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HomeMy WebLinkAboutCAG1988-0038 - Original - Group Health Cooperative - Group Medical Coverage Agreement - 01/01/1988 Group Health , Cooperative of Puget Sound GROUP MEDICAL COVERAGE AGREEMENT Group Health Cooperative of Puget Sound (also GROUP HEALTH COOPERATIVE OF PUGET SOUND referred to as "GHC" or the "Cooperative") is a • non-profit health maintenance organization furnishing By ""`�►•. health care primarily on a prepayment basis. As a direct service provider, the Cooperative is dedicated Title Vice-President,Health Plan and Insurance Services to providing to its Enrollees quality health care, including preventive medical services. GROUP CITY OF KENT This Agreement states the terms of enrollment, #0369 payment, and coverage under which a Group may secure GHC health benefits. The Schedule of B Benefits lists the benefits to which those enrolled y under this Agreement are entitled. Words with Title c lD �.rr l 1�/�L� l�W12�-4,74,special meaning are capitalized. They are defined in Section I. ENROLLEES ARE ENTITLED TO COVERED SERVICES ONLY AT GHC FACILITIES, UNLESS THE ENROLLEE HAS BEEN REFERRED BY A GHC PHYSICIAN OR HAS RECEIVED EMER- This Agreement will become effective 01 L0,1/88 GENCY SERVICES ACCORDING TO SECTION X.I. and will continue in effect until terminated as herein ded for. OF THE SCHEDULE OF BENEFITS. provi PA-758 I00131WS.1 01/87 Rev. 01/88 GROUP MEDICAL COVERAGE AGREEMENT Table of Contents I. Definitions II. Dues and Fees III. Termination IV. 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 List of Attachments 1. Dues and Fees Schedule 2. Service Area Map 3. Coordination of Benefits Contract Attachment 4. Medicare High Option Endorsement 5. Medicare Standard Option Endorsement 6. Continuation Coverage, Conversion, and Transfer Contract Endorsement 7. Emergency Department Copayment Contract Endorsement 8. Maternity Care Contract Endorsement 9. Pre-existing Conditions Contract Endorsement PA-758 TyiW by 01/87 Rev.01/88 #0369 Section I. DEFINITIONS Map.) Designated Facilities may be changed by GHC upon appropriate notice. AGREEMENT: This Medical Coverage Agreement, including the Schedule of Benefits, Enrollment GHC FACILITY: A hospital or medical center and Eligibility Schedule, Dues and Fees owned and operated by Group Health Coopera- Schedule, Coordination of Benefits Attachment, tive of Puget Sound. (See Service Area Map.) Service Area Map, and any applicable endorsements. - GHC MEDICARE PLAN: A plan of coverage for persrns enrolled in Medicare Part A (hospital ALLOWANCE: The maximum amount payable by insurance) and Part B (medical insurance), or GHC for certain Covered Services under this Part B only. Agreement, as set forth in the Dues and Fees Schedule. GROUP: An employer, union, welfare trust, or association which has entered into a Group COVERED SERVICES: The services and benefits Medical Cover.-e Agreement with GHC. to which an Enrollee is entitled under this Agreement. HOSPITAL CARE: Those Medically Necessary services generally provided by acute general DEDUCTIBLE: A specific maximum amount paid hospitals for admitted patients which a GHC by an Enrollee for certain Covered Services physician has prescribed, directed, or authorized. before benefits are payable under this Agree- Hospital care does not include convalescent or ment. The applicable Deductible amounts are custodial care which can, in the opinion of the set forth in the Dues and Fees Schedule. GHC physician, be provided by a nursing home or convalescent care center. DIRECTORY OF SERVICES: A fee-for-service schedule adopted by GHC, setting forth the fees MEDICAL PERSONNEL: The Medical Staff, Clinic for medical and hospital services not covered by Associate Staff, and Allied Health Professionals a GHC prepayment agreement. employed by GHC, and any other health care professional with whom GHC has entered into a EMERGENCY: The sudden, unexpected onset of a formal legal arrangement. medical condition that, in the reasonable opinion of the Enrollee or person assuming respon- MEDICALLY NECESSARY: Required for the sibility for transporting the Enrollee, is of such a diagnosis or treatment of illness or injury, as nature that failure to render immediate care by a determined by a GHC physician, and consistent licensed medical provider would place the with professionally recognized standards of Enrollee's life in danger, or cause serious health care. impairment to the Enrollee's health. MEDICARE: The federal health insurance program ENROLLEE: Any Subscriber or Family Dependent for the aged and disabled. covered by this Agreement. OPEN ENROLLMENT: An annual period, specified FAMILY DEPENDENT: Any member of a Sub- by the Group and GHC, during which an eligible scriber's family who meets all applicable person may apply for coverage. eligibility requirements, is enrolled hereunder, and for whom the dues prescribed in the Dues PRE-EXISTING CONDITION: A condition for and Fees Schedule have been paid. which there has been diagnosis, treatment (including prescribed drugs), or medical advice FAMILY UNIT: A Subscriber and all his/her Family within the twelve (12) month period prior to the Dependents. effective date of coverage, or a condition for which symptoms existed within the twelve (12) GHC DESIGNATED FACILITY: A facility, not month period prior to the date of coverage and including a GHC Facility, which the GHC Board for which a prudent person would have or- of Trustees has specified to provide health care dinarily sought treatment. services to its Enrollees. (See Service Area PA-758 100131WS.3 01/87 Rev.01/88 REFERRAL: A prior written authorization by a B. Subscriber's Liability. The Subscriber is liable GHC physician, approved by GHC, which for payment to the Group of his/her contribution entitles an Enrollee to receive Covered Services toward the monthly dues, if any, and payment to from a specified non-GHC health care provider. the Cooperative of any fees charged for non- Entitlement to such services shall not exceed the Covered Services provided to the Subscriber and limits of the Referral and is subject to all terms his/her Family Dependents. and conditions of this Agreement. C. Self-Payments During a Strike, Lock-Out, or SERVICE AREA: King, Kitsap, Pierce, Skagit, Other Labor Dispute. In the event of suspen- Snohomish, Thurston, and Whatcom Counties, sion or termination of employee compensation and any other areas designated by GHC. (See due to a strike, lock-out, or other labor dispute, a Service Area Map.) Subscriber may continue uninterrupted coverage under this Agreement through payment of SKILLED HOME HEALTH CARE. Reasonable monthly dues directly to the Group. Coverage and necessary care for tl-e treatment of an illness may be continued for the lesser of the term of or injury which requires the skill of a nurse or the strike, lock-out, or other labor dispute, or for therapist, based on the complexity of the service six (6) months after the cessation of work. and the condition of the patient, and which is If the Group Agreement is no longer available, performed directly by an appropriately licensed the Subscriber shall have the opportunity to professional provider. apply for individual Group Conversion or, if SUBSCRIBER: A person who meets all applicable applicable, continuation coverage (see Section IV.), or an Individual and Family Medical eligibility requirements, is enrolled hereunder, Coverage Agreement at the duly approved rates. and for whom the dues specified in the Dues and Fees Schedule have been paid. THE GROUP IS RESPONSIBLE FOR IM- MEDIATELY NOTIFYING EACH AFFECTED URGENT CONDITION: The sudden, unexpected SUBSCRIBER OF HIS/HER RIGHTS OF onset of a medical condition that is of sufficient SELF-PAYMENT UNDER THIS PROVISION. severity to require medical treatment within twenty-four (24) hours of its onset. Section III. TERMINATION USUAL, CUSTOMARY, AND REASONABLE: A A. Termination of Entire Agreement. This term used to define the level of benefits which Agreement may be terminated in the following are payable by GHC when expenses are incurred circumstances: from a non-GHC physician or provider. Ex- penses are considered Usual, Customary, and 1. Termination on Notice. Either GHC or the Reasonable if (1) the charges are consistent with Group may terminate this Agreement by those normally charged by the provider or giving thirty (30) days written notice to the organization for the same services or supplies; other. and (2) the charges are within the general range 2. Non-Payment. Failure to make any monthly of charges made by other providers in the same dues payment in accordance with Section geographical area for the same services or II.A. shall result in termination of this supplies. Agreement as of the due date. Section II. DUES AND FEES B. Termination of Specific Enrollees. This A. Monthly Dues Payments. The Group shall Agreement may be terminated as to a specific submit to GHC for each Enrollee the monthly Enrollee for any of the following reasons: dues set forth in the current Dues and Fees 1. Loss of Eligibility. If an Enrollee no longer Schedule and a verification of enrollment, on or meets the applicable eligibility requirements before the due date, subject to a grace period of ten (10) days. Dues are subject to change by set forth in Section IX.B., coverage under GHC upon thirty (30) days written notice. this Agreement shall terminate at the end of the month during which loss of eligibility occurs. PA-758 I0013IWS.4 01/87 Rev.01/88 2. For Cause. Coverage of an Enrollee may be following termination under this Agreement. terminated upon written notice for: Coverage under the GHC Group Conversion Plan is subject to all terms and conditions of a. Non-payment of dues for a specific such plan, including dues payment. A Enrollee by the Group. physical examination or statement of health b. Material misrepresentation or fraud in is not required for enrollment in the Group obtaining coverage for an Enrollee or Conversion Plan. non-Enrbllee. B. Persons Entitled to, or Eligible to Purchase c. Permitting the use of a GHC identifica- McAcare. Except as defined by federal regula- tion card by another person, or using tions, all Enrollees entitled to, or eligible to another person's identification card to purchase Medicare must transfer to the GHC obtain care to which one is not entitled. Medicare Plan upon such entitlement or d. Failure to comply with the rules and eligibility. A condition of coverage under the regulations of the Cooperative. GHC Medicare Plan requires that an Enrollee be continuously fully qualified and enrolled for the C. Persons Hospitalized on the Date or Termina- hospital (Part A) and medical (Part B) benefits, tion. An Enrollee who is a registered bed or Part B only, available from the Social patient receiving Covered Services in a GHC Security Administration, and sign any papers Facility or GHC Designated Facility on the date that may be required by GHC or Medicare. All of termination shall continue to be eligible for applicable provisions of the GHC Medicare Plan Covered Services for the condition for which the are fully set forth in the Medicare En- Enrollee was hospitalized, until discharge from dorsement(s) attached to this Agreement. the facility. This continued coverage will also apply to an Enrollee hospitalized in a non-GHC C. Persons Age Sixty-five (65) or Older Who Are Designated Facility as a result of an Emergency Not Entitled to, or Eligible to Purchase or Referral as set forth in Section XI.B.1. Medicare. Upon reaching age sixty-five (65), if not entitled to, or eligible to purchase Medicare, D. Services Provided after Termination. Any Enrollees may continue coverage under this services provided by GHC after the effective Agreement upon payment of the applicable dues date of termination (except those services as set forth in the Dues and Fees Schedule. covered under Section III.C.) shall be charged Section V. COORDINATION OF BENEFITS according to the Directory of Services. The Subscriber shall be liable for payment of all such Benefits provided under this Agreement do not charges for services provided to the Subscriber duplicate other coverage for medical care or treat- and all Family Dependents. ment. If an Enrollee is entitled to receive benefits or Section IV. CONVERSION AND TRANSFER services for medical care or treatment under another group or governmental plan, GHC may recover the A. GHC Group Conversion Plan. reasonable cash value of services provided under this Agreement so that benefits and services under all 1. Eligibility. Any Subscriber or Family Plans do not exceed one hundred percent (100%). Dependent eighteen (18) years of age or older is entitled to convert to GHC's Group This provision is fully set forth in the attach- ment to this Agreement titled "Coordination of Conversion Plan if his/her coverage under Benefits." this Agreement is terminated for any reason other than non-payment or cause. (See Section VI. SUBROGATION Section III.B.2.) Following termination of marriage or death of the Subscriber, all F "Injured person" under this section means an Family Dependents are entitled to make such Enrollee covered by this Agreement who sustains a conversion. compensable injury. Cooperatives medical ex- 2. Application. Application for conversion pense" means the expense incurred by the Cooperative must be made within thirty-one (31) days for the care or treatment of the injury sustained. PA-758 I00131WS.5 01/87 Rev.01/88 If the injured person was injured by an act or Section VII. GRIEVANCE PROCEDURES omission of a third party giving rise to a claim of legal liability against the third party, the Cooperative The Consumer Relations Program is designed to shall have the right to recover its cost of providing help an Enrollee resolve formal complaints and benefits to the injured person (subrogation) from the concerns about medical and business service. GHC third party. The Cooperative shall be subrogated to will record, research, and respond in a timely manner and may enforce all rights of the injured person to the to an Enrollee's concern. A concern should initially extent of its medical expense. The Cooperative's be registered at the Enro'lee's area medical center. If riglit of subrogation shall be limited to the excess of not satisfied, the Enrolee should then contact the the amount required to fully r ompensate the injured regional Consumer Relations Department, which will person for the loss sustained. Full compensation shall arrange for review by appropriate Medical Staff, be measured on an objective, case-by-case basis, but management, and/or GHC consumers. is subject to a presumption that a settlement which does not exhaust the third party's reachable assets is Section VIII. MISCELLANEOUS PROVISIONS full compensation to the injured person. The injured person, or the injured person's A. Dissemination of Information. The Group is representative, must cooperate fully with GHC and responsible for disseminating to Subscribers GHC's legal counsel in effecting collection from written information concerning this Agreement persons causing the injury. If an injured party settles which is provided by the Cooperative. a claim without protecting the Cooperative's interest, the injured person's rights to full compensation may B. Identification Cards. The Cooperative will be lost. furnish cards, for identification only, to all persons enrolled under this Agreement. Except in cases where GHC has retained its own legal counsel, when reasonable collection costs C. Administration of Agreement. GHC may adopt including legal fees have been incurred to recover the reasonable policies and procedures to help in the Cooperative's medical expense, whether incurred in administration of this Agreement. an action for damages or otherwise, and where there is recovery in the Cooperative's behalf, there shall be an D. Modification of Agreement. This Agreement equitable apportionment of such collection costs may be modified by GHC upon thirty (30) days between the Cooperative and the injured person or written notice. Enrollee subject to a limit for GHC of one-third of the amount GHC recovers. GHC shall not pay such collection costs where GHC has retained its own legal Group Health Cooperative of Puget Sound does not counsel to represent its own interests. This provision discriminate on the basis of physical or mental does not apply to occupationally incurred disease, handicaps in its employment practices and services. sickness, and/or injury. (See Section XI.A.8.) PA-758 I00131WS.6 O1/87 Rev.01/88 Section IX. ENROLLMENT AND ELIGIBILITY c. Open Enrollment. A person not en- SCHEDULE rolled as a Subscriber or Family Dependent when newly eligible, as A. Enrollment described above, may make written 1. Application for Enrollment. Application application during the Group's Open for enrollment shall be made on an ap- Enrollment period. plication form furnished or approved by 2. Limitation on Enrollment. This Agree- GHC. No person shall be enrolled or ment will be open for application as set dues accepted until this completed ap- forth in Section IX.A.1. GHC may plication has been received by GHC. limit enrollment, establish quotas, or The Group is responsible for submitting set priorities for acceptance of new ap- completed application forms to GHC. plications if it determines that its capa- a. Newly Eligible Persons. Newly eli- city, in relation to its total enrollment, gible Subscribers may make written is not adequate to provide services to application for enrollment to the additional persons. Group within thirty-one (31) days of 3. Effective Date of Enrollment. eligibility. If the Subscriber wishes a. Provided application is made as set to enroll his/her eligible Depend- forth in Section IX.A.l.a. (above), ents, application must be made dur- enrollment for a newly eligible Sub- ing this same thirty-one (31) day scriber and listed Dependents will period. begin on the date of hire. Written application for enroll- Enrollment for newly depend- ment for a newly acquired Depend- ent persons, other than newborns ent other than a newborn or and adopted children, will begin on adopted child must be made to the the first of the month following ap- Group within thirty-one (31) days plication. after the dependency occurs. Provided newborns are enrolled A Subscriber who, subsequent as specified in Section IX.A.l.a. to his/her enrollment, wishes to en- (above), enrollment is effective roll a newborn child must make from the date of birth. written application to the Group A newborn is defined as a child within sixty (60) days of the child's who is not older than four (4) birthdate. Adopted children must weeks. be enrolled within sixty (60) days For adopted children, enroll- from the day that the child is phys- ment is effective from the date ically placed with the Subscriber that the adopted child is physically for the purpose of adoption and the placed with the Subscriber for the Subscriber assumes financial re- purposes of adoption and the Sub- sponsibility for the medical ex- scriber has assumed financial re- penses of the child. sponsibility for the medical ex- b. If the spouse of a GHC Subscriber penses of the child. loses eligibility under a group med- b. Persons Hospitalized on Effective ical plan provided by his/her em- Date. If a person is confined in a ployer, the spouse and any eligible hospital on the date enrollment Dependents listed on the spouse's would otherwise become effective, insurance may be added to the GHC enrollment for the person(s) hospi- Subscriber's plan. Enrollment must talized will not begin until dis- be continuous between plans and charge from the facility. application must be made prior to, 4. Effective Date of Services and Benefits. or at the same time as, termination Services provided to Enrollees are sub- of previous enrollment. ject to all terms and conditions of this CA-101 E0369CNT.1 01/88 Agreement including the requirement birthday if: that all services must be received at a i. The Dependent is a full-time GHC or GHC Designated Facility under registered student at an ac- the medical management of a GHC credited secondary school, col- physician unless the Enrollee has been lege, or university and under referred by a GHC physician or has re- the age of twenty-three (23); ceived Emergency services according to or Section X.I. ii. The Dependent is incapable of B. Eligibility self-support because of devel- In order to be accepted for enrollment and opmental disability or physical continuing coverage under this Agreement, handicap incurred prior to at- individuals must meet all applicable re- tainment of the limiting age, is quirements set forth below. The Group is chiefly dependent upon the responsible for determining eligibility. Subscriber for support and 1. Subscribers. Elected officials and bona maintenance, and qualifies as a fide employees who are employed on a Dependent for Federal Income regularly scheduled basis of not less Tax purposes. Enrollment for than eighty (80) hours in each calendar such a Dependent may be con- month shall be eligible for enrollment. tinued for the duration of the Uniformed Personnel will not be incapacity, provided enroll- covered under this plan. ment does not terminate for 2. Family Dependents. The Subscriber any other reason. Medical may enroll any of the following: proof of incapacity and proof a. The Subscriber's legal spouse; of financial dependency must b. unmarried dependent children who be furnished to the Coopera- are under the age of twenty-one tive upon request, but not (21), provided they reside regularly more frequently than annually with the Subscriber or qualify as after the two-year period fol- Dependents for Federal Income Tax lowing the Dependent's at- purposes. tainment of the limiting age. "Children" means the children d. Dependents of Uniformed Personnel of the Subscriber including adopted are eligible for coverage under this children, stepchildren, foster chil- contract. dren, and any other children for Ineligible Persons. GHC reserves the right whom the Subscriber is the legal to refuse enrollment to any person whose guardian. coverage under this Agreement or any other c. Enrollment may be extended past Medical Coverage Agreement issued by the limiting age for an unmarried Group Health Cooperative of Puget Sound person enrolled as a Family Depen- has been terminated for cause. (See Section dent on his/her twenty-first (21st) III.B.2.) CA-101 E0369CNT.2 01/88 Section X. SCHEDULE OF BENEFITS 7. Maternity care, including care for complications of pregnancy, and prenatal and postpartum Subject to all provisions of this Group Medical visits. Hospitalization and delivery are Coverage Agreement, persons enrolled for Com- provided, subject to payment of the Maternity prehensive Health Care are entitled to receive the Care Fee set forth in the Dues and Fees services and benefits described in this Schedule. Schedule. The Maternity Care Fee must be paid in equal monthly installments during the A. HOSPITAL CARE prenatal period, with the final installment Hospital care is provided when approved by a GHC payable not later than thirty (30) days prior to physician, limited to the following services: expected date of birth. 1. Room and board, including private room when Voluntary (not medically indicated and non- prescribed, and general nursing services. therapeutic) termination of pregnancy will be 2. Hospital services (including use of operating charged according to the Cooperative's Direc- room, anesthesia, oxygen, x-ray, laboratory, and tory of Services. radiotherapy services). 8. Transplants. When authorized as medically 3. Drugs and medication. appropriate by GHC's Medical Director or 4. Special duty nursing (when prescribed as Medically Necessary). his/her designee and in accordance with criteria established by the Cooperative, limited to heart, Personal comfort items, such as telephone and kidney, corneal, bone marrow, and liver television, are not covered. transplants for children under the age of If an Enrollee is hospitalized in a non-GHC Facility, thirteen (13) with congenital biliary atresia. GHC reserves the right to require transfer of the Organ acquisition costs including applicable Enrollee to a GHC Facility, upon consultation with a hospital and medical costs of the donor are not GHC physician. If the Enrollee refuses to transfer to covered. a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Enrollee. Coverage for heart and liver transplants and/or B. MEDICAL AND SURGICAL CARE any related services, items, and drugs shall be Medical and surgical services are provided, limited excluded until such time as the Enrollee has to the following, when prescribed by GHC Medical been continuously enrolled under this Agree- Personnel: ment, or any prior GHC Medical Coverage 1. Surgical services. Agreement for twelve (12) consecutive months 2. Diagnostic x-ray, nuclear medicine, ultrasound, without any lapse in coverage. and laboratory services. 9. Physician visits (including consultations and 3. Eye examinations and refractions. Contact lens second opinions by a GHC physician) in the examinations and fittings are not covered hospital or office. except as set forth below. When dispensed 10. Physical therapy; occupational therapy; through GHC Facilities, one contact lens per respiratory therapy; and speech therapy to diseased eye in lieu of an intraocular lens, restore speech following severe illness, injury, including exam and fitting, is covered for or surgery. Enrollees following cataract surgery performed 11. Preventive services for health maintenance by a GHC physician, provided the Enrollee has including physical examinations for detection been continuously covered by GHC since such of disease or other conditions, and im- surgery. Replacement of a covered contact lens munizations and vaccinations which are listed will be provided only when needed due to as covered in the GHC Drug Formulary change in the Enrollee's medical condition but (approved drug list). A fee may be charged for may be replaced only one time within any health education programs. twelve (12) month period. 12. Radiation therapy services. 4. Family planning counseling services. 13. Services related to dysfunction of the jaw: 5. Hearing examinations to determine hearing loss. when referred by a GHC physician, evaluation 6. Blood derivatives and the administration of and treatment at a GHC-approved temporoman- blood and blood derivatives. The cost of blood dibular joint (TMJ) care provider, and occlusal is not covered. splint fitting. PA-754 10006IWS.1 (01/87)rev. 01/88 All TMJ appliances, including the occlusal prescription drugs and medicines. splint and night guard, are excluded. Treatment b. Court-ordered treatment shall be provided of jaw dysfunction, including TMJ dysfunction, only if determined to be Medically will NOT be provided when the dysfunction is Necessary by GHC's ADAPT Director or related to malocclusion or when TMJ services his/her designee. are needed due to dental work performed. All 2. Emergency Care. such services and related hospitalization, i a. Coverage for medical Emergencies incident including orthodontic therapy, and orthognathic to the abuse of alcohol and/or drugs is (jaw) surgery, are excluded, regardless of origin subject to the Emergency care benefit as set or cause. forth in Section X.I. 14. The following services are covered by GHC b. Coverage for acute chemical withdrawal is when performed by a GHC physician or GHC provided without prior approval. If an oral surgeon: reduction of a fracture or disloca- lion of the jaw or facial bones; excision of Enrollee is hospitalized in a non-GHC tumors or cysts of the jaw, cheeks, lips, tongue, Designated Facility, coverage is subject to gums, roof and floor of the mouth; and incision payment of the Deductible shown in the Dues and Fees Schedule, and notification of of salivary glands and ducts. GHC by way of the GHC Notification Line 15. Non-experimental implants, limited to the following: cardiac devices, artificial joints, and immediately upon inpatient admission, or as inuaocular lenses. Artificial or mechanical soon thereafter as practicable, but in no hearts are excluded. event more than twenty-four (24) hours following admission. Furthermore, if an 16. When authorized as medically appropriate by Enrollee is hospitalized in a non-GHC GHC's Medical Director or his/her designee, and in accordance with criteria established by Designated Facility, GHC reserves the right the Cooperative, treatment of growth disorders to require transfer of the Enrollee to a GHC by growth hormones. Facility upon consultation with a GHC physician. If the Enrollee refuses transfer Growth hormone treatment shall be excluded to a GHC Facility, all further costs incurred until such time as the Enrollee has been during the hospitalization are the responsi- continuously enrolled under this Agreement or bility of the Enrollee. any prior GHC Medical Coverage Agreement For the purpose of this section, "acute for twelve (12) consecutive months without any chemical withdrawal" means withdrawal of lapse in coverage. alcohol and/or drugs from a person for whom consequences of abstinence are so C. CHEMICAL DEPENDENCY TREATMENT severe as to require medical/nursing Subject to all terms and conditions of this Agree- assistance in a hospital setting and which ment, care is provided as set forth below at a GHC are needed immediately to prevent serious Facility, GHC Designated Facility, or GHC-approved impairment to the Enrollee's health. treatment facility meeting all requirements of RCW 3. Benefit Period and Benefit Period Allowance. 70.96A.010, et. seq., subject to the Benefit Period a. Benefit Period. For the purpose of this Allowance and Lifetime Maximum Benefit as section, "Benefit Period" shall mean a described below and as shown in the Dues and Fees twenty-four (24) consecutive calendar Schedule. month period during which the Enrollee is 1. Chemical Dependency Treatment Services. eligible to receive covered chemical a. All alcoholism and/or drug abuse treatment dependency treatment services as set forth services must be: (1) provided at a facility in this section. The first Benefit Period as described above and must be authorized shall begin on the first day the Enrollee in advance, except for acute chemical receives covered chemical dependency withdrawal as described in Section services under this or any other group X.C.2.b.; and (2) deemed Medically insurance, health care service contractor, Necessary by GHC's ADAPT Director or health maintenance organization, self- his/her designee. Chemical dependency insured plan or any combination thereof, treatment may include the following hereinafter referred to as "group plans," and services received on an inpatient or out- shall continue for twenty-four (24) con- patient basis: diagnostic evaluation and secutive calendar months provided that education, organized individual and group coverage under this Agreement remains in counseling, detoxification services, and force. All subsequent Benefit Periods PA-754 I0006IWS.2 (01/87)rev.01/88 thereafter will begin on the first day one reconstructive breast reduction on the Covered Services are received after expira- nondiseased breast to make it equivalent in size tion of the previous twenty-four (24) month with the diseased breast after definitive re- Benefit Period. constructive surgery on the diseased breast has b. Benefit Period Allowance. The maximum been performed. allowance available for any Benefit Period shall be the total of all chemical depend- E. APPLIANCES which are Medically Necessary, ency benefits provided and payments made limited to the following: ostomy supplies; temporary for chemical dependency treatment under orthopedic appliances for use during treatment up to any group plan(s), not to exceed the Benefit a maximum of six (6) months; and on Referral, Period Allowance shown in the Dues and oxygen and oxygen equipment for home use. Fees Schedule during the Enrollee's Benefit Period. F. DRUGS AND MEDICINES FOR OUTPATIENT USE as prescribed by a GHC physician for condi- 4. Lifetime Maximum Benefit. tions covered by this Agreement. All drugs, sup- Chemical dependency services are not covered plies, medicines and devices must be obtained at a after the Enrollee has reached his/her Lifetime GHC pharmacy. Maximum Benefit amount as shown in the Dues and Fees Schedule. All such benefits provided Excluded are: dietary supplements (except or payments made by therapeutic vitamins for use up to thirty [30] days); a. GHC under any GHC Group Medical outpatient mental health drugs; contraceptive drugs Coverage Agreement, plus and devices and their fitting; medicines and injec- b. all amounts paid on an individual's behalf lions for anticipated illness while traveling; and any under any carrier or plan maintained by the other drugs, medicines, and injections not listed as Group, including self-insured plans, covered in the GHC Drug Formulary (approved drug shall be applied toward this Lifetime Maximum list). Benefit amount. The Enrollee will be charged for mailing or replacing Any Deductibles or Copayments which may be lost or stolen drugs, medicines or devices. borne by the Enrollee under the terms of this Agreement shall not be applied toward the G. HOME HEALTH CARE SERVICES, as set forth in Benefit Period Allowance or Lifetime Maxi- this section, shall be provided by GHC Home Health mum Benefit. Services or by a GHC-authorized home health agency when Referred in advance by a GHC physician for In regard to this section, the Benefit Period(s), Enrollees who meet the following criteria: Benefit Period Allowance(s), and Lifetime 1. The Enrollee is unable to leave home due to his Maximum Benefit shall include only alcoholism or her health problem or illness (unwillingness treatment services received on or after January to travel and/or arrange for transportation does 1, 1987 and alcoholism and/or drug abuse not constitute inability to leave the home); services received on or after January 1, 1988. 