ORD 1993-40 - Amend - Ratify Employee Medical Benefit Plan 12-14-1993ORDINANCE NO. 93 -40
AN ORDINANCE OF THE CITY COUNCIL OF THE CITY OF
HUNTSVILLE, TEXAS, AMENDING AND RATIFYING THE EMPLOYEE
MEDICAL BENEFIT PLAN; AND MAKING OTHER FINDINGS AND
PROVISIONS RELATED THERETO.
WHEREAS the Trustees of the Employee Medical Benefit Plan of the City of Huntsville,
Texas, have recommended certain changes in the Plan encouraging use of generic
drugs, limiting the deductible for hospital stays, broadening the definition of
"child" and "children ", lessening the documentation requirement for spouses and
children, broadening the definition of "physician" to include certain counselors,
amending the definition of "dependent" to cover certain college students who take
fewer course hours; and
WHEREAS the City of Huntsville Employee Health Plan and Plan Summary have been
rewritten to facilitate use; and
WHEREAS the City Council desires to implement and ratify these changes;
NOW, THEREFORE, BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF
HUNTSVILLE, TEXAS, that:
Section 1.
Section 2.
"THE CITY OF HUNTSVILLE EMPLOYEE HEALTH PLAN ", attached hereto
as exhibit "a" is hereby adopted as the plan document of the City of Huntsville
Employee Health Plan and Trust.
The amendments related to preexisting coverage shall take effect as of October
1, 1992. The provisions related to new born and well baby care shall take effect
as of July 1, 1993. All other substantive amendments to the previous plan
document shall take effect October 1, 1993. Except as specifically provided
above, this ordinance shall take effect from and after its adoption by City
Council.
PASSED AND APPROVED this the 14th day of December, 1993.
THE CITY OF HUNTSVILLE
W. >'I. Hodges, Mayor
ATTEST:
'IAA}
elter, City Secretary
APPROVED AS TO FORM:
Scott Bounds, City Attorney
CITY OF HUNTSVILLE
EMPLOYEE HEALTH PLAN
AND TRUST
PLAN DOCUMENT
As amended through December 13, 1993, Ordinance No. 93 -40.
TABLE OF CONTENTS
ARTICLE PAGE
1. PURPOSE OF THE PLAN 1
11. ELIGIBILITY AND EFFECTIVE DATES 1 -4
111. MEDICAL COVERAGE 5 -16
IV. DENTAL COVERAGE 17 -26
V. COORDINATION OF BENEFITS 27 -28
VI. TERMINATION OF COVERAGE 29 -31
VII. CLAIMS 32 -34
VIII. GENERAL PROVISIONS 35 -36
IX. ADMINISTRATION 37
X. AMENDMENT AND TERMINATION
OF THE AGREEMENT 38
XI. DEFINITIONS 39 -44
CITY OF HUNTSVILLE
EMPLOYEE HEALTH PLAN AND TRUST
(PLAN DOCUMENT)
ARTICLE L PURPOSE OF THE PLAN
Effective October 1, 1993, this amendment and restatement of the City of Huntsville Employee Health
Plan and Trust is hereby adopted by the City of Huntsville, Texas, for the benefit of its Employees and
their Dependents. The Plan and the Trust (through which Benefits are provided) are intended to qualify
as a voluntary employees beneficiary association under 501(c)(9) of the Internal Revenue Code of
1986, as amended.
ARTICLE II. ELIGIBILITY AND EFFECTIVE DATES
2.01 ENROLLMENT
All Employees and their Dependents shall be eligible to enroll for Coverage.
An Employee, and the Employee's Dependents if the Employee wants to Cover them, shall:
a. complete an enrollment card (approved by the Administrator) naming each person to be covered;
b. agree to make any contributions that may be required as indicated in the Coverage Schedule; and
c. provide to the Administrator the Social Security number of each Dependent enrolled.
If an Employee is required to make a contribution for the Employee's Coverage, then the enrollment card
must be received by the Administrator on or before the first day of the calendar month immediately
following the date the person became an Employee. Furthermore, if a Covered Employee acquires a new
Dependent, the enrollment card for that new Dependent must be received by the Administrator within
thirty -one (31) days of the date the Employee acquired the Dependent.
If an enrollment card is received later than stated above, the Employee must submit, at the Employee's own
expense, evidence of good health acceptable to the Administrator. The Coverage shall become effective
on the date it is approved by the appropriate authority.
Receipt of an enrollment card after the date required as explained above shall not cause evidence of good
health to be required if the delay is due to the Employee's incapacity or error on the part of the
Administrator.
2.02 EMPLOYEES
Subject to the enrollment and Active Full -Time Work requirements, an Employee's Coverage shall begin
as follows:
a. on the first day of the calendar month immediately following the date the person became an
Employee, or
b. if an Employee is covered as primary under another group plan as of the date Coverage would
otherwise begin, on the day immediately following the date that the Employee no longer has such
other coverage.
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2.03 ACTIVE FULL -TIME WORK REQUIREMENT
If an Employee does not complete one day of Active Full -Time Work on the date that Coverage would
otherwise begin, then Coverage shall not begin until the date that the Employee has completed one day
of such work.
2.04 RETIREES
A retired employee of the Employer shall be entitled to the same medical Coverage as a regular Employee,
based on years of service and age, according to the following schedule:
Years of Service Age
10 65
20 60
25 55
30 50
2.05 DEPENDENTS
A Dependent of an Employee shall be eligible for Coverage on the same date the Employee is eligible.
Subject to the enrollment requirements, the Coverage shall begin on:
a. the date the Employee's Coverage begins or, if the Employee acquires a Dependent at a later date,
b. the date such Employee, while Covered, acquires the Dependent.
If a Dependent, other than a newborn child, is Totally Disabled on the date that the Coverage would
otherwise begin, then the Coverage shall not begin until the person is no longer Totally Disabled.
2.06 COBRA AND NON -COBRA COVERAGE UNDER THIS PLAN
No person shall have COBRA and non -COBRA Coverage under this Plan at the same time.
Regardless of any other provision in this Plan, if a person has COBRA coverage under this Plan on the
day before the person's non -COBRA Coverage would otherwise begin, then the change from COBRA
Coverage to non -COBRA Coverage for that person shall not result in a new effective date.
2.07 OTHER PROVISIONS RELATING TO EFFECTIVE DATES
A Covered Person's effective date of Coverage shall not change:
a. when the person becomes a Dependent of another Employee who has Dependent Coverage; or
b. when the person becomes a Dependent of a Covered Employee who has no Dependent Coverage,
provided that Employee satisfies the enrollment requirements for the Dependent; or
c. when the person's status changes from Dependent to Employee; or
d. when, if that person is a Dependent child, the person's Coverage is terminated by one Covered parent
and the person is enrolled by the other Covered parent in a manner which satisfies the enrollment
requirements.
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2.08 MEDICAL CHILD SUPPORT ORDERS
The provisions of this section shall apply regardless of any other Plan provision to the contrary.
'Medical Child Support Order' (MCSO) is any court judgment, decree, or order (including a court's approval
of a domestic relations settlement agreement) that:
a. provides for child support related to health care benefits with respect to the child of a Participant, or
requires Coverage of such child, and is ordered under state domestic relations law, or
b. enforces a state medical child support law enacted under the Social Security Act with respect to a
group health plan.
When the Administrator receives a MCSO, it shall
a. promptly notify the Participant and each alternate recipient that it has received the order;
b. determine within a reasonable period of time whether the MCSO is qualified and notify the Participant
and any alternate recipients of that determination.
When a MCSO specifies a person as eligible to receive benefits under the Plan, the Plan shall notify that
person of the Plan's determination and administration procedures (explained below) and permit an alternate
recipient to designate a representative to receive any required communication.
'Qualified Medical Child Support Order' ( QMCSO) is a Medical Child Support Order that either creates or
recognizes the right of an alternate recipient - or assigns to an alternate recipient the right - to receive
benefits for which a Participant or other beneficiary is entitled under the Plan. An "alternate recipient" is
any child of a Participant who is recognized under a MCSO as being entitled to enrollment in the Plan.
In addition, a QMCSO must include:
a. the name and last known mailing address of the participant;
b. the name and address of each alternate recipient;
c. a reasonable description of the type of Coverage to be provided or the manner in which such
Coverage is to be determined;
d. the period for which Coverage must be provided; and
e. each plan to which the order applies.
If a Qualified Medical Child Support Order requires Coverage for an Employee's child, that Coverage, if not
already in effect, shall become effective on the later of August 10, 1993, or the date required by the court
order, if the Plan is in force at that time. The Administrator shall not permit such Coverage to be
terminated unless it receives written evidence that the order is no longer in effect or that the child will be
enrolled in another comparable health plan. If contributions are required for Dependent Coverage, the
Employer shall withhold from the Employee's pay any amount of contribution necessary to fund the
Coverage for such child.
Determination Procedure
The procedure to determine whether a MCSO qualifies as a QMCSO shall consist of an evaluation of the
MCSO to determinate whether it meets all of the requirements of a QMCSO based on the definition of a
QMCSO as it appears in this section.
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Administration Procedure
When the plan is required to provide a payment of benefits under a QMCSO to reimburse an alternate
recipient's out -of- pocket medical expenses paid by the alternate recipient, or by his custodial parent or legal
guardian, such payment shall be made to the alternate recipient, custodial parent, or guardian.
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ARTICLE !IL MEDICAL COVERAGE
3.01 COVERAGE SCHEDULE
Recertification Penally
When the instructions for Precertification are not followed correctly for a Hospital admission, Benefits
otherwise payable for expenses incurred during the Hospital confinement shall be paid at a rate no
greater than 50 %.
Deductibles
Calendar Year Deductible $300
Family Deductible (3 separate Deductibles of $300 each) $900
Percentages Payable
Benefits for Covered Expenses will be payable as described below. The Calendar Year Deductible will
apply to all expenses unless otherwise indicated.
a. For the first $5,000 of Covered Expenses
incurred for a person during any one Calendar
Year, excluding Deductibles, expenses affected
by the Precertification Penalty, and the expenses
referred to in D. through I. below 80%
b. For the next $2,500 of expenses incurred for
a person during the same Calendar Year as
referred to in A. above and excluding the
same expenses excluded in that section 90/
c. For surgery performed on an outpatient basis at a
clinic, Hospital emergency room or Freestanding
Surgical Facility 90%
d. For the first $300 of expenses incurred for treatment
of accidental Injury, when the treatment was received
within 72 hours of the time of the accident causing
the Injury* 100%
*No Deductible shall apply to the first $300, but
expenses over that amount shall be subject to a
Deductible.
e. For Wellness Care, per Calendar Year per person
(Deductible waived) 100%
f. For amniocentesis for genetic or fertility studies 50%
g. For reconstructive mammoplasty and orthognathic surgery 50%
h. For a generic drug, subject to submission of a drug
receipt or label which designates the drug as generic 100%
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NOTE: The term "Network," as used below, refers to Interface EAP, an organization which manages the
care of Mental Disorders, Alcoholism and Drug Dependency. The higher payment percentage (90%) and
the higher maximum benefits available through Network care depend on all of the following conditions being
met:
1. Treatment is at an Interface PPA facility;
2. The Physician is under a Managed Care Contract with Interface
EAP;
3. Treatment is managed by Interface EAP; and
4. The level of care and length of stay are approved by Interface
EAP.
