HomeMy WebLinkAboutHR1987-0086 - Original - Blue Cross of Washington and Alaska - Group Health Care Contract - 01/01/1987 weBlue Cross.
of Washington and Aiaska
BLUE CROSS OF WASHINGTON AND ALASKA
15700 Dayton Avenue North
P. 0. Box 327
Seattle, Washington 98111
APPLICATION "
for
6ROup HEALTH CAR$ CONTRACT
Application is hereby made to Blue Cross of Washington and Alaska for a Group
Health Care Contract in the form attached
classesrofoEmployees provisions
defined in which
theare
to be made available to all eligible
Eligibility provisions of this Contract.
The Applicant, in the event this Application is accepted and the Group Health
Care Contract is issued, agrees to the methods and practices outlined in the
Contract relative to submission of monthly Subscription Charges and
information as may be required for the Blue Cross of Washington and Alaska to
adequately administer its obligations.
Coverage under the Contract shall be effective at 12:01 a.m. , on the first
day of January, 1987, in Seattle, Washington, and such coverage shall continue
until terminated in accordance With the Contract.
The Applicant agrees to promptly deliver to all covered employees the
individual identification cards, descriptive booklets or notifications or
modifications thereto, received from Blue Cross of Washington and Alaska.
CITY OF KENT
Applicant's (Applicant)
Address
220 4th Avenue South
Kent, Washington 98032 By
Title:
By
Title:
March 23 1987 By
(Date)
Title:
Contract No. 828-01 -02, -04
P.O. Box 327, Seattle, Washington 98111 206!361 3000
Blue Cross
•�' o?Washington and A'iaska
t
BLUE CROSS OF WASHINGTON AND ALASKA
In response to the Application made by
i,
CITY OF KENT
(Called the Group in this Contract)
a copy of which is attached and made part of this Contract and in
consideration of the advance payment of the Subscription Charges made by the
Group,
BLUE CROSS OF WASHINGTON AND ALASKA AGREES TO PROVIDE
the benefits described in this Contract for the term of this Contract, as
stated in Part Nine, beginning at 12:01 a.m. , in Seattle, Washington on
January 1, 1987.
This Contract is entered into and delivered in the State of Washington,
and is governed by the laws of that State, subject to the conditions specified
on the following pages. This Contract is effective only when signed by the
Blue Cross of Washington and Alaska signatory whose name appears below.
Any existing Health Contract or Agreement between the Group and us which is
being replaced by this Contract is cancelled when this one becomes effective.
Patrick C. Connolly
Executive Vice President
Marketing
Date March 23, 1987
Contract No. 828-01. -02, -04
P.O. Box 327, Seattle, Washington 98111 206;'361 3000
SUP24ARY OF CONTENTS
Page
PART ONE DEFINITIONS . . . . . . . . . . . . . . . . . 2
PART TWO COVERAGE: ELIGIBILITY, TERMINATION . 11
AND CONTINUATION
PART THREE PROVISIONS THAT AFFECT BENEFITS . . . . . . . 20
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS. . 22
UNDER THIS CONTRACT
PART FIVE BENEFITS. . . . . . . . . . . . . . . . . . . 25
PART SIR EXCLUSIONS AND EXCEPTIONS . . . . . . . . . . 76
PART SEVEN BENEFITS AFTER TERMINATION. . . . . . . . . . 90
PART EIGHT GENERAL PROVISIONS. . . . . . . . . . . . . . 92
PART NINE EMPLOYER INFORMATION. . . . . . . . . . . . . 94
- 1 -
PART ONE DEFINITIONS
1.1 Definitions
As used in this Contract, any word or term listed helow has the meaning listed
after it.
ACCIDENTAL BODILY INJURY - or injury, means physical harm or disability
sustained by the Member which is the direct result of an
accident, independent of disease or bodily infirmity or
any other cause. The accidental bodily injury must have
occurred at an identifiable time and place. Accidental
bodily injuries do not include illness or infection, except
infection of a cut or wound resulting from an accident.
APPROVED HOME HEALTH AGENCY - A private or public agency or organization that
administers and provides Home Health Care and is certified
by the Department of Social and Health Services or
approved by Medicare as a Home Health Care Agency.
APPROVED HOSPICE - A private or public agency or organization that administers
and provides hospice care and is certified by the
Department of Social and Health Services or approved by
Medicare as a hospice agency.
APPROVED TREATMENT FACILITY - A facility approved in the State of Washington
pursuant to RCW 70.96A. or RCW 69.54. , in the State of
Alaska pursuant to AS 47.37. , or an approved facility in
any other state in accordance with the licensing or
certification requirements in the jurisdiction where
services are rendered which provides an organized program
of treatment for Chemical Dependency.
BASIC BENEFITS - All benefits of this Contract, except Major Medical.
BLUE CROSS PLAN - An approved Blue Cross Plan licensed in the States of
Washington and Alaska.
BLUE CROSS OF WASHINGTON AND ALASKA - An approved Blue Cross Plan licensed in
the States of Washington and Alaska.
CALENDAR YEAR - A period of twelve (12) consecutive months beginning on
January 1 and ending on December 31 of a given year.
CHEMICAL DEPENDENCY - An illness diagnosed as alcohol and/or drug dependency,
whether physical or psychological or both, which is
characterized by a pattern of pathological use to the
extent that the user's health is substantially impaired or
endangered or his social or economic function is
substantially disrupted. It does not include alcohol or
drug abuse unless it is characterized by an habitual lack
of self-control in regard to the use or consumption of
alcohol or drugs, or any dependence on tobacco, tobacco
products, caffeine or foods.
- 2 -
PART ONE DEFINITIONS
1.1 Definitions . (continued)
CLAIM - A form obtained from us which the Subscriber or
(Proof of Loss) physician or other provider completes and submits to us
along with a copy of the itemized billing containing at
least the following information:
Name of the Subscriber;
Name of the patient;
Subscriber Identification Number;
Name and tax number of the physician or provider;
Other insurance information;
Diagnosis or ICDA code;
Itemized charges of the services rendered; and
If an accident, the date, time, location and brief
description of the accident need to be included.
COMMUNITY MENTAL HEALTH AGENCY - A community mental health agency which is
licensed by the Washington State Department of Social and
Health Services and which has in effect a plan for quality
assurance, peer review, and supervision by a licensed
physician or licensed psychologist.
CONTRACT - The completed Group application for health care
coverage; and
this document between the Group and us, which includes
any documents (Endorsements and Addenda) from us that
change it; and
the completed Enrollment Application form of the
Subscriber indicating participation in this Group
coverage.
CUSTODIAL CARE - Care given, in the reasonable opinion of the Blue Cross
Plan, to sustain a patient without attempting to cure or
heal an illness or injury.
DEDUCTIBLE - The amount of included medical expense for which the
Member is responsible before we provide benefits.
DENTIST - One who is licensed to provide services in the state where
the services are rendered as a:
Doctor of Medical Dentistry; and
Doctor of Dental Surgery.
DURABLE MECHANICAL MEDICAL EQUIPMENT - Equipment which can stand repeated
use and is used in the direct treatment of a covered
illness or injury. It is not useful to a person in the
absence of illness or injury.
- 3 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
EFFECTIVE DATE - The date on which the Member's coverage starts under this
Contract. This date is established by and appears on the
records of the Plan.
EXCEPTION - An exclusion with partial restoration of benefits; or a
provision reducing benefits.
EXCLUSION - A provision that states that this Plan has no obligation
under this Contract to provide any benefits.
EXPERIMENTAL OR INVESTIGATIVE - Any treatment, procedure, facility, equipment,
drug, drug usage, device or supply which, at the time
rendered, does not meet the criteria listed below:
Approval has been granted by the Federal Food and
Drug Administration, or by another United States
governmental agency, for general public use for
treatment of a condition; or
It has been scientifically demonstrated by the medical
profession to have efficacy in terms of:
When the prognosis for the patient 's condition is
death, that the treatment substantially extends
the probabilities of the person's survival for
five (5) or more years;
When deterioration of a body system is progressive
and reasonably certain to (or has) disabled or
incapacitated the patient, that the treatment can
be substantially expected to improve the
probabilities of arresting the condition's
progress for five (5) or more years; or
When the body function has been lost by the
patient, that the treatment has been shown to
restore the body function to usefulness at least
sixty (60%) percent of the time treatment has been
utilized; and
Services and supplies are rendered or provided by
an institution or provider within the United
States that has scientifically demonstrated
proficiency in such treatment.
FAMILY MEMBER - The lawful spouse of the Subscriber or any eligible child.
- 4 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
HOME HEALTH AIDE - An individual employed by an Approved Home Health Agency
or Approved Hospice who provides intermittent care such as
ambulation and exercise, assistance with medications,
reporting changes in the Member's condition and needs,
completing appropriate records, and personal care or
household services that are needed to achieve the
medically desired results. The home health aide must be
under the supervision of a registered nurse, a physical
therapist, occupational therapist, or speech therapist.
HOME HEALTH CARE PLAN OF TREATMENT - A written plan of treatment established
and periodically reviewed by the attending physician who
must be licensed as a Doctor of Medicine (M.D.) or
Doctor of Osteopathy (D.O.) . Such physician must certify
that the Member is homebound and that Hospital confinement
would be required in the absence of the Home Health Care
Plan of Treatment. The plan of treatment shall also
describe the services and supplies for the medically
necessary home health care to be provided to the Member by
the Approved Home Health Agency for treatment of an
illness or injury. Such plan of care is subject to
utilization review performed by us.
HOMEBOUND - When the Member's condition is such that leaving home
would not be medically advisable.
HOSPICE PLAN OF CARE - A written plan of care established and periodically
reviewed by the attending physician who must be licensed
as a Doctor of Medicine (M.D.) or Doctor of Osteopathy
(D.O.) . Such physician must certify that the Member is
terminally ill and that Hospital confinement would be
required in the absence of the Hospice Plan of Care. The
plan of care shall also describe the services and supplies
for the palliative care and medically necessary treatment
to be provided to the Member by the Approved Hospice.
Such plan of care is subject to utilization review
performed by us.
HOSPITAL - An institution which:
Is licensed; and
For compensation from its patients and on an Inpatient
basis is primarily engaged in providing diagnostic and
therapeutic facilities for the surgical and medical
diagnosis, treatment and care of injured and ill
persons by or under the supervision of a staff of
physicians; and
- 5
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
HOSPITAL . . . (continued)
Continuously provides twenty-four (24) hour-a-day
nursing service by or under the supervision of
registered graduate nurses; or
Is any other licensed institution with which the plan
has an agreement to render Hospital service.
The following are not considered "hospitals" unless
specified as such in this Contract.
Skilled Nursing Facilities;
Nursing Homes;
Convalescent Homes;
Custodial Homes;
Health Resorts;
Hospices;
Places for rest;
Places for the aged;
Places for the treatment of drug abuse;
Places for the treatment of alcoholism;
Places for the treatment of pulmonary tuberculosis.
IDENTIFICATION CARD - The card issued by us to the Subscriber containing his
or her Name, Group Number, Identification Number and
Plan Number.
INPATIENT - A registered bed-patient in a hospital for whom the
hospital makes a daily room charge.
LIMITATION - The exclusion or reduction of an exception to a specific
benefit.
MEDICAL EMERGENCY - Sudden illness or injury that requires immediate attention
to prevent death or impairment of health.
MEDICALLY NECESSARY/MEDICAL NECESSITY - Indispensable in the sense that in the
reasonable opinion of this Plan, an illness, injury or
condition harmful to or threatening to the patient's life
or health, or a direct effect of such, could not have been
diagnosed or relieved without the medical service, supply
or setting in question. The mere fact that it was
furnished, prescribed or approved by a physician or other
qualified provider does not in itself mean that it was
medically necessary. A medical service, supply or setting
may be medically necessary in part only.
6 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
MEDICARE - The programs established by Title XVIII of Public
Law 89-97 (79 Statutes 286-343), as amended, "Health
Insurance for the Aged and Disabled." It includes Part A -
"Hospital Insurance Benefits for the Aged and Disabled";
Part B - "Supplementary Medical Insurance Benefits for the
Aged and Disabled"; and Part C - "Miscellaneous
Provisions."
MEMBER - The Subscriber and eligible Family Members enrolled for
coverage under this Contract.
MENTAL, NEUROPSYCHIATRIC OR PERSONALITY DISORDERS - Any condition classified,
at the time an Member receives services, as a mental
disorder in the most recent edition of "International
Classification of .Diseases," except for those conditions
classified as:
Alcoholic psychoses;
Drug psychoses;
Alcohol dependence syndrome;
Drug dependence; or
Nondependent abuse of drugs.
MILIEU THERAPY - Treatment designed to provide a change in environment or a
controlled environment.
NON-PARTICIPATING HOSPITAL - A hospital which does not have an agreement in
effect with any Blue Cross Plan to furnish hospital care
to Members.
ORTHODONTICS - That branch of dentistry which deals with the development,
prevention and correction of irregularities of the teeth
and bite (malocclusion) . Malocclusion is the abnormal
Position and contact of the upper and lower teeth which
may affect chewing or cause facial, jaw and/or joint pain.
OUTPATIENT - One who receives treatment in a hospital while he or she
is not registered as a bed-patient of that hospital.
7 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
PALLIATIVE CARE - A form of treatment directed toward relief or control of
distressing symptoms without attempting to be curative.
PARTICIPATING DENTIST - A dentist who, at the time services are rendered, has
an agreement in effect with this Blue Cross Plan to
furnish dental services to Members.
PARTICIPATING HOSPITAL - A hospital or other institution which, at the time of
admission, has an agreement in effect with any Plan to
furnish hospital care to Members.
PARTICIPATING SKILLED NURSING FACILITY - A facility which, at the time of
admission, has an agreement in effect with any Plan to
furnish certain services to Members.
PARTICIPATING VISION CARE PROVIDER - One who, at the time services are
rendered, has an agreement in effect with this Blue Cross
Plan to furnish Vision services to Members.
PHYSICIAN AND OTHER PROVIDERS OF SERVICE - One of the following who is, licensed
to provide medical services in the state where those
services are received:
Doctor of Medicine and Surgery (M.D)
Doctor of Osteopathy and Surgery (D.O.)
Doctor of Podiatry (D.P.M.) . •
In the event that health care services are performed by
one of the following providers and such services would
have been covered if performed by a physician
(M.D. , D.O. , or D.P.M.) , then such services will be
covered when performed by a:
Psychologist
Chiropractor (D.C.)
Registered Nurse (R.N. ) licensed in the
State of Washington.
This Contract also includes the services of physician
extenders (employees of a physician such as a nurse) when
the physician bills for these services.
Other health care providers may also be included for
certain services under this Contract but only under the
benefits which say so.
The above physicians and health care providers must
perform services within the lawful scope of their licenses.
- 8 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
PLAN, THE - An approved Blue Cross Plan licensed in the States of
Washington and Alaska.
PRESCRIPTION DRUG - Any medical substance, the label of which, under the
Federal Food, Drug and Cosmetic Act, as amended, is
required to bear the legend: Caution: Federal Law
prohibits dispensing without a prescription."
REASONABLE AND CUSTOMARY - Reasonable and Customary, or R&C, means the
Blue Cross Plan will take into consideration the following
criteria in the determination of the actual amount payable
for any given service, procedure or supply:
The charges or fees which fall within the customary
• range of charges or fees prevailing in a locality for
the performance of similar service, procedure or
supply. (In the event there are too few providers in
any given locality from which to determine a customary
range of charges or fees for a given service,
procedure, or supply, the Blue Cross Plan will
determine the amount payable based upon the customary
range of charges or fees in a wider geographical area
such as the state in which the provider of service is
located.)
A charge which, in the reasonable opinion of the
Blue Cross Plan, is justified by the time required for
the service or procedure, the severity of the
condition treated, and other factors required to
perform the service or procedure, or provide the
supply as compared with those required for other
services, procedures or supplies.
Determination of the actual amount payable for any given
service, procedure or supply is within the discretion of
the Blue Cross Plan. If a Member becomes obligated to a
provider for an amount that is more than we determine to
be a "Reasonable and Customary' amount, such excess amount
will be the responsibility of the Member.
With respect to benefits for the treatment of alcoholism
(alcohol dependency) at an Approved Treatment Facility as
provided under the Chemical Dependency Benefit, Reasonable
and Customary charges will be taken into account only on
specific components of such treatment for which a
Reasonable and Customary charge has been established based
on the Plan's statistically reliable measures as
determined by the criteria set forth above.
9
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
RESPITE CARE - For a homebound Member requiring continuous attendance,
care of the Member for a period of time for the purpose of
relieving all persons caring for and residing with the
Member from their duties.
SERVICE AREA - The States of Alaska and Washington, except Clark County.
SUBSCRIBER - The individual in whose name the coverage is established
and to whom we issue the Identification Card.
SUBSCRIPTION CHARGES - The monthly rates established by us as consideration
for the benefits offered in this Contract.
TERMINALLY ILL - The Member's illness, disease or injury has reached a
point where recovery can no longer be expected and the
attending physician certifies that the Member is facing
imminent death.
TOTAL DISABILITY - Inability of the Subscriber due to disease, illness,
injury or pregnancy to engage in any occupation or
employment for wage or profit; or, in the case of a
Family Member, the inability due to disease, illness,
injury or pregnancy to engage in all regular and customary
activities usual for a person of that age and family
status.
VISION CARE PROVIDER - An ophthalmologist, optometrist or optician.
WE, US AND OUR - An approved Blue Cross Plan licensed in the States of
Washington and Alaska.
10 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
A. Who May Be Covered
1. The Subscriber
An employee who has met the eligibility requirements specified below.
a. Eligible Classes of Employees
The following employees of CITY OF KENT are eligible to enroll
and become covered under this Contract:
All permanent, full-time, active employees working a minimum of
forty (40) hours a week.
All permanent, part-time, active employees working a minimum of
twenty-one (21) hours a week.
A retired employee, provided such employee:
has attained age fifty-five (55);
has at least twenty-five (25) years of service with the
employer; and
is eligible to receive a retirement benefit under the
LEOFF I Retirement Plan.
All retired, disabled employees who are eligible to receive a
retirement benefit under the LEOFF I Retirement Plan.
LEOFF I Employees - Full-time, active law enforcement officers
or firefighters who were hired prior to October 1, 1977 and who
were members of the LEOFF System as defined in Sections (3) and
(4) , CH131, Law of 1972 lst Ex. Sess. prior to October 1, 1977.
LEOFF II Employees - Full-time, active law enforcement officers
or firefighters who were hired after October 1, 1977 and who
were not members of the LEOFF System as defined in Sections (3)
and (4), CH131, Law of 1972 1st Ex. Sess. prior to
October 1, 1977.
If an employee becomes permanently disabled, the employer must
maintain medical insurance coverage for the employee,
applicable to LEOFF I Employees only.
b. Ineligible Classes of Employees
The following employees are ineligible to enroll and become
covered under this Contract:
All temporary or seasonal employees.
- 11 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
A. Who May Be Covered . . . (continued)
I. The Subscriber . . . (continued)
b. Ineligible Classes of Employees . . . (continued)
Employees who are covered through GROUP HEALTH COOPERATIVE or
any other employer-sponsored Health Maintenance Organization
(HMO).
2. Eligible Dependents
a. The Lawful Spouse of the Subscriber
b. Children
The lawful offspring of either or both the Subscriber or spouse
and legally adopted children if they meet all of the following
requirements:
The child is unmarried; and
The child is under twenty-three (23) years of age; and
The Subscriber provides the main support for the child and
could claim him or her as a dependent under the
United States Internal -Revenue Code, for tax purposes.
B. Application for Coverage and Effective Date
1. The Subscriber and Existing Dependents
The Subscriber must submit a completed Enrollment Application
through the Group within thirty (30) days following the date of
hire. All dependents to be enrolled must also be listed on the
Enrollment Application. Upon timely receipt of the Subscriber's
Enrollment Application and payment of the required Subscription
Charges by the Group, coverage will begin for the Subscriber and all
enrolled dependents as set forth below.
a. Subscriber
Employees in an eligible class may enroll and have an effective
date of coverage on the latest to occur of:
The effective date of this Contract;
The date the employee enters an eligible class;
The first day of employment;
- 12 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
B. Application for Coverage and Effective Date . . . (continued)
1. The Subscriber and Existing Dependents . . . (continued)
a. Subscriber . . . (continued)
provided such employee is actively at work (performing the
duties of his or her occupation at his or her place of
employment) on such coverage date. If the employee is not
actively at work on such date, coverage for the employee and
his or her enrolled dependents will not begin until the
employee returns to active work. "Coverage Period" means that
period for which the Group has paid, in advance, the required
Subscription Charges on behalf of eligible Members in
consideration for the benefits offered in this Contract.
b. Retirees
Retirees in an eligible class will be eligible to enroll and
have an effective date of coverage on the first day of the
Coverage Period coinciding with or next following date of
retirement.
C. Dependents
Coverage for eligible dependents (other than those acquired
after the Employee's effective date) will become effective on
the same date as the employee's coverage provided proper
application has been made. Eligible dependents are defined in
Part Two Section A.2.
2. Natural Newborn Children
Children of the Subscriber or spouse born while the Subscriber is
covered under this Contract are covered from date of birth. The
Subscriber must make application for coverage of the newborn infant
within sixty (60) days from date of birth. If an additional
Subscription Charge is required, it will begin on the first billing
cycle following date of birth.
3. Dependents Newly Acquired Through Marriage
Application for the addition of a spouse and children newly acquired
through marriage must be made within thirty (30) days of marriage.
Upon timely receipt of the completed Enrollment Application and
required Subscription Charges, if any, coverage will begin on the
first day of the first billing cycle following the date of marriage.
- 13 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
B. Application for Coverage and Effective Date . . .
(continued)
4. Adopted Children Newly Acquired
Newly acquired adopted children physically placed with the
Subscriber on or after the Subscriber's effective date are covered
from the date of such physical placement with the Subscriber
provided application is made within sixty (60) days of said
placement. If an additional Subscription Charge is required, it
will begin on the first billing cycle following the date of physical
placement.
Eligible dependents of LEOFF I retired or retired disabled employees must
self-pay monthly Subscription Charges directly to the Group.
C. Other Provisions Affecting Eligibility and Effective Date
1. Late Enrollment
Eligible employees who are not enrolled when first eligible or who
fail to maintain continuous coverage, may be retroactively enrolled
at any later date provided application is made and full retroactive
Subscription Charges are paid by the Group on the employees' behalf
from the later of the following:
a. the date the employee was first eligible; or
b. retroactively sixty (60) days.
Eligible dependents who are not enrolled when first eligible or who
fail to maintain their coverage may be enrolled only during an Open
Enrollment period which is determined by the Plan. Provided proper
application has been made, coverage will begin on the effective date
of the Group's Open Enrollment.
2. HMO OPTION
Employees who have elected coverage through an HMO may change
coverages and enroll under this Contract only during an Open
Enrollment period which is determined by the Plan.
3. If an Enrolled Dependent is Institutionalized On the Effective Date
If an enrolled dependent is confined in a Hospital, Skilled Nursing
Facility or Approved Treatment Facility on the date his or her
coverage becomes effective, he or she will not receive any benefits
of this Contract for any services or supplies provided prior to
discharge from the facility. This provision does not apply to
services provided for properly enrolled newborn dependents born on
or after the Subscriber's effective date.
- 14 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
D. When Coverage Ends - Circumstances That End Coverage
Except as provided in Part Two, Section E. , Continuation of Coverage -
Under This Contract, and in Part Seven (Benefits After Termination),
coverage will terminate at the end of the period for which Subscription
Charges were paid when the first of the following occurs:
1. For the Subscriber and all dependents covered under this Contract
when this Contract is terminated by the Group or Plan; or
2. For the Subscriber when:
a. the Subscriber ceases to meet the eligibility requirements of
the Group as set forth in Section A. ; or
b. the Subscriber's employment or connection with the Group
terminates; or
C. the Group fails to pay Subscription Charges for the Subscriber;
or
3. For the spouse when:
a. the Subscriber is no longer covered under this Contract; or
b. his or her marriage to the Subscriber terminates due to divorce
or annulment or, if earlier, when the Subscriber is no longer
legally responsible for covered expenses incurred by the
spouse; or
C. the Group fails to pay Subscription Charges for the spouse; or
4. For the children when:
a. the Subscriber is no longer covered under the Contract; or
b• they reach age 23, marry or can no longer be claimed as a
dependent by the Subscriber under the United States Internal
Revenue Code; or
C. the Group fails to pay Subscription Charges for the children.
Members who lose coverage for reasons set forth in Part Two - Section
D•2. , 3. or 4. above, may be eligible to continue their coverage under
one of the provisions of Part Two, Section E. - Continuation of Coverage
Under This Contract. When coverage under this Contract ends, conversion
to a nongroup program is available, subject to the terms and limitations
of Part Two - Section F.
- 15 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
E. Continuation of Coverage - Under This Contract
1. Incapacitated Child
A dependent child may continue coverage under this Contract upon
reaching twenty-three (23) years of age if:
the Subscriber remains covered under this Contract; and
the appropriate Subscription Charges, if applicable, are
paid; and
the child is incapable of self-sustaining support by
reason of developmental disability or physical handicap
and was incapacitated before reaching age twenty-three
(23); and
the child continues to be eligible as a dependent within
the definition of the United States Internal Revenue Code;
and
the Subscriber furnishes us with written certification
acceptable to the Plan, completion of form 711-2450, that
the incapacity exists within thirty-one (31) days of the
child reaching twenty-three (23) years of age; and
the Subscriber re-submits proof acceptable to the Plan of
the incapacity at periodic intervals, upon our request,
but not more frequently than annually after the two
(2)-year period following the child's attainment of age
twenty-three (23) .
2. Leave of Absence
Coverage may be continued for up to ninety (90) days if the employer
grants the Subscriber a leave of absence. The required Subscription
Charges must be submitted with the employer's regular monthly
remittance to the Plan.
3. Labor Dispute
In the event that a Subscriber's compensation or wage is suspended
or terminated by the Group, directly or indirectly, as a result of a
strike, lockout, or other labor dispute, the Subscriber may pay the
Subscription Charges, subject to the terms on the application,
directly to the Group for a period not exceeding six (6) months from
the date of such suspension or termination.
When the Subscriber's compensation or wage is so suspended or
terminated, the Subscriber shall be notified immediately in writing
by the Group. A notice will be mailed to the address last on record
with the Group, that the Subscriber may pay Subscription Charges to
the Group as they are due as provided in this section. At the end
of the six (6)-month period, contract benefits may be continued as
set forth in Part Two Section E.4. below.