2. the Enrollee requires intermittent Skilled Home Health Care services, as described below; and D. PLASTIC AND RECONSTRUCTIVE SERVICES 3. a GHC physician has determined that such will be provided: services are Medically Necessary and are most 1. to correct a functional disorder, as determined appropriately rendered in the Enrollee's home. by a GHC physician, resulting from a congeni- tal disease or anomaly; or Covered Services for home health care may include 2. to correct a medical condition following an the following when prescribed by a GHC physician injury or incidental to surgery covered by GHC, and when rendered pursuant to an approved home provided the Enrollee has. been continuously health care plan of treatment: nursing care, physical covered at GHC since such injury or surgery. therapy, occupational therapy, respiratory therapy, 3. Reconstructive surgery and associated proce- restorative speech therapy, and medical social worker dures following a mastectomy will be covered and limited home health aide services. Home health for Enrollees who are medically suitable services are provided on an intermittent basis in the candidates, as determined by GHC's Medical Enrollee's home. "Intermittent" means care that is to Director or his/her designee. Internal breast be rendered because of a medically predictable recurring need for Skilled Home Health Care prostheses required incident to the surgery will be provided. services. 4. An Enrollee will be covered for all stages of Excluded are: custodial care and maintenance care, PA-754 I00061WS.3 (01/87)rev.01/88 private duty or continuous nursing care in the En- If two or more members of a Family Unit rollee's home, housekeeping or meal services, care in require Emergency care as a result of the same any nursing home or convalescent facility, any care accident, only one Emergency Deductible will provided by or for a member of the patient's family, apply. and any other services not listed specifically as covered Outpatient medications prescribed by a non- when rendered in the home under this Agreement. GHC physician are excluded. H. MENTAL HEALTH CARE SERVICES, limited to 3. Transfer and Follow-up Care. If an Enrollee the following, are provided on an outpatient basis at is hospitalized in a non-GHC Facility, GHC GHC. Subject to the limitations set forth in this reserves the right to require transfer of the section, and all other provisions of this Agreement, Enrollee to a GHC Facility, upon consultation brief focal psychotherapy, chronic intermittent care, with a GHC physician. If the Enrollee refuses and consultation services will be provided in the to transfer to a GHC Facility, all further costs following therapy formats: individual, couple, incurred during the hospitalization are theresponsibility of the Enrollee. family, or group. Follow-up care which is a direct result of the Coverage for each Enrollee is provided according to Emergency must be obtained at GHC, unless a the outpatient mental health care allowance set forth GHC physician has authorized such care in in the Dues and Fees Schedule. advance. Covered Services are limited to those provided for J. AMBULANCE SERVICES are covered as set forth covered conditions for which, in the opinion of the below, provided that the service is authorized in director of GHC's Mental Health Service, or his/her advance by a GHC physician or meets the definition designee, significant improvement can be expected of an Emergency. (See Section I.) within a treatment program of twenty (20) visits or 1. Emergency Transport to a GHC Facility or less. GHC Designated Facility. Each Emergency is covered as set forth in the Dues and Fees Excluded are: all forms of intensive or extensive Schedule. psychotherapy, including but not limited to intensive, 2. Emergency Transport to a Non-GHC Desig- ongoing care for chronic mental health conditions; nated Facility. Each Emergency is covered as treatment of sexual disorders and/or dysfunctions; set forth in the Dues and Fees Schedule. specialty programs not provided by GHC; court- 3. Waiver of Ambulance Services Deductible. If ordered treatment which is not specifically described two or more members of the Family Unit above; day treatment; psychological testing, except require Emergency ambulance transport as a where provided during the course of mental health result of the same accident, only one Am- treatment; hospital and related inpatient or custodial bulance Deductible will apply. care. The Ambulance Deductible will not apply when I. EMERGENCY CARE ambulance service is authorized in advance by the Cooperative. 1. At a GHC Facility or GHC Designated 4. Transfer to a GHC Facility. When authorized Facility. GHC will cover Emergency care for in advance by the Cooperative, an additional all Covered Services. Ambulance Allowance is provided for transfer 2. At a Non-GHC Designated Facility. Usual, to a GHC Facility. Customary, and Reasonable charges for Emer- gency care for Covered Services are covered K. HOSPICE subject to: It is understood and agreed that the following fully sa. payment of the Emergency Deductible sets forth the eligibility requirements and Covered shown in the Dues and Fees Schedule; Services for an Enrollee who wishes to elect to and receive services through GHC' s Hospice Program. b. notification of GHC by way of the GHC Enrollees who elect to receive GHC Hospice Notification Line immediately upon Services do so in lieu of curative treatment for inpatient admission, or as soon thereafter their terminal illness for the period that they are as practicable, but in no event more than in the GHC Hospice Program. twenty-four (24) hours following Hospice Program admission. 1. Eligibility. Hospice Services, as set forth below, shall be provided to Enrollees for as PA-7 54 I0006IWS.4 (01/87)rev. 01/88 long as the following criteria are met: b. Inpatient Hospice Services shall be a. A GHC physician has determined that the provided in a facility designated by GHC's Enrollee's illness is terminal and life Hospice Program when Medically expectancy is six (6) months or less; Necessary and authorized in advance by a b. the Enrollee has chosen a palliative treatment GHC physician and GHC's Hospice focus (emphasizing comfort and supportive Program. Inpatient Hospice Services shall services rather than treatment aimed at curing be provided according to the provisions set the Enrollee's terminal illness); forth in Section X. of this Agreement. c. the Enrollee has elected in writing to 4. Hospice Exclusions: All services not spe- receive hospice care through GHC's cifically listed as covered in this section, Hospice Program; including, but not limited to: d. the Enrollee has available a primary care a. Financial or legal counseling services. person who will be responsible for the b. Housekeeping or meals services. Enrollee's home care; and C. Custodial or maintenance care in the home e. a GHC physician and GHC's Hospice or on an inpatient basis. Director determine that the Enrollee's illness d. Services not specifically listed as covered can be appropriately managed in the home. by this Medical Coverage Agreement. e. Any services provided by members of the 2. Hospice Care shall be defined as a coordinated patient's family. program of palliative and supportive care for All other exclusions listed in Section XI.,f. dying persons by an interdisciplinary team of professionals and volunteers centering primarily Exclusions and Limitations, of this Medical in the Enrollee's home. Coverage Agreement, apply. 3. Covered Services. Hospice Services may Section XI. EXCLUSIONS AND LIMITATIONS include the following as prescribed by a GHC physician and rendered pursuant to an approved hospice plan of treatment: A. EXCLUSIONS a. Home Services 1. Blood for transfusions. i. Intermittent care by a hospice inter- 2. Except as provided in Sections X.B.3., X.D, disciplinary team which may include X.E., and X.F., corrective appliances and services by a physician, nurse, medical artificial aids, including but not limited to: social worker, physical therapist, eyeglasses; contact lenses including ex- speech pathologist, occupational ther- aminations and fittings; prosthetic devices; apist, respiratory therapist, and limited diabetic supplies including insulin pumps; services by a Home Health Aide under hearing aids and examinations in connection the supervision of a Registered Nurse. therewith; arch supports or corrective shoes; ii. One period of continuous care service take-home dressings and supplies following per Enrollee in the Enrollee's home hospitalization; or any other supplies, dress- when prescribed by a GHC physician, ings, appliances, devices or services which are as set forth in this paragraph. A not for the specific treatment of disease or continuous care period is defined as injury. "skilled nursing care provided in the 3. Cosmetic services, including treatment for home during a period of crisis in order complications of cosmetic surgery, except as to maintain the terminally ill patient at provided in Section X.D. home." Continuous care may be 4. Dental care, surgery, services, and appliances, provided for pain or symptom manage- including but not limited to: treatment of ment by a Registered Nurse, Licensed accidental injury to natural teeth, reconstructive Practical Nurse, or Home Health Aide surgery to the jaw incident to denture wear, and under the supervision of a Registered periodontal surgery. The Cooperative's Nurse. Continuous care is provided for Medical Director, or his/her designee, will four (4) or more hours per day for a determine whether the care or treatment period not to exceed five (5) days, or a required is within the category of dental care or total of seventy-two (72) hours, service. whichever first occurs. Continuous care is covered only when a GHC If a GHC physician determines that an unrelated physician determines that the Enrollee medical condition requires that an Enrollee be would otherwise require hospitalization hospitalized for a dental procedure which is in an acute care facility. normally done in a dentist's office, GHC will PA-754 I00061WS.5 (01/87)rev. 01/88 cover associated hospital and anesthesia costs at Agreement for twelve (12) consecutive months a GHC or GHC Designated Facility. GHC will without any lapse in coverage. not cover the dentist's or oral surgeon's fees. 13. Mental health care, except as specifically 5. Certain drugs and medicines. (See Section provided in Section X.H. X.F.) Any exclusion of drugs and medicines 14. Procedures, services, and supplies related to sex will also exclude their administration. transformations. 6. Convalescent or custodial care, including 15. Regardless of origin or cause, diagnostic testing skilled nursing-facility care. and medical treatment of sterility, infertility, 7. Durable medical equipment such as hospital impotency, and frigidity. beds, wheelchairs, and walk-aids, except while 16. Services of practitioners whose licensing in the hospital. category is not represented by GHC Medical 8. Services covered by employment or government Personnel. programs: 17. Surgery directly related to obesity. a. Any illness, condition or injury for which 18. Any services for which an Enrollee has a benefits are available, or could be available, contractual right to recover the cost thereof, through application for coverage under any whether a claim is asserted or not, under federal or state workers' compensation or automobile medical, personal injury protection, industrial insurance law or employer's uninsured or underinsured motorist, home liability contract or insurance. It is ex- owner's or other first party coverage, except for pressly understood that this Agreement is individual health insurance. NOT to serve as private industrial in- 19. Services or supplies not specifically listed as surance, or a self-insured plan maintained covered in the Schedule of Benefits. by the employer. 20. Voluntary (not medically indicated and non- b. Any federal, state, county, municipal, or therapeutic) termination of pregnancy. other governmental agency, including in the 21. The cost of services and supplies resulting from case of service-connected disabilities, the an Enrollee's loss of or willful damage to Veterans Administration. covered appliances, devices, supplies, and GHC reserves all rights to reimbursement materials provided by GHC for the treatment of provided by any of the above-described laws, disease, injury, or illness. private industrial insurance, self-insured plans, 22• Routine circumcision, including newborn or governmental agencies. circumcision, which is not considered Medi- cally Necessary. Services will be provided under this Agreement: a. if there is reasonable doubt whether an B. LIMITATIONS Enrollee should receive benefits under this 1. Conditions and Extent of Coverage. ALL Agreement or from another source; and SERVICES AND BENEFITS UNDER THIS b. if the Enrollee actively seeks to establish AGREEMENT MUST BE PROVIDED BY GHC his/her rights to benefits from that source. MEDICAL PERSONNEL AT A GHC 9. Those parts of an examination and associated FACILITY UNLESS: reports required for employment, immigration, license, or insurance purposes that are not a. The Enrollee has received a Referral from a deemed Medically Necessary by GHC for early GHC physician. detection of disease. b. The Enrollee has received Emergency 10. Investigational procedures, including medical service s.according to Section X.I. and surgical services, drugs, and devices until 2. Recommended Treatment. The Cooperative's formally approved by GHC for medical Medical Director or his/her designee will coverage. Investigational drugs are not covered determine the necessity, nature, and extent of until approved by the U.S. Food and Drug treatment to be provided in each individual case Administration for general marketing and by and the judgment, made in good faith, will be GHC for medical coverage. final. 11. Non-therapeutic sterilization; and procedures Enrollees have the right to participate in and services to reverse a therapeutic or non- decisions regarding their health care. An therapeutic sterilization. Enrollee may refuse recommended treatment or 12. Pre-existing Conditions shall be excluded from diagnostic plan to the extent permitted by law. coverage until such time as the Enrollee has In such case, GHC shall have no further been continuously covered under this Agree- obligation to provide the care in question. ment or any prior GHC Medical Coverage Enrollees who seek other sources of care PA-754 I0006IWS.6 (01/87)rev.01/88 because of such a disagreement do so with the similar causes, GHC shall make a good faith full understanding that GHC has no obligation effort to provide such services through its for the cost, or liability for the outcome, of such then-existing facilities and personnel. In no care. case shall the Cooperative have any liability or 3. Major Disaster or Epidemic. In the event of a obligation on account of delay or failure to major disaster or epidemic, GHC Medical provide or arrange such services. Personnel will provide Covered Services according to their best judgment, within the Section XII. CLAIMS limitations of available facilities and personnel. Enrollees must submit claims for reimbursement of The Cooperative has no liability for delay or Covered Services to GHC within sixty (60) days of the failure to provide or arrange Covered Services service date, or as soon thereafter as is reasonably to the extent facilities or personnel are unavail- possible. In no event, except in the absence of legal able due to a major disaster or epidemic. capacity, shall a claim be accepted later than one (1) year 4. Unusual Circumstances. If the provision of from the service date. This section applies to Covered Covered Services is delayed or rendered Services received under Section X.I. and X.J., or services impossible due to unusual circumstances such for which the Enrollee has received a Referral from a as complete or partial destruction of facilities, GHC physician. military action, civil disorder, labor disputes, or PA-754 I0006IWS.7 (01/87)rev.01/88 DUES AND FEES SCHEDULE For Active Employees and their Dependents For attachment to Group Medical Coverage Agreement with CITY OF KENT. This schedule reflects Group Health Cooperative monthly dues effective January 1, 1988 and guaranteed to January 1, 1989. COMPREHENSIVE COVERAGE HEALTH CARE DUES Subscriber.. . ... . ... ... .... . ... .. . ... .. ... ... . . . .. . . . . . .. . . . . . .$ 78.89 per month Subscriber and spouse. ... .. . . . .. . .. . . .. .. ... ... .. . . . . . . . . .. . ... .. 176.51 per month Subscriber and child(ren)... .... . .. . . .. .. ... .. . .. . . ... . . . . . . ... .. 159.10 per month Subscriber and family. .. . .. . . . . . . ... .. . .. ... ... .. . . . . . . . . . . . ... .. 252.68 per month Spouseonly. ..... .. ... ... ... . . . . . . .. . .. .. ... . .... . . . . .. . . . .. . ... . 97.62 per month Child(ren) only.. .. ... . . .. . . .. . ..... . .. .. . .. .. . . . . . . .. . . . . .... 80.21 per month Spouse and child(ren). ..... . . . . .. . . . . .. . .. .. ..... . . . ... . . . .. ... .. 173.79 per month MEDICARE HEALTH CARE DUES HMO High Option Persons aged 65 and over with parts A & B of Medicare. ... ... .. 61.48 per month Persons aged 65 and over with part B of Medicare only. . ... .... 137.83 per month Subscriber and spouse (one with parts A & B of Medicare).. . .. . 159.44 per month Subscriber and spouse (both with parts A & B of Medicare). . .. . 122.96 per month Subscriber and child(ren) (Subscriber with parts A & B of Medicare) . . .. . � . . . . . . . .. . .. . . ... . 142.03 per month Subscriber and family (one with parts A & B ofMedicare).. .. . . 235.61 per month Subscriber and family (two with parts A & B of Medicare) . . .. . . 218.55 per month Spouse and children (spouse with parts A & B of Medicare) . ... . 156.72 per month HMO Standard Option Persons aged 65 and over with parts A & B of Medicare. . . . . .. . . 35.10 per month Persons age 65 and over with part B of Medicare only. .. . .. ... . 23.50 per month Subscriber and spouse (one with parts A & B of Medicare).. ... . 133.06 per month Subscriber and spouse (both with parts A & B of Medicare). ... . 70.20 per month Subscriber and children) (Subscriber with parts A & B of Medicare) ......... ... .. ... ..... ........... . .. .. .. . .. .. . . per r month Subscriber and family (one with parts A & B of Medicare).. ... . 209.23 per month Subscriber and family (two with parts A & B of Medicare)..... . 165.79 per month Spouse and children (spouse with parts A & bo of Medicare. .... 130.34 per month Not HMO Persons covered by part A only.. .. . .. ... . .. ... .. . .. . . . . ... ... . 130.34 per month NOTE: Medicare rates do not apply to TEFRA eligible enrollees. Page 1 of 3 BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the 1st 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. The Group will submit the full amount of said dues to the Cooperative when the effective date of enrollment for a given Subscriber and Family Dependents is prior to the 16th of the month. Enrollment effective on or after the 16th of the month will be provided without charge for a Subscriber and Family Dependents, and these Enrollees will appear on the subsequent month's billing at the regular charge. Per average enrollee in 1988, 8.7 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 Cooperative Medical Staff. ALLOWANCES, DEDUCTIBLES, COPAYMENTS, AND FEES The following Allowances, Deductibles, Copayments and Fees are subject to Pre-existing Conditions limitations as defined in the Medical Coverage Agreement. Outpatient Mental Health Care 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 out- patient mental health care. Chemical Dependency Allowance Benefit Period Allowance. . . . . .. . . ... . . .. . . . . . . $5,000 maximum per Enrollee per any 24 consecutive calendar month period for outpatient and inpatient services re- ceived. Lifetime Maximum Benefit . . ... .. . .. . . . . . . . . . . $10,000 per Enrollee for outpatient and inpatient services received. Emergency Copayment/Deductible . .. . . . .. . ... .. . . . . . Emergency care at a GHC or GHC-Desig- nated Facility is subject to a $25.00 Copayment amount per Emergency, payable by the Enrollee. Emergency care at a non-GHC Designated Facility is subject to a $100.00 Deductible amount per Emergency, payable by the Enrollee. Stop Loss........ ... ... ... .. .. ... ... .. ... .. . ... ... Total out-of-pocket Copayment expenses for Emergency care at a GHC or GHC Designated Facility are limited to an aggreggate maximum of $750 per Enrollee and $1500 per family per calendar year. Page 2 of 3 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 Designated Facility are subject to a $50.00 Deductible amount per Emerg- ency, payable by the Enrollee. "Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or mental handicaps in its employment practices or services." S07078AT Page 3 of 3 WHATGOM wig Beflinom Mt.Vernon SKAGIT SNOHOMISH Everett LynmmW B Bothell sland `Redmond 5 Settle ................ Bnn Factorla Renton KITSAP a Bunten KING Vashon • `Federal way MASON Tacoma PIERCE THURSTON teal Specialty Hospitals Designated Centers Centers Facilities Group Heafth 4 Coordination of Benefits of Puget Sound Contract Attachment MM For Attachment to Group Medical Coverage Agreement It is understood and agreed that the following fully C. Allowable Expense: sets forth the provisions outlined in Section V., "Allowable Expense" means any necessary, "Coordination of Benefits." reasonable and customary items of expense at least a portion of which is covered under at least COORDINATION OF BENEFITS one of the Plans covering the person for whom the claim is made. When a Plan provides A. Benefits Subject to This Provision: benefits in the form of services rather than cash All of the benefits provided under this payments, the reasonable cash value of each Agreement are subject to this provision. service rendered shall be considered as both an Allowable Expense and a benefit paid. B. Plan: The definition of a "Plan" includes the following D. Claim Determination Period: sources of benefits or services: "Claim Determination Period" means a period 1. Group or blanket disability insurance beginning with any January 1 and ending with policies and health care service contractor the next following December 31 except that the and health maintenance organization group first Claim Determination Period with respect to agreements, issued by insurers, health care any person shall begin on the effective date of service contractors and health maintenance coverage under this Agreement with respect to organizations; such person and end on the following December 2. Labor-management trusteed plans, labor 31. In no event will a Claim Determination organization plans, employer organization Period for any person extend beyond the last day plans or employee benefit organization on which such a person is covered under this plans; Agreement. 3. Governmental programs; and 4. Coverage required or provided by any E. Right to Receive and Release Information: statute. For the purpose of determining the applicability The term "Plan" shall be construed separ- of and implementing this provision and any ately with respect to each policy, agreement provision of similar purpose in any other Plan, or other arrangement for benefits or services, the Cooperative may, with such consent as may and separately with respect to the respective be necessary, release to or obtain from any other portions of any such policy, agreement or insurer, organization or person any information, other arrangement which do and which do with respect to any person which the insurer not reserve the right to take the benefits or considers necessary for such purpose. Any services of other policies, agreements or person claiming benefits under this Agreement other arrangements into consideration in shall furnish to the Cooperative the information determining benefits. necessary for such purpose. PA-868,CA-65 I0046CNT.1,(12/86) F. Facility of Payment:_ Expenses incurred as to such person during Whenever coverage which should have been such Claim Determination Period shall be provided under this Agreement in accordance reduced to the extent necessary so that the with this provision has been provided or paid for sum of the reasonable cash value of benefits under any other Plan, the Cooperative shall have and all benefits payable for such Allowable the right, exercisable alone and in its sole Expenses under all other Plans, except as discretion, to pay over to any Plan making such provided in subparagraph (3) of this Section, other payments any amounts it shall determine to shall not exceed the total of such Allowable be warranted in order to satisfy the intent of this Expenses. Benefits payable under another provision, and amounts so paid shall be Plan include benefits that would have been considered to be coverage or benefits paid under payable had a claim been duly made this Agreement and, to the extent of such therefore. payments, the Cooperative shall be fully 3. If discharged from liability under this Agreement. a. another Plan which is involved in subparagraph (2) of this Section and G. Right of Recovery: which contains a provision coordinating Whenever benefits have been provided by the its benefits with those of this Agreement Cooperative with respect to Allowable Expenses would, according to its rules, determine in total amount, at any time, in excess of the its benefits after the benefits of this Plan maximum amount of payment necessary at that have been determined, and time to satisfy the intent of this provision, the b. the rules set forth in subparagraph (4) of Cooperative shall have the.right to recover the this Section would require this reasonable cash value of such benefits, to the Agreement to determine its benefits extent of such excess, from one or more of the before such other Plan then the benefits following, as the Cooperative shall determine: of such other Plan will be ignored for any persons to or for or with respect to whom the purposes of determining the benefits such benefits were provided, any other insurers, under this Agreement. any service plans or any other organization or 4. For the purposes of subparagraph (3) of this other Plans. Section, the rules establishing the order of benefit determination are: H. Effect on Benefits: a. The benefits of a Plan which covers the 1. This provision shall apply in determining the person on whose expenses a claim is benefits for a person covered under this based other than as a dependent shall be Agreement for a particular Claim determined before the benefits of a Plan Determination Period if, for the Allowable which covers such person as a Expenses incurred as to such person during dependent. such period, the sum of: b. In the case that a dependent is covered a. The reasonable cash value of the under both parents' medical Plan, the benefits that would be provided under benefits of the Plan of the parent whose the Agreement in the absence of this birthday falls earlier in the year are provision, and determined before those of the Plan of a b. The benefits that would be payable parent whose birthday falls later in the under all other Plans in the absence year. This birthdate will refer only to therein or provisions of similar purpose the month and day, not the year in which to this provision would exceed such a person was born. If both parents have Allowable Expenses. the same birthday, the benefits of the 2. As to any Claim Determination Period with Plan which covered the parent longer are respect to which this provision is applicable, determined before those that covered the the reasonable cash value of the benefits other parent for a shorter period of time, provided under this Agreement in the except that in the case of a person for absence of this provision for the Allowable whom claim is made as a dependent PA-868,CA-65 I0046CNT.2,(12/86) child, c. When rules (a) and (b) do not establish i. when the parents are separated or an order of benefit determination, the divorced and the parent with custody benefits of a Plan which has covered the of the child has not remarried, the person on whose expenses claim is based benefits of a Plan which covers the for the longer period of time shall be child as a dependent of the parent determined before the benefits of a Plan with custody of the child will be which has covered such person the determined before the benefits of a shorter period of time, provided that: Plan which covers the child as a i. The benefits of a plan covering the dependent of the parent without person on whose expenses claim is custody; and based as a laid off or retired ii. when the parents are divorced and employee, or dependent of such the parent with custody of the child person shall be determined after the has remarried, the benefits of a Plan benefits of any other Plan covering which covers the child as a de- such person as an employee, other pendent of the parent with custody than a laid off or retired employee, shall be determined before the or dependent of such person; and benefits of a Plan which covers that ii. If either plan does not have a child as a dependent of the step- provision regarding laid off or parent, and the benefits of a Plan retired employees, which results in which covers that child as a each Plan determining its benefits dependent of the stepparent will be after the other, then the provisions determined before the benefits of a of (i) of this subsection shall not Plan which covers that child as a apply. dependent of the parent without S. When this provision operates to reduce custody. the total amount of benefits otherwise to Notwithstanding items (i) and (ii) above, be provided to a person covered under if there is a court decree which would this Agreement during any Claim otherwise establish financial responsibil- Determination Period, the reasonable ity for the medical, dental or other cash value of each benefit that would be health care expenses with respect to the provided in the absence of this provision child, the benefits of a Plan which shall be reduced proportionately, and covers the child as a dependent of the such reduced amount shall be charged parent with such financial responsibility against any applicable benefit limit of shall be determined before the benefits this Agreement. of any other Plan which cover the child as a dependent child. PA-868,CA-65 I0046CNT.3,(12186) Group •, Health • Coopewative of Puget Sound MEDICARE HIGH OPTION ENDORSEMENT Except as defined by Federal Regulations, all endorsement apply only to Enrollees who have both Enrollees entitled to, or eligible to purchase Parts A and B of Medicare. Medicare must transfer to the GHC Medicare Plan upon such entitlement or eligibility. A condition of Section I. DEFINITIONS coverage under the GHC Medicare Plan requires that an Enrollee be continuously fully qualified and CUSTODIAL CARE: Care that is primarily for the enrolled for the hospital (Part A) and medical (Part purpose of meeting personal needs and could be B) benefits, or Part B only, available from the provided by persons without professional skills Social Security Administration, and sign any papers or training. Custodial care includes help in that may be required by GHC or Medicare. walking, bathing, dressing, eating and taking medicine. ENROLLEES ON THE GHC MEDICARE PLAN ARE ENTITLED TO COVERED SERVICES ONLY MEDICALLY NECESSARY: Required for the AT GHC FACILITIES, UNLESS THE ENROLLEE diagnosis or treatment of illness or injury or to HAS BEEN REFERRED BY A GHC PHYSICIAN improve the functioning of a malformed body OR HAS RECEIVED EMERGENCY OR member as determined by a GHC physician, and URGENTLY NEEDED SERVICES ACCORDING consistent with professionally recognized TO SECTION VI.I. OF THIS ENDORSEMENT. standards of health care. NEITHER GHC NOR MEDICARE WILL PAY FOR SERVICES PROVIDED AT NON-GHC MEDICARE HANDBOOK (Titled "Your Medicare FACILITIES UNLESS THESE CONDITIONS ARE Handbook"): A pamphlet published by the U.S. MET. Department of Health and Human Services, Social Security Administration, which provides The provisions of the GHC Group Medical Cov- an easy to read explanation of Medicare erage Agreement, hereinafter referred to as the benefits. "Group Agreement," remain in effect except as modified by this endorsement. Coverage hereunder MENTAL HEALTH CARE: Care for mental or is integrated with the medical and hospital benefits emotional diseases including neurosis, psy- established by Title 18 of the Social Security Act as choneurosis, psychopathy or psychosis. amended, and referred to as "Medicare." For additional information, the Enrollee should refer to PERMANENT RESIDENCE: The residence or "Your Medicare Handbook," which is referenced domicile in which the Subscriber resides for throughout this Agreement. A copy may be more than six (6) consecutive months out of the obtained from the Social Security Administration. calendar year. The benefits and exclusions described in this P00001END.1 (09/86) SKILLED NURSING FACILITY: (GHC Progres- the Group Agreement remain in effect except as sive Care Facility) A licensed facility as modified by this endorsement. Following is a defined by Medicare, primarily engaged in summary of the specific Medicare provisions. providing skilled nursing care or rehabilitation All Medicare deductibles, co-insurance, and and related services for which Medicare pays co-payments are covered by GHC. benefits. Section II. TERMINATION Coverage for Pre-existing Conditions. Restric- tions contained in the Group Agreement on the A. Termination of Specific Enrollees. In addi- care and treatment of pre-existing conditions tion to the provisions set forth in the section shall not be applicable, and all waivers in respect titled "Termination" of the Group Agreement, to such conditions shall be removed, but such coverage under the GHC Medicare Plan may be terminated _as to a specific Enrollee if the care and treatment shall be subject to the other Federal Medicare Program advises GHC that an exclusions and limitations set forth in the Group Enrollee's entitlement to Medicare coverage no Agreement. longer exists. A. HOSPITAL CARE Section III. NOTICES -- CHANGE OF PER- GHC will supplement the hospital benefits of MANENT RESIDENCE Medicare by paying deductible(s), co-insurance and co-payment(s). After Medicare hospital Notices provided for in this Agreement shall be allowances explained in "Your Medicare mailed to the Cooperative at its principal address, Handbook" are exhausted, GHC will provide and to the Subscriber's address as it appears in the further hospital care in accordance with the records of the Cooperative. The Subscriber shall Group Agreement. notify the Cooperative in writing of any changes in Permanent Residence within thirty (30) days of B. MEDICAL AND SURGICAL CARE such change. The following medical and surgical services are provided when prescribed by a GHC physician. Section IV. RECONSIDERATION OF CLAIMS 1. Blood, blood derivatives, and their If GHC denies a request for payment of a claim, or administration. declines to provide services which the Enrollee believes should be provided, the Enrollee may file a 2. Transplants. When allowed by Medicare request for reconsideration. The request must be and authorized by GHC's Medical Director filed within sixty (60) days after denial unless an or his/her designee. Donor costs will be extension is specifically approved. If GHC cannot covered per Medicare guidelines. overturn the initial denial, it will be referred by GHC to the Health Care Financing Administration 3. Physician calls (including consultation and for further review and final determination. second opinion by a GHC Physician) in the hospital, office, or Skilled Nursing Section V. EFFECTIVE DATE OF SERVICES Facility. Physician calls in a nursing AND BENEFITS home or convalescent center are provided up to Medicare limits as described in Coverage under the GHC Medicare Plan is effective "Your Medicare Handbook." on the date specified by GHC and the Social Security Administration. 