HomeMy WebLinkAboutFinal Approval Form 11/20/2003 BlueCross 'BlueShield
BluePlus
of Minnesota
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P.O.Box 64560 11/20/03
St.Paul,MN of Oak Park Heights CdIS7 10
GLy 55164-0560
Carrie Jenkins,Mbar
651.662.8000
Deb Killer,Marketing Representative
1.800.382.2000
Double Gold 81760
www.bluecrossmn.com
® Summary Plan Description (SPD) text is approved
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(-Number of copies to be printed: (If you p/an on doing your own prndng,pease indicate zero(0
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Printed SPD(s) should be sent to the attention of:
Judy Hoist 14168 Oak Park Blvd. N.
Name Address (no PO Box)
City of Oak Park Oak Park Heights , MN 55082-2007
Account Name Heights City, State and Zip
651-439-4439
Phone Number
(? . 1 ///pdat 12-10-03
Appr ed By c Date
PLEASE RETURN FORM TO: Deb Keller E4-12
BLUE CROSS AND BLUE SHIELD OF MINNESOTA
P.O. BOX 64560
ST. PAUL, MN 55164
L02 Blue Cross and Blue Shield of Minnesota and Blue Plus are independent licensees of the Blue Cross and Blue Shield Association
BlueCross BlueShield
BluePlus
of Minnesota
vov
November 20, 2003
Helen Hamble
Zaczkowski Insurance
14261 North 60th Street
P.O.Box 64560
Stillwater, MN 55082
St.Paul,MN
Helen,
55164-0560
651.662.8000 Enclosed is a copy of your plan's Summary Plan Descriptions (SPD) for the City
of Oak Park Heights. The Double Gold was renewed this year. This plan is
1.800.682.2000 effective January 1, 2004 through December 31, 2004.
www.bluecrossmn.com
Please review the SPD, sign the approval form and return to:
Deb Keller E4-12
Blue Cross Blue Shield of Minnesota
P.O. Box 64560
St. Paul, MN 55164
If you have any questions or concerns with the SPDs, please feel free to call me at
651-662-1528.
Sincerely,
-Dc t) C�
Deb Keller
Senior Account Manager
Blue Cross Blue Shield of Minnesota
Enclosure
o24o1; is,; Blue Cross and Blue Shield of Minnesota and Blue Plus are independent licensees of the Blue Cross and Blue Shield Association
DOUBLE GOLD
HEALTH CARE PLAN
For Employees of:
City of Oak Park Heights
(herein called the Plan Administrator or the Employer)
This Plan has been certified as a qualified plan
ANNUAL NOTIFICATIONS
Women's Health and Cancer Rights Act
Under the Federal Women's Health and Cancer Rights Act of 1998 and Minnesota law, you are entitled
to the following services:
1. reconstruction of the breast on which the mastectomy was performed;
2. surgery and reconstruction of the other breast to produce a symmetrical appearance; and
3. prosthesis and treatment for physical complications during all stages of mastectomy, including
swelling of the lymph glands (Iymphedema).
Services are provided in a manner determined in consultation with the physician and patient. Coverage
is provided on the same basis as any other illness.
TABLE OF CONTENTS
INTRODUCTION 1
CUSTOMER SERVICE 2
SPECIAL FEATURES 4
COVERAGE INFORMATION 5
Choosing A Health Care Provider 5
Continuity of Care 5
Liability for Health Care Expenses 6
BlueCard Program 7
Provider Payment Methods 7
Recommendations by Health Care Providers 8
Fraudulent Practices 8
Time Periods 8
Medical Policy Committee 8
NOTIFICATION REQUIREMENTS 9
Prior Authorization 9
Preadmission Notification 11
Emergency Admission Notification 11
CLAIMS PROCEDURES 13
Claims Filing 13
Right of Examination 13
Release of Records 13
Claims Payment 14
REVIEW PROCEDURES 15
Utilization Review 15
Claims Review 16
BENEFIT CHART 18
Benefit Features, Limitations, and Maximums 18
Copays 18
Deductible 18
Out-of-Pocket Maximums 18
Lifetime Maximum 19
Benefit Descriptions 19
Ambulance 20
Chemical Dependency 21
Chiropractic Care 23
Dental Care 24
Emergency Care 25
Home Health Care 26
V1.1.04 PCD 81760 (1/04)
Home Infusion Therapy 28
Hospice Care 29
Hospital Inpatient 31
Hospital Outpatient 32
Infertility Treatment 33
Maternity 34
Medical Equipment, Prosthetics, and Supplies 35
Mental Health Care 37
Organ and Bone Marrow Transplant Coverage 39
Physical Therapy, Occupational Therapy, Speech Therapy 41
Physician Services 42
Prescription Drugs and Insulin 44
Preventive Care 47
Reconstructive Surgery 48
Skilled Nursing Facility 49
Well-Child Care 50
BENEFIT SUBSTITUTION 51
GENERAL EXCLUSIONS 52
ELIGIBILITY 55
Eligible Employees 55
Eligible Dependents 55
Preexisting Condition Limitation for Employees and Covered Dependents 56
Effective Date of Coverage 56
Special Enrollment Periods 57
Coverage Effective Date for Late Entrants 58
TERMINATION OF COVERAGE 59
Termination Events 59
Retroactive Termination 59
Certification of Coverage 60
Extension of Benefits 60
Continuation and Conversion 60
COORDINATION OF BENEFITS 66
Definitions 66
Order of Benefits Rules 67
Effect on Benefits of This Plan 68
Right to Receive and Release Needed Information 68
Facility of Payment 68
Right of Recovery 69
REIMBURSEMENT AND SUBROGATION 70
GENERAL PROVISIONS 71
Plan Administration 71
V1.1.04 PCD 81760 (1/04)
Termination or Changes to the Plan 72
Funding 72
Controlling Law 72
Privacy of Protected Health Information 72
DEFINITIONS 74
V1.1.04 PCD 81760 (1/04)
INTRODUCTION
This Summary Plan Description (SPD) contains a summary of the City of Oak Park Heights Double
Gold Health Care Plan for benefits effective January 1, 2004.
Coverage under this Plan for eligible employees and dependents will begin as defined in the Eligibility
section.
All coverage for dependents and all references to dependents in this Summary Plan Description are
inapplicable for employee-only coverage.
This Plan, financed and administered by the South Central Service Cooperative and City of Oak Park
Heights, is a self-insured medical plan. Blue Cross and Blue Shield of Minnesota (BCBSM), under
contract with the South Central Service Cooperative is the Claims Administrator and provides
administrative services only. The Claims Administrator does not assume any financial risk or obligation
with respect to claims. Payment of benefits is subject to all terms and conditions of this Summary Plan
Description, including medical necessity.
This Plan is not subject to ERISA.
This Plan provides benefits for covered services you receive from eligible health care providers. You
receive the highest level of coverage when you use In-Network Providers. In-Network Providers are
providers that have entered into a service agreement with the Claims Administrator to provide you
quality health services at favorable prices. These providers are also referred to as Participating
Providers. For some services, you may be required to use a special network of Participating Providers
called Blue Select® Providers to receive the highest level of coverage. The Benefit Chart will indicate
which services are provided by this special network. Call 1-800-469-1110 prior to obtaining treatment
for chemical dependency and mental health care and the behavioral health staff will direct you to the
p y aea dt ebe a y
appropriate Behavioral Health Network Provider. If a Behavioral Health Network Provider is not
available within a medically appropriate time for treatment and services, the behavioral health staff will
recommend an alternative provider.
The Plan also provides benefits for covered services you receive from Out-of-Network Providers. In
some cases, you receive a reduced level of coverage when you use these providers. Out-of-Network
Providers include Extended Network and Nonparticipating Providers. Extended Network Providers are
health care professionals that have entered into a service agreement with the Claims Administrator but
do not participate in the special network mentioned above. Nonparticipating Providers have not entered
into a service agreement with the Claims Administrator. You may pay a greater portion of your health
care expenses when you use Nonparticipating Providers.
IMPORTANT! When receiving care, present your identification card to the provider who is rendering
the services. It is also important that you read this entire Summary Plan Description carefully. It
explains the Plan, eligibility, notification procedures, covered expenses, and expenses that are not
covered. If you have questions about your coverage, please contact the Claims Administrator at the
address or phone numbers listed on the following page.
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CUSTOMER SERVICE
Questions? The Claims Administrator's customer service staff is available to answer
your questions about your coverage and direct your calls for preadmission
and emergency admission notification.
Monday through Thursday: 8:00 AM -4:30 PM CT
Friday: 9:00 AM -4:30 PM CT
Hours are subject to change without prior notice.
Customer Service Claims Administrator: (651) 662-5517 or toll free at 1-888-878-0136
Telephone Number
Blue Cross Blue http://www.bluecrossmn.com
Shield of Minnesota
Website
BlueCard Toll free 1-800-810-BLUE (2583)
Telephone Number This number is used to locate providers who participate with Blue Cross and
Blue Shield plans nationwide.
BlueCard Website http://www.bcbs.com
This website is used to locate providers who participate with Blue Cross and
Blue Shield plans nationwide.
Claims Administrator's Claims review requests, and written inquiries may be mailed to the address
Mailing Address below:
Blue Cross and Blue Shield of Minnesota
P.O. Box 64338
St. Paul, MN 55164
Prior authorization requests should be mailed to the following address:
Blue Cross and Blue Shield of Minnesota
Medical Review Department
P.O. Box 64265
St. Paul, MN 55164
Pharmacy Telephone Toll free 1-800-509-0545
Number This number is used to locate a participating pharmacy.
Behavioral Health Toll free 1-800-469-1110
Network Telephone This number is used to direct you to a Behavioral Health Network Provider.
Number
Healthy Start® Toll free 1-866-489-6948 or (651) 662-1818
Telephone Number This number is used to enroll in the Healthy Start Program.
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FirstHelpTM Telephone Toll free 1-800-622-9524
Number This number is used to access health care advice 24 hours a day—seven
days a week.
BluePrint for Health® Toll free 1-800-835-0704
This number is used to enroll in the BluePrint for Health stop smoking
program.
3
SPECIAL FEATURES
Healthy Start
Healthy Start is a program that promotes early, quality prenatal care and provides added support for all
members of the expectant family.
To participate in the program, call the Healthy Start phone line. A registered nurse will work with you to
design a program of risk assessment and education especially for you. The Healthy Start nurse will
work with you and your physician from that point on to promote a healthy pregnancy. As an added
bonus, you will receive a gift if you complete the program.
The Healthy Start number is (651) 662-1818 or toll free 1-866-489-6948. Please call this number to
enroll in Healthy Start or to request further information. You may also contact your Human Resources
Department for an informational brochure.
FirstHelp
FirstHelp is a program that allows you access to health care advice 24 hours a day—seven days a
week. Specially trained nurses can help you make an informed decision about whether to see a doctor
or care for your sickness or injury at home. The First Help TM telephone number is 1-800-622-9524.
FluStopsT
FluStop is a program designed to ensure flu vaccination of all employees. Please check with your
employer for more details regarding the FluStop program.
Tobacco Reduction
BluePrint for Health tobacco reduction is a program designed to reduce tobacco use.
To participate, call BluePrint for Health at 1-800-835-0704. A tobacco cessation specialist will ask a
series of questions to help get you started on the program. A unique computer program then analyzes
your tobacco use behaviors and attitudes to help develop a personalized tobacco use reduction plan for
you. Follow-up can be by phone or mail, whichever you prefer. You will receive materials and
personalized help for up to six months. You can progress at your own pace without any pressure.
Please call to begin your program or to request further information. You may also contact your Human
Resources Department for an informational brochure.
Care Support
This program focuses on disease management for individuals at all health risk levels. The program is
voluntary and is customized to meet your individual unique needs. If you qualify for the program you will
automatically receive a welcome letter and educational materials in the mail, followed by your first
welcome call from the nurse. Future phone calls and personal counseling are provided according to
your condition and level of severity. The program also offers preventive care reminders, educational
materials and special web resources.
You may choose not to participate at any time by calling the care support center and talking to the
program coordinators. If you are invited to participate in the program, or think you are eligible and have
not been invited, you may call toll-free at 1-888-264-1744.
4
COVERAGE INFORMATION
Choosing A Health Care Provider
You may choose any eligible provider of health services for the care you need. The Plan may pay
higher benefits if you choose In-Network Providers.
In-Network Providers
When you choose these providers, you get the most benefits for the least expense and paperwork.
These providers will take care of any notification requirements and send your claims to the Claims
Administrator and the Claims Administrator sends payment to the provider for covered services you
receive. The provider directory lists In-Network Providers and may change as providers enroll or
terminate their agreements. An initial provider directory is provided to you, without charge, when you
become eligible for the Plan. You and your dependents can obtain, without charge, additional copies of
the provider directory from the Plan Administrator, upon your request. For benefit information on these
providers, refer to the Benefit Chart.
Out-of-Network Providers
Extended Network Providers will also take care of any notification requirements and file your claims for
you; however, the benefit level will be less than for services you receive from In-Network Providers.
Nonparticipating Providers may not take care of notification requirements or file claims for you. You
may also pay more of the bill. Refer to the next section for a description of charges that are your
responsibility.
Continuity of Care
Continuity of Care for New Members
If you are new to the Plan this section applies to you. If you are currently receiving care from a provider
or specialist who does not participate with us, you may request to remain with this provider, and
continue to receive care for a special medical need or condition, for a reasonable period of time before
transferring to a participating provider as required under the terms of your coverage with us. We will
authorize this continuation of care if you are engaged in a current course of treatment for any of the
following conditions or situations:
Continuation for up to 120 days:
1. An acute condition;
2. A life-threatening mental or physical illness;
3. A physical or mental disability rendering you unable to engage in one or more major life activities for
at least one year, or that has a terminal outcome;
4. A disabling or chronic condition in an acute phase or that is expected to last permanently;
5. You are receiving culturally appropriate services from a provider with special expertise in delivering
those services; or
6. You are receiving services from a provider that are delivered in a language other than English.
5
Continuation for up to 180 days:
1. A terminal illness in the final stages or for the rest of your life if a physician certifies that your life
expectancy is 180 days or less; or
2. You are receiving or are eligible for hospice services.
Continuation through the first postpartum visit:
1. A pregnancy beyond the first trimester.
Transition to Participating Providers
The Claims Administrator will assist you in making the transition from a nonparticipating to a
participating provider if you request us to do so. Please contact Customer Service for a written
description of the transition process, procedures, criteria, and guidelines.
Liability for Health Care Expenses
Charges That Are Your Responsibility
When you use In-Network and Extended Network Providers for covered services, payment is based on
the allowed amount. You are not required to pay for charges that exceed the allowed amount. You are
required to pay the following amounts:
1. deductibles;
2. copays and coinsurance;
3. charges that exceed the benefit maximum;
4. charges for services that are not covered; and
5. charges for services that are investigative or not medically necessary if you are notified in writing
before you receive services that the services are not covered and you agree in writing to pay all
charges.
When you use Nonparticipating Providers for covered services, payment is still based on the allowed
amount. However, because a Nonparticipating Provider has not entered into a service agreement with
the Claims Administrator, the Nonparticipating Provider is not obligated to accept the allowed amount
as payment in full. You are responsible for payment of any billed charges that exceed the allowed
amount. This means that you may have substantial out-of-pocket expense when you use a
r required to the following amounts:
Nonparticipating Provider. You are equ ed o pay g
1. charges that exceed the allowed amount;
2. deductibles;
3. copays and coinsurance;
4. charges that exceed the benefit maximum;
5. charges for services that are not covered, including services that we determine are not covered
based on claims coding guidelines; and
6
6. charges for services that are investigative or not medically necessary.
If you or the provider fail to contact the Claims Administrator for prior authorization or preadmission
notification, your benefits may be reduced and you could pay additional charges.
BlueCard Program
Liability Disclosure
When you obtain health care services through the BlueCard Program outside the geographic area
BCBSM serves, the amount you pay for covered services is usually calculated on the lower of:
1. The billed charges for your covered services; or
2. The negotiated price that the on-site Blue Cross and/or Blue Shield Plan ("Host Blue") passes on to
the Claims Administrator.
Often, this "negotiated price" consists of a simple discount that reflects the actual price paid by the Host
Blue. Sometimes, however, the negotiated price is either 1) an estimated price that factors expected
settlements, withholds, any other contingent payment arrangements and non-claims transactions with
your health care provider or with a specified group of providers into the actual price; or 2) billed charges
reduced to reflect an average expected savings with your health care provider or with a specified group
of providers. The price that reflects average savings may result in greater variation (more or less) from
the actual price paid than will the estimated price. The negotiated price will be prospectively adjusted to
correct for over-or underestimation of past prices. The amount you pay, however, is considered a final
price and will not be affected by the prospective adjustment.
