6-ATTACHMENT F - Medical Blue Essentials Benefits Program.pdf

Austin ISD Group #392418

Blue Essentials SM Plan

3924180001.0125

BlueCross BlueShield of Texas

A Message to Employees:

This Plan is offered by Your employer as one of the benefits of Your employment. The benefits provided are intended to assist You with many of Your health care expenses for Medically Necessary services and supplies. Coverage under this Plan is provided regardless of Your race, color, national origin, disability, age, sex, gender identity or sexual orientation. There are provisions throughout this Plan that affect Your health care coverage. It is important that You read the Plan carefully so You will be aware of the benefits and requirements of this Plan.

This Plan was designed to meet Your family's health care needs by providing access to a comprehensive network of Hospitals, Primary Care Physicians, Specialist, and other qualified Participating Providers while keeping Your cost for the coverage affordable.

The Claim Administrator for this Plan is Blue Cross and Blue Shield of Texas, a Division of Health Care services corporation (Claim Administrator). The Claim Administrator provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.

Please note: Capitalized words are defined terms and can be found in the DEFINITIONS section of this Benefit Booklet.

Read Your Benefit Booklet Carefully

Be sure to review the limitations and exclusions as well as the COVERED SERVICES AND BENEFITS portions of this benefit booklet.

THIS BENEFIT BOOKLET REPLACES, IN ITS ENTIRETY, ALL PREVIOUSLY ISSUED BENEFIT

BOOKLETS.

Claim Administrator 1001 East Lookout Drive Richardson, Texas 75082

1-877-299-2377

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TABLE OF CONTENTS

SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS ENCLOSURE

DEFINITIONS 1

WHO GETS BENEFITS 10

HOW THE PLAN WORKS 15

SERVICE AREA 23

CLAIM REVIEW AND APPEAL PROCEDURES 25

COVERED SERVICES AND BENEFITS 35

LIMITATIONS AND EXCLUSIONS 50

PHARMACY BENEFITS 55

GENERAL PROVISIONS 65

RIDERS

AMENDMENTS

SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS

Blue EssentialsSM Plan

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The following chart summarizes the coverage available under Your Blue Essentials Plan. For details, refer to COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Female Participants may visit a Participating OB/GYN Physician in their PCP's Provider network for diagnosis and treatment without a Referral from their PCP. Urgent Care, Virtual Visits, Outpatient Professional Behavioral Health, and Retail Health Clinics do not require Primary Care Physician/Practitioner Referral.

IMPORTANT NOTE: Copayment and, if applicable, Co‐Share shown below indicates the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments/Deductibles and out‐of‐pocket maximums may be adjusted for various reasons as permitted by applicable law.

Out‐of‐Pocket Maximums Per Calendar Year Including Pharmacy Benefits

Per Individual Participant

Per Family

$4,500

$9,000

Deductible Per Calendar Year

Per Individual Participant $1,600

Per Family $3,200

Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit

$35 Copay

Participating Specialist Physician (“Specialist”) Office or Home Visit

$50 Copay

Inpatient Hospital Services Inpatient Hospital Services, for each admission $500 Copay, plus 20% Co‐Share after Deductible

Outpatient Facility Services Outpatient Surgery

Outpatient Hospital Based Infusion Therapy

Radiation Therapy

Dialysis

20% Co‐Share after Deductible

20% Co‐Share after Deductible

20% Co‐Share after Deductible

Outpatient Laboratory and X‐Ray Services Arteriograms, Computerized Tomography (CT Scan), Magnetic Resonance Imaging (MRI), Electroencephalogram (EEG), Myelogram, Positron Emission Tomography (PET Scan), per procedure

20% Co‐Share after Deductible

Other X‐Ray Services

Outpatient Lab

20% Co‐Share after Deductible

20% Co‐Share after Deductible

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Rehabilitation Services*

Rehabilitation Services and Therapies, per visit (Limited to 60 visits combined with Chiropractic, Physical Therapy and Occupational Therapy)

$35 Copay for PCP or $50 Copay for Specialist, 20% Co‐Share after Deductible for Inpatient Hospital Services or 20% Co‐Share after Deductible for Outpatient Facility Services, as applicable.

Maternity Care and Family Planning Services Maternity Care

Prenatal and Postnatal Visit ‐ Copay is applied to the first office visit only. Subsequent office visits are covered in full

$35 Copay for PCP or $50 Copay for Specialist

Inpatient Hospital Services, for each admission 20% Co‐Share after Deductible

Family Planning Services:

• Diagnostic counseling, consultations and planning services

• Insertion or removal of intrauterine device (IUD), including cost of device

• Diaphragm or cervical cap fitting, including cost of device

• Insertion or removal of birth control device implanted under the skin, including cost of device

• Injectable contraceptive drugs, including cost of drug

• Voluntary sterilization

$35 Copay for PCP or $50 Copay for Specialist;

unless otherwise covered under Contraceptive Services described in Health Maintenance and Preventive Services.

