EMPLOYEE BEHAVIORAL HEALTH BENEFITS
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EMPWYEE BENEFITS
PRELIMINARY APPLICATION
United HealthCare
Application is hereby made to United HealthCare Insurance Company, as the underwriter providing fonn(s) of insurance checked
below and in
accordance with specifications, by:
Full Legal Name of Applicant City of Clearwater
Address of Applicant (including Zip Code) Post Office Box 4748, Clearwater, FL 33758-4748
Insurance to be provided for Employees and Dependents, except as indicated otherwise, where State pennits: (check below)
~ Mental Health/Substance Abuse Benefits EPO
o Mental Health/Substance Abuse Benefits PPO
o Benefits for Expense of Outpatient Mental Health/Substance Abuse Services
o Benefits for Expenses of Inpatient Mental Health/Substance Abuse Services
o Aggregate Stop Loss
o Complement to Medicare
Other: EAP
PREMIUM PAYMENT: The premium is to be payable in advance and is rated prospectively.
EFFECTIVE DATE: It is requested that the insurance be effective from 12:01 A.M., standard time at the Applicant's address on
January I, 2000. No insurance shall be effective until this application shall have been accepted and
the effective date approved by the Companies and a binder premium shall have been paid, and insurance on a contributory basis shall
not be effective until the date detennined when the required percent of the eligible Employees shall have agreed to make the required
contributions to apply toward the premium for the insurance.
I hereby designate as Agent of Record AON Consulting, Inc.
withAddress(includingZipCode) 7650 W. Courtney Campbell Causeway, Suite 1000, Tampa, FL 33601-14ti2
This is a preliminary application. Final application for any policy issued is to be signed upon delivery of the policy.
99
---
of Clearwater
hael J. .RObf:F..j:~oo, ,City IJ.'.lallager
..Z./~~
-,>-.
arassas, Assistant City t y. C hia E. Goudeau, City Cl~rk
UNITED BEHA VIORAL HEALTH, Third Party J\dministrator, San Francisco, California
Received from N/A Amount S 0 as advance payment towards the premium
for the Employee Benefits Plan for which application has been made on this day to United HealthCare Insurance Company. The
application shall be accepted by the Third Party Administrator for United HealthCare Insurance Company and the policy or policies
issued, and if the advance payment evidenced by the Receipt shall be larger than the first premium, the excess will be returned to the
applicant or at the election of the applicant, will be applied to the payment of the next premium or premiums falling due. If the
application shall not be accepted or if for any reason the insurance does not become effective, the amount of the advance payment will
be returned to the applicant. No agents can make any insurance effective or make, alter or discharge any insurance policy or extend
the time for payment of prem iums nor can the tenns of any application, receipt or policy be varied or altered or its conditions waived
or extended in any respect except by the written agreement of the Insurance Company, signed by its President, one of its V ice
Presidents or Secretaries.
Date
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CITY OF CLEARWATER
Behavioral Health Benefits
January 1, 2000
.
Unit~d B~havioral H~alth
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92880035 - Policy Number Variable
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Table of Contents
Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Schedule of Benefits ................................................................ 2
Effective Date of this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
Behavioral Health Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
Eligibility .......................................................................... 3
Eligible Employees .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Eligible Dependents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Cost of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Enrollment Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Effective Date of Employee Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
Effective Date of Dependent Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
Qualified Medical Child Support Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
Special Provision for Newborn Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
Retired Employee Coverage .......................................................... 5
Behavioral Health Benefits ........................................................... 5
What This Plan Pays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 5
Notification Requirements and Utilization Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7
Emergency Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7
Copayments and Deductibles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7
Maximum Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8
Extended Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8
Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8
Network Provider Charges Not Covered. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 10
Claims Information ................................................................. 10
How to File a Claim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 10
When Claims Must be Filed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11
How and When Claims Are Paid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11
Legal Actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11
Incontestability of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11
Review Procedure for Denied Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
Coordination of Benefits ............................................................ 12
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
How Coordination Works. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 13
Which Plan Pays First. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 13
Right to Exchange Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14
Facility of Payment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14
Right of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14
Recovery Provisions ............................................................... 15
Refund of Overpayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15
Reimbursementof Benefits Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15
Subrogation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15
Effect of Medicare and Government Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16
Government Plans (other than Medicare and Medicaid). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17
Termination of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Employee Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 18
Dependent Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 18
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
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Continuation of Coverage (COBRA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Continuation of Coverage During Family and Medical Leave (FMLA) ....................... 25
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Certification
,of)
CERTIFICATE OF INSURANCE
for Employees of
City of Clearwater
(called the Employer)
insured by
UNITED HEAL THCARE INSURANCE COMPANY
Hartford, Connecticut
(called the Company)
United HealthCare Insurance Company has issued Group Policy No. GA-Policy
Number Variable. It covers certain Employees of the Employer.
The policy provides Behavioral Health Benefits.
This Certificate of Insurance describes the benefits and provisions of the policy.
Additional benefits and provisions may apply based on the requirements of:
The state where the policy is issued.
The state where the Employee lives.
These state benefits and provisions are described in separate Amendments. See
the Employer for details.
This is a Covered Person's Certificate of Insurance only while that person is
insured under the policy. Dependents benefits apply only if the Employee is insured
under the Employer's Plan for Dependent Benefits.
This Certificate describes the Plan in effect as of January 1, 2000.
This Certificate replaces any and all Certificates previously issued for Employees
under the plan.
THIS CERTIFICATE CONTAINS A DEDUCTIBLE
PROVISION.
UNITED HEAL THCARE INSURANCE COMPANY
....wf3/
President and CEO
The Behavioral Health Benefits described in this Plan are administered by United
Behavioral Health.
1-888-224-5672
C-CE1FL, C-SB1, C-EL 1, C-RE1, C-MH3, C-CI1, C-CB1, C-RP1, C-EM1, C-TE1,
C-GL 1
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Schedule of Benefits
Effective Date of January 1, 2000
this Plan
Behavioral
Health Benefits
pO
Network
Employee Assistance up to 3 visits:
Program 100%
Deductibles and Copayments
Inpatient Deductible $200 Per Admission
Office Visit Copayment Visits 1-3: 100%
Visits 4-30: $10
Psych Testing $10 per Hour
Percentage Payable after Deductibles/Copayments Satisfied
Network
Mental Health/Substance 100%
Abuse Inpatient and
Intensive Outpatient
Treatment
Mental Health Outpatient 100% after Copayment
Maximum Benefits
Mental Health 30 Days
Calendar Year Maximum
Inpatient
Substance Abuse 5 Days
Calendar Year Maximum
Inpatient
Mental Health/Substance 30 Days
Abuse Calendar Year
Maximum Intensive
Outpatient Treatment
MentalHealth CalendarYear 30 Visits
Maximum Outpatient
Mental Health/Substance 3 Admissions
Abuse Lifetime Maximum
All benefits are paid in accordance with the Reasonable Charge. Refer to the
Glossary for the definition of Reasonable Charge.
