area, go to any provider or urgent care facility.

The Plan will cover urgent care services received from a non-participating urgent care facility while you are inside the service area at the in-network benefit. If you receive urgent care services from a non-participating urgent care facility when you are outside the Plan’s service area, these services will be covered under the out-of-network benefit. See your plan’s Summary of Benefits for details.

Additional Information

If you receive services from an urgent care facility or emergency room from a non-participating facility outside or inside the Plan’s service area, you must submit a claim if the facility or provider does not submit it for you. Submit claims to:

HEALTHCARE MANAGEMENT ADMINISTRATORS, INC.

PO Box 85008

Bellevue, WA 98015

We request that you submit your claim within 60 days of receiving the service. To be paid, claims must be submitted within 12-months of receiving the service.

Please call HMA at 866/206-7786 if you have questions about this benefit or if you would like additional information.

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Benefits

Introduction

This section lists your covered benefits in the same order that they appear on your Summary of Benefits. Please refer to your Summary of Benefits for your member copayments coinsurance as well as other details of your specific coverage. If the Plan is required by law to modify your benefits, you will be notified in writing prior to any changes.

You must use preferred providers to receive in-network benefits for the covered services listed in this section. If you use non-Preferred Providers, your out-of-network benefits will apply. See the "Using Your Plans Out-of-Network Benefit," section, for details on using your out-of-network benefit.

Eligible Expenses

When medically necessary for the diagnosis or treatment of an illness or an accident, the following services are eligible expenses for participants covered under this Plan. Eligible expenses are payable as shown in the Schedule of Benefits and are limited by certain provisions listed in the General Exclusions. Major Medical expenses are subject to all Plan conditions, exclusions and limitations.

Preventive Health Services

This benefit covers routine physician services and related diagnostic tests that are regularly performed without the presence of symptoms. Your provider will determine which tests are necessary for your physical exam according to your medical history and your current health status. More frequent exams will be covered if your provider determines that they are necessary. Services are payable as shown in the Schedule of Benefits. Routine exams and tests are covered according to the following schedule:

Recommended guidelines:

• Well baby care, up to eight provider office visits during a child’s first 24 months.

• For children age 2-6, one exam per year.

• For children age 7-18, one exam every 24 months.

• For adults age 19-29, one exam every 60 months.

• For adults age 30-39, one exam every 36 months.

• For adults age 40-49, one exam every 24 months.

• For adults age 50 and above, one exam every year.

If, at the time of your routine physical examination or well child care, you need paperwork completed for a third party such as school, camp, team sports, etc., your provider may charge you a fee to complete the paperwork. The Plan will not cover this additional fee.

Immunizations/vaccinations

Routine immunizations/vaccinations (shots) are covered. Coverage for immunizations is provided when ordered or arranged by your provider and received in the provider’s office. Visits to your provider’s office for immunizations are subject to a copayment or member coinsurance. Immunizations required for travel, employment, insurance, licensing purposes or solely for the purpose of participating in camps, sports activities, recreation programs, or college entrance are not covered.

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Children’s vision and hearing screenings

Annual vision and hearing screenings by a provider are covered for children through age 17. If a vision or hearing problem is discovered, the Plan will pay for one visit per calendar year to an eye or hearing specialist to determine the need for vision or hearing correction.

Covered services do NOT include:

• Services for laser surgery, radial keratotomy and any other surgery to correct myopia, hyperopia or stigmatic error; vision therapy, or orthoptic treatment (eye exercises).

• Services for routine eye and vision care, refractive disorders, eyeglass frames and lenses, and contact lenses.

• Hearing aids, including all services related to the examination and fitting of the hearing aids.

Members diagnosed with diabetes

Members diagnosed with either insulin dependent or non–insulin dependent diabetes mellitus, have the following preventive health care benefits:

• Diabetes Education

• Dietary Counseling is covered up to two visits per calendar year.

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Women’s Health Care Services

Annual gynecological exams

Benefits for annual gynecological examinations include breast, pelvic and Pap examinations once every 12 months, or more frequently if your provider determines that they are necessary.

Female members may receive preventive women’s care exams from their personal physician/provider or from any other qualified provider who specializes in women’s health care. Women’s health care providers include physicians specializing in obstetrics or gynecology, nurse practitioners, certified nurse midwives, or physician assistants specializing in women’s health care.

Benefits also include follow-up exams for any medical conditions discovered during an annual gynecological exam that require additional treatment Your follow-up visit copayment/coinsurance may differ from your annual gynecological exam copayment/coinsurance. See your plan’s Summary of Benefits for details on your copayment/coinsurance information.

Mammograms

Mammograms are provided for women at the recommendation of your personal physician/provider or women’s health care provider.

Other Services

Counseling, exams and some services for voluntary family planning are covered. Contact HMA or your Human Resources department for detailed information.

Physician/Provider Services

If you receive office visit services from a preferred personal physician/provider, you may be responsible for charges for services and supplies received from your personal physician/provider in addition to your member copayment. For example – You see your personal physician/provider for an office surgery. You would pay your office visit copayment and also may need to pay additional coinsurance for the office surgery and any medical supplies used for your surgery. See your plan’s Summary of Benefits for details.

Office visits & office surgery

For covered services, the Plan pays the balance in full after you pay your member copayment/coinsurance. Your Summary of Benefits lists your copayment/coinsurance information for various types of office visits.

If you are unable to keep a scheduled office appointment with your provider, please try to notify that office in advance. The Plan does not cover charges for missed appointments.

Inpatient hospital visits

Provider visits in the hospital for approved hospitalization, including skilled nursing facilities, are covered.

Surgery and anesthesia

The Plan will cover provider charges for medically necessary surgery. This may include the fees of a surgeon, an assistant surgeon(s) and an anesthesiologist or registered nurse anesthetist. If two or more surgical procedures are performed through the same incision during an operation, full benefits are only provided for the primary procedure and one half for the lesser procedure. You are responsible for making sure the services are prior authorized by the Plan.

Assistant surgeon fees are limited to 20% of the primary surgeon’s fees.

Some surgical procedures are covered by the Plan only when performed on an outpatient basis. Your provider and/or the Plan will tell you in advance if your procedure is an outpatient surgery.

Allergy shots or injections

Allergy testing, shots or injections are covered. Your member coinsurance for allergy shots is listed on your Summary of Benefits.

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Hospital Services

Hospital services are covered, as stated on your Summary of Benefits. The Plan may require that you obtain a second opinion for some elective procedures. If you do not obtain a second opinion when requested, the Plan will not prior authorize the services and you will be responsible for paying for all of the services you receive.

Covered services do NOT include care received that consists primarily of:

• Room and board and supervisory or custodial services.

• Personal hygiene and other forms of self-care.

• Non-skilled care for senile deterioration, mental deficiency or mental retardation.

In all cases the following are specifically excluded from the hospital and skilled nursing facility benefit:

• Private duty nursing or a private room unless prescribed as medically necessary.

• Take-home medications, supplies and equipment.

• Personal items such as telephone, radio, television and guest meals.

Inpatient acute care

When an inpatient admission or surgery is recommended, the patient, the physician or a family member must call the HMA Medical Review Coordinator at least five days prior to the admission or surgery to obtain authorization. Please see the "Prior Authorization" section (under General Information) for specific information on requirements and penalties.

Only medically necessary hospital services are covered. Covered inpatient services received in a hospital are:

• Acute (inpatient) care, when medically necessary.

• A semi-private room (unless a private room is medically necessary).

• Coronary care and intensive care, when necessary.

• Isolation care, when necessary.

• Hospital services and supplies necessary for treatment and furnished by the hospital, such as operating and recovery rooms, anesthesia, dressings, medications, oxygen, x-ray, and laboratory services during the period of inpatient hospitalization. (Personal items such as guest meals, slippers, etc., are not covered.)

The Plan employs professional clinical staff who may review services you receive in the hospital. They may review your care to determine medical necessity, to make sure that you had quality care and to ensure that you will have proper follow-up care.

Your provider will determine your medically appropriate length of stay. If you choose to stay in the hospital longer than your physician advises, you will be responsible for the cost of additional days in the hospital.

Inpatient rehabilitative care

Inpatient rehabilitative care is covered. This applies when you need a full rehabilitation team approach and the services can be provided to you only as an inpatient. These services must be part of your provider’s treatment program to improve lost function after an illness or an injury. If you are hospitalized when rehabilitative services begin, rehabilitative benefits will begin on the day treatment becomes primarily rehabilitative. Inpatient rehabilitative care is limited to 30 days per calendar year as stated on your Summary of Benefits.

Skilled nursing facility

Skilled nursing facility services are covered when 24-hour skilled or subacute care is required and cannot adequately be provided through a home health program. Only medically necessary services are covered. The Plan may determine that your care needs are better served by transferring you from the hospital to a skilled nursing facility and reserves the right to make such a transfer. Services must be prescribed by your provider and prior authorized by the Plan. The Plan will cover up to 60 days of medically necessary care per calendar year as stated on your Summary of Benefits.

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Maternity Services

Selecting a physician or provider

The Plan covers comprehensive maternity care. Women may go to their personal physician/provider or a women’s health care provider of their choice for obstetric care once pregnancy has been diagnosed. Women’s health care providers include physicians specializing in obstetrics, some personal physicians/ providers (if they provide obstetric services), nurse practitioners, certified nurse midwives or physician assistants specializing in women’s health care.

Covered services

• Normal delivery.

• Cesarean delivery.

• Prenatal care by your physician, provider or certified nurse midwife.

• Birth at an approved facility.

• Postnatal care, including complications of pregnancy and birth.

• Newborn nursery care.

• Emergency treatment for complications of pregnancy and unexpected pre-term birth outside the service area.

The following services are NOT covered:

• Home births and services of a lay midwife.

• Maternity services provided for an unexpected premature delivery outside of the service area are covered as emergency services, as stated above. However, after the 36th week of pregnancy, delivery is not considered to be unexpected. Covered services for deliveries outside the service area are NOT covered as an emergency service unless the Plan determines that you were outside the service area because of circumstances beyond your control. (Does not apply to enrolled Out-of-Area Dependents.)

Length of hospital stay

You will not be discharged from the hospital sooner than 48 hours after a vaginal delivery or 96 hours after a caesarean delivery, unless you choose to be. You and your physician/provider will determine the length of your hospital stay and follow-up care based on accepted medical practice.

Newborn coverage

Select a family practitioner or pediatrician (personal physician/provider) for your baby. As soon as possible after delivery, add your newborn to your Plan coverage by contacting your employer and/or your Customer Service Team. Your baby is covered by PeaceHealth Plan for only 31 days after birth unless we receive a completed enrollment form from you or your employer within 60 days. See the "Newly-acquired dependents," section, for additional information.

Infertility services

Services for the treatment of infertility are covered the same as relevant services as listed on your Summary of Benefits. You must see a Preferred Provider, even if you are an Open Network Plus Plan  member for services to be covered. (Enrolled Out-of-Area Dependents may use a non-Preferred Provider for these services.)

Covered services are limited to: Diagnostic testing and associated office visits to determine the cause of infertility. This includes the physical examination, related laboratory testing, instruction, and medical/surgical procedures when performed for the sole purpose of diagnosing an infertile state. Diagnostic services for infertility include, but are not limited to hysterosalpingogram, laparoscopy and pelvic ultrasound.

All other infertility services are not covered. These include, but are not limited to:

• In-vitro fertilization;

• In-vivo fertilization

• Gamete inter-fallopian transfer (GIFT);

• Reversal of sterilization (tubal ligation or vasectomy); and

• Any method of artificial insemination, including any and all supplies, services, drugs, and treatments leading up to the procedure of artificial insemination, and until impregnation is confirmed.

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Medical and Diabetes Supplies, Durable Medical Equipment, Appliances, Prosthetic Devices

The Plan will provide coverage for the purchase or rental of Plan-approved medical supplies/devices, prosthetic devices and durable medical equipment (DME). All supplies/equipment/devices must be required for the standard treatment of the illness or injury.

All Plan-approved supplies/equipment/devices must be medically necessary and are limited to the most cost-effective equipment. The Plan may authorize the purchase of an item if we determine the cost of purchasing an item would be less than the overall rental of the item. Supplies/equipment/devices must be prescribed by your qualified practitioner.

The reasonable cost of repairing an item is covered as long as this cost does not exceed the purchase of a new piece of equipment or device. Items that are replaced due to loss or negligence are not covered. Items that are replaced due to the availability of a newer or more efficient model are not covered unless the Plan determines otherwise. Repair or replacement is covered if due to normal growth processes or to a change in your physical condition due to illness or bodily injury.

Purchase or rental of durable medical equipment that is over $500 must be reviewed and pre-authorized by HMA’s Medical Review Coordinator.

The Plan covers:

• Casts, braces and supportive devices – Covered when used in the treatment of medical or surgical conditions in acute or convalescent stages or as immediate post-surgical care.

• Initial and replacement contact lenses, intraocular lenses, prescription lenses or standard frame glasses – Covered when required as a result of injury, illness or surgery, such as cataract, corneal transplant surgery or for the treatment of keratoconus.

• Rental of oxygen units used in the home – Covered for members with significant hypoxemia who are unresponsive to other forms of treatment. The benefit is limited to three months from the initial date of service unless there is clinical evidence of the need to continue.

• Orthotics – Limited to a maximum benefit of $300 every 24 months. Orthotics do not include prosthetic devices or childhood braces.

• Prosthetic devices – Covered supplies include prosthetic devices such as artificial limbs, breast implants following mastectomy, and artificial eyes.

• Maxillofacial prosthetic devices – Covered when considered medically necessary for the restoration and management of head and facial structures that cannot be replaced by living tissue. When head and facial structures are impaired due to disease, trauma, or developmental deformity. The devices must be needed to control or eliminate infection and pain and restore facial configuration and function.

• Medical devices surgically implanted in a body cavity to replace or aid the function of an internal organ.

• Medically necessary medical foods – Covered for supplementation or dietary replacement, including non-prescription elemental enteral formula for home use, when determined to be medically necessary for the treatment of severe intestinal malabsorption. Approval of these services will be based on criteria established by the Plan and in accordance with regulatory requirements. Medical foods are defined as foods that are formulated to be consumed or administered enterally under strict medical supervision for the treatment of inborn errors of metabolism including, but not limited to: phenylketonuria (PKU); homocystinuria, citrullinernia, maple syrup disease; and pyruvate dehydrogenase deficiency.

• Other medically necessary supplies – Covered when ordered by a qualified practitioner, including, but not limited to, ostomy supplies, supplies for radiologic procedures, prescribed needles, syringes and blood sugar check strips. You can purchase diabetes supplies through your Prescription Drug Care benefits or your provider's office.

• Durable medical equipment (DME) – Covered for rental of crutches, wheelchairs, hospital beds, or other therapeutic equipment when prescribed by a qualified practitioner, subject to the Plan’s durable medical equipment definition. Covered services for DME do not include items that are primarily and customarily used for a non-medical purpose or which are used for environmental control or enhancement (whether or not prescribed by a physician). All DME purchased in excess of $500 require prior authorization.

No other medical supplies, devices, prosthetic devices or DME are covered.

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Emergent/Urgent & Ambulance Services

Emergency services

Please see the Emergency and Urgent Care section.

Urgent care services

Please see the Emergency and Urgent Care section.

Ambulance

Services of a licensed ambulance company for transportation to the nearest medical facility where the required service is available, if other transportation would endanger the patient's health and the purpose of the transportation is not for personal or convenience reasons. Benefits for licensed air ambulance services will be provided to the nearest hospital equipped to render the necessary treatment, upon review of the Plan Supervisor. Out-of-area ambulance services to provide transportation to the nearest facility, or to a facility specified by the Plan.

We do NOT cover care cars, other medical transportation vehicles and other non-emergency medical transportation.

Diagnostic X-ray and Laboratory Services 

The Plan pays for inpatient and outpatient diagnostic pathology (laboratory), radiology (x-ray) tests and diagnostic procedures that include EMG, nerve conduction studies, nuclear medicine, pulmonary function, electrophysiology and other medically necessary diagnostic procedures when ordered by a qualified provider.

Outpatient Rehabilitative Services

Short-term outpatient rehabilitative services are covered up to 30 visits per calendar year. Therapy is provided by physicians and/or licensed or registered therapists to restore or improve function due to illness or injury. Benefits are limited to covered services that can be expected to result in the significant improvement of your condition. Covered services are for outpatient physical, occupational and speech therapy.

The treatment must be part of a written treatment plan prescribed by a qualified provider. The Plan will NOT provide benefits for exercise programs; Rolfing, polarity therapy and similar therapies; and growth and cognitive therapies.

Outpatient Surgery, Chemotherapy & Radiation outpatient Therapy

Benefits are provided as shown on your Summary of Benefits and include services at a hospital or other facility. Covered services include, but are not limited to, services for a surgical procedure and regularly scheduled therapy such as chemotherapy, inhalation therapy, or radiation therapy as ordered by a qualified practitioner. The Plan may require that you obtain a second opinion for some elective procedures. If you do not obtain a second opinion when requested, we will not prior authorize the services and you will be fully responsible for payment.