Statutes in a small number of states may require the Host Blue either 1) to use a basis for calculating
your liability for covered services that does not reflect the entire savings realized or expected to be
realized on a particular claim; or 2) to add a surcharge. If any state statutes mandate liability calculation
methods that differ from the usual BlueCard method noted above or require a surcharge, the Claims
Administrator will calculate your liability for any covered health care services according to the applicable
state statute in effect at the time you received your care.
Provider Payment Methods
Withhold and Bonus Payment Disclosure
Several methods are used to pay our health care providers. Some providers are paid a portion of their
billed charges for each service or bundle of services, and a portion (generally 5—20%) of the provider's
payment is withheld. As an incentive to promote high quality and cost-effective care, the provider may
receive all or a portion of the withhold amount based upon the cost-effectiveness of the provider's care.
In order to determine cost-effectiveness, a per person per month target is established. The target is
established by using historical payment information to predict average costs. If the provider's costs are
below this target, providers are eligible for a return of all or a portion of the withhold amount and may
also qualify for an additional bonus payment.
In addition, as an incentive to promote high quality care and as a way to recognize those providers that
participate in certain quality improvement projects, providers may be paid a bonus based on the quality
of the provider's care to its patients. In order to determine quality of care, certain factors are measured,
such as patient satisfaction feedback on the provider, compliance with clinical guidelines for preventive
7
services or specific disease management processes, immunization administration and tracking, and
tobacco cessation counseling.
The Plan features a large network of providers. Each provider is an independent contractor and is not
our agent. The above is a general summary of our provider withhold and bonus payment methodology
only. While efforts are made to keep this form as up to date as possible, provider payment
methodologies may change from time to time and every current provider payment methodology may
not be reflected in this summary. Please note that this payment methodology may not apply to your
particular plan.
Recommendations by Health Care Providers
In some cases, your provider may recommend or provide written authorization for services that are
� Y P Y P
specifically excluded by the Plan. When these services are referred or recommended, a written
authorization from your provider does not override any specific Plan exclusions.
Fraudulent Practices
Coverage for you or your dependents will be terminated if you or your dependent: falsify medical history
on the application for coverage; submit fraudulent, altered, or duplicate billings for personal gain; and/or
allow another party not covered under the Plan to use your or your dependent's coverage.
Time Periods
When the time of day is important for benefits or determining when coverage starts and ends, a day
P 9 9 Y
begins at 12:00 a.m. and ends at 12:00 a.m. the following day.
Medical Policy Committee
The Claims Administrator's medical policy committee determines whether new or existing medical
treatment should be covered benefits. The committee is made up of independent community physicians
who represent a variety of medical specialties. The committee's goal is to find the right balance
between making improved treatments available and guarding against unsafe or unproven approaches.
The committee carefully examines the scientific evidence and outcomes for each treatment being
considered.
8
NOTIFICATION REQUIREMENTS
Prior Authorization
The Claims Administrator reviews services to verify that they are medically necessary and that the
treatment provided is the proper level of care. Prior authorization from the Claims Administrator is
recommended before you receive selected services so that you avoid incurring charges for services
that may not be considered medically necessary. In-Network and Extended Network Providers will
obtain prior authorization for you.
If you are using a provider that does not participate with the Claims Administrator, you are
responsible for obtaining prior authorization. The Claims Administrator recommends that you or
the provider contact them at least 10 working days prior to receiving the care to determine if the
services are eligible. The Claims Administrator will notify you of their decision within 10 working days,
provided that the prior authorization request contains all the information needed to review the service.
With prior authorization, the Plan guarantees payment for services approved in advance if the services
are otherwise covered under the Plan and you are covered on the date you receive care. All
applicable preexisting condition limitations, exclusions, deductibles, copays, and coinsurance
provisions continue to apply. The prior authorization will indicate a specified time frame in which you
may receive the services. Any service not performed in the specific time frame will need to be prior
authorized again. You will be responsible for payment of services that the Claims Administrator
determines are not medically necessary.
While all services must be medically necessary, prior authorization is recommended for certain
services. This list is subject to change due to changes in medical policy. The most current list is
available by calling Customer Service.
1. Acupuncture
2. Apheresis
3. Bariatric surgery (all procedures)
4. Blepharoplasty
5. Chiropractic care
6. Coverage of routine care related to cancer clinical trials
7. Deep brain stimulation for treatment of movement disorders
8. Drugs, including, but not limited to the following
a. Alefacept (Amevive)
b. Factor products for the treatment of bleeding disorders
c. Growth hormones
d. Injectable fertility medications (except HCG drugs)
e. Intravenous immune globulin (IVIG)
f. Leuprolide acetate (Lupron) (all uses except for cancer-related diagnoses)
g. Omalizumab (Xolair)
9. Durable Medical Equipment (DME), including, but not limited to the following
a. All unlisted DME over $1,000
9
b. Gravity lumbar reduction
c. Hearing devices
d. Home prothrombin time monitors
e. Specialty beds
f. Uterine contraction monitors
g. Vest percussors
h. Wound healing treatment/devices
10. Endoluminal radiofrequency for treatment of refluxing greater saphenous vein
11. Extracorporeal shock wave treatment for plantar fasciitis and other musculoskeletal conditions
12. Gender reassignment
13. Gynecomastia
14. Home health/Hospice services
15. Humanitarian use devices
16. Hyperhidrosis surgery
17. Hypnotherapy
18. Implantable ventricular assist systems and artificial hearts
19. Infertility treatment
20. Lung volume reduction surgery
21. Mastoplexy
22. Outpatient pain rehabilitation
23. Panniculectomy
24. Pediatric sleep studies/polysomnograms
25. Physical, occupational, and speech therapy for multiple sclerosis or for children under age 10 with
cerebral palsy when services are received from a Participating Provider or for all services received
from a Nonparticipating Provider
26. Reduction mammoplasty
27. Respiratory syncytial virus prophylaxis after age two (2)
28. Rhinoplasty
29. Scar excision/revision
30. Sclerotherapy for varicose veins of the lower extremities
31. Spinal cord stimulation
32. Surgical treatment of obstructive sleep apnea and upper airway resistance syndrome
33. Temporomandibular joint/craniomandibular disorder surgery and temporomandibular joint
arthroscopy
34. Transplants
a. Autologous islet cell transplants
b. Organ transplant procedures
10
4
c. Stem cell and bone marrow procedures
35. Vagus nerve stimulation
All requests for prior authorization must be submitted to the Claims Administrator in writing.
Please submit your request to the address provided in the Customer Service section.
Preadmission Notification
Preadmission notification is required at least five (5) days in advance of being admitted for inpatient
care for any type of nonemergency service and for partial hospitalization, day treatment or intensive
outpatient treatment for behavioral health conditions. In-Network and Extended Network Providers will
provide preadmission notification to the Claims Administrator for you. With preadmission notification,
the Plan guarantees payment for days or services the Claims Administrator authorizes if the services
are otherwise covered under the Plan, and you are covered on the date you receive the services.
If you are going to receive nonemergency care from a Nonparticipating Provider, you are
responsible for providing preadmission notification to the Claims Administrator.
If the Claims Administrator is not notified, a penalty will apply. The Claims Administrator reduces the
allowed amount for the admission by 25 percent before applying deductibles or copays. This means
that without preadmission notification, you will pay a greater portion of the charges. If preadmission
notification is not provided and services are later determined not to be medically necessary, you are
also responsible for payment of those charges.
Preadmission notification is required for the following facilities:
1. Hospitals
a. Acute care admissions
b. Rehabilitation admissions
2. Skilled nursing facilities
3. Residential behavioral health treatment facilities
4. Outpatient behavioral health treatment facilities providing partial hospitalization, day treatment or
intensive outpatient treatment
To provide p ovide preadmission notification, call the customer service number provided in the
Customer Service section. They will direct your call.
Emergency Admission Notification
Notice is required as soon as reasonabl y possible for admission f r pregnancy or for a
emergency or injury that occurred within 48 hours before admission.
If you have an emergency admission to a Nonparticipating Provider, you or the provider must notify the
Claims Administrator as soon as reasonably possible.
11
The Plan pays only for services the Claims Administrator determines are medically necessary. There is
no penalty for failure to notify the Claims Administrator of an emergency admission if the Claims
Administrator determines that the admission was medically necessary.
To provide emergency admission notification, call the customer service number provided in the
Customer Service section. They will direct your call.
12
CLAIMS PROCEDURES
Claims Filing
You are not responsible for submitting claims for services received from In-Network and Extended
Network Providers. These providers will submit claims directly to the Claims Administrator for you and
payment will be made directly to them. If you receive services from Nonparticipating Providers, you may
have to submit the claims yourself. If the provider does not submit the claim for you, send the claim to
the Claims Administrator at the address provided in the Customer Service section.
Claims should be filed in writing within 90 days after a covered service is provided. If this is not
reasonably possible, the Plan will accept claims for up to 15 months after the date of service. Normally,
failure to file a claim within the required time limits will result in denial of your claim. These time limits
are waived if you cannot file the claim because you are legally incapacitated. You may be required to
provide copies of bills, proof of payment, or other satisfactory evidence showing that you have incurred
a covered expense that is eligible for reimbursement.
The Claims Administrator will notify you of the resolution of the claim on an Explanation of Health Care
Benefits (EHCB) form within 30 days of the date the Claims Administrator receives the claim. If, due to
matters beyond its control, the Claims Administrator is unable to make a determination within 30 days,
the Claims Administrator may take an additional 15 days to make a determination and will inform you in
advance of the reasons for the extension. If you do not receive a written explanation within 30 days (or
45 days if there has been an extension) you may consider the claim denied, and you may request a
review of the denial.
If benefits are denied in whole or in part, the reason for the denial will be listed on the bottom of the
EHCB form. You have the right to know the specific reasons for the denial, the provision of the Plan on
which the denial was based, and if there is any additional information the Claims Administrator needs to
process the claim. You also have the right to an explanation of the claims review procedure and the
steps you need to take if you wish to have your claim reviewed. If you have questions that the EHCB
form does not answer, please contact the Claims Administrator at the address or phone numbers
provided in the Customer Service section.
Right of Examination
The Claims Administrator and the Plan Administrator each have the right to ask you to be examined by
a provider during the review of any claim. The Plan pays for the exam whenever the exam is requested
by either the Claims Administrator or the Plan Administrator. Failure to comply with this request may
result in denial of your claim.
Release of Records
You agree to allow all health care providers to give the Claims Administrator needed information about
the care they provide to you. The Claims Administrator may need this information to process claims,
conduct utilization review and quality improvement activities, and for other health plan activities as
permitted by law. The Claims Administrator keeps this information confidential, but the Claims
Administrator may release it if you authorize release, or if state or federal law permits or requires
release without your authorization. If a provider requires special authorization for release of records,
you agree to provide this authorization. Your failure to provide authorization or requested information
may result in denial of your claim.
13
Claims Payment
When you use In-Network and Extended Network Providers and providers outside Minnesota who
participate with other Blue Cross and Blue Shield plans nationwide for covered services, the Plan pays
the provider. When you use a Nonparticipating Provider either inside or outside the State of Minnesota
for covered services, the Plan pays you. You may not assign your benefits to a Nonparticipating
Provider, except when parents are divorced. In that case, the custodial parent may request, in writing,
that the Plan pay a Nonparticipating Provider for covered services for a child. When the Plan pays the
provider at the request of the custodial parent, the Plan has satisfied its payment obligation.
14
REVIEW PROCEDURES
Utilization Review
Some health care services, procedures, or facility admissions require utilization review. Utilization
review is the evaluation of the necessity, appropriateness, and efficacy of the use of health care
services, procedures and facilities, by a person or entity other than the attending health care
professional, for the purpose of determining the medical necessity of the service or admission.
Utilization review applies only when the service, procedure, or facility admission requested is otherwise
covered under this plan.
Participating providers will request utilization review for you. If you are requesting services from a
nonparticipating provider, you may request utilization review by calling the customer service number
provided in the Customer Service section. Please refer to the section entitled Notification
Requirements.
In order to conduct utilization review, the Claims Administrator will need specific information. If you or
your attending health care professional do not release necessary information, approval of the requested
service, procedure, or facility admission may be denied. Utilization review includes a process to appeal
decisions to not cover a health care service, procedure, or facility admission.
Initial Review
When utilization review is required, the Claims Administrator will notify you and your attending
health care professional or provider of the determination within 10 business days of the request
provided that all information reasonably necessary to make a determination has been made
available to the Claims Administrator.
Your attending health care professional may request an expedited review. The Claims
Administrator will notify you and your attending health care professional or provider of the
determination as soon as your medical condition requires, but no later than 72 hours from the
initial request.
Appeals
Utilization review determinations may also be appealed. You or your attending health care
professional may appeal the Claims Administrator's decision to not authorize services in writing
or by telephone. The Claims Administrator will notify you and your attending health care
professional of its determination within 30 days of receipt of your appeal. The Claims
Administrator may take up to 14 additional days to make a determination due to circumstances
outside its control. If the Claims Administrator takes more than 30 days to make a
determination, the Claims Administrator will notify you in advance of the reasons for the
extension.
You or your attending health care professional may request an expedited appeal. When an
expedited appeal is completed, the Claims Administrator will notify you and your attending
health care professional of the determination as soon as your medical condition requires, but no
later than 72 hours from the Claims Administrator's receipt of the expedited appeal request.
The request for appeal of a utilization review determination should include:
1. Your name, identification number and group number
2. The actual service for which coverage was denied
3. A copy of the denial letter
15
4. The reason why you or your attending health care professional believe the service should be
provided
5. Any available medical information to support your reasons for reversing the denial
6. Any other information you believe will be helpful.
External Review
You or your attending health care professional may request an external review of the final
determination the Claims Administrator makes about your utilization review appeal. The State of
Minnesota has contracted with an independent organization to conduct the external review of
your appeal. This independent organization meets the state's requirements to conduct external
review of health-related disputes. Your written request for external review must be submitted to
the Commissioner of Commerce along with a filing fee of$25. The commissioner may waive the
fee in cases of financial hardship.
You may request external review by contacting the Department of Commerce at:
Minnesota Department of Commerce
Attention: Enforcement Division
Suite 500
85 Seventh Place East
St. Paul, Minnesota 55101
The external review organization will notify you and the Claims Administrator that it has received
your request for external review. Within 10 business days of receiving notice from the external
review organization, you and the Claims Administrator must provide the external review
organization any information to be considered. Both you and the Claims Administrator will be
able to present a statement of facts and arguments. You may be assisted or represented by any
person of your choice at your expense. The external review organization will send written notice
of its decision to you, the Claims Administrator, and the commissioner within 40 days of
receiving the request for external review. The external review organization's decision is binding
on the Claims Administrator, but not binding on you.
Claims Review
If you disagree with the action the Claims Administrator has taken on your claim, the Claims
Administrator will review the resolution of your claim using the process outlined below. You may
request an external review of the final determination the Claims Administrator makes about your
request after you have exhausted the Claims Administrator's appeal process. You may contact the
Commissioner of Commerce at any time by calling 1-800-657-3602 or 651-296-4026.
Initial Review
If you disagree with the action the Claims Administrator has taken on your claim, call the Claims
Administrator for an explanation of the claim's resolution at the number provided in the
Customer Service section. The Claims Administrator will try to review the resolution of your
claim within 10 days.
Appeals
If you are not satisfied with the Claim's Administrator's explanation of the claim's resolution, you
may request that your claim be reviewed. You may submit your request for review in writing, or
you may request a form that will include all the necessary information to file your written request
for review. If you need assistance, the Claims Administrator will complete the form and mail it to
16
you for your signature. The Claims Administrator will notify you within 10 days that they have
received your written request for review. Within 30 days of receiving your written request and all
necessary information, the Claims Administrator will notify you in writing of its determination and
the reasons for the determination. If the Claims Administrator is unable to make a determination
within 30 days due to circumstances outside its control, the Claims Administrator may take up to
14 additional days to make a determination. If the Claims Administrator takes more than 30
days to make a determination, the Claims Administrator will inform you in advance of the
reasons for the extension.
If you disagree with the action the Claims Administrator has taken on your written request for
review, you may appeal the determination in writing and request either a hearing or a written
reconsideration. If you request a hearing, you and any person you choose may present
testimony or other information. The Claims Administrator will provide you written notice of its
determination and all key findings within 45 days after the Claims Administrator receives your
written request for a hearing. If you request a written reconsideration, you may provide the
Claims Administrator with any additional information you believe is necessary. The Claims
Administrator will provide you written notice of its determination and all key findings within 30
days after the Claims Administrator receives your request for a written reconsideration. You are
entitled to examine all pertinent documents and to submit issues and comments in writing. If you
request, the Claims Administrator will provide you a complete summary of the appeal decision.
External Review
If your appeal concerns a covered health care service or claim and you disagree with the Claims
Administrator's appeal determination, you or anyone you authorize to act on your behalf, may
submit the appeal determination to external review. The State of Minnesota has contracted with
an independent organization to conduct the external review of your appeal. This independent
organization meets the state's requirements to conduct external review of health-related
disputes. Your written request for external review must be submitted to the Commissioner of
Commerce along with a filing fee of$25. The commissioner may waive the fee in cases of
financial hardship.
