7-Attchement 4 - BCBSNM PPO Plan Certificate.pdf

abc complany Account #: 123456 BluePPO EvolutionSM A Guide To Your Group Preferred Provider (PPO) Health Care Plan

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

County of Bernalillo Account #: 284759 BluePPO EvolutionSM A guide To Your Group Preferred Provider (PPO) Health Care Plan

(July 1, 2024)

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

CUSTOMER ASSISTANCE

Customer Service: — The 24/7 Nurseline can help when you have a health problem or concern. The 24/7 Nurseline is staffed by Registered Nurses who are available 24 hours a day, 7 days a week.

24/7 Nurseline toll-free telephone number: 1-800-973-6329

When you have a non-medical benefit question or concern, call BCBSNM Monday through Friday from 6 A.M. - 8 P.M. and 8 A.M. - 5 P.M. on Saturdays and most holidays or visit the BCBSNM Customer Service department in Albuquerque. (If you need assistance outside normal business hours, you may call the Customer Service telephone number and leave a message. A Customer Service Advocate will return your call by 5 P.M. the next business day.)

You may either call toll-free or visit the BCBSNM office in Albuquerque at:

Street address: 4373 Alexander Blvd. NE Toll-free telephone number: 1-800-432-0750

Send all written inquiries/Prior Authorization requests and submit medical/surgical Claims* to:

Blue Cross and Blue Shield of New Mexico P.O. Box 27630

Albuquerque, New Mexico 87125-7630

Prior Authorizations: Medical/Surgical Services—For Prior Authorization requests, call a Health Services representative, Monday through Friday 8 A.M. - 5 P.M., Mountain Time. Written requests should be sent to the address given above. Note: If you need Prior Authorization assistance between 5 P.M. and 8 A.M. or on weekends, call Customer Service. If you call after normal Customer Service hours, you will be asked to leave a message.

1-505-291-3585 or 1-800-325-8334

Mental Disorder and Chemical Dependency—For inquiries or Prior Authorizations related to Mental Disorder or Chemical Dependency services, call the Behavioral Health Unit (BHU):

24 hours/day, 7 days/week: 1-888-898-0070 Send Claims* to:

Claims, Behavioral Health Unit P.O. Box 27630

Albuquerque, New Mexico 87125-7630

Website—For Provider network information, Claim forms, and other information, or to e-mail your question to BCBSNM, visit the BCBSNM website at:

www.bcbsnm.com

*Exceptions to Claim Submission Procedures—Claims for Health Care Services received from Providers that do not contract directly with BCBSNM, should be sent to the Blue Cross and Blue Shield Plan in the state where services were received. Note: Do not submit drug plan claims to BCBSNM. See Section 8: Claims Payments and Appeals for details on submitting Claims.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Be sure to read this Benefit Booklet carefully and refer to the Summary of Benefits.

A message from

County of Bernalillo

Welcome to the PPO Health Care Benefit Plan for eligible employees of County of Bernalillo and their Eligible Family Members. Blue Cross and Blue Shield of New Mexico (BCBSNM), a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, and an Independent Licensee of the Blue Cross and Blue Shield Association is pleased to serve as the Claims Administrator for the County of Bernalillo self-funded Health Care Benefit Plan. You will be accessing the BCBS Preferred Provider network as if you were insured by

BCBSNM.

Please take some time to get to know your Health Care Benefit Plan coverage, including its benefit limits and exclusions, by reviewing this important document and any enclosures. Learning how this Plan works can help make the best use of your Health Care Benefits.

Note: This Plan’s benefit administrator and County of Bernalillo (your Group) may change the benefits described in this Benefit Booklet. If that happens, your benefit administrator or County of Bernalillo will notify you of those mutually agreed upon changes.

If you have any questions once you have read this Benefit Booklet, talk to your benefits administrator or call us at the number listed on the back of your ID Card, or as listed in Customer Assistance on the inside front cover.

It is important to all of us that you understand the protection this coverage gives you.

Thank you for selecting BCBSNM for your health care coverage. We look forward to working with you to provide personalized and affordable health care now and in the future.

Note: Preferred Provider Option (PPO) - Under the PPO Plan, you are not restricted to using certain Network Providers exclusively, but may also choose to receive most services outside the network at a reduced benefit level. (This network is one of the largest in the state of New Mexico and you will be able to take advantage of the many Preferred Provider contracts that other Blue Cross Blue Shield Plans have throughout the United States.)

Sincerely, County of Bernalillo

TABLE OF CONTENTS

SECTION 1: HOW TO USE THIS BENEFIT BOOKLET

SECTION 2: ENROLLMENT AND TERMINATION INFORMATION

SECTION 3: HOW YOUR PLAN WORKS

SECTION 4: UTILIZATION MANAGEMENT

SECTION 5: COVERED SERVICES

SECTION 6: GENERAL LIMITATIONS AND EXCLUSIONS

SECTION 7: COORDINATION OF BENEFITS (COB) AND REIMBURSEMENT

SECTION 8: CLAIMS PAYMENTS AND APPEALS

SECTION 9: GENERAL PROVISIONS

SECTION 10: DEFINITIONS

APPENDIX A: CONTINUATION COVERAGE RIGHTS UNDER COBRA

APPENDIX B: NOTICE - INQUIRIES/COMPLAINTS AND INTERNAL/EXTERNAL APPEALS FOR SELF-

FUNDED PLANS

BENEFIT BOOKLET NO SURPRISES ACT AMENDMENT

Customer Service: (800) 432-0750 1

284759 (07/24)

SECTION 1: HOW TO USE THIS BENEFIT BOOKLET

This Benefit Booklet describes the medical/surgical, and Mental Disorder/Chemical Dependency coverage available to Members of this health care plan and the Plan’s benefit limitations and exclusions.

