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HomeMy WebLinkAboutCAG1994-0041 - Original - Group Health Cooperative - Group Medical Coverage Agreement - 01/01/1994 Group 04401- Health 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 providing to its Enrollees quality health care,including Title Vice President,Health Plan and Insurance Services preventive medical services. GROUP This Agreement states the terms of enrollment, pay- ment and coverage under which a Group may secure City of Kent, #0369 GHC 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 I. BY ENROLLEES ARE ENTITLED TO COVERED Title 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 1994 and will continue in effect until terminated as SECTION X.I. OF THE SCHEDULE OF herein provided for. BENEFITS. 0369 Pagel Z34 GROUP MEDICAL COVERAGE AGREEMENT Table of Contents I. Definitions II. 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 • Service Area Map 0369 Page 2 Z34 Section I. Definitions ENROLLEE: Any Subscriber or Family Dependent covered by this Agreement. AGREEMENT: This Medical Coverage Agreement, FAMILY DEPENDENT: Any member of a including the Schedule of Benefits, Enrollment Subscriber's-family who meets all applicable and Eligibility Schedule,Dues Schedule,Allowan- eligibility requirements,is enrolled hereunder,and ces, Deductibles, Copayments, and Fees Schedule, for whom the dues prescribed in the Dues Service Area Map, and Medicare endorsements. Schedule have been paid. ALLOWANCE: The maximum amount payable by FAMILY UNIT: A Subscriber and all his/her Family GHC for certain Covered Services under this Dependents. Agreement, as set forth in the Allowances,Deduct- ibles, Copayments,and Fees Schedule. GHC DESIGNATED FACILITY: A facility, not in- cluding a GHC Facility,which the GHC Board of COINSURANCE: An amount that the Enrollee is Trustees has specified to provide health care ser- required to pay for Covered Services received vices to its Enrollees. (See Service Area Map.) under this Agreement,which is a percentage of the Designated Facilities may be changed by GHC Allowance for such services, as set forth in the upon appropriate notice. Allowances, Deductibles, Copayments, and Fees Schedule. GHC FACILITY:A hospital or medical center owned and operated by Group Health Cooperative of COPAYMENT: The specific dollar amount required Puget Sound. (See Service Area Map.) to be paid by an Enrollee for certain Covered Services under this Agreement, as set forth in the GHC MEDICARE PLAN: A plan of coverage for Allowances, Deductibles, Copayments, and Fees persons enrolled in Medicare Part A(hospital in- Schedule. surance)and Part B(medical insurance),or Part B COVERED SERVICES: The services and benefits to only. which an Enrollee is entitled under this Agree- GROUP: An employer, union, welfare trust, or as- ment. sociation which has entered into a Group Medical Coverage Agreement with GHC. DEDUCTIBLE: A specific maximum amount paid by an Enrollee for certain Covered Services before HEALTH EVALUATION: Screening of the applicant benefits are payable under this Agreement. The or other eligible persons prior to enrollment ac- applicable Deductible amounts are set forth in the cording to the standards which may be defined by Allowances, Deductibles, Copayments, and Fees Group Health Cooperative to determine whether Schedule. such person is qualified for enrollment under this Group Medical Coverage Agreement. DIRECTORY OF SERVICES: A fee-for-service schedule adopted by GHC, setting forth the fees HOSPITAL CARE: Those Medically Necessary ser- for medical and hospital services not covered by a vices generally provided by acute general hospitals GHC prepayment agreement. for admitted patients which a GHC physician has prescribed, directed, or authorized. Hospital care EMERGENCY: The sudden, unexpected onset of a does not include convalescent or custodial care medical condition that in the reasonable judgment which can, in the opinion of the GHC physician, of a prudent person is of such a nature that failure be provided by a nursing home or convalescent to render immediate care by a licensed medical care center. provider would place the Enrollee's life in danger, or cause serious impairment to the Enrollee's MEDICAL PERSONNEL: The Medical Staff, Clinic health. Associate Staff, and Allied Health Professionals employed by GHC, and any other health care 0369 Page 3 Z34 professional with whom GHC has entered into a Loss amount is set forth in the Allowances,Deduct- formal legal arrangement. ibles, Copayments,and Fees Schedule. MEDICALLY NECESSARY: Required for the diag- SUBSCRIBER:A person employed by or belonging to nosis or treatment of illness or injury, as deter- the Group who meets all applicable eligibility re- mined by a GHC physician, and consistent with quirements, is enrolled hereunder, and for whom professionally recognized standards of health care. the dues specified in the Dues Schedule have been paid. MEDICARE: The federal health insurance program for the aged and disabled. URGENT CONDITION: The sudden, unexpected onset of a medical condition that is of sufficient OPEN ENROLLMENT: An annual period, specified severity to require medical treatment within twen- by the Group and GHC, during which an eligible ty-four(24) hours of its onset. person may apply for coverage. USUAL, CUSTOMARY, AND REASONABLE: A PRE-EXISTING CONDITION:Acondition for which term used to define the level of benefits which are there has been diagnosis, treatment (including payable by GHC when expenses are incurred from prescribed drugs), or medical advice within the a non-GHC physician or provider. Expenses are twelve (12) month period prior to the effective considered Usual, Customary, and Reasonable if date of coverage, or a condition for which (1)the charges are consistent with those normally symptoms existed within the twelve (12) month charged by the provider or organization for the period prior to the date of coverage and for which same services or supplies; and (2) the charges are a prudent person would have ordinarily sought within the general range of charges made by other treatment. providers in the same geographical area for the same services or supplies. REFERRAL:A written temporary referral agreement authorized in advance by a GHC physician and approved by GHC, which entitles an Enrollee to Section II. Dues, Fees, and Copayments receive Covered Services from a specified non- GHC health care provider. Entitlement to such A. MONTHLY DUES PAYMENTS. The Group services shall not exceed the limits of the Referral shall submit to GHC for each Enrollee the month- and is subject to all the terms and conditions of the ly dues set forth in the current Dues Schedule and Referral and this Agreement. a verification of enrollment,on or before the due date, subject to a grace period of ten (10) days. SERVICE AREA: King, Kitsap, Pierce, Skagit, Dues are subject to change by GHC upon thirty Snohomish, Thurston, and Whatcom Counties, (30) days written notice. and any other areas designated by GHC. (See Service Area Map.) In the event the group increases enrollment at least twenty-five percent (2501o) or more through acquisi- SKILLED HOME HEALTH CARE: Reasonable and tion or merger, GHC reserves the right to require necessary care for the treatment of an illness or re-rating of the group. injury which requires the skill of a nurse or therapist, based on the complexity of the service B. SUBSCRIBER'S LIABILITY. The Subscriber is and the condition of the patient, and which is liable for (1) payment to the Group of his/her performed directly by an appropriately licensed contribution toward the monthly dues, if any; (2) professional provider. payment to the Cooperative of Copayments and/or Coinsurance amounts for Covered Ser- STOP LOSS: The maximum amount of Copayments vices provided to the Subscriber and his/her Fami- paid during the calendar year for Covered Services ly Dependents, as set forth in the Allowances, received by the Subscriber and his/her Family De- Deductibles, Copayments and Fees Schedule, and pendents during the same calendar year.The Stop (3) payment to the Cooperative of any fees charged for non-Covered Services provided to 0369 Page 4 Z34 the Subscriber and his/her Family Dependents. Section III. Termination Failure to pay for services at the time of service may result in a billing fee. A. TERMINATION OF ENTIRE AGREEMENT. At the time of service,Enrollees shall be required This Agreement may be terminated in the follow- to pay Copayments as set forth in the Allowances, ing circumstances: Deductibles, Copayments and Fees Schedule. 1. Termination on Notice. Either GHC or the Failure to pay Copayments at the time of service Group may terminate this Agreement b may result in a billing fee. Failure to cancel a p y g y giving thirty (30) days written notice to the scheduled appointment at least 24 hours prior to the appointment may result in a billing fee or the value other. of the service. 2. Nonpayment. Failure to make any monthly Payment of a Copayment does not exclude the dues payment in accordance with Section possibility of an additional billing if the service is II.A. shall result in termination of this determined to be a non-Covered Service. Agreement as of the due date. Total out-of-pocket Copayment expenses in- 3. Misrepresentation to Obtain Insurance. curred during the same calendar year shall not Group Health Cooperative may Fesei or �G(,�-�5 exceed the aggregate maximum amount (Stop terminate this Agreement upon&written 3 Loss) as set forth in the Allowances, Deductibles, notice in the event of material misrepresen- Copayments,and Fees Schedule. tation, fraud, or omission of information in order to obtain Group coverage. If Copayments have been billed, any applicable billing fees shall not be considered in calculating B. TERMINATION OF SPECIFIC ENROLLEES. total out-of-pocket expenses for Copayments This Agreement may be terminated as to a made. specific Enrollee for any of the following reasons: C. SELF-PAYMENTS DURING A STRIKE, 1. Loss of Eligibility.If an Enrollee no longer LOCK-OUT,OR OTHER LABOR DISPUTE.In meets the eligibility requirements set forth the event of suspension or termination of in Section IX.B. and is not enrolled for con- employee compensation due to a strike,lock-out, tinuation coverage as described in Section or other labor dispute,a Subscriber may continue IV.A., coverage under this Agreement will uninterrupted coverage under this Agreement terminate at the end of the month during through payment of monthly dues directly to the which loss of eligibility occurs, unless other- Group.Coverage may be continued for the lesser wise specified by the Group as set forth in of the term of the strike, lock-out, or other labor Section IX. Enrollment and Eligibility dispute, or for six (6) months after the cessation Schedule. of work. 2. For Cause.Coverage of an Enrollee maybe If the Group Agreement is no longer available, terminated upon written notice for: the Subscriber shall have the opportunity to apply a. Nonpayment of dues for a specific En- for individual Group Conversion or,if applicable, rollee by the Group. continuation coverage (see Section IV.), or an Individual and Family Medical Coverage Agree- b. Material misrepresentation, fraud, or ment at the duly approved rates. omission of information in order to ob- THE GROUP IS RESPONSIBLE FOR IMME- tain coverage. This includes failure to DIATELY NOTIFYING EACH AFFECTED answer fully and correctly all questions SUBSCRIBER OF HIS/HER RIGHTS OF contained in the application forms. In SELF-PAYMENT UNDER THIS PRO- such event, the Cooperative may, VISION. 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 0369 Page 5 Z34 cancel the Enrollee's coverage upon To the extent required by federal law, if the Sub- ten (10)working days written notice. scriber or Family Dependent loses eligibility under this Group Agreement, group coverage c. Permitting the use of a GHC identifica-. may be continued under the circumstances tion card by another person, or using described below. Except as set forth in Section another person's identification card to IV.A.11., below, this provision applies only to obtain care to which one is not entitled. Subscribers and Family Dependents enrolled under this Agreement prior to the date of d. Failure to comply with the rules and eligibility for continuation coverage who would regulations of the Cooperative. otherwise lose coverage as a result of one of the e. Nonpayment of charges as set forth in qualifying events listed below in subsections (1.), g Section ILC. (2.), and (3.). 3. In no event will an Enrollee be terminated solely 1. Subscribers and Family Dependents are eligible for continuation coverage for amax- o on the basis of their physical or mental condi- imum period f up to eighteen (18) months tion provided they meet all other eligibility re- commencing the date that: quirements set forth in this Agreement. C. PERSONS HOSPITALIZED ON THE DATE • The Subscriber's employment is ter- urinated (unless terminated for gross OF TERMINATION. An Enrollee who is a misconduct);or registered bed patient receiving Covered Services in a GHC Facility or GHC Designated Facility on • the Subscriber experiences a reduction the date of termination shall continue to be in work hours resulting in loss of eligible for Covered Services for the condition for eligibility for group benefits. which the Enrollee was hospitalized, until dis- charge from the facility.This continued coverage 2. Family Dependents are eligible for con- will also apply to an Enrollee hospitalized in a tinuation coverage for a maximum period of non-GHC Designated Facility as a result of an up to thirty-six (36) months commencing at Emergency or Referral as set forth in Section the date that: XI.B.1. • The Subscriber is divorced or legally D. SERVICES PROVIDED AFTER TERMINA- separated; TION. Any services provided by GHC after the effective date of termination (except those ser- • the Subscriber dies; vices covered under Section III.C.) shall be charged according to the Directory of Services. • the Subscriber becomes entitled to The Subscriber shall be liable for payment of all Medicare;or such charges for services provided to the Sub- scriber and all Family Dependents. • a Dependent child ceases to qualify as a Family Dependent under Section Section IV. Continuation Coverage, IX.B.2.(b)or(c). Conversion and Transfer 3. A COBRA eligible beneficiary who is dis- abled prior to or on the date he/she loses coverage due to termination of employment A. CONTINUATION COVERAGE (other than for the beneficiary's gross mis- conduct) or reduction of hours may extend This subsection A. only applies to employer his/her coverage under COBRA from groups who must offer continuation coverage eighteen(18)months up to twenty-nine(29) under the applicable provisions of the Con- months, so long as the beneficiary provides solidated Omnibus Budget Reconciliation Act of notice of his/her Social Security disability 1985 ("COBRA"), as amended, and only applies determination within sixty (60) days of such to grant continuation of coverage rights to the determination and before the end of the extent required by federal law. 0369 Page 6 Z34 eighteen(18)month coverage period.Social isting Condition which the Enrollee Security Administration certification of total may have; disability is required.The period of extended coverage provided under this subsection • the Enrollee becomes enrolled under shall terminate on the first day of the first Medicare; month which begins more than 30 days after the date of the Social Security Administra- • the employer ceases to maintain any tion's final determination that the qualified group health plan;or beneficiary is no longer disabled. • the Enrollee is no longer disabled as 4. In the event the group has retirees, the Sub- determined by the Social Security Ad- scriber who is a retiree or the spouse or ministration. Dependent of a retiree, may continue coverage hereunder if the Subscriber andlor 7. Notice. The Group is responsible for assur- Family Dependent would otherwise lose ing compliance with COBRA and that En- coverage hereunder within one year of the rollees are given timely notice of their date a proceeding under Title 11 of the continuation coverage option.The Group is United States Code is commenced with also responsible for notifying GHC in a time- respect to the Group. Coverage under this ly fashion of the election to continue Section IV.A.4., continues only upon pay- coverage and the applicable coverage ment of applicable monthly charges to the period. Group at the time specified by the Group. The Subscriber or Family Dependent must The terms and conditions of this coverage notify the Group, or plan administrator, if are governed by COBRA. any, within sixty (60) days following a 5. If an individual enrolled for continuation divorce, legal separation, or when an en- coverage experiences a second qualifying rolled dependent child no longer meets the event as set forth in subsection (2.) above, eligibility requirements set forth in Section continuation coverage may be extended for IX.B.2., or within sixty (60) days following up to thirty-six(36) months,beginning from the date