Ext_9.FA6_Evidence_of_Coverage__MDOT_MTA_Vision__2025.8.9.pdf

Maryland Transit Administration

Vision Care Option

Exhibit 9 - FA6 Evidence of Coverage ~ Vision

TABLE OF CONTENTS

DEFINITIONS 1

ELIGIBILITY AND ENROLLMENT 5

MEDICAL CHILD SUPPORT ORDERS 10

TERMINATION OF COVERAGE 12

CONTINUATION OF COVERAGE 13

COORDINATION OF BENEFITS 14

HOW THE PLAN WORKS 19

DESCRIPTION OF COVERED SERVICES 22

EXCLUSIONS 24

ELIGIBILITY SCHEDULE 27

SCHEDULE OF BENEFITS 30

CLAIMS PROCEDURES 32

1/1/2024

DEFINITIONS

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

Allowed Benefit means:

1.

For a Participating Provider, the Allowed Benefit for a Covered Service is the lesser of:

a.

b.

The actual charge; or

The amount Contractor allows for the service in effect on the date that the service is rendered.

2.

The benefit is payable to the Participating Provider and is accepted as payment in full, except for any applicable Member payment amounts, as stated in the Schedule of Benefits.

For a Non-Participating Provider, the Allowed Benefit for a Covered Service will be determined in the same manner as the Allowed Benefit payable to a Participating Provider. The benefit is payable to the Subscriber, or to the Non-Participating Provider, at the discretion of Contractor.

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 Non- Participating Provider’s actual charge. It is the Member’s responsibility to apply any Contractor payments to the Non-Participating Provider’s charges.

Benefit Period means the period of time during which Covered Services are eligible for payment. The Benefit Period is:

24 months from the first Covered Service. Benefits are limited to once per Benefit Period.

Contractor means entity providing service to State of Maryland.

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.

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 (1) 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:

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3.

4.

5.

6.

Financial dependency on an individual covered under the Contract;

Marital status;

Residency with an individual covered under the Contract;

Student status;

Employment; or

Satisfaction of any combination of the above factors.

Student Dependent means a Dependent child who is enrolled and whose time is principally devoted to attending school (meets the requirements for full-time status). Student Dependent includes a Dependent child on a medically necessary leave of absence in accordance with Public Law 110-381, 122 Stat. 4081- 4086, Michelle’s Law.•) Upon expiration of the Michelle’s Law leave of absence period, Student Dependent includes a Dependent Child who is enrolled less than full time as a result of a documented disability that prevents the student from maintaining a full-time course load and is maintaining a course load of at least seven (7) credit hours per semester.

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.

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. Services or supplies that do not meet all five of the criteria listed below are deemed to be Experimental/Investigational:

3.

4.

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.

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.

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

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

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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.

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-Participating or Non-Par Provider means any Health Care Provider that does not contract with Contractor.

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

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

Participating Provider or Par Provider means a Health Care Provider who contracts with Contractor to be paid directly for rendering Covered Services to Members.

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

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.

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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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.”

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.

The individual elects coverage;

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 within the Special enrollment for certain individuals who lose coverage subsection below, as special enrollment for certain enrollment who lose coverage is not applicable to retirees.

Special enrollment for certain individuals who lose coverage:

1)

2)

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.

3)

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 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.)

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.

d) e)

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 f) 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.

c.

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).

A

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.

Eligibility and Termination

Upon receipt of an MCSO/QMSO, when coverage of the Subscriber's family members is available under this Evidence of Coverage, Contractor will accept enrollment of the child subject to the MCSO/QMSO submitted by the Subscriber, regardless of enrollment period restrictions. If the Subscriber does not enroll the child, 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 subject to the MCSO/QMSO 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.

c.

d.

e.

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.

Does not reside in the Service Area.

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

The Group has eliminated family member’s coverage for all its 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 the Subscriber;

Provide benefits directly to:

a.

The non-insuring parent;

The Health Care Provider of the Covered Services; or

The appropriate child support enforcement agency of any state or the District of Columbia.