- 16 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
E. Continuation of Coverage - Under This Contract . . . (continued)
4. Continuation of Group Coverage
a. The following Members may elect to continue their coverage
under this Contract as directed by the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA), when that coverage
would have been terminated because of a qualifying event stated
below:
(1) The Subscriber and covered dependents may continue
coverage for up to eighteen (18) months if coverage ceases
due to:
reduction of the Subscriber's work hours; or
termination of the Subscriber's employment, except
for discharge due to actions defined by the employer
as gross misconduct.
(2) The covered spouse or children may continue coverage for
up to thirty-six (36) months if coverage ceases due to:
the Subscriber's death;
divorce or legal separation from the Subscriber;
ineligibility for Medicare when the Subscriber has
elected Medicare to be his or her primary health
coverage;
loss of eligibility as a dependent child, as
specified in Part Two Section D.4.
Only Members covered under this Contract before the qualifying
event may elect to continue coverage, and only:
natural newborn children of the continuing Subscriber
or spouse who are born during the continuation
period; and
adopted children, newly acquired, who are sixty
(60) days of age or less on the date of physical
placement with the continuing Subscriber and who are
physically placed during the continuation period,
- 17 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
E. Continuation of Coverage - Under This Contract . . . (continued)
4. Continuation of Group Coverage . . . (continued)
may be added after continued coverage under this Contract
becomes effective. Such natural newborn children will be
covered from birth, if enrolled according to the terms of
Part Two, Section B.2. , and such adopted children newly
acquired will be covered from the date of said physical
placement, if enrolled according to the terms of Part Two,
Section B.4. Their coverage will terminate when the Subscriber
or spouse's continued coverage under this Contract terminates.
Other newly acquired dependents and Members who did not elect
to continue when first eligible may not be added to continued
coverage under this Contract.
b. Notification to qualified Members will be provided by the Group
as required by COBRA. The Member's completed application for
continued coverage must be submitted to the Group within sixty
(60) days from the date coverage would have terminated because
of a qualifying event, or from the date the Group gave the
Member notice of continuation rights, whichever is later. The
initial Subscription Charges, including any retroactive
amounts, must be submitted to the Group no later than
forty-five (45) days after the Member elected continuation.
C. The Group will forward all applications and Subscription
Charges to the Plan with its next billing and delete from the
group health program any qualifying Member who does not elect
to continue coverage. After a Member's Subscription Charges
and application are received by the Plan, continued coverage
will begin on the date that coverage under this Contract would
have terminated because of a qualifying event. Subsequent
Subscription Charges must be paid through the Group and
submitted with the Group's regular monthly billings.
d. Continued coverage is subject to all other terms and
limitations of this Contract.
e. Continued coverage under this Contract will terminate at the
end of the period for which Subscription Charges were paid if
the employer terminates this Contract or if Subscription
Charges are not paid when due. Continued coverage will also
terminate on the date a Member becomes entitled to Medicare.
Otherwise, continued coverage under this Contract will
terminate at the end of the applicable continuation period.
When the continued coverage described in the provisions of Part Two -
Section E. ends, conversion to a nongroup program is available, subject
to the terms and limitations of Part Two - Section F.
- 18 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
F. Conversion to Nongroun Programs
Members who lose their eligibility for coverage under this Contract for
the reasons set forth in Section D. may be eligible to transfer to a
Conversion or Medicare Supplement Program designated by the Plan without
meeting medical underwriting requirements, provided the Member:
submits a completed application and the required Subscription
Charges to the Plan within thirty-one (31) days from the date the
Member's coverage under this Contract terminates; and
meets the specific eligibility requirements described under the
nongroup program.
The rates and benefits of these nongroup programs are different from the
rates and benefits provided under this Contract; and in some cases, the
benefits provided under these nongroup programs will be more limited than
the benefits provided under this Contract.
G. Deletion of Ineligible Members
The Group will promptly delete any employee or dependent who ceases to
meet the above eligibility requirements and will so notify the Plan on a
timely basis.
19 -
PART THREE PROVISIONS THAT AFFECT BENEFITS
The following provisions affect the way benefits are provided.
3.1 Changes To This Contract
After the initial term of this Contract as stated in Part Nine 9.1, the
benefits of this Contract may be changed provided we notify the Group of
any change at least thirty (30) days in advance of the date the change is
to be effective. Payment of Subscription Charges after notification
constitutes acceptance of the change.
No agent of this Plan is authorized to make any oral changes, additions
or deletions to this Contract. Changes can be done only by endorsement,
riders or an acceptance form issued over the signature of an officer of
this Plan.
If a Member is confined in a Hospital, Skilled Nursing Facility or
Approved Treatment Facility at the time a change in benefits is made, he
or she will continue to receive the benefits in effect at the time of
admission. The changed benefits will be available after discharge.
3.2 Prior Blue Cross Coverage
If the Member was hospitalized while enrolled under a prior Contract,
Certificate or Agreement with this Plan which is replaced by this
Contract, these provisions will apply:
• The days of hospital care provided under the prior coverage
will be deducted from the days available under this Contract if
a Member is readmitted within ninety (90) days after discharge.
• The days of hospital care will not be deducted if:
The Subscriber has gone back to work on a full-time basis;
or
The hospitalization of a Member is due to an accident.
20
PART THREE PROVISIONS THAT AFFECT BENEFITS
3.3 Filing of Claims
Benefits will be provided under this Contract only if a claim, see
Part One - Definitions, is filed with us.
Time Limit for Filing Claims
The claim must be received by us within one (1) year from the date:
Of admission to a Hospital, Skilled Nursing Facility or
Approved Treatment Facility; or
On which the professional expenses were incurred.
This time limit does not apply to claims for services furnished by
providers, other than hospitals, who have participating agreements with
US.
21 -
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS UNDER THIS CONTRACT
This Plan has certain rights under this Contract. These rights appear below.
4.1 Subrogation
To the extent of any amounts paid by this Blue Cross Plan to or for a
Member on account of services made necessary by an injury to or condition
of his or her person, it shall be subrogated to his or her rights against
any third party liable for the injury or condition. The Plan shall,
however, not be obligated to pay for such services unless and until the
Member, or someone legally qualified and authorized to act for him or
her, promises in writing to:
Include those amounts in any claim he or she makes against
a third party for the injury or condition;
Repay the Plan those amounts to the extent that the
proceeds of the Member's recovery from a settlement with a
third party by reason of such an injury or condition exceed
his or her own portion of the total loss, prorating any
attorneys' fees incurred in the recovery; and
Cooperate fully with the Plan in asserting its rights under
this Contract, to supply us with any and all information
and execute any and all instruments we reasonably need for
that purpose_
4.2 Right to Receive and Release Necessary Information
When a Member applies for benefits under this Contract, he or she
authorizes health care providers to release to us information and records
about services that have been given. Also, the Member authorizes any
person, organization or insurance company to furnish to or to obtain from
us any information regarding his or her benefits. If a Member does not
authorize access to his or her records, benefits will not be provided.
4.3 Evidence of Medical Necessity
We have the right to require proof of medical necessity from a Member
receiving benefits under this Contract. This proof may be submitted by a
Member or on his or her behalf by providers. No benefits will be
available under this Contract if the proof is not provided or acceptable
to us. We shall not request such proof more often than at ten (10)-day
intervals.
4.4 Limit of Our Liability
Our liability under this Contract, including recovery under any claim of
breach, shall be limited to the actual cost of hospital and medical
services provided. This limitation specifically excludes claims for
general damages including alleged pain, suffering or mental anguish.
-- 22 -
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS UNDER THIS CONTRACT
4.5 Venue
All suits or legal proceedings brought against us by a Member or anyone
claiming any right under this Contract must be filed:
Within fifteen (15) months of the date we denied in writing
the rights claimed under this Contract; and
In the State of Washington or the State in which the Member
resides or is employed.
All suits or legal proceedings brought by us against a Member shall be
filed within the appropriate statutory period of limitation. In all
suits or legal proceedings brought by us venue may lie, at our option, in:
King County, State of Washington; or
The third Judicial District, Anchorage, State of Alaska,
if the Member is a resident of that State.
4.6 Right of Recovery
This Plan will have the right, upon demand, to recover overpayments or
payments obtained through fraud, error, mistake or payments made in
excess of the maximum amount necessary to satisfy the intent of the
Coordination of Benefits provision in Part Six 6.2.8. , made to:
Other insurers; or
• Any service plans; or
• Any other organization, or on behalf of a Member; or
Someone who is not eligible to receive benefits.
If reimbursement is not made, such overpayments or payments will be
deducted from future claims.
4.7 Transfer of Benefits: Assignment, Garnishment and Attachment
All rights to benefits under this Contract are personal and available
only to the Member. They may not be transferred to anyone else.
No benefits or other rights arising in favor of the Member under this
Contract are assignable, or subject to garnishment or attachment by
creditors. We are not obligated by any attempted or purported
assignment, garnishment or attachment. In paying under this Contract for
services or supplies to a Member, we may, at our option, remit funds to
the Member, the provider of the services or supplies, the Group, other
carrier or jointly to any of these. Remittance as aforesaid in
good
faith shall discharge our obligation to the extent of the remittance
amount so that we will not be liable to anyone aggrieved by our selection
of payee.
- 23 -
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS UNDER THIS CONTRACT
4.8 Fraudulent Claims
If the Member claims benefits for which no care, service or supply is
received, the claims will be denied.
4.9 Subscriber Cooperation
The Subscriber, his or her eligible spouse and all eligible dependent
children are under a duty to cooperate in a timely and appropriate manner
with this Blue Cross Plan in its administration of benefits or in the
event of a lawsuit.
24 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS• INSTITUTIONAL CARE
Institutional care, services and supplies shall be provided for
disabilities arising from illness, disease, injury or pregnancy as
indicated in the specific benefits that follow, provided:
They are medically necessary, see Part One - Definitions; and
The Member is under constant care and treatment of a
physician; and
Admission to such institution occurs after the Member's
effective date of coverage under this Contract.
A. Inpatient Care - Participating Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
This inpatient hospital care benefit is available subject these
provisions:
1. The Number of Inpatient Days Available
Inpatient hospital care is available up to:
a. An aggregate (total) of three hundred sixty-five
(365) days per confinement; including
b. One hundred twenty (120) days each calendar year for
mental, neuropsychiatric or personality disorders.
2. Inpatient Services and Supplies
The inpatient services and supplies listed on the following
page are available for inpatient care subject to the number of
days available.
25 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE (continued)
A. Inpatient Care - Participating Hospital In or Out of the Service
Area -and a Legally Operated Hospital Out of the Service Area
. . . (continued)
2. Inpatient Services and Supplies . . . (continued)
a. Daily hospital services in a room of two (2) or more beds.
b. Use of an intensive care unit, includes coronary and
constant-care units. Services in an intensive care unit
include nursing services provided by hospital employees as
a regular service.
C. Use of operating, recovery, isolation, cystoscopic and
cast rooms.
d. Anesthetic supplies and use of hospital anesthetic
equipment. Administration of anesthesia when administered
by a hospital employee as a regular hospital service.
e. Casts, splints, and surgical dressings.
f. X-ray and radium therapy.
g. Oxygen and all drugs and medicines prescribed and used
while the Member is in the hospital which are listed and
accepted in the:
"United States Pharmacopoeia"; or
"National Formulary"; or
"AMA Drug Evaluations" published by the
American Medical Association.
h. Blood, blood plasma, blood derivatives and their
administration.
i. Physiotherapy and hydrotherapy.
j . Diagnostic laboratory and x-ray services.
k. Electrocardiograms.
1. Respiratory and other gas therapy.
- 26
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE (continued)
A. Inpatient Care - ParticiDatina Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
. . . (continued)
3. Limitations
In addition to Exclusions and Exceptions of Part Six, these
limitations apply to this inpatient hospital care benefit.
a. We do not provide benefits for convalescent care when:
The need for definitive medical treatment no
longer exists; or
Acute care provided as an inpatient is no longer
necessary.
b. If the Member occupies a private room, we provide benefits
only for the hospital's charge for a room of two (2) beds.
If the hospital has only private room accommodations, we
will determine the amount of expenses to be allowed.
C. We do not provide benefits for any other room reserved for
the Member during a period he or she may be confined in an
intensive care unit.
d. We do not provide benefits for personal items, such as:
Meals for guests; or
Long distance telephone charges or
telegraph charges; or
Radio or television charges; or
Barber or beautician charges.
- 27 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
A. Inpatient Care - Participating Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
. . . (continued)
3. Limitations . . . (continued)
e. Successive hospital confinements are considered one
confinement if they are not separated by a period of
ninety (90) days unless:
The patient is the Subscriber and proof is
furnished that he or she has returned to full-time
work; or
Readmission by a Member to a hospital is required
as a result of an accident.
f. We do not provide benefits for admission to a hospital for
diagnostic purposes only.
g. We do not provide benefits for admission to a hospital for
dental procedures except as stated in Part Six 6.2.4.
- 28 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE .
. (continued)
B. Emergency Inpatient Care - Non-Participating Hospital in the
Service Area
1. Amount of Benefit Provided
Benefits for the number of inpatient hospital days stated in
5.1.A.1. and the services stated in 5.1.A.2. are available for
services rendered, furnished and billed by a Non-Participating
Hospital in the service area up to the Reasonable and Customary
charge, but only when the condition being treated is a medical
emergency.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six, all
limitations of 5.1.A.3. will apply.
29 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
C. Outpatient Care - Participating Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
This outpatient hospital care benefit is available subject to these
provisions:
1. When Services Are Provided
Outpatient services are provided in a Participating Hospital
for these situations only:
a. Accidental In_iury
We provide benefits for treatment of an accidental injury
rendered within seven (7) days of the accident.
b. Medical Emergency
We provide benefits for treatment for an injury or illness
that is a medical emergency (see Part One - Definitions)
including but not limited to:
Heart attacks,
Cardiovascular accidents,
Poisonings,
Loss of consciousness, or
Respiration.
C. Minor Surgery
d. X Ray Therapy and Radium Therapy Treatments
e. Chemotherapy Treatments
30 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
C. Outpatient Care - Participating Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
. . . (continued)
1. When Services Are Provided . . . (continued)
f. Preadmission Tests
Certain diagnostic services are covered in this benefit
when rendered in the outpatient department within
seventy-two (72) hours of admission to that hospital.
These services must be related to the condition the Member
is admitted for and are:
Labordtory examinations,
Electrocardiograms, and
X-ray examinations.
2. Outpatient Services and Supplies
Only the outpatient services below are available when the
Member receives care for the situations named in Part Five
5.1.C.1.
a. Use of operating, recovery, isolation, cystoscopic and
cast rooms.
b. Anesthetic supplies and use of hospital anesthetic
equipment; administration of anesthesia by a hospital
employee as a regular hospital service.
C. Casts, splints and surgical dressings.
d. X-ray therapy and radium therapy.
e. Oxygen and all drugs and medicines, prescribed and used
while the Member is in the hospital, listed and accepted
in the:
"United States Pharmacopoeia"; or
"National Formulary"; or
"AMA Drug Evaluations" published by the
American Medical Association.
- 31 -
PART FIVE BENEFITS
5 .1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
C. Outpatient Care - Participating Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
. . . (continued)
2. Outpatient Services and Supplies . . . (continued)
f. Blood, blood plasma and blood derivatives and their
administration.
g. Chemotherapy for malignancies only.
h. Diagnostic laboratory and x-ray services and
electrocardiograms.
i. Physiotherapy and hydrotherapy.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations apply to this outpatient hospital care
benefit.
a. We do not provide benefits for outpatient care received in
a Non-Participating Hospital within our service area
except as described in 5.1.D.
b. We do not provide hospital outpatient benefits for the
services of a physician.
D. Emergency Outpatient Care - Non-Participating Hospital In the
Service Area
1. Amount of Benefit Provided
The benefits stated in 5.1.C. are available up to the
Reasonable and Customary charge, but only when the condition
being treated is a medical emergency.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
limitations of 5.1.C.3. will apply.
- 32 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE
. (continued)
E. Skilled Nursin Facilit - Partici atin In the Service Area and
Medicare-ADprOVed Out of the Service Area
This benefit is available in a participating Skilled Nursing
Facility for skilled nursing services that must include direct
medical supervision of the treatment provided each Member. It must
also include nursing service under the supervision of a registered
nurse, plus other therapeutic services. This service is designed
for the patient who does not need care in an acute facility, yet is
at a point in his or her illness or disability which requires care
in a facility offering lesser services subject to these provisions.
1. The Number of Days of Skilled Nursing Care Available
Each day of care received in a Skilled Nursing Facility will be
charged as one-half (1/2) day of inpatient hospital care
against the maximum benefit as specified in Part Five 5.1.A.l.a.
2. Skilled Nursing Services and Supplies
Only the services listed below are available for skilled
nursing care:
a. Skilled nursing services in a room of two (2) or more beds.
b. Use of special treatment rooms.
C. Routine laboratory tests and examinations.
d. Physical, occupational or speech therapy treatments.
e. Respiratory and other gas therapy.
f. Drugs, biologicals and solutions used while the Member is
in the Skilled Nursing Facility.
g. Gauze, cotton, fabrics, solutions, plaster and other
materials used in dressings and casts.
33 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
E. Skilled Nursing Facility - Participating In the Service
ued)Ar a and
Medicare-Approved Out of the Service Area . . .
3, Limitations
In addition to the Exclusions and Exceptions of Part Six, these
limitations apply to this Skilled Nursing Facility care benefit.
a. We do not provide benefits for skilled nursing care
received in a Non-Participating Skilled Nursing Facility
within our service area, except as described in 5.1.F.
b. We do not provide benefits for custodial care, see
Part One - Definitions.
C. We do not provide benefits for care which is for:
Senile deterioration; or
Mental deficiency; or
Mental retardation; or
Mental illness.
F. Skilled Nursing Facility - Non-Participating in the Service Area
1. Amount of Benefit Provided
Benefits for the number of days stated in 5.1.E.1. and the
services stated in 5.1.E.2. are available up to the Reasonable
and Customary charge, but only when the condition being treated
is a medical emergency.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
limitations of 5.1.E.3. will apply.
34 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
G. Treatment of Chemical Dependency
Treatment for Chemical Dependency is not covered under this
Contract's Basic Benefits. However, services for the treatment of
Chemical Dependency are covered as a Major Medical Benefit in
Part Five - Section 5.4.C.17.
35
PART FIVE BENEFITS
5.2 BASIC BENEFITS• PROFESSIONAL SERVICES
This benefit will be provided for professional services by a physician
qualified to diagnose and treat an illness, disease, injury or pregnancy
only as indicated in the specific benefits that follow, provided that:
They are medically necessary, see Part One - Definitions; and
The services are received on or after the Member's Effective Date of
coverage under this Contract.
5.2.1 Surgical and Medical Benefits (Subscriber and Family Member)
The basic benefits for professional surgical and medical services are
listed below.
A. Surgical Benefits
This surgical benefit is available subject to these provisions:
1. Amount of Benefits Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
If more than one surgical procedure is performed, benefits
will be provided as follows:
At different times due to entirely unrelated causes,
benefits will be provided for each procedure;
At the same time in the same operative area,
benefits will be provided only for the procedure
with the largest allowance;
At the same time in different operative areas, full
benefits will be provided for the procedure with the
largest allowance plus one-half (1/2) of the
allowance for each additional procedure.
2. Surgical Services and Supplies
'_'his surgical benefit covers only the providers and services
stated below:
a. Services of a physician and assistant surgeon for
surgical services (operating and cutting procedures for
the treatment of disease, illness or injury and
treatment of fractures and dislocations. ) Services of
an assistant surgeon are included for major surgery only.
- 36 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
A. Surgical Benefit . . . (continued)
2. Surgical Services and Supplies . . . (continued)
b. Services of a dentist (D.D.S. or D.M.D.) for only the
non-dental surgical procedures in the oral region
listed below:
Excision of tumors or cysts of the jaw, tongue,
roof and floor of the mouth.
Excision of exostoses of the jaw and hard palate.
Incision and drainage of cellulitis.
Incision or excision of accessory sinuses, salivary
glands or ducts.
Surgical procedures required due to an injury
involving oral conditions such as fractured jaw.
37 -
PART FIVE BENEFITS
5 .2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
B. Anesthesia Benefit (Subscriber and Family Member)
This anesthesia benefit is available subject to these provisions.
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Anesthesia Services
This benefit covers only the services of an anesthesiologist
or Registered Nurse Anesthetist (R.N.A.) .
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
these limitations apply:
a. We provide this benefit only when hospital and surgical
benefits are being provided to the Member.
b. We do not provide benefits for administration of
anesthesia by the operating surgeon; or for a hospital
employee when the hospital bills for his or her
services as a hospital benefit.
38
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
C. Physician Hospital or Skilled Nursing Facility Visit Benefit
(Subscriber and Family Member)
This physician hospital or Skilled Nursing Facility benefit is
available subject to these provisions:
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Physician Visit Services
This benefit covers only one visit by a physician for each
day the Member is confined in a hospital or Skilled Nursing
Facility.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
these limitations apply:
a. We provide this benefit only when inpatient hospital or
skilled nursing facility benefits are being provided to
the Member.
b. We do not provide this benefit during a hospital stay
in which basic surgical benefits are paid.
39 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES
. (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
D. Consultation Service Benefit (Subscriber and Family Member)
This consultation service benefit is available subject to these
provisions.
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Consultation Services
This benefit covers only professional consultation services
by a physician when a Member is confined in the hospital.
This is opinion or advice provided in the evaluation or
treatment of a patient.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
these limitations apply:
Consultation services must be requested by the
attending physician.
40 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
E. Physician Medical Emergency Benefit - Outpatient Hospital Only
(Subscriber and Family Member)
This physician medical emergency benefit is available subject to
these provisions.
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One — Definitions, for an included service.
2. Physician Services
This benefit covers only treatment by a physician in
connection with a medical emergency, see Part One -
Definitions.
3. Limitations
In addition to Exclusions and Exceptions of Part Six, these
limitations apply:
a. We provide this benefit only when the outpatient
hospital medical emergency benefit in Part Five
5.1.C.l.b. is being provided to a Member.
b. We do not provide this benefit for treatment that is
paid with basic surgical, physician hospital visit, or
physician home and office visit benefits.
41
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
F. Physician Radiotherapy Benefit (Subscriber and Family Member)
This physician radiotherapy benefit is available subject to these
provisions:
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Physician Radiotherapy Services
This benefit covers only the services of a physician for
radiotherapy treatments.
3. Limitations
The Exclusions and Exceptions of Part Six apply to this
benefit.
- 42 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
G. Physician Home and Office Benefit
Physician home and office visits are not covered as Basic
Benefits under this Contract.
- 43 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
H. Second Surgical Opinion Benefit
1. Amount of Benefit Provided
When surgery is recommended to the Member by a physician for
a non-emergency surgical procedure stated in paragraph 2
below, the Plan will pay up to the Reasonable and Customary '
charge for the professional services of a physician, other
than the operating surgeon, for a second surgical opinion
consultation prior to the Member undergoing surgery,
including necessary x-ray and laboratory tests required by
the physician as a part of the consultation.
The term "non-emergency surgical procedure" shall mean one of
the elective surgical procedures stated in paragraph 2 below,
that may be scheduled at the Member's convenience without
jeopardizing the Member's life or causing serious impairment
to the Member's bodily functions.
2. Procedures Requiring a Second Physician's Opinion
The following elective surgical procedures, as listed in the
Physician's Current Procedure_Terminology, Fourth Edition,
are eligible for a second physician's opinion when surgery
has been recommended by a physician on a non-emergency basis
as defined in paragraph 1 above:
Procedures and CPT 4 Codes:
Hysterectomy, 58150, 58180 Surgery on the Spine, 22555
58260 through 58270, 58275 through 22735 and 62295
& 58280 through 63076
Surgery on the Knee, 27373 Surgery on the Heart, 33510
through 27379, 27405 through 33528, 33405, 33430
through 27425, 27444 and 93570
through 27447, 27487 Surgery on the Nose, 30140
and 27488 through 30160 and 30400
Surgery on the Hip, through 30520
27130 and 27135 Gallbladder Surgery, 47600
Surgery on the Foot, 28080 through 47620
through 28299 Tonsils and Adenoids, 42820
through 42836
- 44 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
H. Second Surgical Opinion Benefit . . . (continued)
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
this benefit does not include:
a. Consultation services performed by the operating
surgeon.
b. Consultation services for procedures not listed in
paragraph 2 above.
C. Diagnostic tests which are not directly related to the
condition being treated.
d. Consultation services where the Member is not
personally examined by the physician.
e. Consultation services when the Member has already been
admitted to the hospital for the surgical procedure.
45 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES
. (continued)
5.2.1 Surgical and Medical Benefits
- (continued)
I. Professional Nervous and Mental Benefit
This Contract does not provide a Basic professional nervous and
mental outpatient benefit.
However, benefits for mental, neuropsychiatric and personality
disorders are provided for under the Major Medical Benefit, if
available.
- 46 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.2 Diagnostic X-ray and Laboratory (Subscriber and Family Member)
This diagnostic x-ray and laboratory benefit is available subject to
these provisions:
1. Maximum Amount of Benefit Provided
This benefit provides payment of the provider's charge, not to
exceed the Reasonable and Customary charge, see Part One -
Definitions, for an included service, subject to the limitations
set forth below:
for each accident, up to one hundred dollars ($100.00) .
for all illnesses, up to an aggregate of one hundred dollars
($100.00) in any Calendar Year.
2. Diagnostic X-ray and Laboratory Services
This benefit covers only diagnostic x-ray and laboratory services
medically necessary in the diagnosing or treatment of:
Illness,
Injury, or
Disease.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations apply to this diagnostic x-ray and
laboratory benefit.
a. We do not cover services under this benefit while a Member
is receiving services provided while in an institution.
b. We do not provide benefits for eye examinations or
treatments.
C. We do not provide benefits for dental examinations or
treatments.
d. We do not provide benefits for routine physical examinations.
e. We do not provide benefits for mental, neuropsychiatric or
personality disorders.
47 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.3 Ambulance Benefit (Subscriber and Family Member)
This licensed ambulance benefit is available subject to these
provisions.
1. Maximum Amount of Benefit Provided
We provide licensed ambulance service, up to an aggregate of
fifty dollars ($50.00) for each accident or for each hospital
confinement, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Ambulance Services
This ambulance benefit covers only services to the nearest
hospital equipped to provide treatment.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations apply to this ambulance benefit.
