24-V8 - Vision COC COB.pdf

UnitedHealthcare Vision

UnitedHealthcare Insurance Company

Certificate of Coverage

For the Plan: VH652 of

City of Burleson

Group Number: 906435

Effective Date: January 1, 2025

TX Notice

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Certificate of Coverage

UnitedHealthcare Insurance Company What Is the Certificate of Coverage?

This Certificate of Coverage (Certificate) is part of the Policy that is a legal document between UnitedHealthcare Insurance Company and the Group. The Certificate describes Covered Vision Care Services, subject to the terms, conditions, exclusions and limitations of the Policy. We issue the Policy based on the Group's Application and payment of the required Policy Charges.

In addition to this Certificate, the Policy includes:

• The Schedule of Covered Vision Care Services.

• The Group's Application.

• Riders.

• Amendments.

You can review the Policy at the Group's office during regular business hours.

Can This Certificate Change?

We may, from time to time, change this Certificate by attaching legal documents called Riders and/or Amendments that may change certain provisions of this Certificate. When this happens we will send you a new Certificate, Rider or Amendment.

Other Information You Should Have We have the right to change, interpret, withdraw or add Benefits, or to end the Policy, as permitted by law, without your approval.

On its effective date, this Certificate replaces and overrules any Certificate that we may have previously issued to you. This Certificate will in turn be overruled by any Certificate we issue to you in the future.

The Policy will take effect on the date shown in the Policy. Coverage under the Policy starts at 12:01 a.m.

and ends at 12:00 midnight in the time zone of the Group's location. The Policy will remain in effect as long as the Policy Charges are paid when they are due, subject to Section 4: When Coverage Ends.

We are delivering the Policy in Texas. The Policy is governed by ERISA unless the Group is not an employee health and welfare plan as defined by ERISA. To the extent that state law applies, Texas law governs the Policy.

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF

WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO

DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS'

COMPENSATION SYSTEM.

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Introduction to Your Certificate This Certificate and the other Policy documents describe your Benefits, as well as your rights and responsibilities, under the Policy.

What Are Defined Terms?

Certain capitalized words have special meanings. We have defined these words in Section 9: Defined Terms.

When we use the words "we," "us," and "our" in this document, we are referring to UnitedHealthcare Insurance Company. When we use the words "you" and "your," we are referring to people who are Covered Persons, as that term is defined in Section 9: Defined Terms.

How Do You Use This Document?

Read your entire Certificate and any attached Riders and/or Amendments. You may not have all of the information you need by reading just one section. Keep your Certificate and Schedule of Covered Vision Care Services and any attachments in a safe place for your future reference.

Review the Benefit limitations of this Certificate by reading the attached Schedule of Covered Vision Care Services along with Section 1: Covered Vision Care Services and Section 2: Exclusions and Limitations.

Read Section 8: General Legal Provisions to understand how this Certificate and your Benefits work. Call us if you have questions about the limits of the coverage available to you.

If there is a conflict between this Certificate and any summaries provided to you by the Group, this Certificate controls.

Please be aware that your Vision Provider is not responsible for knowing or communicating your Benefits.

How Do You Contact Us?

Call us at 1-800-638-3120. Throughout the document you will find statements that encourage you to contact us for more information.

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Your Responsibilities Enrollment and Required Contributions Benefits are available to you if you are enrolled for coverage under the Policy. Your enrollment options, and the corresponding dates that coverage begins, are listed in Section 3: When Coverage Begins. To be enrolled and receive Benefits, both of the following apply:

• Your enrollment must be in accordance with the requirements of the Policy issued to your Group, including the eligibility requirements.

• You must qualify as a Subscriber or a Dependent as those terms are defined in Section 9: Defined Terms.

Your Group may require you to make certain payments to them, in order for you to remain enrolled under the Policy. If you have questions about this, contact your Group.

Be Aware the Policy Does Not Pay for All Vision Care Services The Policy does not pay for all vision care services. Benefits are limited to Covered Vision Care Services.

The Schedule of Covered Vision Care Services will tell you the portion you must pay for Covered Vision Care Services.

Decide What Services You Should Receive Care decisions are between you and your Vision Provider. We do not make decisions about the kind of care you should or should not receive.

Choose Your Vision Provider It is your responsibility to select the vision care professionals who will deliver your care. We arrange for Vision Providers and facilities to participate in a Network. Our credentialing process confirms public information about the professionals' licenses and other credentials, but does not assure the quality of their services. These professionals and facilities are independent practitioners that are solely responsible for the care they deliver.