Always carry your current Plan ID Card issued by BCBSNM. When you arrive at the Provider’s office or at the Hospital, show the receptionist your Plan ID Card.

To find Doctors and Hospitals nearby, you may use the Internet, make a phone call, or request a hard copy of a directory from BCBSNM. See details in Section 3: How Your Plan Works.

Call BCBSNM (or the Behavioral Health Unit) for Prior Authorization, if necessary. The phone numbers are on your Plan ID Card. See Section 4: Utilization Management for details about the Prior Authorization process.

Please read this Benefit Booklet and familiarize yourself with the details of your Plan before you need services.

Doing so could save you time and money.

In an Emergency, call 911 or go directly to the nearest Hospital.

DEFINITIONS

Throughout this Benefit Booklet, many words are used that have a specific meaning when applied to your health care coverage. When you come across these terms while reading this Benefit Booklet, please refer to Section 10:

Definitions, for an explanation of the limitations or special conditions that may apply to your benefits.

SUMMARY OF BENEFITS AND COVERAGE (SBC)

The Summary of Benefits and Coverage is referred to as the Summary of Benefits throughout this Benefit Booklet.

The Summary of Benefits shows specific Member cost-sharing amounts and coverage limitations of your Plan. If you do not have a Summary of Benefits, please contact a BCBSNM Customer Service Advocate (the phone number is at the bottom of each page of this Benefit Booklet). You will receive a new Summary of Benefits if changes are made to your health care plan.

IDENTIFICATION (ID) CARD

You will receive a BCBSNM Identification (ID) Card. The ID Card contains your “Group” number and your identification number (including an alpha prefix) and tells Providers that you are entitled to benefits under this health care plan with BCBSNM.

Carry it with you. Do not let anyone who is not named in your coverage use your Card to receive benefits. If you need an additional Card or need to replace a lost Card, contact a BCBSNM Customer Service Advocate.

PROVIDER NETWORK DIRECTORY

The Provider network directory is available through the BCBSNM website at www.bcbsnm.com. It lists all Providers and their qualifications in the BCBSNM Preferred Provider (PPO) network and Participating Pharmacies. It also provides links to the listings of Preferred Providers in other states. (If you want a paper copy of a directory, you may request one from Customer Service. It will be mailed to you free of charge.) Note: Although Provider directories are current as of the date shown at the bottom of each page, they can change without notice. To verify a Provider’s status or if you have any questions about the directory, contact a Customer Service Advocate or visit the BCBSNM website.

BLUECARD BROCHURE

As a Member of a PPO health plan administered by BCBSNM, you take your health plan benefits with you – across the country and around the world. The BlueCard Program gives you access to Preferred Providers almost everywhere you travel or live. Almost 90 percent of Physicians in the United States contract with Blue Cross and Blue Shield (BCBS) Plans. You and your Eligible Family Members can receive the Preferred Provider level of benefits – even when traveling or living outside New Mexico – by using Health Care Providers that contract as Preferred Providers with their local BCBS Plan. You should have received a brochure describing this program in more detail. It’s a

Customer Service: (800) 432-0750 2 valuable addition to your health care plan coverage. Instructions for locating a Preferred Provider outside New Mexico are in the brochure or can be found on the BCBSNM website at www.bcbsnm.com.

LIMITATIONS AND EXCLUSIONS

Each provision in Section 5: Covered Services not only describes what is covered, but may list some limitations and exclusions that specifically relate to a particular type of service. Section 6: General Limitations and Exclusions lists limitations and exclusions that apply to all services.

PRIOR AUTHORIZATION REQUIRED

To receive full benefits for some non-Emergency Admissions and certain medical/surgical services, you or your Provider must call the BCBSNM Health Services department before you receive treatment. Call Monday through Friday, 8 A.M. to 5 P.M., Mountain Standard Time. See Section 4: Utilization Management for details. Note: Call Customer Service if you need Prior Authorization assistance after 5 P.M.

Emergency/Maternity Admission Notification To receive full benefits for Emergency Hospital Admissions, you (or your Provider) should notify BCBSNM within 48 hours of Admission, or as soon as reasonably possible following Admission. Call BCBSNM’s Health Services department, Monday through Friday, 8 A.M. to 5 P.M., Mountain Standard Time. Also, if you have a routine delivery and stay in the Hospital more than 48 hours, or if you have a C-section delivery and stay in the Hospital more than 96 hours, you must call BCBSNM for Prior Authorization before you are discharged.