We provide benefits only for licensed ambulance
. service. An ambulance must be licensed by the Federal
Government, State or Municipality in which it operates.
We do not provide this benefit for:
Private automobiles; or
Taxi services.
48 -
PART FIVE BENEFITS
5.3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member)
We pay up to the Reasonable and Customary charges, see Part One -
Definitions, for services rendered to a Member as the result of an
accident subject to these provisions:
The services received are medically necessary as defined in
Part One - Definitions; and
The services are prescribed by a physician; and
The accident occurs while the Member is covered under this
Contract.
1. Maximum Amount of Benefits Provided
We provide Supplemental Accident Benefits up to three hundred
dollars ($300.00) for each accident, in addition to the benefits
provided elsewhere in this Contract.
2. Supplemental Accident Services and Supplies
This benefit covers only the services listed below in connection
with an accident:
a. Services furnished and billed by a legally operated hospital up
to a two (2)-bed room except as stated in 5.3.3.a. and 5.3.3.b.
b. Professional services of a licensed physician. This benefit is
not available if the services are rendered by a physician who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
When a physician performs more than one surgical procedure the
following will apply:
At different times due to entirely unrelated causes,
benefits will be provided for each procedure;
At the same time in the same operative area, benefits will
be provided only for the procedure with the largest
allowance;
At the same time in different operative areas, full
benefits will be provided for the procedure with the
largest allowance plus one-half (1/2) of the allowance for
each additional procedure.
C. Necessary laboratory and x-ray examinations.
- 49 -
PART FIVE BENEFITS
5 .3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member) . . . (continued)
2. Supplemental Accident Services and Supplies . . . (continued)
d. Acute nursing services of a Registered Nurse when ordered by a
physician. This benefit is not available if the services are
rendered by a registered nurse who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
e. Professional services rendered by a physician or dentist
(D.M.D. or D.D.S.) for:
Treatment of a fractured jaw; or
Accidental injury to natural teeth.
f. Anesthetic supplies and administration of anesthesia by:
An anesthesiologist; or
A registered nurse anesthetist.
g. Services of a physician or a licensed or registered physical
therapist for physical therapy treatments.
This benefit is not available if the services are rendered by a
physician or a licensed or registered physical therapist who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
h. Licensed ambulance services to the nearest facility equipped to
render treatment of the condition.
Licensed ambulance service is not available unless other means
of transportation would endanger the health and safety of the
Members. This benefit is not available for:
Private automobiles; or
Taxi services.
i. Drugs and medicines when:
Directly related to the treatment of an injury; and
Requiring a written prescription; and
Dispensed by a licensed pharmacist or physician.
50 -
PART FIVE BENEFITS
5.3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member) . . . (continued)
2. Supplemental Accident Services and Supplies . . . (continued)
J. Medical supplies and prosthetic devices directly required for
the appropriate treatment of an accidental injury, such as:
Casts;
Splints;
Trusses;
Braces;
Crutches;
Prosthetic devices to replace all or part of an absent body
organ or to aid in its function when impaired, except that
only the initial charge for the first such prosthetic device
will be included. Benefits will not be provided for the
replacement of prosthetic devices, except when the existing
device cannot be repaired and replacement is recommended by
a physician due to a change in the Member's physical
condition (growth or physical deterioration) . Covered
prosthetic devices include, but are not limited to:
artificial limbs or eyes, and contact lens(es) to replace a
missing portion of the eye.
k. Rental or, at our option, the initial purchase of durable
mechanical medical equipment, see Part One - Definitions, which
is prescribed by a physician and required for therapeutic use in
the direct treatment of an accidental injury, such as:
Wheelchair;
Hospital-type bed;
Intermittent Positive Pressure Breathing Apparatus.
Special or extra-cost features and options which are convenience
items and do not primarily serve a medical purpose will not be
covered. In cases where there is an appropriate alternative
type of equipment that is less costly and serves the same
medical purpose, the Plan will provide benefits for the
equipment carrying the lesser charge.
1. Blood transfusions, including the cost of blood and blood
derivatives.
51 -
PART FIVE BENEFITS
5.3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member) . . . (continued)
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations will apply:
a. We do not provide benefits for items of a personal nature
billed by a legally operated hospital such as:
Meals for guests; or
Long distance telephone charges or telegraph charges; or
Radio or television charges; or
Barber or beautician charges.
b. If a Member uses a private room, he or she is responsible for
the difference in cost between the private room and the
hospital's most common two (2)-bed room rate. If the hospital
has only private rooms, we will determine a room allowance
based upon two (2)-bed room charges of other hospitals in the
area.
C. The amount of charges for care, services or supplies paid under
other benefits of this Contract are not included under this
benefit.
d. We do not provide benefits for treatment received more than
ninety (90) days after the date of the accident.
e. We do not provide benefits for disease or infection, except for
infection occurring as a result of an accidental cut or wound.
f. We do not provide benefits for the services of a dentist,
except as specifically provided in 5.3.2.e.
g. We do not provide benefits for eye refraction, eye glasses or
their fitting, or contact lens(es) due to an accident, except
as specifically provided in 5.3.2.j .
h. We do not provide benefits for food poisoning.
i. We do not provide benefits for an accident that occurred before
a Member's effective date under this Contract.
Termination of the Member's coverage under this Contract will not
affect any claim under this Supplemental Accident Benefit. See
Part Seven for benefits after termination.
- 52 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT (Subscriber and Family Member)
We provide benefits up to the Reasonable and Customary charge, see
Part One - Definitions, for services rendered in the treatment of `.9
illness, injury or pregnancy as indicated below, provided:
It is medically necessary (see Part One - Definitions) ; and
The Member is under the care and treatment of a physician; and
Services are received on or after the Member's Effective Date
of coverage under this Contract.
A. Major Medical Deductible
Before Major Medical Benefits are provided, a required deductible
must be met. The deductible is the first $50.00 of expenses
incurred for covered services by each Member. The deductible amount
is applied as follows:
ied once
calendar
1. The dedutible asclo g as0°thetMember must bremainsf h continuouslycovered.
year,
If a Member's coverage lapses for any period of time, a new
deductible must be satisfied upon renewal of coverage under
this group contract.
2. A family unit will be required to satisfy an aggregater(total)
of only $150.00 in deductible amounts during
Once this amount is satisfied, the deductible for all family
members is satisfied for that calendar year, as long as the
Subscriber remains continuously covered.
If the Subscriber's coverage lapses for any period of time, the
family unit will be required to satisfy a new aggregate
deductible upon renewal of coverage under this contract.
3. If two or more family members suffer
deductbodily
ible injury
ount as atresult
of the same accident, only one
be
satisfied before the Major Medical benefits of this Contract
will be provided for covered expenses as the result of that
accident during the year in which the accident occurs.
4. When expenses incurred in the last quarter of the year are used
to satisfy that year's deductible, the amount applied to the
deductible also applies to the following year's deductible. If
the expenses carried forward are in connection with an accident
involving two (2) or more family members, the expenses incurred
by these members as a result of that accident are subject to
only one deductible amount in the next year.
- 53 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
B. Maximum Amount of Benefits Provided
We provide Major Medical Benefits for covered services up to the
following maximum amounts:
1. When a Member remains continuously covered and incurs expenses
for covered services that exceed any deductible amounts stated
in Part Five 5.4.A. , we will pay up to a lifetime maximum of
two hundred fifty thousand dollars ($250,000.00) at the
following percentages except where a different percentage is
stated for specified benefits under 5.4.C. :
(a) eighty percent (80%) until two thousand dollars
($2,000.00) has been paid for expenses incurred during any
Calendar Year on a Member's behalf; and
(b) one hundred percent (100%) of the charges for all other
covered expenses incurred during the remainder of that
Calendar Year.
If a Member's coverage lapses for any period of time, the
Member will return to the 80% level of coverage, as stated in
(a), above, upon renewal of coverage under this group Contract.
After fifty thousand dollars ($50,000.00) have been paid under
this Major Medical Benefit for a Member, payment will be made
by the Plan for one hundred percent (100%) of the Major Medical
expenses for that Member, without further requirements of a
Deductible Amount or co-insurance, up to a lifetime maximum of
two hundred fifty thousand dollars ($250,000.00) .
2. Each Calendar Year the Member is covered under this Contract we
will restore up to five thousand dollars ($5,000.00) of a
Member's benefit that has been paid by us. The restored
amounts will be added to the two hundred fifty thousand dollar
($250,000.00) lifetime maximum.
3. If this group coverage is replaced by a new Contract, any
amounts of the lifetime maximum which have been used will
transfer to the new Contract as long as the Member remains
continuously covered under the same group. If the Member's
coverage lapses, or he or she transfers to other Blue Cross
group coverage, a new lifetime maximum will be reinstated upon
renewal.
- 54 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Maior Medical Services and Supplies
This Major Medical Benefit includes only these services and supplies:
1. Services furnished and billed by a legally operated hospital up
to a two (2)-bed room except as stated in Part Six 6.1.14. and
6.1.15.
Use of an intensive care unit (includes coronary and constant
care units) is included in this benefit. Services in an
intensive care unit including nursing services provided by
hospital employees as a regular service are also included in
this benefit.
2. Professional services of a licensed physician. This benefit is
not available if the services are rendered by a physician who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
When a physician performs more than one surgical procedure, the
following will apply:
(a) at different times due to entirely unrelated causes,
- benefits will be provided for each procedure;
(b) at the same time in the same operative area, benefits will
be provided only for the procedure with the largest
allowance;
(c) at the same time in different operative areas, full
benefits will be provided for the procedure with the
largest allowance plus one-half (1/2) of the allowance for
each additional procedure.
- 55 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies (continued)
3. Professional services rendered by a dentist for:
Treatment of a fractured jaw; or
• Accidental injury to natural teeth if the Member is covered
• at the time of the accident and services are rendered
within twelve (12) months of the accident; or
Excision of tumors or cysts of the jaw, tongue, roof and
floor of the mouth; or
Excision of exostosis of the jaw and hard palate; or
. Incision and drainage of cellulitis; or
Incision or excision of accessory sinuses, salivary glands
or ducts; or
Surgical procedures required due to an injury involving
oral conditions such as fractured jaw, lacerations and
dislocations.
4. Acute nursing services of a Registered Nurse in the home when
such services are ordered by a physician. The maximum amount
of benefits payable on a Member's behalf is two thousand five
hundred dollars ($2,500.00) for such services during any
Calendar Year. This benefit is not available if the services
are rendered by a Registered Nurse who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
5. Anesthetic supplies and administration of anesthesia by:
An anesthesiologist; or
A registered nurse anesthetist.
6. X-ray therapy, radium therapy and radioactive isotope therapy.
7. Services of a physician or a licensed or registered physical
therapist rendered in connection with physical therapy
treatments. This benefit is not available if the services are
rendered by a physician or a licensed or registered physical
therapist who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
- 56 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies . . . (continued)
8. Diagnostic x-ray and laboratory services.
9. Licensed ambulance service to the nearest facility equipped to
render treatment of the condition.
Licensed ambulance service is not available unless other means
of transportation would endanger the health and safety of the
Members. This benefit is not available for:
Private automobiles; or
Taxi services.
10. Drugs and medicines lawfully obtainable when:
Directly required for the treatment of an illness,
injury or condition of pregnancy; and
Requiring a written prescription; and
Dispensed by a licensed pharmacist or physician.
11. Medical supplies and prosthetic devices directly required for
the appropriate treatment of illness, injury or conditions of
pregnancy, such as:
Casts;
Splints;
Trusses;
Braces;
Crutches;
Prosthetic devices to replace all or part of an absent
body organ or to aid in its function when impaired,
except that only the initial charge for the first such
prosthetic device will be included. Benefits will not
be provided for the replacement of prosthetic devices,
except when the existing device cannot be repaired and
replacement is recommended by a physician due to a
change in the Member's physical condition
(growth or physical deterioration) . Covered
prosthetic devices include, but are not limited to:
artificial limbs or eyes, and contact lens(es)
following cataract surgery or to replace a missing
portion of the eye (conditions of aphakia) .
57
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies (continued)
12. Rental or, at our option, the initial purchase of durable
mechanical medical equipment, see Part One - Definitions, which
is prescribed by a physician and required for therapeutic use
in the direct treatment of illness, injury or conditions of
pregnancy, such as:
Wheelchair;
Hospital-type bed;
Intermittent Positive Pressure Breathing Apparatus.
Special or extra-cost features and options which are
convenience items and do not primarily serve a medical purpose
will not be covered. In cases where there is an appropriate
alternative type of equipment that is less costly and serves
the same medical purpose, the Plan will provide benefits for
the equipment carrying the lesser charge.
13. Blood transfusions, including the cost of blood and blood
derivatives.
14. Services of a Chiropractor (D.C. ) as those of any other
physician, within the scope of the D.C. license. See
Part One - Definition of a Physician.
- 58 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies
(continued)
15. Services for a mental, neuropsychiatric, or personality
disorder. Benefits are limited to:
a. Inpatient care received during a medically necessary
Hospital stay, payable at the percentages stated in Part
Five 5.4.B.1. ; and
b. A maximum of twenty (20) visits in any one Calendar Year
for treatment received while a Member is not confined in a
Hospital, payable at fifty percent (50%) of the covered
expenses instead of the percentages stated in Part Five
5.4.B.1. Services must be rendered by a physician,
licensed psychologist or a Community Mental Health Agency.
Benefits are subject to any applicable waiting periods as
stated in Part Six 6.2.11.
16. Services provided by a Skilled Nursing Facility are not covered
under this Major Medical Benefit. However, skilled nursing
services are covered as Basic Benefits in Part Five 5.1.E. and
5.1.F.
- 59 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies . . . (continued)
17. Benefits for medically necessary covered services received by
the Member and rendered by an Approved Treatment Facility for
the treatment of Chemical Dependency, including detoxification
services, will be provided up to a maximum benefit of:
$5,000 per Member during any 24-consecutive-month
period for alcohol dependency, subject to a lifetime
maximum benefit of $10,000.
$5,000 per Member during any 24-consecutive-month
• period for drug dependency, subject to a lifetime
maximum benefit of $10,000.
Benefits for medically necessary covered therapeutic and
supporting services provided to enrolled Family Members to
assist in the patient's diagnosis and treatment will be subject
to the benefit maximum(s) of the patient undergoing treatment
for alcohol and/or drug dependency.
In addition to the Exclusions and Exceptions of Part Six,
Chemical Dependency Benefits will not be provided for:
Voluntary support groups such as Alanon, Alcoholics
. Anonymous, Narcotics Anonymous, and Cocaine Anonymous;
Separate charges for transportation, records and
reports;
Court ordered services, services related to deferred
. prosecution, deferred sentencing, suspended
sentencing, or services related to motor vehicle
driving rights unless deemed medically necessary by
the Plan. In such instances, the Member must, at the
Member's expense, furnish the Plan, no less than ten
(10) and no more than thirty (30) days before
treatment is to begin, an initial assessment of the
need for Chemical Dependency treatment and a treatment
plan. Such, assessment and treatment plan must be made
by a qualified alcohol and/or drug dependency
counselor or who is employed by an Approved Treatment
Facility or by a physician (M.D. or D.O.) .
- 60 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Maior Medical Services and Supplies . . . (continued)
18. Home Health Care is not covered under this Major Medical
Benefit. However, Home Health Care is covered as a Basic
Benefit under Part Five 5.10, if available.
61 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Maior Medical Services and Supplies (continued)
19. Hospice care is not covered as a Major Medical Benefit in this
Contract.
- 62 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies . . . (continued)
20. The Second Surgical Opinion is not covered under this Major
Medical Benefit. However, the Second Surgical Opinion Benefit
is covered as a Basic Benefit under Part Five 5.2.1.H. , if
available.
63 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT (continued)
D. Limitations
In addition to the Exclusions and Exceptions of Part Six, we do not
provide Major Medical Benefits for services or supplies that are
provided for under other benefits of this Contract. Basic Benefits,
if any, will be provided before Major Medical Benefits.
64
PART FIVE BENEFITS
5.5 BASIC BENEFITS: VISION CARE (Subscriber and Family Member)
This Contract does not provide a vision benefit.
65 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. (continued)
C. Predetermination of Benefits (continued)
If the dentist submits a treatment plan for P redeterm ross Pinationwil oadjust
Benefits and then changes the plan,
.this its payments accordingly. If the dentist makes a major change in
the treatment plan, the dentist may submit a revised Plan.
A Predetermination of Benefits is an estimate only and not a
guarantee of coverage or payment. Benefits provided to the Member
will be subject to the specific benefits, exceptions, exclusions,
limitations and eligibility provisions set forth in this Contract in
effect at the time the services are rendered.
D. Amount of Dental Benefits Provided
Benefits are provided at the percentages specified below for all
covered dental services (subject to the Reasonable and rendered during anyubenefit
stomary
charge, see Part One - Definitions) ,
year for any Member up to a maximum benefit of one thousand dollars
($1,000.00) . A benefit year is a period of twelve (12) consecutive
months beginning on the Member's effective date of coverage under
ecutive months
this Contract and each period of twelve (12) cons
thereafter.
During the first Benefit Year in which a Member utilizes the Type A
Dental Services listed below, the Plan shall pay toward expenses
incurred seventy percent (70%) of the amount specified herein for
the Dental Service performed, except that when a Member utilizes
such Dental Services during successive Benefit Years, commencing
with the second of such successive Benefit Years the percentage of
the amount payable by the Plan toward such benefits shall be
increased over such seventy percent (70%) by an additional ten
percent (10%) of the amount specified herein
for eachdsuccessive
Benefit Year until the Plan will be paying
one hercent
(100%) of the amount specified herein. However the
erc enta such of
the amount specified herein that the Plan will pay toward
benefits in a Benefit Year immediately following one or more Benefit
Years in which none of such benefits was utilized by a Member willercent
be reduced by ten percent (10%) but not to less than seventy p
(70%) of the amount specified herein for the service rendered.
During any Benefit Year, the Plan shall pay toward expenses incurred
for Type B Dental Services listed below, fifty percent (50%) .
67 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS; DENTAL CARE (Subscriber and Family Member)
. . . (continued)
E. Covered Dental Services
1. Type A Dental Services
a. Routine oral examinations (for diagnosing the oral health
of the patient and determining the dental care required) ,
limited to two (2) each Calendar Year.
b. Prophylaxis (cleaning, scaling and polishing of teeth),
limited to two (2) each Calendar Year.
C. Topical application of fluoride, for Members under age
twenty (20) , limited to two (2) treatments each
Calendar Year.
d. Dental x-rays.
e. Space maintainers, for Members under age twenty (20) .
f. Sealants, for Members under age fourteen (14), limited to
use on permanent teeth.
g. Simple extractions.
h. Oral surgery consisting of surgical extractions, fracture
and dislocation treatment, alveolar ridge augmentation,
and diagnosis and treatment of cysts or abscesses.
i. Fillings, consisting of silver amalgam, silicate and
plastic restorations. For other types of fillings, such.
as gold foils, the allowance will be limited to what would
have been otherwise allowed for amalgam fillings.
j . Treatment of periodontal and other diseases of the gums
and tissues of the mouth.
k. Endodontic treatment.
1. Repair or recementing of crowns, inlays, bridgework or
dentures.
M. Emergency palliative treatments.
68 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
E. Covered Dental Services . . . (continued)
2. Type B Dental Services
a. Inlays, onlays, or the initial placement of crowns, when
in the reasonable opinion of the Plan, amalgam fillings
would not adequately restore the teeth.
b. Replacement crowns, but only when:
The existing crown was seated at least five (5) years
prior to replacement; or
Repreparation of the natural teeth is required as a
result of an accidental injury.
C. Initial installation of dentures (including adjustments
during the first six (6) month period following
installation) or fixed bridgework (including inlays and
crowns to form abutments. )
d. Replacement dentures or fixed bridgework, but only when:
The existing denture or bridgework was installed at
least five (5) years prior to replacement; or
The replacement or addition of teeth is required to
replace one or more additional teeth extracted after
initial placement; or
Repreparation of the natural teeth in the existing
fixed bridgework is required as a result of an
accidental injury.
e. Relining of dentures.
F. Limitations, Exceptions and Exclusions
In addition to the Exclusions and Exceptions of Part Six, the
following limitations, exceptions and exclusions shall apply to this
benefit:
1. We provide benefits as if only one dentist provided the service
or supply if:
The Member transfers from the care of one dentist to
that of another dentist during the course of his or
her treatment; or
More than one dentist renders services for one dental
procedure.
- 69 -
PART FIVE BENEFITS
5 .6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
F. Limitations, Exceptions and Exclusions (continued)
2. Benefits for restorative or prosthetic dental services are
limited to standard techniques regardless of whether the Member
and the dentist decide:
On personalized restoration; or
To employ, special techniques, such as precision
attachments.
3. Except for extractions incidental to orthodontic services, we
do not provide benefits for services or supplies related to
orthodontia (see Part One - Definitions) .
4. Except for a child covered under this Contract from birth, we
do not provide benefits for the treatment of congenital
malformations.
5. We do not provide benefits for expenses incurred after
termination of a Member's coverage under this Contract except
for prosthetic devices, crowns, or root canals which:
Were fitted, prepared, started or ordered prior to the
date of termination of the Member's coverage under
this Contract; and
Were delivered to the Member, completed or seated
• within thirty (30) days after the date of the
termination of the Member's coverage under this
Contract.
6. In all cases where there are, in the reasonable opinion of this
Plan, alternate courses of treatment carrying different fees,
the Plan will only provide benefits for the treatment carrying
the lesser fee.
7. This Contract must be in effect at the time the Member receives
services or supplies, except as provided in Part Five 5.6.F.5. ,
above.
8. We do not provide benefits for dental services received from a:
Dental or medical department maintained for employees
by or on behalf of an employer; or
Mutual benefit association, labor union, trustee or
similar person or group.
9. We do not provide benefits for facility charges for dental
procedures.
70 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
F. Limitations, Exceptions and Exclusions . . . (continued)
10. We do not provide benefits for services or supplies which:
Are not customary and accepted by the dental
profession in the States of Washington or Alaska; or
Are for the purpose of research; or
Are experimental.
11. We do not provide benefits for dietary planning for the control
of dental caries, oral hygiene instruction and training in
preventive dental care.
12. We do not provide benefits for charges for services or supplies
for implantology (tooth implantation).
13. We do not provide benefits for charges for broken appointments.
14. We do not provide benefits for services or supplies to increase
or alter the vertical dimension.
15. We do not provide benefits for services or supplies not
necessary, in the reasonable opinion of the Plan, for proper
dental care.
16. We do not provide benefits for separate charges for study
models or casts.
17. We do not provide benefits for extra dentures or other covered
appliances, including replacements due to loss or theft.
18. We do not provide benefits for drugs and medicines, whether or
not they require a prescription.
However, benefits for prescription drugs and medicines are
provided for under the Major Medical Benefit, if available.
19. We do not provide benefits for braces, banding or retainers.
20. Dental services, supplies and treatment must be provided by a
dentist performing within the scope of his or her license.
Dental services, supplies and treatment may also be provided by
a licensed dental hygienist or other individual performing
within the scope of his or her responsibilities as allowed by
Washington or Alaska law if the treatment is rendered under the
supervision and guidance of the dentist.
- 71 -
PART FIVE BENEFITS
5.7 BASIC BENEFITS: PRESCRIPTION DRUGS (Subscriber and Family Member)
Prescription Drugs are not covered as a Basic Benefit under this
Contract. See, however, 5.4.C.10. for related Major Medical Benefits,
if available.
72 -
PART FIVE BENEFITS
5.8 BASIC BENEFITS: HEARING AIDS
This Contract does not provide a hearing aid benefit.
5.9 BASIC BENEFITS: ORTHODONTIA
This Contract does not provide an orthodontia benefit.
73
PART FIVE BENEFITS
5.10 BASIC BENEFITS: HOME HEALTH CARE
This home health care benefit is available subject to these provisions:
A. Amount of Benefits Provided
This benefit provides payment at one hundred percent (100%) of the
provider's charge, not to exceed the Reasonable and Customary charge
(see Part One - Definitions) for services provided and billed by a
Medicare-approved or Department of Social and Health Services
certified home health care agency for medically necessary treatment
of illness or injury. The services must be part of a formal written
treatment plan prescribed by a physician (M.D. or D.O.) , who must
certify that the Member is homebound and that hospital or skilled
nursing facility confinement would be required in the absence of
this benefit. The plan of treatment must begin within four days of
a hospital or skilled nursing facility confinement lasting at least
three consecutive days.
B. Home Health Care Agency Services and Supplies
Covered services of a home health agency are those visits for
intermittent care by a registered nurse or licensed practical nurse,
licensed physical therapist, a certified occupational therapist, an
American Speech and Hearing Association certified speech therapist,
a certified respiratory therapist, and a home health aide acting
under the direct supervision of one of the above therapists while
performing services specifically ordered by a physician. Also
covered are disposable medical supplies and drugs and medicines
prescribed by a physician when provided by the agency.
C. Limitations
In addition to the Exclusions and Exceptions of Part Six, Home
Health Care benefits are not available for:
homemaker or housekeeping services,
supportive environmental materials (handrails, ramps, etc.),
services performed by family members and volunteer workers,
social services,
psychiatric care,
separate transportation charges,
unnecessary and inappropriate services,
maintenance or custodial care, or
any services or supplies not included in the written treatment
plan or not specifically mentioned as covered.
74 -
PART FIVE BENEFITS
5.11 BASIC BENEFITS: HOSPICE CARE
Hospice Care is not included as a Basic Benefit under this Contract.
75 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions
In addition to the limitations listed in Part Five - Benefits, we do not
provide benefits for the following:
1. Routine Examinations, X-Ray and Laboratory Testing
Physical examinations; including screening examinations, tests,
x-ray, laboratory, pathological services, and machine diagnostic
tests if they are not directly related to an:
Illness; or
Disease; or
Injury; or
Pregnancy; or
Definitive set of symptoms.
2. Treatment for Obesity
Treatment for obesity, including:
Surgery; or
Complications of surgery.
3. Routine Foot Care
Routine foot-care procedures such as, but not limited to:
Trimming of nails, corns or calluses; or
Routine hygienic care.
4. Symptomatic Complaints of the Feet and Orthotics
Services and supplies for:
Fallen arches; or
Other symptomatic complaints of the feet; or
Impression casting for prosthetics and appliances
(orthotics) including the prescriptions needed to make them.
