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HomeMy WebLinkAboutCAG1992-0039 - Original - Group Health Cooperative - Group Medical Coverage Agreement - 01/01/1992 Grou •, Heath Cooperative of Puget Sound GROUP MEDICAL COVERAGE AGREEMENT Group Health Cooperative of Puget Sound (also GROUP HEALTH COOPERATIVE referred to as "GHC" or "the Cooperative") is a non- OF PUGET SOUND • profit health maintenance organization furnishing y .10 health care primarily on a prepayment basis.As a direct aY = f service provider, the Cooperative is dedicated to f� providing to its Enrollees quality health care,including Titk Vice President,Health Plan and Insurance Services preventive medical services. GROUP This Agreement states the terms of enrollment, pay- CITY OF KFNT ment and coverage under which a Group may secure GHC health benefits. The Schedule of Benefits lists #0369 the benefits to which those enrolled under this Agree- ment are entitled. Words with special meaning are By capitalized.They are defined in Section I. 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 01/01/92 EMERGENCY SERVICES ACCORDING TO and will continue in effect until terminated as herein SECTION X.I. OF THE SCHEDULE OF provided for. BENEFITS. 0369 7A5 Pagel GROUP MEDICAL COVERAGE AGREEMENT Table of Contents I. Definitions II. Dues and Fees III. Termination IV. Continuation Coverage, Conversion and Transfer V. Coordination of Benefits VI. Subrogation VII. Grievance Procedures VIII. Miscellaneous Provisions IX. Enrollment and Eligibility Schedule X. Schedule of Benefits XI. Exclusions and Limitations XII. Claims • Medicare Endorsements • Dues and Fees Schedule • Service Area Map 0369 7A5 Page 2 Section I. Definitions eligibility requirements,is enrolled hereunder,and for whom the dues prescribed in the Dues and Fees Schedule have been paid. AGREEMENT: This Medical Coverage Agreement, including the Schedule of Benefits, Enrollment FAMILY UNIT: A Subscriber and all his/her Family and Eligibility Schedule,Dues and Fees Schedule, Dependents. Coordination of Benefits Attachment, Service Area Map, and any applicable endorsements. GHC DESIGNATED FACILITY: A facility, not in- cluding a GHC Facility,which the GHC Board of ALLOWANCE: The maximum amount payable by Trustees has specified to provide health care ser- GHC for certain Covered Services under this vices to its Enrollees. (See Service Area Map.) Agreement, as set forth in the Dues and Fees Designated Facilities may be changed by GHC Schedule. upon appropriate notice. COINSURANCE: An amount that the Enrollee is GHC FACILITY: A hospital or medical center owned required to pay for Covered Services received and operated by Group Health Cooperative of under this Agreement,which is a percentage of the Puget Sound. (See Service Area Map.) cost of such services, as set forth in the Dues and Fees Schedule. GHC MEDICARE PLAN: A plan of coverage for persons enrolled in Medicare Part A(hospital in- COPAYMENT: A fee charged by GHC to an Enrollee surance)and Part B(medical insurance),or Part B for certain Covered Services under the Agree- only. ment, as set forth in the Dues and Fees Schedule. GROUP: An employer, union, welfare trust, or as- COVERED SERVICES: The services and benefits to sociation which has entered into a Group Medical which an Enrollee is entitled under this Agree- Coverage Agreement with GHC. ment. HEALTH EVALUATION: Screening of the applicant DEDUCTIBLE: A specific maximum amount paid by or other eligible persons prior to enrollment sc- an Enrollee for certain Covered Services before cording to the standards which may be defined by benefits are payable under this Agreement. The Group Health Cooperative to determine whether applicable Deductible amounts are set forth in the such person is qualified for enrollment under this Dues and Fees Schedule. Group Medical Coverage Agreement. DIRECTORY OF SERVICES: A fee-for-service HOSPITAL CARE: Those Medically Necessary ser- schedule adopted by GHC, setting forth the fees vices generally provided by acute general hospitals for medical and hospital services not covered by a for admitted patients which a GHC physician has GHC prepayment agreement. prescribed, directed, or authorized. Hospital care does not include convalescent or custodial care EMERGENCY: The sudden, unexpected onset of a which can, in the opinion of the GHC physician, medical condition that in the reasonable judgment be provided by a nursing home or convalescent of a prudent person is of such a nature that failure care center. to render immediate care by a licensed medical provider would place the Enrollee's life in danger, MEDICAL PERSONNEL: The Medical Staff, Clinic or cause serious impairment to the Enrollee's Associate Staff, and Allied Health Professionals health. employed by GHC, and any other health care professional with whom GHC has entered into a ENROLLEE: Any Subscriber or Family Dependent formal legal arrangement. covered by this Agreement. MEDICALLY NECESSARY: Required for the diag- nosis or treatment of illness or injury, as deter- Subscriber's family who meets all applicable 0369 7A5 Page 3 mined by a GHC physician, and consistent with URGENT CONDITION: The sudden, unexpected professionally recognized standards of health care. onset of a medical condition that is of sufficient severity to require medical treatment within twen- MEDICARE: The federal health insurance program ty-four(24) hours of its onset. for the aged and disabled. USUAL, CUSTOMARY, AND REASONABLE: A OPEN ENROLLMENT: An annual period, specified term used to define the level of benefits which are by the Group and GHC, during which an eligible payable by GHC when expenses are incurred from person may apply for coverage. a non-GHC physician or provider. Expenses are P considered Usual, Customary, and Reasonable if RE-EXISTING CONDITION:A condition for which (1) the charges are consistent with those normally there has been diagnosis, treatment (including charged by the provider or organization for the prescribed drugs), or medical advice within the same services or supplies; and (2) the charges are twelve (12) month period prior to the effective within the general range of charges made by other date of coverage, or a condition for which providers in the same geographical area for the symptoms existed within the twelve (12) month same services or supplies. period prior to the date of coverage and for which a prudent person would have ordinarily sought treatment. Section II. Dues, Fees, and Copayments REFERRAL:A prior written authorization by a GHC A. MONTHLY DUES PAYMENTS. The Group physician, approved by GHC, which entitles an shall submit to GHC for each Enrollee the month- Enrollee to receive Covered Services from a ly dues set forth in the current Dues and Fees specified non-GHC health care provider. Entitle- Schedule and a verification of enrollment, on or ment to such services shall not exceed the limits of before the due date, subject to a grace period of the Referral and is subject to all terms and condi- ten(10)days.Dues are subject to change by GHC tions of this Agreement. upon thirty(30)days written notice. SERVICE AREA: King, Kitsap, Pierce, Skagit, B. SUBSCRIBER'S LIABILITY. The Subscriber is Snohomish, Thurston, and Whatcom Counties, liable for (1) payment to the Group of his/her and any other areas designated by GHC. (See contribution toward the monthly dues,if any; (2) Service Area Map.) payment to the Cooperative of Copayments and/or Coinsurance amounts for Covered Ser- SKILLED HOME HEALTH CARE: Reasonable and vices provided to the Subscriber and his/her Fami- necessary care for the treatment of an illness or ly Dependents, as set forth in the Dues and Fees injury which requires the skill of a nurse or Schedule; and (3)payment to the Cooperative of therapist, based on the complexity of the service any fees charged for non-Covered Services and the condition of the patient, and which is provided to the Subscriber and his/her Family performed directly by an appropriately licensed Dependents. professional provider. At the time of service,Enrollees shall be required STOP LOSS: The maximum amount of Copayments to pay Copayments as set forth in the Dues and paid during the calendar year for Covered Services Fees Schedule.Failure to pay Copayments at the received by the Subscriber and his/her Family De- time of service may result in a billing fee not to pendents during the same calendar year.The Stop exceed five dollars ($5.00). Loss amount is set forth in the Dues and Fees Payment of a Copayment does not exclude the Schedule. possibility of an additional billing if the service is SUBSCRIBER: A person who meets all applicable determined to be a non-Covered Service. eligibility requirements,is enrolled hereunder,and Total out-of-pocket Copayment expenses in- for whom the dues specified in the Dues and Fees curred during the same calendar year shall not Schedule have been paid. 0369 7A5 Page 4 exceed the aggregate maximum amount (Stop or omission of information in order to obtain Loss)as set forth in the Dues and Fees Schedule. Group coverage. If Copayments have been billed, any applicable B. TERMINATION OF SPECIFIC ENROLLEES. billing fees shall not be considered in calculating This Agreement may be terminated as to a total out-of-pocket expenses for Copayments specific Enrollee for any of the following reasons: made. 1. Loss of Eligibility.If an Enrollee no longer C. SELF-PAYMENTS DURING A STRIKE, meets the eligibility requirements set forth LOCK-OUT,OR OTHER LABOR DISPUTE.In in Section IX.B. and is not enrolled for con- the event of suspension or termination of tinuation coverage as described in Section employee compensation due to a strike,lock-out, IV.A., coverage under this Agreement will or other labor dispute,a Subscriber may continue terminate at the end of the month during uninterrupted coverage under this Agreement which loss of eligibility occurs. through payment of monthly dues directly to the 2 For Cause.Coverage of an Enrollee may be Group.Coverage may be continued for the lesser terminated upon written notice for: of the term of the strike, lock-out, or other labor P dispute, or for six (6) months after the cessation a. Nonpayment of dues for a specific En- of work. rollee by the Group. If the Group Agreement is no longer available, b. Material misrepresentation, fraud, or the Subscriber shall have the opportunity to apply omission of information in order to ob- for individual Group Conversion or,if applicable, tain coverage. This includes failure to continuation coverage (see Section IV.), or an answer fully and correctly all questions Individual and Family Medical Coverage Agree- contained in the application forms. In ment at the duly approved rates. such event, the Cooperative may, THE GROUP IS RESPONSIBLE FOR IMME- within two(2)years from the date of the DIATELY NOTIFYING EACH AFFECTED application, refuse to cover any service SUBSCRIBER OF HIS/HER RIGHTS OF for a condition(s) to which such ques- SELF-PAYMENT UNDER THIS tion was relevant, or may rescind or PROVISION. cancel the Enrollee's coverage upon ten (10)working days written notice. Section III. Termination c. Permitting the use of a GHC identifica- tion card by another person, or using another person's identification card to A. TERMINATION OF ENTIRE AGREEMENT. obtain care to which one is not entitled. This Agreement may be terminated in the follow- ing circumstances: d. Failure to comply with the rules and 1. Termination on Notice. Either GHC or the regulations of the Cooperative. Group may terminate this Agreement by e. Nonpayment of charges as set forth in giving thirty (30) days written notice to the Section II.C. other. C. PERSONS HOSPITALIZED ON THE DATE 2. Nonpayment. Failure to make any monthly OF TERMINATION. An Enrollee who is a dues payment in accordance with Section registered bed patient receiving Covered Services II.A. shall result in termination of this in a GHC Facility or GHC Designated Facility on Agreement as of the due date. the date of termination shall continue to be 3. Misrepresentation to Obtain Insurance. eligible for Covered Services for the condition for Group Health Cooperative may terminate which the Enrollee was hospitalized, until dis- charge from the facility.This continued coverage this Agreement upon written notice in the will also apply to an Enrollee hospitalized in a event of material misrepresentation, fraud, 0369 7A5 Page 5 non-GHC Designated Facility as a result of an 2. Family Dependents are eligible for con- Emergency or Referral as set forth in Section tinuation coverage for a maximum period of XI B.1. up to thirty-six (36) months commencing at the date that: D. SERVICES PROVIDED AFTER TERMINA- TION. Any services provided by GHC after the • The Subscriber is divorced or legally effective date of termination (except those ser- separated; vices covered under Section III.C.) shall be charged according to the Directory of Services. • the Subscriber dies; The Subscriber shall be liable for payment of all • the Subscriber becomes entitled to such charges for services provided to the Sub- scriber and all Family Dependents. Medicare; or • a Dependent child ceases to qualify as Section IV. Continuation Coverage, a Family Dependent under Section Conversion and Transfer IX.B.2.(b)or (c). 3. A COBRA eligible beneficiary who is dis- A. CONTINUATION COVERAGE abled prior to or on the date he/she loses coverage due to termination of employment This subsection A. only applies to employer (other than for the beneficiary's gross mis- groups who must offer continuation coverage conduct) or reduction of hours may extend under the applicable provisions of the Con- his/her coverage under COBRA from solidated Omnibus Budget Reconciliation Act of eighteen(18)months up to twenty-nine(29) 1985 ("COBRA"), as amended, and only applies months, so long as the beneficiary provides to grant continuation of coverage rights to the notice of his/her Social Security disability extent required by federal law. determination within sixty (60)days of such determination and before the end of the To the extent required by federal law,if the Sub- eighteen(18)month coverage period.Social scriber or Family Dependent loses eligibility Security Administration certification of total under this Group Agreement, group coverage disability is required.The period of extended may be continued under the circumstances coverage provided under this subsection described below. Except as set forth in Section shall terminate on the first day of the first IV.A.11., below, this provision applies only to month which begins more than 30 days after Subscribers and Family Dependents enrolled the date of the Social Security Admimstra- under this Agreement prior to the date of tion's final determination that the qualified eligibility for continuation coverage who would beneficiary is no longer disabled. otherwise lose coverage as a result of one of the qualifying events listed below in subsections (1.), 4. A Subscriber who is a retiree or the spouse (2.), and (3.). or Dependent of a retiree may continue coverage hereunder if the Subscriber would 1. Subscribers and Family Dependents are otherwise lose coverage hereunder within eligible for continuation coverage for a max- one year of the date a proceeding under Title imum period of up to eighteen (18) months 11 of the United States Code is commenced commencing at the date that: with respect to the Group. Coverage under • The Subscriber's employment is ter- this Section IV.A.4., continues only upon payment of applicable monthly charges to minated (unless terminated for gross the Group at the time specified by the misconduct); or Group. The terms and conditions of this • the Subscriber experiences a reduction coverage are governed by COBRA. in work hours resulting in loss of 5. If an individual enrolled for continuation eligibility for group benefits. coverage experiences a second qualifying event as set forth in subsection (2.) above, 0369 7A5 Page 6 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 first qualifying event. When IX.B.