Written Request Required If a written request for Prior Authorization is required in order for a service to be covered, you or your Provider should send the request, along with appropriate documentation, to:

Blue Cross and Blue Shield of New Mexico Attn: Health Services Department

P.O. Box 27630 Albuquerque, NM 87125-7630

Please ask your Health Care Provider to submit your request early enough to ensure that there is time to process the request before the date you are planning to receive services.

PRIOR AUTHORIZATION OF BEHAVIORAL HEALTH CARE

Prior Authorization must be obtained for all Inpatient and specified Outpatient Mental Disorder and Chemical Dependency services by the Behavioral Health Unit (BHU) at the phone number below (also listed on the back of your ID Card). For services requiring Prior Authorization, you or your Physician should call the BHU before you schedule treatment. Services performed in an emergency room may be obtained within 48 hours of admission or, if the patient’s condition makes it impossible to call within 48 hours, as soon as possible. The BHU will coordinate Covered Services with an In-Network Provider near you. If you do not call and receive Prior Authorization before receiving non-Emergency services, benefits for services may be denied. Call 7 days a week, 24 hours a day:

Toll-Free Phone Number: 1-888-898-0070

PRIOR AUTHORIZATION AND COMPLAINT/APPEAL PROCEDURES

In addition to the summary of complaint and appeal procedures presented in this booklet, Appendix B: Notice - Inquiries/Complaints and Internal/External Appeals for Self-Funded Plans provides all of the details of the BCBSNM complaint and appeals procedures, including independent external review and other actions that may be available under your health plan.

HEALTH AND WELLNESS MAINTENANCE AND IMPROVEMENT PROGRAMS

BCBSNM and your employer have the right to offer programs for the purposes of medical management programs, quality improvement programs, and health behavior wellness, maintenance or improvement over and above the

Customer Service: (800) 432-0750 3 standard benefits provided by this Plan. These programs may allow for a reward, a contribution, a disincentive, a differential in premiums or a differential in medical, Prescription Drug or equipment Copayments, Coinsurance, Deductibles or costs, or a combination of incentives and/or disincentives for participation in any program offered or administered by BCBSNM or any retailer, Provider, or manufacturer chosen by BCBSNM to administer such program. Discount programs for various health behavior wellness or insurance-related items and services may also be available from time to time. For details of current discounts or other programs available, please contact a Customer Service representative by calling the phone number on the back of your ID Card. Such programs may be discontinued with or without notice. Contact your employer for additional information regarding any value-based programs offered by your employer.

For individuals in wellness programs who are unable to participate in these incentives or disincentives due to an adverse health factor shall not be penalized based upon an adverse status and unless otherwise permitted by law. Blue Cross Blue Shield will allow a reasonable alternative to any individual for whom it is unreasonably difficult, due to a medical condition, to satisfy otherwise applicable wellness program standards.

Contact Blue Cross Blue Shield for additional information regarding any value-based programs offered by Blue Cross Blue Shield.

VIRTUAL VISITS

Covered Services provided via consultation with a Virtual Visit Provider through interactive video via online portal or mobile application. Virtual Visits provide access (only for In-Network) to Providers who can provide diagnosis and treatment of non-Emergency in situations that may be handled without a traditional office visit, Urgent Care visit or Emergency Care visit.

See your Summary of Benefits for the member cost share for Virtual Visits for primary care office visit and for Mental Disorders and Chemical Dependency.

TELEMEDICINE MEDICAL SERVICES

Covered Services provided via consultation with a contracted Provider through information and telecommunication technology. Telemedicine provides access to Providers who can provide diagnosis and treatment of non-Emergency medical conditions, Mental Disorders and Chemical Dependency in situations that may be handled without a traditional office visit, Urgent Care visit or Emergency Care visit.

See your Summary of Benefits for the member cost share for Telemedicine for primary care office visits and for Mental Disorder and Chemical Dependency visits delivered via Telemedicine.

IDENTITY THEFT PROTECTION SERVICES

As a Member, BCBSNM makes available at no additional cost to you, identity theft protection services, including credit monitoring, fraud detection, credit/identity repair and insurance to help protect your information. These identity theft protection services are currently provided by BCBSNM’s designated outside vendor and acceptance or declination of these services is optional to Member. Members who wish to accept such identity theft protection services will need to individually enroll in the program online at www.bcbsnm.com or telephonically by calling the toll free telephone number on your Identification Card. Services may automatically end when the person is no longer an eligible Member. Services may change or be discontinued at any time with or without notice and BCBSNM does not guarantee that a particular vendor or service will be available at any given time. The services are provided as a convenience and are not considered covered benefits under this benefit program.

CUSTOMER SERVICE

If you have any questions about your coverage, call or e-mail BCBSNM’s Customer Service department. Customer Service Advocates are available Monday through Friday from 6 A.M. - 8 P.M. and 8 A.M. - 5 P.M., Mountain Standard Time on Saturdays and most holidays. If you need assistance outside normal business hours, you may call the Customer Service telephone number and leave a message. A Customer Service Advocate will return your call by 5 P.M. the next business day.