coverage ends in accordance with the date of the first qualifying event. When the termination provisions under this Agree- the Subscriber becomes entitled to ment,whichever is later. Medicare, the period of continuation g, Application. Written application for con- coverage for family dependents as a result of the Subscriber's Medicare entitlement or tinuation coverage must be made within sixty any later event described in Section IV.A.2. (60) days of the termination date ofcoverage, or the date that the Enrollee above shall extend up to a maximum of thir- receives specific notice of his/her right to ty-six (36) months from the date the Sub- continuation coverage, whichever is later. scriber becomes entitled to Medicare. For the purpose of this Agreement 6. In addition to the conditions set forth in "receives" means that written notice was Section III. Termination, continuation mailed by the Group to the Enrollee's most coverage may be terminated prior to the recent address as recorded with the Group. prescribed period set forth in subsections No lapse in coverage prior to continuation (l.), (2.), and (3.) above if: coverage is permitted, except as provided above. The application shall be deemed by • there is a failure to make timely pay- GHC to include all Family Dependents ment of any monthly dues required eligible for continuation coverage unless under this Agreement; specifically stated otherwise. A physical ex- amination or statement of health is not re- • the Enrollee becomes covered under quired. any other group health plan, unless such plan contains an exclusion or 9. Monthly Dues. Monthly dues must be paid limitation on coverage for any Pre-ex- directly to the Group.The Group is respon- 0369 Page 7 Z34 sible for submitting such dues with its regular ment. Coverage under the GHC Group monthly dues payment to GHC. Conversion Plan is subject to all terms and conditions of such plan, including dues pay- Payment of the initial dues payment,which ment. A physical examination or statement includes the period from the election of health is not required for enrollment in retroactive to the qualifying event, and any the Group Conversion Plan. regular dues payment that becomes due prior to the initial dues payment date, for C. PERSONS ENTITLED TO, OR ELIGIBLE TO continuation coverage under COBRA is due PURCHASE MEDICARE. Except as defined by forty-five(45)days after the date of the elec- federal regulations, all Enrollees entitled to, or tion. Subsequent dues payments are due on eligible to purchase Medicare must transfer to the a monthly basis.Dues for persons extending GHC Medicare Plan upon such entitlement or COBRA coverage from eighteen (18) eligibility. A condition of coverage under the months to twenty-nine(29)months because GHC Medicare Plan requires that an Enrollee be of total disability may be charged at one continuously fully qualified and enrolled for the hundred fifty percent(150%)of the Group's hospital (Part A) and medical (Part B) benefits, dues rate that would otherwise apply to or Part B only, available from the Social Security them. Administration, and sign any papers that may be required by GHC or Medicare. All applicable 10. Group Conversion. In addition to Group provisions of the GHC Medicare Plan are fully set Conversion rights as set forth in Section forth in the Medicare Endorsement(s) attached IV.B., the Subscriber or Family Dependent to this Agreement. enrolled for continuation coverage is en- titled to convert to GHC's Group Conver- D. PERSONS AGE SIXTY-FIVE (65) OR OLDER sion Plan within a 180-day period prior to WHO ARE NOT ENTITLED TO, OR termination of continuation coverage, if ELIGIBLE TO PURCHASE MEDICARE.Upon his/her coverage under this Agreement is reaching age sixty-five (65), if not entitled to, or terminated for any reason other than non- eligible to purchase Medicare, Enrollees may payment or cause.See Section IV.13.2.GHC continue coverage under this Agreement upon Group Conversion Plan-Application. payment of the applicable dues as set forth in the Dues Schedule. 11. Open Enrollment and Adding Dependents. To the extent required under COBRA, a qualified beneficiary under COBRA may Section V. Coordination of Benefits add Family Dependents during the Group's Open Enrollment period and newly eligible Benefits provided under this Agreement do not dupli- persons according to the procedures cate other group coverage for medical care or treat- specified in Section IX.A. ment. If an Enrollee is entitled to receive benefits or B. GHC GROUP CONVERSION PLAN. services for medical care or treatment under another group or governmental plan, GHC may recover the 1. Eligibility. Any Subscriber or Family De- reasonable cash value of services provided under this pendent is entitled to convert to GHC's Agreement so that benefits and services under all plans Group Conversion Plan if his/her coverage do not exceed one hundred percent (100%) of allow- under this Agreement is terminated for any able expenses (except copayments, coinsurances, and reason other than nonpayment or cause. deductibles), as fully set forth in this section. (See Section III.B.2.)Following termination of marriage or death of the Subscriber, all A. Benefits Subject to This Provision: Family Dependents are entitled to make such a conversion. All of the benefits provided under this Agreement are subject to this provision. 2. Application. Application for conversion must be made within thirty-one (31) days B. Plan: following termination under this Agree- 0369 Page 8 Z34 The definition of a "Plan" includes the following E. Right to Receive and Release Information: sources of benefits or services: For the purpose of determining the applicability 1. Group or blanket disability insurance of and implementing this provision and any policies and health care service contractor provision of similar purpose in any other Plan,the and health maintenance organization group Cooperative may, with such consent as may be agreements, issued by insurers, health care necessary, release to or obtain from any other service contractors and health maintenance insurer, organization or person any information, organizations; with respect to any person which the insurer con- siders necessary for such purpose. Any person 2. Labor-management trusteed plans,labor or- claiming benefits under this Agreement shall fur- ganization plans, employer organization nish to the Cooperative the information neces- plans or employee benefit organization sary for such purpose. plans; F. Facility of Payment: 3. Governmental programs; and Whenever coverage which should have been 4. Coverage required or provided by any provided under this Agreement in accordance statute. The term "Plan" shall be construed with this provision has been provided or paid for separately with respect to each policy,agree- under any other Plan,the Cooperative shall have ment or other arrangement for benefits or the right, exercisable alone and in its sole discre- services, and separately with respect to the tion, to pay over to any Plan making such other respective portions of any such policy,agree- payments any amounts it shall determine to be ment or other arrangement which do and warranted in order to satisfy the intent of this which do not reserve the right to take the provision, and amounts so paid shall be con- benefits or services of other policies, agree- sidered to be coverage or benefits paid under this ments or other arrangements into considera- Agreement and, to the extent of such payments, tion in determining benefits. the Cooperative shall be fully discharged from liability under this Agreement. C. Allowable Expense: G. Right of Recovery: "Allowable Expense" means any necessary, reasonable and customary items of expense at Whenever benefits have been provided by the least a portion of which is covered under at least Cooperative with respect to Allowable Expenses one of the Plans covering the person for whom in total amount at any time, in excess of the max- the claim is made.When a Plan provides benefits imum amount of payment necessary at that time in the form of services rather than cash payments, to satisfy the intent of this provision,the Coopera- the reasonable cash value of each service tive shall have the right to recover the reasonable rendered shall be considered as both an Allow- cash value of such benefits, to the extent of such able Expense and a benefit paid. excess, from one or more of the following, as the Cooperative shall determine: any persons to or D. Claim Determination Period: for or with respect to whom such benefits were "Claim Determination Period" means a period provided, any other insurers, any service plans or P any other organization or other Plans. beginning with any January 1 and ending with the next following December 31 except that the first H. Effect on Benefits: Claim Determination Period with respect to any person shall begin on the effective date of 1. This provision shall apply in determining the coverage under this Agreement with respect to benefits for a person covered under this such person and end on the following December Agreement for a particular Claim Deter- 3 1.In no event will a Claim Determination Period mination Period if,for the Allowable Expen- for any person extend beyond the last day on ses incurred as to such person during such which such a person is covered under this Agree- period, the sum of: ment. 0369 Page 9 Z34 a. The reasonable cash value of the a. The benefits of a Plan which covers the benefits that would be provided under person on whose expenses a claim is the Agreement in the absence of this 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 lowable Expenses. benefits of the Plan of the parent whose birthday falls earlier in the year are 2. As to any Claim Determination Period with determined before those of the Plan of respect to which this provision is applicable, 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- month and day, not the year in which a sence of this provision for the Allowable person was born. If both parents have Expenses incurred as to such person during the same birthday, the benefits of the such Claim Determination Period shall be Plan which covered the parent longer reduced to the extent necessary so that the are determined before those that sum of the reasonable cash value of benefits covered the other parent for a shorter and all benefits payable for such Allowable period of time, except that in the case Expenses under all other Plans, except as of a person for whom claim is made as provided in subparagraph(3)of this Section, a dependent child, shall not exceed the total of such Allowable Expenses. Benefits payable under another i. when the parents are separated or Plan include benefits that would have been divorced and the parent with cus- payable had a claim been duly made there- tody of the child has not remarried, 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 take into consideration, deductibles, copay- parent with custody of the child ments,or other cost-sharing provisions. will be determined before the 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 the parent with custody of the benefits with those of this Agreement child has remarried,the benefits of would,according to its rules,determine a Plan which covers the child as a its benefits after the benefits of this 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 stepparent, and the benefits of a Agreement to determine its benefits Plan which covers that child as a before such other Plan, then the dependent of the stepparent will benefits of such other Plan will be ig- 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 4. For the purposes of subparagraph(3)of this custody. 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 Z34 responsibility for the medical,dental or shall be charged against any applicable other health care expenses with respect benefit limit of this Agreement. to the child,the benefits of a Plan which covers the child as a dependent of the parent with such financial responsibility Section VI. Subrogation shall be determined before the benefits of any other Plan which cover the child "Injured person"under this section means an Enrollee as a dependent child. covered by this Agreement who sustains compensable c. When rules(a)and(b)do not establish injury. "GHC's medical expenses" means the expense an order of benefit determination, the incurred and the reasonable value of the services benefits of a Plan which has covered the provided by the Cooperative for the care or treatment person on whose expenses claim is of the injury sustained. based for the longer period of time shall be determined before the benefits of a If the injured person was injured by an act or omission Plan which has covered such person the of a third party giving rise to a claim of legal liability shorter period of time,provided that: against the third party, GHC shall have the right to recover from the third party GHC's medical expenses. i. The benefits of a plan covering the This right is commonly referred to as "subrogation." person on whose expenses claim is GHC shall be subrogated to and may enforce all rights based as a laid off or retired of the injured person to the extent of GHC's medical employee, or dependent of such expenses. GHC's equitable and contractual rights of person shall be determined after subrogation are limited in accordance with the benefits of any other Plan Washington law. covering such person as an employee, other than a laid off or The injured person and his or her agents must retired employee,or dependent of cooperate fully with GHC in its efforts to collect such person; and GHC's medical expenses. This cooperation shall in- ii. If either plan does not have a clude supplying GHC with information about any defendants and/or insurers related to the injured provision regarding laid off or erson's claim. The injured person and his or her retired employees,which results in p �each Plan determining its benefits agents shall permit GHC, at GHC's option, to as- after the other,then the provisions sociate with the injured party or to intervene in any of (i) of this subsection shall not action filed against any third party.The injured person apply. and his or her agents shall do nothing to prejudice GHC's subrogation rights.The injured person shall not d. If none of the above rules determines settle a claim without protecting GHC's interest. the order of benefits,the benefits of the Plan which covered an employee or GHC shall not recover anything under this section Subscriber for the longer period of time until the Enrollee has been made whole,except in the shall be determined before those of the case that the Enrollee fails to cooperate fully with Plan which covered that person for the GHC in recovery of medical expenses as described shorter time period. above.In which case,the Enrollee shall be responsible 5. When this provision operates to reduce the for reimbursing GHC for such medical expenses. total amount of benefits otherwise to be GHC shall not pay any attorney's fees or collection provided to a person covered under this costs to attorneys representing the injured person Agreement during any Claim Determination where it has retained its own legal counsel or acts on Period, the reasonable cash value of each its own behalf to represent its interests and unless benefit that would be provided in the ab- sence of this provision shall be reduced there is a written fee agreement signed by GHC prior to any collection efforts. When reasonable collection proportionately, and such reduced amount costs have been incurred with GHC's prior written 0369 Page 11 Z34 agreement,to recover GHC's medical expenses,there F. INDEMNIFICATION.GHC agrees to indemnify shall be an equitable apportionment of such collection and hold the Group harmless against all claims, costs between GHC and the injured person subject to damages, losses, and expenses, including reason- a maximum responsibility of GHC equal to one-third able attorney's fees, arising out of GHC's failure of the amount recovered on behalf of GHC. to perform or negligent performances of its ex- press obligations under the Group Medical Coverage Agreement. GHC further agrees to in- Section VII.Grievance Procedures demnify and hold the Group harmless against claims, damages, losses or expenses, including reasonable attorney's fees, for injury or damage The Consumer Relations Program is designed to help caused to any person which is the result of or is an Enrollee resolve formal complaints and concerns alleged to be the result of the failure to provide about medical and business service. GHC will record, or the negligent provision of medical services or research, and respond in a timely manner to an supplies specified under this contract by any Enrollee's concern. A concern should initially be health care provider who is employed by, is an registered at the Enrollee's area medical center.If not agent of or who has a direct contractual relation- satisfied,the Enrollee should then contact the regional ship with GHC. Provided, however, that the Consumer Relations Department,which will arrange Group notifies GHC in writing promptly of any for review by appropriate Medical Staff,management, such claims, that it will assist GHC (at GHC's and/or GHC consumers. expense) in the defense of same, and that GHC has the right to direct and arrange the defense of the case. Section VIII. Miscellaneous Provisions The foregoing shall not in any way be construed A. DISSEMINATION OF INFORMATION. The as applying to any claim, demand or loss arising Group is responsible for disseminating to Sub- out of negligent acts or omissions of the Group, its agents,officers or employees,or failure by the scribers written information concerning this Agreement which is provided by the Cooperative. Group to carry out any of its responsibilities under this Agreement. B. IDENTIFICATION CARDS. The Cooperative Group Health Cooperative of Puget Sound does not will furnish cards, for identification only, to all discriminate on the basis of physical or mental hand- persons enrolled under this Agreement. icaps in its employment practices and services. C. ADMINISTRATION OF AGREEMENT. GHC may adopt reasonable policies and procedures to Section IX. Enrollment and Eligibility help in the administration of this Agreement. Schedule D. MODIFICATION OF AGREEMENT. This Agreement may be modified by GHC upon thirty A. ENROLLMENT (30) days written notice. 