MEDICA COMPLETEHEALTH

PLAN DOCUMENT

Administered by Medica Self-Insured

DUNN COUNTY WISCONSIN

MEDICA COMPLETEHEALTH

3000-20% HSA

BPL #47874

GROUP #25355

JANUARY 1, 2021

MEDICA CUSTOMER SERVICE

The specific customer service phone number for your plan is found on the back of your ID card.

General Customer Service:

1-877-252-5564 TTY Users: National Relay Center:

711 then ask them to dial Medica at 1-877-252-5564

Find more information about your benefits by logging on to mymedica.com.

©2020 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health services companies that includes Medica Health Plans, Medica Community Health Plan, Medica Insurance Company, Medica Self-Insured, MMSI, Inc. d/b/a Medica Health Plan Solutions, Medica Health Management, LLC and the Medica Foundation.

MSI WI ACO (1/21) DUNN COUNTY WISCONSIN 3000-20% HSA

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Welcome!

We’re glad you’re a covered person under the plan. Health insurance can be complicated. The information found in the pages of this plan can help you better understand your coverage and how it works.

You may need to reference multiple sections to get a complete picture of your coverage and what you will pay when you receive care. If you have more than one service during a visit, you may pay a separate copayment or coinsurance for each service. The most specific section of this plan will apply. Use the Where to Find It section to learn about related benefits when you access common services.

Some terms used have specific meanings.

In this plan, the words “you,” “your” and “yourself” refer to you, the covered person. See the Definitions section at the end of this document for more terms with specific meanings.

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Where to Find It Note: This is a quick guide to some common benefits. For a complete understanding of your coverage, be sure to read any other related sections in this plan.

Do you need… Read section(s):

Immediate medical attention?

• Ambulance Ambulance

• Emergency room Emergency Room Care

• Urgent care Physician and Professional

Services

Quick access to care?

• Convenience care

• Retail health clinic

• Virtual care

• Telemedicine

Physician and Professional Services

Telemedicine Health Services

To visit a provider or clinic?

• Chiropractic care

• Office visit

Physician and Professional Services

Preventive care?

• Immunizations Preventive Health Care

• Physicals

• Women’s preventive services

Prescription drugs or supplies?

• Diabetic equipment and supplies Prescription Drugs

• Outpatient medications

• Preventive medications and products

• Specialty medications Prescription Specialty Drugs

A medical test?

Examples: blood work , ultrasounds

• Genetic testing and counseling Genetic Testing and Counseling

• Lab and pathology services Lab and Pathology

• X-rays, imaging, MRI, CT and PET CT scans X-Rays and Other Imaging

Outpatient surgery?

• Anesthesia services Anesthesia

• Outpatient/ambulatory surgical center services

(facility charge) Hospital Services

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Do you need… Read section(s):

• Physician services (doctor charge) Physician and Professional

Services

Services provided during a hospital stay?

• Anesthesia services Anesthesia

• Hospital services (facility charge) Hospital Services

• Physician services (doctor charge) Physician and Professional

Services

Mental health or behavioral health services?

• Inpatient services Behavioral Health – Mental Health • Office visit

Substance abuse services?

• Inpatient services Behavioral Health – Substance

Abuse • Office visit

Pregnancy care services?

• Breast pumps Durable Medical Equipment, Prosthetics and Medical Supplies

• Inpatient services Pregnancy – Maternity Care

• Postnatal services

• Prenatal services

Medical supplies or equipment?

Examples: crutches, CPAP, wheelchair, oxygen

• Insulin pumps and related supplies Durable Medical Equipment, Prosthetics and Medical Supplies

• Durable medical equipment and medical supplies

• Hearing aids

• Prosthetics

Medical-related dental care?

• Accident-related dental services Medical-Related Dental Services

• Oral surgery

• Treatment of temporomandibular joint (TMJ) and craniomandibular disorder Temporomandibular Joint (TMJ) and Craniomandibular Disorder

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Do you need… Read section(s):

Help recovering?

Example: Help received after a hospital stay, injury or surgery

• Home health care services Home Health Care

• Physical, speech and occupational therapies Physical, Speech and

Occupational Therapies

• Skilled nursing facility services Skilled Nursing Facility

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Table of Contents Table of Contents

Introduction

How you accept coverage If you need language interpretation Medica’s nondiscrimination policy

Plan Overview

General plan information Funding Benefits HIPAA compliance

Before You Access Care

What you must do to receive benefits Provider network Coverage when you travel Prior authorization Standing referrals to non-network providers Visiting non-network providers and why you pay more When do I need to submit a claim Continuity of care

