SMCO-TPA-RFP-APP-B-SPD-with-amendments.pdf

Summit County Government Employee Benefit Plan

Plan Document and Summary Plan Description

Effective: January 01, 2022

Summit County Government Employee Benefit Plan Plan Document and Summary Plan Description 1

TABLE OF CONTENTS

ESTABLISHMENT OF THE PLAN: ADOPTION OF THE PLAN DOCUMENT AND SUMMARY

PLAN DESCRIPTION

INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION

DEFINITIONS

ELIGIBILITY FOR COVERAGE

TERMINATION OF COVERAGE

CONTINUATION OF COVERAGE

GENERAL LIMITATIONS AND EXCLUSIONS

PLAN ADMINISTRATION

CLAIM PROCEDURES; PAYMENT OF CLAIMS

COORDINATION OF BENEFITS

MEDICARE

THIRD PARTY RECOVERY, SUBROGATION AND REIMBURSEMENT

MISCELLANEOUS PROVISIONS

SUMMARY OF BENEFITS

Summary of Benefits – Plan 1

MEDICAL BENEFITS

Medical Exclusions

UTILIZATION MANAGEMENT

PRESCRIPTION DRUG BENEFITS

HIPAA PRIVACY

HIPAA SECURITY

ESTABLISHMENT OF THE PLAN: ADOPTION OF THE PLAN DOCUMENT AND

SUMMARY PLAN DESCRIPTION

THIS PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION ("Plan Document"), made by Summit County Government (the "Company" or the "Plan Sponsor") as of January 01,2022, hereby sets forth the provisions of the Summit County Government Employee Benefit Plan (the "Plan"). Any wording which may be contrary to Federal Laws or Statutes is hereby understood to meet the standards set forth in such. Also, any changes in Federal Laws or Statutes which could affect the Plan are also automatically a part of the Plan, if required.

Effective Date The Plan Document is effective as of the date first set forth above, and each amendment is effective as of the date set forth therein, (the "Effective Date").

Adoption of the Plan Document The Plan Sponsor, as the settlor of the Plan, hereby adopts this Plan Document as the written description of the Plan. This Plan Document represents both the Plan Document and the Summary Plan Description.

This Plan Document amends and replaces any prior statement of the health care coverage contained in the Plan or any predecessor to the Plan.

lN WITNESS WHEREOF, the Plan Sponsor has caused this Plan Document to be executed.

Summit County Government

Name: Yc# vovac

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Date

Summit County Government Employee Benefit Plan PIan Document and Summary Plan Description

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Plan Document and Summary Plan Description 3

INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION

Introduction and Purpose The Plan Sponsor has established the Plan for the benefit of eligible Employees and their eligible Dependents, in accordance with the terms and conditions described herein. Plan benefits are funded solely from the general assets of the Plan Sponsor. Participants in the Plan may be required to contribute toward their benefits. Contributions received from Participants are used to cover Plan costs and are expended immediately.

The Plan Sponsor’s purpose in establishing the Plan is to protect eligible Employees and their Dependents against certain health expenses and to help defray the financial effects arising from Injury or Illness. To accomplish this purpose, the Plan Sponsor must be mindful of the need to control and minimize health care costs through innovative and efficient plan design and cost containment provisions, and of abiding by the terms of the Plan Document, to allow the Plan Sponsor to effectively assign the resources available to help Participants in the Plan to the maximum feasible extent.

The Plan Sponsor has adopted this Plan Document as the written description of the Plan to set forth the terms and provisions of the Plan that provide for the payment or reimbursement of all or a portion of certain expenses for eligible benefits. The Plan Document is maintained by Summit County Government and may be reviewed at any time during normal working hours by any Participant.

General Plan Information

Name of Plan: Summit County Government Employee Benefit Plan

Plan Sponsor: Summit County Government PO Box 68 208 E Lincoln Avenue Breckenridge, CO 80424 Phone: 1-970-453-3459 Fax: 1-970-453-3453 Website: www.summitcountyco.gov

Plan Administrator (Named Fiduciary): Summit County Government PO Box 68 208 E Lincoln Avenue Breckenridge, CO 80424 Phone: 1-970-453-3459 Fax: 1-970-453-3453 Website: www.summitcountyco.gov

Plan Sponsor ID No. (EIN): 84-6000808

Source of Funding: Self-Funded

Plan Status: Non-Grandfathered

Plan Year (Renewal Year): January through December

Plan Type: Medical Prescription Drug

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Third Party Administrator: Cypress Benefit Administrators (LHS), LLC A Lucent Health Company PO Box 7020 Appleton, WI 54912-7020 Phone: 1-877-236-0844 Fax: 1-920-968-4616 Website: www.lucent health.com/cypress

Prescription Drug Plan Administrator: Elixir E Aurora Rd.