• Vasectomy $35 Copay for PCP or $50 Copay for Specialist or 20% Co‐Share after Deductible for Outpatient Surgery, as applicable.

• Tubal Ligation 20% Co‐Share after Deductible for Inpatient Hospital Services or 20% Co‐Share after Deductible for Outpatient Surgery, as applicable.

Infertility Services

• Diagnostic counseling, consultations, planning and treatment services

$35 Copay for PCP or $50 Copay for Specialist

• Artificial insemination, for each procedure and all services related to procedure (cost of sperm not covered)

$35 Copay for PCP or $50 Copay for Specialist 20% Co‐Share after Deductible for Outpatient Surgery

In Vitro Fertilization, benefits paid same as any other pregnancy‐related illness (limited to $50,000 lifetime maximum)

$35 Copay for PCP or $50 Copay for Specialist 20% Co‐Share after Deductible for Outpatient Surgery, as applicable.

Pregnancy Terminations, limited to Medically Necessary therapeutic terminations of pregnancy

$35 Copay for PCP or $50 Copay for Specialist, 20% Co‐Share after Deductible for Inpatient Hospital Services or 20% Co‐Share after Deductible for Outpatient Surgery, as applicable.

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Behavioral Health Services Outpatient Mental Health Care Same as PCP amount described in Professional

Services.

Inpatient Mental Health Care Any charges described in Inpatient Hospital Services will apply.

Serious Mental Illness Benefits paid same as any other physical illness.

Chemical Dependency Services Benefits paid same as any other physical illness.

Emergency Services Facility

Physician

$500 Copay after Deductible, waived if admitted.

(If admitted, any charges described in Inpatient Hospital Services will apply.)

20% Co‐Share after Deductible

Urgent Care Services Urgent Care, per visit $50 Copay

Any additional charges as described in Outpatient Laboratory and X‐Ray Services may also apply.

Retail Health Clinics Retail Health Clinics PCP amount listed in Professional Services

Telehealth and Telemedicine Services Telehealth and Telemedicine Medical Services

Primary Care telehealth/telemedicine visit/consultation

Primary Care telehealth/telemedicine visit/consultation for treatment of Behavioral Health

Specialty telehealth/telemedicine visit/consultation

$35 Copay

$35 Copay

$35 Copay

$50 Copay

Virtual Visits Virtual Visits $10 Copay

Ambulance Services Ambulance Services, per service 20% Co‐Share after Deductible

Extended Care Services Skilled Nursing Facility Services, for each day, up to 60 days per Calendar Year

20% Co‐Share after Deductible

Hospice Care, per visit $500 Copay; unless otherwise covered under Inpatient Hospital Services.

Home Health Care, per visit, up to 60 visits per Calendar Year 20% Co‐Share after Deductible

Health Maintenance and Preventive Services Well child care through age 22 No Copay

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Periodic health assessments for Participants age 18 and older No Copay

Immunizations

• Childhood immunizations required by law for Participants through age 6

No Copay

• Immunizations for Participants over age 6 No Copay

Bone mass measurement for osteoporosis No Copay

Well‐woman exam, once every twelve months, includes, but not limited to, exam for cervical cancer (Pap smear)

No Copay

Screening mammogram for female Participants age 35 and over and for female Participants with other risk factors, once every twelve months

• Outpatient facility or imaging centers

No Copay

No Copay

Contraceptive Services and Supplies

• Contraceptive education, counseling and certain female FDA approved contraceptive methods, female sterilization procedures and devices

Breastfeeding Support, Counseling and Supplies

• Electric breast pumps limited to one (1) per benefit period

No Copay

No Copay

Hearing Loss

• Screening test from birth through 30 days No Copay

• Follow‐up care from birth through 24 months No Copay

Rectal screening for the detection of colorectal cancer for Participants age 45 and older:

• Annual fecal occult blood test, once every twelve months No Copay

• Flexible sigmoidoscopy with hemoccult of the stool, limited to 1 every 5 years

No Copay

• Colonoscopy, limited to 1 every 10 years No Copay

Eye and ear screenings for Participants through age 17, once every twelve months

No Copay

Eye and ear screening for Participants age 18 and older, once every two years

No Copay

Early detection test for ovarian cancer (CA125 blood test), once every twelve months

$35 Copay for PCP or $50 Copay for Specialist

No Copayment/Co‐Share after Deductible and out‐of‐pocket maximum has been met.

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Exam for prostate cancer, once every twelve months No Copay

No Copayment/Co‐Share after Deductible and out‐of‐pocket maximum has been met.

Dental Surgical Procedures Dental Surgical Procedures (limited Covered Services) $35 Copay for PCP or $50 Copay for Specialist

20% Co‐Share after Deductible for Inpatient Hospital Services or 20% Co‐Share after Deductible for Outpatient Surgery, as applicable.

