Ext 9.FA5 Evidence of Coverage (MDOT MTA PPO) 2025.8.9.pdf

Maryland Transit Administration Preferred Provider Option

Exhibit 9 – FA5 Evidence of Coverage ~ PPO

Table of Contents

DEFINITIONS 4

ELIGIBILITY AND ENROLLMENT 15

MEDICAL CHILD SUPPORT ORDERS 20

TERMINATION OF COVERAGE 22

CONTINUATION OF COVERAGE 23

COORDINATION OF BENEFITS; SUBROGATION 25

HOW THE PLAN WORKS 31

REFERRALS 37

UTILIZATION MANAGEMENT REQUIREMENTS 39

INTER-PLAN ARRANGEMENTS DISCLOSURE 45

INTER-PLAN PROGRAMS ANCILLARY SERVICES 48

BENEFITS FOR MEMBERS ENTITLED TO MEDICARE 49

DESCRIPTION OF COVERED SERVICES 52

EXCLUSIONS 85

ELIGIBILITY SCHEDULE 93

SCHEDULE OF BENEFITS 98

ADDITIONAL COVERED SERVICES AND PROGRAMS ADDENDUM 120

CLAIMS PROCEDURES 124

COVID-19 AMENDMENT 142

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DEFINITIONS

The Evidence of Coverage uses certain defined terms. When these terms are capitalized, they have the following meaning:

Air Ambulance Service means medical transport of Members by a rotary wing air ambulance, as defined in 42 C.F.R. 414.605, or fixed wing air ambulance, as defined in 42 C.F.R. 414.605.

All-Payer Model Agreement means an agreement between the Centers for Medicare & Medicaid Services (CMS) and a state to test and operate systems of all-payer payment reform for the medical care of residents of the particular state, under the authority granted under section 1115A the Social Security Act.

Allowed Benefit means:

1.

2.

Preferred Health Care Providers: For a Health Care Provider that is a Preferred Health Care Provider, the Allowed Benefit for a Covered Service is the lesser of the actual charge which, in some cases, will be a rate set by a regulatory agency; or the amount Contractor allows for the service in effect on the date that the service is rendered. The benefit is payable to the Health Care Provider and is accepted as payment in full, except for any applicable Member payment amounts, as stated in the Schedule of Benefits.

Non-Preferred Health Care Providers:

a.

b.

c.

d.

For Emergency Services, the Allowed Benefit for a Covered Service is the Recognized Amount. The benefit is payable to the Non-Preferred Health Care Provider. Additionally, the Member is responsible for any applicable Member payment amounts, as stated in the Schedule of Benefits.

For Non-Emergency Services performed by Non-Preferred Providers at Preferred Health Care facilities (including Ancillary Services and services for unforeseen urgent medical needs), the Allowed Benefit for a Covered Service is the Recognized Amount. The benefit is payable to the Non-Preferred Health Care Provider. Additionally, the Member is responsible for any applicable Member payment amounts, as stated in the Schedule of Benefits.

For Non-Preferred Health Care Providers of Air Ambulance Services, the Allowed Benefit is the lesser of the provider’s actual charge or the Qualifying Payment Amount.

The benefit is payable to the Non-Preferred Health Care Provider. Additionally, the Member is responsible for any applicable Member payment amounts, as stated in the Schedule of Benefits.

For all other Covered Services provided by:

1)

2)

A health care practitioner that is a Non-Preferred Health Care Provider, the Allowed Benefit for a Covered Service is a negotiated rate or an amount based upon the lesser of the provider’s actual charge or established fee schedule which, in some cases, will be a rate specified by applicable law. The benefit is payable to the Subscriber or to the health care practitioner, at the discretion of Contractor.

If Contractor pays the Subscriber, it is the Member’s responsibility to pay the health care practitioner. Additionally, the Member is responsible for any applicable Member payment amounts, as stated in the Schedule of Benefits, and for the difference between the Allowed Benefit and the health care practitioner’s actual charge.

A hospital or health care facility that is a Non-Preferred Health Care Provider, the Allowed Benefit for a Covered Service is a negotiated rate or an amount

3.

based upon the lower of the provider’s actual charge or established fee schedule, which, in some cases, will be a rate specified by applicable law. In some cases, and on an individual basis, Contractor is able to negotiate a lower rate with an eligible provider. In that instance, the Contractor payment will be based on the negotiated fee and the provider agrees to accept the amount as payment in full except for any applicable Member payment amounts, as stated in the Schedule of Benefits. The benefit is payable to the Subscriber or to the hospital or health care facility, at the discretion of Contractor. Benefit payments to United States Department of Defense and United States Department of Veteran Affairs providers will be made directly to the provider. If Contractor pays the Subscriber, it is the Member’s responsibility to pay the hospital or health care facility.