Pay Your Share You must meet any applicable Deductible and pay a Co-payment and/or Co-insurance for most Covered Vision Care Services. These payments are due at the time of service or when billed by the Vision Provider. Any applicable Deductible, Co-payment and Co-insurance amounts are listed in the Schedule of Covered Vision Care Services. You must also pay any amount that exceeds your Benefits.

Pay the Cost of Excluded Services You must pay the cost of all excluded services and items. Review Section 2: Exclusions and Limitations to become familiar with the Policy's exclusions.

File Claims with Complete and Accurate Information When you receive Covered Vision Care Services from an out-of-Network Vision Provider, you are responsible for requesting payment from us. You must file the claim in a format that contains all of the information we require, as described in Section 5: How to File a Claim.

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Our Responsibilities Determine Benefits We make administrative decisions regarding whether the Policy will pay for any portion of the cost of a vision care service you intend to receive or have received. Our decisions are for payment purposes only.

We do not make decisions about the kind of care you should or should not receive.

We have the authority to do the following:

• Interpret Benefits and the other terms, limitations and exclusions set out in this Certificate, the Schedule of Covered Vision Care Services and any Riders and/or Amendments.

• Make factual determinations relating to Benefits.

We may assign this authority to other persons or entities that may provide administrative services for the Policy, such as claims processing. The identity of the service providers and the nature of their services may be changed from time to time as we determine. In order to receive Benefits, you must cooperate with those service providers.

Pay for Our Portion of the Cost of Covered Vision Care Services We pay Benefits for Covered Vision Care Services as described in Section 1: Covered Vision Care Services and in the Schedule of Vision Care Services, unless the service is excluded in Section 2:

Exclusions and Limitations. This means we only pay our portion of the cost of Covered Vision Care Services. It also means that not all of the vision care services you receive may be paid for (in full or in part) by the Policy.

Pay Network Providers It is the responsibility of Network Vision Providers and facilities to file for payment from us. When you receive Covered Vision Care Services from Network providers, you do not have to submit a claim to us.

Pay for Covered Vision Care Services Provided by Out-of-Network Providers In accordance with any state prompt pay requirements, we pay Benefits after we receive your request for payment that includes all required information. See Section 5: How to File a Claim. Your cost sharing may be more when you see an out-of-Network Vision Provider.

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Certificate of Coverage Table of Contents p

Section 1: Covered Vision Care Services Section 2: Exclusions and Limitations Section 3: When Coverage Begins Section 4: When Coverage Ends Section 5: How to File a Claim Section 6: Questions, Complaints and Appeals Section 7: Coordination of Benefits Section 8: General Legal Provisions Section 9: Defined Terms

WHAT TO KNOW ABOUT COORDINATION OF BENEFITS (COB)

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Section 1: Covered Vision Care Services When Are Benefits Available for Covered Vision Care Services?

Benefits are available only when all of the following are true:

• The vision care service, including materials as shown in the Schedule of Covered Vision Care Services.

• You receive Covered Vision Care Services while the Policy is in effect.

• You receive Covered Vision Care Services prior to the date that any of the individual termination conditions listed in Section 4: When Coverage Ends occurs.

• The person who receives Covered Vision Care Services is a Covered Person and meets all eligibility requirements specified in the Policy.

This section describes Covered Vision Care Services for which Benefits are available. Please refer to the attached Schedule of Covered Vision Care Services for details about:

The amount you must pay for these Covered Vision Care Services (including any Co-payment).

• Any limit that applies to these Covered Vision Care Services (including frequency and dollar limits on services and materials).

1. Routine Vision Examination A routine vision exam of the eyes and according to the standards of care in your area, including:

A. A patient history that includes reasons for the exam, patient medical/eye history, and current medications;

B. Visual acuity with each eye and both eyes, far and near, with and without glasses or contact lenses (for example, 20/20 and 20/40);

C. Cover test at 20 feet and 16 inches (checks how the eyes work together as a team);

D. Ocular motility (how the eyes move) near point convergence (how well eyes move together for near vision tasks, such as reading), and depth perception (3D Vision);

E. Pupil reaction to light and focusing;

F. Exam of the eye lids, lashes, and outside of the eye;

G. Refraction (when applicable) - to determine power of corrective lenses for distance and near vision;

Retinoscopy (when applicable): Objective refraction to determine lens power of corrective lenses.

