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HomeMy WebLinkAboutCAG1995-0042 - Original - Group Health Cooperative - Group Medical Coverage Agreement - 01/01/1995 Glalth Cooperative of Puget Sound GROUP MEDICAL COVERAGE AGREEMENT Group Health Cooperative of Puget Sound (also GROUP HEALTH COOPERATIVE referred to as "GHC" or "the Cooperative") is a non- OF PUGET SOUND profit health maintenance organization furnishing health care primarily on a prepayment basis.As a direct By service provider, the Cooperative is dedicated to Title Vice President,Health Plan and Insurance Services providing to its Enrollees quality health care,including preventive medical services. GROUP This Agreement states the terms of enrollment, pay- ment and coverage under which a Group may secure jHC health benefits. The Schedule of Benefits lists the benefits to which those enrolled under this Agree- ment are entitled. Words with special meaning are capitalized.They are defined in Section 1. By ENROLLEES ARE ENTITLED TO COVERED Ti e SERVICES ONLY AT GHC FACILITIES, UN- LESS THE ENROLLEE HAS BEEN REFERRED BY A GHC PHYSICIAN OR HAS RECEIVED This Agreement will become effective January 1, EMERGENCY SERVICES ACCORDING TO 1995 and will continue in effect until terminated as SECTION X.I. OF THE SCHEDULE OF herein provided for. BENEFITS. 0369 Page 1 W5Z GROUP MEDICAL COVERAGE AGREEMENT Table of Contents I. Definitions H. Dues and Fees III. Termination IV. Continuation Coverage, Conversion and Transfer V. Coordination of Benefits VI. Subrogation VII. Grievance Procedures VIII. Miscellaneous Provisions IX. Enrollment and Eligibility Schedule X. Schedule of Benefits XI. Exclusions and Limitations XII. Claims • Medicare Endorsements • Allowances,Deductibles, Copayments, and Fees Schedule • Dues Schedule 0 Service Area Map 0369 Page 2 W5Z Section I. Definitions AGREEMENT: This Medical Coverage Agreement, including the Schedule of Benefits, Enrollment and Eligibility Schedule, Dues Schedule, Allowan- ces, Deductibles, Copayments, and Fees Schedule, Service Area Map, and Medicare endorsements. ALLOWANCE: The maximum amount payable by GHC for certain Covered Services under this Agreement, as set forth in the Allowances, De- ductibles, Copayments, and Fees Schedule. COINSURANCE: An amount that the Member is re- quired to pay for Covered Services received under this Agreement, which is a percentage of the Al- lowance for such services, as set forth in the Al- lowances, Deductibles, Copayments, and Fees Schedule. COPAYMENT: The specific dollar amount required 14 be paid by a Member for certain Covered Ser- eligibility requirements, is enrolled hereunder, and for whom the dues prescribed in the Dues Schedule have been paid. FAMILY UNIT: A Subscriber and all his/her Family Dependents. GHC DESIGNATED FACILITY: A facility, not in- cluding a GHC Facility, which the GHC Board of Trustees has specified to provide health care ser- vices to its Members. (See Service Area Map.) Designated Facilities may be changed by GHC upon appropriate notice. GHC FACILITY: A hospital or medical center owned and operated by Group Health Cooperative of Puget Sound. (See Service Area Map.) GHC MEDICARE PLAN: A plan of coverage for persons enrolled in Medicare Part A (hospital in- surance) and Part B (medical insurance), or Part B only. MEDICARE: The federal health insurance program for the aged and disabled. MEMBER: Any Subscriber or Family Dependent covered by this Agreement. OPEN ENROLLMENT: An annual period, specified by the Group and GHC, during which an eligible person may apply for coverage. PRE-EXISTING CONDITION: Acondition forwhich there has been diagnosis, treatment (including prescribed drugs), or medical advice within the three (3) month period prior to the effective date of coverage, or a condition for which symptoms existed within the three (3) month period prior to the date of coverage and for which a prudent person would have ordinarily sought treatment. REFERRAL: A written temporary referral agreement authorized in advance by a GHC physician and approved by GHC, which entitles a Member to receive Covered Services from a specified non- GHC health care provider. Entitlement to such services shall not exceed the limits of the Referral and is subject to all the terms and conditions of the Referral and this Agreement. SERVICE AREA: Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom Counties, and any other areas desig- nated by GHC. (See Service Area Map.) SKILLED HOME HEALTH CARE: Reasonable and necessary care for the treatment of an illness or injury which requires the skill of a nurse or therapist, based on the complexity of the service and the condition of the patient, and which is performed directly by an appropriately licensed professional provider. STOP LOSS: The maximum amount of Copayments paid during the calendar year for Covered Services received by the Subscriber and his/her Family De- pendents during the same calendar year. The Stop Loss amount is set forth in the Allowances, De- ductibles, Copayments, and Fees Schedule. SUBSCRIBER: A person employed by or belonging to the Group who meets all applicable eligibility re- quirements, is enrolled hereunder, and for whom 0369 W5Z the dues specified in the Dues Schedule have been paid. URGENT CONDITION: The sudden, unexpected onset of a medical condition that is of sufficient severity to require medical treatment within twen- ty-four (24) hours of its onset. USUAL, CUSTOMARY, AND REASONABLE: A term used to define the level of benefits which are payable by GHC when expenses are incurred from a non-GHC physician or provider. Expenses are considered Usual, Customary, and Reasonable if (1) the charges are consistent with those normally charged by the provider or organization for the same services or supplies; and (2) the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies. Section II. Dues, Fees, and Copayments A. MONTHLY DUES PAYMENTS. The Group shall submit to GHC for each Member the month- ly dues set forth in the current Dues Schedule and a verification of enrollment, on or before the due date, subject to a grace period of ten (10) days. Dues are subject to change by GHC upon thirty (30) days written notice. In the event the group increases enrollment at least twenty-five percent (25%) or more through acquisition or merger, GHC reserves the right to require re -rating of the group. B. SUBSCRIBER'S LIABILITY. The Subscriber is liable for (1) payment to the Group of his/her contribution toward the monthly dues, if any; (2) payment to the Cooperative of Copayments and/or Coinsurance amounts for Covered Ser- vices provided to the Subscriber and his/her Fami- ly Dependents, as set forth in the Allowances, Deductibles, Copayments and Fees Schedule; and (3) payment to the Cooperative of any fees charged for non -Covered Services provided to the Subscriber and his/her Family Dependents. Failure to pay for services at the time of service may result in a billing fee. At the time of service, Members shall be required to pay Copayments as set forth in the Allowances, Deductibles, Copayments and Fees Schedule. Page 4 Failure to pay Copayments at the time of service may result in a billing fee. Failure to cancel a scheduled appointment at least 24 hours prior to the appointment may result in a billing for the value of the service. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non -Covered Service. Total out-of-pocket Copayment expenses in- curred during the same calendar year shall not exceed the aggregate maximum amount (Stop Loss) as set forth in the Allowances, Deductibles, Copayments, and Fees Schedule. If Copayments have been billed, any applicable billing fees shall not be considered in calculating total out-of-pocket expenses for Copayments made. C. SELF -PAYMENTS DURING A STRIKE, LOCK -OUT, OR OTHER LABOR DISPUTE. In the event of suspension or termination of employee compensation due to a strike, lock -out, or other labor dispute, a Subscriber may continue uninterrupted coverage under this Agreement through payment of monthly dues directly to the Group. Coverage may be continued for the lesser of the term of the strike, lock -out, or other labor dispute, or for six (6) months after the cessation of work. If the Group Agreement is no longer available, the Subscriber shall have the opportunity to apply for individual Group Conversion or, if applicable, continuation coverage (see Section IV.), or an Individual and Family Medical Coverage Agree- ment at the duly approved rates. THE GROUP IS RESPONSIBLE FOR IMME- DIATELY NOTIFYING EACH AFFECTED SUBSCRIBER OF HIS/HER RIGHTS OF SELF -PAYMENT UNDER THIS PRO- VISION. Section III. Termination A. TERMINATION OF ENTIRE AGREEMENT. This Agreement may be terminated in the follow- ing circumstances: 0369 W5Z 1. Termination on Notice. This is a guaranteed renewable contract and cannot be terminated without the mutual approval of each of the parties except as set forth below (Subsection 2., 3., and 4.). 2. Nonpayment. Failure to make any monthly dues payment in accordance with Section II.A. shall result in termination of this Agreement as of the due date. 3. Misrepresentation to Obtain Insurance. Group Health Cooperative may terminate this Agreement upon written notice in the event of material misrepresentation, fraud, or omission of information in order to obtain Group coverage. 4. The group may terminate this Agreement by giving thirty (30) days written notice to GHC. B. TERMINATION OF SPECIFIC MEMBERS. This Agreement may be terminated as to a specific Member for any of the following reasons: 1. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section IX.B. and is not enrolled for con- tinuation coverage as described in Section IV.A., coverage under this Agreement will terminate at the end of the month during which loss of eligibility occurs, unless other- wise specified by the Group as set forth in Section IX. Enrollment and Eligibility Schedule. 2. For Cause. Coverage of a Member may be terminated upon written notice for: a. Material misrepresentation, fraud, or omission of information in order to ob- tain coverage. This includes failure to answer fully and correctly all questions contained in the application forms. In such event, the Cooperative may, within two (2) years from the date of the application, refuse to cover any service for a condition(s) to which such ques- tion was relevant, or may rescind or cancel the Member's coverage upon ten (10) working days written notice. Page 5 b. Permitting the use of a GHC identifica- to grant continuation of coverage rights to the tion card by another person, or using extent required by federal law. another person's identification card to obtain care to which one is not entitled. To the extent required by federal law, if the Sub- scriber or Family Dependent loses eligibility c. Failure to comply with the rules and under this Group Agreement, group coverage regulations of the Cooperative. may be continued under the circumstances described below. Except as set forth in Section d. Nonpayment of charges as set forth in IV.A.11., below, this provision applies only to Section II.C. Subscribers and Family Dependents enrolled under this Agreement prior to the date of 3. Nonpayment of dues for a specific Member eligibility for continuation coverage who would by the Group. otherwise lose coverage as a result of one of the qualifying events listed below in subsections (1.), 4. In no event will a Member be terminated (2.), and (3.). solely on the basis of their physical or mental condition provided they meet all other 1. Subscribers and Family Dependents are eligibility requirements set forth in this eligible for continuation coverage for a max - Agreement. imum period of up to eighteen (18) months commencing at the date that: C. PERSONS HOSPITALIZED ON THE DATE OF TERMINATION. A Member who is a • The Subscriber's employment is ter - registered bed patient receiving Covered Services minated (unless terminated for gross in a GHC Facility or GHC Designated Facility on misconduct); or the date of termination shall continue to be eligible for Covered Services for the condition for • the Subscriber experiences a reduction which the Member was hospitalized, until dis- in work hours resulting in loss of charge from the facility. This continued coverage eligibility for group benefits. will also apply to a Member hospitalized in a non-GHC Designated Facility as a result of an 2. Family Dependents are eligible for con - Emergency or Referral as set forth in Section tinuation coverage for a maximum period of up to thirty-six (36) months commencing at XI.B.1. the date that: D. SERVICES PROVIDED AFTER TERMINA- TION. Any services provided by GHC after the • The Subscriber is divorced or legally effective date of termination (except those ser- separated; vices covered under Section III.C.) shall be charged according to the Directory of Services. the Subscriber dies; The Subscriber shall be liable for payment of all such charges for services provided to the Sub- 0 the Subscriber becomes entitled to scriber and all Family Dependents. Medicare; or • a Dependent child ceases to qualify as Section IV. Continuation Coverage, a Family Dependent under Section Conversion and Transfer IX.B.2.(b) or (c). 3. A COBRA eligible beneficiary who is dis- A. CONTINUATION COVERAGE abled prior to or on the date he/she loses coverage due to termination of employment This subsection A. only applies to employer who must offer continuation coverage (other than for the beneficiary's gross mis- conduct) or reduction of hours may extend groups under the applicable provisions of the Con- solidated Omnibus Budget Reconciliation Act of his/her coverage under COBRA from eighteen (18) months up to twenty-nine (29) 1985 ("COBRA"), as amended, and only applies months, so long as the beneficiary provides notice of his/her Social Security disability 0369 Page 6 W5Z determination within sixty (60) days of such determination and before the end of the eighteen (18) month coverage period. Social Security Administration certification of total disability is required. The period of extended coverage provided under this subsection shall terminate on the first day of the first month which begins more than 30 days after the date of the Social Security Administra- tion's final determination that the qualified beneficiary is no longer disabled. 4. In the event the group has retirees, the Subscriber who is a retiree or the spouse or Dependent of a retiree, may continue coverage hereunder if the Subscriber and/or Family Dependent would otherwise lose coverage hereunder within one year of the date a proceeding under Title 11 of the United States Code is commenced with respect to the Group. Coverage under this Section IV.A.4., continues only upon pay- ment of applicable monthly charges to the Group at the time specified by the Group. The terms and conditions of this coverage are governed by COBRA. 5. If an individual enrolled for continuation coverage experiences a second qualifying event as set forth in subsection (2.) above, continuation coverage may be extended for up to thirty-six (36) months, beginning from the date of the first qualifying event. When the Subscriber becomes entitled to Medi- care, the period of continuation coverage for family dependents as a result of the Sub- scriber's Medicare entitlement or any later event described in Section IV.A.2. above shall extend up to a maximum of thirty-six (36) months from the date the Subscriber becomes entitled to Medicare. 6. In addition to the conditions set forth in Section III. Termination, continuation cov- erage may be terminated prior to the pre- scribed period set forth in subsections (1.), (2.), and (3.) above if: • there is a failure to make timely pay- ment of any monthly dues required under this Agreement; • the Member becomes covered under any other group health plan, unless 0369 W5Z such plan contains an exclusion or limitation on coverage for any Pre-ex- isting Condition which the Member may have; • the Member becomes enrolled under Medicare; • the employer ceases to maintain any group health plan; or • the Member is no longer disabled as determined by the Social Security Ad- ministration. 7. Notice. The Group is responsible for assur- ing compliance with COBRA and that Mem- bers are given timely notice of their continuation coverage option. The Group is also responsible for notifying GHC in a time- ly fashion of the election to continue cover- age and the applicable coverage period. The Subscriber or Family Dependent must notify the Group, or plan administrator, if any, within sixty (60) days following a divorce, legal separation, or when an en- rolled dependent child no longer meets the eligibility requirements set forth in Section IX.B.2., or within sixty (60) days following the date coverage ends in accordance with the termination provisions under this Agree- ment, whichever is later. 8. Application. Written application for con- tinuation coverage must be made within sixty (60) days of the termination date of cover- age, or the date that the Member receives specific notice of his/her right to continua- tion coverage, whichever is later. For the purpose of this Agreement "receives" means that written notice was mailed by the Group to the Member's most recent address as recorded with the Group. No lapse in coverage prior to continuation coverage is permitted, except as provided above. The application shall be deemed by GHC to in- clude all Family Dependents eligible for con- tinuation coverage unless specifically stated otherwise. A physical examination or state- ment of health is not required. 9. Monthly Dues. Monthly dues must be paid directly to the Group. The Group is respon- Page 7 B. sible for submitting such dues with its regular monthly dues payment to GHC. Payment of the initial dues payment, which includes the period from the election retro- active to the qualifying event, and any regu- lar dues payment that becomes due prior to the initial dues payment date, for continua- tion coverage under COBRA is due forty- five (45) days after the date of the election. Subsequent dues payments are due on a monthly basis. Dues for persons extending COBRA coverage from eighteen (18) months to twenty-nine (29) months because of total disability may be charged at one hundred fifty percent (150%) of the Group's dues rate that would otherwise apply to them. 10. Group Conversion. In addition to Group Conversion rights as set forth in Section IV.B., the Subscriber or Family Dependent enrolled for continuation coverage is en- titled to convert to GHC's Group Conver- sion Plan within a 180-day period prior to termination of continuation coverage, if his/her coverage under this Agreement is terminated for any reason other than non- payment or cause. See Section IV.B.2. GHC Group Conversion Plan - Application. 