Additionally, the Member is responsible for any applicable Member payment amounts, as stated in the Schedule of Benefits and, unless negotiated, for the difference between the Allowed Benefit and the hospital or health care facility's actual charge.

Outside of the Service Area, for a Health Care Provider that has contracted with a Contractor, the Allowed Benefit is calculated as stated in the Inter-Plan Arrangements Disclosure section of this Evidence of Coverage.

Adverse Decision means a utilization review determination that a proposed or delivered health care service covered under the Claimant’s contract is or was not Medically Necessary, appropriate, or efficient; and may result in non-coverage of the health care service.

Ancillary Services means facility services that may be rendered on an inpatient and/or outpatient basis.

These services include, but are not limited to:

4.

5.

Items and services furnished by a Non-Participating Health Care Provider in Participating Health Care facility related to emergency medicine, anesthesiology, pathology, radiology, and neonatology.

Items and services provided by health care practitioners.

Diagnostic services, including radiology and laboratory services.

Items and services provided by a Non-Participating Health Care Provider if there is no Participating Health Care Provider who can provide the services to the Member within the health care facility.

Other facility-based services like operating room services, incremental nursing services, blood administration and handling, pharmaceutical services, Durable Medical Equipment and Medical Supplies.

Ancillary Services do not include room and board services billed by a facility for inpatient care.

Balance Bill or Balance Billing means the difference between the Non-Preferred Health Care Provider’s actual charge for a Covered Service and the Allowed Benefit.

Applied Behavior Analysis means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

Authorized Representative means an individual authorized by law to provide consent on behalf of the Member, provided that the individual is not a Health Care Provider affiliated with the health care facility or an employee of the health care facility, unless the Health Care Provider or employee is a family member of the Member.

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Benefit Period means the period of time during which Covered Services are eligible for payment. The Benefit Period is: January 1st through December 31st.

Cardiac Rehabilitation means inpatient or outpatient services designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction, control cardiac symptoms, stabilize or reverse atherosclerotic process and enhance the psychosocial and vocational status of Eligible Members.

Claims Administrator means Contractor.

Coinsurance means the percentage of the Allowed Benefit allocated between Contractor and the Member whereby Contractor and the Member share in the payment for Covered Services.

Contracted Health Care Provider means, for purposes of the Inter-Plan Ancillary Services section of this Evidence of Coverage, a Health Care Provider that has contracted with the local Licensee (not Contractor) and provides Ancillary Services to the Member outside of the Contractor Service Area, as stated in the Inter-Plan Ancillary Services section.

Convenience Item means any item that increases physical comfort or convenience without serving a Medically Necessary purpose (e.g., elevators, hoyer/stair lifts, ramps, shower/bath bench, items available without a prescription).

Convenience Care means services provided at a Retail Health Clinic. Convenience Care are non- Emergency/non-Urgent Care services for the treatment of common ailments (e.g., ear, bladder, and sinus infections; pink eye; flu; and strep throat).

Copayment (Copay) means a fixed dollar amount that a Member must pay for certain Covered Services.

When a Member receives multiple services on the same day by the same Health Care Provider, the Member will only be responsible for one Copay.

Cosmetic means the use of a service or supply which is provided with the primary intent of improving appearance, not restoring bodily function or correcting deformity resulting from disease, trauma, or previous therapeutic intervention, as determined by Contractor.

Covered Service means a Medically Necessary service or supply provided in accordance with the terms of this Evidence of Coverage.

Deductible means the dollar amount of Covered Services based on the Allowed Benefit, which must be Incurred before Contractor will pay for all or part of remaining Covered Services. The Deductible is met when the Member receives Covered Services that are subject to the Deductible and pays for these him/herself.

Dependent means a Member other than the Subscriber, meeting the eligibility requirements established by the Group, who is covered under this Evidence of Coverage.

Dependent includes a child who has not attained the Limiting Age stated in the Eligibility Schedule irrespective of the child’s:

1.

2.

Financial dependency on an individual covered under this Evidence of Coverage;

Marital status;

Residency with an individual covered under this Evidence of Coverage;

Student status;

5. Employment; or

6. Satisfaction of any combination of the above factors.

Diabetes Supplies means Medical Supplies prescribed by a Health Care Provider for the treatment of diabetes.

Effective Date means the date on which the Member’s coverage becomes effective. Covered Services rendered on or after the Member’s Effective Date are eligible for coverage.

Emergency Facility means:

1.

An emergency department of a hospital;

An Independent Freestanding Emergency Department; or

For purposes of covered post-stabilization Emergency Services, as described in this Evidence of overage, provided by Non-Preferred Health Care Providers, a hospital (regardless of the department of the hospital where the post-stabilization services are provided to the Member).

Emergency Medical Condition means a medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

Serious impairment to bodily functions; or

Serious dysfunction of any bodily organ or part.