Cosmetic, Reconstructive or Plastic Surgery Cosmetic, Reconstructive or Plastic Surgery (limited Covered Services)

$35 Copay for PCP or $50 Copay for Specialist 20% Co‐Share after Deductible for Inpatient Hospital Services or 20% Co‐Share after Deductible for Outpatient Surgery, as applicable

Allergy Care Testing and Evaluation 20% Co‐Share after Deductible

Injections 20% Co‐Share after Deductible

Serum 20% Co‐Share after Deductible

Diabetes Care Diabetes Self‐Management Training, for each visit $35 Copay for PCP or $50 Copay for Specialist

Diabetes Equipment 20% Co‐Share after Deductible

Diabetes Supplies

Some Diabetes Supplies are only available utilizing pharmacy benefits, through a Participating Pharmacy. You must pay the applicable PHARMACY BENEFIT amount shown in the

SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS

and any applicable pricing differences.

20% Co‐Share after Deductible

Prosthetic Appliances and Orthotic Devices Prosthetic Appliances and Orthotic Devices $300 maximum benefit for purchase of one (1) wig needed as a result of current chemotherapy or radiation treatment for cancer.

Cochlear Implants Limit one (1) per impaired ear, with replacements as Medically Necessary or audiologically necessary.

20% Co‐Share after Deductible

20% Co‐Share after Deductible Any additional charges as described in Outpatient Surgery may also apply.

Durable Medical Equipment Durable Medical Equipment 20% Co‐Share after Deductible

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Morbid Obesity Morbid obesity (including bariatric services) 20% Co‐Share after Deductible

Hearing Aids Hearing Aids

Maximum benefit ‐ one per ear, every 36 months.

20% Co‐Share after Deductible

*Benefits for Autism Spectrum Disorder(s) will not apply towards Rehabilitation Services and Therapies maximums.

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Pharmacy Benefits Retail Pharmacy

One Copayment amount per 30‐day supply, up to a 30‐day supply only Tier 1*

Tier 2*

Tier 3*

Out‐of‐Area Drug

$10 Copay

$55 Copay

$75 Copay

$75 Copay

Mail‐Order Program

One Copayment amount per 90‐day supply, up to a 90‐day supply only

Extended Prescription Drug Supply Program (if allowed by the prescription Order) ‐ One Copayment amount per 90‐day supply, up to a 90‐day supply only. Cost share will be based on day supply (1-30 day supply, 31-60 day supply, 61-90 day supply) dispensed.

Tier 1*

Tier 2*

Tier 3*

$25 Copay

$137.50 Copay

$187.50 Copay

Specialty Pharmacy Program

One Copayment amount per 30‐day supply, up to a 30‐day supply only Tier 1*

Tier 2*

Tier 3*

$10 Copay

$55 Copay

$75 Copay

Fertility Drugs Limited to $50,000 lifetime maximum

Additional Provisions

If you or your health care Provider request a Brand Name Drug when a generic equivalent is available, you will be responsible for the applicable Brand Name Drug payment amount, plus the difference in cost between the Brand Name Drug and the generic equivalent, except as otherwise provided under this booklet.

Vision enhancement products Covered at applicable tier

Copayments for Pharmacy Benefits apply toward the out‐of‐pocket maximum per Calendar Year.

*For information on the type of drugs covered under each respective tier level, please see the “Your Cost” provision under the PHARMACY BENEFITS section of this booklet.

For additional information regarding the applicable Drug List, please call customer service or visit the website at https://www.bcbstx.com.

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DEFINITIONS

Acquired Brain Injury means a neurological insult to the brain, which is not hereditary, congenital, or degenerative. The injury to the brain has occurred after birth and results in a change in neuronal activity, which results in an impairment of physical functioning, sensory processing, cognition, or psychosocial behavior.

Advance Practice Nurse (APN) means a registered nurse approved by the Texas Board of Nursing to practice as an advanced practice nurse based on completing an advanced educational program acceptable to the Board. The term includes a nurse practitioner, nurse‐midwife, nurse anesthetist, and a clinical nurse specialist. An Advance Practice Nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including but not limited to homes, Hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice.

An Advance Practice nurse acts independently and/or in collaboration with other Health Care Professionals in the delivery of health care services.

Allowable Amount means the maximum amount determined by the Claim Administrator to be eligible for consideration of payment for a particular service, supply or procedure rendered by a Participating Provider.

The Allowable Amount is based on the provisions of the Participating Provider contract and the payment methodology in effect on the date of service, whether diagnostic related grouping (DRG), capitation, relative value, fee schedule, per diem or other.