Interface EAP may be reached at 1-800-324-4327 or (713) 781-3364.
I. For Mental Disorders:
Inpatient Care
Non-network 80%
Network 90%
Outpatient Care
Non-network ..... _ . _ ....... _ ........... _ ..... _ 80%
Network 90%
Benefits for outpatient care shall be based on no more than one
(1) treatment per day and a maximum eligible charge per treatment as follows:
Non-network $20
Network $80
Benefits for Mental Disorders are never payable at 100%.
For Alcoholism or Drug Dependency, Separately or Combined
Inpatient Care
Non-network 80%
Network ....... . — .......... — — . . — — . . _ 90%
Outpatient Care
Non-network 80%
Network............ . . . ........ ............... — . 90%
No Benefits are payable for Alcoholism and Drug Dependency if the full course of treatment
prescribed by the Physician is not completed.
For inpatient treatment of any person, Benefits are limited to 30 days per Calendar Year and a
maximum of 60 days while that person is covered under this Plan, whether for Alcoholism, Drug
Dependency or both combined.
Stop Loss Amount*
$7,500 per Covered Person
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*The stop loss amount includes only expenses of the types described in A., B. and C. above. After a total
of $7,500 of such expenses are incurred for a Covered Person during a Calendar Year, the Plan will pay
100% of additional Covered Expenses in those categories which are incurred for that same person during
the remainder of the same year. This provision shall, however, not apply to any expense for which a benefit
is paid or payable under any other "plan," as defined in the section entitled Coordination of Benefits. For
such an expense, benefits under this plan shall not exceed 80 %.
Maximum Benefits
For all Sicknesses, Injuries and Wellness Care, Combined:
Lifetime Maximum
For Mental Disorders:
Calendar Year Maximum for Inpatient and Outpatient Care
.$1,000,000
Non - Network $ 500
Network 1,500
Lifetime Maximum 10,000
For Alcoholism or Drug Dependency, Separately or Combined:
Calendar Year Maximum
Non - network $ 1,200
Network 2,400
Lifetime Maximum
Inpatient $ 10,000
Outpatient 2,400
For Care and Treatment by a Doctor of Chiropractic:
Calendar Year Maximum* $ 750
*This maximum is based on charges of no
more than $25 per visit, not including x -rays.
For the Purchase and Repair of Glucometers:
Lifetime Maximum
For Supplies used to Monitor Blood Glucose Levels, as explained under "Covered Expenses ":
Calendar Year Maximum
For Amniocentesis for Genetic or Fertility Studies:
Calendar Year Maximum
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$ 150
$ 600
$ 300
For Reconstructive Mammoplasty:
Lifetime Maximum $ 5,000
For Wellness Care:
Calendar Year Maximum $ 200*
*Includes a maximum of $100 for eye examinations, eyeglasses, contact lenses and
any other eye care or eye wear.
Employee Eligibility Requirement
30 hours per week
Age When a Child's Coverage Ends
Non-Student
Full-Time Student
Contributions Required
Employee Coverage - No
Dependent Coverage - Yes
Preexisting Conditions
19 years
25 years
As of August 10, 1993, this section shall not apply to an adopted child, meaning any person under age
18 as of the date of adoption or being placed for adoption (see definition of "Dependent" for the
meaning of "being placed for adoption").
"Preexisting Condition" shall mean Sickness or Injury of a Covered Person for which either that person
received any professional care, treatment or service, or any item, including prescription drugs or
medicines, was purchased for that person, during any part of the six-month period immediately prior to
the effective date of the person's Coverage.
The Plan shall, to the extent otherwise provided by the Plan, provide limited Benefits for a Preexisting
Condition:
a. For any person whose coverage under the Plan began before October 1, 1992, there shall be no
exclusion of benefits based upon a Preexisting Condition for any expense incurred after that person
is covered by the Plan for twelve (12) consecutive months. The Coverage must, however, have been
continuous from the date it began through the date the expense was incurred.
b. For any other person, the Plan will provide:
1 up to a maximum Benefit of $500 of the Covered Expenses related to the Preexisting Condition
and incurred by the person during the first year (twelve consecutive months) of Coverage, and
2. up to a maximum Benefit of $3,000 of the Covered Expenses related to the Preexisting Condition
and incurred during the second continuous year (twelve consecutive months) of Coverage.
No restriction due to a Preexisting Condition will apply to any expense incurred for such a person
if (a) the expense was incurred after that person had been Covered for at least twenty-four
consecutive months and (b) the Coverage had not terminated from the time it began through the
date the expense was incurred.
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Well Baby Care
Covered Expenses for a newborn Covered child shall include Reasonable and Customary Charges for
routine care provided only during the first five (5) days of the Hospital confinement following the child's
birth.
302 PRECERTIFICATION
"Precertification" means a procedure to determine if and how long a patient needs to be hospitalized.
If the instructions described below are not followed correctly when a Covered Person needs to be
hospitalized, the Precertification Penalty described in the Coverage Schedule shall apply.
For the employee and the employee's Dependents, unless it is not reasonably possible for the Employee
to do so, the Employee must notify the Precertification Administrator, by telephone, of every Hospital
admission. This must be done before admission occurs or within seventy -two (72) hours immediately
following Emergency admission.
"Precertification Administrator" shall mean the program, organization or entity designated by the
Administrator to perform Precertification.
303 CALENDAR YEAR DEDUCTIBLE
The amount of the Calendar Year Deductible is shown in the Coverage Schedule.
A separate Calendar Year Deductible shall be required for each Covered Person. The only exception to
this requirement shall apply to Covered Expenses incurred in the same Calendar Year as follows:
The Calendar Year Deductible shall not apply to any expense incurred for a Covered family member after
the date during that year that the Family Deductible shown in the Coverage Schedule has been satisfied.
304 DEDUCTIBLE CARRYOVER
Covered Expenses incurred in the last three (3) months of a Calendar Year which were correctly applied
to a person's Calendar Year Deductible for that year may be applied to the same person's Calendar Year
Deductible for the immediately following Calendar Year.
305 COMMON ACCIDENT
When two or more Covered Persons of one family incur Covered Expenses during a Calendar Year as a
result of Injuries received in the same Accident, no more than one (1) Calendar Year Deductible shall apply
to expenses related to those same Injuries which are incurred in the year of the accident or in the next
year. This shall not affect any other Deductible requirement.
3.06 PERCENTAGES PAYABLE
The Plan shall pay Benefits for Covered Expenses as explained under "Percentages Payable" and "Stop
Loss Amount" in the Coverage Schedule.
307 MAXIMUM BENEFIT AMOUNT
The Maximum Benefit Amount for each category of coverage is shown in the Coverage Schedule. Where
shown in that schedule as "Calendar Year Maximum," it is the total amount of Benefits available for
expenses incurred by or for a Covered Person during a Calendar Year; where shown as "Lifetime
Maximum," it is the total amount of Benefits available for a Covered Person while covered under this Plan.
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3.08 COVERED EXPENSES
A Covered Expense for a service or item shall be considered incurred on the date the service was rendered
or the item was fumished.
Covered Expenses shall mean Reasonable and Customary Charges incurred for a Covered Person, while
that person is covered under this Plan, for voluntary sterilization, oral contraceptives, Well Baby Care,
Wellness Care and the following items when these items qualify as Necessary Care and Treatment of
Sickness or Injury:
a. Hospital room and board and general nursing care, but limited to the Hospital's most common
semi - private room rate. The semi - private room limit shall not apply to charges for Intensive Care
(meaning special Hospital care, including twenty -four (24) hour nursing service for the treatment of
severely or critically injured or sick patients, including Coronary Care and Neo -Natal Care), nor shall
it apply to charges for Intermediate Care or Private Room, if such accommodations are Necessary
Care and Treatment. All such charges shall be considered as miscellaneous Hospital services and
supplies.
b. Miscellaneous Hospital services and supplies.
c. The following, if not included under "(a)" or "(b)" above:
1. Professional services of Physicians.
2. Private -duty nursing services of a registered nurse (R.N.) or a licensed vocational nurse (L.V.N.).
Such services must be rendered when the Covered Person is confined in a Hospital as a
registered bed patient, or as part of 24 -hour private -duty nursing service prescribed by a
Physician, where a combination of R.N.'s and L.V.N.'s is used for the various eight -hour shifts.
Services of any nurse who ordinarily resides in the Covered Person's household shall be excluded
from Coverage.
3. Physiotherapy by a physiotherapist who does not live in the Covered Person's home and is not
a member of the Covered Person's immediate family.
4. X -rays, diagnostic laboratory procedures and oxygen.
5. Local professional ambulance service. A charge for this item shall be a Covered Expense only
if the service is to and from a Hospital. Service shall be considered local only if the person is
carried no more than 50 miles from the place of pickup.
6. Transporting a Covered Person from the first area of care for a condition to and from a Hospital
in another area. This shall be subject to a Benefit payment maximum of $500 for each period of
disability. This transportation shall be subject to these conditions: (a) no Hospital in the local area
is equipped to care for the person's condition, (b) the trip is to the nearest Hospital that is so
equipped and (c) the trip is from one area of the continental United States to another.
7. Insulin and drugs and medicines which can be purchased only with the prescription of a
Physician.
8. Blood and other fluids to be injected into the circulatory system.
9. Casts, splints and surgical dressings.
10. The initial supply, but not the replacement of, trusses, braces, crutches and artificial limbs and
eyes.
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11. The rental or, at the option of the Administrator, the purchase of medical or surgical equipment
which meets all of the following requirements:
a) It is certified by the attending physician as necessary for treatment.
b) It improves the function of a malformed body member or retards deterioration of a Covered
Person's physical condition.
c) It is suited particularly to the needs of the Covered Person because of Sickness or Injury and
is not useful to any person in the absence of Injury or Sickness.
d) It is primarily used for medical purposes rather than for transportation, comfort or
convenience.