Emergency Services means, with respect to an Emergency Medical Condition:

A medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd, or as would be required under such section if such section applied to an Independent Freestanding Emergency Department) that is within the capability of the emergency department of a hospital, as applicable, including Ancillary Services routinely available to the emergency department to evaluate such Emergency Medical Condition;

Any such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital or the Independent Freestanding Emergency Department, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd) to stabilize the Member, regardless of the department of the hospital in which such further examination or treatment is furnished to the Member. The term “to stabilize” with respect to an Emergency Medical Condition, means to provide such medical treatment of the Emergency Medical Condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the Member from a facility; and

Post-stabilization services (i.e., services provided after the Member has been stabilized, as part of outpatient observation, or an inpatient or outpatient stay related to the Emergency Services provided, as described above) as described in the Description of Covered Services of this Evidence of Coverage.

Essential Health Benefits has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act and as further defined by the Secretary of the United States Department of Health

7 Maryland Transit Administration and Human Services and includes ambulatory patient services; emergency services; hospitalization;

maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Evidence of Coverage means this agreement, which includes the acceptance, riders and amendments, if any, between the Group and Contractor (also referred to as the Group Contract).

Experimental/Investigational means a service or supply that is in the developmental stage and in the process of human or animal testing excluding Controlled Clinical Trial Patient Cost Coverage as stated in the Description of Covered Services. Services or supplies that do not meet all five of the criteria listed below are deemed to be Experimental/Investigational:

The Technology* must have final approval from the appropriate government regulatory bodies;

The scientific evidence must permit conclusions concerning the effect of the Technology on health outcomes;

The Technology must improve the net health outcome;

The Technology must be as beneficial as any established alternatives; and

The improvement must be attainable outside the Investigational settings.

*Technology includes drugs, devices, processes, systems, or techniques.

FDA means the U.S. Food and Drug Administration.

Fertility Awareness–Based Methods means methods of identifying times of fertility and infertility by an individual to avoid pregnancy including:

1.

2.

Cervical mucus methods;

Symptom-thermal or symptom-hormonal methods;

The standard days method; and, The lactational amenorrhea method.

Group means the Subscriber's employer/Plan Sponsor or other organization to which Contractor has issued the Group Contract and Evidence of Coverage.

Group Contract means the agreement issued by Contractor to the Group through which the benefits described in this Evidence of Coverage are made available. In addition to the Evidence of Coverage, the Group Contract includes any riders and/or amendments attached to the Group Contract or Evidence of Coverage and signed by an officer of Contractor.

Habilitative Services means health care services and devices, including, but not limited to, Occupational Therapy, Physical Therapy, and Speech Therapy that help a child keep, learn, or improve skills and functioning for daily living.

Health Care Provider means a hospital, health care facility, or health care practitioner licensed or otherwise authorized by law to provide health care services.

Home Health Care means the continued care and treatment of a Member by a Health Care Provider in the home if:

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The Member is under the care of a Health Care Provider;

Institutionalization of the Member would have been required and deemed Medically Necessary, if Home Health Care was not provided; and

The Member’s physician establishes and approves in writing the Plan of Treatment recommending the Home Health Care service.

Incurred means a Member's receipt of a health care service or supply for which a charge is made.

Independent Freestanding Emergency Facility means a health care facility that is geographically separate and distinct, and licensed separately from a hospital under applicable law, and which provides Emergency Services.

Infusion Therapy means treatment that places therapeutic agents into the vein, including intravenous feeding.

Insulin-Using Beneficiary means a Member who uses insulin as part of a treatment plan prescribed by his/her Health Care Provider.

Lifetime Maximum means the maximum dollar amount payable toward a Member's claims for Covered Services while the Member is covered under this Evidence of Coverage. Essential Health Benefits Covered Services are not subject to the Lifetime Maximum. See the Schedule of Benefits to determine if there is a Lifetime Maximum for Covered Services that are not Essential Health Benefits.

Limiting Age means the maximum age to which an eligible child may be covered under this Evidence of Coverage as stated in the Eligibility Schedule.

Medical Director means a board-certified physician who is appointed by Contractor. The duties of the Medical Director may be delegated to qualified persons.

Medically Necessary or Medical Necessity means health care services or supplies that a Health Care Provider, exercising prudent clinical judgment, renders to or recommends for, a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. These health care services, or supplies are:

In accordance with generally accepted standards of medical practice;

Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for a patient's illness, injury or disease;

Not primarily for the convenience of a patient or Health Care Provider; and

Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results in the diagnosis or treatment of that patient's illness, injury, or disease.

For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations and views of Health Care Providers practicing in relevant clinical areas, and any other relevant factors.