Approved Clinical Trial means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other Life‐Threatening Disease or Condition and is not designed exclusively to test toxicity or disease pathophysiology. The trial must be:

A. conducted under an investigational new drug application reviewed by the United States Food and Drug Administration;

B. exempt from obtaining an investigational new drug application; or C. approved or funded by:

1. the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, or a cooperative group or center of any of the foregoing entities;

2. a cooperative group or center of the United States Department of Defense or the United States Department of Veterans Affairs;

3. a qualified nongovernmental research entity identified in the guidelines issued by the National Institutes of Health for center support groups; or

4. the United States Departments of Veterans Affairs, Defense, or Energy if the study or investigation has been reviewed and approved through a system of peer review determined by the United States Secretary of Health and Human Services to:

a. be comparable to the system of peer review of studies and investigations used by the

National Institutes of Health; and

b. provide unbiased scientific review by individuals who have no interest in the outcome of the review.

Autism Spectrum Disorder means a Neurobiological Disorder that includes autism, Asperger's syndrome, or pervasive developmental disorder‐‐not otherwise specified. “Neurobiological Disorder” means an illness of the nervous system caused by genetic, metabolic, or other biological factors.

Calendar Year means the period beginning January 1 of any year and ending December 31 of the same year.

Chemical Dependency means the abuse of or psychological or physical dependence on or addiction to alcohol or a Controlled Substance.

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Chemical Dependency Treatment Center means a facility that provides a program for the treatment of Chemical Dependency pursuant to a written treatment plan approved by the HMO or its designated behavioral health administrator. The facility must be:

• Affiliated with a Hospital under a contractual agreement with an established system for patient Referral;

• Accredited as such a facility by the Joint Commission on Accreditation of Healthcare Organizations;

• Licensed, certified or approved as a Chemical Dependency treatment program or center by an agency of the state of Texas having legal authority to so license, certify or approve; or

• If outside Texas, licensed, certified or approved as a Chemical Dependency treatment program or center by the appropriate agency of the state in which it is located having the legal authority to so license, certify or approve.

Claim Administrator means Blue Cross and Blue Shield of Texas, a Division of health Care Service Corporation. The Claim Administrator has no fiduciary responsibility for the operation of the Plan. The Claim Administrator assumed only the authority and discretion as given by the employer to interpret the Plan provisions and make eligibility and benefit determinations.

Clinical Ecology means the inpatient or outpatient diagnosis or treatment of allergic symptoms by:

• cytotoxicity testing (testing the result of food or inhalant by whether or not it reduces or kills white blood cells);

• urine auto injection (injecting one's own urine into the tissue of the body);

• skin irritation by Rinkel method;

• subcutaneous provocative and neutralization testing (injecting the patient with allergen); or

• sublingual provocative testing (droplets of allergenic extracts are placed in mouth).

Complications of Pregnancy means conditions, requiring Hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, Physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and nonelective cesarean section, termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible.

Contract Month means the period of each succeeding month beginning on the Administrative Services Agreement date.

Controlled Substance means an abusable volatile chemical as defined in the Texas Health and Safety Code, or a substance designated as a Controlled Substance in the Texas Health and Safety Code.

Copayment or Copay means the dollar amount required to be paid by You or on Your behalf at the time of service to a Participating Provider in connection with Covered Services provided as described in COVERED

SERVICES AND BENEFITS and in PHARMACY BENEFITS.

Co‐Share means the dollar amount or percentage of the Allowable Amount required to be paid by You or on Your behalf at the time of service to a Participating Provider in connection with Covered Services provided as described in COVERED SERVICES AND BENEFITS and in PHARMACY BENEFITS.

Cosmetic, Reconstructive or Plastic Surgery means surgery that can be expected or is intended to improve Your physical appearance, is performed for psychological purposes, or restores form but does not correct or materially restore a bodily function.

Covered Services means those Medically Necessary health services specified and described in COVERED

SERVICES AND BENEFITS.

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Crisis Stabilization Unit means a twenty‐four (24) hour residential program that is usually short‐term in nature and provides intensive supervision and highly structured activities to Participants who show signs of an acute demonstrable psychiatric crisis of moderate to severe proportions.

Custodial Care means any service primarily for personal comfort or convenience that provides general maintenance, preventive, and/or protective care without any clinical likelihood of improvement of Your condition. Custodial Care Services also means those services which do not require the technical skills, professional training and clinical assessment ability of medical and/or nursing personnel in order to be safely and effectively performed. These services can be safely provided by trained or capable nonprofessional personnel, are to assist with routine medical needs (including but not limited to dressings, administration of routine medications, ventilator suctioning and other care) and are to assist with activities of daily living (including but not limited to bathing, eating and dressing).

Deductible means the dollar amount required to be paid by You or on Your behalf to a Participating Provider before benefits are available in connection with Covered Services provided as described in COVERED

SERVICES AND BENEFITS and in PHARMACY BENEFITS.

Dependent(s) means the Subscriber's family members who meet the eligibility requirements of this Plan and have been enrolled by the Subscriber.

Dietary and Nutritional Services means Your education, counseling, or training (including printed material) regarding diet, regulation or management of diet, or the assessment or management of nutrition.