Twinsburg, OH 44084 Phone: 1-800-361-4542

Participating Employer(s): Summit County Government

Agent for Service of Process: Summit County Government PO Box 68 208 E Lincoln Avenue Breckenridge, CO 80424 Phone: 1-970-453-3459 Fax: 1-970-453-3453 Website: www.summitcountyco.gov

The Plan shall take effect for each Participating Employer on the Effective Date, unless a different date is set forth above opposite such Participating Employer’s name.

Non-English Language Notice

This Plan Document contains a summary in English of a Participant’s plan rights and benefits under the Plan. If a Participant has difficulty understanding any part of this Plan Document, he or she may contact the Plan Administrator at the contact information above.

Legal Entity; Service of Process The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan Administrator.

Not a Contract This Plan Document and any amendments constitute the terms and provisions of coverage under this Plan.

The Plan Document is not to be construed as a contract of any type between the Company and any Participant or to be consideration for, or an inducement or condition of, the employment of any Employee.

Nothing in this Plan Document shall be deemed to give any Employee the right to be retained in the service of the Company or to interfere with the right of the Company to discharge any Employee at any time;

provided, however, that the foregoing shall not be deemed to modify the provisions of any collective bargaining agreements which may be entered into by the Company with the bargaining representatives of any Employees.

Mental Health Parity Pursuant to the Mental Health Parity Act (MHPA) of 1996 and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), collectively, the mental health parity provisions, this Plan applies its terms uniformly and enforces parity between covered health care benefits and covered mental health and substance disorder benefits relating to financial cost sharing restrictions and treatment duration limitations. For further details, please contact the Plan Administrator.

Non-Discrimination No eligibility rules or variations in contribution amounts will be imposed based on an eligible Employee’s and his or her Dependent’s/Dependents’ health status, medical condition, claims experience, receipt of

Plan Document and Summary Plan Description 5 health care, medical history, genetic information, evidence of insurability, disability, or any other health status related factor. Coverage under this Plan is provided regardless of an eligible Employee’s and his or her Dependent’s/Dependents’ race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or benefits of this Plan that are based on clinically indicated reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination.

Applicable Law This Plan is a governmental (sponsored) plan and as such it is exempt from the requirements of the Employee Retirement Income Security Act of 1974 (also known as ERISA), which is a Federal law regulating Employee welfare and pension plans. The Participants' rights in the Plan are governed by the plan documents and applicable State law and regulations.

Discretionary Authority

To the extent allowed by law, the Plan Administrator shall have sole, full and final discretionary authority to interpret all Plan provisions, including the right to remedy possible ambiguities, inconsistencies and/or omissions in the Plan and related documents; to make determinations in regards to issues relating to eligibility for benefits; to decide disputes that may arise relative to a Participant's rights; and to determine all questions of fact and law arising under the Plan.

Plan Document and Summary Plan Description 6

DEFINITIONS

The following words and phrases shall have the following meanings when used in the Plan Document.

Some of the terms used in this document begin with a capital letter, even though the term normally would not be capitalized. These terms have special meaning under the Plan. Most terms will be listed in this Definitions section, but some terms are defined within the provision the term is used. Becoming familiar with the terms defined in the Definitions section will help to better understand the provisions of this Plan.

The following definitions are not an indication that charges for particular care, supplies or services are eligible for payment under the Plan, however they may be used to identify ineligible expenses;

please refer to the appropriate sections of the Plan Document for that information.

“Accident” “Accident” shall mean an event which takes place without one’s foresight or expectation, or a deliberate act that results in unforeseen consequences.

“Accidental Bodily Injury” or “Accidental Injury” “Accidental Bodily Injury” or “Accidental Injury” shall mean an Injury sustained as the result of an Accident, due to an outside traumatic event, or due to exposure to the elements.

“Actively at Work” or “Active Employment” An Employee is “Actively at Work” or in “Active Employment” on any day the Employee performs in the customary manner all of the regular duties of employment. An Employee will be deemed Actively at Work on each day of a regular paid vacation or on a regular non-working day, provided the covered Employee was Actively at Work on the last preceding regular work day. An Employee shall be deemed Actively at Work if the Employee is absent from work due to a health factor, as defined by HIPAA, subject to the Plan’s Leave of Absence provisions (including any State-mandated leave). An Employee will not be considered under any circumstances Actively at Work if he or she has effectively terminated employment.

“ADA”

“ADA” shall mean the American Dental Association.

“Adverse Benefit Determination” “Adverse Benefit Determination” shall mean any of the following:

1. A denial in benefits.

2. A reduction in benefits.

3. A rescission of coverage, even if the rescission does not impact a current claim for benefits.

4. A termination of benefits.

5. A failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Claimant’s eligibility to participate in the Plan.

6. A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review.

7. A failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary or appropriate.

Explanation of Benefits (EOB) “Explanation of Benefits” shall mean a statement a health plan sends to a Participant which shows charges, payments and any balances owed. It may be sent by mail or e-mail. An Explanation of Benefits may serve as an Adverse Benefit Determination.