Temporomandibular Joint (TMJ) Services

Benefits are provided for TMJ services from a Preferred Provider as shown on your Summary of Benefits. Enrolled out-of-area dependents may receive covered services from a non-Preferred Provider.

Covered services do NOT include dental or orthodontia services.

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Treatment of specified dental services and restoration of head and facial structures

Covered services include restoration and management of head and facial structures, including teeth, dental implants and bridges, that cannot be replaced with living tissue and that are impaired because of trauma, disease or birth or development deformities. Benefits are covered as those services listed on your Summary of Benefits based upon the type of services received. 

Conditions for receiving this benefit:

• All treatment, except emergency services, must be prior authorized by the Plan.

• Conditions related to trauma must be diagnosed within 30 days of injury and treatment must be completed within twelve months of the injury.

• Services must be prior authorized by the Plan and are only provided for members with complicating medical conditions.  Examples of these conditions include, but are not limited to, mental handicaps, physical disabilities, or a combination of medical conditions or disabilities that cannot be managed safely and efficiently in a dental office, or emotionally unstable, uncooperative, combative patients where treatment is extensive and impossible to accomplish in the office, or healthy children, under 7 years of age, with physician documented necessity.

Covered services do NOT include:

• Cosmetic services.

• Services rendered to improve a condition that falls within the normal range of such conditions.

• Orthodontia.

• Services to treat tooth decay, periodontal conditions and deficiencies in dental hygiene. Removal of impacted teeth.

• The making or repairing of dentures.

• Orthognathic surgery to shorten or lengthen the upper or lower jaw, unless related to a traumatic injury or to a neoplastic or degenerative disease.

• Services to treat TMJ joint disorder, except as specified in the covered TMJ services section above.

Outpatient hospitalization and anesthesia for dental services

Benefits for outpatient hospitalization and anesthesia for dental services are covered the same as relevant services listed on your Summary of Benefits.

Services must be prior authorized by the Plan and are only provided for members with complicating medical conditions. Examples of these conditions include, but are not limited to, mental handicaps, physical disabilities, or a combination of medical conditions or disabilities that cannot be managed safely and efficiently in a dental office.

All other dental services are excluded.

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Home health care

Home health visits are covered as shown on your Summary of Benefits. To be a covered benefit, a home health care provider must provide services at your home under a home health care treatment plan. Each visit by a person providing services under a home health care treatment plan, or each visit to evaluate the need for or development of a plan, is considered to be one home health care visit. Up to four consecutive hours in a 24-hour period of home health care service is considered to be one home health care visit. A home health care visit of more than four hours is considered one visit for every four hours or part thereof.

For home health care to be a covered benefit, your qualified provider needs to certify that the home health care services will be provided or coordinated by a state-licensed or Medicare-certified home health agency or certified rehabilitation agency. If you were hospitalized immediately prior to the start of your home health care, the home health plan must be initially approved by the same qualified practitioner who was the primary provider of the services you received during your hospitalization.

This benefit is not intended to provide custodial care but is provided for care in lieu of inpatient hospital, medical facility or skilled nursing facility care for patients who are homebound.

The following services will be considered eligible expenses:

• Part-time or intermittent nursing care by a registered nurse, a licensed vocational nurse or by a licensed practical nurse.

• Physical therapy by a licensed, registered or certified physical therapist.

• Speech therapy services by a licensed, registered or certified speech therapist.

• Occupational therapy services by a registered, certified or licensed occupational therapist.

• Nutritional guidance by a registered dietitian.

• Nutritional supplements such as diet substitutes administered intravenously or by enteral feeding.

• Respiratory therapy services by a certified inhalation therapist.

• Home health aide services by an aide who is providing intermittent care under the supervision of a registered nurse, physical therapist, occupational therapist or speech therapist. Such care includes ambulation and exercise, assistance with self-administered medications, reporting changes in your condition and needs, completing appropriate records.

• Medical supplies, drugs and medicines prescribed by a physician, and laboratory services normally used by a patient in a skilled nursing facility, medical facility or hospital, but only to the extent that they would have been covered under this Plan if the participant had remained in the hospital or medical facility.

• Services for Home Health Care must be pre-authorized by the UR Coordinator prior to services being rendered.

Home health care benefits do NOT include:

• Charges for mileage or travel time to and from your home.

• Wage or shift differentials for home health providers.

• Charges for supervision of home health providers.

• Services that consist principally of custodial care including, but not limited to, care for senile deterioration, mental deficiency, mental retardation or mental illness, or care of a chronic or congenital condition on a long-term basis.

• Services provided that are not otherwise covered under the Plan.

• Meals on Wheels or similar home delivered food services.

• Services performed by a member of the patient’s family or household.

• Supportive environmental materials such as handrails, ramps, telephones, air conditioners or similar appliance or device.

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Hospice care

Covered hospice care services are provided, as stated on your Summary of Benefits, for members who have a terminal illness and are expected to live six months or less. This determination needs to be certified by your qualified provider and determined by the Plan to be medically necessary. Hospice care services are limited to medical care that provides comfort and support for a dying person, usually in his or her home, but does not effect a cure. Covered services provided must be reasonable and necessary for the condition and symptoms being treated.

When the above criteria are met, the Plan will provide benefits for a full range of covered services that a certified hospice care program is required to include.

Covered services include:

• Nursing care provided by or under the supervision of a registered nurse.

• Medical social services provided by a medical social worker who is working under the direction of a physician. This may include counseling for the purpose of helping the patient and caregivers adjust to the approaching death.

• Services provided by your qualified practitioner or a physician associated with the hospice program

• Durable medical equipment, medical supplies and devices, including medications used primarily for the relief of pain and control of symptoms related to the terminal illness.

• Home health aide services for personal care, maintenance of a safe and healthy environment and general support for the goals of the plan of care; including a maximum of 120 hours of respite care to the primary care giver during a three-month period.

• Rehabilitation therapies (including physical, speech, occupational and respiratory therapies) provided for purposes of symptom control or to enable the patient to maintain activities of daily living and basic functional skills.

• Continuous home care during a period of crisis in which the patient requires skilled intervention to achieve palliation or management of acute medical symptoms.

• Benefits for hospice care services may be extended an additional six months in cases where a member is facing imminent death, or is entering a remission, and the member’s condition has been certified in writing by the attending physician.

No other services are covered under the hospice care benefit.

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Podiatry/foot services

Covered services include the services provided by a podiatrist or other qualified practitioner and are covered as stated on your Summary of Benefits under the Physician/Provider Services section. Covered services include, but are not limited to, the fitting and follow-up exam for orthotics when required as a result of surgery, congenital defect or diabetes. Orthotics are covered as stated under the "Orthotics," section.

Covered services do NOT include routine foot care and the removal of corns or calluses, unless you have diabetes.

Reconstructive Breast Surgery

Medically necessary reconstructive breast surgery following a mastectomy is a covered benefit. This includes reconstruction of the involved breast following a mastectomy due to disease, illness or injury; surgery and construction of the other breast to produce a symmetrical appearance; and prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas. A member receiving benefits for a medically necessary mastectomy who elects breast reconstruction after the mastectomy, will also receive 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

• Prostheses

• Treatment of physical complications of all stages of mastectomy, including lymphedemas.

Cosmetic/Reconstructive Surgery

Reconstructive surgery that is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part is covered. The Plan also will provide covered services for the treatment of congenital disease or anomaly of a covered dependent child that has resulted in a defect. Benefits are covered as those services listed on your Summary of Benefits based upon the type of services received. All covered services must be prior authorized by the Plan.

Not covered: All other forms of cosmetic surgery, such as services and supplies that are applied to normal structures of the body for the purpose of improving or changing appearance or enhancing self-esteem, are excluded.

Inborn Errors

Covered services include services received for diagnosing, monitoring and controlling of Metabolism inborn errors of metabolism, including PKU, that involve amino acid, carbohydrate and fat metabolism. Covered services include clinical visits, biochemical analysis and medical foods used in the treatment of such disorders. See the"Medically Necessary Medical Foods," section, for coverage information on medical food supplies. Coverage is provided as shown on your Summary of Benefits based upon the type of services received.

Human organ/tissue transplants

Benefits for human organ and tissue transplants include covered services to theextent shown on your Summary of Benefits that are not experimental, investigational or for research purposes. Combined transplant services are limited to a $250,000 lifetime maximum.

Covered services consist of all phases of prior authorized treatment:

1. Evaluation;

2. Pre-transplant care;

3. Transplant and any donor covered services; and

4. Follow-up treatment, including any prescription drugs received relating to the transplant, are covered when provided within two years of the transplant procedure.

Covered services incurred by a live donor are provided under this benefit (to a maximum of $25,000 per transplant) as though the donor’s expense is the expense of the member when both of the following apply:

• The recipient is a PeaceHealth Plan member; and

• The services are not provided by any other plan.

Covered services are only provided when:

• Prior authorization is received from HMA;

• Services are provided at a facility approved by the Plan; and

• The procedure is in accordance with standard medical practice in the judgment of the Plan.

Covered human organ/tissue transplants include, but are not limited to, the following when medically necessary and approved in advance by the Plan:

• Kidney; corneal; heart; lung; liver; and bone marrow transplants and combinations thereof; pediatric liver transplants, including the treatment of children with biliary atresia and other rare congenital abnormalities;

• Bone marrow transplants under the following circumstances:

• Aplastic anemia;

• Leukemia; and

• Other diseases in accordance with standard medical practice in the judgment of the Plan.

The following organ transplant covered services apply to the transplant benefit:

• All covered services related to the transplant surgery before the actual surgery, including high dosage chemotherapy for autologous bone marrow transplant for the treatment of breast cancer;

• All resultant covered services related to the transplant after the surgery. The term "resultant covered services" includes, but is not limited to, medical services, medical supplies, inpatient and outpatient drugs and medications, diagnostic modalities, prosthesis and therapy. Benefits for FDA-approved outpatient immunosuppressive drugs furnished to an organ transplant patient whose transplant was covered by the Plan are provided;

• Treatment of conditions resulting from the transplant; and

• Donor’s initial medical evaluation and surgical expenses related to actual harvesting of the organ, as well as the cost of treating complications directly resulting from the surgery, but only if the recipient is a member and the donor is not eligible for coverage under any other health plan or government funding program.

Reasonable and necessary transportation expenses related to covered transplant services are covered subject to the following:

• The travel expense reimbursement is limited to a maximum of $5,000 per transplant.

• The benefit includes expenses of the member receiving the transplant and one companion, or two companions if the member receiving the transplant is a minor.

• All transportation expenses must be prior authorized by the Plan.

No benefits will be provided for the following:

• Transplant services or supplies received during the first 12 consecutive months of an Enrollee’s coverage under this Plan.

• Any procedure that has not been proven effective or is experimental or investigative or is not standard of care for the community. (See definition of Experimental and Investigative.)

• When donor benefits are available through other group coverage.

• When government funding of any kind is available.

• When the recipient is not covered under this Plan.

• Private nursing care by a Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.)

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Travel Benefits Ketchikan General Hospital Employees Only

If you work at Ketchikan General Hospital (Southeast Alaska Region Employees), you may be eligible for travel benefits related to medical treatment received outside of Ketchikan. Travel benefits may include up to two trips per calendar year at an equivalent of coach airfare to Seattle. When travel benefits are authorized for a covered dependent child, airfare is also provided for one parent, who is covered under the plan, to accompany the child. Please contact your local Human Resources Department for detailed information. All travel benefits must be pre-authorized by HMA. Failure to pre-authorize may result in the denial of your claim.

Smoking Cessation

The services of a provider listed under the definition of physician, operating within the scope of their license, will be covered for a completed smoking cessation program. Medications to aid nicotine withdrawal will also be covered under this benefit. Benefits are payable as shown in the Schedule of Benefits.

Eligible expenses under this Plan shall not include, acupuncture, vitamins, and other food supplements, books, or tapes.

Taxes

Charges for surcharges required by the New York Health Care Reform Act of 1996 (or as later amended) will be considered covered expenses by this Plan. Local, State and Federal taxes, associated with supplies or services covered under this Plan, will also be considered covered expenses by this Plan.

Alternative care coverage

What is alternative medicine?

The idea behind alternative medicine is to help the body heal itself. Alternative care practitioners view the body holistically, rather than focusing on a single disease or condition. Alternative medicine is sometimes called "complementary care" because it can complement the care you receive from your regular medical physician or provider. Alternative medicine may be especially useful for conditions such as headaches, backaches and chronic pain. It may offer an alternative for people who wish to avoid relying on medications to control pain. Many alternative care providers place a high priority on teaching their patients how to incorporate healthier habits into their lifestyles.

Acupuncture is an ancient Chinese method of healing dating back to 1600 B.C. The acupuncturist inserts ultra-thin needles beneath the skin in a painless method designed to open "energy pathways" (known in China as ch’i) in the body. Many people turn to acupuncture for relief from conditions such as asthma, nausea, bronchitis, chronic pain, sports injuries, and addictions. Acupuncturists are licensed (LAc) health care providers.

Naturopathy draws on a number of methods to facilitate healing, which include massage, homeopathy, herbal therapy, nutrition and more. The naturopathic physician incorporates natural therapies into his or her practice, using an extensive personal medical history of the patient to help guide each diagnosis and recommendation for treatment. Naturopathy can be especially useful for people who want to improve their overall health. Naturopathic physicians hold a Degree of Doctor of Naturopathic Medicine (ND).

How do I use the Alternative Care Benefit?

• When you feel that you need services from an alternative care provider, just call one of the providers listed in the Regence Preferred Provider List. Services are not covered when you use alternative care providers who are not on this list.
• Pay your $10 co-payment to your alternative care provider at the time of service. That is your complete out-of-pocket charge for covered services, up to a maximum benefit of $1,000 per member annually. This co-payment is not applied toward your Plan’s medical annual out-of-pocket maximums or any applicable deductibles. You do not need to meet any applicable medical plan deductibles before receiving this benefit.
• Enrolled Out-of-Area Dependents only: Please refer to your Out-of-Area Summary of Benefits for Out-of-Area Member information.

How do I know I can trust the alternative care providers on the provider list?

Providers are carefully screened for ethical and quality standards, using the same rigorous credentialing process that many health plans use with medical physicians. Providers are reviewed each year, and any complaints received from patients are thoroughly evaluated by an independent team.

Will my acupuncturist use sterilized needles?

Absolutely. In order to be credentialed, all acupuncturists agree to use only disposable FDA-approved sterilized needles.

What is covered?

Covered acupuncture services are limited to the following, as deemed medically necessary by HMA or its authorizing agent:

• Acupuncture.
• Electro-acupuncture.
• Cupping.
• Moxibustion.
• Extravasation and Gua Sha/Tui Na.

Covered naturopathic services are provided only when services are determined to be medically necessary by HMA or its authorizing agent.

General Exclusions and Limitations for Alternative Care Benefits

• Treatment of alcohol, drug or chemical dependency in a specialized inpatient or residential facility.
• Behavioral training and modification including, but not limited to, biofeedback, hypnotherapy, play therapy and sleep therapy.
• Cosmetics, dietary supplements, health or beauty aids.
• Services furnished by a facility that is primarily for rest, custodial care, a place for the aged, a nursing home or any facility of like character.
• Devices or appliances, durable medical equipment, supplies, appliances or prosthetics.
• Drugs and medications, prescription or non-prescription, including vitamins, minerals, nutritional or dietary supplements, or any other supply or product whether or not prescribed or recommended by the member's participating chiropractic physician, naturopathic physician or acupuncturist.
• Services provided in the emergency room.
• Exercise, recreation, hygienic and beautification classes and equipment.
• Services considered experimental or investigational.
• Services that exceed the limitations or fail to meet the conditions of covered services.
• Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT Scan) diagnostic services. Please see your plan’s medical summary of benefits and member handbook for coverage of diagnostic services. Charges for these services do not apply toward the alternative care annual benefit maximum.
• Services deemed not medically necessary by HMA or its authorizing agent.
• Military service connected disability care for which the treatment is legally entitled through a federal government facility
• Services not delivered by a participating provider.
• Services and charges for the condition under treatment from the time the patient refuses, for personal reasons, to accept a recommended treatment or procedure after being advised that the treating participating health care provider believes no professionally acceptable alternative exists.
• Personal or comfort items; environmental enhancements; modifications to dwellings, property or motor vehicles; adaptive equipment and training in the use of equipment; personal lodging, travel expenses or meals.
• Physical exams; vocational rehabilitation; workers’ compensation illnesses or injuries; evaluations and reports such as those for employment, licensing, school, sports, premarital or required for court proceedings.
• Services rendered prior to the effective date of coverage.
• Public facility care in which services or care are required by federal, state or local law.
• Self-help or educational programs including any diagnostic testing related to such services.
• Thermography.
• Transportation services (including ambulance and care cars).
• Weight control supplies or products.