Subjective refraction to determine lens power of corrective lenses;

H. Photometry/Binocular testing - far and near: how well eyes work as a team;

I. Tonometry, when indicated: test pressure in eye (glaucoma check);

J. Ophthalmoscopic exam of the internal eye;

K. Visual field testing;

L. Biomicroscopy;

M. Color vision testing;

N. Diagnosis/prognosis;

O. Dilation (when indicated) - Examine the internal structures of the eye; and

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P. Specific recommendations.

Post exam procedures will be performed only when materials are required.

Or in lieu of a complete exam, Retinoscopy (when applicable) - objective refraction to determine lens power of corrective lenses and subjective refraction to determine lens power of corrective lenses.

2. Retinal Photography Film or digital pictures taken of the back of your eye, which includes the retina and optic nerve.

3. Eyeglass Lenses Lenses that are mounted in an eyeglass frame and worn on the face to correct visual acuity limitations.

4. Eyeglass Frame A structure that contains eyeglass lenses, holding the lenses in front of the eyes and supported by the bridge of the nose.

5. Optional Lens Extras Special lens stock or modifications to lenses that do not correct visual acuity problems. Optional Lens Extras include options such as, but not limited to, lens tints, polycarbonate lenses, high-index lenses, ultraviolet coating, scratch-resistant coating, edge coating, and photochromic.

6. Contact Lenses Lenses worn on the surface of the eye to correct visual acuity limitations.

7. Necessary Contact Lenses This benefit is available where a Vision Provider has determined a need for and has prescribed the service. Such determination will be made by the Vision Provider and not by us.

Contact lenses are necessary if the Covered Person has:

A. Keratoconus;

B. Anisometropia;

C. Irregular corneal/astigmatism;

D. Aphakia;

E. Facial deformity;

F. Corneal deformity;

G. Pathological myopia;

H. Aniseikonia;

I. Aniridia;

J. Post-traumatic disorders;

K. Post-cataract surgery without intraocular lens; or

L. Visual acuity in the better eye of less than 20/70 with visual correction by eyeglasses but better than 20/70 with visual correction by contact lenses.

8. Contact Lens Fitting & Evaluation

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A contact lens evaluation and fitting includes examination and measurement of the eyes and adjacent structures to determine the contact lens size, design and power to achieve and maintain eye health, comfort and vision.

9. Virtual Visits Virtual visits for Covered Vision Care Services through live audio and video technology. Virtual visits provide a Routine Vision Examination for the patient by a distant Vision Provider.

Network Benefits are available only when services are delivered through a Designated Virtual Network Vision Provider. You can find a Designated Virtual Network Vision Provider by contacting us at www.myuhcvision.com or by calling us at 1-800-638-3120.

Please Note: Not all Routine Examinations or other services can be provided through virtual visits. The Designated Virtual Network Vision Provider will identify any patients for which services by in-person Vision Provider is needed.

Benefits do not include email or fax.

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Section 2: Exclusions and Limitations We Do Not Pay Benefits for Exclusions We will not pay Benefits for any of the services, treatments, and materials described in this section, even if it is recommended or prescribed by a Physician or Vision Provider.

The services, treatments, and materials listed in this section are not Covered Vision Care Services, except as may be specifically provided for in Section 1: Covered Vision Care Services or through a Rider to the Policy.

Where Are Benefit Limitations Shown?

When Benefits are limited within any of the Covered Vision Care Service categories described in Section 1: Covered Vision Care Services, those limits are stated in the corresponding Covered Vision Care Service category in the Schedule of Covered Vision Care Services. Please review all limits carefully, as we will not pay Benefits for any of the services, treatments, items or supplies that exceed these Benefit limits.

The following Services and materials are excluded from coverage under the Policy:

A. Non-prescription items (e.g. Plano lenses) other than those listed in the Schedule(s) of Covered Vision Care Services.

B. Services that the Covered Person, without cost, obtains from any governmental organization or program.

C. Services for which the Covered Person may be compensated under Workers' Compensation Law, or other similar employer liability law.

D. Any eye examination required by an employer as a condition of employment, by virtue of a labor agreement, a government body, or agency.

E. Medical or surgical treatment for eye disease, which requires the services of a Physician.

F. Replacement or repair of lenses and/or frame that have been lost or broken.

G. Optional Lens Extras not listed in the Schedule of Covered Vision Care Services.

H. Technological devices such as smart phones and tablets used as Optical Low Vision Aids.

I. Missed appointment charges.

J. Applicable sales tax charged on Services.

K. Services that are not specifically covered by the Policy.

L. Procedures that are considered to be Experimental, Investigational or Unproven. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.