1. Application for Enrollment.Application for E. Group Health Cooperative reserves the right to enrollment shall be made on an application construe the provisions of this Medical Coverage form furnished and approved by GHC. No Agreement, and to determine any and all ques- person shall be enrolled or dues accepted tions pertaining to benefit entitlement and until this completed application has been coverage. received and approved by GHC.The Group No oral statement o an person shall modify or is responsible for submitting completed ap- plication forms to GHC. otherwise affect the benefits, limitations, and ex- clusions of this Agreement, convey or void any a. Newly Eligible Persons.Newly eligible coverage, increase or reduce any benefits under this Subscribers may make written applica- Agreement or be used in the prosecution or defense tion for enrollment to the Group within of a claim under this Agreement. thirty-one (31) days of eligibility. If the 0369 Page 12 Z34 Subscriber wishes to enroll his/her ment to the Group within sixty(60)days eligible Dependents, application must following the date of birth. be made during this same thirty-one (31) day period. In the event there is a change in the monthly dues payment as a result of the Written application for enrollment for addition of an adoptive child,including a newly dependent person,other than a adopted newborns,the Subscriber must newborn or newborn adopted child, make written application for enroll- must be made to the Group within thir- ment within sixty(60)days from the day ty-one (31) days after the dependency that the child is physically placed with occurs. the Subscriber for the purpose of adop- 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 of a GHC Subscriber loses nated Facility;or eligibility under a group medical plan provided by his/her employer, the ii. at a non-GHC Facility due to an spouse and any eligible Dependents Emergency, provided that all the listed on the spouse's insurance may be requirements of Section X.I. of added to the GHC Subscriber's plan. this Agreement are met,including Enrollment must be continuous be- notification of GHC by way of the tween plans and application must be GHC Notification Line within made prior to, or at the same time as, twenty-four (24) hours following termination of previous enrollment. inpatient admission, or as soon thereafter as medically possible. c. Open Enrollment. A person not en- rolled as a Subscriber or Family De- GHC shall provide notice of such en- pendent when newly eligible, as rollment to the Subscriber and the described above, may make written ap- Group. It is the Subscriber's respon- plication during the Group's Open En- sibility to complete and submit a revised rollment period. application form to the Group. If the Subscriber does not want the newborn d. Health Evaluation. If a Subscriber or child enrolled,he/she must notify GHC Family Dependent wishes to enroll out- within sixty (60) days of the date of side the periods of eligibility as set forth birth. in Section IX.A.1., he/she must first satisfy all Health Evaluation require- If subsequent to enrollment it is dis- ments 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 disenroll the child retroactive to the will be open for application as set forth in effective date of coverage. Section IX.A.1. GHC may limit enrollment, establish quotas, or set priorities for accep- Children who are born in a non-GHC tance of new applications if it determines Facility on a nonemergency basis will that its capacity,in relation to its total enroll- not be automatically enrolled. In the ment, is not adequate to provide services to event there is a change in the monthly additional persons. dues payment as a result of the addition of a newborn child,the Subscriber must 3. Effective Date of Enrollment. make written application for enroll- 0369 Page 13 Z34 a. Provided application is made as set at a GHC or GHC Designated Facility under forth in Section IX.A.l.a. (above), en- the medical management of a GHC rollment for a newly eligible Subscriber physician unless the Enrollee has been and listed Dependents will begin on the Referred by a GHC physician or has date of hire. received Emergency services according to Section X.I. Subscribers who return to work from a leave without pay status within ninety B. ELIGIBILITY (90) days, shall be eligible for enroll- ment on the first of the month following In order to be accepted for enrollment and con- their date of return to work. tinuing coverage under the Group Agreement, individuals must meet all applicable requirements For eligible Subscribers and Family De- set forth below. The Group is responsible for pendents who have satisfied the Health determining eligibility. Evaluation requirement as set forth in Section IX.A.1., following acceptance Subscribers and Family Dependents must reside in by the Cooperative, enrollment will the GHC Service Area (as defined in Section L) in begin on the date specified by GHC. order to be eligible for enrollment under this Agree- meet, except for temporary residency outside the Enrollment for newly dependent per- Service area for purposes of attending school,court- sons,other than newborns and adopted ordered coverage for Dependents,or when approved children,will begin on the first (1st) of in advance by GHC, other unique family arrange- the month following application. ments. All non-urgent/emergent care must be provided at GHC Facilities or GHC Designated Provided newborns are enrolled as Facilities. specified in Section IX.A.l.a. (above), enrollment is effective from the date of 1. Subscribers. Bona fide employees and birth. LEOFF II employees who are employed on a regularly scheduled basis of not less than A newborn is defined as a child who is twenty(20) hours per week shall be eligible not older than four (4)weeks. for enrollment. For adopted children,enrollment is ef- Elected officials and councilmembers shall fective from the date that the adopted be eligible for enrollment. child is physically placed with the Sub- scriber for the purpose of adoption and LEOFF I employees will not be covered the Subscriber has assumed financial under this plan. responsibility for the medical expenses of the child. 2. Family Dependents.The Subscriber may en- roll any of the following: b. Persons Hospitalized on Effective Date.If a person,other than a newborn, a. The Subscriber's legal spouse; is confined in a hospital on the date enrollment would otherwise become b. Unmarried dependent children who effective, the effective date of enroll- are under the age of twenty-one (21), ment for the person(s)hospitalized will provided they reside regularly with the not begin until discharge from the Subscriber or qualify as Dependents for facility. Federal Income Tax purposes. 4. Effective Date of Services and Benefits.Ser- "Children" means the children of the vices provided to Enrollees, including new- Subscriber including adopted children, borns,are subject to all terms and conditions stepchildren, foster children, children of the Group Agreement including the re- for whom the Subscriber has a court order quirement that all services must be received to provide coverage, and any other 0369 Page 14 Z34 children for whom the Subscriber is the under the Group Agreement or any other Medi- legal guardian. cal Coverage Agreement issued by Group Health Cooperative of Puget Sound has been terminated c. Enrollment may be extended past the for cause. limiting age for an unmarried person enrolled as a Family Dependent on C. CONTINUATION OF ENROLLMENT his/her twenty-first(21st)birthday if: While on a group approved leave of absence,the i. the Dependent is a full-time Subscriber and listed Dependents will continue to registered student at an accredited receive services and benefits under this Agree- secondary school, college, or ment for up to one hundred eighty (180) days, university and under the age of provided the employer or Group continues to twenty-three(23);or remit dues to GHC for the Subscriber and such Dependents. ii. the Dependent is incapable of self-sustaining employment be- cause of a developmental dis- Section X. Schedule of Benefits ability or a physical handicap incurred prior to attainment of the Subject to all provisions of this Group Medical limiting age as set forth in Section Coverage Agreement, persons enrolled for Com- IX.B.2.b.,or prior to attainment of prehensive Health Care are entitled to receive the the student limiting age as set forth in Section IX.B.2.c., and is chiefly benefits and services that are Medically Necessary as dependent upon the Subscriber determined by GHC's Medical Director, or his/her designee, and as described in this Schedule of for support and maintenance. A dependent child shall be con- Benefits. sidered chiefly dependent upon the Subscriber for support and A. HOSPITAL CARE maintenance when, as a result of disability, one-half (1/2) or more Hospital care is provided when approved by a of the total support of the depend- GHC physician, limited to the following services: ent child is provided by the Sub- 1. Room and board, including private room scriber as determined under when prescribed, and general nursing ser- Internal Revenue Service regula- tion. Enrollment for such a De- pendent may be continued for the 2. Hospital services(including use of operating duration of the incapacity, room, anesthesia, oxygen, x-ray, laboratory, provided enrollment does not ter- and radiotherapy services). minate for any other reason. Medical proof of incapacity and 3. Drugs and medications which are listed as proof of financial dependency covered in the GHC Drug Formulary (ap- must be furnished to the Coopera- proved drug list). tive upon request, but not more frequently than annually after the 4. Special duty nursing (when prescribed as two (2) year period following the Medically Necessary). Dependent's attainment of the limiting age. Personal comfort items, such as telephone and television, are not covered. d. Dependents of LEOFF I employees are eligible for coverage under this con- If an Enrollee is hospitalized in a non-GHC tract. Facility,GHC reserves the right to require trans- fer of the Enrollee to a GHC Facility, upon con- Ineligible Persons. GHC reserves the right to sultation with a GHC physician. If the Enrollee refuse enrollment to any person whose coverage refuses to transfer to a GHC Facility, all further 0369 Page 15 Z34 costs incurred during the hospitalization are the Prenatal testing for the detection of con- responsibility of the Enrollee. genital and heritable disorders when Medi- cally Necessary as determined by GHC's B. MEDICAL AND SURGICAL CARE Medical Director,or his/her designee. Medical and surgical services are provided, Voluntary(not medically indicated and non- limited to the following,when prescribed by GHC 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, his/her designee,and in accordance with cri- ultrasound, 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 correct surgery and hospitalization related to refractions which are not related to eye pathol- the transplant, and medications; and ogy 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 below. When dispensed through GHC Transportation expenses,except as set forth Facilities, one contact lens per diseased eye under Section X.J. of this Agreement, and in lieu of an intraocular lens,including exam living expenses are excluded. and fitting, is covered for Enrollees follow- ing cataract surgery performed by a GHC Donor costs for a covered organ recipient are physician, provided the Enrollee has been covered,limited to procurement center fees, continuously covered by GHC since such travel costs for a surgical team,excision fees, surgery. Replacement of a covered contact and matching tests. GHC shall exclude lens will be provided only when needed due coverage for donor costs to the extent that to change in the Enrollee's medical condi- the donor costs are reimbursable by the tion but may be replaced only one time organ donor's insurance. within any twelve (12) month period. Except for children who have been continu- 4. Family planning counseling services. ously enrolled at GHC since birth,coverage for all transplants and any related services, 5. Hearing examinations to determine hearing items,and drugs shall be excluded until such loss. time as the Enrollee has been continuously enrolled under this Agreement,or any prior 6. Blood derivatives and the administration of GHC Medical Coverage Agreement, for blood and blood derivatives. The cost of twelve(12)consecutive months without any blood is not covered. lapse in coverage,unless the Enrollee requires 7. Maternitycare,including care for com lica- a transplant as the result of a condition which g P had a sudden unexpected onset after the tions of pregnancy;prenatal and postpartum Enrollee's effective date of coverage. visits; and hospitalization and delivery. 0369 Page 16 Z34 9. Physician visits (including consultations and lips, tongue, gums, roof and floor of the second opinions by a GHC physician)in the mouth; and incision of salivary glands and hospital or office. ducts. 10. Preventive services for health maintenance 14. Nonexperimental implants, limited to the including routine mammography screening following: cardiac devices, artificial joints, and physical examinations in accordance and intraocular lenses.Artificial or mechani- with criteria established by the Cooperative, cal hearts are excluded. for the detection of disease; and immuniza- tions and vaccinations which are listed as 15. When authorized as medically appropriate covered in the GHC Drug Formulary (ap- by GHC's Medical Director,or his/her desig- proved drug list). A fee may be charged for nee, and in accordance with criteria estab- health education programs. lished by the Cooperative, treatment of growth disorders by growth hormones. 