Acupuncture Exclusions:

• Intradermal needles.
• Non-FDA approved acupuncture needles.

Naturopathic Exclusions

• Cosmetic or reconstructive surgery, surgical treatment to correct a congenital abnormality.
• Dental services.
• Hearing exams for the purpose of prescribing hearing aids.
• Immunizations.
• Infertility services, sterilizations, reversals of sterilizations, or penile implants.
• Massages for palliation, relaxation or maintenance.
• Non-medicallay necessary or experimental treatments for obesity.
• Obstetrics.
• Optometry.
• Psychological counseling.
• Routine foot care.
• Sigmoidoscopy.

The following tests are also excluded:

• Comprehensive digestive stool analysis.
• Cytotoxic food allergy test.
• Darkfield examination for toxicity or parasites.
• EAV and electronic tests for diagnosis and allergy.
• Fecal transient and retention time.
• Henshaw test.
• Intestinal permeability.
• Loomis 24 hour urine nutrient/enzyme analysis.
• Melatonin biorhythm challenge.
• Salivary caffeine clearance.
• Sulfate/creatinine ratio.
• Tryptophan load test.
• Urinary sodium benzoate.
• Urine/saliva pH.
• Zinc tolerancy test.

Your Open Network Plus Plan Chiropractic Benefit provides coverage for chiropractic visits and treatment.

How to access services

You must receive all your chiropractic care from the preferred doctors of chiropractic medicine listed in the Regence Preferred Provider List. You do not need to meet any applicable medical plan deductibles before receiving this benefit.

Covered benefits

• Covered chiropractic services must be consistent with current procedural terminology (CPT) guidelines and are limited to the following, as deemed medically necessary by HMA or its authorizing agent:
• Initial evaluation visit for each diagnosis or injury.
• Chiropractic treatment such as manipulation for neuromusculoskeletal disorders.
• Related diagnostic laboratory or x-ray services.
• Physical therapy services only when associated with spinal manipulation and provided by a participating chiropractic physician.
• A $10 copayment will be charged at the time the service is rendered. This copayment is not applied toward your plan’s medical annual out-of-pocket maximums or any applicable deductibles. You do not need to meet any applicable medical plan deductibles before receiving this benefit. The maximum chiropractic benefit per calendar year is $500 per member.
• Enrolled Out-of-Area Dependents only: Please refer to your Out-of-Area Summary of Benefits for Out-of-Area Member information.

Exclusions and Limitations

• Treatment of alcohol, drug or chemical dependency in a specialized inpatient or residential facility.
• Behavioral training and modification including, but not limited to, biofeedback, hypnotherapy, play therapy and sleep therapy.
• Cosmetics, dietary supplements, health or beauty aids.
• Services furnished by a facility that is primarily for rest, custodial care, a place for the aged, a nursing home or any facility of like character.
• Devices or appliances, durable medical equipment, supplies, appliances or prosthetics.
• Drugs and medications, prescription or non-prescription, including vitamins, minerals, nutritional or dietary supplements, or any other supply or product whether or not prescribed or recommended by the member's participating chiropractic physician.
• Services provided in the emergency room.
• Exercise, recreation, hygienic and beautification classes and equipment.
• Services considered experimental or investigational.
• Services that exceed the limitations or fail to meet the conditions of covered services.
• Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT Scan) diagnostic services. Please see your plan’s medical summary of benefits and member handbook for coverage of diagnostic services. Charges for these services do not apply toward the alternative care annual benefit maximum.
• Services deemed not medically necessary by HMA or its authorizing agent.
• Military service connected disability care for which the treatment is legally entitled through a federal government facility
• Services not delivered by a participating provider.
• Services and charges for the condition under treatment from the time the patient refuses, for personal reasons, to accept a recommended treatment or procedure after being advised that the treating participating health care provider believes no professionally acceptable alternative exists.
• Personal or comfort items; environmental enhancements; modifications to dwellings, property or motor vehicles; adaptive equipment and training in the use of equipment; personal lodging, travel expenses or meals.
• Physical exams; vocational rehabilitation; workers’ compensation illnesses or injuries; evaluations and reports such as those for employment, licensing, school, sports, premarital or required for court proceedings.
• Physical therapy, unless associated with spinal manipulation and provided by the member's participating chiropractic physician.
• Services rendered prior to the effective date of coverage.
• Public facility care in which services or care are required by federal, state or local law.
• Self-help or educational programs including any diagnostic testing related to such services.
• Thermography.
• Transportation services (including ambulance and care cars).
• Weight control supplies or products.

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Mental Health & Chemical Dependency Services

Non–emergency outpatient, inpatient, residential, and day treatment mental health and chemical dependency services are covered benefits only when prior authorized.

Please contact the Plan’s authorizing agent for services at:

• Mental Health Match at 1-800-457-3798 (Corporate office, Southeast Alaska Region, Lower Columbia Region and Corporate employees located in the Southeast Alaska and Lower Columbia Regions).

• Health Promotion Network at 1-800-244-6142 or 360/715-6575 (Whatcom Region and Corporate employees located in the Whatcom Region).

Arranging mental health or chemical dependency services

The Plan’s authorizing agent and your qualified practitioner will coordinate your Mental health and chemical dependency care.

For emergency mental health or chemical dependency services, go directly to a hospital emergency room. You do not need prior authorization for emergency treatment. You, or a relative, should notify the Plan within 48 hours of emergency treatment, or as soon as reasonably possible.

Mental health services

Mental Health benefits have the following limitations:

• Inpatient:........30 days every 24 months (combined inpatient and residential)

• Outpatient:......20 visits per calendar year

Benefits are limited to covered services provided in the least costly treatment setting which, in the judgment of the Plan and its authorizing agent, is medically necessary for the individual patient’s condition.

Covered services:

• Outpatient diagnostic evaluation and mental health treatment including individual and group therapy.

• Inpatient, residential and day or partial hospitalization for the treatment of mental disorders. These services must be obtained at a treatment facility approved by the Plan’s authorizing agent.

• Eating Disorders such as anorexia nervosa, bulimia, or other eating disorders are covered under the mental health benefits when diagnosed and treated by a mental health professional.  Services in a Licensed Residential Care Facility are provided when prior authorization by the Plans’ Mental Health Authorizing Agent.

Chemical dependency Services

Chemical Dependency (both inpatient and outpatient) benefits are limited to $10,000 every two calendar years.

Benefits include covered services necessary for the diagnosis and treatment of chemical dependency (drug and alcohol treatment), including detoxification. Treatment involving the use of methadone is covered only when such treatment is part of a medically supervised treatment program approved by the Plan or its authorizing agent.

Covered services:

• Outpatient diagnosis and treatment for chemical dependency including, detoxification. Treatment includes individual and group therapy.

• Inpatient, residential and day or partial hospitalization for the treatment of chemical dependency disorders. These services must be obtained at a treatment facility approved by the Plan’s authorizing agent.

Medically necessary detoxification

Medically necessary detoxification will be treated as an emergency medical condition when members are not enrolled in other chemical dependency treatment programs at the time services are received. Members do not need prior authorization for this emergency treatment; however, the Plan’s authorizing agent must be notified within 48 hours following the onset of treatment, or as soon as reasonably possible, in order for coverage to continue. If a member is to be transferred to a Preferred Provider for continued inpatient care, the cost of medically necessary transportation will be covered. Continuing or follow-up care is not a covered service unless prior authorized by our authorizing agent.

When you need to access both mental health and chemical dependency covered services, covered services for mental health will be applied to the mental health benefit limits and covered services for chemical dependency will be applied to the chemical dependency benefit limits up to the benefit maximums for each category of services as stated on your Summary of Benefits.

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Prescription Drug Card Program

Benefits will be provided as described below and as shown in your Schedule of Benefits for state and federal legend drugs requiring a prescription and for other items as specifically provided, when such drug or other items are furnished by an approved pharmacy or a approved mail order supplier. Benefits will be subject to any waiting periods, limitations and exclusions. The prescription drug benefits will not be subject to the Coordination of Benefits provisions or to any deductible or out of pocket maximums under the medical Plan.

Legend Drugs are those drugs which cannot be purchased without a prescription written by a physician or other lawful prescriber.

Generic Substitution

Over 400 commonly prescribed drug products are now available in a generic form at an average cost of 50% less than the brand name products. This Plan encourages the use of generic prescription drugs. By law, generic and brand name drugs must meet the same standards of safety, purity, strength, and effectiveness. At the same time, brand name drugs are often 2 to 3 times more expensive than generic drugs. Use of generics with this benefit will save you money and we encourage you to ask your physician to prescribe them whenever possible.

Payment Schedule

A co-pay (or coinsurance) is payable for each prescription filled according to the amounts shown in the Schedule of Benefits.

This Plan requires the pharmacist to fill the prescription with a generic product whenever it is available, unless the prescription is written as "Dispense as Written." If the prescription is not specified as "Dispense as Written" and the prescription is filled with a name brand prescription at the Plan participants request, then the co-pay (or coinsurance) plus the difference between the cost of the generic drug and the brand name drug will be charged.

Brand Name Performance Drugs

An important element of your Advance PCS Prescription Drug Card Program is the opportunity to select drugs from the Performance Drug List. The Performance Drug List is a guide to the best values within select therapeutic categories which helps the provider identify products that will provide optimal clinical results at a lower cost. The Performance Drug List undergoes a thorough review and/or revision annually. Interim changes could occur to reflect changes in the market. These changes could include; entry of new products or other events that alter the clinical or economic value of the products on the Performance Drug List. Please see your Human Resources Department for a copy of the Performance Drug List, or the AdvancePCS website address.

Other brand name drugs are any brand name drugs covered through the AdvancePCS Plan, but not listed on the Performance Drug List.

Drugs Covered

The following is a list of those drugs covered by the Plan.

• Legend drugs. Exceptions: See Exclusions below.

• Insulin.

• Disposable needles/syringes.

• Disposable blood/urine glucose/acetone testing agents (e.g. Chemstrips, Acetest tablets, Clinitest tablets, Diastix Strips and Tes-Tape.)

• Tretinoin, all dosage forms (e.g. Retin-A), for individuals through the age of 25 years, limited to the condition of acne.

• Compounded medication of which at least one ingredient is a legend drug.

• Any other drug which under the applicable state law may only be dispensed upon the written prescription of a physician or other lawful prescriber.

Drugs Excluded & Limited

The following is a list of those drugs not covered by the Plan.

• Anorectics (any drug used for the purpose of weight loss).

• Dietary supplements.

• Fluoride for participants over age 10.

• Growth Hormones.

• Immunization agents, biological sera, blood or blood plasma.

• Infertility medications.

• Levonorgestrel (Norplant).

• Medications for cosmetic purposes (e.g., Sporanox for unsightly toenails, Botox, Myobloc).

• Minoxidil (Rogaine) for the treatment of alopecia.

• Non-legend drugs other than insulin.

• Oral progesterone compound products.

• Sildenafil Citrate (Viagra).

• Smoking Deterrent Medications containing nicotine or any other smoking cessation aids, all dosage forms (e.g. Nicorette, Nicoderm, etc.).

• Tretinoin, all dosage forms (e.g. Retin-A) for conditions other than acne (physician documentation required for individuals 26 years of age or older).

• Vitamins, singly or in combination. Exception: prenatal vitamins.

• Therapeutic devices or appliances, including support garments and other non-medical substances, regardless of intended use, except those listed above.

• Charges for the administration or injection of any drug.

• Prescriptions which an eligible individual is entitled to receive without charge from any Worker's Compensation Laws.

• Drugs labeled Caution-limited by federal law to investigational use, or experimental drugs, even though a charge is made to the individual.

• Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed medical facility, rest home, sanitarium, extended care facility, convalescent medical facility, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.

• Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician's original order

Prescription Drug Managed Access

Drugs listed as excluded or limited may be eligible as a covered benefit when medically necessary and prescribed as part of an approved treatment plan.

Coordination of Benefits

Coordination of Benefits does not apply to outpatient prescription drug card programs.

Benefit Limitations

If the prescription card is not used by the participant at the time of the prescription purchase or the prescription is purchased at a non-participating pharmacy, you must file a claim directly with the drug card service agency using their claim form.

When you do not use the prescription card, the benefit is less because the prescription drugs cost more. When you submit a prescription claim to the drug card service agency, the charges which include: (1) the copay you would normally pay; (2) the difference between the pharmacy retail price and the amount the pharmacy would have charged if the prescription card was used; and (3) a handling fee, will be deducted from your total reimbursement.

Benefits For Employees And Dependents Without A Card

Prescription drugs that are eligible for reimbursement by the prescription drug card  program can be submitted to the AdvancePCS prior to the enrollee's receipt of the card.To claim this benefit, a receipt for the paid prescription with an AdvancePCS claim form must be submitted to the AdvancePCS. AdvancePCS will reimburse eligible claims as if the card had been used (100% reimbursement following the applicable copay).

Dispensing Limitations, The following are the dispensing limitations for both retail and mail order prescription drugs.

Retail:    The amount normally prescribed by a physician, but not to exceed a 30 day supply.

Mail Order:    The amount normally prescribed by a physician, but not to exceed a 90 day supply.

When to Use Your Mail Order Prescription Drug Card Program

You should continue to have non-maintenance prescriptions (prescribed for urgent illness or injury) filled at the local pharmacy. However, if you are ordering maintenance medications (those taken on a regular or long term basis such as heart, allergy, diabetes or blood pressure medications), use the Certifax MailService program and have the medications delivered directly to your home.

Using the Certifax MailService program when purchasing prescriptions and paying the applicable copay, the Plan pays 100% of the eligible balance due direct to the pharmacy.

Ordering Information

For an existing prescription, provide Certifax MailService with the information requested on the initial order form and a Certifax MailService Pharmacist will transfer the existing prescription to the Certifax MailService Pharmacy. The provider can also phone in refill prescriptions to save time. Refills can be ordered over the telephone with a credit card by calling 800/635-3070 (Certifax) OR 800/966-5772 (AdvancePCS). The provider can also phone or fax new prescriptions to Certifax MailService if credit card payment information has previously been provided by the participant. Certifax MailService Pharmacists automatically call the provider for refills when the prescriptions expire.

Pharmacists are available for counseling Monday through Friday from 7:00 am to 5:00 pm, at 800/635-3070 Pacific Time.

Certifax MailService maintains a quick turnaround time. Orders which do not require a communication with either the participant or the provider, prior to dispensing, will be filled and mailed within 1 or 2 days. Prescriptions that require communication with either the participant or the provider will not be filled until all questions have been answered.

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General Exclusions and Limitations

In addition to those services listed as not covered in the "Benefits" section, the following are not included or have coverage limitations as noted.

General Exclusions:

• Services that are not provided.

• Services received before your effective date of coverage.

• Services that are not a covered service or relate to complications resulting from a non-covered service.

• Services that are not furnished by a qualified practitioner or qualified treatment facility.

• Services provided by or payable under any plan or law through a government or any political subdivision, unless prohibited by law.

• Services provided while you are confined in a hospital or institution owned or operated by the United States Government or any of its agencies, except to the extent provided by 38 U. S. C. 1729 as it relates to non-military services provided at a Veterans Administration hospital or facility.

• Services provided by a person who ordinarily resides in your home or who is a member of your immediate family (parent, spouse, sibling or child).

• Services provided for convenience, educational or vocational purposes including, but not limited to, videos and books, educational programs to which drivers are referred by the judicial system and volunteer mutual support groups.

• Services performed in association with a service that is not covered under the Plan.

• Services provided in an institution for the developmentally disabled, except while in an acute care hospital for conditions other than mental retardation.

• Services provided for treatment or testing required by a third party or court of law which are not medically necessary.

• Services that are experimental, investigational or for research purposes.

• Services that are determined by the Plan not to be medically necessary for diagnosis and treatment of a bodily injury or illness.

• Services and supplies which relate to any condition sustained as a result of engagement in an illegal occupation, the commission or attempted commission of an assault or other illegal act, a civil revolution or riot, duty as a member of the armed forces of any state or country, or a war or act of war which is declared or undeclared.

• Services for which no charge is made, or you would not be required to pay, or for charges which would not have been made in absence of this coverage.

• Services and supplies received by a qualified member under the Oregon Death with Dignity Act.

• Payment or expense coverage is provided under a motor vehicle insurance policy, as required by Oregon state mandated minimum personal injury protection (PIP) limits.

• Services and supplies provided for any bodily injury or illness that is sustained by an eligible employee or family member that arises out of, or as the result of, any work for wage or profit when coverage under any Workers' Compensation Act or similar law is required for the eligible employee or family member. This exclusion does not apply to Plan members who are exempt under any Workers’ Compensation Act or similar law.

• Charges in excess of the usual, customary and reasonable (UCR) charge as defined by the Plan Supervisor.