5. Milieu Therapy
Milieu Therapy, see Part One - Definitions.
6. Conditions Resulting From War
Conditions caused by or arising out of the following:
An act of war; or
Armed invasion or aggression.
7F ..
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions .
. (continued)
7. Services or Procedures Not Accepted by the Medical Profession
Services or procedures which are not
by the medical generally performed or accepted
profession in the States of Washington and Alaska;
any treatment, procedure, facility, equipment, drug, drug usage,
device or supply which is considered experimental or investigative
at the time rendered. See Part One - Definitions.
8. Reproductive and Sexual Disor
-- ��uG1s and Defects
Services, supplies and procedures for reproductive and sexual
disorders and defects, whether or not the consequences of illness,
disease or injury, including but not limited to the following
conditions and procedures:
Impotency;
Frigidity;
Infertility;
Reversal of surgical sterilization;
Artificial insemination and in-vitro fertilization.
9. Sex Transformations
Services and supplies or drugs for sex transformations.
10. Services or Su lies Not Medically Necessar
Services or supplies not medically necessary, see Part One -
Definitions, even if ordered by a court of law.
11. Services or Su lies Not Charged For
Any services or supplies for which no charge is made; or
• That would not have been made if this Contract were not in
effect; or
For services or supplies for which a Member is not legally
liable.
- 77 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions . . . (continued)
12. Work-Related Conditions and Workers' compensation
a. For those non-uniformed (#828-01) and LEOFF II (#828-02)
employees: any condition, ailment or injury for which the
Member is entitled to receive benefits, even if he or she fails
to make timely application for those benefits or waives his or
her rights to them:
under occupational coverage, required of or voluntarily
obtained by the employer; or
state or federal workers' compensation acts; or
employer liability acts; or
other laws providing compensation for work-incurred
injuries.
b. LEOFF I employees of Group #828-04 covered under the Law
Enforcement Officers and Firefighters Act of 1969 will be
covered under this Contract for non-occupational injuries,
conditions or ailments and conditions, injuries and ailments
connected with their occupation as law enforcement officers or
firefighters as employees of the Group, notwithstanding
Part Six 6.1.1. through 6.1.12.a.
13. Counseling or Training Services
Services or supplies for:
Learning disabilities; and
Marital, family or sexual counseling; and
Other counseling or training services.
14. Personal Charges Billed Bv An Institution
We do not provide benefits when billed by an institution for
services of a personal nature such as:
Meals for guests; or
Long-distance telephone charges; or
Radio or television charges; or
Barber or beautician charges.
- 78 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions . . . (continued)
15. Private Room Charges - Inpatient Hospital
We do not provide benefits for the use of private rooms during an
inpatient Hospital stay.
If a Member uses a private room, he or she is responsible for the
difference in cost between the private room and the Hospital's most
common two (2)-bed room rate. If the Hospital has only private
rooms, we will determine a room allowance based upon the two (2)-bed
room charges of other Hospitals in the area.
16. Rehabilitative Care
Admissions or treatment for rehabilitative care, including but not
limited to, speech and occupational therapy, are not included
benefits
17. Convalescent or Custodial Care
See the exception in Part Six, 6.2.1.
18. Motor Vehicle Liability. or Personal In ury Protection Insurance
Services and supplies to the extent that benefits are payable under
the terms of any automobile medical, automobile no-fault, automobile
uninsured motorist and/or underinsured motorist, personal injury
protection (PIP), commercial liability, homeowner's policy, or other
similar type of insurance or Contract.
19. Hearing Aid Services or Supplies
We do not provide services for:
Hearing examinations
Hearing aids, new or replacement.
- 79 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions . . . (continued)
20. Vision Care, Services or Supplies
We will not provide benefits for:
Eye examinations; or
Eye glasses; or
Visual analysis; or
Vision therapy; or
Training relating to muscular imbalance of the eye
(orthoptics); or
Pleoptics; or
Services, supplies and procedures relating to altering the
refractive character of the cornea, and their results, both
direct and indirect, including, but not limited to
radial keratotomy, corneal modulation, keratomileusis, or
refractive keratoplasty; or
Services of an optometrist.
21. Orthodontia
We do not provide benefits for services and supplies for orthodontia
(see Part One - Definitions) .
22. Hospice Care
We do not provide benefits for services and supplies furnished and
billed by a Hospice.
80 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions
This Contract does not provide benefits for treatment, care, services or
supplies except as stated in the paragraphs below or in the specific
Benefits of Part Five.
1. Convalescent or Custodial Services
Unless stated in Part Five 5.1.E. or 5.1.F. , we do not provide
benefits for convalescent or custodial services no matter where the
services are rendered, for any portion of a Hospital stay that
becomes convalescent or custodial care, or for services furnished by
an institution that is:
A Skilled Nursing Facility; or
A place of rest; or
A place for the aged; or
A nursing home; or
A convalescent home.
2. Well Baby Care
We do not provide benefits for well baby care except for Hospital
infant nursery care for the newborn infant. Thq mother must also be
hospitalized and receiving benefits for maternity care under this
Contract.
3. Dental Care, Services or Supplies
We do not provide benefits for dental services or services of a
dentist unless stated in Part Five:
5.2.1.A.2.b. - Surgical Benefit; or
5.6. - Dental Benefit; or
5.3.2.e. - Supplemental Accident; or
5.4.C.3. - Major Medical.
4. Inpatient Hospital Care for Dental Procedures
We do not provide inpatient Hospital care for dental procedures
unless:
Adequate treatment cannot be provided without the use of
Hospital facilities; and
There is a co-existing medical condition, other than the
condition for which the Member requires treatment, that
makes hospitalization necessary for health and safety.
- 81 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
5. Cosmetic Services, Supplies and Procedures
Services, supplies and procedures for cosmetic, plastic and
reconstructive purposes and their results, direct or indirect, are
not included benefits, except:
To repair a defect caused by an accidental injury occurring
while covered under this Contract;
To repair a dependent child's congenital anomaly;
For the initial reconstruction of the involved breast
following a mastectomy necessitated by disease, illness or
injury. Benefits will also be provided for all stages of one
reconstructive breast reduction on the non-diseased breast
to make it equal in size with the diseased breast after
definitive reconstructive surgery on the diseased breast has
been performed; or
When incidental to or following a covered surgery which
resulted from disease of the involved body part and necessary
to improve or correct the function of the involved body part.
Below are some examples of what are not included benefits:
Surgery for sagging skin of the eyelids (blepharochalasis) ,
face, neck, abdomen, hips or extremities
(meloplasty, rhytidectomy or lipectomy);
Breast 'enlargement, reduction or uplift procedures
(except as stated above); or
Reshaping of the nose (rhinoplasty) .
6. Hospital Admissions for Testing or Physical Examinations
We do not provide inpatient Hospital care for diagnostic studies,
physical examinations, check-ups, medical evaluations or
observations unless:
The services cannot be provided without the use of inpatient
Hospital facilities; or
There is a medical condition that makes hospitalization
necessary for the Member's health and safety.
7. Care Received in a County, State or U.S. Government Hospital
We do not provide benefits for care, services or supplies received
in a Non-Participating Hospital owned or operated by a county, state
or federal agency, except:
For treatment of a medical emergency
(See Part One - Definitions); or
As otherwise required by federal law.
All services and supplies must be furnished and billed by the
Hospital.
- 82 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
8. Coordination of Benefits
A. Benefits Subject to This Provisions
All of the benefits provided under this Contract are subject to
these provisions.
B. Definitions
1. Program means the following sources of benefits which will
be recognized for coordination of benefits purposes:
(a) Group or blanket disability insurance or health care
program issued by insurers, health care services
contractors and health maintenance organizations;
(b) Labor-management trustee plans, labor organization
plans, employer organization plans or employee
benefit organization plans;
(c) Governmental Programs which provide benefits for
their own civilian employees or their dependents.
This does not include Medicare.
(d) Coverage required or provided by any statute.
(e) Group student coverage provided or sponsored by a
school or other educational institution which
includes medical benefits for illness or disease.
The term "Program" will be separately understood to mean
each program which does or which does not provide for
coordination of benefits. Each portion of a Program which
separately states whether it is not or is not subject to
this provision will also be determined to mean a separate
"Program."
2. Allowable Expense means any necessary, reasonable and
customary item of expense at least a portion of which is
covered by at least one of the Programs covering the
Member for whom the claim is made. When a Program
provides benefits in the form of services rather than cash
payments, the reasonable cash value of the service will be
considered as both an allowable expense and a benefit paid.
3. Claim Determination Period means a Calendar Year.
- 83 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
8. Coordination of Benefits . . . (continued)
C. Effect on Benefits
Coordination of Benefits comes into effect when a Member has
health care coverage under more than one Program. If, in the
absence of this provision, the sum of the benefits available
under this Program and the benefits available under all other
Programs covering the Member, would be greater than the total
amount of Allowable Expenses incurred by that Member during the
Claim Determination Period, the Programs involved will
coordinate their benefits according to this provision.
In order to coordinate benefits, it must be determined which
Program will be responsible for providing benefits first. Such
Program is determined to be "Primary." The Primary Program is
responsible for paying available Program benefits as if the
coordination of benefits provision did not exist. The
remaining Programs are determined to be "Secondary." The
Secondary Programs will reduce the benefits that would have
been paid in the absence of this provision, so that the sum of
the benefits paid by all the Programs covering the person will
not exceed the total amount of Allowable Expenses incurred.
Benefits payable under another Program include the benefits
that would have been payable whether or not a claim was
actually submitted to the Program.
The following rules will apply in determining which Program
will be Primary:
1. A Program which does not provide for coordination of
benefits will always be Primary over a Program which
includes a coordination of benefits provision.
2. When a Member is covered by more than one Program and each
Program involved includes this provision, the following
rules shall apply in determining which Program is Primary:
(a) Non-Dependent/Dependent
The Program which covers the Member as other than a
dependent shall be Primary over the Program which
covers the Member as a dependent.
(b) Dependent Child/Parents Not Separated or Divorced
If the Member is a dependent Child and the parents of
the Child are not separated or divorced, the
following rules will apply:
- 84 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 EXce�S • • • (continued)
g, Coordination of Benefits .
(continued)
C. Effect on Benefits . . . (continued)
(i) The Program which covers the Member as the
dependent of the parent whose birthday falls
earlier in a year will be Primary over the
Program which covers the Member as the
dependent of the parent whose birthday falls
later in that year.
(ii) If the other Program does not have the rule
described in (i) immediately above regarding
dependents, which results in each Program
determining its benefits before the other or
in each Program determining its benefits after
the other, the provisions of subsection (i)
above shall not apply, and the rule set forth
in the Program which does not have the
provisions of subsection (i) above shall
determine the order of benefits.
(c) Dependent Child/Separated or Divorced Parents
However, if the Member is a dependent Child and the
parents of the Child are separated or divorced, the
following rules will apply:
(i) If the parent with custody of the Child has
not remarried, the Program which covers the
Child as a dependent of the parent with
custody of the Child will be Primary over the
Program which covers the Child as a dependent
of the parent without custody.
(ii) If the parent with custody has remarried, the
Program which covers the Child as the
dependent of the parent with custody will be
Primary over the Program which covers the
Child as the dependent of a step-parent.
the Program which covers the Child as the
dependent of the step-parent will be Primary
over a Program which covers the Child as a
dependent of the parent without custody.
- 85 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exce�ns . . . (continued)
8. Coordination of Benefits
. (continued)
C. Effect on Benefits
. (continued)
(iii) If there is a court decree which establishes
financial responsibility for the health care
expenses of the Child, this will take
precedence over (i) and (ii), above. In this
case, the Program which covers the Child as the
dependent of the parent with such financial
responsibility will be Primary over any other
Program which covers the Child as a dependent.
(d) Active/Inactive Employee
When rules (a), (b) or (c) do not determine which
Program has responsibility for Primary payment of
benefits, the Program which has covered the Member
for the longer period of time will be Primary over
the Program which has covered the Member for the
shorter period of time provided that:
M The benefits of a program covering the person
on whose expenses claim is based as a laid off
or retired employee, or dependent of such
person, shall be determined after the benefits
of any other program covering such person as an
employee, other than a laid off or retired
employee, or dependent of such person; and
(ii) If either program does not have a provision
regarding laid off or retired employees, which
results in each program determining its
benefits after the other, then the provisions
Of (i) above of this subsection shall not apply.
(e) Longer/Shorter Length of Coverage
If none of the above rules determines the order of
benefits, the benefits of the program which covered
an employee, Member or Subscriber longer are
determined before those of the program which covered
that person for the shorter time.
86 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
8. Coordination of Benefits . . . (continued)
C. Effect on Benefits . . . (continued)
3. When this provision operates to reduce the total amount of
benefits otherwise payable as to a Member covered under
this Program during any Claim Determination Period, each
benefit that would be payable in the absence of this
provision shall be reduced proportionately, and the amount
reduced will be applied toward any Allowable Expense
incurred during a Claim Determination Period. The Member
shall not be entitled to benefits in excess of the total
maximum benefits of the Program during the Claim
Determination Period.
D. Determination of Other Coverage
This Plan will not be required to determine the existence or
extent of any other group coverage. The benefits payable under
this Program shall be affected by coordination of benefits only
to the extent that other Program information is supplied to the
Plan by the Member, the other group, the provider of services,
or any other organization or person.
E. Facility of Payment
Whenever payments which should have been made under this
Program in accordance with this provision have been made under
any other Program, the Plan shall have the right, exercisable
alone and in its sole discretion, to pay over to any Program
making such other payments any amounts it shall determine to be
warranted in order to satisfy the intent of this provision, and
amounts so paid shall be considered benefits paid under this
Program and, to the extent of such payments, the Plan shall be
fully discharged from liability under this Program.
9. Rights to Benefits After Termination
Unless provided in Part Seven 7.1. , we do not provide benefits under
this Contract for services, treatment, medical attention or care
which a Member received after his or her termination date.
No rights are vested under this Contract.
10. Contract Must Be In Effect
Unless stated in Part Seven 7.1 - Benefits After Termination, this
Contract must be in effect at the time a Member receives services.
- 87 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
11. Waiting Periods
Waiting periods do not apply to this Contract.
12. Upper or Lower Augmentation or a
R_••uction Procedures
Except for Members continuously covered by this Plan from date of
birth, upper or lower ,jaw augmentation or reduction procedures,
orthognathic surgery, are not covered.
13. Mental Neuro s chiatric or Personality Disorders
Unless stated in Part Five 5.1.A. or 5.4.C.15. , we do not provide
benefits for mental, neuropsychiatric or personality disorders.
14. Treatment of Chemical Dependency
Treatment for alcohol or drug use, abuse or dependency, except as
specifically defined under the definition of Chemical Dependency and
as provided under Part Five 5.4.C.17.
15. Charges Over Reasonable and Customary
Except for the charges of a Participating Dentist, charges or fees
in excess of the Reasonable and Customary charge, see Part One -
Definitions, shall be the responsibility of the Members.
16. Governmental Plan or Program
Services and supplies for which the Member is entitled to receive
benefits from any federal, state, or governmental program, including
Medicare (even though the Member fails to make timely application
for or waives rights to such benefits), except as otherwise required
by law.
Effect of Medicare: If the employer is subject to federal
"working aged" laws, this Contract provides benefits primary over
Medicare for covered, active employees or their covered spouses, who
are sixty-five (65) or older and have elected primary coverage under
this Contract.
This Contract also provides benefits primary over Medicare, to the
extent that an employer-sponsored health care program is required to
do so by federal law, for covered services for a Member's kidney
transplant or renal dialysis, and for covered active employees or
their dependents when the employee or dependent is under age
sixty-five (65), disabled, and covered by Medicare.
- 88 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . ,
. (continued)
16. Governmental Plan or Program .
• (continued)
In all other instances, benefits payable by Medicare will be
subtracted from total covered expenses before the benefits of this
Contract are calculated, whether or not such Medicare benefits have
been claimed.
17. Second Surgical Opinion
Unless stated in Part Five 5.2.1.H. , we do not provide benefits for
Second Surgical Opinion Benefit.
18. Home Health Care
Unless stated in Part Five 5.10. , we do not
provide
for
services and supplies furnished and billed byaHomeb Health sCare
Agency.
19. Chiropractic Services
Unless stated in Part Five 5.4.C.14. , we do not provide benefits for
care, services and supplies furnished by a chiropractor.
- 89 -
PART SEVEN BENEFITS AFTER TERMINATION
As stated in Part Two, Section D. , the benefits of this Contract may continue
after termination or cancellation subject to the following provisions:
7.1 Individual and Group Cancellation of Coverage Under This Contract
Coverage under this Contract shall terminate automatically upon
termination of the Member's eligibility or upon Group cancellation of
this Contract unless:
1. Coverage terminates while a Member is confined in a Hospital,
Skilled Nursing Facility or Approved Treatment Facility. Inpatient
benefits specified in this Contract will continue to be available
until the first of the following occurs:
The Member is discharged; or
The Member no longer requires such care; or
We have provided the maximum amount of benefits.
2. The Member is totally disabled and no longer employed or connected
with the Group at the time coverage ends. The Major Medical
Benefits will be available only for the condition which caused the
disability. Such benefits will be available until the first of the
following occurs:
Benefits have been provided for the number of months equal
to the number of months the Member was covered, up to a
maximum of twelve (12) months; or
We have provided the maximum Major Medical Benefits.
Payment for covered services will be made if:*
The Member is under a physician's care: and
The Member submits evidence of the disability within ninety
(90) days after coverage ends. The Member's physician must
complete a Statement of Disability (Form 400-1496) which is
available from us. The Member must notify us if the total
disability ceases.
The total disability benefits specified in this section are not
available if the disability occurs after the termination of the
Member's eligibility under this Contract or the Cancellation of this
Contract.
*If this Contract is cancelled after the Member has commenced his or
her total disability period, the termination will not affect the
Member's right to total disability benefits.
90 -
PART SEVEN BENEFITS AFTER TERMINATION
7.1 Individual and Group Cancellation of Coverage Under This Contract
. . . (continued)
3. The Member is receiving the Supplemental Accident Benefit outlined
in Part Five 5.3. Such benefits will continue until the first of
the following occurs:
The end of ninety (90) days from the date of the accident;
or
We have provided the maximum Supplemental Accident Benefit.
7.2 Continuation of Employment - Nonpayment of Subscription Charges
If the Subscriber or the Group ceases to pay the Subscription Charges
required by this Contract while he or she remains employed or connected
with the Group, the coverage terminates automatically. The Terminal
Benefit of 7.1.2. will not apply.
- 91 -
PART EIGHT GENERAL PROVISIONS
8.1 Availability of Health Care
The services provided under this Contract are at all times subject to
availability of Hospital facilities and the ability of Hospitals,
Hospital employees, physicians and other providers to furnish services.
We assume no liability for conditions beyond our control which make it
impossible for services provided by this Contract to be obtained, such as:
Epidemics; or
Natural disasters; or
Civil disorders; or
War; or
Labor dispute.
8.2 Hospitals Furnishing Care - Independent Contractors
We are not liable for any death, injury, illness or other condition
occurring to a Member while receiving care by, through or from a Health
Care Provider or Participating Hospital or other institution. Those who
furnish care or other benefits to a Member do so as independent
contractors.
8.3 Notice
Any notice this Plan is required to submit to the Group will be
considered delivered if mailed to the Group at the address appearing on
the records of the Plan. The Plan may submit notices, including
individual identification cards and descriptive benefit booklets or
notifications of modifications thereto, to covered employees by the same
means. The Group agrees to receive and promptly deliver all notices on
behalf of the covered employees.
8.4 Claim Appeal Procedure
Upon our final review and denial of a specific claim, the Plan will send
the Member an Explanation of Benefits (E.O.B.) form explaining how the
claim was processed.
92 -
PART EIGHT GENERAL PROVISIONS
8.4 Claim Appeal Procedure . . . (continued)
If the Subscriber disagrees with our denial in whole or in part, and the
Plan's Customer Service Department confirms the original denial, the
aggrieved Subscriber or his or her authorized representative must request
a formal review in writing within sixty (60) days of receipt of the
E.O.B. form. This written request must be received by us within the
sixty (60)-day period and contain the following information:
Subscriber name
Subscriber Identification number
Other identifying information found on the face of the
E.O.B. form.
A concise statement of issues
Any data, document(s) or comments the Subscriber wants to
have considered.
We will notify the appealing Subscriber of our determination within sixty
(60) days following our receipt of the Subscriber's request. If special
circumstances require an extension of time, the Subscriber will be
notified of the delay and the reasons therefor. The delay will be no
more than an additional sixty (60) days. Our determination in response
to an appeal will .be final in the opinion of the Plan.
- 93 -
PART NINE EMPLOYER INFORMATION
9.1 Subscription Charges and Grace Period
A. The Group shall pay to this Plan monthly the following
Subscription Charges:
For Group 828-01:
Employee $107.07
Employee and Spouse $184.81
Employee, Spouse and Children $232.94
Employee and Children $155.20
For Group 828-02. -04:
Employee $132.69
Employee and Spouse $210.43
Employee, Spouse and Children $258.56
Employee and Children $180.82
Subscription Charges are initially due in advance of the Effective
Date as stated on the first page of this Contract. Thereafter,
periodic payment(s) of Subscription Charges are due each month by
the day preceding the day of the month corresponding with said
effective date. However, a grace period of ten (10) days from each
due date is allowed to the Group for payment of any periodic
payment. No benefits are payable for claims incurred during any
time period for which Subscription Charges have not been paid.
The initial term and Subscription Charges of this Contract shall be
for twelve (12) months from its effective date as stated on the
first page and monthly thereafter, unless changed or terminated as
stated in 9.3. However, if any government imposes or changes any
tax on Plan revenue or mandates a change in benefits, the Plan may
then adjust Subscription Charges at any time to offset the effect on
its revenue.
B. After the expiration of the term of the Contract stated in 9.1.A.
above, the amount of the monthly Subscription Charges may be changed
by the Plan. The Plan shall notify the Group of any change at least
thirty (30) days before the date the change is to be effective.
Payment of the revised Subscription Charges constitutes acceptance
of the change.
94 -
PART NINE EMPLOYER INFORMATION
9.2 Records
A record of all employees and their dependents shall be maintained by the
Group and shall contain all information the Plan may require to
administer the provisions of the Contract. Such records shall be open
for inspection by the Plan at any reasonable time.
9.3 Termination By Group or Plan
A. By the Group
The Group may terminate this Contract at any time by giving at least
thirty (30) days' advance written notice to the Plan.
B. By the Plan
The Plan may terminate this Contract at the end of the initial term,
or at the end of any subsequent term, by giving at least thirty
(30) days advance written notice to the Group. The Plan reserves
the right to cancel the Contract at any time, by written notice as
specified above, on any monthly Subscription due date, if the Group
fails to maintain the enrollment requirements as specified or fails
to administer the provisions of the Contract.
95 -
ENDORSEMENT ONE
The Contract between CITY OF KENT and BLUE CROSS OF WASHINGTON AND ALASKA,
which became effective January 1, 1987, is hereby amended.
The purpose of this Endorsement is to amend the Benefits Section of the
Contract by moving the Chemical Dependency Benefit from the Major Medical
Benefits section of the Contract to the Basic Benefits section of the Contract.
1. PART FIVE, BENEFITS, 5.1. , BASIC BENEFITS: INSTITUTIONAL CARE, paragraph G,
Treatment of Chemical Dependency, page 35, is hereby deleted and replaced
with the following:
"G. Treatment of Chemical Dependency
This chemical dependency benefit is available subject to these
provisions:
I. Amount of Benefits Provided
Benefits for medically necessary covered services received by
the Member and rendered by an Approved Treatment Facility for
the treatment of Chemical Dependency, including detoxification
services, will be provided at one hundred percent (100%) of the
provider 's charge, not to exceed the Reasonable and Customary
charge, up to a maximum benefit of:
$5,000 per Member during any 24-consecutive-month period
for alcohol dependency, subject to a lifetime maximum
benefit of $10,000.
$5,000 per Member during any 24-consecutive-month period
for drug dependency, subject to a lifetime maximum benefit
of $10,000.
Benefits for medically necessary covered therapeutic and
supporting services provided to enrolled Family Members to
assist in the patient 's diagnosis and treatment will be subject
to the benefit maximum(s) of the patient undergoing treatment
for alcohol and/or drug dependency.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six,
Chemical Dependency Benefits will not be provided for:
a. Voluntary support groups such as Alanon, Alcoholics
Anonymous, Narcotics Anonymous, and Cocaine Anonymous;
b. Separate charges for transportation, records and reports;
- 1 -
Contract No. 828-01,-02,-04-ED1
ENDORSEMENT ONE . . . . (continued)
CITY OF KENT
C. Court ordered services, services related to deferred
prosecution, deferred sentencing, suspended sentencing, or
services related to motor vehicle driving rights unless
deemed medically necessary by the Plan. In such instances,
the Member must, at the Member's expense, furnish the Plan,
no less than ten (10) and no more than thirty (30) days
before treatment is to begin, an initial assessment of the
need for Chemical Dependency treatment and a treatment
plan. Such assessment and treatment plan must be made by a
qualified alcohol and/or drug dependency counselor who is
employed by an Approved Treatment Facility or by a
physician (M.D. or D.C. ) . "
2 . PART FIVE, BENEFITS, 5.4.C. , MAJOR MEDICAL BENEFIT, paragraph 17. ,
T reatment of Chemical Dependency, page 60, is hereby deleted and replaced
with the following:
"17. Treatment for Chemical Dependency is not covered under this
Contract 's Major Medical Benefits. However, services for the
treatment of Chemical Dependency are covered as a Basic Benefit in
Part Five - Section 5.1.G. "
3. PART SIX, EXCLUSIONS AND EXCEPTIONS, 6.2 . , Exceptions, paragraph 14,
Treatment of Chemical Dependency, page 88 , is hereby amended to read as
follows:
"14. Treatment of Chemical Dependency
Treatment for alcohol or drug use, abuse or dependency, except as
specifically defined under the definition of Chemical Dependency and
as provided under Part Five 5 .1 .G. "
All other provisions of the Contract remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1987.