M. Any Vision Service Covered under an Essential Health Benefit plan is not Covered under this Policy.

N. Any Vision Service rendered by the Policyholder.

O. Intraocular lenses.

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Section 3: When Coverage Begins How Do You Enroll?

Eligible Persons must complete an enrollment form given to them by the Group. The Group will submit the completed forms to us, along with any required Premium. We will not provide Benefits for vision care services that you receive before your effective date of coverage.

Who Is Eligible for Coverage?

The Group determines who is eligible to enroll and who qualifies as a Dependent.

Eligible Person Eligible Person usually refers to an employee or member of the Group who meets the eligibility rules.

When an Eligible Person enrolls, we refer to that person as a Subscriber. For a complete definition of Eligible Person, Group and Subscriber, see Section 9: Defined Terms.

Eligible Persons must live within the United States.

If both spouses are Eligible Persons of the Group, each may enroll as a Subscriber or be covered as an Enrolled Dependent of the other, but not both.

Dependent Dependent generally refers to the Subscriber's spouse and children. When a Dependent enrolls, we refer to that person as an Enrolled Dependent. For a complete definition of Dependent and Enrolled Dependent, see Section 9: Defined Terms.

Dependents of an Eligible Person may not enroll unless the Eligible Person is also covered under the Policy.

If both parents of a Dependent child are enrolled as a Subscriber, only one parent may enroll the child as a Dependent.

When Do You Enroll and When Does Coverage Begin?

Except as described below, Eligible Persons may not enroll themselves or their Dependents.

Initial Enrollment Period When the Group purchases coverage under the Policy from us, the Initial Enrollment Period is the first period of time when Eligible Persons can enroll themselves and their Dependents.

Coverage begins on the date shown in the Policy. We must receive the completed enrollment form and any required Premium within 31 days of the date the Eligible Person becomes eligible.

Open Enrollment Period The Group sets the Open Enrollment Period. During the Open Enrollment Period, Eligible Persons can enroll themselves and their Dependents.

Coverage begins on the date identified by the Group. We must receive the completed enrollment form and any required Premium within 31 days of the date the Eligible Person becomes eligible.

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New Eligible Persons Coverage for a new Eligible Person and his or her Dependents begins on the date agreed to by the Group. We must receive the completed enrollment form and any required Premium within 31 days of the date the new Eligible Person first becomes eligible.

Adding New Dependents Subscribers may enroll Dependents who join their family because of any of the following events:

• Birth.

• Legal adoption.

• Placement for adoption.

• The Subscriber is a party in a suit seeking adoption.

• The date the adoption becomes final.

• Marriage.

• Legal guardianship.

• Court or administrative order.

Coverage for the Dependent begins on the date of the event. We must receive the completed enrollment form and any required Premium within 31 days of the event.

Coverage for a new Dependent child by birth or adoption begins on the date of the event and remains in effect for 31 days. To continue coverage beyond the initial 31 day period, the Subscriber must notify us of the event and pay any required Premium within 31 days of the event. If no additional monthly premium will be required, a newborn child will be covered from the moment of birth.

Special Enrollment Period An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period. A special enrollment period is not available to an Eligible Person and his or her Dependents if coverage under the prior plan ended for cause, or because premiums were not paid on a timely basis.

An Eligible Person and/or Dependent does not need to elect COBRA continuation coverage to preserve special enrollment rights. Special enrollment is available to an Eligible Person and/or Dependent even if COBRA is not elected.

A special enrollment period applies to an Eligible Person and any Dependents when one of the following events occurs:

• Birth.

• Legal adoption.

• Placement for adoption.

• The Subscriber is a party in a suit seeking adoption.

• The date the adoption becomes final.

• Marriage.

A special enrollment period also applies for an Eligible Person and/or Dependent who did not enroll during the Initial Enrollment Period or Open Enrollment Period if any of the following are true:

• The Eligible Person previously declined coverage under the Policy, but the Eligible Person and/or Dependent becomes eligible for a premium assistance subsidy under Medicaid or Children's Health

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Insurance Program (CHIP). Coverage will begin only if we receive the completed enrollment form and any required Premium within 60 days of the date of determination of subsidy eligibility.

• The Eligible Person and/or Dependent had existing vision coverage under another plan at the time they had an opportunity to enroll during the Initial Enrollment Period or Open Enrollment Period and coverage under the prior plan ended because of any of the following:

▪ Loss of eligibility (including legal separation, divorce or death).