• Charges for any injury to a participant sustained while driving a vehicle that is involved in an accident where the participant is found guilty of Driving While Intoxicated (under the influence of alcohol or illegal drugs).

• Charges in connection with any injury or illness arising out of or in the course of any employment for wage or profit; or related to professional or semi-professional athletics, including practice.

• Pre-existing conditions. Coverage will be provided for covered services and supplies for pre-existing conditions after the pre-existing condition exclusion period ends.

• Medical facility services performed in a facility other than as defined herein.

• Charges for any illegal treatment or treatment listed by the American Medical Association (AMA) as having no medical value.

Exclusions that apply to provider services:

• Services of licensed acupuncturists, a physician performing acupuncture services, naturopathic physicians and chiropractic physicians, except as provided in the Alternative Care Benefits and the Chiropractic Benefits.

• Services of professional private duty nurses, homeopaths, faith healers, or lay midwives.

• Wage or shift differentials or charges for supervision of home health providers.

Exclusions that apply to reproductive services:

• Sexual disorders or dysfunctions regardless of gender, including, but not limited to, services, surgery, prescription drugs; and services, supplies and medications related to preparation for sex change operations and medical or psychological counseling or hormonal therapy in preparation for, or subsequent to, any such procedure.

• Termination of pregnancy, unless there is a severe threat to the mother, or if the life of the fetus cannot be sustained.

• Reversal of voluntary sterilization.

• Condoms.

• All services for non-member surrogate mothers.

• All services associated with surrogate parenting, including infertility testing and treatment.

• Services for pregnancy or complications of pregnancy for dependent children.

• Home births and all related services.

• Services provided in a premenstrual syndrome clinic or holistic medicine clinic.

• All infertility services except for diagnostic testing and associated office visits to determine the cause of infertility.

• Charges associated with impotency, infertility, and procedures to restore fertility or to induce pregnancy, including but not limited to: corrective or reconstructive surgery; hormone injections; in-vitro fertilization; artificial insemination, gamma intra-fallopian transfer (G.I.F.T); fertility drugs (such as Clomid, Pergonal or Serophene); or any other artificial means of conception; and penile implants.

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Exclusions that apply to vision services:

• Surgical procedures which alter the refractive character of the eye, including, but not limited to laser eye surgery, radial keratotomy, myopic keratomelelusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia, hyperopia or astigmatism.

• Services for routine eye and vision care, routine vision exams, refractive disorders, except as stated under "Children’s Vision and Hearing Screenings".

• Eyeglass frames and lenses, contact lenses and other routine vision supplies, except as stated under "Initial and Replacement Contact Lenses, Intraocular Lenses, Prescription Lenses or Standard Frame Glasses".

• Orthoptics and vision training.

Exclusions that apply to dental services:

• Oral surgery (non-dental or dental) or other dental services (all procedures involving the teeth; wisdom teeth; areas surrounding the teeth), except as approved by the Plan and described under "Treatment of Specified Dental Services and Restoration of Head and Facial Structures".

• Services for temporomandibular joint syndrome (TMJ) and orthognathic surgery, except as approved by the Plan and described under "Non-surgical Temporomandibular Joint (TMJ) Service".

• Dentures and orthodontia.

• Upper or lower jaw augmentation or reduction procedures (orthognathic surgery), except in the case of a participant covered continuously under this Plan from birth or from the date of placement for adoption.

Exclusions that apply to foot care services:

• Routine foot care, such as removal of corns and calluses, trimming of nails, routine hygienic care, and other symptomatic complaints of the feet, except for diabetes.

• Services for insoles, arch supports, heel wedges, lifts and orthopedic shoes. Covered Services for orthotics are described under "Orthotics".

Exclusions that apply to mental health and chemical dependency:

• Conditions that are not responsive to therapeutic management after a diagnosis is made by a physician who has treated or examined the patient, except when the treatment or services provided are effective in maintaining existing functionality or preventing a decline in functionality.

• Conditions other than mental disorders specified in the current edition of the Diagnostic and Statistical Manual of Disorders (DSM).

• Services provided under a court order or as a condition of parole, probation or instead of incarceration.

• Services related to marriage counseling, personal growth services such as assertiveness training or consciousness raising, mental retardation and learning disabilities.

• Any mental health service or supply related to the condition of autism or Asperger disorder.

• Counseling related to family, marriage, sex and career, in the absence of illness.

• Vocational, pastoral or spiritual counseling.

• Dance, poetry, music or art therapy, except as part of a treatment program in an inpatient setting.

• Non-organic therapies including, but not limited to, bioenergetics therapy, confrontation therapy, crystal healing therapy, educational remediation, EMDR, guided imagery, marathon therapy, primal therapy, rolfing, sensitivity training, training psychoanalysis, transcendental mediation, and Z therapy.

• Organic therapies including, but not limited to, aversion therapy, carbon dioxide therapy, environmental ecological treatment or remedies, herbal therapies, hemodialysis for schizophrenia, vitamin or orthomolecular therapy, narcotherapy with LSD, and sedative action electrostimulation therapy.

• Treatments which do not meet the national standards for mental health professional practice.

Exclusions that apply to miscellaneous services and items:

• Custodial care, sanitarian or rest cures.

• Transplants, including transplant services or supplies received during the first 12 consecutive months of an Enrollee’s coverage under this Plan, except as described under "Human organ/tissue Transplants".

• Services for durable medical equipment (DME), medical supplies/devices and prosthetic devices except as described under "Medical and Diabetes Supplies, Durable Medical Equipment, Appliances, Prosthetic Device,".

• Any drug, medicine, or device that does not have the United States Food and Drug Administration formal market approval through a New Drug Application or Pre-market Approval.

• Charges for services that are primarily and customarily used for a non-medical purpose or used for environmental control or enhancement (whether or not prescribed by a physician) including, but not limited to, air conditioners, air purifiers, vacuum cleaners, motorized transportation equipment, escalators, elevators, tanning beds, ramps, waterbeds, hypoallergenic mattresses, cervical pillows, swimming pools, whirlpools, spas, exercise equipment, gravity lumbar reduction chairs, home blood pressure kits, personal computers and related equipment or other similar items or equipment.

• Expenses for preparing medical reports, itemized bills or claim forms.

• Mailing and/or shipping and handling expenses.

• Biofeedback and Milieu therapies.

• Hospital take home prescriptions.

• Treatment for anorexia nervosa, bulimia, or other eating disorders.

• Diagnosis of and treatment for sleep disorders except when prior-authorized by the Plan Supervisor.

• Salabrasion, chemosurgery or other such skin abrasion procedures associated with the removal of scars or tattoos, or in the treatment of acne.

• Physical therapy and rehabilitation services, including exercise programs, Rolfing, polarity therapy and similar therapies, and growth and cognitive therapies, except as described under "Inpatient Rehabilitation Care,", and "Outpatient Rehabilitative Services".

• "Telephone visits" by a physician or "environment intervention" or "consultation" by telephone for which a charge is made to the patient. "Get acquainted" visits without physical assessment or diagnostic or therapeutic intervention provided and treatment sessions by computer Internet service.

• Missed or cancelled appointments.

• Non-emergency medical transportation.

• Therapy and testing for treatment of allergies including, but not limited to, services related to clinical ecology, environmental allergy and allergic immune system dysregulation and sublingual antigen(s), extracts, neutralization tests and/or treatment UNLESS such therapy or testing is approved by the American Academy of Allergy and Immunology or the Department of Health and Human Services or any of its offices or agencies.

• All services and supplies related to the treatment of obesity as a primary or secondary (co-morbid) condition, except as stated as covered in the bullet below and under "Weight Management".

• Services for dietary therapy including medically supervised formula weight-loss programs or unsupervised self-managed programs. Over-the-counter weight loss formulas are not covered; however, a Member may be referred from a qualified provider for two visits per calendar year for nutritional counseling, see "Weight Management,".

• Communication charges and lodging accommodations.

• Transportation or travel time, except as described under "Travel Benefits – Ketchikan General Hospital Employees Only", and with the Plan’s prior authorization.

• Charges for health clubs or health spas, aerobic and strength conditioning, work-hardening programs, and all related material and products for these programs.

• Medications, drugs or hormones to stimulate growth, except for children through age 18 when diagnosis of growth hormone deficiency is laboratory confirmed, and for adults only when they are being treated for pituitary destruction. Covered services are limited and subject to prior authorization and may be accessed through the prescription drug benefit or through your provider.

• Massage therapy.

• Light therapy for seasonal affective disorder, including equipment.

• Hearing aids, including all services related to the examination and fitting of the hearing aids. Routine hearing exams, except as stated under "Children’s Vision and Hearing Screenings".

• Any vitamins, dietary supplements, and other non-prescription supplements, except when prescribed as part of a nutrition therapy plan for the treatment of diabetes.

• Services and supplies in connection with the diagnosis and treatment of learning disabilities.

• Services for the treatment of developmental delay.

• Services for genetic testing in the absence of disease.

• Services to modify the use of tobacco and nicotine, except as described in the wellness program materials included in your member material packet.

• Services for cosmetic services including supplies, drugs and breast implants, except as approved by the Plan and described under "Cosmetic/reconstructive Surgery" .

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• Services for routine physical examinations for insurance, employment, licensing purposes, or solely for the purpose of participating in camps, sports activities, recreation programs, college entrance or for the purpose of traveling or obtaining a passport for foreign travel.

• Services for immunizations or vaccinations for employment, licensing, passports, travel purposes, and high risk occupations.

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Benefits From Other Sources

Third Party Liability (Subrogation)

Sometimes, a third party pays for a member’s medical expenses because the member was injured by them. For example, if you are hurt in a store and the owner was at fault for your injury, the owner or owner’s insurance may be responsible for your medical care and services related to your injury.

In these types of situations, your PeaceHealth Plan coverage is secondary. We need detailed information from you whenever you use your Plan benefits because of:

• a workplace accident, injury or illness;

• an injury or illness that may result in a lawsuit, or for which you expect to receive a settlement;

• a motor vehicle accident.

Recovering money from a third party

The Plan and HMA may recover money from a third party, usually an insurance carrier, who may be responsible for paying for your treatment for an illness or injury. PeaceHealth Plan may sue in your name, if necessary.

By accepting membership in PeaceHealth Plan, you make an agreement with us – if you receive a settlement for an illness or injury, you must pay us back for the cost of your treatment.

Example: You are injured while on a weekend visit to a coastal resort. You sue, and are awarded $7,500 plus attorney’s fees. Meanwhile, your PeaceHealth Plan has paid a total of $6,000 for treatment of your injury, so you must reimburse us for $6,000 out of your settlement.

Before you accept any settlement, you must let us know the terms, and tell the third party that we have an interest in the settlement. If you have medical bills after your receive a settlement, we will not pay those bills until your settlement is exhausted.

Notification  

If you are using your PeaceHealth Plan benefits for an illness or injury you think may be the responsibility of another party, notify us in writing as soon as possible. In addition, if we identify a claim that may be the responsibility of a third party, we will ask you for more information about how you were injured, and what you are doing to determine the legal liability of the third party who may be at fault.

We also will ask you to agree in writing to the following:

• Repay us for medical expenses that we paid related to your subrogated situation to the extent that the law allows.

• Include our claims paid for you in any claim you make against the party who injured you.

• Prorate any attorney fees that you spent in your recovery related to our repayment.

This Agreement requires that you cooperate with us so that we can recover the amount due to us by law.

Motor vehicle coverage

Oregon law requires motor vehicle liability policies to provide primary medical payment insurance. When coverage is available from motor vehicle liability insurance, the Plan will be entitled to recover the cost of services provided. Also, we will cover the cost of services in excess of those covered by the motor vehicle insurance per Plan guidelines. PeaceHealth Plan’s right to recover the amounts it pays is described above.

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The Plan’s right to receive and release necessary information

The Plan may, with your written consent, release to, or obtain from any other insurer, organization or person, any necessary information we need to administer third party liability. To claim benefits from PeaceHealth Plan, you will need to give us the necessary information for this purpose.

Coordination of Benefits

Sometimes you or your covered dependents are eligible for benefits under another medical insurance plan. If so, benefits for PeaceHealth Plan covered services will be coordinated with those from the other insurance plan. Your PeaceHealth Plan also coordinates benefits with Medicare. This is called coordination of benefits (COB).

Definitions

The term "allowable expense" shall mean the usual, customary and reasonable (UCR) expense, at least a portion of which is paid under at least one of any multiple plans covering the participant for whom the claim is made. In no event will more than 100% of total allowable expenses be paid between all plans, nor will total payment by this Plan exceed the amount which this Plan would have paid as primary Plan.

Coordination of Benefits does not apply to prescription drug card programs.

The term "order of benefits determination" shall mean the method for ascertaining the order in which the Plan renders payment. The principle applies when another plan has a Coordination of Benefits provision.

Application

Under the order of benefits determination method, the plan that is obligated to pay its benefits first is known as the primary Plan. The plan that is obligated to pay additional benefits for allowable expenses not paid by the primary Plan is known as the secondary Plan. If your other plan does not contain a Coordination of Benefits provision, that plan shall be primary to this Plan. Where your plan contains a Coordination of Benefits provision, the rules below, applied in the order in which they appear, will establish the responsibility for payment.

1. This Plan will pay secondary to any individual policy.

2. If this Plan is covering the participant as a Continuation of Coverage participant, this Plan is always secondary to the participant’s other plan.

3. The plan covering the patient as an employee shall be deemed the primary plan and is obligated to pay before the plan covering the patient as a dependent.

4. When a child is covered under the plans of both parents, and the parents are not separated or divorced, the following rule applies: The plan of the parent whose birthday occurs earlier in the calendar year shall be deemed to be primary over the plan of the parent whose birthday occurs later in the calendar year. A parent's year of birth is not relevant in applying this rule. If the birthday anniversaries are identical, the plan which has been in force the longer period of time shall be deemed to be primary.

If either plan is lawfully issued in another State or in this State and does not have the coordination of benefits procedure regarding dependents based on birthday anniversaries as provided herein, and as a result each plan determines its benefits after the other, the Coordination of Benefits procedure set forth in the plan which does not have the Coordination of Benefits procedure based on birthday anniversaries shall be used instead.

When a child is covered under the plans of both parents, and the parents are separated or divorced, the following order will establish responsibility for payment. If this order of benefit determination is not recognized by the plan being coordinated with, order will be determined at the option of the Plan Supervisor on a case-by-case basis.

1. If a court decree has determined financial responsibility for a child's health care expenses, the plan of the parent having that responsibility pays first.

2. The plan of the parent with custody of the child pays before the plan of the other parent or the plan of any stepparent.

3. The plan of the stepparent married to the parent with custody of the child pays before the plan of the parent not having custody.

5. Where the order of payment cannot be determined in accordance with (1), (2), (3) or (4) above, the primary Plan shall be deemed to be the plan which has covered the patient for the longer period of time.

6. Where the order of payment cannot be determined in accordance with (1), (2), (3), (4), or (5) above, the primary Plan shall be deemed to be the plan which has covered the employee for the longest time.

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Examples

Below are a few examples of how COB works:

PRIMARY PLAN		PeaceHealth is    SECONDARY PLAN
Claims Amount	$5,000	Claims Amount	$5,000
Less Deductible	100	Less Deductible	1,000
Adjusted Total	4,900	Adjusted Total	4,000
Paid at 50%	2,450	Paid at 90%	3,600
Plan pays	$2,450	Less Primary Insurance	2,450
		Plan Pays	$1,150
PRIMARY PLAN		SECONDARY PLAN
Claims Amount	$5,000	Claims Amount	$5,000
Less Deductible	100	Less Deductible	1,000
Adjusted Total	4,900	Adjusted Total	4,000
Paid at 50%	2,450	Paid at 60%	2,400
Plan pays	$2,450	Less Primary Insurance	2,400
		Play Pays	$ 0

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Eligibility And Enrollment Provisions

Eligibility 

Employee Eligibility

Employees eligible for coverage under this Plan are:

All employees in the Corporate Center, Whatcom Region, and Lower Columbia Region of PeaceHealth who are regularly scheduled to work 20 hours or more per week; and

All employees in the Alaska Region of PeaceHealth who are regularly scheduled to work 24 hours or more per week.

Ineligible classes of employees, regardless of the number of hours worked, are: (1) temporary employees, (2) individuals providing services to the Employer under contracts that designate the individuals as independent contractors regardless of whether such individuals are treated as employees for federal withholding and employment tax purposes, and (3) leased employees.

Dependent Eligibility

Dependents eligible for coverage under this Plan are:

• An eligible employee’s legally married spouse. Coverage may continue during a legal separation only if ordered by a court decree, or if elected under the Continuation of Coverage provisions of this Plan.

• An eligible employee’s unmarried dependent child(ren) under age 23.

• An eligible employee’s unmarried dependent child(ren) who is incapable of self-support because of mental retardation, mental illness, or physical incapacity that began prior to the date on which the child's eligibility would have terminated due to age. Proof of incapacity must be received within 120 days after the date on which the maximum age is attained. Subsequent evidence of disability or dependency may be required as often as is reasonably needed to verify continued eligibility for benefits.