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.A.2. 8. 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. Termination, continuation mailed by the Group to the Enrollee's most coverage may be terminated prior to the recent address as recorded with the Group. prescribed period set forth in subsections No lapse in coverage prior to continuation (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 may sible for submitting such dues with its regular 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 a time- them. ly fashion of the election to continue coverage and the applicable coverage period 10. Group Conversion. In addition to Group (eighteen [18] or thirty-six [36] months). Conversion rights as set forth in Section The Subscriber or Family Dependent endent must IV.B., the Subscriber or Family Dependent enrolled for continuation coverage is en- notify the Group, or plan administrator, if titled to convert to GHC's Group Conver- any, within sixty (60) days following a Sion Plan within a 180-day period prior to divorce, legal separation, or when an en- termination of continuation coverage, if 0369 7A5 Page 7 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.GHQ continue coverage under this Agreement upon Group Conversion Plan-Application. 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 qualified beneficiary under COBRA may Section V. Coordination of Benefits add Family Dependents during the Group's Open Enrollment period and newly eligible Benefits provided under this Agreement do not dupli- persons according to the procedures cate other group coverage for medical care or treat- specified in Section IX.A. ment. If an Enrollee is entitled to receive benefits or B. GHC GROUP CONVERSION PLAN. services for medical care or treatment under another group or governmental plan, GHC may recover the 1. Eligibility. Any Subscriber or Family De- reasonable cash value of services provided under this pendent is entitled to convert to GHC's Agreement so that benefits and services under all plans Group Conversion Plan if his/her coverage do not exceed one hundred percent (100%)of allow- under this Agreement is terminated for any able expenses, 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 following termination under this Agree- The definition of a "Plan" includes the following ment. Coverage under the GHC Group sources of benefits or services: Conversion Plan is subject to all terms and conditions of such plan, including dues pay- 1. Group or blanket disability insurance ment. A physical examination or statement policies and health care service contractor of health is not required for enrollment in and health maintenance organization group the Group Conversion Plan. agreements, issued by insurers, health care service contractors and health maintenance C. PERSONS ENTITLED TO, OR ELIGIBLE TO organizations; PURCHASE MEDICARE. Except as defined by federal regulations, all Enrollees entitled to, or 2• Labor-management trusteed plans,labor or- eligible to purchase Medicare must transfer to the ganization plans, employer organization plans or employee benefit organization GHC Medicare Plan upon such entitlement or eligibility. A condition of coverage under the plans; 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 provisions of the GHC Medicare Plan are fully set services, and separately with respect to the forth in the Medicare Endorsement(s) attached respective portions of any such policy,agree- to this Agreement. ment or other arrangement which do and D. PERSONS AGE SIXTY-FIVE (65) OR OLDER which do not reserve the right to take the WHO ARE NOT ENTITLED TO, OR benefits or services of other policies, agree- ELIGIBLE TO PURCHASE MEDICARE.Upon 0369 7A5 Page 8 sidered o be coverage or benefits paid under this ments or other arrangements into considera- Agreement and, to he extent of Such payments, tion in determining benefits. g 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 for 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 coverage 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 the right, exercisable alone and in its sole discre- and all benefits payable for such Allowable tion, to pay over to any Plan making such other Expenses under all other Plans, except as payments any amounts it shall determine to be provided in subparagraph(3)of this Section, warranted in order to satisfy the intent of this shall not exceed the total of such Allowable provision, and amounts so paid shall be con- Expenses. Benefits payable under another 0369 7A5 Page 9 Plan include benefits that would have been the child as a dependent of the payable had a claim been duly made there- parent with custody of the child for. will be determined before the benefits of a Plan which covers the 3. If child as a dependent of the parent without custody;and a. another Plan which is involved in sub- paragraph(2)of this Section and which ii. when the parents are divorced and contains a provision coordinating its the parent with custody of the benefits with those of this Agreement child has remarried,the benefits of would,according to its rules,determine a Plan which covers the child as a its benefits after the benefits of this dependent of the parent with cus- Plan have been determined; and tody shall be determined before the benefits of a Plan which covers b. the rules set forth in subparagraph (4) that child as a dependent of the of this Section would require this stepparent, and the benefits of a Agreement to determine its benefits Plan which covers that child as a before such other Plan, then the dependent of the stepparent will benefits of such other Plan will be ig- be determined before the benefits nored for the purposes of determining of a Plan which covers that child as the benefits under this Agreement. a dependent of the parent without custody. 4. For the purposes of subparagraph(3)of this Section, the rules establishing the order of Notwithstanding items (i) and (ii) benefit determination are: above, if there is a court decree which would otherwise establish financial a. The benefits of a Plan which covers the responsibility for the medical,dental or person on whose expenses a claim is other health care expenses with respect based other than as a dependent shall to the child,the benefits of a Plan which be determined before the benefits of a covers the child as a dependent of the Plan which covers such person as a de- parent with such financial responsibility pendent. shall be determined before the benefits 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 benefits of the Plan of the parent whose c. When rules(a) and(b)do not establish birthday falls earlier in the year are an order of benefit determination, the determined before those of the Plan of benefits of a Plan which has covered the a parent whose birthday falls later in the person on whose expenses claim is year.This birthdate will refer only to the based for the longer period of time shall month and day,not the year in which a be determined before the benefits of a person was born. If both parents have Plan which has covered such person the the same birthday, the benefits of the shorter period of time, provided that: Plan which covered the parent longer are determined before those that i. The benefits of a plan covering the covered the other parent for a shorter person on whose expenses claim is period of time, except that in the case based as a laid off or retired of a person for whom claim is made as employee, or dependent of such a dependent child, person shall be determined after the benefits of any other Plan i. when the parents are separated or covering such person as an divorced and the parent with cus- employee, other than a laid off or tody of the child has not remarried, retired employee,or dependent of the benefits of a Plan which covers such person; and 0369 7A5 Page 10 ii. If either plan does not have a defendants and/or insurers related to the injured provision regarding laid off or person's claim. The injured person and his or her retired employees,which results in agents shall permit GHC, at GHC's option, to as- each Plan determining its benefits sociate with the injured party or to intervene in any after the other,then the provisions action filed against any third party.The injured person of (i) of this subsection shall not and his or her agents shall do nothing to prejudice apply. GHC's subrogation rights.The injured person shall not d. If none of the above rules determines settle a claim without protecting GHC's interest. the order of benefits,the benefits of the 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 total amount of benefits otherwise to be GHC shall not pay any attorney's fees or collection provided to a person covered under this costs to attorneys representing the injured person Agreement during any Claim Determination where it has retained its own legal counsel or acts on Period, the reasonable cash value of each its own behalf to represent its interests and unless benefit that would be provided in the ab- there is a written fee agreement signed by GHC prior sence of this provision shall be reduced to any collection efforts. When reasonable collection proportionately, and such reduced amount costs have been incurred with GHC's prior written shall be charged against any applicable agreement,to recover GHC's medical expenses,there benefit limit of this Agreement. shall be an equitable apportionment of such collection costs between GHC and the injured person subject to Section VI. Subrogation a maximum responsibility of GHC equal to one-third g of the amount recovered on behalf of GHC. "Injured person"under this section means an Enrollee covered by this Agreement who sustains compensable Section VII.Grievance Procedures injury. "GHC's medical expenses" means the expense incurred and the reasonable value of the services The Consumer Relations Program is designed to help provided by the Cooperative for the care or treatment an Enrollee resolve formal complaints and concerns 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 against the third party, GHC shall have the right to registered at the Enrollee's area medical center.If not recover from the third party GHC's medical expenses. satisfied,the Enrollee should then contact the regional 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 Section VIII. Miscellaneous Provisions Washington law. The injured person and his or her agents must A. DISSEMINATION OF INFORMATION. The cooperate fully with GHC in its efforts to collect Group is responsible for disseminating to Sub- GHC's medical expenses. This cooperation shall in- scribers written information concerning this clude supplying GHC with information about any Agreement which is provided by the Cooperative. 0369 7A5 Page 11 B. IDENTIFICATION CARDS. The Cooperative i. at a GHC Facility or GHC Desig- will furnish cards, for identification only, to all nated Facility;or persons enrolled under this Agreement. ii. at a non-GHC Facility due to an C. ADMINISTRATION OF AGREEMENT. GHC Emergency, provided that all the may adopt reasonable policies and procedures to requirements of Section X.I. of help in the administration of this Agreement. this Agreement are met,including notification of GHC by way of the D. MODIFICATION OF AGREEMENT. This GHC Notification Line within Agreement may be modified by GHC upon thirty twenty-four (24) hours following (30)days written notice. inpatient admission, or as soon thereafter as medically possible. E. Group Health Cooperative reserves the right to construe the provisions of this Medical Coverage GHC shall provide notice of such en Agreement, and to determine any and all ques- rollment to the Subscriber and the tions pertaining to benefit entitlement and Group. It is the Subscriber's respon- coverage. sibility to complete and submit a revised application form to the Group. If the Group Health Cooperative of Puget Sound does not Subscriber does not want the newborn discriminate on the basis of physical or mental hand- child enrolled,he/she must notify GHC icaps in its employment practices and services. within sixty (60) days of the date of birth. Section IX. Enrollment and Eligibility If subsequent to enrollment it is dis- Schedule covered that the newborn child is not eligible or if the Group does not initiate dues payments on or before sixty (60) A. ENROLLMENT days from the date of birth, GHC shall disenroll the child retroactive to the 1. Application for Enrollment.Application for effective date of coverage. enrollment shall be made on an application form furnished and approved by GHC. No Children who are born in a non-GHC person shall be enrolled or dues accepted Facility on a nonemergency basis will until this completed application has been not be automatically enrolled. In the received and approved by GHC.The Group event there is a change in the monthly is responsible for submitting completed ap- dues payment as a result of the addition plication forms to GHC. of a newborn child,the Subscriber must make written application for enroll- s. Newly Eligible Persons. Newly eligible ment to the Group within sixty(60)days Subscribers may make written applica- following the date of birth. tion for enrollment to the Group within thirty-one (31) days of eligibility. If the In the event there is a change in the Subscriber wishes to enroll his/her monthly dues payment as a result of the eligible Dependents, application must addition of an adoptive child, including be made during this same thirty-one newborns, the Subscriber must make (31)day period. written application for enrollment Written application for enrollment for within sixty (60)days from the day that PP the child is physically placed with the a newly dependent person:other than a Subscriber for the purpose of adoption newborn or adopted child, must be and the Subscriber assumes financial made to the Group within thirty-one responsibility for the medical expenses (31)days after the dependency occurs. of the child. A Subscriber's newborn child shall be automatically enrolled when born: 0369 7A5 Page 12 b. If the spouse of a GHC Subscriber loses children,will begin on the first (1st) of eligibility under a group medical plan the month following application. provided by his/her employer, the spouse and any eligible Dependents Provided newborns are enrolled as listed on the spouse's insurance may be specified in Section IX.A.l.a. (above), added to the GHC Subscriber's plan. enrollment is effective from the date of Enrollment must be continuous be- birth. tween plans and application must be made prior to, or at the same time as, A newborn is defined as a child who is termination of previous enrollment. not older than four(4)weeks. c. Open Enrollment. A person not en- For adopted children, enrollment is ef- rolled as a Subscriber or Family De- fective from the date that the adopted pendent when newly eligible, as child is physically placed with the Sub- described above, may make written ap- scriber for the purpose of adoption and plication during the Group's Open En- the Subscriber has assumed financial rollment period. responsibility for the medical expenses of the child. d. Health Evaluation. If a Subscriber or Family Dependent wishes to enroll out- b. Persons Hospitalized on Effective side the periods of eligibility as set forth Date.If a person,other than a newborn, in Section IX.A.1., he/she must first is confined in a hospital on the date satisfy all Health Evaluation require- enrollment would otherwise become ments as established by GHC and effective, the effective date of enroll- defined in Section I. of the Group ment for the person(s)hospitalized will Medical Coverage Agreement. not begin until discharge from the facility. 