Customer Service: (800) 432-0750 4

Customer Service representatives can help with the following:

answer questions about your benefits assist with Prior Authorization requests check on a Claims status order a replacement ID Card, Provider directory, Benefit Booklet, or forms For your convenience, the toll-free customer service number is printed at the bottom of every page in this Benefit Booklet. Refer to Customer Assistance on the inside cover of this booklet for important phone numbers, website, and mailing information. You can also e-mail the Customer Service unit via the BCBSNM website noted below:

In addition to accepting e-mail inquiries, the BCBSNM website contains valuable information about BCBSNM Provider networks, and other Plan benefits. It also has various forms you can print off that could save you time when you need to file a Claim.

Website: www.bcbsnm.com

Behavioral Health Customer Service When you have questions about your Mental Disorder and Chemical Dependency benefits, call the BCBSNM Behavioral Health Unit (BHU) for assistance.

Toll-free: 1-888-898-0070

Deaf and Speech Disabled Assistance Deaf, hard-of-hearing, and speech disabled callers may use the New Mexico Relay Network. Dialing 711 connects the caller to the state transfer relay service for TTY and voice calls.

Translation Assistance If you need help communicating with BCBSNM, BCBSNM offers Spanish bilingual interpreters for Members who call Customer Service. If you need multilingual services, call the Customer Service phone number on the back of your ID Card.

After Hours Help If you need or want help to file a complaint outside normal business hours, you may call Customer Service. Your call will be answered by an automatic phone system. You can use the system to:

leave a message for BCBSNM to call you back on the next business day leave a message saying you have a complaint or appeal talk to a nurse at the 24/7 Nurseline right away if you have a health problem

24/7 Nurseline If you can’t reach your Doctor, the free 24/7 Nurseline will connect you with a nurse who can help you decide if you need to go to the Emergency room or Urgent Care center, or if you should make an appointment with your Doctor. The Nurseline will also give you advice if you call your Doctor and he or she can’t see you right away when you think you might have an urgent problem. To learn more, call:

Toll-free: 1-800-973-6329 BCBSNM also has a phone library of more than 1000 health topics available through the Nurseline, including over 600 topics available in Spanish.

BLUE ACCESS FOR MEMBERSSM

To help Members track Claim payments, make health care choices, and reduce health care costs, BCBSNM maintains a flexible array of online programs and tools for health care plan Members. The online “Blue Access for Members”

Customer Service: (800) 432-0750 5

(BAM) tool provides convenient and secure access to Claim information and account management features and the Cost Estimator tool. While online, Members can also access a wide range of health and wellness programs and tools, including a health assessment and personalized health updates. To access these online programs, go to www.bcbsnm.com, log into Blue Access for Members and create a user ID and password for instant and secure access.

If you need help accessing the BAM site, call:

BAM Help Desk (toll-free): 1-888-706-0583 Help Desk Hours: Monday through Friday 6 A.M. - 9 P.M., Mountain Standard Time

Saturday 6 A.M. - 2:30 P.M. Mountain Standard Time Note: Depending on your Group’s coverage, you may not have access to all online features. Check with your benefits administrator or call Customer Service at the number on the back of your ID Card. BCBSNM uses data about program usage and Member feedback to make changes to online tools as needed. Therefore, programs and their rules are updated, added, or terminated, and may change without notice as new programs are designed and/or as our Members’ needs change. We encourage you to enroll in BAM and check the online features available to you - and check back in as frequently as you like. BCBSNM is always looking for ways to add value to your health care plan and hope you will find the website helpful.

HEALTH CARE FRAUD INFORMATION

Health care and insurance fraud results in cost increases for health care plans. You can help; always:

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 what your health care insurance will be charged for the tests.

Review the bills from your Providers and the Explanation of Benefits (EOB) you receive from BCBSNM.

Verify that services for all charges were received. If there are any discrepancies, call a BCBSNM Customer Service Advocate.

Be very cautious about giving information about your health care insurance over the phone.

If you suspect fraud, contact the BCBSNM Fraud Hotline at 1-888-841-7998.

Customer Service: (800) 432-0750 6

SECTION 2: ENROLLMENT AND TERMINATION INFORMATION

WHO IS ELIGIBLE

Unless otherwise specified in the Administration Services Agreement, all active employees who have completed the Employee Probationary Period and who are regularly working the minimum number of hours specified in the Administration Services Agreement and their Eligible Family Members are eligible for coverage. (No such probationary period may exceed 90 days unless permitted by applicable laws and rules, including but not limited to statutes, ordinances, judicial decisions and regulations. If BCBSNM records show that your Group has a probationary period that exceeds the time period permitted by applicable laws and rules, including but not limited to statutes, ordinances, judicial decisions and regulations, then BCBSNM reserves the right to begin your coverage on a date that BCBSNM believes is within the required period. Regardless of whether BCBSNM exercises that right, your Group is responsible for your probationary period. If you have questions about your probationary period or the number of hours you must work per week or to learn of any other eligibility criteria specified by your Group, contact your benefits administrator.)

