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HomeMy WebLinkAboutCAG1993-0040 - Original - Group Health Cooperative - Group Medical Coverage Agreement - 01/01/1993 GHe�lth .. 11 COOpefBtillE'. of Pugets«,a 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 PUGETTJSSOOUND profit health maintenance organization furnishing health care primarily on a prepayment basis.As a direct By service provider, the Cooperative is dedicated to Title Vice President Health Plan and Insurance Services providing to its Enrollees quality health care,including preventive medical services. GROUP This Agreement states the terms of enrollment, pay- ment and coverage under which a Group may secure 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 B capitalized.They are defined in Section I. Y 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 1993 and will continue in effect until terminated as SECTION X.I. OF THE SCHEDULE OF herein provided for. BENEFITS. 0369 Page 1 B90 GROUP MEDICAL COVERAGE AGREEMENT Table of Contents I. Definitions H. Dues and Fees III. Termination IV. Continuation Coverage,Conversion and Transfer V. Coordination of Benefits VI. Subrogation VII. Grievance Procedures VIII. Miscellaneous Provisions DC Enrollment and Eligibility Schedule X. Schedule of Benefits XI. Exclusions and Limitations XII. Claims Attachments • Medicare Endorsements • Dues and Fees Schedule • Service Area Map 0369 Page 2 B90 Section I. Definitions FAMILY DEPENDENT: Any member of a Subscriber's family who meets all applicable eligibility requirements,is enrolled hereunder,and AGREEMENT: This Medical Coverage Agreement, for whom the dues prescribed in the Dues and Fees including the Schedule of Benefits, Enrollment Schedule have been paid. and Eligibility Schedule,Dues and Fees Schedule, Coordination of Benefits Attachment, Service FAMILY UNIT: A Subscriber and all his/her Family Area Map,and any applicable endorsements. Dependents. ALLOWANCE: The maximum amount payable by GHC DESIGNATED FACILITY: A facility, not in- GHC for certain Covered Services under this cluding a GHC Facility,which the GHC Board of Agreement, as set forth in the Dues and Fees Trustees has specified to provide health care ser- Schedule. vices to its Enrollees. (See Service Area Map.) Designated Facilities may be changed by GHC COINSURANCE: An amount that the Enrollee is upon appropriate notice. required to pay for Covered Services received under this Agreement,which is a percentage of the GHC FACILITY:A hospital or medical center owned Allowance for such services, as set forth in the and operated by Group Health Cooperative of Dues and Fees Schedule. Puget Sound. (See Service Area Map.) COPAYMENT: The specific dollar amount required GHC MEDICARE PLAN: A plan of coverage for to be paid by an Enrollee for certain Covered persons enrolled in Medicare Part A(hospital in- Services under this Agreement,as set forth in the surance)and Part B(medical insurance),or Part B Dues and Fees Schedule. only. COVERED SERVICES: The services and benefits to GROUP: An employer, union, welfare trust, or as- which an Enrollee is entitled under this Agree- sociation which has entered into a Group Medical ment. Coverage Agreement with GHC. DEDUCTIBLE: A specific maximum amount paid by HEALTH EVALUATION: Screening of the applicant an Enrollee for certain Covered Services before or other eligible persons prior to enrollment ac- benefits are payable under this Agreement. The cording to the standards which may be defined by applicable Deductible amounts are set forth in the Group Health Cooperative to determine whether Dues and Fees Schedule. such person is qualified for enrollment under this DIRECTORY OF SERVICES: A fee-for-service Group Medical Coverage Agreement. 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 ENROLLEE: Any Subscriber or Family Dependent professional with whom GHC has entered into a covered by this Agreement. formal legal arrangement. 0369 Page 3 B90 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 and Fees 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:A condition 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 H. 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 1y dues set forth in the current Dues and Fees Referral and this Agreement. Schedule and a verification of enrollment, on or before the due date, subject to a grace period of SERVICE AREA: King, Kitsap, Pierce, Skagit, ten(10)days.Dues are subject to change by GHC Snohomish, Thurston, and Whatcom Counties, upon thirty(30)days written notice. and any other areas designated by GHC. (See Service Area Map.) B. SUBSCRIBER'S LIABILITY. The Subscriber is liable for (1) payment to the Group of his/her SKILLED HOME HEALTH CARE:Reasonable and contribution toward the monthly dues,if any;(2) necessary care for the treatment of an illness or payment to the Cooperative of Copayments injury which requires the skill of a nurse or and/or Coinsurance amounts for Covered Ser- therapist, based on the complexity of the service vices provided to the Subscriber and his/her Fami- and the condition of the patient, and which is ly Dependents,as set forth in the Dues and Fees performed directly by an appropriately licensed Schedule;and(3)payment to the Cooperative of professional provider. any fees charged for non-Covered Services provided to the Subscriber and his/her Family STOP LOSS: The maximum amount of Copayments Dependents. paid during the calendar year for Covered Services At the time of service,Enrollees shall be required received by the Subscriber and his/her Family De- to pay Copayments as set forth in the Dues and pendents during the same calendar year.The Stop Fees Schedule.Failure to pay Copayments at the Loss amount is set forth in the Dues and Fees time of service may result in a billing fee. Schedule. 0369 Page 4 B90 Payment of a Copgment does not exclude the II.A. shall result in termination of this possibility of an additional billing if the service is Agreement as of the due date. determined to be a non-Covered Service. 3. Misrepresentation to Obtain Insurance. Total out-of-pocket Copayment expenses in- Group Health Cooperative may terminate cuffed during the same calendar year shall not this Agreement upon written notice in the exceed the aggregate maximum amount (Stop event of material misrepresentation, fraud, Loss)as set forth in the Dues and Fees Schedule. 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 W.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 for individual Group Conversion or,if applicable, a. Nonpayment of dues for a specific En- continuation coverage (see Section IV.), or an rollee by the Group. 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- Section III. Termination tion was relevant, or may rescind or cancel the Enrollee's coverage upon A. TERMINATION OF ENTIRE AGREEMENT. ten(10)working days written notice. This Agreement may be terminated in the follow- c. Permitting the use of a GHC identifica- ing circumstances: tion card by another person, or using 1. Termination on Notice.Either GHC or the another person's identification card to Group may terminate this Agreement by obtain care to which one is not entitled. giving thirty (30) days written notice to the d. Failure to comply with the rules and other. regulations of the Cooperative. 2. Nonpayment. Failure to make any monthly e. Nonpayment of charges as set forth in dues payment in accordance with Section Section II.C. 0369 Page 5 B90 C. PERSONS HOSPITALIZED ON THE DATE • The Subscriber's employment is ter- OF TERMINATION. An Enrollee who is a minated (unless terminated for gross registered bed patient receiving Covered Services misconduct);or in a GHC Facility or GHC Designated Facility on • the Subscriber experiences a reduction the date of termination shall continue to be xpe eligible for Covered Services for the condition for in work hours resulting in loss of which the Enrollee was hospitalized, until dis- eligibility for group benefits. charge from the facility.This continued coverage will also apply to an Enrollee hospitalized in a 2. Family Dependents are eligible for con- non-GHC Designated Facility as a result of an tinuation coverage for a maximum period of Emergency or Referral as set forth in Section up to thirty-six (36) months commencing at XI.B.1. the date that: D. SERVICES PROVIDED AFTER TERMINA- • The Subscriber is divorced or legally TION. Any services provided by GHC after the separated; 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 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 A. CONTINUATION COVERAGE coverage due to termination of employment (other than for the beneficiary's gross mis- This subsection A. only applies to employer conduct) or reduction of hours may extend groups who must offer continuation coverage his/her coverage under COBRA from under the applicable provisions of the Con- eighteen(18)months up to twenty-nine(29) solidated Omnibus Budget Reconciliation Act of months, so long as the beneficiary provides 1985 ("COBRA"), as amended, and only applies notice of his/her Social Security disability to grant continuation of coverage rights to the determination within sixty(60)days of such extent required by federal law. determination and before the end of the eighteen(18)month coverage period.Social To the extent required by federal law,if the Sub- Security Administration certification of total scriber or Family Dependent loses eligibility disability is required.The period of extended under this-Group Agreement, group coverage coverage provided under this subsection may be continued under the circumstances shall terminate on the first day of the first described below. Except as set forth in Section month which begins more than 30 days after W.A.1 L, below, this provision applies only to the date of the Social Security Administra- Subscribers and Family Dependents enrolled tion's final determination that the qualified under this Agreement prior to the date of beneficiary is no longer disabled. eligibility for continuation coverage who would otherwise lose coverage as a result of one of the 4. A Subscriber who is a retiree or the spouse qualifying events listed below in subsections (L), or Dependent of a retiree may continue (2.), and(3.). coverage hereunder if the Subscriber would otherwise lose coverage hereunder within 1. Subscribers and Family Dependents are one year of the date a proceeding under Title eligible for continuation coverage for a max- 11 of the United States Code is commenced imum period of up to eighteen(18) months with respect to the Group. Coverage under commencing at the date that: this Section IV.A.4., continues only upon 0369 Page 6 B90 payment of applicable monthly charges to ly fashion of the election to continue the Group at the time specified by the coverage and the applicable coverage period Group. The terms and conditions of this (eighteen[181 or thirty-six[361 months). coverage are governed by COBRA The Subscriber or Family Dependent must 5. If an individual enrolled for continuation notify the Group, or plan administrator, if coverage experiences a second qualifying any, within sixty (60) days following a event as set forth in subsection (2.) above, divorce, legal separation, or when an en- continuation coverage may be extended for rolled dependent child no longer meets the up to thirty-six(36)months,beginning from eligibility requirements set forth in Section the date of the fast qualifying event. When DCB.2., or within sixty (60) days following the Subscriber becomes entitled to the date coverage ends in accordance with Medicare, the period of continuation the termination provisions under this Agree- coverage for family dependents as a result of ment,whichever is later. the Subscriber's Medicare entitlement or any later event described in Section IV.A2. 9. Application. Written application for con- above shall extend up to a maximum of thir- tinuation coverage must be made within sixty ty-six (36) months from the earlier of the (60) days of the termination date of date the Subscriber becomes entitled to coverage, or the date that the Enrollee Medicare or the initial qualifying event as set receives specific notice of his/her right to forth (in subsection 2) above. continuation coverage, whichever is later. For the purpose of this Agreement 6. In addition to the conditions set forth in "receives" means that written notice was Section III. jMjbjaj= 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 (1.), (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- isting Condition which the Enrollee sible for submitting such dues with its regular may have; monthly dues payment to GHC. • the Enrollee becomes enrolled under Payment of the initial dues payment,which Medicare; includes the period from the election retroactive to the qualifying event, and any • the employer ceases to maintain any regular dues payment that becomes due group health plan;or prior to the initial dues payment date, for continuation coverage under COBRA is due • the Enrollee is no longer disabled as forty-five(45)days after the date of the elec- determined by the Social Security Ad- tion.Subsequent dues payments are due on ministration. a monthly basis.Dues for persons extending COBRA coverage from eighteen (18) 7. Notice.The Group is responsible for assur- months to twenty-nine(29)months because ing compliance with COBRA and that En- of total disability may be charged at one rollees are given timely notice of their hundred fifty percent(150%)of the Group's continuation coverage option.The Group is dues rate that would otherwise apply to also responsible for notifying GHC in atime- them. 0369 Page 7 B90 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- D. PERSONS AGE SIXTY-FIVE (65) OR OLDER titled to convert to GHC's Group Conver- WHO ARE NOT ENTITLED TO, OR lion Plan within a 180-day period prior to ELIGIBLE PURCHASE MEDICARE.Upon termination of continuation coverage, if 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.B.2.QHC continue coverage under this Agreement upon Group Conversion Plan-Ap licit ation. payment of the applicable dues as set forth in the Dues and Fees Schedule. 