11. Radiation therapy services. Growth hormone treatment shall be ex- 12. Medical and surgical services and related cluded until such time as the Enrollee has hospital charges, including orthognathic been continuously enrolled under this (jaw) surgery for the treatment of tem- Agreement or any prior GHC Medical Cov- poromandibular joint (TMJ) disorders, are erage Agreement for twelve (12) consecu- covered as setforth in the Allowances,Deduct- tive months without any lapse in coverage. ibles, Copayments, and Fees Schedule when determined to be Medically Necessary and 16. Respiratory therapy. referred in advance by GHC.Such disorders may exhibit themselves in the form of pain, 17. Dietary formula for the treatment of phenyl- infection, disease, difficulty in speaking, or ketonuria (PKU) when determined Medi- difficulty in chewing or swallowing food. cally Necessary by GHC's Medical Director TMJ appliances are covered as set forth or his/her designee. Coverage for this for- under orthopedic appliances (Section mula is not subject to a Pre-existing Condi- X.E.1.). tions waiting period, if any. Orthognathic (jaw)surgery,radiology services Outpatient Total Parenteral Nutritional and TAU specialist services, including fit- Therapy, when Medically Necessary and in ting/adjustment of splints, is subject to the accordance with medical criteria as estab- beneftt limit set forth in the Allowances, De- lished by GHC is covered including supplies ductibles, Copayments,and Fees Schedule. necessary for its administration. Outpatient enteral therapy is excluded. The following services, including related hospitalizations, are excluded regardless of Dietary formulas and special diets, except origin or cause: for treatment of phenylketonuria (PKU) and total parenteral nutritional therapy as • orthognathic(jaw)surgery in the absence set forth above, are excluded. of a TAU diagnosis, 18. Pre-existing Conditions are covered in the • treatment for cosmetic purposes,and same manner as any other illness. • all dental services(except as noted above), 19. Skilled Nursing Facility care in a GHC-ap- including orthodontic therapy. proved skilled nursing facility up to a maxi- mum of thirty (30) days per condition when 13. The following services are covered by GHC full-time skilled nursing care is necessary in when performed by a GHC physician or the opinion of the attending GHC physician. GHC oral surgeon: reduction of a fracture or dislocation of the jaw or facial bones; When prescribed by a GHC physician, such excision of tumors or cysts of the jaw,cheeks, care may include board and room; general nursing care;drugs,biologicals,supplies,and 0369 Page 17 Z34 equipment ordinarily provided or arranged approval. If an Enrollee is hospitalized by a skilled nursing facility; and short-term in a non-GHC Designated Facility, physical therapy, occupational therapy, and coverage is subject to payment of the restorative speech therapy. Deductible shown in the Allowances, Deductibles, Copayments, and Fees Excluded from coverage are personal com- Schedule, and notification of GHC by fort items such as telephone and television; way of the GHC Notification Line and rest cures,custodial, domiciliary or con- within twenty-four(24)hours following valescent care. inpatient admission, or as soon there- after as medically possible. Further- C. CHEMICAL DEPENDENCY TREATMENT more,if an Enrollee is hospitalized in a non-GHC Designated Facility, GHC Subject to all terms and conditions of this Agree- reserves the right to require transfer of ment,care is provided as set forth below at a GHC the Enrollee to a GHC Facility upon Facility, GHC Designated Facility, or GHC-ap- consultation with a GHC physician. If proved treatment facility, subject to the Benefit the Enrollee refuses transfer to a GHC Period Allowance and Lifetime Maximum Facility, all further costs incurred Benefit as described below and as shown in the during the hospitalization are the Allowances, Deductibles, Copayments, and Fees responsibility of the Enrollee. Schedule. For the purpose of this section, "acute chemical withdrawal" means with- 1. Chemical Dependency Treatment Services. drawal of alcohol and/or drugs from a P Y person for whom consequences of a. All alcoholism and/or drug abuse treat- abstinence are so severe as to require ment services must be: (1) provided at medical/nursing assistance in a hospital a facility as described above and must be setting and which is needed immedi- authorized in advance,except for acute ately to prevent serious impairment to chemical withdrawal as described in the Enrollees health. Section X.C.2.b.;and(2)deemed Medi- 3. Benefit Period and Benefit Period Al- cally Necessary by GHC's ADAPT lowance. Director or his/her designee. Chemical dependency treatment may include the a. Benefit Period.For the purpose of this following services received on an in- section, "Benefit Period" shall mean a patient or outpatient basis: diagnostic twenty-four (24) consecutive calendar evaluation and education,organized in- month period during which the Enrol- dividual and group counseling, lee is eligible to receive covered chemi- detoxification services, and prescrip- cal dependency treatment services as tion drugs and medicines. set forth in this section. The first b. Court-ordered treatment shall be Benefit Period shall begin on the first provided only if determined to be Medi- day the Enrollee receives covered P Y chemical dependency services under cally Necessary by GHC's ADAPT this or any other group insurance, Director or his/her designee. health care service contractor, health 2. Emergency Care. maintenance organization,self-insured plan or any combination thereof, a. Coverage for medical Emergencies in- hereinafter referred to as"group plans," cident to the abuse of alcohol and/or and shall continue for twenty-four (24) drugs is subject to the Emergency care consecutive calendar months, provided benefit as set forth in Section X.I. that coverage under this Agreement remains in force. All subsequent b. Coverage for acute chemical Benefit Periods thereafter will begin on withdrawal is provided without prior the first day Covered Services are 0369 Page 18 Z34 received after expiration of the pre- correct a medical condition following an in- vious twenty-four (24) month Benefit jury or incidental to surgery covered by GHC Period. which has produced a major effect on the Enrollee's appearance, provided: b. Benefit Period Allowance. The maxi- mum allowance available for any • the Enrollee has been continuously en- Benefit Period shall be the total of all rolled with GHC since the date of such chemical dependency benefits provided injury or surgery; and and payments made for chemical de- pendency treatment under any group • when in the opinion of a G H C plan(s), not to exceed the Benefit physician, such services can reasonably Period Allowance shown in the Al- be expected to correct the condition. lowances, Deductibles, Copayments, and Fees Schedule during the Enrollee's Complications of noncovered surgical ser- Benefit Period. vices are excluded. 4. Lifetime Maximum Benefit. 2. for reconstructive surgery and associated procedures following a mastectomy for En- Chemical dependency services are not rollees who are medically suitable can- covered after the Enrollee has reached didates, as determined by GHC's Medical his/her Lifetime Maximum Benefit amount Director or his/her designee, regardless of as shown in the Allowances, Deductibles, when the mastectomy was performed.Inter- Copayments, and Fees Schedule. All such nal breast prostheses required incident to benefits provided or payments made by: the surgery will be provided. a. GHC under any GHC Group Medical An Enrollee will be covered for all stages of Coverage Agreement; plus one reconstructive breast reduction on the nondiseased breast to make it equivalent in b. all amounts paid on an individual's be- size with the diseased breast after definitive half under any carrier or plan main- reconstructive surgery on the diseased tained by the Group, including breast has been performed. self-insured plans, 3. for women who have not undergone breast shall be applied toward this Lifetime Maxi- reconstruction, external breast prostheses mum Benefit amount. following mastectomy and post-mastectomy bras limited to one external breast prosthesis Any Deductibles or Copayments which may be per diseased breast every two years,and two borne by the Enrollee under the terms of this post-mastectomy bras every six (6) months, Agreement shall not be applied toward the up to four(4)in any twelve(12)consecutive Benefit Period Allowance or Lifetime Maximum month period. Coverage for post-mastec- Benefit. tomy bras is subject to the Coinsurance as set forth in the Allowances, Deductibles, Copay- In regard to this section, the Benefit Period(s), ments, and Fees Schedule. Benefit Period Allowance(s), and Lifetime Max- imum Benefit shall include only alcoholism treat- E. APPLIANCES,DEVICES AND SUPPLIES ment services received on or after January 1,1987 and alcoholism and/or drug abuse services 1. Orthopedic Appliances.When Medically received on or after January 1, 1988. Necessary,orthopedic appliances,which are attached to an impaired body segment for D. PLASTIC AND RECONSTRUCTIVE SER- the purpose of protecting the segment or VICES are covered: assisting in restoration or improvement of its function, are covered. Medically Necessary 1. to correct an existing functional disorder repair, adjustment or replacement of an or- resulting from a congenital disease or anom- thopedic appliance is covered when aly as determined by a GHC physician;or to 0369 Page 19 Z34 authorized in advance by a GHC physician. The Enrollee will be charged for mailing drugs, Covered Services are subject to the Coin- medicines or devices and replacing lost or stolen surance set forth in the Allowances, Deduct- drugs, medicines or devices. ibles, Copayments, and Fees Schedule. Excluded are arch supports; orthopedic G. HOME HEALTH CARE SERVICES,as set forth shoes that are not attached to an appliance; in this section, shall be provided by GHC Home or any orthopedic appliances that are not Health Services or by a GHC-authorized home listed as covered in GHC's Orthopedic Ap- health agency when Referred in advance by a pliance Formulary. GHC physician for Enrollees who meet the fol- lowing criteria: 2. Nasal CPAP Device. When Medically Necessary, the purchase of a nasal CPAP 1. The Enrollee is unable to leave home due to device,and the initial purchase of associated his or her health problem or illness (unwill- supplies, is covered. The initial one-month ingness to travel and/or arrange for transpor- rental of the device prior to purchase,which tation does not constitute inability to leave is required to establish compliance, is also the home); covered. Medically Necessary repair or re- placement of a nasal CPAP device is covered 2. the Enrollee requires intermittent Skilled when authorized in advance by a GHC Home Health Care services, as described physician. Covered Services are subject to below; and the allowance as set forth in the Allowances, 3. a GHC physician has determined that such Deductibles, Copayments,and Fees Schedule. Coverage for replacement of supplies is ex- services are Medically Necessary and are C Cover. most appropriately rendered in the cludedEnrollee's home. 3. Ostomy Supplies. Ostomy supplies neces- sary for the removal of bodily secretions or Covered Services for home health care may in- waste are covered. clude the following when prescribed by a GHC physician and when rendered pursuant to an ap- 4. Oxygen and Oxygen Equipment. When proved home health care plan of treatment:nurs- medical criteria as established by GHC are ing care, physical therapy, occupational therapy, met, and upon Referral, oxygen and oxygen respiratory therapy, restorative speech therapy, equipment for home use is covered. and medical social worker and limited home health aide services. Home health services are Replacement or repair of appliances,devices and provided on an intermittent basis in the Enrollee's supplies that are due to loss,breakage from willful home. "Intermittent" means care that is to be damage, neglect or wrongful use, or due to per- rendered because of a medically predictable sonal preference are excluded. recurring need for Skilled Home Health Care services. F. DRUGS AND MEDICINES FOR OUT- PATIENT USE as prescribed by a GHC physician Excluded are: custodial care and maintenance for conditions covered by this Agreement. All care, private duty or continuous nursing care in drugs, supplies, medicines and devices must be the Enrollee's home, housekeeping or meal ser- obtained at a GHC pharmacy. vices, care in any nursing home or convalescent facility, any care provided by or for a member of Excluded are: dietary supplements, except the patient's family, and any other services therapeutic vitamins for use up to thirty(30)days; rendered in the home which are not specifically dietary formulas and special diets, except as set listed as covered under this Agreement. forth in Section X.B.; contraceptive drugs and devices and their fitting;medicines and injections H. MENTAL HEALTH CARE SERVICES for anticipated illness while traveling; and any other drugs, medicines, and injections not listed 1. Inpatient Services: as covered in the GHC Drug Formulary (ap- proved drug list). 0369 Page 20 Z34 Usual, Customary, and Reasonable charges Allowance set forth in the Dues and Fees for services described in this section,includ- Schedule. All individual, family and group ing mental health Emergencies resulting in visits of one and one-half (1-1/2) hours or inpatient services, shall be covered up to a less are regarded as one full visit per individ- maximum benefit of seven(7)days at eighty ual. A missed appointment will be consid- percent (80%) per Enrollee per calendar ered a "visit" unless the Mental Health year.This benefit shall include coverage for Service is notified at least twenty-four (24) mental health treatment in a GHC-ap- hours in advance of a scheduled session.The proved hospital or other facility devoted length of the treatment program and the primarily to treatment of mental or nervous frequency and type of visits shall be deter- disorders. All non-Emergent care must be mined by GHC's Mental Health Service. authorized in advance by the Director of GHC's Mental Health Service, or his/her 3. Exclusions and Limitations for Outpatient designee, and the facility approved by the and Inpatient Mental Health Treatment Cooperative. Services. Subject to the maximum Inpatient Mental Covered Services are limited to those Health Care Allowance as set forth above, provided for covered conditions for which, services provided under involuntary commit- in the opinion of the Director of GHC's ment statutes shall be covered at facilities Mental Health Service, or his/her designee, approved by GHC for any court-ordered ob- significant improvement can be expected servation period and/or treatment up to through a short-term treatment program. seventy-two(72)hours.Services for a court- Enrollees who need long-term individual ordered treatment program beyond the psychotherapy or who have conditions that seventy-two(72)hours shall be covered only cannot be treated within the limits of the if determined to be Medically Necessary by benefit described in this section and the the Director of GHC's Mental Health Ser- Dues and Fees Schedule are not covered. vice, or his/her designee. Partial hospitalization programs are covered Coverage for voluntary Emergency in- only under Section H.1. (Inpatient Services) patient mental health services is subject to of this Agreement. Treatment under this the Emergency Care benefit as set forth in Agreement is limited to acute care only. Section X.I., including the twenty-four (24) hour notification and transfer provisions. Excluded are: all forms of extensive psycho- therapy including ongoing care for chronic Payment of bills incurred for non-GHC mental health conditions; day treatment; treatment shall exclude any charges that custodial care;treatment of sexual disorders would otherwise be excluded for hospitaliza- and/or dysfunctions; specialty programs for tion within a GHC Facility, such as mental health therapy which are not telephone, television, and personal items. provided by GHC; court-ordered treatment which is not specifically described above; 2. Outpatient Services: psychological testing,except when provided during the course of mental health treat- Mental health services,limited to the follow- ment;classes or courses such as(a)behavior ing, are provided on an outpatient basis at modification programs, (b) "Parent Effec- GHC. Subject to the limitations set forth in tiveness Training," and (c) adult develop- this section, diagnostic evaluation, brief ment programs,when obtained at non-GHC focal psychotherapy, intermittent care, and facilities;or any other services not specifical- consultation services will be provided in the ly listed as covered in this section.All other following formats:individual,couple,family, provisions, exclusions and limitations under or group. this Agreement also apply. Coverage for each Enrollee is provided ac- I. EMERGENCY CARE cording to the Outpatient Mental Health 0369 Page 21 Z34 1. At a GHC Facility or GHC Designated authorized in advance by a GHC physician or Facility.GHC will cover Emergency care for meets the definition of an Emergency. (See Sec- all Covered Services subject to payment of tion I.) the Copayment set forth in the Allowances, Deductibles, Copayments,and Fees Schedule. 1. Emergency Transport to a GHC Facility or GHC Designated Facility.Each Emergency If two (2) or more members of the Family is covered as set forth in the Allowances, Unit require Emergency care as a result of Deductibles, Copayments,and Fees Schedule. the same accident, only one (1) Emergency Care Copayment will apply. 2. Emergency Transport to a Non-GHC Designated Facility. Each Emergency is If the Enrollee is admitted to a GHC or GHC covered as set forth in the Allowances, De- Designated Facility directly from the emer- ductibles, Copayments,and Fees Schedule. gency room, the Emergency Care Copay- ment is waived. 