12. Daily room and board and nursing care in a Skilled Nursing Facility which (a) does not exceed
50% of the most common daily semi-private room rate of the Hospital from which the Covered
Person was most recently confined as an inpatient and (b) are for no more than thirty (30) days
during any period of twelve (12) consecutive months. Such charges, however, shall be considered
Covered Expenses only if:
a) they are incurred for a continuous confinement in a Skilled Nursing Facility which began
within fourteen (14) days after the patient was discharged from a Hospital where the person
was an inpatient for at least three (3) consecutive days under circumstances permitting
payment of Benefits for charges made by that Hospital;
b) the confinement is certified by a Physician as necessary for continuing care of the condition
for which the patient was hospitalized immediately prior to the person's admission to the
Skilled Nursing Facility;
c) a Physician supervises the care of the patient during the entire period of such confinement;
and
d) the confinement is not for custodial or domiciliary care.
13. Services provided to a Covered Person by or through a home health care agency. Such services
must be necessary to treat Injury or Sickness for which the Covered Person would otherwise have
required inpatient confinement in a Hospital or similar institution. Home health care services shall
be limited to the following:
a) part-time or intermittent nursing care rendered by a registered nurse or a licensed vocational
nurse under the supervision of a registered nurse;
b) physical, occupational and speech therapy rendered or supervised by a duly qualified
therapist;
c) medical supplies, drugs and medicines prescribed by a Physician;
d) laboratory services; and
e) part-time or intermittent home health aide services provided in the Covered Person's home.
Such services shall consist primarily of patient care of a medical or therapeutic nature. They
shall be limited to 100 home health aide visits during any one Calendar Year for all Injuries
and Sicknesses of any one Covered Person. No benefits shall be payable for care given
mainly to help the Covered Person in the activities of daily living.
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14. Therapy given by a qualified speech therapist to treat a speech defect if:
a) the defect is the direct result of Injury or Sickness of a Covered Person which began while
that person was covered under the Plan; and
b) the type and duration of treatment has been prescribed by a Physician.
No Benefits shall be payable, however, for speech therapy given after a period of three (3)
consecutive months beginning with the first day of the therapy.
15. Hearing aids and related examinations, if:
a) the expenses are necessary to correct an impairment of a Covered Person caused directly
by an Injury;
b) that person was covered under this Plan when the Injury occurred; and
c) the hearing aid and examination were obtained within a period of three (3) consecutive
months immediately following the date of the Injury.
16. Services and supplies furnished by a Freestanding Surgical Facility in connection with outpatient
surgery.
17. Services provided by a Birthing Center in connection with childbirth.
18. Glucometers and their repair, and supplies used in connection with monitoring blood glucose
levels, excluding swabs, alcohol, bandages and battery packs.
19. Charges for psychological testing.
20. Services and supplies in connection with an organ transplant procedure, as follows:
a) Recipient Costs: When the recipient is a Covered Person, Benefits shall be payable for
recipient costs whether or not the donor is a Covered Person.
b) Donor Costs:
i. when the donor is a Covered Person, Benefits shall be payable for donor costs whether
or not the recipient is a Covered Person;
ii. when the donor is not a Covered Person, and the recipient is a Covered Person, only
those expenses of the donor not paid by the donor's plan shall be recognized as
Covered Expenses.
Benefits shall be payable only to the extent that Benefits remain available under the
recipient's plan.
c) Limitations: If the donor is not a Covered Person, Benefits for donor costs shall be limited to
those directly related to the transplant procedure itself, including complications. They shall
not include any costs related to other treatment of the donor. Donor transportation costs shall
be excluded whether or not the donor is a Covered Person. No Benefits shall be payable for
experimental procedures or for organ transplants performed under a study, grant or research
program for either recipient or donor costs.
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21. Treatment of Mental Disorders, Alcoholism and Drug Dependency as follows:
a) Inpatient Benefits:
If a Covered Person is confined as a registered bed patient in a Hospital or Specialized
Treatment Facility for treatment of a Mental Disorder and/or Alcoholism and/or Drug
Dependency, Coverage shall be provided as described in the Coverage Schedule.
b) Outpatient Benefits:
i. To be considered for Coverage, outpatient treatment of Mental Disorders, Alcoholism or
Drug Dependency must be ordered by a Physician and be rendered by a Physician, a
Hospital, a Specialized Treatment Facility, or an Outpatient Treatment Center.
ii. Benefits for outpatient treatment of Mental Disorders, Alcoholism and/or Drug
Dependency shall be payable as described in the Coverage Schedule.
22. Hospice care, as follows:
Hospice Care shall be an alternative to the Hospital confinement of a terminally ill person. A
terminally ill person shall mean a person who has a life expectancy of six months or less, as
confirmed by the attending Physician. Hospice Benefits shall be available to a terminally ill
Covered Person for a maximum period of six months. The attending Physician must approve the
program.
"Hospice" shall mean an agency which:
a) is primarily engaged in providing counseling, medical services or room and board to
terminally ill persons;
b) has professional service policies established by a group associated with it. This group must
include at least one Physician, one registered nurse (R.N.) and one social service
coordinator;
c) has full -time supervision by a Physician;
d) has a full -time administrator;
e) provides services 24 hours a day, seven days a week;
f) maintains a complete medical record of each patient; and
g) is licensed by the appropriate licensing authority.
Hospice charges eligible for coverage under the Plan shall be the Reasonable and Customary
Charges made by the Hospice for:
a) room and board;
b) private duty nursing care provided by or under the supervision of a registered nurse (R.N.);
c) part-time or intermittent home health aide services rendered by employees of the Hospice;
d) social work performed by a licensed social worker;
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e) nutritional services, including special meals;
f) emotional support services;
g) bereavement counseling sessions for immediate family members; and
h) drugs and medication.
309 LIMITATIONS AND EXCLUSIONS
NOTE: Any exception to a limitation or exclusion, whether stated or implied, is still subject to all other
terms, conditions and provisions of the Plan.
No benefits shall be payable for any of the following:
1. treatment, services or supplies not prescribed by a Physician;
2. services rendered to the Covered Person by such person's spouse, child, brother, sister, parent
or parent of such person's spouse;
3. treatment, service or supplies for which the Covered Person is not legally required to pay;
4. services rendered or supplies furnished by a hospital owned or operated by the government of
the United States or any agency thereof;
5. loss caused or contributed to by:
a) war or act of war, whether war is declared or not, or
b) a person's Sickness or Injury which occurs while that person is on active duty in the armed
forces of any country or intemational authority;
6. sickness caused by or Injury arising out of or in the course of any occupation for pay or profit;
7. treatment, services or supplies which do not qualify as Necessary Care and Treatment of
Sickness or Injury (this exclusion shall not apply, however, to charges for Wellness Care);
8. charges in excess of Reasonable and Customary Charges;
9. dental services, meaning services in connection with the teeth or any of their surrounding tissues
or structures (this exclusion shall not apply, however, to charges in connection with any of the
following):
a) tumors;
b) the removal of unerupted teeth;
c) charges for care, service, or supplies furnished for dental treatment by (i) a Hospital on an
inpatient or outpatient basis, or (ii) by a Freestanding Surgical Facility;
d) treatment of Injury to natural teeth; and
e) treatment for the correction of a congenital defect of a child who was a Covered Person when
born;
10. eyeglasses or lenses, except initial corrective lenses following cataract surgery; eye refractions
or any other examinations to determine the need for lenses or a change of same;
14
11. treatment or removal, in whole or in part, of corns, callosities, hypertrophy or hyperplasia of the
skin or any subcutaneous tissue; the cutting, trimming or partial removal of toenails unless the
matrix is wholly or partially excised; orthopedic shoes unless such shoes are part of a brace
specifically built and fitted in accordance with a Physician's prescription; devices to be placed
inside of shoes unless fitted in accordance with a Physician's prescription;
12. any care, services or supplies provided primarily as rest cure or maintenance or Custodial Care;
13. air - conditioners, air - purification units, humidifiers, allergy -free pillows, blankets or mattress covers,
electric heating units, swimming pools, orthopedic mattresses, water beds, exercising equipment,
vibratory equipment, elevators or stair lifts, blood pressure instruments, stethoscopes, clinical
thermometers, scales, wigs, devices for simulating natural female body contours except when
required to replace tissue lost as a result of Sickness or Injury; elastic stockings, unless
specifically designed and fitted in accordance with a Physician's prescription or given directly to
a patient by a Physician or Hospital; and elastic bandages, unless given directly to a patient by
a Physician or Hospital;
14. services performed for cosmetic purposes; this exclusion shall not apply, however, to correction
of disfigurement due to tissue lost or damaged as a result of Sickness or Injury, provided, in the
case of Injury, that treatment begins within ninety (90) consecutive days after the Injury occurred.
It also shall not apply to the correction of a congenital defect of a person who was born while the
person's parent was covered under the Plan;
15. sickness or Injury which is intentionally self - induced or self - inflicted, or which results directly or
indirectly from the Covered Person's commission of a crime or participation in a riot;
16. a Preexisting Condition, except as explained in the Coverage Schedule;
17. treatment by a doctor of chiropractic, except as shown in the Coverage Schedule;
18. hospital room and board on a Friday and the immediately following Saturday if the admitting day
is a Friday, and on a Saturday if that is the day of admission. This exclusion shall not apply,
however, when admission is required by Emergency;
19. prescription drugs for a person who, as determined by the Administrator, has overutilized or
abused drugs, regardless of the medical necessity that exists as a result of such overutilization
or abuse; or prescription drugs or supplies to the greater of (a) the extent that such drugs or
supplies were used or will be used after the termination date of coverage of the person for whom
they were prescribed, or (b) the quantity purchased at any time exceeds a three (3) month supply;
20. weight reduction or treatment of obesity, unless required because of existing diabetes or
pulmonary or circulatory disease, or unless the Covered Person is 50% or 100 pounds
overweight, whichever is greater;
21. reversals of bypass surgery in connection with obesity, and treatment of complications due to
bypass surgery for obesity or reversals of such surgery;
22. treatment or services in connection with abortions, unless necessary to save the life of the patient;
23. orthognathic surgery, except that after the Deductible, the Plan will pay 50% of otherwise Covered
Expenses for such surgery, with no out -of- pocket maximum;
24. amniocentesis for genetic or fertility studies, except that this exclusion shall not apply to a
maximum Benefit of $300 per person, based on otherwise Covered Expenses incurred during a
single Calendar Year;
15
25. diagnosis and treatment of behavioral problems and learning disabilities;
26. reduction mammoplasty;
27. reconstructive mammoplasty, except as shown in the Coverage Schedule;
28. any care for which there would be no legal obligation to pay in the absence of coverage provided
by this Plan;
29. biofeedback;
30. artificial insemination and any related service;
31. reversal of a surgically performed sterilization;
32. radial keratotomy;
33. psychoanalysis or psychotherapy that can be credited toward the earning of a degree or
furtherance of education or training, regardless of the medical necessity;
34. treatments, procedures, devices, drugs or medicines which are experimental or investigational.