What’s Covered and How Much Will I Pay

Important information about your benefits Key concepts Deductibles, Out-Of-Pocket Maximums and Lifetime Maximum Ambulance Anesthesia Autism Spectrum Disorder Services Behavioral Health – Mental Health Behavioral Health – Substance Abuse Clinical Trials Durable Medical Equipment, Prosthetics and Medical Supplies Emergency Room Care Genetic Testing and Counseling Home Health Care Hospice Services Hospital Services Infertility Diagnosis Kidney Disease Treatment Lab and Pathology Medical-Related Dental Services Physical, Speech and Occupational Therapies Physician and Professional Services Pregnancy – Maternity Care Prescription Drugs Prescription Specialty Drugs Preventive Health Care

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Reconstructive and Restorative Surgery Skilled Nursing Facility Telemedicine Health Services Temporomandibular Joint (TMJ) and Craniomandibular Disorder Transplant Services X-Rays and Other Imaging

What’s Not Covered

What if I Have More Than One Insurance Plan

Coordination for Medicare-eligible individuals When coordination of benefits applies Definitions that apply to this section Order of benefit determination rules Effect on the benefits of this plan Right to receive and release needed information Facility of payment Right of recovery

Right to Subrogation and Reimbursement

Harmful Use of Medical Services

When this applies

How Do I Submit a Claim

Claims for benefits from network providers Claims for benefits from non-network providers Claims for services provided outside the United States Time limits

How Do I File a Complaint

Complaint procedures Grievance procedures Independent review

Who’s Eligible for Coverage and How Do They Enroll

Who can enroll How to enroll Initial enrollment and effective date of coverage Open enrollment and effective date of coverage Special enrollment and effective date of coverage Medical Support Order

When Does My Coverage End and What Are My Options for Continuing Coverage

When your coverage ends Continuing your coverage

How Providers are Paid

Network providers Non-network providers

Additional Terms of Your Coverage

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Definitions

Signature

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Introduction Dunn County Wisconsin (sponsor) has established the Dunn County Employee Medical Plan (plan) through which medical benefits are provided to certain employees and their dependents.

The plan is administered by Dunn County Wisconsin (plan administrator). This plan was originally established January 1, 1985. This restatement of the plan is effective January 1, 2021, unless specifically stated otherwise.

The plan is not an employee welfare benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 (ERISA). The plan is a self-insured medical plan generally intended to meet the requirements of Section 106 and Section 105(h) of the Internal Revenue Code of 1986 (Code) and applicable Wisconsin law.

When changes are made to the plan, the plan administrator will notify enrollees or covered persons as required by law and those individuals will receive a new plan or an amendment to this plan.

This plan defines benefits and describes the health services for which you have coverage and the procedures you must follow to obtain in-network coverage. Coverage is subject to all terms and conditions of the plan. As a condition of coverage under the plan, you must consent to the release and re-release of medical information necessary for the administration of this plan. The confidentiality of such information will be maintained in accordance with existing law.

How you accept coverage

When you accept the health care coverage described in this plan, you, on behalf of yourself and any dependents enrolled under the plan:

1. Authorize the use of your Social Security number for purpose of identification unless otherwise prohibited by state law; and

2. Agree that the information you supplied the plan for purposes of enrollment is accurate and complete.

In addition, you understand and agree that if you intentionally omit or incorrectly state any material facts in connection with your enrollment under the plan, the plan administrator may retroactively cancel your coverage.

Covered persons are subject to all terms and conditions of the plan and health services must meet the definition of “medically necessary” (see Definitions).

Medica may arrange for others to administer services on its behalf, including arrangement of access to a provider network, claims processing and medical necessity reviews. To ensure that your benefits are managed appropriately, please work with these persons or vendors when needed as they conduct their work for Medica.

The sponsor or its designee is responsible for notifying you of any changes to this plan (as required by applicable law).

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If you need language interpretation

Language interpretation services are available to help you understand your benefits under this plan. To request these services, call Customer Service at one of the telephone numbers listed at the front of this plan.

If you need alternative formats, such as Braille or large print, call Customer Service at one of the telephone numbers listed at the front of this plan to request these materials.

If this plan is translated into another language or an alternative format is used, this written English version governs all coverage decisions.

Medica’s nondiscrimination policy

Medica’s policy is to treat all persons alike, without distinctions based on race, color, creed, religion, national origin, gender, marital status, status with regard to public assistance, disability, sexual orientation, age, genetic information or any other classification protected by law.

If you have questions, call Customer Service at one of the telephone numbers listed at the front of this plan.

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Plan Overview The information contained in this section of the plan provides general information regarding the plan. It is important to remember that this section of the plan is only an overview. You also need to refer to the section that describes a particular plan requirement in detail.