• An eligible employee’s unmarried dependent child(ren) whose coverage is required pursuant to a valid court or administrative order.

• Adopted children are eligible under the same terms and conditions that apply to dependent, natural children of parents covered under this Plan.

• Any individual who is covered as an eligible employee can also be covered as a dependent. Dependents can be covered as a dependent of more than one employee.

The term "dependent children" means any of the employee’s natural children, legally adopted children, or children who have been placed for adoption with the employee prior to the age of 18, or step-children who depend on the employee for support, or children who have been placed under the legal guardianship of the employee or the employee’s spouse by a court decree or placement by a State agency. Placement for adoption is defined as the assumption and retention of an obligation for total or partial support of a child in anticipation of adoption irrespective of whether the adoption has become final. The child's eligibility terminates upon termination of the legal obligation.

A dependent is defined as an individual who is: (1) listed on the employee's application for coverage as a dependent of the employee; (2) eligible for dependent coverage (based on the criteria above); (3) whose application has been accepted by the Plan Supervisor; and (4) for whom the applicable rate of coverage has been paid.

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Enrollment

Regular Enrollment

To apply for coverage under this Plan, the employee must complete and submit an on- line enrollment form within 31 days of the date the individual first becomes eligible for coverage. The completed on-line enrollment form should list all eligible dependents to be covered. Individuals not enrolled during the enrollment eligibility period will be enrolled in the medical plan as specified by PeaceHealth. Individuals will be required to wait until the next open enrollment period to make changes, unless they are eligible to enroll as a result of a qualifying event.

When the employee acquires an eligible dependent (through birth, marriage, adoption etc.), the dependents must be enrolled within the enrollment eligibility periods specified below:

Newly acquired dependent: A newly acquired dependent (except a newborn child or a child placed for adoption) must be enrolled within 30 days of the date of acquisition.

Newborn: A newborn child may be covered from birth provided the child is enrolled within 60 days of the date of birth.

Adopted Child: A child placed for adoption may be covered from the date of placement provided the child is enrolled within 60 days of the date of placement.

Special Enrollment for Loss of Other Coverage

A special enrollment period is available for employees and their dependents who lose coverage under another group health plan or had other health insurance coverage if the following conditions are met:

• The employee or dependent is eligible for coverage under the terms of the Plan, but not enrolled.

• Enrollment in the Plan was previously offered to the employee.

• The employee declined coverage under the Plan because, at the time, the employee and/or dependent were covered by another group health plan or other health insurance coverage.

• The employee has declared in writing that the reason for the declination was the other coverage.

The employee or dependent may request the special enrollment within 30 days of loss of other health coverage under the following circumstances.

• If the other group coverage is not COBRA continuation coverage, special enrollment can only be requested after losing eligibility for the other coverage due to a COBRA qualifying event or after cessation of Employer contributions for the other coverage. Loss of eligibility of other coverage does not include a loss due to failure to pay premiums on a timely basis. COBRA continuation does not have to be elected in order to preserve the right to a special enrollment.

• If the other group coverage is COBRA continuation coverage, the special enrollment can only be requested after exhausting COBRA continuation coverage.

The effective date of coverage under the Plan will be the first of the month following the date the employee dates the on-line enrollment.

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Special Enrollment for New Dependents

A special enrollment period is available for employees who acquire a new dependent by birth, marriage, adoption, or placement for adoption. This special enrollment applies to the following events:

• When an employee marries, a special enrollment period is available for the employee and newly acquired dependents. As long as the proper enrollment material is received by PeaceHealth within 30 days after the marriage, the effective date of coverage will the first of the month following the wedding date.

• When an employee or spouse acquires a child through birth, adoption or placement for adoption, a special enrollment period is available for the employee, the spouse and the newly acquired dependents. As long as the proper enrollment material is received by the PeaceHealth within 60 days after the date of birth, adoption or placement of adoption, the effective date of coverage will be the date of the birth, adoption or placement of adoption.

Open Enrollment

An open enrollment period is held once every 12 months to allow eligible employees to change their participation. The open enrollment period will be held during the last quarter of the year.

The pre-existing condition exclusion period for newly enrolled participants will start on the date the Plan coverage becomes effective. Refer to the "Pre-Existing Condition Exclusion" provision of this Plan for further details.

Effective Date Of Coverage

Employee Effective Date

The effective date of coverage for eligible employees is the first of the month following the waiting period.

Coverage Waiting Period:

Corporate Center Employees, Lower Columbia Region Physicians, Southeast Alaska Region Physicians, and Southeast Alaska Region Management: Coverage begins for eligible employees on the first of the month following the date they become benefit eligible.

Lower Columbia Region Non-Physicians, Whatcom Region Employees and Southeast Alaska Region Non-Management: The waiting period is 90 days (from the date they become benefit eligible). Coverage begins for eligible employees on the earlier of: (1) the first of the month coinciding with the end of the 90 day wait; or (2) the first of the month following the end of the 90 day wait; or (3) the first of the month following the date the employee becomes eligible, provided the employee has been employed 90 days or more.

Past Service Credit policy:

If an employee was working for an organization that is acquired or if working for an organization which has a formal contract, the pre-existing condition exclusion is waived if the employee’s prior service was sufficient to satisfy the Plan requirements.

Dependent Effective Date

If the employee elects coverage for dependents during the first 31 days of eligibility, the dependents’ effective date will be the same as the employee’s effective date.

If the covered employee marries, the employee must add the newly acquired dependents within 30 days of the date of marriage and the effective date of coverage is the date of marriage.

If the covered employee acquires a child through birth, adoption or placement for adoption, the employee must add the child within 60 days of the date of birth, adoption or placement for adoption and the effective date of coverage for the child is the date of birth, adoption or placement for adoption.

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Termination Of Coverage

Except as provided in the Plan's Continuation of Coverage provisions, coverage will terminate on the earliest of the following occurrences:

Employee

• The date the Employer terminates the Plan and offers no other group health plan.

• The last day of the month in which the employee ceases to meet the eligibility requirements of the Plan.

• The last day of the month in which the employee's employment ends.

• The last day of the month in which the employee begins active service in the armed forces.

• The day the employee fails to make any required contribution when coverage is contributory.

• The last day of the month an employee fails to return to work following an approved leave of absence.

• The last day of the month in which the employee retires.

Dependent(s)

• The date the Employer terminates the Plan and offers no other group health plan.

• The last day of the month in which the employee's coverage terminates.

• The last day of the month in which such individual ceases to meet the eligibility requirements of the Plan.

• The last day of the month in which contributions have been made on their behalf.

• The last day of the month in which the dependent becomes an active, full-time member of the armed forces of any country.

• The last day of the month in which the dependent coverage is discontinued under the Plan.

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Approved Family And Medical Leave

If an employee is absent from work because of an approved leave of absence under the provisions of the Family and Medical Leave Act of 1993, coverage under the Plan shall be continued for the employee and covered dependents for up to twelve weeks during any twelve month period, provided the employee continues to pay the same share of the cost of coverage that he or she would pay when not on leave. PeaceHealth will let employees know how and when their contributions must be paid. The Employer may require employees who fail to return from Family and Medical Leave to repay any health plan premiums paid on their behalf during that leave. If the employee’s leave extends more than 12 weeks, the employee will be eligible to continue coverage under the Plan’s Continuation of Coverage provision.

Please contact the Participating Group’s Human Resources Department for information on how to qualify for a Family/Medical Leave of Absence.

Military Leave Of Absence

Employees going into or returning from military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act of 1994. These rights apply only to eligible employees and eligible dependents covered under the Plan before leaving for military service.

The maximum period of coverage of a person under such an election shall be the lesser of:

1. The 18 month period beginning on the date that Uniformed Service leave commences; or

2. The period beginning on the date that Uniformed Service leave commences and ending on the day after the date on which the person was required to apply for or return to a position of employment and fails to do so.

A person who elects to continue Plan coverage may be required to pay up to 102% of the full contribution under the Plan, except a person on active duty for 30 days or less cannot be required to pay more than the employee’s share, if any, for the coverage.

A preexisting condition exclusion may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated because of service. However, Plan exclusions and waiting periods may be imposed for any sickness or injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, military service.

Reinstatement Of Coverage

If an employee or dependent who was covered under this Plan terminates employment or loses eligibility for coverage and is rehired or again becomes eligible for coverage, all waiting periods, deductibles and out-of-pockets must be re-satisfied, unless the employee or dependent is continually covered under the Continuation of Coverage provision of this Plan.

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Continuation of Coverage

Introduction

This provision contains important information about your rights to Continuation Coverage, which is a temporary extension of coverage under the Plan available to you when you lose coverage by reason of certain stipulated events (Qualifying Event).  Because your Plan is sponsored by a church organization, it is not required by law to offer Continuation Coverage.  However, PeaceHealth voluntarily provides a form of Continuation Coverage which for the most part is consistent with federal law.  However, PeaceHealth is not undertaking to provide Continuation Coverage which is identical in all respects with federal law.

In general, if a “qualified beneficiary” (generally you, your spouse or dependent) covered under the Plan experiences a “qualifying event” (generally a loss of coverage due to a specified event), the qualified beneficiary may elect to continue health coverage under the Plan for a period of time.

Coverage must be elected on the election form provided by PeaceHealth.  You, your spouse and dependents should take time to carefully read the Continuation Coverage provisions.

If you have questions, contact PeaceHealth Human Resources.  

Continuation Coverage

Continuation Coverage is continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.”  Specific qualifying events are listed later in this notice.  Continuation Coverage is offered to each person who is a “qualified beneficiary.”  A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event.  Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries.  Under the Plan, qualified beneficiaries who elect Continuation Coverage must pay for Continuation Coverage. 

In order to be a qualified beneficiary, you, your spouse or dependent must be covered under the Plan on the day before the event that causes a loss of coverage.  In addition, if a child is born to you or placed for adoption with you during a period of Continuation Coverage, you may cover that child if you give proper notification within the time required.

If at the time you would otherwise become eligible for Continuation Coverage, you and/or your covered dependents (spouse, children, etc.) are covered by another health plan or by Medicare and you and/or your covered dependents are not subject to any exclusion or limitation for a preexisting condition, then you and/or they will not be eligible to elect Continuation Coverage under this Plan.  So, by way of example, if at the time you terminate employment you are covered as a dependent under your spouse’s group health plan, you are not eligible for Continuation Coverage.

If you are an employee, you will become a qualified beneficiary if you lose coverage under the Plan because either of the following qualifying events happens:

1. Your hours of employment are reduced, or
2. Your employment ends for any reason other than gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens:

1. Your spouse dies;
2. Your spouse’s hours of employment are reduced;
3. Your spouse’s employment ends for any reason other than his or her gross misconduct;
4. Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or
5. You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens:

1. The parent (employee) dies;
2. The parent’s (employee’s) hours of employment are reduced;
3. The parent’s (employee’s) employment ends for any reason other than his or her gross misconduct;
4. The parent (employee) becomes enrolled in Medicare (Part A, Part B, or both);
5. The parent (employee) becomes divorced or legally separated from their spouse; or
6. The child ceases to be eligible for coverage under the Plan as a “dependent child.”

Notices and Election

If you lose coverage under the Plan as a result of one of the events listed above, then you may be entitled to elect Continuation Coverage.  You must give notice to PeaceHealth Human Resources of the occurrence of the event which causes the loss of coverage within 30 days.

If you or a family member fail to notify PeaceHealth during the 30 day notice period, any family member who loses coverage will NOT be offered the option to elect Continuation Coverage.  Further, if you or a family member fail to notify PeaceHealth and, contrary to Plan terms, any claims are paid for expenses incurred after the last day of the month of the divorce, legal separation, or a child losing dependent status, then you and your family members will be required to reimburse the Plan for any claims so paid.

Once PeaceHealth receives notice that a qualifying event has occurred, Continuation Coverage will be offered to each of the qualified beneficiaries.  For each qualified beneficiary who elects Continuation Coverage, Continuation Coverage will begin on the date that Plan coverage would otherwise have been lost.

You (the employee) or your family member must elect Continuation Coverage within 60 days after Plan coverage ends, or if later, 60 days after PeaceHealth sends you or your family member notice of the right to elect Continuation Coverage.  If you or your family member do not elect Continuation Coverage within this 60-day election period, you will lose your right to elect Continuation Coverage.

A covered employee or covered spouse of the covered employee may elect Continuation Coverage for all family members who were covered under the Plan on the day before the qualifying event.   The covered employee, and his or her covered spouse and covered dependent children, however, each have an independent right to elect Continuation Coverage.  Thus a covered spouse or dependent child may elect Continuation Coverage even if the covered employee does not elect it.

Type of Coverage & Premium Payments

If Continuation Coverage is elected, your coverage will be identical to the coverage provided under the Plan to similarly situated employees or family members.  If the coverage for similarly situated employees or family members is modified, Continuation Coverage will be modified the same way.

You (the employee) or a family member must pay the premium payments for the “initial premium months” by the 45th day after electing Continuation Coverage.  The initial premium months are the months that end on or before the 45th day after the date of the Continuation Coverage election.  All other premiums are due on the 1st of the month for which the premium is paid, subject to a 30-day grace period.  If the premium payments are not received within the 30-day grace period, your eligibility to continue Continuation Coverage will terminate.

Maximum Coverage Periods

1.  18 Months.  If you (employee, spouse or dependent child) lose group health coverage because of the employee’s termination of employment (for reasons other than gross misconduct), reduction in hours, retirement or leave of absence, the maximum Continuation Coverage period (for the employee, spouse and dependent child) is 18 months from the date of termination or reduction in hours.  There are three exceptions:

·    If an employee or family member is disabled at any time during the first 60 days of Continuation Coverage (running from the date of termination of employment or reduction in hours), the continuation of coverage period for all qualified beneficiaries under the qualifying event is 29 months from the date of termination or reduction in hours.  The Social Security Administration must formally determine under Title II (Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security Income) of the Social Security Act that the disability exists and when it began.  For the 29-month Continuation Coverage period to apply, notice of the determination of disability under the Social Security Act must be provided by the disabled individual to PeaceHealth within the 18-month coverage period and within 60 days after the date of the disability determination.

·    If a second qualifying event occurs (for example, the employee dies or becomes divorced) within the 18-month or 29-month coverage period, the maximum coverage period becomes 36 months from the date of the initial termination or reduction in hours.

·    If the qualifying event occurs within 18 months after the employee becomes entitled to Medicare, the maximum coverage period (for the spouse and dependent child) ends 36 months from the date the employee became entitled to Medicare.

2.  36 Months.  If you (spouse or dependent child) lose group health coverage because of the employee’s death, divorce, legal separation, or the employee’s becoming entitled to Medicare, or because you lose your status as a dependent under the Plan, the maximum coverage period (for spouse and dependent child) is 36 months from the date of the qualifying event.

Special Circumstances

Newborn Children of, or Children Placed for Adoption with, the Covered Employee after the Qualifying Event

If, during the period of Continuation Coverage, a child is born to the covered employee or is placed for adoption with the covered employee, the child is considered a qualified beneficiary.  The covered employee or other guardian may elect Continuation Coverage for the child, provided the child satisfies the otherwise applicable plan eligibility requirements (for example, age).  The covered employee or a family member must notify PeaceHealth within 60 days of the birth or placement to enroll the child on Continuation Coverage.  (The 60-day period is the Plan’s normal enrollment window for newborn or adopted children.)  If the covered employee or family member fails to so notify PeaceHealth in a timely fashion, the covered employee will NOT be offered the option to elect Continuation Coverage for the newborn or adopted child.

Termination Before the End of Maximum Coverage Period

Continuation Coverage of the employee, spouse or dependent child will automatically terminate (even before the end of the maximum coverage period) when any one of the following five events occurs:

1.  PeaceHealth no longer provides group health coverage to any of its employees;

2.  The premium for Continuation Coverage is not timely paid;

3.  You (employee, spouse or dependent child) become covered under another group health plan (as an employee or otherwise) that has no exclusion or limitation with respect to any preexisting condition that you have.  If the other plan has applicable exclusions or limitations, your Continuation Coverage will terminate after that exclusion or limitation no longer applies (for example, after a 12-month preexisting condition waiting period expires).  If you have elected Continuation Coverage, you have a duty to notify PeaceHealth within 30 days after the date you or your covered spouse or dependent becomes covered under another group health plan.

4.  You (employee, spouse or dependent child) became entitled to Medicare benefits (applies only to the person who becomes entitled to Medicare);

5.  If you (employee, spouse or dependent child) became entitled to a 29-month maximum coverage period due to disability of a qualified beneficiary, but then there is a final determination under Title II or XVI of the Social Security Act that the qualified beneficiary is no longer disabled (however, Continuation Coverage will not end until the month that begins more than 30 days after the determination).

