6-Attachment 3 - Presbyterian PPO Plan Certificate.pdf

Presbyterian Health Plan, Inc.

Summary Plan Description and Guide to Your Preferred Provider Organization (PPO) Plan

County of Bernalillo

Offered by the County of Bernalillo Administered by Presbyterian Health Plan

County of Bernalillo PPO Plans 07/01/2025

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County of Bernalillo 07/01/2025

Welcome

This benefit booklet describes the medical benefits offered through the County of Bernalillo.

Our medical plans are self-insured. This means the County of Bernalillo is responsible for the design of the plan and the setting of contributions. We set the contribution rates to be adequate to pay for the claims we all incur. When our claims exceed the contributions, the contribution rates have to go up.

All medical plans offer no cost In-network preventive care. Please take advantage of this benefit after you enroll. Early diagnosis plays a big part in the eventual outcome of any health condition.

This booklet is intended to provide you with an easy-to-understand explanation of the Plan effective July 1, 2025. Every effort has been made to make these explanations as accurate as possible. If any conflict should arise between this booklet and the claims administrative procedures of our Third-Party Administrator, Presbyterian Health Plan, Inc., or if any provision is not covered or is only partially covered, the terms of the Professional Services Agreement will govern in all cases.

This booklet does not imply a contract of employment. The County of Bernalillo reserves the right to terminate, modify or change this Plan or any provision of this Plan at any time.

It is your responsibility to read and understand the terms and conditions in this booklet. We urge you to read it carefully and use it to make well-informed benefit decisions for you and your family.

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Understanding This Summary Plan Description

We use visual symbols throughout this Summary Plan Description (SPD) to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction and information. These symbols are listed below:

Refer To – This “Refer To” symbol will direct you to read related information in other sections of the SPD or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded.

Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol.

Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In-network Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of-network. In the case of a Hospital In-patient Admission following an Emergency Room visit, you or your Provider should call as soon as possible.

Time Frame Requirement – This “Time frame” symbol appears to remind you when you must take action within a certain time frame to comply with your Plan. An example of a Time frame Requirement is when you must enroll your newborn within 31 days of birth.

Important Information – This “Important Information” symbol appears when there are special instructions or important information about your Covered Benefits or your Plan that requires special attention. An example of Important Information would be if there are no Covered Benefits when you receive care Out-of-network.

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Call Presbyterian Customer Service Center – This “Call PCSC” symbol appears whenever we refer to our Presbyterian Customer Service Center or to remind you to call us for information.

In addition, some important terms used throughout this SPD and the Summary of Benefits and Coverage will be capitalized. These terms are defined in the Glossary of Terms Section.

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Introduction

The County of Bernalillo provides group healthcare coverage through the Preferred Provider Organization (PPO) Medical Plan (Plan) administered by Presbyterian Health Plan, Inc.

This booklet is your Summary Plan Description (SPD). It describes the benefits and limitations of the Plan. It explains how to file claims (if applicable), how to request reconsideration of a claim, or file for an adjustment of a benefit payment.

You should know several basic facts as you read this booklet:

• Providers are Physicians, Hospitals and other Healthcare Professionals or facilities that provide Healthcare Services.

• Preferred Providers have contractual agreements with Presbyterian Health Plan, Inc., and allow lower Out-of-pocket expenses and additional benefits for covered persons.

• Non-preferred Providers do not have contractual agreements with Presbyterian Health Plan, Inc., which may increase the Out-of-pocket expenses and limit benefits for covered persons.

This PPO Plan allows you to choose, at the time you receive services, the level of benefits that will apply. You receive the highest benefit level with the lowest cost to you when you obtain services from a Preferred Provider. The Presbyterian Health Plan Provider Directory lists the Preferred Providers. The Provider Directory is available through the Presbyterian Health Plan website at www.phs.org, or you can obtain one by contacting our Presbyterian Customer Service Center, Monday through Friday from 7 a.m. to 6 p.m. at (505) 923-5678 or 1-800-356-2219.

(TTY: 711).

Additionally, Presbyterian Health Plan now contracts with National PPO Network Provider, a National Preferred Provider organization with over 3,500 acute care Hospitals and 400,000 Providers. If you live or are traveling outside the State of New Mexico, and require medical attention, we encourage you to see National PPO Network Providers and facilities. National PPO Network Providers provide care to Presbyterian Health Plan Members at discounted rates, which help keep the cost of Medical Care down. Additionally, you cannot be charged for any difference between what Presbyterian Health Plan pays the Provider and what the Provider charges beyond your appropriate Copayment and/or Deductible and Coinsurance (see “How the Plan Works” Section). The National PPO Network Provider Directory is available through their website at https://www.aetna.com/asa or you can contact the Presbyterian Customer Service Center, Monday through Friday from 7 a.m. to 6 p.m. at (505) 923-5678 or 1-800-356-2219 (TTY: 711).