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Eligibility
Eligible
Employees
Eligible
Dependents
Cost of
Coverage
Enrollment
Requirements
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All Employees of the Employer.
Employees must reside in the United States.
Dependents are:
A wife or husband of an eligible Employee.
Any unmarried child from birth through age 19 of an eligible Employee.
An unmarried child under age 25 of an eligible Employee, if the child is a
registered student in regular full-time attendance at school. The child must be
mainly dependent on the Employee for care and support. The child cannot be
employed on a regular full-time basis by one or more employers for a total of
30 or more hours per week
Child includes the following:
A stepchild who resides in the eligible Employee's home.
A legally adopted child. (A child is considered legally adopted on the earlier of
the date of placement or the date the legal adoption proceedings have been
started. )
Any other child related to an eligible Employee, mainly dependent on the
eligible Employee for care and support and residing in the eligible Employee's
home.
Any grandchildren of an eligible Employee until the age of two.
Dependents must reside in the United States.
The coverage under this Plan is non-contributory. This means that the Employer
pays for the full cost of the coverage.
Enrollment Date
The date the person is enrolled under this Plan.
Employee Coverage
An Employee enrolls for Employee coverage by:
completing an enrollment form, and
giving the form to the Employer.
Dependent Coverage
No person can be covered both as an Employee and as a Dependent.
Initial Dependents are those family members who are eligible Dependents on the
date the Employee first becomes eligible for Employee coverage.
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Effective Date of
Employee
Coverage
Effective Date of
Dependent
Coverage
Qualified
Medical Child
Support Order
Special
Provision for
Newborn
Children
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Subsequent Dependents are any family members who become Eligible
Dependents after the date the Employee first becomes eligible under this Plan.
Employee coverage is effective on the first day of the month coincident with or next
following the latest of:
The Effective Date shown in Schedule of Benefits.
The date the Employee enrolls for coverage.
The first of the month after the Employee starts work.
Coverage for an Initial Dependent(s) is effective on the later of the following dates:
The date the Employee becomes covered.
The date the Employee enrolls the Dependents.
Coverage for a Subsequent Dependent is effective as follows:
For a spouse, the first day of the month coincident or next following the later of
the date the spouse is enrolled and the date of marriage.
For a newborn child, the date of birth.
For an adopted child, the date of adoption or placement for adoption.
For any other child, the date the child becomes a Dependent.
If an Employee is required by a qualified medical child support order, as defined in
the Omnibus Budget Reconciliation Act of 1993 (OBRA 93), to provide coverage
for his/her children, these children can be enrolled as timely enrollees as required
by OBRA 93.
If the Employee is not already enrolled, the Employee may also enroll as a timely
enrollee at the same time.
Plan Benefits are payable for a newborn child for 31 days after the child's birth,
even if the Employee has not enrolled the child.
Plan Benefits are payable for a newborn child for 31 days after the child's birth,
even if the Employee has not enrolled the child.
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Retired Employee Coverage
Retired Employees are eligible for the benefits as described below after they stop
being an Active Employee.
As a Retired Employee, Plan Benefits are continued. The continued coverage will
be the same coverage as for Active Employees, except as described below.
The coverage is contributory. Retired Employees must make contributions
toward the cost of their coverage.
The continued benefits for Medicare Eligibles are modified as shown in
Medicare and Other Government Plans.
Definitions
Retired Employee
Retired Employee means an Employee who meets all of the following:
The Employee is retired by the Employer.
The Employee receives retirement income either from the Employer or as a
result of service with the Employer.
The Employee was covered under this Plan or the Former Plan on the day
before the date of retirement.
Totally Disabled or Total Disability
A Retired Employee's inability due to accidental injury or sickness to perform the
normal activities of a person in good health and of like age and sex.
Behavioral Health Benefits
What This Plan
Pays
Behavioral Health Benefits are payable for Covered Expenses incurred by a
Covered Person for Behavioral Health Services received from a Network Provider.
To receive benefits, the Covered Person must call United Behavioral Health (UBH)
before Covered Expenses are incurred. (See Notification Requirements and
Utilization Review.)
Each Covered Person must satisfy certain Copayments and/or Deductibles before
any payment is made for certain Behavioral Health Services. The Behavioral
Health Benefit will then pay the percentage of Covered Expenses shown in
Schedule of Benefits.
A Covered Expense is incurred on the date that the Behavioral Health Service is
given.
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Covered Expenses are the actual cost to the Covered Person of the Reasonable
Charge for Behavioral Health Services given. The Company, at its discretion, will
calculate Covered Expenses following evaluation and validation of all provider
billings in accordance with the methodologies:
In the most recent edition of the Current Procedural Terminology and/or DSM
IV Code;
As reported by Generally recognized professionals or publications.
Behavioral Health Services are services and supplies which are:
Clinically Necessary, as determined by the Company, for Mental Disorder
Treatment.
Given while the Covered Person is covered under this Plan.
Given by one of the following providers:
Physician.
Psychologist.
Licensed Counselor.
Health Care Provider.
Hospital.
Treatment Center.
Behavioral Health Services include but are not limited to the following:
Assessment.
Diagnosis.
Treatment Planning.
Medication Management.
Individual, family and group psychotherapy.
Psychological testing.
Services and supplies will not automatically be considered Clinically Necessary
because they were prescribed by a health care provider.
Services or supplies are Clinically Necessary, as determined by the Company, if
they meet all of the following:
They are consistent with the symptoms and signs of diagnosis and treatment
of the Covered Person's behavioral disorder, psychological injury or substance
abuse.
They are consistent in type and amount with regard to the standards of good
clinical practice.
They are not solely for the convenience or preference of the Covered Person,
or his/her health care provider.
They are the least restrictive and least intrusive appropriate supplies or level
of service which can be safely provided to the Covered Person.