11. Open Enrollment and Adding Dependents. To the extent required under COBRA, a qualified beneficiary under COBRA may add Family Dependents during the Group's Open Enrollment period and newly eligible persons according to the procedures speci- fied in Section IX.A. GHC GROUP CONVERSION PLAN. 1. Eligibility. Any Subscriber or Family De- pendent is entitled to convert to GHC's Group Conversion Plan if his/her coverage under this Agreement is terminated for any reason other than cause. (See Section III.B.2.) Following termination of marriage or death of the Subscriber, all Family De- pendents are entitled to make such a conver- sion. 2. Application. Application for conversion must be made within thirty-one (31) days following termination under this Agree- ment. Coverage under the GHC Group Conversion Plan is subject to all terms and conditions of such plan, including dues pay- ment. A physical examination or statement of health is not required for enrollment in the Group Conversion Plan. C. PERSONS ENTITLED TO, OR ELIGIBLE TO PURCHASE MEDICARE. Except as defined by federal regulations, all Members entitled to, or eligible to purchase Medicare must transfer to the GHC Medicare Plan upon such entitlement or eligibility. A condition of coverage under the GHC Medicare Plan requires that a Member be continuously fully qualified and enrolled for the hospital (Part A) and medical (Part B) benefits, or Part B only, available from the Social Security Administration, and sign any papers that may be required by GHC or Medicare. All applicable provisions of the GHC Medicare Plan are fully set forth in the Medicare Endorsement(s) attached to this Agreement. D. PERSONS AGE SIXTY-FIVE (65) OR OLDER WHO ARE NOT ENTITLED TO, OR ELIGI- BLE TO PURCHASE MEDICARE. Upon reach- ing age sixty-five (65), if not entitled to, or eligible to purchase Medicare, Members may continue coverage under this Agreement upon payment of the applicable dues as set forth in the Dues Schedule. Section V. Coordination of Benefits As described in Subsection H., benefits provided under this Agreement do not duplicate other group coverage for medical care or treatment. If a Member is entitled to receive benefits or services for medical care or treatment under another group or governmental plan, GHC may recover the reasonable cash value of ser- vices provided under this Agreement so that benefits and services under all plans do not exceed one hundred percent (100%) of allowable expenses (except copay- ments, coinsurances, and deductibles), as fully set forth in this section. A. Benefits Subject to This Provision: All of the benefits provided under this Agreement are subject to this provision. B. Plan: 0369 Page 8 W5Z C. III The definition of a 'Plan" includes the following sources of benefits or services: 1. Group or blanket disability insurance poli- cies and health care service contractor and health maintenance organization group agreements, issued by insurers, health care service contractors and health maintenance organizations; 2. Labor-management trusteed plans, labor or- ganization plans, employer organization plans or employee benefit organization plans; 3. Governmental programs; and 4. Coverage required or provided by any statute. The term 'Plan" shall be construed separately with respect to each policy, agree- ment or other arrangement for benefits or services, and separately with respect to the respective portions of any such policy, agree- ment or other arrangement which do and which do not reserve the right to take the benefits or services of other policies, agree- ments or other arrangements into considera- tion in determining benefits. Allowable Expense: "Allowable Expense" means any necessary, rea- sonable and customary items of expense at least a portion of which is covered under at least one of the Plans covering the person for whom the claim is made. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be considered as both an Allowable Expense and a benefit paid. Claim Determination Period: "Claim Determination Period" means a period beginning with any January 1 and ending with the next following December 31 except that the first Claim Determination Period with respect to any person shall begin on the effective date of cover- age under this Agreement with respect to such person and end on the following December 31. In no event will a Claim Determination Period for any person extend beyond the last day on which such a person is covered under this Agreement. E. Right to Receive and Release Information: For the purpose of determining the applicability of and implementing this provision and any provision of similar purpose in any other Plan, the Cooperative may, with such consent as may be necessary, release to or obtain from any other insurer, organization or person any information, with respect to any person which the insurer con- siders necessary for such purpose. Any person claiming benefits under this Agreement shall fur- nish to the Cooperative the information neces- sary for such purpose. F. Facility of Payment: Whenever coverage which should have been provided under this Agreement in accordance with this provision has been provided or paid for under any other Plan, the Cooperative shall have the right, exercisable alone and in its sole discre- tion, to pay over to any Plan making such other payments any amounts it shall determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be con- sidered to be coverage or benefits paid under this Agreement and, to the extent of such payments, the Cooperative shall be fully discharged from liability under this Agreement. G. Right of Recovery: Whenever benefits have been provided by the Cooperative with respect to Allowable Expenses in total amount at any time, in excess of the max- imum amount of payment necessary at that time to satisfy the intent of this provision, the Coopera- tive shall have the right to recover the reasonable cash value of such benefits, to the extent of such excess, from one or more of the following, as the Cooperative shall determine: any persons to or for or with respect to whom such benefits were provided, any other insurers, any service plans or any other organization or other Plans. H. Effect on Benefits: This provision shall apply in determining the benefits for a person covered under this Agreement for a particular Claim Deter- mination Period if, for the Allowable Expen- ses incurred as to such person during such period, the sum of: 0369 Page 9 W5Z a. The reasonable cash value of the a. The benefits of a Plan which covers the on whose expenses a claim is benefits that would be provided under the Agreement in the absence of this person based other than as a dependent shall provision, and be determined before the benefits of a Plan which covers such person as a de- b. The benefits that would be payable pendent. under all other Plans in the absence therein or provisions of similar purpose b. In the case that a dependent is covered to this provision would exceed such Al- under both parents' medical Plan, the benefits of the Plan of the parent whose towable Expenses. birthday falls earlier in the year are 2. As to any Claim Determination Period with respect to which this provision is applicable, determined before those of the Plan of a parent whose birthday falls later in the the reasonable cash value of the benefits year. This birthdate will refer only to the provided under this Agreement in the ab- sence of this provision for the Allowable month and day, not the year in which a person was bom. If both parents have Expenses incurred as to such person during such Claim Determination Period shall be the same birthday, the benefits of the Plan which covered the parent longer reduced to the extent necessary so that the sum of the reasonable cash value of benefits are determined before those that covered the other parent for a shorter and all benefits payable for such Allowable as period of time, except that in the case of a for whom claim is made as Expenses under all other Plans, except in subparagraph (3) of this Section, person a dependent child, provided shall not exceed the total of such Allowable Expenses. Benefits payable under another when the parents are separated or i wP se P Plan include benefits that would have been divorced and the parent with cus- tody of the child has not remarried, payable had a claim been duly made there- for. In determining liability under this para- the benefits of a Plan which covers graph, the Plan is not required, and will not the child as a dependent of the parent with custody of the child take into consideration, deductibles, copay- will be determined before the ments, or other cost -sharing provisions. benefits of a Plan which covers the 3. If child as a dependent of the parent without custody; and a. another Plan which is involved in sub- paragraph (2) of this Section and which ii. when the parents are divorced and contains a provision coordinating its benefits with those of this Agreement the parent with custody of the child has remarried, the benefits of would, according to its rules, determine its benefits after the benefits of this a Plan which covers the child as a dependent of the parent with cus- Plan have been determined; and tody shall be determined before the benefits of a Plan which covers b. the rules set forth in subparagraph (4) that child as a dependent of the of this Section would require this Agreement to determine its benefits stepparent, and the benefits of a Plan which covers that child as a before such other Plan, then the benefits of such other Plan will be ig- dependent of the stepparent will be determined before the benefits nored for the purposes of determining of a Plan which covers that child as the benefits under this Agreement. a dependent of the parent without custody. 4. For the purposes of subparagraph (3) of this Section, the rules establishing the order of Notwithstanding items (i) and (ii) benefit determination are: above, if there is a court decree which would otherwise establish financial 0369 Page 10 W5Z responsibility for the medical, dental or other health care expenses with respect to the child, the benefits of a Plan which covers the child as a dependent of the parent with such financial responsibility shall be determined before the benefits of any other Plan which cover the child as a dependent child. c. When rules (a) and (b) do not establish an order of benefit determination, the benefits of a Plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a Plan which has covered such person the shorter period of time, provided that: i. The benefits of a plan covering the person on whose expenses claim is based as a laid off or retired employee, or dependent of such person shall be determined after the benefits of any other Plan cov- ering such person as an employee, other than a laid off or retired employee, or dependent of such person; and ii. If either plan does not have a pro- vision regarding laid off or retired employees, which results in each Plan determining its benefits after the other, then the provisions of (i) of this subsection shall not apply. d. If none of the above rules determines the order of benefits, the benefits of the Plan which covered an employee or Subscriber for the longer period of time shall be determined before those of the Plan which covered that person for the shorter time period. When this provision operates to reduce the total amount of benefits otherwise to be provided to a person covered under this Agreement during any Claim Determination Period, the reasonable cash value of each benefit that would be provided in the ab- sence of this provision shall be reduced pro- portionately, and such reduced amount shall be charged against any applicable benefit limit of this Agreement. Section VI. Subrogation "Injured person" under this section means a Member covered by this Agreement who sustains compensable injury. "GHC's medical expenses" means the expense incurred and the reasonable value of the services provided by the Cooperative for the care or treatment of the injury sustained. If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability against the third party, GHC shall have the right to recover from the third party GHC's medical expenses. This right is commonly referred to as "subrogation." GHC shall be subrogated to and may enforce all rights of the injured person to the extent of GHC's medical expenses. GHC's equitable and contractual rights of subrogation are limited [only as required] by Washing- ton law. The injured person and his or her agents must cooperate fully with GHC in its efforts to collect GHC's medical expenses. This cooperation shall in- clude supplying GHC with information about any defendants and/or insurers related to the injured person's claim. The injured person and his or her agents shall permit GHC, at GHC's option, to as- sociate with the injured party or to intervene in any action filed against any third party. The injured person and his or her agents shall do nothing to prejudice GHC's subrogation rights. The injured person shall not settle a claim without protecting GHC's interest. GHC shall be subrogated to and may enforce all rights of the injured person to the extent of its medical expense. GHC's right of subrogation shall be limited to the excess of the amount required to fully compensate the injured person for the loss sustained. Full compensation shall be measured on an objective, case -by -case basis, but is sub- ject to a presumption that a settlement which does not exhaust the thud party's reachable assets is full compen- sation to the injured person. If the Member fails to cooperate fully with GHC in recovery of medical ex- penses as described above, the Member shall be responsible for reimbursing GHC for such medical expenses. 0369 Page 11 W5Z ,._t„ .� _ _-.. -�&- ,.,,na,.+Ln„ Nn oral statement of any person shall modify or person shall be enrolled or dues accepted disenroll the child retroactive to the until this completed application has been effective date of coverage. received and approved by GHC. The Group is for submitting completed ap- Children who are born in a non-GHC responsible plication forms to GHC. Facility on a nonemergency basis will not be automatically enrolled. In the a. Newly Eligible Persons. Newly eligible event there is a change in the monthly dues payment as a result of the addition Subscribers may make written applica- tion for enrollment to the Group within of a newborn child, the Subscriber must thirty-one (31) days of eligibility. If the Subscriber wishes to enroll his/her make written application for enroll - ment to the Group within sixty (60) days eligible Dependents, application must following the date of birth. be made during this same thirty-one In the event there is a change in the (31) day period. monthly dues payment as a result of the Written application for enrollment for addition of an adoptive child, including adopted newborns, the Subscriber must a newly dependent person, other than a or newborn adopted child, make written application for enroll - newborn must be made to the Group within thir- ment within sixty (60) days from the day that the child is physically placed with ty-one (31) days after the dependency the Subscriber for the purpose of adop- occurs. tion and the Subscriber assumes finan- A Subscriber's newborn child shall be cial responsibility for the medical automatically enrolled when born: expenses of the child. i. at a GHC Facility or GHC Desig- b. If the spouse and/or eligible Family De- of a GHC Subscriber loses nated Facility; or pendents eligibility under a comparable medical ii. at a non-GHC Facility due to an plan they may be added to the GHC Emergency, provided that all the requirements of Section X.I. of Subscriber's plan. There must be no more than a three (3) month lapse of this Agreement are met, including coverage between plans, and applica- notification of GHC by way of the tion must be made prior to the expira- GHC Notification Line within tion of this three (3) month period. twenty-four (24) hours following inpatient admission, or as soon c. Open Enrollment. A person not en - thereafter as medically possible. rolled as a Subscriber or Family De- pendent when newly eligible, as GHC shall provide notice of such en- rollment to the Subscriber and the described above, may make written ap- plication during the Group's Open En - Group. It is the Subscriber's respon- rollment period. sibility to complete and submit a revised application form to the Group. If the d. Health Evaluation. If a Subscriber or Subscriber does not want the newborn child enrolled, he/she must notify GHC Family Dependent wishes to enroll out - side the periods of eligibility as set forth within sixty (60) days of the date of in Section IX.A.1., or as set forth in Section IX.A.l.b. above, he/she must birth. first satisfy all Health Evaluation re If subsequent to enrollment it is dis- quirements as established by GHC and covered that the newborn child is not defined in Section I. of the Group eligible or if the Group does not initiate Medical Coverage Agreement. dues payments on or before sixty (60) days from the date of birth, GHC shall 2. Limitation on Enrollment. This Agreement will be open for application as set forth in 0369 Page 13 W5Z Section IX.A.1. GHC may limit enrollment, establish quotas, or set priorities for accep- tance of new applications if it determines that its capacity, in relation to its total enroll- ment, is not adequate to provide services to additional persons. 3. Effective Date of Enrollment. a. Provided application is made as set forth in Section IX.A-La. (above), en- rollment for a newly eligible Subscriber and listed Dependents will begin on the date of hire. Subscribers who return to work from a leave without pay status within ninety (90) days, shall be eligible for enroll- ment on the first of the month following their date of return to work. For eligible Subscribers and Family De- pendents who have satisfied the Health Evaluation requirement as set forth in Section IX.A.1., following acceptance by the Cooperative, enrollment will begin on the date specified by GHC. Enrollment for newly dependent per- sons, other than newborns and adopted children, will begin on the first (1st) of the month following application. Provided newborns are enrolled as specified in Section IX.A.l.a. (above), enrollment is effective from the date of birth. For adopted children, enrollment is ef- fective from the date that the adopted child is physically placed with the Sub- scriber for the purpose of adoption and the Subscriber has assumed financial responsibility for the medical expenses of the child. b. Persons Hospitalized on Effective Date. If a person, other than a newborn or adoptive child, is confined in a hospi- tal on the date enrollment would other- wise become effective, the effective date of enrollment for the person(s) hospitalized will not begin until dis- charge from the facility. 