“Affordable Care Act (ACA)” The “Affordable Care Act (ACA)” means the health care reform law enacted in March 2010. The law was enacted in two parts: the Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name

Plan Document and Summary Plan Description 7

“Affordable Care Act” is commonly used to refer to the final, amended version of the law. In this document, the Plan uses the name Affordable Care Act (ACA) to refer to the health care reform law.

“AHA”

“AHA” shall mean the American Hospital Association.

“Allowable Expense(s)” “Allowable Expense(s)” shall mean the Maximum Allowable Charge for any Medically Necessary, eligible item of expense, at least a portion of which is covered under this Plan. When some Other Plan pays first in accordance with the Application to Benefit Determinations provision in the Coordination of Benefits section, this Plan’s Allowable Expenses shall in no event exceed the Other Plan’s Allowable Expenses.

When some “Other Plan” provides benefits in the form of services (rather than cash payments), the Plan Administrator shall assess the value of said benefit(s) and determine the reasonable cash value of the service or services rendered, by determining the amount that would be payable in accordance with the terms of the Plan. Benefits payable under any Other Plan include the benefits that would have been payable had the claim been duly made therefore, whether or not it is actually made.

“Alternate Recipient” “Alternate Recipient” shall mean any Child of a Participant who is recognized under a Medical Child Support Order as having a right to enrollment under this Plan as the Participant’s eligible Dependent. For purposes of the benefits provided under this Plan, an Alternate Recipient shall be treated as an eligible Dependent.

“AMA”

“AMA” shall mean the American Medical Association.

“Ambulatory Surgical Center” “Ambulatory Surgical Center” shall mean any permanent public or private State licensed and approved (whenever required by law) establishment that operates exclusively for the purpose of providing Surgical Procedures to patients not requiring hospitalization with an organized medical staff of Physicians, with continuous Physician and nursing care by Registered Nurses (R.N.s). The patient is admitted to and discharged from the facility within the same working day as the facility does not provide service or other accommodations for patients to stay overnight.

“Applied Behavioral Analysis (ABA)” “Applied Behavioral Analysis (ABA)” is a type of therapy used to improve social, communication, and learning skills through reinforcement strategies. ABA therapy is considered to be an effective treatment for Autism Spectrum Disorder (ASD) or other developmental disorders.

“Approved Clinical Trial” “Approved Clinical Trial” means a phase I, II, III or IV trial that is Federally funded by specified Agencies (National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare and Medicaid Services (CMS), Department of Defense (DOD) or Veterans Affairs (VA), or a non-governmental entity identified by NIH guidelines) or is conducted under an Investigational new drug application reviewed by the Food and Drug Administration (FDA) (if such application is required).

The Affordable Care Act requires that if a “qualified individual” is in an “Approved Clinical Trial,” the Plan cannot deny coverage for related services (“routine patient costs”).

A “qualified individual” is someone who is eligible to participate in an “Approved Clinical Trial” and either the individual’s doctor has concluded that participation is appropriate or the Participant provides medical and scientific information establishing that their participation is appropriate.

“Routine patient costs” include all items and services consistent with the coverage provided in the plan that is typically covered for a qualified individual who is not enrolled in a clinical trial. Routine patient costs do

Plan Document and Summary Plan Description 8 not include 1) the Investigational item, device or service itself; 2) items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; and 3) a service that is clearly inconsistent with the widely accepted and established standards of care for a particular Diagnosis. Plans are not required to provide benefits for routine patient care services provided outside of the Plan’s Network area unless Out-of-Network benefits are otherwise provided under the Plan.

“Autism Spectrum Disorder (ASD)” “Autism Spectrum Disorder” is a complex developmental condition that involves persistent challenges in social interaction, speech and nonverbal communication, and restricted/repetitive behaviors, including, but not limited to, autism disorder, Asperger’s syndrome and pervasive development disorders.

“Calendar Year” “Calendar Year” shall mean the 12 month period from January 1 through December 31 of each year.

“Cardiac Care Unit” “Cardiac Care Unit” shall mean a separate, clearly designated service area which is maintained within a Hospital and which meets all the following requirements:

1. It is solely for the care and treatment of critically ill patients who require special medical attention because of their critical condition.

2. It provides within such area special nursing care and observation of a continuous and constant nature not available in the regular rooms and wards of the Hospital.

3. It provides a concentration of special lifesaving equipment immediately available at all times for the treatment of patients confined within such area.

4. It contains at least two beds for the accommodation of critically ill patients.

5. It provides at least one professional Registered Nurse, in continuous and constant attendance of the patient confined in such area on a 24 hour a day basis.

“CDC”

“CDC” shall mean Centers for Disease Control and Prevention.