Please take the time to read this booklet carefully before placing it in a safe place for future reference. If you have any questions regarding this booklet, please call our Presbyterian Customer Service Center, Monday through Friday from 7 a.m. to 6 p.m. at (505) 923-5678, or 1800-356-2219. (TTY: 711). It is best to call for clarification before services are rendered to ensure that the proper procedures are followed in order to afford you with the maximum level of benefits available under the Plan.

http://www.phs.org/ https://www.aetna.com/asa

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Table of Contents

Welcome Understanding This Summary Plan Description Introduction How The Plan Works

In-Network Providers National Network Provider Out-of-Network Providers How To Access Care What is Prior Authorization?

What Procedures Require Prior Authorization?

Prior Authorization – Inpatient Prior Authorization – Other Medical Services Case Management Program Federal and State Healthcare Reform Transition of Care Cost Sharing Features Copayment Plan Year Deductible (July 1 – June 30) Coinsurance Out-of-Pocket Maximum Maximum Benefits Medically Necessary Services Healthcare Fraud Message

Eligibility Enrollment, Effective and Termination Dates

Employee Eligibility Dependent Eligibility Enrolling For Coverage How To Enroll Dependents When Coverage Starts Health Insurance Portability & Accountability Act Of 1996 (HIPAA) Changing Your Coverage Family Status or Employment Status Changes (Qualifying Events) Special Enrollment/Notice Of Employee Rights ID Card

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Termination Cobra and the Family and Medicial Leave Act (FMLA)

Covered Services

Accidental Injury/Medical Emergency Care/Urgent Care

Medical Emergency Care

Urgent Care

Telehealth Visits

Acupuncture Services Ambulance Services Autism Spectrum Disorder Behavioral Health And Alcohol and/or Substance Use Disorder Behavioral Health Services

Alcohol and/or Substance Use Disorder Services

Biofeedback

Clinical Trials

Cardiac/Pulmonary Rehabilitation

Chemotherapy/Dialysis/Radiation Therapy

Chiropractic Services Dental Care and Medical Conditions of the Mouth and Jaw

Dental Accidents

Hospitalization for Dental Care

Oral Surgery and TMJ Treatment

Diabetes Services

Diagnostic Services

Durable Medical Equipment And Appliances, Hearing Aids, Medical Supplies, Orthotics, And Prosthetics

Medical Supplies

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Family Planning and Related Services Genetic Inborn Errors of Metabolism Disorders (IEM) Gym Membership Habilitative

Autism Spectrum Disorder

Home Health Care Hospice Care Hospital Inpatient Services Blood Physical Rehabilitation – Inpatient Massage Therapy Maternity and Newborn Care Newborn and Mothers Health Protection Act Provider Services Allergy Services Chronic Pain Treatment Contraceptive Devices Injectable Drugs Inpatient Provider Visits and Consultations Office Visits Weight Management and Nutritional Counseling Prescription Drug Medications Preventive Services

Preventive Services For Women

Cytologic Screening (Pap Smear Screening)

Evidence-based items or services

Human Papillomavirus (HPV) Screening

Health Education and Counseling

Mammography Coverage

Prostate Exams

Routine Vision Screening

Routine Hearing Screening

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Routine Immunizations

Routine Physical Examinations

Well-Child Care

Skilled Nursing Facility Smoking Cessation Surgery

Cardiac Surgery

Cataract Surgery

Cochlear Implants

Congenital Anomalies

Morbid Obesity

Oral Surgery

Outpatient Surgery

Reconstructive Surgery

Mastectomy Services

Therapy

Physical, Occupational and Speech Therapy

Restorative Speech Therapy

Transplant Services

Limitations and Exclusions

Limitations Exclusions

Filing Claims

Emergency Services or Out-of-Network Providers Out-of-Network Service Claims Claims Outside the United States

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Itemized Bills How Payments are Made Overpayments Coordination of Benefits Effect of Medicare on Benefits Effect of Medicaid on Benefits Subrogation Assignment of Benefits Fraudulent Application or Claim Appeals and Grievance Procedures

Overview

Member Rights and Responsibilities

Member Rights:

Member Responsibilities:

Glossary of Terms Acceptance Page

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How The Plan Works

Your Group healthcare plan is a Preferred Provider Organization (PPO) Plan whereby you obtain all routine Covered Services from In-network Providers within the Presbyterian Health Plan (PHP) Provider network or from our National Network Providers outside of New Mexico.

In-Network Providers

You may choose an In-network Primary Care Provider (PCP) to coordinate your care. In-network PCPs are Providers who have a contract with PHP to provide, coordinate and manage your healthcare needs. In-network PCPs include family and general practice, internal medicine and pediatric Providers who are conveniently located throughout the PPO network area. When you see an In-network PCP or any other In-network Provider, you pay a Deductible and/or Copayment for most services. The In-network Provider handles any necessary Prior Authorizations for you.

In-network OB/GYNs can be seen. This benefit, called Open Access, allows female Members to see their OB/GYN for care related to pregnancy or any gynecological condition.

If you want to know more about your In-network Provider, the Presbyterian Customer Service Center (PCSC) can tell you information such as medical school attended, residency completed and board certification status.