Member means an individual who meets all applicable eligibility requirements, is enrolled either as a Subscriber or Dependent, and for whom payment has been received by Contractor.

Non-Contracted Health Care Provider means, for purposes of the Inter-Plan Ancillary Services section of this Evidence of Coverage, a Health Care Provider that does not contract with the local

9 Maryland Transit Administration

Licensee (not Contractor) and provides Ancillary Services to the Member outside of the Contractor Service Area, as stated in the Inter-Plan Ancillary Services section.

Non-Preferred Health Care Provider means any Health Care Provider that is not a Preferred Provider.

Occupational Therapy means the use of purposeful activity or interventions designed to achieve functional outcomes that promote health, prevent injury or disability, and that develop, improve, sustain or restore the highest possible level of independence of an individual who has an injury, illness, cognitive impairment, psychosocial dysfunction, mental illness, developmental or learning disability, physical disability, loss of a body part, or other disorder or condition.

Open Enrollment means a single period of time during which the Group gives eligible individuals the opportunity to change coverage or enroll in coverage.

Out-of-Pocket Maximum means the maximum amount the Member will have to pay for his/her share of benefits in any Benefit Period.

Over-the-Counter means any item or supply, as determined by Contractor, that is available for purchase without a prescription. This includes, but is not limited to, non-prescription eye wear, family planning and contraception products, cosmetics or health and beauty aids, food and nutritional items, support devices, non-medical items, foot care items, first aid and miscellaneous medical supplies (whether disposable or durable), personal hygiene supplies, incontinence supplies, and Over-the-Counter medications and solutions, except for Over-the-Counter medication or supply dispensed under a written prescription by a Health Care Provider that is identified in the current recommendations of the United States Preventive Services Task Force that have in effect a rating of “A” or “B”.

Paid Claims means the amount paid by Contractor for Covered Services. Inter-Plan Arrangements Fees and Compensation are also included in Paid Claims. Other payments relating to fees and programs applicable to Contractor’s role as Claims Administrator may also be included in Paid Claims.

Partial Hospitalization means the provision of medically directed intensive or intermediate short-term treatment in a licensed or certified facility or program for treatment of mental illnesses, emotional or behavioral disorders, or substance use disorders.

Physical Therapy means the short-term treatment described below that can be expected to result in an improvement of a condition. Physical Therapy is the treatment of disease or injury through the use of therapeutic exercise and other interventions that focus on improving a person’s ability to go through the functional activities of daily living, to develop and/or restore maximum potential function, and to reduce disability following an illness, injury, or loss of a body part. These may include improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, and alleviating pain.

Plan means that portion of the Group Health Plan established by the Group that provides for health care benefits for which Contractor is the Claims Administrator under this Group Contract.

Plan of Treatment means the plan written and given to Contractor by the attending Health Care Provider on Contractor forms which shows the Member's diagnoses and needed treatment.

Preferred Provider means a Health Care Provider who contracts with Contractor to be paid directly for rendering Covered Services to Members. The “Preferred” terminology relates only to method of payment and is not an indication that any Health Care Provider is more or less qualified than another.

Prescription Drug means:

1. A drug, biological, or compounded prescription intended for outpatient use that carries the FDA legend “may not be dispensed without a prescription.”

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Drugs prescribed for treatments other than those stated in the labeling approved by the FDA, if the drug is recognized for such treatment in standard reference compendia or in the standard medical literature as determined by Contractor.

Over-the-Counter medication or supply, if Over-the-Counter medications or supply are Covered Services under this Evidence of Coverage.

Diabetes Supplies.

Prescription Drugs do not include:

Compounded bulk powders that contain ingredients that:

3)

Do not have FDA approval for the route of administration being compounded, or

Have no clinical evidence demonstrating safety and efficacy, or

Do not require a prescription to be dispensed.

Compounded drugs that are available as a similar commercially available Prescription Drug unless:

There is no commercially available bio-equivalent Prescription Drug; or

The commercially available bio-equivalent Prescription Drug has caused or is likely to cause the Member to have an adverse reaction.

Primary Care Provider (PCP) means a health care practitioner, including nurse practitioners, in the following disciplines:

1.

2.

3.

4.

5.

6.

7.

Family practice medicine;

Adult health medicine;

General practice medicine;

Internal practice medicine

Pediatric medicine;

Geriatric medicine; or

Any other practice area determined by the Group.

Private Duty Nursing means Skilled Nursing Care services, ordered by a Health Care Provider, that can only be provided by a licensed health care professional, based on a Plan of Treatment that specifically defines the skilled services to be provided as well as the time and duration of the proposed services.