BLUE CROSS OF WASHINGTON AND ALASKA
-=By
Patrick C. Connoll
Executive Vice President
Marketing
Date June 12 1987
2 -
Contract No. 828-01 ,-02,-04-EDl
Blue Cross
of Washington and Alaska ID
15700 Dayton Avenue North/P O. Box 327
Seattle. Washington 98111-0227
206/361-3000
June 12, 1987
CITY OF KENT
220 4th Avenue South
Kent, Washington 98032
Dear Group Administrator :
In response to the Washington State Insurance Commissioner's recent
interpretation of the regulation governing alcoholism benefits, Blue Cross of
Washington and Alaska is revising the Chemical Dependency benefit in your
group' s 1987 contract.
The Chemical Dependency benefit is now provided under the "Basic Benefits,"
not the "Major Medical Benefits, " section of your contract, retroactive to
your 1987 contract effective or renewal date. The enclosed endorsement to
your contract reflects this Chemical Dependency benefit change.
Consequently, subscribers under your group program should be advised that
Chemical Dependency benefits are no longer subject to the Major Medical
deductible (if applicable to your program) or to the Major Medical coinsurance
requirements . The $5000/$10,000 benefit maximums will remain the same. In
those instances where benefits provided were less than these maximum amounts,
a review of those claims may be requested.
Covered individuals who have filed Chemical Dependency claims for expenses
incurred on or after your 1987 contract effective or renewal date may contact
our Customer Service Department to request a review of their 1987 claims to
determine if a benefit adjustment may be necessary.
Our Customer Service Representatives are available to answer any questions you
or your employees may have regarding this change to your benefit program. For
assistance, please call the number shown on your ID card.
Thank you for your time.
Sincerely,
BLUE CROSS OF WASHINGTON AND ALASKA
' Blue Cross
E of Washington and Alaska
c
BLUE CROSS OF WASHINGTON AND ALASKA
a
15700 Dayton Avenue North t
P. 0. Box 327
Seattle, Washington 98111
APPLICATION
for
GROUP HEALTH CARE CONTRACT
Application is hereby made to Blue Cross of Washington and Alaska for a Group
Health Care Contract in the form attached hereto, the provisions of which are
to be made available to all eligible classes of Employees as defined in the
Eligibility provisions of this Contract.
The Applicant, in the event this Application is accepted and the Group Health f
Care Contract is issued, agrees to the methods and practices outlined in the
Contract relative to submission of monthly Subscription Charges and
information as may be required for the Blue Cross of Washington and Alaska to
adequately administer its obligations.
Coverage under the Contract shall be effective at 12:01 a.m. , on the first day
of January, 1988, in Seattle, Washington, and such coverage shall continue
until terminated in accordance with the Contract.
The Applicant agrees to promptly deliver to all covered employees the
individual identification cards, descriptive booklets or notifications or
modifications thereto, received from Blue Cross of Washington and Alaska.
Applicant's CITY OF KENT
Address (Applicant)
220 4th Avenue South By `
Kent Washington 98032Title:
y
By
Title:
January 25, 1988 By
(Date)
Title:
Contract No. 828-01 -02. -04
Blue Cross
of Washington and Alaska
BLUE CROSS OF WASHINGTON AND ALASKA
In response to the Application made by
CITY OF KENT
(Called the Group in this Contract)
a copy of which is attached and made part of this Contract and in
consideration of the advance payment of the Subscription Charges made by the
Group,
BLUE CROSS OF WASHINGTON AND ALASKA AGREES TO PROVIDE
the benefits described in this Contract for the term of this Contract, as
stated in Part Nine, beginning at 12:01 a.m. , in Seattle, Washington on
January 1, 1988.
This Contract is entered into and delivered in the State of Washington, and is
governed by the laws of that State, subject to the conditions specified on the
following pages. This Contract is effective only when signed by the Blue
Cross of Washington and Alaska signatory whose name appears
Any existing Health Contract or Agreement between the Group and us which is
being replaced by this Contract is cancelled when this one becomes effective.
Patrick C. Connolly
Executive Vice Presi ent
Marketing
e
Date January 25 1988
Contract No. 828-01 -02, -04
SUMMARY OF CONTENTS
Page
PART ONE DEFINITIONS . . . . . . . . . . . . . . . . . 2
PART TWO COVERAGE: ELIGIBILITY, TERMINATION . . . . . 11
AND CONTINUATION
PART THREE PROVISIONS THAT AFFECT BENEFITS . . . . . . . 21
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS. . . . . . 22
UNDER THIS CONTRACT
PART FIVE BENEFITS. . . . . . . . . . . . . . . . . . . 26
PART SIX EXCLUSIONS AND EXCEPTIONS . . . . . . . . . . 72
PART SEVEN BENEFITS AFTER TERMINATION. . . . . . . . . . 87
PART EIGHT GENERAL PROVISIONS. . . . . . . . . . . . . . 89
PART NINE EMPLOYER INFORMATION. . . . . . . . . . . . . 91
- 1 -
PART ONE DEFINITIONS
1.1 Definitions
ACCIDENTAL BODILY INJURY
Accidental bodily injury, or injury, means physical harm or disability
sustained by the Member which is the direct result of an accident, independent
of disease or bodily infirmity or any other cause. The accidental bodily
injury must have occurred at an identifiable time and place. Accidental
bodily injuries do not include illness or infection, except infection of a cut
or wound resulting from an accident.
APPROVED HOME HEALTH AGENCY
A private or public agency or organization that administers and provides Home
Health Care and is certified by the Department of Social and Health Services
or approved by Medicare as a Home Health Care Agency.
APPROVED HOSPICE
A private or public agency or organization that administers and provides
hospice care and is certified by the Department of Social and Health Services
or approved by Medicare as a hospice agency.
APPROVED TREATMENT FACILITY
A facility approved in the State of Washington pursuant to RCW 70.96A.020(2)
or RCW 69.54.030, in the State of Alaska pursuant to Chapter 47.37 AS, or an
approved facility in any other state in accordance with the licensing or
certification requirements in the jurisdiction where services are rendered
which provides an organized program of treatment for Chemical Dependency.
BASIC BENEFITS
All benefits of this Contract, except Major Medical.
BLUE CROSS PLAN
An approved Blue Cross Plan licensed in the States of Washington and Alaska.
BLUE CROSS OF WASHINGTON AND ALASKA
An approved Blue Cross Plan licensed in the States of Washington and Alaska.
CALENDAR YEAR
A period of twelve (12) consecutive months beginning on January 1 and ending
on December 31 of a given year.
CHEMICAL DEPENDENCY
An illness characterized by a physiological or psychological dependency, or
both, on a controlled substance regulated under Chapter 69 .50 RCW and/or
alcoholic beverages. It is further characterized by a frequent or intense
pattern of pathological use to the extent the user exhibits a loss of
self-control over the amount and circumstances of use; develops symptoms of
tolerance or physiological and/or psychological withdrawal if use of the
controlled substance or alcoholic beverage is reduced or discontinued; and the
user's health is substantially impaired or endangered or his or her social or
economic function is substantially disrupted.
- 2 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
CLAIM (Proof of Loss)
A form obtained from us which the Subscriber or physician or other provider
completes and submits to us along with a copy of the itemized billing
containing at least the following information:
Name of the Subscriber;
Name of the patient;
Subscriber Identification Number;
Name and tax number of the physician or provider;
Other insurance information;
Diagnosis or ICDA code;
Itemized charges of the services rendered; and
If an accident, the date, time, location and brief description of the
accident need to be included.
COMMUNITY MENTAL HEALTH AGENCY
A community mental health agency which is licensed by the Washington State
Department of Social and Health Services and which has in effect a plan for
quality assurance, peer review, and supervision by a licensed physician or
licensed psychologist.
CONTRACT
The completed Group application for health care coverage;
This document between the Group and us, which includes any documents
(Endorsements and Addenda) from us that change it; and
The completed Enrollment Application form of the Subscriber indicating
participation in this Group coverage.
CUSTODIAL CARE
Care given, in the reasonable opinion of the Blue Cross Plan, to sustain a
patent without attempting to cure or heal an illness or injury.
DEDUCTIBLE
The amount of included medical expense for which the Member is responsible
before we provide benefits.
DENTIST
One who is licensed to provide services in the state where the services are
rendered as a:
Doctor of Medical Dentistry; and
Doctor of Dental Surgery.
DURABLE MECHANICAL MEDICAL EQUIPMENT
Equipment which can stand repeated use and is used in the direct treatment of
a covered illness or injury. It is not useful to a person in the absence of
illness or injury.
3 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
EFFECTIVE DATE
The date on which the Member's coverage starts under this Contract. This date
is established by and appears on the records of the Plan.
EXCEPTION
An exclusion with partial restoration of benefits; or a provision reducing
benefits.
EXCLUSION
A provision that states that this Plan has no obligation under this Contract
to provide any benefits.
EXPERIMENTAL OR INVESTIGATIVE
Any treatment, procedure, facility, equipment, drug, drug usage, device or
supply which, at the time rendered, does not meet the criteria listed below:
Approval has been granted by the Federal Food and Drug Administration, or
by another United States governmental agency, for general public use for
treatment of a condition; or
It has been scientifically demonstrated by the medical profession to have
efficacy in terms of:
When the prognosis for the patient's condition is death, that the
treatment substantially extends the probabilities of the person's
survival for five (5) or more years;
When deterioration of a body system is progressive and reasonably
certain to (or has) disabled or incapacitated the patient, that the
treatment can be substantially expected to improve the probabilities
of arresting the condition's progress for five (5) or more years; or
When the body function has been lost by the patient, that the
treatment has been shown to restore the body function to usefulness
at least sixty (60%) percent of the time treatment has been utilized;
and
Services and supplies are rendered or provided by an institution or
provider within the United States that has scientifically
demonstrated proficiency in such treatment.
FAMILY MEMBER
The lawful spouse of the Subscriber or any eligible child.
4 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
HOME HEALTH AIDE
An individual employed by an Approved Home Health Agency or Approved Hospice
who provides intermittent care such as ambulation and exercise, assistance
with medications, reporting changes in the Member's condition and needs,
completing appropriate records, and personal care or household services that
are needed to achieve the medically desired results. The home health aide
must be under the supervision of a registered nurse, a physical therapist,
occupational therapist, or speech therapist.
HOME HEALTH CARE PLAN OF TREATMENT
A written plan of treatment established and periodically reviewed by the
attending physician who must be licensed as a Doctor of Medicine (M.D.) or
Doctor of Osteopathy (D.O.) . Such physician must certify that the Member is
homebound and that Hospital confinement would be required in the absence of
the Home Health Care Plan of Treatment. The plan of treatment shall also
describe the services and supplies for the medically necessary home health
care to be provided to the Member by the Approved Home Health Agency for
treatment of an illness or injury. Such plan of care is subject to
utilization review performed by us.
HOMEBOUND
When the Member's condition is such that leaving home would not be medically
advisable.
HOSPICE PLAN OF CARE
A written plan of care established and periodically reviewed by the attending
physician who must be licensed as a Doctor of Medicine (M.D.) or Doctor of
Osteopathy (D.O.) . Such physician must certify that the Member is terminally
ill and that Hospital confinement would be required in the absence of the
Hospice Plan of Care. The plan of care shall also describe the services and
supplies for the palliative care and medically necessary treatment to be
provided to the Member by the Approved Hospice. Such plan of care is subject
to utilization review performed by us.
HOSPITAL
An institution which:
Is licensed; and
For compensation from its patients and on an Inpatient basis is primarily
engaged in providing diagnostic and therapeutic facilities for the
surgical and medical diagnosis, treatment and care of injured and ill
persons by or under the supervision of a staff of physicians; and
Continuously provides twenty-four (24) hour-a-day nursing service by or
under the supervision of registered graduate nurses; or
Is any other licensed institution with which the plan has an agreement to
render Hospital service.
- 5 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
HOSPITAL . . . (continued)
The following are not considered "hospitals" unless specified as such in this
Contract:
Skilled Nursing Facilities;
Nursing Homes;
Convalescent Homes;
Custodial Homes;
Health Resorts;
Hospices;
Places for rest;
Places for the aged;
Places for the treatment of drug abuse;
Places for the treatment of alcoholism; or
Places for the treatment of pulmonary tuberculosis.
IDENTIFICATION CARD
The card issued by us to the Subscriber containing his or her Name, Group
Number, Identification Number and Plan Number.
INPATIENT
A registered bed-patient in a hospital for whom the hospital makes a daily
room charge.
LIMITATION
The exclusion or reduction of an exception to a specific benefit.
MEDICAL EMERGENCY
Sudden illness or injury that requires immediate attention to prevent death or
impairment of health.
MEDICALLY NECESSARY/MEDICAL NECESSITY
Indispensable in the sense that in the reasonable opinion of this Plan, an
illness, injury or condition harmful to or threatening to the patient's life
or health, or a direct effect of such, could not have been diagnosed or
relieved without the medical service, supply or setting in question. The mere
fact that it was furnished, prescribed or approved by a physician or other
qualified provider does not in itself mean that it was medically necessary.
A medical service, supply or setting may be medically necessary in part only.
- 6 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
MEDICARE
The programs established by Title XVIII of Public Law 89-97 (79 Statutes
286-343), as amended, "Health Insurance for the Aged and Disabled." It
includes Part A "Hospital Insurance Benefits for the Aged and Disabled";
Part B - "Supplementary Medical Insurance Benefits for the Aged and Disabled";
and Part C - "Miscellaneous Provisions."
MEMBER
The Subscriber and eligible Family Members enrolled for coverage under this
Contract.
MENTAL, NEUROPSYCHIATRIC OR PERSONALITY DISORDERS
Any condition listed, at the time a Member receives services, as a mental
disorder in the most recent edition of "International Classification of
Diseases."
Benefits will not be provided for services rendered for learning disabilities;
marital, family, sexual or other counseling or training services; milieu
therapy, custodial care; services rendered after a court-ordered admission or
for services not medically necessary.
MILIEU THERAPY
Treatment designed to provide a change in environment or a controlled
environment.
NON-PARTICIPATING HOSPITAL
A hospital which does not have an agreement in effect with any Blue Cross Plan
to furnish hospital care to Members.
ORTHODONTICS
That branch of dentistry which deals with the development, prevention and
correction of irregularities of the teeth and bite (malocclusion) .
Malocclusion is the abnormal position and contact of the upper and lower teeth
which may affect chewing or cause facial, jaw and/or joint pain.
OUTPATIENT
One who receives treatment in a hospital while he or she is not registered as
a bed-patient of that hospital.
7 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
PALLIATIVE CARE
A form of treatment direc cll ative
drd relief or control of distressing Symptoms
without attempting to be
PARTICIPATING DENTIST re rendered, has an agreement in effect
A dentist who, at the time services a
ices to Members.
with this Blue Cross Plan to furnish dental sery
PARTICIPATING HOSPITAL at the time of admission, has an
A hospital or other institution which,
agreement in effect with any Plan to furnish hospital care to Members.
PARTICIPATING SKILLED NURSING FACILITY has an agreement in effect with
A facility which, at the time of admission,
any Plan to furnish certain services to Members.
PARTICIPATING VISION CARE PROVIDER has an agreement in effect with
One who, at the time services are rendered,
this Blue Cross Plan to furnish Vision services to Members.
PHYSICIAN AND OTHER PROVIDERS OF SERVICE
One of the following who is licensed to provide medical services in the state
where those services are received:
Doctor of Medicine and Surgery (M.D)
Doctor of Osteopathy and Surgery (D.O.)
. Doctor of Podiatry (D.P.M.).
In the event that health care services are per
by one of the following
ed by a
providers and such services would haven ve been
suc c ervioverecesewpllfbemcovered when
physician (M.D. , D.O. , or D.P.M.) ,
performed by a:
Psychologist
Chiropractor (D.C.)
• Registered Nurse (R.N.) licensed in the State of Washington.
(em
This Contract also includes the services of sicias extenders serpiceses of
a physician such as a nurse) when the physician
Other health care providers may also be included for certain services under
this Contract but only under the benefits which say so.
The above physicians and health care providers must perform services within
the lawful scope of their licenses.
- 8 -
PART ONE DEFINITIONS
1.1 Definitions (continued)
PLAN, THE
An approved Blue Cross Plan licensed in the States of Washington and Alaska.
PRESCRIPTION DRUG Drug and
Any medical substance, the label of which, under the Federal Food,
Cosmetic Act, as amended, is required to bear the legend:
"Caution: Federal Law prohibits dispensing without a prescription."
REASONABLE AND CUSTOMARY CHARGE*
Reasonable and Customary (or R&C) Charge means a charge that is, in the
reasonable opinion of the Blue Cross Plan:
Within the range of usual charges for the same or a similar service or
. supply billed by most providers within a given area; or
Justified by all the attending circumstances, including but not limited
. to, the time required to perform the service or procedure, the severity of
the condition treated, and the complexity of treatment of a particular
case.
*With respect to benefits for the treatment of alcoholism (alcohol dependency)
at an Approved Treatment Facility as provided under the Chemical Dependency
Benefit, Reasonable and Customary Charges will be taken into account only on
specific components of such treatment for which a Reasonable and Customary
Charge has been established based on the Plan's statistically reliable
measures as determined by the criteria set forth above in this Reasonable and
Customary Charge definition.
RESPITE CARE
For a homebound Member requiring continuous attendance, care of the Member for
a period of time for the purpose of relieving all persons caring for and
residing with the Member from their duties.
SERVICE AREA except Clark County.
The States of Alaska and Washington,
SUBSCRIBER
verage is established and to whom we issue
The individual in whose name the co
the Identification Card.
SUBSCRIPTION CHARGES
The monthly rates established by us as consideration for the benefits offered
in this Contract.
- 9 -
PART ONE DEFINITIONS
1.1 Definitions . . . (continued)
TERMINALLY ILL
The Member's illness, disease or injury has reached a point where recovery can
no longer be expected and the attending physician certifies that the Member is
facing imminent death.
TOTAL DISABILITY
Inability of the Subscriber due to disease, illness, injury or pregnancy to
engage in any occupation or employment for wage or profit; or, in the case of
a Family Member, the inability due to disease, illness, injury or pregnancy to
engage in all regular and customary activities usual for a person of that age
and family status.
VISION CARE PROVIDER
An ophthalmologist, optometrist or optician.
WE, US AND OUR
An approved Blue Cross Plan licensed in the States of Washington and Alaska.
10 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
A. Who May Be Covered
1. The Subscriber
An employee who has met the eligibility requirements specified below.
a. Eligible Classes of Employees
The following employees of CITY OF KENT are eligible to enroll
and become covered under this Contract:
All regular full-time active employees working a minimum of
forty (40) hours a week.
All regular part-time active employees working a minimum of
twenty-one (21) hours a week.
A retired employee, provided such employee:
has attained age fifty-five (55);
has at least twenty-five (25) years of service with the
employer; and
is eligible to receive a retirement benefit under the
LEOFF I Retirement Plan.
All retired, disabled employees who are eligible to receive a
retirement benefit under the LEOFF I Retirement Plan.
LEOFF I Employees - Full-time active law enforcement officers
or fire fighters who were hired prior to October 1, 1977, and
who were members of the LEOFF system as defined in Sections (3)
and (4), CH131, Law of 1972 1st Ex. Sess. prior to October 1,
1977.
LEOFF II Employees - Full-time active law enforcement officers
or fire fighters who were hired after October 1, 1977, and were
not members of the LEOFF System as defined in Sections (3) and
(4) , CH131, Law of 1972 1st Ex. Sess. prior to October 1, 1977.
If an employee becomes permanently disabled, the employer must
maintain medical insurance coverage for the employee,
applicable to LEOFF I Employees only.
- 11 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
A. Who May Be Covered
(continued)
1, The Subscriber (continued)
b. Ineligible Classes of Employees
The following employees are ineligible to enroll and become
covered under this Contract:
All temporary or seasonal employees.
Employees who are covered through GROUP HEALTH COOPERATIVE or
any other employer-sponsored Health Maintenance Organization
(HMO) .
2. Elig ble Dependents
a, The Lawful S ouse of the Subscriber
b. Children
The lawful offspring of either or both the Subscriber or spouse
and legally adopted children if they meet all of the following
requirements:
The child is unmarried; and ears of age; and
The child is under twenty-three (23) ort for the child and
• The Subscriber provides the main supp
could claim him or her as a dependent under the
United States Internal Revenue Code, for tax purposes.
- 12 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
B. Application for Coverage and Effective Date
1. The Subscriber and Existing Dependents
The Subscriber must submit a completed Enrollment Application
through the Group within thirty (30) days following the date of
hire. All dependents to be enrolled must also be listed on the
Enrollment Application. Upon timely receipt of the Subscriber's
Enrollment Application and payment of the required Subscription
Charges by the Group, coverage will begin for the Subscriber and all
enrolled dependents as set forth below.
a. Subscriber
Employees in an eligible class may enroll and have an effective
date of coverage on the latest to occur of:
The effective date of this Contract;
The date the employee enters an eligible class;
The first day of employment;
provided such employee is actively at work (performing the
duties of his or her occupation at his or her place of
employment) on such coverage date. If the employee is not
actively at work on such date, coverage for the employee and
his or her enrolled dependents will not begin until the
employee returns to active work.
b. Retirees
Retirees in an eligible class will be eligible to enroll and
have an effective date of coverage on the first day of the
Coverage Period coinciding with or next following date of
retirement. "Coverage Period" means that period for which the
Group has paid, in advance, the required Subscription Charges
on behalf of eligible Members in consideration for the benefits
offered in this Contract.
- 13 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
C. Other Provisions Affectin Eli ib lity and Effective Date
1, Late Enrollment
Eligible employees who are not enrolled wheny be firstretro eligibleeor who
rolled
fail to maintain continuous coverage,
at any later date provided application is made and full retroactive
Subscription Charges are paid by the Group on the employee's behalf
from the later of the following:
a, the date the employee was first eligible; or
b, retroactively sixty (60) days.
Eligible dependents who are not enrolled when first eligibleaorO en who
fail to maintain their coverage may be enrolled only
durEnrollment period which is determined
will beginlon•thereffectiveodate
application has been made,
of the Group's Open Enrollment.
2. HMO OPtiOn
Employees who have elected coverage through an HMO may change
coverages and enroll under this Contract only
yPduaring an Open
Enrollment period which is determined by
the n.
3. If an Enrolled Dependent is Institutionalized On the Effective Date
n the
If an enrolled dependent is hesortsheowillzed notoreceiveaany benefits his or r
coverage becomes effective, provided prior to
of this Contract for any services or supplies
discharge from the facility. This provision does not apply to
services provided for properly enrolled newborn dependents born on
or after the Subscriber's effective date.
15 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
D. When Coverage Ends - Circumstances That End Coverage
Except as provided in Part Two Section E. , Continuation of Coverage -
Under This Contract, and in Part Seven (Benefits After Termination) ,
coverage will terminate at the end of the period for which Subscription
Charges were paid when the first of the following occurs:
1. For the Subscriber and all Dependents covered under this Contract
when this Contract is terminated by the Group or Plan; or
2. For the Subscriber when:
a. the Subscriber ceases to meet the eligibility requirements of
the Group as set forth in Section A. ; or
b. the Subscriber's employment or connection with the Group
terminates; or
C. the Group fails to pay Subscription Charges for the Subscriber;
or
3. For the spouse when:
a. the Subscriber is no longer covered under this Contract; or
b. his or her marriage to the Subscriber terminates due to divorce
or annulment or, if earlier, when the Subscriber is no longer
legally responsible for covered expenses incurred by the
spouse; or
C. the Group fails to pay Subscription Charges for the spouse; or
4. For the children when:
a. the Subscriber is no longer covered under the Contract; or
b. they reach age 23, marry or can no longer be claimed as a
dependent by the Subscriber under the United States Internal
Revenue Code; or
C. the Group fails to pay Subscription Charges for the children.
Members who lose coverage for reasons set forth in Part Two - Section
D.2. , 3. or 4. above, may be eligible to continue their coverage under
one of the provisions of Part Two, Section E. - Continuation of Coverage
Under This Contract. When coverage under this Contract ends, conversion
to a nongroup program is available, subject to the terms and limitations
of Part Two - Section F.
- 16 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
E. Continuation of Coverage - Under This Contract
1. Incapacitated Child
A dependent child may continue coverage under this Contract upon
reaching twenty-three (23) years of age if:
the Subscriber remains covered under this Contract; and
the appropriate Subscription Charges, if applicable, are
paid; and
the child is incapable of self-sustaining support by
reason of developmental disability or physical handicap
and was incapacitated before reaching age twenty-three
(23); and
the child continues to be eligible as a dependent within
the definition of the United States Internal Revenue Code;
and
the Subscriber furnishes us with written certification
acceptable to the Plan, completion of form 711-2450, that
the incapacity exists within thirty-one (31) days of the
child reaching twenty-three (23) years of age; and
the Subscriber re-submits proof acceptable to the Plan of
the incapacity at periodic intervals, upon our request,
but not more frequently than annually after the two
(2)-year period following the child's attainment of age
twenty-three (23) .
2. Leave of Absence
Coverage may be continued for up to ninety (90) days if the employer
grants the Subscriber a leave of absence. The required Subscription
Charges must be submitted with the employer's regular monthly
remittance to the Plan. This period of coverage will be concurrent
with the period of continued coverage provided under Part Two
Section E.4.
3. Labor Dispute
In the event that a Subscriber's compensation or wage is suspended
or terminated by the Group, directly or indirectly, as a result of a
strike, lockout, or other labor dispute, the Subscriber may pay the
Subscription Charges, subject to the terms on the application,
directly to the Group for a period not exceeding six (6) months from
the date of such suspension or termination. This period of coverage
will be concurrent with any period of continued coverage provided
under Part Two Section E.4.
When the Subscriber's compensation or wage is so suspended or
terminated, the Subscriber shall be notified immediately in writing
by the Group. A notice will be mailed to the address last on record
with the Group, that the Subscriber may pay Subscription Charges to
the Group as they are due as provided in this section.
- 17 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
E. Continuation of Coverage - Under This Contract . . . (continued)
4. COBRA Continuation of Group Coverage
Public Law 99-272, also known as the Consolidated Omnibus
Reconciliation Act of 1985 (COBRA) was signed into Law on April 7,
1986. The intent of this section is to summarize the provisions of
the Law, and its amendments, regarding rights for certain
Subscribers and their dependents who are eligible for continuation
of coverage under COBRA as a result of a "qualifying event."
a. Qualifying Events
The continuation periods described below extend from the date
of the qualifying event.
(1) The Subscriber and covered dependents may continue
coverage for up to eighteen (18) months if coverage ends
due to:
Reduction of the Subscriber's work hours; or
Termination of the Subscriber's employment, except for
discharge due to actions defined by the employer as
gross misconduct.