General plan information

Plan Name

Dunn County Employee Medical Plan

Sponsoring Employer (Sponsor), Address and Telephone Number of Sponsor

Dunn County Wisconsin 800 Wilson Avenue Menomonie, WI 54751

(715) 232-2429

Plan Administrator, Business Address and Business Telephone Number of Plan Administrator

Dunn County Wisconsin 800 Wilson Avenue Menomonie, WI 54751

(715) 232-2429

Agent for Service of Legal Process

County Manager

Sponsor IRS Employer Identification Number (EIN)

39-6005690

Plan Year

January 1 through December 31

This is also your record keeping year.

Type of Welfare Plan Medical

Type of Administration Self-insured

The sponsor has entered into a service agreement with Medica Self-Insured (Medica) under which Medica performs a variety of administrative services with respect to the medical benefits

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provided under the plan. The agreement is for administrative services only. Medica does not insure the provision of benefits under the plan; Medica is not a health insurer. The plan offers Medica CompleteHealth.

Name and Address of Claims Administrator Medica Self-Insured 401 Carlson Parkway Minnetonka, MN 55305

Funding

Benefits under the plan are paid from the general assets of sponsor. You may be responsible for a portion of the cost of the coverage provided under this plan.

Benefits

Plan benefits are furnished in accordance with this plan, which is issued by the plan administrator. This plan provides an explanation of the benefits offered by the plan. If there is a conflict between any other document and the plan document, the plan document shall govern.

The benefits described in this plan document detail the medical benefits available under the plan. What’s Covered and How Much Will I Pay describes the coinsurance and deductible amounts that impact how much the plan pays and how much you pay. The procedures to be followed in obtaining benefits or presenting claims for benefits under the plan and seeking remedies for redress of claims that are denied in whole or in part are described in this plan.

This plan covers medically necessary health services as described throughout the plan. Please pay particular attention to the benefits that have limitations. Some benefits require that certain things be done first (i.e., prior authorization be obtained). Not following these requirements may impact whether benefits are paid under this plan. Additionally, you consent to the release and re-release of medical information necessary for the administration of this plan as a condition of coverage under this plan. Certain services are specifically excluded from coverage under this plan. The fact that a provider recommends or orders services does not always mean the services are covered or medically necessary. For additional details, see What’s Not Covered.

This plan coordinates the benefits it provides with other coverage and/or other sources of payment. For additional details, see Right to Subrogation and Reimbursement.

HIPAA compliance

This plan will be administered in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all implementing regulations. The HIPAA privacy standards address disclosure to a plan sponsor of protected health information (or PHI). With some exceptions, protected health information or PHI is information that: (i) identifies or could reasonably be used to identify you and (ii) relates to your physical or mental health or condition, the provision of your health care or your payment for health care. The sponsor may use or

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disclose PHI received from the plan or from another party acting on behalf of the plan for certain limited purposes. These include health care operations purposes and health care payment purposes relating to the plan. However, with respect to such PHI, the sponsor agrees as follows:

1. The sponsor will not use or further disclose such PHI other than as permitted or required by this plan or as required by law (as defined in the HIPAA privacy standards).

2. The sponsor will ensure that any agents, including a subcontractor, to whom the sponsor provides PHI received from the plan or from another party acting on behalf of the plan, agree to the same restrictions and conditions that apply to the sponsor with respect to such PHI.

3. The sponsor will not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the sponsor, except under an authorization which meets the requirements of the HIPAA privacy standards.

4. The sponsor will report to the plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which the sponsor becomes aware.

5. The sponsor will make available PHI in accordance with your right of access under the HIPAA privacy standards.

6. The sponsor will make available PHI for amendment and incorporate any amendments to PHI in accordance with the HIPAA privacy standards.

7. The sponsor will make available the information required to provide an accounting of certain disclosures of PHI in accordance with the HIPAA privacy standards.

8. The sponsor will make its internal practices, books and records relating to the use and disclosure of PHI received from the plan or another party on behalf of the plan, available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the plan with the HIPAA privacy standards.

9. If feasible, the sponsor will return or destroy all PHI received from the plan, or another party acting on behalf of the plan, that the sponsor still maintains in any form and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made. If such return or destruction is not feasible, the sponsor will limit further uses and disclosures to those purposes that make the return or destruction of the PHI infeasible.

10. The sponsor will ensure that adequate separation between the plan and the sponsor is established as follows:

a. Only the following persons under control of the sponsor may be given access to the PHI that is disclosed:

HR Director, HR/RM Coordinator, County Manager

b. The access to and use of PHI by the persons described above is restricted to the plan administration functions that the sponsor performs for the plan.

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c. If any of the persons described above do not comply with the above provisions relating to HIPAA compliance, the sponsor will impose sanctions as necessary, in its discretion, to ensure that no further non-compliance occurs. Such sanctions may be imposed progressively (for example, an oral warning, a written warning, time off without pay and termination), if appropriate. Sanctions, when imposed, will be commensurate with the severity of the violation.