11. Open Enrollment and Adding Dependents. To the extent required under COBRA, a Coordination of Benefits qualified beneficiary under COBRA may Section V. 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,as fully set forth in this section. reason other than nonpayment or cause. (See Section III.B.2.)Following termination A. Benefits Subject to This Provision: of marriage or death of the Subscriber, all Family Dependents are entitled to make All of the benefits provided under this Agreement such a conversion. are subject to this provision. 2. Application. Application for conversion B. Plan: must be made within thirty-one (31) days The definition of a"Plan" includes the following following termination under this Agree- sources of benefits or services: ment. Coverage under the GHC Group Conversion Plan is subject to all terms and 1. Group or blanket disability insurance conditions of such plan,including dues pay- policies and health care service contractor ment. A physical examination or statement and health maintenance organization group of health is not required for enrollment in agreements, issued by insurers, health care the Group Conversion Plan. service contractors and health maintenance C. PERSONS ENTITLED TO,OR ELIGIBLE TO organizations; PURCHASE MEDICARE.Except as defined by 2 Labor-management trusteed plans,labor or- federal regulations, all Enrollees entitled to, or ganization plans, employer organization eligible to purchase Medicare must transfer to the plans or employee benefit organization GHC Medicare Plan upon such entitlement or plans; eligibility. A condition of coverage under the GHC Medicare Plan requires that an Enrollee be 3. Governmental programs; and continuously fully qualified and enrolled for the hospital (Part A) and medical (Part B) benefits, 4. Coverage required or provided by any or Part B only, available from the Social Security statute. The term "Plan" shall be construed Administration, and sign any papers that may be separately with respect to each policy,agree- required by GHC or Medicare. All applicable ment or other arrangement for benefits or 0369 Page 8 B90 services, and separately with respect to the the right,exercisable alone and in its sole discre- respective portions of any such policy,agree- tion, to pay over to any Plan making such other ment or other arrangement which do and payments any amounts it shall determine to be which do not reserve the right to take the warranted in order to satisfy the intent of this benefits or services of other policies, agree- provision, and amounts so paid shall becon- ments or other arrangements into considera- sidered to be coverage or benefits paid under this tion in determining benefits. Agreement and, to the extent of such payments, the Cooperative shall be fully discharged from C. Allowable Expense: liability under this Agreement. "Allowable Expense" means any necessary, G. Right of Recovery: reasonable and customary items of expense at least a portion of which is covered under at least Whenever benefits have been provided by the one of the Plans covering the person for whom Cooperative with respect to Allowable Expenses the claim is made.When a Plan provides benefits in total amount at any time,in excess of the max- in the form of services rather than cash payments, imum amount of payment necessary at that time the reasonable cash value of each service to satisfy the intent of this provision,the Coopera- rendered shall be considered as both an Allow- tive shall have the right to recover the reasonable able Expense and a benefit paid. cash value of such benefits,to the extent of such excess,from one or more of the following, as the D. Claim Determination Period: Cooperative shall determine: any persons to or for or with respect to whom such benefits were "Claim Determination Period" means a period provided, any other insurers,any service plans or beginning with any January 1 and ending with the any other organization or other Plans. next following December 31 except that the first Claim Determination Period with respect to any H. Effect on Benefits: person shall begin on the effective date of coverage under this Agreement with respect to 1. This provision shall apply in determining the such person and end on the following December benefits for a person covered under this 31.In no event will a Claim Determination Period Agreement for a particular Claim Deter- for any person extend beyond the last day on mination Period if,for the Allowable Expen- which such a person is covered under this Agree- ses incurred as to such person during such ment. period,the sum of- E. Right to Receive and Release Information: a. The reasonable cash value of the benefits that would be provided under For the purpose of determining the applicability the Agreement in the absence of this of and implementing this provision and any provision,and provision of similar purpose in any other Plan,the Cooperative may, with such consent as may be b. The benefits that would be payable necessary, release to or obtain from any other under all other Plans in the absence insurer, organization or person any information, therein or provisions of similar purpose with respect to any person which the insurer con- to this provision would exceed such Al- siders necessary tor such purpose. Any person lowable Expenses. claiming benefits under this Agreement shall fur- nish to the Cooperative the information neces- 2. As to any Claim Determination Period with sary for such purpose. respect to which this provision is applicable, the reasonable cash value of the benefits F. Facility of Payment: provided under this Agreement in the ab- sence of this provision for the Allowable Whenever covera*e which should have been Expenses incurred as to such person during provided under this Agreement in accordance such Claim Determination Period shall be with this provision has been provided or paid for reduced to the extent necessary so that the under any other Plan,the Cooperative shall have sum of the reasonable cash value of benefits 0369 Page 9 B90 and all benefits payable for such Allowable i. when the parents are separated or Expenses under all other Plans, except as divorced and the parent with cus- provided in subparagraph(3)of this Section, tody of the child has not remarried, shall not exceed the total of such Allowable the benefits of a Plan which covers Expenses. Benefits payable under another the child as a dependent of the Plan include benefits that would have been parent with custody of the child payable had a claim been duly made there- will be determined before the for. benefits of a Plan which covers the child as a dependent of the parent 3. If without custody;and a. another Plan which is involved in sub- H. when the parents are divorced and paragraph(2)of this Section and which the parent with custody of the contains a provision coordinating its child has remarried,the benefits of benefits with those of this Agreement a Plan which covers the child as a would,according to its rules,determine dependent of the parent with cus- its benefits after the benefits of this tody shall be determined before Plan have been determined;and the benefits of a Plan which covers that child as a dependent of the b. the rules set forth in subparagraph (4) stepparent, and the benefits of a of this Section would require this Plan which covers that child as a Agreement to determine its benefits dependent of the stepparent will before such other Plan, then the be determined before the benefits benefits of such other Plan will be ig- of a Plan which covers that child as nored for the purposes of determining a dependent of the parent without the benefits under this Agreement. custody. 4. For the purposes of subparagraph(3)of this Notwithstanding items (i) and (ii) Section, the rules establishing the order of above, if there is a court decree which benefit determination are: would otherwise establish financial a. The benefits of a Plan which covers the responsibility for the medical,dental or other health care expenses with respect person on whose expenses a claim is to the child,the benefits of a Plan which based other than as a dependent shall covers the child as a dependent of the be determined before the benefits of a parent with such financial responsibility Plan which covers such person as a de- shall be determined before the benefits pendent. of any other Plan which cover the child b. In the case that a dependent is covered as a dependent child. under both parents medical Plan, the c. When rules(a)and(b)do not establish benefits of the Plan of the parent whose an order of benefit determination, the birthday falls earlier in the year are benefits of a Plan which has covered the determined before those of the Plan of person on whose expenses claim is a parent whose birthday falls later in the based for the longer period of time shall year.This birthdate will refer only to the be determined before the benefits of a month and day,not the year in which a Plan which has covered such person the person was born. If both parents have shorter period of time,provided that: the same birthday, the benefits of the Plan which covered the parent longer i. The benefits of a plan covering the are determined before those that person on whose expenses claim is covered the other parent for a shorter based as a laid off or retired period of time, except that in the case employee, or dependent of such of a person for whom claim is made as person shall be determined after a dependent child, the benefits of any other Plan 0369 Page 10 B90 covering such person as an The injured person and his or her agents must employee,other than a laid off or cooperate fully with GHC in its efforts to collect retired employee,or dependent of GHC's medical expenses. This cooperation shall in- such person;and clude supplying GHC with information about any defendants and/or insurers related to the injured ii. If either plan does not have a person's claim. The injured person and his or her provision regarding laid off or agents shall permit GHC, at GHC's option, to as- retired employees, results in sociate with the injured party or to intervene in any each Plan determining ng its benefits action filed against any third party.The injured person after the other,then the provisions and his or her agents shall do nothing to prejudice apply. of ly.of this subsection shall not GHC's subrogation rights.The injured person shall not settle a claim without protecting GHC's interest. d. If none of the above rules determines the order of benefits,the benefits of the GHC shall not recover anything under this section Plan which covered an employee or until the Enrollee has been made whole,except in the Subscriber for the longer period of time case that the Enrollee fails to cooperate fully with shall be determined before those of the GHC in recovery of medical expenses as described Plan which covered that person for the above.In which case,the Enrollee shall be responsible shorter time period. for reimbursing GHC for such medical expenses. 