This means that one or more of the following is true:
a) the device, drug or medicine cannot be marketed without approval of the U.S. Food and Drug
Administration and approval for marketing has not been given at the time the device, drug
or medicine is furnished;
b) reliable evidence shows that the treatment, procedure, device, drug or medicine is the subject
of ongoing phase 1, 11, or 111 clinical trials or under study to determine its maximum tolerated
dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means
of treatment or diagnosis;
c) reliable evidence shows that the consensus of opinion among experts regarding the
treatment, procedure, device, drug or medicine is that further studies or clinical trials are
necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its
efficacy as compared with the standard means of treatment or diagnosis.
Reliable evidence means only published reports and articles in the authoritative medical and
scientific literature; the written protocol or protocols used by the treating facility or the protocol(s)
of another facility studying substantially the same treatment, procedure, device, drug or medicine;
or the written informed consent used by the treating facility or by another facility studying
substantially the same treatment, procedure, device, drug or medicine.
16
ARTICLE IV. DENTAL COVERAGE
4.01 SCHEDULE OF DENTAL BENEFITS
Deductibles
Calendar Year Deductible, per person* $ 50
*The Deductible applies to all procedures, except that
beginning with the placement of appliances, no Deductible
will apply to orthodontic procedures.
Percentages Payable
Type I :: Preventive and Diagnostic Procedures* 80%
* These procedures are shown in the List
of Dental Procedures under the headings
"Visits and Examinations," "X- rays" and
"Space Maintainers ".
Type 1: Restorative and Surgical Services 80%
Type II: Prosthodontic Services 50%
Type II: Orthodontic Treatment 50%
Maximum Benefits
Calendar Year Maximum per person, including
orthodontic treatment $1,000
Lifetime maximum for Orthodontic Treatment, per person $1,000
4.02 CALENDAR YEAR DEDUCTIBLE
The amount of the Calendar Year Deductible is shown in the Schedule of Dental Benefits. A separate
Deductible shall apply to Covered dental expenses incurred during each Calendar Year for each Covered
Person, unless otherwise shown in the Schedule of Dental Benefits.
4.03 PERCENTAGES PAYABLE
Benefits based on Covered Dental Expenses shall be payable at the rates shown under the heading
"Percentages Payable" in the Schedule of Dental Benefits.
4.04 MAXIMUM BENEFIT
The maximum Benefit available for all Covered Dental Expenses incurred for any one (1) Covered Person
shall be as shown in the Schedule of Dental Benefits. Where shown in that schedule as "Calendar Year
Maximum", it shall mean the maximum amount of Benefits payable for all Covered Dental Expenses
incurred for a Covered Person during a Calendar Year; where shown as "Lifetime Maximum," it shall mean
the maximum amount of Benefits for Covered Dental Expenses incurred for a Covered Person while
covered under this Plan.
17
4.05 ALLOCATION OF DEDUCTIBLE
The Plan reserves the right to allocate the amount of the Calendar Year Deductible to any Covered Dental
Expenses and to apportion the Benefits to the Covered Employee and any assignees. Such allocation and
apportionment shall be binding upon the Covered Employee and all assignees.
4.06 FREE CHOICE OF DENTIST
A Covered Person shall have free choice of any legally qualified dentist. If more than one dentist furnishes
services or materials for one dental procedure, the Plan shall be liable for not more than its liability had one
dentist fumished the services or materials.
4.07 COVERED DENTAL EXPENSES
"Covered Dental Expenses" shall mean Reasonable and Customary Charges:
a. made by a legally licensed dentist for (i) any procedure, or its equivalent, which is included in the List
of Dental Procedures of the Plan, and (ii) orthodontic treatment;
b. which are incurred for a Covered Person while that person has dental coverage under this Plan; and
c. which are not excluded from Coverage.
4.08 ALTERNATIVE PROCEDURES
If two or more procedures are separately adequate and appropriate treatment for the correction of a specific
condition, the amount of the Covered Dental Expenses shall be limited to the charge for the least expensive
procedure.
The Administrator may request submission of dental x -rays to determine the Plan's liability for any dental
procedure. Should the x -rays not be submitted, the Administrator shall have the right to determine, to the
best of its ability, such procedures which would provide professionally adequate restoration, replacement
or treatment. If, upon receipt of such dental x -rays, the Administrator determines that procedures other
than those previously determined are more appropriate, the Administrator shall make such adjustments as
it deems proper.
4.09 EXPENSES INCURRED
For an appliance or modification of an appliance an expense shall be considered incurred at the time the
impression is made. For a crown, bridge or gold restoration an expense shall be considered incurred at
the time the tooth or teeth are prepared. For root canal therapy an expense shall be considered incurred
at the time the pulp chamber is opened. All other expenses shall be considered incurred at the time
service is rendered or a supply furnished.
4.10 LIST OF DENTAL PROCEDURES
The following is a list of the dental procedures for which benefits are available under this section.
18
TYPE 1 PROCEDURES
PROC.
NO. DESCRIPTION OF SERVICE
VISITS AND EXAMINATIONS
0110 Initial Exam.
0120 Periodic Exam.
0130 Emergency Exam.
1120 Prophylaxis for children under age 14 (limited to one treatment every six months).
1110 Prophylaxis for individuals age 14 and over, treatment to include scaling and polishing (limited to
one treatment every 6 months).
1221 Topical application of fluoride, including prophylaxis (limited to one treatment per year for children
under age 19).
X -RAYS Except for injuries, film fees include examination and diagnosis.
0220 Single film.
0230 Additional films (up to 12) each.
0210 Entire denture series consisting of at least 14 films, including bitewings if necessary (limited to
once every three years).
0240 lntra -oral, occlusal view, maxillary and mandibular, each.
0250 Superior or inferior maxillary, extra -oral, single, first.
0260 Superior or inferior maxillary, extra -oral, each additional.
0272 Bitewing films, two including examination (once every 6 months).
0274 Bitewing films, four including examination (once every 6 months).
0330 Panoramic survey, maxilla and mandible film.
OTHER VISITS/CONSULTATIONS
9430 Office visit during regular office hours for treatment and observation of injuries to teeth and
supporting structure (other than for routine operative procedures).
9440 Professional visit after hours (payment will be made on basis of services rendered or visit,
whichever is greater).
9310 Special consultation fee by a specialist for case presentation when diagnostic procedures have
been performed by a general dentist.
9110 Emergency palliative treatment, per visit.
SPACE MAINTAINERS
(fee includes all adjustments within six months after installation).
1510 Fixed space maintainer, unilateral.
1515 Fixed space maintainer, bilateral.
1520 Removable space maintainer, unilateral.
1525 Removable space maintainer, bilateral.
0470 Diagnostic casts.
8210 Removable inhibiting appliance to correct thumbsucking.
8220 Fixed or cemented inhibiting appliance to correct thumbsucking.
1560 Office visit for observation, adjustment and activation, more than 6 months after installation, per
visit.
PATHOLOGY
7285 Biopsy of oral tissue, hard.
7286 Biopsy of oral tissue, soft.
0450 Histopathologic examination.
19
PROC.
NO. DESCRIPTION OF SERVICE
ORAL SURGERY
Extractions. Includes local anesthesia and routine post operative visits.
7110 Uncomplicated (single).
7120 Each additional tooth.
7210 Surgical removal of erupted teeth.
9930 Post-operative visit (sutures and complications) after multiple extractions and impaction.
IMPACTED TEETH
7220 Removal of tooth (soft tissue).
7230 Removal of tooth (partially bony).
7240 Removal of tooth (completely bony).
ALVEOLAR OR GINGIVAL RECONSTRUCTION
7320 Alveolectomy (without extractions), per quadrant.
7310 Alveolectomy (with extraction), per quadrant.
7350 Stomatoplasty - complicated - with ridge extension, per arch.
7470 Remove exostosis, maxilla or mandible.
7970 Excision of hyperplastic tissue, per arch.
CYSTS AND NEOPLASMS
7510 Intra-oral incision and drainage of abscess.
7520 Extra-oral incision and drainage of abscess.
7425 Excision of pericoronal gingiva.
7980 Sialolithotomy: removal of salivary calculus.
7983 Closure of salivary fistula.
7984 Dilation of salivary duct.
7430 Excision of tumor, up to 1.25 cm.
7431 Excision of tumor, 1.25 cm and over.
7272 Transplantation of tooth or tooth bud.
7540 Removal of foreign body from bone (independent procedure).
7490 Radical resection of bone for tumor with bone graft.
7560 Maxillary sinusotomy for removal of tooth fragment or foreign body.
7260 Closure of oral fistula of maxillary sinus.
7550 Sequestrectomy for osteomyelitis.
7840 Condylectomy.
7850 Meniscectomy.
MISCELLANEOUS
7530 Incision and removal of foreign body from soft tissue.
7960 Frenectomy.
7910 Suture of soft tissue wound or injury, up to 5 cm.
7280 Crown exposure for orthodontia.
ANESTHESIA
9220 General, related to surgical procedures only (not available without cutting procedures).
20
PROC.
NO. DESCRIPTION OF SERVICE
PERIODONTICS
4220 Subgingival curettage, root planing, per quadrant.
4330 Correction of occlusion when performed in conjunction with periodontal procedures, per quadrant.
4210 Gingivectomy (including post - surgical visits), per quadrant.
4260 Gingivectomy, osseous or muco - gingival surgery (includes post - surgical visits), per quadrant.
4212 Gingivectomy, treatment per tooth (fewer than six teeth).
ENDODONTICS
3110 Pulp capping.
3220 Pulpotomy (in addition to restoration), per treatment.
3940 Remineralization (Calcium Hydroxide, temporary restoration), as a separate procedure only, per
tooth.
ROOT CANALS
(including necessary X -Rays and cultures but excluding final restoration.
3310 Anterior tooth.
3320 Bicuspid.
3330 Molar.
3420 Apicoectomy (including filling of root canal).
3410 Apicoectomy (separate procedure).
RESTORATIVE DENTISTRY, excluding inlays, crowns and bridges.
AMALGAM RESTORATIONS - PRIMARY TEETH.
2110 Cavities involving one tooth surface.
2120 Cavities involving two tooth surfaces.
2130 Cavities involving three tooth surfaces.
2131 Cavities involving four tooth surfaces.
AMALGAM RESTORATIONS - PERMANENT TEETH
2140 Cavities involving one tooth surface.
2150 Cavities involving two tooth surfaces.
2160 Cavities involving three tooth surfaces.
2161 Cavities involving four or more tooth surfaces.
SYNTHETIC RESTORATIONS
2210 Silicate cement filling.
2310 Acrylic or plastic filling.
2330 Composite resin involving one surface.
2331 Composite resin involving two surfaces.2332 Composite resin involving three surfaces.
CROWNS
2830 Stainless Steel.
FULL AND PARTIAL DENTURE REPAIRS, ACRYLIC
5610 Broken dentures, no teeth involved.
5620 Repair denture, replace one missing or broken tooth.
5630 Replace additional missing or broken tooth, each tooth.
5640 Replace missing or broken tooth on denture, no other repairs.
5611 Partial denture repairs; based on time and laboratory charges.
21
TYPE I1 PROCEDURES
PROC.