Qualifying Payment Amount means an amount calculated based on the median contracted rate for all plans offered by Contractor in the self-funded group medical benefits plan market for the same or similar item or service that is:

1. Provided by a Health Care Provider in the same or similar specialty or facility of the same or similar facility type; and

2. Provided in the geographic region in which the item or service is furnished.

Recognized Amount means an amount determined as follows:

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In a state or jurisdiction that has an applicable All-Payer Model Agreement, the amount that the state or jurisdiction approves under the All-Payer Model Agreement for the particular Covered Service.

If there is no applicable All-Payer Model Agreement, in a state or jurisdiction that has in effect an applicable law, the amount for the Covered Service determined in accordance with the law.

If neither an applicable All-Payer Model Agreement nor law apply to the specific Covered Service, the lesser of:

The Non-Preferred Health Care Provider’s actual charge; or

The Qualifying Payment Amount.

Rehabilitative Services include Physical Therapy, Occupational Therapy, and Speech Therapy for the treatment of individuals who have sustained an illness. The goal of Rehabilitative Services is to return the individual to his/her prior skill and functional level.

Rescission means a cancellation or discontinuance of coverage that has retroactive effect. For example, a cancellation that treats coverage as void from the time of the individual's or group's enrollment is a Rescission. As another example, a cancellation that voids benefits paid up to a year before the cancellation is also a Rescission for this purpose. A cancellation or discontinuance of coverage is not a Rescission if:

1. The cancellation or discontinuance of coverage has only a prospective effect; or

2. The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay charges when due, by the Group.

Residential Crisis Services means intensive mental health and support services that are:

Provided to a child or an adult Member with a mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the ability of the Member to function in the community; and

Designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, shorten the length of inpatient stay, or reduce the pressure on general hospital emergency departments; and

Provided by entities that are licensed by the applicable licensing laws of any state or the District of Columbia to provide Residential Crisis Services; or

Located in subacute beds in an inpatient psychiatric facility for an adult Member.

Retail Health Clinic means mini-medical office chains typically staffed by nurse practitioners with an on-call physician and which provides Convenience Care services.

Service Area means Contractor’s Service Area, a clearly defined geographic area in which Contractor has arranged for the provision of health care services to be generally available and readily accessible to Members.

Skilled Nursing Care, depending on the place of service or benefit, means:

Inpatient hospital/facility or Skilled Nursing Facility:

Skilled Nursing Care rendered on an inpatient basis, means care for medically fragile Members with limited endurance who require a licensed health care professional to provide skilled services in order to ensure the Member’s safety and to achieve the medically desired result, provided on a 24-hour basis, seven days a week.

Skilled Nursing Care provided in the home:

Medically Necessary skilled care services performed by a licensed Registered Nurse (RN) or licensed Practical Nurse (LPN).

Skilled Nursing Care home visits must be a substitute for hospital care or for care in a Skilled Nursing Facility (i.e., if the visits were not provided, the Member would have to be admitted to a hospital or Skilled Nursing Facility).

Services of a home health aide, medical social worker or registered dietician performed under the supervision of a licensed professional (RN or LPN) nurse.

Skilled Nursing Care services in a Home Health Care setting must be based on a Plan of Treatment submitted by a Health Care Provider.

Outpatient Private Duty Nursing:

Medically Necessary skilled care services performed by a licensed Registered Nurse (RN) or licensed Practical Nurse (LPN).

Skilled Nursing Care must be a substitute for hospital care or for care in a Skilled Nursing Facility (i.e., if the visits were not provided, the Member would have to be admitted to a hospital or Skilled Nursing Facility).

Skilled Nursing Care must be ordered by a Health Care Provider and based on a Plan of Treatment that specifically defines the skilled services to be provided as well as the time and duration of the proposed services.

Skilled Nursing Care is not Medically Necessary if the proposed services can be provided by a caregiver or the caregiver can be taught and demonstrates competency in the administration of same. Performing the Activities of Daily Living (ADL), including, but not limited to, bathing, feeding, and toileting is not Skilled Nursing Care.

Skilled Nursing Facility means a licensed institution (or a distinct part of a hospital) that provides continuous Skilled Nursing Care or Rehabilitative Services.

Sound Natural Teeth include teeth restored with intra- or extra-coronal restorations (fillings, inlays, onlays, veneers, and crowns) that are in good condition, absent decay, fracture, bone loss, periodontal disease, root canal pathology or root canal therapy and excludes any tooth replaced by artificial means (fixed or removable bridges, or dentures).

Specialist means a physician who is certified or trained in a specified field of medicine.

Specialty Drug means Prescription Drugs which include, but are not limited to, drugs that are high cost, large molecule, with high potential for adverse effects, have stability concerns requiring special handling, and/or are often derived from biologic processes rather than chemical processes. These drugs are often highly effective when used according to a strict administration regimen and therefore may require support and management services.

Speech Therapy means the treatment of communication impairment and swallowing disorders. Speech Therapy facilitates the development and maintenance of human communication and swallowing through assessment, diagnosis, and rehabilitation.