You may request external review by contacting the Department of Commerce at:
Minnesota Department of Commerce
Attention Enforcement Division
Suite 500
85 Seventh Place East
St. Paul, Minnesota 55101
The external review organization will notify you and the Claims Administrator that it has received
your request for external review. Within 10 business days of receiving notice from the external
review organization, you and the Claims Administrator must provide the external review
organization any information to be considered. Both you and the Claims Administrator will be
able to present a statement of facts and arguments. You may be assisted or represented by any
person of your choice at your expense. The external review organization will send written notice
of its decision to you, the Claims Administrator, and the commissioner within 40 days of
receiving the request for external review. The external review organization's decision is binding
on the Claims Administrator, but not binding on you.
17
BENEFIT CHART
This section lists covered services and the benefits the Plan pays. All benefit payments are
based on the allowed amount. Coverage is subject to all other terms and conditions of this
Summary Plan Description and must be medically necessary.
Benefit Features, Limitations, and Maximums
Benefit Features Your Liability
Copays
• Emergency room facility copay $60
• Prescription drugs:
■ Formulary drug copay (retail pharmacy) $4.50
• Formulary drug copay (mail services $9.00
pharmacy)
• Nonformulary drug copay (retail $10.00
pharmacy)
• Nonformulary drug copay (mail services $20.00
pharmacy)
Y)
Deductible
(Deductible carryover applies)
(Does not include prescription drug copays)
• Out-of-Network Providers $300 per person per calendar year
$900 per family per calendar year
Benefit Features Limitations and Maximums
Out-of-Pocket Maximums
• All providers combined $2,500 per person per calendar year
(Does not include prescription drug copays)
• Prescription Drug Out-of-Pocket Maximum $150 per person per calendar year
(Does not include drugs used during inpatient
admission)
18
Lifetime Maximum
• Total benefit paid to all providers combined $3 million per person
Benefit Descriptions
Please refer to the following pages for a more detailed description of Plan benefits.
19
Ambulance
The Plan Covers: In-Network Providers Out-of-Network Providers
• Air or ground transportation 80% 80%
for basic or advanced life
support from the place of
departure to the nearest
facility equipped to treat the
illness
• Medically necessary,
prearranged or scheduled air
or ground ambulance
transportation requested by
an attending physician or
nurse
NOTES:
• Please see the Notification Requirements section.
• If the Claims Administrator determines air ambulance was not medically necessary but ground
ambulance would have been, the Plan pays up to the allowed amount for medically necessary
ground ambulance.
NOT COVERED:
• transportation services that are not medically necessary for basic or advanced life support
• transportation services that are mainly for your convenience
• please refer to the General Exclusions section
20
Chemical Dependency
The Plan Covers: In-Network Providers Out-of-Network Providers
• Outpatient health care 100% when you use a 80% after you pay the
professional charges Behavioral Health Network deductible when you use an
Provider. Extended Network or a
Nonparticipating Provider.
• Outpatient 100% 80% after you pay the
hospital/outpatient deductible.
behavioral health facility
charges
• Inpatient health care 100% when you use a 80% after you pay the
professional charges Behavioral Health Network deductible when you use an
Provider. Extended Network or a
Nonparticipating Provider.
• Inpatient hospital/residential 100% 80% after you pay the
behavioral health facility deductible.
charges
NOTES:
• Please see the Notification Requirements section.
• To receive the highest level of coverage you must use a Behavioral Health Network Provider.
Call 1-800-469-1110 prior to obtaining treatment and the behavioral health staff will direct
you to the appropriate Behavioral Health Network Provider. If a Behavioral Health Network
Provider is not available within a medically appropriate time for treatment and services, the
behavioral health staff will recommend an alternative provider.
• Court-ordered treatment for mental health and chemical dependency care that is based on an
evaluation and recommendation for such treatment or services by a physician or a licensed
psychologist, a licensed alcohol and drug dependency counselor or a certified chemical
dependency assessor is deemed medically necessary. An initial court-ordered exam for a
dependent child under the age of 18 is also considered medically necessary without further review
by the Claims Administrator.
• Court-ordered treatment for mental health and chemical dependency care that is not based on an
evaluation and recommendation as described above will be evaluated to determine medical
necessity. Court-ordered treatment will be covered if it is determined to be medically necessary and
otherwise covered under this Plan.
• Outpatient family therapy is covered if part of a recommended treatment plan.
• Admissions that qualify as "emergency holds", as the term is defined in Minnesota Statutes, are
considered medically necessary for the entire admission.
• For lab and x-ray services billed by a professional, please refer to Physician Services. For lab and
x-ray billed by a facility, please refer to Hospital Inpatient or Hospital Outpatient.
• For mental health and chemical dependency services or treatment, the allowed amount for
Nonparticipating Providers is either at the amount agreed to between the Claims Administrator and
the provider, or if no such agreement, the lesser of the provider's billed charges or the prevailing
payment amount for the treatment or services in the area where services are performed.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
21
NOT COVERED:
• services to hold or confine a person under chemical influence when no medical services are
required
• custodial and supportive care
• court-ordered services that are not medically necessary
• please refer to the General Exclusions section
22
Chiropractic Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• Chiropractic care 100% when you use a Blue 80% after you pay the
Select Provider. deductible when you use an
Extended Network Provider.
When you use a
Nonparticipating Provider, there
is NO COVERAGE unless an
exception is noted below.
NOTES:
• Please see the Notification Requirements section.
• You must use a Blue Select Provider to obtain the highest level of coverage.
• There is no coverage for services you receive from a Nonparticipating Provider unless the provider
is located outside the State of Minnesota and is a member of the participating network of their local
I Cross
Blue C oss and/or Blue Shield Plan.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• services primarily educational in nature
• vocational rehabilitation
• self-care and self-help training (non-medical)
• health clubs and spas
• recreational therapy
• rehabilitation services that are not expected to make measurable or sustainable improvement within
a reasonable period of time
• please refer to the General Exclusions section
23
Dental Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• Treatment from a physician 100% 80% after you pay the
or dentist for an accidental deductible.
injury to sound natural teeth
when performed within 12
months from the date of
injury
• Treatment of cleft lip and
palate for a dependent child
under age 18
NOTES:
• Please see the Notification Requirements section.
• Treatment must occur while you are covered under this Plan.
• The Plan covers anesthesia and inpatient and outpatient hospital charges for dental care provided
to a covered person who is a child under age five (5); is severely disabled; or has a medical
condition that requires hospitalization or general anesthesia for dental treatment.
• The Plan covers surgical and nonsurgical treatment of temporomandibular joint disorder(TMJ) and
craniomandibular disorder on the same basis as any other body joint.
• Orthognathic dental procedures, for dependent children only, may be covered under the
Reconstructive Surgery Benefit.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• dental services to treat an injury from biting or chewing
• dental implants and prosthesis, including any related hospital charges
• osteotomies and other procedures associated with the fitting of dentures or dental implants
• any orthodontia, including associated orthognathic procedures or accident-related dental injuries,
except when related to the treatment of cleft lip and palate
• oral surgery and anesthesia for removal of impacted teeth and removal of a tooth root without
removal of the whole tooth
• root canal therapy
• tooth extractions, unless otherwise specified as covered
• accident-related dental services performed more than 12 months after the date of injury
• any other dental procedure or treatment
• please refer to the General Exclusions section
24
Emergency Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• Outpatient hospital/facility
charges
• emergency room 100% after you pay the 100% after you pay the
emergency room facility copay. emergency room facility copay.
• Outpatient health care 100% 80% after you pay the
professional charges deductible.
NOTES:
• Please see the Notification Requirements section.
• When determining if a situation is a medical emergency, the Claims Administrator will take into
consideration a reasonable layperson's belief that the circumstances required immediate medical
care that could not wait until the next business day.
• The emergency room facility copay is waived if you are admitted within 24 hours.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• please refer to the General Exclusions section
25
Home Health Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• Skilled care ordered in 100% 80% after you pay the
writing by a physician and "deductible.
provided by Medicare
approved or other
preapproved home health
agency employees,
including, but not limited to:
• registered nurse;
• licensed registered
physical therapist;
• master's level clinical
social worker;
• registered occupational
therapist;
• certified speech and
language pathologist;
• medical technologist; or
• registered dietician
• Services of a home health
aide or social worker
employed by the home
health agency when
provided in conjunction with
services provided by the
above listed agency
employees
• Use of appliances that are
owned or rented by the
home health agency
• Medical supplies provided by
the home health agency
• Home health care following
early maternity discharge.
See Maternity.
NOTES:
• Please see the Notification Requirements section.
• Coverage is limited to a maximum benefit of$25,000 per person per calendar year.
• The one (1) home health care visit following early maternity discharge does not apply to the
$25,000 maximum.
• Benefits for home infusion therapy and related home health care are listed under Home Infusion
Therapy.
26
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• custodial or nonskilled care
• services of a nonmedical nature
• please refer to the General Exclusions section
27
Home Infusion Therapy
The Plan Covers: In-Network Providers Out-of-Network Providers
• Home infusion therapy 80% When you use a
services when ordered by a Nonparticipating Provider, there
physician is NO COVERAGE unless an
exception is noted below.
• Solutions and
pharmaceutical additives,
pharmacy compounding and
dispensing services
• Durable medical equipment
• Ancillary medical supplies
• Nursing services to:
• train you or your
caregiver; or
• monitor your home
infusion therapy
• Collection, analysis, and
reporting of lab tests to
monitor response to home
infusion therapy
• Other eligible home health
services and supplies
provided during the course
of home infusion therapy
NOTES:
• Please see the Notification Requirements section.
• There is no coverage for services you receive from a Nonparticipating Provider unless the provider
is located outside the State of Minnesota and is a member of the participating network of their local
Blue Cross and/or Blue Shield Plan.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• home infusion services or supplies not specifically listed as covered services
• nursing services to administer therapy that you or another caregiver can be successfully trained to
administer
• services that do not involve direct patient contact, such as delivery charges and recordkeeping
• please refer to the General Exclusions section
28
Hospice Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• Hospice care for terminally ill 100% When you use an Out-of-
patients provided by a Network Provider, there is NO
Medicare approved hospice COVERAGE.
provider or other
preapproved hospice
• Inpatient and outpatient
hospital care, routine and
continuous home nursing
care, home health aide
visits, physical therapy,
speech and language
therapy, occupational
therapy, social worker visits,
dietary/nutritional
counseling, durable medical
equipment, routine medical
supplies and other
supportive services provided
to meet the physical,
psychological, spiritual, and
social needs of the dying
individual
• Prescription drugs, in-home
lab services, IV therapy, and
other supplies related to the
terminal illness or injury
prescribed by the attending
physician or any physician
that is part of the hospice
care team
• Instructions for the care of
the dying patient,
bereavement counseling,
respite care and other
supportive services for the
family of the dying individual,
both before and after the
death of the individual
NOTES:
• Please see the Notification Requirements section.
• Medical care services unrelated to the terminal illness may be covered according to other Plan
benefits and requirements.
• Services provided by the primary care physician are covered but are separate from the hospice
benefit.
29
• Services provided by a skilled nursing facility are covered but are separate from the hospice benefit.
• Prior approval is required for entrance into the hospice benefit, for any inpatient admission while the
patient is receiving hospice benefits, for any patient living beyond six (6) months, and for
determination of coverage for services unrelated to the terminal illness.
• Benefits are restricted to terminally ill patients with a life expectancy of six (6) months or less. The
patient's primary physician must certify in writing a life expectancy of six (6) months or less.
Hospice benefits begin on the date of admission to a hospice program with prior approval.
• Coverage for respite care is limited to not more than five (5) consecutive days at a time up to a
maximum of 15 days during the episode of hospice care.
• There is no coverage for services you receive from an Out-of-Network Provider.
NOT COVERED:
• room and board expenses in a non-approved residential hospice facility
• please refer to the General Exclusions section
30
Hospital Inpatient
The Plan Covers: In-Network Providers Out-of-Network Providers
• Semiprivate room and board 100% 80% after you pay the
and general nursing care deductible.
(private room is covered only
when medically necessary)
• Intensive care and other
special care units
• Operating, recovery, and
treatment rooms
• Anesthesia
• Prescription drugs and
supplies used during a
covered hospital stay
• Lab and x-ray
• Communication services of a
personal care assistant up to
120 hours during a hospital
admission
NOTES:
• Please see the Notification Requirements section.
• The Plan covers kidney and cornea transplants. For other kinds of transplants, refer to Organ and
Bone Marrow Transplant Coverage.
• The Plan covers the following kidney donor services when billed under the donor recipient's name
and the donor recipient is covered for the kidney transplant under the Plan:
• potential donor testing
• donor evaluation and work-up; and
• hospital and professional services related to organ procurement
• The Plan covers anesthesia and inpatient hospital charges for dental care provided to a covered
person who is a child under age five (5); is severely disabled; or has a medical condition that
requires hospitalization or general anesthesia for dental treatment.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• communication services provided on an outpatient basis or in the home
• travel expenses for a kidney donor
• kidney donor expenses for complications incurred after the organ is removed if the donor is not
covered under this Plan
• kidney donor expenses when the recipient is not covered for the kidney transplant under this Plan
• please refer to the General Exclusions section
31
Hospital Outpatient
The Plan Covers: In-Network Providers Out-of-Network Providers
• Scheduled 100% 80% after you pay the
surgery/anesthesia deductible.
• Radiation and chemotherapy
• Kidney dialysis
• Respiratory therapy
• Physical, occupational, and
speech therapy
• Lab and x-ray
• Diabetes outpatient self-
management training and
education, including medical
nutrition therapy
• All other eligible outpatient
hospital care
NOTES:
• Please see the Notification Requirements section.
• The Plan covers anesthesia and outpatient hospital charges for dental care provided to a covered
person who is a child under age five (5); is severely disabled; or has a medical condition that
requires hospitalization or general anesthesia for dental treatment.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• please refer to the General Exclusions section
32
Infertility Treatment
The Plan Covers: In-Network Providers Out-of-Network Providers
• Artificial and intrauterine 100% 80% after you pay the
insemination procedures deductible.
• Related services and
supplies
• Prescription drugs for eligible For the level of coverage, refer For the level of coverage, refer
infertility treatment to Prescription Drugs and to Prescription Drugs and
Insulin. Insulin.
NOTES:
• Please see the Notification Requirements section.
• Benefits for artificial insemination (Al) or intrauterine insemination (IUI) procedures are limited to six
(6) cycles per patient per lifetime, or per pregnancy. The six (6)-cycle limit will be renewed if
successful pregnancy is attained. Pregnancy must be confirmed by a live birth, an ultrasound, or by
a miscarriage documented by a pathology report.
• Benefits for injectable prescription drugs for eligible infertility treatment are limited to six (6) cycles
per person per lifetime, or per pregnancy. The six (6)-cycle limit will be renewed if successful
pregnancy is attained. Pregnancy must be confirmed by a live birth, an ultrasound, or by a
miscarriage documented by a pathology report.
• Any cycle billed to the Claims Administrator using artificial insemination, intrauterine insemination,
and/or injectable prescription drugs will be applied to the six (6)-cycle maximum. If the patient
abandons a treatment regimen before the cycle is complete, the partial cycle may be counted as
one of the six (6) eligible cycles or the patient may assume all charges for that cycle in order to
preserve benefits for six (6) complete cycles.
• A cycle is defined as one (1) partial or complete fertilization attempt extending through the
implantation phase only.
• Refer to Hospital Inpatient and Hospital Outpatient for facility charges.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• reversal of sterilization
• sperm banking
• donor ova or sperm
• services and prescription drugs for or related to assisted reproductive technology (ART)
procedures, except that the Plan does cover artificial and intrauterine insemination procedures
• services and prescription drugs for or related to gender selection services
• please refer to the General Exclusions section
33
Maternity
The Plan Covers: In-Network Providers Out-of-Network Providers
• Health care professional and 100% 80% after you pay the
hospital/facility charges for deductible.
prenatal care
• Health care professional
services for:
• delivery in a
hospital/facility
• postpartum care
• Hospital/facility charges for
inpatient hospital care
NOTES:
• Please see the Notification Requirements section.
• Please refer to the Eligibility section to determine when baby's coverage will begin.
• Under Federal law, group health plans such as this Plan generally may not restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn child to less than 48
hours following a vaginal delivery, or less than 96 hours following a cesarean section. However,
Federal law generally does not prohibit the mother's or newborn child's attending provider, after
consultation with the mother, from discharging the mother or her newborn child earlier than 48
hours (or 96 hours as applicable).
• Under Federal law, the Plan may not require that a provider obtain authorization from the Plan for
prescribing a length of stay less than the 48 hours (or 96 hours) mentioned above.