11. The HIPAA security standards govern the security of electronic protected health information created, received, maintained or transmitted by the plan. The sponsor agrees as follows:

a. The sponsor will implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the electronic protected health information that it creates, receives, maintains or transmits on behalf of the plan.

b. The sponsor will ensure that the adequate separation required by the HIPAA privacy standard is supported by reasonable and appropriate security measures.

c. The sponsor will ensure that any agent, including a subcontractor, to whom it provides electronic protected health information, agrees to implement reasonable and appropriate security measures to protect the information.

d. The sponsor will report to the plan any security incident of which it becomes aware.

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Before You Access Care This section provides information for you to consider before you access care. More information about when and where to get care can be found at medica.com/membertips.

What you must do to receive benefits

Each time you receive health services, you must:

1. For your highest level of coverage, confirm that your provider is in your plan’s network;

and

2. Present your Medica identification (ID) card. Having and using a Medica ID card does not guarantee coverage.

If your provider asks for your ID card information and you do not provide it within 180 days of when you received services, you may be responsible for paying the full cost of those services.

(Network providers must submit claims within 180 days from when you receive a service.)

It is your responsibility to alert Medica regarding any discounts, coupons, rebates or financial arrangements between you and a provider or manufacturer for health care items or services, prescribed drugs and/or devices. Discounts, coupons, rebates or similar reimbursement provided to you by providers or manufacturers will not satisfy your out-of-pocket cost-sharing responsibilities. Such amounts will not accumulate toward your deductible and out-of-pocket maximum. You can contact Medica by calling the telephone number on your Medica ID card.

Provider network

In-network benefits are available through your plan’s provider network. To see which providers are in your plan’s network, check the online search tool on mymedica.com or contact Customer Service. Certain providers may be in other Medica networks, but not in your network.

Additional network administrative support is provided by one or more organizations under contract with Medica.

While a particular provider may be in your provider directory at the time you enroll, it is not guaranteed that this provider will be available to provide you with health services or will remain a network provider.

If you access services from providers that are not in your network, your out-of-network benefits will apply. For more information about out-of-network care, see the tip sheet at medica.com/membertips.

NOTICE: LIMITED BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS

ARE USED. You should be aware that when you elect to utilize the services of a nonparticipating provider for a covered service, benefit payments to such nonparticipating provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy’s fee schedule, usual and customary charge (which is determined by comparing charges for similar services

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adjusted to the geographical area where the services are performed) or other method as defined by the policy. YOU RISK PAYING MORE THAN THE COINSURANCE, DEDUCTIBLE AND COPAYMENT AMOUNT DEFINED IN THE POLICY AFTER THE PLAN

HAS PAID ITS REQUIRED PORTION. Nonparticipating providers may bill enrollees for any amount up to the billed charge after the plan has paid its portion of the bill.

Participating providers have agreed to accept discounted payment for covered services with no additional billing to the enrollee other than copayment, coinsurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll free telephone number on your identification card.

Coverage when you travel

When you travel outside the Medica service area (Minnesota, North Dakota, South Dakota and western Wisconsin), you can get coverage at the in-network benefit level by visiting a provider in the travel program network. Travel coverage is subject to all of the terms and conditions described in this plan.

When you see a provider in the travel network, simply show your Medica ID card. If you have a deductible or coinsurance, it will apply. Travel network providers will file claims for you. To find a provider in the travel network, log on to mymedica.com.

Certain services are not included in the travel program (i.e., chiropractic services) or may not be available in all areas. If you receive these services outside the Medica service area, your out-of-network benefits will apply.

Prior authorization

You may need prior authorization (approval in advance) from Medica before you receive certain services or supplies, even if a provider has directed or recommended that you receive them.

When reviewing your request for prior authorization, Medica uses written procedures and criteria to determine whether a particular service or supply is medically necessary and is a covered benefit. This applies even when the services are provided by a network provider or provided as the result of a referral or direction by a network provider. To verify whether a specific service or supply requires prior authorization, please call Customer Service at one of the telephone numbers listed at the front of this plan.

Emergency services do not require prior authorization.

You do not require prior authorization to obtain access to obstetrical or gynecological care from a network provider who specializes in obstetrics or gynecology. However, certain specific services provided by that network provider may require prior authorization, as described further in this plan.

You, someone on your behalf or your attending provider may contact Customer Service to request prior authorization. Your network provider will contact Medica to request prior authorization for a service or supply. If a network provider fails to request prior authorization

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after you have consulted with them about services requiring prior authorization, you will not be penalized for this failure.

You must contact Customer Service to request prior authorization for services or supplies received from a non-network provider.

We recommend that you confirm with us that all services and supplies requiring prior authorization, including those received from a network provider, have been prior authorized by Medica. You may contact Customer Service for this confirmation.