NO. DESCRIPTION OF SERVICE
RESTORATIVE (Crowns and gold restorations are covered only when necessitated by decay or
traumatic injury.)
INLAYS
2510 One tooth surface.
2520 Two tooth surfaces.
2530 Three or more tooth surfaces.
2540 Onlays per tooth, in addition to inlay allowance.
CROWNS
2710 Plastic (acrylic).
2720 Plastic with gold.
2721 Plastic with nonprecious metal.
2722 Plastic with semiprecious metal.
2740 Porcelain.
2750 Porcelain with gold.
2751 Porcelain with nonprecious metal.
2752 Porcelain with semiprecious metal.
2790 Gold (full).
2791 Nonprecious metal (full).
2792 Semiprecious metal (full).
2810 3/4 Gold.
2891 Gold dowel pin, in addition to crown.
PROSTHETICS
Bridge Abutments (See Inlays and Crowns).
PONTICS
6210 Cast gold.
6211 Cast nonprecious.
6212 Cast semiprecious.
6220 Slotted facing.
6230 Slotted pontic.
6240 Porcelain fused to gold.
6241 Porcelain fused to nonprecious metal.
6242 Porcelain fused to semiprecious metal.
6250 Plastic processed to gold.
6251 Plastic processed to nonprecious metal.
6252 Plastic processed to semiprecious metal.
REMOVABLE (Unilateral Bridges)
5281 One piece chrome casting, clasp attachments (all types, per unit).
RECEMENTATION
2910 Inlay.
2920 Crown.
6930 Bridge.
22
PROC.
NO. DESCRIPTION OF SERVICE
REPAIRS, CROWNS AND BRIDGES
6970 Repairs - Fee based on time and laboratory charges.
DENTURES AND PARTIALS (Fees for dentures, partial dentures and relining include
adjustments within six months after installation. Specialized techniques and characterizations are
considered optional and the expense shall be borne by the patient).
5110 Complete upper denture.
5120 Complete lower denture.
5216 Partial upper with chrome clasps, acrylic base.
5218 Partial lower with chrome clasps, acrylic base.
5231 Partial lower with chrome lingual bar and acrylic base.
5251 Partial upper with chrome palatal bar and acrylic base.
6940 Stress breaker.
5820 Stayplate, upper.
5821 Stayplate, lower.
5812 Immediate splint denture, upper.
5813 Immediate splint denture, lower.
5410 Adjustment to dentures more than 6 months after installation.
5730 Office reline, complete denture.
5740 Office reline, partial denture.
5750 Lab reline, complete denture.
5760 Lab reline, partial denture.
5850 Special tissue conditioning, per denture.
5710 Denture duplication (jumpcase), complete denture.
5720 Denture duplication (jumpcase), partial denture.
Adding teeth to partial denture to replace extracted natural teeth.
5650 First tooth, without clasp or abutment.
5660 First tooth, with clasp or abutment.
5651 Each additional tooth.
5690 Each additional clasp with rest.
23
TYPE 11 PROCEDURES
Orthodontic Expense Benefits
If a Covered Person undergoes necessary orthodontic treatment from a licensed orthodontist, the Plan
will pay Benefits based on expenses incurred in accordance with the following:
Orthodontic Treatment
The term "Orthodontic Treatment" means the movement of teeth by means of active appliances to
correct the position of maloccluded or malpositioned teeth.
In order to be considered orthodontic treatment, such movement of teeth must result from one (1) or
more of the following:
a. Overbite or Overjet;
b. Maxillary and mandibular arches in either protrusive or retrusive relation;
c. Crossbite; and
d. Overcrowding of teeth.
Treatment Program:
The term "Treatment Program" (referred to here as Program) means an interdependent series of
orthodontic services prescribed by a Physician for the purpose of correcting a specific dental condition.
A Program shall begin upon insertion of the active appliances. A Program shall end when the services are
done, or after a period twenty -four (24) months starting with the day the appliances were inserted,
whichever is earlier.
Amount of Benefits:
The amount of benefits payable is equal to 50% of Covered Expenses up to the maximum amount shown
in the Schedule of Dental Benefits. Because of the extended nature of orthodontic treatment, expenses
and benefit payments are spread over the duration of the Program.
Expenses Incurred: An expense is incurred:
a. at the end of each month of a Program for a person who pursues a Program, but not beyond the date
the Program ends, or
b. at the time the service is rendered for a person who incurs Covered Dental Expenses for orthodontic
treatment but does not pursue a Program.
Payment of Benefits:
Benefits will be payable when a Covered Expense is incurred. The Covered Expenses for a Program are
based on the estimated cost of the Covered Person's Program. They are prorated monthly over the
estimated length of the Program, but not for more than twenty-four (24) months. The last monthly payment
for a Program may be changed if the estimated and actual cost of the Program differ.
If a person's Coverage terminates during the course of the person's Program, the total benefit shall be
equal to the sum of only those monthly Benefits which came due while the person was Covered.
24
4.11 DENTAL LIMITATIONS AND EXCLUSIONS
Dental benefits are not provided for any expenses incurred by or for any Covered Person:
a. During the period of 12 consecutive months immediately following that person's effective date of
coverage for dental benefits under this Plan, if the effective date is more than 31 days following the
first date the person was eligible to enroll for that coverage.
b. For any treatment which is primarily for cosmetic purposes or for the correction of congenital
malformations. Facings on crowns or pontics beyond the second bicuspid are considered cosmetic.
c. For any procedure begun (a) before the Covered Person was covered under this Plan or (b) after such
person's coverage under this Plan terminates; or for any prosthetic dental appliance finally installed
or delivered more than ninety (90) days after termination of the Covered Person's coverage under this
Plan.
d. For the replacement of lost, misplaced or stolen appliances.
e. For appliances, restorations, or procedures to alter vertical dimension, restore or maintain occlusion,
splint or replace tooth structure lost as a result of abrasion or attrition, or treat disturbances of the
temporomandibular joint.
f. In connection with an injury arising out of or in the course of any employment for wage or profit.
g. By an individual in connection with a sickness for which the person is entitled to benefits under any
Worker's Compensation Act or similar legislation.
h. Which the person is not legally required to pay or which would not have been made had no coverage
existed.
i. For services which do not qualify as Necessary Care and Treatment.
j. In connection with war or any act of war, whether declared or undeclared.
k. Expenses which are Covered Expenses under the medical benefit provisions of the Plan.
1. For education or training in and supplies used for, dietary or nutritional counseling, personal oral
hygiene or dental plaque control.
m. For missed appointments or the completion of claim forms.
n. Which exceed Reasonable and Customary Charges.
o. Which are for dental care furnished by or through (a) a Health Maintenance Organization, or similar
organization or (b) the United States Government or any political subdivision thereof.
Which are for dental care that does not meet the standards established by the American Dental
Association.
q. For implants; and for overdentures, including root canal therapy and supportive restorations.
P.
25
For any prosthetic device which replaces one or more teeth lost prior to coverage under this Plan.
This exclusion shall not apply, however, to a prosthetic device which replaces a natural tooth of a
Covered Person which was lost or extracted while that person was covered under this Plan and was
not an abutment to a partial denture or fixed bridge installed within the five (5) year period immediately
preceding such loss or extraction.
s. For the replacement of any prosthetic appliance, crown, inlay or onlay restoration or fixed bridge within
five (5) years of the date of the last placement of any such item, unless replacement is required for
a person as a result of Injury sustained by him while covered under this section of the Plan.
t. Expenses incurred for orthodontic treatment of a Dependent child of a Participant if appliances were
not initially affixed prior to such Dependent's 19th birthday.
u. Expenses incurred for an Orthodontic Treatment Program which was begun before the Covered
Person became covered for Orthodontic Expense Benefits.
v. Expenses incurred after the Covered Person's coverage under this section terminates.
26
ARTICLE V. COORDINATION OF BENEFITS
This section explains when the Plan is 'primary' or 'secondary' A plan is 'primary" when it pays
benefits without regard to payment by other plans. A plan is "secondary" to another plan when it
adjusts payment so that the total of benefits available will not exceed 100% of Allowable Expenses (see
definition below). This Plan shall be primary or secondary as follows:
a. If the other plan contains no provision for coordination of benefits, that plan shall be primary and this
Plan shall be secondary.
b. For Covered Expenses incurred by an Employee who is covered under another plan as a dependent,
this Plan shall be primary and the other plan secondary.
c. For Covered Expenses incurred by a dependent who is covered under another plan as an employee
or member, this Plan shall be secondary and the other plan primary.
d. If a child is covered under plans of both parents, of which this Plan is one, then the plan covering the
parent whose birthday, excluding year of birth, falls earlier in the Calendar Year shall be primary and
the plan of the other parent secondary, when neither (a) nor (c) is determinative. When parents are
separated or divorced, however, the primary plan for the dependent child shall be the plan of the
parent who has custody of the child.
Secondary liability for the dependent child rests with the plan of the stepparent who has custody of
the dependent child and shall be determined before the plan of the parent who does not have custody
of the child.
If a divorce decree states which parent has responsibility for the medical expenses of a dependent
child, then the plan of that parent shall be primary, and the plan of the other parent shall be
secondary.
e. The plan which has covered the Participant or Dependent continuously for the longer period of time
shall be primary when neither (a), (b), (c), nor (d) is determinative.
'Plan', as used in this section, means any of the following which provides benefits for or services in the
form of medical or dental care or treatment:
a. group insurance or any other arrangement of coverage for persons in a group whether on an insured
or uninsured basis; or
b. coverage on a group basis through Blue Cross, Blue Shield or any other prepayment plan; or
c. any coverage for students which is sponsored by, or provided through, a school or other educational
institution; or
d. any coverage under government programs, and any other coverage required or provided by any
statute.
'Allowable Expenses' means the Reasonable and Customary Charges incurred by a Participant or
Dependent, all or a portion of which is covered under at least one of the plans covering that Participant or
Dependent. When a plan provides benefits in the form of services rather than cash payments, the
Reasonable and Customary cash value of each service rendered shall be considered both Allowable
Expenses and a benefit paid.
27
'Claim Determination Period" means a Calendar Year or that portion of a Calendar Year during which a
person was covered under a plan.
The total amount of benefits payable under this Plan for expenses incurred or services provided during any
Claim Determination Period shall not exceed:
a. the amount which would be payable under this Plan in the absence of this coordination of benefits
provision; or,
b. if this Plan is secondary, the amount determined by subtracting the amount of benefits payable under
all other plans from the amount which would be payable under this Plan if it were primary.