TERMINATION OF COVERAGE

Disenrollment of Individua1 Members The Group has the sole and complete authority to make determinations regarding eligibility and termination of coverage in the Plan.

The Group Health Plan will not rescind coverage under the Plan with respect to an individual (including a group to which the individual belongs or family coverage in which the individual is included) once the individual is covered under the Plan, unless the individual (or a person seeking coverage on behalf of the individual) performs an act, practice, or omission that constitutes fraud, or unless the individual makes an intentional misrepresentation of material fact, as prohibited by the terms of the Plan. The Group Health Plan will provide at least thirty (30) days advance written notice to each participant who would be affected before coverage is rescinded regardless of whether the Rescission applies to an entire group or only to an individual within the group.

Coverage of individual Members will terminate on the date stated in the Eligibility Schedule for the following reasons:

Contractor may terminate a Member’s coverage for nonpayment of charges when due, by the Group.

The Group is required to terminate a Member’s coverage if the individual (or a person seeking coverage on behalf of the individual) performs an act, practice, or omission that constitutes fraud, or if the individual makes an intentional misrepresentation of material fact, as prohibited by the terms of the Plan.

The Group is required to terminate the Subscriber’s coverage and the coverage of the Dependents, if applicable, if the Subscriber no longer meets the Group’s eligibility requirements for coverage.

The Group is required to terminate a Member’s coverage if the Member no longer meets the Group’s eligibility requirements for coverage.

The Group is required to notify the Subscriber if a Member’s coverage is cancelled. If the Group does not notify the Subscriber, this will not continue the Member’s coverage beyond the termination date of coverage. The Member’s coverage will terminate on the termination date set forth in the Eligibility Schedule.

Except in the case of a Dependent child enrolled pursuant to an MCSO or QMSO, coverage of any Dependents, if Dependent coverage is available, will terminate if the Subscriber changes the Type of Coverage to an Individual or other non-family contract.

C.

D.

Death of a Subscriber If Dependent coverage is available, in the event of the Subscriber's death, coverage of any Dependents will continue under the Subscriber's enrollment as stated in the Eligibility Schedule under termination of coverage Death of a Subscriber.

Effect of Termination Except as provided under the Extension of Benefits provision, no benefits will be provided for any services received on or after the date on which the Member’s coverage under this Evidence of Coverage terminates. This includes services received for an injury or illness that occurred before the effective date of termination.

Reinstatement Coverage will not reinstate automatically under any circumstances.

CONTINUATION OF COVERAGE

Continuation of Eligibility upon Loss of Group Coverage

Federal Continuation of Coverage under COBRA If the Group health benefit Plan provided under this Evidence of Coverage is subject to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended from time to time, and a Member's coverage terminates due to a “Qualifying Event” as described under COBRA, continuation of participation in this Group health benefit Plan may be possible. The employer offering this Group health benefit Plan is the Plan Administrator. It is the Plan Administrator's responsibility to notify a Member concerning terms, conditions and rights under COBRA. If a Member has any questions regarding COBRA, the Member should contact the Plan Administrator.

Uniformed Services Employment and Reemployment Rights Act (USERRA) USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the Natural Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services and applicants to the uniformed services.

If a Member leaves their job to perform military service, the Member has the right to elect to continue their Group coverage including any Dependents for up to twenty-four

(24) months while in the military. Even if continuation of coverage was not elected during the Member’s military service, the Member has the right to be reinstated in their Group coverage when reemployed, without any Waiting Periods or pre-existing condition exclusions except for service-connected illnesses or injuries. If a Member has any questions regarding USERRA, the Member should contact the Plan Administrator.

Extension of Benefits During an extension period under this Evidence of Coverage, premium may not be charged.

Benefits will cease as of 11:59 p.m., Eastern Standard Time, on the Subscriber's termination date.

If a Member has ordered lenses and frames or contact lenses before the date coverage terminates, Contractor will provide coverage for the lenses and frames or contact lenses if received within thirty (30) days after the date of the order.