• The Plan covers one (1) home health care visit within four (4) days of discharge from the hospital if
either the mother or the newborn child is confined for a period less than the 48 hours (or 96 hours)
mentioned above. See Home Health Care.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• health care professional charges for deliveries in the home
• adoption
• surrogate pregnancy
• child-birth classes
• please refer to the General Exclusions section
34
Medical Equipment, Prosthetics, and Supplies
The Plan Covers: In-Network Providers Out-of-Network Providers
• Durable medical equipment 80% 80%
(DME), including
wheelchairs, ventilators,
oxygen, oxygen equipment,
continuous positive airway
pressure (CPAP) devices
and hospital beds
• Medical supplies, including
splints, nebulizers, surgical
stockings, casts, and
dressings
• Insulin pumps, glucometers
and related equipment and
devices
• Blood, blood plasma, and
blood clotting factors
• Prosthetics, including breast
prosthesis, artificial limbs,
and artificial eyes
• Special dietary treatment for
Phenylketonuria (PKU) when
recommended by a
physician
• Corrective lenses for
aphakia
• Hearing aids for children age
18 and younger who have a
hearing loss due to a
congenital malformation that
cannot be corrected by other
covered procedures.
Maximum of one (1) hearing
aid for each ear every three
(3) years.
• Cochlear implants
Scalp hair prosthesis (wigs)
provided hair loss is due to
alopecia areata. Maximum of
$350 per person per
calendar year.
35
• Custom foot orthotics if you
have a diagnosis of diabetes
with neurological
manifestations and you have
arthropathy and/or ulcer(s) of
the lower limbs.
NOTES:
• Please see the Notification Requirements section.
• Durable medical equipment is covered up to the allowed amount to rent or buy the item. Allowable
rental charges are limited to the allowed amount to buy the item.
• Coverage for durable medical equipment will not be excluded solely because it is used outside the
home.
• For coverage of insulin and diabetic supplies, refer to Prescription Drugs and Insulin.
• Rental of an electric breast pump is eligible for coverage only when there is maternal-infant
separation due to illness, prematurity, or hospitalization and only for the duration of the separation.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• solid or liquid food, standard and specialized infant formula, banked breast milk, nutritional
supplements and electrolyte solution, except when administered by tube feeding
• personal and convenience items or items provided at levels which exceed the Claims
Administrator's determination of medically necessary
• services or supplies that are primarily and customarily used for a nonmedical purpose or used for
environmental control or enhancement (whether or not prescribed by a physician), including, but not
limited to: exercise equipment, air purifiers, air conditioners, dehumidifiers, heat/cold appliances,
water purifiers, hypoallergenic mattresses, waterbeds, computers and related equipment, car seats,
feeding chairs, pillows, food or weight scales, hot tubs, whirlpools, and incontinence pads or pants
• modifications to home, vehicle, and/or the workplace, including vehicle lifts and ramps
• blood pressure monitoring devices
• communication devices, except when exclusively used for the communication of daily medical
needs and without such communication the patient's medical condition would deteriorate
• eyeglasses, contact lenses, or other optical devices or professional services to fit or supply them,
except as provided in this Benefit Chart
• duplicate equipment, prosthetics, or supplies
• services for or related to arch supports, orthopedic shoes, and foot orthotics, including, but not
limited to, such related services as biomechanical evaluation, range of motion measurements and
report, and negative foot mold impressions except as provided in this Benefit Chart
• hearing aids or devices, whether internal, external, or implantable, and related fitting or adjustment,
except as specified in this Benefit Chart
• non-prescription supplies such as alcohol, cotton balls and alcohol swabs
• rental or purchase of a manual breast pump and/or the purchase of an electric breast pump
• please refer to the General Exclusions section
36
Mental Health Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• Outpatient health care 100% when you use a 80% after you pay the
professional charges Behavioral Health Network deductible when you use an
Provider. Extended Network or a
Nonparticipating Provider.
• Outpatient 100% 80% after you pay the
hospital/outpatient deductible.
behavioral health facility
charges
• Inpatient health care 100% when you use a 80% after you pay the
professional charges Behavioral Health Network deductible when you use an
Provider. Extended Network or a
Nonparticipating Provider.
• Inpatient hospital/residential 100% 80% after you pay the
behavioral health facility deductible.
charges
NOTES:
• Please see the Notification Requirements section.
• To receive the highest level of coverage you must use a Behavioral Health Network Provider.
Call 1-800-469-1110 prior to obtaining treatment and the behavioral health staff will direct
you to the appropriate Behavioral Health Network Provider. If a Behavioral Health Network
Provider is not available within a medically appropriate time for treatment and services, the
behavioral health staff will recommend an alternative provider.
• Court-ordered treatment for mental health and chemical dependency care that is based on an
evaluation and recommendation for such treatment or services by a physician or a licensed
psychologist, a licensed alcohol and drug dependency counselor or a certified chemical
dependency as sesso r is deemed medically necessary. An initial court-ordered exam for
a
dependent child under the age of 18 is also considered medically necessary without further review
by the Claims Administrator.
• Court-ordered treatment for mental health and chemical dependency care that is not based on an
evaluation and recommendation as described above will be evaluated to determine medical
necessity. Court-ordered treatment will be covered if it is determined to be medically necessary and
otherwise covered under this Plan.
• Outpatient family therapy is covered if part of a recommended treatment plan.
• Coverage is provided for diagnosable mental health conditions, including autism and eating
disorders.
• Treatment of emotionally handicapped children in a licensed residential treatment facility is covered
the same as any other inpatient hospital medical admission.
• For lab and x-ray services billed by a professional, please refer to Physician Services. For lab and
x-ray billed by a facility, please refer to Hospital Inpatient or Hospital Outpatient.
• For mental health and chemical dependency services or treatment, the allowed amount for
Nonparticipating Providers is either at the amount agreed to between the Claims Administrator and
the provider, or if no such agreement, the lesser of the provider's billed charges or the prevailing
payment amount for the treatment or services in the area where services are performed.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
37
NOT COVERED:
• services for mental illness not listed in the most recent edition of International Classification of
Diseases
• custodial and supportive care
• court-ordered services that are not medically necessary
• services for marriage counseling or training services
• please refer to the General Exclusions section
38
Organ and Bone Marrow Transplant Coverage
Blue Quality Centers for Non-Blue Quality Centers for
The Plan Covers: Transplant (BQCT) Providers Transplant (BQCT) Providers
The following human organ and 100% of the Transplant Participating Transplant Provider
bone marrow transplant and Payment Allowance for the
peripheral stem cell support transplant admission. 80% after you pay the
procedures: deductible of the Transplant
If you live more than 50 miles Payment Allowance for the
• Allogeneic and syngeneic from a BQCT Provider, there transplant admission.
bone marrow transplant and may be benefits available for
peripheral stem cell support travel, meals and lodging Nonparticipating Transplant
procedures expenses directly related to a Provider
preauthorized transplant. For
• Autologous bone marrow more information contact the NO COVERAGE.
transplant and peripheral Transplant Coordinator at the
stem cell support procedures number listed below. For services not included in the
Transplant Payment Allowance,
• Heart, heart-lung, liver For services not included in the refer to the individual benefit
(cadaver and living), lung Transplant Payment Allowance, sections that apply to the
(single or double) refer to the individual benefit services being performed to
sections that apply to the determine the correct level of
• Small-bowel or small- services being performed to coverage.
bowel/liver determine the correct level of
coverage.
• Pancreas transplant
• Cadaver—eligible as
pancreas transplantation
alone (PTA),
simultaneous pancreas
and kidney
transplantation (SPK), or
pancreas transplantation
after kidney
transplantation (PAK), or
• Living donor segmental
pancreas transplantation
—eligible alone, at the
time of, or following
kidney transplantation
NOTES:
• As technology changes, the covered transplants listed above will be subject to
modifications in the form of additions or deletions, when appropriate.
• Kidney and cornea transplants are eligible procedures that are covered on the same basis as any
other eligible service and are not subject to the special requirements for organ and bone marrow
transplants listed above. See Hospital inpatient and Physician Services.
39
• Prior authorization is required for all transplant and stem cell support procedures. All
requests for prior authorization must be submitted in writing to:
Blue Cross and Blue Shield of Minnesota
Transplant Coordinator
P.O. Box 64179
St. Paul, Minnesota 55164
If you have specific questions on Organ and Bone Marrow Transplant Coverage, call the
Transplant Coordinator of Blue Cross and Blue Shield of Minnesota, Monday through Friday,
from 8:00 a.m. to 4:30 p.m. (Central Time) at (651) 662-1624 or 1-888-878-0139, extension
21624.
NOT COVERED:
• Benefits for travel, meals and lodging expenses when you are using a Non-BQCT Provider.
• Services, supplies, drugs, and aftercare for or related to artificial or nonhuman organ implants.
• Services, supplies, drugs, and aftercare for or related to human organ transplants not specifically
listed above as covered.
• Services, chemotherapy, radiation therapy (or any therapy that results in marked or complete
suppression of blood producing organs), supplies, drugs, and aftercare for or related to bone
marrow and peripheral stem cell support procedures that are considered investigative or not
medically necessary.
• Living donor organ and/or tissue transplants unless otherwise specified in this Plan.
• Transplantation of animal organs and/or tissue.
• Additional exclusions are listed in the General Exclusions section.
DEFINITIONS:
• BQCT Provider means a hospital or other institution that has a contract with the Blue Cross and
Blue Shield Association to provide organ or bone morrow transplant or peripheral stem cell support
procedures. These providers have been selected to participate in this nationwide network based on
their ability to meet defined clinical criteria that are unique for each type of transplant. Once.
selected for participation, institutions are re-evaluated annually to insure that they continue to meet
the established criteria for participation in this network.
• Participating Transplant Provider means a hospital or other institution that has a contract with Blue
Cross and Blue Shield of Minnesota or with their local Blue Cross and/or Blue Shield Plan to
provide organ or bone marrow transplant or stem cell support procedures.
• Transplant Payment Allowance means the amount the Plan pays for covered services to a BQCT
Provider or a Participating Transplant Provider for services related to organ or bone marrow
transplant or peripheral stem cell support procedures in the agreement with that provider.
40
Physical Therapy, Occupational Therapy, Speech Therapy
The Plan Covers: In-Network Providers Out-of-Network Providers
• Physical therapy 100% 80% after you pay the
deductible.
• Occupational therapy
• Speech therapy
NOTES:
• Please see the Notification Requirements section.
• Speech therapy is limited to a maximum benefit of$500 per person per calendar year when you
use a Nonparticipating Provider.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• services primarily educational in nature
• vocational rehabilitation
• developmental delay services
• self-care and self-help training (non-medical)
• health clubs and spas
• learning disabilities and disorders
• recreational therapy
• rehabilitation services that would not result in measurable progress relative to established goals.
• please refer to the General Exclusions section
41
Physician Services
The Plan Covers: In-Network Providers Out-of-Network Providers
• Office visits for illness 100% 80% after you pay the
deductible.
• Allergy testing, serum, and
injections
• Diabetes outpatient self-
management training and
education, including medical
nutrition therapy
• Lab and x-ray
• Inpatient hospital/facility
visits during a covered
admission
• Outpatient hospital/facility
visits
• Anesthesia by a provider
other than the operating,
delivering, or assisting
provider
• Surgery, including
circumcision and sterilization
• Assistant surgeon
• Bariatric surgery to correct
morbid obesity
• Kidney and cornea
transplants
NOTES:
• Please see the Notification Requirements section.
• If more than one (1) surgical procedure is performed during the same operative session, the Plan
covers the surgical procedures based on the allowed amount for each procedure. The Plan does
not cover a charge separate from the surgery for pre- and post-operative care.
• The Plan covers treatment of diagnosed Lyme disease on the same basis as any other illness.
• The Plan covers the following kidney donor services when billed under the donor recipient's name
and the donor recipient is covered for the kidney transplant under the Plan:
• potential donor testing
• donor evaluation and work-up; and
• hospital and professional services related to organ procurement
42
• If the following services are covered under your Plan, you are entitled to receive care at the In-
Network level for the following services from providers who are not affiliated with the Claims
Administrator:
• the voluntary planning of the conception and bearing of children;
• the diagnosis of infertility;
• the testing and treatment of a sexually transmitted disease; or
• the testing of AIDS or other HIV-related conditions.
• The Plan covers certain physician services for preventive care. Refer to Preventive Care.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• repair of scars and blemishes on skin surfaces
• separate charges for pre- and post-operative care for surgery
• cosmetic surgery to repair a physical defect
• travel expenses for a kidney donor
• kidney donor expenses for complications incurred after the organ is removed if the donor is not
covered under this Plan
• kidney donor expenses when the recipient is not covered for the kidney transplant under this Plan
• please refer to the General Exclusions section
43
Prescription Drugs and Insulin
The Plan Covers: In-Network Providers Out-of-Network Providers
• Prescription drugs 100% after you pay the 100% after you pay the
prescription drug copay. prescription drug copay, but you
• insulin must pay the full amount of the
• drug therapy supplies When you present your ID card prescription at the time of
• injectable drugs that are or otherwise provide notice of purchase and submit the claim
self-administered or coverage at the time of for reimbursement yourself. You
administered by a health purchase, you pay only the will be reimbursed only the
care professional prescription drug copay. discounted pricing that has been
• self-administered negotiated between us and a
contraceptives If you do not present your ID participating pharmacy for that
• smoking cessation drugs card or otherwise provide notice prescription drug less your
of coverage at the time of prescription drug copay.
purchase, you will be charged
the full amount of the
prescription drug. You will be
reimbursed only the discounted
pricing that has been negotiated
between us and the participating
pharmacy for that prescription
drug less your prescription drug
copay. Your out-of-pocket costs
may be significantly higher when
you do not provide proof of
insurance at the time of
purchase.
NOTES:
• Please see the Notification Requirements section.
• A nonformulary copay applies for prescription drugs, insulin and drugs therapy supplies not on our
formulary.
• The Blue Cross formulary is a list of brand and generic prescription drugs and drug supplies that
are commonly used by patients in an ambulatory care setting. Over-the-counter, injectable
medications and drug supplies are not included in this formulary unless they are specifically listed.
The Blue Cross Pharmacy and Therapeutics (P&T) Committee is responsible for the selection of
this list of products. The formulary is subject to periodic review and modification by this committee.
• Prescription drugs and diabetic supplies are covered in a 34-day supply or 100 units, whichever is
greater from a retail pharmacy or up to a 90-day supply from a mail service pharmacy. Some
medications may be subject to a quantity limitation per day supply or to a maximum dosage per
day.
• Up to 3-cycle supply of self-administered contraceptives may be purchased at a retail pharmacy at
one time for one (1) copay.
• The following diabetic supplies are covered at the same level as prescription drugs when prescribed
by a physician: blood/urine testing tabs/strips, needles and syringes, lancets and insulin.
• All lancets, needles and syringes are covered as formulary. Insulin and blood/urine testing
tabs/strips will be covered according to their actual status on the formulary.
• The Plan will cover prescription smoking cessation products and over-the-counter nicotine
replacement products (limited to nicotine patches and gum) with a physician's prescription. Some
quantity limitation may apply.
44
• The Plan will cover off label drugs used for cancer treatment as specified by law.
• When identical chemical entities are manufactured by separate companies, the Blue Cross
Pharmacy and Therapeutics (P&T) Committee may determine that only one of those drug products
is covered and the other equivalent products are not covered.
• Prescription drugs for nonformulary antipsychotic drugs prescribed to treat emotional disturbance or
mental illness will be covered at the same level as formulary drugs if the prescribing health care
professional indicates that the prescription must be dispensed as written (DAW) and certifies in
writing to us that he or she has considered all equivalent drugs in the formulary and has determined
that the drug prescribed will best treat the patient's condition.
• If you are taking a formulary drug to treat mental illness or emotional disturbance and the drug is
removed from the formulary, or if you are taking a nonformulary drug to treat mental illness or
emotional disturbance when you change health plans and the medication has shown to effectively
treat your condition, the nonformulary drug will be covered at the same level as a formulary drug for
up to one year if:
• You have been treated with the drug for 90 days prior to a change in the formulary or a change
in your health plan;
• The prescribing health care professional indicates that the prescription must be DAW; and
• The prescribing health care professional certifies in writing to us that the drug prescribed will
best treat your condition.
• The continuing care provision described above may be extended annually if the prescribing health
care professional indicates that the prescription must be DAW and certifies in writing to us that the
drug prescribed will best treat your condition.
• To locate a participating pharmacy in your area, call the pharmacy information number provided in
the Customer Service section.
• For drugs dispensed and used during an admission, see Hospital Inpatient.
• For supplies or appliances, except as provided in this Benefit Chart, see Medical Equipment,
Prosthetics and Supplies.
• A compound drug is a prescription where two or more drugs are mixed together. One of these must
be a Federal legend drug. The end product must not be available in an equivalent commercial form.
A prescription will not be considered a compound if only water or sodium chloride solution are
added to the active ingredient.
• When you pay for the claim in full at the pharmacy or use an Out-of-Network Pharmacy you are
required to submit the drug receipt(s) with the claim form for reimbursement.