“Certified IDR Entity” “Certified IDR Entity” shall mean an entity responsible for conducting determinations under the No Surprises Act and that has been properly certified by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury.

“Child” and/or “Children” “Child” and/or "Children" shall mean the Employee’s natural Child, any stepchild, legally adopted Child, or any other Child for whom the Employee has been named legal guardian. For purposes of this definition, a legally adopted Child shall include a Child placed in an Employee’s physical custody in anticipation of adoption. “Child” shall also mean a covered Employee’s Child who is an Alternate Recipient under a Qualified Medical Child Support Order, as required by the Federal Omnibus Budget Reconciliation Act of 1993. A “legal guardian” is a person recognized by a court of law as having the duty of taking care of the person and managing the property and rights of a minor child.

“CHIP”

“CHIP” refers to the Children’s Health Insurance Program or any provision or section thereof, which is herein specifically referred to, as such act, provision or section may be amended from time to time.

“CHIPRA”

“CHIPRA” refers to the Children’s Health Insurance Program Reauthorization Act of 2009 or any provision or section thereof, which is herein specifically referred to, as such act.

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“Chiropractic Care” “Chiropractic Care” shall mean the detection and correction, by manual or mechanical means, of the interference with nerve transmissions and expressions resulting from distortion, misalignment or dislocation of the spinal (vertebrae) column.

“Claim Determination Period” “Claim Determination Period” shall mean each Calendar Year.

“Claimant” “Claimant” shall mean a Participant of the Plan, or entity acting on his or her behalf, authorized to submit claims to the Plan for processing, and/or appeal an Adverse Benefit Determination.

“Clean Claim” A “Clean Claim” is one that can be processed in accordance with the terms of this document without obtaining additional information from the service Provider or a third party. It is a claim which has no defect or impropriety. A defect or impropriety shall include a lack of required sustaining documentation as set forth and in accordance with this document, or a particular circumstance requiring special treatment which prevents timely payment as set forth in this document, and only as permitted by this document, from being made. A Clean Claim does not include claims under investigation for fraud and abuse or claims under review for Medical Necessity or other coverage criteria, or fees under review for application of the Maximum Allowable Charge, or any other matter that may prevent the charge(s) from being Covered Expenses in accordance with the terms of this document.

Filing a Clean Claim. A Provider submits a Clean Claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements or revisions to data elements, attachments and additional elements, of which the Provider has knowledge. The Plan Administrator may require attachments or other information in addition to these standard forms (as noted elsewhere in this document and at other times prior to claim submittal) to ensure charges constitute Covered Expenses as defined by and in accordance with the terms of this document. The paper claim form or electronic file record must include all required data elements and must be complete, legible, and accurate. A claim will not be considered to be a Clean Claim if the Participant has failed to submit required forms or additional information to the Plan as well.

“CMS”

“CMS” shall mean Centers for Medicare and Medicaid Services.

“COBRA”

“COBRA” shall mean the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

“Coinsurance” “Coinsurance” shall mean a cost sharing feature of many plans which requires a Participant to pay out-of-pocket a prescribed portion of the cost of Covered Expenses. The defined Coinsurance that a Participant must pay out-of-pocket is based upon his or her health plan design. Coinsurance is established as a predetermined percentage of the Maximum Allowable Charge for covered services and usually applies after a Deductible is met in a Deductible plan.

“Copayment” or “Copay” “Copayment” or “Copay” shall mean a dollar amount per visit the Participant pays to the Provider for health care expenses. In most plans, the Participant pays this after he or she meets his or her Deductible limit.

“Cosmetic Surgery” “Cosmetic Surgery” shall mean any expenses Incurred in connection with the care and treatment of, or operations which are performed for plastic, reconstructive, or cosmetic purposes or any other service or supply which are primarily used to improve, alter, or enhance appearance of a physical characteristic which is within the broad spectrum of normal but which may be considered displeasing or unattractive, except when required by an Injury.

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“Covered Expense(s)” “Covered Expense(s)” shall mean a service or supply provided in accordance with the terms of this document, whose applicable charge amount does not exceed the Maximum Allowable Charge for an eligible Medically Necessary service, treatment or supply, meant to improve a condition or Participant’s health, which is eligible for coverage in accordance with this Plan. When more than one treatment option is available, and one option is no more effective than another, the Covered Expense is the least costly option that is no less effective than any other option.

All treatment is subject to benefit payment maximums shown in the Summary of Benefits and as set forth elsewhere in this document.

“Custodial Care” “Custodial Care” shall mean care or confinement designated principally for the assistance and maintenance of the Participant, in engaging in the activities of daily living, whether or not totally disabled. This care or confinement could be rendered at home or by persons without professional skills or training. This care may relieve symptoms or pain but is not reasonably expected to improve the underlying medical condition.

Custodial Care includes, but is not limited to, assistance in eating, dressing, bathing and using the toilet, preparation of special diets, supervision of medication which can normally be self-administered, assistance in walking or getting in and out of bed, and all domestic activities.