3. Waiver of Ambulance Services Deductible. If two (2) or more members of the Family 2. At a Non-GHC Designated Facility. Usual, Unit require Emergency ambulance Customary, and Reasonable charges for transport as a result of the same accident, Emergency care for Covered Services are only one (1) Ambulance Deductible will covered subject to: apply. a. payment of the Emergency Deductible The Ambulance Deductible will not apply shown in the Allowances, Deductibles, when ambulance service is authorized in ad- Copayments,and Fees Schedule;and vance by the Cooperative. b. notification of GHC by way of the GHC 4. Transfer to a GHC Facility. When Notification Line within twenty-four authorized in advance by the Cooperative, (24) hours following inpatient admis- an additional Ambulance Allowance is sion,or as soon thereafter as medically provided for transfer to a GHC Facility. possible. K. HOSPICE If two(2)or more members of a Family Unit require emergency care as a result of the It is understood and agreed that the following same accident,only one(1) Emergency De- fully sets forth the eligibility requirements and ductible will apply. Covered Services for an Enrollee who elects to receive services through GHC's Hospice Pro- Outpatient medications prescribed by a non- gram. Enrollees who elect to receive GHC GHC physician are excluded. Hospice Services do so in lieu of curative treat- ment for their terminal illness for the period that 3. Transfer and Follow-up Care.If an Enrollee they are in the GHC Hospice Program. is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Hospice Program Enrollee to a GHC Facility, upon consult- ation with a GHC physician. If the Enrollee 1. Eligibility. Hospice Services, as set forth refuses to transfer to a GHC Facility, all below, shall be provided to Enrollees for as further costs incurred during the hospitaliza- long as the following criteria are met: tion are the responsibility of the Enrollee. a. a GHC physician has determined that Follow-up care which is a direct result of the the Enrollee's illness is terminal and life Emergency must be obtained at GHC, un- expectancy is six(6) months or less; less a GHC physician has authorized such care in advance. b. the Enrollee has chosen a palliative treatment focus (emphasizing comfort J. AMBULANCE SERVICES are covered as set and supportive services rather than forth below, provided that the service is 0369 Page 22 Z34 treatment aimed at curing the supervision of a Registered Nurse. Enrollee's terminal illness); Continuous care is provided for four(4)or more hours per day for c. the Enrollee has elected in writing to a period not to exceed five (5) receive hospice care through GHC's days,or a total of seventy-two(72) Hospice Program; hours, whichever first occurs. Continuous care is covered only d. the Enrollee has available a primary when a GHC physician deter- care person who will be responsible for mines that the Enrollee would the Enrollee's home care; and otherwise require hospitalization e. a GHC physician and GHC's Hospice in an acute care facility. Director determine that the Enrollee's b. Inpatient Hospice Services shall be illness can be appropriately managed in provided in a facility designated by the home. GHC's Hospice Program when Medi- 2. Hospice Care shall be defined as a coor- cally Necessary and authorized in ad- p vance by a GHC physician and GHC's dinated program of palliative and supportive Hospice Program. Inpatient Hospice care for dying persons by an interdisciplinary Services shall be provided according to team of professionals and volunteers center- the provisions set forth in Section X.of ing primarily in the Enrollee's home. this Agreement. 3. Covered Services. Hospice Services may in- 4. Hospice Exclusions:All services not specifi- clude the following as prescribed by a GHC tally listed as covered in this section includ- physician and rendered pursuant to an ap- ing: proved hospice plan of treatment: a. Home Services a. Financial or legal counseling services. i. Intermittent care by a hospice in- b. Housekeeping or meals services. terdisciplinary team which may in- c. Custodial or maintenance care in the clude services by a physician, home or on an inpatient basis. nurse, medical social worker, physical therapist, speech d. Services not specifically listed as therapist, occupational therapist, covered by this Medical Coverage respiratory therapist, and limited Agreement. services by a Home Health Aide under the supervision of a e. Any services provided by members of Registered Nurse. the patient's family. ii. One period of continuous care f. All other exclusions listed in Section service per Enrollee in the XI.,Exclusions and Limitations, of this Enrollee's home when prescribed Medical Coverage Agreement, apply. by a GHC physician,as set forth in this paragraph.A continuous care L. REHABILITATION SERVICES are covered as period is defined as "skilled nurs- set forth in this section, limited to the following: ing care provided in the home physical therapy; occupational therapy; and during a period of crisis in order to speech therapy to restore function following ill- maintain the terminally ill patient ness,injury,or surgery. Services are subject to all at home."Continuous care may be terms, conditions, and limitations of this Agree- provided for pain or symptom ment, including the following: management by a Registered Nurse, Licensed Practical Nurse, 1. All services must be provided at GHC or a or Home Health Aide under the GHC-approved rehabilitation facility and must be prescribed and provided by a GHC- 0369 Page 23 Z34 approved rehabilitation team that may in- tion and improvement of function for clude medical,nursing,physical therapy,oc- neurodevelopmentally disabled children age cupational therapy and speech therapy six(6)and under shall be covered.Coverage providers. includes maintenance of a covered Enrollee in cases where significant deterioration in 2. The Enrollee must be referred for the Enrollee's condition would result rehabilitation services in advance by a GHC without the services. Coverage for inpatient physician. and outpatient services is limited to the al- lowance set forth in the Allowances,Deduct- 3. Services are limited to those necessary to ibles, Copayments,and Fees Schedule. restore or improve functional abilities when physical, sensori-perceptual and/or com- Services excluded under this benefit include: munication impairment exists due to injury specialty rehabilitation programs;long-term or illness. Such services are provided only rehabilitation programs; physical therapy, when GHC's Medical Director, or his/her occupational therapy, and speech therapy designee, determines that significant, services when such services are available measurable improvement to the Enrollee's (whether application is made or not) condition can be expected within a sixty(60) through governmental programs; programs day period as a consequence of intervention offered by public school districts; except as by covered therapy services described in set forth above, therapy for degenerative or paragraph one (1) above. static conditions when the expected out- come is primarily to maintain the Enrollee's 4. Coverage for inpatient and outpatient ser- level of functioning; implementation of vices is limited to the allowances set forth in home maintenance programs; programs for theAllowances,Deductibles,Copayments,and treatment of learning problems; any treat- Fees Schedule. ment not considered Medically Necessary; any services not specifically included as Services excluded under this benefit include covered in this Section;and any services that the following: specialty rehabilitation are excluded under Section XI. programs not provided by GHC; long-term rehabilitation programs; physical therapy, M. SMOKING CESSATION. When provided occupational therapy, and speech therapy through Group Health,services related to smok- services when such services are available ing cessation are covered, limited to: (whether application is made or not) through governmental programs including 1. participation in one individual and/or group programs offered by public school districts; program per calendar year; therapy for degenerative or static conditions when the expected outcome is primarily to 2. educational materials; and maintain the Enrollee's level of functioning (except for neurodevelopmental therapies); 3. one course of nicotine replacement therapy implementation of home maintenance per calendar year, provided the Enrollee is programs; programs for treatment of learn- actively participating in the Group Health ing problems; any other treatment not con- Smoking Cessation Program. sidered Medically Necessary by GHC; any services not specifically included as covered Covered services are subject to the allowances set in this section; and any services that are ex- forth in the Allowances, Deductibles, Copayments, cluded under Section XI. and Fees Schedule. Neurodevelopmental Therapies for Children Age Six (6) and Under. When Section XI. Exclusions and Limitations determined to be Medically Necessary by GHC's Medical Director, or his/her desig- A. EXCLUSIONS nee, physical therapy,occupational therapy, and speech therapy services for the restora- 1. Blood for transfusions. 0369 Page 24 Z34 2. Except as provided in Sections X.B., X.D., 9. Those parts of an examination and associ- X.E., and X.F., corrective appliances and ated reports and immunizations required for artificial aids including: eyeglasses; contact employment, immigration, license, or in- lenses including services related to their fit- surance purposes that are not deemed Medi- ting;prosthetic devices;diabetic supplies in- cally Necessary by GHC for early detection cluding insulin pumps; hearing aids and of disease. examinations in connection therewith;take- home dressings and supplies following 10. Investigational or experimental treatment, hospitalization;or any other supplies,dress- including medical and surgical services, ings, appliances, devices or services which drugs, devices and biological products, until are not for the specific treatment of disease formally approved by GHC for medical cov- or injury,or not specifically listed as covered erage. GHC's determination shall be made under Section X. in accordance with criteria for determining investigational status as established by GHC 3. Cosmetic services, including treatment for as generally outlined below. Specific indica- complications of cosmetic surgery,except as tions and methods of use shall be considered provided in Section X.D. in GHC's review of evidence provided by evaluations of national medical associations, 4. Dental care, surgery, services, and applian- consensus panels, and/or other technologi- ces,including:treatment of accidental injury cal evaluations,including the scientific qual- to natural teeth, reconstructive surgery to ity of such supporting evidence and the jaw incident to denture wear, periodon- rationale.Any investigational or experimen- tal surgery,and any other dental services not tal treatment,including medical and surgical specifically listed as covered under Section services, drugs, devices and biological prod- X. The Cooperative's Medical Director, or ucts not meeting GHC's determination pur- his/her designee,will determine whether the suant to its criteria as outlined below are care or treatment required is within the excluded. category of dental care or service. a. Investigational or experimental drugs, If a GHC physician determines that an unre- devices and biological products until lated medical condition requires that an En- clinical trials have been completed and rollee be hospitalized for a dental procedure approved by the U.S. Food and Drug which is normally done in a dentist's office, Administration (FDA) as being safe GHC will cover associated hospital and and efficacious for general marketing anesthesia costs at a GHC or GHC Desig- and permission has been granted by the nated Facility. GHC will not cover the FDA for commercial distribution; dentist's or oral surgeon's fees. b. there is sufficient scientific evidence in 5. Certain drugs, medicines, and injections. published medical literature to permit (See Section X.F.) Any exclusion of drugs, conclusions concerning the effect of the medicines, and injections, including those treatment on health outcomes; not listed as covered in the GHC Drug For- mulary(approved drug list),will also exclude C. there is conclusive evidence in pub- their administration. lished peer-reviewed medical literature that the treatment will result in a de- 6. Convalescent or custodial care. monstrable benefit for the particular injury,disease or condition in question, 7. Durable medical equipment such as hospital and that the benefits are not out- beds, wheelchairs, and walk-aids, except weighed by the risks; while in the hospital or as set forth in Section X.E. d. evidence that the new treatment is as safe and effective as all existing conven- 8. Services rendered as a result of work-in- tional treatment alternatives; and curred injuries, illness or conditions. 0369 Page 25 Z34 e. that treatment will satisfy (c) and (d) The Enrollee and his or her agents must outside of a research setting. cooperate fully with GHC in its efforts to en- force this exclusion. This cooperation shall in- Appeals regarding denial of coverage must clude supplying GHC with information about be submitted to your regional Consumer any available insurance coverage.The Enrollee Relations Department, or to GHC's Con- and his or her agents shall permit GHC, at tracts and Coverage Department at 1730 GHC's option,to associate with the Enrollee or Minor Avenue, Suite 1910, Seattle, WA to intervene in any actionfiled against anyparty 98101. GHC will respond in writing within related to the injury. The Enrollee and his or twenty (20)working days of the receipt of a her agents shall do nothing to prejudice GHC's fully documented request. right to enforce this exclusion. 11. Nontherapeutic sterilization and proce- GHC shall not enforce this exclusion as to dures and services to reverse a therapeutic coverage available under uninsured motorist or or nontherapeutic sterilization. underinsured motorist coverage until the En- rollee has been made whole,unless the Enrollee 12. See coverage for Pre-existing Conditions fails to cooperate fully with GHC as described under Section X.B. above. In the event the Enrollee fails to 13. Mental health care, exce t as specifically cooperate fully, the Enrollee shall be respon- P P Y sible for reimbursing GHC for such medical provided in Section X.H. expenses. 14. Procedures,services,and supplies related to GHC shall not pay any attorneys'fees or collec- sex transformations. tion costs to attorneys representing the injured 15. Regardless of origin or cause, diagnostic person where it has retained its own legal coun- testin and medical treatment of sterility, sel or acts on its own behalf to represent its g Y interests and unless there is a written fee agree- ment signed by GHC prior to any collection 16. Services of practitioners whose licensing efforts. category is not represented by GHC Medical 19. Services or supplies not specifically listed as Personnel. covered in the Schedule of Benefits. 17. Services directly related to obesity, except 20. See coverage under Section X.B.7. for nutritional counseling provided by GHC staff. 21. The cost of services and supplies resulting 18. An services to the extent bene s are available from an Enrollee's loss of or willful damage y to the Enrollee under the terms of any vehicle, to covered appliances,devices,supplies,andmaterials provided by GHC for the treat- homeowner's, property or other insurance ment of disease,injury, or illness. policy, except for individual or group health insurance,whether the Enrollee asserts a claim 22. Routine circumcision, including newborn or not,pursuant to:(1)medical coverage,medi- circumcision,which is not considered Medi- cal"no fault"coverage,Personal Injury Protec- cally Necessary. tion coverage, or similar medical coverage contained in said policy,and/or(2) uninsured 23. Orthoptic (eye training) therapy. motorist or underinsured motorist coverage contained in said policy.For the purpose of this 24. Specialty treatment programs not provided exclusion,benefits shall be deemed to be"avail- by GHC including weight reduction, able"to the Enrollee if the Enrollee is a named rehabilitation, and behavior modification insured, comes within the policy definition of programs. insured, is a third party donee beneficiary under the terms of the policy,or otherwise has 25. Services required as a result of war,whether the right to receive benefits under the policy. declared or not declared. 