0369 W5Z 4. Effective Date of Services and Benefits. Ser- vices provided to Members, including new- borns and adoptive children, are subject to all terms and conditions of the Group Agree- ment including the requirement that all ser- vices must be received at a GHC or GHC Designated Facility under the medical management of a GHC physician unless the Member has been Referred by a GHC physician or has received Emergency ser- vices according to Section X.I. B. ELIGIBILITY In order to be accepted for enrollment and con- tinuing coverage under the Group Agreement, individuals must meet all applicable requirements set forth below. The Group is responsible for determining eligibility. Subscribers and Family Dependents must reside in the GHC Service Area (as defined in Section I.) in order to be eligible for enrollment under this Agreement, except for temporary residency out- side the Service area for purposes of attending school, court -ordered coverage for Dependents, or when approved in advance by GHC, other unique family arrangements. All non-ur- gent/emergent care must be provided at GHC Facilities or GHC Designated Facilities. 1. Subscribers. Bona fide employees and LEOFF II employees who are employed on a regularly scheduled basis of not less than twenty (20) hours per week shall be eligible for enrollment. Elected officials and councilmembers shall be eligible for enrollment. LEOFF I employees will not be covered under this plan. 2. Family Dependents. The Subscriber may en- roll any of the following: a. The Subscriber's legal spouse; b. Unmarried dependent children who are under the age of twenty-one (21), provided they reside regularly with the Subscriber or are chiefly dependent on the Subscriber for support and main - Page 14 tenance, provided proof of such de- pendency is furnished to GHC. "Children" means the children of the Subscriber including adopted children, stepchildren, foster children, children for whom the Subscriber has a qualified court order to provide coverage, and any other children for whom the Sub- scriber is the legal guardian. c. Enrollment may be extended past the limiting age for an unmarried person enrolled as a Family Dependent on his/her twenty-first (21st) birthday if: i. the Dependent is a full-time registered student at an accredited secondary school, college, or university and under the age of twenty-three (23); or ii. the Dependent is totally incapable of self-sustaining employment be- cause of a developmental dis- ability or a physical handicap incurred prior to attainment of the limiting age as set forth in Section IX.B.2.b., or prior to attainment of the student limiting age as set forth in Section IX.B.2.c., and is chiefly dependent upon the Subscriber for support and maintenance. En- rollment for such a Dependent may be continued for the duration of the continuous total incapacity, provided enrollment does not ter- minate for any other reason. Medical proof of incapacity and proof of financial dependency must be furnished to the Coopera- tive upon request, but not more frequently than annually after the two (2) year period following the Dependent's attainment of the limiting age. d. Dependents of LEOFF I employees are eligible for coverage under this con- tract. Ineligible Persons. GHC reserves the right to refuse enrollment to any person whose coverage under the Group Agreement or any other Medi- 0369 W5Z cal Coverage Agreement issued by Group Health Cooperative of Puget Sound has been terminated for cause. C. CONTINUATION OF ENROLLMENT While on a group approved leave of absence, the Subscriber and listed Dependents will continue to receive services and benefits under this Agree- ment for up to one hundred eighty (180) days, provided the employer or Group continues to remit dues to GHC for the Subscriber and such Dependents. While on a group approved leave of absence the Subscriber and listed Dependents can continue to be covered under this Agreement, provided they remain eligible for coverage, such leave is in compliance with the employer's established leave of absence policy consistently applied to all employees, the employer's leave policy is in compliance with the Family and Medical Leave Act when applicable, and the employer or Group continues to remit dues for the Subscriber and Dependents to the Cooperative. Section X. Schedule of Benefits Subject to all provisions of this Group Medical Coverage Agreement, persons enrolled for Com- prehensive Health Care are entitled to receive the benefits and services that are Medically Necessary as determined by GHC's Medical Director, or his/her designee, and as described in this Schedule of Benefits. A. HOSPITAL CARE Hospital care is provided when approved by a GHC physician, limited to the following services: 1. Room and board, including private room when prescribed, and general nursing ser- vices. 2. Hospital services (including use of operating room, anesthesia, oxygen, x-ray, laboratory, and radiotherapy services). As a cost-effective alternative to hospitalization or other institutional care which is covered by this Agreement, skilled home health services or skilled nursing facility services will be covered when a determination is made in advance by Page 15 B. the GHCphysician that such care is appropri- ate based on the patient's medical condition. All below. When dispensed through GHC Facilities, one contact lens per diseased eye alternative care must be approved in advance in lieu of an intraocular lens, including exam and fitting, is covered for Members following by GHC cataract surgery performed by a GHC When approved in advance and only when it is physician, provided the Member has been in lieu of covered hospitalization or other cov- continuously covered by GHC since such ered institutional care, other alternative care arrangements may be covered at the sole discre- surgery. Replacement of a covered contact lens will be provided only when needed due tion of GHC. to change in the Member's medical condi- tion but may be replaced only one time See Section X.G. Skilled Home Health Care within any twelve (12) month period. Services and Section XX Hospice. 4. Family planning counseling services. 4. Drugs and medications which are listed as covered in the GHC Drug Formulary (ap- 5. Hearing examinations to determine hearing proved drug list). loss. 5. Special duty nursing (when prescribed as 6. Blood derivatives and the administration of Medically Necessary). blood and blood derivatives. The cost of blood is not covered. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require trans- 7. Maternity care, including care for complica- fer of the Member to a GHC Facility, upon con- tions of pregnancy; prenatal and postpartum sultation with a GHC physician. If the Member visits; and hospitalization and delivery. refuses to transfer to a GHC Facility, all further costs incurred during the hospitalization are the Prenatal testing for the detection of con - responsibility of the Member. genital and heritable disorders when Medi- cally Necessary as determined by GHC's MEDICAL AND SURGICAL CARE Medical Director, or his/her designee. Medical and surgical services are provided, limited to the following, when prescribed by GHC Voluntary (not medically indicated and non - therapeutic) or involuntary termination of Medical Personnel: pregnancy. 1. Surgical services. 8. Transplants. When authorized as medically appropriate by GHC's Medical Director, or 2. Diagnostic x-ray, nuclear medicine, ultra- his/her designee, and in accordance with cri- sound, and laboratory services. teria established by the Cooperative, for heart, heart-lung, single lung, double lung, 3. Routine eye examinations and refractions, kidney, simultaneous pancreas/kidney, cor- limited to once every twelve (12) months, nea, bone marrow, and liver transplants, lim- except when Medically Necessary. Services ited to the following: for routine eye examinations must be received at a GHC Facility and in accord- • evaluation testing to determine recipi- ance with GHC medical criteria in order to ent candidacy; be covered. • transplantation, limited to costs for the Evaluations and surgical procedures to cor- surgery and hospitalization related to rect refractions which are not related to eye the transplant, and medications; and pathology are not covered. Complications related to such surgery are also excluded. • follow-up services for specialty visits, re -hospitalization, and maintenance Contact lens fittings and related examina- medications. tions are not covered except as set forth 0369 Page 16 W5Z Transportation expenses, except as set forth under Section X.J. of this Agreement, and living expenses are excluded. Donor costs for a covered organ recipient are covered, limited to procurement center fees, travel costs for a surgical team, excision fees, and matching tests. GHC shall exclude coverage for donor costs to the extent that the donor costs are reimbursable by the organ donor's insurance. Except for children who have been continu- ously enrolled at GHC since birth, coverage for all transplants and any related services, items, and drugs shall be excluded until such time as the Member has been continuously enrolled under this Agreement, or any prior GHC Medical Coverage Agreement, for twelve (12) consecutive months without any lapse in coverage, unless the Member re- quires a transplant as the result of a condi- tion which had a sudden unexpected onset after the Member's effective date of cover- age. 9. Physician visits (including consultations and second opinions by a GHC physician) in the hospital or office. 10. Preventive services for health maintenance including routine mammography screening and physical examinations in accordance with criteria established by the Cooperative, for the detection of disease; and immuniza- tions and vaccinations which are listed as covered in the GHC Drug Formulary (ap- proved drug list). A fee may be charged for health education programs. 11. Radiation therapy services. 12. Medical and surgical services and related hospital charges, including orthognathic (jaw) surgery for the treatment of temporo- mandibular joint (TMJ) disorders, are cov- ered as set forth in the Allowances, Deductibles, Copayments, and Fees Sched- ule when determined to be Medically Neces- sary and referred in advance by GHC. Such disorders may exhibit themselves in the form of pain, infection, disease, difficulty in speak- ing, or difficulty in chewing or swallowing food. TMJ appliances are covered as set 0369 W5Z forth under orthopedic appliances (Section X.E.1.). Orthognathic (jaw) surgery, radiology ser- vices and TMJ specialist services, including fitting/adjustment of splints, is subject to the benefit limit set forth in the Allowances, Deductibles, Copayments, and Fees Sched- ule. The following services, including related hospitalizations, are excluded regardless of origin or cause: e orthognathic (jaw) surgery in the ab- sence of a TMJ diagnosis, • treatment for cosmetic purposes, and • all dental services (except as noted above), including orthodontic therapy. 13. The following services are covered by GHC when performed by a GHC physician or GHC oral surgeon: reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or cysts of the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth; and incision of salivary glands and ducts. 14. Nonexperimental implants, limited to the following: cardiac devices, artificial joints, and intraocular lenses. Artificial or mechani- cal hearts are excluded. 15. When authorized as medically appropriate by GHC's Medical Director, or his/her desig- nee, and in accordance with criteria estab- lished by the Cooperative, treatment of growth disorders by growth hormones. Growth hormone treatment shall be ex- cluded until such time as the Member has been continuously enrolled under this Agreement or any prior GHC Medical Cov- erage Agreement for twelve (12) consecu- tive months without any lapse in coverage. 16. Respiratory therapy. 17. Dietary formula for the treatment of phenyl- ketonuria (PKU) when determined Medi- cally Necessary by GHC's Medical Director or his/her designee. Coverage for this for - Page 17 C. mula is not subject to a Pre-existing Condi- tions waiting period, if any. Outpatient Total Parenteral Nutritional Therapy, when Medically Necessary and in accordance with medical criteria as estab- lished by GHC is covered including supplies necessary for its administration. Outpatient enteral therapy is excluded. Dietary formulas and special diets, except for treatment of phenylketonuria (PKU) and total parenteral nutritional therapy as set forth above, are excluded. 18. Pre-existing Conditions are covered in the same manner as any other illness. 19. Skilled Nursing Facility care in a GHC-ap- proved skilled nursing facility up to a maxi- mum of thirty (30) days per condition when full-time skilled nursing care is necessary in the opinion of the attending GHC physician. When prescribed by a GHC physician, such care may include board and room; general nursing care; drugs, biologicals, supplies, and equipment ordinarily provided or arranged by a skilled nursing facility; and short-term physical therapy, occupational therapy, and restorative speech therapy. Excluded from coverage are personal com- fort items such as telephone and television; and rest cures, custodial, domiciliary or con- valescent care. CHEMICAL DEPENDENCY TREATMENT Subject to all terms and conditions of this Agree- ment, care is provided as set forth below at a GHC Facility, GHC Designated Facility, or GHC-ap- proved treatment facility, subject to the Benefit Period Allowance and Lifetime Maximum Benefit as described below and as shown in the Allowances, Deductibles, Copayments, and Fees Schedule. 1. Chemical Dependency Treatment Services. a. All alcoholism and/or drug abuse treat- ment services must be: (1) provided at a facility as described above and must be authorized in advance, except for acute chemical withdrawal as described in Section X.C.2.b.; and (2) deemed Medi- cally Necessary by GHC's ADAPT Director or his/her designee. Chemical dependency treatment may include the following services received on an in- patient or outpatient basisAiagnostic evaluation and education, organized in- dividual and group counseling, detoxification services, and prescrip- tion drugs and medicines. b. Court -ordered treatment shall be provided only if determined to be Medi- cally Necessary by GHC's ADAPT Director or his/her designee. 2. Emergency Care. a. Coverage for medical Emergencies in- cident to the abuse of alcohol and/or drugs is subject to the Emergency care benefit as set forth in Section X.I. b. Coverage for acute chemical withdrawal is provided without prior approval. If a Member is hospitalized in a non-GHC Designated Facility, coverage is subject to payment of the Deductible shown in the Allowances, Deductibles, Copayments, and Fees Schedule, and notification of GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admission, or as soon there- after as medically possible. Further- more, if a Member is hospitalized in a non-GHC Designated Facility, GHC reserves the right to require transfer of the Member to a GHC Facility upon consultation with a GHC physician. If the Member refuses transfer to a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Member. For the purpose of this section, "acute chemical withdrawal" means with- drawal of alcohol and/or drugs from a person for whom consequences of abstinence are so severe as to require medical/nursing assistance in a hospital setting and which is needed immedi- 0369 Page 18 W5Z ately to prevent serious impairment to the Member's health. 3. Benefit Period and Benefit Period Al- lowance. a. Benefit Period. For the purpose of this section, "Benefit Period" shall mean a twenty-four (24) consecutive calendar month period during which the Mem- ber is eligible to receive covered chemi- cal dependency treatment services as set forth in this section. The first Benefit Period shall begin on the first day the Member receives covered chemical dependency services under this or any other group insurance, health care service contractor, health maintenance organization, self -insured plan or any combination thereof, hereinafter referred to as "group plans," and shall continue for twenty-four (24) consecutive calendar months, provided that coverage under this Agreement remains in force. All subsequent Benefit Periods thereafter will begin on the first day Covered Services are received after expiration of the pre- vious twenty-four (24) month Benefit Period. b. Benefit Period Allowance. The maxi- mum allowance available for any Benefit Period shall be the total of all chemical dependency benefits provided and payments made for chemical de- pendency treatment under any group plan(s), not to exceed the Benefit Period Allowance shown in the Al- lowances, Deductibles, Copayments, and Fees Schedule during the Member's Benefit Period. 4. Lifetime Maximum Benefit. Chemical dependency services are not covered after the Member has reached his/her Lifetime Maximum Benefit amount as shown in the Allowances, Deductibles, Copayments, and Fees Schedule. All such benefits provided or payments made by: a. GHC under any GHC Group Medical Coverage Agreement; plus 0369 W5Z b. all amounts paid on an individual's be- half under any carrier or plan main- tained by the Group, including self -insured plans, shall be applied toward this Lifetime Maxi- mum Benefit amount. Any Deductibles or Copayments which may be borne by the Member under the terms of this Agreement shall not be applied toward the Benefit Period Allowance or Lifetime Maximum Benefit. In regard to this section, the Benefit Period(s), Benefit Period Allowance(s), and Lifetime Max- imum Benefit shall include only alcoholism treat- ment services received on or after January 1,1987 and alcoholism and/or drug abuse services received on or after January 1, 1988. D. PLASTIC AND RECONSTRUCTIVE SEW VICES are covered: 1. To correct a disorder resulting from a con- genital disease or anomaly as determined by a GHC physician; or to correct a medical condition following an injury or incidental to surgery covered by GHC which has produced a major effect on the Member's appearance, provided: • the Member has been continuously en- rolled with GHC since the date of such injury or surgery; and • when in the opinion of a GHC physician, such services can reasonably be expected to correct the condition. Complications of noncovered surgical ser- vices are excluded. 