Domestic Partner means a person with whom You have entered into a domestic partnership in accordance with the Group's guidelines and who has been determined eligible for coverage by the Claim Administrator.

Note: Domestic Partner coverage is available at Your employer's discretion. Contact Your employer for information on whether Domestic Partner coverage is available for Your Group and if COBRA‐like benefits are available For specific criteria or forms needed to establish eligibility for coverage under this Plan, contact Your Group's Human Resources Department.

Durable Medical Equipment (DME) means equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in absence of illness or injury, and is appropriate for use in the home.

Effective Date of Coverage means the commencement date of coverage under this Plan as shown on the records of the Claim Administrator.

Emergency Care means health care services provided in a Hospital emergency facility, freestanding emergency medical care facility, or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

• placing the patient's health in serious jeopardy;

• serious impairment to bodily functions;

• serious dysfunction of any bodily organ or part;

• serious disfigurement; or

• in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Environmental Sensitivity means the inpatient or outpatient treatment of allergic symptoms by controlling environment, sanitizing the surroundings (removal of toxic materials), or use of special nonorganic, nonrepetitive diet techniques.

Experimental/Investigational means the use of any treatment, procedure, facility, equipment, drug, device or supply not accepted as Standard Medical Treatment of the condition being treated or any of such items requiring federal or other governmental agency Approval not granted at the time services were provided.

“Approval” by a federal agency means that the treatment, procedure, facility, equipment, drug, device or supply has been approved for the condition being treated and, in the case of a drug, in the dosage used on the

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patient. Approval by a federal agency will be taken into consideration by the Claim Administrator in assessing Experimental/Investigational status but will not be determinative. Medical treatment includes medical, surgical or dental treatment. “Standard Medical Treatment” means the services or supplies that are in general use in the medical community in the United States, and:

• have been demonstrated in peer‐reviewed literature to have scientifically established medical value for curing or alleviating the condition being treated;

• are appropriate for the Hospital or Participating Provider; and

• the Health Care Professional has had the appropriate training and experience to provide the treatment or procedure.

The Claim Administrator shall determine whether any treatment, procedure, facility, equipment, drug, device, or supply is Experimental/Investigational, and will consider factors such as the guidelines and practices of Medicare, Medicaid, or other government‐financed programs and approval by a federal agency in making its determination.

Although a Health Care Professional may have prescribed treatment, and the services or supplies may have been provided as the treatment of last resort, such services or supplies still may be considered to be Experimental/Investigational within this definition. Treatment provided as part of a clinical trial or a research study is Experimental/Investigational.

Group means the employer or party that has entered into a Administrative Services Agreement with the Claim Administrator under which the Claim Administrator will provide for or arrange health services for eligible Participants of the Group who enroll.

Group Health Plan (GHP) as applied to this Benefit Booklet means a self‐funded employee welfare benefit plan as defined in subsection 160.103 of HIPAA. For additional information, refer to the definition of Plan Administrator.

Health Benefit Plan means a group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group Hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services.

Health Care Professional(s) means Physicians, nurses, audiologists, Physician Assistants or Advance Practice Nurses, nurse first assistants, acupuncturists, clinical psychologists, pharmacists, occupational therapists, physical therapists, speech and language pathologists, surgical assistants and other professionals engaged in the delivery of health services who are licensed, practice under an institutional license, or certified, or practice under authority of a Physician or legally constituted professional association, or other authority consistent with state law.

Hospice means an organization, licensed by appropriate regulatory authority or certified by Medicare as a supplier of Hospice care, which has entered into an agreement with the Claim Administrator to render Hospice care to Participants.

Hospital means a duly licensed institution for the care of the sick which provides service under the care of a Physician including the regular provision of bedside nursing by registered nurses. It does not mean health resorts, rest homes, nursing homes, skilled nursing facilities, convalescent homes, custodial homes of the aged or similar institutions.

Hospital Services (except as expressly limited or excluded in this Plan) means those Medically Necessary Covered Services that are generally and customarily provided by acute general Hospitals; and prescribed, directed or authorized by the PCP.

Identification Card means the card issued to the Employee by the Claim Administrator of the Plan indicating pertinent information applicable to his coverage.

Infertility means the condition of a presumably healthy Participant who is unable to conceive or produce conception after a period of one year of frequent, unprotected heterosexual sexual intercourse. This does not

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include conditions for male Participants when the cause is a vasectomy or orchiectomy or for female Participants when the cause is a tubal ligation or hysterectomy.

Life‐Threatening Disease or Condition means, for the purposes of a clinical trial, any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

Limited Provider Network means a subnetwork within an HMO delivery network in which contractual relationships exist between Physicians, certain Providers, independent Physician associations and/or Physician groups which limit Your access to only the Physicians and Providers in the subnetwork..

Medical Director means a Physician of the Claim Administrator, or his designee, who is responsible for monitoring the provision of Covered Services to Participants.