▪ The employer stopped paying the contributions. This is true even if the Eligible Person and/or Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer.

▪ In the case of COBRA continuation coverage, the coverage ended.

▪ The plan no longer offers benefits to a class of individuals that includes the Eligible Person and/or Dependent.

▪ The Eligible Person and/or Dependent loses eligibility under Medicaid or Children's Health Insurance Program (CHIP). Coverage will begin only if we receive the completed enrollment form and any required Premium within 60 days of the date coverage ended.

When an event takes place (for example, a birth, marriage or determination of eligibility for state subsidy), coverage begins on the date of the event. We must receive the completed enrollment form and any required Premium within 31 days of the event unless otherwise noted above.

For an Eligible Person and/or Dependent who did not enroll during the Initial Enrollment Period or Open Enrollment Period because they had existing health coverage under another plan, coverage begins on the day following the day coverage under the prior plan ends. Except as otherwise noted above, coverage will begin only if we receive the completed enrollment form and any required Premium within 31 days of the date coverage under the prior plan ended.

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Section 4: When Coverage Ends General Information about When Coverage Ends As permitted by law, we may end the Policy and/or all similar benefit plans at any time for the reasons explained in the Policy.

Your right to Benefits automatically ends on the date that coverage ends. When your coverage ends, we will still pay claims for Covered Vision Care Services that you received before the date your coverage ended. However, once your coverage ends, we will not pay claims for any vision care services received after that date.

Unless otherwise stated, an Enrolled Dependent's coverage ends on the date the Subscriber's coverage ends.

What Events End Your Coverage?

Coverage ends on the earliest of the dates specified below:

• The Entire Policy Ends Your coverage ends on the date the Policy ends. In this event, the Group is responsible for notifying you that your coverage has ended.

• You Are No Longer Eligible Your coverage ends on the last day of the month in which you are no longer eligible to be a Subscriber or Enrolled Dependent. Please refer to Section 9: Defined Terms for definitions of the terms "Eligible Person," "Subscriber," "Dependent" and "Enrolled Dependent."

• We Receive Notice to End Coverage The Group is responsible for providing the required notice to us to end your coverage. Your coverage ends on the date we receive the required notice from the Group to end your coverage, or on the date requested in the notice, if later.

• Subscriber Retires or Is Pensioned The Group is responsible for providing the required notice to us to end your coverage. Your coverage ends the date the Subscriber is retired or receiving benefits under the Group's pension or retirement plan.

This provision applies unless there is specific coverage classification for retired or pensioned persons in the Group's Application, and only if the Subscriber continues to meet any applicable eligibility requirements. The Group can provide you with specific information about what coverage is available for retirees.

Fraud or Intentional Misrepresentation of a Material Fact We will provide at least 15 days advance required notice to the Subscriber that coverage will end on the date we identify in the notice because you committed an act, practice, or omission that constituted fraud, or an intentional misrepresentation of a material fact. Examples include knowingly providing incorrect information relating to another person's eligibility or status as a Dependent. You may appeal this decision during the notice period. The notice will contain information on how to appeal the decision.

If we find that you have performed an act, practice, or omission that constitutes fraud, or have made an intentional misrepresentation of material fact we have the right to demand that you pay back all Benefits we paid to you, or paid in your name, during the time you were incorrectly covered under the Policy.

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If Covered Vision Care Services are in progress on the date which coverage terminated, such Services will be completed, except where termination is due to fraud, misrepresentation, material violation of the terms of the Policy, or failure to pay required Premiums.

Coverage for a Disabled Dependent Child Coverage for an unmarried Enrolled Dependent child who is disabled will not end just because the child has reached a certain age. We will extend the coverage for that child beyond this age if both of the following are true:

• The Enrolled Dependent child is not able to support him/herself because of mental or physical handicap or disability.

• The Enrolled Dependent child depends mainly on the Subscriber for support.

Coverage will continue as long as the Enrolled Dependent child is medically certified as disabled and dependent unless coverage otherwise ends in accordance with the terms of the Policy.

You must furnish us with proof of the medical certification of disability within 31 days of the date coverage would have ended because the child reached a certain age. Before we agree to this extension of coverage for the child, we may require that a Physician we choose examine the child. We will pay for that examination.

We may continue to ask you for proof that the child continues to be disabled and dependent. Such proof might include medical exams at our expense. We will not ask for this information more than once a year.

If you do not provide proof of the child's disability and dependency within 31 days of our request as described above, coverage for that child will end.