2. Limitation on Enrollment.This Agreement will be open for application as set forth in 4. Effective Date of Services and Benefits. Section IX.A.1. GHC may limit enrollment, Services provided to Enrollees, including establish quotas, or set priorities for accep- newborns, are subject to all terms and con- tance of new applications if it determines ditions of the Group Agreement including that its capacity,in relation to its total enroll- the requirement that all services must be ment, is not adequate to provide services to received at a GHC or GHC Designated additional persons. Facility under the medical management of a GHC physician unless the Enrollee has been 3. Effective Date of Enrollment. Referred by a GHC physician or has received Emergency services according to a. Provided application is made as set Section X.I. forth in Section IX.A.La. (above), en- rollment for a newly eligible Subscriber B. ELIGIBILITY and listed Dependents will begin on the date of hire. In order to be accepted for enrollment and con- tinuing coverage under the Group Agreement, For eligible Subscribers and Family De- individuals must meet all applicable requirements pendents who have satisfied the Health set forth below. The Group is responsible for Evaluation requirement as set forth in determining eligibility. Section IX.A.1., following acceptance by the Cooperative, enrollment will 1. Subscribers. Bona fide employees who are begin on the date specified by GHC. employed on a regularly scheduled basis of not less than twenty-one(21)hours perweek Enrollment for newly dependent per- shall be eligible for enrollment. sons,other than newborns and adopted 0369 7A5 Page 13 2. Family Dependents.The Subscriber may en- proof of financial dependency roll any of the following: must be furnished to the Coopera- tive upon request, but not more a. The Subscriber's legal spouse; frequently than annually after the dependent children who two (2) year period following the b. Unmarried de P Dependent's attainment of the are under the age of nineteen (19), limiting age. provided they reside regularly with the Subscriber or qualify as Dependents for Ineligible Persons. GHC reserves the right to Federal Income Tax purposes. refuse enrollment to any person whose coverage under the Group Agreement or any other Medi- "Children" means the children of the cal Coverage Agreement issued by Group Health Subscriber including adopted children, Cooperative of Puget Sound has been terminated stepchildren, foster children, and any for cause. other children for whom the Subscriber is the legal guardian. C. CONTINUATION OF ENROLLMENT c. Enrollment may be extended past the While on a group approved leave of absence,the limiting age for an unmarried person Subscriber and listed Dependents will continue to enrolled as a Family Dependent on receive services and benefits under this Agree- his/her nineteenth (19th) birthday if: ment for up to sixty (60) days, provided the employer or Group continues to remit dues to i. the Dependent is a full-time GHC for the Subscriber and such Dependents. registered student at an accredited secondary school, college, or university and under the age of Section X. Schedule of Benefits twenty-three (23);or ii. the Dependent is incapable of Subject to all provisions of this Group Medical self-sustaining employment be- Coverage Agreement, persons enrolled for Com- cause of a developmental dis- prehensive Health Care are entitled to receive the ability or a physical handicap benefits and services that are Medically Necessary as incurred prior to attainment of the determined by GHC's Medical Director, or his/her limiting age as set forth in Section designee, and as described in this Schedule of IX.B.2.b.,or prior to attainment of Benefits. the student limiting age as set forth in Section IX.13.2.c., and is chiefly A. HOSPITAL CARE dependent upon the Subscriber for support and maintenance. A Hospital care is provided when approved by a dependent child shall be con- GHC physician, limited to the following services: sidered chiefly dependent upon the Subscriber for support and 1. Room and board, including private room maintenance when, as a result of when prescribed, and general nursing ser- disability, one-half (1/2) or more vices. of the total support of the depend- ent child is provided by the Sub- 2. Hospital services(including use of operating scriber as determined under room, anesthesia, oxygen, x-ray, laboratory, Internal Revenue Service regula- and radiotherapy services). tion. Enrollment for such a De- 3. Drugs and medications which are listed as pendent may be continued for the covered in the GHC Drug Formulary (ap- duration of the incapacity, provided enrollment does not ter- minate for any other reason. 4. Special duty nursing (when prescribed as Medical proof of incapacity and Medically Necessary). 0369 7A5 Page 14 Personal comfort items, such as telephone and 7. Maternity care,including care for complica- television, are not covered. tions of pregnancy:prenatal and postpartum visits; and hospitalization and delivery. If an Enrollee is hospitalized in a non-GHC Facility, GHC reserves the right to require trans- Prenatal testing for the detection of con- fer of the Enrollee to a GHC Facility, upon con- genital and heritable disorders when Medi- sultation with a GHC physician. If the Enrollee cally Necessary as determined by GHC's refuses to transfer to a GHC Facility, all further Medical Director, or his/her designee. costs incurred during the hospitalization are the Voluntary(not medically indicated and non- responsibility of the Enrollee. therapeutic) or involuntary termination of B. MEDICAL AND SURGICAL CARE pregnancy. Medical and surgical services are provided, 8. Transplants. When authorized as medically limited to the following,when prescribed by GHC appropriate by GHC's Medical Director, or Medical Personnel: his/her designee, and in accordance with criteria established by the Cooperative, for 1. Surgical services. heart,heart-lung,single lung or double lung, kidney, simultaneous pancreas/kidney, cor- 2. Diagnostic x-ray, nuclear medicine, nea, bone marrow, and liver transplants, ultrasound, and laboratory services. limited to the following: 3. Routine eye examinations and refractions, • evaluation testing to determine limited to once every twelve (12) months, recipient candidacy; except when Medically Necessary. Services for routine eye examinations must be • transplantation, limited to costs for the received at a GHC Facility and in accord- surgery and hospitalization related to ance with GHC medical criteria in order to the transplant, and medications;and be covered. • follow-up services for specialty visits, Contact lens fittings and related examina- re-hospitalization, and maintenance tions are not covered except as set forth medications. below. When dispensed through GHC Facilities, one contact lens per diseased eye Transportation expenses,except as set forth in lieu of an intraocular lens,including exam under Section X.J. of this Agreement, and and fitting, is covered for Enrollees follow- living expenses are excluded. ing cataract surgery performed by a GHC physician, provided the Enrollee has been Donor costs are covered,limited to procure- continuously covered by GHC since such ment center fees, travel costs for a surgical surgery. Replacement of a covered contact team, excision fees, and matching tests. lens will be provided only when needed due GHC shall exclude coverage for donor costs to change in the Enrollee's medical condi- to the extent that the donor costs are reim- tion but may be replaced only one time bursable by the organ donor's insurance. within any twelve(12) month period. Except for children who have been con- 4. Family planning counseling services. tinuously enrolled at GHC since birth, coverage for all transplants and any related 5. Hearing examinations to determine hearing services, items, and drugs shall be excluded loss. until such time as the Enrollee has been continuously enrolled under this Agree- 6. Blood derivatives and the administration of ment, or any prior GHC Medical Coverage blood and blood derivatives. The cost of Agreement, for twelve (12) consecutive blood is not covered. months without any lapse in coverage. 0369 7A5 Page 15 9. Physician visits (including consultations and Growth hormone treatment shall be ex- second opinions by a GHC physician)in the cluded until such time as the Enrollee has hospital or office. been continuously enrolled under this Agreement or any prior GHC Medical 10. Preventive services for health maintenance Coverage Agreement for twelve (12) con- including routine mammography screening secutive months without any lapse in and physical examinations in accordance coverage. with criteria established by the Cooperative, for the detection of disease; and immuniza- 16. Respiratory therapy. tions and vaccinations which are listed as covered in the GHC Drug Formulary (ap- 17. Dietary formula for the treatment of proved drug list).A fee may be charged for phenylketonuria (PKU) when determined health education programs. Medically Necessary by GHC's Medical Director or his/her designee. Coverage for 11. Radiation therapy services. this formula is not subject to a Pre-existing Conditions waiting period, if any. 12. Services related to dysfunction of the jaw: when referred by a GHC physician, evalua- Outpatient Total Parenteral Nutritional tion and treatment at a GHC-approved tem- Therapy, when Medically Necessary and in poromandibular joint (TMJ) care provider, accordance with medical criteria as estab- and occlusal splint fitting. lished by GHC is covered including supplies necessary for its administration. Outpatient All TMJ appliances, including the occlusal enteral therapy is excluded. splint and night guard, are excluded. Treat- ment of jaw dysfunction,including TMJ dys- Dietary formulas and special diets, except function, will NOT be provided when the for treatment of phenylketonuria (PKU) dysfunction is related to malocclusion or and total parenteral nutritional therapy as when TMJ services are needed due to dental set forth above, are excluded. work performed. All such services and re- lated hospitalization, including orthodontic 18. Pre-existing Conditions are covered in the therapy,and orthognathic(jaw)surgery,are same manner as any other illness. excluded, regardless of origin or cause. 19. Skilled Nursing Facility care in a GHC-ap- 13. The following services are covered by GHC proved skilled nursing facility up to a maxi- when performed by a GHC physician or mum of thirty (30) days per condition when GHC oral surgeon: reduction of a fracture full-time skilled nursing care is necessary in or dislocation of the jaw or facial bones; the opinion of the attending GHC physician. excision of tumors or cysts of the jaw,cheeks, b When prescribed a GHC physician, such lips, tongue, gums, roof and floor of the p y p eneral mouth; and incision of salivary glands and care may include board and room; g ducts. nursing care;drugs,biologicals,supplies,and equipment ordinarily provided or arranged 14. Nonexperimental implants, limited to the by a skilled nursing facility; and short-term following: cardiac devices, artificial joints, physical therapy. and intraocular lenses.Artificial or mechani- cal hearts are excluded. Excluded from coverage are personal com- fort items such as telephone and television; 15. When authorized as medically appropriate and rest cures,custodial,domiciliary or con- by GHC's Medical Director,or his/her desig- valescent care. nee, and in accordance with criteria estab- lished by the Cooperative, treatment of C. CHEMICAL DEPENDENCY TREATMENT growth disorders by growth hormones. Subject to all terms and conditions of this Agree- ment,care is provided as set forth below at a GHC Facility, GHC Designated Facility, or GHC-ap- 0369 7A5 Page 16 proved treatment facility, subject to the Benefit during the hospitalization are the Period Allowance and Lifetime Maximum responsibility of the Enrollee. Benefit as described below and as shown in the For the purpose of this section, "acute Dues and Fees Schedule. chemical withdrawal" means with- 1. Chemical Dependency Treatment Services. drawal of alcohol and/or drugs from a person for whom consequences of a. All alcoholism and/or drug abuse treat- abstinence are so severe as to require ment services must be: (1) provided at medical/nursing assistance in a hospital a facility as described above and must be setting and which is needed immedi- authorized in advance,except for acute ately to prevent serious impairment to chemical withdrawal as described in the Enrollee's health. Section X.C.2.b.;and(2)deemed Medi- cally Necessary by GHC's ADAPT 3. Benefit Period and Benefit Period Al- Director or his/her designee. Chemical lowance. dependency treatment may include the a. Benefit Period.For the purpose of this following services received on an in- patient or outpatient basis: diagnostic section, "Benefit Period" shall mean a evaluation and education,organized in- twenty-four (24) consecutive calendar dividual and group counseling, month period during which the Enrol- detoxification services, and prescrip- lee is eligible to receive covered chemi- tion drugs and medicines. cal dependency treatment services as set forth in this section. The first b. Court-ordered treatment shall be Benefit Period shall begin on the first provided only if determined to be Medi- day the Enrollee receives covered cally Necessary by GHC's ADAPT chemical dependency services under Director or his/her designee. this or any other group insurance, health care service contractor, health 2. Emergency Care. maintenance organization,self-insured plan or any combination thereof, a. Coverage for medical Emergencies in- hereinafter referred to as"group plans," cident to the abuse of alcohol and/or and shall continue for twenty-four(24) drugs is subject to the Emergency care consecutive calendar months,provided benefit as set forth in Section X.I. that coverage under this Agreement remains in force. All subsequent b. Coverage for acute chemical Benefit Periods thereafter will begin on withdrawal is provided without prior the first day Covered Services are approval. If an Enrollee is hospitalized received after expiration of the pre- in a non-GHC Designated Facility, vious twenty-four (24) month Benefit coverage is subject to payment of the Period. Deductible shown in the Dues and Fees Schedule, and notification of GHC by b. Benefit Period Allowance. The maxi- way of the GHC Notification Line mum allowance available for any within twenty-four(24)hours following Benefit Period shall be the total of all inpatient admission, or as soon there- chemical dependency benefits provided after as medically possible. Further- and payments made for chemical de- more,if an Enrollee is hospitalized in a pendency treatment under any group non-GHC Designated Facility, GHC plan(s), not to exceed the Benefit reserves the right to require transfer of Period Allowance shown in the Dues the Enrollee to a GHC Facility upon and Fees Schedule during the consultation with a GHC physician. If Enrollee's Benefit Period. the Enrollee refuses transfer to a GHC Facility, all further costs incurred 4. Lifetime Maximum Benefit. 