Other Information

If You Have Questions

If you (the employee) or a family member have questions about your Continuation Coverage, you should contact your regional Human Resources department. 

Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep PeaceHealth informed of any changes in the addresses of family members.  You should keep a copy of this notice and any notices you send to PeaceHealth for your records.

General Procedures

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Pre-Existing Conditions Exclusions

Introduction

Pre-authorization from the UR Coordinator does not constitute Plan liability for any pre-existing condition charges during the pre-existing exclusion period.

If a claim is paid that was related to a pre-existing condition, the payment will not constitute a waiver of this exclusion for that claim or any subsequent claim if it is later determined that the condition was pre-existing.

When this Plan replaces another group health coverage program previously held by the Employer, the waiting periods will be credited for the time those employees and their eligible dependents were enrolled under the prior coverage.

Pre-Existing Conditions

A pre-existing condition, whether physical or mental, and regardless of the cause of the condition, is a condition for which medical advice, diagnosis, care, or treatment has been recommended or received within the three month period ending on the enrollment date. In order to be taken into account, the medical advice, diagnosis, care or treatment must have been recommended or received from an individual licensed or similarly authorized to provide such services under State law and who operates within the scope of practice authorized by the State law.

Pre-Existing Condition Exclusion

This Plan does not cover pre-existing conditions during the pre-existing exclusion period. The pre-existing exclusion period commences on the participant’s enrollment date in the Plan and lasts for six months, less any period of creditable coverage.

The pre-existing conditions exclusion does not apply to pregnancy or genetic information.

The length of the pre-existing conditions exclusion is reduced if an eligible person has Creditable Coverage from another health plan as of the enrollment date. That is, so long as the person did not have a Significant Break in Coverage, then one day from this Plan’s pre-existing condition exclusion period will be subtracted for each day of Creditable Coverage from the other health plan. All other Plan terms and limits still apply.

An eligible person will need to request a certificate of Creditable Coverage from his or her prior plan. The Plan Administrator will assist any eligible person in obtaining a certificate of Creditable Coverage from a prior plan if you are experiencing difficulty in obtaining a certificate. If, after Creditable Coverage has been taken into account, there will still be a pre-existing condition exclusion under this Plan imposed on an individual, that individual will be so notified by HMA.

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Newborns And Adopted Children

If a newborn child of a covered employee, a child under the age of 18 years of age who is placed for adoption with the covered employee, or a child who is actually adopted by a covered employee, is enrolled in the Plan within 60 days of birth, placement for adoption, or the date of actual adoption, the pre-existing conditions exclusion period of the Plan will not apply. If the child was continuously covered under another Plan from birth, placement for adoption, or actual adoption prior to being covered under this Plan and such child becomes covered under this Plan without a break in coverage of 63 days or more, the pre-existing conditions exclusion period of the Plan will not apply.

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Member Rights and Responsibilities

As a member of our health plan, you should know what to expect from us, as well as what we ask from you. Nobody knows more about your health than you and your doctor. We take responsibility for providing the very best health care services and benefits possible; your responsibility is to know how to use them well. Please take time to read and understand your benefits. We want you to have a positive experience with PeaceHealth Plan, and we’re ready to help in any way.

Members Have The Right To:

• Be cared for by people who respect your privacy and dignity.

• Be informed about the Plan, our providers, and the benefits and services you have available to you as a member.

• Receive information that helps you select a participating physician or provider whom you trust and with whom you feel comfortable.

• A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.

• Receive information and clinical guidelines from your health care provider or your health plan that will enable you to make thoughtful decisions about your health care.

• Actively participate in decisions that relate to your health and your medical care through discussions with your health care provider or through written advance directives.

• Have access to medical services that are appropriate for your needs.

• Express a concern and receive a timely response from the Plan.

• Have your claims paid accurately and promptly.

• Request a review of any service not approved, and to receive prompt information regarding the outcome.

• Make recommendations regarding the member rights and responsibilities policy.

• Refuse care from specific providers.

You Have The Responsibility To:

• Read and understand the information you receive about the Plan, and call Customer Service if you have questions.

• Talk openly with your physician or provider and work toward a relationship built on mutual trust and cooperation.

• Follow the treatment plan that you and your practitioner have agreed upon.

• Provide to the extent possible medical information your physicians or providers request from you.

• Do your part to prevent disease and injury. Try to make positive, healthful choices. If you do become ill or injured, seek appropriate medical care promptly.

• Treat your physicians or providers courteously.

• Make your required copayment at the time of service.

• Show your member identification card whenever you receive medical services.

• Let us know if you have concerns, or if you feel that any of your rights are being compromised, so that we can act on your behalf.

• Call or write within 60 days of service if you wish to request a review of services provided or appeal a Plan decision.

• Notify Customer Service if your address changes.

The Plan Has The Responsibility To:

• Respect and honor your rights.

• Ensure timely access to appropriate health care services.

• Enable you to see physicians or providers who meet your needs.

• Develop a variety of benefits to serve you well.

• Assure the ongoing quality of our providers and services.

• Contract with providers who are capable, competent, and committed to excellence.

• Make it easy and convenient for you to appeal any policy or decision that you believe prevents you from receiving appropriate care.

• Provide you with accurate up-to-date information about the Plan and Preferred Providers.

• Provide you with information and services designed to help you maintain good health and receive the greatest benefit from the services we offer.

• Ensure privacy and confidentiality of your medical records with access according to law.

• Ensure that your interests are well represented in decisions about Plan policy and governance.

• Encourage physicians and providers to make medical decisions that are always in your best interest.

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Conditions for Receiving Benefits

Medically necessary services

Plan members are entitled to comprehensive medical care within the standards of good medical practice. The Plan Supervisor’s medical directors and special committees of Preferred Providers determine which services are medically necessary using these guidelines:

• All medical services that are appropriate and necessary for the diagnosis and treatment of symptoms, illness, disease, injury or condition that is harmful or threatening to your life or health.

• Services that are within the standard of good medical practice within the organized medical community.
  Example: Your provider suggests a treatment using a machine that has not been approved for use in the United States. The Plan probably would not pay for that treatment.

• Services at the most appropriate level that can safely be provided.
  Example: You go to a hospital emergency room to have stitches removed, rather than wait for an appointment in your doctor’s office. The Plan would not pay for that visit.

• Services that are not primarily for your convenience, or the convenience of your provider, hospital or any other health care provider:
  Example: You stay an extra day in the hospital only because the relative who will help you during recovery can’t pick you up until the next morning. The Plan may not pay for the extra day.

Please Note: Just because a treatment was prescribed or performed by a qualified health care provider does not necessarily mean that it is medically necessary under our guidelines.

The Plan has the legal right to determine which medical conditions are covered by this plan, and to what extent the conditions are covered.

Medical cost management

The Plan reserves the right to deny payment for services that are judged not to meet the criteria maintained by the PeaceHealth Plan and HMA or to determine medical necessity. A decision by the Plan following this review may be appealed as described under "Problem Resolution". When there is more than one alternative available, the least costly among medically appropriate alternatives will be approved.

In addition, the Plan reserves the right to make substitutions for the covered services listed in this Member Handbook and your Employer Group Contract. Substituted services must be:

• Medically necessary.

• Have your knowledge and agreement while receiving the service.

• Be prescribed and approved by an approved category of provider.

• Offer a medical therapeutic value at least equal to the covered service that would otherwise be performed or given.

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General Provisions

Administration Of The Group Medical Plan

The Plan is administered through PeaceHealth. PeaceHealth has retained services of an independent Plan Supervisor, HMA, experienced in claims processing. PeaceHealth shall have complete and absolute discretion and authority to make all fiduciary decisions relative to the benefits payable under the Plan, including without limitation, interpretations of Plan documentation, determinations of eligibility and benefit entitlement, and all other decisions necessary to administer the Plan. PeaceHealth has made HMA its minister to carry out its decisions.

Legal notices may be filed with, and legal process served upon the Plan Administrator.

Amendment Of Plan Document

PeaceHealth may terminate, modify or amend the Plan in its sole discretion at any time without prior notice. Once the Plan Administrator has signed the amendment, such termination, amendment, or modification shall be the basis for determining all Plan payments for all expenses incurred on or after the effective date of such termination, amendment, or modification. Plan payments made under the Plan prior to such termination, amendment, or modification shall continue to be included as Plan payments in determining the total benefits remaining toward satisfaction of any benefit maximums calculated on either a Plan year, calendar year or lifetime basis.

Appealing A Claim

INFORMAL MEMBER PROBLEM RESOLUTION 

Every HMA employee shares responsibility for ensuring member satisfaction.  If you have a problem or concern about your coverage, or services you have received, let us know what the problem or concern is and how you would like it to be addressed. 

Your Customer Service Team is available to provide information and assistance.  Please contact us so we my help you with whatever special needs you may have.

CLAIMS PROCEDURE

The Group Health Plan offered you by PeaceHealth is not subject to the Employee Retirement Income Security Act of 1974 (the Act).  The claims procedure which follows is designed to comply with the requirements of the Act, and PeaceHealth and its third party administrator will normally in good faith administer the claims procedure in accordance with its terms but may not strictly adhere to its requirements.  There may be circumstances in which the third party administrator or PeaceHealth will deviate from the requirements of the procedure.  Other and/or additional procedures may be imposed by PeaceHealth and/or its third party administrator in its or their sole discretion.  By way of example, but not limitation, PeaceHealth and its third party administrator may not at all times comply with the timing requirements imposed by the procedure but will exercise good faith to notify a claimant of a benefit determination (adverse or not) within a reasonable time period.  

INITIATING A CLAIM

To initiate a claim, whether for prior authorization or for payment for services received, contact your HMA Customer Service Team.  See page _____ for contact information.  Prior authorization is required for certain services.  See page _____ for a list of these services and how to obtain prior authorization.  If you receive a bill from a provider for which you want payment, send it to Health Care Management Administrators, Inc., P.O. Box 85008, Bellevue, Washington 98015.  The period of time within which your claim will be processed depends upon whether it is a Pre‑Service claim or a Post-Service claim and whether or not it is an Urgent Pre-Service claim.

• Urgent Pre-Service Claim.  You will be notified as soon as possible but not later than 72 hours after receipt of the claim unless you or your physician provide insufficient information

• Other Pre-Service Claims.  You will be notified not later than 15 days after receipt of the claim by the HMA.

• Post-Service Claims.  You will be notified not later than 30 days after receipt of the claim by HMA.

Urgent Care Claims are defined as claims that involve a decision that, if treated as non-urgent, could seriously jeopardize the claimant’s life, health or ability to regain maximum function; or would, according to a physician, subject the claimant to severe pain.  

APPEALING A CLAIM

Post-Service Claim: If your Post-Service claim is denied in whole or in part, you will receive an Explanation of Benefits showing the calculation of the total amount payable, charges not payable, the reason for the determination, and if applicable, a description of any additional information needed.  If additional information is needed, you may be requested to provide the information prior to payment of your claim.

First Level Review:  You may request a review within 180 days by filing a written appeal with the Plan Supervisor.  The written appeal must clearly state that it is an appeal, and clearly state the reason for appeal.  You must supply any additional information to support your appeal reason.  The Plan Supervisor will make a decision within 30 days.  This decision will be delivered to you in writing setting forth specific references to the pertinent Plan provision rule, protocol or guidelines upon which the decision is based.  You will also be given a description of any additional information needed to overturn the decision.  The review will be conducted by someone other than the individual who made the initial decision who is not a subordinate of that individual.  If you are dissatisfied with the result of the first level review, you may request a second level review.

Second Level Review:  You may request a review within 180 days by filing a written appeal with the Plan Supervisor.  The written appeal must clearly state that it is an appeal, and clearly state the reason for appeal.  You must supply any additional information to support your appeal reason.  The Plan Supervisor will make a decision within 30 days.  This decision will be delivered to you in writing setting forth specific references to the pertinent Plan provision rule, protocol or guidelines upon which the decision is based.  You will also be given a description of any additional information needed to overturn the decision.  The review will be conducted by someone other than the individual who made the initial decision on your claim and the adverse decision at the first level review.  The person or committee conducting the second level review will not be subordinate to the person making the initial claim decision or the first level review.

Subsequent Action:  Upon exhaustion of the full member appeals process, you have no further rights to review of your claim.  However, you are entitled to seek redress in the court system.

Pre-Service Claim: If your Pre-Service claim (or Pre-Authorization request) is denied in whole or in part, you will receive written notification of the decision, and the reason for the determination, and if applicable, a description of any additional information needed.  If additional information is needed, you may be requested to provide the information prior to a decision on your claim.

First Level Review:  You may request a review within 180 days by filing a written appeal with the Plan Supervisor.  The written appeal must clearly state that it is an appeal, and clearly state the reason for appeal.  You must supply any additional information to support your appeal reason.  The Plan Supervisor will make a decision within 15 days.  This decision will be delivered to you in writing setting forth specific references to the pertinent Plan provision rule, protocol or guidelines upon which the decision is based.  You will also be given a description of any additional information that will aid in making a determination.  The review will be conducted by someone other than the individual who made the initial decision who is not a subordinate of that individual.  If you are dissatisfied with the result of the first level review, you may request a second level review.

Second Level Review:  You may request a review within 180 days by filing a written appeal with the Plan Supervisor.  The written appeal must clearly state that it is an appeal, and clearly state the reason for appeal.  You must supply any additional information to support your appeal reason.  The Plan Supervisor will make a decision within 15 days.  This decision will be delivered to you in writing setting forth specific references to the pertinent Plan provision rule, protocol or guidelines upon which the decision is based.  You will also be given a description of any additional information that will aid in making a determination.  The review will be conducted by someone other than the individual who made the initial decision on your claim and the adverse decision at the first level review.  The person or committee conducting the second level review will not be subordinate to the person making the initial claim decision or the first level review.

Subsequent Action:  Upon exhaustion of the full member appeals process, you have no further rights to review of your claim.  However, you are entitled to seek redress in the court system.

Urgent Pre-Service Claim: If your Urgent Pre-Service claim (or Pre-Authorization request) is denied in whole or in part, you will receive oral and written notification of the decision, and the reason for the determination, and if applicable, a description of any additional information needed.  If additional information is needed, you may be requested to provide the information prior to a decision on your claim.  If your Urgent Care Claim is denied, you may seek an immediate review and the first and second level review will be consolidated to expedite the process.

First & Second Level Review:  You may request a review within 180 days by filing a written appeal with the Plan Supervisor.  The appeal must clearly state that it is an appeal, and clearly state the reason for appeal.  It is also recommended that you supply any additional information to support your appeal reason.  The Plan Supervisor will make a decision within 72 hours and the decision will reflect both a first and second level review.  This decision will be delivered to you orally and in writing setting forth specific references to the pertinent Plan provision rule, protocol or guidelines upon which the decision is based.  You will also be given a description of any additional information needed to overturn the decision.  The first level review will be conducted by someone other than the individual who made the initial decision who is not a subordinate of that individual.  The second level review will be conducted by someone other than the individual who made the initial decision and the individual or individuals who conducted the first level review.  The person or committee conducting the second level review will not be subordinate to the person making the initial claim decision or the first level review.

Subsequent Action:  Upon exhaustion of the full member appeals process, you have no further rights to review of your claim.  However, you are entitled to seek redress in the court system.

Applicable Law

This Plan is a Church sponsored plan and as such it is exempt from the requirements of the Employee Retirement Income Security Act of 1974 (also known as ERISA), which is a federal law regulating employee welfare and pension plans. Your rights as a participant in the Plan are governed by the plan documents and applicable state law and regulations.

Application and Identification Card

To obtain coverage, an eligible employee must complete and deliver to the Plan Administrator an application or on-line enrollment supplied by the Plan Supervisor.

Approval to Release Medical Information

When you accept these benefits, you also agree to have your medical records examined by the Plan under certain specific circumstances. Medical records may be examined for the purpose of utilization review, quality assurance, and peer review by the Plan or our designee. Medical information, such as claims data may be analyzed for quality improvement purposes. The Plan respects the privacy of our members. Please refer to the following page for the Plan’s confidentiality policy.

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Assignment of Payment

The Plan will pay any benefits accruing under this Plan to the employee unless the employee shall assign benefits to a Medical facility, physician or other provider of service furnishing the services for which benefits are provided herein. No assignment, however, shall be binding on the Plan unless the Plan Supervisor is notified in writing of such assignment prior to payment. Preferred providers normally bill the Plan directly. If service has been received from a preferred provider, benefits are automatically paid to that provider. Any balance due after the Plan payment will then be billed to the patient by the preferred provider.

Audit and Case Management

Reasonable charges made by an audit and/or case management firm when the services are requested by the Plan Supervisor and approved by the Plan Administrator shall be payable.

Audit Incentives

If a covered employee or a dependent discovers an error in the provider's medical billing which is subsequently recovered or if the benefits payable are reduced due to the identification of the error, the medical plan will reimburse the participant 50% of the recovered or reduced amount up to $200 per incident. No benefit is payable for any errors made by the Plan Supervisor in processing the claim.