National Network Provider

You can also obtain Covered Services outside of New Mexico from one of our National Healthcare Provider Network Practitioners/Providers. Your Deductible, Copayment and/or Coinsurance will be the same as if you received the services from an In-network Provider. You can contact a PCSC representative for additional information regarding National Healthcare Practitioner/Providers. However, these Providers are not considered In-network Providers. If a Covered Service requires Prior Authorization, you are responsible for obtaining that Prior Authorization before obtaining that covered Service from one of our National Healthcare providers. If you fail to obtain Prior Authorization when required, you will be responsible for Copayments, Deductibles and/or Coinsurance as listed in the Summary of Benefits.

You will not have any claims to file or papers to fill out in order to be reimbursed for medical services obtained from In-network Providers and out-of-state National Healthcare Provider Network Practitioners/Providers. Your In-network Provider or out-of-state Practitioner/Provider will bill us directly. Most Provider visits and Hospital Admissions, however, do require Copayment at the time of service. The amount of your Copayment for each service can be found in the Summary of Benefits.

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Out-of-Network Providers

Out-of-network Providers are those Providers that are not part of the PHP Provider Network and are not an out-of-state National Network Provider. Services provided by Out-of-network Providers other than in Out-of-network Student Health Centers, and except for injury, urgent or emergency care, are excluded under this Plan.

How To Access Care

Though not required, it is highly recommended that you select an In-network PCP to coordinate your healthcare needs. Your In-network PCP will be able to meet most of your healthcare needs.

A list of In-network PCPs can be found in the PHP Provider Directory or on the PHP website at www.phs.org. You may choose any Provider, nurse practitioner or physician assistant on that list as your In-network PCP. If you choose an In-network PCP from this list and notify Presbyterian Health Plan of your selection, that PCP information will appear on your ID Card.

You may choose to obtain PCP services from an out-of-state National Network Provider. If you chose this option, no PCP data will appear on your ID Card. If you decide to obtain PCP services from an out-of-state National Network Provider, you will have to manage more of your healthcare. National Network Provider are not required to utilize In-network Providers, In-network Hospitals or facilities or other out-of-state National Network Provider or facilities for laboratory tests, X-rays or any other Covered Service. Therefore, if you choose to obtain services from a National Network Provider and they request laboratory tests, X-rays, etc., or refer you to another Provider/Specialist, it is your responsibility to ensure the Provider or facility providing Covered Services is an In-network or an out-of-state National Network Provider or facility.

Otherwise, the services may not be covered, and your claim may be denied.

What is Prior Authorization?

Prior Authorization determines only the medical necessity of a procedure or an Admission and an allowable length of stay. Prior Authorizations do not guarantee payment, and do not validate eligibility (for example, to receive non-specified services from a particular Provider). Benefit payments are based on your eligibility and benefits in effect at the time you receive services. Services not listed as covered and services that are not Medically Necessary are not covered.

The Prior Authorization requirements affect whether the Plan pays for your Covered Services.

However, Prior Authorization does not deny your right to be admitted to any Hospital.

you make the best use of your Covered Benefits. You should keep this Summary Plan

IMPORTANT: If you have Coverage that includes Dependent or Family Medical Coverage, Prior Authorization requirements apply to your family members who are also covered persons.

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What Procedures Require Prior Authorization?

Certain procedures or services, as identified in the next subsection of this document, do require Prior Authorization. The responsibility for obtaining Prior Authorization is as follows:

• In-network Provider - When accessing services from an In-network Provider, the In-network Provider is responsible for obtaining Prior Authorization from Presbyterian Health Plan before providing these services to you.

• Out-of-network Provider or National Network Providers - When accessing services from an Out-of-network Provider or a National Network Provider, you are responsible for obtaining Prior Authorization from Presbyterian Health Plan before obtaining services from an Out-of-network or National Network Provider. If Prior Authorization is not obtained when required, the benefits will be reduced as listed on the Summary of Benefits.

Prior Authorization – Inpatient

If your In-network Provider recommends you be admitted as an Inpatient to a Hospital or treatment facility, your In-network Provider is responsible for any Prior Authorization requirement for Inpatient Admissions. If an Out-of-network Provider or National Network Provider recommends you be admitted as an Inpatient to a Hospital or treatment facility, you are responsible for any Prior

Authorization requirement for Inpatient Admissions. If Prior Authorization is not obtained, the Member will be responsible for Copayments, Deductibles and/or Coinsurance as listed in the Summary of Benefits.

If Presbyterian Health Plan determines that the Admission was for a Covered Service, but hospitalization was not Medically Necessary, no benefits are paid for Inpatient room and board charges, and these expenses do not apply toward the Out-of-pocket Maximum. Other Covered Services are paid as explained in the Summary of Benefits and in the Covered Services Section. If the Admission is not for a Covered Service, no payment is made.