2. For reconstructive surgery and associated procedures following a mastectomy for Members who are medically suitable can- didates, as determined by GHC's Medical Director or his/her designee, regardless of when the mastectomy was performed. Inter- nal breast prostheses required incident to the surgery will be provided. A Member will be covered for all stages of one reconstructive breast reduction on the nondiseased breast to make it equivalent in Page 19 size with the diseased breast after definitive reconstructive surgery on the diseased breast has been performed. 3. For women who have not undergone breast reconstruction, external breast prostheses following mastectomy and post -mastectomy bras limited to one external breast prosthesis per diseased breast every two years, and two post -mastectomy bras every six (6) months, up to four (4) in any twelve (12) consecutive month period. Coverage for post -mastec- tomy bras is subject to the Coinsurance as set forth in the Allowances, Deductibles, Copayments, and Fees Schedule. E. APPLIANCES, DEVICES AND SUPPLIES 1. Orthopedic Appliances.When Medically Necessary, orthopedic appliances, which are attached to an impaired body segment for the purpose of protecting the segment or assisting in restoration or improvement of its function, are covered. Medically Necessary repair, adjustment or replacement of an or- thopedic appliance is covered when authorized in advance by a GHC physician. Covered Services are subject to the Coin- surance set forth in the Allowances, Deduct- ibles, Copayments, and Fees Schedule. Excluded are arch supports; orthopedic shoes that are not attached to an appliance; or any, orthopedic appliances that are not listed as covered in GHC's Orthopedic Ap- pliance Formulary. 2. Nasal CPAP Device. When Medically Necessary, the purchase of a nasal CPAP device, and the initial purchase of associated supplies, is covered. The initial one -month rental of the device prior to purchase, which is required to establish compliance, is also covered. Medically Necessary repair or re- placement of a nasal CPAP device is covered when authorized in advance by a GHC physician. Covered Services are subject to the allowance as set forth in the Allowances, Deductibles, Copayments, and Fees Schedule. Coverage for replacement of sup- plies is excluded. 3. Ostomy Supplies. Ostomy supplies neces- sary for the removal of bodily secretions or waste are covered. 0369 W5Z 4. Oxygen and Oxygen Equipment. When medical criteria as established by GHC are met, and upon Referral, oxygen and oxygen equipment for home use is covered. Replacement or repair of appliances, devices and supplies that are due to loss, breakage from willful damage, neglect or wrongful use, or due to per- sonal preference are excluded. F. DRUGS AND MEDICINES FOR OUT- PATIENT USE as prescribed by a GHC physician for conditions covered by this Agreement, includ- ing off -label use of FDA -approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well -designed clinical trials published in peer - reviewed medical literature document improved effi- cacy or safely of the agent over standard therapies, or over placebo if no standard therapies exist; or by thefederal secretary of Health and Human Services). All drugs, supplies, medicines and devices must be obtained at a GHC pharmacy. "Standard reference compendia" means the Ameri- can Hospital Formulary Service — Drug Informa- tion; the American Medical Association Drug Evaluation; the United States Pharmacopoeia — Drug Information, or other authoritative compendia as identified from time to time by thefederal secretary of Health and Human Services. "Peer -reviewed med- ical literature" means scienti, fee studies printed in healthcare journals or other publications in which original manuscripts arepublished only after having been critically reviewed for scientific accuracy, valid- ity, and reliability by unbiased independent experts. Peer -reviewed medical literature does not include in-house publications of pharmaceutical manufac- turing companies. Excluded are: dietary supplements, except thera- peutic vitamins for use up to thirty (30) days; dietary formulas and special diets, except as set forth in Section X.B.; contraceptive drugs and devices and their fitting; medicines and injections for anticipated illness while traveling; and any other drugs, medicines, and injections not listed as covered in the GHC Drug Formulary (ap- proved drug list). The Member will be charged for mailing drugs, medicines or devices and replacing lost or stolen drugs, medicines or devices. Page 20 G. HOME HEALTH CARE SERVICES, as set forth in this section, shall be provided by GHC Home Health Services or by a GHC-authorized home health agency when Referred in advance by a GHC physician for Members who meet the fol- lowing criteria: 1. The Member is unable to leave home due to his or her health problem or illness (unwill- ingness to travel and/or arrange for transpor- tation does not constitute inability to leave the home); 2. the Member requires intermittent Skilled Home Health Care services, as described below; and 3. a GHC physician has determined that such services are Medically Necessary and are most appropriately rendered in the Mem- ber's home. Covered Services for home health care may in- clude the following when prescribed by a GHC physician and when rendered pursuant to an ap- proved home health care plan of treatment: nurs- ing care, physical therapy, occupational therapy, respiratory therapy, restorative speech therapy, and medical social worker and limited home health aide services. Home health services are provided on an intermittent basis in the Member's home. "Intermittent" means care that is to be rendered because of a medically predictable recurring need for Skilled Home Health Care services. Excluded are: custodial care and maintenance care, private duty or continuous nursing care in the Member's home, housekeeping or meal ser- vices, care in any nursing home or convalescent facility, any care provided by or for a member of the patient's family, and any other services rendered in the home which are not specifically listed as covered under this Agreement. H. MENTAL HEALTH CARE SERVICES 1. Outpatient Services. Mental health services are provided on an outpatient basis at GHC in individual, couple, family, and group therapy formats. Services provided place priority on restoring social and occupational 0369 W5Z functioning, such as evaluation, crisis inter- vention, managed psychotherapy, intermit- tent care, psychological testing, and consultation services. The length and type of the treatment and the frequency and modality of visits shall be determined by the Director of GHC's Mental Health Service, or his/her designee. Coverage for each Member is provided ac- cording to the Outpatient Mental Health Allowance set forth in the Allowances De- ductibles, Copayments, and Fees Schedule. Psychiatric medical services including medi- cal management and medications are covered as set forth in Sections X.B. and X.F. All individual, family, couple, and group visits of one and one-half (1-1/2) hours or less are regarded as one full visit per individ- ual. A missed appointment will be consid- ered a "visit" unless GHC's Mental Health Service is notified at least twenty-four (24) hours in advance of a scheduled session. 2. Inpatient Services. Usual, Customary, and Reasonable charges for services described in this section, including psychiatric Emergen- cies resulting in inpatient services, shall be covered up to the maximum benefit as set forth in the Allowances, Deductibles, Copayments, and Fees Schedule. This benefit shall include coverage for acute treatment and stabilization of psychiatric emergencies in GHC-approved hospitals. When medically indicated, outpatient electro-convulsive therapy (ECT) is covered in lieu of inpatient services. Payment of bills incurred at non-GHC facilities shall exclude any charges that would otherwise be ex- cluded for hospitalization within a GHC Facility, such as telephone, television, and personal items. When authorized in advance by the Director of GHC's Mental Health Service, or his/her designee, partial hospitalization and out- patient electro-convulsive therapy programs are covered subject to the maximum in- patient benefit limit described in the Al- lowances, Deductibles, Copayments, and Fees Schedule. Every two (2) partial hospitalization days or two (2) electrocon- vulsive therapy treatments are equivalent to one inpatient hospital day. The total maxi - Page 21 mum annual benefit under this section shall not exceed the number of inpatient days described in the Allowances, Deductibles, Copayments, and Fees Schedule. I. Subject to the maximum Inpatient Mental Health Care Allowance as set forth in the Allowances, Deductibles, Copayments, and Fees Schedule, services provided under in- voluntary commitment statutes shall be covered at facilities approved by GHC. Ser- vices for any court -ordered treatment pro- gram beyond the seventy-two (72) hours shall be covered only if determined to be Medically Necessary by the Director of GHC's Mental Health Service, or his/her designee. Coverage for voluntary/involuntary Emer- gency inpatient psychiatric services is subject to the Emergency Care benefit as set forth in Section X.I., including the twenty-four (24) hour notification and transfer provisions. All other voluntary psychiatric care must be authorized in advance by the Director of GHC's Mental Health Service, or his/her designee; the facility must be ap- proved by the Cooperative. All voluntary care not authorized in advance by GHC's Mental Health Service is not covered. 3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services. Covered Services are limited to those considered to be Medically Necessary by the Director of GHC's Mental Health Service, or his/her designee.Covered Ser- vices are limited to those provided for covered conditions for which, in the opinion of the Director of GHC's Mental Health Service, or his/her designee, improvement or stabilization can be expected. Partial hospitalization programs and electro-convulsive therapy are covered only under subsection H.2. (Inpatient Services). Excluded are all forms of extensive psycho- therapy; day treatment; custodial care; treat- ment of sexual disorders; specialty programs for mental health therapy which are not provided by GHC; court -ordered treatment which is not specifically described above; or any other services not specifically listed as 0369 WSZ covered in this section. All other provisions, exclusions and limitations under this Agree- ment also apply. EMERGENCY CARE 1. At a GHC Facility or GHC Designated Facility. GHC will cover Emergency care for all Covered Services subject to payment of the Copayment set forth in the Allowances, Deductibles, Copayments, and Fees Schedule. If two (2) or more members of the Family Unit require Emergency care as a result of the same accident, only one (1) Emergency Care Copayment will apply. If the Member is admitted to a GHC or GHC Designated Facility directly from the emer- gency room, the Emergency Care Copay- ment is waived. 2. At a Non-GHC Designated Facility. Usual, Customary, and Reasonable charges for Emergency care for Covered Services are covered subject to: a. payment of the Emergency Deductible shown in the Allowances, Deductibles, Copayments, and Fees Schedule; and b. notification of GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admis- sion, or as soon thereafter as medically possible. If two (2) or more members of a Family Unit require emergency care as a result of the same accident, only one (1) Emergency De- ductible will apply. Outpatient medications prescribed by a non- GHC physician are excluded. 3. Transfer and Follow-up Care. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consult- ation with a GHC physician. If the Member refuses to transfer to a GHC Facility, all further costs incurred during the hospitaliza- tion are the responsibility of the Member. Page 22 Follow-up care which is a direct result of the Emergency must be obtained at GHC, un- less a GHC physician has authorized such care in advance. J. AMBULANCE SERVICES are covered as set forth below, provided that the service is authorized in advance by a GHC physician or meets the definition of an Emergency. (See Sec- tion I.) 1. Emergency Transport to a GHC Facility or GHC Designated Facility. Each Emergency is covered as set forth in the Allowances, Deductibles, Copayments, and Fees Schedule. 2. Emergency Transport to a Non-GHC Designated Facility. Each Emergency is covered as set forth in the Allowances, De- ductibles, Copayments, and Fees Schedule. 3. Waiver of Ambulance Services Deductible. If two (2) or more members of the Family Unit require Emergency ambulance transport as a result of the same accident, only one (1) Ambulance Deductible will apply. The Ambulance Deductible will not apply when ambulance service is authorized in ad- vance by the Cooperative. 4. Transfer to a GHC Facility. When authorized in advance by the Cooperative, an additional Ambulance Allowance is provided for transfer to or from a GHC Facility. K. HOSPICE It is understood and agreed that the following fully sets forth the eligibility requirements and Covered Services for a Member who elects to receive services through GHC's Hospice Pro- gram. Members who elect to receive GHC Hospice Services do so in lieu of curative treat- ment for their terminal illness for the period that they are in the GHC Hospice Program. Hospice Program 1. Eligibility. Hospice Services, as set forth below, shall be provided to Members for as long as the following criteria are met: 0369 W5Z a. a GHC physician has determined that the Member's illness is terminal and life expectancy is six (6) months or less; b. the Member has chosen a palliative treatment focus (emphasizing comfort and supportive services rather than treatment aimed at curing the Member's terminal illness); c. the Member has elected in writing to receive hospice care through GHC's Hospice Program; d. the Member has available a primary care person who will be responsible for the Member's home care; and e. a GHC physician and GHC's Hospice Director determine that the Member's illness can be appropriately managed in the home. 2. Hospice Care shall be defined as a coor- dinated program of palliative and supportive care for dying persons by an interdisciplinary team of professionals and volunteers center- ing primarily in the Member's home. 3. Covered Services. Hospice Services may in- clude the following as prescribed by a GHC physician and rendered pursuant to an ap- proved hospice plan of treatment: a. Home Services i. Intermittent care by a hospice in- terdisciplinary team which may in- clude services by a physician, nurse, medical social worker, physical therapist, speech therapist, occupational therapist, respiratory therapist, and limited services by a Home Health Aide under the supervision of a Registered Nurse. ii. One period of continuous care service per Member in the Member's home when prescribed by a GHC physician, as set forth in this paragraph. A continuous care period is defined as "skilled nurs- ing care provided in the home Page 23 during a period of crisis in order to maintain the terminally ill patient at home." Continuous care may be provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse, or Home Health Aide under the supervision of a Registered Nurse. Continuous care is provided for four (4) or more hours per day for a period not to exceed five (5) days, or a total of seventy-two (72) hours, whichever first occurs. Continuous care is covered only when a GHC physician deter- mines that the Member would otherwise require hospitalization in an acute care facility. b. Inpatient Hospice Services shall be provided in a facility designated by GHC's Hospice Program when Medi- cally Necessary and authorized in ad- vance by a GHC physician and GHC's Hospice Program. Inpatient Hospice Services shall be provided according to the provisions set forth in Section X. of this Agreement. 4. Hospice Exclusions: All services not specifi- cally listed as covered in this section includ- ing: a. Financial or legal counseling services. b. Housekeeping or meals services. c. Custodial or maintenance care in the home or on an inpatient basis. d. Services not specifically listed as covered by this Medical Coverage Agreement. e. Any services provided by members of the patient's family. f. All other exclusions listed in Section XI., Exclusions and Limitations, of this Medical Coverage Agreement, apply. L. REHABILITATION SERVICES are covered as set forth in this section, limited to the following: physical therapy; occupational therapy; and 0369 W5Z speech therapy to restore function following ill- ness, injury, or surgery. Services are subject to all terms, conditions, and limitations of this Agree- ment, including the following: 1. All services must be provided at GHC or a GHC-approved rehabilitation facility and must be prescribed and provided by a GHC- approved rehabilitation team that may in- clude medical, nursing, physical therapy, occupational therapy and speech therapy providers. 2. The Member must be referred for rehabilita- tion services in advance by a GHC physician. 3. Services are limited to those necessary to restore or improve functional abilities when physical, sensori-perceptual and/or com- munication impairment exists due to injury or illness. Such services are provided only when GHC's Medical Director, or his/her designee, determines that significant, measurable improvement to the Member's condition can be expected within a sixty (60) day period as a consequence of intervention by covered therapy services described in paragraph one (1) above. 