0369 Page 26 Z34 B. LIMITATIONS delay or failure to provide or arrange Covered Services to the extent facilities or 1. Conditions and Extent of Coverage. ALL personnel are unavailable due to a major SERVICES AND BENEFITS UNDER disaster or epidemic. THIS AGREEMENT MUST BE PRO- VIDED BY GHC MEDICAL PERSON- 4. Unusual Circumstances.If the provision of NEL AT A GHC FACILITY UNLESS: Covered Services is delayed or rendered im- possible due to unusual circumstances such a. the Enrollee has received a Referral as complete or partial destruction of from a GHC physician; or facilities,military action,civil disorder,labor disputes, or similar causes, GHC shall pro- b. the Enrollee has received Emergency vide or arrange for services that, in the services according to Section X.I. reasonable opinion of GHC's Medical Director, or his/her designee, are emergent 2. Recommended Treatment. The Coopera- or urgently needed. In regard to nonurgent tive's Medical Director or his/her designee and routine services,GHC shall make a good will determine the necessity, nature,and ex- faith effort to provide services through its tent of treatment to be provided in each then-available facilities and personnel.GHC individual case and the judgment, made in shall have the option to defer or reschedule good faith,will be final. services that are not urgent or routine while Enrollees have the right to artici ate in its facilities and services are so affected. In decisions regarding their healthh g p no case shall the Cooperative have any care.An en- liability or obligation on account of delay or rollee may refuse recommended treatment failure to provide or arrange such services. or diagnostic plan to the extent permitted by law.In such case,GHC shall have no further obligation to provide the care in question. Section XII. Claims Enrollees who seek other sources of care because of such a disagreement do so with the full understanding that GHC has no Enrollees must submit claims for reimbursement of obligation for the cost, or liability for the Covered Services to GHC within sixty(60)days of the outcome, of such care. service date, or as soon thereafter as is reasonably possible. In no event, except in the absence of legal 3. Major Disaster or Epidemic.In the event of capacity, shall a claim be accepted later than one (1) a major disaster or epidemic, GHC Medical year from the service date. This section applies to Personnel will provide Covered Services ac- Covered Services received under Section X.I.and X.J., cording to their best judgment, within the or services for which the Enrollee has received a limitations of available facilities and person- Referral from a GHC physician. nel. The Cooperative has no liability for 0369 Page 27 Z34 OGroup Heaith Cooperative 't Puget Sound Medicare Endorsement For Persons Covered by Parts A and B of Medicare THE PROVISIONS OF THE GROUP MEDICAL UNLESS THE ENROLLEE HAS BEEN REFERRED COVERAGE AGREEMENT SHALL REMAIN IN BY GHC OR THE ENROLLEE HAS RECEIVED EFFECT EXCEPT AS MODIFIED BY THE ADDI- EMERGENCY OR URGENTLY NEEDED SER- TION OF THE PROVISIONS,EXCLUSIONS,AND VICES ACCORDING TO SECTION V.D. OF THIS LIMITATIONS CONTAINED IN THIS MEDICARE MEDICARE ENDORSEMENT. ENDORSEMENT. IN NO EVENT SHALL THE BENEFITS UNDER THIS ENDORSEMENT For those enrolled under GHC's Medicare plan,as set DUPLICATE THE BENEFITS UNDER THE forth in this Endorsement,all copayments are waived GROUP MEDICAL COVERAGE AGREEMENT. except the prescription drug copayment. COVERAGE UNDER THE GROUP MEDICAL COVERAGE AGREEMENT IS INTEGRATED This Endorsement does not constitute a Medicare WITH THE MEDICAL AND HOSPITAL BENEFITS supplemental contract. ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED,AND REFERRED Section I. DEFINITIONS TO AS "MEDICARE." THE BENEFITS AND EX- CLUSIONS DESCRIBED IN THIS ENDORSE- CUSTODIAL CARE: Care that is primarily for the MENT APPLY ONLY TO ENROLLEES WHO ARE COVERED UNDER BOTH PART A AND PART B purpose of meeting personal needs and could be OF MEDICARE. provided by persons without professional skills or training. Custodial Care includes help in walking, Except as defined by Federal Regulations, all Enrol- bathing, dressing, eating, and taking medicine. lees entitled to,or eligible to purchase Medicare must EMERGENCY SERVICES (Medicare defined): In- transfer to the GHC Medicare Plan upon such entitle- patient or outpatient services that are rendered ment or eligibility.A condition of enrollment under the immediately by an appropriate non-GHC provider GHC Medicare Plan requires that an Enrollee be continuously enrolled for the hospital (Part A) and because of an injury or sudden illness, and for medical (Part B) benefits available from the Social which the time required to reach GHC or a GHC Security Administration, and sign any papers that may Designated Facility would risk permanent damage be required by GHC or Medicare. For additional in- to the Enrollee's health. formation, the Enrollee may refer to "The Medicare HEALTH CARE FINANCING ADMINISTRATION Handbook." (HCFA): The federal agency that administers the NEITHER GHC NOR MEDICARE MAY PAY FOR Medicare program. SERVICES PROVIDED AT NON-GHC FACILITIES 0369 Page 28 Z34 MEDICARE: The federal health insurance program a non-GHC physician or provider. Expenses are for the aged and disabled. considered Usual, Customary and Reasonable if (1) the charges are consistent with those normally MEDICARE GUIDELINES: Coverage rules and charged by the provider or organization for the policies established by the Health Care Financing same services or supplies; and (2) the charges are Administration (HCFA), a federal agency. within the general range of charges made by other providers in the same geographical area for the MEDICARE HANDBOOK (Titled "The Medicare same services or supplies. Handbook"): A pamphlet published by the U.S. Department of Health and Human Services,Social Security Administration, which provides an easy- Section II. TERMINATION to-read explanation of Medicare benefits. Enrollment under the GHC Medicare Plan for a PERMANENT MOVE: An uninterrupted absence of specific Enrollee, may be terminated in the cir- cumstances set forth below. Area. REFERRAL:A written temporary referral agreement Until such time as an Enrollee's termination of en- authorized in advance b GHC physician, and rollment is effective,neither GHC nor Medicare shall y a p formally approved in advance through GHC's pay for services provided at non-GHC Facilities un- less the Enrollee has been referred by GHC or the Medicare medical coverage approval process,that Enrollee has received Emergency or Urgently Needed entitles an Enrollee to receive Covered Services Services according to Section V.D. of this Medicare from a specified non-GHC health care provider. Endorsement. Entitlement to such services shall not exceed the limits of the Referral and is subject to all terms and A. Termination of Specific Enrollees. conditions of the Referral and this Agreement. 1. Loss of Medicare Part B Entitlement.If the SERVICE AREA: The geographic area comprised of Health Care Financing Administration King,Kitsap,Pierce,Skagit,Snohomish,Thurston, (HCFA) advises GHC that an Enrollee's and Whatcom Counties,and any other areas desig- entitlement to Medicare coverage no longer nated by GHC and approved by the Health Care exists,or the Enrollee voluntarily terminates Financing Administration. (See Service Area Medicare enrollment,enrollment under the Map.) GHC Medicare Plan shall terminate the first of the month as specified by HCFA. SKILLED NURSING FACILITY: A Medicare cer- tified and licensed facility, as defined in Medicare 2. Change of Permanent Residence Outside regulations, primarily engaged in providing skilled GHC's Service Area.If an Enrollee makes a nursing care or rehabilitation and related services Permanent Move as set forth in Section I.of for which Medicare pays benefits or qualifies to this Medicare Endorsement, enrollment receive such approval. shall terminate the first day of the month following the month in which GHC receives URGENTLY NEEDED SERVICES (Medicare notification of such move. defined): Services needed in order to prevent a 3. For Cause. Enrollment may be terminated serious deterioration of the Enrollee's health due upon written notice for: to an unforeseen illness or injurywhile temporarily absent from GHC's Service Area, and which can- a. Knowingly providing fraudulent infor- not be delayed until the Enrollee returns to the mation to obtain coverage. In such Service Area. event, GHC may rescind or cancel en- rollment upon ten (10) working days' USUAL, CUSTOMARY, AND REASONABLE: A written notice. term used to define the level of benefits which are payable by GHC when expenses are incurred from 0369 Page 29 Z34 b. Permitting the use of a GHC identifica- amount required to fully compensate the injured per- tion card by another person. son for the loss sustained. Full compensation shall be measured on an objective, case-by-case basis, but is c. Failure to comply with the rules and subject to a presumption that a settlement which does regulations of GHC including disrup- not exhaust the third parry's reachable assets is full tive, unruly, abusive or uncooperative compensation to the injured person. conduct. Such termination shall be subject to review The injured person and his or her agents must and approval by HCFA_ cooperate fully with GHC in its efforts to collect GHC's medical expenses. This cooperation shall in- B. Persons Hospitalized on the Date of Termina- clude,but is not limited to,supplying GHC with infor- tion.An Enrollee who is a registered bed patient mation about any defendants and/or insurers related receiving Covered Services in a GHC Facility or to the injured person's claim. The injured person and GHC Designated Facility on the date of termina- his or her agents shall permit GHC, at GHC's option, tion shall continue to receive covered inpatient to associate with the injured party or to intervene in services, until discharge from the facility. This any action filed against any third party. The injured continued coverage will also apply to an Enrollee person and his or her agents shall do nothing to hospitalized in a Medicare-certified non-GHC prejudice GHC's subrogation rights. The injured per- Designated Facility as a result of Emergency or son shall not settle a claim without protecting GHC's Urgently Needed Services or Referral as set forth interest. in Section VI.B. of this Medicare Endorsement. GHC shall not pay any attorney's fees or collection C. Services Provided After Termination. Any ser- costs to attorneys representing the injured person vices provided by GHC after the effective date of where it has retained its own legal counsel or acts on termination(except those services covered under its own behalf to represent its interests and unless Section II.B.of this Medicare Endorsement)shall there is a written fee agreement signed by GHC prior be charged according to the Directory of Services. to any collection efforts. When reasonable collection The Subscriber shall be liable for payment of all costs have been incurred, with GHC's prior written such charges for services provided to the Sub- agreement,to recover GHC's medical expenses,there scriber and all Family Dependents. shall be an equitable apportionment of such collection costs between GHC and the injured person subject to Section III. SUBROGATION a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. "Injured person"under this section means an Enrollee covered by this Agreement who sustains compensable This provision does not apply to occupationally in- injury. "GHC's medical expense" means the expense curred disease, sickness, and/or injury. incurred by GHC for the care or treatment of the injury sustained. Section IV. GRIEVANCE PROCEDURES If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability A. GHC Consumer Relations Program. against the third party, GHC shall have the right to The Consumer Relations Program is designed to recover its cost of providing benefits to the injured help an Enrollee resolve formal complaints and person (subrogation) from the third party as set forth concerns about medical and business service. in this Agreement and in compliance with Medicare GHC will record,research,and respond in a time- regulations and guidelines. GHC shall be subrogated ly manner to an Enrollee's concern. A concern to and may enforce all rights of the injured person to should be registered initially at the Enrollee's the extent of its medical expense.After Medicare laws area medical center.If not satisfied,the Enrollee and regulations mandating recovery of Medicare pay- should then contact the regional Consumer Rela- ments have been satisfied, the Cooperative's right of tions Department, which will arrange for review subrogation shall be limited to the excess of the 0369 Page 30 Z34 by appropriate medical staff,management and/or hospice services as provided under the Medicare GHC consumers. Hospice Program. Enrollees who elect to receive hospice services do so in lieu of curative treat- B. Reconsideration of Claims. ment for their terminal illness for the period that they are in the hospice program. To receive If GHC denies a request for payment of a claim, hospice services,the Enrollee is required to sign or declines to provide services which the Enrollee the Hospice Election Form. believes should be provided,the Enrollee may file a request for reconsideration with GHC or a So- Covered Services. In addition to the hospice ser- cial Security Administration office. The request vices provided under the Group Medical must be filed in writing within sixty (60) days of Coverage Agreement, the following hospice ser- GHC's written notice of denial unless an exten- vices shall be provided: sion is specifically approved. If GHC does not overturn the denial in full, it will be referred by 1. Home Services GHC to the Health Care Financing Administra- tion for reconsideration. Continuous care services per Enrollee in the Enrollee's home when prescribed by a GHC physician,as set forth in this paragraph.Con- Section V. SCHEDULE OF BENEFITS tinuous care is defined as "skilled nursing care provided in the home during a period of All benefits and services listed in this Schedule of crisis in order to maintain the terminally ill Benefits: patient at home." Continuous care may be provided for pain or symptom management • are subject to all provisions of this Agree- by a Registered Nurse, Licensed Practical ment and Medicare Endorsement; Nurse, or Home Health Aide under the su- pervision of a Registered Nurse.Continuous • must be approved in advance by GHC except care may be provided up to twenty-four(24) for Emergency and Urgently Needed Ser- hours per day during periods of crisis. Con- vices as set forth in Section V.D. of this tinuous care is covered only when a GHC Medicare Endorsement; and physician determines that the Enrollee otherwise would require hospitalization in • must meet Medicare guidelines and limita- an acute care facility. tions unless otherwise specified. 2. Inpatient Hospice Services for short-term GHC covers all Medicare deductibles and coin- care shall be provided through a Medicare- surance. The booklet, "The Medicare Handbook" certified Hospice Program when Medically provides additional information about Medicare Necessary, and authorized in advance by a benefits. GHC physician. Respite care is covered for a maximum of five (5) consecutive days per A. Skilled Nursing Facility.Upon Referral and fol- occurrence in order to continue care for the lowing a Medicare-certified three(3)day hospital Enrollee in the temporary absence of the stay,GHC will cover up to one hundred(100)days Enrollee's primary care-giver(s). of care in a Skilled Nursing Facility,in accordance with Medicare Guidelines, when Medically 3. Other hospice services may include the fol- Necessary, as determined by GHC's Medical lowing: Director,or his/her designee. a. drugs and biologicals that are used B. Hospice. primarily for the relief of pain and symptom management; Enrollees with Part A and Part B of Medicare who elect to receive Medicare-covered hospice ser- b. medical appliances and supplies pri- vices may select any Medicare-certified hospice marily for the relief of pain and symp- program. Enrollees who elect to receive services tom management; from the GHC Hospice Program are entitled to 0369 Page 31 Z34 c. counseling services for the Enrollee charges when required to replace the natural and his/her primary care-giver(s); and lens of the eye.Covered eyeglasses and con- tact lenses must be dispensed through GHC d. bereavement counseling services for Facilities. Replacements will be provided the family. when needed due to change in the Enrollee's medical condition or when deemed ap- C. Mental Health Care, Alcoholism and Drug propriate by a GHC physician. Abuse Treatment Services. 3. Blood, blood derivatives, and their ad- 1. Outpatient mental health, alcoholism and ministration. substance abuse treatment services are covered for each Enrollee in accordance 4. Maternity and pregnancy-related services, with Medicare Guidelines. including visits before and after birth; in- voluntary termination of pregnancy; and 2. Inpatient mental health care services are care for any other complication of pregnan- covered in full up to a 190-day lifetime cy. benefit when such services are provided in a Medicare-certified mental health facility. 