Employers may request coverage for a regular part-time employee expected to work an average of at least 30 hours per week over a six month period. Each employer may choose whether or not to offer health insurance to these part-time employees. Please contact your employer to find out if this optional coverage may affect you. (This optional coverage for part-time employees is not available to temporary or seasonal workers.)

BCBSNM may request proof that a valid employer-employee relationship exists, if applicable, and/or that the applicant meets the eligibility requirements stated in the Administrative Service Agreement and the Members application. The Group also agrees to permit BCBSNM to perform payroll audits.

No eligibility rules or variations in premium will be imposed on you based on your specific health status, medical condition, Claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or any other health status-related factor. You will not be discriminated against for coverage under this Plan on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes, or benefits of this policy that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination.

See “Re-Enrollment” in this section for important information if you or an Eligible Family Member were previously enrolled in a health care plan administered by BCBSNM.

ELIGIBLE FAMILY MEMBERS

Covered family member, covered spouse, covered child - An eligible spouse or Eligible Child (as defined below) who has applied for and been granted coverage under the Subscriber’s policy based on his/her family relationship to the Subscriber.

Eligible Family Members - Family members of the Subscriber, limited to the following persons:

the Subscriber’s legal spouse the Subscriber’s Eligible Child through the end of the month in which the child reaches age 26 (Once a covered child reaches age 26, the child is automatically removed from coverage and rates adjusted accordingly - unless the child is an Eligible Family Member under this Plan due to a disability as described below.)

the Subscriber’s child age 26 or older who was enrolled as the Subscriber’s covered child in this health plan at the time of reaching the age limit, and who is medically certified as disabled, chiefly dependent upon the Subscriber for support and maintenance, and incapable of self-sustaining employment by reason of his/her disability. Such condition must be certified by a Physician and BCBSNM. Also, a child may continue to be eligible for coverage age 26 or older only if the condition began before or during the month in which the child would lose coverage due to his/her age. BCBSNM must receive written notice of the disabling condition within 31 days of the child’s attainment of the limiting age and subsequently, as may

Customer Service: (800) 432-0750 7 be required by BCBSNM, but not more frequently than annually after the two-year period following the child’s attainment of the limiting age of 26.

the Subscriber’s Domestic Partner Eligible Child - The following family members of the Subscriber through the end of the month during which the child turns age 26:

natural or legally adopted child of the Subscriber child placed in the Subscriber’s home for purposes of adoption (including a child for whom the

Subscriber is a party in a suit in which the adoption of the child by the Subscriber is being sought) stepchild of the Subscriber (or otherwise Eligible Child of a Domestic Partner, if Domestic Partners are covered under your benefit plan) child for whom the Subscriber must provide coverage because of a court order or administrative order pursuant to state law A child meeting the criteria above is an “Eligible Child” whether or not the Subscriber is the custodial or noncustodial parent, and whether or not the Eligible Child is claimed on income tax, employed, married, attending school or residing in the Subscriber’s home, except that:

once the Subscriber is no longer a legal guardian of a child or there is no longer a court order to provide coverage to a child, the child must be eligible as a natural child, legally adopted child or stepchild of the Subscriber in order to retain eligibility as a family member under this health plan.

A Domestic Partner is a person of the same or opposite sex who meets all of the following criteria:

shares your permanent residence and has resided with you for no less than one year;

is not less than 18 years of age;

is financially interdependent with you and has proven such interdependence by providing documentation of at least two of the following arrangements: common ownership of real property or a common leasehold interest in such property; community ownership of a motor vehicle; a joint bank account or a joint credit account; designation as a beneficiary for life insurance or retirement benefits or under your partner’s will;

assignment of a durable power of attorney or health care power of attorney; or such other proof as is considered by BCBSNM to be sufficient to establish financial interdependency under the circumstances of your particular case;

is not a blood relative any closer than would prohibit legal marriage; and has signed jointly with you, a notarized affidavit which can be made available to BCBSNM on request.

In addition, you and your Domestic Partner will meet the terms of this definition as long as neither of you nor your Domestic Partner:

has signed a Domestic Partner affidavit or declaration with any other person within 12 months prior to designating each other as Domestic Partners hereunder;

is currently legally married to another person; or has any other Domestic Partner, spouse, or spouse equivalent of the same or opposite sex.

You and your Domestic Partner must have registered as Domestic Partners if you reside in a state that provides for such registration. In any case, if your employer allows coverage for Domestic Partners and their children, BCBSNM will require a notarized Affidavit of Domestic Partnership and at least three corroborating documents:

joint lease/mortgage or ownership of property jointly owned motor vehicle, bank or credit account (only one qualifies) Domestic Partner named as beneficiary of the employee’s life insurance and/or retirement benefits, and/or as primary beneficiary under employees will Domestic Partner assigned as power of attorney or legal designee by the employee both names on a utility bill and/or on an investment account

Customer Service: (800) 432-0750 8

The federal government does not recognize Domestic Partners as qualified Eligible Family Members and therefore, the premium paid for their coverage cannot be pre-tax. In addition, the employee must pay tax on the portion of the premium paid by the employer for the Domestic Partner and his/her covered children. Employees wanting to change benefit elections involving a Domestic Partner must adhere to the same rules regarding qualifying events.