4. Coverage for inpatient and outpatient ser- vices is limited to the allowances set forth in the Allowances, Deductibles, Copayments, and Fees Schedule. Services excluded under this benefit include the following: specialty rehabilitation programs not provided by GHC; long-term rehabilitation programs; physical therapy, occupational therapy, and speech therapy services when such services are available (whether application is made or not) through governmental programs including programs offered by public school districts; therapy for degenerative or static conditions when the expected outcome is primarily to maintain the Member's level of functioning (except for neurodevelopmental therapies); implementation of home maintenance programs; programs for treatment of learn- ing problems; any other treatment not con- sidered Medically Necessary by GHC; any services not specifically included as covered in this section; and any services that are ex- cluded under Section XI. Page 24 Neurodevelopmental Therapies for Children Age Six (6) and Under. When determined to be Medically Necessary by GHC's Medical Director, or his/her desig- nee, physical therapy, occupational therapy, and speech therapy services for the restora- tion and improvement of function for neurodevelopmentally disabled children age six (6) and under shall be covered. Coverage includes maintenance of a covered Member in cases where significant deterioration in the Member's condition would result without the services. Coverage for inpatient and outpatient services is limited to the al- lowance set forth in the Allowances, De- ductibles, Copayments, and Fees Schedule. Services excluded under this benefit include: specialty rehabilitation programs; long-term rehabilitation programs; physical therapy, occupational therapy, and speech therapy services when such services are available (whether application is made or not) through governmental programs; programs offered by public school districts; except as set forth above, therapy for degenerative or static conditions when the expected out- come is primarily to maintain the Member's level of functioning; implementation of home maintenance programs; any treatment not considered Medically Necessary; any services not specifically included as covered in this Section; and any services that are excluded under Section XI. M. SMOKING CESSATION. When provided through Group Health, services related to smok- ing cessation are covered, limited to: 1. participation in one individual and/or group program per calendar year; 2. educational materials; and 3. one course of nicotine replacement therapy per calendar year, provided the Member is actively participating in the Group Health Smoking Cessation Program. Covered services are subject to the allowances set forth in the Allowances, Deductibles, Copay- ments, and Fees Schedule. 0369 W5Z Section XI. Exclusions and Limitations A. EXCLUSIONS 1. Blood for transfusions. 2. Except as provided in Sections X.B., X.D., X.E., and X.F., corrective appliances and artificial aids including: eyeglasses; contact lenses including services related to their fit- ting; prosthetic devices; diabetic supplies in- cluding insulin pumps; hearing aids and examinations in connection therewith; take- home dressings and supplies following hospitalization; or any other supplies, dress- ings, appliances, devices or services which are not for the specific treatment of disease or injury, or not specifically listed as covered under Section X. 3. Cosmetic services, including treatment for complications of cosmetic surgery, except as provided in Section X.D. 4. Dental care, surgery, services, and applian- ces, including: treatment of accidental injury to natural teeth, reconstructive surgery to the jaw incident to denture wear, periodon- tal surgery, and any other dental services not specifically listed as covered under Section X. The Cooperative's Medical Director, or his/her designee, will determine whether the care or treatment required is within the category of dental care or service. If a GHC physician determines that an unre- lated medical condition requires that a Member be hospitalized for a dental proce- dure which is normally done in a dentist's office, GHC will cover associated hospital and anesthesia costs at a GHC or GHC Designated Facility. GHC will not cover the dentist's or oral surgeon's fees. Drugs, medicines, and injections, except as set forth in Section X.F. Any exclusion of drugs, medicines, and injections, including those not listed as covered in the GHC Drug Formulary (approved drug list), will also ex- clude.their administration. 6. Convalescent or custodial care. Page 25 7. Durable medical equipment such as hospital injury, disease or condition in question, beds, wheelchairs, and walk -aids, except and that the benefits are not out - while in the hospital or as set forth in Section weighed by the risks; X.E. d. evidence that the new treatment is as 8. Services rendered as a result of work-in- safe and effective as all existing conven- curred injuries, illness or conditions. tional treatment alternatives; and 9. Those parts of an examination and associ- e. that treatment will satisfy (c) and (d) ated reports and immunizations required for outside of a research setting. employment, immigration, license, or in- surance purposes that are not deemed Medi- Appeals regarding denial of coverage must cally Necessary by GHC for early detection be submitted to your regional Member Ser- vices Department, or to GHC's Contracts and of disease. Coverage Department at 1730 Minor 10. Investigational or experimental treatment, Avenue, Suite 1910, Seattle, WA 98101. including medical and surgical services, GHC will respond in writing within twenty drugs, devices and biological products, until (20) working days of the receipt of a fully formally approved by GHC for medical cov- documented request. erage. GHC's determination shall be made in accordance with criteria for determining 11. Nontherapeutic sterilization and proce- investigational status as established by GHC dures and services to reverse a therapeutic as generally outlined below. Specific indica- or nontherapeutic sterilization. tions and methods of use shall be considered in GHC's review of evidence provided by 12. See coverage for Pre-existing Conditions evaluations of national medical associations, under Section X.B. consensus panels, and/or other technologi- cal evaluations, including the scientific qual- 13. Mental health care, except as specifically ity of such supporting evidence and provided in Section X.H. rationale. Any investigational or experimen- 14. Procedures, services, and supplies related to tal treatment, including medical and surgical sex transformations. services, drugs, devices and biological prod- ucts not meeting GHC's determination pur- 15. Regardless of origin or cause, diagnostic suant to its criteria as outlined below are testing and medical treatment of sterility, excluded. infertility, and sexual dysfunction. a. Investigational or experimental drugs, 16. Services of practitioners whose licensing devices and biological products until category is not represented by GHC Medical clinical trials have been completed and Personnel. approved by the U.S. Food and Drug Administration (FDA) as being safe 17. Services directly related to obesity, except and efficacious for general marketing for nutritional counseling provided by GHC and permission has been granted by the staff. FDA for commercial distribution; 18. Any services to the extent benefits are avail- b. there is sufficient scientific evidence in able to the Member under the terms of any published medical literature to permit vehicle, homeowner's, property or other in - conclusions concerning the effect of the surance policy, except for individual or treatment on health outcomes; group health insurance, whether the Mem- ber asserts a claim or not, pursuant to: (1) c. there is conclusive evidence in pub- medical coverage, medical "no fault" lished peer -reviewed medical literature coverage, Personal Injury Protection that the treatment will result in a de- coverage, or similar medical coverage con- monstrable benefit for the particular tained in said policy; and/or (2) uninsured 0369 Page 26 W5Z motorist or underinsured motorist coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be "available" to the Member if the Member is a named insured, comes within the policy definition of insured, is a third -party donee beneficiary under the terms of the policy, or otherwise has the right to receive benefits under the policy. The Member and his or her agents must cooperate fully with GHC in its efforts to enforce this exclusion. This cooperation shall include supplying GHC with informa- tion about any available insurance coverage. The Member and his or her agents shall permit GHC, at GHC's option, to associate with the Member or to intervene in any ac- tion filed against any party related to the injury. The Member and his or her agents shall do nothing to prejudice GHC's right to enforce this exclusion. GHC shall not enforce this exclusion as to coverage available under uninsured motorist or underinsured motorist coverage until the Member has been made whole, unless the Member fails to cooperate fully with GHC as described above. In the event the Member fails to cooperate fully, the Member shall be responsible for reimbursing GHC for such medical expenses. GHC shall not pay any attorneys' fees or collection costs to attorneys representing the injured person where it has retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a written fee agreement signed by GHC prior to any collection efforts. 19. Services or supplies not specifically listed as covered in the Schedule of Benefits. 20. See coverage under Section X.B.7. 21. The cost of services and supplies resulting from a Member's loss of or willful damage to covered appliances, devices, supplies, and materials provided by GHC for the treat- ment of disease, injury, or illness. 0369 W5Z 22. Routine circumcision, including newborn circumcision, which is not considered Medi- cally Necessary. 23. Orthoptic (eye training) therapy. 24. Specialty treatment programs not provided by GHC including weight reduction, rehabilitation, and behavior modification programs. 25. Services required as a result of war, whether declared or not declared. B. LIMITATIONS 1. Conditions and Extent of Coverage. ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE PRO- VIDED BY GHC MEDICAL PERSON- NEL AT A GHC FACILITY UNLESS: a. the Member has received a Referral from a GHC physician; or b. the Member has received Emergency services according to Section X.I. 2. Recommended Treatment. The Coopera- tive's Medical Director or his/her designee will determine the necessity, nature, and ex- tent of treatment to be provided in each individual case and the judgment, made in good faith, will be final. Members have the right to participate in decisions regarding their health care. A Member may refuse recommended treat- ment or diagnostic plan to the extent per- mitted by law. In such case, GHC shall have no further obligation to provide the care in question. Members who seek other sources of care because of such a disagreement do so with the full understanding that GHC has no obligation for the cost, or liability for the outcome, of such care. 3. Major Disaster or Epidemic. In the event of a major disaster or epidemic, GHC Medical Personnel will provide Covered Services ac- cording to their best judgment, within the limitations of available facilities and person- nel. The Cooperative has no liability for delay or failure to provide or arrange Cov- ered Services to the extent facilities or per - Page 27 sonnel are unavailable due to a major dis- aster or epidemic. 4. Unusual Circumstances. If the provision of Covered Services is delayed or -rendered im- possible due to unusual circumstances such as complete or partial destruction of facili- ties, military action, civil disorder, labor dis- putes, or similar causes, GHC shall provide or arrange for services that, in the reasona- ble opinion of GHC's Medical Director, or his/her designee, are emergent or urgently needed. In regard to nonurgent and routine services, GHC shall make a good faith effort to provide services through its then -avail- able facilities and personnel. GHC shall have the option to defer or reschedule services that are not urgent or routine while its facili- 0369 W5Z ties and services are so affected. In no case shall the Cooperative have any liability or obligation on account of delay or failure to provide or arrange such services. Section XII. Claims Members must submit claims for reimbursement of Covered Services to GHC within sixty (60) days of the service date, or as soon thereafter as is reasonably possible. In no event, except in the absence of legal capacity, shall a claim be accepted later than one (1) year from the service date. This section applies to Covered Services received under Section X.I. and X.J., or services for which the Member has received a Refer- ral from a GHC physician. Page 28 (OGrOU lth Cooperative of Puget Sound Medicare Endorsement For Persons Covered by Parts A and B of Medicare THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL REMAIN IN EFFECT EXCEPT AS MODIFIED BY THE ADDI- TION OF THE PROVISIONS, EXCLUSIONS, AND LIMITATIONS CONTAINED IN THIS MEDICARE ENDORSEMENT. IN NO EVENT SHALL THE BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE BENEFITS UNDER THE GROUP MEDICAL COVERAGE AGREEMENT THE HIGHER LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THE GROUP MEDICAL COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL AND HOSPITAL BENEFITS ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED, AND REFERRED TO AS "MEDICARE." THE BENEFITS AND EX- CLUSIONS DESCRIBED IN THIS ENDORSE- MENT APPLY ONLY TO MEMBERS WHO ARE COVERED UNDER BOTH PART A AND PART B OF MEDICARE. Except as defined by Federal Regulations, all Mem- bers entitled to, or eligible to purchase Medicare must transfer to the GHC Medicare Plan upon such entitle- ment or eligibility. A condition of enrollment under the GHC Medicare Plan requires that a Member be con- tinuously enrolled for the hospital (Part A) and medi- cal (Part B) benefits available from the Social Security Administration, and sign any papers that may be re- quired by GHC or Medicare. For additional informa- tion, the Member may refer to "The Medicare Handbook," which can be obtained from your local Social Security office. 0369 W5Z NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC FACILITIES UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE MEMBER HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SER- VICES ACCORDING TO SECTION V.D. OF THIS MEDICARE ENDORSEMENT. For those enrolled under GHC's Medicare plan, as set forth in this endorsement, all Copayments are waived except the prescription drug Copayment. This Endorsement does not constitute a Medicare supplemental contract. Section I. DEFINITIONS CUSTODIAL CARE: Care that is primarily for the purpose of meeting personal needs and could be provided by persons without professional skills or training. Custodial Care includes help in walking, bathing, dressing, eating, and taking medicine. EMERGENCY SERVICES (Medicare defined): In- patient or outpatient services that are rendered immediately by an appropriate non-GHC provider because of an injury or sudden illness, and for which the time required to reach GHC or a GHC Designated Facility would risk permanent damage to the Member's health. Page 29 HEALTH CARE FINANCING ADMINISTRATION (HCFA): The federal agency that administers the Medicare program. MEDICARE: The federal health insurance program for the aged and disabled. MEDICARE GUIDELINES: Coverage rules and policies established by the Health Care Financing Administration (HCFA), a federal agency. MEDICARE HANDBOOK (Titled The Medicare Handbook"): A pamphlet published by the U.S. Department of Health and Human Services, Social Security Administration, which provides an easy - to -read explanation of Medicare benefits and can be obtained from your local Social Security office. PERMANENT MOVE: An uninterrupted absence of more than ninety (90) days from GHC's Service Area. REFERRAL: A written temporary referral agreement authorized in advance by a GHC physician, and formally approved in advance through GHC's Medicare medical coverage approval process, that entitles a Member to receive Covered Services from a specified non-GHC health care provider. Entitlement to such services shall not exceed the limits of the Referral and is subject to all terms and conditions of the Referral and this Agreement. SERVICE AREA: The geographic area comprised of King, Kitsap, Pierce, Skagit, Snohomish, Thurston, and Whatcom Counties, and any other areas desig- nated by GHC and approved by the Health Care Financing Administration. (See Service Area Map.) SKILLED NURSING FACILITY: A Medicare cer- tified and licensed facility, as defined in Medicare regulations, primarily engaged in providing skilled nursing care or rehabilitation and related services for which Medicare pays benefits or qualifies to receive such approval. URGENTLY NEEDED SERVICES (Medicare defined): Services needed in order to prevent a serious deterioration of the Member's health due to an unforeseen illness or injury while temporarily absent from GHC's Service Area, and which can- 0369 W5Z not be delayed until the Member returns to the Service Area. USUAL, CUSTOMARY, AND REASONABLE: A term used to define the level of benefits which are payable by GHC when expenses are incurred from a non-GHC physician or provider. Expenses are considered Usual, Customary and Reasonable if (1) the charges are consistent with those normally charged by the provider or organization for the same services or supplies; and (2) the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies. Section II. TERMINATION Enrollment under the GHC Medicare Plan for a specific Member, may be terminated in the circumstan- ces set forth below. Until such time as a Member's termination of enroll- ment is effective, neither GHC nor Medicare shall pay for services provided at non-GHC Facilities unless the Member has been referred by GHC or the Member has received Emergency or Urgently Needed Services according to Section V.D. of this Medicare Endorse- ment. A. Termination of Specific Members. 