5. Organ transplants, limited to heart, kidney, cornea,bone marrow,and liver,when estab- Inpatient alcoholism and drug abuse treat- lished criteria are met. ment services are covered in full when such services are provided in a hospital-based 6. Physician calls (including consultations and treatment center. second opinions by a GHC physician)in the hospital, office, home, Skilled Nursing 3. Coverage for Medical Emergencies incident Facility, nursing home,or convalescent cen- to alcoholism and drug abuse or for acute ter. alcoholism or drug abuse, including acute detoxification,is provided as set forth in Sec- 7. Restorative physical, occupational, and tion V.D. of this Medicare Endorsement. speech therapy following illness, injury, or D. Emergency/Urgently Needed Services. When an surgery. Emergency meets the Medicare definition for 8. Immunizations and vaccinations that are Emergency or Urgently Needed Services as listed as covered in the GHC Drug Formu- defined in Section I. of this Medicare Endorse- lary (approved drug list) or approved by ment,services are covered in full. Medicare. E. Medicare Ambulance Benefit. Medically Neces- 9. Services related to dysfunction of the jaw. sary ambulance transportation to or from a hospi- When Referred by a GHC physician,evalua- tal or Skilled Nursing Facility is covered in full tion and treatment by a GHC-approved tem- only if transportation by any other vehicle could poromandibular joint (TMJ)care provider. endanger the patient's health and the ambulance, equipment, and personnel meet Medicare re- All TMJ appliances,other than the occlusal quirements. splint and its fitting, are excluded. F. Medical and Surgical Care.The following medi- Treatment of jaw dysfunction, including cal and surgical services are covered when TMJ dysfunction, will NOT be provided prescribed by GHC Medical Personnel and when the dysfunction is related to maloc- Medicare requirements are met: clusion or when TMJ services are needed due to dental work performed.All such ser- f. Eye examinations and treatment for eye vices and related hospitalization, including pathology. orthodontic therapy and orthognathic (jaw) surgery, are excluded regardless of origin or 2. One pair of eyeglasses or contact lenses, cause. including examination and fitting, following cataract surgery,are covered subject to UCR 0369 Page 32 Z34 (See Section X.B.12. of Group Medical b. provided by GHC Community Health Coverage Agreement for Covered Services Services or by a GHC-approved agency; not meeting Medicare Guidelines). and 10. Chiropractic care limited to spinal manipula- c. that the Enrollee has incurred no less tions. Excluded are any other diagnostic or than the equivalent of$6,870.00 in ex- therapeutic services, including x-rays, fur- penses for Medicare Part B Covered nished by a chiropractor. Enrollees must Services during the calendar year in receive all chiropractic services from GHC- which respite benefits are to be designated licensed practitioners in order to provided. be covered. A list of GHC-designated licensed practitioners is available by contact- 2. Covered Services.Covered respite care Ber- ing any GHC area medical center. vices are provided up to a maximum of eighty (80) hours for the twelve(12)month period 11. Podiatric care. Excluded is treatment of flat following the date all eligibility requirements feet or other misalignments of the feet; are met.Covered respite services are limited removal of corns and calluses; and routine to the following: foot care such as hygienic care,except in the presence of a nonrelated medical condition a. Services of a homemaker or home affecting the lower limbs. Enrollees who health aide; receive their primary care in portions of the GHC Service Area where GHC designated b. Personal care services; and licensed practitioners are available must util- c. Nursing care provided by a licensed ize GHC s designated providers in order to professional nurse. be covered. 12. Home intravenous (IV) drug therapy ser- "Chronically dependent persons" under this sec- vices. tion means persons who live with a voluntary care-giver;are dependent upon the care-giver for G. Prosthetic Devices, such as cardiac devices, in- assistance with at least two activities of daily traocular lenses, artificial joints, breast pros- living, such as eating, bathing, dressing, toileting, theses, artificial eyes, and braces, are covered. or transferring in and out of a bed or chair; and Excluded are: orthopedic shoes unless they are who meet the eligibility requirements described part of leg braces; dental plates or other dental above. devices; and experimental devices. H. Medical/Surgical Supplies,such as casts,splints, Section VI. EXCLUSIONS AND post-surgical dressings, and ostomy supplies, are LIMITATIONS covered. 1. Rental or Purchase of Durable Medical Equip- A. Exclusions. ment, such as oxygen and oxygen equipment, 1. Investigational procedures, including medi- wheelchairs and other walk-aids, and hospital cal and surgical services, drugs and devices beds, is covered. until formally approved by Medicare unless J. Respite Care. specifically provided herein (See Section XI.A.10. in the Group Medical Coverage 1. Eligibility. Respite care is provided to Agreement). chronically dependent persons for reason- 2. Supportive devices for the feet. able and necessary in-home services, provided that such services are: 3. Services directly related to obesity except as a. authorized in advance by a GHC phys- provided by Medicare. ician; 0369 Page 33 Z34 4. Services or supplies not specifically listed as providers other than Group Health Cooperative covered by Medicare or GHC. should be sent to: Medicare Claims, Group Health Cooperative of Puget Sound. If you must receive B. Limitations. Emergency or Urgently Needed Services from a non- Conditions and Extent of Coverage. EXCEPT GHC provider, be sure to show your GHC I.D. card AS PROVIDED IN SECTIONS V.F.10. AND and your red,white, and blue Medicare card. V.F.11., ALL SERVICES AND BENEFITS A. The Enrollee must file claims for services UNDER THIS AGREEMENT MUST BE rendered during the first nine (9) months of a PROVIDED BY GHC MEDICAL PERSON- calendar year by December 31 of the following NEL AT A GHC OR GHC DESIGNATED calendar year. FACILITY UNLESS: 1. the Enrollee has received a Referral from B. The Enrollee must file claims for services GHC, including formal advance approval rendered in the last three(3)months of a calendar through GHC's Medicare medical coverage year the same as if the services had been furnished approval process,or in the subsequent calendar year.The time limit on filing claims for services furnished in the last three 2. the Enrollee has received Emergency or Ur- (3) months of the calendar year is December 31 gently Needed Services as defined in Section of the second calendar year following the calen- I. and as set forth in Section V.D. of this dar year in which the services were rendered. Medicare Endorsement. See"The Medicare Handbook"for additional in- formation regarding filing claims. Section VII. CLAIMS PROCEDURE GHC may obtain information which it deems necessary concerning the medical care and Claims for services or supplies and explanation of hospitalization for which payment is requested. Medicare benefits for services or supplies from 0369 Page 34 Z34 Group Health Cooperative of Puget Sound Medicare Endorsement For Persons Covered by Part B only of Medicare THE PROVISIONS OF THE GROUP MEDICAL EMERGENCY OR URGENTLY NEEDED SER- COVERAGE AGREEMENT SHALL REMAIN IN VICES ACCORDING TO SECTION V.C. OF THIS EFFECT EXCEPT AS MODIFIED BY THE ADDI- MEDICARE ENDORSEMENT. TION OF THE PROVISIONS, EXCLUSIONS AND LIMITATIONS CONTAINED IN THIS MEDICARE For those enrolled under GHC's Medicare plan,as set ENDORSEMENT. IN NO EVENT SHALL THE forth in this Endorsement,all copayments are waived BENEFITS UNDER THIS ENDORSEMENT except the prescription drug copayment. DUPLICATE THE BENEFITS UNDER THE GROUP MEDICAL COVERAGE AGREEMENT. This Endorsement does not constitute a Medicare COVERAGE UNDER THE GROUP MEDICAL supplemental contract. COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL BENEFITS ESTABLISHED Section I. DEFINITIONS BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED, AND REFERRED TO AS "MEDI- CUSTODIAL CARE: Care that is primarily for the DESCRIBED IN THIS ENDORSEMENT APPLY purpose of meeting personal needs and could be ONLY TO ENROLLEES WHO ARE COVERED provided by persons without professional skills or UNDER PART B ONLY OF MEDICARE. training. Custodial Care includes help in walking, bathing, dressing,eating, and taking medicine. Except as defined by Federal Regulations, all Enrol- EMERGENCY SERVICES (Medicare defined): lees entitled to,or eligible to purchase Medicare must Medicare Part B services that are rendered imme- transfer to the GHC Medicare Plan upon such entitle- diately by an appropriate non-GHC provider Be- ment or eligibility.A condition of enrollment under the cause of an injury or sudden illness, and for which GHC Medicare Plan requires that an Enrollee be the time required to reach GHC or a GHC Desig- continuously enrolled for medical (Part B) benefits nated Facility would risk permanent damage to the available from the Social Security Administration,and Enrollee's health. sign any papers that may be required by GHC or Medicare. For additional information, the Enrollee HEALTH CARE FINANCING ADMINISTRATION may refer to "The Medicare Handbook." (HCFA): The federal agency that administers the NEITHER GHC NOR MEDICARE MAY PAY FOR Medicare program. SERVICES PROVIDED AT NON-GHC FACILITIES MEDICARE: The federal health insurance program UNLESS THE ENROLLEE HAS BEEN REFERRED for the aged and disabled. BY GHC OR THE ENROLLEE HAS RECEIVED 0369 Page 35 Z34 MEDICARE GUIDELINES: Coverage rules and Section II. TERMINATION policies established by the Health Care Financing Administration (HCFA), a federal agency. Enrollment under the GHC Medicare Plan for a MEDICARE HANDBOOK (Titled The Medicare specific Enrollee, may be terminated in the cir- Handbook"): A pamphlet published by the U.S. cumstances set forth below. Department of Health and Human Services,Social Until such time as an Enrollee's termination of en- Security Administration, which provides an easy- rollment is effective,neither GHC nor Medicare shall to-read explanation of Medicare benefits. pay for services provided at non-GHC Facilities un- PERMANENT MOVE: An uninterrupted absence of less the Enrollee has been referred by GHC or the more than ninety (90) days from GHC's Service Enrollee has received Emergency or Urgently Needed Area. Services according to Section V.C. of this Medicare Endorsement. REFERRAL:A written temporary referral agreement authorized in advance by a GHC physician, and A. Termination of Specific Enrollees. formally approved in advance through GHC's 1. Loss of Part B Medicare Entitlement.If the Medicare medical coverage approval process,that Health Care Financing Administration entitles an Enrollee to receive Covered Services (HCFA) advises GHC that an Enrollee's from a specified non-GHC health care provider. entitlement to Medicare coverage no longer Entitlement to such services shall not exceed the exists,or the Enrollee voluntarily terminates limits of the Referral and is subject to all terms and Medicare Part B enrollment, enrollment conditions of the Referral and this Agreement. under the GHC Medicare Plan shall ter- minate SERVICE AREA: The geographic area comprised of HCFA.the first of the month as specified by King,Kitsap,Pierce,Skagit,Snohomish,Thurston, and Whatcom Counties,and any other areas desig- 2. Change of Permanent Residence Outside nated by GHC and approved by the Health Care GHC's Service Area.If an Enrollee makes a Financing Administration. (See Service Area Permanent Move as set forth in Section I.of Map.) this Medicare Endorsement, enrollment shall terminate the first day of the month URGENTLY NEEDED SERVICES (Medicare following the month in which GHC receives defined):Medicare Part B services needed in order notification of such move. to prevent a serious deterioration of the Enrollee's health due to an unforeseen illness or injury while 3. For Cause. Enrollment may be terminated temporarily absent from GHC's Service Area,and upon written notice for: which cannot be delayed until the Enrollee returns a. Knowingly providing fraudulent infor- to the Service Area. mation to obtain coverage. In such USUAL, CUSTOMARY, AND REASONABLE: A event, GHC may rescind or cancel en- term used to define the level of benefits which are rollment upon ten (10) working days' written notice. payable by GHC when expenses are incurred from a non-GHC physician or provider. Expenses are b. Permitting the use of a GHC identifica- considered Usual, Customary and Reasonable if tion card by another person. (1) the charges are consistent with those normally charged by the provider or organization for the C. Failure to comply with the rules and same services or supplies; and (2) the charges are regulations of GHC including disrup- within the general range of charges made by other tive, unruly, abusive or uncooperative providers in the same geographical area for the conduct. same services or supplies. Such termination shall be subject to review and approval by HCFA. 0369 Page 36 Z34 Section III. SUBROGATION 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. "Injured person"under this section means an Enrollee covered by this Agreement who sustains compensable This provision does not apply to occupationally in- injury. "GHC's medical expense" means the expense curred disease,sickness, and/or injury. incurred by GHC for the care or treatment of the injury sustained. Section IV. GRIEVANCE PROCEDURES If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability A. GHC Consumer Relations Program. against the third party, GHC shall have the right to recover its cost of providing benefits to the injured The Consumer Relations Program is designed to person (subrogation) from the third party as set forth help an Enrollee resolve formal complaints and in this Agreement and in compliance with Medicare concerns about medical and business service. regulations and guidelines. GHC shall be subrogated GHC will record,research,and respond in a time- to and may enforce all rights of the injured person to ly manner to an Enrollee's concern. A concern the extent of its medical expense.After Medicare laws should be registered initially at the Enrollee's and regulations mandating recovery of Medicare pay- area medical center.If not satisfied,the Enrollee ments have been satisfied, the Cooperative's right of should then contact the regional Consumer Rela- subrogation shall be limited to the excess of the tions Department, which will arrange for review amount required to fully compensate the injured per- by appropriate medical staff,management and/or son for the loss sustained. Full compensation shall be GHC consumers. measured on an objective, case-by-case basis, but is B. Reconsideration of Claims. subject to a presumption that a settlement which does not exhaust the third party's reachable assets is full If GHC denies a request for payment of a claim, compensation to the injured person. or declines to provide services which the Enrollee believes should be provided,the Enrollee may file The injured person and his or her agents must a request for reconsideration with GHC or a So- cooperate fully with GHC in its efforts to collect cial Security Administration office. The request GHC's medical expenses. This cooperation shall in- must be filed in writing within sixty (60) days of clude,but is not limited to,supplying GHC with infor- GHC's written notice of denial unless an exten- mation about any defendants and/or insurers related sion is specifically approved. If GHC does not to the injured person's claim. The injured person and overturn the denial in full, it will be referred by his or her agents shall permit GHC, at GHC's option, GHC to the Health Care Financing Administra- to associate with the injured party or to intervene in tion for reconsideration. any action filed against any third party. The injured person and his or her agents shall do nothing to Section V. SCHEDULE OF BENEFITS prejudice GHC's subrogation rights. The injured per- son shall not settle a claim without protecting GHC's interest. All benefits and services listed in this Schedule of Benefits: GHC shall not pay any attorney's fees or collection are subject to all provisions of this Agree- costs to attorneys representing the injured person ment and Medicare Endorsement; where it has retained its own legal counsel or acts on its own behalf to represent its interests and unless • must be approved in advance by GHC except there is a written fee agreement signed by GHC prior for Emergency and Urgently Needed Ser- to any collection efforts. When reasonable collection vices as set forth in Section V.C. of this costs have been incurred, with GHC's prior written Medicare Endorsement; and agreement,to recover GHC's medical expenses,there shall be an equitable apportionment of such collection 0369 Page 37 Z34 • must meet Medicare guidelines and limita- the temporary absence of the Enrollee's tions unless otherwise specified. primary care-giver(s). GHC covers all Medicare deductibles and coin- 3. Other hospice services may include the fol- surance. The booklet, "The Medicare Handbook" lowing: provides additional information about Medicare benefits. a. drugs and biologicals that are used primarily for the relief of pain and A. Hospice. symptom management; It is understood and agreed that the following b. medical appliances and supplies fully sets forth Covered Services for an Enrollee primarily for the relief of pain and with Part B Medicare only who elects to receive symptom management; hospice services. Enrollees who elect to receive hospice services do so in lieu of curative treat- c. counseling services for the Enrollee ment for their terminal illness for the period that and his/her primary care-giver(s); and they are in the hospice program. To receive d. bereavement counseling services for hospice services,the Enrollee is required to sign the family. the Hospice Election Form. y' Covered Services. Hospice services may include B. Outpatient Mental Health Care,Alcoholism and the following as prescribed by a GHC physician Drug Abuse Treatment Services are covered for and rendered pursuant to an approved hospice each Enrollee in accordance with Medicare plan of treatment: Guidelines. 