The Company may consult with professional clinical consultants, peer review
committees or other appropriate sources for recommendations regarding whether
particular services, supplies or accommodations provided or to be provided to a
Covered Person were/are Clinically Necessary.
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Notification
Requirements
and Utilization
Review
Emergency
Care
Copayments
and Deductibles
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To receive benefits under this Plan the Covered Person must call United
Behavioral Health (UBH) before Behavioral Health Services are given. The toll-
free number is 1-888-224-5672. UBH is ready to take the Covered Person's
call 7 days a week, 24 hours a day. This call starts the Utilization Review process.
The Covered Person will be referred to a Network Provider who is experienced in
addressing his/her specific issues.
If the Covered Person is not satisfied with a Network Provider, he/she may call
UBH and ask for a referral to another Network Provider. The Covered Person may
do this more than once, but he/she will only be referred to one Network Provider at
a time.
UBH performs a Utilization Review to determine the Clinical Necessity of
Behavioral Health Services. The Covered Person and his/her health care provider
decide which Behavioral Health Services are given, but this Plan only pays for
Behavioral Health Services that are Clinically Necessary as determined by UBH
and given by a Network Provider.
Appeals
The Covered Person may appeal a Utilization Review or benefit reduction. Call
UBH for further information.
Emergency Care does not require a referral from UBH to a UBH Network Provider.
When Emergency Care is required for Mental Disorder Treatment, the Covered
Person (or his/her representative or his/her health care provider) must call UBH
within one day after the Emergency Care is given. If it is not reasonably possible to
make this call within one calendar day, the call must be made as soon as
reasonably possible.
When the Emergency Care has ended, the Covered Person must get a referral
from UBH before any additional services will be covered.
Before Behavioral Health Benefits are payable, each Covered Person must satisfy
certain Copayments and/or Deductibles.
A Copayment is the amount of Covered Expenses the Covered Person must pay
to a Network Provider at the time services are given. Copayments are not counted
toward any Deductible. Behavioral Health Services which require a Copayment are
not subject to a Deductible.
A Deductible is the amount of Covered Expenses the Covered Person must pay
before Behavioral Health Benefits are payable. After the Deductible has been met,
Covered Expenses are payable at the percentage shown in Schedule of Benefits.
The amount of each CopaymenUDeductible is shown in Schedule of Benefits. A
Covered Expense can only be used to satisfy one Copayment or Deductible.
Office Visit Copayment
The Office Visit Copayment applies to services given by a Network Provider. It
applies to all services and supplies given in connection with each office visit.
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Maximum
Benefit
Extended
Benefits
Not Covered
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Inpatient Deductible
The Inpatient Deductible applies to each confinement in a Network Provider
Facility.
The Maximum Benefit payable for each Covered Person is shown in Schedule of
Benefits. This maximum applies to each Covered Person's lifetime.
Extended Benefits are payable for a Totally Disabled Covered Person for up to 3
months. Extended Benefits are only payable for Behavioral Health Services given
during the 3-month period after the person's coverage ends.
The person must be continuously Totally Disabled due to the same cause from the
date coverage ends until the date Behavioral Health Services are given.
Extended Benefits are only payable for Behavioral Health Services given for the
injury or sickness causing Total Disability.
This Plan does not cover any expenses incurred for services, supplies, medical
care or treatment relating to, arising out of, or given in connection with, the
following:
Services or supplies given by a Non-Network Provider.
Services or supplies which are not Clinically Necessary, including any
confinement or treatment given in connection with a service or supply which is
not Clinically Necessary.
Services or supplies received before the Covered Person or his/her Dependent
becomes covered under this Plan.
Expenses incurred by a Dependent if the Dependent is covered as an
Employee for the same services under this Plan.
Treatment given in connection with any of the following diagnoses: mental
retardation (except initial diagnosis), autism, pervasive developmental
disorders, chronic organic brain syndrome, learning disability, or
transsexualism.
Completion of claim forms or missed appointments.
Custodial Care that has not been approved by UBH. This is care made up of
services and supplies that meets one of the following conditions:
Care furnished mainly to train or assist in personal hygiene or other
activities of daily living, rather than to provide medical treatment.
Care that can safely and adequately be provided by persons who do not
have the technical skills of a covered health care professional.
Care that meets one of the conditions above is custodial care regardless of any
of the following:
Who recommends, provides or directs the care.
Where the care is provided.
Whether or not the patient or another caregiver can be or is being
trained to care for himself or herself.
Ecological or environmental medicine, diagnosis and/or treatment.
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Education, training and bed and board while confined in an institution which is
mainly a school or other institution for training, a place of rest, a place for the
aged or a nursing home.
Herbal medicine, holistic or homeopathic care, including drugs.
Services, supplies, medical care or treatment given by one of the following
members of the Employee's immediate family:
The Employee's spouse.
The child, brother, sister, parent or grandparent of either the Employee or
the Employee's spouse.
Services or supplies, treatments or drugs which are considered investigational
because they do not meet generally accepted standards of medical practice in
the United States. This includes any related confinements, treatment, service
or supplies.
Services and supplies for which the Covered Person is not legally required to
pay.
Membership costs for health clubs, weight loss clinics and similar programs.
Nutritional counseling.
Occupational injury or sickness - an occupational injury or sickness is an injury
or sickness which is covered under a workers' compensation act or similar law.
For persons for whom coverage under a workers' compensation act or similar
law is optional because they could elect it or could have it elected for them,
occupational injury or sickness includes any injury or sickness that would have
been covered under the workers' compensation act or similar law had that
coverage been elected.
Examinations or treatment ordered by a court in connection with legal
proceedings unless such examinations or treatment otherwise qualify as
Behavioral Health Services.
Examinations provided for employment, licensing, insurance, school, camp,
sports, adoption or other non-Clinically Necessary purposes, and related
expenses for reports, including report presentation and preparation.
Services given by a pastoral counselor.
Personal convenience or comfort items including, but not limited to, such items
as TVs, telephones, first aid kits, exercise equipment, air conditioners
humidifiers, saunas, hot tubs.
Private duty nursing services while confined in a facility.
Sensitivity training, educational training therapy or treatment for an education
requirement.
Sex-change surgery.
Stand-by services required by a Physician.
Telephone consultations.
Tobacco dependency.
Services or supplies received as a result of war declared or undeclared, or
international armed conflict.
Weight reduction or control (unless there is a diagnosis of morbid obesity),
special foods, food supplements, liquid diets, diet plans or any related
products.