5. When this provision operates to reduce the GHC shall not pay any attorney's fees or collection total amount of benefits otherwise to be costs to attorneys representing the injured person provided to a person covered under this where it has retained its own legal counsel or acts on Agreement during any Claim Determination its own behalf to represent its interests and unless Period, the reasonable cash value of each there is a written fee agreement signed by GHC prior benefit that would be provided in the ab- to any collection efforts. When reasonable collection sence of this provision shall be reduced costs have been incurred with GHC's prior written proportionately, and such reduced amount agreement,to recover GHC's medical expenses,there shall be charged against any applicable shall be an equitable apportionment of such collection benefit limit of this Agreement. costs between GHC and the injured person subject to a maximum responsibility of GHC equal to one-third Section VI. Subrogation of the amount recovered on behalf of GHC. "Injured person"under this section means an Enrollee Section VII.Grievance Procedures covered by this Agreement who sustains compensable injury. "GHC's medical expenses" means the expense The Consumer Relations Program is designed to help incurred and the reasonable value of the services an Enrollee resolve formal complaints and concerns provided by the Cooperative for the care or treatment of the injury sustained. about medical and business service. GHC will record, research, and respond in a timely manner to an If the injured person was injured by an act or omission Enrollee's concern. A concern should initially be of a third party giving rise to a claim of legal liability registered at the'Enrollee's area medical center.If not against the third party, GHC shall have"the right to satisfied,the Enrollee should then contact the regional recover from the third party GHC's medical expenses. Consumer Relations Department, which will arrange This right is commonly referred to as "subrogation." for review by appropriate Medical Staff,management, GHC shall be subrogated to and may enforce all rights and/or GHC consumers. of the injured person to the extent of GHC's medical expenses. GHC's equitable and contractual rights of subrogation are limited in accordance with Washington law. 0369 Page 11 B90 Section VIII. Miscellaneous Provisions Group to carry out any of its responsibilities under this Agreement. A. DISSEMINATION OF INFORMATION. The Group Health Cooperative of Puget Sound does not Group is responsible for disseminating to Sub- discriminate on the basis of physical or mental hand- scribers written information concerning this icaps in its employment practices and services. Agreement which is provided by the Cooperative. B. IDENTIFICATION CARDS. The Cooperative Section IX. Enrollment and Eligibility will furnish cards, for identification only, to all Schedule persons enrolled under this Agreement. C. ADMINISTRATION OF AGREEMENT. GHC A. ENROLLMENT may adopt reasonable policies and procedures to help in the administration of this Agreement. 1. Application for Enrollment.Application for enrollment shall be made on an application D. MODIFICATION OF AGREEMENT. This form furnished and approved by GHC. No Agreement may be modified by GHC upon thirty person shall be enrolled or dues accepted (30)days written notice. until this completed application has been received and approved by GHC.The Group E. Group Health Cooperative reserves the right to is responsible for submitting completed ap- construe the provisions of this Medical Coverage plication forms to GHC. Agreement, and to determine any and all ques- tions pertaining to benefit entitlement and a. Newly Eligible Persons.Newly eligible coverage. Subscribers may make written applica- tion for enrollment to the Group within F. INDEMNIFICATION.GHC agrees to indemnify thirty-one(31)days of eligibility.If the and hold the Group harmless against all claims, Subscriber wishes to enroll his/her damages, losses, and expenses,including reason- eligible Dependents, application must able attorney's fees, arising out of GHC's failure be made during this same thirty-one to perform or negligent performances of its ex- (31)day period. press obligations under the Group Medical Coverage Agreement.GHC further agrees to in- Written application for enrollment for demnify and hold the Group harmless against a newly dependent person,other than a claims, damages, losses or expenses, including newborn or newborn adopted child, reasonable attorney's fees, for injury or damage must be made to the Group within thir- caused to any person which is the result of or is ty-one (31) days after the dependency alleged to be the result of the failure to provide occurs. or the negligent provision of medical services or supplies specified under this contract by any A Subscriber's newborn child shall be health care provider who is employed by, is an automatically enrolled when born: agent of or who has a direct contractual relation- ship with GHC. Provided, however, that the i. at a GHC Facility or GHC or Desig- Group notifies GHC in writing promptly of any nated Facility; such claims, that it will assist GHC (at GHC's expense) in the defense of same, and that GHC ii. at a non-GHC Facility due to an has the right to direct and arrange the defense of Emergency, provided that all the the case. requirements of Section X.I. of this Agreement are met,including The foregoing shall not in any way be construed notification of GHC by way of the as applying to any claim, demand or loss arising GHC Notification Line within out of negligent acts or omissions of the Group, twenty-four (24) hours following its agents,officers or employees,or failure by the inpatient admission, or as soon thereafter as medically possible. 0369 Page 12 B90 GHC shall provide notice of such en- described above,may make written ap- rollment to the Subscriber and the plication during the Group's Open En- Group. It is the Subscriber's respon- rollment period. sibility to complete and submit a revised application form to the Group. If the d. Health Evaluation. If a Subscriber or Subscriber does not want the newborn Family Dependent wishes to enroll out- child enrolled,he/she must notify GHC side the periods of eligibility as set forth within sixty (60) days of the date of in Section IX.A.1., he/she must first birth. satisfy all Health Evaluation require- ments as established by GHC and If subsequent to enrollment it is dis- defined in Section I. of the Group covered that the newborn child is not Medical Coverage Agreement. eligible or if the Group does not initiate dues payments on or before sixty (60) 2. Limitation on Enrollment.This Agreement days from the date of birth, GHC shall will be open for application as set forth in disenroll the child retroactive to the Section IX.A.1. GHC may limit enrollment, effective date of coverage. establish quotas, or set priorities for accep- tance of new applications if it determines Children who are born in a non-GHC that its capacity,in relation to its total enroll- Facility on a nonemergency basis will ment, is not adequate to provide services to not be automatically enrolled. In the additional persons. event there is a change in the monthly dues payment as a result of the addition 3. Effective Date of Enrollment. of a newborn child,the Subscriber must make written application for enroll- a. Provided application is made as set merit to the Group within sixty(60)days forth in Section IX.A.l.a. (above), en- following the date of birth. rollment for a newly eligible Subscriber and listed Dependents will begin on the In the event there is a change in the date of hire. monthly dues payment as a result of the Subscribers who return to work from a addition of an adoptive child,including leave without pay status within ninety adopted newborns,the Subscriber must days, shall b eligible for enroll- make written application for enroll- (90) �� e merit on the first of the month following merit within sixty(60)days from the day that the child is physically placed with their date of return to work. the Subscriber for the purpose of adop- For eligible Subscribers and Family De- tion and the Subscriber assumes finan- pendents who have satisfied the Health cial responsibility for the medical Evaluation requirement as set forth in expenses of the child. Section IX.A.1., following acceptance b. If the souse of a GHC Subscriber loses by the Cooperative, enrollment will eligibility under a group medical plan begin on the date specified by GHC. provided by his/her employer, the Enrollment for newly dependent per- spouse and any eligible Dependents sons,other than newborns and adopted listed on the spouses insurance may be children,will begin on the first (1st)of added to the GHC Subscribers plan. the month following application. Enrollment must be continuous be- tween plans and application must be Provided newborns are enrolled as made prior to, or at the same time as, specified in Section IX.A.l.a. (above), termination of previous enrollment. enrollment is effective from the date of c. Open Enrollment. A person not en- birth. rolled as a Subscriber or Family De- pendent when newly eligible, as 0369 Page 13 B90 A newborn is defined as a child who is b. Unmarried dependent children who not older than four(4)weeks. are under the age of twenty-one (21), provided they reside regularly with the For adopted children,enrollment is ef- Subscriber or qualify as Dependents for fective from the date that the adopted Federal Income Tax purposes. child is physically placed with the Sub- scriber or the purpose of adoption and "Children" means the children of the the Subscriber has assumed financial Subscriber including adopted children, responsibility for the medical expenses stepchildren, foster children, and any of the child. other children for whom the Subscriber is the legal guardian. b. Persons Hospitalized on Effective Date.If a person,other than a newborn, C. Enrollment may be extended past the is confined in a hospital on the date limiting age for an unmarried person enrollment would otherwise become enrolled as a Family Dependent on effective, the effective date of enroll- his/her twenty-first(21st)birthday if: ment for the person(s)hospitalized will not begin until discharge from the i. the Dependent is a full-time facility. registered student at an accredited secondary school, college, or 4. Effective Date of Services and Benefits.Ser- university and under the age of vices provided to Enrollees, including new- twenty-three(23);or bores,are subject to all terms and conditions of the Group Agreement including the re- ii. the Dependent is incapable of quirement that all services must be received self-sustaining employment be- at a GHC or GHC Designated Facility under cause of a developmental dis- the medical management of a GHC ability or a physical handicap physician unless the Enrollee has been incurred prior to attainment of the Referred by a GHC physician or has limiting age as set forth in Section received Emergency services according to IX.B.2.b.,or prior to attainment of Section X.I. the student limiting age as set forth in Section IX.B.2.c., and is chiefly B. ELIGIBILITY dependent upon the Subscriber for support and maintenance. A In order to be accepted for enrollment and con- dependent child shall be con- tinuing coverage under the Group Agreement, sidered chiefly dependent upon individuals must meet all applicable requirements the Subscriber for support and set forth below. The Group is responsible for maintenance when, as a result of determining eligibility. disability, one-half (1/2) or more of the total support of the depend- 1. Subscribers. Elected officials, bona fide ent child is provided by the Sub- employees and LEOFF II employees who scriber as determined under are employed on a regularly scheduled basis Internal Revenue Service regula- of not less than twenty-one (21) hours per tion. Enrollment for such a De- week shall be eligible for enrollment. pendent may be continued for the duration of the incapacity, LEOFF I employees will not be covered provided enrollment does not ter- under this plan. minate for any other reason. Dependents.The Subscriber may en- Medical proof of incapacity and 2. Family Pe Y proof of financial dependency roll any of the following: must be furnished to the Coopera- a. The Subscriber's legal spouse; tive upon request, but not more frequently than annually after the two (2) year period following the 0369 Page 14 B90 Dependent's attainment of the Personal comfort items, such as telephone and limiting age. television,are not covered. d. Dependents of LEOFF I employees If an Enrollee is hospitalized in a non-GHC are eligible for coverage under this con- Facility,GHC reserves the right to require trans- tract. fer of the Enrollee to a GHC Facility,upon con- sultation with a GHC physician. If the Enrollee Ineligible Persons. GHC reserves the right to refuses to transfer to a GHC Facility, all further refuse enrollment to any person whose coverage costs incurred during the hospitalization are the under the Group Agreement or any other Medi- responsibility of the Enrollee. cal Coverage Agreement issued by Group Health Cooperative of Puget Sound has been terminated B. MEDICAL AND SURGICAL CARE for cause. Medical and surgical services are provided, C. CONTINUATION OF ENROLLMENT limited to the following,when prescribed by GHC Medical Personnel: While on a group approved leave of absence,the Subscriber and listed Dependents will continue to 1. Surgical services. receive services and benefits under this Agree- 2 Diagnostic x-ray, nuclear medicine, ment for up to one hundred eighty (180) days, ultrasound,and laboratory services. provided the employer or Group continues to remit dues to GHC for the Subscriber and such 3. Routine eye examinations and refractions, Dependents. limited to once every twelve (12) months, except when Medically Necessary. Services Section X. Schedule of Benefits for routine eye examinations must be received at a GHC Facility and in accord- ance with GHC medical criteria in order to Subject to all provisions of this Group Medical be covered. Coverage Agreement, persons enrolled for Com- prehensive Health Care are entitled to receive the Contact lens fittings and related examina- benefits and services that are Medically Necessary as tions are not covered except as set forth determined by GHC's Medical Director, or his/her below. When dispensed through GHC designee, and as described in this Schedule of Facilities, one contact lens per diseased eye Benefits. in lieu of an intraocular lens,includingg exam and fitting, is covered for Enrollees follow- A. HOSPITAL CARE ing cataract surgery performed by a GHC physician, provided the Enrollee has been Hospital care is provided when approved by a continuously covered by GHC since such GHC physician,limited to the following services: surgery. Replacement of a covered contact lens will be provided only when needed due 1. Room and board, including private room to change in the Enrollee's medical condi- when prescribed, and general nursing ser- tion but may be replaced only one time vices. within any twelve(12)month period. 