0369 7A5 Page 17 Chemical dependency services are not An Enrollee will be covered for all stages of covered after the Enrollee has reached one reconstructive breast reduction on the his/her Lifetime Maximum Benefit amount nondiseased breast to make it equivalent in as shown in the Dues and Fees Schedule.All size with the diseased breast after definitive such benefits provided or payments made by: reconstructive surgery on the diseased breast has been performed. a. GHC under any GHC Group Medical Coverage Agreement; plus 3. External breast prostheses following mas- tectomy and post-mastectomy bras shall be b. all amounts paid on an individual's be- covered limited to one external breast pros- half under any carrier or plan main- thesis per diseased breast every two years, tained by the Group, including and two post-mastectomy bras every six (6) self-insured plans, months, up to four (4) in any twelve (12) consecutive month period. Coverage is sub- shall be applied toward this Lifetime Maxi- ject to the Coinsurance as set forth in the mum Benefit amount. Dues and Fees Schedule. Any Deductibles or Copayments which may E. APPLIANCES,DEVICES AND SUPPLIES be borne by the Enrollee under the terms of this Agreement shall not be applied toward 1. Orthopedic Appliances.When Medically the Benefit Period Allowance or Lifetime Necessary,orthopedic appliances,which are Maximum Benefit. attached to an impaired body segment for the purpose of protecting the segment or In regard to this section, the Benefit assisting in restoration or improvement of its Period(s),Benefit Period Allowance(s),and function, are covered. Medically Necessary Lifetime Maximum Benefit shall include repair, adjustment or replacement of an or- only alcoholism treatment services received thopedic appliance is covered when on or after January 1, 1987 and alcoholism authorized in advance by a GHC physician. and/or drug abuse services received on or Covered Services are subject to the Coin- after January 1, 1988. surance set forth in the Dues and Fees Schedule. Excluded are arch supports; or- D. PLASTIC AND RECONSTRUCTIVE SER- thopedic shoes that are not attached to an VICES are covered: appliance;or any orthopedic appliances that are not listed as covered in GHC's Or- a. to correct an existing functional disorder, as thopedic Appliance Formulary. determined by a GHC physician, resulting from a congenital disease or anomaly; or to 2. Nasal CPAP Device. When Medically correct a medical condition following an in- Necessary, the purchase of a nasal CPAP jury or incidental to surgery covered by device,and the initial purchase of associated GHC, provided the Enrollee has been con- supplies, is covered. The initial one-month tinuously covered at GHC since such injury rental of the device prior to purchase,which or surgery. Complications of surgical ser- is required to establish compliance, is also vices not covered by GHC, including cos- covered. Medically Necessary repair or re- metic surgery, are excluded. placement of a nasal CPAP device is covered when authorized in advance by a GHC 2. Reconstructive surgery and associated pro- physician. Covered Services are subject to cedures following a mastectomy will be the allowance as set forth in the Dues and covered for Enrollees who are medically Fees Schedule.Coverage for replacement of suitable candidates,as determined by GHC's supplies is excluded. Medical Director or his/her designee, regardless of when the mastectomy was per- 3, Ostomy Supplies. Ostomy supplies neces- formed. Internal breast prostheses required sary for the removal of bodily secretions or incident to the surgery will be provided. waste are covered. 0369 7A5 Page 18 4. Oxygen and Oxygen Equipment. When physician and when rendered pursuant to an ap- medical criteria as established by GHC are proved home health care plan of treatment:nurs- met, and upon Referral,oxygen and oxygen ing care, physical therapy, occupational therapy, equipment for home use is covered. respiratory therapy, restorative speech therapy, and medical social worker and limited home Replacement or repair of appliances,devices and health aide services. Home health services are supplies that are due to loss,breakage from willful provided on an intermittent basis in the Enrollee's damage, neglect or wrongful use, or due to per- home. "Intermittent" means care that is to be sonal preference are excluded. rendered because of a medically predictable recurring need for Skilled Home Health Care F. DRUGS AND MEDICINES FOR OUT- services. PATIENT USE as prescribed by a GHC physician for conditions covered by this Agreement. All Excluded are: custodial care and maintenance drugs, supplies, medicines and devices must be care, private duty or continuous nursing care in obtained at a GHC pharmacy. the Enrollee's home, housekeeping or meal ser- vices, care in any nursing home or convalescent Excluded are: dietary supplements, except facility, any care provided by or for a member of therapeutic vitamins for use up to thirty(30)days; the patient's family, and any other services dietary formulas and special diets, except as set rendered in the home which are not specifically forth in Section X.B.; contraceptive drugs and listed as covered under this Agreement. devices and their fitting;medicines and injections for anticipated illness while traveling; and any H. MENTAL HEALTH CARE SERVICES other drugs, medicines, and injections not listed as covered in the GHC Drug Formulary (ap- 1. Inpatient Services: proved drug list). Usual, Customary, and Reasonable charges The Enrollee will be charged for mailing or for services described in this section,includ- replacing lost or stolen drugs, medicines or ing mental health Emergencies resulting in devices. inpatient services, shall be covered up to a maximum benefit of seven(7)days at eighty G. HOME HEALTH CARE SERVICES,as set forth percent (80%) per Enrollee per calendar in this section, shall be provided by GHC Home year.This benefit shall include coverage for Health Services or by a GHC-authorized home mental health treatment in a GHC-ap- health agency when Referred in advance by a proved hospital or other facility devoted GHC physician for Enrollees who meet the fol- primarily to treatment of mental or nervous lowing criteria: disorders. All non-Emergent care must be authorized in advance by the Director of 1. The Enrollee is unable to leave home due to GHC's Mental Health Service, or his/her his or her health problem or illness (unwill- designee, and the facility approved by the ingness to travel and/or arrange for transpor- Cooperative. tation does not constitute inability to leave the home); Subject to the maximum Inpatient Mental Health Care Allowance as set forth in the 2. the Enrollee requires intermittent Skilled Dues and Fees Schedule, services provided Home Health Care services, as described under involuntary commitment statutes shall below;and be covered at facilities approved by GHC for 3. a GHC has determined that such any court-ordered observation period physician and/or treatment up to seventy-two (72) services are Medically Necessary and are hours. Services for a court-ordered treat- most appropriately rendered in the ment program beyond the seventy-two (72) Enrollee's home. hours shall be covered only if determined to Covered Services for home health care may in- be Medically Necessary by the Director of clude the following when prescribed by a GHC GHC s Mental Health Service, or his/her designee. 0369 7A5 Page 19 Coverage for voluntary Emergency in- Day treatment programs are covered only patient mental health services is subject to under Section H.1. (Inpatient Services) of the Emergency Care benefit as set forth in this Agreement. Section X.I., including the twenty-four (24) hour notification and transfer provisions. Treatment under this Agreement is limited to acute care only;custodial care is excluded. Payment of bills incurred for non-GHC treatment shall exclude any charges that Excluded are: all forms of extensive would otherwise be excluded for hospitaliza- psychotherapy including: ongoing care for tion within a GHC Facility, such as chronic mental health conditions; custodial telephone,television, and personal items. care;day treatment;treatment of sexual dis- orders and/or dysfunctions; specialty 2. Outpatient Services: programs for mental health therapy which are not provided by GHC; court-ordered Mental health services,limited to the follow- treatment which is not specifically described ing, are provided on an outpatient basis at above; psychological testing, except when GHC. Subject to the limitations set forth in provided during the course of mental health this section, diagnostic evaluation, brief treatment;classes or courses such as(a)be- focal psychotherapy, intermittent care, and havior modification programs (b) "Parent consultation services will be provided in the Effectiveness Training," and (c) adult following formats:individual,couple,family, development programs, when obtained at or group. non-GHC facilities;or any other services not specifically listed as covered in this section. Coverage for each Enrollee is provided ac- All other provisions, exclusions and limita- cording to the Outpatient Mental Health tions under this Agreement also apply. Allowance set forth in the Dues and Fees Schedule. All individual, family and group I. EMERGENCY CARE visits of one and one-half (1-1/2) hours or less are regarded as one full visit per in- 1. At a GHC Facility or GHC Designated dividual.A missed appointment will be con- Facility.GHC will cover Emergency care for sidered a "visit" unless the Mental Health all Covered Services subject to payment of Service is notified at least twenty-four (24) the Copayment set forth in the Dues and hours in advance of a scheduled session.The Fees Schedule. length of the treatment program and the frequency and type of visits shall be deter- If two (2) or more members of the Family mined by GHC's Mental Health Service. Unit require Emergency care as a result of the same accident, only one (1) Emergency 3. Exclusions and Limitations for Outpatient Care Copayment will apply. and Inpatient Mental Health Treatment Services. If the Enrollee is admitted to a GHC or GHC Designated Facility directly from the emer- Covered Services are limited to those gency room, the Emergency Care Copay- provided for covered conditions for which, ment is waived. in the opinion of the Director of GHC's Mental Health Service, or his/her designee, 2. At a Non-GHC Designated Facility. Usual, significant improvement can be expected Customary, and Reasonable charges for through a short-term treatment program. Emergency care for Covered Services are Enrollees who need long-term individual covered subject to: psychotherapy or who have conditions that cannot be treated within the limits of the a. payment of the Emergency Deductible benefit described in this section and the shown in the Dues and Fees Schedule; Dues and Fees Schedule are not covered. and 0369 7A5 Page 20 b. notification of GHC byway of the GHC 4. Transfer to a GHC Facility. When Notification Line within twenty-four authorized in advance by the Cooperative, (24) hours following inpatient admis- an additional Ambulance Allowance is sion,or as soon thereafter as medically provided for transfer to a GHC Facility. possible. K. HOSPICE If two(2)or more members of a Family Unit require emergency care as a result of the It is understood and agreed that the following same accident,only one (1)Emergency De- fully sets forth the eligibility requirements and ductible will apply. Covered Services for an Enrollee who elects to receive services through GHC's Hospice Pro- Outpatient medications prescribed by a non- gram. Enrollees who elect to receive GHC GHC physician are excluded. Hospice Services do so in lieu of curative treat- ment for their terminal illness for the period that 3. Transfer and Follow-up Care.If an Enrollee they are in the GHC Hospice Program. is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Hospice Program Enrollee to a GHC Facility, upon consult- ation with a GHC physician. If the Enrollee 1. Eligibility. Hospice Services, as set forth refuses to transfer to a GHC Facility, all below, shall be provided to Enrollees for as further costs incurred during the hospitaliza- long as the following criteria are met: tion are the responsibility of the Enrollee. a. a GHC physician has determined that Follow-up care which is a direct result of the the Enrollee's illness is terminal and life Emergency must be obtained at GHC, un- expectancy is six(6) months or less; less a GHC physician has authorized such b. the Enrollee has chosen a palliative care in advance. treatment focus (emphasizing comfort J. AMBULANCE SERVICES are covered as set and supportive services rather than forth below, provided that the service is treatment aimed at curing the authorized in advance by a GHC physician or Enrollee's terminal illness); meets the definition of an Emergency. (See Sec- c. the Enrollee has elected in writing to tion I.) receive hospice care through GHC's 1. Emergency Transport to a GHC Facility or Hospice Program; GHC Designated Facility.Each Emergency d. the Enrollee has available a primary is covered as set forth in the Dues and Fees care person who will be responsible for Schedule. the Enrollee's home care; and 2. Emergency Transport to a Non-GHC e. a GHC physician and GHC's Hospice Designated Facility. Each Emergency is Director determine that the Enrollee's covered as set forth in the Dues and Fees illness can be appropriately managed in Schedule. the home. 3. Waiver of Ambulance Services Deductible. 2. Hospice Care shall be defined as a coor- If two (2) or more members of the Family p Unit require Emergency ambulance dinated program of palliative and supportive transport as a result of the same accident, care for dying persons by an interdisciplinary only one (1) Ambulance Deductible will team of professionals and volunteers center- apply. ing primarily in the Enrollee's home. 