“Deductible” “Deductible” shall mean an aggregate amount for certain expenses for covered services that is the responsibility of the Participant to pay for him or herself each Calendar Year before the Plan will begin its payments.

“Dentist” “Dentist” shall mean a properly trained person holding a D.D.S. or D.M.D. degree and practicing within the scope of a license to practice dentistry within their applicable geographic venue.

“Dependent” “Dependent” shall mean one or more of the following person(s):

1. An Employee’s present spouse (including a common law spouse) thereby possessing a valid marriage license, not annulled or voided in any way and legal in the state in which the marriage was formalized. A Dependent spouse shall therefore not be one who is divorced or Legally Separated from the Employee. A Dependent spouse shall also include an Employee’s partner in a civil union under Colorado state law.

2. An Employee’s verified same or opposite-sex domestic partner meeting the standards for a domestic partnership as set forth by Summit County Government. An Affidavit of domestic partnership must be properly executed and filed with Summit County and all parties must have concurred with and adhered to the terms and conditions theron and in all applicable and addenda to such affidavit. NOTE: To the extent COBRA coverage is applicable, an Employee’s domestic partner is not considered a qualified beneficiary and does not have independent rights under COBRA; however, an Employee’s domestic partner will be entitled to COBRA continuation coverage as a dependent of a qualified beneficiary. An Employee’s domestic partner and the domestic partner's enrolled children will be considered a qualified beneficiary and eligible to continue coverage under the COBRA provisions to the same extent as an Employee’s spouse or Child.

3. An Employee’s Child who is less than 26 years of age. NOTE: Coverage of a Dependent Child will continue until the end of the calendar month he or she turns 26 years of age.

4. An Employee’s Child, regardless of age, who was continuously covered prior to attaining the limiting age as stated in the numbers above, who is mentally or physically incapable of sustaining his or her own living. Such Child must have been mentally or physically incapable of earning his or her own living prior to attaining the limiting age as stated in the numbers above. Written proof of such incapacity and dependency satisfactory to the Plan must be furnished and approved by the Plan within 30 days after the date the Child attains the limiting age as stated in the numbers above.

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The Plan may require, at reasonable intervals, subsequent proof satisfactory to the Plan during the next two years after such date. After such two year period, the Plan may require such proof, but not more often than once each year.

An Employee’s spouse or domestic partner who is an active duty member of any armed force shall not be deemed to be a “Dependent.”

An Employee’s spouse or domestic partner who is a resident of a country other than the United States shall not be deemed to be a “Dependent.”

To establish a Dependent relationship, the Plan reserves the right to require documentation satisfactory to the Plan Administrator.

NOTE: Tax treatment for certain dependents. Please be advised, the definition of “Dependent” may not be the same definition as established by the Internal Revenue Code (IRC) for individuals that can be enrolled as an eligible Dependent for tax-free benefits (i.e., Domestic Partner or non-IRC Section 152 Dependent). There may be tax implications for the Employee if he or she enrolls certain eligible Dependent(s). The Employee should consult his or her tax advisor with any questions on the tax consequences of benefits for his or her eligible Dependent(s).

“Diagnosis” “Diagnosis” shall mean the act or process of identifying or determining the nature and cause of an Illness or Injury through evaluation of patient history, examination, and review of laboratory data. Diagnosis shall also mean the findings resulting from such act or process.

“Diagnostic Service” “Diagnostic Service” shall mean an examination, test, or procedure performed for specified symptoms to obtain information to aid in the assessment of the nature and severity of a medical condition or the identification of an Illness or Injury. The Diagnostic Service must be ordered by a Physician or other professional Provider.

“Drug” “Drug” shall mean a Food and Drug Administration (FDA) approved Drug or medicine that is listed with approval in the United States Pharmacopeia, National Formulary or AMA Drug Evaluations published by the American Medical Association (AMA), that is prescribed for human consumption, and that is required by law to bear the legend: “Caution—Federal Law prohibits dispensing without prescription,” or a State restricted drug (any medicinal substance which may be dispensed only by prescription, according to State law), legally obtained and dispensed by a licensed drug dispenser only, according to a written prescription given by a Physician and/or duly licensed Provider. “Drug” shall also mean insulin for purposes of injection.

“Durable Medical Equipment” “Durable Medical Equipment” shall mean equipment and/or supplies ordered by a health care Provider for everyday or extended use which meets all of the following requirements:

1. Can withstand repeated use.

2. Is primarily and customarily used to serve a medical purpose.

3. Generally is not useful to a person in the absence of an Illness or Injury.

4. Is appropriate for use in the home.

“Elected and/or Appointed County Official” “Elected and/or Appointed County Official” shall mean a person who is an official by virtue of election, appointment or selection.