Cancellation

An employee may cancel their coverage by giving written notice to the Plan Administrator who will notify the Plan Supervisor.

In the event of the cancellation of this Plan, or the cancellation of the Participating Group's participation in the Plan, all employees’ and dependents’ coverage shall cease automatically without notice. Employees and dependents shall not be entitled to further coverage or benefits, whether or not any medical condition was covered by the Plan prior to termination or cancellation.

The Plan may be canceled or terminated at any time without advance notice by the Participating Group or Groups. Any Participating Group may cancel its participation at any time without notice and without effect on any remaining Participating Group.

Upon termination of this Plan, or the cancellation of the Participating Group's participation in the Plan, all claims incurred prior to termination, but not submitted to the Plan Supervisor within 75 days of the effective date of termination of this Plan, will be excluded from any benefit consideration.

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Condition Precedent to the Payment of Benefits

The employee or dependent shall present the Plan identification card to the provider of service upon admission to a medical facility or upon receiving service from a physician.

Written proof of the nature and extent of service performed by a physician or other provider of service shall be furnished to the Plan Supervisor within one year after the service was rendered. Claim forms are available through the Plan Supervisor, and are required along with an itemized statement with a diagnosis, the employee's name and Social Security number and the name of the Plan Administrator or the Participating Group.

The employee and all dependents agree that in order to receive benefits, any physician, nurse, medical facility or other provider of service, having rendered service or being in possession of information or records relating thereof, is authorized and directed to furnish the Plan Supervisor, at any time, upon request, any and all such information and records, or copies thereof.

The Plan Supervisor shall have the right to review these records with the Plan's insurance company and with any medical consultant or with the UR Coordinator as needed to determine the medical necessity of the treatment being rendered.

Credit For Prior Group Coverage

This Plan amends and replaces the prior plan. Employees and dependents whowere covered under the prior Plan sponsored by the Employer immediately prior to the time this Plan became effective shall not lose their eligibility or benefits due to the change in Plans. If a participant is disabled on the date a Plan change is to take affect that increases the benefit, the disabled participant will remain at the old benefit level until they are no longer disabled. All charges incurred on or after the effective date of this Plan will be subject to the benefits available under this Plan and not the prior Plan. Credit will be given for time enrolled under the prior Plan in meeting the pre-existing waiting periods and for payments towards coinsurance and deductibles.

Facility of Payment

If, in the opinion of the Plan Supervisor, a valid release cannot be rendered for the payment of any benefit payable under this Plan, the Plan Supervisor may, at its option, make such payment to the individuals as have, in the Plan Supervisor's opinion, assumed the care and principal support of the covered person and are therefore equitably entitled thereto. In the event of the death of the covered person prior to such time as all benefit payments due him/her have been made, the Plan Supervisor may, at its sole discretion and option, honor benefit assignments, if any, prior to the death of such covered person.

Any payment made by the Plan Supervisor in accordance with the above provisions shall fully discharge the Plan and the Plan Supervisor to the extent of such payment.

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Free Choice Of Physician

The employee and dependents shall have free choice of any licensed physician or surgeon, and the physician-patient relationship shall be maintained. Please refer to the Schedule of Benefits for the appropriate coinsurance reimbursement level.

Nothing contained herein shall confer upon an employee or dependent any claim, right, or cause of action, either at law or in equity, against the Plan for the acts of any medical facility in which he/she receives care, for the acts of any physician from whom he/she receives service under this Plan, or for the acts of the UR Coordinator in performing their duties under this Plan.

Funding

If contributions are required of employees or dependents covered under this Plan, the Plan Administrator will maintain a Trust or otherwise account for the receipt of money and property to fund the Plan, for the management and investment of such funds and for the payment of claims and expenses from such funds. The terms of the Trust (when applicable) are hereby incorporated by reference, as of the effective date of the Trust, as a part of this Plan.

The Participating Groups shall deliver from time to time to the Plan Administrator or the Trust such amounts of money and property as shall be necessary to provide the Trust with sufficient funds to pay all claims and reasonable expenses of administering the Plan as the same shall be due and payable. The Plan Administrator may provide for all or any part of such funding by insurance issued by a company duly qualified to issue insurance for such purpose in the state of situs, and may pay the premiums therefore directly or by funds deposited in the Trust.

All funds received by the Trust and all earnings of the Trust shall be applied toward the payment of claims and reasonable expenses of administration of the Plan except to the extent otherwise provided by the Plan Documents. The Plan Administrator may appoint an investment manager or managers to manage (including the power to acquire and dispose of) any assets of the Plan.

Any fiduciary, employee, agent, representative or other individual performing services to or for the Plan or Trust shall be entitled to reasonable compensation for services rendered, unless such individual is the Plan Administrator, and for reimbursement of expenses properly and actually incurred.

HIPAA Privacy (Effective April 14, 2003)

Use and Disclosure of Protected Health Information

Under the HIPAA privacy rules effective April 14, 2003; the Plan Sponsor must establish the permitted and required uses of Protected Health Information (PHI). 

Plan Sponsor’s Certification of Compliance

Neither the Plan nor any health insurance issuer or business associate servicing the Plan will disclose Plan Enrollees’ Protected Health Information to the Employer (Plan Sponsor) unless the Employer (Plan Sponsor) certifies its compliance with 45 Code of Federal Regulations §164.504(f)(2) (collectively referred to as The Privacy Rule) as set forth in this Article, and agrees to The Privacy Rules.

Restrictions on Disclosure of Protected Health Information to Employer (Plan Sponsor)

The Plan and any health insurance issuer or business associate servicing the Plan will disclose Plan Enrollees’ Protected Health Information to the Employer (Plan Sponsor) only to permit the Employer (Plan Sponsor) to carry out plan administration functions for the Plan consistent with the requirements of the Privacy Rule.  Any disclosure to and use by the Employer (Plan Sponsor) of Plan Enrollees’ Protected Health Information will be subject to and consistent with the provisions of paragraphs on Employer (Plan Sponsor) Obligations Regarding Protecting Health Information and Adequate Separation Between the Employer (Plan Sponsor) and the Plan of this Article.

Neither the Plan nor any health insurance issuer or business associate servicing the Plan will disclose Plan Enrollees’ Protected Health Information to the Employer (Plan Sponsor) unless the disclosures are explained in the Notice of Privacy Practices distributed to the Plan Enrollees.

Neither the Plan nor any health insurance issuer or business associate servicing the Plan will disclose Plan Enrollees’ Protected Health Information to the Employer (Plan Sponsor) for the purpose of employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Employer (Plan Sponsor).

Employer (Plan Sponsor) Obligations Regarding Protecting Health Information

The Employer (Plan Sponsor) will:

• Neither use nor further disclose Plan Enrollees’ Protected Health Information, except as permitted or required by the Plan Documents, as amended, or required by law.

• Ensure that any agent, including any subcontractor, to whom it provides Plan Enrollees’ Protected Health Information agrees to the restrictions and conditions of the Plan Documents, including this Article, with respect to Plan Enrollees’ Protected Health Information.

• Not use or disclose Plan Enrollees’ Protected Health Information for employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Employer (Plan Sponsor).

• Report to the Plan any use or disclosure of Plan Enrollees’ Protected Health Information that is inconsistent with the uses and disclosures allowed under this Article promptly upon learning of such inconsistent use or disclosure.

• Make Protected Health Information available to the Plan Enrollee who is the subject of the information in accordance with 45 Code of Federal Regulations § 164.524.

• Make Plan Enrollees’ Protected Health Information available for amendment, and will on notice amend Plan Enrollees’ Protected Health Information, in accordance with 45 Code of Federal Regulations § 164.526.

• Track disclosures it may make of Plan Enrollees’ Protected Health Information so that it can make available the information required for the Plan to provide an accounting of disclosures in accordance with 45 Code of Federal Regulations § 164.528.

• Make available its internal practices, books, and records, relating to its use and disclosure of Plan Enrollees’ Protected Health Information, to the Plan and to the U.S. Department of Health and Human Services to determine compliance with 45 Code of Federal Regulations Parts 160-64.

• If feasible, return or destroy all Plan Enrollee Protected Health Information, in whatever form or medium (including in any electronic medium under the Employer’s (Plan Sponsor’s) custody or control), received from the Plan, including all copies of and any data or compilations derived from and allowing identification of any Enrollee who is the subject of the Protected Health Information, when the Plan Enrollees’ Protected Health Information is no longer needed for the plan administration functions for which the disclosure was made.  If it is not feasible to return or destroy all Plan Enrollee Protected Health Information, the Employer (Plan Sponsor) will limit the use or disclosure of any Plan Enrollee Protected Health Information it cannot feasibly return or destroy to those purposes that make the return or destruction of the information infeasible.

Adequate Separation Between the Employer (Plan Sponsor) and the Plan

The following classes of employees or other workforce members under the control of the Employer (Plan Sponsor) may be given access to Plan Enrollees’ Protected Health Information received from the Plan or a health insurance issuer or business associate servicing the Plan: 

• Directors of Human Resources;

• Benefit Managers; 

• Benefit Administrators;

• Benefit Specialist; and

• Internal Auditors when performing Health Plan Audits.

This list includes every class of employees or other workforce members under the control of the Employer (Plan Sponsor) who may receive Plan Enrollees’ Protected Health Information relating to payment under, health care operations of, or other matters pertaining to the Plan in the ordinary course of business.  The identified classes of employees or other workforce members will have access to Plan Enrollees’ Protected Health Information only to perform the plan administration functions that the Employer (Plan Sponsor) provides for the Plan.

The identified classes of employees or other workforce members will be subject to disciplinary action and sanctions, including termination of employment or affiliation with the Employer (Plan Sponsor), for any use or disclosure of Plan Enrollees’ Protected Health Information in breach or violation of or noncompliance with the provisions of this Article to the Plan Documents.  Employer (Plan Sponsor) will promptly report such breach, violation or noncompliance to the Plan, and will cooperate with the Plan to correct the breach, violation or noncompliance, to impose appropriate disciplinary action or sanctions on each employee or other workforce member causing the breach, violation or noncompliance, and to mitigate any deleterious effect of the breach, violation or noncompliance on any Enrollee, the privacy of whose Protected Health Information may have been compromised by the breach, violation or noncompliance.

Inadvertent Error

Inadvertent error by the Plan Administrator in the keeping of records or in the transmission of employee's applications shall not deprive any employee or dependent of benefits otherwise due, provided that such inadvertent error be corrected by the Plan Administrator within ninety (90) days after it was made. The Plan Supervisor shall only be liable to the Employer and to the employees of the Employer for its actions or failure to act with regard to processing and payment of claims as provided in the Plan Agreement at the level expected of a professional claim administrator; or for its negligence or willful misconduct. The Employer shall hold the Plan Supervisor harmless from and indemnify it against any claims and all costs and expense or fees incurred in connection therewith, which might be asserted by the Plan, Employer’s employees or other persons which are beyond Plan Supervisor’s control or beyond the scope of this Agreement.

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Medicare

Medicare - As used in this section shall mean Title XVIII (Health Insurance for the Aged) of the United States Social Security Act, as added to by the Social Security Amendments of 1965, the Tax Equity and Fiscal Responsibility Act of 1982, or as later amended.

Person - As used in this section means a person who is eligible for benefits as an employee in an eligible class of this Plan and who is or could be covered by Medicare Parts A and B, whether or not actually enrolled.

Eligible Expenses - As used in this section with respect to services, supplies and treatment shall mean the same benefits, limits and exclusions as defined in this Plan Document. However, if the provider accepts Medicare assignment as payment in full, then Eligible Expenses shall mean the lesser of the total amount of charges allowable by Medicare, whether enrolled or not, and the total eligible expenses allowable under this Plan exclusive of coinsurance and deductible.

Order of Benefits Determination - As used in this section shall mean the order in which Medicare benefits are paid, in relation to the benefits of this Plan.

Total benefits of this Plan shall be determined as follows:

Employees - For employees and/or non-working spouses of employees age 65 or over: This Plan will be primary and Medicare will be secondary.

Disabled Employees with Medicare (Except those with End-Stage Renal Disease) -For persons eligible for Medicare by reason of Disability the order of determination will be as shown below:

This Plan will be primary and Medicare will be secondary. The Employer will remain the primary payor of medical benefits until the earliest of the following events occurs: (1) the group coverage ends for all employees; (2) the group coverage as an active individual ends.

The Omnibus Budget Reconciliation Act of 1986 defines a large group health plan as one that covers employees of at least one employer that normally employed at least 100 employees on a typical business day during the previous calendar year. A typical business day is defined as 50 percent or more of the employer's regular business days during the previous calendar year.

Disabled Employees with End-Stage Renal Disease (ESRD)

This Plan shall be primary for ESRD Medicare beneficiaries during the initial 30 months of Medicare coverage, in addition to the usual three month waiting period, or a maximum of 33 months. ESRD Medicare Entitlement usually begins on the fourth month of renal dialysis, but can start as early as the first month of dialysis for individuals who take a course in self-dialysis training during the three month waiting period.

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Misrepresentation Notice

Any material misrepresentation on the part of the Plan Administrator or the employee in making application for coverage, or any application for reclassification thereof, or for service thereunder shall render the coverage null and void.

Any notice given under this Plan shall be sufficient, if given to the Plan Administrator when addressed to it at its office; if given to the Plan Supervisor, when addressed to it at its office; or if given to an employee, when addressed to the employee at their address as it appears on the records of the Plan Supervisor on the employee's enrollment form and any corrections made to it.

Photocopies

Reasonable charges made by a provider for photocopies of medical records when the copies are requested by the Plan Supervisor shall be payable.

Plan is Not a Contract For Employment

The Plan shall not be deemed to constitute a contract of employment between the Plan

Administrator or Participating Company and any employee or to be a consideration for, or an inducement to or condition of the employment of any employee. Nothing in the Plan shall be deemed to give any employee the right to be retained in the service of the Plan Administrator or Participating Company or to interfere with the right of the Plan Administrator or Participating Company to discharge any employee at any time; provided however, that the foregoing shall not be deemed to modify the provisions of any collective bargaining agreements which may be made by the Plan Administrator or Participating Company with the bargaining representative of any employees.

Privileges as to Dependents

The employee shall have the privilege of adding or withdrawing the name ornames of any dependent(s) to or from this coverage, as permitted by the Plan, by submitting to the Plan Administrator an application for reclassification on the enrollment form furnished by the Plan Supervisor. Each dependent added to the coverage shall be subject to all conditions and limitations contained in this Plan.

Utilization Management

The Plan works with physicians and other health care providers to offer appropriate medical care and to improve the health of our members. Your health is our first priority.

We support providers to make sound medical decisions on behalf of their patients, our members. We do not offer incentives or reward any provider or PHP staff for denying claims or not providing care. We encourage providers to explain all medical options to members, whether those options are covered by the Plan or not. We want you and your provider to work together to make the best decisions for treatment.

We encourage providers to manage and improve care for our members, not to restrict care. Like most health benefit plans, we do have some restrictions about which benefits are covered by the Plan, by you as an individual or by a government contract. We explain what benefits are covered in your Member Handbook so you can know about those in advance.

We do ask you whenever possible to work with participating health care providers who have agreed in advance to the schedule of fees, to the Plan’s routines of care known as clinical practice guidelines, and who will refer you to other care providers with whom we work. The health care providers we ask you to work with are listed in the Online Regence Preferred Provider Directory (www.regence.com).

The Plan does require advance notification – or prior authorization – from providers for some medical procedures. This allows the plan to commit to appropriate payment for these services and ensure their medical appropriateness. This may include review of the member’s medical records by appropriate the Plan Supervisor’s clinical staff so to ensure appropriate application of benefits and payments. Also, we have contracted for case management assistance for members with complex medical needs who may benefit from additional assistance to maximize and coordinate the care they receive from health care providers.

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Definitions

• Accident/Accidental Injury - Shall mean a personal bodily injury to the employee or dependent effected solely through external violent and unintentional means. All injuries sustained in connection with one accident will be considered one Accidental Injury. Accidental Injury does not include ptomaine poisoning, disease or infection (except pyogenic infection occurring through an accidental cut or wound).

• Acute Care – Shall mean care received in an inpatient hospital setting.

• Anesthesia - A drug/gas which produces unconsciousness and insensitivity to pain.

• Approved Chemical Dependency Treatment Facility - For the purpose of treatment of chemical dependency, the definition of the term facility includes any public or private treatment facility providing services for the treatment of chemical dependency that has been licensed or approved as a chemical dependency treatment facility by the State in which it is located.

• Approved Treatment Plan - A written outline of proposed treatment that is submitted by the attending physician to the Plan Supervisor or Chemical Dependency/Mental Health Coordinator for review and approval.

• Biofeedback - Biofeedback is an electronic method which allows the patient to monitor the functioning of the body’s autonomic systems (e.g., body temperature, heart rate) that were previously thought to be involuntary.