Medically Necessary means services or supplies (except as limited or excluded herein) that are:

• essential to, consistent with, and provided for the diagnosis or the direct care and treatment of the condition, sickness, disease, injury, or bodily malfunction;

• provided in accordance with and consistent with generally accepted standards of medical practice in the United States;

• not primarily for Your convenience, or the convenience of Your Participating Provider;

• the most economical supplies or levels of service appropriate for Your safe and effective treatment;

and

• If more than one health intervention meets the requirements listed above, Medically Necessary means the most cost effective in terms of type, frequency, extent, site, duration, which is safe and effective for the patient's illness, injury or disease.

When applied to hospitalization, this further means that You require acute care as an inpatient due to the nature of the services rendered or Your condition, and You cannot receive safe or adequate care as an outpatient.

In determining whether a service is Medically Necessary, the medical staff of the Claim Administrator may consider the views of the state and national medical communities and the guidelines and practices of Medicare, Medicaid, or other government‐financed programs and peer reviewed literature. Although a Participating Provider may have prescribed treatment, such treatment may not be Medically Necessary within this definition. This definition applies only to the Claim Administrator's determination of whether health care services are Covered Services under this Plan.

Medicare means Title XVIII of the Social Security Act and all amendments thereto.

Mental Health Care means any one or more of the following:

1. The diagnosis or treatment of a mental disease, disorder, or condition listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as revised, or any other diagnostic coding system as used by the Claim Administrator or its designated behavioral health administrator, whether or not the cause of the disease, disorder, or condition is physical, chemical, or mental in nature or origin;

2. The diagnosis or treatment of any symptom, condition, disease, or disorder by a Participating Provider when the Covered Service is:

• individual, group, family, or conjoint psychotherapy,

• counseling,

• psychoanalysis,

• psychological testing and assessment,

• the administration or monitoring of psychotropic drugs, or

• Hospital visits (if applicable) or consultations in a facility listed in item 5, below;

3. Electroconvulsive treatment;

4. Psychotropic drugs;

5. Any of the services listed in items 1 ‐ 4, above, performed in or by a Hospital (if applicable), or other licensed facility or unit providing such care.

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Mental Health Treatment Facility means a facility that:

• meets licensing standards;

• mainly provides a program for diagnosis, evaluation and treatment of acute mental or nervous disorders;

• prepares and maintains a written plan of treatment for each patient based on medical, psychological and social needs;

• provides all normal infirmary level medical services or arranges with a Hospital for any other medical services that may be required;

• is under the supervision of a psychiatrist; and

• provides skilled nursing care by licensed nurses who are directed by a registered nurse.

Obstetrician/Gynecologist means a Participating Physician contracted by the Claim Administrator as an Obstetrician and/or Gynecologist who may be selected by a female to provide:

• well‐woman exams;

• obstetrical care;

• care for all active gynecological conditions; and

• diagnosis, treatment, and Referral for any disease or condition within the scope of the professional practice of the Obstetrician/Gynecologist.

Open Enrollment Period means those periods of time (at least thirty‐one (31) days) established by Group and the Claim Administrator from time to time, but no less frequently than once in any twelve (12) consecutive months, during which eligible persons who have not previously enrolled with the Claim Administrator may do so.

Out‐of‐Area means not within the Service Area.

Participant means a Subscriber or Dependent(s) covered under this Plan. This Plan may refer to a Participant as You or Your.

Participating describes a Provider that has entered into a contractual agreement with the Claim Administrator for the provision of Covered Services to Participants.

Physician means a physician duly licensed to practice medicine in all of its branches.

Physician Assistant means a physician assistant licensed under Texas Occupations Code Chapter 204.

Plan Administrator means the Group Health Plan (GHP) or a named administrator of the Plan having fiduciary responsibility form its operation. The Claim Administrator is not the Plan Administrator.

Post‐Delivery Care means postpartum health care services provided in accordance with accepted maternal and neonatal physical assessments, including parent education, assistance and training in breast and bottle feeding, and the performance of necessary and appropriate clinical tests.

Post‐Service Medical Necessity Review means a review, sometimes referred to as a retrospective review or post‐service claims request, is the process of determining coverage after treatment has already occurred and is based on Medical Necessity guidelines.

Primary Care Physician/Practitioner or PCP means a Physician who is a Network Provider at the time Covered Services are rendered who is selected by or assigned to a Covered Person to coordinate and arrange for the Covered Person's medical care and who provides medical care within the scope of a license permitting him/her to legally practice medicine in the recognized areas of pediatrics, obstetrics and gynecology, internal medicine and family practice.

Prior Authorization means a determination by the Claim Administrator that health care services proposed to be provided to a patient are Medically Necessary and appropriate.

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Professional Services means those Medically Necessary Covered Services rendered by Physicians and other Health Care Professionals in accordance with this Plan. All services must be performed, prescribed, directed, or authorized in advance by the PCP.