4. Speech therapy per Medicare guidelines. Section VI. SCHEDULE OF BENEFITS -- GHC S. Prosthetic devices approved by Medicare, HIGH OPTION MEDICARE PLAN including the following: cardiac devices, artificial joints, intraocular lenses, and The provisions of the sections titled "Schedule of artificial eyes and limbs. (See "YourMedicare Handbook.") Benefits" and "Exclusions and Limitations" of P00001END.2 (09/86) 6. Chiropractic care limited to spinal G. MENTAL HEALTH CARE manipulations subject to Medicare- approved GHC guidelines. Excluded are 1. Outpatient. Coverage is provided ac- any other diagnostic or therapeutic cording to Medicare guidelines. (See services, including x-rays, furnished by a "Your Medicare Handbook.") When chiropractor. (See "Your Medical Medicare guidelines are not met, out- Handbook.") patient mental health care will be provided as described in the subsection titled 7. Podiatric care including removal of plantar "Mental Health Care" of the "Schedule of warts, subject to Medicare guidelines. Benefits" of the Group Agreement. Excluded is routine foot care such as hygenic care; treatment of flat feet or 2. Inpatient. Upon referral, GHC will other misalignments of the feet; and provide hospitalization for mental health removal of corns, calluses and most warts. according to Medicare guidelines. (See (See "Your Medical Handbook.") "Your Medicare Handbook.") C. SUBSTANCE ABUSE TREATMENT H. SKILLED NURSING FACILITY: GHC will Alcoholism and drug abuse/addiction treatment provide care in its Progressive Care Facility up will be provided per Medicare guidelines. to Medicare limits, when Medically Necessary in the opinion of the GHC physician and D. PLASTIC AND RECONSTRUCTIVE SERV- Medicare guidelines are met. (See "Your ICES WILL BE PROVIDED AS FOLLOWS: Medicare Handbook.") 1. to improve the functioning of a malformed body part, or I. GHC HIGH OPTION EMERGENCY BENEFIT: When emergency services meet 2. to correct a medical condition following an Medicare guidelines, coverage will be provided injury or incident to surgery. in full. When emergency services do not meet Medicare guidelines, GHC coverage will be 3. Reconstructive surgery and associated provided according to the guidelines set forth in procedures following a mastectomy will be the subsection titled "Emergency Care" of the covered for Enrollees who are medically "Schedule of Benefits" of the Group Agreement. suitable candidates, as determined by Because a claim may initially be processed by a GHC's Medical Director or his/her Medicare Intermediary using only Medicare designee. Breast prostheses required guidelines, any unpaid claim or portions of a incident to the surgery will be provided. claim should be submitted to GHC. (See Claims Procedure below.) E. APPLIANCES which are Medically Necessary, limited to the following when approved by J. MEDICARE AMBULANCE BENEFIT: Medicare: ostomy supplies, orthopedic Medically Necessary ambulance transportation appliances, orthopedic shoes covered ONLY is covered by Medicare only if transportation by when they are part of leg braces. Dental plates any other vehicle could endanger the patient's or other dental devices are NOT covered. (See health and the ambulance, equipment, and "Your Medicare Handbook.") personnel meet Medicare requirements. (See "Your Medicare Handbook.") F. RENTAL OR PURCHASE OF DURABLE MEDICAL EQUIPMENT• Oxygen equipment, When ambulance services meet Medicare wheelchairs, home dialysis systems, and other guidelines, coverage will be provided in full. Medically Necessary equipment when approved by Medicare and prescribed by a GHC physician for use in your home. (See "Your Medicare K. GHC HIGH OPTION EMERGENCY AMBU- Handbook.") LANCE BENEFIT: When emergency ambu- lance services do not meet Medicare guidelines, P00001END.3 (09/86) benefits will be provided as set forth in the If a GHC physician determines that an subsection titled "Ambulance Services" of the unrelated medical condition requires that "Schedule of Benefits" of the Group Agreement. an Enrollee be hospitalized for a dental procedure which is normally done in a L. EMERGENCY CLAIMS PROCEDURE: dentist's office, or if the severity of the Claims for services or supplies and Explanation dental procedure requires hospitalization, of Medicare Benefits forms for services or GHC will cover associated hospital and supplies from providers other than Group anesthesia costs at a GHC or GHC Health Cooperative should be sent to: Medicare Designated Facility. GHC will not cover Claims, Group Health Cooperative of Puget the dentist's or oral surgeon's fees. Sound, P.O. Box C-19165, Seattle, WA 98109. If you must receive emergency or urgently B. LIMITATIONS needed care from a non-GHC provider, you must show your GHC I.D. card and your red, 1. Conditions and Extent of Coverage. white and blue Medicare card. ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE 1. The Enrollee must submit claims as soon PROVIDED BY GHC MEDICAL PER- as possible, but in no case later than the SONNEL AT A GHC FACILITY UNLESS: fifteen (15) month limit set in "Your Medicare Handbook." a. The Enrollee has received a Referral from a GHC physician. 2. The Cooperative may secure information which it deems necessary concerning the b. The Enrollee has received emergency medical care and hospitalization for which or urgently needed service according payment is requested. to the subsection titled "Emergency Care" of the "Schedule of Benefits" of Section VII. EXCLUSIONS AND LIMITATIONS the Group Agreement or Section VI.I. of this Medicare Endorsement. A. EXCLUSIONS 2. Duty to Maintain Federal Medicare 1. Corrective shoes, except when orthopedic Status. A condition of coverage under the shoes are part of leg braces. GHC Medicare Plan requires that an Enrollee be continuously fully qualified 2. Dental care and service unless the service and enrolled for the hospital (Part A) and would be covered if provided by a medical (Part B) benefits, or Part B only, physician. The Cooperative's Medical available from the Social Security Director, or his/her designee, will Administration, and sign any papers that determine whether the care or treatment may be required by GHC or Medicare. required is within the category of dental care or service. P00001ENDA (09/86) Group Health �� rave of Puget Sound MEDICARE STANDARD OPTION ENDORSEMENT Except as defined by Federal Regulations, all Section I. DEFINITIONS Enrollees entitled to, or eligible to purchase Medicare must transfer to the GHC Medicare Plan CUSTODIAL CARE: Care that is primarily for the upon such entitlement or eligibility. A condition of purpose of meeting personal needs and could coverage under the GHC Medicare Plan requires be provided by persons without professional that an Enrollee be continuously fully qualified and skills or training. Custodial care includes help enrolled for the hospital (Part A) and medical (Part in walking, bathing, dressing, eating and B) benefits, or Part B only, available from the taking medicine. Social Security Administration, and sign any papers that clay be required by GHC or Medicare. MEDICALLY NECESSARY: Required for the diagnosis or treatment of illness or injury or to ENROLLEES ON THE GHC MEDICARE PLAN improve the functioning of a malformed body ARE ENTITLED TO COVERED SERVICES ONLY member as determined by a GHC physician, AT GHC FACILITIES, UNLESS THE ENROLLEE and consistent with professionally recognized HAS BEEN REFERRED BY A GHC PHYSICIAN standards of health care. OR HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SERVICES ACCORDING MEDICARE HANDBOOK (Titled "Your Medicare TO SECTION VI.K. OF THIS ENDORSEMENT. Handbook"): A pamphlet published by the NEITHER GHC NOR MEDICARE WILL PAY FOR U.S. Department of Health and Human SERVICES PROVIDED AT NON-GHC Services, Social Security Administration, FACILITIES UNLESS THESE CONDITIONS ARE which provides an easy to read explanation of MET. Medicare benefits. The provisions of the GHC Group Medical Cov- MENTAL HEALTH CARE: Care for mental or erage Agreement, hereinafter referred to as the emotional diseases including neurosis, psy- "Group Agreement," remain in effect except as choneurosis, psychopathy or psychosis. modified by this endorsement. The Enrollee should refer to "Your Medicare Handbook," the provisions PERMANENT RESIDENCE: The residence or of which apply to this endorsement. A copy may be domicile in which the Subscriber resides for obtained from the Social Security Administration. more than six (6) consecutive months out of The benefits and exclusions described in this the calendar year. endorsement apply only to Enrollees who have both Parts A and B of Medicare. SKILLED NURSING FACILITY: (GHC Progres- sive Care Facility) A licensed facility as defined by Medicare, primarily engaged in P0002END.1 (09/86) providing skilled nursing care or rehabilitation Following is a summary of the major benefits. and related services for which Medicare pays All Medicare deductibles, co-insurance, and benefits. co-payments are covered by GHC. Any service Section II. TERMINATION or benefit not covered by Medicare is excluded. A. Termination of- Specific Enrollees. In A. HOSPITAL CARE addition to the provisions set forth in the GHC will supplement the hospital benefits of section titled "Termination" of the Group Medicare by paying deductible(s), co- Agreement, coverage under the GHC Medicare insurance and co-payment(s). After Medicare Plan may be terminated as to a specific hospital allowances explained in "Your Enrollee if the Federal Medicare Program Medicare Handbook" are exhausted, GHC will advises GHC that an Enrollee's entitlement to not cover further hospital care. Medicare coverage no longer exists. Subject to Medicare hospital allowances Section III. NOTICES .- CHANGE OF PERMA. explained in "Your Medicare Handbook", NENT RESIDENCE hospital care is provided when approved by a GHC physician, including the following Notices provided for in this Agreement shall be services: mailed to the Cooperative at its principal address, 1. Room and board, and general nursing and to the Subscriber's address as it appears in the services. records of the Cooperative. The Subscriber shall notify the Cooperative in writing of any changes in 2. Hospital services (including use of oper- Permanent Residence within thirty (30) days of ating room, labor and delivery rooms, such change. anesthesia, oxygen, x-ray, laboratory, and Section IV. RECONSIDERATION OF CLAIMS radiotherapy services.) If GHC denies a request for payment of a claim, or 3. Drugs and medication administered during declines to provide services which the Enrollee an approved hospital stay. believes should be provided, the Enrollee may file a Personal comfort items, such as telephone and request for reconsideration. The request must be television, and special duty nursing are not filed within sixty (60) days after denial unless an covered. extension is specifically approved. If GHC cannot overturn the initial denial, it will be referred by B. MEDICAL AND SURGICAL CARE GHC to the Health Care Financing Administration The following medical and surgical services for further review and final determination. are provided when prescribed by a GHC Section V. EFFECTIVE DATE OF SERVICES physician. AND BENEFITS 1. Surgical services. Coverage under the GHC Medicare Plan is effective 2. Diagnostic x-ray, nuclear medicine, on the date specified by GHC and the Social ultrasound, and laboratory services. Security Administration. 3. Blood, blood derivatives, and their Section VI. SCHEDULE OF BENEFITS -- GHC administration. STANDARD OPTION MEDICARE PLAN 4. Transplants. When allowed by Medicare The section titled "Schedule of Benefits" of the and authorized by GHC's Medical Director Group Agreement is deleted in its entirety. or his/her designee. Donor costs will be Benefits are limited to those covered by covered per Medicare guidelines. Medicare. (See "Your Medicare Handbook.") P0002END.2 (09/86) 5. Physician calls (including consultation and C. SUBSTANCE ABUSE TREATMENT second opinion by a GHC Physician) in the Alcoholism and drug abuse/addiction treat- hospital, office, or Skilled Nursing ment will be provided per Medicare Facility. Physician calls in a nursing guidelines. home or convalescent center are provided up to Medicare limits as described in D. PLASTIC AND RECONSTRUCTIVE "Your Medicare Handbook." SERVICES WILL BE PROVIDED AS 6. Speech therapy per Medicare guidelines. FOLLOWS: 1. to improve the functioning of a malformed 7. Radiation therapy services. body part, or 8. Specified services related to dysfunction 2. to correct a medical condition following an of the jaw: When referred by a GHC injury or incident to surgery. physician, evaluation and treatment by 3. Reconstructive surgery and associated GHC's Temporomandibular Joint (TMJ) procedures following a mastectomy will be Clinic, and occlusal splint therapy. covered for Enrollees who are medically Treatment of jaw dysfunction, including suitable candidates, as determined by TMJ dysfunction, will NOT be provided GHC's Medical Director or his/her when the dysfunction is related to designee. Breast prostheses required malocclusion. All such services and incident to the surgery will be provided. related hospitalization, including orthodontic therapy and orthognathic (jaw) 4. An Enrollee will be covered for all stages surgery, are excluded. of one reconstructive breast reduction on the nondiseased breast to make it equiv- 9. The following services are provided by alent in size with the diseased breast after GHC when performed by a GHC physician definitive reconstruction surgery on the or GHC oral surgeon: reduction of a diseased breast has been performed. fracture or dislocation of the jaw or facial bones; excision of tumors or cysts of the E. APPLIANCES which are Medically Neces- jaw, cheeks, lips, tongue, gums, roof and sary, limited to the following when approved floor of the mouth; and incision of salivary by Medicare: ostomy supplies, orthopedic glands and ducts. appliances, orthopedic shoes covered ONLY when they are part of leg braces. Dental plates 10. Prosthetic devices approved by Medicare, or other dental devices are NOT covered. (See including the following: cardiac devices, "Your Medicare Handbook.") artificial joints, intraocular lenses, and artificial eyes and limbs. (See "Your F. DRUGS AND MEDICINES will be covered Medicare Handbook.") while hospitalized during an approved stay in a hospital or Skilled Nursing Facility. Ex- 11. Chiropractic care limited to spinal ma- cluded are outpatient drugs and medicines. nipulations subject to Medicare-approved (See "Your Medicare Handbook.") GHC guidelines. Excluded are any other diagnostic or therapeutic services, including G. HOME HEALTH CARE SERVICES by a x-rays, furnished by a chiropractor. (See visiting nurse, nurse's aide, physical therapist, "Your Medicare Handbook.") occupational therapist, speech therapist, or medical social worker are provided through 12. Podiatric care including removal of plantar the GHC home health agency for Enrollees warts, subject to Medicare guidelines. who meet the established criteria. Care must Excluded is routine foot care such as be authorized in advance by a GHC physician. hygenic care; treatment of flat feet or other Nursing care on a full-time basis in your home misalignments of the feet; and removal of is excluded. (See "Your Medicare corns, calluses and most warts. (See "Your Handbook.") Medicare Handbook.") P0002END.3 (09/86) H. RENTAL OR PURCHASE OF DURABLE only when an Enrollee is temporarily MEDICAL EQUIPMENT: Oxygen absent from the Service Area for no longer equipment, wheelchairs, home dialysis than one hundred twenty (120) days. systems, and other Medically Necessary equipment when approved by Medicare and When emergency or urgently needed care prescribed by a GHC physician for use in your meets Medicare guidelines, coverage will home. (See "Your Medicare Handbook.") be provided up to the Medicare Reasonable Charge. Amounts beyond the Medicare I. MENTAL HEALTH CARE Reasonable Charge are the responsibility of the Enrollee. 1. Outpatient. Covered to Medicare mon- etary limit. (See "Your Medicare 3. Care covered by this subsection shall Handbook.") include the following: 2. Hospitalization for Mental Health. Upon • physicians' services, referral, GHC will cover to the extent allowed by Medicare. (See "Your . Hospital Care, and Medicare Handbook.") drugs and medicines only while J. SKILLED NURSING FACILITY: GHC will patient is hospitalized. provide care in its Progressive Care Facility up to Medicare limits, when Medically Neces- L. MEDICARE AMBULANCE BENEFIT: sary in the opinion of the GHC physician and Medically Necessary ambulance transportation Medicare guidelines are met. (See "Your is covered by Medicare only if transportation Medicare Handbook.") by any other vehicle could endanger the patient's health and the ambulance, equipment, K. MEDICARE EMERGENCY BENEFIT and personnel meet Medicare requirements. Excluded from coverage is ambulance use 1. Emergency Services Emergency Services from your home to a doctor's office. (See are those required to prevent death or "Your Medicare Handbook.") serious impairment to the Enrollee's health, and will be covered anywhere When ambulance services meet Medicare within the Medicare geographic limits of guidelines, coverage will be provided up to the the United States, Puerto Rico, the Virgin Medicare Reasonable Charge. Amounts Islands, Guam, American Samoa, and the beyond the Medicare Reasonable Charge are Northern Mariana Islands. the responsibility of the Enrollee. Such services are considered emergency M. EMERGENCY CLAIMS PROCEDURE: services only so long as the transfer of the Claims for services or supplies and Explana- Enrollee to GHC Facilities (or GHC tion of Medicare Benefits forms for services or Designated Facilities) is precluded because supplies from providers other than Group of risk to the Enrollee's health, or the Health Cooperative should be sent to: distance and nature of illness involved Medicare Claims, Group Health Cooperative would make the transfer unreasonable. of Puget Sound, P.O. Box C-19165, Seattle, WA 98109. If you must receive emergency or 2. Urgently Needed Services. Urgently urgently needed care from a non-GHC Needed Services are those required to provider, you must show your GHC I.D. card prevent a serious deterioration in the and your red, white and blue Medicare card. Enrollee's health, and will be covered within the Service Area ONLY AT GHC 1. The Enrollee must submit claims as soon FACILITIES OR GHC DESIGNATED as possible, but in no case later than the FACILITIES. Outside the GHC Service fifteen (15) month limit set in "Your Area, urgently needed care will be covered Medicare Handbook." P0002ENDA (09/86) 2. The Cooperative may secure information 5. Services covered by employment or which it deems necessary concerning the government programs: medical care and hospitalization for which payment is requested. a. Any federal, state, county, or mu- nicipal worker's compensation, Section VII. EXCLUSIONS AND LIMITATIONS employer's liability, or laws of similar purpose; or under any private in- A. EXCLUSIONS dustrial insurance or self-insured plans maintained by the employer; or The subsection titled "Exclusions" of the section b. Any federal, state, county, municipal, title "Exclusions and Limitations" of the Group or other governmental agency; Agreement is deleted in its entirety. Benefits including in the case of service- shall be limited to those covered by Medicare. connected disabilities, the Veterans (See "Your Medicare Handbook.") Following is Administration. a summary of the major exclusions. GHC reserves all rights to reimbursement 1. Eyeglasses, contact lenses including provided by any of the above-described examinations and fittings (except where laws, private industrial insurance, self- eyeglasses or contact lenses are required to insured plan, or governmental agencies. replace the natural lens of the eye); diabetic supplies including insulin pumps; It is expressly understood that this hearing aids and examinations in Agreement is NOT intended to serve as connection therewith; corrective shoes private industrial insurance, or as a (except when orthopedic shoes are part of self-insured plan maintained by the leg braces); or any other supplies or employer. dressings which are not for the specific treatment of disease or injury. c. Services will be provided under this Agreement: 2. Cosmetic services, except as provided in Section VI.D. i. if there is reasonable doubt whether an Enrollee should receive 3. Dental care and service unless the service benefits under this Agreement or would be covered if provided by a from another source; and physician. The Cooperative's Medical ii, if the Enrollee active/ Director, or his/her designee, will y seeks to determine whether the care or treatment establish his/her rights to benefits required is within the category of dental from that source. care or service. 6. Examinations and associated reports If a GHC physician determines that an required for employment, immigration, unrelated medical condition requires that license, or insurance purposes. an Enrollee be hospitalized for a dental procedure which is normally done in a 7. Investigational procedures, including dentist's office, or if the severity of the medical and surgical services, drugs, and dental procedure requires hospitalization, supplies until approved by GHC. GHC will cover associated hospital and anesthesia costs at a GHC or GHC 8. Supportive devices for the feet. Designated Facility. GHC will not cover the dentist's or oral surgeon's fees. 9. Health evaluations (routine physical and health screening examinations). 4. Custodial or convalescent care, including homemaker services. 10. Drugs and medicines and the adminis- tration thereof (except as a hospital P0002END.S (09/86) inpatient under care of a GHC physician or motorist, homeowner's or other first party while a hospital inpatient and entitled to coverage, except for individual health Emergency or Urgently Needed Care). insurance. 11. Special Duty Nursing Care. B. LIMITATIONS 12. Hospital care exceeding Medicare The subsection titled "Limitations" of the allowance. section title "Exclusions and Limitations" 13. Immunizations and vaccinations, except as of the Group Agreement is modified to covered by Medicare (See "Your Medicare include the following: Handbook.") I. Conditions and Extent of Coverage. 14. Hearing examinations for the prescription ALL SERVICES AND BENEFITS UNDER of hearing aids. THIS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL PER- 15. Diagnostic testing and medical treatment SONNEL AT A GHC FACILITY UNLESS: of sterility, infertility and frigidity. a. The Enrollee has received a Referral 16. Non-therapeutic sterilization. from a GHC physician. 17. Procedures and services to reverse a b. The Enrollee has received emergency therapeutic or non-therapeutic sterilization. or urgently needed services according to Section VIX of this Medicare 18. Procedures, services and supplies related Endorsement. to sex transformations. 2. Duty to Maintain Federal Medicare 19. Surgery directly related to obesity. Status. A condition of coverage under the GHC Medicare Plan requires that an 20. Voluntary termination of pregnancy. Enrollee be continuously fully qualified and enrolled for the hospital (Part A) and 21. Any services for which an Enrollee has a medical (Part B) benefits, or Part B only, contractual right to recover the cost available from the Social Security thereof, whether a claim is asserted or not, Administration, and sign any papers that under automobile, medical, personal injury may be required by GHC or Medicare. protection, uninsured or underinsured P0002END.6 (09/86) Group Continuation Coverage, • Health Conversion, and Transfer Cooperative of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement Section IV. is retitled Continuation Coverage, Conver- and the non-Medicare eligible Family sion, and Transfer, and is modified to include the Dependent as a result would be ineligible following as the new subsection A. The current subset- under this Agreement; or tions A., B., and C. are renumbered B., C., and D. a Dependent child ceases to qualify as a accordingly. Family Dependent under Section IX.B.2.(b) A. Continuation Coverage or(c). 3. A Subscriber who is a retiree or the spouse or This subsection A. only applies to employer Dependent of a retiree may continue coverage groups who must offer continuation coverage hereunder if the Subscriber would otherwise under the applicable provisions of the Con- lose coverage hereunder within one year of the solidated Omnibus Budget Reconciliation Act date a proceeding under Title 11 of the United of 1986 ("COBRA"), as amended, and only States Code is commenced with respect to the applies to grant continuation of coverage rights Group. Coverage under this Section IV.A.3., to the extent required by federal law. continues only upon payment of applicable monthly charges to the Group at the time To the extent required by federal law, if the Subscriber or specified by the Group. The terms and condi- Family Dependent loses eligibility under this Group tions of this coverage are governed by COBRA. Agreement, group coverage may be continued under the circumstances described below. Except as set forth in 4. If an individual enrolled for continuation Section IV.A.10., below, this provision applies only to coverage experiences a second qualifying event Subscribers and Family Dependents enrolled under this as set forth in subsection (2.) above, continua- Agreement prior to the date of eligibility for continuation tion coverage may be extended for up to coverage who would otherwise lose coverage as a result thirty-six (36) months, beginning from the date of one of the qualifying events listed below in subset- of the first qualifying event. tions (1.), (2.), and (3.). 5. In addition to the conditions set forth in Section 1. Subscribers and Family Dependents are eligible III. Termination, continuation coverage may be for continuation coverage for a maximum terminated prior to the prescribed period set period of up to eighteen (18) months comment- forth in subsections (1.), (2.), and (3.) above if: ing at the date that: There is a failure to make timely payment • The Subscriber's employment is terminated of any monthly dues required under this (unless terminated for gross misconduct); or Agreement; • the Subscriber experiences a reduction in the Enrollee becomes covered under any work hours. other group health plan; • the Enrollee becomes eligible to enroll 2. Family Dependents are eligible for continuation under Medicare whether he or she enrolls or coverage for a maximum period of up to thirty-six (36) months commencing at the date not. that: 6. Notice • The Subscriber is divorced or legally The Group is responsible for assuring com- separated; or pliance with COBRA and that Enrollees are • the Subscriber dies; or given timely notice of their continuation • the Subscriber becomes entitled to Medicare coverage option. The Group is also responsible for notifying GHC in a timely fashion of the CA-50 I0007IWS (01/87)Rev.(01/88) election to continue coverage and the applicable 9. Group Conversion coverage period (eighteen [181 or thirty-six [361 Within a 180-day period prior to termination of months). continuation coverage, the Subscriber or Family Dependent enrolled for continuation coverage is The Subscriber or Family Dependent must entitled to convert to GHC's Group Conversion notify the Group, or plan administrator, if any, Plan if his/her coverage under this Agreement is within sixty (60) days of a divorce, legal terminated for any reason other than non- separation, or when an enrolled dependent child payment or cause. See Section IV.B.2. GHC no longer meets the eligibility requirements set Group Conversion Plan - Application. forth in Section IX.B.2. 10. Open Enrollment and Adding Dependents 7. Application To the extent required under COBRA, a Written application for continuation coverage qualified beneficiary under COBRA may add must be made within sixty (60) days of the Family Dependents during the Group's Open termination date of coverage or the date the Enrollment period and newly eligible persons Enrollee receives specific notice of his/her right according to the procedures specified in Section to continuation coverage. No lapse in coverage IX.A. prior to continuation coverage is permitted. It is further understood and agreed that Section III.B.1. is The application shall be deemed by GHC to deleted in its entirety and replaced with the following: include all Family Dependents eligible for continuation coverage unless specifically stated 1. Loss of Eligibility. If an Enrollee no longer otherwise. A physical examination or statement meets the eligibility requirements set forth in of health is not required. Section IX.B. and is not enrolled for continua- tion coverage as described in Section IV.A., 8. Monthly Dues coverage under this Agreement will terminate at Monthly dues must be paid directly to the the end of the month during which loss of Group. The Group is responsible for submitting eligibility occurs. such dues with its regular monthly dues All other provisions of Sections III., IV., and IX. payment to GHC. shall remain in full force and effect. CA-SO I00071WS (01/87)Rev.(01/88) Group Emergency Department • Health Copayment " Cooperative of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement It is understood and agreed that Section I. of the Payment of a Copayment does not exclude the Group Medical Coverage Agreement is modified to possibility of an additional billing if the service include the following: is determined to be a non-Covered Service. COPAYMENT• A fee charged by GHC to an Total out-of-pocket Copayment expenses Enrollee for certain Covered Services under this incurred during the same calendar year shall not Agreement, as set forth in the Dues and Fees exceed the aggregate maximum amount (Stop Schedule. Loss) as set forth in the Dues and Fees Schedule. If Copayments have been billed, any applicable STOP LOSS: The maximum amount of Copayments billing fees shall not be considered in calculat- paid during the calendar year for Covered Services ing total out-of-pocket expenses for Copayments received by the Subscriber and his/her Family made. Dependents during the same calendar year. The Stop Section III.B.2. is modified to include the following: Loss amount is set forth in the Dues and Fees Schedule. 