28
ARTICLE VI. TERMINATION OF COVERAGE
6.01 IN GENERAL
If all or any part of an Employee's Coverage terminates, then the corresponding Coverage for the
Employee's Dependents, if any, shall terminate simultaneously, subject to the provision below entitled
"Continuation of Medical Coverage (COBRA) ".
6.02 EMPLOYEES
An Employee's Coverage shall terminate on the earliest to occur of the following:
a. the date on which the Plan terminates;
b. the date on which the person ceases to be an Employee;
c. the last day of the most recent period for which any required contribution for the Employee's Coverage
has been made, if such contribution ceases;
d. the date on which the person is no longer Actively at Work, except that the Coverage may be allowed
to continue for a period of time as determined by the Employer, if Active Full -Time Work ends because
of Total Disability or approved leave of absence.
6.03 DEPENDENTS
Coverage for an Employee's Dependent shall terminate on the earliest to occur of the following:
a. the date on which the Plan Terminates;
b. the last day of the most recent period for which any required contribution for that Coverage has been
made, if contributions cease;
c. the date on which the Dependent ceases to be a Dependent as defined in the Plan; or
d. the date on which the Employee's Coverage terminates.
6.04 DEPENDENT CHILD WITH DISABILITIES
A Dependent's Child with disabilities is an Employee's child who is physically or mentally unable to earn
a living and is primarily dependent upon the Employee for support and maintenance. The following shall
apply to a child who reaches the age at which the child would otherwise cease to be a Dependent: If the
person is then a Dependent Child with disabilities, the Plan shall continue to consider the person as a
Dependent while the person remains a Dependent Child with disabilities if the Employee submits to the
Administrator proof of the child's incapacity as described above.
Furthermore, if a Dependent Child with disabilities was covered under any group health plan of the
Employer on the date immediately preceding the effective date of the Employee's Coverage, then the child
shall be considered as a Dependent while remaining a Dependent Child with disabilities.
The Administrator shall have the right to require satisfactory proof of continuance of the incapacity of a
Dependent Child with disabilities and the right to examine such child, but not more than once a year. Upon
failure to submit such required proof or to undergo such an examination, or when such child ceases to be
so incapacitated, Coverage with respect to the person shall cease. The continuance of Coverage shall be
subject to all provisions of this Plan relating to termination of Coverage except as modified in this section.
29
6.05 CONTINUATION OF MEDICAL COVERAGE (COBRA)
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows certain individuals the
option of continuing their group health coverage under specified conditions.
A person who is eligible for continuation is called a "qualified beneficiary." The circumstances allowing a
person to be eligible for continuation are called "qualifying events."
Eligibility for Continuation
A Covered Person becomes a qualified beneficiary as follows:
If an Employee's medical and dental coverage terminates because of termination of employment (other
than because of the Employee's gross misconduct) or reduction in the number of hours worked, such
an Employee is a qualified beneficiary and may elect to continue the medical or medical and dental
coverage for the Employee and any of the Employee's Dependents whose coverage is being lost
because of either one of these events.
A Dependent becomes a qualified beneficiary and may also elect to continue the medical or medical
and dental coverage if any of the following qualifying events would otherwise cause a loss of such
Dependent's coverage under this Plan:
a. death of the Employee;
b. termination of the Employee's employment (for reasons other than the Employee's gross misconduct)
or reduction in the number of hours worked;
c. divorce or legal separation;
d. the Employee becoming covered under Medicare; or
e. a Dependent child ceasing to be a "Dependent" as defined in this Plan.
The Plan shall provide the same medical or medical and dental coverage to a qualified beneficiary that it
provides to all active Participants, including the right to enroll eligible Dependents who are not yet covered.
A newly added Dependent shall not be considered a qualified beneficiary, and coverage under the Plan
for such a Dependent shall terminate in accordance with the termination provisions of this Plan, with no
right of continuation of coverage under federal law.
Duration of Continued Coverage
Continuation coverage shall terminate on the earliest to occur of the following:
a. At the end of a continuous period of:
1. 18 months, in a case where the coverage originally terminated because of termination of
employment or reduction in hours worked, except that (1) such period may be extended to 29
months if, at the beginning of such 18 month period, a qualified beneficiary is totally disabled as
determined by the Social Security Administration and the Plan receives the Notice of
Determination of Disability from the Social Security Administration before the expiration of the 18
months and within 60 days of the determination and (2) in the case of a Dependent, if another
qualifying event occurs during the 18 month continuation, 36 months after the first qualifying
event; or
30
2. 36 months for other qualifying events.
b. The date following election of continuation coverage on which the person first becomes:
1. covered under any other group health plan which does not contain any exclusion or limitation with
respect to any preexisting condition (this rule has not been clarified and is subject to varying
interpretations. Any questions concerning this matter should be addressed to the Administrator);
or
2. covered under Medicare.
c. The date this Plan and all other group health plans of the Employer ends.
d. At the end of the most recent period for which a required contribution has been made if such
contributions cease.
Payment for Continuation Coverage
A person electing to continue coverage under COBRA must pay to the Employer on a monthly basis
the entire amount due for such coverage. The amount due will be no more than 102% of the actual
cost monthly, except that beneficiaries who qualify for an extension of continuation coverage on the
basis of disability shall be required to pay 150% (instead of 102%) of the cost monthly for each
additional month of coverage after the initial 18 month period. The first contribution must cover the
period from the date coverage would otherwise have terminated until the end of the month in which the
first contribution is made. Subsequent contributions shall be due and payable on the first day of each
month, subject to a 30 day grace period. The first contribution must be received by the Plan no later
than 45 days after continuation coverage is elected.
Notice of Qualifying Event
It is the responsibility of the Employee or a member of the Employee's family to notify the Plan of a
divorce, legal separation or a child losing Dependent status under the Plan, within 60 days of the later
of the date of the qualifying event or the date on which coverage would be lost because of such event.
If notice is not given within this time period the right to continuation coverage will be lost.
Section Period
A qualified beneficiary must elect continuation of coverage within 60 days after the later of:
a. the date coverage under this Plan terminates because of the qualifying event; or
b. the date the qualified beneficiary receives notice from the Plan of the right to such continuation.
31
ARTICLE VB. CLAIMS
7.01 SUBMISSION OF CLAIMS
All claims for Benefits under this Plan shall be submitted to the Administrator. They shall include properly
completed proof of loss on forms approved by the Administrator and supporting documentation as required.
The Administrator shall decide whether a Benefit will be paid or denied after providing a full and fair review
of the proof of loss and documentation submitted.
7.02 CLAIM FORM
The Administrator shall furnish a claim form to the Participant to file proof of loss. Such proof shall include
the dates, occurrence, nature and extent of loss for which claim is made.
7.03 TIME LIMIT FOR PROOF OF LOSS
For any expense incurred, the following items must be must be received by the Administrator within one
(1) year after the date that expense was incurred, but no later than three (3) consecutive months
immediately following termination of the Plan:
a. proof of loss in proper form as required by the Administrator, and
b. any other information required by the Administrator to determine the liability of the Plan for that
expense.
No benefit shall be paid for an expense when these items relating to that expense are not received by the
Administrator within the time period provided in this section.
7.04 EXAMINATION
The Administrator shall have the right and opportunity to have an independent examination performed of
the person whose Injury or Sickness is the basis of a claim under this Plan. Such examination shall be
permitted as often as reasonably required while claim is being made.
7.05 RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION
To determine how and when the terms and provisions of this Plan or other plans shall apply, the
Administrator may, without the consent of or notice to any person, release to or obtain from any
organization or person any information it considers necessary. Any person claiming Benefits under this Plan
shall furnish to the Administrator any information that may be necessary to implement this provision.
7.06 PAYMENT OF CLAIM
All unassigned Benefits shall be paid to the Participants.
Should any claim under this Plan remain unpaid at the Covered Person's death, or if the Covered Person
is a minor, or is, in the opinion of the Administrator, legally incapable of giving a valid receipt and discharge
for any payment, the Administrator may at its option pay the whole or any part of the Benefit to any one
or more of the following relatives of the Participant: spouse, child or children, mother, father, brother or
brothers, sister or sisters.
Any payment made by the Administrator under this Plan shall constitute a complete discharge of the
Employer's obligation to the extent of such payment and the Employer shall not be required to see or
supervise the application of the money so paid.
32
7.07 ASSIGNMENTS
Benefits may be assigned by a Participant to the person or institution which made the charges on which
the Benefits are based. No assignment of a Benefit shall bind the Administrator if it is not in writing or was
not received by the Administrator prior to payment of that Benefit. The Administrator shall not be
responsible for determining whether any assignment is valid. Payment shall be made directly to the
assignee unless a written request not to honor the assignment, signed by both the Participant and the
assignee, was received by the Administrator before the proof of loss is submitted.
7.08 ALLOCATION AND APPORTIONMENT OF BENEFITS
The Administrator reserves the right to allocate a deductible to any Covered Expenses and to apportion
Benefits to the Participant and any assignees. Such allocation and apportionment shall be binding upon
the Participant and all assignees.
7.09 CHARGES REPORTED IN FOREIGN CURRENCY
Benefits based on charges reported in foreign currency shall be determined in accordance with the rate
of exchange between such currency and United States dollars in effect at the time the Benefits are
calculated.
7.10 FACILITY OF PAYMENT
If payments made under any other plan should have been made under this Plan, the Administrator shall
have the right, exercisable alone and in its sole discretion, to pay to any organization making such other
payments any amounts it shall determine to be warranted in order to satisfy the intent of this Plan.
Amounts so paid shall be deemed to be Benefits paid under the Plan and, to the extent of such payments,
the Administrator shall be fully discharged from liability under this Plan.
7.11 RIGHT OF RECOVERY
Whenever payments have been made in excess of the amount provided by the Plan, the Administrator shall
have the right to:
a. recover such payment, to the extent of any excess, from among one or more of the following, as the
Administrator will determine: any persons to or for or with respect to whom the payment was made,
any insurance companies, or other organizations;
b. deduct the total or any partial amount of such payment from any Benefits properly payable under this
Plan. Such deduction may be made against any claim for Benefits under this Plan by a Participant
or by any of the person's covered Dependents if such payment is made with respect to such
Participant or any person covered or asserting coverage as a Dependent of such Participant.
7.12 SUBROGATION
To the extent of any Benefit paid under the Plan, the Plan Administrator shall be subrogated to all the rights
of recovery of the Covered Person arising out of any claim or cause of action which may accrue against
a third party. Any such Covered Person shall agree to reimburse the Plan for any Benefits so paid, out
of any monies recovered from such third party as a result of judgement, settlement or otherwise; and such
Covered Person shall agree to take such action, to furnish such information and assistance, and to execute
and deliver all necessary instruments as the Plan Administrator may require to facilitate the enforcement
of their rights.