1. Home Services C. Outpatient Emergency/Urgently Needed Ser- vices. When an Emergency meets the Medicare Continuous care services per Enrollee in the definition for Emergency or Urgently Needed Enrollee's home when prescribed by a GHC Services as defined in Section I.of this Medicare physician,as set forth in this paragraph.Con- Endorsement,services are covered in full. tinuous care is defined as "skilled nursing D. Medicare Ambulance Benefit. Medically Neces- care provided in the home during a period of sary ambulance transportation to or from a hospi- crisis in order to maintain the terminally ill tal or Skilled Nursing Facilityis covered in full patient at home." Continuous care may be only if transportation by any other vehicle could provided for pain or symptom management endanger the patient's health and the ambulance, by a Registered Nurse, Licensed Practical equipment, and personnel meet Medicare re- Nurse, or Home Health Aide under the su- quirements. pervision of a Registered Nurse.Continuous care may be provided up to twenty-four(24) E. Medical and Surgical Care.The following medi- hours per day during periods of crisis. Con- cal and surgical services are covered when tinuous care is covered only when a GHC prescribed by GHC Medical Personnel and physician determines that the Enrollee Medicare requirements are met: otherwise would require hospitalization in an acute care facility. 1. Eye examinations and treatment for eye 2. Inpatient Hospice Services for short-term pathology. care shall be provided in a facility designated 2. One pair of eyeglasses or contact lenses, by GHC's Hospice Program when Medically including examination and fitting, following Necessary and authorized in advance by a cataract surgery,are covered subject to UCR GHC physician and GHC's Hospice Pro- charges when required to replace the natural gram.Respite care is covered for a maximum lens of the eye.Covered eyeglasses and con- of five (5) consecutive days per occurrence tact lenses must be dispensed through GHC in order to continue care for the Enrollee in Facilities. Replacements will be provided when needed due to change in the Enrollee's 0369 Page 38 Z34 medical condition or when deemed ap- therapeutic services, including x-rays, fur- propriate by a GHC physician. nished by a chiropractor. Enrollees must receive all chiropractic services from GHC- 3. Blood, blood derivatives, and their ad- designated licensed practitioners in order to ministration. be covered. A list of GHC-designated licensed practitioners is available by contact- 4. Maternity and pregnancy-related services, ing any GHC area medical center. including visits before and after birth; in- voluntary termination of pregnancy; and 11. Podiatric care. Excluded is treatment of flat care for any other complication of pregnan- feet or other misalignments of the feet; cy. removal of corns and calluses; and routine foot care such as hygienic care,except in the 5. Organ transplants, limited to heart, kidney, presence of a nonrelated medical condition cornea,bone marrow,and liver,when estab- affecting the lower limbs. Enrollees who lished criteria are met. receive their primary care in portions of the GHC Service Area where GHC designated 6. Physician calls (including consultations and licensed practitioners are available must util- second opinions by a GHC physician)in the ize GHC's designated providers in order to hospital, office, home, Skilled Nursing be covered. Facility,nursing home,or convalescent cen- ter. 12. Home intravenous (IV) drug therapy ser- vices. 7. Restorative physical, occupational, and speech therapy following illness, injury, or F. Prosthetic Devices, such as cardiac devices, in- surgery. traocular lenses, artificial joints, breast pros- 8. Immunizations and vaccinations that are theses, artificial eyes, and braces, are covered. Excluded are: orthopedic shoes unless they are listed as covered in the GHC Drug For- part of leg braces; dental plates or other dental mulary (approved drug list) or approved by devices; and experimental devices. Medicare. 9. Services related to dysfunction of the jaw. G. Medical/Surgical Supplies,such as casts,splints, Y J When Referred by a GHC physician,evalua- post-surgical dressings, and ostomy supplies, are covered, tion and treatment by a GHC-approved tem- poromandibular joint (TMJ)care provider. H. Rental or Purchase of Durable Medical Equip- ment, such as oxygen and oxygen equipment, All TMJ appliances,other than the occlusal wheelchairs and other walk-aids, and hospital splint and its fitting, are excluded. beds, is covered. Treatment of jaw dysfunction, including I. Respite Care. TMJ dysfunction, will NOT be provided when the dysfunction is related to maloc- L Eligibility. Respite care is provided to clusion or when TMJ services are needed chronically dependent persons for due to dental work performed.All such ser- reasonable and necessary in-home services, vices and related hospitalization, including provided that such services are: orthodontic therapy and orthognathic (jaw) surgery, are excluded regardless of origin or a. authorized in advance by a GHC cause. physician; (See Section X.B.12 of the Group Medical b. provided by GHC Community Health Coverage Agreement for Covered Services Services or by a GHC-approved agency; not meeting Medicare Guidelines). and 10. Chiropractic care limited to spinal manipula- C. that the Enrollee has incurred no less tions. Excluded are any other diagnostic or than the equivalent of$6,870.00 in ex- 0369 Page 39 Z34 penses for Medicare Part B Covered Conditions and Extent of Coverage. EXCEPT Services during the calendar year in AS PROVIDED IN SECTIONS V.E.10. AND which respite benefits are to be V.E.11., ALL SERVICES AND BENEFITS provided. UNDER THIS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL PERSON- 2. Covered Services.Covered respite care ser- NEL AT A GHC OR GHC DESIGNATED vices are provided up to a maximum of eighty FACILITY UNLESS: (80) hours for the twelve(12)month period following the date all eligibility requirements 1. the Enrollee has received a Referral from are met.Covered respite services are limited GHC, including formal advance approval to the following: through GHC's Medicare medical coverage approval process,or a. Services of a homemaker or home health aide; 2. the Enrollee has received outpatient Emer- gency or Urgently Needed Services as b. Personal care services; and defined in Section I. and as set forth in Sec- tion V.C.of this Medicare Endorsement. c. Nursing care provided by a licensed professional nurse. Section VII. CLAIMS PROCEDURE "Chronically dependent persons" under this sec- tion means persons who live with a voluntary Claims for services or supplies and explanation of care-giver;are dependent upon the care-giver for Medicare benefits for services or supplies from assistance with at least two activities of daily providers other than Group Health Cooperative living, such as eating,bathing, dressing, toileting, or transferring in and out of a bed or chair; and should be sent to: Medicare Claims, Group Health who meet the eligibility requirements described Cooperative of Puget Sound. If you must receive above. Emergency or Urgently Needed Services from a non- GHC provider, be sure to show your GHC I.D. card Section VI. EXCLUSIONS AND and your red,white, and blue Medicare card. LIMITATIONS A. The Enrollee must file claims for services rendered during the first nine (9) months of a A. Exclusions. calendar year by December 31 of the following calendar year. 1. Investigational procedures, including medi- B. The Enrollee must file claims for services cal and surgical services, drugs and devices rendered in the last three(3)months of a calendar until formally approved by Medicare unless year the same as if the services had been furnished specifically provided herein (See Section in the subsequent calendar year.The time limit on XI.A.10. in the Group Medical Coverage filing claims for services furnished in the last three Agreement). (3) months of the calendar year is December 31 2. Supportive devices for the feet. of the second calendar year following the calen- dar year in which the services were rendered. 3. Services directly related to obesity except as See"The Medicare Handbook"for additional in- provided by Medicare. formation regarding filing claims. 4. Services or supplies not specifically listed as GHC may obtain information which it deems covered by Medicare or GHC. necessary concerning the medical care and B. Limitations. hospitalization for which payment is requested. 0369 Page 40 Z34 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. BENEFIT ALLOWANCES/DEDUCTIBLES/COPAYMENTS/FEES Stop Total out-of-pocket Copayment expenses for Limited to an aggregate maximum of$750 per Emergency care at a GHC or GHC Designated Enrollee and$1,500 per family per calendar year Facility Mental Health Care • Outpatient Services First ten (10)visits at GHC covered in full; ten (10) additional visits covered at 50% per calendar year; no coverage after twenty(20) visits per calendar year. • Inpatient Services Coverage allowance up to 7 days at 80% per Enrollee 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 Enrollee per any 24 consecutive calendar month period for outpatient and inpatient services combined • Lifetime Maximum Benefit $10,000 per Enrollee Emergency Care • At a GHC or GHC Designated Facility $25 Copayment per Emergency visit per Enrollee. Copayment is waived if Enrollee is admitted directly from the Emergency department. 0369 Page 41 Z34 • At a non-GHC Designated Facility $100 Deductible per Emergency visit per Enrollee. Emergency Deductible does not apply to Stop Loss. Ambulance Services $1,000 Allowance per Emergency transport per Enrollee • To a GHC or GHC Designated Facility No Copayment • To a non-GHC Designated Facility $50 Deductible per Emergency transport per Enrollee.Ambulance Deductible does not apply to Stop Loss. Additional$1,000 transfer Allowance per Enrollee • Transfer to a GHC or GHC Designated No Copayment Facility Rehabilitation Services • Inpatient physical, occupational and Covered up to 60 days per condition per restorative speech therapy services calendar year 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 Covered up to 60 visits per condition per restorative speech therapy services calendar year combined, including services for neurodevelopmentally disabled children age six(6) and under Orthopedic Appliances Orthopedic appliances when prescribed by a Covered Services are subject to a 50% GHC physician and listed as covered in the Coinsurance. Coinsurance amount does not Orthopedic Appliance Formulary apply to Stop Loss. 0369 Page 42 Z34 Nasal CPAP Device Nasal CPAP device,when Medically Necessary Covered Services are subject to a 50% and authorized in advance by GHC Coinsurance. Coinsurance amount does not apply to Stop Loss. Post-Mastectomy Bras Covered Services are subject to a 50% Coinsurance. Coinsurance amount does not apply to Stop Loss. Temporomandibular Joint (TMI) Services Inpatient and outpatient TMJ services when $1,000 maximum per Enrollee per calendar year Medically Necessary and authorized by GHC Lifetime Maximum Benefit $5,000 per Enrollee Smoking Cessation • Individual/Group Sessions Covered at 50% of the total charges. Coinsurance amount does not apply to Stop Loss. • Nicotine replacement therapy Covered when provided at GHC facilities and prescribed by a GHC physician. Skilled Nursing Facility Care in a GHC-approved skilled nursing facility Coverage allowance up to thirty(30)days per condition per Enrollee 0369 Page 43 Z34 PA-754-Basic Agreement CA-174-Medicare A& B CA-175 -Medicare B Only PA-1117-Service Area Map CA-7-ER Copay CA-66-M&A CA-18-Pec(0) CA-210-Inpt MH-O CA-61 -SN-A 0369 Page 44 Z34 Health Cooperative Dues Schedule of Puget Sound For attachment to Group Medical Coverage Agreement with: CITY OF KENT GROUP # 0369 This schedule reflects Group Health Cooperative monthly dues effective January 1, 1994 and guaranteed to January 1, 1995. MONTHLY HEALTH CARE DUES Subscriberonly.......................................................................................... $160.94 per month Subscriber and spouse.............................................................................. $360.09 per month Subscriber and child(ren)........................................................................... $324.58 per month Subscriber and family................................................................................. $515.50 per month Spouseonly ............................................................................. $199.15 per month ) Y Child ren only ........................................................... $163.64 per month ( .................................Spouse and children................................................................................. $354.56 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. WashD hIeHIV1 Cooperative Group Health Service AreaK� o, s ,L:♦ ................ Legend \ as `�va.',\�`'•,,,�-. .`•�..\� \`\.\\r,+:�•�\\\\�4\\'�+.@,>�v'�'\�\fit\\\,:�.�i '•?'��.. 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Area of Detail 9liealth ►► COOp@��IVG Facilities �► Group Health Medical Northshore Medical Center Snohomish County Group Health 11913 N.E. 195th St. New Medical Center to open Designated and Specialty Centers Bothell,WA 98011 (206)489 3100 July 1994: Facilities Kin Count Group Health Everett Medical Center g y 2930 Maple St. Burien Medical Center Rainier Medical Center Everett,WA 98201 Anacortes 140 S.W. 146th St. 5316 Rainier Ave.S. Island Hospital Seattle,WA 98166 Seattle, - Everett Medical Center 1211 24th St. (206)433-2900 (206)7215600 14 E.Casino Rd. Anacortes,WA 98221 Renton Medical Center Everett,WA 98208 (206)293-3181 Capitol Hill Family Health Center 275 Bronson Way N.E. (206)347-7800 122 16th Ave.E. (Relocating to new Medical Center Bellingham Seattle,WA 98112 Renton,WA 98056 July 1994) (206)235'2800 St.Joseph Hospital (206)326-3454 2901 Squalicum Parkway University Medical Center Lynnwood Medical Center Bellingham,WA 98225 The Care Center at Kelsey Creek 4225 Roosevelt Way N.E., 20200 Lynnwood, Ave.W. (206)734-5400 fourth floor 2210 132nd Ave.S.E. Lynnwood,WA 98036 Bellevue,WA 98005 Seattle,W 98105 (206)672.6822 St.Joseph Hospital S A (206)957-2400 206)634 98 South Campus North Everett Satellite 809 E.Chestnut St. Central Medical Center South 1410 Broadway Bellingham,WA 98225 125 16th Ave.E. Kitsap County Everett,WA 98201 (206)734-8300 Seattle,WA 98112 Bainbridge Island Medical Center (206)388-4000 (206)326.3000 621 High School Rd.N.W. (Relocating to new Medical Center Bremerton Bainbridge Island,WA 98110 July 1994) Harrison Memorial Hospital Downtown Seattle Medical Center (206)842-9911 2520 Cherry Ave. Medical-Dental Bldg.,ninth floor Bremerton,WA 98310 509 Olive Way Port Orchard Medical Center OB/GYN and Women's Seattle,WA 98101ealthcare Services (206)3773911 t Pottery AveAvc. 1330 Rockefeller,Suite 120 (206)223-2611 Port Orchard,WA 98366 Everett (206)895-5000 Everett,WA 98201 Eastsidc Primary Care Center (206)3884050 Providence General Medical Center 2701 156th Ave.N.E. Port Orchard Medical 916 Pacific Redmond,WA 98052 Center—Tremont Thurston County Everett,WA 98201 (206)883-5151 1400 Pottery Ave. Olympia Medical Center (206)258-7123 Port Orchard,WA 98366 700 N.Lilly Rd. Mount Vernon Eastside Specialty Center (206)895-5000 Olympia,WA 98506 2700 152nd Ave.N.E. (206)456-1700 Skagit Valley Hospital Redmond,WA 98052 - 1415 E.Kincaid Group Health Medical (206)883-5151 Center—Silverdale West Olympia Medical Center Mount Vernon,WA 98273 10452 Silverdale Way N.W. 3030 Limited Lane N.W. (206)424-4111 Factoria Medical Center Silverdale,WA 98383 Olympia,WA 98502 13451 S.E.36th St. (206)692-3880 (206)352-5200 Olympia Bellevue,WA 98006 (206)562-1330 St.Peter Hospital Pierce County 413 N.Lilly Rd. Family Practice Residency Tacoma Medical Center Group Health Olympia,WA 98506 200 15th Ave.E. 1112 S.Cushman Hospitals (206)491-9480 Seattle,WA 98112 Tacoma,WA 98405 Sedro Woolley (206)326-3580 (206)383-7801 King County Central Hospital United General Hospital Federal Way Medical Center Tacoma South Medical Center 1971 Hospital Drive 301 S.320th St. 9505 S.Steelc St. 200 15th Ave.E. Sedro Woolley,WA 98284 Federal Way,WA 98003 Tacoma,WA 98444 Seattle,WA 98112 (206)856,6021 (206)874-7000(King Co.) (206)597-6800 (206)320-3000 (206)927-7511(Pierce Co.) Tacoma Tacoma Specialty tal Center Eastsidc Hospital 2700 152nd Ave.N.E. Mary Bridge Children's Hospital Madrona Medical Center 209 Martin Luther King Jr.Way Redmond,WA 98052 317 Martin Luther King Jr.Way 1403 34th Ave. Tacoma,WA 98405 (206)883-5151 Tacoma,WA 98405 Seattle,WA 98122 (206)596-3300 (206)594-1404 (206)720-6000 Tacoma Avenue Pierce County Tacoma General Hospital Northgatc Medical Center Primary Care Center Group Health Inpatient Center 315 Martin Luther King Jr.Way 9800 4th Ave.N.E. 124th Tacoma Ave.S. at Tacoma General Hospital Tacoma,WA 98405 Seattle,WA 98115 Tacoma,WA 98402 315 Martin Luther King Jr.Way (206)594-1000 (206)527-7100 (206)383.6125 Tacoma,WA 98405 (206)594-1335 Vashon Vashon Health Center Sunrise Ridge Center 10030 S.W.210th St. Vashon,WA 98070 (206)463-3671 GS.9581(4B4) ®Printed an recycled peak