A second qualifying event during this eighteen (18) months may
extend the continuation period. The extended period will end
no later than thirty-six (36) months from the date the
continuation period for the first qualifying event began.
(2) The covered Spouse or children may continue coverage for
up to thirty-six (36) months if coverage ceases due to:
The Subscriber's death;
Divorce or legal separation from the Subscriber;
The Subscriber's entitlement to and election of
Medicare as his or her primary health coverage; or
Loss of eligibility as a dependent child, as specified
in Part Two Section D.4.b. or Section E.1.
(3) The retired Subscriber and covered dependents may continue
their retiree coverage for up to the rest of the
Subscriber's life if that coverage ends due to the former
employer's filing of Chapter 11 bankruptcy. If a
subsequent qualifying event stated in (2) above occurs,
the affected dependents may continue coverage for up to
thirty-six (36) additional months, even if entitled to
Medicare.
18 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
E. Continuation of Coverage - Under This Contract . . . (continued)
4. COBRA Continuation of Group Coverage . . . (continued)
a. Qualifying Events . . . (continued)
Dependents who are enrolled on the continuing Member's
continued coverage after the initial election are not eligible
for further coverage if they subsequently have a qualifying
event.
b. Notification
Continued coverage is not automatic. The following steps must
be taken in order for continuation to become effective for the
eligible continuee:
(1) The employer must notify those eligible for continued
coverage of their rights under COBRA within fourteen (14)
days of receiving notice of a qualifying event.
(2) The Member must elect continued coverage within sixty (60)
days from the date coverage would have terminated because
of a qualifying event, or from the date the employer gave
notice of continuation rights, whichever is later.
(3) The completed application and initial Subscription Charges
must be submitted to the employer no later than forty-five
(45) days after the continuing Member elected continuation.
(4) The employer will forward all applications and
Subscription Charges to the Plan with its next billing and
delete from the group health program any continuing Member
who does not elect to continue coverage.
(5) Subsequent Subscription Charges must be paid to the
employer and submitted to the Plan with the employer's
regular monthly billings.
Continued coverage is subject to all other terms and
limitations of this Contract.
- 19 -
PART TWO COVERAGE: ELIGIBILITY, TERMINATION AND CONTINUATION
E. Continuation of Coverage - Under This Contract . . . (continued)
4. COBRA Continuation of Group Coverage . . . (continued)
C. When COBRA Continued Coverage Ends
(1) Continued coverage under this Contract will end at the end
of the period for which Subscription Charges are paid in
which the first of the following events occurs:
The applicable continuation period expires;
The next required Subscription payment is not made when
due;
The Member enrolls in another group health care program;
• The Member becomes entitled to Medicare, except for
• retirees and their dependents who are continuing
coverage as a result of a Chapter 11 filing; or
The Contract between the Group and the Plan is
terminated.
(2) Continued coverage through the employer will end when the
employer ceases to make any health program available to
any employee.
When the continued coverage described in the provisions of Part Two -
Section E. ends, conversion to a nongroup program is available, subject
to the terms and limitations of Part Two - Section F.
F. Conversion to Nongroup Programs
Members who lose their eligibility for coverage under this Contract for
the reasons set forth in Section D. may be eligible to transfer to a
Conversion or Medicare Supplement Program designated by the Plan without
meeting medical underwriting requirements, provided the Member:
submits a completed application and the required Subscription
Charges to the Plan within thirty-one (31) days from the date the
Member's coverage under this Contract terminates; and
meets the specific eligibility requirements described under the
nongroup program.
The rates and benefits of these nongroup programs are different from the
rates and benefits provided under this Contract; and in some cases, the
benefits provided under these nongroup programs will be more limited than
the benefits provided under this Contract.
G. Deletion of Ineligible Members
The Group will promptly delete any employee or dependent who ceases to
meet the above eligibility requirements and will so notify the Plan on a
timely basis.
- 20 -
PART THREE PROVISIONS THAT AFFECT BENEFITS
The following provisions affect the way benefits are provided.
3.1 Changes To This Contract
After the initial term of this Contract as stated in Part Nine 9.1, the
benefits of this Contract may be changed provided we notify the Group of
any change at least thirty (30) days in advance of the date the change is
to be effective. Payment of Subscription Charges after notification
constitutes acceptance of the change.
No agent of this Plan is authorized to make any oral changes, additions or
deletions to this Contract. Changes can be done only by endorsement,
riders or an acceptance form issued over the signature of an officer of
this Plan.
If a Member is confined in a Hospital, Skilled Nursing Facility or
Approved Treatment Facility at the time a change in benefits is made, he
or she will continue to receive the benefits in effect at the time of
admission. The changed benefits will be available after discharge.
3.2 Prior Blue Cross Coverage
If the Member was hospitalized while enrolled under a prior Contract,
Certificate or Agreement with this Plan which is replaced by this
Contract, these provisions will apply:
The days of hospital care provided under the prior coverage will be
deducted from the days available under this Contract if a Member is
readmitted within ninety (90) days after discharge.
The days of hospital care will not be deducted if:
The Subscriber has gone back to work on a full-time basis; or
The hospitalization of a Member is due to an accident.
3.3 Filing of Claims
Benefits will be provided under this Contract only if a claim, see Part
One - Definitions, is filed with us.
Time Limit for Filing Claims
The claim must be received by us within one (1) year from the date:
Of admission to a Hospital, Skilled Nursing Facility or Approved
Treatment Facility; or
On which the professional expenses were incurred.
This time limit does not apply to claims for services furnished by
providers, other than hospitals, who have participating agreements with us.
- 21 -
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS UNDER THIS CONTRACT
4.1 SUBROGATION . . . (continued)
C. Collection by the Member
If the Member obtains a settlement or judgement for less than the
amount of the "third party s policy limits or reachable assets, the
Member is considered as having been fully compensated and is
obligated to reimburse the Plan for the full amount of benefits paid
under this Contract. If a settlement is made or a judgement is
recovered that is equal to, or greater than, the amount of the "third
party s policy limits or reachable assets, the Plan's subrogation
rights shall be limited to the excess of the amount necessary to
fully compensate the Member.
D. Agreement to Arbitrate
Any dispute arising under this provision will be resolved by binding
arbitration conducted in accordance with the rules prescribed by the
American Arbitration Association, as amended from time to time. All
such disputes will be resolved by a single arbitrator. The Member or
the Plan may demand arbitration by serving notice of intention to
arbitrate upon the other party. Each party shall bear its own
arbitration costs with the parties equally sharing the fees of the
arbitrator. The Member and the Plan are bound by the decisions of
the arbitration proceedings. This agreement to arbitrate commences
from the effective date of this Contract and continues until any
controversy or dispute involving the Plan's subrogation claim has
been resolved.
4.2 RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION
When a Member applies for benefits under this Contract, he or she
authorizes health care providers to release to us information and records
about services that have been given. Also, the Member authorizes any
person, organization or insurance company to furnish to or to obtain from
us any information regarding his or her benefits. If a Member does not
authorize access to his or her records, benefits will not be provided.
4.3 EVIDENCE OF MEDICAL ITECESSITY
We have the right to require proof of medical necessity from a Member
receiving benefits under this Contract. This proof may be submitted by a
Member or on his or her behalf by providers. No benefits will be
available under this Contract if the proof is not provided or acceptable
to us. We shall not request such proof more often than at ten (10)-day
intervals.
- 23 -
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS UNDER THIS CONTRACT
4.4 LIMIT OF OUR LIABILITY
Our liability under this Contract, including recovery under any claim of
breach, shall be limited to the actual cost of hospital and medical
services provided. This limitation specifically excludes claims for
general damages including alleged pain, suffering or mental anguish.
4.5 VENUE
All suits or legal proceedings brought against us by a Member or anyone
claiming any right under this Contract must be filed:
Within fifteen (15) months of the date we denied in writing the
rights claimed under this Contract; and
In the State of Washington or the State in which the Member resides
or is employed.
All suits or legal proceedings brought by us against a Member shall be
filed within the appropriate statutory period of limitation. In all suits
or legal proceedings brought by us venue may lie, at our option, in:
King County, State of Washington; or
The third Judicial District, Anchorage, State of Alaska, if the
Member is a resident of that State.
4.6 RIGHT OF RECOVERY
This Plan will have the right, upon demand, to recover overpayments _or
payments obtained through fraud, error, mistake or payments made in excess
of the maximum amount necessary to satisfy the intent of the Coordination
of Benefits provision in Part Six 6.2.9. , made to:
Other insurers;
Any service plans;
Any other organization, or on behalf of a Member; or
Someone who is not eligible to receive benefits.
If reimbursement is not made, such overpayments or payments will be
deducted from future claims.
- 24 -
PART FOUR PLAN RIGHTS AND MEMBER OBLIGATIONS UNDER THIS CONTRACT
4.7 TRANSFER OF BENEFITS: ASSIGNMENT GARNISHMENT AND ATTACHMENT
All rights to benefits under this Contract are personal and available only
to the Member. They may not be transferred to anyone else.
No benefits or other rights arising in favor of the Member under this
Contract are assignable, or subject to garnishment or attachment by
creditors. We are not obligated by any attempted or
Purported assignment,
garnishment or attachment. In
paying under this Contract for services or
supplies to a Member, we may, at our option, remit funds to the Member,
the provider of the services or supplies, the Group, other carrier or
jointly to any of these. Remittance as aforesaid in good faith shall
discharge our obligation to the extent of the remittance amount so that we
will not be liable to anyone aggrieved by our selection of payee.
4.8 FRAUDULENT CLAIMS
If the Member claims benefits for which no care, service or supply is
received, the claims will be denied.
4.9 SUBSCRIBER COOPERATION
The Subscriber, his or her eligible spouse and all eligible dependent
children are under a duty to cooperate in a timely and appropriate manner
with this Blue Cross Plan in its administration of benefits or in the
event of a lawsuit.
- 25 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE
Institutional care, services and supplies shall be provided for
disabilities arising from illness, disease, injury or pregnancy as
indicated in the specific benefits that follow, provided:
They are medically necessary, see Part One - Definitions; and
The Member is under constant care and treatment of a physician; and
Admission to such institution occurs after the Member's effective
date of coverage under this Contract.
A. Inpatient Care - Participating Hospital In or Out of the Service Area
and a Ltgally Operated Hospital Out of the Service Area
This inpatient hospital care benefit is available subject to these
provisions:
1. The Number of Inpatient Days Available
Inpatient hospital care is available up to:
a. An aggregate (total) of three hundred sixty-five (365) days
per confinement; including
b. One hundred twenty (120) days each calendar year for
mental, neuropsychiatric or personality disorders.
2. _inpatient Services and Supplies
The inpatient services and supplies listed on the following page
are available for inpatient care subject to the number of days
available.
- 26 -
PART FIVE BENEFITS
5 .1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
A. Inpatient Care - Participating Hospital In or Out of the Service Area
and a Legally Operated Hospital Out of the Service Area
. . . (continued)
2. Inpatient Services and Supplies (continued)
a. Daily hospital services in a room of two (2) or more beds.
b. Use of an intensive care unit, includes coronary and
constant-care units. Services in an intensive care unit
include nursing services provided by hospital employees as
a regular service.
C. Use of operating, recovery, isolation, cystoscopic and cast
rooms.
d. Anesthetic supplies and use of hospital anesthetic
equipment. Administration of anesthesia when administered
by a hospital employee as a regular hospital service.
e. Casts, splints, and surgical dressings.
f. X-ray and radium therapy.
g. Oxygen and all drugs and medicines prescribed and used
while the Member is in the hospital which are listed and
accepted in the:
"United States Pharmacopoeia"; or
"National Formulary"; or
"AMA Drug Evaluations" published by the American
Medical Association.
h. Blood, blood plasma, blood derivatives and their
administration.
i. Physiotherapy and hydrotherapy.
j . Diagnostic laboratory and x-ray services.
k. Electrocardiograms.
1. Respiratory and other gas therapy.
- 27 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE
• (continued)
A. Inpatient Care - Pa.rticiipating Hospital In or Out of the Service Area
and a Le�g.all_v Operated Hos ital Out of the Service Area
. . (continued)
3. Limitations
In addition to Exclusions and Exceptions of Part Six, these
limitations apply to this inpatient hospital care benefit.
a. We do not provide benefits for convalescent care when:
The need for definitive medical treatment no longer
exists; or
Acute care provided as an inpatient is no longer
necessary.
b. If the Member occupies a private room, we provide benefits
only for the hospital's charge for a room of two (2) beds.
If the hospital has only private room accommodations, we
will determine the amount of expenses to be allowed.
C. We do not provide benefits for any other room reserved for
the Member during a period he or she may be confined in an
intensive care unit.
d. We do not provide benefits for personal items, such as:
Meals for guests; or
Long distance telephone charges or telegraph charges;
or
Radio or television charges; or
Barber or beautician charges.
e. Successive hospital confinements are considered one
confinement if they are not separated by a period of ninety
(90) days unless:
The patient is the Subscriber and proof is furnished
that he or she has returned to full-time work; or
Readmission by a Member to a hospital is required as a
result of an accident.
f. We do not provide benefits for admission to a hospital for
diagnostic purposes only.
g. We do not provide benefits for admission to a hospital for
dental procedures except as stated in Part Six 6.2.4.
- 28 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE (continued)
B. Emergency Inpatient Care - Non-Participating Hospital in the
Service Area
1. Amount of Benefit Provided
Benefits for the number of inpatient hospital days stated in
5.1.A.1. and the services stated in 5.1.A.2. are available for
services rendered, furnished and billed by a Non-Participating
Hospital in the service area up to the Reasonable and Customary
charge, but only when the condition being treated is a medical
emergency.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six, all
limitations of 5.1.A.3. will apply.
C. Outpatient Care - Participating Hospital In or Out of the Service
Area and a Legallv Operated Hospital Out of the Service Area
This outpatient hospital care benefit is available subject to these
provisions:
1. When Services Are Provided
Outpatient services are provided in a Participating Hospital for
these situations only:
a. Accidental Iniury
We provide benefits for treatment of an accidental injury
rendered within seven (7) days of the accident.
b. Medical Emergency
We provide benefits for treatment for an injury or illness
that is a medical emergency (see Part One - Definitions)
including but not limited to:
Heart attacks,
Cardiovascular accidents,
Poisonings,
Loss of consciousness, or
Respiration.
C. Minor Surgery
d. X-Ray Therapy and Radium Therapy Treatments
e. Chemotherapy Treatments
- 29 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
C. Outpatient Care - Participating Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
. . . (continued)
1. When Services Are Provided . . . (continued)
f. Preadmission Tests
Certain diagnostic services are covered in this benefit
when rendered in the outpatient department within
seventy-two (72) hours of admission to that hospital.
These services must be related to the condition the Member
is admitted for and are:
Laboratory examinations,
Electrocardiograms, and
X-ray examinations.
2. Outpatient Services and Supplies
Only the outpatient services below are available when the
Member receives care for the situations named in Part Five
5.1.C.1.
a. Use of operating, recovery, isolation, cystoscopic and
cast rooms.
b. Anesthetic supplies and use of hospital anesthetic
equipment; administration of anesthesia by a hospital
employee as a regular hospital service.
C. Casts, splints and surgical dressings.
d. X-ray therapy and radium therapy.
e. Oxygen and all drugs and medicines, prescribed and used
while the Member is in the hospital, listed and accepted
in the:
"United States Pharmacopoeia"; or
"National Formulary"; or
"AMA Drug Evaluations" published by the
American Medical Association.
- 30 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE
• (continued)
C. Out atient Care - Participating Hospital In or Out of the Service
Area and a Legally Operated Hospital Out of the Service Area
• . . (continued)
2. Outpatient Services and Su
lies (continued)
f. Blood, blood plasma and blood derivatives and their
administration.
g. Chemotherapy for malignancies only.
h. Diagnostic laboratory and x-ray services and
electrocardiograms.
i. Physiotherapy and hydrotherapy.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations apply to this outpatient hospital care
benefit.
a. We do not provide benefits for outpatient care received in
a Non-Participating Hospital within our service area except
as described in 5.1.1).
b. We do not provide hospital outpatient benefits for the
services of a physician.
D. Emergency Outpatient Care - Non-Partici atin Hop ital In the Service
1. Amount of Benefit Provided
The benefits stated in 5.1.C. are available up to the Reasonable
and Customary charge, but only when the condition being treated
is a medical emergency.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
limitations of 5.1.C.3. will apply.
- 31 -
PART FIVE BENEFITS
5 .1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
E. Skilled Nursing Facility - Participating In the Service Area and
Medicare-Approved Out of the Service Area
This benefit is available in a participating Skilled Nursing Facility
for skilled nursing services that must include direct medical
supervision of the treatment provided each Member. It must also
include nursing service under the supervision of a registered nurse,
plus other therapeutic services. This service is designed for the
patient who does not need care in an acute facility, yet is at a
point in his or her illness or disability which requires care in a
facility offering lesser services subject to these provisions.
1. The Number of Days of Skilled Nursing Care Available
Each day of care received in a Skilled Nursing Facility will be
charged as one-half (1/2) day of inpatient hospital care against
the maximum benefit as specified in Part Five 5.1.A.l.a.
2. Skilled Nursing Services and Supplies
Only the services listed below are available for skilled nursing
care:
a. Skilled nursing services in a room of two (2) or more beds.
b. Use of special treatment rooms.
C. Routine laboratory tests and examinations.
d. Physical, occupational or speech therapy treatments.
e. Respiratory and other gas therapy.
f. Drugs, biologicals and solutions used while the Member is
in the Skilled Nursing Facility.
g. Gauze, cotton, fabrics, solutions, plaster and other
materials used in dressings and casts.
- 32 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
E. Skilled Nursing Facility - Participating In the Service Area and
Medicare-Approved Out of the Service Area . . . (continued)
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, these
limitations apply to this Skilled Nursing Facility care benefit.
a. We do not provide benefits for skilled nursing care
received in a Non-Participating Skilled Nursing Facility
within our service area, except as described in 5.1.F.
b. We do not provide benefits for custodial care, see Part One
- Definitions.
C. We do not provide benefits for care which is for:
Senile deterioration; or
Mental deficiency; or
Mental retardation; or
Mental illness.
F. Skilled Nursing Facility - Non-Participating in the Service Area
1. Amount of Benefit Provided
Benefits for the number of days stated in 5.1.E.1. and the
services stated in 5.1.E.2. are available up to the Reasonable
and Customary charge, but only when the condition being treated
is a medical emergency.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
limitations of 5.1.E.3. will apply.
- 33 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
G. Treatment of Chemical Dependency
This Chemical Dependency benefit is available subject to these
provisions: '
1. Amount of Benefits Provided
Benefits for medically necessary covered services received by
the Member and rendered by an Approved Treatment Facility for
the treatment of Chemical Dependency, including detoxification
services, will be provided at one hundred percent (100%) of the
provider's charge, not to exceed the Reasonable and Customary
Charge, up to a maximum benefit of $5,000 per Member during any
24-consecutive-month period, subject to a lifetime maximum
benefit of $10,000.
Benefits for medically necessary covered therapeutic and
supporting services provided to enrolled Family Members to
assist in the patient's diagnosis and treatment will be subject
to the benefit maximum(s) of the patient undergoing treatment
for Chemical Dependency.
Chemical Dependency Benefits provided for covered services
rendered to a Member on or after January 1, 1987, under this or
any other Contract between the Group and the Plan, shall accrue
toward the maximums stated above, provided the Member has
remained continuously covered under the Group, with no lapse in
coverage.
2. Limitations
In addition to the Exclusions and Exceptions of Part Six,
Chemical Dependency Benefits will not be provided for:
a. Voluntary support groups such as Alanon, Alcoholics
Anonymous, Narcotics Anonymous, and Cocaine Anonymous;
b. Separate charges for transportation, records and reports;
- 34 -
PART FIVE BENEFITS
5.1 BASIC BENEFITS: INSTITUTIONAL CARE . . . (continued)
G. Treatment of Chemical Dependency . . . (continued)
2. Limitations . . . (continued)
C. Court ordered services, services related to deferred prosecution, deferred sentencing, suspended sentencing, or
services related to motor vehicle driving rights unless
deemed medically necessary by the Plan. In such instances,
the Member must, at the Member's expense, furnish the Plan,
no less than ten (10) and no more than thirty (30) days
before treatment is to begin, an initial assessment of the
need for Chemical Dependency treatment and a treatment
plan. Such assessment and treatment plan must be made by a
qualified alcoholism and/or drug treatment counselor who is
employed by an Approved Treatment Facility or by a
physician (M.D. or D.O.) .
35 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES
This benefit will be provided for professional services by a
physician qualified to diagnose and treat an illness, disease, injury
or pregnancy only as indicated in the specific benefits that follow,
provided that:
They are medically necessary, see Part One - Definitions, and
are received in a medically necessary setting; and
They are received on or after the Member's Effective Date of
coverage under this Contract.
5.2.1 Surgical and Medical Benefits (Subscriber and Family Member)
The basic benefits for professional surgical and medical services are
listed below.
A. Surgical Benefits
This surgical benefit is available subject to these provisions:
1. Amount of Benefits Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
If more than one surgical procedure is performed, benefits
will be provided as follows:
At different times due to entirely unrelated causes,
benefits will be provided for each procedure;
At the same time in the same operative area, benefits
will be provided only for the procedure with the
largest allowance;
At the same time in different operative areas, full
• benefits will be provided for the procedure with the
largest allowance plus one-half (1/2) of the allowance
for each additional procedure.
2. Surgical Services and Supplies
This surgical benefit covers only the providers and
services stated below:
a. Services of a physician and assistant surgeon for
surgical services (operating and cutting procedures
for the treatment of disease, illness or injury and
treatment of fractures and dislocations.) Services of
an assistant surgeon are included for major surgery
only.
36 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
A. Surgical Benefit . . . (continued)
2. Surgical Services and Supplies . . . (continued)
b. Services of a dentist (D.D.S. or D.M.D.) for only the
non-dental surgical procedures in the oral region
listed below:
Excision of tumors or cysts of the jaw, tongue,
roof and floor of the mouth.
Excision of exostoses of the jaw and hard palate.
Incision and drainage of cellulitis.
Incision or excision of accessory sinuses,
salivary glands or ducts.
Surgical procedures required due to an injury
involving oral conditions such as fractured jaw,
lacerations and dislocations.
B. Anesthesia Benefit (Subscriber and Family Member)
This anesthesia benefit is available subject to these provisions.
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Anesthesia Services
This benefit covers only the services of an
anesthesiologist or Registered Nurse Anesthetist (R.N.A.) .
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
these limitations apply:
a. We provide this benefit only when hospital and
surgical benefits are being provided to the Member.
b. We do not provide benefits for administration of
anesthesia by the operating surgeon; or for a hospital
employee when the hospital bills for his or her
services as a hospital benefit.
- 37 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES
• (continued)
5.2.1 Surgical and Medical Benefits .
. (continued)
C. Physician Hospital or Skilled Nursing Facility Visit Benefit
(Subscriber and Family Member)
This physician hospital or Skilled Nursing Facility benefit is
available subject to these provisions:
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Physician Visit Services
This benefit covers only one visit by a physician for each
day the Member is confined in a hospital or Skilled Nursing
Facility.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
these limitations apply:
a. We provide this benefit only when inpatient hospital
or skilled nursing facility benefits are being
provided to the Member.
b. We do not provide this benefit during a hospital stay
in which basic surgical benefits are paid.
- 38 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
D. Consultation Service Benefit (Subscriber and Family Member)
This consultation service benefit is available subject to these
provisions.
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2, Consultation Services
This benefit covers only professional consultation services
by a physician when a Member is confined in the hospital.
This is opinion or advice provided in the evaluation or
treatment of a patient.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
these limitations apply:
Consultation services must be requested by the
attending physician.
- 39 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
E. Physician Medical Emergency Benefit - Outpatient Hospital Only
(Subscriber and Family Member)
This physician medical emergency benefit is available subject to
these provisions.
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Physician Services
This benefit covers only treatment by a physician in
connection with a medical emergency, see Part One -
Definitions.
3. Limitations
In addition to Exclusions and Exceptions of Part Six, these
limitations apply:
a. We provide this benefit only when the outpatient
hospital medical emergency benefit in Part Five
5.1.C.l.b. is being provided to a Member.
b. We do not provide this benefit for treatment that is
paid with basic surgical, physician hospital visit, or
physician home and office visit benefits.
- 40 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
F. Physician Radiotherapy Benefit (Subscriber and Family Member)
This physician radiotherapy benefit is available subject to
these provisions:
1. Amount of Benefit Provided
This benefit provides payment at 100% of the provider's
charge, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Physician Radiotherapy Services
This benefit covers only the services of a physician for
radiotherapy treatments.
3. Limitations
The Exclusions and Exceptions of Part Six apply to this
benefit.
G. Physician Home and Office Benefit
Physician home and office visits are not covered as Basic
Benefits under this Contract.
- 41 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
H. Second Surgical Opinion Benefit
1. Amount of Benefit Provided
When surgery is recommended to the Member by a physician for
a non-emergency surgical procedure stated in paragraph 2
below, the Plan will pay up to the Reasonable and Customary
charge for the professional services of a physician, other
than the operating surgeon, for a second surgical opinion
consultation prior to the Member undergoing surgery,
including necessary x-ray and laboratory tests required by
the physician as a part of the consultation.
The term "non-emergency surgical procedure" shall mean one of
the elective surgical procedures stated in paragraph 2 below,
that may be scheduled at the Member's convenience without
jeopardizing the Member's life or causing serious impairment
to the Member's bodily functions.
2. Procedures Requiring a Second Physician's Opinion
The following elective surgical procedures, as listed in the
Physician's Current Procedure Terminology, Fourth Edition,
require a second physician's opinion when surgery has been
recommended by a physician on a non-emergency basis as
defined in paragraph 1 above:
Procedures and CPT 4 Codes:
Hysterectomy, 58150, 58180 Surgery on the Spine, 22555
58260 through 58270, 58275 through 22735 and 62295
& 58280 through 63076
Surgery on the Knee, 27373 Surgery on the Heart, 33510
through 27379, 27405 through 33528, 33405, 33430
through 27425, 27444 and 93570
through 27447, 27487 Surgery on the Nose, 30140
and 27488 through 30160 and 30400
Surgery on the Hip, through 30520
27130 and 27135 Gallbladder Surgery, 47600
Surgery on the Foot, 28080 through 47620
through 28299 Tonsils and Adenoids, 42820
through 42836
- 42 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES (continued)
5.2.1 Surgical and Medical Benefits . . . (continued)
H. Second Surgical Opinion Benefit . . . (continued)
3. Limitations
In addition to the Exclusions and Exceptions of Part Six,
this benefit does not include:
a. Consultation services performed by the operating surgeon.
b. Consultation services for procedures not listed in
paragraph 2 above.