1. Loss of Medicare Part B Entitlement. If the Health Care Financing Administration (HCFA) advises GHC that a Member's en- titlement to Medicare coverage no longer exists, or the Member voluntarily terminates Medicare enrollment, enrollment under the GHC Medicare Plan shall terminate the first of the month as specified by HCFA. 2. Change of Permanent Residence Outside GHC's Service Area. If a Member makes a Permanent Move as set forth in Section I. of this Medicare Endorsement, enrollment shall terminate the first day of the month following the month in which GHC receives notification of such move. 3. For Cause. Enrollment may be terminated upon written notice for: Page 30 B. C. a. Knowingly providing fraudulent infor- mation to obtain coverage. In such event, GHC may rescind or cancel en- rollment upon ten (10) working days' written notice. b. Permitting the use of a GHC identifica- tion card by another person. c. Failure to comply with the rules and regulations of GHC including disrup- tive, unruly, abusive or uncooperative conduct. Such termination shall be subject to review and approval by HCFA. Persons Hospitalized on the Date of Termina- tion. A Member who is a registered bed patient receiving Covered Services in a GHC Facility or GHC Designated Facility on the date of termina- tion shall continue to receive covered inpatient services, until discharge from the facility. This continued coverage will also apply to a Member hospitalized in a Medicare -certified non-GHC Designated Facility as a result of Emergency or Urgently Needed Services or Referral as set forth in Section VI.B. of this Medicare Endorsement. Services Provided After Termination. Any ser- vices provided by GHC after the effective date of termination (except those services covered under Section II.B. of this Medicare Endorsement) shall be charged according to the Directory of Services. The Subscriber shall be liable for payment of all such charges for services provided to the Sub- scriber and all Family Dependents. Section III. SUBROGATION "Injured person" under this section means a Member covered by this Agreement who sustains compensable injury. "GHC's medical expense" means the expense incurred by GHC for the care or treatment of the injury sustained. If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability against the third party, GHC shall have the right to recover its cost of providing benefits to the injured person (subrogation) from the third party as set forth in this Agreement and in compliance with Medicare 0369 W5Z regulations and guidelines. GHC shall be subrogated to and may enforce all rights of the injured person to the extent of its medical expense. After Medicare laws and regulations mandating recovery of Medicare pay- ments have been satisfied, the Cooperative's right of subrogation shall be limited to the excess of the amount required to fully compensate the injured per- son for the loss sustained. Full compensation shall be measured on an objective, case -by -case basis, but is subject to a presumption that a settlement which does not exhaust the third parry's reachable assets is full compensation to the injured person. The injured person and his or her agents must cooperate fully with GHC in its efforts to collect GHC's medical expenses. This cooperation shall in- clude, but is not limited to, supplying GHC with infor- mation about any defendants and/or insurers related to the injured person's claim. The injured person and his or her agents shall permit GHC, at GHC's option, to associate with the injured party or to intervene in any action filed against any third party. The injured person and his or her agents shall do nothing to prejudice GHC's subrogation rights. The injured per- son shall not settle a claim without protecting GHC's interest. GHC shall not pay any attorney's fees or collection costs to attorneys representing the injured person where it has retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a written fee agreement signed by GHC prior to any collection efforts. When reasonable collection costs have been incurred, with GHC's prior written agreement, to recover GHC's medical expenses, there shall be an equitable apportionment of such collection costs between GHC and the injured person subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. This provision does not apply to occupationally in- curred disease, sickness, and/or injury. Section IV. GRIEVANCE PROCEDURES A. GHC Member Services Program. The Member Services Program is designed to help a Member resolve formal complaints and con - Page 31 cerns about medical and business service. GHC will record, research, and respond in a timely manner to a Member's concern. A concern should be registered initially at the Member's area medi- B. cal center. If not satisfied, the Member should then contact the regional Member Services Department, which will arrange for review by appropriate medical staff, management and/or GHC consumers. B. Reconsideration of Claims. If GHC denies a request for payment of a claim, or declines to provide services which the Member believes should be provided, the Member may file a request for reconsideration with GHC or a So- cial Security Administration office. The request must be filed in writing within sixty (60) days of GHC's written notice of denial unless an exten- sion is specifically approved. If GHC does not overturn the denial in full, it will be referred by GHC to the Health Care Financing Administra- tion for reconsideration. Section V. SCHEDULE OF BENEFITS All benefits and services listed in this Schedule of Benefits: • are subject to all provisions of this Agree- ment and Medicare Endorsement; • must be approved in advance by GHC except for Emergency and Urgently Needed Ser- vices as set forth in Section V.D. of this Medicare Endorsement; and • must meet Medicare guidelines and limita- tions unless otherwise specified. GHC covers all Medicare deductibles and coin- surance. The booklet, "The Medicare Handbook" provides additional information about Medicare benefits and can be obtained from your local Social Security office. A. Skilled Nursing Facility. Upon Referral and fol- lowing a Medicare -certified three (3) day hospital stay, GHC will cover up to one hundred fifty (150) days of care in a Skilled Nursing Facility, in ac- cordance with Medicare Guidelines, when Medi- 0369 W5Z cally Necessary, as determined by GHC's Medical Director, or his/her designee. Hospice. Members with Part A and Part B of Medicare who elect to receive Medicare -covered hospice ser- vices may select any Medicare -certified hospice program. Members who elect to receive services from the GHC Hospice Program are entitled to hospice services as provided under the Medicare Hospice Program. Members who elect to receive hospice services do so in lieu of curative treat- ment for their terminal illness for the period that they are in the hospice program. To receive hospice services, the Member is required to sign the Hospice Election Form. Covered Services. In addition to the hospice ser- vices provided under the Group Medical Coverage Agreement, the following hospice ser- vices shall be provided: 1. Home Services Continuous care services per Member in the Member's home when prescribed by a GHC physician, as set forth in this paragraph. Con- tinuous care is defined as "skilled nursing care provided in the home during a period of crisis in order to maintain the terminally ill patient at home." Continuous care may be provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse, or Home Health Aide under the su- pervision of a Registered Nurse. Continuous care may be provided up to twenty-four (24) hours per day during periods of crisis. Con- tinuous care is covered only when a GHC physician determines that the Member otherwise would require hospitalization in an acute care facility. 2. Inpatient Hospice Services for short-term care shall be provided through a Medicare - certified Hospice Program when Medically Necessary, and authorized in advance by a GHC physician. Respite care is covered for a maximum of five (5) consecutive days per occurrence in order to continue care for the Member in the temporary absence of the Member's primary care-giver(s). Page 32 3. Other hospice services may include the fol- lowing: a. drugs and biologicals that are used primarily for the relief of pain and symptom management; b. medical appliances and supplies pri- marily for the relief of pain and symp- tom management; c. counseling services for the Member and his/her primary care-giver(s); and d. bereavement counseling services for the family. C. Mental Health Care, Alcoholism and Drug Abuse Treatment Services. 1. Outpatient mental health, alcoholism and substance abuse treatment services are covered for each Member in accordance with Medicare Guidelines. 2. Inpatient mental health care services are covered in full up to a 190-day lifetime benefit when such services are provided in a Medicare -certified mental health facility. Inpatient alcoholism and drug abuse treat- ment services are covered in full when such services are provided in a hospital -based treatment center. 3. Coverage for Medical Emergencies incident to alcoholism and drug abuse or for acute alcoholism or drug abuse, including acute detoxification, is provided as set forth in Sec- tion V.D. of this Medicare Endorsement. D. Emergency/Urgently Needed Services. When an Emergency meets the Medicare definition for Emergency or Urgently Needed Services as defined in Section I. of this Medicare Endorse- ment, services are covered in full. Dl. Out Of The ServiceArea Non -Emergent and/orNon- Urgently Needed Care. Non -Emergent and/or non - urgently needed care will be covered outside GHC�s defined ServiceArea, up to a maximum of $2,000.00 (GHC's Service Area is defined in Section L of this Agreement). Coverage under this benefit does NOT include coverage of prescription drugs. 0369 W5Z Services as noted in this section, are available to Members traveling outside GHC's defined Service Area, except when travelingprimarily forthepurpose of seeking medical care. The services received under this benefit are subject to all limitations set forth in this Agreement. All Medicare non -covered expenses, including hospi- tal inpatient deductibles and inpatient and out- patient Coinsurances, are the responsibility of the Member. E. Medicare Ambulance Benefit. Medically Neces- sary ambulance transportation to or from a hospi- tal or Skilled Nursing Facility is covered in full only if transportation by any other vehicle could endanger the patient's health and the ambulance, equipment, and personnel meet Medicare re- quirements. F. Medical and Surgical Care. The following medi- cal and surgical services are covered when prescribed by GHC Medical Personnel and Medicare requirements are met: 1. Eye examinations and treatment for eye pathology. Evaluations and surgical procedures to cor- rect refractions which are not related to eye pathology are not covered. Complications related to such surgery are also excluded. 2. One pair of eyeglasses or contact lenses, including examination and fitting, following cataract surgery, are covered subject to UCR charges when required to replace the natural lens of the eye. Covered eyeglasses and con- tact lenses must be dispensed through GHC Facilities. Replacements will be provided when needed due to change in the Member's medical condition or when deemed ap- propriate by a GHC physician. 3. Blood, blood derivatives, and their ad- ministration. 4. Maternity and pregnancy -related services, including visits before and after birth; in- voluntary termination of pregnancy; and care for any other complication of pregnan- cy. Page 33 5. Organ transplants, limited to heart, kidney, cornea, bone marrow, and liver, when estab- lished criteria are met. 6. Physician calls (including consultations and second opinions by a GHC physician) in the hospital, office, home, Skilled Nursing Facility, nursing home, or convalescent cen- ter. 7. Restorative physical, occupational, and speech therapy following illness, injury, or surgery. 8. Immunizations and vaccinations that are listed as covered in the GHC Drug Formu- lary (approved drug list) or approved by Medicare. 9. Services related to dysfunction of the jaw. When Referred by a GHC physician, evalua- tion and treatment by a GHC-approved tem- poromandibular joint (TMJ) care provider. All TMJ appliances, other than the occlusal splint and its fitting, are excluded. Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when the dysfunction is related to maloc- clusion or when TMJ services are needed due to dental work performed. All such ser- vices and related hospitalization, including orthodontic therapy and orthognathic (jaw) surgery, are excluded regardless of origin or cause. (See Section X.B.12. of Group Medical Coverage Agreement for Covered Services not meeting Medicare Guidelines). 10. Chiro=are e limited to spinal manipula- tions. any other diagnostic or therapeutic services, including x-rays, fur- nished by a chiropractor. Members who receive their primary care in portions of the GHC Service Area where GHC designated licensed practitioners are available must util- ize GHC's designated providers in order to be covered. 11. Podiatric care. Excluded is treatment of flat feet or other misalignments of the feet; removal of corns and calluses; and routine 0369 W5Z foot care such as hygienic care, except in the presence of a nonrelated medical condition affecting the lower limbs. Members who receive their primary care in portions of the GHC Service Area where GHC designated licensed practitioners are available must util- ize GHC's designated providers in order to be covered. 12. Home intravenous (IV) drug therapy ser- vices. 13. Routine eye examinations and refractions, limited to once every twenty-four (24) months, except when Medically Necessary. Services for routine eye examinations must be received at a GHC Facility and in accordance with GHC medical criteria in order to be covered and are not subject to Medicare requirements. Lenses. One pair of standard glass single vision, lenticular, or nonblended bifocal ortrifocal len- ses, or contact lenses, will be covered subject to UCR charges once every twenty-four (24) months, and replaced as specified below, when received at a GHC facility and in accordance with GHC medical criteria. Frames. An Allowance of up to $100 per Mem- ber once every 24 months will be provided for frames. Replacements. Lens replacementfor any reason (includingloss, breakage or change inprescrip- tion) will be provided not more often than once every 24 months. Replacement of frames will be provided subject to the frames Allowance set forth above not more often than once every 24 months. 14. Hearing examinations to determine hearing loss. Hearingaids, includingexaminations and fitting, must be received at a GHC Facility and are covered up to a maximum of $250 per Member once every 24 months. G. Prosthetic Devices, such as cardiac devices, in- traocular lenses, artificial joints, breast pros- theses, artificial eyes, and braces, are covered. Excluded are: orthopedic shoes unless they are part of leg braces; dental plates or other dental devices; and experimental devices. Page 34 H. Medical/Surgical Supplies, such as casts, splints, post -surgical dressings, and ostomy supplies, are covered. I. Rental or Purchase of Durable Medical Equip- ment, such as oxygen and oxygen equipment, wheelchairs and other walk -aids, and hospital beds, is covered. J. Respite Care. 1. Eligibility. Respite care is provided to chronically dependent persons for reason- able and necessary in -home services, provided that such services are: a. authorized in advance by a GHC phys- ician; b. provided by GHC Community Health Services or by a GHC-approved agency; and c. that the Member has incurred no less than the equivalent of $6,870.00 in ex- penses for Medicare Part B Covered Services during the calendar year in which respite benefits are to be pro- vided. 2. Covered Services. Covered respite care ser- vices are provided up to a maximum of eighty (80) hours for the twelve (12) month period following the date all eligibility requirements are met. Covered respite services are limited to the following: a. Services of a homemaker or home health aide; b. Personal care services; and c. Nursing care provided by a licensed professional nurse. "Chronically dependent persons" under this sec- tion means persons who live with a voluntary care -giver; are dependent upon the care -giver for assistance with at least two activities of daily living, such as eating, bathing, dressing, toileting, or transferring in and out of a bed or chair; and who meet the eligibility requirements described above. 0369 W5Z K Professional Home Care Services. (RN, MSW, PT, OT and Speech Therapy Services) as setforth in this section shall be provided by GHC Community Health Services or by a GHC Authorized Home Health Agency when referred in advance by a GHC physician and authorized in advance by GHC Com- munity Health Services. This benefit is limited to five (5) visits per calendar year when the following criteria have been met. I. Care must be deemed appropriate by GHC, based upon functional and clinical needs; and 2. Members must requireprofessional monitoring of chronic illness or injury; and 3. services must be provided immediately follow- inga GHC covered hospital stay, covered skilled nursing facility stay or covered home health stay; "immediately following" is defined as within five (5) days of discharge from such facility. L. Health Education and Fitness Classes will be covered up to $30 percalendaryear. Health club membership and educational materials are excluded. Section VI. EXCLUSIONS AND LIMITATIONS A. Exclusions. 1. Investigational procedures, including medi- cal and surgical services, drugs and devices until formally approved by Medicare unless specifically provided herein (See Section XI.A.10. in the Group Medical Coverage Agreement). 2. Supportive devices for the feet. 3. Services directly related to obesity except as provided by Medicare. 4. Services or supplies not specifically listed as covered by Medicare or GHC. B. Limitations. Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS V.F.10. AND V.F.11., ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE Page 35 PROVIDED BY GHC MEDICAL PERSON- NEL AT A GHC OR GHC DESIGNATED FACILITY UNLESS: 1. the Member has received a Referral from GHC, including formal advance approval through GHC's Medicare medical coverage approval process, or 2. the Member has received Emergency or Ur- gently Needed Services as defined in Section I. and as set forth in Section V.D. of this Medicare Endorsement. Section VII. CLAIMS PROCEDURE Claims for services or supplies and explanation of Medicare benefits for services or supplies from providers other than Group Health Cooperative should be sent to: Medicare Claims, Group Health Cooperative of Puget Sound. If you must receive Emergency or Urgently Needed Services from a non- 0369 W5Z GHC provider, be sure to show your GHC I.D. card and your red, white, and blue Medicare card. A. The Member must file claims for services rendered during the first nine (9) months of a calendar year by December 31 of the following calendar year. B. The Member must file claims for services rendered in the last three (3) months of a calendar year the same as if the services had been furnished in the subsequent calendar year. The time limit on filing claims for services furnished in the last three (3) months of the calendar year is December 31 of the second calendar year following the calen- dar year in which the services were rendered. See "The Medicare Handbook" for additional in- formation regarding filing claims, which can be obtained from your local Social Security office. GHC may obtain information which it deems necessary concerning the medical care and hospitalization for which payment is requested. Page 36 Vith 41 erative of Puget Sound Medicare Endorsement For Persons Covered by Part B only of Medicare THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL REMAIN IN EFFECT EXCEPT AS MODIFIED BY THE ADDI- TION OF THE PROVISIONS, EXCLUSIONS AND LIMITATIONS CONTAINED IN THIS MEDICARE ENDORSEMENT. IN NO EVENT SHALL THE BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE BENEFITS UNDER THE GROUP MEDICAL COVERAGE AGREEMENT THE HIGHER LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THE GROUP MEDICAL COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL BENEFITS ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED, AND REFERRED TO AS MEDI- CARE." THE BENEFITS AND EXCLUSIONS DESCRIBED IN THIS ENDORSEMENT APPLY ONLY TO MEMBERS WHO ARE COVERED UNDER PART B ONLY OF MEDICARE. Except as defined by Federal Regulations, all Mem- bers entitled to, or eligible to purchase Medicare must transfer to the GHC Medicare Plan upon such entitle- ment or eligibility. A condition of enrollment under the GHC Medicare Plan requires that a Member be con- tinuously enrolled for medical (Part B) benefits avail- able from the Social Security Administration, and sign any papers that may be required by GHC or Medicare. For additional information, the Member may refer to "The Medicare Handbook," which can be obtained from your local Social Security office. NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC FACILITIES 0369 W5Z UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE MEMBER HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SER- VICES ACCORDING TO SECTION V.C. OF THIS MEDICARE ENDORSEMENT. For those enrolled under GHC's Medicare plan, as set forth in this endorsement, all Copayments are waived except the prescription drug Copayment. This Endorsement does not constitute a Medicare supplemental contract. Section I. DEFINITIONS CUSTODIAL CARE: Care that is primarily for the purpose of meeting personal needs and could be provided by persons without professional skills or training. Custodial Care includes help in walking, bathing, dressing, eating, and taking medicine. EMERGENCY SERVICES (Medicare defined): Medicare Part B services that are rendered imme- diately by an appropriate non-GHC provider be- cause of an injury or sudden illness, and for which the time required to reach GHC or a GHC Desig- nated Facility would risk permanent damage to the Member's health. HEALTH CARE FINANCING ADMINISTRATION (HCFA): The federal agency that administers the Medicare program. Page 37 MEDICARE: The federal health insurance program for the aged and disabled. MEDICARE GUIDELINES: Coverage rules and policies established by the Health Care Financing Administration (HCFA), a federal agency. MEDICARE HANDBOOK (Titled "The Medicare Handbook"): A pamphlet published by the U.S. Department of Health and Human Services, Social Security Administration, which provides an easy - to -read explanation of Medicare benefits and can be obtained from your local Social Security office. PERMANENT MOVE: An uninterrupted absence of more than ninety (90) days from GHC's Service Area. REFERRAL: A written temporary referral agreement authorized in advance by a GHC physician, and formally approved in advance through GHC's Medicare medical coverage approval process, that entitles a Member to receive Covered Services from a specified non-GHC health care provider. Entitlement to such services shall not exceed the limits of the Referral and is subject to all terms and conditions of the Referral and this Agreement. SERVICE AREA: The geographic area comprised of King, Kitsap, Pierce, Skagit, Snohomish, Thurston, and Whatcom Counties, and any other areas desig- nated by GHC and approved by the Health Care Financing Administration. (See Service Area Map.) URGENTLY NEEDED SERVICES (Medicare defined): Medicare Part B services needed in order to prevent a serious deterioration of the Member's health due to an unforeseen illness or injury while temporarily absent from GHC's Service Area, and which cannot be delayed until the Member returns to the Service Area. USUAL, CUSTOMARY, AND REASONABLE: A term used to define the level of benefits which are payable by GHC when expenses are incurred from a non-GHC physician or provider. Expenses are considered Usual, Customary and Reasonable if (1) the charges are consistent with those normally charged by the provider or organization for the same services or supplies; and (2) the charges are within the general range of charges made by other 0369 W5Z providers in the same geographical area for the same services or supplies. Section II. TERMINATION Enrollment under the GHC Medicare Plan for a specific Member, may be terminated in the circumstan- ces set forth below. Until such time as a Member's termination of enroll- ment is effective, neither GHC nor Medicare shall pay for services provided at non-GHC Facilities unless the Member has been referred by GHC or the Member has received Emergency or Urgently Needed Services according to Section V.C. of this Medicare Endorse- ment. A. Termination of Specific Members. 1. Loss of Part B Medicare Entitlement. If the Health Care Financing Administration (HCFA) advises GHC that a Member's en- titlement to Medicare coverage no longer exists, or the Member voluntarily terminates Medicare Part B enrollment, enrollment under the GHC Medicare Plan shall ter- minate the first of the month as specified by HCFA. 2. Change of Permanent Residence Outside GHC's Service Area. If a Member makes a Permanent Move as set forth in Section I. of this Medicare Endorsement, enrollment shall terminate the first day of the month following the month in which GHC receives notification of such move. 3. For Cause. Enrollment may be terminated upon written notice for: a. Knowingly providing fraudulent infor- mation to obtain coverage. In such event, GHC may rescind or cancel en- rollment upon ten (10) working days written notice. b. Permitting the use of a GHC identifica- tion card by another person. c. Failure to comply with the rules and regulations of GHC including disrup- Page 38 tive, unruly, abusive or uncooperative conduct. Such termination shall be subject to review and approval by HCFA. Section III. SUBROGATION "Injured person" under this section means a Member covered by this Agreement who sustains compensable injury. "GHC's medical expense" means the expense incurred by GHC for the care or treatment of the injury sustained. If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability against the third party, GHC shall have the right to recover its cost of providing benefits to the injured person (subrogation) from the third party as set forth. in this Agreement and in compliance with Medicare regulations and guidelines. GHC shall be subrogated to and may enforce all rights of the injured person to the extent of its medical expense. After Medicare laws and regulations mandating recovery of Medicare pay- ments have been satisfied, the Cooperative's right of subrogation shall be limited to the excess of the amount required to fully compensate the injured per- son for the loss sustained. Full compensation shall be measured on an objective, case -by -case basis, but is subject to a presumption that a settlement which does not exhaust the third party's reachable assets is full compensation to the injured person. The injured person and his or her agents must cooperate fully with GHC in its efforts to collect GHC's medical expenses. This cooperation shall in- clude, but is not limited to, supplying GHC with infor- mation about any defendants and/or insurers related to the injured person's claim. The injured person and his or her agents shall permit GHC, at GHC's option, to associate with the injured party or to intervene in any action filed against any third party. The injured person and his or her agents shall do nothing to prejudice GHC's subrogation rights. The injured per- son shall not settle a claim without protecting GHC's interest. GHC shall not pay any attorney's fees or collection costs to attorneys representing the injured person where it has retained its own legal counsel or acts on 0369 W5Z its own behalf to represent its interests and unless there is a written fee agreement signed by GHC prior to any collection efforts. When reasonable collection costs have been incurred, with GHC's prior written agreement, to recover GHC's medical expenses, there shall be an equitable apportionment of such collection costs between GHC and the injured person subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. This provision does not apply to occupationally in- curred disease, sickness, and/or injury. Section IV. GRIEVANCE PROCEDURES A. GHC Member Services Program. The Member Services Program is designed to help a Member resolve formal complaints and con- cerns about medical and business service. GHC will record, research, and respond in a timely manner to a Member's concern. A concern should be registered initially at the Member's area medi- cal center. If not satisfied, the Member should then contact the regional Member Services Department, which will arrange for review by appropriate medical staff, management and/or GHC consumers. B. Reconsideration of Claims. If GHC denies a request for payment of a claim, or declines to provide services which the Member believes should be provided, the Member may file a request for reconsideration with GHC or a So- cial Security Administration office. The request must be filed in writing within sixty (60) days of GHC's written notice of denial unless an exten- sion is specifically approved. If GHC does not overturn the denial in full, it will be referred by GHC to the Health Care Financing Administra- tion for reconsideration. Section V. SCHEDULE OF BENEFITS All benefits and services listed in this Schedule of Benefits: Page 39 • are subject to all provisions of this Agree- ment and Medicare Endorsement; • must be approved in advance by GHC except for Emergency and Urgently Needed Ser- vices as set forth in Section V.C. of this Medicare Endorsement; and • must meet Medicare guidelines and limita- tions unless otherwise specified. GHC covers all Medicare deductibles and coin- surance. The booklet, "The Medicare Handbook" provides additional information about Medicare benefits and can be obtained from your local Social Security office. A. Hospice. It is understood and agreed that the following fully sets forth Covered Services for a Member with Part B Medicare only who elects to receive hospice services. Members who elect to receive hospice services do so in lieu of curative treat- ment for their terminal illness for the period that they are in the hospice program. To receive hospice services, the Member is required to sign the Hospice Election Form. Covered Services. Hospice services may include the following as prescribed by a GHC physician and rendered pursuant to an approved hospice plan of treatment: 1. Home Services Continuous care services per Member in the Member's home when prescribed by a GHC physician, as set forth in this paragraph. Con- tinuous care is defined as "skilled nursing care provided in the home during a period of crisis in order to maintain the terminally ill patient at home." Continuous care may be provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse, or Home Health Aide under the su- pervision of a Registered Nurse. Continuous care may be provided up to twenty-four (24) hours per day during periods of crisis. Con- tinuous care is covered only when a GHC physician determines that the Member otherwise would require hospitalization in an acute care facility. 0369 W5Z 2. Inpatient Hospice Services for short-term care shall be provided in a facility designated by GHC's Hospice Program when Medically Necessary and authorized in advance by a GHC physician and GHC's Hospice Pro- gram. Respite care is covered for a maximum of five (5) consecutive days per occurrence in order to continue care for the Member in the temporary absence of the Member's primary care-giver(s). 3. Other hospice services may include the fol- lowing: a. drugs and biologicals that are used primarily for the relief of pain and symptom management; b. medical appliances and supplies primarily for the relief of pain and symptom management; c. counseling services for the Member and his/her primary care-giver(s); and d. bereavement counseling services for the family. B. Outpatient Mental Health Care, Alcoholism and Drug Abuse Treatment Services are covered for each Member in accordance with Medicare Guidelines. C. Outpatient Emergency/Urgently Needed Ser- vices. When an Emergency meets the Medicare definition for Emergency or Urgently Needed Services as defined in Section I. of this Medicare Endorsement, services are covered in full. Cl. Out Of the Service Area Non -Emergent and/or Non - Urgently Needed Care. Non -Emergent and/or non - urgently needed care will be covered outside GHC s defined ServiceArea, up to a maximum of $2,000.00 (GHC's Service Area is defined in Section L of this Agreement). Coverage under this benefit does NOT include coverage of prescription drugs. Services, as noted in this section, are available to Members traveling outside GHC's defined Service Area, except when travelingprimarily for thepurpose of seeking medical care. The Services received under this benefit are subject to all limitations set forth in this Agreement. Page 40 All Medicare non -covered expenses including hospi- tal inpatient deductibles and inpatient and out- patient coinsurances are the responsibility of the Member. D. Medicare Ambulance Benefit. Medically Neces- sary ambulance transportation to or from a hospi- tal or Skilled Nursing Facility is covered in full only if transportation by any other vehicle could endanger the patient's health and the ambulance, equipment, and personnel meet Medicare re- quirements. E. Medical and Surgical Care. The following medi- cal and surgical services are covered when prescribed by GHC Medical Personnel and Medicare requirements are met: 1. Eye examinations and treatment for eye pathology. Evaluations and surgical procedures to cor- rect refractions which are not related to eye pathology are not covered. Complications related to such surgery are also excluded. 2. One pair of eyeglasses or contact lenses, including examination and fitting, following cataract surgery, are covered subject to UCR charges when required to replace the natural lens of the eye. Covered eyeglasses and con- tact lenses must be dispensed through GHC Facilities. Replacements will be provided when needed due to change in the Member's medical condition or when deemed ap- propriate by a GHC physician. 3. Blood, blood derivatives, and their ad- ministration. 4. Maternity and pregnancy -related services, including visits before and after birth; in- voluntary termination of pregnancy; and care for any other complication of pregnan- cy. 5. Organ transplants, limited to heart, kidney, cornea, bone marrow, and liver, when estab- lished criteria are met. 6. Physician calls (including consultations and second opinions by a GHC physician) in the hospital, office, home, Skilled Nursing 0369 W5Z Facility, nursing home, or convalescent cen- ter. 7. Restorative physical, occupational, and speech therapy following illness, injury, or surgery. 8. Immunizations and vaccinations that are listed as covered in the GHC Drug For- mulary (approved drug list) or approved by Medicare. 9. Services related to dysfunction of the jaw. When Referred by a GHC physician, evalua- tion and treatment by a GHC-approved tem- poromandibular joint (TMJ) care provider. All TMJ appliances, other than the occlusal splint and its fitting, are excluded. Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when the dysfunction is related to maloc- clusion or when TMJ services are needed due to dental work performed. All such ser- vices and related hospitalization, including orthodontic therapy and orthognathic (jaw) surgery, are excluded regardless of origin or cause. (See Section X.B.12 of the Group Medical Coverage Agreement for Covered Services not meeting Medicare Guidelines). 10. Chiropractic care limited to spinal manipula- tions. Excluded are any other diagnostic or therapeutic services, including x-rays, fur- nished by a chiropractor. Members who receive their primary care in portions of the GHC Service Area where GHC designated licensed practitioners are available must util- ize GHC's designated providers in order to be covered. 11. Podiatric care. Excluded is treatment of flat feet or other misalignments of the feet; removal of corns and calluses; and routine foot care such as hygienic care, except in the presence of a nonrelated medical condition affecting the lower limbs. Members who receive their primary care in portions of the GHC Service Area where GHC designated licensed practitioners are available must util- Page 41 ize GHC's designated providers in order to be covered. 12. Home intravenous (IV) drug therapy ser- vices. 13. Routine eye examinations and refractions, limited to once every twenty-four months, except when Medically Necessary. Services for routine eye examinations must be received at a GHC Facility and in accordance with GHC medical criteria in order to be covered and are not subject to Medicare requirements. Lenses. Onepair ofstandard glass single vision, lenticular, or nonblended bifocal or trifocal len- ses, or contact lenses, will be covered subject to UCR charges once every twenty-four (24) months, and replaced as specified below, when received at a GHC facility and in accordance with GHC medical criteria. Frames. An Allowance of up to $100 per Mem- ber once every 24 months will be provided for frames. Replacements. Lens replacementfor any reason (including loss, breakage or change in prescrip- tion) will be provided not more often than once every 24 months. Replacement of frames will be provided subject to the frames Allowance set forth above not more often than once every 24 months. 14. Hearing examinations to determine hearing loss. Hearing aids, includingexaminations and fitting, must be received at a GHC Facility and are covered up to a maximum of $250 per Member once every 24 months. F. Prosthetic Devices, such as cardiac devices, in- traocular lenses, artificial joints, breast pros- theses, artificial eyes, and braces, are covered. Excluded are: orthopedic shoes unless they are part of leg braces; dental plates or other dental devices; and experimental devices. G. Medical/Surgical Supplies, such as casts, splints, post -surgical dressings, and ostomy supplies, are covered. H. Rental or Purchase of Durable Medical Equip- ment, such as oxygen and oxygen equipment, 0369 W5Z wheelchairs and other walk -aids, and hospital beds, is covered. I. Respite Care. 1. Eligibility. Respite care is provided to chronically dependent persons for reasona- ble and necessary in -home services, provided that such services are: a. authorized in advance by a GHC physi- cian; b. provided by GHC Community Health Services or by a GHC-approved agency; and c. that the Member has incurred no less than the equivalent of $6,870.00 in ex- penses for Medicare Part B Covered Services during the calendar year in which respite benefits are to be pro- vided. 