• You must present your insurance identification card to all providers and pharmacies. If you do not
present your identification card, the provider may require payment prior to rendering a service.
• The Plan Administrator and/or the Claims Administrator may receive pharmaceutical manufacturer
volume discounts in connection with the purchase of certain prescription drugs covered under the
Plan. Such discounts are the sole property of the Plan Administrator and/or Claims Administrator
and will not be considered in calculating any coinsurance, copay, or benefit maximums.
• You must present your ID card or otherwise provide notice of coverage at the time of purchase to
receive the highest level of benefits. The information on your ID card enables the participating
pharmacy to connect electronically with us to access discounted pricing information. If you do not
present your ID card or otherwise provide notice of coverage at the time of purchase, the pharmacy
will charge you the full amount of the prescription drug. You will be reimbursed based on the
discounted pricing. Therefore, in addition to any copays and/or deductibles, you will also be liable
for the difference between the amount the pharmacy charges you for the prescription drug at the
time of purchase and any discounted pricing we have negotiated with participating pharmacies for
that prescription drug.
45
NOT COVERED:
• drugs removed from the formulary for safety reasons may not be covered
• charges for giving injections that can be self-administered
• over-the-counter drugs unless otherwise specified
• investigative or non-FDA approved drugs
• vitamin or dietary supplements
• smoking cessation drugs without a prescription
• prescription drugs for or related to infertility treatments, except that the Plan does cover
prescriptions for artificial and intrauterine insemination
• non-prescription supplies such as alcohol, cotton balls and alcohol swabs
• selected drugs or classes of drugs which have shown no benefit regarding efficacy, safety or side
effects
• please refer to the General Exclusions section
46
Preventive Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• Routine cancer screening 100% 80% after you pay the
(including, but not limited to, deductible.
mammograms, Pap smears,
flexible sigmoidoscopies,
colonoscopies, occult blood
work, and prostate specific
antigen (PSA) testing)
• Routine physical exams
• Routine gynecological
exams
• Routine hearing exams
• Routine vision exams
• Lab and x-ray
• Immunizations
NOTES:
• Please see the Notification Requirements section.
• Benefits for routine physical exams are limited to one (1) per person per calendar year.
• Benefits for routine gynecological exams are limited to one (1) per person per calendar year.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• physicals for research or obtaining licensure, employment, or insurance
• educational classes or programs
• eyewear, including lenses, frames, and contact lenses, and fitting, except where eligible under
Medical Equipment, Prosthetics, and Supplies
• please refer to the General Exclusions section
47
Reconstructive Surgery
The Plan Covers: In-Network Providers Out-of-Network Providers
• Reconstructive surgery For the level of coverage, see For the level of coverage, see
which is incidental to or Hospital Inpatient, Hospital Hospital Inpatient, Hospital
follows surgery resulting Outpatient, and Physician Outpatient, and Physician
from injury, sickness, or Services. Services.
other diseases of the
involved body part
• Reconstructive surgery
performed on a dependent
child because of congenital
disease or anomaly which
has resulted in a functional
defect as determined by the
attending physician
• Treatment of cleft lip and
palate for a dependent child
under age 18
• Elimination or maximum
feasible treatment of port
wine stains
NOTES:
• Please see the Notification Requirements section.
• Under the Federal Women's Health and Cancer Rights Act of 1998 and Minnesota law, you are
entitled to the following services: reconstruction of the breast on which the mastectomy was
performed; surgery and reconstruction of the other breast to produce a symmetrical appearance;
and prosthesis and treatment for physical complications during all stages of mastectomy, including
swelling of the lymph glands (lymphedema). Services are provided in a manner determined in
consultation with the physician and patient. Coverage is provided on the same basis as any other
illness.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• repair of scars and blemishes on skin surfaces
• please refer to the General Exclusions section
48
Skilled Nursing Facility
The Plan Covers: In-Network Providers Out-of-Network Providers
• Skilled care ordered by a 80% 80% after you pay the
physician and eligible under deductible.
Medicare guidelines
• Semiprivate room and board
• General nursing care
• Prescription drugs used
during a covered admission
• Physical, occupational, and
speech therapy
NOTES:
• Please see the Notification Requirements section:
• You must be admitted within 30 days after hospital admission of at least three (3) consecutive days
for the same illness.
• If you are unable to obtain a bed in an In-Network skilled nursing facility within a 50-mile radius of
your home due to full capacity, you may be eligible to receive services at an Out-of-Network skilled
nursing facility at the In-Network level of coverage.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• custodial or non-skilled care
• services of a non-medical nature
• please refer to the General Exclusions section
49
Well-Child Care
The Plan Covers: In-Network Providers Out-of-Network Providers
• The following services for a 100% 80% after you pay the
dependent child from birth to deductible.
age six (6):
• preventive services
• developmental
assessments
• laboratory services
• Immunizations for a
dependent child from birth to
age 18
NOTES:
• Please see the Notification Requirements section.
• You pay all charges that exceed the allowed amount when you use a Nonparticipating Provider.
NOT COVERED:
• please refer to the General Exclusions section
50
BENEFIT SUBSTITUTION
Benefit substitution, a process of substituting one covered benefit for another covered benefit is used
by our care/case managers to facilitate care/case management plans for patients with complex health
care needs. The benefit substitution process will be used only when:
1. a care/case management plan is developed in collaboration with the patient and the health care
provider prior to the services being provided; and
2. a physician writes an order stating the services to be provided are medically necessary; and
3. the services being provided under the care/case management plan meet the skilled care
requirements of the benefit to be used; and
4. the services do not exceed the allowed amount of the benefit being used.
The benefit substitution process cannot be applied retrospectively, and benefit substitution cannot be
used to allow coverage for services or supplies excluded by the Plan.
The decision to use the benefit substitution process is at the Claims Administrators sole discretion. The
decision to use the benefit substitution process in a particular case in no way commits us to do so at
another point in the same case or in another case, nor does it prevent us from strictly applying the
express benefits, limitations and exclusions of the Plan at any other time or for any other insured
person.
51
GENERAL EXCLUSIONS
The Plan does not pay for:
1. Treatments, services, or supplies which are not medically necessary.
2. Charges for or related to care that is investigative, except for certain routine care for approved
cancer clinical trials by approved investigators at qualified performance sites and approved by us in
advance of treatment.
3. Charges for or related to care that is custodial or not normally provided as preventive care or
treatment of an illness.
4. Services that are normally provided without charge, including services of the clergy.
5. Services a provider gives to himself/herself or to a close relative (such as spouse, brother, sister,
parent, grandparent, child, etc.).
6. Services for conditions that are determined to be preexisting conditions in accordance with the
terms of the Plan.
7. Services performed before the effective date of coverage, and services received after your
coverage terminates, even though your illness started while your coverage was in force.
8. The portion of eligible services and supplies paid or payable under Medicare.
9. Services for dependents if you have employee-only coverage.
10. Services or supplies that are primarily and customarily used for nonmedical purpose, or used for
environmental control or enhancement (whether or not prescribed by a physician), including, but not
limited to: exercise equipment, air purifiers, air conditioners, dehumidifiers, heat/cold appliances,
water purifiers, hypoallergenic mattresses, waterbeds, computers and related equipment, car seats,
feeding chairs, pillows, food or weight scales, hot tubs, whirlpools, and incontinence pads or pants.
11. Modifications to home, vehicle, and/or the workplace, including vehicle lifts and ramps.
12. Blood pressure monitoring devices
13. Communication devices, except when exclusively used for the communication of daily medical
needs and without such communication the patient's medical condition would deteriorate.
14. Charges for over-the-counter drugs except as specified in the Benefit Chart; vitamin or dietary
supplements; and investigative or non-FDA approved drugs.
15. Personal comfort items, such as telephone, television, barber and beauty supplies, guest services,
etc.
16. Autopsies.
17. Travel, transportation, or living expenses, whether or not recommended by a physician, except as
specified in the Benefit Chart.
18. Charges made by a health professional for telephone consultations.
19. Charges for furnishing medical records or reports.
52
20. Charges for failure to keep scheduled visits.
21. Services for or related to treatment of illness or injury which occurs while on military duty that are
recoe V ' ove to srveneted injuries.
22. Services gniz that d by are the provided eteran to s Administrati you for the treatment n as ser of ices an r employment-related lated e ic -con
injury c for which you
are entitled to make a workers' compensation claim.
23. Charges that are eligible, paid or payable, under any medical payment, personal injury protection,
automobile or other coverage that is payable without regard to fault, including charges for services
that are applied toward any copay or coinsurance requirement of such a policy.
24. Services needed because you engaged in an illegal occupation, or committed or attempted to
commit a felony.
25. Services that are prohibited by law or regulation.
26. Admission for diagnostic tests that can be performed on an outpatient basis.
27. Services or confinements ordered by a court or law enforcement officer that are not medically
necessary. Services that are not considered medically necessary include, but are not limited to the
following; custody evaluations, parenting assessment, education classes for DUI offenses,
competency evaluations, adoption home status, parental competency, and domestic violence
programs.
28. Inpatient hospital room and board expense that exceeds the semiprivate room rate, unless a private
room is approved by the Claims Administrator as medically necessary.
29. Services for or related to reconstructive surgery or cosmetic health services, except as specified in
the Benefit Chart.
30. Services for or related to private-duty nursing.
31. Nursing services to administer home infusion therapy when the patient or caregiver can be
successfully trained to administer therapy. Services that do not involve direct patient contact, such
as delivery charges and recordkeeping.
32. Charges for giving injections which can be self-administered.
33. Services, supplies, drugs and aftercare for or related to artificial or nonhuman organ implants.
34. Services, chemotherapy, radiation therapy (or any therapy that results in marked or complete
suppression of blood producing organs), supplies, drugs and aftercare for or related to bone
marrow and peripheral stem cell support procedures, except as specified in the benefit chart.
35. Charges for rehabilitation services that would not result in measurable progress relative to
established goals.
36. Services for or related to recreational or educational therapy, or forms of nonmedical self care or
self-help training, including, but not limited to: health club memberships, aerobic conditioning,
therapeutic exercises, work hardening programs, etc., and all related material and products for
these programs.
37. Services for or related to gender reassignment surgery, sex hormones related to the surgery,
related preparation and follow-up treatment, or care and counseling, unless medically necessary as
determined by the Claims Administrator prior to receipt of the services.
53
38. Services and prescription drugs for or related to assisted reproductive technology (ART), except
that the Plan does cover artificial and intrauterine insemination procedures.
39. Services for or related to reversal of sterilization.
40. Services for or related to routine physical exams for purposes of medical research, obtaining
employment or insurance, or obtaining or maintaining a license of any type, unless such physical
examination would normally have been provided in the absence of the third party request.
41. Services for or related to hearing aids or devices, whether internal, external, or implantable, and
related fitting or adjustments, except as specified in the Benefit Chart.
42. Services for or related to lenses, frames, contact lenses, and other fabricated optical devices or
professional services for the fitting and/or supply thereof, including the treatment of refractive errors
such as radial keratotomy, except as specified in the Benefit Chart.
43. Services for or related to dental or oral care, except as specified in the Benefit Chart.
44. Services for or related to transportation other than local ambulance service to the nearest medical
facility equipped to treat the illness or injury, except as specified in the Benefit Chart.
45. Services for or related to therapeutic acupuncture, except for the treatment of chronic pain when
treatment is provided through a comprehensive pain management program.
46. Services for or related to weight loss programs, fees or dues, nutritional supplements, food,
vitamins and exercise therapy, and all associated labs, physician visits, and services related to such
programs.
47. Treatment, equipment, drug, and/or device that the Claims Administrator determines does not meet
generally accepted standards of practice in the medical community for cancer and/or allergy testing
and/or treatment. Services for or related to chelation therapy that the Claims Administrator
determines is not medically necessary. Services for or related to systemic candidiasis, homeopathy,
and/or immunoaugmentative therapy.
48. Services for or related to fetal tissue transplantation.
49. Services for or related to gene therapy as a treatment for inherited or acquired disorders.
50. Services for or related to growth hormone, except that replacement therapy is eligible for conditions
that meet medical necessity criteria as determined by the Claims Administrator prior to receipt of
the services.
51. Services for or related to functional capacity evaluations for vocational purposes and/or
determination of disability or pension benefits.
52. Services for or related to smoking cessation program fees and/or related program supplies except
as specified in the Special Features section.
53. Services which are not within the scope, licensure or certification of a provider.
54
ELIGIBILITY
Eligible Employees
All full time employees working an average of 32 hours per week.
Eligible Dependents
1. Married spouse.
2. Unmarried natural-born dependent children to age 19.
3. Unmarried legally adopted children and children placed with you for legal adoption to age 19. Date
of placement means the assumption and retention by a person of a legal obligation for total or
partial support of a child in anticipation of adoption of the child. The child's placement with a person
terminates upon the termination of the legal obligation of total or partial support.
4. Unmarried stepchildren to age 19.
5. Unmarried legal wards to age 19.
6. Unmarried grandchildren to age 19 who live with you continuously from birth and are financially
dependent upon you.
7. Unmarried children of the employee who are required to be covered by reason of a Qualified
Medical Child Support Order(QMCSO), as defined in Minnesota statute §518.171. The Plan has
detailed procedures for determining whether an order qualifies as a QMCSO. You and your
dependents can obtain, without charge, a copy of such procedures from the Plan Administrator.
8. Unmarried dependent children as defined to age 25 if the following apply:
a. your dependent child must attend an accredited college, university or trade school on a full-time
basis as defined by that educational institution; or
b. if dependent child is unable to carry 100% of the full-time course load due to illness, injury or
physical or mental disability documented by a physician your dependent will remain eligible if
he/she carries at least 60% of the full-time course load.
If your dependent child has not graduated or completed a defined course of study, your student
dependent may miss one (1) academic term, as defined below during an academic year and remain
eligible as a student dependent. However, if your student dependent does not return to school on a
full-time basis immediately following the missed academic term coverage will be terminated at the
end of the last month of the missed academic term. For the purposes of this section "academic
term" is defined as follows:
• Fall academic term — September 1 through December 31;
• Spring academic term —January 1 through May 31;
• Summer academic term—June 1 through August 31.
Coverage will terminate at the end of the month in which the student dependent child graduates or
completes a defined course of study.
55
9. Unmarried handicapped dependent children who reach the limiting age while covered under this
Plan if all of the following apply:
a. primarily dependent upon you
b. are incapable of self-sustaining employment because of physical handicap, mental retardation,
mental illness, or mental disorders
c. for whom application for extended coverage as a handicapped dependent child is made within
31 days after reaching the age limit. After this initial proof, the Claims Administrator may request
proof again two (2) years later, and each year thereafter
d. must have become handicapped prior to reaching limiting age
NOTE: If both you and your spouse are employees of the employer, you may be covered as either an
employee or as a dependent, but not both. Your eligible dependent children may be covered under
either parent's coverage, but not both.
Preexisting Condition Limitation for Employees and Covered Dependents
A preexisting condition limitation applies to employees and covered dependents. A preexisting
condition is defined as a medical condition for which medical advice, diagnosis, care, or treatment was
recommended or received during the six (6) months immediately preceding the enrollment date.
Newly Eligible Applicants— For such a condition, benefits for you and your covered dependents will
be payable only after a period of 12 consecutive months beginning from the enrollment date. This
period will be reduced by any prior continuous creditable coverage. At your request and with
appropriate authorization we will assist you in obtaining a certificate of creditable coverage from your
prior plan.
With timely application, this limitation does not apply to a newborn infant, or a child placed with you for
adoption. In addition, an existing pregnancy is not considered a preexisting condition.
Late Entrants— For such a condition, benefits for you and your covered dependents will be payable
only after a period of 18 consecutive months beginning from the enrollment date. This period will be
reduced by any prior continuous creditable coverage: At your request and with appropriate
authorization we will assist you in obtaining a certificate of creditable coverage from your prior plan.
An existing pregnancy is not considered a preexisting condition.
Effective Date of Coverage
Coverage for you or your eligible dependents who were eligible on the effective date of the Plan will
take effect on that date.
Adding New Employees
1. If the Plan Administrator receives your application within 30 days after you become eligible,
coverage for you and your eligible dependents starts on the first of the month following the date of
eligibility.
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2. If the Plan Administrator receives your application more than 30 days after you become eligible, you
and your eligible dependents will be considered a Late Entrant unless you meet the requirements of.
the special enrollment period. Please see Coverage Effective Date for Late Entrants in this section
to determine when coverage will begin.
Adding New Dependents
This section outlines the time period for application and the date coverage starts.
Adding spouse and/or stepchildren
1. If the Plan Administrator receives the application within 30 days of the date of marriage, coverage
for your spouse and/or stepchildren starts on the date of marriage.
2. If the Plan Administrator receives the application more than 30 days after the date of marriage, your
spouse and/or stepchildren will be considered Late Entrants unless your spouse and/or stepchildren
meet the requirements of the special enrollment period. Please see Coverage Effective Date for
Late Entrants in this section to determine when coverage will begin.