Note:

All Admissions for Behavioral Health and Alcohol and/or substance use disorder services require Prior Authorization from Presbyterian Health Plan’s Behavioral Health Department (1-800-453-4347). If Prior Authorization is not obtained, services may not be covered if they do not fall within the benefits and limitations of this Plan. For emergencies, Presbyterian Health Plan Behavioral Health Department must be notified by the end of the next business day or as soon as reasonably possible or benefits may be denied.

Prior Authorization procedures also apply in the event you are transferred from one facility to another, you are readmitted, or when a newborn child remains hospitalized after the mother is discharged.

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Prior Authorization – Other Medical Services

Prior Authorization requirements are subject to change at the discretion of Presbyterian Health Plan with the approval of the County of Bernalillo. Contact the Presbyterian Customer Service Center, Monday through Friday from 7 a.m. to 6 p.m. at (505) 923-5678 or toll-free at 1-800- 356-2219 (TTY: 711) to verify services requiring Prior Authorization.

In addition to Prior Authorization for all Inpatient services, Prior Authorization is required for the following services. For certain services, Prior Authorization may be requested over the telephone. If Prior Authorization is not obtained for the following services, benefits will be reduced or denied for all related services.

Your In-network Provider will request Prior Authorizations for you. If you access care from an Out-of-network Provider or National Network Provider, you will have to obtain Prior Authorization. Discuss the need for Prior

Authorizations with your Provider before obtaining any of the following services:

• Clinical Trials (as specified in the Covered Services Section)

• Detoxification (acute requiring medical intervention)

• Podiatric and Orthopedic Appliances

• Rentals

• Home Health Care

• Hospice

• Hospital admissions

• Injectables over $100 and certain injectables received in the Provider’s office

• Medical supplies greater than $1,000

• Morbid obesity treatment

• Positron Emission Tomography (PET) scans

• Repair or replacement of non-rental DME

• Selected Surgical Procedures including but not limited to blepharoplasty (surgery on the upper eyelid), breast reduction surgery, morbid obesity surgery, vein surgery

• Skilled Nursing Facilities

• Transplants

• In addition, some prescription drugs/medications may require Prior Authorization from

ClearScript, the pharmacy benefit manager for County of Bernalillo.

Case Management Program Presbyterian Health Plan’s Case Management Program is a program that, as early as possible, identifies patients who have the potential for having high-cost medical expenses, may require extensive hospitalization, or have complicated discharge planning needs so that cost-effective alternative care arrangements can be made. Special care arrangements are coordinated with the Provider and may include benefits for services that are not ordinarily covered. In addition, the Case Management Program acts to assist the patient and Provider in complex situations and coordinates care across the healthcare spectrum.

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Federal and State Healthcare Reform

Presbyterian Health Plan (PHP) shall comply with all applicable state and federal laws, rules and regulations. In addition, upon the compliance date of any changes in law, or the promulgation of any final rule or regulation which directly affects Presbyterian Health Plan’s obligations under this Summary Plan Description will be deemed automatically amended such that Presbyterian Health Plan shall remain in compliance with the obligations imposed by such law, rule or regulation.

Transition of Care

If you are a new Member and are in an ongoing course of treatment with an Out-of-network Provider, you will be allowed to continue receiving care from this Provider for a transitional period of time (usually not to exceed 90 days). Similarly, if you are in an ongoing course of treatment with an In-network Provider and that Provider becomes an Out-of-network Provider, you will be allowed to continue care from this Provider for a transitional period of time. Application must be made within 30 days of the event.

Please contact Presbyterian Health Plan’s Health Services Department at 1-888- 923-5757 for further information on Transition of Care.

Cost Sharing Features

The Plan shares the cost of your healthcare expenses with you. The following describes the different cost-sharing methods available, as detailed in the Summary of Benefits.

Copayment

For most services obtained from an In-network Provider, you pay a Copayment and the Plan pays a portion of the remainder. The Copayment is stated as a set dollar amount. See the Summary of Benefits for all applicable Copayments.

Plan Year Deductible (July 1 – June 30)

Most services are subject to a Plan Year Deductible. The amount of your Plan Year Deductible can be found in the Summary of Benefits. This Deductible must be paid for by you each Plan Year toward Covered Services before health benefits for that Member will be paid by the Plan (except for those services requiring only a Copayment).

For Single Coverage, the annual Plan Year Deductible requirement is fulfilled when one Member meets the Individual Deductible listed in the Summary of Benefits and Coverage.

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For Double Coverage, the Annual Plan Year Deductible requirement is fulfilled when both Members each meet their Individual Deductible listed in the Summary of Benefits and Coverage.

For Family Coverage, with three or more enrolled Members, the entire family Deductible must be met before benefits will be paid for the family. However, if one (family) Member reaches the individual Deductible amount before the family has met the Family Deductible, the Plan will begin paying benefits for that Member who has met the Individual Deductible. The family and individual Deductible amounts are listed in the Summary of Benefits and Coverage.

Charges for the In-network Provider services are applied to the Out-of-network Deductible (until the In-network Provider Deductible is met) and vice versa.