Continuation of Coverage If your coverage ends under the Policy, you may have the right to elect continuation coverage (coverage that continues on in some form) in accordance with federal or state law.

Continuation coverage under COBRA (the federal Consolidated Omnibus Budget Reconciliation Act) is available only to Groups that are subject to the terms of COBRA. Contact your plan administrator to find out if your Group is subject to the provisions of COBRA.

If you chose continuation coverage under a prior plan which was then replaced by coverage under the Policy, continuation coverage will end as scheduled under the prior plan or in accordance with federal or state law, whichever is earlier.

We are not the Group's designated "plan administrator" as that term is used in federal law, and we do not assume any responsibilities of a "plan administrator" according to federal law.

We are not obligated to provide continuation coverage to you if the Group or its plan administrator fails to perform its responsibilities under federal law. Examples of the responsibilities of the Group or its plan administrator are:

• Notifying you in a timely manner of the right to elect continuation coverage.

• Notifying us in a timely manner of your election of continuation coverage.

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Section 5: How to File a Claim How Are Covered Vision Care Services from Network Providers Paid?

We pay Network providers directly for your Covered Vision Care Services. If a Network provider bills you for any Covered Vision Care Service, contact us. However, you are required to meet any applicable Deductible and to pay any required Co-payments and/or Co-insurance to a Network provider. You will also be responsible for any charges that are not Covered by the Policy to your Vision Provider.

How Are Covered Vision Care Services from an Out-of-Network Provider Paid?

When you receive Covered Vision Care Services from an out-of-Network provider you will be required to pay all billed charges to your Vision Provider. You are also responsible for requesting payment from us.

You must file the claim in a format that contains all of the information we require, as described below.

You should submit a request for payment of Benefits within 90 days after the date of service. If you don't provide this information to us within one year of the date of service, Benefits for that vision care service will be denied or reduced, as determined by us. This time limit does not apply if you are legally incapacitated.

Required Information When you request payment of Benefits from us, you must provide us with all of the following information:

• The Subscriber's name and address.

• The patient's name and age.

• Your identification number.

• The name and address of the provider of the service(s).

• An itemized bill from your provider that includes a description of each charge.

The above information should be filed with us at Claims Department, P.O. Box 30978, Salt Lake City, UT 84130 or by fax to 248-733-6060. If you would like to use a claim form, you may access a form on the Internet at www.myuhcvision.com or call us at 1-800-638-3120 and a claim form will be provided to you. If you do not receive the claim form within 15 calendar days of your request, send in the proof of loss with the information stated above.

Payment of Benefits You may not assign your Benefits under the Policy or any cause of action related to your Benefits under the Policy to an out-of-Network Vision Provider without our consent. When an assignment is not obtained, we will send the reimbursement directly to the Subscriber for reimbursement to an out-of-Network provider. We may, as we determine, pay an out-of-Network provider directly for services rendered to you.

In the case of any such assignment of Benefits or payment to an out-of-Network Vision Provider, we have the right to offset Benefits to be paid to the provider by any amounts that the provider owes us.

When you assign your Benefits under the Policy to an out-of-Network Vision Provider with our consent, and the out-of-Network Vision Provider submits a claim for payment, you and the out-of-Network Vision Provider represent and warrant the following:

• The Covered Vision Care Services were actually provided.

• The Covered Vision Care Services were appropriate.

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Payment of Benefits under the Policy shall be in cash or cash equivalents, or in a form of other consideration that we determine to be adequate. Where Benefits are payable directly to a provider, such adequate consideration includes the forgiveness in whole or in part of the amount the provider owes us, or to other plans for which we make payments where we have taken an assignment of the other plans' recovery rights for value.

If the Covered Vision Care Services you received are covered by the Texas Department of Human Services ("DHS"), we will reimburse DHS.

If there is a court order providing for the managing conservator of a minor child, we will reimburse the conservator on your behalf.

Obtaining Services To find a Network Vision Provider, you may access a listing of Network Vision Providers on the Internet at www.myuhcvision.com. You may also call the UnitedHealthcare Provider Locator Service at 1-800-839- 3242.

You also may obtain Vision Care Services from an out-of-Network Vision Provider. However, the amount of Benefits may be reduced.

Foreign Services Foreign Services will be treated as Out-of-Network Benefits under this Policy. Payments will be made in U.S. currency and dispersed to the U.S. address of the Subscriber. We make no guarantee on value of payment and will not protect against currency risk. Currency valuations for payment liability will be based on exchange rates published on the date the Vision Care Services were rendered.