“Emergency” “Emergency” shall mean a situation or medical condition with symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention and treatment would reasonably be expected

Plan Document and Summary Plan Description 12 to result in: (a) serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the woman's unborn child); (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. An Emergency includes, but is not limited to, severe chest pain, poisoning, unconsciousness, and hemorrhage. Other Emergencies and acute conditions may be considered on receipt of proof, satisfactory to the Plan, per the Plan Administrator’s discretion, that an Emergency did exist. The Plan may, at its own discretion, request satisfactory proof that an Emergency or acute condition did exist.

“Emergency Medical Condition” “Emergency Medical Condition” shall mean a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so 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 a condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act (42 U.S.C. 1395dd(e)(1)(A)). In that provision of the Social Security Act, clause (i) refers to 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; clause (ii) refers to serious impairment to bodily functions; and clause (iii) refers to serious dysfunction of any bodily organ or part.

“Emergency Services” “Emergency Services” shall mean, with respect to an Emergency Medical Condition, the following:

1. An appropriate medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a Hospital or of an Independent Freestanding Emergency Department, as applicable, including ancillary services routinely available to the emergency department to evaluate such Emergency Medical Condition; and

2. Within the capabilities of the staff and facilities available at the Hospital or the Independent Freestanding Emergency Department, as applicable, such further medical examination and treatment as are 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, to stabilize the patient (regardless of the department of the Hospital in which such further examination or treatment is furnished).

When furnished with respect to an Emergency Medical Condition, Emergency Services shall also include an item or service provided by a Non-Network Provider or Non-Participating Health Care Facility (regardless of the department of the Hospital in which items or services are furnished) after the Participant is stabilized and as part of Outpatient observation or an Inpatient or Outpatient stay with respect to the visit in which the Emergency Services are furnished, until such time as the Provider determines that the Participant is able to travel using non-medical transportation or non-emergency medical transportation, and the Participant is in a condition to, and in fact does, give informed consent to the Provider to be treated as a Non-Network Provider.

“Employee” “Employee” shall mean a person who is employed by the Employer on a regular basis. Employees eligible for coverage must meet the following criteria:

Class 1: All Active Employees of the Employer.

Class 2: Elected and/or appointed County Officials.

Eligibility Requirements for Employee Coverage

1. A Full-Time, Active Employee of the Employer. An Employee is considered to be Full-Time if he or she normally works at least 30 hours per week for 12 months per year and is on the regular payroll of the Employer for that work.

2. A Seasonal, Full-Time Active Employee who is regularly scheduled to work a minimum of 30 hours per week, for at least three months but less than 12 months per year.

Plan Document and Summary Plan Description 13

3. A Part-Time, Active Employee of the Employer. An Employee is considered to be Part-Time if he or she normally works at least 20 hours per week, but less than 30 hours per week for 12 months per year and is on the regular payroll of the Employer for that work.

Seasonal Part-Time and Temporary Employees are generally not eligible to participate.

Please refer to information below related to Measurement Periods. “Seasonal Part-Time” shall mean an Employee who is regularly scheduled to work 20 or more hours, but less than 30 hours per week, for at least three months but less than 12 months per year. “Temporary” shall mean an Employee who is regularly scheduled to work less than three months per year.

NOTE: The description of full-time, part-time and seasonal Employees are provided for purposes of coverage under this group health plan only and do not define Employee status in any other classification pertaining to employment.

4. An Elected and/or Appointed County Official without regard to scheduled hours. The term Employee shall also mean Elected and/or Appointed County Official unless otherwise specified.

5. If the Employee is not designated as a Full-Time Active Employee, Seasonal Full-Time Active

Employee or Part-Time Active Employee by the Employer at the time of hire, or an Elected and/or Appointed County Official, the Employer may use a 12-month look-back measurement period to determine the Full-Time status as defined under the Plan. The Employee must average or be expected to average the required minimum hours of service established by the Employer each week during the Employer's 12-month measurement period to become eligible for coverage.

The Employer's 12-month measurement period is October 1st through September 30th. Coverage is effective on the first day of the stability period following the applicable measurement period. The stability period is from January 1st through December 31st each year. To remain eligible for coverage, the Employee must average the required minimum hours of service during each subsequent standard measurement period.

For more information on benefit measurement periods, contact the Employer’s Human Resources Department.

Coverage will begin as stated in the “Effective Dates for Individual Coverage” provision under the Eligibility for Coverage section of the Plan.

“Employer” “Employer” is Summit County Government.

“Essential Health Benefits” “Essential Health Benefits” shall mean, under section 1302(b) of the Affordable Care Act, those health benefits to include at least the following general categories and the items and services covered within the categories: ambulatory patient services; Emergency Services; hospitalization; maternity and newborn care;

mental health and substance abuse 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.

“Exclusion” “Exclusion” shall mean conditions or services that this Plan does not cover.