2. For Cause. Coverage of an Enrollee may be terminated upon written notice for: Section II.B. is deleted in its entirety and replaced with the following: Non-payment of charges as set forth in Section II.B. B. Subscriber's Liability. The Subscriber is liable for (1) payment to the Group of his/her contribu- Section X.I.I. is deleted and replaced with the tion toward the monthly dues, if any; (2) following: payment to the Cooperative of Copayments for Covered Services provided to the Subscriber and I. Emergency Care his/her Family Dependents, as set forth in the 1. At a GHC Facility or GHC Designated Dues and Fees Schedule; and (3) payment to the Cooperative of any fees charged for non- Facility. GHC will cover Emergency care Covered Services provided to the Subscriber and for all Covered Services subject to payment his/her Family Dependents. of the Copayment set forth in the Dues and Fees Schedule. Section II. is further modified to include the If two or more members of the Family Unit following: require Emergency care as a result of the D. Copayments. At the time of service, Enrollees same accident, only one Emergency Care shall be required to pay Copayments as set forth Copayment will apply. in the Dues and Fees Schedule. Failure to pay All other provisions of the Group Medical Copayments at the time of service may result in Coverage Agreement shall remain in full force a billing fee not to exceed five dollars (S5.00). and effect. ER-CP CA-7(01/88) I00221WS Group Health Maternity Care Cooperative of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement It is understood and agreed that Section X.B.7. of the Group Medical Coverage Agreement is deleted in its entirety and replaced with the following: The Cooperative shall provide maternity care, including care for complications of pregnancy; prenatal and postpartum visits; and voluntary termination of pregnancy. It is further understood and agreed that Sec- tion XI.A.20 is deleted in its entirety. Voluntary termination of pregnancy shall be covered. All other provisions of Sections X.H. and XI.A. remain in full force and effect. MT-A, AB-A CA-66 (01/88) I0213CNT Group •,�• Health Pre-Existing Conditions Cooperative of Puget sound Contract Endorsement For Attachment to Group Medical Coverage Agreement It is understood and agreed that Section XI.A.12. of the Group Medical Coverage Agreement is deleted in its entirety. Except as provided under Section X.B., 8. and 16., Pre-existing Conditions shall be covered in the same manner as any other illness. All other provisions of Section XI.A. shall re- main in full force and effect. PC-A CA-18 (01/88) I0136CNT a R.L EVANS I L C E 8 V 16 COMPANY INC. n' 1210 Plaza 600 Bldg. • Seattle,WA 98101 •206/448-7878• FAX 206/448-3589 JUN 2 0 1989 CITY OF KEIVT June 9, 1989 CITY CLERK Ms. Carol Katonias-Ray Group Health Coopertive 521 Wall Street Seattle, WA 98121 RE: City of Kent Dear Carol, In follow up to our discussion last week with regard to the City of Kent' s premium payments for added and deleted employees, we wish to continue the arrangement as out lined last year. This being that the City is not charged for new enrollees for the month in which they are added. This includes employees who enroll with Group Health at open enrollment each year. We also agreed last year that the City would pay for the entire month when an employee was deleted from coverage. If you should have any questions, please feel free to call me. SinFerely,_ -� Douglas's Evans Vice President Employee Benefits DE:me cc: Lori Brown, City of Kent Estate&Business Planning•Group Insurance• Financial&Insurance Planning• 401ktPension/Profit Suring Plans Securities offered through Integrated Resources Equity Corp..Member NASD&S1PC Registered Investment Advisory Services offered through Evans Financial Advisory Service R.L. EVkNS COMPANY IN(, 1l 1210 Plaza 600 Bldg. •Seattle,WA 98101 • 2061448-7878 • FAX 206/448-3589 May 25, 1989 Ms. Lori Brown City of Kent 220 Fourth Avenue So. 2,unt, IVA 98032-5895 Dear Lori, Enclosed please find a copy of the revised eligibility endorseement from Group Health Cooperative, allowing LEOFF II employees to be covered under the plan. Please let me know if you have any questions. Sincerely, DouglasBEvans Vice President Employee Benefits DE:ceb Estate&Business Planning•Group Insurance • Financial&Insurance Planning•401k/Pension/Profit Sharing Plans Securities offered through Integrated Resources Equity Corp.,Member NASD&SIPC Registered Investment Advisory Services offered through Evans Financial Advisory Service Section IX. ENROLLMENT AND ELIGIBILITY child enrolled, he/she must notify SCHEDULE GHC within sixty (60) days of the date of birth. A. Enrollment If subsequent to enrollment it 1. Application for Enrollment. Application is discovered that the newborn for enrollment shall be made on an ap- child is not eligible or if the Group plication form furnished or approved by does not initiate dues payments on GHC. No person shall be enrolled or or before sixty (60) days from the dues accepted until this completed ap- date of birth, GHC shall disenroll plication has been received by GHC. the child retroactive to the ef- The Group is responsible for submitting fective date of coverage. completed application forms to GHC. Children who are born in a a. Newly Eligible Persons. Newly eli- non-GHC Facility on a non- gible Subscribers may make written emergency basis will not be auto- application for enrollment to the matically enrolled. The Subscriber Group within thirty-one (31) days of must make written application for eligibility. If the Subscriber wishes enrollment to the Group within to enroll his/her eligible Depend- sixty (60) days following the date of ents, application must be made dur- birth. ing this same thirty-one (31) day All adopted children, including period. newborns, must be enrolled within Written application for enroll- sixty (60) days from the day that ment for a newly dependent person, the child is physically placed with other than a newborn or adopted the Subscriber for the purpose of child, must be made to the Group adoption and the Subscriber within thirty-one (31) days after assumes financial responsibility for the dependency occurs. the medical expenses of the child. A Subscriber's newborn child b. If the spouse of a GHC Subscriber shall be automatically enrolled loses eligibility under a group med- when born: ical plan provided by his/her em- i. at a GHC Facility or GHC De- ployer, the spouse and any eligible signated Facility; or Dependents listed on the spouse's ii. at a non-GHC Facility due to insurance may be added to the GHC an Emergency, provided that Subscriber's plan. Enrollment must all the requirements of Section be continuous between plans and X.I. of this Agreement are application must be made prior to, met, including notification of or at the same time as, termination GHC by way of the GHC Noti- of previous enrollment. fication Line immediately upon c. Open Enrollment. A person not en- inpatient admission, or as soon rolled as a Subscriber or Family thereafter as practicable, but Dependent when newly eligible, as in no event more than twenty- described above, may make written four (24) hours following ad- application during the Group's Open mission. Enrollment period. GHC shall provide notice of 2. Limitation on Enrollment. This Agree- such enrollment to the Subscriber ment will be open for application as set and the Group. It is the Sub- forth in Section IX.A.1. GHC may limit scriber's responsibility to complete enrollment, establish quotas, or set pri- and submit a revised application orities for acceptance of new applica- form to the Group. If the Sub- tions if it determines that its capacity, scriber does not want the newborn in relation to its total enrollment, is not CA-133 E0369.1 Rev. 03/89, Eff. 04/89 adequate to provide services to addi- B. Eligibility tional persons. In order to be accepted for enrollment and 3. Effective Date of Enrollment. continuing coverage under this Agreement, a. Provided application is made as set individuals must meet all applicable re- forth in Section IX.A.l.a. (above), quirements set forth below. The Group is enrollment for a newly eligible Sub- responsible for determining eligibility. scriber and listed Dependents will 1. Subscribers. Elected officials, bona fide begin on the date of hire. employees and LEOFF II employees who Subscribers who return to work are employed on a regularly scheduled from a leave without pay status basis of not less than eighty (80) hours within ninety (90) days, shall be eli- in each calendar month shall be eligible gible for enrollment on the first of for enrollment. the month following their date of LEOFF I employees will not be return to work. covered under this plan. Enrollment for newly depend- 2. Family Dependents. The Subscriber ent persons, other than newborns may enroll any of the following: and adopted children, will begin on a. The Subscriber's legal spouse; the first of the month following ap- b. Unmarried dependent children who plication. are under the age of twenty-one Provided newborns are enrolled (21), provided they reside regularly as specified in Section IX.A.l.a. with the Subscriber or qualify as (above), enrollment is effective Dependents for Federal Income Tax from the date of birth. purposes. A newborn is defined as a child "Children" means the children who is not older than four (4) of the Subscriber including adopted weeks. children, stepchildren, foster chil- For adopted children, enroll- dren, and any other children for ment is effective from the date whom the Subscriber is the legal that the adopted child is physically guardian. placed with the Subscriber for the c. Enrollment may be extended past purpose of adoption and the Sub- the limiting age for an unmarried scriber has assumed financial re- person enrolled as a Family Re- sponsibility for the medical ex- pendent on his/her twenty-first penses of the child. (21st) birthday if: b. Persons Hospitalized on Effective i. the Dependent is a full-time Date. If a person is confined in a registered student at an ac- hospital on the date enrollment credited secondary school, col- would otherwise become effective, lege, or university and under enrollment for the person(s) hospi- the age of twenty-three (23); talized will not begin until dis- or charge from the facility. ii. the Dependent is incapable of 4. Effective Date of Services and Benefits. self-support because of a de- Services provided to Enrollees are sub- velopmental disability or a ject to all terms and conditions of this physical handicap incurred Agreement including the requirement prior to attainment of the that all services must be received at a limiting age, is chiefly depend- GHC or GHC Designated Facility under ent upon the Subscriber for the medical management of a GHC support and maintenance, and physician unless the Enrollee has been qualifies as a Dependent for referred by a GHC physician or has re- Federal Income Tax purposes. ceived Emergency services according to Enrollment for such a Depend- Section X.I. CA-133 E0369.2 Rev. 03/89, Eff. 04/89 ent may be continued for the pendent's attainment of the duration of the incapacity, limiting age. provided enrollment does not d. Dependents of LEOFF I employees terminate for any other are eligible for coverage under this reason. Medical proof of in- contract. capacity and proof of financial Ineligible Persons. GHC reserves the right dependency must be furnished to refuse enrollment to any person whose to the Cooperative upon re- coverage under this Agreement or any other quest, but not more frequently Medical Coverage Agreement issued by than annually after the two- Group Health Cooperative of Puget Sound year period following the De- has been terminated for cause. (See Section III. Termination.) CA-133 E0369.3 Rev. 03/89, Eff. 04/89 Group •� Health Cooperative of Puget Sound ENDORSEMENTS TO THE GROUP MEDICAL COVERAGE AGREEMENT GROUP HEALTH COOPERATIVE OF PUGET SOUND Byaw a�40wo* Title Vice-President,Health Plan and Insurance Services GROUP CITY OF KENT #0369 By Title These Endorsements to the Agreement will become effective _ 01/01/89 and will continue in effect until terminated as herein provided for. PA-758 100131WS.1 01/87 Rev.01/89 Section IX. ENROLLMENT AND ELIGIBILITY c. Open Enrollment. A person not en- SCHEDULE rolled as a Subscriber or Family Dependent when newly eligible, as A. Enrollment described above, may make written 1. Application for Enrollment. Application application during the Group's Open for enrollment shall be made on an ap- Enrollment period. plication form furnished or approved by 2. Limitation on Enrollment. This Agree- GHC. No person shall be enrolled or ment will be open for application as set dues accepted until this completed ap- forth in Section IX.A.1. GHC may plication has been received by GHC. limit enrollment, establish quotas, or The Group is responsible for submitting set priorities for acceptance of new ap- completed application forms to GHC. plications if it determines that its capa- a. Newly Eligible Persons. Newly eli- city, in relation to its total enrollment, gible Subscribers may make written is not adequate to provide services to application for enrollment to the additional persons. Group within thirty-one (31) days of 3. Effective Date of Enrollment. eligibility. If the Subscriber wishes a. Provided application is made as set to enroll his/her eligible Depend- forth in Section IX.A.l.a. (above), ents, application must be made dur- enrollment for a newly eligible Sub- ing this same thirty-one (31) day scriber and listed Dependents will period. begin on the date of hire. Written application for enroll- Subscribers who return to work ment for a newly acquired Depend- from a leave without pay status ent other than a newborn or within ninety (90) days, shall be eli- adopted child must be made to the gible for enrollment on the first of Group within thirty-one (31) days the month following their date of after the dependency occurs. return to work. A Subscriber who, subsequent Enrollment for newly depend- to his/her enrollment, wishes to en- ent persons, other than newborns roll a newborn child must make and adopted children, will begin on written application to the Group the first of the month following ap- within sixty (60) days of the child's plication. birthdate. Adopted children must Provided newborns are enrolled be enrolled within sixty (60) days as specified in Section IX.A.l.a. from the day that the child is phys- (above), enrollment is effective ically placed with the Subscriber from the date of birth. for the purpose of adoption and the A newborn is defined as a child Subscriber assumes financial re- who is not older than four (4) sponsibility for the medical ex- weeks. penses of the child. For adopted children, enroll- b. If the spouse of a GHC Subscriber ment is effective from the date loses eligibility under a group med- that the adopted child is physically ical plan provided by his/her em- placed with the Subscriber for the ployer, the spouse and any eligible purposes of adoption and the Sub- Dependents listed on the spouse's scriber has assumed financial re- insurance may be added to the GHC sponsibility for the medical ex- Subscriber's plan. Enrollment must penses of the child. be continuous between plans and b. Persons Hospitalized on Effective application must be made prior to, Date. If a person is confined in a or at the same time as, termination hospital on the date enrollment of previous enrollment. would otherwise become effective, CA-101 E0369CNT.1 01/88 REV. 1/89 enrollment for the person(s) hospi- the limiting age for an unmarried talized will not begin until dis- person enrolled as a Family De- charge from the facility. pendent on his/her twenty-first 4. Effective Date of Services and Benefits. (21st) birthday if: Services provided to Enrollees are sub- i. The Dependent is a full-time ject to all terms and conditions of this registered student at an ac- Agreement including the requirement credited secondary school, col- that all services must be received at a lege, or university and under GHC or GHC Designated Facility under the age of twenty-three (23); the medical management of a GHC or physician unless the Enrollee has been ii. The Dependent is incapable of referred by a GHC physician or has re- self-support because of de- ceived Emergency services according to velopmental disability or phys- Section X.I. ical handicap incurred prior to B. Eligibility attainment of the limiting age, In order to be accepted for enrollment and is chiefly dependent upon the continuing coverage under this Agreement, Subscriber for support and individuals must meet all applicable re- maintenance, and qualifies as a quirements set forth below. The Group is Dependent for Federal Income responsible for determining eligibility. Tax purposes. Enrollment for 1. Subscribers. Elected officials and bona such a Dependent may be con- fide employees who are employed on a tinued for the duration of the regularly scheduled basis of not less incapacity, provided enroll- than eighty (80) hours in each calendar ment does not terminate for month shall be eligible for enrollment. any other reason. Medical Uniformed Personnel will not be proof of incapacity and proof covered under this plan. of financial dependency must 2. Family Dependents. The Subscriber be furnished to the Coopera- may enroll any of the following: tive upon request, but not a. The Subscriber's legal spouse; more frequently than annually b. unmarried dependent children who after the two-year period fol- are under the age of twenty-one lowing the Dependent's at- (21), provided they reside regularly tainment of the limiting age. with the Subscriber or qualify as d. Dependents of Uniformed Personnel Dependents for Federal Income Tax are eligible for coverage under this purposes. contract. "Children" means the children Ineligible Persons. GHC reserves the right of the Subscriber including adopted to refuse enrollment to any person whose children, stepchildren, foster chil- coverage under this Agreement or any other dren, and any other children for Medical Coverage Agreement issued by whom the Subscriber is the legal Group Health Cooperative of Puget Sound guardian. has been terminated for cause. (See Section c. Enrollment may be extended past III.B.2.) CA-101 E0369CNT.2 01/88 REV. 1/89 ALLOWANCES, DEDUCTIBLES, COP. .AENTS, AND FEES The following Allowances, Deductibles, Copayments and Fees are subject to Pre-existing Conditions limitatio-ns 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 for Emergency mental health care at a state mental health hospital . Coverage is subject to the $100 Emergency Care Deductible. Chemical Dependency Allowance Benefit Period Allowance. . . . . . . . . . . . . . . . . . . . . . $5,000 maximum per Enrollee per any 24 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/Deductible... . . . .. . . . . . . . . . . . . Emergency care at a GHC or GHC- Designated Facility is subject to a $25.00 Copayment amount per Emergency, payable by the Enrollee. Copayment is waived if Enrollee is admitted to the hospital from the Emergency Room. Emergency care at a non-GHC Designated Facility is subject to a $100.00 Deductible amount per Emergency, payable by the Enrollee. StopLoss. . ... . . . .. . . . . . . . .. . .... . . . . . . . . . . . . . . . . . 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 $1500 per family per calendar year. Ambulance Allowance/Deductible.. . . . . . . . . . . . . . . . . . . An allowance of up to $1,000 per Emergency is allowed for transport to GHC or non-GHC facilities. Ambulance charges for transport to a non-GHC Designated Facility are subject to a $50.00 Deductible amount per Emergency, payable by the Enrollee. ALLOWANCES, DEDUCTIBLES, CO —MENTS, AND FEES, Continued Rehabilitation Services Inpatient Allowance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inpatient physical and occupational therapy, and restorative speech pathology services combined, 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 and occupational therapy and restorative speech pathology services combined will be covered in full up to a maximum of 60 visits per condition per calendar year. "Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or mental handicaps in its employment practices or services." 01/89 Section X. SCHEDULE OF BENEFITS covered for Enrollees following cataract surgery performed by a GHC physician, provided the Subject to all provisions of this Group Medical Enrollee has been continuously covered by Coverage Agreement, persons enrolled for GHC since such surgery. Replacement of a Comprehensive Health Care are entitled to receive the covered contact lens will be provided only benefits and services that are Medically Necessary as when needed due to change in the Enrollee's determined by GHC's Medical Director, or his/her medical condition but may be replaced only one designee, and as described in this Schedule. time within any twelve (12) month period. 4. Family planning counseling services. A. HOSPITAL CARE 5. Hearing examinations to determine hearing loss. 6. Blood derivatives and the administration of Hospital care is provided when approved by a GHC blood and blood derivatives. The cost of blood physician, limited to the following services: is not covered. 1. Room and board, including private room when 7. Maternity care, including care for complications prescribed, and general nursing services. of pregnancy, and prenatal and postpartum 2. Hospital services (including use of operating visits. Hospitalization and delivery are room, anesthesia, oxygen, x-ray, laboratory, and provided, subject to payment of the Maternity radiotherapy services). Care Fee set forth in the Dues and Fees 3. Drugs and medications which are listed as Schedule. The Maternity Care Fee must be paid covered in the GHC Drug Formulary (approved in equal monthly installments during the drug list). prenatal period, with the final installment 4. Special duty nursing (when prescribed as payable not later than thirty (30) days prior to Medically Necessary). expected date of birth. Personal comfort items, such as telephone and Voluntary (not medically indicated and television, are not covered. non-therapeutic) termination of pregnancy will If an Enrollee is hospitalized in a non-GHC Facility, be charged according to the Cooperative's GHC- reserves the right to require transfer of the Directory of Services. Enrollee to a GHC Facility, upon consultation.__with a 8. Transplants. When authorized as medically GHC physician. If the Enrollee refuses to transfer to appropriate by GHC's Medical Director, or a GHC Facility, all further costs incurred during the his/her designee, and in accordance with criteria hospitalization are the responsibility of the Enrollee. established by the Cooperative, limited to heart, kidney, corneal, bone marrow, and liver B. MEDICAL AND SURGICAL CARE transplants. Organ acquisition costs, including applicable Medical and surgical services are provided, limited hospital and medical costs of the donor, are not to the following, when prescribed by GHC Medical covered, except that the costs of liver harvest- Personnel: ing and preservation are covered up to a 1. Surgical services. maximum of$25,000.00 per organ. 2. Diagnostic x-ray, nuclear medicine, ultrasound, and laboratory services. Coverage for heart and liver transplants and/or 3. Routine eye examinations and refractions, any related services, items, and drugs shall be limited to once every twelve (12) months, excluded until such time as the Enrollee has except when Medically Necessary. Services for been continuously enrolled under this routine eye examinations must be received at a Agreement, or any prior GHC Medical GHC Facility and in accordance with GHC Coverage Agreement for twelve (12) medical criteria in order to be covered. consecutive months without any lapse in coverage. Contact lens fittings and related examinations g physician visits (including consultations and are not covered except as set forth below. second opinions by a GHC physician) in the When dispensed through GHC Facilities, one hospital or office. contact lens per diseased eye in lieu of an 10. Preventive services for health maintenance intraocular lens, including exam and fitting, is PA-7 54 I0006IWS.1 (01/87)rev. 01/89 including physical examinations for detection Benefit Period Allowance and Lifetime Maximum of disease or other conditions, and im- Benefit as described below and as shown in the Dues munizations and vaccinations which are listed and Fees Schedule. as covered in the GHC Drug Formulary 1. Chemical Dependency Treatment Services. (approved drug list). A fee may be charged for a. All alcoholism and/or drug abuse treatment health education programs. services must be: (1) provided at a facility 11. Radiation therapy services. as described above and must be authorized 12. Services related to dysfunction of the jaw: in advance, except for acute chemical when referred by a GHC physician, evaluation withdrawal as described in Section and treatment at a GHC-approved X.C.2.b.; and (2) deemed Medically temporomandibular joint (TMJ) care provider, Necessary by GHC's ADAPT Director or and occlusal splint fitting. his/her designee. Chemical dependency treatment may include the following All TMJ appliances, including the occlusal services received on an inpatient or out- splint and night guard, are excluded. Treatment patient basis: diagnostic evaluation and of jaw dysfunction, including TMJ dysfunction, education, organized individual and group will NOT be provided when the dysfunction is counseling, detoxification services, and related to malocclusion or when TMJ services prescription drugs and medicines. are needed due to dental work performed. All b. Court-ordered treatment shall be provided such services and related hospitalization, only if determined to be Medically including orthodontic therapy, and orthognathic Necessary by GHC's ADAPT Director or (jaw) surgery, are excluded, regardless of origin his/her designee. or cause. 2. Emergency Care. 13. The following services are covered by GHC a. Coverage for medical Emergencies incident when performed by a GHC physician or GHC to the abuse of alcohol and/or drugs is oral surgeon: reduction of a fracture or subject to the Emergency care benefit as set dislocation of the jaw or facial bones; excision forth in Section X.I. of tumors or cysts of the jaw, cheeks, lips, b. Coverage for acute chemical withdrawal is tongue, gums, roof and floor of the mouth; and provided without prior approval. If an incision of salivary glands and ducts. Enrollee is hospitalized in a non-GHC 14. Nonexperimental implants, limited to the Designated Facility, coverage is subject to following: cardiac devices, artificial joints, and payment of the Deductible shown in the intraocular lenses. Artificial or mechanical Dues and Fees Schedule, and notification of hearts are excluded. GHC by way of the GHC Notification Line 15. When authorized as medically appropriate by immediately upon inpatient admission, or as GHC's Medical Director, or his/her designee, soon thereafter as practicable, but in no and in accordance with criteria established by event more than twenty-four (24) hours the Cooperative, treatment of growth disorders following admission. Furthermore, if an by growth hormones. Enrollee is hospitalized in a non-GHC Growth hormone treatment shall be excluded Designated Facility, GHC reserves the right until such time as the Enrollee has been to require transfer of the Enrollee to a GHC continuously enrolled under this Agreement or Facility upon consultation with a GHC any prior GHC Medical Coverage Agreement physician. If the Enrollee refuses transfer for twelve (12) consecutive months without any to a GHC Facility, all further costs incurred lapse in coverage. during the hospitalization are the responsi- 16. Respiratory therapy. bility of the Enrollee. C. CHEMICAL DEPENDENCY TREATMENT The Enrollee, or person taking respon- sibility for the Enrollee, is responsible for notifying GHC by way of the GHC Subject to all terms and conditions of this Agree- Notification Line immediately upon ment, Gaze is provided as set forth below at a GHC inpatient admission to a GHC Designated Facility, GHC Designated Facility, or GHC-approved Facility, or as soon thereafter as prac- treatment facility meeting all requirements of RCW ticable, but in no event more than twenty- four and RCW 69.54.030, subject to the four (24) hours following admission. PA-754 I00061WS.2 (01/87)rev.01/89 For the purpose of this section, "acute borne by the Enrollee under the terms of this chemical withdrawal" means withdrawal of Agreement shall not be applied toward the alcohol and/or drugs from a person for Benefit Period Allowance or Lifetime whom consequences of abstinence are so Maximum Benefit. severe as to require medical/nursing In regard to this section, the Benefit Period(s), assistance in a hospital setting and which is Benefit Period Allowance(s), and Lifetime needed immediately to prevent serious Maximum Benefit shall include only alcoholism impairment to the Enrollee's health. treatment services received on or after January 3. Benefit Period and Benefit Period Allowance. 1, 1987 and alcoholism and/or drug abuse a. Benefit Period. For the purpose of this services received on or after January 1, 1988. section, "Benefit Period" shall mean a twenty-four (24) consecutive calendar D. PLASTIC AND RECONSTRUCTIVE SERVICES month period during which the Enrollee is will be provided: eligible to receive covered chemical 1. to correct a functional disorder, as determined dependency treatment services as set forth by a GHC physician, resulting from a in this section. The first Benefit Period congenital disease or anomaly; or shall begin on the first day the Enrollee 2 to correct a medical condition following an receives covered chemical dependency injury or incidental to surgery covered by GHC, services under this or any other group provided the Enrollee has been continuously insurance, health care service contractor, covered at GHC since such injury or surgery. health maintenance organization, 3. Reconstructive surgery and associated self-insured plan or any combination procedures following a mastectomy will be thereof, hereinafter referred to as "group covered for Enrollees who are medically plans," and shall continue for twenty-four suitable candidates, as determined by GHC's (24) consecutive calendar months, provided Medical Director or his/her designee. Internal that coverage under this Agreement remains breast prostheses required incident to the in force. All subsequent Benefit Periods surgery will be provided. thereafter will begin on the first day 4. An Enrollee will be covered for all stages of Covered Services are received after one reconstructive breast reduction on the expiration of the previous twenty-four (24) nondiseased breast to make it equivalent in size month Benefit Period. with the diseased breast after definitive re- b. Benefit Period Allowance. The maximum constructive surgery on the diseased breast has allowance available for any Benefit Period been performed. - shall be the total of all chemical dependency benefits provided and payments E. APPLIANCES which are Medically Necessary, made for chemical dependency treatment limited to the following: ostomy supplies; temporary under any group plan(s), not to exceed the orthopedic appliances for use during treatment up to Benefit Period Allowance shown in the a maximum of six (6) months; and on Referral, Dues and Fees Schedule during the oxygen and oxygen equipment for home use. Enrollee's Benefit Period. 4. Lifetime Maximum Benefit. F. DRUGS AND MEDICINES FOR OUTPATIENT Chemical dependency services are not covered USE as prescribed by a GHC physician for after the Enrollee has reached his/her Lifetime conditions covered by this Agreement. All drugs, Maximum Benefit amount as shown in the Dues supplies, medicines and devices must be obtained at and Fees Schedule. All such benefits provided a GHC pharmacy. or payments made by a. GHC under any GHC Group Medical Excluded are: dietary supplements (except Coverage Agreement, plus therapeutic vitamins for use up to thirty [301 days); b. all amounts paid on an individual's behalf outpatient mental health drugs; contraceptive drugs under any carrier or plan maintained by the and devices and their fitting; medicines and Group, including self-insured plans, injections for anticipated illness while traveling; and shall be applied toward this Lifetime Maximum any other drugs, medicines, and injections not listed Benefit amount. as covered in the GHC Drug Formulary (approved Any Deductibles or Copayments which may be drug list). PA-7 54 10006IWS.3 (01/87)rev.01/89 The Enrollee will be charged for mailing or replacing tion period and or treatment. Services for a lost or stolen drugs, medicines or devices. court-ordered treatment program beyond the seventy-two (72) hours shall be covered only if G. HOME HEALTH CARE SERVICES, as set forth in determined to be Medically Necessary by the this section, shall be provided by GHC Home Health director of GHC's Mental Health Service, or Services or by a GHC-authorized home health agency his/her designee. All care under these statutes, when Referred in advance by a GHC physician for including any observation/holding period, is Enrollees who meet the following criteria: chargeable against the maximum benefit. 1. The Enrollee is unable to leave home due to his Coverage for Emergency inpatient mental or her health problem or illness (unwillingness health services at state mental health hospitals to travel and/or arrange for transportation does as set forth in this section is subject to payment not constitute inability to leave the home); of the $100 Emergency Care Deductible and 2. the Enrollee requires intermittent Skilled Home notification of GHC by way of the GHC Health Care services, as described below; and Notification Line immediately upon inpatient 3. a GHC physician has determined that such admission, or as soon thereafter as practicable, services are Medically Necessary and are most but in no event more than twenty-four (24) appropriately rendered in the Enrollee's home. hours following admission. Follow-up care Covered Services for home health care may include which is a direct result of the Emergency must the following when prescribed by a GHC physician be obtained at GHC, unless the director of and when rendered pursuant to an approved home GHC's Mental Health Service, or his/her health care plan of treatment: nursing care, physical designee, has authorized such follow-up care in therapy, occupational therapy, respiratory therapy, advance. restorative speech therapy, and medical social worker Payment of bills incurred for non-GHC treat- and limited home health aide services. Home health ment shall exclude any charges that would services are provided on an intermittent basis in the otherwise be excluded for hospitalization within Enrollee's home. "Intermittent" means care that is to a GHC Facility, such as telephone, television, be rendered because of a medically predictable and personal items. recurring need for Skilled Home Health Care 2. Outpatient Services. services. Mental Health Care services, limited to the Excluded are: custodial care and maintenance care, following, are provided on an outpatient basis private duty or continuous nursing care in the at GHC. Subject to the limitations set forth in Enrollee's home, housekeeping or meal services, care this section, and all other provisions of this in any nursing home or convalescent facility, any Agreement, brief focal psychotherapy, chronic care provided by or for a member of the patient's intermittent care, and consultation services will family, and any other services not listed specifically be provided in the following formats: in- as covered when rendered in the home under this dividual, couple, family, or group. Agreement. Coverage for each Enrollee is provided accord- H. MENTAL HEALTH CARE SERVICES ing to the Outpatient Mental Health Care Allowance set forth in the Dues and Fees 1. Inpatient Services. Schedule. Usual, Customary, and Reasonable charges for Covered Services are limited to those provided Mental Health Emergencies resulting in for covered conditions for which, in the opinion inpatient services shall be covered only for of the director of GHC's Mental Health Service, Emergency inpatient mental health treatment in or his/her designee, significant improvement a state mental health hospital meeting the can be expected within a treatment program of requirements of RCW 72.23.010. Coverage for twenty (20) visits or less. each Enrollee is limited to the Inpatient Mental 3. Exclusions and Limitations. Health Care allowance set forth in the Dues and Treatment for inpatient services is limited to Fees Schedule. Emergency care only at a state mental health Services provided under involuntary commit- hospital meeting the requirements of RCW72.23.010. ment statutes shall be covered up to seventy- two (72) hours for any court-ordered observa- Excluded are: all forms of extensive PA-754 I0006IWS.4 (01/87)rev.01/89 psychotherapy including, but not limited to, responsibility of the Enrollee. ongoing care for chronic mental health condi- Follow-up care which is a direct result of the tions; custodial care; day treatment; treatment Emergency must be obtained at GHC, unless a of sexual disorders and/or dysfunctions; GHC physician has authorized such care in specialty programs for mental health therapy advance. which are not provided by GHC; court-ordered treatment which is not specifically described J. AMBULANCE SERVICES are covered as set forth above; psychological testing, except when below, provided that the service is authorized in provided during the course of mental health advance by a GHC physician or meets the definition treatment; classes or courses such as (1) of an Emergency. (See Section I.) behavior modification programs, (2) "Parent 1. Emergency Transport to a GHC Facility or Effectiveness Training", and (3) adult develop- GHC Designated Facility. Each Emergency is ment programs, when obtained at non-GHC covered as set forth in the Dues and Fees Facilities. Schedule. I. EMERGENCY CARE 2• Emergency Transport to a Non-GHC Designated Facility. Each Emergency is 1. At a GHC Facility or GHC Designated covered as set forth in the Dues and Fees Facility. GHC will cover Emergency care for Schedule. 