Prior authorization is required for the following services and supplies, as described below and in the sections of this plan that discuss the applicable benefit:

• Solid organ and blood and marrow transplant services - this prior authorization must be obtained before the transplant workup is initiated;

• In-network benefits for services from non-network providers, with the exception of emergency services;

• Certain reconstructive or restorative surgery procedures;

• Certain drugs, biologics and biosimilars;

• Certain home health care services;

• Certain medical supplies and durable medical equipment;

• Certain outpatient surgical procedures;

• Certain genetic tests;

• Certain imaging services;

• Non-emergency licensed air ambulance transportation; and

• Skilled nursing facility services.

Pregnancy/maternity care services do not require prior authorization and will be covered at the appropriate in-network or out-of-network benefit level.

This is not a complete list of all services and supplies that may require prior authorization.

When you, someone on your behalf or your attending provider calls, the following information may be required:

• Name and telephone number of the provider making the request;

• Name, telephone number, address and, if applicable, the type of specialty of the provider to whom you are being referred;

• Services being requested and the date those services are to be provided (if scheduled);

• Specific information related to your condition (for example, a letter of medical necessity from your provider); and

• Other applicable covered person information (i.e., Medica identification number).

Medica will review your request for prior authorization and respond to you and your attending provider within a reasonable period of time appropriate to your medical circumstances. Medica will generally respond within 5 business days of the date your request was received if your request is for an experimental procedure and within 10 business days after the date your

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request was received for all other requests, provided all information reasonably necessary to make a decision has been given to Medica.

However, Medica will respond within a time period not exceeding 72 hours from the time of the initial request if:

• your attending provider believes that an expedited review is warranted; or

• if it is concluded that a delay could seriously jeopardize your life, health or ability to regain maximum function; or

• you could be subject to severe pain that cannot be adequately managed without the care or treatment you are requesting.

If we do not approve your request for prior authorization, you have the right to appeal Medica’s decision as described in How Do I File a Complaint.

Under certain circumstances, Medica may conduct concurrent reviews to verify whether services are still medically necessary. If we conclude that services are no longer medically necessary, Medica will advise both you and your attending provider in writing of our decision. If we do not approve continuing coverage, you or your attending provider may appeal our initial decision (see How Do I File a Complaint).

Standing referrals to non-network providers

A standing referral is a referral issued by a network provider for conditions that require ongoing services from a specialist provider. Standing referrals to non-network providers are available if the services you need are not reasonably available from a network provider. In this situation, in-network benefits will apply to the services described in the referral. Standing referrals will only be provided for the period of time appropriate to your medical condition.

You may apply for and, if appropriate, receive a standing referral for: a chronic health condition;

a life threatening mental or physical illness; pregnancy beyond the first trimester; a degenerative disease or disability; or any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist provider.

Standing referrals will not be issued to accommodate personal preferences, family convenience or other non-medical reasons.

If your request for a standing referral is denied, you have the right to appeal this decision as described in How Do I File a Complaint.

Visiting non-network providers and why you pay more

In general, eligible health services and supplies are only covered as in-network benefits if they’re provided by network providers, provided by a non-network provider to whom you were specifically directed by a network provider or if Medica approves them.

In the event your network provider directs you to a non-network provider, for example, a non-network hospital or ambulatory surgical center, you must ensure your network provider has

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submitted a care direction form to Medica prior to you receiving care in order to ensure you get the highest level of benefits. If Medica does not receive a care direction form from your network provider prior to you receiving care, the benefits may be considered out-of-network benefits.

If the care you need is not available from a network provider, Medica may authorize non-network provider services at the in-network benefit level.

Be aware that if you use out-of-network benefits, you will likely have to pay much more than if you use in-network benefits. The amounts billed by the non-network provider may be more than what the plan would pay, leaving a balance for you to pay in addition to any coinsurance and deductible amount you owe. This additional amount you must pay the provider will not be counted toward your out-of-pocket maximum amount. You will owe this amount whether or not you previously reached your out-of-pocket maximum. Please see the example calculation below.

It is important that you do the following before receiving services from a non-network provider:

• Discuss with the non-network provider what the bill is expected to be; and

• Contact Customer Service to verify the estimated amount the plan would pay for those services; and

• Calculate your likely share of the costs.

An example of how to calculate your out-of-pocket costs*

Example:

You choose to receive inpatient care (not an emergency) at a non-network hospital without having been specifically directed there by a network provider or having an authorization from Medica. Your out-of-network benefits apply to these services.

Assumptions:

1. You have previously fulfilled your deductible.

2. The non-network hospital bills $30,000 for your hospital stay.

3. The plan’s non-network provider reimbursement amount for those hospital services is $15,000.

a. You must pay a portion of this amount, generally a percentage coinsurance. In this example, we will use 40% coinsurance.

b. In addition, the non-network provider will likely bill you for the difference between what they charge and the amount that the plan pays them.