C. Diagnostic tests which are not directly related to the
condition being treated.
d. Consultation services where the Member is not personally
examined by the physician.
e. Consultation services when the Member has already been
admitted to the hospital for the surgical procedure.
I. Professional Nervous and Mental Benefit
This Contract does not provide a Basic professional nervous and
mental outpatient benefit.
However, benefits for mental, neuropsychiatric and personality
disorders are provided for under the Major Medical Benefit, if
available.
- 43 -
PART FIVE BENEFITS
5.2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.2 Diagnostic X-ray and Laboratory (Subscriber and Family Member)
This diagnostic x-ray and laboratory benefit is available subject to
these provisions:
1. Maximum Amount of Benefit Provided
This benefit provides payment of the provider's charge, not to
exceed the Reasonable and Customary charge, see Part One -
Definitions, for an included service, subject to the limitations
set forth below:
for each accident, up to one hundred dollars ($100.00) .
for all illnesses, up to an aggregate of one hundred
dollars ($100.00) in any Calendar Year.
2. Diagnostic X-ray and Laboratory Services
This benefit covers only diagnostic x-ray and laboratory
services medically necessary in the diagnosing or treatment of:
Illness,
Injury, or
Disease.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations apply to this diagnostic x-ray and
laboratory benefit.
a. We do not cover services under this benefit while a Member
is receiving services provided while in an institution.
b. We do not provide benefits for eye examinations or
treatments.
C. We do not provide benefits for dental examinations or
treatments.
d. We do not provide benefits for routine physical
examinations.
e. We do not provide benefits for mental, neuropsychiatric or
personality disorders.
- 44 -
PART FIVE BENEFITS
5 .2 BASIC BENEFITS: PROFESSIONAL SERVICES . . . (continued)
5.2.3 Ambulance Benefit (Subscriber and Family Member)
This licensed ambulance benefit is available subject to these
provisions.
1. Maximum Amount of Benefit Provided
We provide licensed ambulance services, up to an aggregate of
fifty dollars ($50.00) for each accident or for each hospital
confinement, not to exceed the Reasonable and Customary charge,
see Part One - Definitions, for an included service.
2. Ambulance Services
This ambulance benefit covers only:
Services to the nearest hospital equipped to provide
treatment.
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations apply to this ambulance benefit.
We provide benefits only for licensed ambulance
service. An ambulance must be licensed by the Federal
Government, State or Municipality in which it operates.
We do not provide this benefit for:
Private automobiles; or
Taxi services.
- 45 -
PART FIVE BENEFITS
5.3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member)
We pay up to the Reasonable and Customary charges, see Part One -
Definitions, for services rendered to a Member as the result of an
accident subject to these provisions:
The services received are medically necessary as defined in
Part One - Definitions; and
The services are prescribed by a physician; and
The accident occurs while the Member is covered under this
Contract.
1. Maximum Amount of Benefits Provided
We provide Supplemental Accident Benefits up to three hundred dollars
($300.00) for each accident, in addition to the benefits provided
elsewhere in this Contract.
2. Supplemental Accident Services and Supplies
This benefit covers only the services listed below in connection with
an accident:
a. Services furnished and billed by a legally operated hospital up
to a two (2)-bed room except as stated in 5.3.3.a. and 5.3.3.b.
b. Professional services of a licensed physician. This benefit is
not available if the services are rendered by a physician who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
When a physician performs more than one surgical procedure the
following will apply:
At different times due to entirely unrelated causes,
benefits will be provided for each procedure;
At the same time in the same operative area, benefits will
be provided only for the procedure with the largest
allowance;
At the same time in different operative areas, full
benefits will be provided for the procedure with the
largest allowance plus one-half (1/2) of the allowance for
each additional procedure.
C. Necessary laboratory and x-ray examinations.
- 46 -
PART FIVE BENEFITS
5.3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member) . . . (continued)
2. Supplemental Accident Services and Supplies . . . (continued)
d. Acute nursing services of a Registered Nurse when ordered by a
physician. This benefit is not available if the services are
rendered by a registered nurse who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
e. Professional services rendered by a physician or dentist (D.M.D.
or D.D.S.) for:
Treatment of a fractured jaw; or
Accidental injury to natural teeth.
f. Anesthetic supplies and administration of anesthesia by:
An anesthesiologist; or
A registered nurse anesthetist.
g. Services of a physician or a licensed or registered physical
therapist for physical therapy treatments.
This benefit is not available if the services are rendered by a
physician or a licensed or registered physical therapist who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
h. Licensed ambulance services to the nearest facility equipped to
render treatment of the condition.
Licensed ambulance service is not available unless other means
of transportation would endanger the health and safety of the
Members. This benefit is not available for:
Private automobiles; or
Taxi services.
i. Drugs and medicines when:
Directly related to the treatment of an injury; and
Requiring a written prescription; and
Dispensed by a licensed pharmacist or physician.
- 47 -
PART FIVE BENEFITS
5.3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member) . . . (continued)
2. Supplemental Accident Services and Supplies . . . (continued)
j . Medical supplies and prosthetic devices directly required for
the appropriate treatment of an accidental injury, such as:
Casts;
Splints;
Trusses;
Braces;
Crutches;
Prosthetic devices to replace all or part of an absent body
organ or to aid in its function when impaired, except that
only the initial charge for the first such prosthetic
device will be included. Benefits will not be provided for
the replacement of prosthetic devices, except when the
existing device cannot be repaired and replacement is
recommended by a physician due to a change in the Member's
physical condition (growth or physical deterioration) .
Covered prosthetic devices include, but are not limited
to: artificial limbs or eyes, and contact lens(es) to
replace a missing portion of the eye.
k. Rental or, at our option, the initial purchase of durable
mechanical medical equipment, see Part One - Definitions, which
is prescribed by a physician and required for therapeutic use in
the direct treatment of an accidental injury, such as:
Wheelchair;
Hospital-type bed;
Intermittent Positive Pressure Breathing Apparatus.
Special or extra-cost features and options which are convenience
items and do not primarily serve a medical purpose will not be
covered. In cases where there is an appropriate alternative
type of equipment that is less costly and serves the same
medical purpose, the Plan will provide benefits for the
equipment carrying the lesser charge.
1. Blood transfusions, including the cost of blood and blood
derivatives.
- 48 -
PART FIVE BENEFITS
5.3 BASIC BENEFITS: SUPPLEMENTAL ACCIDENT BENEFIT
(Subscriber and Family Member) . . . (continued)
3. Limitations
In addition to the Exclusions and Exceptions of Part Six, the
following limitations will apply:
a. We do not provide benefits for items of a personal nature billed
by a legally operated hospital such as:
Meals for guests; or
Long distance telephone charges or telegraph charges; or
Radio or television charges; or
Barber or beautician charges.
b. If a Member uses a private room, he or she is responsible for
the difference in cost between the private room and the
hospital's most common two (2)-bed room rate. If the hospital
has only private rooms, we will determine a room allowance based
upon two (2)-bed room charges of other hospitals in the area.
C. The amount of charges for care, services or supplies paid under
other benefits of this Contract are not included under this
benefit.
d. We do not provide benefits for treatment received more than
ninety (90) days after the date of the accident.
e. We do not provide benefits for disease or infection, except for
infection occurring as a result of an accidental cut or wound.
f. We do not provide benefits for the services of a dentist, except
as specifically provided in 5.3.2.e.
g. We do not provide benefits for eye refraction, eye glasses or
their fitting, or contact lens(es) due to an accident, except as
specifically provided in 5.3.2.j .
h. We do not provide benefits for food poisoning.
i. We do not provide benefits for an accident that occurred before
a Member's effective date under this Contract.
Termination of the Member's coverage under this Contract will not
affect any claim under this Supplemental Accident Benefit. See
Part Seven for benefits after termination.
- 49 -
PART FIVE BENEFITS
5 .4 MAJOR MEDICAL BENEFIT (Subscriber and Family Member)
We provide benefits up to the Reasonable and Customary charge, see Part
One - Definitions, for services rendered in the treatment of illness,
injury or pregnancy as indicated below, provided:
It is medically necessary (see Part One - Definitions); and
The Member is under the care and treatment of a physician; and
Services are received on or after the Member's Effective Date of
coverage under this Contract.
A. Major Medical Deductible
Before Major Medical Benefits are provided, a required deductible
must be met. The deductible is the first $50.00 of expenses incurred
for covered services by each Member. The deductible amount is
applied as follows:
1. The deductible amount must be satisfied once each calendar year,
as long as the Member remains continuously covered.
If a Member's coverage lapses for any period of time, a new
deductible must be satisfied upon renewal of coverage under this
group contract.
2. A family unit will be required to satisfy an aggregate (total)
of only $150.00 in deductible amounts during a calendar year.
Once this amount is satisfied, the deductible for all family
members is satisfied for that calendar year, as long as the
Subscriber remains continuously covered.
If the Subscriber's coverage lapses for any period of time, the
family unit will be required to satisfy a new aggregate
deductible upon renewal of coverage under this contract.
3. If two or more family members suffer bodily injury as a result
of the same accident, only one deductible amount needs to be
satisfied before the Major Medical benefits of this Contract
will be provided for covered expenses as the result of that
accident during the year in which the accident occurs.
4. When expenses incurred in the last quarter of the year are used
to satisfy that year's deductible, the amount applied to the
deductible also applies to the following year's deductible. If
the expenses carried forward are in connection with an accident
involving two (2) or more family members, the expenses incurred
by these members as a result of that accident are subject to
only one deductible amount in the next year.
- 50 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
B. Maximum Amount of Benefits Provided
We provide Major Medical Benefits for covered services up to the
following maximum amounts:
1. When a Member remains continuously covered and incurs expenses
for covered services that exceed any applicable deductible
amounts stated in Part Part Five 5.4.A. , we will pay up to a
lifetime maximum of two hundred fifty thousand dollars
($250,000.00) at the following percentages except where a
different percentage is stated for specified benefits under
5.4.C. .
(a) eighty percent (80%) until two thousand dollars ($2,000.00)
has been paid for expenses incurred during any Calendar
Year on a Member's behalf; and
(b) one hundred percent (100%) of the charges for all other
covered expenses incurred during the remainder of that
Calendar Year.
If a Member's coverage lapses for any period of time, the Member
will return to the 80% level of coverage, as stated in (a),
above, upon renewal of coverage under this group Contract.
After fifty thousand dollars ($50,000.00) have been paid under
this Major Medical Benefit for a Member, payment will be made by
the Plan for one hundred percent (100%) of the Major Medical
expenses for that Member, without further requirements of a
Deductible Amount or co-insurance, up to a lifetime maximum of
two hundred fifty thousand dollars ($250,000.00) .
2. Each Calendar Year the Member is covered under this Contract we
will restore up to five thousand dollars ($5,000.00) of a
Member's benefit that has been paid by us. The restored amounts
will be added to the two hundred fifty thousand dollar
($250,000.00) lifetime maximum.
3. If this group coverage is replaced by a new Contract, any
amounts of the lifetime maximum which have been used will
transfer to the new Contract as long as the Member remains
continuously covered under the same group. If the Member's
coverage lapses, or he or she transfers to other Blue Cross
group coverage, a new lifetime maximum will be reinstated upon
renewal.
- 51 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies
This Major Medical Benefit includes only these services and supplies:
1. Services furnished and billed by a legally operated hospital up
to a two (2)-bed room except as stated in Part Six 6.1.14. and
6.1.15.
Use of an intensive care unit (includes coronary and constant
care units) is included in this benefit. Services in an
intensive care unit including nursing services provided by
hospital employees as a regular service are also included in
this benefit.
2. Professional services of a licensed physician. This benefit is
not available if the services are rendered by a physician who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
When a physician performs more than one surgical procedure, the
following will apply:
(a) at different times due to entirely unrelated causes,
benefits will be provided for each procedure;
(b) at the same time in the same operative area, benefits will
be provided only for the procedure with the largest
allowance;
(c) at the same time in different operative areas, full
benefits will be provided for the procedure with the
largest allowance plus one-half (1/2) of the allowance for
each additional procedure.
- 52 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Maior Medical Services and Supplies . . . (continued)
3. Professional services rendered by a dentist for:
Treatment of a fractured jaw; or
Accidental injury to natural teeth if the Member is covered
. at the time of the accident and services are rendered
within twelve (12) months of the accident; or
Excision of tumors or cysts of the jaw, tongue, roof and
floor of the mouth; or
Excision of exostosis of the jaw and hard palate; or
• Incision and drainage of cellulitis; or
Incision or excision of accessory sinuses, salivary glands
or ducts; or
Surgical procedures required due to an injury involving
. oral conditions such as fractured jaw, lacerations and
dislocations.
4. Acute nursing services of a Registered Nurse in the home when
such services are ordered by a physician. The maximum amount of
benefits payable on a Member's behalf is two thousand five
hundred dollars ($2,500.00) for such services during any
Calendar Year. This benefit is not available if the services
are rendered by a Registered Nurse who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
5. Anesthetic supplies and administration of anesthesia by:
An anesthesiologist; or
A registered nurse anesthetist.
6. X-ray therapy, radium therapy and radioactive isotope therapy.
7. Services of a physician or a licensed or registered physical
therapist rendered in connection with physical therapy
treatments. This benefit is not available if the services are
rendered by a physician or a licensed or registered physical
therapist who:
Ordinarily resides in the Subscriber's home; or
Is related by blood or marriage.
- 53 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Maior Medical Services and Supplies . . . (continued)
8. Diagnostic x-ray and laboratory services.
9. Licensed ambulance service to the nearest facility equipped to
render treatment of the condition.
Licensed ambulance service is not available unless other means
of transportation would endanger the health and safety of the
Members. This benefit is not available for:
Private automobiles; or
Taxi services.
10. Drugs and medicines lawfully obtainable when:
Directly required for the treatment of an illness,
injury or condition of pregnancy; and
Requiring a written prescription; and
. Dispensed by a licensed pharmacist or physician.
11. Medical supplies and prosthetic devices directly required for
the appropriate treatment of illness, injury or conditions of
pregnancy, such as:
. Casts;
Splints;
Trusses;
Braces;
Crutches;
Prosthetic devices to replace all or part of an absent
body organ or to aid in its function when impaired,
except that only the initial charge for the first such
prosthetic device will be included. Benefits will not
be provided for the replacement of prosthetic devices,
except when the existing device cannot be repaired and
replacement is recommended by a physician due to a
change in the Member's physical condition
(growth or physical deterioration) . Covered
prosthetic devices include, but are not limited to:
artificial limbs or eyes, and contact lens(es)
following cataract surgery or to replace a missing
portion of the eye (conditions of aphakia) .
- 54 -
PART FIVE BENEFITS
5 .4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies . . . (continued)
12. Rental or, at our option, the initial purchase of durable
mechanical medical equipment, see Part One - Definitions, which
is prescribed by a physician and required for therapeutic use in
the direct treatment of illness, injury or conditions of
pregnancy, such as:
Wheelchair;
Hospital-type bed;
Intermittent Positive Pressure Breathing Apparatus.
Special or extra-cost features and options which are convenience
items and do not primarily serve a medical purpose will not be
covered. In cases where there is an appropriate alternative
type of equipment that is less costly and serves the same
medical purpose, the Plan will provide benefits for the
equipment carrying the lesser charge.
13. Blood transfusions, including the cost of blood and blood
derivatives.
14. Services of a Chiropractor (D.C.) as those of any other
physician, within the scope of the D.C. license. See Part One -
Definition of a Physician.
15. Services for a mental, neuropsychiatric, or personality
disorder. Benefits are limited to:
a. Inpatient care received during a medically necessary
Hospital stay, payable at the percentages stated in Part
Five 5.4.B.1. ; and
b. A maximum of twenty (20) visits in any one Calendar Year
for treatment received while a Member is not confined in a
Hospital, payable at fifty percent (50%) of the covered
expenses instead of the percentages stated in Part Five
5.4.B.1.
C. Services must be rendered by a legally operated hospital,
physician, licensed psychologist or a Community Mental
Health Agency.
Benefits are subject to any applicable waiting periods as stated
in Part Six 6.2.12.
- 55 -
PART FIVE BENEFITS
5.4 MAJOR MEDICAL BENEFIT . . . (continued)
C. Major Medical Services and Supplies . . . (continued)
16. Services provided by a Skilled Nursing Facility are not covered
under this Major Medical Benefit. However, skilled nursing
services are covered as Basic Benefits in Part Five 5.1.E. and
5.1.F.
17. Treatment for Chemical Dependency is not covered under this
Contract's Major Medical Benefits. However, services for the
treatment of Chemical Dependency are covered as a Basic Benefit
in Part Five - Section 5.1.G.
18. Home Health Care is not covered under this Major Medical
Benefit. However, Home Health Care is covered as a Basic
Benefit under Part Five 5.10, if available.
19. Hospice care is not covered as a Major Medical Benefit in this
Contract. However, hospice care is covered as a Basic Benefit
under Part Five 5.11, if available.
20. The Second Surgical Opinion is not covered under this Major
Medical Benefit. However, the Second Surgical Opinion Benefit
is covered as a Basic Benefit under Part Five 5.2.1.H. , if
available.
D. Limitations
In addition to the Exclusions and Exceptions of Part Six, we do not
provide Major Medical Benefits for services or supplies that are
provided for under other benefits of this Contract. Basic Benefits,
if any, will be provided before Major Medical Benefits.
- 56 -
PART FIVE BENEFITS
5.5 BASIC BENEFITS: VISION CARE (Subscriber and Family Member)
This Contract does not provide a vision benefit.
- 57 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
A. When Benefits Are Available
1. The Plan will provide the benefits described below for covered
services and supplies incurred in connection with necessary
dental care. Necessary dental care means, that in the
reasonable opinion of this Plan, the disease, injury or
condition cannot be diagnosed, prevented or relieved without the
dental service, treatment or supply. The mere fact that the
service or supply was approved by a qualified provider does not
in itself mean that the service or supply constituted necessary
dental care. A service or supply may be necessary in part
only. All benefits are subject to the limitations, exceptions,
and exclusions and other provisions set forth in this Contract.
2. The Subscriber or Family Member is responsible for furnishing to
the Plan all diagnostic evaluative material, such as study
models, dental x-rays and charts, which we may require to
determine available benefits. We will not provide benefits for
those dental services which we are unable to verify as covered
services when any necessary material is not furnished upon our
request.
3. In providing benefits under this Contract we have the right to
have a dentist of our choice examine a Member. This will be
done upon our request and at our expense. Failure to comply
will result in denial of claims.
B. Alternate Benefits.'
The Plan will determine benefits available under this Contract taking
into account alternate procedures or services carrying different fees
which are, in the reasonable opinion of the Plan, consistent with
acceptable standards of dental practice. In all cases where there
are alternate courses of treatment carrying different fees, the Plan
will only provide benefits for the treatment carrying the lesser
fee. If the Member and the dentist decide upon a more costly
treatment, then the Member is responsible for the additional charges
beyond those for the less costly alternate treatment and for which
benefits have been provided by the Plan.
- 58 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
C. Predetermination of Benefits
With respect to any proposed dental service or series of dental
services for which the total charge(s) will exceed three hundred
dollars ($300.00) , the dentist may submit a predetermination request
to this Blue Cross Plan showing the treatment plan and fees. The
Plan will then review the predetermination request to determine the
estimated dental benefit under this Contract, and notify the dentist
and the Member accordingly.
If the dentist submits a treatment plan for Predetermination of
Benefits and then changes the Plan, this Blue Cross Plan will adjust
its payments accordingly. If the dentist makes a major change in the
treatment plan, the dentist may submit a revised Plan.
A Predetermination of Benefits is an estimate only and not a
guarantee of coverage or payment. Benefits provided to the Member
will be subject to the specific benefits, exceptions, exclusions,
limitations and eligibility provisions set forth in this Contract in
effect at the time the services are rendered.
D. Amount of Dental Benefits Provided
Benefits are provided at the percentages specified below for all
covered dental services (subject to the Reasonable and Customary
Charge, see Part One - Definitions), rendered during any benefit year
for any Member up to a maximum benefit of one thousand dollars
($1,000.00) . A benefit year is a period of twelve (12) consecutive
months beginning on the Member's Effective Date of coverage under
this Contract and each period of twelve (12) consecutive months
thereafter.
During the first Benefit Year in which a Member utilizes the Type A
Dental Services listed below, the Plan shall pay toward expenses
incurred seventy percent (70%) of the amount specified herein for the
Dental Service performed, except that when a Member utilizes such
Dental Services during successive Benefit Years, commencing with the
second of such successive Benefit Years the percentage of the amount
payable by the Plan toward such benefits shall be increased over such
seventy percent (70%) by an additional ten percent (10%) of the
amount specified herein for each successive Benefit Year until the
Plan will be paying one hundred percent (100%) of the amount
specified herein. However the percentage of the amount specified
herein that the Plan will pay toward such benefits in a Benefit Year
immediately following one or more Benefit Years in which none of such
benefits was utilized by a Member will be reduced by ten percent
(10%) but not less than seventy percent (70%) of the amount specified
herein for the service rendered.
During any Benefit Year, the Plan shall pay toward expenses incurred
for Type B Dental Services listed below, fifty percent (50%) .
- 59 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
E. Covered Dental Services
1. Type A Dental Services
a. Routine oral examinations (for diagnosing the oral health
of the patient and determining the dental care required),
limited to two (2) each benefit year.
b. Prophylaxis (cleaning, scaling and polishing of teeth),
limited to two (2) each benefit year.
C. Topical application of fluoride, for Members underage
twenty (20), limited to two (2) treatments each benefit
year.
d. Dental x-rays.
e. Space maintainers, for Members under age twenty (20) .
f. Sealants, for Members under age fourteen (14) , limited to
use on permanent teeth.
g. Simple extractions.
h. Oral surgery consisting of surgical extractions, fracture
and dislocation treatment, alveolar ridge augmentation, and
diagnosis and treatment of cysts or abscesses.
i. Fillings, consisting of silver amalgam, silicate and
plastic restorations. For other types of fillings, such as
gold foils, the allowance will be limited to what would
have been otherwise allowed for amalgam fillings.
j . Treatment of periodontal and other diseases of the gums and
tissues of the mouth.
k. Endodontic treatment.
1. Repair or recementing of crowns, inlays, bridgework or
dentures.
M. Emergency palliative treatment.
- 60 -
PART FIVE BENEFITS
5 .6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
E. Covered Dental Services . . . (continued)
2. Type B Dental Services
a. Inlays, onlays, or the initial placement of crowns, when in
the reasonable opinion of the Plan, amalgam fillings would
not adequately restore the teeth.
b. Replacement crowns, but only when:
The existing crown was seated at least five (5) years
prior to replacement; or
Repreparation of the natural teeth is required as a
result of an accidental injury.
C. Initial installation of dentures (including adjustments
during the first six (6) month period following
installation) or fixed bridgework (including inlays and
crowns to form abutments) .
d. Replacement dentures or fixed bridgework, but only when:
The existing denture or bridgework was installed at
least five (5) years prior to replacement; or
The replacement or addition of teeth is required to
replace one or more additional teeth extracted after
initial placement; or
Repreparation of the natural teeth in the existing
fixed bridgework is required as a result of an
accidental injury.
e. Relining of dentures.
- 61 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
F. Limitations, Exceptions and Exclusions
In addition to the Exclusions and Exceptions of Part Six, the
following limitations, exceptions and exclusions shall apply to this
benefit:
1. We provide benefits as if only one dentist provided the service
or supply if:
The Member transfers from the care of one dentist to that
of another dentist during the course of his or her
treatment; or
More than one dentist renders services for one dental
procedure.
2. Benefits for restorative or prosthetic dental services are
limited to standard techniques regardless of whether the Member
and the dentist decide:
On personalized restoration; or
To employ special techniques, such as precision attachments.
3. Except for extractions incidental to orthodontic services, we do
not provide benefits for services or supplies related to
orthodontia (see Part One - Definitions) .
4. Except for a child covered under this Contract from birth, we do
not provide benefits for the treatment of congenital
malformations.
5. We do not provide benefits for expenses incurred after
termination of a Member's coverage under this Contract except
for prosthetic devices, crowns, or root canals which:
Were fitted, prepared, started or ordered prior to the date
of termination of the Member's coverage under this
Contract; and
Were delivered to the Member, completed or seated within
thirty (30) days after the date of the termination of the
Member's coverage under this Contract.
62 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS: DENTAL CARE (Subscriber and Family Member)
. . . (continued)
F. Limitations Exceptions and Exclusions . . . (continued)
6. In all cases where there are, in the reasonable opinion of this
Plan, alternate courses of treatment carrying different fees,
the Plan will only provide benefits for the treatment carrying
the lesser fee.
7. This Contract must be in effect at the time the Member receives
services or supplies, except as provided in Part Five 5.6.F.5. ,
above.
g. We do not provide benefits for dental services received from a:
Dental or medical department maintained for employees by or
on behalf of an employer; or
Mutual benefit association, labor union, trustee or similar
person or group.
9. We do not provide benefits for facility charges for dental
procedures.
10. We do not provide benefits for services or supplies which:
Are not customary and accepted by the dental profession in
the States of Washington or Alaska;
Are for the purpose of research; or
Are experimental.
11. We do not provide benefits for dietary planning for the control
of dental caries, oral hygiene instruction and training in
preventive dental care.
12. We do not provide benefits for charges for services or supplies
for implantology (tooth implantation) .
13. We do not provide benefits for charges for broken appointments.
14. We do not provide benefits for services or supplies to increase
or alter the vertical dimension.
15 . We do not provide benefits for services or supplies not
necessary, in the reasonable opinion of the Plan, for proper
dental care.
- 63 -
PART FIVE BENEFITS
5.6 BASIC BENEFITS ; DENTAL CARE (Subscriber and Family Member)
. . . (continued)
F. Limitations Exceptions and Exclusions (continued)
16. We do not provide benefits for separate charges for study models
or casts.
17. We do not provide benefits for extra dentures or other covered
appliances, including replacements due to loss or theft.
18. We do not provide benefits for drugs and medicines, whether or
not they require a prescription.