Within 31 days of hire, you must submit all required forms to your benefits administrator. Once you have made an election during your initial enrollment period of 31 days from your date of hire, you are locked into that decision until the next annual open enrollment period.

BCBSNM may require acceptable proof (such as copies of income tax forms, legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Family Member under this coverage. Unless listed as an Eligible Family Member, no other family member, relative or person is eligible for coverage as a family member. Common-law spouses are not considered legal spouses; in order to be considered eligible for coverage, a common-law spouse must meet the definition of “Domestic Partner.”

Information for Noncustodial Parents When a child is covered by the Plan through the child’s noncustodial parent, then County of Bernalillo will:

provide such information to the custodial parent as may be necessary for the child to obtain benefits through the County of Bernalillo Plan;

permit the custodial parent or the Provider (with the custodial parent’s approval) to submit Claims for Covered Services with the approval of the noncustodial parent; and make payments on Claims submitted in accordance with the above provision directly to the custodial parent, the Provider, or the state Medicaid agency as applicable.

MEDICARE-ELIGIBLE MEMBERS

Shortly before you turn age 65 or qualify for Medicare benefits for other reasons, you are responsible for contacting the local Social Security office to establish Medicare eligibility. You should then contact your benefits administrator to discuss coverage options.

If an active employee qualifies under the provisions of federal law for the working aged (TEFRA), then the working employee age 65 or older and/or his/her eligible spouse age 65 or older who is covered by Medicare may continue this Plan coverage as primary over Medicare until the eligible employee retires.

A Member under age 65 receiving Medicare benefits due to disability or End-Stage Renal Disease (ESRD) also has primary benefits under this Plan coverage, but for only a limited period of time. (For ESRD patients, this Plan coverage is primary only during the CMS-defined ESRD coordination time period - usually 30 months after the start of Dialysis. Medicare becomes primary when the Medicare ESRD coordination time period expires.)

In any case, if you are a Medicare beneficiary and you actively select Medicare as your primary coverage, this Plan is not available to you, and your employer may not offer you any other employer-sponsored health care plan.

Refer to a Medicare Handbook or contact the Social Security Administration for more information and eligibility guidelines that apply to you.

APPLYING FOR COVERAGE

An eligible person can apply for coverage, including for his/her Eligible Family Members, by submitting an enrollment/change form to your benefits administrator within 31 days after becoming eligible according to the terms of the Administrative Services Agreement. Note: Your benefits administrator cannot use genetic information or require genetic testing in order to determine or to limit or deny coverage.

WHEN COVERAGE BEGINS

Your benefits administrator will determine your Effective Date of Coverage according to the provisions of the Administrative Services Agreement.

Customer Service: (800) 432-0750 9

This Plan does not cover any service received before your Effective Date of Coverage (which, for Eligible Family Members, may be later than the Subscriber’s effective date). Also, if your prior coverage has an extension of benefits provision, this Plan will not cover those charges incurred after your Effective Date that are covered under the prior benefit plan.

CHANGES TO COVERAGE

After initial enrollment, you may need to add Eligible Family Members to, or remove them from your coverage, update your address, or switch from Individual to Family Coverage, or vice versa.

Your ability to change coverage types (e.g., from Family to Individual coverage, etc.) will depend on the rules and regulations set forth by your employer. Please contact your employer to find out when you can change your coverage type or remove a person from your coverage.

ADDING A FAMILY MEMBER TO COVERAGE

A Subscriber may apply for coverage of an Eligible Family Member (such as a new spouse or a newborn child).

Within 31 days of acquiring the newly Eligible Family Member, the Subscriber must:

request that the employer notify BCBSNM of the change, complete and submit all necessary enrollment/change forms and legal documentation of proof of dependency, and pay any additional premium or other employee contribution for coverage, which may mean changing, for example, from Individual to Family coverage.

Adding a Spouse or a Domestic Partner If a Subscriber adds coverage for a spouse within 31 days of marriage, the effective date of the new Eligible Family Members coverage will be no later than the first of the month following the date your benefits administrator received the completed and signed enrollment/change application form. If the Subscriber does not submit a completed and signed enrollment/change application form to his/her benefits administrator or to BCBSNM (or to the COBRA administrator), along with necessary documentation and, if required, change from Individual (or Employee + Child(ren) coverage, if applicable) to Family coverage within 31 days of marriage, the spouse may not be added to coverage except as a Late Applicant (or as specified under “Special Enrollment” later in this section). You may also have the option of applying for a Two-Person (Employee + Spouse) coverage type. Ask your employer which coverage types are available to you. For example, if you are applying for coverage for a new spouse and his/her Eligible Child(ren), you will have to change to Family coverage. See “Adding an Eligible Child,” below.

Domestic Partners and their Eligible Children may be added to existing coverage only during the annual open enrollment period.

Adding an Eligible Child If you do not submit an application for an Eligible Child or add additional coverage, if required, within the time frames below, the child will be considered a Late Applicant, except as specified under “Special Enrollment.”