For this non-network hospital stay, you will be required to pay:

40% coinsurance (40% of $15,000 = $6,000), and

The provider’s billed amount that exceeds the non-network provider reimbursement amount ($30,000 - $15,000 = $15,000)

Therefore, the total amount you will owe is $6,000 + $15,000 = $21,000.

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The $6,000 amount you pay as coinsurance will be applied to your out-of-pocket maximum.

The $15,000 amount you pay for billed amounts in excess of the non-network provider reimbursement amount will not be applied toward your out-of-pocket maximum.

You will owe the provider this $15,000 amount whether or not you have previously reached your out-of-pocket maximum.

*Note: The numbers in this example are used only for purposes of illustrating how out-of-network benefits are calculated. The actual numbers will depend on the services you receive.

For more information about out-of-network care, see the tip sheet at medica.com/membertips.

When do I need to submit a claim

When you visit non-network providers, you will be responsible for filing claims in order to be reimbursed for the non-network provider reimbursement amount. See How Do I Submit a Claim for details.

Continuity of care

In certain situations, you have a right to continuity of care. To request this, or if you have questions about how this may apply to you, call Customer Service at one of the telephone numbers listed at the front of this plan.

In-network benefits will continue to apply to health services you received from a provider who terminates his/her participation with Medica if that provider was listed as a network provider in the provider directory at your last enrollment period or your last coverage renewal period, for the following periods of time:

1. For health services received from a primary care physician whom you have chosen to receive services from and who is no longer a network provider, until the end of your current plan year as stated in your plan.

2. For health services received from any other type of provider whom you have chosen to receive services from and who is no longer a network provider, for the remainder of your course of treatment for which care was being received at the time of termination or for 90 days after such provider’s participation terminates, whichever is less, provided it does not extend beyond the end of your current plan year as stated in your plan.

3. If your course of treatment is maternity care and you are in the second or third trimester of pregnancy, health services may be continued to be provided by the terminated provider through the completion of postpartum care.

In-network benefits will not continue to be applied to health services you receive from a provider:

1. Whose contract is terminated for misconduct on the part of the provider; or

2. Who is no longer practicing in Medica’s geographic service area.

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If Medica terminates your current provider’s contract for cause, we will inform you of the change and how your care will be transferred to another network provider.

Coverage will not be provided for services or treatments that are not otherwise covered under the plan.

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What’s Covered and How Much Will I Pay This section describes the services eligible for coverage and any expenses that you will need to pay.

Important information about your benefits

• Before you receive certain services or supplies, you will need to get prior authorization from Medica, even if a provider has directed or recommended that you receive them. To find out when you need to do this, see What to keep in mind after each benefit section or call Customer Service at one of the telephone numbers listed at the front of this plan. Also refer to Before You Access Care for more information about the prior authorization process.

• When you use out-of-network benefits, in addition to the deductible and coinsurance, you will likely need to pay your provider any billed amount above what the plan pays the provider (the non-network provider reimbursement amount). These charges are not applied to your deductible or out-of-pocket maximum. Please see Visiting non-network providers and why you pay more in Before You Access Care for more information and an example showing out-of-pocket costs associated with out-of-network benefits.

• Certain benefits in this plan have limits. These limits might include day limits, visit limits or dollar limits. These limits are noted in this plan and apply whether or not you have met your deductible.

Key concepts

Deductibles Your plan may require that you pay a certain dollar amount before your plan starts to pay. This amount is called a deductible. Please note that amounts reimbursed or paid by a provider or manufacturer, including manufacturer coupons, rebates, coupon cards, debit cards or other forms of reimbursement or payment on your behalf for a product or service, will not apply toward your deductible.

The table below shows whether your plan has a deductible, how much it is and whether you have separate deductibles for each family member or a combined deductible for everyone.

Each benefit table in this plan shows whether the deductible applies to a particular service.

For more information about deductibles and other common cost-sharing terms, see the tip sheet at medica.com/membertips.

Out-of-pocket maximum

Your out-of-pocket maximum is an accumulation of coinsurance and deductibles that you paid for benefits received during the calendar year. Unless otherwise noted, you won’t have to pay more than this amount. Amounts reimbursed or paid by a provider or manufacturer, including

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manufacturer coupons, rebates, coupon cards, debit cards or other forms of reimbursement or payment on your behalf for a product or service, will not apply toward your out-of-pocket maximum.

Please note: The following amounts do not apply toward your out-of-pocket maximum:

• Charges for services that aren’t covered; and

• Charges a non-network provider bills you that are more than the non-network provider reimbursement amount; and

• Charges you pay in addition to your deductible or coinsurance when you choose to use a preferred brand or non-preferred brand prescription drug when a chemically equivalent generic drug is available.

You will owe these amounts even if you have already reached your out-of-pocket maximum.