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Section 6: Questions, Complaints and Appeals To resolve a question, complaint, or appeal, just follow these steps:

What if You Have a Question?

Contact Customer Service at 1-800-638-3120. Representatives are available to take your call during regular business hours, Monday through Friday.

What if You Have a Complaint?

Contact Customer Service at 1-800-638-3120. Representatives are available to take your call during regular business hours, Monday through Friday.

If you would rather send your complaint to us in writing, the representative can provide you with the address.

If the representative cannot resolve the issue over the phone, he/she can help you prepare and submit a written complaint. We will notify you of our decision regarding your complaint within 60 days of receiving it.

How Do You Appeal a Claim Decision?

How to Request an Appeal If you disagree with either claim determination or a rescission of coverage determination, you can contact us in writing or orally to request an appeal.

Your request for an appeal should include:

• The patient's name and Policy number.

• The date(s) of vision service(s).

• The provider's name.

• The reason you believe the claim should be paid.

• Any documentation or other written information to support your request for claim payment.

Your appeal request must be submitted to us within 180 days after you receive claim denial.

Appeal Process A qualified individual who was not involved in the decision being appealed will be chosen to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a vision care professional with expertise in the field, who was not involved in the prior determination. We may consult with, or ask vision experts to take part in the appeal process. You consent to this referral and the sharing of needed vision claim information. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records and other information related to your claim for Benefits. If any new or additional evidence is relied upon or generated by us during the determination of the appeal, we will provide it to you free of charge and in advance of the due date of the response to the adverse benefit determination.

Appeals Determinations You will be provided written or electronic notification of the decision on your appeal as follows:

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• For appeals of Benefits, the appeal will take place and you will be notified of the decision within 30 days from receipt of a request for appeal of a denied request for Benefits.

Please note that our decision is based only on whether or not Benefits are available under the Policy for the proposed treatment or procedure.

Section 7: Coordination of Benefits Benefits When You Have Coverage under More than One Plan This section describes how Benefits under the Policy will be coordinated with those of any other plan that provides benefits to you. The language in this section is specific to Texas law regarding coordination of benefits.

When Does Coordination of Benefits Apply?

This Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one Plan. Plan is defined below.

The order of benefit determination rules below govern the order in which each Plan will pay a claim for benefits.

• Primary Plan. The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses.

• Secondary Plan. The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Expense. Allowable Expense is defined below.

Definitions For purposes of this section, terms are defined as follows:

A. Plan. A Plan is any of the following that provides benefits or services for medical, pharmacy or vision care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts.

1. Plan includes: group, blanket, or franchise accident and health insurance policies, excluding disability income protection coverage; individual and group health maintenance organization evidences of coverage; individual accident and health insurance policies; individual and group preferred provider benefit plans and exclusive provider benefit plans; group insurance contracts, individual insurance contracts and subscriber contracts that pay or reimburse for the cost of vision care; medical care components of individual and group long-term care contracts; limited benefit coverage that is not issued to supplement individual or group in-force policies; uninsured arrangements of group or group-type coverage; the medical benefits coverage in automobile insurance contracts; and Medicare or other governmental benefits, as permitted by law.

2. Plan does not include: disability income protection coverage; the Texas Health Insurance Pool; workers' compensation insurance coverage; hospital confinement indemnity coverage or other fixed indemnity coverage; specified disease coverage; supplemental benefit coverage; accident only coverage; specified accident coverage; school accident-type coverages that cover students for accidents only, including athletic injuries, either on a "24-hour" or a "to and from school" basis; benefits provided in long-term care insurance contracts for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care, and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services; Medicare supplement policies; a state plan under Medicaid; a governmental plan that, by law, provides benefits that are in excess of those of any private insurance plan; or

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other nongovernmental plan; or an individual accident and health insurance policy that is designed to fully integrate with other policies through a variable deductible.

Each contract for coverage under 1. or 2. above is a separate Plan. If a Plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate Plan.

B. This Plan. This Plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the contract providing health care benefits is separate from This Plan.

A contract may apply one COB provision to certain benefits, such as vision benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits.

C. Order of Benefit Determination Rules. The order of benefit determination rules determine whether This Plan is a Primary Plan or Secondary Plan when the person has health care coverage under more than one Plan. When This Plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits. When This Plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits equal100% of the total Allowable Expense.

D. Allowable Expense. Allowable Expense is a health care expense, including deductibles, co-insurance and co-payments, that is covered at least in part by any Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering the person is not an Allowable Expense. In addition, any expense that a provider by law or according to contractual agreement is prohibited from charging a Covered Person is not an Allowable Expense.