This extension of benefits will not apply if:

Coverage is terminated for non-payment of the required premium by the Member;

Coverage is terminated for fraud or material misrepresentation by the Member;

or

The member obtained uninterrupted and comparable coverage under a succeeding vision plan that is less than the cost to the Member of the extended benefit.

COORDINATION OF BENEFITS

Coordination of Benefits

Applicability

This Coordination of Benefits (COB) provision applies to this Contractor Plan when a Member has health care coverage under more than one Plan.

If this COB provision applies, the Order of Determination Rules should be looked at first. Those rules determine whether the benefits of this Contractor Plan are determined before or after those of another Plan. The benefits of this Contractor Plan:

Shall not be reduced when, under the order of determination rules, this Contractor Plan determines its benefits before another Plan; and

May be reduced when, under the order of determination rules, another Plan determines its benefits first. The above reduction is explained in the Effect on the Benefits section of this Contractor Plan Evidence of Coverage.

Definitions For the purpose of this COB section, the following terms are defined. The definitions of other capitalized terms are found in the definitions section of this Evidence of Coverage.

Allowable Expenses means any health care expense, including deductibles, coinsurance or copayments, that is covered in whole or in part by any of the Plans covering the Member. This means that any expense or portion of an expense that is not covered by any of the Plans is not an Allowable Expense. If this Contractor Plan is advised by a Member that all Plans covering the Member are high-deductible health plans and the Member intends to contribute to a health savings account, the primary Plan’s deductible is not an Allowable Expense, except for any health care expense incurred that may not be subject to the deductible, as stated in section 223(c)(2)(C) of the Internal Revenue Code of 1986.

Contractor Plan means this Evidence of Coverage.

Intensive Care Policy means a health insurance policy that provides benefits only when treatment is received in that specifically designated health care facility of a hospital that provides the highest level of care and which is restricted to those patients who are physically, critically ill or injured.

Plan means any health insurance policy, including those of nonprofit health service Plan and those of commercial group, blanket, and individual policies, any subscriber contracts issued by health maintenance organizations, and any other established programs under which the insured may make a claim. The term Plan includes coverage required or provided by law or coverage under a governmental Plan, except a governmental plan which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan. This does not include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended from time to time).

The term Plan does not include:

An individually underwritten and issued, guaranteed renewable, specified disease policy, or specified accident policy;

f.

g.

h.

i.

j.

k.

An intensive care policy, which does not provide benefits on an expense incurred basis;

Coverage regulated by a motor vehicle reparation law;

Any hospital indemnity or other fixed indemnity coverage contract;

An elementary and/or secondary school insurance program sponsored by a school or school system and any school accident-type coverage that covers for accidents only, including athletics injuries;

Medicare supplemental policies;

Limited benefit health coverage as defined by state law;

Long-term care insurance policies for non-medical services;

Personal Injury Protection (PIP) benefits under a motor vehicle liability insurance policy.

A state plan under Medicaid; or

A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan.

Primary Plan or Secondary Plan means the order of benefit determination rules stating whether this Contractor Plan is a Primary Plan or Secondary Plan as to another Plan covering the Member.

When this Contractor Plan is a Primary Plan, its benefits are determined before those of the other Plan and without considering the other Plan's benefits.

When this Contractor Plan is a Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other Plan's benefits.

When there are more than two Plans covering the Member, this Contractor Plan may be a Primary Plan as to one of the other Plans, and may be a Secondary Plan as to a different Plan or Plans.

Specified Disease Policy means a health insurance policy that provides (1) benefits only for a disease or diseases specified in the policy or for the treatment unique to a specific disease; or (2) additional benefits for a disease or diseases specified in the policy or for treatment unique to a specified disease or diseases.

Order of Benefit Determination Rules

General When there is a basis for a claim under this Contractor Plan and another Plan, this Contractor Plan is a Secondary Plan which has its benefits determined after those of the other Plan, unless:

The other Plan has rules coordinating benefits with those of this Contractor Plan; and

Both those rules and this Contractor Plan's rules require that this Contractor Plan's benefits be determined before those of the other Plan.