Adding newborns and children placed for adoption
The Plan Administrator requests that you submit written application to add your newborn child or
newborn grandchild within 90 days of the date of birth. Coverage for your newborn child or newborn
grandchild starts on the date of birth.
The Plan Administrator requests that you submit written application to add your adopted child within 90
days of the date of placement. Coverage for your adopted child starts on the date of placement.
Adding handicapped children or handicapped dependents
A handicapped dependent may be added to the Plan if the handicapped dependent is otherwise eligible
under the Plan. Coverage starts the first of the month following the day the Plan Administrator receives
the application. A handicapped dependent will not be denied coverage and will not be subject to any
preexisting condition limitation period.
Special Enrollment Periods
Special enrollment periods are periods when eligible employees or dependents may enroll in the health
plan under certain circumstances after the initial 30 days when they were first eligible. Employees or
dependents who are eligible but not enrolled in the health plan may enroll for coverage under the terms
of the Plan if each of the following conditions are met:
1. The employee or dependent was covered under a group health plan or other health insurance
coverage at the time coverage was previously offered to the employee or dependent;
2. The employee must complete any required written waiver of coverage and state in writing that, at
such time, other health insurance coverage was the reason for declining enrollment;
3. The employee's or dependent's coverage is terminated because his/her continuation has been
exhausted, they are no longer eligible for the Plan due to a divorce, legal separation, death,
termination of employment, reduction in hours, or employer's contributions toward the coverage
were terminated; and
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4. The employee or dependent requested enrollment not later than 30 days after the termination of
coverage or employer contribution.
Coverage is effective the day after the termination of prior coverage.
In addition, the special enrollment period is available to the employee and spouse who have not been
covered under other group coverage following marriage, a birth, adoption, or placement for adoption.
Dependent children other than the newly acquired dependent(s) are not eligible for the special
enrollment period and will be considered a Late Entrant.
Coverage Effective Date for Late Entrants
Late entrants are subject to a preexisting condition limitation period described in the Preexisting
Condition Limitations section. Credit will be given for prior continuous creditable coverage. Coverage
for late entrants starts on the first of the month following the day the Plan Administrator receives the
application.
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TERMINATION OF COVERAGE
Termination Events
Coverage ends on the earliest of the following dates:
1. For you and your dependents, the date on which the Plan terminates.
2. For you and your dependents, the last day of the month during which:
a. required charges for coverage were paid, if payment is not received when due. Your payment of
charges to the employer does not guarantee coverage unless the Claims Administrator receives
full payment when due. If the Claims Administrator terminates coverage for all employees in the
Plan for nonpayment of the charges, the Claims Administrator will give all employees a 30 day
notice of termination prior to the effective date of cancellation using a list of addresses which is
updated every 12 months.
b. you are no longer eligible.
c. you enter military services for duty lasting more than 31 days.
d. you request that coverage be terminated.
e. you retire.
3. For the spouse, the date the spouse is no longer eligible for coverage. This is the last day of the
month during which the employee and spouse divorce.
4. For a dependent child, the date the dependent child is no longer eligible for coverage. This is the
last day of the month during which:
a. a covered stepchild is no longer eligible because the employee and spouse divorce.
b. the dependent child marries or reaches the dependent-child age limit.
c. the student dependent child no longer meets the student dependent eligibility requirements.
d. the dependent child becomes covered as an employee under any health coverage plan
sponsored by the employer.
e. the handicapped dependent is no longer eligible.
f. the dependent grandchild is no longer eligible.
5. The date charges are incurred that result in payment up to the lifetime maximum.
Retroactive Termination
If the Plan Administrator erroneously enrolled the employee or dependent in the Plan and subsequently
requests that coverage be terminated retroactive to the effective date of coverage, coverage will remain
in force to a current paid-to-date unless the Plan Administrator obtains and forwards to the Claims
Administrator the employee's or dependent's written consent authorizing retroactive termination of
coverage. If written consent is not obtained and forwarded to the Claims Administrator with the
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cancellation request, the Plan Administrator must pay the required charges for the employee's or
dependent's coverage in full to current paid-to-date.
Certification of Coverage
When you or your covered dependents terminate coverage under the Plan, a certification of coverage
form will be issued to you specifying your coverage dates under the health plan and any waiting periods
you were required to satisfy. The certification of coverage form will contain all the necessary information
another health plan will need to determine if you have prior continuous coverage that should be
credited toward any preexisting condition limitation period. Health plans will require that you submit a
copy of this form when you apply for coverage.
The certification of coverage form will be issued to you if your request it before losing coverage or when
you terminate coverage with the group and, if applicable, at the expiration of any continuation period.
The Claims Administrator will also issue the certification of coverage form if you request a copy at any
time within the 24 months after your coverage terminates.
Extension of Benefits
If you or your dependent is confined as an inpatient on the date coverage ends due to the replacement
of the Claims Administrator, the Plan will automatically extend coverage until the date you or your
dependent is discharged from the facility or the date Plan maximums are reached, whichever is earlier.
Coverage is extended only for the person who is confined as an inpatient, and only for inpatient
charges incurred during the admission. For purposes of this provision, "replacement" means that the
administrative service agreement with the Claims Administrator has been terminated and your
employer maintains continuous group coverage with a new claims administrator or insurer.
Continuation and Conversion
You or your covered dependents may continue coverage under this Plan if coverage ends due to any of
the qualifying events listed below. You must be covered under the Plan before the qualifying event in
order to continue coverage. In all cases, continuation ends if the group Plan ends or required charges
are not paid when due.
Qualifying Events
If you are an employee of the employer and are covered, you have the right to elect continuation
coverage if you lose coverage because of any one of the following qualifying events:
1. Termination of your employment (for reasons other than gross misconduct).
2. Reduction in the hours of your employment.
3. Total disability- Total disability means the employee's inability to engage in or perform the duties of
the employee's regular occupation or employment within the first two (2) years of disability. After
the first two (2) years, it means the employee's inability to engage in any occupation for which the
employee is educated and trained. For employees disabled prior to January 1, 1992, total disability
means the employee's inability to engage in or perform the duties of the employee's regular
occupation or employment from the date of disability.
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If you are the spouse of a covered employee, you have the right to elect continuation coverage if you
lose coverage because of any of the following qualifying events:
1. The death of your spouse.
2. A termination of your spouse's employment (for reasons other than gross misconduct) or reduction
in your spouse's hours of employment with the employer.
3. Divorce from your spouse. (Also, if an employee eliminates coverage for his or her spouse in
anticipation of a divorce and a divorce later occurs, then the later divorce will be considered a
qualifying event even though the ex-spouse lost coverage earlier. If the ex-spouse notifies the
administrator within 60 days after the later divorce and can establish that the coverage was
eliminated earlier in anticipation of the divorce, then continuation coverage may be available for the
period after the divorce.)
4. Your spouse becomes entitled to Medicare benefits.
5. Your spouse becomes totally disabled (as defined above).
In the case of a dependent child of a covered employee, the dependent child has the right to elect
continuation coverage if they lose coverage because of any of the following qualifying events:
1. The death of the employee.
2. The termination of the employee's employment (for reasons other than gross misconduct) or
reduction in the employee's hours of employment with the employer.
3. Parents' divorce.
4. The employee becomes entitled to Medicare benefits.
5. The dependent ceases to be a "dependent child" under the Plan.
6. The total disability of the employee (as defined above).
Your Notice Obligations
If your dependents lose coverage under the Plan because of divorce or the loss of dependent status
under the Plan, then you or your dependents have the responsibility to notify the Plan Administrator of
the divorce or the loss of dependent status. You or your dependents must provide this notice no later
than 60 days after the date coverage terminates under the Plan. Your employer must notify you of the.
option to continue coverage within 10 days of receiving notice of a qualifying event.
If you or your dependents fail to provide this notice to the Plan Administrator during this 60-day notice
period, any dependent who loses coverage will NOT be offered the option to elect continuation
coverage. Furthermore, if you or your dependents fail to provide this notice to the Plan Administrator,
and if any claims are mistakenly paid for expenses incurred after the date coverage was to terminate
then you and your dependents will be required to reimburse the Plan for any claims paid.
If the Plan Administrator is provided with notice of a divorce or a loss of dependent status that has
caused a loss of coverage, then the Plan Administrator will notify the affected family member of the
right to elect continuation coverage.
The Plan Administrator will also notify you and your dependents of the right to elect continuation
coverage after receiving notice that one of the following events occurred and resulted in a loss of
61
coverage: the employee's termination of employment (other than for gross misconduct), reduction in
hours, or death, or the employee's becoming entitled to Medicare.
Election Procedures
You and your dependents must elect continuation coverage within 60 days after coverage ends, or, if
later, 60 days after the Plan Administrator provides you or your family member with notice of the right to
elect continuation coverage. If you or your dependents do not elect continuation coverage within this
60-day election period, you will lose your right to elect continuation coverage.
You and your dependents may elect continuation coverage for all qualifying family members. You and
your dependents each have an independent right to elect continuation coverage. Thus, a dependent
may elect continuation coverage even if the covered employee does not elect continuation coverage.
You and your dependents may elect continuation coverage even if covered under another employer-
sponsored group health plan or entitled to Medicare.
Type of Coverage
Ordinarily, the continuation coverage that is offered will be the same coverage that you or your
dependent had on the day before the qualifying event. Therefore, anyone who is not covered under the
Plan on the day before the qualifying event generally is not entitled to continuation coverage except, for
example, when there is no coverage because it was eliminated in anticipation of a qualifying event such
as divorce.
Maximum Coverage Periods
The maximum duration for continuation coverage is described below. Continuation coverage terminates
before the maximum coverage period in certain situations described later under the heading
"Termination of Continuation Coverage Before the End of the Maximum Coverage Period."
Indefinite. If you or your dependents lose group health coverage because of the employee's total
disability (as defined above), then the maximum coverage period is indefinite. If a dependent loses
group health coverage because of the employee's death or divorce, then the maximum coverage period
(for spouse and dependent child) is indefinite.
36 Months. If a dependent loses group health coverage because the employee became entitled to
Medicare or because of a loss of dependent status under the Plan, then the maximum coverage period
(for spouse and dependent child) is three years from the date of the qualifying event.
18 Months. If you or your dependent loses group health coverage because of the employee's
termination of employment (other than for gross misconduct) or reduction in hours, then the maximum
continuation coverage period is 18 months from the date of termination or reduction in hours. See
below for exceptions:
• If you or your dependents are disabled at any time during the first 60 days after the date of
termination of employment or reduction in hours, then the continuation 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 to the Plan Administrator within both the 18-month coverage period and 60 days after the
date of the determination.
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• If a second qualifying event that gives rise to a 36-month maximum coverage period for the
dependent (for example, the employee dies or become divorced) occurs within an 18-month or 29-
month coverage period, then the maximum coverage period (for a dependent) becomes three years
from the date of the initial termination or reduction in hours. For the 36-month maximum coverage
period to apply, notice of the second qualifying event must be provided to the Plan Administrator
within 60 days after the date of the event. If no notice is given within the required 60-day period, no
extension of continuation coverage will occur.
• If a second qualifying event that gives rise to an indefinite maximum coverage period for the
dependent (for example, the employee dies or becomes divorced) occurs within an 18-month or 29-
month coverage period, then the maximum coverage period (for a dependent) becomes indefinite.
For an indefinite maximum coverage period to apply, notice of the second qualifying event must be
provided to the Plan Administrator within 60 days after the date of the event. If no notice is given
within the required 60-day period, no extension of continuation coverage will occur.
• If a second qualifying event that gives rise to a 36-month maximum coverage period for the
dependent (for example, the employee becomes entitled to Medicare or a dependent loses
dependent status under the Plan) occurs within an 18-month or 29-month coverage period, then the
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ma mum coverage period (for a dependent) becomes three years from the date of the initial
termination or reduction in hours. For the 36-month maximum coverage period to apply, notice of
the second qualifying event must be provided to the Plan Administrator within 60 days after the date
of the event. If no notice is given within the required 60-day period, no extension of continuation
coverage will occur.
• If the qualifying event occurs within 18 months after the employee becomes entitled to Medicare,
then the maximum coverage period ends three years from the date the employee became entitled
to Medicare.
Retirees of Political Subdivisions
Retirees of political subdivisions and the retiree's dependents may elect to continue to participate
indefinitely in the employer's Plan. This continuation requirement applies only to a former employee
who is receiving a disability benefit or an annuity from a Minnesota public pension plan (other than a
volunteer firefighter plan), or who has met age and service requirements necessary to receive an
annuity from such a plan.
Children Born to or Placed for Adoption With the Covered Employee During
Continuation Period
A child born to, adopted by or placed for adoption with a covered employee during a period of
continuation coverage is considered to be a qualified beneficiary provided that, if the covered employee
is a qualified beneficiary, the covered employee has elected continuation coverage for himself or
herself. The child's continuation coverage begins when the child is enrolled in the Plan, whether
through special enrollment or open enrollment, and it lasts for as long as continuation coverage lasts for
other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise
applicable Plan eligibility requirements.
Open Enrollment Rights and Special Enrollment Rights
Qualified beneficiaries who have elected continuation will be given the same opportunity available to
similarly-situated active employees to change their coverage options or to add or eliminate coverage for
dependents at open enrollment. Special enrollment rights will apply to those who have elected
continuation. Except for certain children described above, dependents who are enrolled in a special
enrollment period or open enrollment period do not become qualified beneficiaries—their coverage will
63
end at the same time that coverage ends for the person who elected continuation and later added them
as dependents.
Termination of Continuation Coverage Before the End of Maximum Coverage Period
Continuation coverage of the employee and dependents will automatically terminate (before the end of
the maximum coverage period) when any one of the following events occurs.
1. The employer no longer provides group health coverage to any of its employees.
2. The premium for the qualified beneficiary's continuation coverage is not paid. Charges for
continuation are the group rate plus a two (2) percent administration fee (if the qualifying event for
continuation is the employee's total disability, the administration fee is not required). All charges are
paid directly to your employer.
3. After electing continuation, you or your dependents 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, then
your continuation coverage will terminate after the exclusion or limitation no longer applies. This
rule applies only to the qualified beneficiary who becomes covered by another group health plan.
(Note that under HIPAA, an exclusion or limitation of the other group health plan might not apply at
all to the qualified beneficiary, depending on the length of his or her creditable health plan coverage
prior to enrolling in the other group health plan.)
4. After electing continuation coverage, you or your dependent becomes entitled to Medicare benefits.
This will apply only to the person who becomes entitled to Medicare. This will not apply if the
qualifying event is the employee's total disability
5. You or your dependent 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).
6. Occurrence of any event (e.g., submission of fraudulent benefit claims) that permits termination of
coverage for cause with respect to covered employees or their dependents who have coverage
under the Plan for a reason other than the continuation coverage requirements of federal law.
Address Changes, Marital Status Changes, Dependent Status Changes and Disability
Status Changes
If your or your dependent's address changes, you must notify the Plan Administrator in writing (the Plan
Administrator needs up-to-date addresses in order to mail important continuation notices and other
information). Also, if your marital status changes or if a dependent ceases to be a dependent eligible for
coverage under the Plan terms, you or your dependent must notify the Plan Administrator in writing. In
addition, you must notify the Plan Administrator if a disabled employee or family member is no longer
disabled.
Additional events
In addition to the events outlined above, you may choose to continue your coverage during an
approved leave of absence or vacation by paying the monthly required charges to your employer in the
manner required by your employer. Coverage may be continued for six (6) months after the end of the
Plan month during which the temporary leave began.
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Conversion
You or your dependents may convert your coverage to an individual qualified plan if coverage ends
because:
a. you become ineligible;
b. you leave the group for any reason; or
c. the Plan ends an d is not replaced by continuous g r oup coverage.
age.
If your coverage ends because you become ineligible or leave the group, you must apply for
conversion coverage within 63 days after your coverage (or continuation) ends. If your coverage
ends because the Plan ends, you must apply for conversion coverage within 63 days after receiving
notice of cancellation of the Plan.
Conversion coverage and charges will not be the same as the Plan. Evidence of good health is not
required. Regardless of the reason coverage ends, you are not eligible for conversion if you are
covered under another qualified plan or you do not make timely application.
65
COORDINATION OF BENEFITS
This section applies when you have health care coverage under more than one (1) plan, as defined
below. If this section applies, you should look at the Order of Benefits Rules first to determine which
plan determines benefits first. Your benefits under this Plan are not reduced if the Order of Benefits
Rules require this Plan to pay first. Your benefits under this Plan may be reduced if another plan pays
first.
Definitions
These definitions apply only to this section.
1. The term "plan" means any of the following that provides benefits or services for, or because of,
medical or dental care or treatment:
a. group insurance or group-type coverage, whether insured or uninsured. This includes
prepayment, group practice, individual practice coverage, and group coverage other than school
accident-type coverage
b. coverage under a government plan or required or provided by law
c. individual coverage. Group coverage is always primary and pays first.