The following are examples of expenses or services that are not Allowable Expenses:

1. The difference between the cost of a semi-private hospital room and a private room is not an Allowable Expense unless one of the Plans provides coverage for private hospital room expenses.

2. If a person is covered by two or more Plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology, any amount in excess of the highest reimbursement amount for a specific benefit is not an Allowable Expense.

3. If a person is covered by two or more Plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable Expense.

4. If a person is covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary Plan's payment arrangement shall be the Allowable Expense for all Plans. However, if the provider has contracted with the Secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary Plan's payment arrangement and if the provider's contract permits, the negotiated fee or payment shall be the Allowable Expense used by the Secondary Plan to determine its benefits.

5. The amount of any benefit reduction by the Primary Plan because a Covered Person has failed to comply with the Plan provisions is not an Allowable Expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions and preferred provider arrangements.

E. Allowed Amount. Allowed Amount is the amount of a billed charge that a carrier determines to be covered for services provided by a nonpreferred health care provider or physician. The allowed

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amount includes both the carrier's payment and any applicable deductible, copayment, or coinsurance amounts for which the insured is responsible..

F. Closed Panel Plan. Closed Panel Plan is a Plan that provides health care benefits to Covered Persons primarily in the form of services through a panel of providers that have contracted with or are employed by the Plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member.

G. Custodial Parent. Custodial Parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation.

What Are the Rules for Determining the Order of Benefit Payments?

When a person is covered by two or more Plans, the rules for determining the order of benefit payments are as follows:

A. The Primary Plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other Plan.

B. Except as provided in the next paragraph, a Plan that does not contain a coordination of benefits provision that is consistent with this provision is always primary unless the provisions of both Plans state that the complying plan is primary.

Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage shall be in excess of any other parts of the Plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits and insurance type coverages that are written in connection with a Closed Panel Plan to provide out-of-network benefits.

C. A Plan may consider the benefits paid or provided by another Plan in determining its benefits only when it is secondary to that other Plan.

D. If the primary plan is a closed panel plan and the secondary plan is not, the secondary plan must pay or provide benefits as if it were the primary plan where a covered person uses a noncontracted health care provider or physician, except for emergency services or authorized referrals that are paid or provided by the primary plan.

E. When multiple contracts providing coordinated coverage are treated as a single plan under this subchapter, this section applies only to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the plan, the carrier designated as primary within the plan must be responsible for the plan's compliance with this subchapter.

F. If a person is covered by more than one secondary plan, the order of benefit determination rules of this subchapter decide the order in which secondary plans benefits are determined in relation to each other. Each secondary plan must take into consideration the benefits of the primary plan or plans and the benefits of any other plan that, under the rules of this contract, has its benefits determined before those of that secondary plan.

G. Each Plan determines its order of benefits using the first of the following rules that apply:

1. Non-Dependent or Dependent. The Plan that covers the person other than as a dependent, for example as an employee, member, policyholder, subscriber or retiree is the Primary Plan and the Plan that covers the person as a dependent is the Secondary Plan.

However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent; and primary to the Plan covering the person as other than a dependent (e.g. a retired employee); then the order of benefits between the two Plans is reversed so that the Plan covering the person as an employee, VCOC.18.TX 4 member, policyholder, subscriber or retiree is the Secondary Plan and the other Plan is the Primary Plan.

2. Dependent Child Covered Under More Than One Coverage Plan. Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:

For a dependent child whose parents are married or are living together, whether or not they have ever been married:

(1) The Plan of the parent whose birthday falls earlier in the calendar year is the Primary Plan; or

(2) If both parents have the same birthday, the Plan that covered the parent longest is the Primary Plan.

For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:

(1) If a court order states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. This rule applies to plan years commencing after the plan is given notice of the court decree.

(2) If a court order states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subparagraph a) above shall determine the order of benefits.

(3) If a court order states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subparagraph a) above shall determine the order of benefits.

(4) If there is no court order allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows:

(a) The Plan covering the Custodial Parent.

(b) The Plan covering the Custodial Parent's spouse.

(c) The Plan covering the non-Custodial Parent.

(d) The Plan covering the non-Custodial Parent's spouse.

For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under subparagraph a) or b) above as if those individuals were parents of the child.

(i) For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the rule in paragraph (5) applies.

(ii) In the event the dependent child's coverage under the spouse's plan began on the same date as the dependent child's coverage under either or…