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DEDUCTIBLES, OUT-OF-POCKET MAXIMUMS AND LIFETIME MAXIMUM

Deductibles, Out-Of-Pocket Maximums and Lifetime Maximum

Your cost if you visit a:

Network provider: Non-network provider:

Coinsurance See specific benefit for applicable coinsurance.

Deductible

Per covered person $3,000 $6,000

Per family $6,000 $12,000

The deductible is the amount you must pay for eligible services each calendar year before the plan will begin to pay claims. If you have family members on the plan, you will each have to meet your own individual deductible before receiving benefits, unless the family deductible is met. Once the family deductible has been met, the plan will pay benefits for all covered family members.

Please note amounts reimbursed or paid by a provider or manufacturer, including manufacturer coupons, rebates, coupon cards, debit cards or other forms of reimbursement or payment on your behalf for a product or service, will not apply toward your deductible.

Out-of-pocket maximum

Per covered person $6,000 $12,000

Per family $12,000 $24,000

This plan has both a per covered person out-of-pocket maximum and a per family out-of-pocket maximum. The per covered person out-of-pocket maximum applies individually to each family member until the family out-of-pocket maximum is met. Coinsurance and deductibles paid by each covered family member for covered benefits for the calendar year count toward the individual’s annual per covered person out-of-pocket maximum and toward the annual per family out-of-pocket maximum.

Please note amounts reimbursed or paid by a provider or manufacturer, including manufacturer coupons, rebates, coupon cards, debit cards or other forms of reimbursement or payment on your behalf for a product or service, will not apply toward your out-of-pocket maximum.

Lifetime maximum amount the plan will pay per covered person

Unlimited Unlimited

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AMBULANCE

Ambulance

Your cost if you visit a:

Benefits Network provider: Non-network provider:

1. Emergency ambulance services or emergency ambulance transportation

20% coinsurance after deductible

Covered as an in-network benefit.

2. Non-emergency licensed ambulance service that is arranged through an attending physician, as follows:

20% coinsurance after deductible

40% coinsurance after deductible

a. Transportation from hospital to hospital when:

i. Care for your condition is not available at the hospital where you were first admitted; or

ii. Required by Medica

b. Transportation from hospital to skilled nursing facility

What’s covered

Covered non-emergency licensed ambulance transportation services are eligible for in-network coverage when services are:

1. Provided by a network provider; or

2. Provided by a non-network provider to whom you have been specifically directed by a network provider.

When you use out-of-network benefits, in addition to the deductible and coinsurance, you will likely need to pay your provider any billed amount above what the plan pays the provider (the

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non-network provider reimbursement amount). These charges are not applied to your deductible or out-of-pocket maximum. Please see Visiting non-network providers and why you pay more in Before You Access Care for more information and an example showing out-of-pocket costs associated with out-of-network benefits.

What to keep in mind

Ambulance services for an emergency are covered when provided by a licensed ambulance service. If you are taken to a non-network hospital, only emergency health services at that hospital are covered as described in Emergency Room Care.

Non-emergency ambulance transportation that’s arranged through an attending physician is eligible for coverage when certain criteria are met. Prior authorization (approval in advance) is required before you receive non-emergency licensed air ambulance transportation.

What’s not covered

1. Ambulance transportation to another hospital when care for your condition is available at the network hospital where you were first admitted.

2. Non-emergency ambulance transportation services, except as described above.

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ANESTHESIA

Anesthesia

Your cost if you visit a:

Benefits Network provider: Non-network provider:

1. Anesthesia services received during an office visit

20% coinsurance after deductible

40% coinsurance after deductible

2. Anesthesia services received during an outpatient hospital or ambulatory surgical center visit

20% coinsurance after deductible

40% coinsurance after deductible

3. Anesthesia services received during an inpatient stay

20% coinsurance after deductible

40% coinsurance after deductible

What to keep in mind

Anesthesia services can be received from a provider during an office visit, an outpatient hospital visit, an ambulatory surgical center visit or during an inpatient stay.

Anesthesia services ordered or prescribed by a physician will be covered as in-network benefits if they are:

1. Received from a network provider; or

2. Received from a non-network provider to whom you have been specifically directed by a network provider.

When you use out-of-network benefits, in addition to the deductible and coinsurance, you will likely need to pay your provider any billed amount above what the plan pays the provider (the non-network provider reimbursement amount). These charges are not applied to your deductible or out-of-pocket maximum. Please see Visiting non-network providers and why you pay more in Before You Access Care for more information and an example showing out-of-pocket costs associated with out-of-network benefits.