Therefore, "plan" does not include:
a. a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the
United States Social Security Act as amended from time to time);
b. Medicare (Title XVIII, United States Code, as amended from time to time) for Medicare benefits
paid or payable to any person for whom Medicare is primary; or
c. any benefits that, by law, are excess to any private or other nongovernmental program.
If any of the above coverages include group-type hospital indemnity coverage, "Plan" only includes
that amount of indemnity benefits which exceeds $100 a day.
2. The term "This Plan" means the part of the Plan document that provides health care benefits.
3. "Primary Plan/Secondary Plan" is determined by the Order of Benefits Rules.
When This Plan is a Primary Plan, its benefits are determined before any other plan and without
considering the other plan's benefits.
When This Plan is a Secondary Plan, its benefits are determined after those of the other plan and
may be reduced because of the other plan's benefits.
When you are covered under more than two (2) plans, This Plan may be a Primary Plan to some
plans, and may be a Secondary Plan to other plans.
4. "Allowable expense" means the necessary, reasonable, and customary items of expense for health
care, covered at least in part by one (1) or more plans covering the person making the claim.
"Allowable expense" does not include an item or expense that exceeds benefits that are limited by
statute or This Plan.
66
The difference between the cost of a private and a semiprivate hospital room is not considered an
allowable expense unless admission to a private hospital room is medically necessary under
generally accepted medical practice or as defined under This Plan.
When a plan provides benefits in the form of services, the reasonable cash value of each service
rendered will be considered both an allowable expense and a benefit paid.
5. "Claim determination period" means a calendar year. However, it does not include any part of the
year the person is not covered under This Plan, or any part of a year before the date this section
takes effect.
Order of Benefits Rules
1. General: When a claim is filed under This Plan and another plan, This Plan is a Secondary Plan
and determines benefits after the other plan, unless:
a. the other plan has rules coordinating its benefits with This Plan's benefits; and
b. the other plan's rules and This Plan's rules, in part 2. below, require This Plan to determine
benefits before the other plan.
2. Rules: This Plan determines benefits using the first of the following rules that applies:
a. Nondependent/dependent: The plan that covers the person as an employee, member, or
subscriber(that is, other than as a dependent) determines its benefits before the plan that
covers the person as a dependent.
b. Dependent child of parents not separated or divorced: When This Plan and another plan cover
the same child as a dependent of different persons, called "parents":
1) the plan that covers the parent whose birthday falls earlier in the year determines benefits
before the plan that covers the parent whose birthday falls later in the year; but
2) if both parents have the same birthday, the plan that has covered the parent longer
determines benefits before the plan that has covered the other parent for a shorter period of
time.
However, if the other plan does not have this rule for children of married parents, and instead
the other plan has a rule based on the gender of the parent, and if as a result the plans do not
agree on the order of benefits, the rule in the other plan determines the order of benefits.
c. Dependent child of parents divorced or separated: If two (2) or more plans cover a dependent
child of divorced or separated parents, This Plan determines benefits in this order:
1) first, the plan of the parent with custody of the child;
2) then, the plan that covers the spouse of the parent with custody of the child;
3) finally, the plan that covers the parent not having custody of the child; or
4) in the case of joint custody, b. above applies.
However, if the court decree requires one (1) of the parents to be responsible for the health care
expenses of the child, and the plan that covers that parent has actual knowledge of that
requirement, that plan determines benefits first. This does not apply to any claim determination
67
period or plan year during which any benefits are actually paid or provided before the plan has
that actual knowledge.
d. Active/inactive employee: The Plan that covers a person as an employee who is neither laid-off
nor retired (or as that employee's dependent) determines benefits before a plan that covers that
person as a laid-off or retired employee (or as that employee's dependent). If the other plan
does not have this rule, and if as a result the plans do not agree on the order of benefits, then
this rule is ignored.
e. Longer/shorter length of coverage: If none of the above determines the order of benefits, the
plan that has covered an employee, member, or subscriber longer determines benefits before
the plan that has covered that person for a shorter time.
Effect on Benefits of This Plan
1. When this section applies: When the Order of Benefits Rules above require This Plan to be a
Secondary Plan, this part applies. Benefits of This Plan may be reduced.
2. Reduction in This Plan's benefits
When the sum of:
a. the benefits payable for allowable expenses under This Plan, without applying coordination of
benefits; and
b. the benefits payable for allowable expenses under the other plans, without applying
coordination of benefits or a similar provision, whether or not claim is made, exceeds those
allowable expenses in a claim determination period. In that case, the benefits of This Plan are
reduced so that benefits payable under all plans do not exceed allowable expenses.
When benefits of This Plan are reduced, each benefit is reduced in proportion and charged
against any applicable benefit limit of This Plan.
Right to Receive and Release Needed Information
Certain facts are needed to apply these coordination of benefits rules. The Claims Administrator has
the right to decide which facts are needed. The Claims Administrator may get needed facts from, or
give them to, any other organization or person. They do not need to tell, or get the consent of, any
person to do this. Each person claiming benefits under This Plan must provide any facts needed to pay
the claim.
Facility of Payment
A payment made under another plan may include an amount that should have been paid under This
Plan. If this happens, This Plan may pay that amount to the organization that made that payment. That
amount will then be considered a benefit under This Plan. This Plan will not have to pay that amount
" includes providing benefits in the form of services, in which case
again. The term "payment made udes p o g ,
"payment made" means reasonable cash value of the benefits provided in the form of services.
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Right of Recovery
If This Plan pays more than it should have paid under these coordination of benefit rules, This Plan may
recover the excess from any of the following:
1. the persons This Plan paid or for whom This Plan has paid
2. insurance companies
3. other organizations
The amount paid includes the reasonable cash value of any benefits provided in the form of services.
69
REIMBURSEMENT AND SUBROGATION
If the Plan pays medical benefits for medical or dental expenses you incur as a result of any act of a
third party for which the third party is or may be liable, and you later obtain full recovery, you are
obligated to reimburse the Plan for the benefits paid in accord with Minnesota statutes §62A.095 and
§62A.096, the laws related to subrogation rights.
The Plan's right to reimbursement and subrogation is subject to subtraction for actual monies paid to
account for the pro rata share of your costs, disbursements and reasonable attorney fees, and other
expenses incurred in obtaining the recovery from another source unless the Plan is separately
represented by its own attorney.
If the Plan is separately represented by an attorney, the Plan Administrator may enter into an
agreement with you regarding your costs, disbursements and reasonable attorney fees, and other
expenses. If an agreement cannot be reached on such allocation, the matter shall be submitted to
binding arbitration.
Nothing herein shall limit the Plan's right to recovery from another source which may otherwise exist at
law. For purposes of this provision, full recovery does not include payments made by the Plan to or for
your benefit. You must cooperate with the Plan Administrator in assisting it to protect its legal rights
under this provision.
If you make a claim against a third party for damages that include repayment for medical and medically-
related expenses incurred for your benefit, you must provide timely written notice to the Plan
Administrator of the pending or potential claim. The Plan Administrator, at its option, may take such
action as may be appropriate and necessary to preserve its rights under this reimbursement and
subrogation provision, including the right to intervene in any lawsuit you have commenced with a third
party.
The Plan Administrator may delegate such functions to the Claims Administrator.
Notwithstanding any other law to the contrary, the statute of limitations applicable to the Plan's rights for
reimbursement or subrogation does not commence to run until notice has been given.
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GENERAL PROVISIONS
Plan Administration
Plan Administrator
The general administration of the Plan and the duty to carry out its provisions is vested in the Employer.
The board of directors will perform such duties on behalf of the Employer, provided it may delegate
such duty or any portion thereof to a named person, including employees and agents of the Employer,
and may from time to time revoke such authority and delegate it to another person. Any delegation of
responsibility must be in writing and accepted by the designated person. Notwithstanding any
designation or delegation, the Plan Administrator will have the final authority to administer the Plan.
Powers and Duties of the Plan Administrator
The Plan Administrator will have the authority to control and manage the operation and administration
of the Plan. This will include all rights and powers necessary or convenient to carry out its functions as
Plan Administrator. Without limiting that general authority, the Plan Administrator will have the express
authority to:
1. construe and interpret the provisions of the Plan, decide all questions of eligibility, and determine
the amount, manner, and time of payment of any benefits under this Plan.
2. prescribe forms, procedures, policies, and rules to be followed by you and other persons claiming
benefits under the Plan;
3. prepare and distribute information to you explaining the Plan;
4. receive from you and any other parties the necessary information for the proper administration of
the Plan;
5. receive, review, and maintain reports of the financial condition and receipts and disbursements of
the Plan;
6. provide a full and fair review to any claimant whose claim for benefits has been denied in whole or
in part; and
7. to retain such actuaries, accountants, consultants, third party administration service providers, legal
counsel, or other specialists, as it may deem appropriate or necessary for the effective
administration of the Plan.
Actions of the Plan Administrator
The Plan Administrator may adopt such rules as it deems necessary, desirable, or appropriate. All
determinations, interpretations, rules, and decisions of the Plan Administrator shall be made in its sole
discretion and shall be conclusive and binding upon all persons having or claiming to have any interest
or right under the Plan. All rules and decisions of the Plan Administrator will be uniformly and
consistently applied so that all individuals who are similarly situated will receive substantially the same
treatment.
The Plan Administrator or the Employer may contract with one (1) or more service agents, including the
Claims Administrator, to assist in the handling of claims under the Plan and/or to provide advice and
assistance in the general administration of the Plan. Such service agent(s) may also be given the
71
authority to make payments of benefits under the Plan on behalf of and subject to the authority of the
Plan Administrator. Such service agent(s) may also be given the authority to determine claims in
accordance with procedures, policies, interpretations, rules, or practices made, adopted, or approved
by the Plan Administrator.
Nondiscrimination
The Plan shall not discriminate in favor of"highly compensated employees" as defined in Section
105(h) of the Internal Revenue Code, as to eligibility to participate or as to benefits.
Termination or Changes to the Plan
No agent can legally change the Plan or waive any of its terms.
The Employer reserves the power at any time and from time to time (and retroactively if necessary or
appropriate to meet the requirements of the Internal Revenue Code) to terminate, modify or amend, in
whole or in part, any or all provisions of the Plan, provided however, that no modification or amendment
shall divest an employee of a right to which he or she is entitled under the Plan. Any amendment to this
Plan may be effected by a written resolution adopted by the Board of Directors. The Plan Administrator
will communicate any adopted changes to the employees.
Funding
This Plan is a self-insured medical plan funded by contributions from the employer and/or employees.
Funds for benefit payments are provided through a special arrangement with your local service
cooperative according to the terms of its agreement with the Claims Administrator. Your contributions
toward the cost of coverage under the Plan will be determined by the employer each year. The Claims
Administrator provides administrative services only and does not assume any financial risk or obligation
with respect to providing benefits. The Claims Administrator's payment of claims is contingent upon the
Plan Administrator continuing to provide sufficient funds for benefits.
Controlling Law
Except as they may be subject to federal law. Any questions, claims, disputes, or litigation concerning
or arising from the Plan will be governed by the laws of the State of Minnesota.
Privacy of Protected Health Information
Protected Health Information (PHI) is individually identifiable information created or received by a health
care provider or a health care plan. This information is related to your past, present, or future health or
the payment for such health care. PHI includes demographic information that either identifies you or
provides a reasonable basis to believe that it could be used to identify you.
Restrictions on the Use and Disclosure of Protected Health Information
The employer may not use or disclose PHI for employment-related actions or decisions. The employer
may only use or further disclose PHI as permitted or required by law and will report any use or
disclosure of PHI that is inconsistent with the allowed uses and disclosures.
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Separation Between the Employer and the Plan
The employees, classes of employees or other workforce members below will have access to PHI only
to perform the plan administration functions that the employer provides for the plan. The following may
be given access to PHI:
• Benefit Administrator
This list includes every employee or class of employees or other workforce members under the control
of the employee who may receive PHI relating to the ordinary course of business.
The employees, classes of employees or other workforce members identified above will be subject to
disciplinary action and sanctions for any use or disclosure of PHI that is in violation of these provisions.
The employer will promptly report such instances to the Plan and will cooperate to correct the problem.
The employer will impose appropriate disciplinary actions on each employee or workforce member and
will reduce any harmful effects of the violation.
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DEFINITIONS
Admission A period of one (1) or more days and nights while you occupy a bed
and receive inpatient care in a facility.
Advanced practice nurses Licensed registered nurses who have gained additional knowledge and
skills through an organized program of study and clinical experience
that meets the criteria for advanced practice established by the
professional nursing organization having the authority to certify the
registered nurse in the advanced nursing practice. Advanced practice
nurses include clinical nurse specialists (C.N.S.), nurse practitioners
(N.P.), certified registered nurse anesthetists (C.R.N.A.), and certified
nurse midwives (C.N.M.).
Allowed amount The amount that payment is based on for a given covered service of a
specific provider. The allowed amount may vary from one provider to
another for the same service. All benefits are based on the allowed
amount, except as noted in the Benefit Chart.
For In-Network and Extended Network Providers, the allowed amount is
the negotiated amount of payment that the In-Network and Extended
Network Provider has agreed to accept as full payment for a covered
service at the time your claim is processed. The Claims Administrator
periodically may adjust the negotiated amount of payment at the time
your claim is processed for covered services at In-Network and
Extended Network Providers as a result of expected settlements or
other factors. The negotiated amount of payment with In-Network and
Extended Network Providers for certain covered services may not be
based on a specified charge for each service, and the Claims
Administrator uses a reasonable allowance to establish a per-service
allowed amount for such covered services. Through settlements,
rebates, and other methods, the Claims Administrator may
subsequently adjust the amount due to an In-Network or Extended
Network Provider. These subsequent adjustments will not impact or
cause any change in the amount you paid at the time your claim was
processed. If the payment to the provider is decreased, the amount of
the decrease is credited to the Claims Administrator or the Plan
Administrator, and the percentage of the allowed amount paid by the
Claims Administrator is lower than the stated percentage for the
covered service. If the payment to the provider is increased, the Claims
Administrator pays that cost on your behalf, and the percentage of the
allowed amount paid is higher than the stated percentage.
For Nonparticipating Providers, the allowed amount is the lesser of
billed charge or a percentage of what the Plan would pay an In-Network
or Extended Network Provider for the same or similar services.
Assisted Reproductive Any treatment or procedures employed to bring about conception
Technology (ART) without sexual intercourse.
Attending Health Care A health care professional with primary responsibility for the care
Professional provided to a sick or injured person.
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Average semiprivate room The average rate charged for semiprivate rooms. If the provider has no
rate semiprivate rooms, the Claims Administrator uses the average
semiprivate room rate for payment of the claim.
Behavioral Health Network A health professional that participates in a special network for the
Provider provision of mental health or chemical dependency treatment services.
BlueCard Program A national Blue Cross and Blue Shield program in which you can
receive health plan benefits while travelling or living outside of your
service area. You must use Participating Providers and show your
membership ID to secure BlueCard Program benefits.
Blue Select Provider A health professional that participates in a special network for the
provision of certain services. These services are covered at a greater
amount when you use a Blue Select Provider.
Calendar year The period starting on January 1st of each year and ending at midnight
December 31st of that year.
Care/case management A plan for health care services developed for a specific patient by one
plan of our care/case managers after an assessment of the patient's
condition in collaboration with the patient and the patient's health care
team. The plan sets forth both the immediate and the ongoing skilled
health care needs of the patient to sustain or achieve optimal health
status.
Chemical dependency Alcohol or drug dependence as defined in the most current edition of
the International Classification of Diseases.
Claims Administrator Blue Cross and Blue Shield of Minnesota.
Coinsurance The percentage of the allowed amount you must pay for certain
covered services after you have paid any applicable deductibles and
copays and until you reach your out-of-pocket maximum. For covered
services from In-Network and Extended Network Providers,
coinsurance is calculated based on the lesser of the allowed amount or
the In-Network and Extended Network Provider's billed charge.
Because payment amounts are negotiated with In-Network and
Extended Network Providers to achieve overall lower costs, the allowed
amount for In-Network and Extended Network Providers is generally,
but not always, lower than the billed charge. However, the amount used
to calculate your coinsurance will not exceed the billed charge. When
your coinsurance is calculated on the billed charge rather than the
allowed amount for In-Network and Extended Network Providers, the
percentage of the allowed amount paid by the Claims Administrator will
be greater than the stated percentage.
For covered services from Nonparticipating Providers, coinsurance is
calculated based on the allowed amount. In addition, you are
responsible for any excess charge over the allowed amount.
Your coinsurance and deductible amount will be based on the
negotiated payment amount the Claims Administrator has established
with the provider or the provider's charge, whichever is less. The
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negotiated payment amount includes discounts that are known and can
be calculated when the claim is processed. In some cases, after a claim
is processed, that negotiated payment amount may be adjusted at a
later time if the agreement with the provider so provides. Coinsurance
and deductible calculation will not be changed by such subsequent
adjustments or any other subsequent reimbursements the Claims
Administrator may receive from other parties.