3. Waiver of Ambulance Services Deductible. If all Covered Services. two or more members of the Family Unit The Enrollee, or person taking responsibility require Emergency ambulance transport as a for the Enrollee, is responsible for notifying result of the same accident, only one GHC by way of the GHC Notification Line Ambulance Deductible will apply. immediately upon inpatient admission to a GHC The Ambulance Deductible will not apply when Designated Facility, or as soon thereafter as ambulance service is authorized in advance by practicable, but in no event more than twenty- the Cooperative. four (24) hours following admission. 4. Transfer to a GHC Facility. When authorized 2. At a Non-GHC Designated Facility. Usual, in advance by the Cooperative, an additional Customary, and Reasonable charges for Ambulance Allowance is provided for transfer Emergency care for Covered Services are to a GHC Facility. covered subject to: a. payment of the Emergency Deductible K. HOSPICE hown in the Dues and Fees Schedule; and It is understood and agreed that the following fully b. notification of GHC by way of the GHC sets forth the eligibility requirements and Covered Notification Line immediately upon Services for an Enrollee who wishes to elect to inpatient admission, or as soon thereafter receive services through GHC's Hospice Program. as practicable, but in no event more than Enrollees who elect to receive GHC Hospice twenty-four (24) hours following Services do so in lieu of curative treatment for admission. their terminal illness for the period that they are If two or more members of a Family Unit in the GHC Hospice Program. require Emergency care as a result of the same Hospice Program accident, only one Emergency Deductible will 1. Eligibility. Hospice Services, as set forth apply• below, shall be provided to Enrollees for as Outpatient medications prescribed by a long as the following criteria are met: non-GHC physician are excluded. a. A GHC physician has determined that the 3. Transfer and Follow-up Care. If an Enrollee Enrollee's illness is terminal and life is hospitalized in a non-GHC Facility, GHC expectancy is six (6) months or less; reserves the right to require transfer of the b. the Enrollee has chosen a palliative Enrollee to a GHC Facility, upon consultation treatment focus (emphasizing comfort and with a GHC physician. If the Enrollee refuses supportive services rather than treatment to transfer to a GHC Facility, all further costs aimed at curing the Enrollee's terminal incurred during the hospitalization are the illness); PA-754 10006IWS.5 (01/87)rev.01/89 c. the Enrollee has elected in writing to Necessary and authorized in advance by a receive hospice care through GHC's GHC physician and GHC's Hospice Hospice Program; Program. Inpatient Hospice Services shall d. the Enrollee has available a primary care be provided according to the provisions set person who will be responsible for the forth in Section X. of this Agreement. Enrollee's home care; and 4. Hospice Exclusions: All services not spe- e. a GHC physician and GHC's Hospice cifically listed as covered in this section, Director determine that the Enrollee's including, but not limited to: illness can be appropriately managed in the a. Financial or legal counseling services. home. b. Housekeeping or meals services. 2. Hospice Care shall be defined as a coordinated c. Custodial or maintenance care in the home program of palliative and supportive care for or on an inpatient basis. dying persons by an interdisciplinary team of d. Services not specifically listed as covered professionals and volunteers centering primarily by this Medical Coverage Agreement. in the Enrollee's home. e. Any services provided by members of the 3. Covered Services. Hospice Services may patient's family. include the following as prescribed by a GHC f. All other exclusions listed in Section XI., physician and rendered pursuant to an approved Exclusions and Limitations, of this Medical hospice plan of treatment: Coverage Agreement, apply. a. Home Services i. Intermittent care by a hospice L. REHABILITATION SERVICES are covered as set interdisciplinary team which may forth in this section, limited to the following: include services by a physician, nurse, physical therapy; occupational therapy; and speech medical social worker, physical pathology to restore function following illness, therapist, speech pathologist, occupa- injury, or surgery. Services are subject to all terms, tional ther- apist, respiratory therapist, conditions, and limitations of this Agreement, and limited services by a Home Health including the following: Aide under the supervision of a Regis- 1. All services must be provided at GHC or a tered Nurse. GHC-approved rehabilitation facility and must ii. One period of continuous care service be prescribed and provided by a GHC-approved per Enrollee in the Enrollee's home rehabilitation team that may include medical, when prescribed by a GHC physician, nursing, physical therapy, occupational therapy as set forth in this paragraph. A and speech pathology providers. continuous care period is defined as 2. The Enrollee must be referred for rehabilitation "skilled nursing care provided in the services in advance by a GHC physician. home during a period of crisis in order 3. Services are limited to those necessary to to maintain the terminally ill patient at restore or improve functional abilities when home." Continuous care may be physical, sensori-perceptual and/or provided for pain or symptom communication impairment exists due to injury management by a Registered Nurse, or illness. Such services are provided only Licensed Practical Nurse, or Home when GHC's Medical Director, or his/her Health Aide under the supervision of a designee, determines that significant, Registered Nurse. Continuous care is measurable improvement to the Enrollee's provided for four (4) or more hours per condition can be expected within a sixty (60) day for a period not to exceed five (5) day period as a consequence of intervention by days, or a total of seventy-two (72) covered therapy services described in paragraph hours, whichever first occurs. one (1) above. Continuous care is covered only when a 4. Coverage for inpatient and outpatient services GHC physician determines that the is limited to the allowances set forth in the Enrollee would otherwise require Dues and Fees Schedule. hospitalization in an acute care facility. b. Inpatient Hospice Services shall be Services excluded under this benefit include, but are provided in a facility designated by GHC's not limited to, the following: specialty rehabilitation Hospice Program when Medically Programs not provided by GHC; long-term rehabilitation programs; physical therapy, PA-754 I0006IWS.6 (01/87)rev.01/89 occupational therapy, and speech pathology services 6. Convalescent or custodial care, including when such services are available (whether skilled nursing facility care. application is made or not) through governmental 7. Durable medical equipment such as hospital programs including, but not limited to, programs beds, wheelchairs, and walk-aids, except while offered by public school districts; therapy for in the hospital. degenerative or static conditions when the expected 8. Services covered by employment or government outcome is primarily to maintain the Enrollee's level programs: of functioning; implementation of home maintenance a. Any illness, condition or injury for which programs; and any other treatment not considered benefits are available, or could be available, Medically Necessary by GHC. through application for coverage under any federal or state workers' compensation or Section XI. EXCLUSIONS AND LIMITATIONS industrial insurance law or employer's liability contract or insurance. It is A. EXCLUSIONS expressly understood that this Agreement is NOT to serve as private industrial in- 1. Blood for transfusions. surance, or a self-insured plan maintained 2. Except as provided in Sections X.B.3., X.D, by the employer. X.E., and X.F., corrective appliances and b. Any federal, state, county, municipal, or artificial aids, including but not limited to: other governmental agency, including in the eyeglasses; contact lenses including services case of service-connected disabilities, the related to their fitting; prosthetic devices; Veterans Administration. diabetic supplies including insulin pumps; GHC reserves all rights to reimbursement hearing aids and examinations in connection provided by any of the above-described laws, therewith; arch supports or corrective shoes; private industrial insurance, self-insured plans, take-home dressings and supplies following or governmental agencies. hospitalization; or any other supplies, dressings, appliances, devices or services which Services will be provided under this Agreement: are not for the specific treatment of disease or a. if there is reasonable doubt whether an injury. Enrollee should receive benefits under this 3. Cosmetic services, including treatment for Agreement or from another source; and complications of cosmetic surgery, except as b. if the Enrollee actively seeks to establish provided in Section X.D. his/her rights to benefits from that source. 4. Dental care, surgery, services, and appliances, 9. Those parts of an examination and associated including but not limited to: treatment of reports required for employment, immigration, accidental injury to natural teeth, reconstructive license, or insurance purposes that are not surgery to the jaw incident to denture wear, and deemed Medically Necessary by GHC for early periodontal surgery. The Cooperative's detection of disease. Medical Director, or his/her designee, will 10. Investigational procedures, including medical determine whether the care or treatment and surgical services, drugs, and devices until required is within the category of dental care or formally approved by GHC for medical service. coverage. Investigational drugs are not covered If a GHC physician determines that an unrelated until approved by the U.S. Food and Drug medical condition requires that an Enrollee be Administration for general marketing and by hospitalized for a dental procedure which is GHC for medical coverage. normally done in a dentist's office, GHC will 11. Nontherapeutic sterilization; and procedures cover associated hospital and anesthesia costs at and services to reverse a therapeutic or a GHC or GHC Designated Facility. GHC will non-therapeutic sterilization. not cover the dentist's or oral surgeon's fees. 12. Pre-existing Conditions shall be excluded from 5. Certain drugs, medicines, and injections. (See coverage until such time as the Enrollee has Section X.F.) Any exclusion of drugs, been continuously covered under this Agreement or any prior GHC Medical Coverage medicines, and injections, including those not Agreement for twelve (12) consecutive months listed as covered in the GHC Drug Formulary without any lapse in coverage. (approved drug list), will also exclude their 13. Mental health care, except as specifically administration. PA-754 I0006IWS.7 (01/87)rev.01/89 provided in Section X.H. treatment to be provided in each individual case 14. Procedures, services, and supplies related to sex and the judgment, made in good faith, will be transformations. final. 15. Regardless of origin or cause, diagnostic testing Enrollees have the right to participate in and medical treatment of sterility, infertility, decisions regarding their health care. An impotency, and frigidity. Enrollee may refuse recommended treatment or 16. Services of practitioners whose licensing diagnostic plan to the extent permitted by law. category is not represented by GHC Medical In such case, GHC shall have no further Personnel. obligation to provide the care in question. 17. Services directly related to obesity, except for Enrollees who seek other sources of care nutritional counseling provided by GHC staff. because of such a disagreement do so with the 18. Any services for which an Enrollee has a full understanding that GHC has no obligation contractual right to recover the cost thereof, for the cost, or liability for the outcome, of such whether a claim is asserted or not, under care. automobile medical, personal injury protection, uninsured or underinsured motorist, home 3. Major Disaster or Epidemic. In the event of a owner's or other first party coverage, except for major disaster or epidemic, GHC M dical individual health insurance. Personnel will provide Covered Services 19. Services or supplies not specifically listed as according to their best judgment, within the covered in the Schedule of Benefits. limitations of available facilities and personnel. 20. Voluntary (not medically indicated and The Cooperative has no liability for delay or non-therapeutic) termination of pregnancy. failure to provide or arrange Covered Services 21. The cost of services and supplies resulting from to the extent facilities or personnel are unavail- an Enrollee's loss of or willful damage to able due to a major disaster or epidemic. covered appliances, devices, supplies, and 4. Unusual Circumstances. If the provision of materials provided by GHC for the treatment of Covered Services is delayed or rendered disease, injury, or illness. impossible due to unusual circumstances such 22. Routine circumcision, including newborn as complete or partial destruction of facilities, circumcision, which is not considered military action, civil disorder, labor disputes, or Medically Necessary. similar causes, GHC shall make a good faith 23. Orthoptic (eye training) therapy. effort to provide such services through its 24. Specialty treatment programs that are not then-existing facilities and personnel. In no provided at GHC. case shall the Cooperative have any liability or B. LIMITATIONS obligation on account of delay or failure to provide or arrange such services. I. Conditions and Extent of Coverage. ALL SERVICES AND BENEFITS UNDER THIS Section XII. CLAIMS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL PERSONNEL AT A GHC Enrollees must submit claims for reimbursement of FACILITY UNLESS: Covered Services to GHC within sixty (60) days of the a. The Enrollee has received a Referral from a service date, or as soon thereafter as is reasonably GHC physician. possible. In no event, except in the absence of legal b. The Enrollee has received Emergency capacity, shall a claim be accepted later than one (1) year services according to Section X.I. from the service date. This section applies to Covered 2. Recommended Treatment. The Cooperative's Services received under Section X.I. and X.J., or services Medical Director or his/her designee will for which the Enrollee has received a Referral from a determine the necessity, nature, and extent of GHC physician. PA-754 I00061WS.8 (01/87)rev.01/89 Group k Health„ Cooperative Coordination of Benefits 1 of Puget Sound Contract Attachment For Attachment to Group Medical Coverage Agreement It is understood and agreed that the following fully C. Allowable Expense: sets forth the provisions outlined in Section V., "Allowable Expense" means any necessary, "Coordination of Benefits." reasonable and customary items of expense at least a portion of which is covered under at least COORDINATION OF BENEFITS one of the Plans covering the person for whom the claim is made. When a Plan provides benefits in A. Benefits Subject to This Provision: the form of services rather than cash payments, All of the benefits provided under this Agreement the reasonable cash value of each service rendered are subject to this provision. shall be considered as both an Allowable Expense and a benefit paid. B. Plan: The definition of a "Plan" includes the following D. Claim Determination Period: sources of benefits or services: "Claim Determination Period" means a period 1. Group or blanket disability insurance policies beginning with any January 1 and ending with the and health care service contractor and health next following December 31 except that the first maintenance organization group agreements, Claim Determination Period with respect to any issued by insurers, health care service person shall begin on the effective date of contractors and health maintenance coverage under this Agreement with respect to organizations; such person and end on the following December 2. Labor-management trusteed plans, labor 31. In no event will a Claim Determination organization plans, employer organization Period for any person extend beyond the last day plans or employee benefit organization plans; on which such a person is covered under this 3. Governmental programs; and Agreement. 4. Coverage required or provided by any statute. The term "Plan" shall be construed separately E. Right to Receive and Release Information: with respect to each policy, agreement or For the purpose of determining the applicability other arrangement for benefits or services, of and implementing this provision and any and separately with respect to the respective provision of similar purpose in any other Plan, the portions of any such policy, agreement or Cooperative may, with such consent as may be other arrangement which do and which do not necessary, release to or obtain from any other reserve the right to take the benefits or insurer, organization or person any information, services of other policies, agreements or other with respect to any person which the insurer arrangements into consideration in considers necessary for such purpose. Any person determining benefits. claiming benefits under this Agreement shall furnish to the Cooperative the information necessary for such purpose. ?A-868,CA-65 100021WS.1 (12/86) Rev. (01/89) F. Facility of Payment: reasonable cash value of benefits and all Whenever coverage which should have been benefits payable for such Allowable Expenses provided under this Agreement in accordance with under all other Plans, except as provided in this provision has been provided or paid for under subparagraph (3) of this Section, shall not any other Plan, the Cooperative shall have the exceed the total of such Allowable Expenses. right, exercisable alone and in its sole discretion, Benefits payable under another Plan include to pay over to any Plan making such other benefits that would have been payable had a payments any amounts it shall determine to be claim been duly made therefor. warranted in order to satisfy the intent of this 3. If provision, and amounts so paid shall be a. another Plan which is involved in considered to be coverage or benefits paid under subparagraph (2) of this Section and this Agreement and, to the extent of such which contains a provision coordinating payments, the Cooperative shall be fully its benefits with those of this Agreement discharged from liability under this Agreement. would, according to its rules, determine its benefits after the benefits of this Plan G. Right of Recovery: have been determined; and Whenever benefits have been provided by the b. the rules set forth in subparagraph (4) of Cooperative with respect to Allowable Expenses this Section would require this Agreement in total amount, at any time, in excess of the to determine its benefits before such other maximum amount of payment necessary at that Plan, then the benefits of such other Plan time to satisfy the intent of this provision, the will be ignored for the purposes of Cooperative shall have the right to recover the determining the benefits under this reasonable cash value of such benefits, to the Agreement. extent of such excess, from one or more of the 4. For the purposes of subparagraph (3) of this following, as the Cooperative shall determine: Section, the rules establishing the order of any persons to or for or with respect to whom benefit determination are: such benefits were provided, any other insurers, a. The benefits of a Plan which covers the any service plans or any other organization or person on whose expenses a claim is other Plans. based other than as a dependent shall be determined before the benefits of a Plan H. Effect on Benefits: which covers such person as a dependent. 1. This provision shall apply in determining the b. In the case that a dependent is covered benefits for a person covered under this under both parents' medical Plan, the Agreement for a particular Claim benefits of the Plan of the parent whose Determination Period if, for the Allowable birthday falls earlier in the year are Expenses incurred as to such person during determined before those of the Plan of a such period, the sum of: parent whose birthday falls later in the a. The reasonable cash value of the benefits year. This birthdate will refer only to the that would be provided under the month and day, not the year in which a Agreement in the absence of this person was born. If both parents have the provision, and same birthday, the benefits of the Plan b. The benefits that would be payable under which covered the parent longer are all other Plans in the absence therein or determined before those that covered the provisions of similar purpose to this other parent for a shorter period of time, provision would exceed such Allowable except that in the case of a person for Expenses. whom claim is made as a dependent child, 2. As to any Claim Determination Period with i. when the parents are separated or respect to which this provision is applicable, divorced and the parent with custody the reasonable cash value of the benefits of the child has not remarried, the provided under this Agreement in the absence benefits of a Plan which covers the of this provision for the Allowable Expenses child as a dependent of the parent incurred as to such person during such Claim with custody of the child will be Determination Period shall be reduced to the determined before the benefits of a extent necessary so that the sum of the Plan which covers the child as a PA-868,CA-65 10002IWS.2 (12/86) Rev. (01/89) dependent of the parent without i. The benefits of a plan covering the custody; and person on whose expenses claim is ii. when the parents are divorced and the based as a laid off or retired parent with custody of the child has employee, or dependent of such remarried, the benefits of a Plan person shall be determined after the which covers the child as a dependent benefits of any other Plan covering of the parent with custody shall be such person as an employee, other determined before the benefits of a than a laid off or retired employee, or Plan which covers that child as a dependent of such person; and dependent of the stepparent, and the ii. If either plan does not have a benefits of a Plan which covers that provision regarding laid off or retired child as a dependent of the stepparent employees, which results in each Plan will be determined before the benefits determining its benefits after the of a Plan which covers that child as a other, then the provisions of (i) of this dependent of the parent without subsection shall not apply. custody. d. If none of the above rules determines the Notwithstanding items (i) and (ii) above, order of benefits, the benefits of the Plan if there is a court decree which would which covered an employee or Subscriber otherwise establish financial responsibil- for the longer period of time shall be ity for the medical, dental or other health determined before those of the Plan which care expenses with respect to the child, covered that person for the shorter time the benefits of a Plan which covers the period. child as a dependent of the parent with 5. When this provision operates to reduce the such financial responsibility shall be total amount of benefits otherwise to be determined before the benefits of any provided to a person covered under this other Plan which cover the child as a Agreement during any Claim Determination dependent child. Period, the reasonable cash value of each c. When rules (a) and (b) do not establish an benefit that would be provided in the absence order of benefit determination, the of this provision shall be reduced benefits of a Plan which has covered the proportionately, and such reduced amount person on whose expenses claim is based shall be charged against any applicable for the longer period of time shall be benefit limit of this Agreement. determined before the benefits of a Plan which has covered such person the shorter period of time, provided that: PA-868,CA-65 100021WS.3 (12/86) Rev.(01/89) Group Health cooperative Contract Endorsement of Puget Sound Medicare Endorsement For Persons Covered by Parts A and B of Medicare THE PROVISIONS OF THE GROUP MEDI- Section I. DEFINITIONS CAL COVERAGE AGREEMENT SHALL RE- MAIN IN EFFECT EXCEPT AS MODIFIED BY CUSTODIAL CARE: Care that is primarily for the THIS MEDICARE ENDORSEMENT. COVER- purpose of meeting personal needs and could be AGE UNDER THIS GROUP MEDICAL COVER- provided by persons without professional skills AGE AGREEMENT IS INTEGRATED WITH or- training. Custodial Care includes help in THE MEDICAL AND HOSPITAL BENEFITS walking, bathing, dressing, eating, and taking ESTABLISHED BY TITLE 18 OF THE SOCIAL medicine. SECURITY ACT AS AMENDED, AND RE- FERRED TO AS"MEDICARE". THE BENEFITS EMERGENCY SERVICES (Medicare defined): AND EXCLUSIONS DESCRIBED IN THIS Inpatient or outpatient services that are ENDORSEMENT APPLY ONLY TO EN- rendered immediately by an appropriate ROLLEES WHO ARE COVERED UNDER non-GHC provider because of an injury or BOTH PART A AND PART B OF MEDICARE. sudden illness, and for which the time required Except as defined by Federal Regulations, all to reach GHC or a GHC Designated Facility Enrollees entitled to, or eligible to purchase would risk permanent damage to the Enrollee's Medicare must transfer to the GHC Medicare Plan health. upon such entitlement or eligibility. A condition of HEALTH CARE FINANCING ADMINISTRATION enrollment under the GHC Medicare Plan requires (HCFA): The federal agency that administers that an Enrollee be continuously enrolled for the the Medicare program. hospital (Part A) and medical (Part B) benefits available from the Social Security Administration, MEDICARE: The federal health insurance pro- and sign any papers that may be required by GHC gram for the aged and disabled. or Medicare. For additional information, the Enrollee may refer to"Your Medicare Handbook" MEDICARE GUIDELINES: Coverage rules and NEITHER GHC NOR MEDICARE MAY PAY policies established by the Health Care Financ- FOR SERVICES PROVIDED AT NON-GHC ing Administration (HCFA), a federal agency. FACILITIES UNLESS THE ENROLLEE HAS BEEN REFERRED BY GHC INCLUDING MEDICARE HANDBOOK (Titled "Your Medicare FORMAT. ADVANCE APPROVAL THROUGH Handbook': A pamphlet published by the GHC'S MEDICARE MEDICAL COVERAGE U.S. Department of Health and Human Ser- APPROVAL PROCESS OR THE ENROLLEE vices, Social Security Administration, which HAS RECEIVED EMERGENCY OR URGENTLY provides an easy-to-read explanation of NEEDED SERVICES ACCORDING TO SEC- Medicare benefits. TION V.D. OF THIS MEDICARE ENDORSEMENT. CA-174 ABNEnd. MOO 101W S.1 (0vss) PERMANENT MOVE: An uni' rupted absence of entitlem to Medicare coverage no longer more than ninety (90) days rrom GHC's Service exists, enrollment under the GHC Medicare Area. Plan shall terminate the first of the month as specified by HCFA REFERRAL: A prior written authorization by a 2. Change of Permanent Residence Out- GHC physician, formally approved in advance side GHC's Service Area. If an Enrollee through GHC's Medicare medical coverage makes a Permanent Move as set forth in approval process, that entitles an Enrollee to Section I. of this Medicare Endorsement, receive Covered Services from a specified enrollment shall terminate the first day of non-GHC health care provider. Entitlement to the month following the month in which such services shall not exceed the limits of the GHC receives notification of such move. Referral and is subject to all terms and condi- 3. For Cause. Enrollment may be terminated tions of this Agreement. upon written notice for: SERVICE AREA: The geographic area comprised of a. Knowingly providing fraudulent infor- King, Kitsap, Pierce, Skagit, Snohomish, mation to obtain coverage. In such Thurston, and Whatcom Counties, and any other event, GHC may, within two (2) years areas designated by GHC and approved by the from the date of the application, rescind Health Care Financing Administration. (See or cancel enrollment upon five (5) Service Area Map.) working days' written notice. b. Permitting the use of a GHC identifica- SKILLED NURSING FACILITY: A Medicare tion card by another person. certified and licensed facility, as defined in Medicare regulations, primarily engaged in c. Failure to comply with the rules and providing skilled nursing care or rehabilitation regulations of GHC including disruptive, and related services for which Medicare pays unruly, abusive or uncooperative benefits. conduct. Such termination shall be subject to review and approval by HCFA URGENTLY NEEDED SERVICES (Medicare defined): Services needed in order to prevent a B. Persons Hospitalized on the Date of Ter- serious deterioration of the Enrollee's health due urination. An Enrollee who is a registered bed to an unforeseen illness or injury while tempo- patient receiving Covered Services in a GHC rarily absent from GHC's Service Area, and Facility or GHC Designated Facility on the date which cannot be delayed until the Enrollee of termination shall continue to receive covered returns to the Service Area. inpatient services, until discharge from the facility. This continued coverage will also apply Section II. TERM1NATION to an Enrollee hospitalized in a Medicare- Enrollment under the GHC Medicare Plan for a certified non-GHC Designated Facility as a result of Emergency or Urgently Needed Serv- specific Enrollee, may be terminated in the cir- ices or Referral as set forth in Section VI.B.1. of cumstances set forth below. this Medicare Endorsement. Until such time as an Enrollee's termination of C. Services Provided After Termination. Any enrollment is effective, neither GHC nor services provided by GHC after the effective date Medicare shall pay for services provided at of termination (except those services covered non-GHC Facilities unless the Enrollee has under Section II.B. of this Medicare Endorse- been Referred by GHC, including formal ment) shall be charged according to the Direc- advance approval through GHC's Medicare tory of Services. The Subscriber shall be liable medical coverage approval process, or the for payment of all such charges for services Enrollee has received Emergency or Urgently provided to the Subscriber and all Family Needed Services according to Section V.D. of Dependents. this Medicare Endorsement. A. Termination of Specific Enrollees. Section IIL SUBROGATION 1. Loss of Medicare Entitlement. If the 'Injured person" under this section means an Enrollee covered by this Agreement who sustains Health Care Financing Administration compensable injury. "GHC's medical expense" (HCFA) advises GHC that an Enrollee s CA-174 ABNEnd. M0010IWS.2 (O V89) means the expense incurred by ("'C for the care or B. Rec:onsiderat -n of Claims. treatment of the injury sustained. If GHC denies u request for payment of a claim, If the injured person was injured by an act or or declines to provide services which the En- omission of a third party giving rise to a claim of rollee believes should be provided, the Enrollee legal liability against the third party, GHC shall may file a request for reconsideration with GHC. have the right to recover its cost of providing The request must be filed in writing within sixty benefits to the injured person (subrogation) from the (60) days of GHC's written notice of denial third party as set forth in this Agreement and in unless an extension is specifically approved. If compliance with Medicare regulations and GHC does not overturn the denial in full, it will guidelines. GHC shall be subrogated to and may be referred by GHC to the Health Care Financ- enforce all rights of the injured person to the extent ing Administration for reconsideration. of its medical expense. Subject to Medicare laws and regulations mandating recovery by GHC, the Section V. SCHEDULE OF BENEFITS Cooperative's right of subrogation shall be limited to All benefits and services listed.in this Schedule of the excess of the amount required to fully compen- Benefits are: sate the injured person for the loss sustained. Full 1. subject to all provisions of this Agreement compensation shall be measured on an objective, and Medicare Endorsement; case-by-case basis, but is subject to a presumption 2 must be approved in advance by GHC except that a settlement which does not exhaust the third for Emergency and Urgently Needed Serv- party's reachable assets is full compensation to the ices as set forth in Section V.D. of this injured person. Medicare Endorsement;and The injured person, or the injured person's repre- 3. must meet Medicare guidelines and limita- sentative, must cooperate fully with GHC and tions unless otherwise specified. GHC's legal counsel in effecting collection from GHC covers all Medicare deductibles and coin- persons causing the injury. If an injured party surance. The booklet,"Your Medicare Handbook" settles a claim without protecting GHC's interest, the injured person's rights to full compensation may provides additional information about Medicare be lost. benefits. When reasonable collection costs including legal fees A. Skilled Nursing Facility. Upon Referral, have been incurred to recover GHC's medical GHC will cover up to one hundred fifty (150) expense in an action for damages or otherwise, and days care in a Skilled Nursing Facility, when where there is recovery in GHC's behalf, there shall Medically Necessary, as determined by GHC's be an equitable apportionment of such collection Medical Director or his/her designee. costs between GHC and the injured person or Enrollee, subject to a limit for GHC of one-third of B. Hospice. the amount recovered by GHC. Notwithstanding Enrollees with Part A and Part B of Medicare the above, GHC shall not pay for such collection who elect to receive Medicare-covered hospice costs where GHC retains its own legal counsel or services, may select any Medicare certified acts on its own behalf to represent its interests. hospice program. Enrollees who elect to receive This provision does not apply to occupationally services from the GHC Hospice Program are incurred disease, sickness, and/or injury. entitled to hospice services as provided under the Medicare Hospice Program. Enrollees who Section IV. GRIEVANCE PROCEDURES elect to receive hospice services do so in A. GHC Consumer Relations Program. lieu of curative treatment for their termi- The Consumer Relations Program is designed to nal illness for the period that they are in help an Enrollee resolve formal complaints and the hospice program- To receive hospice concerns about medical and business service. services, the Enrollee is required to sign GHC will record, research, and respond in a the Hospice Election Form. timely manner to an Enrollee's concern. A Hospice Program. concern should be registered initially at the 1. Eligibility. Hospice services, as set forth Enrollee's area medical center. If not satisfied, below, shall be provided to Enrollees for as the Enrollee should then contact the regional long as the following criteria are met: Consumer Relations Department, which will arrange for review by appropriate medical staff, a. A GHC physician has determined that management and/or GHC consumers. the Enrollee's illness is terminal and life CA-174 ABNEnd. M0010IW S.3 (01/89) expectancy is six (6)r- iths or less; wr 'd require hospitalization in an b. the Enrollee has c- sen a palliative at , care facility. treatment focus (emphasizing comfort b. Inpatient Hospice Services for and supportive services rather than short-term care shall be provided in a treatment aimed at curing the Enrollee's facility designated by GHC's Hospice terminal illness); Program when Medically Necessary and c. the Enrollee has elected in writing to authorized in advance by a GHC physi- receive hospice care through GHC's cian and GHC's Hospice Program. Hospice Program; Respite care is covered for a maximum of d. the Enrollee has available a primary five (5) consecutive days per occurrence care person who will be responsible for in order to continue care for the Enrollee the Enrollee's home care;and in the temporary absence of the En- e. a GHC physician and GHC's Hospice rollee's primary care-giver(s). Director determine that the Enrollee's c. Other hospice services may include illness can be appropriately managed in the followings the home. i. drugs and biologicals that are used 2. Hospice Care shall be defined as a coordi- primarily for the relief of pain and nated program of palliative and supportive symptom management; care for terminally ill persons by an interdis- ii. medical appliances and supplies ciplinary team of professionals and volun- primarily for the relief of pain and teers centering primarily in the Enrollee's symptom management; home. iii. counseling services for the Enrollee and his/her primary care-giver(s); 3. Covered Services. Hospice services may and include the following as prescribed by a GHC iv. bereavement counseling services for physician and rendered pursuant to an the family. approved hospice plan of treatment: 4. Hospice Exclusions. All services not a. Home Services specifically listed as covered in this section, i. Intermittent care by a hospice including, but not limited to the following interdisciplinary team which may are excluded: include services by a physician, nurse, medical social worker, a. financial or legal counseling services. physical therapist, speech patholo- b. meal services. gist, occupational therapist, c. custodial or maintenance care in the respiratory therapist, services by a home or on an inpatient basis, except as Home Health Aide under the super- Provided above. vision of a Registered Nurse and d. services not specifically listed as covered homemaker services. by this Medical Coverage Agreement. ii. Continuous care services per En- e. any services provided by members of the rollee in the Enrollee's home when Patient's family. prescribed by a GHC physician, as f. all other exclusions listed in Section DC, set forth in this paragraph. Continu- Exclusions and Limitations, of this ous care is defined as• "skilled Medical Coverage Agreement apply. nursing care provided in the home during a period of crisis in order to C. Mental Health Care, Alcoholism and Drug maintain the terminally ill patient Abuse Treatment Services. at home." Continuous care may be 1. Outpatient mental health, alcoholism provided for pain or symptom and substance abuse treatment services management by a Registered Nurse, are covered in full subject to a combined Licensed Practical Nurse, or Home aggregate limit of $2,200.00 per Enrollee Health Aide under the supervision of per calendar year when such services are a Registered Nurse. Continuous care rendered by a physician. Provided the limit may be provided up to twenty-four has not been reached, services rendered by a (24) hours per day during periods of non-physician are covered in full. crisis. Continuous care is covered 2. Inpatient mental health care services only when a GHC physician deter- are covered in full up to a 190-day lifetime mines that the Enrollee otherwise CA-174 AB/MEnd. M0010rW S.4 (01/89) benefit when such services - provided in a Facility, up--) consultation with a GHC Medicare-certified mental 1. .th facility. physician. 