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Services given by volunteers or persons who do not normally charge for their
services.
Network
Provider
Charges Not
Covered
A Network Provider has contracted to participate in the Network and provide
services at a negotiated rate. Under this contract a Network Provider may not
charge for certain expenses, except as stated below. A Network Provider cannot
charge for:
Services or supplies which are not Clinically Necessary;
Fees in excess of the negotiated rate.
A Covered Person may agree with the Network Provider to pay any charges for
services and supplies which are not Clinically Necessary. In this case, the Network
Provider may make charges to the Covered Person. The Covered Person will be
asked to sign a patient financial responsibility form agreeing to pay for the services
that are found to not be Clinically Necessary. However, these charges are not
Covered Expenses under this Plan and are not payable by the Company.
Claims Information
How to File a
Claim
A claim form does not need to be filed when a Network Provider is used.
The following steps should be completed when submitting bills for payment:
Get a claim form from the Employer, the Plan Administrator or United
Behavioral Health.
Complete the Employee portion of the form.
Have the provider complete the provider portion of the form.
Send the form and bills to the address shown on the form.
Make sure the bills and the form include the following information:
The Employee's name and social security number.
The Employer's name and contract number (Policy Number Variable).
The patient's name.
The diagnosis.
The date the services or supplies were incurred.
The specific services or supplies provided.
If the covered Employee asks for a claim form but does not receive it within 15
days, the covered Employee can file a claim without it by sending the bills with a
letter, including all of the information listed above.
10
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When Claims
Must be Filed
How and When
Claims Are Paid
Legal Actions
Incontestability
of Coverage
!(J
J
I
The covered Employee must give the Company written proof of loss within 15
months after the date the expenses are incurred.
The Company will determine if enough information has been submitted to enable
proper consideration ofthe claim. If not, more information may be requested.
No benefits are payable for claims submitted after the 15-month period, unless it
can be shown that:
It was not reasonably possible to submit the claim during the 15-month period.
Written proof of loss was given to the Company as soon as was reasonably
possible.
All payments will be paid to the covered Employee as soon as United Behavioral
Health receives satisfactory proof of loss, except in the following cases:
If the covered Employee has financial responsibility under a court order for a
Dependent's medical care, United Behavioral Health will make payments
directly to the provider of care.
If United Behavioral Health pays benefits directly to Network Providers.
If the covered Employee requests in writing that payments be made directly to
a provider. A covered Employee does this when completing the claim form.
These payments will satisfy the Company's obligation to the extent of the payment.
United Behavioral Health will send an Explanation of Benefits (EOB) to the covered
Employee. The EOB will explain how United Behavioral Health considered each of
the charges submitted for payment. If any claims are denied or denied in part, the
covered Employee will receive a written explanation.
Any benefits continued for Dependents after a covered Employee's death will be
paid to one of the following:
The surviving spouse.
A Dependent child who is not a minor, if there is no surviving spouse.
A provider of care who makes charges to the covered Employee's Dependents
for Behavioral Health Services.
The legal guardian of the covered Employee's Dependent.
The covered Employee may not sue on a claim before 60 days after proof of loss
has been given to the Company. The covered Employee may not sue after three
years from the time proof of loss is required, unless the law in the area where the
covered Employee lives allows for a longer period of time.
This Plan cannot be declared invalid after it has been in force for two years. It can
be declared invalid due to nonpayment of premium.
No statement used by any person to get coverage can be used to declare coverage
invalid if the person has been covered under this Plan for two years. I n order to use
a statement to deny coverage before the end of two years, it must have been
signed by the person. A copy ofthe signed statement must be given to the person.
11
Review
Procedure for
Denied Claims
I
I
In cases where a claim for benefits payment is denied in whole or in part, the
claimant may appeal the denial. A request for review must be directed to United
Behavioral Health within 60 days after the claim payment date or the date of the
notification of denial of benefits. When requesting a review, the claimant should
state the reason he or she believes the claim was improperly paid or denied and
submit any data or comments to support the claim.
A review of the denial will be made and United Behavioral Health will provide the
claimant with a written response within 60 days of the date the Company receives
the claimant's request for review. If, because of extenuating circumstances, the
Company is unable to complete the review process within 60 days, the Company
will notify the claimant of the delay within the 60 day period and will provide a final
written response to the request for review within 120 days of the date the Company
received the claimant's written request for review.
If the denial is upheld, United Behavioral Health's written response to the claimant
will cite the specific Plan provision(s) upon which the denial is based.
Coordination of Benefits
Definitions
/YJ
Coordination of benefits applies when a covered Employee or a covered
Dependent have health coverage under this Plan and one or more Other Plans.
One of the plans involved will pay the benefits first: that plan is Primary. Other
Plans will pay benefits next: those plans are Secondary. The rules shown in this
provision determine which plan is Primary and which plan is Secondary.
Whenever there is more than one plan, the total amount of benefits paid in a
Calendar Year under all plans cannot be more than the Allowable Expenses
charged for that Calendar Year.
"Other Plans" are any of the following types of plans which provide health benefits
or services for medical care or treatment:
Group policies or plans, whether insured or self-insured. This does not include
school accident-type coverage.
Group coverage through HMOs and other prepayment, group practice and
individual practice plans.
Group-type plans obtained and maintained only because of membership in or
connection with a particular organization or group.
Government or tax supported programs. This does not include Medicare or
Medicaid.
No-Fault motor vehicle laws.
"Primary Plan": A plan that is Primary will pay benefits first. Benefits under that
plan will not be reduced due to benefits payable under Other Plans.
"Secondary Plan": Benefits under a plan that is Secondary may be reduced due
to benefits payable under Other Plans that are Primary.
"Allowable Expenses" means the necessary, reasonable and customary
expense for health care when the expense is covered in whole or in part under at
least one of the plans.
12
How
Coordination
Works
Which Plan
Pays First
;JLJ
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The difference between the cost of a private hospital room and the cost of a semi-
private hospital room is not considered an Allowable Expense unless the patient's
stay in a private hospital room is medically necessary either in terms of generally
accepted medical practice, or as defined in the plan.
When a plan provides benefits in the form of services, instead of a cash payment,
the reasonable cash value of each service rendered will be considered both an
Allowable Expense and a benefit paid.
When this Plan is Primary, it pays its benefits as if the Secondary Plan or Plans did
not exist.