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: 0369 7A5 Page 21 a. Home Services b. Housekeeping or meals services. i. Intermittent care by a hospice in- c. Custodial or maintenance care in the terdisciplinary team which may in- home or on an inpatient basis. clude services by a physician, nurse, medical social worker, d. Services not specifically listed as physical therapist, speech covered by this Medical Coverage therapist, occupational therapist, Agreement. respiratory therapist, and limited e. Any services provided by members of services by a Home Health Aide under the supervision of a the patient's family. Registered Nurse. f. All other exclusions listed in Section ii. One period of continuous care XI.,Exclusions and Limitations,of this service per Enrollee in the Medical Coverage Agreement,apply. Enrollee's home when prescribed L. REHABILITATION SERVICES are covered as by a GHC physician,as set forth in set forth in this section, limited to the following: this paragraph.A continuous care physical therapy; occupational therapy; and period is defined as "skilled nuts- care provided in the home speech therapy to restore function following ill- ing care t in a period of crisis order to ness,injury,or surgery. Services are subject to all maintain the terminally ill patient terms, conditions, and limitations of this Agree- at home."Continuous care may be ment, including the following: provided for pain or symptom 1. All services must be provided at GHC or a management by a Registered GHC-approved rehabilitation facility and Nurse, Licensed Practical Nurse, must be prescribed and provided by a GHC- or Home Health Aide under the approved rehabilitation team that may in- supervision of a Registered Nurse. clude medical, nursing, physical therapy, Continuous care is provided for occupational therapy and speech therapy four(4)or more hours per day for providers. a period not to exceed five (5) days,or a total of seventy-two(72) 2. The Enrollee must be referred for hours, whichever first occurs. rehabilitation services in advance by a GHC Continuous care is covered only physician. when a GHC physician deter- mines that the Enrollee would 3. Services are limited to those necessary to otherwise require hospitalization restore or improve functional abilities when in an acute care facility. physical, sensori-perceptual and/or com- munication impairment exists due to injury b. Inpatient Hospice Services shall be provided in a facility designated by or illness. Such services are provided only when GHC's Medical Director, or his/her GHC's Hospice Program when Medi- designee, determines that significant, tally Necessary and authorized in ad-vance by a GHC physician and GHC's measurable improvement to the Enrollee's condition can be expected within a sixty(60) Hospice Program. Inpatient Hospice day period as a consequence of intervention Services shall be provided according to by covered therapy services described in the provisions set forth in Section X.of paragraph one (1) above. this Agreement. 4. Coverage for inpatient and outpatient ser- 4. Hospice Exclusions:All services not specifi- cally listed as covered in this section includ- the Dues and Fees Schedule. ing: Services excluded under this benefit include a. Financial or legal counseling services. the following: specialty rehabilitation 0369 7A5 Page 22 programs not provided by GHC; long-term Section XI. Exclusions and Limitations rehabilitation programs; physical therapy, occupational therapy, and speech therapy A. EXCLUSIONS services when such services are available (whether application is made or not) 1. Blood for transfusions. through governmental programs including programs offered by public school districts; 2. Except as provided in Sections X.B., X.D., therapy for degenerative or static conditions X.E., and X.F., corrective appliances and when the expected outcome is primarily to artificial aids including: eyeglasses; contact maintain the Enrollee's level of functioning lenses including services related to their fit- (except for neurodevelopmental therapies); ting;prosthetic devices;diabetic supplies in- implementation of home maintenance cluding insulin pumps; hearing aids and programs; programs for treatment of learn- examinations in connection therewith;take- ing problems; any other treatment not con- home dressings and supplies following sidered Medically Necessary by GHC; any hospitalization;or any other supplies,dress- services not specifically included as covered ings, appliances, devices or services which in this section; and any services that are ex- are not for the specific treatment of disease cluded under Section XI. or injury,or not specifically listed as covered Neurodevelopmental Therapies for under Section X. Children Age Six (6) and Under. When 3. Cosmetic services, including treatment for determined to be Medically Necessary by complications of cosmetic surgery,except as GHC's Medical Director, or his/her desig- provided in Section X.D. nee,physical therapy,occupational therapy, and speech therapy services for the restora- 4. Dental care, surgery, services, and applian- tion and improvement of function for ces,including:treatment of accidental injury neurodevelopmentally disabled children age to natural teeth, reconstructive surgery to six(6)and under shall be covered.Coverage the jaw incident to denture wear,periodon- includes maintenance of a covered Enrollee tal surgery,and any other dental services not in cases where significant deterioration in specifically listed as covered under Section the Enrollee's condition would result X. The Cooperative's Medical Director, or without the services.Coverage for inpatient his/her designee,will determine whether the and outpatient services is limited to the al- care or treatment required is within the lowance set forth in the Dues and Fees category of dental care or service. Schedule. If a GHC physician determines that an unre- Services excluded under this benefit include: lated medical condition requires that an En- rehabilitation programs; physical therapy, specialty rehabilitation programs;long-term rollee be hospitalized for a dental procedure which is normally done in a dentist's office, occupational therapy, and speech therapy GHC will cover associated hospital and services when such services are available anesthesia costs at a GHC or GHC Desig- (whether application is made or not) nated Facility. GHC will not cover the through governmental programs; programs dentist's or oral surgeon's fees. offered by public school districts; except as set forth above, therapy for degenerative or 5. Certain drugs, medicines, and injections. static conditions when the expected out- (See Section X.F.) Any exclusion of drugs, come is primarily to maintain the Enrollee's medicines, and injections, including those level of functioning; implementation of not listed as covered in the GHC Drug For- home maintenance programs; programs for mulary(approved drug list),will also exclude treatment of learning problems; any treat- their administration. ment not considered Medically Necessary; any services not specifically included as 6. Convalescent or custodial care. covered in this Section;and any services that are excluded under Section XI. 0369 7A5 Page 23 7. Durable medical equipment such as hospital 15. Regardless of origin or cause, diagnostic beds, wheelchairs, and walk-aids, except testing and medical treatment of sterility, while in the hospital or as set forth in Section infertility, and sexual dysfunction. X.E. 16. Services of practitioners whose licensing 8. Services rendered as a result of work-in- category is not represented by GHC Medical curred injuries,illness or conditions. Personnel. 9. Those parts of an examination and as- 17. Services directly related to obesity, except sociated reports required for employment, for nutritional counseling provided by GHC immigration, license, or insurance purposes staff. that are not deemed Medically Necessary by GHC for early detection of disease. 18. Any services for which an Enrollee has a contractual right to recover the cost thereof, 10. Investigational procedures, including medi- whether a claim is asserted or not, under cal and surgical services, drugs, devices and automobile medical, personal injury protec- tion,biological products, until formally approved uninsured or underinsured motorist, by GHC for medical coverage.GHC's deter- mination shall be made in accordance with except for individual health insurance. criteria for determining investigational status as established by GHC. Specific in- 19. Services or supplies not specifically listed as dications and methods of use shall be con- covered in the Schedule of Benefits. sidered in GHC's review of evidence 20. See coverage under Section X.B.7. provided by evaluations of national medical associations,consensus panels, and/or other 21. The cost of services and supplies resulting technological evaluations, including the from an Enrollee's loss of or willful damage scientific quality of such supporting evidence to covered appliances,devices,supplies,and and rationale. Investigational drugs,devices materials provided by GHC for the treat- and biological products are not covered until ment of disease, injury,or illness. clinical trials have been completed and ap- proved by the U.S. Food and Drug Ad- 22. Routine circumcision, including newborn ministration as being safe and efficacious for circumcision,which is not considered Medi- general marketing and permission has been cally Necessary. granted for commercial distribution, unless approved for coverage by GHC Medical 23. Orthoptic (eye training) therapy. Staff and Management in accordance with GHC's established criteria for such excep- 24. Specialty treatment programs that are not tion. provided at GHC. 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. B. LIMITATIONS 12. See coverage for Pre-existing Conditions under Section X.B. 1. Conditions and Extent of Coverage. ALL SERVICES AND BENEFITS UNDER 13. Mental health care, except as specifically THIS AGREEMENT MUST BE provided in Section X.H. PROVIDED BY GHC MEDICAL PER- SONNEL AT A GHC FACILITY UN- 14. Procedures,services,and supplies related to LESS: sex transformations. a. the Enrollee has received a Referral from a GHC physician; or 0369 7A5 Page 24 b. the Enrollee has received Emergency 4. Unusual Circumstances.If the provision of services according to Section X.I. Covered Services is delayed or rendered im- possible due to unusual circumstances such 2. Recommended Treatment. The as complete or partial destruction of Cooperative's Medical Director or his/her facilities,military action,civil disorder,labor designee will determine the necessity, na- disputes, or similar causes, GHC shall pro- ture,and extent of treatment to be provided vide or arrange for services that, in the in each individual case and the judgment, reasonable opinion of GHC's Medical made in good faith,will be final. Director, or his/her designee, are emergent or urgently needed. In regard to nonurgent Enrollees have the right to participate in and routine services,GHC shall make a good decisions regarding their health care.An en- faith effort to provide services through its rollee may refuse recommended treatment then-available facilities and personnel.GHC or diagnostic plan to the extent permitted by shall have the option to defer or reschedule law.In such case,GHC shall have no further services that are not urgent or routine while obligation to provide the care in question. its facilities and services are so affected. In Enrollees who seek other sources of care no case shall the Cooperative have any because of such a disagreement do so with liability or obligation on account of delay or the full understanding that GHC has no failure to provide or arrange such services. obligation for the cost, or liability for the outcome, of such care. Section XII. Claims 3. Major Disaster or Epidemic.In the event of a major disaster or epidemic, GHC Medical Enrollees must submit claims for reimbursement of Personnel will provide Covered Services ac- Covered Services to GHC within sixty(60)days of the cording to their best judgment, within the limitations of available facilities and person- service date, or as soon thereafter as is reasonably nel. The Cooperative has no liability for possible. In no event, except in the absence of legal delay or failure to provide or arrange capacity, shall a claim be accepted later than one (1) Covered Services to the extent facilities or year from the service date. This section applies to personnel are unavailable due to a major Covered Services received under Section X.I.and X.J., disaster or epidemic. or services for which the Enrollee has received a Referral from a GHC physician. 0369 7A5 Page 25 Group • Health Cooperative of Puget Sound Medicare Endorsement For Persons Covered by Parts A and B of Medicare THE PROVISIONS OF THE GROUP MEDICAL UNLESS THE ENROLLEE HAS BEEN REFERRED COVERAGE AGREEMENT SHALL REMAIN IN BY GHC OR THE ENROLLEE HAS RECEIVED EFFECT EXCEPT AS MODIFIED BY THE ADDI- EMERGENCY OR URGENTLY NEEDED SER- TION OF THE PROVISIONS,EXCLUSIONS,AND VICES ACCORDING TO SECTION V.D. OF THIS LIMITATIONS CONTAINED IN THIS MEDICARE MEDICARE ENDORSEMENT. ENDORSEMENT. IN NO EVENT SHALL THE This Endorsement does not constitute a Medicare BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE BENEFITS UNDER THE supplemental contract. GROUP MEDICAL COVERAGE AGREEMENT. COVERAGE UNDER THE GROUP MEDICAL Section I. Definitions COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL AND HOSPITAL BENEFITS CUSTODIAL CARE: Care that is primarily for the ESTABLISHED BY TITLE 18 OF THE SOCIAL of meeting SECURITY ACT AS AMENDED,AND REFERRED purpose gersonal needs and could be P TO AS "MEDICARE." THE BENEFITS AND EX- provided by persons without professional skills or CLUSIONS DESCRIBED IN THIS ENDORSE- training. Custodial Care includes help in walking, MENT APPLY ONLY TO ENROLLEES WHO ARE bathing,dressing,eating, and taking medicine. COVERED UNDER BOTH PART A AND PART B EMERGENCY SERVICES (Medicare defined): In- OF MEDICARE. patient or outpatient services that are rendered Except as defined by Federal Regulations, all Enrol- immediately by an appropriate non-GHC provider lees entitled to,or eligible to purchase Medicare must because of an injury or sudden illness, and for transfer to the GHC Medicare Plan upon such entitle- which the time required to reach GHC or a GHC ment or eligibility.A condition of enrollment under the Designated Facility would risk permanent damage GHC Medicare Plan requires that an Enrollee be to the Enrollee's health. continuously enrolled for the hospital (Part A) and HEALTH CARE FINANCING ADMINISTRATION medical (Part B) benefits available from the Social (HCFA): The federal agency that administers the Security Administration,and sign any papers that may Medicare program. be required by GHC or Medicare. For additional in- formation, the Enrollee may refer to "The Medicare MEDICARE: The federal health insurance program Handbook." for the aged and disabled. NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC FACILITIES 0369 7A5 Page 26 MEDICARE GUIDELINES: Coverage rules and Until such time as an Enrollee's termination of en- policies established by the Health Care Financing rollment is effective,neither GHC nor Medicare shall Administration (HCFA), a federal agency. pay for services provided at non-GHC Facilities un- less the Enrollee has been referred by GHC or the MEDICARE HANDBOOK (Titled "The Medicare Enrollee has received Emergency or Urgently Needed Handbook"): A pamphlet published by the U.S. Services according to Section V.D. of this Medicare Department of Health and Human Services,Social Endorsement. Security Administration, which provides an easy- to-read explanation of Medicare