2. Hospital services(including use of operating 4. Family planning counseling services. room, anesthesia, oxygen,x-ray, laboratory, and radiotherapy services). 5. Hearing examinations to determine hearing loss. 3. Drugs and medications which are listed as covered in the GHC Drug Formulary (ap- 6. Blood derivatives and the administration of proved drug list). blood and blood derivatives. The cost of blood is not covered. 4. Special duty nursing (when prescribed as Medically Necessary. 0369 Page 15 B90 7. Maternity care,including care for complica- 9. Physician visits(including consultations and tions of pregnancy;prenatal and postpartum second opinions by a GHC physician)in the visits;and hospitalization and delivery. hospital or office. Prenatal testin* for the detection of con- 10. Preventive services for health maintenance genital and heritable disorders when Medi- including routine mammography screening cally Necessary as determined by GHC's and physical examinations in accordance Medical Director,or his/her designee. with criteria established by the Cooperative, for the detection of disease; and immuniza- Voluntary(not medically indicated and non- tions and vaccinations which are listed as therapeutic) or involuntary termination of covered in the GHC Drug Formulary (ap- pregnancy. proved drug list).A fee may be charged for health education programs. 8. Transplants. When authorized as medically appropriate by GHC's Medical Director,or 11. Radiation therapy services. his/her designee, and in accordance with criteria established by the Cooperative, for 12. Medical and surgical services, including or- heart, heart-lung, single lung, double lung, thognathic(jaw)surgery for the treatment of kidney, simultaneous pancreas/kidney, cor- temporomandibular joint (TMJ) disorders nea, bone marrow, and liver transplants, are covered when determined to be Medical- limited to the following: ly Necessary and referred in advance by GHC. Such disorders may exhibit them- e evaluation testing to determine selves in the form of pain,infection,disease, recipient candidacy; difficulty in speaking,or difficulty in chewing or swallowing food.TMJ appliances are cov- 0 transplantation,limited to costs for the ered as set forth under orthopedic applian- surgery and hospitalization related to ces(Section X.E.1.). the transplant,and medications;and Treatment for cosmetic purposes and all • follow-up services for specialty visits, dental services including orthodontic ther- re-hospitalization, and maintenance apy are excluded regardless of origin or medications. cause. Transportation expenses,except as set forth 13. The following services are covered by GHC under Section X.J. of this Agreement, and when performed by a GHC physician or living expenses are excluded. GHC oral surgeon: reduction of a fracture or dislocation of the jaw or facial bones; Donor costs are covered,limited to procure- excision of tumors or cysts of the jaw,cheeks, ment center fees, travel costs for a surgical lips, tongue, gums, roof and floor of the team, excision fees, and matching tests. mouth; and incision of salivary glands and GHC shall exclude coverage for donor costs ducts. to the extent that the donor costs are reim- bursable by the organ donor's insurance. 14. Nonexperimental implants, limited to the following: cardiac devices, artificial joints, Except for children who have been con- and intraocular lenses.Artificial or mechani- tinuously enrolled at GHC since birth, cal hearts are excluded. coverage for all transplants and any related services, items, and drugs shall be excluded 15. When authorized as medically appropriate until such time as the Enrollee has been by GHC's Medical Director,or his/her desig- continuously enrolled under this Agree- nee, and in accordance with criteria estab- ment, or any prior GHC Medical Coverage lished by the Cooperative, treatment of Agreement, for twelve (12) consecutive growth disorders by growth hormones. months without any lapse in coverage. 0369 Page 16 B90 Growth hormone treatment shall be ex- proved treatment facility, subject to the Benefit cluded until such time as the Enrollee has Period Allowance and Lifetime Maximum been continuously enrolled under this Benefit as described below and as shown in the Agreement or any prior GHC Medical Dues and Fees Schedule. Coverage Agreement for twelve (12) con- secutive months without any ]apse in 1. Chemical Dependency Treatment Services. coverage. a. All alcoholism and/or drug abuse treat- 16. Respiratory therapy. ment services must be: (1) provided at a facility as described above and must be 17. Dietary formula for the treatment of authorized in advance,except for acute pphenylketonuria (PKU) when determined chemical withdrawal as described in Medically Necessary by GHC's Medical Section X.C.2.b.;and(2)deemed Medi- Director or his/her designee. Coverage for cally Necessary by GHC's ADAPT this formula is not subject to aPre-existing Director or his/her designee.Chemical Conditions waiting period,if any. dependency treatment may include the following services received on an in- Outpatient Total Parenteral Nutritional patient or outpatient basis: diagnostic Therapy, when Medically Necessary and in evaluation and education,organized in- accordance with medical criteria as estab- dividual and group counseling, lished by GHC is covered including supplies detoxification services, and prescnp- necessary for its administration. Outpatient tion drugs and medicines. enteral therapy is excluded. b. Court-ordered treatment shall be Dietary formulas and special diets, except provided only if determined to be Medi- for treatment of phenylketonuria (PKU) cally Necessary by GHC's ADAPT and total parenteral nutritional therapy as Director or his/her designee. set forth above,are excluded. 2. Emergency Care. 18. Pre-existing Conditions are covered in the same manner as any other illness. a. Coverage for medical Emergencies in- cident to the abuse of alcohol and/or 19. Skilled Nursing Facility care in a GHC-ap- drugs is subject to the Emergency care proved skilled nursing facility up to a maxi- benefit as set forth in Section X.I. mum of thirty(30)days per condition when full-time skilled nursing care is necessary in b. Coverage for acute chemical the opinion of the attending GHC physician. withdrawal is provided without prior approval.If an Enrollee is hospitalized When prescribed by a GHC physician,such in a non-GHC Designated Facility, care may include board and room; feneral coverage is subject to payment of the nursing care;drugs,biologicals,supplies,and Deductible shown in the Dues and Fees equipment ordinarily provided or arranged Schedule, and notification of GHC by by a skilled nursing facility; and short-term way of the GHC Notification Line physical therapy. within twenty-four(24)hours following inpatient admission, or as soon there- Excluded from coverage are personal com- after as medically possible. Further- fort items such as telephone and television; more,if an Enrollee is hospitalized in a and rest cures,custodial,domiciliary or con- non-GHC Designated Facility, GHC valescent care. reserves the right to require transfer of the Enrollee to a GHC Facility upon C. CHEMICAL DEPENDENCY TREATMENT consultation with a GHC physician. If the Enrollee refuses transfer to a GHC Subject to all terms and conditions of thisAgree- Facility, all further costs incurred ment,care is provided as set forth below at a GHC Facility, GHC Designated Facility, or GHC-ap- 0369 Page 17 B90 during the hospitalization are the covered after the Enrollee has reached Chemical dependency services responsibility of the Enrollee. o his/her Lifetime Maximum Benefit amount For the purpose of this section, "acute as shown in the Dues and Fees Schedule.All chemical withdrawal" means with- such benefits provided or payments made by: drawal of alcohol and/or drugs from a person for whom consequences of a. GHC under any GHC Group Medical abstinence are so severe as to require Coverage Agreement;plus medical/nursing assistance in a hospital b. all amounts paid on an individual's be- setting and which is needed immedi- half under any carrier or plan main- ately to prevent serious impairment to the Enrollee's health. tained by the Group, including self-insured plans, 3. Benefit Period and Benefit Period Al- shall be applied toward this Lifetime Maxi- lowance. mum Benefit amount. a. Benefit Period.For the purpose of this An Deductibles or Co a ents which may section, "Benefit Period" shall mean a Y p twenty-four (24) consecutive calendar be borne by the Enrollee under the terms of Agreement shall not be applied toward month period during which the Enrol- this� . lee is eligible to receive covered chemi- the Benefit Period Allowance or Lifetime cal dependency treatment services as Maximum Benefit. set forth in this section. The first In regard to this section, the Benefit Benefit Period shall begin on the first g day the Enrollee receives covered Period(s),Benefit Period Allowance(s),and Lifetime Maximum Benefit shall include chemical dependency services under only alcoholism treatment services received this or any other group insurance, health care service contractor, health on or after January 1, 1987 and alcoholism and/or drug abuse services received on or maintenance organization,self-insured plan or any combination thereof, after January 1, 1988. hereinafter referred to as"group plans," D. PLASTIC AND RECONSTRUCTIVE SER- and shall continue for twenty-four(24) VICES are covered: consecutive calendar months,provided that coverage under this Agreement 1. to correct an existing functional disorder remains in force. All subsequent resulting from a congenital disease or anom- Benefit Periods thereafter will begin on aly as determined by a GHC physician;or to the first day Covered Services are correct a medical condition following an in- received after expiration of the pre- jury or incidental to surgery covered by GHC vious twenty-four (24) month Benefit which has produced a major effect on the Period. Enrollee's appearance,provided: b. Benefit Period Allowance. The maxi- the Enrollee has been continuously en- mum allowance available for any rolled with GHC since the date of such Benefit Period shall be the total of all injury or surgery;and chemical dependency benefits provided and payments made for chemical de- • when in the opinion of a GHC pendency treatment under any group physician,such services can reasonably plan(s), not to exceed the Benefit be expected to correct the condition. Period Allowance shown in the Dues and Fees Schedule during the Complications of noncovered surgical ser- Enrollee's Benefit Period. vices are excluded. 4. Lifetime Maximum Benefit. 2. for reconstructive surgery and associated procedures following a mastectomy for En- 0369 Page 18 B90 rollees who are medically suitable can- Fees Schedule.Coverage for replacement of didates, as determined by GHC's Medical supplies is excluded. Director or his/her designee, regardless of when the mastectomy was performed.Inter- 3. Ostomy Supplies. Ostomy supplies neces- nal breast prostheses required incident to sary for the removal of bodily secretions or the surgery will be provided. waste are covered. An Enrollee will be covered for all stages of 4. Oxygen and Oxygen Equipment. When one reconstructive breast reduction on the medical criteria as established by GHC are nondiseased breast to make it equivalent in met,and upon Referral,oxygen and oxygen size with the diseased breast after definitive equipment for home use is covered. reconstructive surgery on the diseased Replacement or repair of appliances,devices and breast has been performed. supplies that are due to loss,breakage from willful 3. for external breast prostheses following mas- damage, neglect or wrongful use, or due to per- tectomy and post-mastectomy bras limited to sonal preference are excluded. one external breast prosthesis per diseased F. DRUGS AND MEDICINES FOR OUT- breast every two years,and two post-mastec- PATIENT USE as prescribed by a GHC physician tomy bras every six(6)months,up to four(4) in any twelve(12)consecutive month period. for conditions covered by this Agreement. All Coverage is subject to the Coinsurance as set drugs, supplies, medicines and devices must be forth in the Dues and Fees Schedule. obtained at a GHC pharmacy. E. APPLIANCES,DEVICES AND SUPPLIES Excluded are: dietary supplements, except therapeutic vitamins for use up to thirty(30)days; 1. Orthopedic Appliances.When Medically dietary formulas and special diets, except as set Necessary,orthopedic appliances,which are forth in Section X.B.; contraceptive drugs and attached to an impaired body segment for devices and their fitting;medicines and injections the purpose of protecting the segment or for anticipated illness while traveling; and any assisting in restoration or improvement of its other