Prosthetic Appliances means artificial devices including limbs or eyes, braces or similar prosthetic or orthopedic devices, which replace all or part of an absent body organ (including contiguous tissue) or replace all or part of the function of a permanently inoperative or malfunctioning body organ (dental appliances and the replacement of cataract lenses are not considered Prosthetic Appliances).

Provider means any Hospital, health care facility, laboratory, person or entity duly licensed to render Covered Services to a Covered Person or any other provider of medical or dental services, products or supplies which are Covered Services and/or the Independent Physician Association(s) that facilitate(s) provision of Covered Services to Covered Persons.

Recommended Clinical Review means an optional voluntary review of a Provider's recommended medical procedure, treatment or test, that does not require Prior Authorization, to make sure it meets approved HMO medical policy guidelines and Medical Necessity requirements.

Reconstructive Surgery for Craniofacial Abnormalities means surgery to improve the function of, or to attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease.

Referral means specific directions or instructions from Your PCP, in conformance with the Claim Administrator policies and procedures that direct You to a Participating Provider for Medically Necessary care.

Research Institution means an institution or Provider (person or entity) conducting a phase I, phase II, phase III, or phase IV clinical trial.

Residential Treatment Center - a facility setting offering a defined course of therapeutic intervention and special programming in a controlled environment which also offers a level of security, supervision, and structure medically necessary to meet the needs of patients served or to be served by such facility. Residential Treatment Centers must be licensed by the appropriate state and local authority as a Residential Treatment Facility or its equivalent under the laws or regulations of such locality and/or must be accredited by a national accrediting body as a Residential Treatment Center or its equivalent. Accepted accrediting bodies are The Joint Commission, Commission on Accreditation of Rehabilitation Facilities (CARF), Accreditation Association for Ambulatory Healthcare (AAAHC), Council on Accreditation of Services for Families and Children Inc. (COA), or National Integrated Accreditation of Healthcare Organizations (NIAHOSM). This includes any specialized licensing that may be applicable given the services to be provided or population to be served. As they do not provide the level of care, security, or supervision appropriate of a Residential Treatment Center, the following shall not be included in the definition of Residential Treatment Center:

half‐way houses, supervised living, group homes, wilderness programs, boarding houses or other facilities that provide primarily a supportive/custodial environment and/or primarily address long term social needs, even if counseling is provided in such facilities. To qualify as a Residential Treatment Center, patients must be medically monitored with 24‐hour medical professional availability and on‐site nursing care and supervision for at least one shift a day with on call availability for the other shifts.

Residential Treatment Center for Children and Adolescents means a childcare institution that provides residential care and treatment for emotionally disturbed children and adolescents and that is accredited as a Residential Treatment Center by the Council on Accreditation, the Joint Commission on Accreditation of Healthcare Organizations or the American Association of Psychiatric Services for Children.

Retail Health Clinic means a Participating provider that has entered into a contractual agreement with the Claim Administrator to provide treatment of uncomplicated minor illnesses. Retail Health Clinics are typically located in retail stores and are typically staffed by Advanced practice Nurses or Physician Assistants.

Rider means additional or expanded benefits which are made available to the Group. Such rider, when purchased, will be attached to and incorporated into the Plan.

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Routine Patient Care Costs means the costs of any Medically Necessary health care service for which benefits are provided under the Health Benefit Plan, without regard to whether the Participant is participating in a clinical trial.

Routine patient care costs do not include:

• The investigational item, device, or service, itself;

• Items and services that are provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient; or

• A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.

Serious Mental Illness means the following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM):

• schizophrenia;

• paranoid and other psychotic disorders;

• bipolar disorders (hypomanic, manic, depressive and mixed);

• major depressive disorders (single episode or recurrent);

• schizo‐affective disorders (bipolar or depressive);

• obsessive‐compulsive disorders; and

• depression in childhood or adolescence.

Service Area means the geographical area served by the Claim Administrator and approved by state regulatory authorities. The Service Area includes the area shown and described in this Plan.

Skilled Nursing Facility means an institution or distinct part of an institution that is licensed or approved under state or local law, and primarily provides skilled nursing care and related services as a Skilled Nursing Facility, extended care facility or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations, the Bureau of Hospitals of the American Osteopathic Association or as otherwise determined by the Claim Administrator to meet the reasonable standards applied by either of those authorities.

Specialist means a duly licensed Physician, other than a PCP.

Subscriber means a person who meets all applicable eligibility and enrollment requirements of this Plan, and whose enrollment application and contributions have been received by the Claim Administrator.

Substance Use Disorder means the abuse of or psychological or physical dependence on or addiction to alcohol or a controlled substance.