When this Plan is a Secondary Plan, its benefits are reduced so that the total
benefits paid or provided by all plans during a Calendar Year are not more than
total Allowable Expenses. The amount by which this Plan's benefits have been
reduced shall be used by this Plan to pay Allowable Expenses not otherwise paid,
which were incurred during the Calendar Year by the person for whom the claim is
made. As each claim is submitted, this Plan determines its obligation to pay for
Allowable Expenses based on all claims which were submitted up to that point in
time during the Calendar Year.
The benefits of this Plan will only be reduced when the sum of the benefits that
would be payable for the Allowable Expenses under the Other Plans, in the
absence of provisions with a purpose like that of this Coordination of Benefits
provision, whether or not claim is made, exceeds those Allowable Expenses in a
Calendar Year.
When the benefits of this Plan are reduced as described above, each benefit is
reduced in proportion. It is then charged against any applicable benefit limit of this
Plan.
When two or more plans provide benefits for the same Covered Person, the benefit
payment will follow the following rules in this order:
A plan with no coordination provision will pay its benefits before a plan that has
a coordination provision.
The benefits of the plan which covers the person other than as a dependent
are determined before those of the plan which covers the person as a
dependent.
The benefits of the plan covering the person as a dependent are determined
before those of the plan covering that person as other than a dependent, if the
person is also a Medicare beneficiary and both of the following are true:
Medicare is secondary to the plan covering the person as a dependent.
Medicare is primary to the plan covering the person as other than a
dependent (example, a retired employee).
When this Plan and another plan cover the same child as a dependent of
parents who are not separated or divorced, the benefits of the plan of the
parent whose birthday falls earlier in a year are determined before those of the
plan of the parent whose birthday falls later in that year. This is called the
"Birthday Rule." The year of birth is ignored.
If both parents have the same birthday, the benefits of the plan which covered
one parent longer are determined before those of the plan which covered the
other parent for a shorter period of time.
If the other plan does not have a birthday rule, but instead has a rule based on
the gender of the parent, and if, as a result, the plans do not agree on the order
of benefits, the rule in the other plan will determine the order of benefits.
13
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If two or more plans cover a person as a dependent child of divorced or
separated parents, benefits for the child are determined in this order:
First, the plan of the parent with custody for the child.
Second, the plan of the spouse of the parent with the custody of the child.
Finally, the plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the parents is
responsible for the health care expense of the child, and the entity obligated to
payor provide the benefits of the plan of that parent has actual knowledge of
those terms, the benefits of that plan are determined first. The plan of the other
parent shall be the Secondary Plan. This rule does not apply with respect to
any claim for which any benefits are actually paid or provided before the entity
has that actual knowledge.
If the specific terms of a court decree state that the parents shall share joint
custody, without stating that one of the parents is responsible for the health
care expenses of the child, the plans covering the child shall follow the order
of benefit determination rules that apply to dependents of parents who are not
separated or divorced.
The benefits of a plan which covers a person as an employee who is neither
laid off nor retired are determined before those of a plan which covers that
person as a laid off or retired employee. The same rule applies if a person is a
dependent of a person covered as a retiree or an employee. If the other plan
does not have this rule, and if, as a result, the plans do not agree on the order
of benefits, this rule is ignored.
If none of the above rules determines the order of benefits, the benefits of the plan
which covered an employee, member or subscriber for the longer period are
determined before those of the plan which covered that person for the shorter
period.
Right to
Exchange
Information
In order to coordinate benefit payments, the Company needs certain information.
It may get needed facts from or give them to any other organization or person. The
Company need not tell, or get the consent of, any person to do this.
A Covered Person must give the Company the information it asks for about other
plans. If the Covered Person cannot furnish all the information the Company
needs, the Company has the right to get this information from any source. If any
other organization or person needs information to apply its coordination provision,
the Company has the right to give that organization or person such information.
Information can be given or obtained without the consent of any person to do this.
Facility of
Payment
It is possible for benefits to be paid first under the wrong plan. The Company may
pay the plan or organization or person for the amount of benefits that the Company
determines it should have paid. That amount will be treated as if it was paid under
this Plan. The Company will not have to pay that amount again.
Rig ht of
Recovery
The Company may pay benefits that should be paid by another plan or organization
or person. The Company may recover the amount paid from the other plan or
organization or person.
The Company may pay benefits that are in excess of what it should have paid. The
Company has the right to recover the excess payment.
14
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i
Recovery Provisions
Refund of
Overpayments
Reim bu rsement
of Benefits Paid
Subrogation
;;4
If the Company pays benefits for expenses incurred on account of a Covered
Person, that Covered Person or any other person or organization that was paid
must make a refund to the Company if:
All or some of the expenses were not paid by the Covered Person or did not
legally have to be paid by the Covered Person.
All or some of the payment made by the Company exceeded the benefits
under this Plan.
The refund equals the amount the Company paid in excess of the amount it should
have paid under this Plan.
If the refund is due from another person or organization, the Covered Person
agrees to help the Company get the refund when requested.
If the Covered Person, or any other person or organization that was paid, does not
promptly refund the full amount, the Company may reduce the amount of any future
benefits that are payable under this Plan. The Company may also reduce future
benefits under any other group benefits plan administered by the Company for the
Employer. The reductions will equal the amount of the required refund. The
Company may have other rights in addition to the right to reduce future benefits.
If the Company pays benefits for expenses incurred on account of a Covered
Person, the Employee or any other person or organization that was paid must
make a refund to the Company if all or some of the expenses were recovered from
or paid by a source other than this Plan as a result of claims against a third party
for negligence, wrongful acts or omissions. The refund equals the amount of the
recovery or payment, up to the amount the Company paid.
If the refund is due from another person or organization, the Covered Person
agrees to help the Company get the refund when requested.
If the Covered Person, or any other person or organization that was paid, does not
promptly refund the full amount, the Company may reduce the amount of any future
benefits that are payable under this Plan. The Company may also reduce future
benefits under any other group benefits plan administered by the Company for the
Employer. The reductions will equal the amount of the required refund. The
Company may have other rights in addition to the right to reduce future benefits.
In the event a Covered Person suffers an injury or sickness as a result of a
negligent or wrongful act or omission of a third party, the Company has the right to
pursue subrogation where permitted by law.
The Company will be subrogated and succeed to the Covered Person's right of
recovery against a third party. The Company may use this right to the extent of the
benefits under this Plan.
The Covered Person agrees to help the Company use this right when requested.