Coinsurance

For most services, you will pay a Coinsurance. This is the amount of the covered healthcare expense that is partially paid by the Plan and partially paid by you on a percentage basis. This Coinsurance is in addition to the Plan Year Deductible you are responsible for and continues to be your responsibility after the Plan Year Deductible is met. See the Summary of Benefits for Coinsurance amounts.

Out-of-Pocket Maximum

This Plan includes a Plan Year Out-of-pocket Maximum amount to protect you from catastrophic healthcare expenses. After your Plan Year Out-of-pocket Maximum is reached in a Plan Year, the Plan pays 100% for Covered Services for the remainder of that Plan Year, up to the Maximum benefit amounts. Refer to the Summary of Benefits for the Plan Year Out-of-pocket Maximum amounts.

The Plan Year Out-of-pocket Maximum includes the Deductible, Copayments and Coinsurance amounts listed in the Summary of Benefits. Penalty amounts, non-covered charges and any amounts over Medicare Allowable Amounts are not included in the Out-of-pocket Maximum.

For Single Coverage, the Out-of-pocket Maximum requirement is fulfilled when one Member meets the Individual Out-of-pocket Maximum listed in the Summary of Benefits and Coverage.

For Double or Family Coverage, with two or more enrolled Members, the entire Family Out-of-pocket Maximum must be met before benefits will be paid at 100%. However, if one (family) Member reaches the Individual Out-of-pocket Maximum amount before the family has met the Family Out-of-pocket Maximum, benefits will be paid at 100% for that Member who has met the Individual Out-of-pocket Maximum. The Family and Individual Out-of-pocket Maximums amounts are listed in the Summary of Benefits and Coverage.

The Out-of-pocket Maximum includes all medical Cost-sharing (Copayment and Coinsurance) amounts.

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Maximum Benefits

There is no lifetime Maximum payment under the Plan. However, certain benefits are specifically limited and have Maximum limits per Plan Year or lifetime, as described in the Summary of Benefits and in the Limitations and Exclusions Section.

Medically Necessary Services

Medically Necessary: A service or supply is Medically Necessary when it is provided to diagnose or treat a covered medical condition, is a service or supply that is covered under the Plan and is determined by Presbyterian Health Plan’s medical director to meet all of the following conditions:

• It is medical in nature

• It is recommended by the treating Provider

• It is the most appropriate supply or level of service, taking into consideration:

o Potential benefits o Potential harms o Cost, when choosing between alternatives that are equally effective o Cost-effectiveness, when compared to the alternative services or supplies

• It is known to be effective in improving health outcomes as determined by credible scientific evidence published in the peer-reviewed medical literature (for established services or supplies, professional standards and expert opinion may also be taken into account), and

• It is not for the convenience of the Member, the treating Provider, the Hospital, or any other healthcare Provider

Presbyterian Health Plan determines whether a Healthcare Service or supply is Medically Necessary and, therefore, whether the expense is covered. (Note: If you disagree with Presbyterian Health Plan’s decision regarding the Medical Necessity of any item or service, you may file a Grievance or complaint. You may also request an external review of Presbyterian Health Plan’s decision at any time. See “Grievance Procedures” in the Filing Claims Section).

The fact that a Provider has prescribed, ordered, recommended or approved a service or supply does not make it Medically Necessary or make the expense a Covered Service, even though it is not specifically listed as an exclusion.

Healthcare Fraud Message

Insurance fraud may result in cost increases for this healthcare Plan. The following describes ways that you can help eliminate healthcare fraud:

• Be wary of offers to waive Copayments, Deductibles or Coinsurance. These costs are passed on to you eventually.

• Be wary of mobile health testing labs. Ask how much the insurance company will be charged for the tests.

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• Always review the explanation of benefits (EOB) you receive from Presbyterian Health Plan. If there are any discrepancies, call one of our PCSC representatives.

• Be very cautious about giving information about your insurance coverage over the telephone.

If you suspect fraud, please call the Presbyterian Health Plan’s Fraud Hotline at

(505) 923-5959 or 1-800-239-3147.

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Eligibility Enrollment, Effective and Termination Dates

Employee Eligibility

An eligible employee includes anyone hired as classified, probationary, term or hourly, if the employee works an average of at least 20 hours per week over the course of a pay period and whose length of employment, when hired, is for at least six months. Independent contractors are not eligible under the County’s benefit plan.

Dual coverage is not allowed. If both an employee and their spouse/domestic partner are eligible employees, they cannot enroll each other as a spouse/domestic partner, nor can they both cover their children. If both eligible employees seek to enroll their spouse/domestic partner and/or Dependents, the enrollment will be rejected, and forms returned for proper election.

Dependent Eligibility

Dual coverage is not allowed. An eligible Dependent cannot be covered by more than one employee participating in the Plan.

An eligible employee’s Dependents are eligible to be covered under the Group Benefits Plan as follows:

• An eligible employee’s lawful spouse may be enrolled as a Dependent after presenting a marriage certificate or other documentation which establishes that the couple entered into a valid common-law marriage in another jurisdiction.

o An eligible employee’s domestic partner may be enrolled as a Dependent upon submission of executed Affidavits of Domestic Partnership. Please see Domestic Partner Section for further information.