benefits. A. Termination of Specific Enrollees. PERMANENT MOVE: An uninterrupted absence of 1. Loss of Medicare Part B Entitlement.If the more than ninety (90) days from GHC's Service Health Care Financing Administration Area. (HCFA) advises GHC that an Enrollee's entitlement to Medicare coverage no longer REFERRAL:A prior written authorization by a GHC exists,or the Enrollee voluntarily terminates physician, formally approved in advance through Medicare enrollment,enrollment under the GHC's Medicare medical coverage approval GHC Medicare Plan shall terminate the first process, that entitles an Enrollee to receive of the month as specified by HCFA. Covered Services from a specified non-GHC 2. Change of Permanent Residence Outside health care provider. Entitlement to such services GHC's Service Area.If an Enrollee makes a shall not exceed the limits of the Referral and is Permanent Move as set forth in Section I.of subject to all terms and conditions of this Agree- this Medicare Endorsement, enrollment ment. shall terminate the first day of the month following the month in which GHC receives SERVICE AREA: The geographic area comprised of notification of such move. King,Kitsap,Pierce,Skagit,Snohomish,Thurston, and Whatcom Counties,and any other areas desig- 3. For Cause. Enrollment may be terminated nated by GHC and approved by the Health Care upon written notice for: Financing Administration. (See Service Area Map.) a. Knowingly providing fraudulent infor- mation to obtain coverage. In such SKILLED NURSING FACILITY: A Medicare cer- event, GHC may rescind or cancel en- tified and licensed facility, as defined in Medicare rollment upon ten (10) working days' regulations,primarily engaged in providing skilled written notice. nursing care or rehabilitation and related services b. Permitting the use of a GHC identifica- for which Medicare pays benefits or qualifies to tion card by another person. receive such approval. c. Failure to comply with the rules and URGENTLY NEEDED SERVICES (Medicare regulations of GHC including disrup- defined): Services needed in order to prevent a tive, unruly, abusive or uncooperative serious deterioration of the Enrollee's health due conduct. to an unforeseen illness or injury while temporarily absent from GHC's Service Area, and which can- Such termination shall be subject to review not be delayed until the Enrollee returns to the and approval by HCFA. Service Area. B. Persons Hospitalized on the Date of Termina- tion.An Enrollee who is a registered bed patient Section II. Termination receiving Covered Services in a GHC Facility or GHC Designated Facility on the date of termina- Enrollment under the GHC Medicare Plan for a tion shall continue to receive covered inpatient specific Enrollee, may be terminated in the cir- services, until discharge from the facility. This cumstances set forth below. continued coverage will also apply to an Enrollee 0369 7A5 Page 27 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 attorneys 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 H.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 A. GHC Consumer Relations Program. of a third party giving rise to a claim of legal liability against the third party, GHC shall have the right to The Consumer Relations Program is designed to recover its cost of providing benefits to the injured help an Enrollee resolve formal complaints and person (subrogation) from the third party as set forth concerns about medical and business service. in this Agreement and in compliance with Medicare GHC will record,research,and respond in a time- regulations and guidelines. GHC shall be subrogated ly manner to an Enrollee's concern. A concern to and may enforce all rights of the injured person to should be registered initially at the Enrollee's the extent of its medical expense.After Medicare laws area medical center.If not satisfied,the Enrollee and regulations mandating recovery of Medicare pay- should then contact the regional Consumer Rela- ments have been satisfied, the Cooperative's right of tions Department, which will arrange for review subrogation shall be limited to the excess of the by appropriate medical staff,management and/or amount required to fully compensate the injured per- GHC consumers. son for the loss sustained. Full compensation shall be B. Reconsideration of Claims. measured on an objective, case-by-case basis, but is subject to a presumption that a settlement which does If GHC denies a request for payment of a claim, not exhaust the third parry's reachable assets is full or declines to provide services which the Enrollee compensation to the injured person. believes should be provided,the Enrollee may file a request for reconsideration with GHC or a So- cial Security Administration office. The request cooperate fully with GHC in its efforts to collect must be filed in writing within sixty (60) days of GHC's medical expenses. This cooperation shall in- GHC's written notice of denial unless an exten- clude,but is not limited to,supplying GHC with infor- sion is specifically approved. If GHC does not mation about any defendants and/or insurers related overturn the denial in full, it will be referred by to the injured person's claim. The injured person and GHC to the Health Care Financing Administra- his or her agents shall permit GHC, at GHC's option, tion for reconsideration. to associate with the injured party or to intervene in any action filed against any third party. The injured person and his or her agents shall do nothing to 0369 7A5 Page 28 Section V. Schedule of Benefits physician,as set forth in this paragraph.Con- tinuous care is defined as "skilled nursing care provided in the home during a period of All benefits and services listed in this Schedule of crisis in order to maintain the terminally ill Benefits: patient at home." Continuous care may be provided for pain or symptom management • are subject to all provisions of this Agree- by a Registered Nurse, Licensed Practical ment and Medicare Endorsement; Nurse, or Home Health Aide under the su- pervision of a Registered Nurse.Continuous • must be approved in advance by GHC except care may be provided up to twenty-four(24) for Emergency and Urgently Needed Ser- hours per day during periods of crisis. Con- vices as set forth in Section V.D. of this tinuous care is covered only when a GHC Medicare Endorsement; and physician determines that the Enrollee otherwise would require hospitalization in • must meet Medicare guidelines and limita- an acute care facility. tions unless otherwise specified. 2. Inpatient Hospice Services for short-term GHC covers all Medicare deductibles and coin- care shall be provided through a Medicare- surance. The booklet, "The Medicare Handbook" certified Hospice Program when Medically provides additional information about Medicare Necessary, and authorized in advance by a benefits. GHC physician. Respite care is covered for a maximum of five (5) consecutive days per A. Skilled Nursing Facility.Upon Referral and fol- occurrence in order to continue care for the lowing a three (3) day hospital stay, GHC will Enrollee in the temporary absence of the cover up to one hundred (100) days of care in a Enrollee's primary care-giver(s). Skilled Nursing Facility, in accordance with Medicare Guidelines,when Medically Necessary, 3. Other hospice services may include the fol- as determined by GHC's Medical Director, or lowing: his/her designee. a. drugs and biologicals that are used B. Hospice. primarily for the relief of pain and symptom management; Enrollees with Part A and Part B of Medicare who elect to receive Medicare-covered hospice ser- b. medical appliances and supplies vices may select any Medicare-certified hospice primarily for the relief of pain and program. Enrollees who elect to receive services symptom management; from the GHC Hospice Program are entitled to hospice services as provided under the Medicare c. counseling services for the Enrollee Hospice Program. Enrollees who elect to receive and his/her primary care-giver(s); and hospice services do so in lieu of curative treat- ment for their terminal illness for the period that d. bereavement counseling services for they are in the hospice program. To receive the family. hospice services,the Enrollee is required to sign the Hospice Election Form. C. Mental Health Care, Alcoholism and Drug Abuse Treatment Services. Covered Services.In addition to the hospice ser- vices provided under the Group Medical 1. Outpatient mental health, alcoholism and Coverage Agreement, the following hospice ser- substance abuse treatment services are vices shall be provided: covered for each Enrollee in accordance with Medicare Guidelines. 1. Home Services 2. Inpatient mental health care services are Continuous care services per Enrollee in the covered in full up to a 190-day lifetime Enrollee's home when prescribed by a GHC 0369 7A5 Page 29 d to heart, benefit when such services are provided in a 5. Organ cornea,bone marrow,and liver,when kidney, Medicare-certified mental health facility. estab- lished criteria are met. Inpatient alcoholism and drug abuse treat- ment services are covered in full when such 6. =aopinions n calls (including consultations and services are provided in a hospital-based by a GHC physician)in the treatment center. hospital, office, home, Skilled Nursing Facility,nursing home,or convalescent cen- 3. Coverage for Medical Emergencies incident ter. to alcoholism and drug abuse or for acute alcoholism or drug abuse, including acute 7. Restorative physical, occupational, and detoxification,is provided as set forth in Sec- speech therapy following illness, injury, or tion V.D.of this Medicare Endorsement. surgery. D. Emergency/Urgently Needed Services. When an 8. Immunizations and vaccinations that are Emergency meets the Medicare definition for listed as covered in the GHC Drug For- Emergency or Urgently Needed Services as mulary (approved drug list) or approved by defined in Section I. of this Medicare Endorse- Medicare. ment,services are covered in full. 9. Services related to dysfunction of the jaw. E. Medicare Ambulance Benefit. Medically Neces- When Referred by a GHC physician,evalua- sary ambulance transportation to or from a hospi- tion and treatment by a GHC-approved tem- tal or Skilled Nursing Facility is covered in full poromandibular joint (TMJ) care provider. only if transportation by any other vehicle could All TMJ appliances,other than the occlusal endanger the patient's health and the ambulance, lint and its fitting, are excluded. equipment, and personnel meet Medicare re- splint quirements. Treatment of jaw dysfunction, including F. Medical and Surgical Care.The following medi- TMJ dysfunction, will NOT be provided cal and surgical services are covered when when the dysfunction is related to maloc- prescribed by GHC Medical Personnel and clusion or when TMJ services are needed Medicare requirements are met: due to dental work performed.All such ser- vices and related hospitalization, including 1. Eye examinations and treatment for eye orthodontictherapy and ts nathic i pathology. g ryeare excluded regardless of origin or cause. 2. One pair of eyeglasses or contact lenses, including examination and fitting, following 10. Chiropractic care limited to spinal manipula- cataract surgery, when required to replace tions. Excluded are any other diagnostic or the natural lens of the eye.Covered eyeglas- therapeutic services, including x-rays, fur- ses and contact lenses must be dispensed nished by a chiropractor. Enrollees must through GHC Facilities. Replacements will receive all chiropractic services from GHC- be provided when needed due to change in designated licensed practitioners in order to the Enrollee's medical condition or when be covered. A list of GHC-designated deemed appropriate by a GHC physician. licensed practitioners is available by contact- ing any GHC area medical center. 3. Blood, blood derivatives, and their ad- ministration. 11. Podiatric care. Excluded is treatment of flat feet or other misalignments of the feet; 4. Maternity and pregnancy-related services, removal of corns and calluses; and routine including visits before and after birth; in- foot care such as hygienic care,except in the voluntary termination of pregnancy; and presence of a nonrelated medical condition care for any other complication of pregnan- affecting the lower limbs. Enrollees who c,_ receive their primary care in portions of the 0369 7A5 Page 30 GHC Service Area where GHC designated c. Nursing care provided by a licensed licensed practitioners are available must util- professional nurse. ize GHC's designated providers in order to be covered. "Chronically dependent persons" under this sec- tion means persons who live with a voluntary 12. Home intravenous (IV) drug therapy ser- care-giver;are dependent upon the care-giver for vices assistance with at least two activities of daily living, such as eating,bathing, dressing,toileting, G. Prosthetic Devices, such as cardiac devices, in- or transferring in and out of a bed or chair; and traocular lenses, artificial joints, breast pros- who meet the eligibility requirements described theses, artificial eyes, and braces, are covered. above. Excluded are: orthopedic shoes unless they are part of leg braces; dental plates or other dental Exclusions and Limitations devices; and experimental devices. Section VI. H. Medical/Surgical Supplies,such as casts,splints, A. Exclusions. post-surgical dressings, and ostomy supplies, are covered. 1. Dental care, surgery, services, and applian- ces including, but not limited to: treatment I. Rental or Purchase of Durable Medical Equip- of accidental injury to natural teeth, ment, such as oxygen and oxygen equipment, reconstructive surgery to the jaw incident to wheelchairs and other walk-aids, and hospital denture wear, and periodontal surgery. beds, are covered. GHC's Medical Director, or his/her desig- nee, will determine whether the care or treatment required is within the category of 1. Eligibility. Respite care is provided to dental care or service. chronically dependent persons for If a GHC physician determines that an unre- reasonable and necessary in-home services, lated medical condition requires that the En- provided that such services are: rollee be hospitalized for a dental procedure a. authorized in advance by a GHC which is normally done in a dentist's office, GHC will cover associated hospital and physician; anesthesia costs at a GHC or GHC Desig- b. provided by GHC Community Health nated Facility. GHC will not cover the Services or by a GHC-approved agency; dentist's or oral surgeon's fees. and 2. Investigational procedures, including medi- c. that the Enrollee has incurred no less cal and surgical services, drugs and devices than the equivalent of$6,870.00 in ex- until formally approved by Medicare unless penes for Medicare Part B Covered specifically provided herein. Services during the calendar year in 3. Supportive devices for the feet. which respite benefits are to be provided. 