15
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Effect of Medicare and Government Plans
Medicare
When a Covered Person becomes eligible for Medicare, this Plan pays its benefits
in accordance with the Medicare Secondary Payer requirements of federal law. If
the Employer is subject to the Medicare Secondary Payer requirements, this Plan
will pay primary.
When This Plan Pays Primary to Medicare
This Plan pays primary to Medicare for Covered Persons who are Medicare eligible
if:
Eligibility for Medicare is due to age 65 and the employee has "current
employment status" with the employer as defined by federal law and
determined by the employer.
Eligibility for Medicare is due to disability and the employee has "current
employment status" with the employer as defined by federal law and
determined by the employer.
Eligibility for Medicare is due to end stage renal disease (ESRD) under the
conditions and for the time periods specified by federal law.
When Medicare Pays Primary to this Plan
Medicare pays primary to this Plan for Covered Persons who are Medicare eligible
if:
The employee is a Retired Employee.
Eligibility is due to disability and the Employee does NOT have "current
employment status" with the employer as defined by federal law and
determined by the employer.
Eligibility for Medicare is due to end stage renal disease (ESRD), but only after
the conditions and/or time periods specified in federal law cause Medicare to
become primary.
See How this Plan Pays When Medicare is Primary.
Important! - Medicare Enrollment Requirements
When this Plan pays benefits first, without regard to Medicare, and the Covered
Person wants Medicare to pay after this Plan, the Covered Person must enroll for
Medicare Parts A and B. If the Covered Person does not enroll for Medicare when
he or she is first eligible, the Covered Person must enroll during the special
enrollment period which applies to that person when the person stops being eligible
under this Plan.
When Medicare pays benefits first, benefits available under Medicare are deducted
from the amounts payable under this Plan, whether or not the person has enrolled
for Medicare. If Medicare pays first, the Covered Person should enroll for both
Parts A and 8 of Medicare when that Covered Person is first eligible; otherwise, the
expenses may not be covered by the Plan or Medicare.
16
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Government
Plans (other
than Medicare
and Medicaid)
0;:7
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I
How This Plan Pays When Medicare Is Primary
If Medicare pays benefits first, this Plan pays benefits as described below. This
method of payment only applies to Medicare eligibles. It does not apply to any
Covered Person unless that Covered Person becomes eligible under Medicare.
If the provider has agreed to limit charges for services and supplies to the charges
allowed by Medicare (participating physicians), this Plan determines the amount of
Covered Expenses based on the amount of charges allowed by Medicare.
If the provider has not agreed to limit charges for services and supplies to the
charges allowed by Medicare (non-participating physicians), this Plan determines
the amount of Covered Expenses based on the lesser of the following:
The Reasonable Charges.
The amount of the Limiting Charge as defined by Medicare.
This Plan determines the amount payable without regard to Medicare benefits.
Then this Plan subtracts the amount payable under Medicare for the same
expenses from Plan benefits. This Plan pays only the difference between Plan
benefits and Medicare benefits.
The amount payable under Medicare which is subtracted from this Plan's benefits
is determined as the amount that would have been payable to a Medicare eligible
covered under Medicare even if:
The person is not enrolled for Medicare Parts A and B. Benefits are determined
as if the person were covered under Medicare Parts A and B.
The expenses are paid under another employer's group health plan which is
primary to Medicare. Benefits are determined as if benefits under that other
employer's plan did not exist.
The person is enrolled in a Health Maintenance Organization (HMO) or
Competitive Medical Plan (CMP) to receive Medicare benefits, and receives
unauthorized services (out-of-plan services not covered by the HMO/CMP).
Benefits are determined as if the services were authorized and covered by the
HMO/CMP.
If the Covered Person is also covered under a Government Plan, this Plan does
not cover any services or supplies to the extent that those services or supplies, or
benefits for them, are available to that Covered Person under the Government
Plan.
This provision does not apply to any Government Plan which by law requires this
Plan to pay primary.
A Government Plan is any plan, program, or coverage - other than Medicare or
Medicaid - which is established under the laws or regulations of any government,
or in which any government participates other than as an employer.
17
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Termination of Coverage
Employee
Coverage
Employee coverage ends on the earliest of the following:
The day this Plan ends.
The last day of the month in which employment stops. See Disability and
Leave of Absence below.
The last day of the month in which the person stops being an eligible
Employee.
Disability
The Employer has the right to continue a person's employment and coverage
under this Plan during a period in which the person is away from work due to
disability. The period of continuation is determined by the Employer based on the
Employer's general practice for an Employee in the person's job class.
Coverage ends on the date the Employer notifies the Company that the person's
employment has stopped and coverage is to be ended.
Leave of Absence
The Employer has the right to continue the person's employment and coverage
under this Plan during a period in which the person is away from work due to an
approved leave of absence or temporary layoff. The period of continuation is
determined by the Employer based on the Employer's general practice for an
Employee in the person's job class.
Coverage will end on the earlier of:
The last day of the month following the month in which the leave begins.
The date the Employer notifies the Company that the person's employment
has stopped and coverage is to be ended.
Dependent
Coverage
Coverage for all of an Employee's Dependents ends on the earlier of the following:
The day the Employee's coverage ends.
Coverage for an individual Dependent ends on the earlier of:
The day the Dependent becomes covered as an Employee under this Plan.
The last day of the month in which the Dependent stops being an eligible
Dependent.
Continuation of Coverage for Incapacitated Children
A mentally or physically incapacitated child's coverage will not end due to age. It
will continue as long as Dependents coverage under this Plan continues and the
child continues to meet the following conditions:
The child is incapacitated.
The child is not capable of self-support.
The child depends mainly on the Employee for support.
The Employee must give the Company proof that the child meets these conditions
when requested. The Company will not ask for proof more than once a year.
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Glossary
(These definitions apply when the following terms are used.)
Calendar Year
A period of one year beginning with a January 1.
Covered Person
The Employee and the Employee's wife or husband and/or Dependent children
who are covered under this Plan.
Emergency Care
Immediate Mental Disorder Treatment when the lack of the treatment could
reasonably be expected to result in the patient harming himself or herself and/or
other persons.
Employee
A person on the payroll of the Employer and regularly employed by the Employer
on a full-time basis of not less than 30 hours per week.
Employee Assistance Program
An organized outreach and intervention counseling program to identify and assist
Covered Persons who are experiencing personal problems which currently and/or
predictably effect work performance.