• Children of an eligible employee’s domestic partner under the age of 26 may be enrolled as Dependents upon submission of a birth certificate, legal adoption papers, and/or guardianship order.

• An eligible employee’s children and legal Dependents under the age of 26 may be enrolled as dependents upon submission of a birth certificate, legal adoption papers and/or guardianship order.

• Disabled legal Dependents that are incapable of self-support are eligible for medical, dental and vision coverage beyond age 26. Evidence of legal guardianship and disability is required upon enrollment.

• A court order directing that an employee and/or employee’s Dependent provide insurance for someone else does not require the County of Bernalillo to grant eligibility. Individual coverage may need to be purchased separately. NOTE: A Power of Attorney is not considered a court order to establish State Plan eligibility or otherwise extend coverage under the County of Bernalillo.

• If an employee’s spouse has stepchildren from a previous marriage, and neither the employee nor spouse has adopted them or obtained legal guardianship, the stepchildren are not eligible for coverage.

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According to the Federal IRS Guidelines, premiums for domestic partners/child(ren) cannot be taken on a pre-tax basis.

To receive benefits under this Plan, you and your eligible Dependents must reside within the Plan’s authorized Service Area. However, please review the following as it relates to Dependents who live both in and/or out of the authorized Service Area, who are also eligible for benefits.

• If the Dependent attends school in any Presbyterian Health Plan Service Area, services may either be received through the Primary Care Provider or at the Student Health Center.

• If the Dependent is eligible for coverage under this Plan as the result of a court order and the Dependent does not live within the Service Area:

o You or the covered Dependent is responsible for obtaining any required Prior Authorizations from the Plan. If you obtain services from an In-network Provider, they will request Prior Authorization from Presbyterian Health Plan. If you obtain services from an Out-of-network MP/PHCS Provider, then it is your responsibility to obtain Prior Authorization. Failure to do so will result in benefits being denied or responsibility for any Copayment, Deductible and/or Coinsurance amounts listed on the Summary of Benefits.

o Medically Necessary Covered Services provided by Out-of-network Providers will be reimbursed less the appropriate Copayment up to the Medicare Allowable Amounts. You and/or your Dependent will be responsible for paying any amounts over Medicare Allowable Amounts or for services not covered under this Plan.

During initial enrollment, you must provide proof of incapacity and dependency to your agency group representative. Thereafter, proof of incapacity and dependency may be requested periodically by the Claim Administrator.

Benefits are not provided for Hospital room and board or Inpatient Provider care for any Hospital Admission or portion of an Admission that is for a Member who is not covered or who, at the beginning of the Admission was not a Member, an eligible Dependent or the natural-born child of an employee.

It is your responsibility to notify your agency group representative, who will then notify the Claim Administrator, of any change in your coverage status, including a name or address change.

The Claim Administrator reserves the right to verify your eligibility for coverage by requesting proof from you or your agency group representative that a valid employer-employee relationship exists and that you otherwise meet all applicable eligibility requirements.

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Enrolling For Coverage

You must complete and return an enrollment form within 31 days of your eligibility date. If you don’t elect coverage within 31 days of your eligibility date and later want coverage, you must wait until the next open enrollment period to receive coverage – unless you have a qualified change in status or you are eligible as a result of a special enrollment event. If you have a qualified change in status or special enrollment event, you will be able to elect coverage within 31 days of the change.

Once you complete an enrollment form, your elections remain in effect through the Plan Year – from July 1 to June 30. Each year you will have an opportunity to change your group health Plan 1 to June 30. Each year you will have an opportunity to change your group health Plan elections.

The change is effective the following July 1. You and your Dependents will be automatically re-enrolled in the Plan each year unless you complete a new enrollment form changing your election during the enrollment period.

How To Enroll Dependents

You may apply for coverage of your eligible Dependents, which may mean changing from Employee only coverage to Coverage that Includes Dependent or Family Coverage. Each additional Dependent added to your coverage must be enrolled within 31 days of becoming eligible for the Plan.

Newly adopted children are effective on the date of placement and must be enrolled within 31 days of that date.

When Coverage Starts

If you enroll on or before the day you become eligible, your coverage becomes effective the day you are eligible. If you enroll within 31 days of becoming eligible, your coverage becomes effective on the day that you enroll or the first day of the following pay period. Coverage begins on the first day of the current pay period if forms are completed and required documents are brought to New Employee Orientation or submitted to the Benefits Office by the end of the first week. If forms are submitted after that but within the 31-day enrollment period, coverage begins on the first day of the pay period following the submission of completed forms and verification of the Dependent eligibility.

Contact your agency group representative for further details.

The Plan pays for Covered Services that a Member receives on or after the effective date of coverage.