4. Services directly related to obesity except as 2. Covered Services.Covered respite care ser- provided by Medicare. vices are provided as shown in the Respite 5. Services or supplies not specifically listed as Care Allowance set forth in the Dues and covered by Medicare or GHC. Fees Schedule,limited to the following: a. Services of a homemaker or home B. Limitations. health aide; Conditions and Extent of Coverage. EXCEPT b. Personal care services; and AS PROVIDED IN SECTIONS V.F.10. AND V.F.11., ALL SERVICES AND BENEFITS 0369 7A5 Page 31 UNDER THIS AGREEMENT MUST BE Urgently Needed Services from a non-GHC provider, PROVIDED BY GHC MEDICAL PERSON- be sure to show your GHC I.D. card and your red, NEL AT A GHC OR GHC DESIGNATED white, and blue Medicare card. FACILITY UNLESS: A. The Enrollee must file claims for services L the Enrollee has received a Referral from rendered during the first nine (9) months of a GHC, including formal advance approval calendar year by December 31 of the following through GHC's Medicare medical coverage calendar year. approval process,or B. The Enrollee must file claims for services 2. the Enrollee has received Emergency or Ur- rendered in the last three(3)months of a calendar gently Needed Services as defined in Section year the same as if the services had been furnished I. and as set forth in Section V.D. of this in the subsequent calendar year.The time limit on Medicare Endorsement. filing claims for services furnished in the last three (3) months of the calendar year is December 31 of the second calendar year following the calen- dar year in which the services were rendered. Claims for services or supplies and explanation of See"The Medicare Handbook"for additional in Medicare benefits for services or supplies from formation regarding filing claims. providers other than Group Health Cooperative GHC may obtain information which it deems should be sent to: Medicare Claims, Group Health necessary concerning the medical care and Cooperative of Puget Sound,P.O.Box C-19165,Seat- hospitalization for which payment is requested. tle, WA 98109. If you must receive Emergency or 0369 7A5 Page 32 Group • Health Cooperative of Puget Sound Medicare Endorsement For Persons Covered by Part B only of Medicare THE PROVISIONS OF THE GROUP MEDICAL EMERGENCY OR URGENTLY NEEDED SER- COVERAGE AGREEMENT SHALL REMAIN IN VICES ACCORDING TO SECTION V.C. OF THIS EFFECT EXCEPT AS MODIFIED BY THE ADDI- MEDICARE ENDORSEMENT. TION OF THE PROVISIONS, EXCLUSIONS AND LIMITATIONS CONTAINED IN THIS MEDICARE This Endorsement does not constitute a Medicare ENDORSEMENT. IN NO EVENT SHALL THE supplemental contract. BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE BENEFITS UNDER THE Section I. DEFINITIONS GROUP MEDICAL COVERAGE AGREEMENT. COVERAGE UNDER THE GROUP MEDICAL CUSTODIAL CARE: Care that is primarily for the COVERAGE AGREEMENT IS INTEGRATED of meeting personal needs and could be WITH THE MEDICAL BENEFITS ESTABLISHED purpose g BY TITLE 18 OF THE SOCIAL SECURITY ACT AS provided by persons without professional skills or training. Custodial Care includes help in walking, AMENDED, AND REFERRED TO AS "MEDICARE." THE BENEFITS AND EX- bathing,dressing,eating, and taking medicine. CLUSIONS DESCRIBED IN THIS ENDORSE- EMERGENCY SERVICES (Medicare defined): MENT APPLY ONLY TO ENROLLEES WHO ARE Medicare Part B services that are rendered imme- COVERED UNDER PART B ONLY OF MEDICARE. diately by an appropriate non-GHC provider be- Except as defined by Federal Regulations, all Enrol- cause of an injury or sudden illness, and for which lees entitled to,or eligible to purchase Medicare must the time required to reach GHC or a GHC Desig- transfer to the GHC Medicare Plan upon such entitle- nated Facility would risk permanent damage to the ment or eligibility.A condition of enrollment under the Enrollee's health. GHC Medicare Plan requires that an Enrollee be HEALTH CARE FINANCING ADMINISTRATION continuously enrolled for medical (Part B) benefits (HCFA): The federal agency that administers the available from the Social Security Administration,and Medicare program. sign any papers that may be required by GHC or Medicare. For additional information, the Enrollee MEDICARE: The federal health insurance program may refer to"The Medicare Handbook." for the aged and disabled. NEITHER GHC NOR MEDICARE MAY PAY FOR MEDICARE GUIDELINES: Coverage rules and SERVICES PROVIDED AT NON-GHC FACILITIES policies established by the Health Care Financing UNLESS THE ENROLLEE HAS BEEN REFERRED Administration (HCFA), a federal agency. BY GHC OR THE ENROLLEE HAS RECEIVED 0369 Page 33 7A5 MEDICARE HANDBOOK (Titled "The Medicare 1. Loss of Part B Medicare Entitlement.If the Handbook"): A pamphlet published by the U.S. Health Care Financing Administration A Department of Health and Human Services,Social eHCFntitlem advises GHC that an Enrollee's entitlement to Medicare coverage no longer Security Administration, which provides an easy- exists,or the Enrollee voluntarily terminates to-read explanation of Medicare benefits. Medicare Part B enrollment, enrollment PERMANENT MOVE: An uninterrupted absence of under the GHC Medicare Plan shall ter- more than ninety (90) days from GHC's Service minate the first of the month as specified by Area. HCFA. REFERRAL:A prior written authorization by a GHC 2. Change of Permanent Residence Outside GHC's Service Area.If an Enrollee makes a physician, formally approved in advance through GHC's Medicare medical coverage approval permanent Move as set forth in Section I.of this Medicare Endorsement, enrollment process, that entitles an Enrollee to receive shall terminate the first day of the month Covered Services from a specified non-GHC following the month in which GHC receives health care provider.Entitlement to such services notification of such move. shall not exceed the limits of the Referral and is subject to all terms and conditions of this Agree- 3. For Cause. Enrollment may be terminated ment. upon written notice for: SERVICE AREA: The geographic area comprised of a. Knowingly providing fraudulent infor- King,Kitsap,Pierce,Skagit,Snohomish,Thurston, mation to obtain coverage. In such and Whatcom Counties,and any other areas desig- event, GHC may rescind or cancel en- nated by GHC and approved by the Health Care rollment upon ten (10) working days' Financing Administration. (See Service Area written notice. Map.) b. Permitting the use of a GHC identifica- URGENTLY NEEDED SERVICES (Medicare tion card by another person. defined):Medicare Part B services needed in order c. Failure to comply with the rules and to prevent a serious deterioration of the Enrollee's regulations of GHC including disrup- health due to an unforeseen illness or injury while tive, unruly, abusive or uncooperative temporarily absent from GHC's Service Area,and conduct. which cannot be delayed until the Enrollee returns to the Service Area. Such termination shall be subject to review and approval by HCFA. Section II. Termination Section III. Subrogation Enrollment under the GHC Medicare Plan for a specific Enrollee, may be terminated in the cir- "Injured person"under this section means an Enrollee cumstances set forth below. covered by this Agreement who sustains compensable injury. "GHC's medical expense" means the expense Until such time as an Enrollee's termination of en- incurred by GHC for the care or treatment of the injury rollment is effective,neither GHC nor Medicare shall sustained. pay for services provided at non-GHC Facilities un- less the Enrollee has been referred by GHC or the If the injured person was injured by an act or omission Enrollee has received Emergency or Urgently Needed of a third party giving rise to a claim of legal liability Services according to Section V.C. of this Medicare against the third party, GHC shall have the right to Endorsement recover its cost of providing benefits to the injured person (subrogation) from the third party as set forth A. Termination of Specific Enrollees. in this Agreement and in compliance with Medicare 0369 7A5 Page 34 regulations and guidelines. GHC shall be subrogated GHC will record,research,and respond in a time- to and may enforce all rights of the injured person to ly manner to an Enrollee's concern. A concern the extent of its medical expense.After Medicare laws should be registered initially at the Enrollee's and regulations mandating recovery of Medicare pay- area medical center.If not satisfied,the Enrollee ments have been satisfied, the Cooperative's right of should then contact the regional Consumer Rela- subrogation shall be limited to the excess of the tions Department,which will arrange for review amount required to fully compensate the injured per- by appropriate medical staff,management and/or son for the loss sustained.Full compensation shall be GHC consumers. measured on an objective, case-by-case basis, but is B. Reconsideration of Claims. subject to a presumption that a settlement which does not exhaust the third party's reachable assets is full If GHC denies a request for payment of a claim, compensation to the injured person. or declines to provide services which the Enrollee believes should be provided,the Enrollee may file The injured person and his or her agents must a request for reconsideration with GHC or a So- cooperate fully with GHC in its efforts to collect cial Security Administration office. The request GHC's medical expenses. This cooperation shall in- must be filed in writing within sixty (60) days of clude,but is not limited to,supplying GHC with infor- GHC's written notice of denial unless an exten- mation about any defendants and/or insurers related sion is specifically approved. If GHC does not to the injured person's claim. The injured person and overturn the denial in full, it will be referred by his or her agents shall permit GHC, at GHC's option, GHC to the Health Care Financing Administra- to associate with the injured party or to intervene in tion for reconsideration. any action filed against any third party. The injured person and his or her agents shall do nothing to Section V. Schedule of Benefits prejudice GHC's subrogation rights.The injured per- son shall not settle a claim without protecting GHC's 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 0 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 • must meet Medicare guidelines and limita- costs between GHC and the injured person subject to tions unless otherwise specified. a maximum responsibility of GHC equal to one-third GHC covers all Medicare deductibles and coin- of the amount recovered on behalf of GHC. surance. The booklet, "The Medicare Handbook" This provision does not apply to occupationally in- provides additional information about Medicare curred disease,sickness, and/or injury. benefits. A. Hospice. Section IV. Grievance Procedures It is understood and agreed that the following A. GHC Consumer Relations Program. fully sets forth Covered Services for an Enrollee with Part B Medicare only who elects to receive The Consumer Relations Program is designed to hospice services. Enrollees who elect to receive help an Enrollee resolve formal complaints and hospice services do so in lieu of curative treat- concerns about medical and business service. ment for their terminal illness for the period that they are in the hospice program. To receive 0369 7A5 Page 35 hospice services,the Enrollee is required to sign d. bereavement counseling services for the Hospice Election Form. the family. Covered Services. Hospice services may include B. Outpatient Mental Health Care,Alcoholism and the following as prescribed by a GHC physician Drug Abuse Treatment Services are covered for and rendered pursuant to an approved hospice each Enrollee in accordance with Medicare plan of treatment: Guidelines. 1. Home Services C. Outpatient Emergency/Urgently Needed Ser- vices. When an Emergency meets the Medicare Continuous care services per Enrollee in the definition for Emergency or Urgently Needed Enrollee's home when prescribed by a GHC Services as defined in Section I. of this Medicare physician,as set forth in this paragraph.Con- Endorsement,services are covered in full. tinuous care is defined as "skilled nursing care provided in the home during a period of D. Medicare Ambulance Benefit. Medically Neces- crisis in order to maintain the terminally ill sary ambulance transportation to or from a hospi- patient at home." Continuous care may be tal or Skilled Nursing Facility is covered in full provided for pain or symptom management only if transportation by any other vehicle could by a Registered Nurse, Licensed Practical endanger the patient's health and the ambulance, Nurse, or Home Health Aide under the su- equipment, and personnel meet Medicare re- pervision of a Registered Nurse.Continuous quirements. care may be provided up to twenty-four(24) hours per day during periods of crisis. Con- E. Medical and Surgical Care.The following medi- tinuous care is covered only when a GHC cal and surgical services are covered when physician determines that the Enrollee prescribed by GHC Medical Personnel and otherwise would require- hospitalization in Medicare requirements are met: 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 by GHC's Hospice Program when Medically 2. One pair of eyeglasses or contact lenses, Necessary and authorized in advance by a including examination and fitting, following GHC physician and GHC's Hospice Pro- cataract surgery, when required to replace gram.Respite care is covered for a maximum the natural lens of the eye.Covered eyeglas- of five (5) consecutive days per occurrence ses and contact lenses must be dispensed in order to continue care for the Enrollee in through GHC Facilities. Replacements will the temporary absence of the Enrollee's be provided when needed due to change in primary care-giver(s). the Enrollee's medical condition or when deemed appropriate by a GHC physician. 3. Other hospice services may include the fol- lowing: 3. Blood, blood derivatives, and their ad- ministration. a. drugs and biologicals that are used primarily for the relief of pain and 4. Maternity and pregnancy-related services, symptom management; including visits before and after birth; in- voluntary termination of pregnancy; and b. medical appliances and supplies care for any other complication of pregnan- primarily for the relief of pain and cy symptom management; 5. Organ transplants, limited to heart, kidney, c. counseling services for the Enrollee cornea,bone marrow,and liver,when estab- and his/her primary care-giver(s); and lished criteria are met. 6. Physician calls (including consultations and second opinions by a GHC physician) in the 0369 7A5 Page 36 hospital, office, home, Skilled Nursing 12. Home intravenous (IV) drug therapy ser- Facility,nursing home,or convalescent cen- vices. ter. F. Prosthetic Devices, such as cardiac devices, in- 7. Restorative physical, occupational, and traocular lenses, artificial joints, breast pros- speech therapy following illness, injury, or theses, artificial eyes, and braces, are covered. surgery. Excluded are: orthopedic shoes unless they are part of leg braces; dental plates or other dental 8. Immunizations and vaccinations that are devices; and experimental devices. listed as covered in the GHC Drug For- mulary (approved drug list) or approved by G. Medical/Surgical Supplies,such as casts,splints, Medicare. post-surgical dressings, and ostomy supplies, are covered. 