Subscriber means a Member who is covered under this Evidence of Coverage as an eligible employee or eligible participant of the Group, rather than as a Dependent.

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Supplemental Breast Examinations means medically necessary examination of the breast that is used to screen for breast cancer when there is no abnormality seen or suspected from a prior examination and there is a personal or family medical history or additional factors that may increase the Member’s risk of breast cancer. Supplemental breast examination includes an examination using breast magnetic resonance imaging or breast ultrasound.

Telemedicine Services means the use of audio, video, or other electronic media for the purpose of diagnosis, consultation, or treatment of the Member at a site other than the site where the Member is located.

Treating Health Care Provider means a physician or other Health Care Provider who has evaluated the Member.

Type of Coverage means either Individual coverage, which covers the Subscriber only, or Family Coverage, under which a Subscriber may also enroll his or her Dependents. Some Group Contracts include additional categories of coverage, such as Individual and Adult and Individual and Child. The Types of Coverage available under this Evidence of Coverage are Individual, Individual and Child, Individual and Adult, Family.

NOTE: If both the Subscriber and Dependent spouse qualify as “Subscribers” of the Group, they may not enroll under separate Individual Type of Coverage memberships; i.e., as separate "Subscribers.•)

Urgent Care means treatment for a condition that is not a threat to life or limb but does require prompt medical attention. Also, the severity of an urgent condition does not necessitate a trip to a hospital emergency room or department.

For purposes of Emergency Services, an Urgent Care facility is considered an Independent Freestanding Emergency Department (i.e., an Emergency Facility), if the Urgent Care facility:

Is located in a state where health care facility licensure laws allow Urgent Care facilities to provide Emergency Services;

Is geographically separate and distinct from a hospital; and

Is licensed separately from a hospital.

Waiting Period means the period of time that must pass before an employee or dependent is eligible to enroll under the terms of the Group Health Plan. A Waiting Period determined by the Group may not exceed the limits required by applicable federal law and regulation.

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A.

ELIGIBILITY AND ENROLLMENT

Requirements for Coverage The Group has the sole and complete authority to make determinations regarding eligibility and enrollment for membership in the Plan.

An eligible participant of the Group, and his or her Dependent(s) meeting the eligibility requirements established by the Group, may be covered under the Evidence of Coverage (see Eligibility Schedule) when all of the following conditions are met:

1.

2.

The individual elects coverage;

The individual is entitled to Medicare, if Medicare Complementary coverage applicable;

The Group accepts the individual’s election and notifies Contractor; and

Payments are made on behalf of the Member by the Group.

B.

Enrollment Opportunities and Effective Dates Eligible individuals may elect coverage as Subscribers or Dependents, as applicable, only during the following times and under the following conditions. If an individual meets these conditions, his or her enrollment will be treated as timely enrollment. Enrollment at other times will be treated as special enrollment and will be subject to the conditions and limitations stated in Special Enrollment Periods. Disenrollment is not allowed during a contract year except as stated in section B.1.,and as stated in the Termination of Coverage section of the Evidence of Coverage.

Open Enrollment Period Open Enrollment changes will be effective on the Open Enrollment effective date stated in the Eligibility Schedule.

During the Open Enrollment period, all eligible persons may elect, change, or voluntarily disenroll from coverage, or transfer coverage between Contractor and all other alternate health care plans available through the Group.

In addition, Subscribers already enrolled in Contractor may change their Type of Coverage (e.g., from Individual to Family Coverage) and/or add eligible Dependents not previously enrolled under their coverage.

Newly Eligible Subscriber A newly eligible individual and his/her Dependents may enroll and will be effective as stated in the Eligibility Schedule. If such individuals do not enroll within this period and do not qualify for special enrollment as described below, they must wait for the Group’s next Open Enrollment period.

Special Enrollment Periods Special enrollment is allowed for certain individuals who lose coverage. Special enrollment is also allowed with respect to certain dependent beneficiaries. Enrollment will be effective as stated in the Eligibility Schedule.

These special enrollment periods are not the same as Medicare special enrollment periods.

If only the Subscriber is eligible under this Evidence of Coverage and dependents are not eligible to enroll, special enrollment periods for a spouse/Dependent child are not applicable.

If retirees are eligible for coverage under this Evidence of Coverage, references to an employee shall be construed to include a retiree, except for references made in the context of special enrollment for certain individuals who lose coverage, as special enrollment for certain individuals who lose coverage is not applicable to retirees.

Special enrollment for certain individuals who lose coverage:

Contractor will permit current employees and dependents to enroll for coverage without regard to the dates on which an individual would otherwise be able to enroll under this Evidence of Coverage.