1 ie Enrollee refuses to transfer Inpatient alcoholism and drug abuse to a GHC Facility, all further costs incurred treatment services are covered in full during the hospitalization are the respon- when such services are provided in a sibility of the Enrollee. hospital-based treatment center. 6. Follow-up Care which is a direct result of the Emergency or Urgently Needed Services 3. Coverage for Medical Emergencies must be obtained at GHC, unless a GHC incident to alcoholism and drug abuse or for physician has authorized such care in acute alcoholism or drug abuse, including advance. acute detoxification, is provided as set forth in Section V.D. of this Medicare E. Medicare Ambulance Benefit. Medically Endorsement. Necessary ambulance transportation to or from s hospital or Skilled Nursing Facility is covered D. GHC Emergency/Urgently Needed Services. in full only if transportation by any other vehicle 1. At a GHC Facility. GHC will cover could endanger the patient's health and the Emergency or Urgently Needed care for all ambulance, equipment, and personnel meet Covered Services. Medicare requirements. 2. At a GHC Designated Facility. GHC will c F. GHC Emergency Ambulance Benefit. When over Emergency or Urgently Needed care for all Covered Services. The Enrollee is Emergency ambulance services do not meet Medicare guidelines, GHC will cover ambulance responsible for notifying GHC by way of the GHC Notification Line immediately upon services as set forth below, provided that the inpatient admission, or as soon thereafter as service is authorized in advance by a GHC practicable. physician or meets the definition of an Emer- gency or Urgently Needed Services. (See Section 3. At a Non-GHC Designated Facility. I. of the Group Medical Coverage Agreement.) When an Emergency meets the Medicare definition for Emergency or Urgently Needed 1. Emergency Transport to a GHC Facility or GHC Designated Facility. Each Services as defined in Section I. of this Medicare Endorsement, services are covered Emergency is covered as set forth in the in full. When Emergency or Urgently Group Medical Coverage Agreement. Needed Services do not meet Medicare 2. Emergency Transport to a Non-GHC Guidelines, GHC will cover Emergency care Designated Facility. Each Emergency is for Covered Services, subject to: covered as set forth in the Group Medical a. payment of the Emergency/Urgently Coverage Agreement. Needed Services Deductible shown S. Waiver of Ambulance Services Deduct- in the Group Medical Coverage ible. If two or more members of a Family Agreement;and Unit require Emergency ambulance b. notification of GHC by way of the transport as a result of the same accident, GHC Notification Line immediately only one ambulance Deductible will apply. upon inpatient admission, or as The ambulance Deductible will not apply soon thereafter as practicable, but when ambulance service is authorized in in no event more than twenty-four advance by the Cooperative. (24) hours following admission. 4. Transfer to a GHC Facility. When If two or more members of a Family Unit authorized in advance by GHC, an addi- require Emergency/Urgently Needed care as tional ambulance Allowance is provided for a result of the same accident, only one transfer to a GHC Facility. Emergency/Urgently Needed Services Deductible will apply. G. Medical and Surgical Care. 4. Outpatient Medications prescribed by a The following medical and surgical services are non-GHC physician are excluded. covered when prescribed by GHC Medical b. Transfer. If an Enrollee is hospitalized in a personnel and Medicare requirements are met: non-GHC Facility, GHC reserves the right to 1 Eye examinations and treatment for eye require transfer of the Enrollee to a GHC pathology. CA-174 AMAEnd. Moo lorwsl (OV89) 2. Eyeglasses and cont--t lens, including remove' -f corns and calluses; and routine examination and fitth. , following cataract foot ca, .uch as hygienic care except in the surgery, when required to replace the presence of a nonrelated medical condition natural lens of the eye. Covered eyeglasses affecting the lower limbs. Enrollees who and contact lenses must be dispensed receive their primary care in portions of the through GHC Facilities. Replacements will GHC Service Area where GHC designated be provided only when needed due to licensed practitioners are available must change in the Enrollee's medical condition. utilize GHC's designated providers in order 3. Blood, blood derivatives, and their to be covered. administration. 4. Maternity and pregnancy-related services, H. Prosthetic Devices, such as cardiac devices, including visits before and after birth; intraocular lenses, artificial joints, breast involuntary termination of pregnancy; and prostheses, and braces, are covered. Excluded care for any other complication of are: orthopedic shoes unless they are part of leg pregnancy. braces; dental plates or other dental devices; and 5. Organ transplants. experimental devices. 6. Physician calls (including consultations and second opinions by a GHC physician) I. Medical/Surgical Supplies, such as casts, in the hospital, office, home, Skilled splints, post-surgical dressings, and ostomy Nursing Facility, nursing home, or con- supplies, are covered. valescent center. 7. Restorative physical; occupational; and J. Rental or Purchase of Durable Medical speech therapy following illness, injury, or Equipment, such as oxygen and oxygen surgery. equipment, wheelchairs and other walk-aids, 8. Immunizations and vaccinations that are and hospital beds, are covered. listed as covered in the GHC drug for- mulary (approved drug list) or approved by Section VL EXCLUSIONS AND LIMITATIONS Medicare. A. Exclusions. 9. Services related to dysfunction of the jaw. When Referred by a GHC physician, 1. Dental care, surgery, services, and ap- evaluation and treatment by a GHC- pliances including, but not limited to: approved temporomandibular joint (TMJ) treatment of accidental injury to natural care provider. teeth, reconstructive surgery to the jaw incident to denture wear, and periodontal All TMJ appliances, other than the occlusal surgery. GHC's Medical Director, or his/her splint and its fitting, are excluded. designee, will determine whether the care or treatment required is within the category of Treatment of jaw dysfunction, including dental care or service. TMJ dysfunction, will NOT be provided when the dysfunction is related to maloc- If a GHC physician determines that an clusion or when TMJ services are needed unrelated medical condition requires that due to dental work performed. All such the Enrollee be hospitalized for a dental services and related hospitalization, procedure which is normally done in a including orthodontic therapy and or- dentist's office, GHC will cover associated thognathic (jaw) surgery, are excluded hospital and anesthesia costs at a GHC or regardless of origin or cause. GHC Designated Facility. GHC will not 10. Chiropractic care limited to spinal cover the dentist's or oral surgeon's fees. manipulations. Excluded are any other 2. Investigational procedures, including diagnostic or therapeutic services, includ- medical and surgical services, drugs and ing x-rays, furnished by a chiropractor. devices until formally approved by Medicare Enrollees who receive their primary care in unless specifically provided herein. portions of the GHC Service Area where 3. Supportive devices for the feet. GHC designated licensed practitioners are 4. Services directly related to obesity except as available must utilize GHC's designated provided by Medicare. providers in order to be covered. 5. Services or supplies not specifically listed as 11. Podiatric care. Excluded is treatment of covered by Medicare or GHC. flat feet or other misalignments of the feet; CA•174 ABNEnd. M0010IW S.6 (01/89) B. Limitations. Seattle, WA 98109. If you must receive Emergency 1. Conditions and ExtL , of Coverage. or Urgently Ne d Services from a non-GHC EXCEPT AS PROVIDED IN SECTIONS provider, be sure to show your GHC I.D. card and V.G.10., AND V.G.11. ALL SERVICES AND your red, white, and blue Medicare card. BENEFITS UNDER THIS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL A The Enrollee must file claims for services PERSONNEL AT A GHC OR GHC DESIG- rendered the first nine (9) months of a calendar NATED FACILITY UNLESS: year by December 31 of the following calendar year. a. the Enrollee has received a Referral from GHC, including formal advance approval B. The Enrollee must file claims for services through GHC's Medicare medical rendered in the last three (3) months of a coverage approval process, or calendar year the same as if the services had been furnished in the subsequent calendar year. b. the Enrollee has received Emergency or The time limit on filing claims for --vices Urgently Needed Services as defined in furnished in the last three (3) months :' the Section I. and as set forth in Section V.D. calendar year is December 31 of the second of this Medicare Endorsement. calendar year following the calendar year in which the services were rendered. Section VII. CLAIMS PROCEDURE See"Your Medicare Handbook"for additional Claims for services or supplies and explanation of information regarding filing claims. Medicare benefits for services or supplies from 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 hospitalization for which payment is requested. Cooperative of Puget Sound, P.O. Box C-19165, CA-174 ABN End. M0010IWS.7 (01/89) Group Health ► Cooperative of Puget Sousa Contract Endorsement Medicare Endorsement For Persons Covered by Parts B only of Medicare THE PROVISIONS OF THE GROUP MEDI- Section I. DEFINITIONS CAL COVERAGE AGREEMENT SHAD. RE- MAIN IN EFFECT EXCEPT AS MODIFIED BY CUSTODIAL CARE: Care that is primarily for the THIS MEDICARE ENDORSEMENT. COVER- purpose of meeting personal needs and could be AGE UNDER THIS GROUP MEDICAL COVER- provided by persons without professional skills AGE AGREEMENT IS INTEGRATED WITH or-training. Custodial Care includes help in THE MEDICAL AND HOSPITAL BENEFITS walking, bathing, dressing, eating, and taking ESTABLISHED BY TITLE 18 OF THE SOCIAL medicine. SECURITY ACT AS AMENDED, AND RE- FERRED TO AS"MEDICARE". THE BENEFITS EMERGENCY SERVICES (Medicare defined): AND EXCLUSIONS DESCRIBED IN THIS Inpatient or outpatient services that are ENDORSEMENT APPLY ONLY TO EN- rendered immediately by an appropriate ROM S WHO ARE COVERED UNDER PART non-GHC provider because of an injury or B ONLY OF MEDICARE. sudden illness, and for which the time required Except as defined by Federal Regulations, all to reach GHC or a GHC Designated Facility Enrollees entitled to, or eligible to purchase would risk permanent damage to the Enrollee's Medicare must transfer to the GHC Medicare Plan health. upon such entitlement or eligibility. A condition of HEALTH CARE FINANCING ADMINISTRATION enrollment under the GHC Medicare Plan requires (HCFA): The federal agency that administers that an Enrollee be continuously enrolled for the Medicare program. medical (Part B) benefits available from the Social Security Administration, and sign any papers that MEDICARE: The federal health insurance pro- may be required by GHC or Medicare. For addi- gram for the aged and disabled. tional information, the Enrollee may refer to 'Your Medicare Handboole' MEDICARE GUIDELINES: Coverage rules and NEITHER GHC NOR MEDICARE MAY PAY policies established by the Health Care Financ- FOR SERVICES PROVIDED AT NON-GHC ing Administration (HCFA), a federal agency. FACILITIES UNLESS THE ENROLLEE HAS BEEN REFERRED BY GHC INCLUDING MEDICARE HANDBOOK (Titled "Your Medicare FORMAL ADVANCE APPROVAL THROUGH Handbook': A pamphlet published by the GHC'S MEDICARE MEDICAL COVERAGE U.S. Department of Health and Human Ser- APPROVAL PROCESS OR THE ENROLLEE vices, Social Security Administration, which HAS RECEIVED EMERGENCY OR URGENTLY provides an easy-to-read explanation of NEEDED SERVICES ACCORDING TO SEC- Medicare benefits. TION V.C. OF THIS MEDICARE ENDORSEMENT. CA-175 B/MEnd. M0011IW S.1 (O V89) PERMANENT MOVE: An unin upted absence of Section I f this Medicare Endorsement, more than ninety (90) days from GHC's Service enrollment shall terminate the first day of Area. the month following the month in which GHC receives notification of such move. REFERRAL: A prior written authorization by a g, For Cause. Enrollment may be terminated GHC physician, formally approved in advance upon written notice for: through GHC's Medicare medical coverage approval process, that entitles an Enrollee to a. Knowingly providing fraudulent infor- receive Covered Services from a specified mation to obtain coverage. In such non-GHC health care provider. Entitlement to event, GHC may, within two (2) years such services shall not exceed the limits of the from the date of the application, rescind Referral and is subject to all terms and condi- or cancel enrollment upon five (5) tions of this Agreement. working days'written notice. b. Permitting the use of a GHC identifica- SERVICE AREA: The geographic area comprised of tion card by another person. King, Kitsap, Pierce, Skagit, Snohomish, Thurston, and Whatcom Counties, and any other C. Failure to comply with the rules and areas designated by GHC and approved by the regulations of GHC including disruptive, unruly, abusive or uncooperative Health Care Financing Administration. (See conduct. Such termination shall be Service Area Map.) subject to review and approval by HCFA URGENTLY NEEDED SERVICES (Medicare defined): Services needed in order to prevent a Section IIL SUBROGATION serious deterioration of the Enrollee's health due "Injured person" under this section means an to an unforeseen illness or injury while tempo- Enrollee covered by this Agreement who sustains rarily absent from GHC's Service Area, and compensable injury. "GHC's medical expense" which cannot be delayed until the Enrollee means the expense incurred by GHC for the care or returns to the Service Area. treatment of the injury sustained. Section II. TERMINATION If the injured person was injured by an act or omission of a third party giving rise to a claim of Enrollment under the GHC Medicare Plan for a legal liability against the third party, GHC shall specific Enrollee, may be terminated in the cir- have the right to recover its cost of providing cumstances set forth below. benefits to the injured person (subrogation) from the third party as set forth in this Agreement and in Until such time as an Enrollee's termination of compliance with Medicare regulations and enrollment is effective, neither GHC nor guidelines. GHC shall be subrogated to and may Medicare shall pay for services provided at enforce all rights of the injured person to the extent non-GHC Facilities unless the Enrollee has of its medical expense. Subject to Medicare laws been Referred by GHC, including formal and regulations mandating recovery by GHC, the advance approval through GHC's Medicare Cooperative's right of subrogation shall be limited to medical coverage approval process, or the the excess of the amount required to fully compen- Enrollee has received Emergency or Urgently sate the injured person for the loss sustained. Full Needed Services according to Section V.C. of compensation shall be measured on an objective, this Medicare Endorsement. case-by-case basis, but is subject to a presumption that a settlement which does not exhaust the third A. Termination of Specific Enrollees. party's reachable assets is full compensation to the 1. Loss of Medicare Entitlement. If the injured person. Health Care Financing Administration The injured person, or the injured person's repre- (HCFA) advises GHC that an Enrollee's sentative, must cooperate fully with GHC and entitlement to Medicare coverage no longer GHC's legal counsel in effecting collection from exists, enrollment under the GHC Medicare persons causing the injury. If an injured party Plan shall terminate the first of the month settles a claim without protecting GHC's interest, as specified by HCFA_ the injured person's rights to full compensation may 2. Change of Permanent Residence Out- be lost. side GHC's Service Area. If an Enrollee When reasonable collection costs including legal fees makes a Permanent Move as set forth in have been incurred to recover GHC's medical CA-175 B/MEnd. MOO 11IW S.2 (01/89) expense in an action for damages otherwise, and A. Hospice. where there is recovery in GHC's behalf, there shall It is understood and agreed that the following be an equitable apportionment of such collection fully sets forth the eligibility requirements and costs between GHC and the injured person or Covered Services for an Enrollee with Part B Enrollee, subject to a limit for GHC of one-third of Medicare only who wishes to elect to receive the amount recovered by GHC. Notwithstanding hospice services. Enrollees who elect to the above, GHC shall not pay for such collection receive hospice services do so in lieu of costs where GHC retains its own legal counsel or curative treatment for their terminal acts on its own behalf to represent its interests. illness for the period that they are in the This provision does not apply to occupationally hospice program. To receive hospice incurred disease, sickness, and/or injury. services, the Enrollee is required to sign the Hospice Election Form. Section IV. GRIEVANCE PROCEDURES Hospice Program. A. GHC Consumer Relations Program. 1. Eligibility. Hospice services, as set forth The Consumer Relations Program is designed to below, shall be provided to Enrollees for as help an Enrollee resolve formal complaints and long as the following criteria are met: concerns about medical and business service. a. A GHC physician has determined that GHC will record, research, and respond in a the Enrollee's illness is terminal and life timely manner to an Enrollee's concern. A expectancy is six(6)months or less; concern should be registered initially at the b the Enrollee has chosen a palliative Enrollee's area medical center. If not satisfied, treatment focus (emphasizing comfort the Enrollee should then contact the regional and supportive services rather than Consumer Relations Department, which will treatment aimed at curing the Enrollee's arrange for review by appropriate medical staff, management and/or GHC consumers. terminal illness); c. the Enrollee has elected in writing to B. Reconsideration of Claims. receive hospice care through GHC's Hospice Program; If GHC denies a request for payment of a claim, d. the Enrollee has available a primary or declines to provide services which the En- care person who will be responsible for rollee believes should be provided, the Enrollee the Enrollee's home care; and may file a request for reconsideration with GHC. e. a GHC physician and GHC's Hospice The request must be filed in writing within sixty Director determine that the Enrollee's (60) days of GHC's written notice of denial illness can be appropriately managed in unless an extension is specifically approved. If the home. GHC does not overturn the denial in full, it will 2. Hospice Care shall be defined as a coordi- be referred by GHC to the Health Care F inanc- nated program of palliative and supportive ing Administration for reconsideration. care for terminally ill persons by an interdis- Section V. SCHEDULE OF BENEFITS ciplinary team of professionals and volun- teers centering primarily in the Enrollee's All benefits and services listed in this Schedule of home. Benefits are: 3. Covered Services. Hospice services may 1. subject to all provisions of this Agreement include the following as prescribed by a GHC and Medicare Endorsement; physician and rendered pursuant to an 2. must be approved in advance by GHC except approved hospice plan of treatment: for Emergency and Urgently Needed Serv- ices as set forth in Section V.C. of this a. Home Services i. Intermittent care by a hospice Medicare Endorsement; and interdisciplinary team which may 3. must meet Medicare guidelines and limits- tions unless otherwise specified. include services by a physician, nurse, medical social worker, GHC covers all Medicare deductibles and coin- physical therapist, speech patholo- surance. The booklet,'Your Medicare Handbook" gist, occupational therapist, provides additional information about Medicare respiratory therapist, services by a benefits. Home Health Aide under the super- vision of a Registered Nurse and CA-176 B/MEnd. MOO 111W S.3 (01/89) homemaker sery by th ledical Coverage Agreement. ii. Continuous care services per En- e. any services provided by members of t:ie rollee in the Enrollee's home when patient's family. prescribed by a GHC physician, as f. all other exclusions listed in Section DC, set forth in this paragraph. Continu- Exclusions and Limitations, of this ous care is defined as "skilled Medical Coverage Agreement apply. nursing care provided in the home during a period of crisis in order to B. Outpatient Mental Health Care, Alcoholism maintain the terminally ill patient and Drug Abuse Treatment Services are at home." Continuous care may be covered in full subject to a combined aggregate provided for pain or symptom limit of $2,200.00 per Enrollee perr calendar management by a Registered Nurse, year when such services are rendered by a Licensed Practical Nurse, or Home physician. Provided the limit has not been Health Aide under the supervision of reached, services rendered by a non-physician a Registered Nurse. Continuous care are covered in full. may be provided up to twenty-four (24) hours per day during periods of C. Outpatient Emergency/Urgently Needed crisis. Continuous care is covered Services. only when a GHC physician deter- 1. At a GHC Facility. GHC will cover mines that the Enrollee otherwise Emergency or Urgently Needed care for all would require hospitalization in an Covered Services. acute care facility. b. Inpatient Hospice Services for 2. At a GHC Designated Facility. GHC will short-term care shall be provided in a cover Emergency or Urgently Needed care facility designated by GHC's Hospice for all Covered Services. Program when Medically Necessary and 3. At a Non-GHC Designated Facility. authorized in advance by a GHC physi- When an Emergency meets the Medicare cian and GHC's Hospice Program. definition for Emergency or Urgently Needed Respite care is covered for a maximum of Services as defined in Section I. of this five (5) consecutive days per occurrence Medicare Endorsement, services are covered in order to continue care for the Enrollee in full. When Emergency or Urgently in the temporary absence of the En- Needed Services do not meet Medicare rollee's primary care-giver(s). Guidelines, GHC will cover Emergency care c. Other hospice services may include for Covered Services, subject to: the following: i. drugs and biologicals that are used a. payment of the Emergency/Urgently primarily for the relief of pain and Needed Services Deductible shown in the Group Medical Coverage symptom management; ii. medical appliances and supplies Agreement. primarily for the relief of pain and If two or more members of a Family Unit symptom management; require Emergency/Urgently Needed care as iii. counseling services for the Enrollee a result of the same accident, only one and his/her primary care-giver(s); Emergency/Urgently Needed Services and Deductible will apply. iv. bereavement counseling services for 4. Outpatient Medications prescribed by a the family. non-GHC physician are excluded. 4. Hospice Exclusions. All services not 5. Follow-up Care which is a direct result of specifically listed as covered in this section, the Emergency or Urgently Needed Services including, but not limited to the following must be obtained at GHC, unless a GHC are excluded: physician has authorized such care in a. financial or legal counseling services. advance. b. meal services. c. custodial or maintenance care in the D. Medicare Ambulance Benefit. Medically home or on an inpatient basis, except as Necessary ambulance transportation to or from provided above. a hospital or Skilled Nursing Facility is covered d. services not specifically listed as covered in full only if transportation by any other vehicle CA-175 B/MEnd. MOO 11IW S.4 (0 V89) could endanger the patient's -,alth and the 10. Chiropract care limited to spinal ambulance, equipment, and personnel meet manipulations. Excluded are any other Medicare requirements. diagnostic or therapeutic services, includ- ing x-rays, furnished by a chiropractor. E. Medical and Surgical Care. Enrollees who receive their primary care in The following medical and surgical services are portions of the GHC Service Area where covered when prescribed by GHC Medical GHC designated licensed practitioners are Personnel and Medicare requirements are met: available must utilize GHC's designated providers in order to be covered. 1. Eye examinations and treatment for eye 11. Podiatric care. Excluded is treatment of pathology. flat feet or other misalignments of the feet; 2. Eyeglasses and contact lens, including removal of corns and calluses; and routine examination and fitting, following cataract foot care such as hygienic care except in the surgery, when required to replace the presence of a nonrelated medical condition natural lens of the eye. Covered eyeglasses affecting the lower limbs. Enrollees who and contact lenses must be dispensed receive their primary care in portions of the through GHC Facilities. Replacements will GHC Service Area where GHC designated be provided only when needed due to licensed practitioners are available must change in the Enrollee's medical condition. utilize GHC's designated providers in order 3. Blood, blood derivatives, and their to be covered. administration. 4. Maternity and pregnancy-related services, F. Prosthetic Devices, such as cardiac devices, including visits before and after birth; intraocular lenses, artificial joints, breast involuntary termination of pregnancy; and prostheses, and braces, are covered. Excluded care for any other complication of are: orthopedic shoes unless they are part of leg pregnancy. braces; dental plates or other dental devices; and 5. Organ transplants. experimental devices. 6. Physician calls (including consultations and second opinions by a GHC physician) G. Medical/Surgical Supplies, such as casts, in the hospital, office, home, Skilled splints, post-surgical dressings, and ostomy Nursing Facility, nursing home, or con- supplies, are covered. valescent center. 7. Restorative physical; occupational; and H. Rental or Purchase of Durable Medical speech therapy following illness, injury, or Equipment, such as oxygen and oxygen surgery. equipment, wheelchairs and other walk-aids, 8. Immunizations and vaccinations that are and hospital beds, are covered. listed as covered in the GHC drug for- mulary (approved drug list) or approved by Section VL EXCLUSIONS AND LIMITATIONS Medicare. A. Exclusions. 9. Services related to dysfunction of the jaw. When Referred by a GHC physician, 1. Dental care, surgery, services, and ap- evaluation and treatment by a GHC- pliances including, but not limited to: approved temporomandibular joint (TMJ) treatment of accidental injury to natural care provider. teeth, reconstructive surgery to the jaw incident to denture wear, and periodontal All TMJ appliances, other than the occlusal surgery. GHC's Medical Director, or his/her splint and its fitting, are excluded. designee, will determine whether the care or treatment required is within the category of Treatment of jaw dysfunction, including dental care or service. TMJ dysfunction, will NOT be provided If a GHC physician determines that an when the dysfunction is related to maloc- unrelated medical condition requires that clusion or when TMJ services are needed the Enrollee be hospitalized for a dental due to dental work performed. All such procedure which is normally done in a services and related hospitalization, dentist's office, GHC will cover associated including orthodontic therapy and or- hospital and anesthesia costs at a GHC or thognathic (jaw) surgery, are excluded GHC Designated Facility. GHC will not regardless of origin or cause. cover the dentist's or oral surgeon's fees. CA-175 B/MEnd. M00111W S.5 (0 vs9) 2. Investigational proc Yes, including Section VII. C" IRS PROCEDURE medical and surgical services, drugs and Claims for services or supplies and explanation of devices until formally approved by Medicare Medicare benefits for services or supplies from unless specifically provided herein. providers other than Group Health Cooperative 3. Supportive devices for the feet. should be sent to: Medicare Claims, Group Health 4. Services directly related to obesity except as Cooperative of Puget Sound, P.O. Box C-19165, provided by Medicare. Seattle, WA 98109. If you must receive Emergency 5. Services or supplies not specifically listed as or Urgently Needed Services from a non-GHC covered by Medicare or GHC. provider, be sure to show your GHC I.D. card and your red, white, and blue Medicare card. B. Limitations. A. The Enrollee must file claims for services L Conditions and Extent of Coverage. rendered the first nine (9) months of a calendar EXCEPT AS PROVIDED IN SECTIONS year by December 31 of the following calendar V.E.10., AND V.E.11. ALL SERVICES AND year. BENEFITS UNDER THIS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL B. The Enrollee 'must file claims for services PERSONNEL AT A GHC OR GHC DESIG- rendered in the last three (3) months of a NATED FACILITY UNLESS: calendar year the same as if the services had been furnished in the subsequent calendar year. a. the Enrollee has received a Referral from The time limit on filing claims for services GHC, including formal advance approval furnished in the last three (3) months of the through GHC's Medicare medical calendar year is December 31 of the second coverage approval process, or calendar year following the calendar year in which the services were rendered. b. the Enrollee has received outpatient Emergency or Urgently Needed Services See"Your Medicare Handbook"for additional as defined in Section I. and as set forth information regarding filing claims. in Section V.C. of this Medicare GHC may obtain information which it deems Endorsement. necessary concerning the medical care and hospitalization for which payment is requested. CA-175 B/MEnd. MOO 11IW S.6 (ovs9) Continuation Coverage, Groin Conversion, and Transfer • Health ► Cooperative Contract Endorsement of Puget Sound _ For Attachment to Group Medical Coverage Agreement Dependent as a result would be ineligible Section IV. is retitled Continuation Coverage, under this Agreement; or Conversion, and Transfer, and is modified to include the g following as the new subsection A. The current a Dependent child ceases to qualify as a subsections A., B., and C. are renumbered B., C., and D. Family Dependent under Section IX.B.2.