• Calendar Year - The 12 months beginning January 1 and ending December 31 of the same year.

• Contributory - The employee is required to pay a portion of the cost to be eligible to participate in the Plan.

• Cosmetic Treatment -- Medical or surgical treatment primarily for the purpose of improving appearance or self esteem.

• Coinsurance Percentage -- The coinsurance is the percentage of the usual, customary and reasonable (UCR) charge that the Plan will pay for non-preferred providers, or the percentage of the negotiated rate for preferred providers. Once the deductible is satisfied, the Plan shall pay benefits for covered expenses incurred during the remainder of the calendar year at the applicable coinsurance as specified in the Schedule of Benefits. The participant is responsible for paying the remaining percentage. The participant's portion of the coinsurance represents their out-of-pocket expense. The non-preferred provider of service may charge more than the UCR. The portion of the non-preferred provider's bill in excess of UCR is not a covered expense under this Plan and is the responsibility of the participant.

• Copay -- This is the amount paid by you each time treatment is received. Only one copay is to be taken per day for related outpatient services rendered.  The copay amounts are listed on your Summary of Benefits.

• Covered Individual Or Participant - An employee, spouse or child who is eligible for benefits under this Plan.

• Creditable Coverage - The period of prior coverage under an individual or group health plan, including Medicare, Medicaid, governmental and church plans. However, the following are not "creditable coverage": accident-only plans, disability income plans, liability and limited-scope insurance, credit-only insurance, coverage for on-site medical clinics, coverage issued as supplemental to liability insurance automobile medical coverage, Workers’ Compensation, and limited-scope dental or vision plans.

• Custodial Care - Care or service which is not medically necessary, and is designed essentially to assist a participant in the activities of daily living. Such care includes, but is not limited to: bathing, feeding, preparation of special diets, assistance in walking, dressing, getting into or out of bed and supervision over taking of medication which can normally be self-administered.

• Deductible - The deductible is the amount of eligible expenses each calendar year that an employee or dependent must incur before any benefits are payable by the Plan. The individual deductible amount is listed in the Schedule of Benefits.

• Developmental Delay -- Defined as a delay in the ability to learn, reason or communicate.

• Disability - See Total Disability.

• Donor - A donor is the individual who provides the organ for the recipient in connection with organ transplant surgery. A donor may or may not be an employee or covered under the provisions of this Plan.

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• Durable Medical Equipment - Equipment prescribed by the attending Physician which meets all of the following requirements:

  • Is medically necessary;

  • Is designed for prolonged and repeated use;

  • Is for a specific purpose in the treatment of an Illness or Injury;

  • Would have been covered if provided in a medical facility; and

  • Is appropriate for use in the home.

• Effective Date - The effective date shall mean the first day this Plan was in effect as shown in the Plan Specifications. As to the participant, it is the first day the benefits under this Plan would be in effect, after satisfaction of the waiting period and any other provisions or limitations contained herein.

• Enrollment Date - The enrollment date is the first day of coverage or, if there is a waiting period for coverage to begin under the Plan, the first day of the waiting period. The term "waiting period" refers to the period after employment starts and the first day of coverage under the Plan. For a person who enrolls on a special enrollment date, the "enrollment date" will be the first date of actual coverage.

• Experimental Or Investigative - This Plan does not consider eligible for benefits any treatment, procedure, facility, equipment, drug, drug usage, device or supply which, at the time rendered, does not meet the criteria listed below:

  • Approval has been granted by the Federal Food and Drug Administration (FDA), or by another United States governmental agency, for general public use for treatment of a condition.

  • It has been scientifically demonstrated by the medical profession to have efficacy in terms of:

    • When the prognosis for the patient's condition is terminal, that the treatment substantially extends the probabilities of the participant's survival.

    • When deterioration of a body system is progressive and reasonably certain to (or has) disabled or incapacitated the patient, that the treatment can be substantially expected to improve the probabilities of arresting the condition's progress.

    • When the body function has been lost by the patient, that the treatment has been shown to restore the body function to usefulness at least sixty percent of the time treatment has been utilized.

  • Treatment must be ordered by an institution or provider within the United States that has scientifically demonstrated proficiency in such treatment. All services directly connected with a non-approved experimental or investigational procedure are not covered.

• Family And Medical Leave Act Of 1993 (FMLA) - A leave of absence granted to an eligible participant by the Employer in accordance with Public Law 103-3 for the birth or adoption of the participant’s child, placement in the participant’s care of a foster child, the serious health condition of the participant’s spouse, child or parent, and the participant’s own disabling serious health condition.

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Fluoride - A substance when topically applied or applied to drinking water is effective in resisting tooth decay.

• Generic Drug - A drug that is generally equivalent to a higher-priced brand name drug and meets all FDA bioavailability standards.

• Homebound - A patient is homebound when leaving the home could be harmful, involves a considerable and taxing effort, and the patient is unable to use transportation without the assistance of another.

• Identification Card –A card issued to each member enrolled in the Plan. The card identifies you as a Plan member and includes important information about your coverage. Always present your card when you seek medical care or benefits.

• Illness - The term "illness" means an illness causing loss to the participant whose illness is the basis of the claim. For the purposes of this Plan only, "illness" shall also be deemed to include disability caused or contributed to by pregnancy of the covered employee or spouse, including miscarriage, childbirth and recovery therefrom. It shall only mean illness or disease which requires treatment by a physician.

• Incurred Charge - The charge for a service or supply is considered to be incurred on the date it is furnished or delivered. In the absence of due proof to the contrary, when a single charge is made for a series of services, each service will be considered to bear a pro rata share of the charge.

• Infertility -- The inability to become pregnant after a year of unprotected intercourse. Or, the inability to carry pregnancy to term as evidenced by three (3) consecutive spontaneous abortions (miscarriages).

• Injury - The term injury shall mean only bodily injury caused by an accident while the Plan is in force as to the participant whose injury is the basis of the claim. Injury shall mean only those injuries which require treatment by a physician.

• Inpatient - Anyone treated as a registered bed patient in a medical facility or other institutional facility.

• Lifetime - While covered under this Plan or any other Employer plan. Wherever this word appears in this Plan Document in reference to benefit maximums and limitations. Under no circumstances does lifetime mean during the lifetime of the covered person.

• Medical Emergency - An illness or injury which is life threatening or one that must be treated promptly to avoid serious adverse health consequences to the participant.

• Medical Facility (Hospital) - An institution accredited by the Joint Commission on Accreditation of Healthcare Organizations and which receives compensation from its patients for services rendered. On an inpatient basis, it is primarily engaged in providing all of the following:

  • Diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment, and care of injured and ill participants.

  • Services performed by or under the supervision of a staff of physicians who are duly licensed to practice medicine.

  • Continuous 24 hours a day nursing services by registered graduate nurses.

  It is not, other than incidentally, a place for rest, or for the aged.

  For the services covered under this Plan and for no other purpose, inpatient treatment of mental illness or chemical dependency, provided by any psychiatric medical facility licensed by the State Board of Health or the Department of Mental Health, will be considered services rendered in a medical facility as defined subject to the limitations shown in this booklet.

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• Medical Lifetime Maximum – The maximum lifetime benefit allowed per participant. The Medical Lifetime Benefit per participant under this Plan is $1,000,000.

• Medically Necessary - Medical services and/or supplies which are absolutely needed and essential to diagnose or treat an illness or injury of a covered employee or dependent while covered by this Plan. The following criteria must be met. The treatment must be:

  • Consistent with the symptoms or diagnosis and treatment of the participant's condition.

  • Appropriate with regard to standards of good medical practice.

  • Not solely for the convenience of the participant, family members or a provider of services or supplies.

  • The least costly of the alternative supplies or levels of service which can be safely provided to the participant. When specifically applied to a medical facility inpatient, it further means that the service or supplies cannot be safely provided in other than a medical facility inpatient setting without adversely affecting the participant's condition or the quality of medical care rendered.

• Medicare - The programs established by Title XVIII of the U.S. Social Security Act as amended and as may be amended, entitled Health Insurance for the Aged Act, and which includes Part A - Hospital Insurance Benefits for the Aged; and Part B - Supplementary Medical Insurance Benefits for the Aged.

• Members -- The eligible individuals covered by the Plan.

• Non-Emergency Medical Facility Admissions - A medical facility admission (including normal childbirth) which may be scheduled at the convenience of a participant without endangering such participant's life or without causing serious impairment to that participant's bodily functions.

• Order Of Benefits Determination - The method for ascertaining the order in which the Plan renders payment. The principle applies when another plan has a Coordination of Benefits provision.

• Orthotics - An orthopedic appliance or apparatus used to support, align, prevent or correct deformities or to improve function of movable parts of the body.

• Out-of-Area Dependent -- An eligible family dependent of a subscriber, who does not reside in the Plan’s service area and who is properly enrolled in the Plan as an Out-of-Area Dependent. A dependent child who is an eligible family dependent and who resides out of the service area for the purpose of attending school is eligible to be enrolled as an Out-of-Area Dependent. The subscriber’s spouse also is eligible to be enrolled as an Out-of-Area Dependent.

• Outpatient Surgical Facility - A licensed surgical facility, surgical suite or medical facility surgical center in which a surgery is performed and the patient is not admitted for an overnight stay.

• Preferred Provider (or Plan Provider) -- Any credentialed physician, provider, hospital, or facility which has an Agreement with Regence Blue Shield to provide care to Plan members.  Personal Physician or Provider is a Preferred Provider specializing in family practice, general practice, internal medicine or pediatrics; a nurse practitioner; a certified nurse midwife; or a physician assistant, when providing services under the supervision of a physician; who agrees to be responsible for the member’s continuing medical care by serving as case manager. Adult female members also may select a provider specializing in obstetrics or gynecology; a nurse practitioner; a certified nurse midwife; or a physician assistant specializing in women’s health care as their personal physician/provider. (Note: Not all these providers are personal physicians/providers — see the Online Preferred Provider Directory for a listing of designated personal physicians/providers.)

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• Physician - The term physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.) or a Physician’s Assistant (P.A.) who is legally qualified and licensed without limitation to practice medicine, surgery, or obstetrics at the time and place service is rendered. For services covered by this Plan and for no other purpose, Doctors of dental surgery, Doctors of dental medicine, Doctors of podiatry, optometrists, and licensed health service providers in psychology are deemed to be physicians when acting within the scope of their license for services covered by this Plan.

  Registered Physical Therapists, Licensed Speech Therapists, Certified Occupational Therapists, who is registered, licensed or certified by the state will be covered under this definition.

  Registered Nurses (R.N.), Licensed Vocational Nurses (L.V.N.), and Licensed Practical Nurses (L.P.N.) will be covered under this definition.

  A Licensed Masters in Social Work (M.S.W.), Licensed Masters of Arts (M.A.), Licensed Masters of Education (M.Ed.), or Licensed Masters of Counseling (M.C.) who is licensed or certified by the state will be covered under this definition.

  A Licensed Midwife or Nurse Practitioner who is licensed by the state to perform services for which benefits are provided under the Plan, and who acts within the scope of such license is included in the term physician will be covered under this definition.

• Plan - Shall mean the Benefits described in the Plan Document.  The Plan is the Covered Entity as defined in HIPAA (§160.103).

• Plan Administrator/Plan Sponsor - The individual, group or organization responsible for the day-to-day functions and management of the Plan.  The Plan Administrator/Plan Sponsor may employ individuals or firms to process claims and perform other Plan connected services.  The Plan Administrator/Plan Sponsor is as shown in the Plan Specifications.

• Plan Document - The term Plan Document whenever used herein shall, without qualification, mean the document containing the complete details of the benefits provided by this Plan. The Plan Document is kept on file at the office of the Plan Administrator.

• Plan Supervisor - The individual or group providing administrative services to the Plan Administrator in connection with the operation of the Plan and performing such other functions, including processing and payment of claims, as may be delegated to it by the Plan Administrator.

• Plan Year - The term Plan Year means an annual period beginning on the effective date of this Plan and ending twelve (12) calendar months thereafter or upon termination of the Plan, whichever occurs earliest.

• Preferred Provider - A provider who is part of a network of providers contracted to accept a negotiated rate as payment in full for services rendered.

• Prior Authorized Services --Services which require you and/or your provider to seek Plan confirmation before seeking or receiving care. Final determination will be based on the covered benefits and eligibility on the date of service.

• Protected Health Information (PHI) – Individually identifiable information (as provided for in the privacy rules of HIPAA), whether it is in electronic, paper or oral form that is created or received by or on behalf of the Plan Sponsor or the Plan Supervisor.

• Recipient - The recipient is the participant who receives the organ for transplant from the organ donor. The recipient shall be an employee or dependent covered under the provisions of this Plan. Only those organ transplants not considered experimental in nature and specifically covered herein are eligible for coverage under this Plan.

• Relative - When used in this document shall mean a husband, wife, son, daughter, mother, father, sister or brother of the employee or any covered dependent.

• Room And Board Charges - The institution's charges for room and board and its charges for other necessary institutional services and supplies, made regularly at a daily or weekly rate as a condition of occupancy of the type of accommodations occupied.

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• Semi-Private Rate - The daily room and board charge which an institution applies to the greatest number of beds in its semi-private rooms containing 2 or more beds. If the institution has no semi-private rooms, the semi-private rate will be the daily room and board rate most commonly charged for semi-private rooms with two or more beds by similar institutions in the area. The term "area" means a city, a county, or any greater area necessary to obtain a representative cross section of similar institutions.

• Service Area -- A defined geographical area. See our service area map on page at the end of this document.

• Significant Break In Coverage - Any period of 63 days or more without Creditable Coverage. Periods of no coverage during an HMO affiliation period or a waiting period shall not be taken into account for purposes of determining whether a Significant Break in Coverage has occurred.

• Skilled Nursing/Rehabilitation Facility - An institution, or a distinct part of an institution meeting all of the following tests:

  • It is licensed to provide and is engaged in providing, on an inpatient basis, for participants convalescing from injury or disease, professional nursing services rendered by a Registered Graduate Nurse (R.N.), Licensed Vocational Nurse (L.V.N.) or by a Licensed Practical Nurse (L.P.N.) under the direction of a Registered Graduate Nurse, physical restoration services to assist patients to reach a degree of body functioning to permit self-care in essential daily living activities.

  • Its services are provided for compensation from its patients and patients are under the full-time supervision of a physician or Registered Graduate Nurse (R.N.).

  • It provides 24 hours per day nursing services by a licensed nurse, under the direction of a full-time Registered Graduate Nurse (R.N.).

  • It maintains a complete medical record on each patient.

  • It has an effective utilization review plan.

  • It is not, other than incidentally, a place for rest for the aged, drug addicts, alcoholics, the mentally handicapped, custodial or educational care, or care of mental disorders.

• Spouse - The man or woman to whom the employee is legally married, not including a common-law marriage.

• Subscriber --The employee of the Group whose employment or membership in the Group establishes eligibility for his or her dependents under the Plan policy.

• Summary of Benefits -- The description of your plan’s benefits and copayments/coinsurance.

• Summary Of The Plan – The document containing a summary of the benefits provided under the Plan. In the event of a discrepancy between the summary and the Plan Document, the provisions stated in the Plan Document will supersede.

• Surgical Procedure - A surgical procedure is defined as:

  • A cutting operation.

  • Treatment of a fracture.

  • Reduction of a dislocation.

  • Radiotherapy if used in lieu of a cutting operation for removal of a tumor.

  • Electrocauterization.

  • Diagnostic and therapeutic endoscopic procedures.

  • Injection treatment of hemorrhoids and varicose veins.

• Temporomandibular Joints - The joint just ahead of the ear, upon which the lower jaw swings open and shut, and can also slide forward.

• Total Disability And Disabled - The terms total disability and disabled mean for the:

  • Employee - their inability to engage, as a result of accident or illness, in their normal occupation with the Participating Company on a full time basis;

  • Dependent - their inability to perform the usual and customary duties or activities of a participant in good health and of the same age.

• Treatment - Any service or supply used to evaluate, diagnose or remedy a condition of an participant or their covered dependents.

• Usual, Customary And Reasonable (UCR) - A reasonable fee that is commonly accepted as payment for a given service by physicians or suppliers of services in a geographical area.

• Utilization Review Coordinator Or UR Coordinator- The individual or organization designated by the Plan Administrator to authorize medical facility admissions and surgeries and to determine the medical necessity of treatment for which Plan benefits are claimed.

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Plan Specifications

PeaceHealth, of Bellevue, Washington hereby establishes this Plan for the payment of certain expenses for the benefit of its eligible employees to be known as the PeaceHealth Employee Health Care Plan.

PeaceHealth assures its covered employees that during the continuance of the Plan, all benefits herein described shall be paid to or on behalf of the employees in the event they become eligible for benefits.

The Plan is subject to all the terms, provisions and conditions recited on the preceding pages hereof.

This Plan is not in lieu of and does not affect any requirement for coverage by Worker's Compensation Insurance.

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