“Experimental” and/or “Investigational” “Experimental” and/or “Investigational” (“Experimental”) shall mean services or treatments that are not widely used or accepted by most practitioners or lack credible evidence to support positive short or long-term outcomes from those services or treatments and that are not the subject of, or in some manner related to, the conduct of an Approved Clinical Trial, as such term is defined herein; these services are not included

Plan Document and Summary Plan Description 14 under or as Medicare reimbursable procedures, and include services, supplies, care, procedures, treatments or courses of treatment which meet either of the following requirements:

1. Do not constitute accepted medical practice under the standards of the case and by the standards of a reasonable segment of the medical community or government oversight agencies at the time rendered.

2. Are rendered on a research basis as determined by the United States Food and Drug Administration and the AMA’s Council on Medical Specialty Societies.

A drug, device, or medical treatment or procedure is Experimental if one of the following requirements is met:

1. If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;

2. If reliable evidence shows that the drug, device or medical treatment or procedure is the subject of ongoing Phase I, II, or III clinical trials or under study to determine all of the following:

a. Maximum tolerated dose.

b. Toxicity.

c. Safety.

d. Efficacy.

e. Efficacy as compared with the standard means of treatment or Diagnosis.

3. If reliable evidence shows that the consensus among experts regarding the drug, device, or medical treatment or procedure is that further studies or clinical trials are necessary to determine all of the following:

a. Maximum tolerated dose.

b. Toxicity.

c. Safety.

d. Efficacy.

e. Efficacy as compared with the standard means of treatment or Diagnosis.

Reliable evidence shall mean one or more of the following:

1. Only published reports and articles in the authoritative medical and scientific literature.

2. The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or medical treatment or procedure.

3. The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

Notwithstanding the above, a prescription drug for a treatment that has been approved by the Food and Drug Administration (FDA) but is used as a non-approved treatment shall not be considered Experimental/Investigational for purposes of this Plan and shall be afforded coverage to the same extent as any other prescription drug, provided that the drug is recognized by one of the following as being Medically Necessary for the specific treatment for which it has been prescribed:

1. The American Medical Association Drug Evaluations.

2. The American Hospital Formulary Service Drug Information.

3. The United States Pharmacopeia Drug Information.

4. A clinical study or review article in a reviewed professional journal.

The Plan Administrator retains maximum legal authority and discretion to determine what is Experimental.

“Family Unit” “Family Unit” shall mean the Employee and his or her Dependents covered under the Plan.

Plan Document and Summary Plan Description 15

“FDA”

“FDA” shall mean Food and Drug Administration.

“Final Internal Adverse Benefit Determination” "Final Internal Adverse Benefit Determination" shall mean an Adverse Benefit Determination that has been upheld by the Plan at the conclusion of the internal claims and appeals process, or an Adverse Benefit Determination with respect to which the internal claims and appeals process has been deemed exhausted.

“Final Post-Service Appeal” “Final Post-Service Appeal” shall mean a post-service appeal, which constitutes the last internal appeal available to the Claimant, to be filed with the Plan Administrator, Plan Sponsor, and/or other named fiduciary assigned authority and the duty to otherwise handle appeals. The term “Final Post-Service Appeal” shall only refer to such appeals if medical services and/or supplies have already been provided. Upon filing, adjudication and conclusion of this appeal, external review becomes available to the Claimant; otherwise in accordance with applicable terms found within the Plan Document and applicable law. The Plan Administrator, Plan Sponsor, and/or other named fiduciary assigned authority and the duty to otherwise handle appeals, reserves the right to allocate certain discretionary authority as it applies to adjudication of Final Post-Service Appeals to the Plan Appointed Claim Evaluator (PACE).

“FMLA”

“FMLA” shall mean the Family and Medical Leave Act of 1993, as amended.

“FMLA Leave” “FMLA Leave” shall mean an unpaid, job protected Leave of Absence for certain specified family and medical reasons, which the Company is required to extend to an eligible Employee under the provisions of the FMLA.

“Gene Therapy” “Gene Therapy” shall mean a technique that modifies a person’s genes to treat or cure a disease by replacing a disease-causing gene with a healthy copy of the gene, inactivating a disease-causing gene that is not functioning properly, or introducing a new or modified gene into the body to help treat a disease.

Gene Therapy replaces a faulty gene or adds a new gene in an attempt to cure a disease or improve the body’s ability to fight disease such as cancer, cystic fibrosis, heart disease, hemophilia and AIDS.

“GINA”

“GINA” shall mean the Genetic Information Nondiscrimination Act of 2008 (Public Law No. 110-233), which prohibits group health plans, issuers of individual health care policies, and employers from discriminating on the basis of genetic information.

“Habilitation/Habilitative Services” “Habilitation/Habilitative Services” shall mean health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of Inpatient and/or Outpatient settings.

“HIPAA”

“HIPAA” shall mean the Health Insurance Portability and Accountability Act of 1996, as amended.