drugs, medicines, and injections not listed function, are covered. Medically Necessary as covered in the GHC Drug Formulary (ap- repair, adjustment or replacement of an or- proved drug list). thopedic appliance is covered when The Enrollee will be charged for mailing or authorized in advance by a GHC physician. Covered Services are subject to the Coin- replacing lost or stolen drugs, medicines or surance set forth in the Dues and Fees devices. Schedule. Excluded are arch supports; or- G. HOME HEALTH CARE SERVICES,as set forth thopedic shoes that are not attached to an in this section, shall be provided by GHC Home appliance;or any orthopedic appliances that Health Services or by a GHC-authorized home are not listed as covered in GHC's Or- health agency when Referred in advance by a thopedic Appliance Formulary. GHC physician for Enrollees who meet the fol- 2. Nasal CPAP Device. When Medically lowing criteria: 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 Dues and 0369 Page 19 B90 3. a GHC physician has determined that such seventy-two(72)hours.Services for a court- services are Medically Necessary and are ordered treatment program beyond the most appropriately rendered in the seventy-two(72)hours shall be covered only Enrollee's home. if determined to be Medically Necessary by the Director of GHC's Mental Health Ser- Covered Services for home health care may in- vice,or his/her designee. clude the following when prescribed by a GHC physician and when rendered pursuant to an ap- Coverage for voluntary Emergency in- proved home health care plan of treatment:nurs- patient mental health services is subject to ing care, physical therapy, occupational therapy, the Emergency Care benefit as set forth in respiratory therapy, restorative speech therapy, Section X.I.,including the twenty-four (24) and medical social worker and limited home hour notification and transfer provisions. health aide services. Home health services are Payment of bills incurred for non-GHC provided on an intermittent basis in the Enrollee's ym home. "Intermittent" means care that is to be treatment shall exclude any charges that rendered because of a medically predictable would otherwise be excluded for hospitaliza- recurring need for Skilled Home Health Care tion within a GHC Facility, such as services telephone,television, and personal items. Excluded are: custodial care and maintenance 2. Outpatient Services: care, private duty or continuous nursing care in Mental health services,limited to the follow- the Enrollee's home, housekeeping or meal ser- vices, care in any nursing home or convalescent GH are C. Subject to the limitations set forth in facility, any care provided by or for a member of this section, diagnostic evaluation, brief the patient's family, and any other services focal psychotherapy, intermittent care, and rendered in the home which are not specifically psy py� listed as covered under this Agreement. consultation services will be provided in the following formats:individual,couple,family, H. MENTAL HEALTH CARE SERVICES or group. 1. Inpatient Services: Coverage for each Enrollee is provided ac- cording to the Outpatient Mental Health 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. 0369 Page 20 B90 Enrollees who need long-term individual a. payment of the Emergency Deductible psychotherapy or who have conditions that shown in the Dues and Fees Schedule; cannot be treated within the limits of the and benefit described in this section and the Dues and Fees Schedule are not covered b. notification of GHC by way of the GHC Notification Line within twenty-four Partial hospitalization programs are covered (24) hours following inpatient admis- only under Section H.1.(Inpatient Services) sion,or as soon thereafter as medically of this Agreement. Treatment under this possible. Agreement is limited to acute care only.Day treatment and custodial care are excluded. If two(2)or more members of a Family Unit require emergency care as a result of the Excluded are:all forms of extensive psycho- same accident,only one(1)Emergency De- therapy including ongoing care for chronic ductible will apply. mental health conditions; custodial care; treatment of sexual disorders and/or dys- Outpatient medications prescribed by a non- functions; specialty programs for mental GHC physician are excluded. health therapy which are not provided by GHC;court-ordered treatment which is not 3. Transfer and Follow-up Care.If an Enrollee specifically described above; psychological is hospitalized in a non-GHC Facility,GHC testing, except when provided during the reserves the right to require transfer of the course of mental health treatment;classes or Enrollee to a GHC Facility, upon consult- courses such as (a) behavior modification ation with a GHC physician.If the Enrollee ro ams, refuses to transfer to a GHC Facility, all in (b) Parent Effectiveness Train- g, and (c) adult development programs, further costs incurred during the hospitaliza- when obtained at non-GHC facilities;or any tion are the responsibility of the Enrollee. other services not specifically listed as covered in this section.All other provisions, Follow-up care which is a direct result of the Emergency must be obtained at GHC, un- exclusions and limitations under this Agree- less a GHC physician has authorized such ment also apply. care in advance. I. EMERGENCY CARE J. AMBULANCE SERVICES are covered as set 1. At a GHC Facility or GHC Designated forth below, provided that the service is Facility.GHC will cover Emergency care for authorized in advance by a GHC physician or all Covered Services subject to payment of meets the definition of an Emergency. (See Sec- the Copayment set forth in the Dues and tion I.) Fees Schedule. 1. Emergency Transport to a GHC Facility or If two (2) or more members of the Family GHC Designated Facility.Each Emergency Unit require Emergency care as a result of is covered as set forth in the Dues and Fees the same accident, only one(1) Emergency Schedule. Care Copayment will apply. 2. Emergency Transport to a Non-GHC If the Enrollee is admitted to a GHC or GHC Designated Facility. Each Emergency is Designated Facility directly from the emer- covered as set forth in the Dues and Fees gency room, the Emergency Care Copay- Schedule. ment is waived. 3. Waiver of Ambulance Services Deductible. 2. At a Non-GHC Designated Facility.Usual, If two (2) or more members of the Family Customary, and Reasonable charges for Unit require Emergency ambulance Emergency care for Covered Services are transport as a result of the same accident, covered subject to: only one (1) Ambulance Deductible will apply. 0369 Page 21 B90 The Ambulance Deductible will not apply 3. Covered Services.Hospice Services may in- when ambulance service is authorized in ad- clude the following as prescribed by a GHC vance by the Cooperative. physician and rendered pursuant to an ap- proved hospice plan of treatment: 4. Transfer to a GHC Facility. When authorized in advance by the Cooperative, a. Home Services an additional Ambulance Allowance is i. Intermittent care by a hospice in- provided for transfer to a GHC Facility. terdisciplinary team which may in- IL HOSPICE clude services by a physician, nurse, medical social worker, It is understood and agreed that the following physical therapist, speech fully sets forth the eligibility requirements and therapist, occupational therapist, Covered Services for an Enrollee who elects to respiratory therapist, and limited receive services through GHC's Hospice Pro- services by a Home Health Aide gram. Enrollees who elect to receive GHC under the supervision of a Hospice Services do so in lieu of curative treat- Registered Nurse. ment for their terminal illness for the period that they are in the GHC Hospice Program. ii. One period of continuous care service per Enrollee in the Hospice Program Enrollee's home when prescribed by a GHC physician,as set forth in 1. Eligibility. Hospice Services, as set forth this paragraph.A continuous care below,shall be provided to Enrollees for as period is defined as "skilled nurs- long as the following criteria are met: mg care provided in the home during a period of crisis in order to a. a GHC physician has determined that maintain the terminally ill patient the Enrollee's illness is terminal and life at home."Continuous care may be expectancy is six(6)months or less; provided for pain or symptom management by a Registered b. the Enrollee has chosen a palliative Nurse, Licensed Practical Nurse, treatment focus (emphasizing comfort or Home Health Aide under the and supportive services rather than supervision of a Registered Nurse. treatment aimed at curing the Continuous care is provided for Enrollee's terminal illness); four(4)or more hours per day for a period not to exceed five (5) c. the Enrollee has elected in writing to days,or a total of seventy-two(72 receive hospice care through GHC's hours, whichever first occurs. Hospice Program; 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 in an acute care facility. e. a GHC physician and GHC's Hospice b. Inpatient Hospice Services shall be Director determine that the Enrollee's provided in a facility designated by illness can be appropriately managed in GHC's Hospice Program when Medi- the home. cally Necessary and authorized in ad- 2. Hospice Care shall be defined as a coor- vane 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. 0369 Page 22 B90 4. Hospice Exclusions:All services not specifi- 4. Coverage for inpatient and outpatient ser- cally listed as covered in this section includ- vices is limited to the allowances set forth in ing: the Dues and Fees Schedule. a. Financial or legal counseling services. Services excluded under this benefit include the following: specialty rehabilitation b. Housekeeping or meals services. programs not provided by GHC; long-term c. Custodial or maintenance care in the rehabilitation programs; physical therapy, occupational therapy, and speech therapy home or on an inpatient basis. services when such services are available d. Services not specifically listed as (whether application is made or not) P y through governmental programs including covered by this Medical Coverage programs offered by public school districts; Agreement. therapy for degenerative or static conditions e. Any services provided by members of when the expected outcome is primarily to the patient's family. maintain the Enrollee's level of functioning (except for neurodevelopmental therapies); f. All other exclusions listed in Section implementation of home maintenance XI.,Exclusions and Limitations,of this programs; programs for treatment of learn- Medical Coverage Agreement, apply. ing problems; any other treatment not con- sidered Medically Necessary by GHC; any L. REHABILITATION SERVICES are covered as services not specifically included as covered set forth in this section, limited to the following: in this section; and any services that are ex- physical therapy; occupational therapy; and cluded under Section XI. speech therapy to restore function following ill- Neurodevelopmental Therapies for ness,injury,or surgery.Services are subject to all Children Age Six (6) and Under. When terms, conditions, and limitations of this Agree- ment,including the following: determined to be Medically Necessary by GHC s Medical Director, or his/her desig- 1. All services must be provided at GHC or a nee,physical therapy,occupational therapy, GHC-approved rehabilitation facility and and speech therapy services for the restora- must be prescribed and provided by a GHC- tion and improvement of function for approved rehabilitation team that may in- neurodevelopmentally disabled children age clude medical, nursing, physical therapy, six(6)and under shall be covered.Coverage occupational therapy and speech therapy includes maintenance of a covered Enrollee providers. in cases where significant deterioration in the Enrollee's condition would result 2. The Enrollee must be referred for without the services.Coverage for inpatient rehabilitation services in advance by a GHC and outpatient services is limited to the al- physician. lowance set forth in the Dues and Fees Schedule. 3. Services are limited to those necessary to restore or improve functional abilities when Services excluded under this benefit include: physical, sensori-perceptual and/or com- specialty rehabilitation programs;long-term munication impairment exists due to injury rehabilitation programs; physical therapy, or illness. Such services are provided only occupational therapy, and speech therapy when GHC's Medical Director, or his/her services when such services are available designee, determines that significant, (whether application is made or not) measurable improvement to the Enrollee's through governmental programs; programs condition can be expected within a sixty(60) offered by public school districts; except as day period as a consequence of intervention set forth above,therapy for degenerative or by covered therapy services described in static conditions when the expected out- paragraph one(1) above. come is primarily to maintain the Enrollee's level of functioning; implementation of 0369 Page 23 B90 home maintenance programs; programs for specifically listed as covered under Section treatment of learning problems; any treat- X. The Cooperative's Medical Director, or ment not considered Medically Necessary; his/her designee,will determine whether the any services not specifically included as care or treatment required is within the covered in this Section;and any services that category of dental care or service. are excluded under Section XI. If a GHC physician determines that an unre- M. SMOKING CESSATION. When provided lated medical condition requires that an En- through Group Health,services related to smok- rollee be hospitalized for a dental procedure ing cessation are covered,limited to: which is normally done in a dentist's office, GHC will cover associated hospital and 1. participation in one individual and/or group anesthesia costs at a GHC or GHC Desig- program per calendar year; nated Facility. GHC will not cover the dentist's or oral surgeon's fees. 2. educational materials;and 5. Certain drugs, medicines, and injections. 