Health Care Provider
A licensed or certified provider other than a Physician whose services the
Company must cover due to a state law requiring payment of services given within
the scope of that provider's license or certification.
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Hospital
I
An institution which is engaged primarily in providing medical care and treatment
of sick and injured persons on an inpatient basis at the patient's expense and which
fully meets one of the following three tests:
It is accredited as a hospital by the Joint Commission on Accreditation of
Healthcare Organizations.
It is approved by Medicare as a hospital.
It meets all of the following tests:
. It maintains on the premises diagnostic and therapeutic facilities for surgical
and medical diagnosis and treatment of sick and injured persons by or
under the supervision of a staff of duly qualified Physicians.
. It continuously provides on the premises 24-hour-a-day nursing service by
or under the supervision of registered graduate nurses.
. It is operated continuously with organized facilities for operative surgery on
the premises.
Licensed Counselor
A person who specializes in Mental Disorder Treatment and is licensed as a
Licensed Professional Counselor (LPC) or Licensed Clinical Social Worker
(LCSW) by the appropriate authority.
Medicare
The Health Insurance For The Aged and Disabled program under Title XVIII of the
Social Security Act.
Mental Disorder Treatment
Mental Disorder Treatment is treatment for both of the following:
Any sickness which is identified in the current edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM), including a psychological and!
or physiological dependence or addiction to alcohol or psychoactive drugs or
medications, regardless of any underlying physical or organic cause, and
Any sickness where the treatment is primarily the use of psychotherapy or
other psychotherapeutic methods.
All inpatient services, including room and board, given by a mental health facility or
area of a Hospital which provides mental health or substance abuse treatment for
a sickness identified in the DSM, are considered Mental Disorder Treatment,
except in the case of multiple diagnoses.
If there are multiple diagnoses, only the treatment for the sickness which is
identified in the DSM is considered Mental Disorder Treatment.
Detoxification services given prior to and independent of a course of
psychotherapy or substance abuse treatment is not considered Mental Disorder
Treatment.
Prescription Drugs are not considered Mental Disorder Treatment.
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Network Provider
A provider which participates in the network.
No-Fault Automobile Insurance Law
The basic reparations provision of a law providing for payments without
determining fault in connection with automobile accidents.
Non-Network Provider
A provider which does not participate in the network.
Physician
A legally qualified:
Doctor of Medicine (M.D.).
Doctor of Osteopathy (D.O.).
Plan
The group policy or policies issued by the Company which provide the benefits
described in this Certificate of Insurance.
Psychologist
A person who specializes in clinical psychology and fulfills one of these
requirements:
A person licensed or certified as a psychologist.
A Member or Fellow of the American Psychological Association, if there is no
government licensure or certification required.
Reasonable Charge
As to charges for services rendered by or on behalf of a Network Physician, an
amount not to exceed the amount determined by the Company in accordance with
the applicable fee schedule.
As to all other charges, an amount measured and determined by the Company by
comparing the actual charge for the service or supply with the prevailing charges
made for it. The Company determines the prevailing charge. It takes into account
all pertinent factors including:
The complexity of the service.
The range of services provided.
The prevailing charge level in the geographic area where the provider is
located and other geographic areas having similar medical cost experience.
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Total Disability or Totally Disabled
An Employee's inability to perform all of the substantial and material duties of
his or her regular employment or occupation.
A Dependent's inability to perform the normal activities of a person of like age
and sex.
Treatment Center
A facility which provides a program of effective Mental Disorder Treatment and
meets all of the following requirements:
It is established and operated in accordance with any applicable state law.
It provides a program of treatment approved by a Physician and the Company.
It has or maintains a written, specific and detailed regimen requiring full-time
residence and full-time participation by the patient.
It provides at least the following basic services:
. Room and board (if this Plan provides inpatient benefits at a Treatment
Center).
. Evaluation and diagnosis.
. Counseling.
. Referral and orientation to specialized community resources.
A Treatment Center which qualifies as a Hospital is covered as a Hospital and not
as a Treatment Center.
Utilization Review
A review and determination as to the Clinical Necessity of services and supplies.
End of Certificate
Continuation of Coverage (COBRA)
This optional continuation only applies to Employees and their Dependents
if it has been made available by the Employer. The Employer is required to
offer this continuation in certain cases as a result of Public Law 99-272
(COBRA). This provision is intended to comply with the law and any pertinent
regulations, and its interpretation is governed by them. See the Employer to
find out if and how this continuation applies to Employees and their
Dependents.
In no event will the Company be obligated to provide continuation to a
Covered Person if the Employer or its designated plan administrator fails to
perform its responsibilities under federal law. These responsibilities include
but are not limited to notifying the Covered Person in a timely manner of the
right to elect continuation and notifying the Company in a timely manner of
the Covered Person's election of continuation.
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The Company is not the Employer's designated Plan Administrator and does
not assume any responsibilities of a Plan Administrator pursuant to federal
law.
If coverage under this Plan would have stopped due to a Qualifying Event, a
Qualified Beneficiary may elect to continue coverage subject to the provisions
below.
The Qualified Beneficiary may continue only the coverage in force immediately
before the Qualifying Event.
The coverage being continued will be the same as the coverage provided to
similarly situated individuals to whom a Qualifying Event has not occurred.
Coverage will continue until the earliest of the following dates:
18 months from the date the Qualified Beneficiary's coverage would have
stopped due to a Qualifying Event based on employment stopping or work
hours being reduced.
If a Qualified Beneficiary is determined to be disabled under the Social Security
Act at any time during the first 60 days of continued coverage due to the
employee's employment stopping or work hours being reduced, that Qualified
Beneficiary may elect an additional 11 months of coverage under this Plan,
subject to the following conditions:
The Qualified Beneficiary must provide the Employer with the Social
Security Administration's determination of disability within 60 days of the
time the determination is made and within the initial 18-month continuation
period.
The Qualified Beneficiary must agree to pay any increase in the required
payment necessary to continue the coverage for the additional 11 months.
If the Qualified Beneficiary entitled to the additional 11 months of coverage
has nondisabled family members who are entitled to continuation
coverage, those nondisabled family members are also entitled to the
additional 11 months of continuation coverage.
36 months from the date the coverage would have stopped due to the
Qualifying Event other than those described above.
The date this Plan stops being in force.
The date the Qualified Beneficiary fails to make the required payment for the
coverage.
The date the Qualified Beneficiary becomes entitled to benefits under
Medicare.