Newborn Children You should submit an application to add the newborn as an eligible Child as soon as possible after birth. If Family coverage (or Employee/Children coverage, if available) is in effect, a newborn, natural child is covered from birth. If, for example, Family coverage is not in effect, you must add coverage for the newborn within 31 days of the birth in order for newborn care to be covered beyond day 31, (e.g., If an Employee + Children coverage type is not available to your Group, you would need to switch to Family coverage.). In any case, if the application is not received within 31 days and additional premium or other employee contributions for coverage, if any, are not paid, the newborn is considered a Late Applicant.

Note: If the parent of the newborn is an Eligible Child of the Subscriber (i.e., the newborn is the Subscriber’s grandchild), benefits are not available for the newborn.

Customer Service: (800) 432-0750 10

Adopted Children A child placed in the Subscriber’s home for the purposes of adoption may be added to coverage as soon as the child is placed in the home. However, application for coverage can be made as late as 31 days following legal adoption without being considered late. (Although a child over the age of 18 is not eligible for adoption, an adopted child is covered as any other child, subject to the same Eligible Child age limitations and restrictions.)

Note: An adopted child who is not enrolled within 31 days of adoption or placement in the home will be considered a Late Applicant unless the child was previously enrolled in a Group health plan or other Creditable Coverage within 30 days of his/her adoption or placement for adoption and has had prior Creditable Coverage since that date with no significant lapse (i.e., 63 or more days).

Legal Guardianship Application for coverage must be made for a child for whom the Subscriber or the Subscriber’s spouse becomes the legal guardian within 31 days of the court or administrative order granting guardianship.

Stepchild Application for coverage must be made for a stepchild within 31 days of the marriage to the stepchild’s biological parent.

Court Ordered Coverage for Children When an employee or employer is required by a court or administrative order to provide coverage for an Eligible Child, the Eligible Child may be enrolled in the Subscriber’s Family Coverage, or Employee/Children coverage, if available and will not be considered a Late Applicant. (If the Subscriber has Individual or Two- Person coverage, he/she may be required to pay additional premium in order for the Eligible Child to be added.)

If not specified in the court or administrative order, the Eligible Child’s Effective Date of Coverage will be the date the order has been filed as public record with the State or the effective date of Family Coverage, or Employee/Children coverage, if available, whichever is later. County of Bernalillo must receive a copy of the court or administrative order.

LATE APPLICANT

Unless eligible for a Special Enrollment, applications from the following enrollees will be considered late:

anyone not enrolled within 31 days of becoming eligible for coverage under this Plan (e.g., a newborn child added to coverage more than 31 days after birth when, for example, Family Coverage (or Employee/Children coverage, if available) is not already in effect, a child added more than 31 days after legal adoption, or a new spouse or stepchild added more than 31 days after marriage) anyone enrolling on the Group’s initial BCBSNM enrollment date who was not covered under the Group’s prior plan (but who was eligible for such coverage) anyone eligible but not enrolled during the Group’s initial enrollment anyone who voluntarily terminates his/her coverage and applies for reinstatement of such coverage at a later date (except as a Provider under USERRA of 1994)

OPEN ENROLLMENT

Open enrollment is the period prior to the Group’s anniversary date (ask your employer when your Group’s open enrollment period is held). During the annual open enrollment period, any eligible employee and his/her Eligible Family Members may enroll as Members under this Plan.

SWITCH ENROLLMENT AND CHANGES IN PLAN

If your employer offers employees more than one choice of health plan, your Plan choice can only be changed outside open enrollment if you, as an active employee or Eligible Family Member of an active employee, are eligible for a Special Enrollment. (See “Special Enrollment for Active Employees and Their Eligible Family Members” for details.)

Customer Service: (800) 432-0750 11

During an Open Enrollment Period During an open enrollment period, the Subscriber and his/her Eligible Family Members may change coverage to one of the other health care plans for which the Subscriber meets eligibility requirements. This is the only period of time during which a Member may “voluntarily” change from one health care plan to another for which he/she is eligible.

Outside the Open Enrollment Period If you or your covered family member must change to another health care plan being offered by the employer because of a change in the Subscriber’s residency (i.e., moving outside a BCBSNM service area) or family status (i.e., a Special Enrollment qualifying event), an enrollment/change form must be submitted to County of Bernalillo as soon as possible (or, for continuation Members, the COBRA administrator). Your effective date under the new health plan will be the first of the month following your change in eligibility status. If you are switching to another health plan due to a Special Enrollment, the effective date of change is explained below.

SPECIAL ENROLLMENT FOR ACTIVE EMPLOYEES AND THEIR COVERED FAMILY

MEMBERS

There are four instances (“qualifying events”) in which an eligible person can obtain a “Special Enrollment” right (see definition in Section 10: Definitions). You have a limited amount of time during which you may request a Special Enrollment. If you do not request Special Enrollment within the time period specified below, you will be considered a Late Applicant.

Note: There are no Special Enrollments for persons applying for any continuation coverage if offered under your Plan. You must enroll in these coverages timely.