3. one course of nicotine replacement therapy (See Section X.F.) Any exclusion of drugs, per calendar year, provided the Enrollee is medicines, and injections, including those actively participating in the Group Health not listed as covered in the GHC Drug For- Smoking Cessation Program. mulary(approved drug list),will also exclude their administration. Covered services are subject to the allowances set forth in the Dues and Fees Schedule. 6. Convalescent or custodial care. 7. Durable medical equipment such as hospital Section XI. Exclusions and Limitations beds, wheelchairs, and walk-aids, except while in the hospital or as set forth in Section A. EXCLUSIONS X.E. 1. Blood for transfusions. 8. Services rendered as a result of work-in- curred injuries,illness or conditions. 2. Except as provided in Sections X.B., X.D., X.E., and X.F., corrective appliances and 9• Those parts of an examination and associ- artificial aids including: eyeglasses; contact ated reports and immunizations required for lenses including services related to their fit- employment, immigration, license, or in- suranceting;prosthetic devices;diabetic supplies in- purposes that are not deemed Medi- cluding insulin pumps; hearing aids and tally Necessary by GHC for early detection examinations in connection therewith;take- of disease. home dressings and supplies following hospitalization;or any other supplies,dress- 10. Investigational or experimental treatment, including medical and surgical services, ings, appliances, devices or services which are not for the specific treatment of disease drugs,devices and biological products, until formally approved by GHC for medical cov- or injury,or not specifically listed as covered under Section X. erage. GHC's determination shall be made in accordance with criteria for determining 3. Cosmetic services, including treatment for investigational status as established by GHC complications of cosmetic surgery,except as as generally outlined below.Specific indica- provided in Section X.D. tions and methods of use shall be considered in GHC's review of evidence provided by 4. Dental care, surgery, services, and applian- evaluations of national medical associations, ces,including:treatment of accidental injury consensus panels, and/or other technologi- to natural teeth, reconstructive surgery to cal evaluations,including the scientific qual- the jaw incident to denture wear,periodon- ity of such supporting evidence and tal surgery,and any other dental services not rationale.Any investigational or experimen- 0369 Page 24 B90 tal treatment,including medical and surgical 14. Procedures,services,and supplies related to services,drugs,devices and biological prod- sex transformations. ucts not meeting GHC's determination pur- suant to its criteria as outlined below are 15. Regardless of origin or cause, diagnostic testing and medical treatment of sterility, excluded. infertility,and sexual dysfunction. a. Investigational or experimental drugs, devices and biological products until 16. Services of practitioners whose licensing clinical trials have been completed and category is not represented by GHC Medical approved by the U.S. Food and Drug Personnel. Administration (FDA) as being safe 17 Services directly related to obesity, except and efficacious for general marketing for nutritional counseling provided by GHC and permission has been granted by the staff. FDA for commercial distribution; b. there is sufficient scientific evidence in 18. Any services for which an Enrollee has a published medical literature to permit contractual right to recover the cost thereof, conclusions concerning the effect of the whether a claim is asserted or not, under treatment on health outcomes; automobile medical,personal injury protec- tion, uninsured or underinsured motorist, c. there is conclusive evidence in pub- home owner's or other first party coverage, lished peer-reviewed medical literature except for individual health insurance. that the treatment will result in a de- monstrable benefit for the particular 19 Services or supplies not specifically listed as injury,disease or condition in question, covered in the Schedule of Benefits. and that the benefits are not out- 20. See coverage under Section X.B.7. weighed by the risks; d. evidence that the new treatment is as 21. The cost of services and supplies resulting safe and effective as all existing conven- from an Enrollees loss of or willful damage tional treatment alternatives;and to covered appliances,devices,supplies,and materials provided by GHC for the treat- e. that treatment will satisfy (c) and (d) ment of disease,injury,or illness. outside of a research setting. 22. Routine circumcision, including newborn Appeals regarding denial of coverage must circumcision,which is not considered Medi- be submitted to your regional Consumer cally Necessary. Relations Department, or to GHC's Con- 23. Orthoptic(eye training)therapy. tracts and Coverage Deppartment at 1730 Minor Avenue, Suite 1910, Seattle, WA 24. Specialty treatment programs not provided 98101. GHC will respond in writing within by GHC including weight reduction, twenty(20)working days of the receipt of a rehabilitation, and behavior modification fully documented request. programs. 11. Nontherapeutic sterilization and proce- 25 Services required as a result of war,whether dures and services to reverse a therapeutic declared or not declared. or nontherapeutic sterilization. 12. See coverage for Pre-existing Conditions B. LIMITATIONS under Section X.B. 1. Conditions and Extent of Coverage. ALL 13. Mental health care, except as specifically SERVICES AND BENEFITS UNDER providedAGREEMENT MUST BE PRO- VIDED BY GHC MEDICAL PERSON- NEL AT A GHC FACILITY UNLESS: 0369 Page 25 B90 a. the Enrollee has received a Referral 4. Unusual Circumstances.If the provision of from a GHC physician;or Covered Services is delayed or rendered im- possible due to unusual circumstances such b. the Enrollee has received Emergency as complete or partial destruction of services according to Section X.I. facilities,military action,civil disorder,labor disputes, or similar causes, GHC shall pro- d. Recommended Treatment. The Coopera- vide or arrange for services that, in the tive's Medical Director or his/her designee reasonable opinion of GHC's Medical will determine the necessity,nature,and ex- Director, or his/her designee, are emergent tent of treatment to be provided in each or urgently needed In regard to nonurgent individual case and the judgment, made in and routine services,GHC shall make a good good faith,will be final. faith effort to provide services through its then-available facilities and personnel.GHC Enrollees have the right to participate in shall have the option to defer or reschedule decisions regarding their health care.An en- services that are not urgent or routine while rollee may refuse recommended treatment its facilities and services are so affected. In or diagnostic plan to the extent permitted by no case shall the Cooperative have any law.In such case,GHC shall have no further liability or obligation on account of delay or obligation to provide the care in question. failure to provide or arrange such services. Enrollees who seek other sources of care because of such a disagreement do so with the full understanding that GHC has no Section XII. Claims obligation for the cost, or liability for the outcome,of such care. Enrollees must submit claims for reimbursement of 3. Major Disaster or Epidemic.In the event of Covered Services to GHC within sixty(60)days of the a major disaster or epidemic,GHC Medical service date, or as soon thereafter as is reasonably Personnel will provide Covered Services ac- possible. In no event, except in the absence of legal cording to their best judgment, within the capacity, shall a claim be accepted later than one (1) limitations of available facilities and person- year from the service date. This section applies to nel. The Cooperative has no liability for Covered Services received under Section X.I.and X.7., delay or failure to provide or arrange or services for which the Enrollee has received a Covered Services to the extent facilities or Referral from a GHC physician. personnel are unavailable due to a major disaster or epidemic. 0369 Page 26 B90 , GFlealth of a,gec s«x,d rdtive 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,asset 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 This Endorsement does not constitute a Medicare COVERAGE AGREEMENT IS INTEGRATED supplemental contract. WITH THE MEDICAL AND HOSPITAL BENEFITS ESTABLISHED BY TITLE 13 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 purpose of meeting personal needs and could be COVERED UNDER BOTH PART A AND PART B provided by persons without professional skills or OF MEDICARE. 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 because of an injury or sudden illness, and for continuously enrolled for the hospital (Part A) and which the time required to reach GHC or a GHC medical (Part B) benefits available from the Social Designated Facility would risk permanent damage Security Administration,and sign any papers that may to the Enrollee's health. be required by GHC or Medicare. For additional in- 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 27 B90 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- more than ninety (90) days from GHC's Service cumstances set forth below. Area. Until such time as an Enrollee's termination of en- REFERRAL.A written temporary referral agreement rollment is effective,neither GHC nor Medicare shall authorized in advance by a GHC physician, and pay for services provided at non-GHC Facilities un- formally approved in advance through GHC's 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- 2. Change of Permanent Residence Outside tired and licensed facility,as defined in Medicare GHC's Service Area.If an Enrollee makes a regulations,primarily engaged in providing skilled Permanent Move as set forth in Section I.of nursing care or rehabilitation and related services this Medicare Endorsement, enrollment for which Medicare pays benefits or qualifies to shall terminate the first day of the month receive such approval. 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 injury while 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 28 B90 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 cooperate fully with GHC in its efforts to collect and approval by HCFA. 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 termma- his or her agents shall permit GHC,at GHC's option, lion 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 This provision does not apply to occupationally in- covered by this Agreement who sustains compensable curred disease,sickness,and/or injury. injury. "GHC's medical expense" means the expense 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 tv 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 29 B90 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- Continuous care services per Enrollee in the tion for reconsideration. Enrollee's home when prescribed by a GHC physician,as set forth in this paragraph.Con- Section V. Schedule of Benefits tenuous 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 Enrollee's primary care- ver s . stay,GHCwill cover up to one hundred(100)days p �' � of care in a Skilled Nursing Facility,in accordance 3. Other hospice services may include the fol- with Medicare Guidelines, when Medically Necessary, as determined by GHC's Medical lowing: Director,or his/her designee. a. drugs and biologicals that are used B. .Hos ice primarily for the relief of pain and p� symptom management; Enrollees with Part A and Part B of Medicare who b. medical appliances and supplies pri- elect to receive Medicare-covered hospice ser- manly for the relief of pain and symp- vices may select any Medicare-certified hospice tom management; program. Enrollees who elect to receive services from the GHC Hospice Program are entitled to 0369 Page 30 B90 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 C. Mental Health Care, Alcoholism and Drugmedical condition or when deemed ap- 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 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/UrgentlyNeeded 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(haw) 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 31 B90 (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- penes 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 ser- 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 corn 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- ize GHC's designated providers in order to c. Nursing care provided by a licensed professional nurse. be covered. 