(b) accordingly. or W. A. Continuation Coverage 3. A Subscriber who is a retiree or the spouse or Dependent of a retiree may continue coverage This subsection A. only applies to employer hereunder if the Subscriber would otherwise lose groups who must offer continuation coverage coverage hereunder within one year of the date a under the applicable provisions of the proceeding under Title 11 of the United States Consolidated Omnibus Budget Reconciliation Code is commenced with respect to the Group. Act of 1985 ("COBRA"), as amended, and only Coverage under this Section IV.A.3., continues applies to grant continuation of coverage rights only upon payment of applicable monthly to the extent required by federal law. charges to the Group at the time specified by the Group. The terms and conditions of this To the extent required by federal law, if the Subscriber or coverage are governed by COBRA. Family Dependent loses eligibility under this Group Agreement, group coverage may be continued under the 4. If an individual enrolled for continuation circumstances described below. Except as set forth in coverage experiences a second qualifying event Section IV.A.10., below, this provision applies only to as set forth in subsection (2.) above, continuation Subscribers and Family Dependents enrolled under this coverage may be extended for up to thirty-six Agreement prior to the date of eligibility for continuation (36) months, beginning from the date of the first coverage who would otherwise lose coverage as a result qualifying event. of one of the qualifying events listed below in subsections (1.), (2.), and (3.). 5. In addition to the conditions set forth in Section III. Termination, continuation coverage may be 1. Subscribers and Family Dependents are eligible terminated prior to the prescribed period set forth for continuation coverage for a maximum period in subsections (1.), (2.), and (3.) above if: of up to eighteen (18) months commencing at the There is a failure to make timely payment of date that: any monthly dues required under this • The Subscriber's employment is terminated Agreement; (unless terminated for gross misconduct); or the Enrollee becomes covered under any • the Subscriber experiences a reduction in other group health plan; work hours. the Enrollee becomes eligible to enroll under Medicare whether he or she enrolls or not. 2. Family Dependents are eligible for continuation coverage for a maximum period of up to 6. Notice thirty-six (36) months commencing at the date The Group is responsible for assuring compliance that: with COBRA and that Enrollees are given timely • The Subscriber is divorced or legally notice of their continuation coverage option. The separated; or Group is also responsible for notifying GHC in a • the Subscriber dies; or timely fashion of the election to continue • the Subscriber becomes entitled to Medicare coverage and the applicable coverage period and the non-Medicare eligible Family (eighteen [181 or thirty-six [361 months). CA-50 I0007IWS.1 (01/87)Rev. (01/89) The Subscriber or Family Dependent must notify 8. Monthly Dues the Group, or plan administrator, if any, within Monthly dues must be paid directly to the Group. sixty (60) days of a divorce, legal separation, or The Group is responsible for submitting such when an enrolled dependent child no longer dues with its regular monthly dues payment to meets the eligibility requirements set forth in GHC. Section IX.B.2. 9. Group Conversion 7. Application In addition to Group Conversion rights as set Written application for continuation coverage forth in Section IV.B.2., the Subscriber or must be made within sixty (60) days of the Family Dependent enrolled for continuation termination date of coverage, or the date that the coverage is entitled to convert to GHC's Group Enrollee receives specific notice of his/her right Conversion Plan within a 180-day period prior to to continuation coverage, whichever is later. termination of continuation coverage, if his/her Notwithstanding the above, if the Group or coverage under this Agreement is terminated for Group's Plan Administrator fails to give the any reason other than nonpayment or cause. See Enrollee timely notice of any required COBRA Section IV.B.2. GHC Group Conversion Plan - continuation rights, GHC shall be entitled to Application. charge the Group and the Group shall pay the greater of: 10. Open Enrollment and Adding Dependents • charges incurred by the Enrollee prior to To the extent required under COBRA, a qualified notice to GHC of the Enrollee's exercise of beneficiary under COBRA may add Family COBRA rights, or Dependents during the Group's Open Enrollment • the applicable dues amount for retroactive period and newly eligible persons according to coverage. the procedures specified in Section IX.A. Upon receipt of the Group's written confirmation It is further understood and agreed that Section III.B.1. is of late notification, GHC shall provide the deleted in its entirety and replaced with the following: Enrollee with continuation coverage under COBRA as described above. 1. Loss of Eligibility. If an Enrollee no longer meets the eligibility requirements set forth in No lapse in coverage prior to continuation Section IX.B. and is not enrolled for continuation coverage is permitted, except as provided above. coverage as described in Section IV.A., coverage The application shall be deemed by GHC to under this Agreement will terminate at the end of include all Family Dependents eligible for the month during which loss of eligibility occurs. continuation coverage unless specifically stated otherwise. A physical examination or statement All other provisions of Sections III., IV., and IX. shall remain in full force and effect. of health is not required. CA-50 100071WS.2 (01/87)Rev. (01/89) Group Health Cooperative of Puget Sound Group Sales Department Marketing Division 221 First Avenue West Seattle, WA 98119 (206)326-7259 PERSONNEL DEPT. i December 11 , 1984 DEC 14 1984 Ms. Barbara L. Fives PERSONNEL DEPT. R. L. Evans Company, Inc, Plaza 600 Building, Suite 1210 Seattle, Washington 98101 Re: City of Kent Dear Barbara: This letter is in followup to our recent conversation regarding coverage eligibility for Uniformed Personnel . As discussed, our enrollment and eligibility schedule states the following: Uniformed Personnel will not be covered under this plan. The above refers only to LEOFF I personnel ; LEOFF II employees are eligible for coverage. Sincerely, Matthew Damon Account Executive Marketing Division MD:mas cc: Mr. Mike Webby City of Kent Puget Sound: Bothell, Burien, Everett, Federal Way, Lynnwood, Olympia, Port Orchard, Redmond, Renton, Seattle(Capitol Hill, Madrona, Northgate, Olive Way, and Rainier), Silverdale, Tacoma, Vashon. Spokane: Maple Street, South Hill, and Valley. RL EMS 1210 Plaza 600 Bldg. • Seattle,WA 98101 2061448-7878• FAX 206/448-3589 088 "' RRWNNCL DEBT December 13 , 1988 Ms. Lori Brown City of Kent 220 4th Ave. So. Kent, WA 98032-5895 RE: City of Kent, employees & Leoff 1 Dependents Dear Lori: Enclosed is the new dues schedule for City of Kent employees and Leoff 1 Dependents. These premiums are guaranteed from January 1, 1989 to January 1, 1990. Changes to the benefits and their administration are shown on the enclosed chart. Should you have any questions about this rate or benefit information, please call me. Sin rely, Dougla Evans Vice President Employee Benefits DE:kf Estate&Business Planning•Group Insurance • Financial&Insurance Planning• 40WPension/Profit Sharing Plans Securities offered through Integrated Resources Equitv Corp.,Member NASD&S1PC Registered Investment Advisory Services offered through Evans Financial Advisory Service CONTRACT REVISIONS For Groups Renewing 01/01/89 to 04/01/89 CONTRACT LANGUAGE/ EXPLANATION BENEFIT CHANGE Rehabilitation Services Benefit change: Inpatient physical and occupational therapy and associated hospital services for the purpose of rehabilitation are covered up to 60 inpatient days per condition per calendar year. Services for outpatient physical, occpational, and restorative speech therapy combined are covered up to 60 visits per condition per calendar year. All services are limited to those for which significant improvement is expected within 60 days. Emergency Inpatient Mental Health Services State-Mandated benefit effective September 1, 1988: Inpatient mental health services are covered up to 7 days at 80% per Enrollee per calendar year for emer- gency mental health care at a state mental health care hospital. Coverage is subject to the emergency deductible and notification requirements. Automatic Implantable Cardioverter Defibrillators Coverage for the AICD is now included under the (AICD) implants benefit: Nonexperimental implants, are covered limited to the following: cardiac devices, automatic implantable cardioverter defibrillators (AICD), artificial joints, and intraocular lenses. Artificial or mechanical hearts are still excluded. Liver Transplants Coverage for adult liver transplants is now included under the transplants benefit: Kidney, corneal, heart, bone marrow and liver transplants are covered, when authorized by GHC. Donor costs are not covered. Coverage for heart and liver transplants will be excluded until the Enrollee has been covered under a GHC Medical Coverage Agree- ment for 12 consecutive months. Emergency Services Copayment Waiver Benefit change: The Emergency services copayment is waived when the enrollee is admitted to a GHC or GHC designated facility directly from the emergency room. I0046IwS.1 Emergency Notification at a GHC Designated Facility Benefit clarification: Emergency services received at a GHC designated facility are covered. The enrollee, or person taking responsibility for the enrollee, is responsible for notifying GHC by way of the GHC Notification Line immediately upon inpatient admission, or as soon thereafter as practicable, but in no event more than twenty-four(24)hours following admission. Continuation Coverage, Conversion and Transfer Clarification of language regarding group conversion (COBRA) rights. Coordination of Benefits (COB) Addition of second "tiebreaker" rule. Investigational Procedures Exclusion clarification: Investigational procedures, including medical and surgical services and devices until approved by GHC for medical coverage. Investigational drugs are not covered until approved by the U.S. Food and Drug Administration for general marketing and by GHC for medical coverage. Eye Training Therapy Exclusion clarification: Orthoptic (eye training) therapy is now specifically excluded. Services Related to Obesity Exclusion clarification: Services directly related to obesity (e.g., surgery, weight reduction programs) are not covered, except for nutritional counseling provided by GHC staff. Specialty Treatment Programs Exclusion clarification: Specialty treatment programs (e.g., rehabilitation, behavior modification) which are not provided at GHC are not covered. I00461WS.2 DUES SCHEDULE 0369 For attachment to Group Medical Coverage Agreement with City of Kent. This schedule reflects Group Health Cooperative monthly dues effective January 1, 1989 and guaranteed to January 1, 1990. MONTHLY HEALTH CARE DUES Subscriber only . . . . . . . . . . . . . . . . . . . . . . . . . $ 78.89 per month Subscriber and spouse . . . . . . . . . . . . . . . . . . . . 176.51 per month Subscriber and child(ren) . . . . . . . . . . . . . . . . . . . . 159.10 per month Subscriber and family . . . . . . . . . . . . . . . . . . . . . . 252.68 per month MEDICARE SUPPLEMENTAL HEALTH CARE DUES HMO High Option Subscriber with parts A & B of Medicare . . . . . . . . . . . . 66.71 per month Subscriber with part B of Medicare only . . . . . . . . . . 149.83 per month Subscriber and spouse (one with parts A & B of Medicare) . . . . 149.48 per month Subscriber and spouse (both with parts A & B of Medicare) . . . 133.42 per month Subscriber and child(ren) . . . . . . . . . . . . . . . . . 132.07 per month (subscriber with parts A & B of Medicare) Subscriber and family (one with parts A & B of Medicare) . . . . 225.65 per month Subscriber and family (two with parts A & B of Medicare) . . . . 198.61 per month HMO Standard Option Subscriber with parts A & B of Medicare . . . . . . . . . . . . 32.25 per month Subscriber with part B of Medicare only . . . . . . . . . . 20.25 per month Subscriber and spouse (one with parts A & B of Medicare) . . . . 115.02 per month Subscriber and spouse (both with parts A & B of Medicare) . . . 64.50 per month Subscriber and child(ren) . . . . . . . . . . . . . . . . . 97.61 per month (subscriber with parts A & B of Medicare) Subscriber and family (one with parts A & B of Medicare) . . . . 191.19 per month Subscriber and family (two with parts A & B of Medicare) . . . . 129.69 per month Not HMO Persons covered by Part A only. . . . . . . . . . . . . . . . . 140.83 per month NOTE: Medicare rates do not apply to TEFRA eligible enrollees. COPAYMENT PROVISION The following copayments apply to this plan. See Group Medical Coverage Agreement for benefit details. $ 25.00 Emergency Room BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the 1st 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. The Group will submit the full amount of said dues to the Cooperative when the effective date of coverage for a given Subscriber and Family Dependents is prior to the 16th of the month. Coverage effective on or after the 16th of the month will be provided without charge for a Subscriber and Family Dependents, and these Enrollees will appear on the subsequent month' s billing at the regular charge. Conversely, when a Subscriber' s date of employment termination is prior to the 16th of the month, the Group will not submit dues for that month. When a Subscriber' s date of employment termination is on or after the 16th of the month, the Group will submit the full amount of said dues to the Cooperative. Per average enrollee in 1988, 8.7 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. DUES SCHEDULE 0369 For attachment to Group Medical Agreement with City of Kent - LEOFF 1 Dependents. This schedule reflects Group Health Cooperative monthly dues effective January 1, 1989 and guaranteed to January 1, 1990. MONTHLY HEALTH CARE DUES Spouse only . . . . . . . . . . . . . . . . . . . . . $ 97.62 per month Chi 1 d(ren) only . . . . . . . . . . . . . . . . . 80.21 per month Spouse and child(ren) . . . . . . . . . . . . . . . . . 173.79 per month MEDICARE SUPPLEMENTAL HEALTH CARE DUES HMO High Option Spouse and child(ren) - Spouse with parts A & B of Medicare . . . . . . . . . . . . . . . . . . . $146.76 per month HMO Standard Option Spouse and child(ren) - Spouse with parts A & B of Medicare . . . . . . . . . . . . . . . . . . . $112.30 per month COPAYMENT PROVISION The following copayment applies to this plan. See Group Medical Coverage Agreement for benefit details. $25.00 Emergency Room BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the 1st 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. The Group will submit the full amount of said dues to the Cooperative when the effective date of coverage for a given Subscriber and Family Dependents is prior to the 16th of the month. Coverage effective on or after the 16th of the month will be provided without charge for a Subscriber and Family Dependents, and these Enrollees will appear on the subsequent month' s billing at the regular charge. Conversely, when a Subscriber' s date of employment termination is prior to the 16th of the month, the Group will not submit dues for that month. When a Subscriber' s date of employment termination is on or after the 16th of the month, the Group will submit the full amount of said dues to the Cooperative. Per average enrollee in 1988, 8.7 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. r R. L. EVANS CO., INC. 401K-Pension Profit Sharing Plans!Financial&Insurance Planning RECEIVED December 3 , 1987 PERSONNEL DEPT. Mike Webby Assistant City Administrator City of Kent 220 4th Ave. S. Kent, WA 98032 RE: City of Kent & LEOFF 1 Dependents Dear Mike: Enclosed is the new dues schedule for City of Kent and LEOFF 1 _ Dependents. These premiums are guaranteed from January 1, 1988 to January 1, 1989 . Following are the contract changes that will be effective on the renewal date. The State of Washington has mandated coverage for chemical dependency. Our current alcoholism benefit has been expanded to include drug abuse treatment to meet this requirement. Treatment of growth disorders by growth hormones will be covered when authorized as medically appropriate by Group Health's Medical Director and in accordance with criteria established by Group Health. To be eligible for this treatment, an enrollee must be continuously covered under our plan for twelve months. If you have questions, or if I can be of further assistance, please call. Sincerely, Do g s L. Evans Vice President Employee Benefits DLE/pb enclosure 1210 PLAZA 600 BLDG. SEATTLE,WA 98101 (206)448-7878 RECEIVED Ott; 8 W1 DUES SCHEDULE PERSONNEL DEP&369 For attachment to Group Medical Coverage Agreement with City of Kent. This schedule reflects Group Health Cooperative monthly dues effective January 1, 1988 and guaranteed to January 1, i989. MONTHLY HEALTH CARE DUES Subscriber only . . . . . . . . . . . . . . . . . . $ 78.89 per month Subscriber and spouse . . . . . . . . . . . . . . . . 176.51 per month Subscriber and child(ren) . . . . . . . . . . . . . . 159.10 per month Subscriber and family . . . . . . . . . . . . . . . . 252.68 per month COPAYMENT PROVISION The following copayment applies to this plan. See Group Medical Coverage Agreement for benefit details. $25.00 Emergency Room BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the 1st 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 1987, 8.4 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. RECEIVED DEC 8 1987 PERSONNEL DEPI". DUES SCHEDULE For attachment to Group Medical Coverage Agreement with City of Kent - LEOFF 1 Dependents.. This schedule reflects Group Health Cooperative monthly dues effective January 1, 1988 and guaranteed to January 1, 1989. MONTHLY HEALTH CARE DUES Spouse only . . . . . . . . . . . . . . . . . . . . . . $ 97.62 per month Child(ren) only . . . . . . . . . . . . . . . . . 80.21 per month Spouse and child(ren) . . . . . . . . . . . . . . . . . 173.79 per month MEDICARE SUPPLEMENTAL HEALTH CARE DUES HMO High Option Spouse and child(ren) - Spouse with parts A & B of Medicare . . . . . . . . . . . . . . . . 156.72 per month HMO Standard Option Spouse and child(ren) - Spouse with parts A & B of Medicare . . . . . . . . . . . . . . . . . . . 130.34 per month COPAYMENT PROVISION The following copayment applies to this plan. See Group Medical Coverage Agreement for benefit details. $ 25.00 Emergency Room BILLING INFORMATION Dues must be remitted on a calendar month basis on or before the 1st 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 1987, 8.4 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. t R. L. EVANS CO., INC. 401K-Pension Profit Sharing Plans I Financial&Insurance Planning April 6, 1987 C E E D f98t Mr. Mike Webby City of Kent �ERSONNE! pFp; P.O. Box 310 Kent, WA 98031 Dear Mike: Enclosed please find a set of contract documents that describe changes to the basic Group Health Medical Coverage Agreement for the City of Kent for the 1987 contract year. As you review these benefit changes, you may want to pay special attention to changes in the following areas: Contact lenses for Reconstructive Willful damage cataract patients breast surgery Circumcision Organ transplants Home health care COBRA TMJ Mental health care Coordination of Implants Hospice benefits Alcoholism treatment Worker' s compensation Stop/Loss If you should have any questions regarding this information, please feel free to give me a call . _Sincetely, Ml— Doi gla Evans Vice President Employee Benefits DE:kf Enclosures 1210 PLAZA 600 BLDG. SEATTLE.WA 98101 (206)448-7878 ALLOWANCES, DEDUCTIBLES, COPAYMENTS, AND FEES The following Allowances, Deductibles, Copayments and Fees are subject to Pre-existing Conditions limitations as defined in the Medical Coverage Agreement. Outpatient Mental Health Care 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 out- patient mental health care. Alcoholism Allowance Benefit Period Allowance. .. . . . .. . ... ... ... ... . $5,000 maximum per Enrollee per any 24 consecutive calendar month period. Lifetime Maximum Benefit. .. . . . . . . .. .. . .... .... $10,000 per Enrollee. Emergency Copayment/Deductible . . . . .. . .. ... ... ... Emergency care at a GHC or GHC- Designated Facility is subject to a $25.00 Copayment amount per Emergency, payable by the Enrollee. Emergency care at a non-GHC Designated Facility is subject to a $100.00 Deductible amount per Emergency, payable by the Enrollee. Stop Loss... ...... ...... .... . . .. .. . . .. .. ... ... ... . Total out-of-pocket Copayment expenses for Emergency care at a GHC or GHC Designated Facility are limited to an aggreggate maximum of $750 per Enrollee and $1500 per family per calendar year. 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 Designated Facility are subject to a $50.00 Deductible amount per Emergency, payable by the Enrollee. "Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or mental handicaps in its employment practices or services." MASTERRENI Group CMP • Health Cooperative of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement It is understood and agreed that the definitions of Sections X. and XI. are deleted in their entirety and "Emergency" and "Service Area" set forth in Section I. of replaced with the following: the Group Medical Coverage Agreement are deleted in their entirety and replaced with the following: Section X. SCHEDULE OF BENEFITS EMERGENCY: The sudden, unexpected onset of a Subject to all provisions of this Group Medical medical condition that, in the reasonable opinion of Coverage Agreement, persons enrolled for Com- the Enrollee or person assuming responsibility for prebensive Health Care are entitled to receive the transporting the Enrollee, is of such a nature that services and benefits described in this Schedule. failure to render immediate care by a licensed medical provider would place the Enrollee's life in A. HOSPITAL CARE danger, or cause serious impairment to the Enrollee's Hospital Care is provided when approved by a GHC health. physician, including the following services: SERVICE AREA: King, Kitsap, Pierce, Snohomish, 1. Room and board, including private room when Thurston, and Whatcom Counties, and any other prescribed, and general nursing services. areas designated by GHC. 2. Hospital services (including use of operating room, anesthesia, oxygen, x-ray, laboratory, and Section I. is further modified to include the following: radiotherapy services). 3. Drugs and medication. ALLOWANCE: The maximum amount payable by GHC 4. Special duty nursing (when prescribed as for certain Covered Services under this Agreement, Medically Necessary). as set forth in the Dues and Fees Schedule. Personal comfort items, such as telephone and DEDUCTIBLE: A specific maximum amount paid by television, are not covered. an Enrollee for certain Covered Services before If an Enrollee is hospitalized in a non-GHC Facility, benefits are payable under this Agreement. The GHC reserves the right to require transfer of the applicable Deductible amounts are set forth in the Enrollee to a GHC Facility, upon consultation with a Dues and Fees Schedule. GHC physician. If the Enrollee refuses to transfer to a GHC Facility, all further costs incurred during the SKILLED HOME HEALTH CARE: Reasonable and hospitalization are the responsibility of the Enrollee. necessary care for the treatment of an illness or injury which requires the skill of a nurse or therapist, B. MEDICAL AND SURGICAL CARE based on the complexity of the service and the The following medical and surgical services are condition of the patient, and which is performed provided when prescribed by GHC Medical directly by an appropriately licensed professional Personnel: provider. 1. Surgical services. USUAL, CUSTOMARY, AND REASONABLE: A 2. Diagnostic x-ray, nuclear medicine, ultrasound, term used to define the level of benefits which are and laboratory services. payable by GHC when expenses are incurred from a 3• Eye examinations and refractions (except non-GHC physician or provider. Expenses are cosmetic contact lens examinations and fit- tings). When dispensed through GHC considered Usual, Customary, and Reasonable if (1) Facilities, one contact lens per diseased eye, the charges are consistent with those normally including exam and fitting, is covered for charged by the provider or organization for the same Enrollees following cataract surgery performed services or supplies; and (2) the charges are within by a GHC physician, provided the Enrollee has the general range of charges made by other providers been continuously covered by GHC since such in the same geographical area for the same services surgery and is not medically suited for an or supplies. I0127CNT.1 (04/87) intraocular lens as determined by a GHC 12. Radiation therapy services. physician. Replacement of a covered contact 13. Services related to dysfunction of th,� jaw: lens will be provided only when needed due to when referred by a GHC physician, evaluation change in the Enrollee's medical condition but and treatment at a GHC-approved temporoman- may be replaced only one time within any dibular joint (TMJ) care provider, and occlusal twelve (12) month period. splint fitting. 4. Family planning counseling services. All TMJ appliances, including the occlusal 5. Hearing examinations to determine hearing loss. splint and night guard, are excluded. Treatment 6. Blood derivatives and the administration of of jaw dysfunction, including TMJ dysfunction, blood and blood derivatives. The cost of blood will NOT be provided when the dysfunction is is not covered. related to malocclusion or when TMJ services 7. Maternity care, including care for complications are needed due to dental work performed. All of pregnancy, and pre- and post-natal visits. such services and related hospitalization, Hospitalization and delivery are provided, including orthodontic therapy, and orthognathic subject to payment of the Maternity Care Fee (jaw) surgery, are excluded, regardless of origin set forth in the Dues and Fees Schedule. The Maternity Care Fee must be paid in equal or cause. 14. The following services are covered by GHC monthly installments during the pre-natal when performed by a GHC physician or GHC period, with the final installment payable not later than thirty (30) days prior to expected date oral surgeon: reduction of a fracture or disloca- of birth. tion of the jaw or facial bones; excision of tumors or cysts of the jaw, cheeks, lips, tongue, Voluntary (not medically indicated and non- gums, roof and floor of the mouth; and incision therapeutic) termination of pregnancy will be of salivary glands and ducts. charged according to the Cooperative's Direc- 15. Non-experimental implants, limited to the tory of Services. following: cardiac devices, artificial joints, and 8. Transplants. When authorized as medically intraocular lenses. Artificial or mechanical appropriate by GHC's Medical Director or hearts are excluded. his/her designee and in accordance with criteria established by the Cooperative, limited to heart, C. ALCOHOLISM TREATMENT kidney, corneal. bone marrow, and liver Subject to all terms and conditions of this Agree- transplants for children under the age of ment, care is provided as set forth below at a GHC thirteen (13) with congenital biliary atresia. Facility, GHC Designated Facility, or GHC-approved Organ acquisition costs including applicable treatment facility meeting all requirements of RCW hospital and medical costs of the donor are not 70.96A.010, et. seq., subject to the Benefit Period covered. Allowance and Lifetime Maximum Benefit as described below and as shown in the Dues and Fees Coverage for heart and liver transplants and/or Schedule. any related services, items, and drugs shall be 1. Alcoholism Treatment Services. excluded until such time as the Enrollee has a. All alcoholism treatment services must be been continuously enrolled under this Agree- provided at a facility as described above ment, or under this Agreement in combination and must be authorized in advance, except with any prior GHC Medical Coverage Agree- for acute alcohol withdrawal as described in ment for twelve (12) consecutive months Section X.C.2.b., and deemed Medically without any lapse in coverage. Necessary by GHC's ADAPT Director or 9. Physician visits (including consultations and his/her designee. Alcoholism treatment second opinions by a GHC physician) in the may include the following services received hospital or office. on an inpatient or outpatient basis: diag- 10. Physical therapy; occupational therapy; nostic evaluation and education, organized respiratory therapy; and speech therapy to individual and group counseling, detoxifica- restore speech following severe illness, injury, tion services, and prescription drugs and or surgery. medicines. 