Rules This Contractor Plan determines its order of benefits using the first of the following rules which applies:

Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is:

Secondary to the Plan covering the person as a dependent; and

Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent.

Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this Contractor Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows:

For a dependent child whose parents are married or are living together:

The benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later in the year;

but

If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time.

For a dependent child whose parents are separated, divorced, or are not living together:

If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s spouse does, that parent’s spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree.

The rule described in 3.b.2)a) above also shall apply if: i) a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a

16 Maryland Transit Administration court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or coverage of the dependent child.

If there is no court decree setting out the responsibility for the child’s health care expenses or health care coverage, the order of benefits for the dependent child are as follows:

(a)

(b)

(c)

(d)

The Plan of the parent with custody of the child;

The Plan of the spouse of the parent with the custody of the child;

The Plan of the parent not having custody of the child; and then

The Plan of the spouse of the parent who does not have custody of the child.

For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in 1) and 2) of this paragraph as if those individuals were parents of the child.

4)

Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Continuation coverage. If a person whose coverage is provided under the right of continuation pursuant to federal or state law also is covered under another Plan, the following shall be the order of benefits determination:

First, the benefits of a Plan covering the person as an employee, retiree, member or subscriber (or as that person's dependent);

Second, the benefits under the continuation coverage.

5)

If the other Plan does not have the rule described above, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Longer/shorter length of coverage. If none of the above rules determines the order of benefits, the benefits of the Plan that covered the person longer are determined before those of the Plan that covered that person for the shorter term.

Effect on the Benefits of this Contractor Plan

When this Section Applies This section applies when, in accordance with the prior section, order of benefits determination rules, this Contractor Plan is a Secondary Plan as to one or more other Plans. In that event the benefits of this Contractor Plan may be reduced under this section. Such other Plan or Plans are referred to as “the other Plans" immediately below.

Reduction in this Contractor Plan’s Benefits When this Contractor Plan is the Secondary Plan, the benefits under this Contractor Plan may be reduced so that the total benefits that would be payable or provided by all the other Plans do not exceed one hundred percent (100%) of the total Allowable Expenses. If the benefits of this Contractor Plan are reduced, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this Contractor Plan.

7.

Right to Receive and Release Needed Information Certain facts are needed to apply these COB rules. Contractor has the right to decide which facts it needs. It may get the needed facts from or give them to any other organization or person for purposes of treatment, payment, and health care operations. Contractor need not tell, or get the consent of, any person to do this. Each person claiming benefits under this Contractor Plan must give this Contractor Plan any facts it needs to pay the claim.

Facility of Payment A payment made under another Plan may include an amount that should have been paid under this Contractor Plan. If it does, this Contractor Plan may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under this Contractor Plan. This Contractor Plan will not have to pay that amount again. The term payment made•) includes providing benefits in the form of services, in which case payment made•) means the reasonable cash value of the benefits provided in the form of services.

Right of Recovery If the amount of the payments made by this Contractor Plan is more than it should have paid under this COB provision, it may recover the excess from one or more of:

a.

The persons it has paid or for whom it has paid;

Insurance companies; or

Other organizations.

The “amount of the payments made" includes the reasonable cash value of any benefits provided in the form of services.

Employer or Governmenta1 Benefits Coverage does not include the cost of services or payment for services for any illness, injury, or condition for which, or as a result of which, a Benefit (as defined below) is provided or is required to be provided either:

Under any federal, state, county or municipal workers' compensation or employer's liability law or other similar program; or

From any federal, state, county or municipal or other government agency, including, in the case of service-connected disabilities, the United States Department of Veterans Affairs, to the extent that benefits are payable by the federal, state, county or municipal or other government agency, but excluding Medicare benefits and Medicaid benefits.

Benefit as used in this provision includes a payment or any other benefit, including amounts received in settlement of a claim for Benefits.