12. Home intravenous (M drug therapy ser- "Chronically dependent person" under this sec- vices tion mean person 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 V1. Exclusions and Limitations post-surgical dressings, and ostomy supplies, are covered. A. Exclusions. I. Rental or Purchase of Durable Medical Equip- 1. Investigational procedures, including medi- ment, such as oxygen and Oxygen equipment, cal and surgical services, drugs and devices wheelchairs and other walk-aids, and hospital until formally approved by Medicare unless beds,is covered. specifically provided herein (See Section XI.A.10. in the Group Medical Coverage J. Respite Care. Agreement). 1. Eligibility. Respite care is provided to 2. Supportive devices for the feet. chronically dependent person for reason- able and necessary hn-home services, 3. Services directly related to obesity except as provided that such services are: provided by Medicare. a. authorized in advance by a GHC phys- 4. Services or supplies not specifically listed as ician; covered by Medicare or GHC. 0369 Page 32 B90 B. Limitations. should be sent to: Medicare Claims, Group Health Cooperative of Puget Sound. If you must receive Conditions and Extent of Coverage. EXCEPT Emergency or Urgently Needed Services from a non- AS PROVIDED IN SECTIONS V.F.10. AND GHC provider, be sure to show your GHC I.D. card V.F.11., ALL SERVICES AND BENEFITS and your red,white,and blue Medicare card. UNDER THIS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL PERSON- A. The Enrollee must file claims for services NEL AT A GHC OR GHC DESIGNATED rendered during the first nine (9) months of a FACILITY UNLESS: calendar year by December 31 of the following 1. the Enrollee has received a Referral from calendar year. GHC, including formal advance approval B. The Enrollee must file claims for services through GHC's Medicare medical coverage rendered in the last three(3)months of a calendar approval process,or year the same as if the services had been furnished in the su uent calendar year.The time limit on 2. the Enrollee has received Emergency or Ur- filing clamor services furnished in the last three gently Needed Services as defined in Section (3) months of the calendar year is December 31 I. and as set forth in Section V.D. of this of the second calendar year following the calen- Medicare Endorsement. dar year in which the services were rendered. Section VII. Claims Procedure See"The Medicare Handbook"for additional in- formation regarding filing claims. Claims for services or supplies and explanation of GHC may obtain information which it deems Medicare benefits for services or supplies from necessary concerning the medical care and providers other than Group Health Cooperative hospitalization for which payment is requested. 0369 Page 33 B90 GHealth 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 This Endorsement does not constitute a Medicare GROUP MEDICAL COVERAGE AGREEMENT. supplemental contract. COVERAGE UNDER THE GROUP MEDICAL 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 CARE." THE BENEFITS AND EXCLUSIONS purpose of meeting personal needs and could be DESCRIBED IN THIS ENDORSEMENT APPLY provided by persons without professional skills or ONLY TO ENROLLEES WHO ARE COVERED training. Custodial Care includes help in walking, UNDER PART B ONLY OF MEDICARE. 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 Facilitywould 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 34 B90 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 A. Termination of Specific Enrollees. authorized in advance by a GHC physician, and 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 the first of the month as specified by SERVICE AREA: The geographic area comprised of HCFA. 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 followin*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 3. For Cause. Enrollment may be terminated health due to an unforeseen illness or injury while upon written notice for: temporarily absent from GHC s Service Area,and 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- rollment upon ten (10) working days' term used to define the level of benefits which are 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 35 B90 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 parry'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 All benefits and services listed in this Schedule of interest. Benefits: GHC shall not pay any attorney's fees or collection 0 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 36 B90 • 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 a. drugs and biologicals that are used benefits. 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 c. counseling services for the Enrollee hospice services do so in lieu of curative treat- and his/her primary care-giver(s); and ment for their terminal illness for the period that 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. Covered Services. Hospice services may include B. Outpatient Mental Health Care,Alcoholism and Drug Abuse Treatment Services are covered for the following as prescribed by a GHC physician each Enrollee in accordance with Medicare and rendered pursuant to an approved hospice Guidelines. plan of treatment: C. Outpatient Emergency/Urgently Needed Ser- 1. Home Services 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 Facility is 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 37 B90 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- theses, artificial eyes, and braces, are covered. 8. Immunizations and vaccinations that are 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. G. Medical/Surgical Supplies,such as casts,splints, 9. Services related to dysfunction of the jaw. post-surgical dressings, and ostomy supplies, are When Referred by a GHC physician,evalua- 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 1. Respite Care. TMJ dysfunction, will NOT be provided when the dysfunction is related to maloc- 1. 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(haw) surgery,are excluded regardless of origin or a. authorized in advance by a GHC cam. 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 38 B90 rises for Medicare Part B Covered Conditions and Extent of Coverage. EXCEPT KeServices 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 ollowing 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, should be sent to: Medicare Claims, Group Health or transferring in and out of a bed or chair; and Cooperative of Puget Sound. If you must receive who meet the eligibility requirements described Emergency or Urgently Needed Services from a non- above. GHC provider, be sure to show your GHC I.D. card and your red,white,and blue Medicare card. Section VI. Exclusions and Limitations A. The Enrollee must file claims for services A. Exclusions. rendered during the first nine (9) months of a calendar year by December 31 of the following 1. Investigational procedures, including medi- calendar year. cal and surgical services, drugs and devices B The Enrollee must file claims for services until formally approved by Medicare unless rendered in the last three(3)months of a calendar specifically provided herein (See Section year the same as if the services had been furnished XI.A.10. in the Group Medical Coverage y Agreement). in the subsequent calendar year.The time limit on filing claims for services furnished in the last three 2. Supportive devices for the feet. (3) months of the calendar year is December 31 of the second calendar year following the calen- 3. Services directly related to obesity except as dar year in which the services were rendered. provided by Medicare. See"The Medicare Handbook"for additional in- 4. Services or supplies not specifically listed as formation regarding filing claims. covered by Medicare or GHC. GHC may obtain information which it deems B. Limitations. necessary concerning the medical care and hospitalization for which payment is requested. 0369 Page 39 B90 AT I.OWANCES DEDUCTIBLES,COPADUMS,AND FEES SCHEDULE The following Allowances,Deductibles,Copayments and Fees are subject to Pre-existing Condition limitations as defined in the Medical Coverage Agreement. ALLOWANCES/DEDUCTIBLES/ BENEFIT COPAYMENTS/FEES 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 DeRcndenCy'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 Eme envy 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. • At a non-GHC Designated Facility $100 Deductible per Emergency visit per Enrollee.Emergency Deductible does not apply to Stop Lou. Stoll Loss 0369 Page 40 B90 Total out-of-pocket Copayment/Coinsurance Limited to an aggregate maximum of$750 per expenses for Emergency care at a GHC or GHC Enrollee and$1,500 per family per calendar year Designated Facility 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 41 B90 Nasal CPAP Deist 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. External Breast Prostheses External breast prostheses following Covered Services are subject to a 50% mastectomy and post-mastectomy bras Coinsurance.Coinsurance amount does not apply to Stop Loss. TemnoromandibLLr Joint CM) 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 prescribed by a GHC physician and obtained at a GHC pharmacy. PA-754-Basic Agreement CA-174-Medicare A&B CA-175-Medicare B Only PA-117-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 42 B90 Group 5. . Cooperative Dues Schedule of Puget Sound For attachment to Group Medical Coverage Agreement with: CITY OF KENT GROUP # 0369 This schedule reflects Options Health Care, Inc monthly dues effective January 1, 1993 and guaranteed to January 1, 1994. MONTHLY HEALTH CARE DUES Subscriber only................................................................................................. $160.67 per month .Subscriber and spouse.................................................................................... $359.48 per month Subscriber and child(ren)................................................................................. $324.03 per month Subscriber and family....................................................................................... $514.62 per month Spouseonly....................................................................................................... $198.81 per month Child(ren) only................................................................................................... $163.36 per month Spouse & Children............................................................................................ $353.95 per month COPAYMENT PROVISION The following copayments apply to this plan. See Group Medical Coverage Agreement for benefit details. $0.00 Outpatient/Office Visit $0.00 Outpatient Prescription Drugs $25.00 Emergency Room 0 Month Pre-existing Condition BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the first day of the coverage month for which they become payable. Each remittance must be accompanied by a list of subscribers for whom such dues are paid. Per average enrollee in 1992, 9.0 percent of the total budgeted revenues from dues, medical services, and copayments is the budgeted cost of pharmaceuticals and prescriptions dispensed on written orders of Group Health practitioners. Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or mental handicaps in its employment practices or services. BILLING INFORMATION, Continued Regardless of the effective date of enrollment for a Subscriber and Family Dependents, the Group will not be required to submit dues to the Cooperative for the month of enrollment, and these Enrollees will appear on the subsequent month's billing at the regular charge. When the Subscriber's enrollment terminates, the group will submit the full amount of dues to the Cooperative regardless of the specific date of termination for that month. WashD Service Areas dRipt9a�d •. ::rF>kttk{k::.>:•:?k:}:-}:•r::i4}•}r<:..>:: ,{.r? .... f4Y{?F}:%•i3::J::•YG:'{4::.ii:'<{4::.i} ::::::.:.. r.•..t,... .. :%r+FF; {>.T.v rn•F'fr �A,Yr};'ktinh.,.'ti+•i}a•�':4 !;jr,.••;3 r .r x�:kFr`:+:'!:$#xa•;:�:q'r{::#$$$$:::::;:}::;_F•r,.FF:•r •;}:.;::.:: , Idsdiosl CW"M I,1 k#•}`yy 'k•r-.:}2;;}:k:{:kk;:Y'}';.ti;#'#:#.. ♦ spsaslty c«h.n j r : ' .SJ r.F... ME ::'•>3;:3Y'Y.;;' M Dsaigrtsasd fodNtlN ,}on3f;h?S.:.. :.{•.air$$. 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Y. x:::..r.?.4xf..;?. }:•:4Frrr;};;;?;k:Fi$r#'{'i$rFF:::sFFFF:k:iii':�:k-r:'��:.:::::::.:.. }i::k' ;¢ 'f rvkkx:i .vJy,4}'i+::::• ..... ::,•ti:: ::. rr:;Jf4{:-0tn:' <::t•r;7.•!r.,>.;.;.;J;•>:. ............r k+r.