2. Covered Services. Covered respite care ser- vices are provided up to a maximum of eighty (80) hours for the twelve (12) month period following the date all eligibility requirements are met. Covered respite services are limited to the following: a. Services of a homemaker or home health aide; b. Personal care services; and C. Nursing care provided by a licensed professional nurse. "Chronically dependent persons" under this sec- tion means persons who live with a voluntary care -giver; are dependent upon the care -giver for assistance with at least two activities of daily living, such as eating, bathing, dressing, toileting, or transferring in and out of a bed or chair; and who meet the eligibility requirements described above. j. Professional Home Care Services. (RN, MSW, PT, OT and Speech Therapy Services) as set forth in this section shall be provided by GHC Community Health Services or by a GHC Authorized Home Health Agency when referred in advance by a GHC physician and authorized in advance by GHC Com- munity Health Services. This benefit is limited to five Page 42 (5) visits per calendar year when the following criteria have been met. 1. Care must be deemed appropriate by GHC, based upon functional and clinical needs; and 2. Member must require professional monitoring of chronic illness or injury; and 3. services must be provided immediately follow- inga GHCcovered hospital stay, covered skilled nursing facility stay or covered home health stay; "immediately following" is defined as within five (5) days of discharge from such facility. K Health Education and Fitness Classes will be covered up to $30 percalendaryear. Health club membership and educational materials are excluded. Section VI. EXCLUSIONS AND LIMITATIONS A. Exclusions. Investigational procedures, including medi- cal and surgical services, drugs and devices until formally approved by Medicare unless specifically provided herein (See Section XI.A.10. in the Group Medical Coverage Agreement). 2. Supportive devices for the feet. 3. Services directly related to obesity except as provided by Medicare. 4. Services or supplies not specifically listed as covered by Medicare or GHC. B. Limitations. Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS V.E.10. AND V.E.11., ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE PROVIDED 13Y GHC MEDICAL PERSON- NEL AT A GHC OR GHC DESIGNATED FACILITY UNLESS: 1. the Member has received a Referral from GHC, including formal advance approval through GHC's Medicare medical coverage approval process, or 2. the Member has received outpatient Emer- gency or Urgently Needed Services as defined in Section I. and as set forth in Sec- tion V.C. of this Medicare Endorsement. Section VII. CLAIMS PROCEDURE Claims for services or supplies and explanation of Medicare benefits for services or supplies from providers other than Group Health Cooperative should be sent to: Medicare Claims, Group Health Cooperative of Puget Sound. If you must receive Emergency or Urgently Needed Services from a non- GHC provider, be sure to show your GHC I.D. card and your red, white, and blue Medicare card. A. The Member must file claims for services rendered during the first nine (9) months of a calendar year by December 31 of the following calendar year. B. The Member must file claims for services rendered in the last three (3) months of a calendar year the same as if the services had been furnished in the subsequent calendar year. The time limit on filing claims for services furnished in the last three (3) months of the calendar year is December 31 of the second calendar year following the calen- dar year in which the services were rendered. See "The Medicare Handbook" for additional in- formation regarding filing claims, which can be obtained from your local Social Security office. GHC may obtain information which it deems necessary concerning the medical care and hos- pitalization for which payment is requested. ALLOWANCES DEDUCTIBLES COPAYMENTS AND FEES SCHEDULE The following Allowances, Deductibles, Copayments and Fees are subject to all provisions, limitations, and exclusions set forth in the Group Medical Coverage Agreement. 0369 W5Z Page 43 BENEFIT ALLOWANCES/DEDUCTIBLES/COPAYMENTS/FEES Total out-of-pocket Copayment expenses for Emergency care at a GHC or GHC Designated Facility • Outpatient Services • Inpatient Services Limited to an aggregate maximum of $750 per Member and $1,500 per family per calendar year Twenty (20) visits covered per Member per calendar year subject to $20 Copayment per individual/family/couple session and $10 per Member per group session; no coverage thereafter. Coverage allowance up to 12 days at 80% per Member per calendar year at a GHC-approved mental health care facility when authorized in advance by GHC. Total expenses and Coinsurance paid for mental health treatment do not apply to Stop Loss. Chemical Dependency Treatment • Benefit Period Allowance $5,000 maximum per Member per any 24 consecutive calendar month period for outpatient and inpatient services combined • Lifetime Maximum Benefit $10,000 per Member Emergency are • At a GHC or GHC Designated Facility • At a non-GHC Designated Facility 0369 W5Z $25 Copayment per Emergency visit per Member. Copayment is waived if Member is admitted directly from the Emergency department. $100 Deductible per Emergency visit per Member. Emergency Deductible does not apply to Stop Loss. Page 44 $1,000 Allowance per Emergency transport per Member • To a GHC or GHC Designated Facility • To a non-GHC Designated Facility Additional $1,000 transfer Allowance per Member • Transfer to a GHC or GHC Designated Facility Rehabilitation Services • Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under, plus associated hospital services for the purpose of rehabilitation • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Orthopedic appliances when prescribed by a GHC physician and listed as covered in the Orthopedic Appliance Formulary Nasal CPAP device, when Medically Necessary and authorized in advance by GHC 0369 W5Z No Copayment $50 Deductible per Emergency transport per Member. Ambulance Deductible does not apply to Stop Loss. No Copayment Covered up to 60 days per condition per calendar year Covered up to 60 visits per condition per calendar year Covered Services are subject to a 50% Coinsurance. Coinsurance amount does not apply to Stop Loss. Covered Services are subject to a 50% Coinsurance. Coinsurance amount does not apply to Stop Loss. Page 45 Inpatient and outpatient TMJ services when Medically Necessary and authorized by GHC Lifetime Maximum Benefit • Individual/Group Sessions • Nicotine replacement therapy 1 M Care in a GHC-approved skilled nursing facility PA-754 - Basic Agreement CA-174 - Medicare A & B CA-175 - Medicare B Only PA-1117 - Service Area Map Covered Services are subject to a 50% Coinsurance. Coinsurance amount does not apply to Stop Loss. $1,000 maximum per Member per calendar year $5,000 per Member Covered at 50% of the total charges. Coinsurance amount does not apply to Stop Loss. Covered when provided at GHC facilities and prescribed by a GHC physician. Coverage allowance up to thirty (30) days per condition per Member 0369 Page 46 W5Z CA-7 - ER Copay CA-66 - M&A CA-18 - Pec (0) CA-574 - IM-UCA-61 - SN-A 0369 Page 47 W5Z Heat h ,► Cooperative Dues Schedule of Puget Sound For attachment to Group Medical Coverage Agreement with: GROUP # 0369 CITY OF KENT This schedule reflects Group Health Cooperative monthly dues effective January 1, 1995 and guaranteed to January 1, 1996. MONTHLY HEALTH CARE DUES Subscriber only. $171.24 per month .................................... Subscriber and spouse.............................................................................. $383.13 per month Subscriber and child(ren).......................................................................... $345.35 per month Subscriber and family................................................................................. $548.49 per month Spouseonly ............................................................................................... $211.89 per month Child(ren) only............................................................................................ $174.11 per month Spouseand children.................................................................................. $377.25 per month COPAYMENT PROVISION The following copayments apply to this plan. See Group Medical Coverage Agreement for benefit details. $0 Outpatient/Office Visit $0 Outpatient Prescription Drugs $25 Emergency Room 0 Month Pre-existing Condition BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the first day of the coverage month for which they become payable. Each remittance must be accompanied by a list of subscribers for whom such dues are paid. 9.0 percent (9%) of each month's medical dues for each member and each family enrollee, as scheduled above, is the budgeted prepayment for cost of all pharmaceuticals and prescriptions to be dispersed on written orders of the Group Health Cooperative Medical Staff for the next fiscal year under coverage of your medical coverage agreement. Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or mental handicaps in its employment practices or services. BILLING INFORMATION, Continued Regardless of the effective date of enrollment for a Subscriber and Family Dependents, the Group will not be required to submit dues to the Cooperative for the month of enrollment, and these Enrollees will appear on the subsequent month's billing at the regular charge. When the Subscriber's enrollment terminates, the group will submit the full amount of dues to the Cooperative regardless of the specific date of termination for that month. Where to Get Care at Group Health0 L.*s•nd I * OHC NedlOa1 C*nts- F� ♦ ONO sp•al■Ity C*ntem Ii * ONC Hespitwe ■ p■rtlolp■M. - MGOOM cenwm a Hor petals Each symbol shows which type of facility is available. Refer to the list inside for the names and exact locations of all facilities. Services are available INSIDE the solid lines only .Services begin in these counties January 1, 1995. Mason Grays Harbor / . Sutnas ■ Lynden ■Ferndale s Everson *san Juan ■ g� Whatoom oracas IS. ■ Eastsound SAKJWN IS. Ai's ■Lopez ■ Sedm Woolley r r °zrs_ ■ Anacortes Skagit ■ Burlington *■���...■ ■ Mt. Vernon ■ Oak Harbor ■ Coupevillea Stanwood Snohomish 4 ■ j�ng� ■s ■Everett PT Bo Bainbridge *Bthcll ---- land Silverdale • : cattle *♦* Redmond Brcme n s *** ♦e Factoria rt orchard * * Renton e Burien King ■ Vashon * Federal Way Tacoma ♦* ■ Thurston ■ Centralia Lewis Pi�ro� Facilities Group Health Medical and Specialty Centers King County Burien Medical Center 140 S.W. 146th St. Seattle, WA 98166 (206) 433-2900 Central Family Health Center 122 16th Ave. E. Seattle, WA 98112 (206) 326-3454 The Care Center at Kelsey Creek 2210 132nd Ave. S.E. Bellevue, WA 98005 (206) 957-2400 Central Medical Center North 310 15th Ave. E. Seattle, WA 98112 (206) 326-3000 Central'Medical Center South 125 16th Ave. E. Seattle, WA 98112 (206) 326-3000 Downtown Seattle Medical Center Medical -Dental Bldg., 9th Floor 509 Olive Way Seattle, WA 98101 (206) 223-2611 Eastside Primary Care Center 2701 156th Ave. N.E. Redmond, WA 98052 (206) 883-5151 Eastside Specialty Center 2700 152nd Ave. N.E. Redmond, WA 98052 (206) 883-5151 Factoria Medical Center 13451 S.E. 36th St. Bellevue, WA 98006 (206) 562-1337 Family Practice Residency 200 15th Ave. E. Seattle, WA 98112 (206) 326-3580 Federal Way Medical Center 301 S. 320th St. Federal Way, WA 98003 (206) 874-7000 (King Co.) (206) 927-7511 (Pierce Co.) Madrona Medical Center 1403 34th Ave. Seattle, WA 98122 (206) 720-60M Northgate Medical Center 9800 4th Ave. N.E. Seattle, WA 98115 (206) 527-7100 Northshore Medical Center 11913 N.E. 195th St. Bothell, WA 98011 (206) 489-3100 Rainier Medical Center 5316 Rainier Ave. S. Seattle, WA 98118 (206) 721-5600 Renton Medical Center 275 Bronson Way N.E. Renton, WA 98056 (206) 235-2800 University Medical Center 4225 Roosevelt Way N.E., 4th Floor Seattle, WA 98105 (206) 634-4000 Kitsap County Bainbridge Island Medical Center 621 High School Rd. N.W. Bainbridge Island, WA 98110 (206) 842-9911 Port Orchard Medical Center 1950 Pottery Ave. Port Orchard, WA 98366 (206) 895-5000 Port Orchard Medical Center —Tremont 1400 Pottery Ave. Port Orchard, WA 98366 (206) 895-5000 Group Health Medical Center—Silverdalc 10452 Silverdale Way N.W Silverdale, WA 98383 (206) 692-3880 Pierce County Tacoma Medical Center 1112 S. Cushman Tacoma, WA 98405 (206) 383-7801 Tacoma South Medical Center 9505 S. Steele St. Tacoma, WA 98444 (206) 597-6800 Tacoma Specialty Center 209 Martin Luther King Jr. Way Tacoma, WA 98405 (206) 596-3300 Tacoma Avenue Primary Care Center 124 Tacoma Ave. S. Tacoma, WA 98402 (206) 383-6125 Snohomish Count Everett Medical Center 2930 Maple St. Everett, WA 98201 (206) 261-1500 Lynnwood Medical Center 20200 54th Ave. W. Lynnwood, WA 98036 (206) 672-6822 OB/GYN and Women's Healthcare Services 1330 Rockefeller, Suite 120 Everett, WA 98201 (206) 388-4050 Thurston County Olympia Medical Center 700 N. Lilly Rd. Olympia, WA 98506 (206) 923-7000 West Olympia Medical Center 3030 Limited Lane N.W. Olympia, WA 98502 (206) 352-5200 Group Health Hospitals King County Central Hospital 200 15th Ave. E. Seattle, WA 98112. (206) 326-3000 The Eastside Hospital 2700 152nd Ave. N.E. Redmond, WA 98052 (206) 883-5151 �0. 11 �� of?ugeco Group Health Participating Facilities Participating hospitals are to be used for selected services only. Island County Drs. Kirkwood, James, and Rieger 7208 700th Ave. W., Suite 109 Oak Harbor, WA 98277 (206) 675-4485 (Services available 1/95) Langley Clinic 114 2nd St. Langley, WA 98260 (206) 221-5272 (Services available 1/95) Whidbey General Hospital 101 Main St. Coupeville, WA 98239 (206) 678-5151 (Services available 1/95) King County Children's Hospital & Medical Center 4800 Sandpoint Way N.E. Seattle, WA 98105 (206) 526-2000 Harborview Medical Center 325 9th Ave. Seattle, WA 98104 (206) 223-3000 Northwest Hospital 1550 N. 115th St. Seattle, WA 98133 (206) 368-1700 Pine Lake Family Medicine 22725 S.E. 29th Issaquah, WA 98027 (206) 455-2845 Providence Medical Center 500 17th Ave. Seattle, WA 98122 (206) 320-2000 Swedish Hospital Medical Center 747 Summit Seattle, WA 98104 (206) 386-6000 University of Washington Medical Center 1959 N.E. Pacific St. Seattle, WA 98195 (206) 548-3300 Lshon Health Center Sunrise Ridge Center 10030 S.W. 210th St. Vashon, WA 98070 (206) 463-3671 Virginia Mason Hospital 925 Seneca St. Seattle, WA 98111 (206) 624-1144 Kitsap County Harrison Memorial Hospital 2520 Cherry Ave. Bremerton, WA 98310 (206) 377-3911 Lewis County Cascade Family Medical Clinic 1740 Cooks Hill Rd. Centralia, WA 98531 (206) 736-2071 Providence Hospital 1820 Cooks Hill Rd. Centralia, WA 98531 (206) 736-2803 fierce County -aulti-Care Medical Center Mary Bridge Children's Hospital 317 Martin Luther King Jr. Way Tacoma, WA 98405 (206) 594-1404 St. Joseph Hospital 1717 S. J St. Tacoma, WA 98405 (206) 627-4101 Multi -Care Medical Center Tacoma General Hospital 315 Martin Luther King Jr. Way Tacoma, WA 98405 (206) 594-1000 San Juan County Inter -Island Medical Center 550 Spring St. W. Friday Harbor, WA 98250 (206) 378-2141 (Services available 1/95) Lopez Island Medical Clinic Lopez Island, WA 98261 - 06) 468-2245 ,ervices available 1/95) Orc nd Medical Center MOU. .Aker Road Eastsound, WA 98245 (206) 376-2561 (Services available 1/95) Skagit County Burlington Family Practice 800 E. Fairhaven Ave. Burlington, WA 98233 (206) 755-0641 Creelman and Shilling Clinic 712 S. Burlington Blvd. Burlington, WA 98233 (206) 757-0027 Drs. Dietrich and Smith 1952 Hospital Drive Sedro Woolley, WA 98284 (206) 8564141 Fidalgo Medical Associates 1213 24th St. Anacortes, WA 98221 (206) 293-3101 Gross and Luther Clinic 830 Ball St. Sedro Woolley, WA 98284 (206) 855-1411 Island Hospital 1211 24th St. Anacortes, WA 98221 (206) 293-3181 Drs. Kirkwood, James, and Rieger 2601 M Ave. Anacortes, WA 98221 (206) 293-9813 North Cascade Family Physicians 120 S. 13th St. Mount Vernon, WA 98273 (206) 428-1700 Skagit Pediatrics 1801 E. Division Mount Vernon, WA 98273 (206) 428-2622 Affiliated Health Services Skagit Valley Hospital 1415 E. Kincaid Mount Vernon, WA 98273 (206) 424-4111 Skagit Valley Medical Center 1400 E. Kincaid Mount Vernon, WA 98273 (206) 428-2500 Affiliated Health Services United General Hospital 1971 Hospital Drive Sedro Woolley, WA 98284 (206) 856-6021 Snohomish Cc Providence General medical center —Colby Campus 1321 Colby Ave. Everett, WA 98206 (206) 261-2000 Providence General Medical Center —Pacific Campus 916 Pacific Everett, WA 98201 (206) 258-7123 Stanwood Family Practice 26920 State Rd. 530 Stanwood, WA 98292 (206) 629-9511 Thurston County St. Peter Hospital 413 N. Lilly Rd. Olympia, WA 98506 (206) 491-9480 Whatcom Count Dr. Greg Anderson 1610 W. Grover Lyndon, WA 98264 (206) 354-1311 Bellingham Pediatrics 3015 Squalicum Parkway Bellingham, WA 98225 (206) 733-1911 Chestnut Family Practice 904 E. Chestnut Bellingham, WA 98225 (206) 671-4400 Family Health Associates 3500 Orchard Place Bellingham, WA 98225 (206) 671-3900 Ferndale Medical Center 5616 3rd St. Ferndale, WA 98248 (206) 384-1511 Drs. Herdman and Tarleton 3015 Squalicum Parkway Bellingham, WA 98225 (206) 733-7974 Drs. Hipskind and Hipskind 3015 Squalicum Parkway Bellingham, WA 98225 (206) 733-4140 Internal Medicine Associates 2950 Squalicum Parkway Bellingham, WA 98225 (206) 671-7140 Dr. John Knudsen 506 W. Grover Lynden, WA 98264 (206) 354-2238 Lyndon Family Medicine 1610 W. Grover Lynden, WA 98264 (206) 354-1333 Drs. McClcnahan and Jacobson 3015 Squalicum Pkwy. Bellingham, WA 98225 (206) 676-9336 Drs. McNichols and Blackwell 518 E. Magnolia Bellingham, WA 98225 (206) 671-4402 North Sound Family Medicine 3015 Squalicum Pkwy. Bellingham, WA 98225 (206) 671-3345 Northwest Pediatrics 3149 Ellis St. Bellingham, WA 98225 (206) 734-4302 Dr. Kenneth Spady 407 E. Main St. Everson, WA 98247 (206) 966-3441 St. Joseph Hospital 2901 Squalicum Pkwy. Bellingham, WA 98225 (206) 734-5400 St. Joseph Hospital South Campus 809 E. Chestnut St. Bellingham, WA 98225 (206) 734-8300 Sumas Family Medicine 112 Columbia Sumac, WA 98295 (206) 988-5223 To request a list of the most current Group Health participating providers, call one of the numbers below: For Island, San Juan, Skagit, and Whatcom counties— (206) 647-7205 or 1-800-552-4330 For Lewis County— (206) 456-7862