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Health Insurance Portability & Accountability Act Of 1996 (HIPAA)

If you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your Dependents in this Plan. You must request enrollment within 31 days after your other coverage ends. In addition, if you have a new Dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your Dependents, provided that you request enrollment within 31 days after marriage, birth, adoption or placement for adoption.

If you have any questions about this law, contact your agency group representative.

Changing Your Coverage

Once you elect coverage, you generally cannot change your elections until the following switch enrollment period. However, there are certain circumstances when you may be eligible to change coverage earlier. You must request the change in coverage within 31 days of the event causing the change. Any change must be consistent with the reason the change was permitted.

Situations governed by HIPAA special enrollment rules:

• You, your spouse or your Dependent children become eligible for Consolidated Omnibus Reconciliation Act (COBRA) continuation coverage.

• Judgment, decree or order that requires accident or group health coverage for your child.

• You, your spouse or Dependent children become entitled to Medicare or Medicaid. (You may cancel coverage for the individual who becomes eligible for Medicare or Medicaid coverage.)

• Change in status event, but only when the change causes you or your Dependent to gain or lose eligibility for coverage. The change must correspond with the gain or loss of coverage.

It is your responsibility to notify your agency group representative, who will then notify the Claim Administrator, of any change in your coverage status, including a name or address change.

Family Status or Employment Status Changes (Qualifying Events)

You may make certain changes to your benefit elections within 31 days of a change in family/employment status. Evidence of a change in family/employment status must be provided to your agency group representative in order to change your benefit elections. Any change in coverage must correspond with the gain or loss of coverage and will become effective on the first pay period following the date the new benefit elections are made. The only exceptions would be birth and adoption, where the additional coverage would take place immediately upon enrollment. The following family/employment status changes are recognized by the County of Bernalillo:

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• Marriage or divorce

• Legal Separation

• Birth or adoption of a child

• Death of a spouse or Dependent child

• A change in your spouse’s employment (loss of job, or a new job that provides healthcare coverage; however, annual enrollment for a spouse’s plan is not a family status change)

• A change in legal responsibility for a child

• The end of the month in which the Dependent child turns 26

• Qualification or disqualification of a domestic partner

• Change in employment status (regular part-time to regular full-time or vice versa)

Special Enrollment/Notice Of Employee Rights

Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, if you are declining enrollment for yourself or your Dependents (including your spouse and eligible children) because of other group health insurance coverage, you may in the future be able to enroll yourself or your Dependents in the Plan. You must request enrollment within 31 days after you or an eligible Dependent loses coverage under another group health plan either because:

• Eligibility ends

• COBRA benefits are exhausted

• You return to work after serving active military/reserve duty, or

• Employer contributions end

In addition, if you have a new Dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your Dependents, provided that you request enrollment within 31 days after the marriage, birth, adoption or placement for adoption.

An otherwise eligible employee and Dependent(s) who did not apply for coverage when initially eligible because of other group coverage at another place of employment, but who later lost their coverage due to a change in employment status, may apply within 31 days if the loss of coverage is due to loss of employment/change in job status, or death of a spouse or divorce from a spouse.

This provision also applies to employees who return to work after serving active military/reserve duty.

ID Card

Your Plan ID Card identifies the cardholder and your Preferred Provider Organization coverage.

Carry it with you.

When you present your card to In-network Providers, they know that you receive special benefits – they will file claims for you and will obtain any needed pre- Admission review or other Prior Authorizations. You are responsible for any Copayments, Coinsurance or expenses for non-Covered Services.

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Your Member identification number and your group number are on your ID Card. Each of your Dependents will also receive an ID Card. If you or your Dependents selected an In-network Primary Care Provider (PCP), their In-network PCP selection and the PCP’s telephone number will also be displayed. (If you or your Dependent(s) did not select an In-network PCP, then no PCP information will be listed on the ID Card.) The reverse side of your ID Card provides the address for Presbyterian Health Plan and some important telephone numbers for your use while using the Plan. It is important that you always show each individual’s own ID Card when obtaining care.

If you want additional cards or need to replace a lost card, contact a Presbyterian Customer Service Center representative.

This card is part of your coverage. Do not let anyone who is not named in your coverage use your card to receive benefits.

Termination

If you are an employee of the County of Bernalillo covered by this healthcare Plan, you have the right to choose this continuation of coverage if you lose your group health coverage due to a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct).

If you are the spouse of an employee covered by the Group healthcare Plan, you have the right to choose continuation of coverage for yourself if you lose group health coverage under the Group’s Plan for any of the following reasons:

• The death of your spouse

• A termination of your spouse’s employment (for reasons other than gross misconduct) or reduction in your spouse’s hours of employment

• Divorce or legal separation from your spouse

• Your spouse becomes entitled to Medicare benefits

A Dependent child of an employee covered by the Group’s healthcare Plan has the right to continuation of coverage if group healthcare coverage under the Group’s Plan is lost for any of the following reasons:

• The death of the parent employee

• The termination of a parent’s employment (for reasons other than gross misconduct) or reduction in a parent’s hours of employment with the employer

• Parent’s divorce or legal separation

• The Dependent ceases to be a Dependent child under the Plan

• The parent employee becomes entitled to Medicare

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Under this law, the employee or a family Member has the responsibility to inform the Plan Administrator (your agency group representative) of a divorce, legal separation, or a child losing Dependent status under the Group Plan.