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AUTISM SPECTRUM DISORDER SERVICES

Autism Spectrum Disorder Services

Your cost if you visit a:

Benefits Network provider: Non-network provider:

1. Intensive-level services for the treatment of autism spectrum disorders provided to a covered person who:

20% coinsurance after deductible

40% coinsurance after deductible

a. Has a primary verified diagnosis of autism spectrum disorder;

b. Commences intensive-level services after the age of two and before the age of nine;

c. Has a treatment plan developed by a qualified provider that includes at least 20 hours per week over a six-month time period with specific cognitive, social, communicative, self-care or behavioral goals that are clearly defined, directly observed, continually measured and address the characteristics of autism spectrum disorder;

d. Is present and engaged in the intervention;

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Autism Spectrum Disorder Services

Your cost if you visit a:

Benefits Network provider: Non-network provider:

e. Has a parent or legal guardian who is present and engaged during the majority of the treatment;

f. Is provided evidence-based behavioral intensive therapy, treatment and services in an environment conducive to achieving the treatment plan goals;

g. Is treated only by qualified providers, supervising providers, professionals, therapists or paraprofessionals;

h. Is directly observed by the qualified provider at least once every two months, or as required by your plan’s designated disorder provider

Evidence-based behavioral therapy that was provided to the child for an average of 20 or more hours per week over a continuous six-month period is considered intensive-level services.

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Autism Spectrum Disorder Services

Your cost if you visit a:

Benefits Network provider: Non-network provider:

2. Nonintensive level services for the treatment of autism spectrum disorders provided to a covered person who:

20% coinsurance after deductible

40% coinsurance after deductible

a. Has a primary verified diagnosis of autism spectrum disorder;

b. Has completed intensive-level services for the treatment of autism spectrum disorder or has not and will not receive intensive-level services, but for whom nonintensive level services will improve the covered person’s condition;

c. Has a treatment plan developed by a qualified provider, supervising provider, professional or therapist that includes specific therapy goals that are clearly defined, directly observed and continually measured and that address the characteristics of disorders;

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Autism Spectrum Disorder Services

Your cost if you visit a:

Benefits Network provider: Non-network provider:

d. Is present and engaged in the intervention;

e. Is provided treatment and services by qualified providers, supervising providers, professionals, therapists or paraprofessionals in an environment most conducive to achieving the goals of the treatment plan;

f. The covered person’s family is actively involved in team meetings and is provided training and consultation to implement the therapeutic goals of the treatment team.

What’s covered

Services to diagnose and treat autism spectrum disorders are covered.

Autism spectrum disorder services will be covered as in-network benefits if they are:

1. Received from a network provider; or

2. Received from a non-network provider to whom you have been specifically directed by a network provider.

When you use out-of-network benefits, in addition to the deductible and coinsurance, you will likely need to pay your provider any billed amount above what the plan pays the provider (the non-network provider reimbursement amount). These charges are not applied to your deductible or out-of-pocket maximum. Please see Visiting non-network providers and

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What to keep in mind

Your plan’s designated autism spectrum disorder provider arranges in-network autism spectrum disorder benefits and will refer you to other autism spectrum disorder providers only if network providers cannot provide the services you require. Call your plan’s designated autism spectrum disorder provider at 1-800-848-8327 or TTY users, please contact: National Relay Center 711, then ask them to dial Medica Behavioral Health at 1-866-567-0550.

Medica requires prior authorization (approval in advance) before you receive certain autism spectrum disorder services. To determine if Medica requires prior authorization for a particular service or treatment, please call your plan’s designated mental health and substance abuse provider at 1-800-848-8327 or TTY users, please contact: National Relay Center 711, then ask them to dial Medica Behavioral Health at 1-866-567-0550. Please see Prior authorization in Before You Access Care for more information about prior authorization requirements and processes.

The following definitions apply for purposes of autism spectrum disorder services:

• “Autism spectrum disorder” means autism disorder, Asperger’s syndrome or pervasive development disorder not otherwise specified.

• “Intensive-level services” means evidence-based behavioral therapies that are directly based on, and related to, an individual’s therapeutic goals and skills as prescribed by a physician familiar with the individual. Intensive-level services may include evidence-based speech therapy and occupational therapy provided by a qualified therapist when such therapy is based on, or related to, an individual’s therapeutic goals and skills and is concomitant with evidence-based behavioral therapy. Coverage for speech therapy and occupational therapy is described in Physical, Speech and Occupational Therapies.

• “Nonintensive level services” means evidence-based therapy that occurs after the completion of treatment for intensive-level services or for an individual who has not and will not receive intensive-level services, evidence-based therapy that will improve the individual’s condition.

• “Qualified provider,” “qualified paraprofessional,” “qualified professional,” “qualified supervising provider,” “qualified intensive-level provider,” “qualified intensive-level professional” and “qualified therapist” have the meanings set forth in Ins. 3.36 Wis. Admin.

Code.

For in-network benefits:

• Your plan’s designated autism spectrum disorder provider arranges in-network autism spectrum disorder benefits.