Substance Use Disorder Treatment Center means a facility which provides a program for the treatment of Substance Use Disorder pursuant to a written treatment plan approved and monitored by a Behavioral Health Practitioner and which facility is also:

1. Affiliated with a Hospital under a contractual agreement with an established system for patient referral;

or

2. Accredited as such a facility by the Joint Commission on Accreditation of Healthcare Organizations; or

3. Licensed as a Substance Use Disorder treatment program by the Texas Commission on Alcohol and Drug Abuse; or

4. Licensed, certified, or approved as a Substance Use Disorder treatment program or center by any other state agency having legal authority to so license, certify, or approve.

Telehealth Services means a health service, other than a Telemedicine Medical Service, delivered by a health professional licensed, certified, or otherwise entitled to practice in Texas and acting within the scope of the health care professional license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

Telemedicine Medical Services means a health service delivered by a Physician licensed in Texas by a health professional acting under the delegation and supervision of a Physician licensed in Texas, and acting within

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the scope of the Physician's or health professional's license to a patient at a different physical location than the Physician or health professional using telecommunications or information technology.

Urgent Care means medical or health care services provided in a situation other than an emergency that are typically provided in a setting such as an Urgent Care Provider's office or Participating Urgent Care center, as a result of an acute injury or illness that is severe or painful enough to lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the person's condition, illness, or injury is of such a nature that failure to obtain treatment within a reasonable period of time would result in serious deterioration of the condition of the person's health.

Urgent Care Provider means a Participating Provider that has entered into a contractual agreement with the Claim Administrator for the provision of Covered Services for Urgent Care to Participants.

Virtual Network Provider means a licensed Participating Provider that has entered into a contractual agreement with the Claim Administrator to provide diagnosis and treatment of injuries and illnesses through either (i) interactive audio communication (via telephone or other similar technology), or (ii) interactive audio/video examination and communication (via online portal, mobile application or similar technology).

Virtual Visits means services provided for the treatment of non‐emergency medical and behavioral health conditions as described in COVERED SERVICES AND BENEFITS.

You and Your means any Participant, including Subscriber and Dependents.

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WHO GETS BENEFITS

Eligibility

No eligibility rules or variations in rates will be imposed based on Your health status, medical condition, claims experience, receipt of care, medical history, genetic information, evidence of insurability, disability, or other health status related factor. Coverage under this Plan is provided regardless of Your race, color, national origin, disability age, sex gender identity or sexual orientation. Variations in the administration, processes or benefits of this Plan are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentive; disincentives and/or other programs do not constitute discrimination.

Subscriber Eligibility. To be eligible to enroll as a Subscriber, a person must:

1. reside, live or work in the Service Area; and

2. be a bona fide employee of Group entitled to participate in the health care benefit program arranged by Group or be entitled to coverage under a trust agreement or employment contract; and

3. satisfy any probationary or waiting period requirements established by Group.

Note: No such waiting period may exceed 90 days unless permitted by applicable law. If our records show that Your Group has a waiting period that exceeds the time period permitted by applicable law, then the Claim Administrator reserves the right to begin Your coverage on a date that we believe is within the required period. Regardless of whether we exercise that right, Your Group is responsible for Your waiting period. If You have questions about Your waiting period, please contact Your Group.

Dependent Eligibility. To be eligible to enroll as a Dependent, a person must:

1. reside in the Service Area or permanently reside with a Subscriber who works in the Service Area, except as provided in item 6, below; and

2. meet all Dependent eligibility criteria established by Group; and

3. be Subscriber's spouse, or Domestic Partner. Subscriber may be required to submit a certified copy of a marriage license or declaration of informal marriage with Dependent's enrollment application/change form before coverage will be extended; or

4. be a Dependent child, which hereafter means a natural child, a stepchild, eligible foster child, an adopted child (including a child for whom the Subscriber or Subscriber's spouse is a party in a suit in which the adoption of the child is sought) or a Dependent child of a Domestic Partner under twentysix years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status eligibility for other coverage or any combination of those factors. To be eligible for coverage, a child of a Subscriber's child must also be dependent upon Subscriber for federal income tax purposes at the time application for coverage is made.

In addition, a Dependent shall include a child for whom Subscriber or Subscriber's spouse or Domestic Partner is a court‐appointed legal guardian, provided proof of such guardianship is submitted with the prospective Dependent's enrollment application/change form; or

5. be a child of any age, as defined in item 4 above, who is and continues to be incapable of sustaining employment by reason of mental retardation or physical handicap and is chiefly dependent upon Subscriber for economic support and maintenance. Subscriber must provide the Claim Administrator with a Dependent Child's Statement of Disability form, including a medical certification of disability, within thirty‐one (31) days of the date of such medical certification and subsequently as may be required by the Claim Administrator, but not more often than once per year.

The Claim Administrator's determination of eligibility shall be conclusive; or

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6. have a court order for coverage to be provided for a spouse or minor child under Subscriber's Health Benefit Plan and a request for enrollment shall be made within thirty‐one (31) days after issuance of the court order.

Coverage of Subscriber shall be a condition precedent to coverage of eligible Dependents, and no Dependent shall be covered hereunder…