•rv� •:,q:to+•:rasa:- 'i'iji: �w A W DoiW 41090 Facliitles aroup Health Medical Nortluhore Medical Caner Snolrsrrdsh'County t;"hol lrnn and specialty Cet 11913 NA 195th St.Bothell,WA 98011 Bve+ett Medical Center St Joseph Hospital (206)ll VA 0 14.E Camino Rd. 2901 Squalicum parkway King County Even t,WA 98M Bellingham,WA 96225 Burien Medical Center Rainier Medical Center Cam)347 7800 (206)734.5400 140 S.W.146th St 5316 Rakder Ave.S. Seattle,WA 98166 Seattle,WA 98118 Lys Medical St Joseph Hospital (206)433-29W (2W 721-%W 20200 54th Ave.W. South Campus Lynnwood,WA 98036 809 E Chestnut St Capita Hill Family Health Center Renton Medical Center C206)672-6822 Bellingham,WA 96225 12216th Ave.E 275 Bronson Way N.E North Everett Satellite (206)734-8300 Seattle,WA 98112 Renton,WA 980% (206)326-3454 C206)235-2800 1410 Broadway Bremerton Eva+ett,WA 98201 (206)388-4000 Harrison Memorial Hospital The Cate Center at Kelsey Creek University Medical Center 2520 Cherry Ave. 2210132nd Ave.S.E 4225 Roosevelt Way N.E.4th ftor Bellevue,WA 98005 $ei�e,WA 98105 'm and Women's Bremerton,WA 9e310 (206)957-2400 (206)634-4000 Healthcare Services (206)377-3911 13"Rockdeller,Suite 120 Central Medical Center South Kits"County Eves,WA 98201 Evorett 125 16th Ave.E (206)3884 M0 providence Hospital Seattle,WA 98112 Bainbridge:Island Medical Center 916 Pacific(206)326-3000 621 High School Rd N.W. Thmnston Coumrty Everett,WA 96201 Bainbeldge Island,WA Sella Downtown Seattle Medical Center C2�842-9911 70000 .� Center (206)258-7123 Rd Medical-Dental Bldg,Ninth Floor Port Orchard M�Canter Olympia,4 WA 9 506 M•Vernon Sea Olive W 1950 Perry Ave. Skagit Valley Hospital Seattle,WA 98101 Part Orchard,WA 98366 1415 E Kincaid (206)223-2611 (206)8953000 West Olympia Medial Carter Mt Vernon,WA 98273 3030 Limited Lune N.W. (206)424-4111 Eastside Primary Care Center Fort Orchard Medical Olympia,WA 98502 2701 156th Ave.N.E (206)352-5200 Redmond,WA 98052 1�Pottery Ave. olynipla (206)883-5151 pon Orchard,WA 98366 St Peter Hospital (206)89 r5000 Qroup Health 413 N.Lilly RA Eastside Specialty Center O WA 98506 2700152nd Ave.N.E Group health Mew Hospitals (206)491-9840 Redmond,WA 98052 CrntatiSBverdmle Ithig Co (2�883.5151 10452 Silverdale Way N.W. Cxnt al�� Sedre Woolley Sibcaddc,WA 98383 United General Hospital 13451fa Medical t. (2�692 3880 2001Sth Ave.1 1971 Hospital Drive 13451 S.E 36th St Seattle,WA 98112 pP Bellevue,WA 98006 (206)326-30W Sedw Woolley,WA 98294 (200 562-1330 Pleree ComrRlty (206)8566021 Tacoma Medical Center Eastside Hospital Family Practice Residency 1112 S.Cushman 27001S2ndAve.N.E Tacoma 20015th Ave.E Tacoma,WA 98405 Redmond,WA 98052 May Bridge Children's Hospital Seattle,WA 98112 (206)383.7801 (206)SOM151 317(206)3263 Tacoma,South A St aco®a,WA 98405 Tacoma South Medical Center pierce Cormrrty (206)594-1404 Federal Way Medical Center 9505 S.Steele St r,�p Heath Inpatient Center Fed S.l Way St Tacoma, -6 98444 at Tacoma General Hospital Tacoma General Hospital Federal Wry,WA 98003 (206)597-6800 �(206)974-7000(King Co.) 315 South•IC'St 31S South•K•St (206)927 7511(Pierce Co.) Tacoma Spedalq Center Tacoma,WA 98405 Tacoma,WA 98405 209 South'K'St (206)394-1335 (206)594-1000 Madrona Medical Center Tacoma,WA 98405 1403 34th Ave Seattle,WA 98122 (206)5963300 Qroup Health Vachon (206)720-60M Tacomawvawe D*Wwu ted Vmhon Heath Center Primary Care Center Faeiptles Sunrise Ridge Center Northgate Medical Center 124 Tacoma Ave.S. 10030 S.W.210th St Vashon,WA 98070 Seat Fourth Ave.N.E Tacoma,WA 98402 Anaaortse (206)463-3671 Seattle,WA 98115 (206)383-6125 (206)527-7100 Island Hospital 1211 24th St Anscortes,WA 9=1 C206)2933181 08-03145 PA-1117 (r.1/9M GS.8370 *G'0U� 1730 Minor Avenue ^H,ea th COO erative P.O.Box 34750 p Seattle,Washington 981241750 of Puget Sand April 20, 1993 DONE ANS R COMPANY INC 1210 PLAZA 600 BLDG SEATTLE WA 98101 Dear Mr.Evans: Enclosed are three copies of the 1993 Group Health medical coverage agreement for City of Kent, #0369. One copy must be signed by the person who represents City of Kent,#0369 and returned to us within three weeks. The second copy is for your records,and the third copy is for City of Kent, #0369's records. The agreement includes changes we've made that reflect enhancements to the plan. We've also corrected or clarified language so it more accurately reflects our current administrative or care delivery practices. The following changes have been made and can be found in the referenced sections: • Definitions of coinsurance,copayment Section I. and referral • Clarification of termination provisions Section III.B.1. • Miscellaneous provisions Section VIII.F. • Organ transplants Section X.B.8. • Temporomandibular joint (TMJ) Section X.B.12. (Also see Allowances Schedule) services • Total parenteral nutrition therapy Section X.B.17. • Plastic and reconstructive services Section X.D.1. • Smoking cessation = Section X.M. (Also see Allowances Schedule) • Employment related immunization Section XI.A.9. exclusion • Investigational or experimental Section XI.A.10. treatment exclusion • Specialty treatment program exclusion Section XI.A.24. • Medicare program See Medicare Endorsements In addition, other benefit or contract provisions that you or Group Health might have requested or negotiated during the contract renewal process are included in the enclosed contract. The dues schedule,which is part of the medical coverage agreement, confirms the dues increases specified in a previous letter which the group has accepted. If you have any questions about this information or your new contract,please call your Marketing account executive: Seattle 448-4140 or toll free in WA 1-800-542-6312 Tacoma 383-6226 Kitsap County 479-6241 Whatcom/Skagit County 647-7222 or toll free in WA 14800-5524330 We appreciate your business. Sincerely, Sonia Rogers Contract Administration cc: Marketing Enclosure CCN4 CONTRACT REVISIONS Effective 01/01/93 CONTRACT LANGUAGEMENEFIT EXPLANATION CLARIFICATION OR CHANGE Definition of Referral "Referral" has been modified to define a referral as a written temporary referral agreement authorized in advance by a GHC physician . . . and is subject to all terms and conditions of the Referral and this Agreement. This language clarification is consistent with OIC request, and has been added to the basic contract. Administration of referral procedures has not changed. Plastic and Reconstructive Surgery In addition to reconstructive surgery following mastectomy, including external breast prostheses, clarification was made to state that plastic and reconstructive services are also covered to correct a medical condition following an injury or incidental to surgery covered by GHC which has produced a major effect on the EnroUee's appearance, provided the Enrollee has been continuously enrolled with GHC since the date of such injury or surgery; and when in the opinion of a GHC physician, such services can reasonably be expected to correct the condition. Complications of noncovered surgical services are still excluded. The contract was formerly silent on the appearance factor associated with medically necessary reconstructive surgeries. This clarification has been added to the basic contract in order to more accurately reflect GHC's previous administration of the benefit. Smoldng Cessation This is a new benefit to be added to the basic contract. The benefit states that When provided through Group Health, services related to smoldng cessation are limited to: • participation in one individual or group program per calendar year covered at 50% of total charges; • educational materials covered in full;and • one course of nicotine replacement therapy per calendar year covered subject to any applicable pharmacy copayment, provided the Enrollee is actively participating in the Group Health Smoking Cessation Program. The 50% coinsurance does not apply to the Stop Loss. I0170INVS (01/93) 1 OSHA-required Immunizations The exclusion of examinations and related reports for employment, immigration, license, or insurance purposes now also includes immunizations related to the above. This added language is a clarification of previous GHC policy that excludes work-related immunizations, and is specified here in response.to OSHA regulations. This change is being added to the basic contract Indemnification Language This provision has been added to the basic contract, and describes GHC's standard indemnification policy. GHC agrees to indemnify and hold the Group harmless against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of GHC's failure to perform or negligent performances of its express obligations under the Group Medical Coverage Agreement GHC further agrees to indemnify and hold the Group harmless against claims, damages, losses or expenses, including reasonable attorney's fives, for injury or damage caused to any person which is the result of or is alleged to be the result of the failure to provide or the negligent provision of medical services or supplies specified under this contract by any health care provider who is employed by,is an agent of or who has a direct contractual relationship with GHC. Provided, however, that the Group notifies GHC in writing promptly of any such claims, that it will assist GHC (at GHC's expense) in the defense of same, and that GHC has the right to direct and arrange the defense of the case. The foregoing shall not in any way be construed as applying to any claim, demand or loss arising out of negligent acts or omissions of the"Group, its agents, officers or employees, or failure by the Group to carry out any of its responsibilities under this Agreement Exclusion of Specialty Treatment Programs A clarification has been made to the following exclusion: Specialty treatment programs that are not provided by GHC, including weight reduction, rehabilitation, and "behavior • modification programs.•, While these programs have always been excluded, they are now being specifically listed as part of this exclusion as clarification. 10170TWS (01193) ? Temporomandibular Joint(IW Services In order to comply with the recent OIC ruling, which specified the minimum limits for -the tempommandibular joint (TMJ) offering, the TMJ provision was changed from: Services related to dysfunction of the jaw: when referred by a GHC= physician, evaluation and treatment at a GHC-approved temporomandibular joint (rW care provider, and occlusal splint fitting. All TMJ appliances, including the occlusal splint and night guard, are excluded. Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when the dysfunction is related to malocclusion or when TMJ services are needed due to dental work performed. All such services and related hospitalization, including orthodontic therapy and orthognathic (jaw) surgery, are ex- cluded, regardless of origin or cause. The language was changed to: Medical and surgical services, including orthog- nathie (jaw) surgery for the treatment of temporo- mandibular joint (TMJ) disorders are covered when determined to be Medically Necessary and referred in advance by GHC. Such disorders may exhibit themselves in the form of pain, infection, disease, doiculty in speaking, or difficulty in chewing or swallowing food. TMJ appliances are covered as set forth under orthopedic appliances (Section X.E.1.). Treatment for cosmetic purposes and all dental services including orthodontic therapy are excluded regardless of origin or cause. Changes to the TMJ offering include coverage for orthognathic surgery, TMJ appliances covered at 50%, and a $1,000 calendar year/$5,000 lifetime - maximum benefit. Note: The maximum benefit should not affect the majority of persons receiving treatment for TMJ. I0170IWS (01/93) 3 Investigational or Experimental Treatment Exclu- In order to comply with the recent OIC ruling, the sion investigational treatment exclusion was changed. Investigational or experimental treatment, includ- ing medical and surgical services, drugs, devices and biological products, until formally approved by GHC for medical coverage. GHC's determination 2 shall be made in accordance with criteria for determining investigational status as established by GHC as generally outlined below. Specific indications and methods of use shall be considered in GHC's review of evidence provided by evalua- tions of national medical associations, consensus panels, and/or other technological evaluations, including the scientific quality of such supporting evidence and rationale. Any investigational or experimental treatment, including medical and surgical services, drugs, devices and biological products not meeting GHC's determination pursuant to its criteria as outlined below are excluded a. Investigational or experimental drugs, devices and biological products until clinical trials have been completed and approved by.the U.S. Food and Drug Administration (FDA) as being safe and efficacious for general marketing and permission has been granted by the FDA for commercial distribution; b. there is sufficient scientific evidence in pub- lished medical literature to permit conclusions concerning the effect of the treatment on health outcomes; c. there is conclusive evidence in published peer-reviewed medical literature that the treatment will result in a.demonstrable benefit for the particular injury, disease or condition - in question, and that the benefits are not outweighed by risks; d. evidence that the new treatment is as safe and effective as all existing conventional treatment alternatives;and e. that treatment will satisfy (c)and(d) outside of a research setting. Appeals regarding denial of coverage must be submitted to your regional Consumer Relations Department, or to GHC's Contracts and Coverage Department at 1730 Minor Avenue, Suite 1910, Seattle, WA 98101. GHC will respond in writing within twenty(20) working days of the receipt of a fully documented request. I01701WS(01/93) 4