Individuals eligible for special enrollment.

a)

When employee loses coverage. A current employee and any dependents (including the employee’s spouse) each are eligible for special enrollment in any benefit package offered by the Group (subject to Group eligibility rules conditioning dependent enrollment on enrollment of the employee) if:

(1)

(2)

(3)

The employee and the dependents are otherwise eligible to enroll;

When coverage was previously offered, the employee had coverage under any group health plan or health insurance coverage; and

The employee satisfies the conditions of paragraph B.3.a.3)a), b), or c) of this section, and, if applicable, paragraph B.3.a.3)d) of this section.

b)

When dependent loses coverage. A dependent of a current employee (including the employee’s spouse) and the employee each are eligible for special enrollment in any benefit package offered by the Group (subject to Group eligibility rules conditioning dependent enrollment on enrollment of the employee) if:

(4)

The dependent and the employee are otherwise eligible to enroll;

When coverage was previously offered, the dependent had coverage under any group health plan or health insurance coverage; and

The dependent satisfies the conditions of paragraph B.3.a.3)a), b), or c) of this section, and, if applicable, paragraph B.3.a.3)d) of this section.

However, Contractor is not required to enroll any other dependent unless the dependent satisfies the criteria of this paragraph B.3.a.2)b), or the employee satisfies the criteria of paragraph B.3.a.2)a) of this section.

Conditions for special enrollment.

Loss of eligibility for coverage. In the case of an employee or dependent who has coverage that is not COBRA continuation coverage, the conditions of this paragraph B.3.a.3)a) are satisfied at the time the coverage is terminated as a result of loss of eligibility (regardless of whether the individual is eligible for or elects COBRA continuation coverage). Loss of eligibility under this paragraph does not include a loss due to the failure of the employee or dependent to pay premiums on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact). Loss of eligibility for coverage under this paragraph includes, but is not limited to:

(4)

Loss of eligibility for coverage as a result of legal separation, divorce, cessation of dependent status (such as attaining the Limiting Age), death of an employee, termination of employment, reduction in the number of hours of employment, and any loss of eligibility for coverage after a period that is measured by any of the foregoing;

In the case of coverage offered through a health maintenance organization, or other arrangement, in the individual market that does not provide benefits to individuals who no longer reside, live, or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual) ;

In the case of coverage offered through a health maintenance organization, or other arrangement, in the group market that does not provide benefits to individuals who no longer reside, live, or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual) and no other benefit package is available to the individual; and

A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes that individual.

c) d)

Termination of employer contributions. In the case of an employee or dependent who has coverage that is not COBRA continuation coverage, the conditions of this paragraph are satisfied at the time employer contributions towards the employee’s or dependent’s coverage terminate. Employer contributions include contributions by any current or former employer that was contributing to coverage for the employee or dependent.

Exhaustion of COBRA continuation coverage. In the case of an employee or dependent who has coverage that is COBRA continuation coverage, the conditions of this paragraph are satisfied at the time the COBRA continuation coverage is exhausted. For purposes of this paragraph, an individual who satisfies the conditions for special enrollment of paragraph B.3.a.3)a) of this section, does not enroll, and instead elects and exhausts COBRA continuation coverage satisfies the conditions of this paragraph.

Written statement. The Group or Contractor may require an employee declining coverage (for the employee or any dependent of the employee) to state in writing whether the coverage is being

4) declined due to other health coverage only if, at or before the time the employee declines coverage, the employee is provided with notice of the requirement to provide the statement (and the consequences of the employee’s failure to provide the statement). If the Group or Contractor requires such a statement, and an employee does not provide it, the Group and Contractor are not required to provide special enrollment to the employee or any dependent of the employee under this paragraph. The Group and Contractor must treat an employee as having satisfied the requirement permitted under this paragraph if the employee provides a written statement that coverage was being declined because the employee or dependent had other coverage; the Group and Contractor cannot require anything more for the employee to satisfy this requirement to provide a written statement. (For example, the Group and Contractor cannot require that the statement be notarized.)

Applying for special enrollment and effective date of coverage. The Group or Contractor will allow an employee a period of at least thirty (30) days after an event described above to request enrollment (for the employee or the employee’s dependent).

Coverage will begin no later than the first day of the first (1st) calendar month beginning after the date the Group or Contractor receives the request for special enrollment.

Special enrollment with respect to certain dependent beneficiaries:

Provided the Group provides coverage for dependents, Contractor will permit the individuals described in paragraph 2), of this section to enroll for coverage in a benefit package under the terms of the Group’s plan, without regard to the dates on which an individual would otherwise be able to enroll under this Evidence of Coverage.

Individuals eligible for special enrollment. An individual is described in this paragraph if the individual is otherwise eligible for coverage in a benefit package under the Group’s plan and if the individual is described in paragraph B.3.a.2)a), b), c), d), e), or f) of this section.