9. Services related to dysfunction of the jaw. When Referred by a GHC physician,evalua- H. Rental or Purchase of Durable Medical Equip- tion and treatment by a GHC-approved tem- ment, such as oxygen and oxygen equipment, poromandibular joint (TMJ) care provider. wheelchairs and other walk-aids, and hospital beds, are covered. All TMJ appliances,other than the occlusal splint and its fitting, are excluded. I. Respite Care. Treatment of jaw dysfunction, including 1. Eligibility. Respite care is provided to TMJ dysfunction, will NOT be provided chronically dependent persons for when the dysfunction is related to maloc- reasonable and necessary in-home services, clusion or when TMJ services are needed provided that such services are: due to dental work performed.All such ser- a. authorized in advance by a GHC vices and related hospitalization, including orthodontic therapy and orthognathic (jaw) physician; surgery, are excluded regardless of origin or b. provided by GHC Community Health cause. Services or by a GHC-approved agency; 10. Chiropractic care limited to spinal manipula- and tions. Excluded are any other diagnostic or c. that the Enrollee has incurred no less therapeutic services, including x-rays, fur- than the equivalent of$6,870.00 in ex- nished by a chiropractor. Enrollees must enses for Medicare Part B Covered receive all chiropractic services from GHC- p Services during the calendar year in designated licensed practitioners in order to which respite benefits are to be be covered. A list of GHC-designated licensed practitioners is available by contact- ing any GHC area medical center. 2. Covered Services. Covered respite care ser- 11. Podiatric care. Excluded is treatment of flat vices are provided as shown in the Respite feet or other misalignments of the feet; Care Allowance set forth in the Dues and removal of corns and calluses; and routine Fees Schedule, limited to the following: foot care such as hygienic care,except in the a. Services of a homemaker or home presence of a nonrelated medical condition health aide; affecting the lower limbs. Enrollees who receive their primary care in portions of the b. Personal care services; and GHC Service Area where GHC designated licensed practitioners are available must util- c. Nursing care provided by a licensed ize GHC's designated providers in order to professional nurse. be covered. "Chronically dependent persons" under this sec- tion means persons who live with a voluntary 0369 7A5 Page 37 care-giver;are dependent upon the care-giver for UNDER THIS AGREEMENT MUST BE assistance with at least two activities of daily PROVIDED BY GHC MEDICAL PERSON- living, such as eating,bathing, dressing,toileting, NEL AT A GHC OR GHC DESIGNATED or transferring in and out of a bed or chair; and FACILITY UNLESS: who meet the eligibility requirements described 1. the Enrollee has received a Referral from above. GHC, including formal advance approval through GHC's Medicare medical coverage Section VI. Exclusions and Limitations approval process,or 2. the Enrollee has received outpatient Emer- A. Exclusions. gency or Urgently Needed Services as defined in Section I. and as set forth in Sec- t. Dental care, surgery, services, and applian- tion V.C.of this Medicare Endorsement. ces including, but not limited to: treatment of accidental injury to natural teeth, reconstructive surgery to the jaw incident to Section VII. Claims Procedure denture wear, and periodontal surgery. GHC's Medical Director, or his/her desig- Claims for services or supplies and explanation of nee, will determine whether the care or treatment required is within the category of Medicare benefits for services or supplies from dental care or service. providers other than Group Health Cooperative should be sent to: Medicare Claims, Group Health If a GHC physician determines that an unre- Cooperative of Puget Sound,P.O.Box C-19165,Seat- lated medical condition requires that the En- tle, WA 98109. If you must receive Emergency or rollee be hospitalized for a dental procedure Urgently Needed Services from a non-GHC provider, which is normally done in a dentist's office, be sure to show your GHC I.D. card and your red, GHC will cover associated hospital and white, and blue Medicare card. anesthesia costs at a GHC or GHC Desig- nated Facility. GHC will not cover the A, The Enrollee must file claims for services dentist's or oral surgeon's fees. rendered during the first nine (9) months of a calendar year by December 31 of the following 2. Investigational procedures, including medi- calendar year. cal and surgical services, drugs and devices until formally approved by Medicare unless B. The Enrollee must file claims for services specifically provided herein. rendered in the last three(3)months of a calendar 3. Su feet. year the same as if the services had been furnished Supportive devices for the in the subsequent calendar year.The time limit on 4. Services directly related to obesity except as filing claims for services furnished in the last three (3) months of the calendar year is December 31 provided by Medicare. of the second calendar year following the calen- 5. Services or supplies not specifically listed as dar year in which the services were rendered. covered by Medicare or GHC. See"The Medicare Handbook"for additional in- B. Limitations. formation regarding filing claims. Conditions and Extent of Coverage. EXCEPT GHC may obtain information which it deems AS PROVIDED IN SECTIONS V.E.10. AND necessary concerning the medical care and V.E.11., ALL SERVICES AND BENEFITS hospitalization for which payment is requested. 0369 7A5 Page 38 PA-754-Basic Agreement CA-174-Medicare A& B CA-175-Medicare B Only CA-7-ER$25 CA-66-M&A CA-18-Pec (0) CA-210-Inpt MH-O CA-61 -SN-A 0369 7A5 Page 39 1 Health cooperative Dues Schedule of Puget Sound For attachment to Group Medical Coverage Agreement with: CITY OF KENT GROUP # 0369 This schedule reflects Group Health Cooperative monthly dues effective January 1, 1992 and guaranteed to January 1, 1993. MONTHLY HEALTH CARE DUES Subscriberonly................................................................................................ $144.87 per month Subscriber and spouse................................................................................... $324.12 per month Subscriber and child(ren)............................................................................... $292.16 per month Subscriber and family..................................................................................... $464.00 per month Spouseonly..................................................................................................... $179.25 per month Children) only................................................................................................. $147.29 per month Spouse and child(ren) only............................................................................ $319.13 per month COPAYMENT PROVISION The following copayments apply to this plan. See Group Medical Coverage Agreement for benefit details. $0 Outpatient/Office Visit $0 Outpatient Prescription Drugs $25 Emergency Room 0 Month Pre-existing Condition BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the first day of the coverage month for which they become payable. Each remittance must be accompanied by a list of subscribers for whom such dues are paid. Per average enrollee in 1991, 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 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. S02282DT Page 2 of 4 ALLOWANCES, DEDUCTIBLES, COF BENTS, AND FEES The following Allowances, Deductibles, Copayments and Fees are subject to Pre-existing Condition limitations as defined in the Medical Coverage Agreement. Mental Health Care Allowance Outpatient Allowance.. . . . . . . . . . . .. . . . . . . . . .. . . Outpatient mental health care services provided through GHC will be covered in full up to a maximum of 10 visits per calendar year. The Enrollee will pay 50% of the charges for the next 10 visits. After a total of 20 visits, the Enrollee pays in full for all outpatient mental health care. Inpatient Allowance. .... . .. . ... . . . .. . . .. . . .. . Inpatient mental health services are covered up to 7 days at 80% per Enrollee per calendar year in a GHC- approved hospital or other facility devoted primarily to treatment of mental or nervous disorders. Chemical Dependency Allowance $5,000 maximum per Enrollee per any 24 Benefit Period Allowance. . . . . . . . . . . . . . • • ••••" consecutive calendar month period for outpatient and inpatient services received. Lifetime Maximum Benefit . ... . ... . .. . .. .. .. . . $10,000 per Enrollee for outpatient and inpatient services received. Emergency Copayment.. . .. . .. . . . . .. . . . . . . .. . . . . ... . . Emergency care at a GHC or GHC-Desig- nated Facility is subject to a $25 Co- payment amount per Emergency, payable by the Enrollee. Copayment is waived if Enrollee is admitted to the hospi- tal directly from the Emergency De- partment. Stop Loss.. .. . . . . . . . . . . .. . . . . . . .. . .. . . . .. . . . . . .. . . Total out-of-pocket Copayment expenses for Emergency care at a GHC or GHC Designated Facility are limited to an aggregate maximum of $750 per Enrollee and $1,500 per family per calendar year. S022820T Page 3 of 4 ALLOWANCES, DEDUCTIBLES, COF TENTS, AND FEES, Continued Ambulance Allowance/Deductible. . ... .. . .. . .... . .. .. An allowance of up to $1,000 per Emer- gency is allowed for transport to GHC or non-GHC facilities. Ambulance charges for transport to a non-GHC De- signated Facility are subject to a $50 Deductible amount per Emergency, pay- able by the Enrollee. An additional $1,000 Allowance per Enrollee is al- lowed for transfer to a HC or GHC De- signated Facility. Rehabilitation Services Inpatient Allowance . . .. . . . . . . . . .. . . . .. . . . . . .. Inpatient physical , occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six and under, plus associated hospital services for the purpose of rehabilitation, will be covered in full up to a maximum of 60 days per condition per calendar year. Outpatient Allowance ..... ... . . . .. .. . .. .. .. ... Outpatient physical , occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six and under, will be covered in full up to a maximum of 60 visits per condition per calendar year. Orthopedic Appliances .. . . .. . . . . . . . . . . . . . .. . . . . . . . Orthopedic appliances are covered at 50% of the total charges when pre- scribed by a GHC physician and listed as covered in the Orthopedic Appliance Formulary. Nasal CPAP Device. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal CPAP Device when medically necessary and authorized in advance by a GHC physician is covered at 50% of total charges. External Breast Prosthesis .. . . . . . . . . . . . .. .. . .. .. External breast prosthesis following mastectomy and post-mastectomy bras are covered at 50% of total charges. "Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or mental handicap in its employment practices or services. " S02282DT Page 4 of 4 Group Health Cooperative of Puget Sound Service Airea GHC Medical and Specialty Centers O Bainbridge Island Medical Center •` Q Burien Medical Center • WHATCOM © Capitol Hill Family Health Center Q Central Specialty Center Q Downtown Seattle Medical Center Q Eastside Primary Care Center Q Eastside Specialty Center © !® SKAGIT Q Everett Medical Center 416 Q Group Health OB/GYN Services—Everett North Everett Satellite Factoria Medical Center ® Family Practice Residency ® Federal Way Medical Center SNOHOMISH Lynnwood Medical Center ©' ® Madrona Medical Center �. Northgate Medical Center ' m Northshore Medical Center 0 Olympia Medical Center .. .. KITSAP 0 West Olympia Medical Center Port Orchard Medical Center , © ' �.. © KING Port Orchard Medical Center—Tremont © Rainier Medical Center ® Renton Medical Center MASON . ® GHC Medical Center—Silverdale ® Tacoma Medical Center Tacoma South Medical Center © PIERCE OD Tacoma Specialty Center University Medical Center / THURSTON Vashon Health Center GHC and GHC-Designated Hospitals 0 GHC Central Hospital—Seattle Q Skagit Valley Hospital and Health Center— GHC Eastside Hospital—Redmond Mt.Vernon GHC Inpatient Center at Tacoma 0 St.Joseph Hospital—Bellingham General Hospital Tacoma 19 St.Joseph Hospital,South Campus-43eUingham Q Harrison Memorial Hospital—Bremerton © St. Peter Hospital—Olympia Q Island Hospital—Anacortes 0 Tacoma General Hospital—Tacoma © Mary Bridge Children's Hospital Tacoma Q United General Hospital--Sedro Woolley Providence Hospital—Everett GHC Specialty Centers GIIC Medical Centers Pierce County King County Kitsap County King County Burien Medical Center Bainbridge Wand Medical Center Central Specialty Center Tacoma Specialty Center 621 N.E.High School Rd- 20015th Ave.E 209 South"K"St. 140 S.W 146th Winslow 98110 Tacoma 98405 Seattle 98166 Seattle 98112 842.9911 326.3000 596.3300 Capitol Capitol Hill Family Health Center Port Orchard Medical Center Eastside Specialty Center Thurston County 12216th Ave.E 1950 Pottery Ave. 2700152nd Ave.N.E. Olympia Medical Center Seattle 98112 Port Orchard 98366 Redmond 98052 700 N.Lilly Rd. 326-3454 8955000 883.5151 Olympia 98506 Downtown Seattle Medical Center Port Orchard Medical Center-Tremont 456.1700 Mac pental Bldg.,Ninth Floor 1400 Pottery Ave. 509 Olive Way Port Orchard 98366 Seattle 98101 895-5000 223-2611 GHC Medical Center-Silverdale Eastside Primary Care Center 10452 Silverdale Way N.W. GHC Hospitals 2701 156th Ave.N.E. Silverdale 98383 Pierce County Redmond 98052 692-3880 King County Central Hospital GHC Inpatient Center at 883.5281 Pierce County 20015th Ave.E Tacoma General Hospital Factona Medical Center Tacoma Medical Center Seattle 98112 315 South"K"St 13451 S.E.36th St 1112 S.Cushman 326-3000 Tacoma 98405 Bellevue 98006 Tacoma 99405 Eastside Hospital 383-6100 562-1330 383.7801 2700152nd Ave.N.E. Family Practice Residency Tacoma South Medical Center Redmond 98052 20015th Ave.E 9505 S.Steele St. 883-5151 Seattle 98112 Tacoma 99W 326.3580 597-6800 Federal Way Medical Center Snohomish County 301 S.320th Everett Medical Center Federal Way 98003 14 E Casino Rd. GHC Designated Facilities 874-7000 Everett 98208 Mt.Vernon Madrona Medical Center 347-7800 Anacortes 1403 34th Ave. Lynnwood Medical Center Island Hospital Skagit Valley Hospital and $eattle 98122 20200 54th Ave.W. 24th&"M"Ave. Health Center 720MM Lynnwood 98036 293.3181(98221) 1415 E Kincaid Northgate Medical Center 672-6822 4244111(98273) 9800 Fourth Ave.N.E.Bellingham North Everett Satellite St Joseph Hospital Olympia Seattle 98115 1410 Broadway 3201 Ellis St. St Peter Hospital 527-7100 Everett 98201 734-5400(98225) 413 N.Lilly Rd Northshore Medical Center 38&4000 491.9480(98506) 11913 N.E.195th St St.Joseph Hospital— Bothell 98011 Thurston County South Campus Sedro Woolley Olympia Medical Center 809 E.Chestnut St. United General Hospital 489.3100 700 N.Lilly Rd. 734-8300(98225) 1971 Hospital Drive Rainier Medical Center Olympia 98506 Bremerton 8566021(98284) 5316 Rainier Ave.S. 456.1700 Seattle 98118 West Olympia Medical Center Harrison Memorial Hospital Tacoma 721-5600 2520 Cherry Ave. Mary Bridge Childreris Hospital 3030 Limited Lane N.W. 377-3911(98310) 317 South"K"St. Renton Medical Center Olympia 98502 594-1404(98405) 275 Bronson Way N.E. 352-5200 Everett Renton 98056 Providence Hospital Tacoma General Hospital 235.2800 916 Pacific 315 South"K"St. University Medical Center 258-7123(98201) 594-1000(98405) 4225 Roosevelt Way N.E. Vashon Seattle 98105 Vashon Health Center 634.4000 Sunrise Ridge Center 463-3671(98070) ?A-1117 08-03145 (12/91)