33
This Plan may withhold payment of benefits until the Covered Person has agreed in writing to reimburse
the Plan out of any monies recovered from such third party. The Administrator may, without the consent
of or notice to any person, take legal action to secure the rights of the Plan under this section. This
provision shall not apply, however, to recovery obtained by a Covered Person from an insurance company
on a policy under which such Covered Person is entitled to indemnity as a named insured person.
The Plan shall have no liability for any expense in connection with recovery under this section or any
attempt to effect such recovery except as authorized by the Employer.
7.13 REVIEW AND APPEAL OF CLAIM
If a claim is denied in whole or in part, the Administrator shall provide the claimant with written notice of
such denial. Such notice shall be written in a manner calculated to be understood by the claimant. It shall
also state the specific reason or reasons for such denial and explain the review procedure. To appeal an
unfavorable determination, the claimant or the claimant's authorized representative must file a written
application for review with the Administrator within sixty (60) days of the receipt of a notice of denial of
benefits. The application for review must state whether a personal appearance or hearing before the
Administrator is requested. An appeal shall be considered as filed on the date received by the
Administrator. After the Ming of an appeal and prior to a final decision on it, the claimant or the claimant's
representative may review Plan documents and submit issues and comments in writing. Upon hearing, the
claimant may be represented by a duly authorized representative. No later than sixty (60) days after
receipt of the request for the review, the Administrator shall render a decision on the appeal, unless special
circumstances, such as a request for a hearing, require a greater period of time. In such a case a final
determination shall be rendered no more than one hundred twenty (120) days after receipt of the request
for review. Upon final decision, the Administrator shall state in writing the specific Plan provision on which
the decision is based.
7.14 CLAIM AUTHORITY OF ADMINISTRATOR
In making initial claim determinations, the Administrator shall consider the terms of the Plan and shall have
the power and discretion to construe such terms. All such determinations made by the Administrator,
whether in the case of an appeal from an initial claim denial or in the case of an initial determination which
is not appealed, arising in connection with the administration, interpretation and/or application of the Plan
shall be conclusive and binding upon all persons.
7.15 LEGAL ACTIONS
No action at law or in equity shall be brought to recover under this Plan until the appeal procedures
described above have been completed with respect to the claim, nor will any action be brought unless
within two (2) years from the expiration of the time within which proof of loss is required by the Plan.
7.16 TIME LIMITATIONS
If any time limitation provided in the Plan Document for furnishing proof of loss or for bringing any action
at law or in equity is less than that permitted by the applicable law, then the time limitation provided in the
Plan is hereby extended to agree with the minimum permitted by the applicable law.
34
ARTICLE Vlll. GENERAL PROVISIONS
8.01 BENEFITS
Regardless of any other provision of the Plan to the contrary, benefits otherwise provided by this Plan shall
be subject to all of the Plan's limitations and exclusions.
8.02 CONTRIBUTIONS
Contributions made to the Plan by Employees are not intended to be held by the Employer longer than a
period of ninety (90) consecutive days. Such contributions shall be used as soon as possible upon their
receipt by the Employer to pay Plan expenses and obligations.
8.03 ERRORS/DELAYS
Coverage shall not be affected by clerical errors on records of the Administrator, or delays caused by
a. the Administrator in making entries on such records;
b. the Administrator in submitting enrollment cards; or
c. an Employee in submitting an enrollment card because of the Employee's incapacity.
Upon discovery of any such error or delay which has caused an erroneous contribution to be made, the
Administrator shall make an equitable adjustment of the contribution.
8.04 COMPLIANCE WITH FEDERAL LAW
The Plan shall comply with all Federal Laws and regulations to which it is subject. If any provision of the
Plan is in conflict with any such law or regulation, the law or regulation will prevail. If, in the opinion of the
Administrator, the applicability of any such law or regulation is unclear, the Administrator shall have the right
to decide the question of such applicability until the law is clarified by the appropriate governmental
authority.
8.05 EFFECT OF CHANGES
All changes to this Plan shall become effective as of the date established by the Administrator, except that:
a. no increase or reduction in Benefits shall be effective with respect to Covered Expenses incurred prior
to the date a change was adopted by the Administrator, regardless of the effective date of the change;
and
b. no increase or reduction in Benefits shall become effective for any Covered Person who was Totally
Disabled on the effective date of such change until the date such person ceases to be Totally Disabled
and, in the case of a Participant, until the date such Participant is Actively at Work.
8.06 EFFEC77VE TIMES
Any coverage or change in the amount of coverage under this Plan shall take effect as of 12:00:01 A.M.
standard time at the Employer's principal office on the effective date of such coverage or change in amount
of coverage.
Termination of this Plan or of any coverage under it shall take effect at 12 :00:00 midnight standard time
at the end of the date of such termination at the Employer's principal office. Plan years and Plan months
shall begin at 12:00:01 A.M. standard time on the dates involved, and they shall end at 12:00:00 midnight
standard time at the end of the dates involved, at the Employer's principal office.
35
8.07 ENTIRE CONTRACT
This Plan and the applications of the Covered Persons shall constitute the entire contract of Coverage
between the Employer and the Covered Persons.
8.08 GENDER
Whenever a personal pronoun with gender is used in this Plan, it shall be deemed to include the feminine
and masculine, unless the context clearly indicates the contrary.
8.09 HEADINGS
The headings used in this Plan are for convenience only. In all cases, the full text of this Plan shall control.
8.10 MISSTATEMENTS
If any relevant information has been misstated or omitted by or on behalf of a person to obtain Coverage,
correct information shall be used to determine whether and to what extent the Coverage shall be in force.
If Coverage is rescinded upon the discovery of any misstatement or omission, the Administrator shall make
an equitable adjustment of any contributions.
8.11 MISTAKE OF FACT
When a fiduciary becomes aware of any mistake of fact filed with the fiduciary in a document, the fiduciary
shall correct the mistake and make any proper adjustment required. A fiduciary shall not be liable in any
manner for any determination of fact made in good faith.
8.12 RELIANCE ON DOCUMENTS AND INFORMATION
Evidence required by the Administrator of anyone under this Plan may be made by any document which
the Administrator considers acceptable and relies upon. The Administrator shall be entitled to rely
conclusively upon and shall be protected in any action taken by it in good faith in relying upon any
information furnished by an Employee or Dependent, the Employer, or any accountant, counsel or other
specialist appointed or employed by it.
8.13 REPRESENTATIONS
Statements made by or on behalf of any person to obtain coverage under this Plan shall be deemed
representations and not warranties.
8.14 WAIVER
The Administrator's failure to enforce strictly any provision of this Plan shall not be construed as a waiver
of the provision. The Administrator reserves the tight to enforce strictly each and every provision of the Plan
at any time, regardless of the nature or number of prior occurrences or the similarity of the circumstances.
8.15 WORDS IN SINGULAR OR PLURAL
Wherever the context permits, a word in the singular shall include the plural and vice-versa.
a16 WORKER'S COMPENSATION
This Plan is not instead of and does not affect any requirement for coverage by worker's compensation
insurance.
36
ARTICLE IX. ADMINISTRATION
9.01 AUTHORITY OF THE ADMINISTRATOR
The Employer, or such other persons as they shall appoint, shall serve as Administrator of this Plan. Such
Administrator shall have the following powers and responsibilities:
a. To adopt administrative procedures for the Plan.
b. To appoint, remove, or substitute insurance carriers and pay premiums for insurance policies.
c. To select, employ, and compensate such consultants, accountants, attorneys, or other agents and
employees as may be deemed necessary for the administration hereof.
d. To submit claims for benefits to the appropriate insurance carriers.
e. To administer claim payments.
9.02 INDEMNIFICATION
At its option, the Employer may indemnify each person appointed to administer or provide services to the
Plan from and against any and all liabilities, costs, or expenses incurred as a result of any act or omission
in connection with performance of duties hereunder, but not for liabilities and claims arising from willful
misconduct.
37
AR77CLE X AMENDMENT AND TERMINATION OF THE AGREEMENT
The Employer shall have the full, absolute and discretionary right to amend, modify, suspend, withdraw,
discontinue or terminate the Plan in whole or in part at any time for any and all participants of the Plan,
without prior notice to or the consent of any person.
No Benefits shall be paid for any expense incurred after the date this Plan terminates. If Coverage for
any type of expense is eliminated or restricted by amendment of the Plan, benefits otherwise payable
for such expense shall be excluded or restricted accordingly, beginning with expenses incurred on the
effective date of the amendment.
38
ARTICLE XL DEFINITIONS
Whenever a term defined below is used in this Plan with its first letter capitalized, that term shall have
the meaning shown, as follows:
11.01 ACTIVELY AT WORK OR ACTIVE FULL- TIME WORK shall mean that an Employee is performing
all the regular duties of the Employee's occupation on a full -time basis of at least an average of the number
of hours per week shown in the Coverage Schedule under the heading "Eligibility Requirement ". An
Employee shall be deemed Actively at Work on the Employee's regular non - working days established by
the Employer. No Employee, however, shall be considered Actively at Work on any day during which the
Employee is Totally Disabled.
11.02 ADMINISTRATOR shall mean the Employer or such other persons as the Employer may
designate.
11.03 ALCOHOLISM shall mean alcoholic addiction or excessive drinking where alcohol intake is great
enough to damage physical health or personal or social functioning.
11.04 BENEFITS shall mean benefits provided by this Plan.
11.05 BIRTHING CENTER shall mean only a specialized institution which fully meets each and every
one of the following requirements:
a. it is primarily engaged in providing, on a full -time outpatient basis and for compensation, a program
for the delivery of full -term normal pregnancies by natural childbirth means only, with no administration
of anesthesia or medication except medication for pain;
b. it is located either within the premise of a Hospital or within such immediate vicinity of a Hospital that
Emergency transfers of patients to such Hospital can be effected without unnecessary risk to the
patient;
c. it provides or has a formal agreement with such Hospital as indicated in (b) above to provide (1) both
Emergency and continuing medical and surgical treatment services on a 24 -hour basis and (ii)
diagnostic x -ray, laboratory and pharmaceutical services;
d. it is under the continuous supervision of one or more legally qualified Physicians on a 24 -hour basis;
e. it continuously provides skilled nursing services on a 24 -hour basis, under the direction of full -time
registered nurses who are on the premises at all times with other full -time licensed personnel, also
on duty at all times;
f. it provides ultrasound and fetal monitoring equipment;
g.
it prepares and maintains, under the direction of a Physician, a written plan for admission, care,
treatment and discharge of each patient;
h. it is licensed as a birthing center in the jurisdiction in which it is located if such license is legally
required.
11.06 CALENDAR YEAR shall mean the period commencing on a January 1st and ending on the
immediately following December 31st, inclusive.