Current employee only. A current employee is described in this paragraph if a person becomes a dependent of the individual through marriage, birth, adoption, or placement for adoption.

Spouse of a participant only. An individual is described in this paragraph if either:

The individual becomes the spouse of a participant; or

The individual is a spouse of a participant and a child becomes a dependent of the participant through birth, adoption, or placement for adoption.

Current employee and spouse. A current employee and an individual who is or becomes a spouse of such an employee, are described in this paragraph if either:

The employee and the spouse become married; or

The employee and spouse are married and a child becomes a dependent of the employee through birth, adoption, or placement for adoption.

e) f)

Dependent of a participant only. An individual is described in this paragraph if the individual is a dependent of a participant and the individual has become a dependent of the participant through marriage, birth, adoption, or placement for adoption.

Current employee and a new dependent. A current employee and an individual who is a dependent of the employee, are described in this paragraph if the individual becomes a dependent of the employee through marriage, birth, adoption, or placement for adoption.

Current employee, spouse, and a new dependent. A current employee, the employee’s spouse, and the employee’s dependent are described in this paragraph if the dependent becomes a dependent of the employee through marriage, birth, adoption, or placement for adoption.

Special enrollment regarding Medicaid and Children’s Health Insurance Program (CHIP) termination or eligibility:

Contractor will permit an employee or dependent who is eligible for coverage, but not enrolled, to enroll for coverage under the terms of this Evidence of Coverage, if either of the following conditions is met:

Termination of Medicaid or CHIP coverage. The employee or dependent is covered under a Medicaid plan under Title XIX of the Social Security Act or under a State child health plan under Title XXI of such Act and coverage of the employee or dependent under such a plan is terminated as a result of loss of eligibility for such coverage.

Eligibility for employment assistance under Medicaid or CHIP. The employee or dependent becomes eligible for premium assistance, with respect to coverage under this Evidence of Coverage, under Medicaid or a State child health plan (including under any waiver or demonstration project conducted under or in relation to such a plan).

MEDICAL CHILD SUPPORT ORDERS

Definitions

Medical Child Support Order (MCSO) means an “order” issued in the format prescribed by federal law; and issued by an appropriate child support enforcement agency to enforce the health insurance coverage provisions of a child support order. An “order” means a judgment, decree or a ruling (including approval of a settlement agreement) that:

Is issued by a court or administrative child support enforcement agency of any state or the District of Columbia.

Creates or recognizes the right of a child to receive benefits under a parent’s health insurance coverage; or establishes a parent’s obligation to pay child support and provide health insurance coverage for a child.

Qualified Medical Support Order (QMSO) means a MCSO issued under State law, or the laws of the District of Columbia and, when issued to an employer sponsored health plan, one that complies with The Child Support Performance and Incentive Act of 1998, as amended.

B

Eligibility and Termination

Upon receipt of an MCSO/QMSO, when coverage of the Subscriber's family members is available under the terms of the Subscriber's contract then Contractor will accept enrollment regardless of enrollment period restrictions. If the Subscriber does not enroll the child then Contractor will accept enrollment from the non-Subscriber custodial parent;

or the appropriate child support enforcement agency of any state or the District of Columbia. If the Subscriber has not completed an applicable Waiting Period for coverage the child will not be enrolled until the end of the Waiting Period.

The Subscriber must be enrolled under this Group Contract in order for the child to be enrolled. If the Subscriber is not enrolled when Contractor receives the MCSO/QMSO, Contractor will enroll both the Subscriber and the child, without regard to enrollment period restrictions. The Effective Date will be that stated in the Eligibility Schedule for a newly eligible Subscriber and a newly eligible Dependent child.

Enrollment for such a child will not be denied because the child:

a.

b.

Was born out of wedlock.

Is not claimed as a dependent on the Subscriber's federal tax return.

Does not reside with the Subscriber.

Is covered under any Medical Assistance or Medicaid program.

Termination. Unless coverage is terminated for non-payment of the premium, a covered child subject to an MCSO/QMSO may not be terminated unless written evidence is provided to Contractor that:

The MCSO/QMSO is no longer in effect;

The child has been or will be enrolled under other comparable health insurance coverage that will take effect not later than the effective date of the termination of coverage; or

c. If coverage is provided under an employer sponsored health plan;

The employer has eliminated family member's coverage for all employees;

or

The employer no longer employs the Subscriber, except if the Subscriber elects continuation under applicable state or federal law, the child will continue in this post-employment coverage.

C.

Administration When the child subject to an MCSO/QMSO does not reside with the Subscriber, Contractor will:

Send the non-insuring custodial parent ID cards, claims forms, the applicable evidence of coverage or member contract and any information needed to obtain benefits;

Allow the non-insuring custodial parent or a Health Care Provider of a Covered Service to submit a claim without the approval of…