11. Preventive services for health maintenance b. Court-ordered treatment shall be provided including physical examinations for detection only if determined to be Medically of disease or other conditions, and im- Necessary by GHC's ADAPT Director or munizations and vaccinations which are listed his/her designee. as covered in the GHC Drug Formulary. A fee 2. Emergency Care. may be charged for health education programs. a. Coverage for medical emergencies incident I0127CNT.2 (04/87) to the abuse of alcohol is subject to the exceed the Benefit Period Allowance shown Emergency care benefit as set forth in in the Dues and Fees Schedule during the Section X.J. Enrollee's Benefit Period. b. Coverage for acute alcohol withdrawal is Any Deductibles or Copayments which may provided without prior approval. If an be borne by the Enrollee under the terms of Enrollee is hospitalized in a non-GHC this Agreement shall not be applied toward Designated Facility, coverage is subject to the Benefit Period Allowance. payment of the Deductible shown in the 4. Lifetime Maximum Benefit. Dues and Fees Schedule, and notification of Alcoholism services are not covered after the GHC by way of the GHC Notification Line Enrollee has reached his/her Lifetime Maximum immediately upon inpatient admission, or as Benefit amount as shown in the Dues and Fees soon thereafter as practicable, but in no Schedule. All alcoholism benefits provided or event more than twenty-four (24) hours payments made by following admission. Furthermore, if an a. GHC under any GHC Group Medical Enrollee is hospitalized in a non-GHC Coverage Agreement, plus Designated Facility, GHC reserves the right b. all amounts paid on an individual's behalf to require transfer of the Enrollee to a GHC under any carrier or plan maintained by the Facility upon consultation with a GHC group, including self-insured plans, physician. If the Enrollee refuses transfer shall be applied toward this Lifetime Maximum to a GHC Facility, all further costs incurred Benefit amount. during the hospitalization are the responsi- bility of the Enrollee. In regard to this section, the Benefit Period(s), For the purpose of this section, "acute Benefit Period Allowance(s), and Lifetime Maximum alcohol withdrawal" means withdrawal of Benefit shall include only services received on or alcohol from a person for whom con- after January 1, 1987. sequences of abstinence are so severe as to require medical/nursing assistance in a D. DRUG ABUSE/ADDICTION hospital setting and which are needed 1. Outpatient services at a GHC Facility include immediately to prevent serious impairment diagnostic evaluation, education, and counsel- to the Enrollee's health. ing. Inpatient drug treatment programs and 3. Benefit Period and Benefit Period Allowance. services related to detoxification are excluded. a. Benefit Period. For the purpose of this 2. Medical treatment (inpatient or outpatient) is section, "Benefit Period" shall mean a provided at GHC for conditions which are a twenty-four (24) consecutive calendar direct result of drug abuse/addiction. month period during which the Enrollee is 3. Emergency care is provided according to the eligible to receive covered alcoholism provisions of Section X.J. treatment services as set forth in this section. The first Benefit Period shall E. PLASTIC AND RECONSTRUCTIVE SERVICES begin on the first day the Enrollee receives will be provided: covered alcoholism services under this or 1. to correct a functional disorder, as determined any other group insurance, health care by a GHC physician, resulting from a congeni- service contractor, health maintenance tal disease or anomaly; or organization, self-insured plan or any 2. to correct a medical condition following an combination thereof, hereinafter referred to injury or incidental to surgery covered by GHC, as "group plans," and shall continue for provided the Enrollee has been continuously twenty-four (24) consecutive calendar covered at GHC since such injury or surgery. months provided that coverage under this 3. Reconstructive surgery and associated proce- Agreement remains in force. All sub- dures following a mastectomy will be covered sequent Benefit Periods thereafter will for Enrollees who are medically suitable begin on the first day Covered Services are candidates, as determined by GHC's Medical received after expiration of the previous Director or his/her designee. Internal breast twenty-four(24) month Benefit Period. prostheses required incident to the surgery will b. Benefit Period Allowance. The maximum be provided. allowance available for any Benefit Period 4. An Enrollee will be covered for all stages of shall be the total of all alcoholism benefits one reconstructive breast reduction on the provided and payments made for alcoholism nondiseased breast to make it equivalent in size treatment under any group plan(s), not to with the diseased breast after definitive re- 10127CNT.3 (04/87) constructive surgery on the diseased breast has care provided by or for a member of the patient's been performed, family, and any other services not listed specifically as covered when rendered in the home under this F. APPLIANCES which are Medically Necessary, Agreement. limited to the following: ostomy supplies; temporary orthopedic appliances for use during treatment up to I. MENTAL HEALTH CARE SERVICES, limited to a maximum of six (6) months; and on Referral, the following, are provided on an outpatient basis at oxygen and oxygen equipment for home use. GHC when determined to be Medically Necessary by GHC's Mental Health Service. Crisis intervention G. DRUGS AND MEDICINES FOR OUTPATIENT and brief focal psychotherapy will be provided in the USE as prescribed by a GHC physician for condi- following areas: individual and group therapy, tions covered by this Agreement. All drugs, sup- couple therapy, child and family counseling, chronic plies, medicines and devices must be obtained at a intermittent care, and consultation services. GHC pharmacy. Coverage for each Enrollee is provided according to Excluded are: dietary supplements (except the Outpatient Mental Health Care Allowance shown therapeutic vitamins for use up to thirty [301 days); in the Dues and Fees Schedule. outpatient mental health drugs; contraceptive drugs Excluded are: psychoanalysis; extensive and devices and their fitting; medicines and injec- psychotherapy; treatment of sexual disorders and/or tions for anticipated illness while traveling; and any dysfunctions; psychological testing unless prescribed other drugs, medicines, and injections not listed as by GHC's Mental Health Service; day treatment; covered in the GHC Drug Formulary (approved drug specialty programs for mental health therapy which list). are not provided by GHC; court-ordered treatment The Enrollee will be charged for mailing or replacing not specifically described above; and hospitalization and related inpatient or custodial care for the lost or stolen drugs, medicines or devices. diagnosis or treatment of mental illness. H. HOME HEALTH CARE SERVICES, as set forth in J. EMERGENCY CARE this section, shall be provided by GHC Home Health 1. At a GHC Facility or GHC Designated Services or by a GHC-authorized home health agency Facility. GHC will cover Emergency care for when Referred in advance by a GHC physician for all Covered Services. Enrollees who meet the following criteria: 2. At a Non-GHC Designated Facility. Usual, 1. The Enrollee is unable to leave home due to his Customary, and Reasonable charges for Emer- or her health problem or illness (unwillingness gency care for Covered Services are covered to travel and/or arrange for transportation does subject to: not constitute inability to leave the home); a. payment of the Emergency Deductible 2. the Enrollee requires intermittent Skilled Home Health Care services, as described below; and shown in the Dues and Fees Schedule; 3. a GHC physician has determined that such and services are Medically Necessary and are most b. notification of GHC by way of the GHC appropriately rendered in the Enrollee's home. Notification Line immediately upon Covered Services for home health care may include inpatient admission, or as soon thereafter the following when prescribed by a GHC physician as practicable, but in no event more than and when rendered pursuant to an approved home twenty-four (24) hours following health care plan of treatment: nursing care, physical admission. therapy, occupational therapy, respiratory therapy, restorative speech therapy, and medical social worker If two or more members of a Family Unit and limited home health aide services. Home health require Emergency care as a result of the same services are provided on an intermittent basis in the accident, only one Emergency Deductible will Enrollee's home. "Intermittent" means care that is to apply. be rendered because of a medically predictable Outpatient medications prescribed by a non- recurring need for Skilled Home Health Care services. GHC physician are excluded. 3. Transfer and Follow-up Care. If an Enrollee Excluded are: custodial care and maintenance care, is hospitalized in a non-GHC Facility, GHC private duty or continuous nursing care in the reserves the right to require transfer of the Enrollee's home, housekeeping or meal services, care Enrollee to a GHC Facility, upon consultation in any nursing home or convalescent facility, any with a GHC physician. If the Enrollee refuses I0127CNT.4 (04/87) to transfer to a GHC Facility, all further costs c. the Enrollee has elected in writing to incurred during the hospitalization are the receive hospice care through GHC's responsibility of the Enrollee. Hospice Program; Follow-up care which is a direct result of the d. the Enrollee has available a primary care Emergency must be obtained at GHC, unless a person who will be responsible for the GHC physician has authorized such care in Enrollee's home care; and advance. e. a GHC physician and GHC's Hospice Director determine that the Enrollee's K. AMBULANCE SERVICES are covered as set forth illness can be appropriately managed in the below, provided that the service is authorized in home. advance by a GHC physician or meets the definition 2. Hospice Care shall be defined as a coordinated of an Emergency. (See Section I.) program of palliative and supportive care for 1. Emergency Transport to a GHC Facility or dying persons by an interdisciplinary team of GHC Designated Facility. Each Emergency is professionals and volunteers centering primarily in the Enrollees home. covered as set forth in the Dues and Fees 3. Covered Services. Hospice Services may Schedule. include the following as prescribed by a GHC 2. Emergency Transport to a Non-GHC Desig- physician and rendered pursuant to an approved nated Facility. Each Emergency is covered as hospice plan of treatment: set forth in the Dues and Fees Schedule. a. Home Services 3. Waiver of Ambulance Services Deductible. If i. Intermittent care by a hospice inter- two or more members of the Family Unit disciplinary team which may include require Emergency ambulance transport as a services by a physician, nurse, medical result of the same accident, only one Am- social worker, physical therapist, bulance Deductible will apply. speech pathologist, occupational The Ambulance Deductible will not apply when therapist, respiratory therapist, and ambulance service is authorized in advance by limited services by a Home Health Aide the Cooperative. under the supervision of a Registered 4. Transfer to a GHC Facility. When authorized Nurse. in advance by the Cooperative, an additional ii. One period of continuous care service Ambulance Allowance is provided for transfer per Enrollee in the Enrollee's home to a GHC Facility. when prescribed by a GHC physician, as set forth in this paragraph. A L. HOSPICE continuous care period is defined as It is understood and agreed that the following fully "skilled nursing care provided in the sets forth the eligibility requirements and Covered home during a period of crisis in order Services for an Enrollee who wishes to elect to to maintain the terminally ill patient at receive services through GHC's Hospice Program. home." Continuous care may be Enrollees who elect to receive GHC Hospice provided for pain or symptom manage- Services do so in lieu of curative treatment for ment by a Registered Nurse, Licensed Practical Nurse, or Home Health Aide their terminal illness for the period that they are under the supervision of a Registered in the GHC Hospice Program. Nurse. Continuous care is provided for four (4) or more hours per day for a Hospice Program period not to exceed five (5) days, or a 1. Eligibility. Hospice Services, as set forth total of seventy-two (72) hours, below, shall be provided to Enrollees for as whichever first occurs. Continuous long as the following criteria are met: care is covered only when a GHC physician determines that the Enrollee a. A GHC physician has determined that the would otherwise require hospitalization Enrollee's illness is terminal and life in an acute care facility. expectancy is six (6) months or less; b. Inpatient Hospice Services shall be b. the Enrollee has chosen a palliative treat- provided in a facility designated by GHC's ment focus (emphasizing comfort and Hospice Program when Medically supportive services rather than treatment Necessary and authorized in advance by a aimed at curing the Enrollee's terminal GHC physician and GHC's Hospice illness); Program. Inpatient Hospice Services shall I0127CNT.S (04l87) be provided according to the provisions set 7. Durable medical equipment such as hospital forth in Section X. of this Agreement. beds, wheelchairs, and walk-aids, except while 4. Hospice Exclusions: All services not spe- in the hospital. cifically listed as covered in this section, 8. Inpatient drug treatment programs; services including, but not limited to: related to detoxification; and outpatient drug a. Financial or legal counseling services. addiction, except as specifically stated in b. Housekeeping or meals services. Section X.D. c. Custodial or maintenance care in the home 9. Services covered by employment or government or on an inpatient basis. programs: d. Services not specifically listed as covered a. Any illness, condition or injury for which by this Medical Coverage Agreement. benefits are available, or could be available, e. Any services provided by members of the through application for coverage under any patient's family. federal or state workers' compensation or f. All other exclusions listed in Section XI., industrial insurance law or employer's Exclusions and Limitations, of this Medical liability contract or insurance. It is ex- Coverage Agreement, apply. pressly understood that this Agreement is NOT to serve as private industrial in- Section XI. EXCLUSIONS AND LIMITATIONS surance, or a self-insured plan maintained by the employer. A. Exclusions b. Any federal, state, county, municipal, or 1. Blood for transfusions. other governmental agency, including in the 2. Except as provided in Sections X.E., X.F., and case of service-connected disabifities, the X.G., corrective appliances and artificial aids, Veterans Administration. including but not limited to: eyeglasses; cosmetic contact lenses including examinations GHC reserves all rights to reimbursement and fittings; prosthetic devices; diabetic provided by any of the above-described laws, supplies including insulin pumps; hearing aids private industrial insurance, self-insured plans, and examinations in connection therewith; arch or governmental agencies. supports or corrective shoes; take-home dressings and supplies following hospi- Services will be provided under this Agreement: talization; or any other supplies, dressings, a. if there is reasonable doubt whether an appliances, devices or services which are not Enrollee should receive benefits under this for the specific treatment of disease or injury. Agreement or from another source; and 3. Cosmetic services, including treatment for b. if the Enrollee actively seeks to establish complications of cosmetic surgery, except as his/her rights to benefits from that source. provided in Section X.E. 10. Those parts of an examination and associated 4. Dental care, surgery, services, and appliances, reports required for employment, immigration, including but not limited to: treatment of license, or insurance purposes that are not accidental injury to natural teeth, reconstructive deemed Medically Necessary by GHC for early surgery to the jaw incident to denture wear, and detection of disease. periodental surgery. The Cooperative's 11. Investigational procedures, including medical Medical Director, or his/her designee, will and surgical services, drugs, and devices until determine whether the care or treatment approved by GHC. required is within the category of dental care or 12. Non-therapeutic sterilization; and procedures service. and services to reverse a therapeutic or non- If a GHC physician determines that an unrelated therapeutic sterilization. medical condition requires that an Enrollee be 0. Pre-existing Conditions shall be excluded from hospitalized for a dental procedure which is coverage until such time as the Enrollee has normally done in a dentist's office, GHC will been continuously covered under this Agree- cover associated hospital and anesthesia costs at ment or a prior GHC Individual and Family, a GHC or GHC Designated facility. GHC will Group, or Group Conversion Agreement for not cover the dentist's or oral surgeon's fees. twelve (12) months. 5. Certain drugs and medicines. (See Section 14. Mental health care, except as specifically X.G.) Any exclusion of drugs and medicines provided in Section X.I. will also exclude their administration. 15. Procedures, services, and supplies related to sex 6. Convalescent or custodial care, including transformations. skilled nursing facility care. 10127CNT.6 (04/87) 16. Regardless of origin or cause, diagnostic testing diagnostic plan to the extent permitted by law. and medical treatment of sterility, infertility, In such case, GHC shall have no further impotency, and frigidity. obligation to provide the care in question. 17. Services of practitioners whose licensing Enrollees who seek other sources of care category is not represented by GHC Medical because of such a disagreement do so with the Personnel. full understanding that GHC has no obligation 18. Surgery directly related to obesity. for the cost, or liability for the outcome, of such 19. Any services for which an Enrollee has a care. contractual right to recover the cost thereof, 3. Major Disaster or Epidemic. In the event of a whether a claim is asserted or not, under major disaster or epidemic, GHC Medical automobile medical, personal injury protection, Personnel will provide Covered Services uninsured or underinsured motorist, home according to their best judgment, within the owner's or other first party coverage, except for limitations of available facilities and personnel. individual health insurance. The Cooperative has no liability for delay or 20. Services or supplies not specifically listed as failure to provide or arrange Covered Services covered in the Schedule of Benefits. to the extent facilities or personnel are unavail- 21. Voluntary (not medically indicated and non- able due to a major disaster or epidemic. therapeutic) termination of pregnancy. 4. Unusual Circumstances. If the provision of 22. The cost of services and supplies resulting from Covered Services is delayed or rendered an Enrollee's loss of or willful damage to impossible due to unusual circumstances such covered appliances, devices, supplies, and as complete or partial destruction of facilities, materials provided by GHC for the treatment of military action, civil disorder, labor disputes, or disease, injury, or illness. similar causes, GHC shall make a good faith 23. Routine circumcision, including newborn effort to provide such services through its circumcision, which is not considered Medi- then-existing facilities and personnel. In no cally Necessary. case shall the Cooperative have any liability or obligation on account of delay or failure to B. Limitations provide or arrange such services. 1. Conditions and Extent of Coverage. ALL SERVICES AND BENEFITS UNDER THIS It is further understood and agreed that Section XII. is AGREEMENT MUST BE PROVIDED BY GHC deleted in its entirety and replaced with the following: MEDICAL PERSONNEL AT A GHC FACILITY UNLESS: Section XII. CLAIMS a. The Enrollee has received a Referral from a GHC physician. Enrollees must submit claims for reimbursement of b. The Enrollee has received Emergency Covered Services to GHC within sixty (60) days of the services according to Section X.J. service date, or as soon thereafter as is reasonably 2. Recommended Treatment. The Cooperative's possible. In no event, except in the absence of legal Medical Director or his/her designee will capacity, shall a claim be accepted later than one (1) year determine the necessity, nature, and extent of from the service date. This section applies to Covered treatment to be provided in each individual case Services received under Section X.J. and X.K., or and the judgment, made in good faith, will be services for which the Enrollee has received a Referral final. from a GHC physician. Enrollees have the right to participate in All other provisions of the Group Medical Coverage decisions regarding their health care. An Agreement shall remain in full force and effect. Enrollee may refuse recommended treatment or I0127CNT.7 (04/87) Group Continuation Coverage, ° Health Conversion, and Transfer 0 Cooperative of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement Section IV. is retitled Continuation Coverage, Conver- if an unmarried dependent child ceases to sion, and Transfer, and is modified to include the qualify as a Family Dependent under following as the new subsection A. The current subsec- Section IX.B.2.(b) or (c). tions A., B., and C. are renumbered B., C., and D. accordingly. 3. If an individual enrolled for continuation coverage experiences a second qualifying event A. Continuation Coverage as set forth in subsection (2.) above, continua- tion coverage may be extended for up to Subsection A. only applies to employer groups thirty-six (36) months, beginning from the date who must offer continuation coverage under the of the first qualifying event. applicable provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986, as 4. In addition to the conditions set forth in Section amended, and only applies to the extent re- III. Termination, continuation coverage may be quired by Federal law. terminated prior to the prescribed period set forth in subsections (1.) and (2.) above if: To the extent required by Federal law, if the Subscriber There is a failure to make timely payment or Family Dependent loses eligibility under this Group of any monthly dues required under this Agreement, group coverage may be continued under the circumstances described below. Except for enrollment of Agreement; newborns as set forth in Section IX.A.l., this provision ° the Enrollee becomes covered under any applies only to Subscribers and Family Dependents other group health plan; enrolled under this Agreement prior to the date of the Enrollee becomes eligible to enroll eligibility for continuation coverage, as described below under Medicare whether he or she enrolls or in subsections 1. and 2. not. 1. Subscribers and Family Dependents are eligible 5. Notice for continuation coverage for a period of up to The Group is responsible for assuring that eighteen (18) months if: Enrollees are given timely notice of their o The Subscriber's employment is terminated continuation coverage option. The Group is (unless terminated for gross misconduct); or also responsible for notifying GHC of the o the Subscriber loses eligibility as the result election to continue coverage and the applicable of a reduction in work hours. coverage period (eighteen [18] or thirty-six [361 months). 2. Family Dependents are eligible for continuation The Subscriber or Family Dependent must coverage for a period of up to thirty-six (36) months under the circumstances described notify the Group, or plan administrator, if any, below: within sixty (60) days of a divorce, legal separation, or when an enrolled dependent child Following the Subscriber's divorce or legal no longer meets the eligibility requirements set separation; or forth in Section IX.B.2. o following the Subscriber's death; or if the Subscriber becomes entitled to 6. Application Medicare and the non-Medicare eligible Written application for continuation coverage Family Dependent as a result would be must be made within sixty (60) days of the ineligible under this Agreement; or termination date of coverage or the date the CA-50 I0169CNT (01/87) V Enrollee receives specific notice of his/her right Plan if his/her coverage under this Agreement is to continuation coverage. No lapse in coverage terminated for any reason other than non- prior to continuation coverage is permitted. payment or cause. See Section IV.B.2. GHC The applicaton shall be deemed by GHC to Group Conversion Plan - Application. include all Family Dependents eligible for continuation coverage unless specifically stated It is further understood and agreed that Section otherwise. A physical examination or statement III.B.1. is deleted in its entirety and replaced with of health is not required. the following: 7. Monthly Dues 1. Loss of Eligibility. If an Enrollee no longer Monthly dues must be paid directly to the meets the eligibility requirements set forth in Group. The Group is responsible for submitting Section IX.B. and is not enrolled for continua- such dues with its regular monthly dues tion coverage as described in Section IV.A., payment to GHC. coverage under this Agreement will terminate at the end of the month during which loss of 8. Group Conversion eligibility occurs. Within a 180-day period prior to termination of continuation coverage, the Subscriber or Family All other provisions of Sections III., IV., and IX. Dependent enrolled for continuation coverage is shall remain in full force and effect. entitled to convert to GHC's Group Conversion CA-50 I0169CNT (01/87) Group Health . �� Coordination of Benefits of Puget Sound Contract Attachment For Attachment to Group Medical Coverage Agreement It is understood and agreed that the following fully C. Allowable Expense: sets forth the provisions outlined in Section V., "Allowable Expense" means any necessary, "Coordination of Benefits." reasonable and customary items of expense at least a portion of which is covered under at least COORDINATION OF BENEFITS one of the Plans covering the person for whom the claim is made. When a Plan provides A. Benefits Subject to This Provision: benefits in the form of services rather than cash All of the benefits provided under this payments, the reasonable cash value of each Agreement are subject to this provision. service rendered shall be considered as both an Allowable Expense and a benefit paid. B. Plan: The definition of a "Plan" includes the following D. Claim Determination Period: sources of benefits or services: "Claim Determination Period" means a period 1. Group or blanket disability insurance beginning with any January 1 and ending with policies and health care service contractor the next following December 31 except that the and health maintenance organization group first Claim Determination Period with respect to agreements, issued by insurers, health care any person shall begin on the effective date of service contractors and health maintenance coverage under this Agreement with respect to organizations; such person and end on the following December 2. Labor-management trusteed plans, labor 31. In no event will a Claim Determination organization plans, employer organization Period for any person extend beyond the last day plans or employee benefit organization on which such a person is covered under this plans; Agreement. 3. Governmental programs; and 4. Coverage required or provided by any E. Right to Receive and Release Information: statute. For the purpose of determining the applicability The term "Plan" shall be construed separ- of and implementing this provision and any ately with respect to each policy, agreement provision of similar purpose in any other Plan, or other arrangement for benefits or services, the Cooperative may, with such consent as may and separately with respect to the respective be necessary, release to or obtain from any other portions of any such policy, agreement or insurer, organization or person any information, other arrangement which do and which do with respect to any person which the insurer not reserve the right to take the benefits or considers necessary for such purpose. Any services of other policies, agreements or person claiming benefits under this Agreement other arrangements into consideration in shall furnish to the Cooperative the information determining benefits. necessary for such purpose. PA-868,CA-65 I0046CNT.1,(12J86) F. Facility of Payment: Expenses incurred as to such person during Whenever coverage which should have been such Claim Determination Period shall.be provided under this Agreement in accordance reduced to the extent necessary so that the with this provision has been provided or paid for sum of the reasonable cash value of benefits under any other Plan, the Cooperative shall have and all benefits payable for such Allowable the right, exercisable alone and in its sole Expenses under all other Plans, except as discretion, to pay over to any Plan making such provided in subparagraph (3) of this Section, other payments any amounts it shall determine to shall not exceed the total of such Allowable be warranted in order to satisfy the intent of this Expenses. Benefits payable under another provision, and amounts so paid shall be Plan include benefits that would have been considered to be coverage or benefits paid under payable had a claim been duly made this Agreement and, to the extent of such therefore. payments, the Cooperative shall be fully 3. If discharged from liability under this Agreement. a. another Plan which is involved in subparagraph (2) of this Section and G. Right of Recovery: which contains a provision coordinating Whenever benefits have been provided by the its benefits with those of this Agreement Cooperative with respect to Allowable Expenses would, according to its rules, determine in total amount, at any time, in excess of the its benefits after the benefits of this Plan maximum amount of payment necessary at that have been determined, and time to satisfy the intent of this provision, the b. the rules set forth in subparagraph (4) of Cooperative shall have the right to recover the this Section would require this reasonable cash value of such benefits, to the Agreement to determine its benefits extent of such excess, from one or more of the before such other Plan then the benefits following, as the Cooperative shall determine: of such other Plan will be ignored for any persons to or for or with respect to whom the purposes of determining the benefits such benefits were provided, any other insurers, under this Agreement. any service plans or any other organization or 4. For the purposes of subparagraph (3) of this other Plans. Section, the rules establishing the order of benefit determination are: H. Effect on Benefits: a. The benefits of a Plan which covers the 1. This provision shall apply in determining the person on whose expenses a claim is benefits for a person covered under this based other than as a dependent shall be Agreement for a particular Claim determined before the benefits of a Plan Determination Period if, for the Allowable which covers such person as a Expenses incurred as to such person during dependent. such period, the sum of: b. In the case that a dependent is covered a. The reasonable cash value of the under both parents' medical Plan, the benefits that would be provided under benefits of the Plan of the parent whose the Agreement in the absence of this birthday falls earlier in the year are provision, and determined before those of the Plan of a b. The benefits that would be payable parent whose birthday falls later in the under all other Plans in the absence year. This birthdate will refer only to therein or provisions of similar purpose the month and day, not the year in which to this provision would exceed such a person was born. If both parents have Allowable Expenses. the same birthday, the benefits of the 2. As to any Claim Determination Period with Plan which covered the parent longer are respect to which this provision is applicable, determined before those that covered the the reasonable cash value of the benefits other parent for a shorter period of time, provided under this Agreement in the except that in the case of a person for absence of this provision for the Allowable whom claim is made as a dependent PA-868,CA-65 I0046CNT.2, (12/86) child, i. when the parents are separated or C. When rules (a) and (b) do not establish an order of benefit determination, the divorced and the parent with custody benefits of a Plan which has covered the of the child has not remarried, the person on whose expenses claim is based benefits of a Plan which covers the for the longer period of time shall be child as a dependent of the parent determined before the benefits of a Plan with custody of the child will be which has covered such person the determined before the benefits of a shorter period of time, provided that: Plan which covers the child as a i. The benefits of a plan covering the dependent of the parent without custody; and person on whose expenses claim is ii. when the parents are divorced and based as a laid off or retired the parent with custody of the child employee, or dependent of such has remarried, the benefits of a Plan person shall be determined after the benefits of any other Plan covering which covers the child as a de- such person as an employee, other pendent of the parent with custody than a laid off or retired employee, shall be determined before the benefits of a Plan which covers that or dependent of such person; and ii. If either plan does not have a child as a dependent of the step- provision regarding laid off or parent, and the benefits of a Plan retired employees, which results in which covers t child as a that dependent of the ha each Plan determining its benefits pparent will be after the other, then the provisions determined before the benefits of a Plan which covers that child as a apply. (i) of this subsection shall not dependent of the parent without apply. custody. 5• When this provision operates to reduce Notwithstanding y. items the total amount of benefits otherwise to (i) and (ii) above, be provided to a person covered under if there is a court decree which would otherwise establish financial responsibil- this Agreement during any Claim Determination Period, the reasonable ity for the medical, dental or other cash value of each benefit that would be health care expenses with respect to the Provided in the absence of this provision child, the benefits of a Plan which covers the child as a dependent of the shall be reduced proportionately, and such reduced amount shall be charged parent with such financial responsibility against any applicable benefit limit of shall be determined before the benefits of any other Plan which cover the child this Agreement. as a dependent child. PA-868,CA-65 10046CNT.3, (12/86) . Group • Health Emergency Department " Cooperative Copayment 14 of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement It is understood and agreed that Section I. of the Total out-of-pocket Copayment expenses Group Medical Coverage Agreement is modified to incurred during the same calendar year shall not include the following: exceed the aggregate maximum amount as set forth in the Dues and Fees Schedule. COPAYMENT: A fee charged by GHC to an Enrollee for certain Covered Services under this If Copayments have been billed, any applicable Agreement, as set forth in the Dues and Fees billing fees shall not be considered in calculat- Schedule. ing total out-of-pocket expenses for Copayments made. Section II.B. is deleted in its entirety and replaced with the following: Section III.B.2. is modified to include the following: B. Subscriber's Liability. The Subscriber is liable 2. For Cause. Coverage of an Enrollee may for (1) payment to the Group of his/her contribu- be terminated upon written notice for: tion toward the monthly dues, if any; (2) payment to the Cooperative of Copayments for Non-payment of charges as set forth in Covered Services provided to the Subscriber and Section II.B. his/her Family Dependents, as set forth in the Dues and Fees Schedule; and (3) payment to the Section X.J.1. is deleted and replaced with the Cooperative of any fees charged for non- following: Covered Services provided to the Subscriber and his/her Family Dependents. J. Emergency Care Section II. is further modified to include the 1. At a GHC Facility or GHC Designated following: Facility. GHC will cover Emergency care D. Copayments. At the time of service, Enrollees for all Covered Services subject to payment shall be required to pay Copayments as set forth of the Copayment set forth in the Dues and in the Dues and Fees Schedule. Failure to pay Fees Schedule. Copayments at the time of service may result in If two or more members of the Family Unit a billing fee. require Emergency care as a result of the Payment of a Copayment does not exclude the same accident, only one Emergency Care possibility of an additional billing if the service Copayment will apply. is determined to be a non-Covered Service. All other provisions of the Group Medical Coverage Agreement shall remain in full force and effect. ER-CP CA-7 (04/87) I0086CNT Group Health Maternity Care Cooperative of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement It is understood and agreed that Section X.B.7. of the Group Medical Coverage Agreement is deleted in its entirety and replaced with the following: The Cooperative shall provide maternity care, including care for complications of pregnancy; pre- and post-natal visits; and voluntary termination of pregnancy. It is further understood and agreed that Sec- tion XI.A.21 is deleted in its entirety. Voluntary termination of pregnancy shall be covered. All other provisions of Sections X.B. and XI.A. remain in full force and effect. MT-A, AB-A CA-66 (01/87) I0213CNT C� i Group Health Pre-Existing Conditions Cooperative of Puget Sound Contract Endorsement For Attachment to Group Medical Coverage Agreement It is understood and agreed that Section XI.A.13. of the Group Medical Coverage Agreement is deleted in its entirety. Except as provided under Section X.B.8., Pre-existing Conditions shall be covered in the same manner as any other illness. All other provisions of Section XI.A. shall re- main in full force and effect. PC-A CA-18 (01/87) I0136CNT