A COBRA qualifying event also occurs upon an employee’s death, termination of employment or any reduction in hours that disqualifies the person for group coverage, or Medicare entitlement (in the case of terminating employees only).

Should one of the above events occur, the Plan Administrator will in turn notify you (within 14 days of receipt of notification) that you have the right to choose continuation of coverage. Under this law, you have at least 60 days from the date you would lose coverage due to one of these events to inform the Plan administrator that you want continuation of coverage.

If you do not choose continuation of coverage, your group health coverage will end.

If you choose continuation of coverage, your employer is required to give you coverage that, as of the time coverage is being provided, is identical to the coverage provided under the Plan to similarly situated employees or family Members. This law requires that you be given the opportunity to maintain continuation of coverage for up to 36 months, unless you lost group healthcare coverage due to a termination of employment or reduction in hours, in which case the required continuation coverage period is 18 months, unless you have been determined to be disabled under the Social Security Act, in which case the required continuation coverage period is 29 months. However, this law also provides that your continuation coverage may be cut short for any of the following reasons:

• The employer no longer provides group health coverage to any of its employees

• The premium for your continuation coverage is not paid on time

• You become covered under another group health plan as a result of employment or re-employment (whether or not you are an employee of that employer), unless the new plan contains an exclusion or limitation relating to any pre-existing condition you may have

• You are a widow or were divorced from a covered employee and subsequently remarry and are covered under your new spouse’s health plan unless the new plan contains an exclusion or limitation relating to any pre-existing condition you may have

• You become entitled to Medicare benefits (coverage may continue for your spouse)

• It is determined that you are no longer disabled (shortens the extended period)

You do not have to show that you are insurable to choose continuation coverage. However, under this law, you may have to pay 102% (150% in the case of the 19th through 29th month for a disabled person) of the full premium for your continuation coverage.

For more information regarding COBRA, contact your agency group representative.

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Cobra and the Family and Medicial Leave Act (FMLA)

A leave that qualifies as a Family and Medical Leave under the FMLA does not make you eligible for COBRA coverage. However, whether or not you lose coverage because of nonpayment of premiums during a Family and Medical Leave, you may be eligible for COBRA on the last day of the leave, which is the earliest of the following:

• The date you unequivocally inform your agency group representative that you are not returning at the end of the leave

• The date your leave ends, assuming you do not return

• The date the FMLA entitlement ends

For purposes of a Family and Medical Leave, you will be eligible for COBRA only if:

• You or your Dependent is covered by the Plan on the day before the date the leave begins (or becomes covered during the leave)

• You do not return to employment at the end of the leave, and

• You or your Dependent loses coverage under the Plan before the end of what would be the maximum COBRA continuation period

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Covered Services

Benefits are subject to the Copayments, Deductibles and Coinsurance listed in the Summary of Benefits. Please refer to the Limitations and Exclusions Section, for details regarding the Limitations and Exclusions applicable to this Plan. Any services received must be Medically Necessary to be covered.

If you disagree with Presbyterian Health Plan’s decision regarding the Medical Necessity of any item or service, you may file a complaint. You may also request an external review of Presbyterian Health Plan’s decision at any time. See “Grievance Procedures” in the Filing Claims Section.

Accidental Injury/Medical Emergency Care/Urgent Care

Medical Emergency Care

Treatment for a medical emergency or Accidental Injury in the Emergency Room of a Hospital or an Urgent Care facility is a benefit. No notification to Presbyterian Health Plan (PHP) is required. Please refer to the Summary of Benefits for Emergency Room visit or Urgent Care Center Copayments and/or Coinsurance. Treatment in a Provider’s office or an Ambulatory Surgical Facility is also a benefit and is paid as any other illness.

Definition of emergency: medical or surgical procedures, treatments, or services delivered after the sudden onset of what reasonably appears to be a medical condition with symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in jeopardy to their health; if pregnant, the health of you or your unborn child; serious impairment of bodily functions; serious dysfunction of any bodily organ or part; or disfigurement. Initial treatment must be sought within 48 hours of the accident or as soon as reasonably possible, or at the onset of symptoms, to qualify as emergency care. Acute Medical Emergency care is available 24 hours per day, seven days a week.

Examples of a medical emergency include but are not limited to a heart attack, poisoning, severe allergic reaction, convulsions, unconsciousness or uncontrolled bleeding.

The Plan will provide reimbursement when a Member, acting in good faith, obtains emergency Medical Care for what reasonably appears to the Member, acting as a reasonable lay person, to be an acute condition that requires immediate medical attention, even if the patient’s condition is subsequently determined to be non-emergent.

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If your emergency treatment requires direct Admission to the Hospital, you are responsible for the Hospital Copayment, but you do not have to pay a…