Qualifying Events The four instances of Special Enrollment are:

Loss of Prior Coverage An eligible employee who declined coverage when initially eligible because of having other comprehensive medical coverage and who later involuntarily loses the other coverage (or who reaches a lifetime maximum under the prior benefit plan), may apply for coverage for himself/herself and Eligible Family Members. (The Eligible Family Members need not have been covered under the prior benefit plan when the employee has been granted a Special Enrollment under this provision.) Currently enrolled employees may also add Eligible Family Members to coverage under this provision if the Eligible Family Member had prior Creditable Coverage that was involuntarily lost or had reached lifetime benefit maximum under the other carrier’s benefit plan. (See definition of “Involuntary Loss of Coverage” in Section 10: Definitions.”) If a completed and signed enrollment/change form is received by the benefits administrator within 31 days of losing the other coverage (or within 31 days of receiving the first denial notice informing the employee or Eligible Family Member that he/she had reached a lifetime limit), the applicant(s) will not be considered late.

Documentation from the prior carrier - supporting the fact that the person had prior Creditable Coverage that was lost involuntarily - may be submitted at a later date with the employer’s approval, but the employee must submit the completed and signed enrollment/change form within 31 days of the loss of coverage (or denial notice). Note: Enrollment changes cannot be processed until all documentation is provided to the benefits administrator.

If the employee lost prior coverage, Special Enrollment is available to the current employee and any Eligible Family Members of the employee (including spouse). If an Eligible Family Member of the current employee lost prior coverage, Special Enrollment is available for the affected Eligible Family Member and the employee (not other Eligible Family Members). The choice to quit paying premiums, for example, because the Subscriber or one family member under the other carrier’s benefit plan reaches a lifetime benefit maximum in not an example of Involuntary Loss of Coverage for the entire family. However, in the case of one Eligible Family Member losing prior coverage, although all family members may not be eligible for a “special” enrollment, Eligible Family Members may be enrolled at the same time as the special enrollee, Customer Service: (800) 432-0750 12 subject to Late Applicant provisions. Also, in order to be eligible for a Special Enrollment due to loss of prior coverage, the declining person must have completed a waiver of coverage statement when first eligible to enroll, and the reason stated for declining coverage must have been due to having other coverage. If an employee requests a Special Enrollment for self only, Eligible Family Member(s) only, or both, BCBSNM requires proof of loss of coverage or proof of the date of the event.

Change in Family Status An employee who acquires a new Eligible Family Member due to marriage, birth, adoption, or placement for adoption may apply for a Special Enrollment in this Plan for himself/herself and other family members who are eligible for coverage under this Plan. Application for Special Enrollment of the employee and his/her Eligible Family Members will not be considered late if submitted within 31 days of the marriage, birth, adoption, or placement of the Eligible Child in the Subscriber’s home. If submitted more than 31 days following the change in family status, Special Enrollment is not available.

Newborn or Adopted Child: For a change in family status due to birth of an eligible newborn or adoption of a child, coverage begins on the date of birth or adoption (or, if earlier, on the date of placement in the Subscriber’s home).

Marriage: The Effective Date of Coverage for all persons granted a Special Enrollment due to marriage will be the same as the new spouse’s Effective Date of Coverage as described under “Adding An Eligible Family Member to Coverage.”

This right to Special Enrollment upon a change in family status applies to the employee and to all Eligible Family Members.

Establishing a new domestic partnership and adding a child to coverage due to a court order are not considered a change in family status for purposes of the “Special Enrollment” provision.

Loss of Medicaid/SCHIP Eligibility If an eligible employee or his/her Eligible Family Member is not currently enrolled in the Plan and loses eligibility under Medicaid or under a State Child Health Plan (SCHIP), the person losing such coverage may enroll in the Plan without being considered a Late Applicant. To be eligible for Special Enrollment, the person must apply for coverage under the Group health plan no later than 60 days after the date of termination of Medicaid or SCHIP coverage. (In order for an Eligible Family Member to be eligible for Special Enrollment, the employee must be covered under the employer Group health plan. If the employee is not enrolled in the Plan when the Eligible Family Member becomes eligible for assistance, the employee must enroll into the Plan at the same time as the Eligible Family Member.) Documentation from the state - supporting the fact that the person had Medicaid/SCHIP coverage that was lost involuntarily - may be submitted at a later date with the employer’s approval, but the employee must submit the completed and signed enrollment/change form within 60 days of the loss of coverage. Note: Enrollment changes cannot be processed until all documentation is provided to the employer.

If the employee lost Medicaid/SCHIP coverage, Special Enrollment is available to the current employee and any Eligible Family Members of the employee (including spouse). If an Eligible Family Member of the current employee lost Medicaid/SCHIP coverage, Special Enrollment is available for the affected Eligible Family Member and the employee (not other Eligible Family Members).

Medicaid/SCHIP Group Health Plan Premium Assistance Eligibility A state may offer premium subsidies through Medicaid or a State Child Health Plan (SCHIP) to low-income children and their families for qualified employer-sponsored coverage. This includes premium assistance for continuation coverage under federal or state law. Therefore, if an eligible employee or an Eligible Family Member is not enrolled in the Plan and later becomes eligible for Group health plan premium assistance under Medicaid or under SCHIP, the eligible person may enroll in the Plan without being considered a Late Applicant.