39
11.07 CALENDAR YEAR DEDUCTIBLE shall mean the amount shown in the Coverage Schedule as
Calendar Year Deductible, which is to be deducted from the first Covered Expenses incurred for a Covered
Person during a Calendar Year before Benefits payable for that year and for that person are determined.
This Deductible shall not apply to expenses Covered at 100% unless otherwise indicated in the Coverage
Schedule.
11.08 COBRA shall mean the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
11.09 Covered Expenses (see definition in Medical Coverage)
11.10 COVERED PERSON shall mean an Employee or Dependent while covered under this Plan. With
reference to an Employee's Dependent, "covered under this Plan" shall mean that the Employee has
Coverage for that Dependent.
11.11 COVER, COVERED AND COVERAGE shall mean or refer to coverage under this Plan.
11.12 CUSTODIAL CARE shall mean that type of care (including room and board needed to provide
that care) which:
a, is given mainly to help a person with personal hygiene or to perform the activities of daily living; and
b. can be safely and adequately given by people who are not trained medical or nursing personnel.
Such care shall be considered Custodial Care regardless of who recommends, provides or directs the care
or where the care is given.
11.13 DEDUCTIBLE shall mean an amount of Covered Expense for which no Benefit is payable and
which must be incurred before any Benefit can be paid.
11.14 DENTAL SERVICES shall mean services in connection with conditions of the mouth due to
periodontal or periapical disease, or involving any of the teeth, their surrounding tissue or structure, or the
alveolar process or gingival tissue.
11.15 DEPENDENT shall mean
a. the spouse of a Participant if such spouse is not legally separated from the Participant;
b. any unmarried child who is less than the age shown for a non-student in the Coverage Schedule
under the heading "Age When a Child's Coverage Ends," who is not employed full-time and who
depends on the Participant for the majority of the child's support; and/or
c. any unmarried child who is the age shown in the Coverage Schedule for a non-student, under the
heading "Age When a Child's Coverage Ends," or no more than the age shown for a full-time student
under the same heading; who depends upon the covered Employee for the majority of the child's
support and is enrolled as a full-time student. A full-time student shall mean a student enrolled for
credit of at least three (3) hours per semester at an accredited high school, junior college, college or
university. With respect to a licensed trade school, a full-time student shall mean a student in
attendance at least twenty (20) hours per week in a course of at least six (6) months duration.
Full-time enrollment or attendance shall be deemed to exist between two semesters at an institution
if the student completed the first of such semesters on a full-time basis and has not yet graduated
from the same institution.
40
d. The word "child" or "children" shall mean (i) the Participant's own or legally adopted child, (ii) a child
being placed for adoption* by a Participant or Plan beneficiary, and (iii) any other child who depends
on the Participant for the majority of the child's support, lives with the Participant in a regular
parent-child relationship and for whom, except in the case of a step-child, the Participant has obtained
legal guardianship. (Each Dependent child of parents who are both Covered Employees shall be
considered a Dependent of one or the other, but not both.)
"Being placed for adoption," as used above, means that a Participant or Plan beneficiary has
assumed and retained a legal obligation for the partial or total support of a child to be adopted. A
child's placement with a Participant or beneficiary ends whenever the legal support obligation ends.
The term "Dependent" shall not include any person who is:
a.
b.
eligible for Coverage as an Employee;
entitled to Benefits as an Employee under any extended coverage provision of the Plan; or
c. on active duty with the armed forces of any country.
11.16 DRUG DEPENDENCY shall mean addiction to or physical dependency upon drugs, including
prescribed drugs and nicotine, but not alcohol.
11.17 EMERGENCY shall mean circumstances under which the absence of immediate medical attention
to a patient could reasonably be expected to result in loss of life or limb or serious impairment to the health
of that patient.
11.18 EMPLOYEE shall mean a person employed by the Employer on a full-time basis of at least an
average of the number of hours per week shown in the Coverage Schedule under the heading "Eligibility
Requirement," and who is compensated for such services. The term *Employee* shall exclude any person
who works with or on behalf of the Employer from time to time, on a temporary basis, or who is primarily
on a consulting basis or an independent contractor.
11.19 EMPLOYER shall mean (a) the organization or entity which established and adopted this Plan,
as named in the first paragraph of the Plan under the heading "Purpose of Plan" and (b) any other entity
which has adopted this Plan.
11.20 FREESTANDING SURGICAL FACILITY: shall mean a specialized institution which meets all of
the following requirements:
a. it is permanently established, equipped and operated solely to accommodate the performance of
outpatient surgery by Physicians who are legally authorized to perform surgery;
b. it has at least two operating rooms and at least one recovery room, is equipped to perform diagnostic
lab and x-ray procedures in connection with surgery, has resuscitation equipment for emergencies
resulting from surgery, a blood bank and other blood supplies;
c. it has the full-time services of registered nurses for patient care in operating and recovery rooms;
d. it has a written agreement with one or more Hospitals in the area for immediate acceptance of patients
who develop complications or require post-operative confinement; and
e. it has an organized medical staff supervising its operations as required by established policy and
maintains adequate medical records for all patients.
41
11.21 HOSPITAL shall mean only an institution which meets all of the following requirements:
a. It is primarily engaged in providing diagnostic and therapeutic facilities for the diagnosis, treatment and
care of injured and sick persons under the supervision of a staff of Physicians for compensation from
its patients and on an inpatient basis;
b. it continuously provides twenty-four (24) hour a day nursing service by or under the supervision of
registered nurses (R.N.'s) on the premises;
it is not primarily a place for rest, the aged, drug addicts, alcoholics, or a nursing or convalescent
home; and
d. it is operated in accordance with the laws of the jurisdiction in which it is located pertaining to
hospitals.
11.22 INJURY shall mean accidental bodily injury sustained by a person while covered under the Plan.
Such injury must result in loss directly and independently of all other causes. All bodily injuries caused by
one (1) accident shall be considered as one (1) Injury.
11.23 MEDICARE shall mean the health insurance provided by Title XVIII of the Social Security Act, as
amended.
11.24 MENTAL DISORDERS shall mean mental, psychoneurotic and personality disorders. The term
shall not, however, include Alcoholism and Drug Dependency as defined in this section.
11.25 NECESSARY CARE AND TREATMENT shall mean any confinement, treatment, service or item
that is (a) prescribed by a Physician; (b) necessary and appropriate; (c) non-experimental (d) consistent
with professionally recognized national standards of quality and (e) customarily employed nationwide for
treatment, taking the Covered Person's condition into account.
11.26 OUTPATIENT TREATMENT CENTER shall mean only an institution that is licensed or approved
by the jurisdiction in which it is located to provide outpatient services for the prevention, care and treatment
of Mental Disorders, Alcoholism and/or Drug Dependency.
11.27 PARTICIPANT shall mean a Covered Employee.
11.28 PHYSICIAN shall mean a person when acting within the scope of the person's license (other than
a hospital resident or intern), who is a Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatry, Doctor
of Dentistry, Doctor of Optometry, Doctor of Chiropractic, Doctor in Psychology or a Certified Registered
Nurse Anesthetist (C.R.N.A.), The term "Physician" shall also mean any person authorized by Interface EAP
to render services to a Covered Person.
11.29 PLAN shall mean the Plan described in this Plan Document.
11.30 PLAN DOCUMENT shall mean this Plan Document.
11.31 PRECERTIFICATION shall mean a procedure to determine if and how long a patient needs to
be hospitalized.
11.32 PREEXISTING CONDITION (See Coverage Schedule)
42
11.33 REASONABLE AND CUSTOMARY CHARGES shall mean the usual charges of a provider for a
service or supply, but not more than the prevailing charges being made for a like service or supply in the
same geographic area. Charges incurred outside the United States or its territories shall be considered as
if incurred in the area in which the claims paying office is located. If the usual and prevailing charge for
a service or supply cannot be determined because of the unusual nature of the service or supply, the
extent to which such charge shall be considered usual and prevailing shall be based on (a) the complexity
involved; (b) the degree of professional skill required, and (c) other pertinent factors.
11.34 SICKNESS shall mean any condition of ill health, disease, pregnancy, bodily or mental
abnormality, infirmity or disorder. All Sicknesses which are due to the same cause or related causes shall
be considered as one Sickness.
11.35 SKILLED NURSING FACILITY shall mean an institution which meets all of the following
requirements:
a. it is approved by and is a participating Extended Care Facility of Medicare;
b. it has organized facilities for medical treatment and provides twenty-four (24) hour nursing service
under the full-time supervision of a Physician or registered nurse (R.N.);
c. it maintains daily clinical records on each patient and has available the services of a Physician under
an established written agreement;
d. it provides appropriate methods of dispensing and administering drugs and medicines;
e. it has transfer arrangements with one or more Hospitals, a utilization review plan in effect and
operational policies developed with the advice of, and reviewed by, a professional group including at
least one Physician;
f. it operates pursuant to state and local law;
g.
it provides room and board primarily for people convalescing from Sickness or Injury;
h. it is not, other than incidentally, a rest home, home for the aged, nursing home or place for custodial
care.
11.36 SPECIALIZED TREATMENT FACILITY shall mean only a legally operated institution which meets
all of the following requirements:
a. it has inpatient services to treat, as the case may be, Mental Disorders, Alcoholism or Drug
Dependency;
b. it charges for its services;
c. it is supervised by a staff of Physicians;
d. it has 24-hour-a-day nursing service, and a registered nurse must be on the premises at all times to
direct these services;
e. its patients are confined 24 hours a day (Note: A person shall not be a bed patient on a day of leave
of absence if the person does not return by midnight of that day);
f. it keeps a written record and plan of treatment for each patient;
43
9.
it is licensed as a Hospital and not as a clinic-type of institution;
h. it is not, other than in a minor way, a place for rest, for the aged or a nursing or convalescent home.
11.37 TOTAL DISABILITY AND/OR TOTALLY DISABLED shall mean:
a. for an Employee: the Employee's inability due to Injury or Sickness to engage in any occupation or
employment for wages or profit; and
b. for a Dependent the Dependent's inability due to an Injury or Sickness to perform activities normal
to persons of like age and sex in good health.
11.38 WELL BABY CARE shall mean routine care of a Covered infant only during the first five (5) days
of the infant's initial Hospital confinement following the infant's birth, including circumcision, immunizations,
regular examinations and testing, and Hospital nursery charges.
11.39 WELLNESS CARE shall mean care or services not normally covered under this Plan, which are
necessary for the prevention of Sickness. These services shall include a routine physical examination, pap
smears, eye examinations, eyeglasses, contact lenses, any other eye care or eyewear, treatment or
services rendered by a Physician or supplies or medication ordered by a Physician for nicotine addiction,
and holistic type services which assist a person in staying well.
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EXECUTION OF DOCUMENT
Executed this /+ day of , 19 .
ATTEST:
Danna Welter, City Secretary
CITY OF HUNTSVILLE
W. H. Hodges, Mayor
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