“Home Health Care” “Home Health Care” shall mean the continual care and treatment of an individual if all of the requirements are met:

1. The institutionalization of the individual would otherwise have been required if Home Health Care was not provided.

Plan Document and Summary Plan Description 16

2. The treatment plan covering the Home Health Care service is established and approved in writing by the attending Physician.

3. The Home Health Care is the result of an Illness or Injury.

“Home Health Care Agency” “Home Health Care Agency” shall mean an agency or organization which provides a program of Home Health Care and which meets one of the following requirements:

1. Is a Federally certified Home Health Care Agency and approved as such under Medicare.

2. Meets the established standards and is operated pursuant to applicable laws in the jurisdiction in which it is located and, is licensed and approved by the regulatory authority having the responsibility for licensing, where licensing is required.

3. Meets all of the following requirements.

a. It is an agency which holds itself forth to the public as having the primary purpose of providing a Home Health Care delivery system bringing supportive services to the home.

b. It has a full-time administrator.

c. It maintains written records of services provided to the patient.

d. Its staff includes at least one Registered Nurse (R.N.) or it has nursing care by a Registered

Nurse (R.N.) available.

e. Its employees are bonded and it provides malpractice insurance.

“Hospital” “Hospital” shall mean an Institution, accredited by the Joint Commission on Accreditation of Hospitals (sponsored by the AMA and the AHA), under the supervision of a staff of Physicians that maintains diagnostic and therapeutic facilities on premises, for the provision of medical (including Surgical facilities for all Institutions other than those specializing in the care and treatment of mentally ill patients, provided such Institution is accredited as such a facility by the Joint Commission on Accreditation of Hospitals sponsored by the AMA and the AHA), diagnosis, treatment, and care to Injured or sick persons, on an Inpatient basis, with 24 hour a day nursing service by Registered Nurses.

To be deemed a “Hospital,” the facility must be duly licensed if it is not a State tax supported Institution, and must not be primarily a place for rest, the aged, and/or a nursing home, custodial, or training institution;

or an Institution which is supported in whole or in part by a Federal government fund.

Institutions and/or facilities not deemed to be a “Hospital” in accordance with Medicare, shall not be deemed to be Hospitals for this Plan’s purposes.

“Hospital” shall also have the same meaning, where appropriate in context, set forth in the definition of “Ambulatory Surgical Center”.

“HRSA”

“HRSA” shall mean Health Resources and Services Administration.

“Illness” “Illness” shall mean any disorder which does not arise out of, which is not caused or contributed to by, and which is not a consequence of, any employment or occupation for compensation or profit; however, if evidence satisfactory to the Plan is furnished showing that the individual concerned is covered as an Employee under any workers’ compensation law, occupational disease law or any other legislation of similar purpose, or under the maritime doctrine of maintenance, wages, and cure, but that the disorder involved is one not covered under the applicable law or doctrine, then such disorder shall, for the purposes of the Plan, be regarded as an Illness.

“Impregnation and Infertility Treatment” “Impregnation and Infertility Treatment” shall mean any services, supplies or Drugs related to the Diagnosis or treatment of infertility.

Plan Document and Summary Plan Description 17

“Incurred” A Covered Expense is “Incurred” on the date the service is rendered or the supply is obtained. With respect to a course of treatment or procedure which includes several steps or phases of treatment, Covered Expenses are Incurred for the various steps or phases as the services related to each step are rendered and not when services relating to the initial step or phase are rendered. More specifically, Covered Expenses for the entire procedure or course of treatment are not Incurred upon commencement of the first stage of the procedure or course of treatment.

“Independent Freestanding Emergency Department” “Independent Freestanding Emergency Department” means a health care facility that is geographically separate and distinct, and licensed separately, from a Hospital under applicable state law, and which provides any Emergency Services.

“Injury” “Injury” shall mean an Accidental Bodily Injury, which does not arise out of, which is not caused or contributed to by, and which is not a consequence of, any employment or occupation for compensation or profit.

“Inpatient” “Inpatient” shall mean a Participant who receives care as a registered and assigned bed patient while confined in a Hospital, other than in its outpatient department, where a room and board is charged by the Hospital.

“Institution” “Institution” shall mean a facility created and/or maintained for the purpose of practicing medicine and providing organized health care and treatment to individuals, operating within the scope of its license, such as a Hospital, Ambulatory Surgical Center, Psychiatric Hospital, community mental health center, Residential Treatment Facility, psychiatric treatment facility, Substance Abuse Treatment Center, alternative birthing center, or any other such facility that the Plan approves.

“Intensive Care Unit” “Intensive Care Unit” shall have the same meaning set forth in the definition of “Cardiac Care Unit”.

“Intensive Outpatient Services” “Intensive Outpatient Services” shall mean programs that have the capacity for planned, structured, service provision of at least two hours per day and three days per week.