The date the Qualified Beneficiary, after electing this continuation, becomes
covered under any other group health plan. (This does not apply if the other
group health plan excludes or limits coverage for a Qualified Beneficiary's
preexisting condition.)
If the Qualified Beneficiary is already covered under any other group health plan
and elects continuation of coverage under this Plan, the Qualified Beneficiary must
stop coverage under that other group health plan. If the Qualified Beneficiary does
not stop coverage under that other plan, coverage under this continuation will stop.
If after the first Qualifying Event another Qualifying Event occurs, coverage can be
continued for an additional period, for a total of 36 months from the date of the first
Qualifying Event.
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Coverage will stop for the same reasons as coverage would have stopped for the
first Qualifying Event.
Election Period
A Qualified Beneficiary has at least 60 days to elect to continue coverage. The
election period ends on the later of:
60 days after the date coverage would have stopped due to the Qualifying
Event.
60 days after the date the person receives notice of the right to continue
coverage.
Unless otherwise specified, an Employee or spouse's election to continue
coverage will be considered an election on behalf of all other Qualified
Beneficiaries who would also lose coverage because of the same Qualifying Event.
Required Payments
A Qualified Beneficiary has 45 days from the date of election to make the first
required payment for the coverage. The first payment will include any required
payment for the continued coverage before the date of the election.
Notification Requirements
A Qualified Beneficiary must notify the Employer within 60 days when any of the
following Qualifying Events happen:
The Qualified Beneficiary's marriage is dissolved.
The Qualified Beneficiary becomes legally separated from his or her spouse.
A child stops being an eligible Dependent.
The Employer will send the appropriate Election Form to the Qualified Beneficiary
within 14 days after receiving this notice.
Claims
File a claim by completing a medical claim form and attaching your bills to the form.
"COBRA" should be written on the claim form and on each of the bills.
Special Terms that Apply to this Continuation Provision
Qualifying Event
A Qualifying Event is any of the following which results in loss of coverage for a
Qualified Beneficiary:
The Employee's employment ends (except in the case of gross misconduct).
The Employee's work hours are reduced.
The Employee becomes entitled to benefits under Medicare.
The Employee's death.
The Employee's marriage is dissolved.
The Employee becomes legally separated from his/her spouse.
The Employee's Dependent child stops being an eligible Dependent.
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A bankruptcy is a Qualifying Event for certain Retired Employees and their
Dependents under certain conditions. If there is a bankruptcy, Retired Employees
should contact the Employer or the Company for more information.
Qualified Beneficiary
Any of the following persons who are not entitled to Medicare on the day before a
Qualifying Event:
The Employee.
An Employee's spouse.
An Employee's former spouse (or legally separated spouse).
A Dependent child, including a child born to or placed for adoption with the
Employee during a period of continued coverage.
Continuation of Coverage During Family and Medical
Leave (FMLA)
The Family and Medical Leave Act of 1993 (FMLA) requires Employers to
provide up to a total of 12 weeks of unpaid, job-protected leave during any
12-month period to eligible Employees for certain family and medical
reasons. This provision is intended to comply with the law and any pertinent
regulations, and its interpretation is governed by them. See the Employer to
find out details about how this continuation applies to you.
Reasons for Taking Leave
FMLA leave must be granted for any of the following reasons:
Care of a child after birth.
Care of a child after placement of that child with the Employee for adoption or
foster care.
Care of the Employee's spouse, child or parent (but not a parent-in-law) who
has a serious health condition.
A serious health condition that makes the Employee unable to work.
Employee Eligibility
To be eligible for FMLA benefits, all of the following must be true:
The Employee must work for a covered Employer.
The Employee must have worked for the Employer for at least 12 months.
The Employee must have worked at least 1,250 hours over the previous 12
months.
The Employee must work at a location where at least 50 employees are
employed by the Employer within 75 miles.
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Advance Notice and Medical Certification
The Employee must provide advance notice and medical certification. Taking of
leave may be denied if requirements are not met.
The employee ordinarily must provide 30 days advance notice when the leave
is "foreseeable."
If the need for the leave is unforeseen, notice must be given as soon as
practicable.
An Employer may require medical certification to support a request for
leave because of a serious health condition, and may require a second or
third opinion (at the Employer's expense) and a fitness for duty report to
return to work.
Continuation of Coverage, Job Benefits and Protection
For the duration of a FMLA leave, the Employer must maintain the Employee's
coverage. The Employee may continue the Plan benefits for himself or herself and
his or her Dependents on the same terms as if the Employee had continued to
work. The Employee must pay the same contributions toward the cost of the
coverage that he or she made while working.
If the Employee fails to make the payments on a timely basis, the Employer, after
giving you written notice, can end the coverage during the leave if payment is more
than 30 days late.
Upon return from a FMLA leave, most Employees must be restored to their
original or equivalent positions with equivalent pay, benefits and other
employment terms.
The use of a FMLA leave cannot result in the loss of any employment benefit
that accrued prior to the start of an Employee's leave.
See the Employer for details about continuing group coverage other than the Plan
benefits.
Intermittent Leave
Under some circumstances, an Employee may take a FMLA leave intermittently
which means taking a leave in blocks of time, or by reducing his or her normal
weekly or daily work schedule.
Where a FMLA leave is for birth or placement for adoption or foster care, use
of intermittent leave is subject to the Employer's approval.
A FMLA leave may be taken intermittently whenever it is medically necessary
to care for a seriously ill family member, or because the Employee is seriously
ill and unable to work.
Substitution of Paid Leave
Subject to certain conditions, Employees or Employers may choose to use accrued
paid leave (such as sick or vacation leave) to cover some or all of the FM LA leave.
The Employer is responsible for designating if paid leave used by the Employee
counts as a FMLA leave, based on information provided by the Employee. In no
case can an Employee's paid leave be credited as a FMLA leave after the leave
has been completed.
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Spouses Who Work for the Same Employer
Spouses employed by the same Employer are jointly entitled to a combined total
of 12 work weeks of family leave for the birth of a child or placement of a child for
adoption or foster care, and to care for such child or to care for a parent who has
a serious health condition.
Reenrollment after a FMLA Leave
If any or all of an Employee's coverages end while the Employee is on a FMLA
leave, the Employee can reenroll for coverage when he or she returns to work from
the FMLA leave.
The Employee and any Dependents will be considered timely enrollees if the
Employee reenrolls within 31 days from the date he or she returns to work.
92880035 (10/99)
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