18 Maryland Transit Administration

HOW THE PLAN WORKS

Contractor has contracted with Davis Vision, Inc., a national provider of vision care services, to administer vision care benefits. Davis Vision, Inc. has special agreements with optometrists and ophthalmologists to provide vision care benefits to Members. These optometrists and ophthalmologists are Participating Providers. If a Member chooses to obtain vision care from a Participating Provider, the cost to the Member is lower than if the Member chooses a Non-Participating Provider. A vision care benefits Non- Participating Provider is always considered an “out-of-network” provider. Throughout the Schedule of Benefits, payments are listed as either “In-Network” or “Out-of-Network.” Hereafter, references to Contractor shall also include Davis Vision, Inc.

Appropriate Care and Medical Necessity Contractor works to make sure that health care is rendered in the most appropriate setting and in the most appropriate way. While ensuring that the Member receives the best care, this also helps to control health care costs. In order to make sure that the setting and treatment are appropriate, some Covered Services require review before a Member receives care. These services are marked throughout this Evidence of Coverage.

Contractor will pay a benefit for Covered Services rendered by a Health Care Provider only when Medically Necessary as determined by Contractor. Benefits are subject to all of the terms, conditions, and maximums, if applicable, as stated in this Evidence of Coverage.

Choosing a Provider

Member/Health Care Provider Relationship

The Member has the exclusive right to choose a Health Care Provider. Whether a Health Care Provider is a Participating Provider or not, relates only to method of payment, and does not imply that any Health Care Provider is more or less qualified than another.

Contractor makes payment for Covered Services, but does not provide these services. Contractor is not liable for any act or omission of any Health Care Provider.

Participating Provider; In-Network Providers

Claims will be submitted directly to Contractor by the Participating Provider.

Contractor will pay benefits directly to the Participating Provider.

The Member is responsible for any applicable Deductible and Coinsurance or Copayment and balance due after Contractor’s payment unless otherwise stated.

Non-Participating Provider; Out-of-Network Providers

Claims may be submitted directly to Contractor or its designee by the Non- Participating Provider, or the Member may need to submit the claim. In either case, it is the responsibility of the Member to make sure that proofs of loss are filed on time.

All benefits for Covered Services will be payable to the Subscriber, or to the Non-Participating Provider will be payable to the Subscriber, at the discretion of Contractor.

In the case of a Dependent child enrolled pursuant to an MCSO or a QMSO, payment will be paid directly to the State of Maryland Department of Health and

Mental Hygiene or the non-insuring parent if proof is provided that such parent has paid the Non-Participating Provider.

Non-Participating Providers are not required to accept the Allowed Benefit as full payment and will collect additional amounts from the Member up to the provider’s actual charge. The Allowed Benefit may be substantially less than the provider’s actual charge to the Member. Therefore, when Covered Services are provided the Non-Participating Provider, Members should expect to pay additional amounts to providers that exceed the Allowed Benefit. The Member is responsible for the difference between Contractor’s payment and the Non- Participating Provider.

C

D

E

F

G

H

Notice of Claim A Member may request a claim form by writing or calling Contractor. Contractor does not require written notice of a claim.

Claim Forms Contractor provides claim forms for filing proof of loss. If Contractor does not provide the claim forms within fifteen (15) days after notice of claim is received, the Member is considered to have complied with the requirements of this Evidence of Coverage as to proof of loss if the Member submits, within the time fixed in this Evidence of Coverage for filing proof of loss, written proof of the occurrence, character, and extent of the loss for which the claim is made.

Proofs of Loss In order to receive benefits for services rendered by a the Non-Participating Provider, a Member must submit written proof of loss to Contractor or its designee within the deadlines described below.

Claims for Vision Care Benefits must be submitted within twelve (12) months following the dates services were rendered.

A Member’s failure to furnish the proof of loss within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the proof within the required time, if the proof is furnished as soon as reasonably possible, and except in the absence of legal capacity of the Member, not later than one (1) year from the time proof is otherwise required.

Contractor will honor claims submitted for Covered Services by…