Coinsurance Example:
You are responsible for payment of any applicable coinsurance
amounts for covered services. The following is an example of how
coinsurance would work for a typical claim:
For instance, when the Claims Administrator pays 80% of the allowed
amount for a covered service, you are responsible for the coinsurance,
which is 20% of the allowed amount. In addition, you would be
responsible for any excess charge over the Claims Administrator's
allowed amount when a Nonparticipating Provider is used. For
example, if a Nonparticipating Provider ordinarily charges $100 for a
service, but the Claims Administrator's allowed amount is $95, the
Claims Administrator will pay 80% of the allowed amount ($76). You
must pay the 20% coinsurance on the Claims Administrator's allowed
amount ($19), plus the difference between the billed charge and the
allowed amount ($5), for a total responsibility of$24.
Remember, if In-Network and Extended Network Providers are used,
your share of the covered charges (after meeting any deductibles) is
limited to the stated coinsurance amounts based on the Claims
Administrator's allowed amount. If Nonparticipating Providers are used,
your out-of-pocket costs will be higher as shown in the example above.
Compound drug A prescription where two or more drugs are mixed together. One of
these must be a Federal legend drug. The end product must not be
available in an equivalent commercial form. A prescription will not be
considered a compound if only water or sodium chloride solution are
added to the active ingredient.
Comprehensive pain A multidisciplinary program including, at a minimum, the following
management program components:
1. A comprehensive physical and psychological evaluation;
2. Physical/occupation therapies;
3. A multidisciplinary treatment plan; and
4. A method to report clinical outcomes.
Continuous coverage The maintenance of continuous and uninterrupted creditable coverage
by an eligible employee or dependent. An eligible employee or
dependent is considered to have maintained continuous coverage if the
individual applies for coverage within 63 days of the termination of his
or her qualifying coverage.
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Copay The dollar amount you must pay for certain covered services. The
Benefit Chart lists the copays and services that require copays.
A negotiated payment amount with the provider for a service requiring a
copay will not change the dollar amount of the copay.
Cosmetic surgery Surgery and other cosmetic health services which are chiefly intended
to improve appearance and are not medically necessary as determined
by the Claims Administrator.
Covered services A health service or supply that is eligible for benefits when performed
and billed by an eligible provider. You incur a charge on the date a
service is received or a supply or a drug is purchased.
Creditable coverage Health coverage provided through an individual policy, a self-funded or
fully-insured group health plan offered by a public or private employer,
medical assistance, General Assistance Medical Care, TRICARE,
Federal Employees Health Benefit Plan (FEHBP), Medical care
program of the Indian Health Service of a tribal organization, a state
health benefit risk pool, or a Peace Corps health plan.
Custodial care Services that the Claims Administrator determines are for the primary
purpose of meeting personal needs. These services can be provided by
persons without professional skills or training. Custodial care does not
include skilled care. Custodial care includes giving medicine that can
usually be taken without help, preparing special foods, and helping you
to walk, get in and out of bed, dress, eat, bathe, and use the toilet.
Deductible The amount you must pay toward the allowed amount for certain
covered services each year before the Claims Administrator begins to
pay benefits. The deductibles for each person and family are shown on
the Benefit Chart.
Your coinsurance and deductible amount will be based on the
negotiated payment amount the Claims Administrator has established
with the provider or the provider's charge, whichever is less. The
negotiated payment amount includes discounts that are known and can
be calculated when the claim is processed. In some cases, after a claim
is processed, that negotiated payment amount may be adjusted at a
later time if the agreement with the provider so provides. Coinsurance
and deductible calculation will not be changed by such subsequent
adjustments or any other subsequent reimbursements the Claims
Administrator may receive from other parties.
Deductible carryover The amount applied toward a deductible during the last three (3)
months of the calendar year. The Claims Administrator applies this
amount toward the deductible for the next calendar year.
Drug therapy supply A disposable article intended for use in administering or monitoring the
therapeutic effect of a drug.
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Durable medical Medical equipment prescribed by a physician that meets each of the
equipment following requirements:
• able to withstand repeated use;
• used primarily for a medical purpose;
• generally not useful in the absence of illness or injury;
• determined to be reasonable and necessary; and
• represents the most cost-effective alternative.
Enrollment date The first day of coverage, or if there has been a waiting period, the first
day of the waiting period (typically the date employment begins).
Extended Network A participating provider that has entered into a service agreement with
Provider the Claims Administrator but is not a part of the special network of
providers used for certain services.
Facility A hospital, home health agency, skilled nursing facility, freestanding
ambulatory facility, residential behavioral health treatment facility, or
outpatient behavioral health treatment facility licensed, certified or
otherwise qualified under state law, in the state in which the services
are rendered, to provide the health services billed by that facility.
Foot orthotic A rigid or semi-rigid orthopedic appliance or apparatus worn to support,
align, and/or correct deformities of the lower extremity.
Formulary The Blue Cross formulary is a list of brand and generic prescription
drugs and drug supplies that are commonly used by patients in an
ambulatory care setting. Over-the-counter, injectable medications and
drug supplies are not included in this formulary unless they are
specifically listed. The Blue Cross Pharmacy and Therapeutics (P&T)
Committee is responsible for the selection of this list of products. The
formulary is subject to periodic review and modification by this
committee.
Freestanding ambulatory A facility that provides medical, surgical, and other professional
facility services to sick and injured persons on an outpatient basis. Such
services are performed by or under the direction of a staff of licensed
doctors of medicine (M.D.) or osteopathy (D.O.) and/or registered
nurses (R.N.). A freestanding ambulatory facility is not part of a
hospital, a clinic, a doctor's office, or other health care professional's
office.
Health care professional A health care professional, licensed for independent practice, certified
or otherwise qualified under state law, in the state in which the services
are rendered, to provide the health services billed by that health care
professional. Health care professionals include only physicians,
chiropractors, mental health professionals, advanced practice nurses,
physician assistants, audiologists, physical, speech and occupational
therapists, dieticians, and nutritionists. Health care professional also
includes supervised employees of: Rule 29 clinics and doctors of
medicine, osteopathy, chiropractic, or dental surgery.
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Home health agency A Medicare approved or other preapproved facility that sends health
professionals and home health aides into a person's home to provide
health services.
Hospice care A coordinated set of services provided at home or in an institutional
setting for covered individuals suffering from a terminal disease or
condition.
Hospital A facility that provides diagnostic, therapeutic and surgical services to
sick and injured persons on an inpatient or outpatient basis. Such
services are performed by or under the direction of a staff of licensed
doctors of medicine (M.D.) or osteopathy (D.O.). A hospital provides
24-hour-a-day professional registered nursing (R.N.) services.
Illness A sickness, injury, pregnancy, mental illness, chemical dependency, or
condition involving a physical disorder.
In-Network Provider A provider that has entered into a service agreement with the Claims
Administrator. In-Network Providers are also known as Participating
Providers.
Investigative A drug, device, diagnostic procedure, technology, or medical treatment
or procedure is investigative if reliable evidence does not permit
conclusions concerning its safety, effectiveness, or effect on health
outcomes. The Claims Administrator bases its decision upon an
examination of the following reliable evidence, none of which is
determinative in and of itself:
1. the drug or device cannot be lawfully marketed without approval of
the U.S. Food and Drug Administration and approval for marketing
has not been given at the time the drug or device is furnished;
2. the drug, device, diagnostic procedure, technology, or medical
treatment or procedure is the subject of ongoing phase I, II, or III
clinical trials (Phase I clinical trials determine the safe dosages of
medication for Phase II trials and define acute effects on normal
tissue. Phase II clinical trials determine clinical response in a
defined patient setting. If significant activity is observed in any
disease during Phase II, further clinical trials usually study a
comparison of the experimental treatment with the standard
treatment in Phase III trials. Phase III trials are typically quite large
and require many patients to determine if a treatment improves
outcomes in a large population of patients);
3. medically reasonable conclusions establishing its safety,
effectiveness, or effect on health outcomes have not been
established. For purposes of this subparagraph, a drug, device,
diagnostic procedure, technology, or medical treatment or
procedure shall not be considered investigative if reliable evidence
shows that it is safe and effective for the treatment of a particular
patient.
Reliable evidence shall also mean consensus opinions and
recommendations reported in the relevant medical and scientific
79
literature, peer-reviewed journals, reports of clinical trial committees, or
technology assessment bodies, and professional expert consensus
opinions of local and national health care providers.
Late entrant An eligible employee or dependent who requests enrollment under the
Plan following the enrollment period after which the individual first
became eligible for coverage. Late entrants will be subject to a
preexisting condition limitation period, with credit for prior continuous
creditable coverage.
An individual will not be considered a late entrant if:
1. the individual was covered under creditable coverage at the time
the individual was eligible to enroll for coverage under this Plan,
declined enrollment on that basis, and presents to the Claims
Administrator a certificate of termination of the qualifying coverage
within 30 days;
2. the individual is applying for coverage within 30 days of the
exhaustion of the maximum continuation period provided by state
and federal law;
3. the individual is applying for coverage within 30 days of losing
eligibility under other creditable coverage due to a divorce, legal
separation, death, termination of employment, reduction in hours, or
employer contributions toward the coverage was terminated;
4. the individual is a new spouse of an eligible employee applying for
coverage within 30 days of becoming legally married;
5. the individual is a new dependent of an eligible employee for whom
coverage is being requested within 30 days of becoming a new
dependent;
6. the individual elects a different plan during an open enrollment
period; or
7. the coverage being requested is the result of a court order for the
addition of a dependent of an eligible employee within 30 days of
the issuance of the order.
Lifetime maximum The cumulative maximum payable for covered services incurred by you
during your lifetime or by each of your dependents during the
dependent's lifetime under all health plans sponsored by the Plan
Administrator. The lifetime maximum does not include amounts which
are your responsibility such as deductibles, coinsurance, copays,
penalties, and other amounts. Refer to the Benefit Chart for specific
dollar maximums on certain services.
Mail service pharmacy A pharmacy that dispenses prescription drugs through the U.S. Mail.
Medical emergency Medically necessary care which a reasonable layperson believes is
immediately necessary to preserve life, prevent serious impairment to
bodily functions, organs, or parts, or prevent placing the physical or
mental health of the patient in serious jeopardy.
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Medically necessary Eligible medical and hospital services that the Claims Administrator
determines are appropriate and necessary based on its internal
standards. In disputed cases, the standard peer review process is
used.
For purposes of mental health care services, the following medically
necessary definition applies:
Health care services must be appropriate in terms of type, frequency,
level, setting, and duration to the individual's diagnosis or condition,
diagnostic testing, and preventive services. Medically necessary care
must:
1. be consistent with generally accepted practice parameters as
determined by health care providers in the same or similar general
specialty as typically manages the conditions, procedures, or
treatment at issue;
2. help restore or maintain the individual's health;
3. prevent deterioration of the individual's condition; or
4. prevent the reasonable likely onset of a health problem or detect an
incipient problem.
Medicare A federal health insurance program established under Title XVIII of the
Social Security Act. Medicare is a program for people age 65 or older;
some people with disabilities under age 65; and people with end-stage
renal disease. The program has two parts, Part A and Part B. Part A
generally covers some costs of inpatient care in hospitals and skilled
nursing facilities. Part B generally covers some costs of physician,
medical, and other services. Both Parts A and B do not pay the entire
cost of services and are subject to cost sharing requirements and
certain benefit limitations.
Mental health professional A psychiatrist, psychologist, independent social worker, or marriage
and family therapist, licensed for independent practice, that provides
treatment for mental health disorders, alcoholism, chemical
dependency, or drug addiction.
Mental illness A mental disorder as defined in the International Classification of
Diseases. It does not include alcohol or drug dependence,
nondependent abuse of drugs, or mental retardation.
Nonparticipating Provider A provider that has not entered into a service agreement with the local
Blue Cross and/or Blue Shield Plan.
Out-of-Network Provider A provider that is not considered In-Network for the service being
provided. Out-of-Network Providers include Extended Network and
Nonparticipating Providers.
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r-
Out-of-pocket maximum The most each person must pay each year toward the allowed amount
for covered services. The following items are applied to the out-of-
pocket maximum:
1. Coinsurance
2. Deductible
3. Copays
4. Penalties for not giving the Claims Administrator preadmission
notification
After a person reaches the out-of-pocket maximum, the Plan pays
100% of the allowed amount for covered services for that person for the
rest of the year. The Benefit Chart lists the out-of-pocket maximum
amounts.
Prescription drug copays do not apply to the out-of-pocket maximum,
except those dispensed and used during an inpatient admission.
Outpatient Behavioral A facility that provides outpatient treatment, by or under the direction of,
Health Treatment Facility a doctor of medicine (M.D.) or osteopathy (D.O.), for mental health
disorders, alcoholism, chemical dependency, or drug addiction. An
outpatient behavioral health treatment facility does not, other than
incidentally, provide educational or recreational services as part of its
treatment program.
Outpatient care Health services a patient receives without being admitted to a facility as
an inpatient. Care received at ambulatory surgery centers is considered
outpatient care.
Participating Provider A provider that has entered into a service agreement with the local Blue
Cross and/or Blue Shield Plan.
Physician A Doctor of Medicine (M.D.), Osteopathy (D.O.), Dental Surgery
(D.D.S.), Medical Dentistry (D.M.D.), Podiatric Medicine (D.P.M.), or
Optometry (O.D.) practicing within the scope of his or her license.
Plan The plan of benefits established by the Plan Administrator.
Preexisting condition A condition the Claims Administrator has determined existed within a
specified time period preceding the enrollment date of your coverage.
Conditions are considered to be preexisting if medical advice,
diagnosis, care, or treatment was recommended or received.
Preexisting condition The time frame based on the enrollment date of your coverage for
limitation period which services for preexisting conditions will not be covered services
under the Plan. This limitation period will be reduced by any prior
continuous creditable coverage.
Prescription drug out-of- The most you must pay toward the allowed amount for prescription
pocket maximum drugs per calendar year. After you reach the prescription drug out-of-
pocket maximum, the Plan pays 100% of the allowed amount for
covered services for the rest of the year. The Benefit Chart lists the
prescription drug out-of-pocket maximum amount.
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Prescription drugs Drugs, including insulin, that are required by federal law to be
dispensed only by prescription of a health professional who is
authorized by law to prescribe the drug.
Provider A health care professional or facility licensed, certified or otherwise
qualified under state law, in the state in which services are rendered, to
provide the health services billed by that provider. Provider also
includes home infusion therapy providers, pharmacies, medical supply
companies, independent laboratories and ambulances.
Residential Behavioral A facility that provides inpatient treatment, by or under the direction of,
Health Treatment Facility a doctor of medicine (M.D.) or osteopathy (D.O.), for mental health
disorders, alcoholism, chemical dependency or drug addiction. A
residential behavioral health treatment facility does not, other than
incidentally, provide educational or recreational services as part of its
treatment program.
Respite care Short-term inpatient or home care provided to the patient when
necessary to relieve family members or other persons caring for the
patient.
Retail pharmacy Any licensed pharmacy that you can physically enter to obtain a
prescription drug.
Skilled care Services that are medically necessary and must be provided by
licensed registered nurses or other eligible providers. A service
performed by, or under the direct supervision of, a licensed registered
nurse or other eligible provider is not considered skilled care if the
service can be safely and effectively self-administered or performed by
a layperson.
Skilled nursing facility A Medicare-approved facility that provides skilled transitional care, by
or under the direction of a doctor of medicine (M.D.) or osteopathy
(D.O.), after a hospital stay. A skilled nursing facility provides 24-hour-
a-day professional registered nursing (R.N.) services.
Smoking cessation drugs Prescription drugs and over-the-counter products that aid in reducing or
eliminating the use of nicotine.
Supervised employees Health care professional employed by a doctor of medicine, osteopathy,
chiropractic, or dental surgery or a Rule 29 clinic. The employing M.D.,
D.O., D.C., D.D.S. or mental health professional must be physically
present and immediately available in the same office suite more than
50% of each day when the employed health care professional is
providing services. Independent contractors are not eligible.
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7
Supply Equipment that must be medically necessary for the medical treatment
or diagnosis of an illness or injury or to improve functioning of a
malformed body part. Supplies are not reusable, and usually last for
less than one (1) year.
Supplies do not include such things as:
1. alcohol swabs;
2. cotton balls;
3. incontinence liners/pads;
4. 0-tips;
5. adhesives; or
6. informational materials.
Terminally ill patient An individual who has a life expectancy of six (6) months or less, as
certified by the person's primary physician.
Treatment The management and care of a patient for the purpose of combating an
illness. Treatment includes medical and surgical care, diagnostic
evaluation, giving medical advice, monitoring, and taking medication.
Waiting period The period of time that must pass before you or your dependents are
eligible for coverage under the health plan.
Year January 1st through December 31st.
84