However, benefits for prescription drugs and medicines are
provided for under the Major Medical Benefit, if available.
19. We do not provide benefits for braces, banding or retainers.
20. Dental services, supplies and treatment must be provided by a
dentist performing within the scope of his or her license.
Dental services, supplies and treatment may also be provided by
a licensed dental hygienist or other individual performing
within the scope of his or her responsibilities as allowed by
Washington or Alaska law if the treatment is rendered under the
supervision and guidance of the dentist.
- 64 -
PART FIVE BENEFITS
5.7 BASIC BENEFITS: PRESCRIPTION DRUGS (Subscriber and Family Member)
Prescription Drugs are not covered as a Basic Benefit under this
Contract. See, however, 5.4.C.10. for related Major Medical Benefits, if
available.
5.8 BASIC BENEFITS: HEARING AIDS
This Contract does not provide a hearing aid benefit.
5.9 BASIC BENEFITS: ORTHODONTIA
This Contract does not provide an orthodontia benefit.
65 -
PART FIVE BENEFITS
5.10 BASIC BENEFITS : HOME HEALTH CARE
1. Amount of Benefit Provided
This benefit provides payment at 100% of the Approved Home Health
Agency's charge, not to exceed the Reasonable and Customary Charge
(see Part One - Definitions) for an included service or supply,
subject to the conditions and limitations set forth herein.
2. Home Health Care Services and Supplies
This home health care benefit covers only the services and supplies
listed below for home health care which is provided and billed by an
Approved Home Health Agency (see Part One - Definitions) , included in
the Home Health Care Plan of Treatment (see Part One - Definitions) ,
and provided to a Member who is homebound (see Part One -
Definitions) in lieu of hospitalization. The Home Health Care Plan
of Treatment must be established and periodically reviewed by a
physician licensed as a Doctor of Medicine (M.D.) or Doctor of
Osteopathy (D.O.) and must describe the medically necessary treatment
of an illness or injury to be provided.
a. Covered Services
Covered expenses include visits by each of the following for
intermittent care, not to exceed four (4) hours in duration per
visit:
A registered or licensed practical nurse;
A licensed physical therapist;
A certified respiratory therapist;
An American Speech and Hearing Association certified speech
therapist;
A certified occupational therapist; or
A home health aide (see Part One - Definitions) ,
limited to a Calendar Year maximum of one hundred thirty (130)
visits. Each visit by an employee of the Approved Home Health
Care Agency shall be counted against the one hundred thirty
(130)-visit maximum.
66 -
PART FIVE BENEFITS
5 .10 BASIC BENEFITS: HOME HEALTH CARE
2. Home Health Care Services and Supplies . . . (continued)
b. Covered Supplies
Benefits for the following covered supplies shall be limited to
$500 per Calendar Year.
(1) Drugs or medicines directly required for the treatment of
the Member's illness that are legally obtainable only upon
a physician's written prescription, and insulin.
(2) Medical supplies normally used for Hospital inpatients,
such as oxygen, catheters, needles, syringes, dressings,
materials used in aseptic techniques, irrigation solutions,
and intravenous solutions.
(3) Rental of durable medical apparatus and medical equipment
such as wheelchairs, Hospital beds, respirators, splints,
trusses, braces, or crutches needed for treatment.
3. Exclusions
In addition to the Exclusions and Exceptions of Part Six, we do not
provide benefits for the following:
a. Services provided to other than the homebound Member;
b. Social services;
C. Services performed by Family Members or volunteer workers;
d. Services or supplies that are non-medical or custodial in
nature; homemaker and housekeeping services, except by home
health aides to achieve the medically desired results;
e. Supportive environmental materials, including but not limited
to, handrails, ramps, air conditioners and telephones;
f. Expenses for the normal necessities of living, including but not
limited to, food, clothing, and household supplies;
67 -
PART FIVE BENEFITS
5.10 BASIC BENEFITS: HOME HEALTH CARE
3. Exclusions . . . (continued)
g. Dietary assistance (e.g. , "Meals on Wheels") or nutritional
guidance;
h. Separate charges for reports, records or transportation;
i. Services and supplies not included in the home health plan of
treatment, or not specifically set forth as a covered expense;
j . Services and supplies in excess of the specified limitations; or
k. Services provided during any period of time in which the Member
is receiving benefits under Part Five 5.11.
68 —
PART FIVE BENEFITS
5 .11 BASIC BENEFITS: HOSPICE CARE
1. Amount of Benefit Provided
This benefit provides payment at 100% of the Approved Hospice's
charge, not to exceed the Reasonable and Customary Charge (see Part
One - Definitions) for an included service or supply, subject to the
conditions and limitations set forth herein.
2. Hospice Care Services and Supplies
This hospice care benefit covers only the services and supplies
listed below, for a six (6)-month period of hospice care, when
provided and billed by an Approved Hospice (see Part One -
Definitions), included in the hospice plan of care (see Part One -
Definitions) , and provided to a terminally ill Member in lieu of
hospitalization. The hospice plan of care must be established and
periodically reviewed by a physician licensed as a Doctor of Medicine
(M.D.) or Doctor of Osteopathy (D.O.) and must describe the
Palliative Care and medically necessary treatment to be provided.
a. Home Care
Covered expenses include only those services listed below,
limited to a maximum benefit of $5,000:
(1) Visits by each of the following for intermittent care, not
to exceed four (4) hours in duration per visit:
A registered or licensed practical nurse;
A licensed physical therapist;
A certified respiratory therapist;
An American Speech and Hearing Association certified
speech therapist;
A certified occupational therapist;
A master of social work; or
A home health aide (see Part One - Definitions) .
(2) Drugs or medicines for the terminal illness that are
legally obtainable only upon a physician's written
prescription, and insulin.
(3) Medical supplies normally used for Hospital inpatients,
such as oxygen, catheters, needles, syringes, dressings,
materials used in aseptic techniques, irrigation solutions,
and intravenous solutions.
- 69 -
PART FIVE BENEFITS
5.11 BASIC BENEFITS: HOSPICE CARE
2. Hospice Care Services and Supplies . . . (continued)
a. Home Care . . . (continued)
(4) Rental of durable medical apparatus and medical equipment
such as wheelchairs, Hospital beds, respirators, splints,
trusses, braces, or crutches needed for treatment.
b. Short Term Care in an Approved Hospice
Inpatient services and supplies provided by an Approved Hospice
when ordered by the attending physician, limited to a maximum of
ten (10) days.
C. Respite Care
Respite care (see Part One - Definitions) for a homebound
Member, limited to one hundred twenty (120) hours in each three
(3)-month period of hospice care. The three (3)-month period
shall commence on the initial date of hospice care covered under
this Contract.
Benefits shall not be available beyond six (6) months from the
initial date of hospice care covered under this Contract. However,
at the end of the six (6)-month period, the Member may apply to the
Plan for an extension if hospice care benefits have not been
exhausted.
3. Exclusions
In addition to the Exclusions and Exceptions of Part Six, we do not
provide benefits for the following:
a. Services provided to other than the terminally ill Member,
including bereavement counseling;
b. Pastoral and spiritual counseling;
C. Services performed by Family Members or volunteer workers;
d. Homemaker or housekeeping services, except by home health aides
as ordered in the hospice plan of care;
e. Supportive environmental materials, including but not limited
to, handrails, ramps, air conditioners and telephones.
- 70 -
PART FIVE BENEFITS
5.11 BASIC BENEFITS: HOSPICE CARE
3. Exclusions . . . (continued)
f. Expenses for the normal necessities of living, including but not
limited to, food, clothing, and household supplies.
g. "Meals on Wheels" or similar food services;
h. Separate charges for reports, records or transportation;
i. Legal and financial counseling services;
j. Services and supplies not included in the hospice plan of care,
or not specifically set forth as a covered expense.
k. Services and supplies in excess of the specified limitations, or
services and supplies provided more than six (6) months from the
initial date of hospice care covered under this Contract.
1. Services provided during any period of time in which the Member
is receiving benefits under Part Five 5.10 - Home Health Care.
- 71 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions
In addition to the limitations listed in Part Five - Benefits, we do not
provide benefits for the following:
1. Routine Examinations, X-Ray and Laboratory Testing
Physical examinations, including screening examinations, tests,
x-ray, laboratory, pathological services, and machine diagnostic
tests if they are not directly related to an:
Illness;
Disease;
Injury;
Pregnancy; or
Definitive set of symptoms.
2. Treatment for Obesity
Treatment for obesity, including:
Surgery; or
Complications of surgery.
3. Routine Foot Care
Routine foot-care procedures such as, but not limited to:
Trimming of nails, corns or calluses; or
Routine hygienic care.
4. Symptomatic Complaints of the Feet and Orthotics
Services and supplies for:
Fallen arches;
Other symptomatic complaints of the feet; or
Impression casting for prosthetics and appliances (orthotics)
including the prescriptions needed to make them.
5. Milieu Therapy
Milieu Therapy, see Part One - Definitions.
- 72 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions . . . (continued)
6. Conditions Resulting From War
Conditions caused by or arising out of the following:
An act of war; or
Armed invasion or aggression.
7. Services or Procedures Not Accepted by the Medical Profession
Services or procedures which are not generally performed or accepted
by the medical profession in the States of Washington and Alaska; any
treatment, procedure, facility, equipment, drug, drug usage, device
or supply which is considered experimental or investigative at the
time rendered. See Part One - Definitions.
8. Reproductive and Sexual Disorders and Defects
Services, supplies and procedures for reproductive and sexual
disorders and defects, whether or not the consequences of illness,
disease or injury, including but not limited to the following
conditions and procedures:
Impotency;
Frigidity;
Infertility;
Reversal of surgical sterilization; or
Artificial insemination and in-vitro fertilization.
9. Sex Transformations
Services and supplies or drugs for sex transformations.
10. Services or Supplies Not Medically Necessary
Services or supplies not medically necessary, see Part One -
Definitions, even if ordered by a court of law.
- 73 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions . . . (continued)
11. Services or Supplies Not Charged For
Any services or supplies for which no charge is made, or:
That would not have been made if this Contract were not in
effect; or
For services or supplies for which a Member is not legally
liable.
12. Work Related Conditions and Workers' Compensation
Any illness, condition or injury for which an employer is required or
has the option to furnish coverage under any legislative act that
provides for compensation or benefits because of illness, condition
or injury arising out of or in the course of employment, such as
Workers' Compensation. (This Exclusion does not apply to the
illnesses, conditions or injuries of the Group's sole proprietor or
partners that arise solely from their occupations with the Group, if
they are exempt from the above laws and if the Group does not furnish
them Workers' Compensation coverage.)
This Exclusion applies whether or not a proper and timely claim for
such benefits has been made.
However, LEOFF I employees of Group #828-04 covered under the Law
Enforcement Officers and Fire Fighters Act of 1969, will be covered
under this Contract for:
Non-occupational injuries, condition or ailments; and
Conditions, injuries or ailments connected with their occupation
as law enforcement officers or firefighters.
13. Counseling or Training Services
Services or supplies for:
Learning disabilities;
Marital, family or sexual counseling; or
Other counseling or training services.
- 74 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions . . . (continued)
14. Personal Charges Billed By An Institution
We do not provide benefits when billed by an institution for services
of a personal nature such as:
Meals for guests;
Long-distance telephone charges;
Radio or television charges; or
Barber or beautician charges.
15. Private Room Charges - Inpatient Hospital
We do not provide benefits for the use of private rooms during an
inpatient Hospital stay.
If a Member uses a private room, he or she is responsible for the
difference in cost between the private room and the Hospital's most
common two (2)-bed room rate. If the Hospital has only private
rooms, we will determine a room allowance based upon the two (2)-bed
room charges of other Hospitals in the area.
16. Rehabilitative Care
See the exception in Part Six, 6.2.6.
17. Convalescent or Custodial Care
See the exception in Part Six, 6.2.1.
18. Motor Vehicle, Liability, or Personal Iniury Protection Insurance
Services and supplies to the extent that benefits are payable under
the terms of any automobile medical, automobile no-fault, automobile
uninsured motorist and/or underinsured motorist, personal injury
protection (PIP), commercial liability, homeowner's policy, or other
similar type of insurance or Contract.
19. Hearing Aid Services or Supplies
We do not provide services for:
Hearing examinations; or
Hearing aids, new or replacement.
- 75 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.1 Exclusions . . . (continued)
20. Vision Care Services or Supplies
We will not provide benefits for:
Eye examinations;
Eye glasses;
Visual analysis;
Vision therapy;
Training relating to muscular imbalance of the eye (orthoptics);
Pleoptics;
Services, supplies and procedures relating to altering the
refractive character of the cornea, and their results, both
direct and indirect, including, but not limited to radial
keratotomy, corneal modulation, keratomileusis, or refractive
keratoplasty; or
Services of an optometrist.
21. Orthodontia
We do not provide benefits for services and supplies for orthodontia
(see Part One - Definitions) .
76 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions
This Contract does not provide benefits for treatment, care, services or
supplies except as stated in the paragraphs below or in the specific
Benefits of Part Five.
1. Convalescent or Custodial Services
Unless stated in Part Five 5.1.E. or 5.1.F. we do not provide
benefits for convalescent or custodial services no matter where the
services are rendered, for any portion of a Hospital stay that
becomes convalescent or custodial care, or for services furnished by
an institution that is:
A Skilled Nursing Facility;
A place of rest;
A place for the aged;
A nursing home; or
A convalescent home.
2. Well Baby Care
We do not provide benefits for well baby care except for Hospital
infant nursery care for the newborn infant. The mother must also be
hospitalized and receiving benefits for maternity care under this
Contract.
3. Dental Care Services or Supplies
We do not provide benefits for dental services or services of a
dentist unless stated in Part Five:
5.2.1.A.2.b. - Surgical Benefit;
5.3.2.e. - Supplemental Accident;
5.4.C.3. - Major Medical; or
5.6. - Dental Benefit.
4. Inpatient Hospital Care for Dental Procedures
We do not provide inpatient hospital care for dental procedures
unless:
Adequate treatment cannot be provided without the use of
Hospital facilities; and
There is a co-existing medical condition, other than the
condition for which the Member requires treatment, that makes
hospitalization necessary for health and safety.
- 77 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
5. Cosmetic Services, Supplies and Procedures
Services, supplies and procedures for cosmetic, plastic and
reconstructive purposes and their results, direct or indirect, are
not included benefits, except:
To repair a defect caused by an accidental injury occurring
while covered under this Contract;
To repair a dependent child's congenital anomaly;
For the initial reconstruction of the involved breast following
a mastectomy necessitated by disease, illness or injury.
Benefits will also be provided for all stages of one
reconstructive breast reduction on the non-diseased breast to
make it equal in size with the diseased breast after definitive
reconstructive surgery on the diseased breast has been
performed; or
When incidental to or following a covered surgery which resulted
from disease of the involved body part and necessary to improve
or correct the function of the involved body part.
Below are some examples of what are not included benefits:
Surgery for sagging skin of the eyelids (blepharochalasis) ,
face, neck, abdomen, hips or extremities (meloplasty,
rhytidectomy or lipectomy) ;
Breast enlargement, reduction or uplift procedures (except as
stated above); or
Reshaping of the nose (rhinoplasty) .
6. Rehabilitative Care
Unless stated in Part Five 5.4.C.7. , admissions or treatment for
rehabilitative care, including but not limited to, speech and
occupational therapy, are not included benefits.
7. Hospital Admissions for Testing or Physical Examinations
We do not provide inpatient Hospital care for diagnostic studies,
physical examinations, check-ups, medical evaluations or observations
unless:
The services cannot be provided without the use of inpatient
Hospital facilities; or
There is a medical condition that makes hospitalization
necessary for the Member's health and safety.
- 78 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
8. Care Received in a County. State or U.S. Government Hospital
We do not provide benefits for care, services or supplies received in
a Non-Participating Hospital owned or operated by a county, state or
federal agency, except:
For treatment of a medical emergency (See Part One -
Definitions) ; or
As otherwise required by state or federal law.
All services and supplies must be furnished and billed by the
Hospital.
9 . Coordination of Benefits
A. Benefits Subject to This Provision
All of the benefits provided under this Contract are subject to
these provisions.
B. Definitions
1. Program means the following sources of benefits which will
be recognized for coordination of benefits purposes:
(a) Group or blanket disability insurance or health care
program issued by insurers, health care services
contractors and health maintenance organizations;
(b) Labor-management trustee plans, labor organization
plans, employer organization plans or employee benefit
organization plans;
(c) Governmental Programs which provide benefits for their
own civilian employees or their dependents. This does
not include Medicare.
(d) Coverage required or provided by any statute.
(e) Group student coverage provided or sponsored by a
school or other educational institution which includes
medical benefits for illness or disease.
The term "Program" will be separately understood to mean
each program which does or which does not provide for
coordination of benefits. Each portion of a Program which
separately states whether it is or is not subject to this
provision will also be determined to mean a separate
"Program."
- 79 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
9. Coordination of Benefits . . . (continued)
B. Definitions . . . (continued)
2. Allowable Expense means any necessary, reasonable and
customary item of expense at least a portion of which is
covered by at least one of the Programs covering the Member
for whom the claim is made. When a Program provides
benefits in the form of services rather than cash payments,
the reasonable cash value of the service will be considered
as both an allowable expense and a benefit paid.
3. Claim Determination Period means a Calendar Year.
C. Effect on Benefits
Coordination of Benefits comes into effect when a Member has
health care coverage under more than one Program. If, in the
absence of this provision, the sum of the benefits available
under this Program and the benefits available under all other
Programs covering the Member, would be greater than the total
amount of Allowable Expenses incurred by that Member during the
Claim Determination Period, the Programs involved will
coordinate their benefits according to this provision.
In order to coordinate benefits, it must be determined which
Program will be responsible for providing benefits first. Such
Program is determined to be "Primary." The Primary Program is
responsible for paying available Program benefits as if the
coordination of benefits provision did not exist. The remaining
Programs are determined to be "Secondary." The Secondary
Programs will reduce the benefits that would have been paid in
the absence of this provision, so that the sum of the benefits
paid by all the Programs covering the person will not exceed the
total amount of Allowable Expenses incurred. Benefits payable
under another Program include the benefits that would have been
payable whether or not a claim was actually submitted to the
Program.
The following rules will apply in determining which Program will
be Primary:
1. A Program which does not provide for coordination of
benefits will always be Primary over a Program which
includes a coordination of benefits provision.
- 80 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
9. Coordination of Benefits . . . (continued)
C. Effect on Benefits . . . (continued)
2. When a Member is covered by more than one Program and each
Program involved includes this provision, the following
rules shall apply in determining which Program is Primary:
(a) Non—Dependent/Dependent
The Program which covers the Member as other than a
dependent shall be Primary over the Program which
covers the Member as a dependent.
(b) Dependent Child/Parents Not Separated or Divorced
If the Member is a dependent Child and the parents of
the Child are not separated or divorced, the following
rules will apply:
(i) The Program which covers the Member as the
dependent of the parent whose birthday falls
earlier in a year will be Primary over the
Program which covers the Member as the dependent
of the parent whose birthday falls later in that
year.
(ii) If the other Program does not have the rule
described in (i) immediately above regarding
dependents, which results in each Program
determining its benefits before the other or in
each Program determining its benefits after the
other, the provisions of subsection (i) above
shall not apply, and the rule set forth in the
Program which does not have the provisions of
subsection (i) above shall determine the order of
benefits.
81 —
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
9. Coordination of Benefits . . . (continued)
C. Effect on Benefits . . . (continued)
(c) Dependent Child/Separated or Divorced Parents
However, if the Member is a dependent Child and the
parents of the Child are separated or divorced, the
following rules will apply:
(i) If the parent with custody of the Child has not
remarried, the Program which covers the Child as
a dependent of the parent with custody of the
Child will be Primary over the Program which
covers the Child as a dependent of the parent
without custody.
(ii) If the parent with custody has remarried, the
Program which covers the Child as the dependent
of the parent with custody will be Primary over
the Program which covers the Child as the
dependent of a step-parent. Also, the Program
which covers the Child as the dependent of the
step-parent will be Primary over a Program which
covers the Child as a dependent of the parent
without custody.
(iii) If there is a court decree which establishes
financial responsibility for the health care
expenses of the Child, this will take precedence
over (i) and (ii) , above. In this case, the
Program which covers the Child as the dependent
of the parent with such financial responsibility
will be Primary over any other Program which
covers the Child as a dependent.
- 82 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
9. Coordination of Benefits . . . (continued)
C. Effect on Benefits . . . (continued)
(d) Active/Inactive Employee
When rules (a), (b) or (c) do not determine which
Program has responsibility for Primary payment of
benefits, the Program which has covered the Member for
the longer period of time will be Primary over the
Program which has covered the Member for the shorter
period of time provided that:
(i) The benefits of a program covering the person on
whose expenses claim is based as a laid off or
retired employee, or dependent of such person,
shall be determined after the benefits of any
other program covering such person as an
employee, other than a laid off or retired
employee, or dependent of such person; and
(ii) If either program does not have a provision
regarding laid off or retired employees, which
results in each program determining its benefits
after the other, then the provisions of (i)
above of this subsection shall not apply.
(e) Longer/Shorter Length of Coverage
If none of the above rules determines the order of
benefits, the benefits of the program which covered an
employee, Member or Subscriber longer are determined
before those of the program which covered that person
for the shorter time.
83 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
9. Coordination of Benefits . . . (continued)
C. Effect on Benefits . . . (continued)
3. When this provision operates to reduce the total amount of
benefits otherwise payable as to a Member covered under
this Program during any Claim Determination Period, each
benefit that would be payable in the absence of this
provision shall be reduced proportionately, and the amount
reduced will be applied toward any Allowable Expense
incurred during a Claim Determination Period. The Member
shall not be entitled to benefits in excess of the total
maximum benefits of the Program during the Claim
Determination Period.
D. Determination of Other Coverage
This Plan will not be required to determine the existence or
extent of any other group coverage. The benefits payable under
this Program shall be affected by coordination of benefits only
to the extent that other Program information is supplied to the
Plan by the Member, the other group, the provider of services,
or any other organization or person.
E. Facility of Payment
Whenever payments which should have been made under this Program
in accordance with this provision have been made under any other
Program, the Plan shall have the right, exercisable alone and in
its sole discretion, to pay over to any Program making such
other payments any amounts it shall determine to be warranted in
order to satisfy the intent of this provision, and amounts so
paid shall be considered benefits paid under this Program and,
to the extent of such payments, the Plan shall be fully
discharged from liability under this Program.
- 84 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
10. Rights to Benefits After Termination
Unless provided in Part Seven 7.1. , we do not provide benefits under
this Contract for services, treatment, medical attention or care
which a Member received after his or her termination date.
No rights are vested under this Contract.
11. Contract Must Be In Effect
Unless stated in Part Seven 7.1 - Benefits After Termination, this
Contract must be in effect at the time a Member receives services.
12. Waiting Periods
Waiting periods do not apply to this Contract.
13. Upper or Lower Augmentation or Reduction Procedures
Except for Members continuously covered by this Plan from date of
birth, upper or lower ,jaw augmentation or reduction procedures,
orthognathic surgery, are not covered.
14. Mental Neuropsvchiatric or Personality Disorders
Unless stated in Part Five 5.1.A. or 5.4.C.15. , we do not provide
benefits for mental, neuropsychiatric or personality disorders.
15. Treatment of Chemical Dependency
Treatment for alcohol or drug use, abuse or dependency, except as
specifically defined under the definition of Chemical Dependency and
as provided under Part Five 5.1.G.
16. Charges Over Reasonable and Customary
We do not provide benefits for charges or fees in excess of the
Reasonable and Customary Charge. See Part Eight 8.5 for information
regarding the Member's financial responsibility with regard to
services rendered, furnished and billed by a participating provider.
- 85 -
PART SIX EXCLUSIONS AND EXCEPTIONS
6.2 Exceptions . . . (continued)
17. Governmental Plan or Program
Services and supplies for which the Member is entitled to receive
benefits from any federal, state, or governmental program, including
Medicare (even though the Member fails to make timely application for
or waives rights to such benefits) , except as otherwise required by
law.
Effect of Medicare: If the employer is subject to federal
"working aged" laws, this Contract provides benefits primary over
Medicare for covered, active employees or their covered spouses, who
are sixty-five (65) or older and have elected primary coverage under
this Contract.
This Contract also provides benefits primary over Medicare, to the
extent that an employer-sponsored health care program is required to
do so by federal law, for Members who are entitled to Medicare
because of a kidney transplant or renal dialysis, and for covered
active employees or their dependents when the employee or dependent
is under age sixty-five (65), disabled, and covered by Medicare.
In all other instances, benefits payable by Medicare will be
subtracted from total covered expenses before the benefits of this
Contract are calculated, whether or not such Medicare benefits have
been claimed.
18. Second Surgical Opinion
Unless stated in Part Five 5.2.1.H. , we do not provide benefits for
Second Surgical Opinion Benefit.
19. Home Health Care
Unless stated in Part Five 5.10. , we do not provide benefits for
services and supplies furnished and billed by a Home Health Care
Agency.
20. Hospice Care
Unless stated in Part Five 5.11. , we do not provide benefits for
services and supplies furnished and billed by a Hospice.
21. Chiropractic Services
Unless stated in Part Five 5.4.C.14. , we do not provide benefits for
care, services and supplies furnished by a chiropractor.
- 86 -
PART SEVEN BENEFITS AFTER TERMINATION
As stated in Part Two Section D. , the benefits of this Contract may continue
after termination or cancellation subject to the following provisions:
7.1 Individual and Group Cancellation of Coverage Under This Contract
Coverage under this Contract shall terminate automatically upon
termination of the Member's eligibility or upon Group cancellation of this
Contract unless:
1. Coverage terminates while a Member is confined in a Hospital, Skilled
Nursing Facility or Approved Treatment Facility. Inpatient benefits
specified in this Contract will continue to be available until the
first of the following occurs:
The Member is discharged;
The Member no longer requires such care; or
We have provided the maximum amount of benefits.
2. The Member is totally disabled and no longer employed or connected
with the Group at the time coverage ends. The Major Medical Benefits
will be available only for the condition which caused the
disability. Such benefits will be available until the first of the
following occurs:
Benefits have been provided for the number of months equal to
the number of months the Member was covered, up to a maximum of
twelve (12) months; or
We have provided the maximum Major Medical Benefits.
Payment for covered services will be made if:*
The Member is under a physician's care: and
The Member submits evidence of the disability within ninety (90)
days after coverage ends. The Member's physician must complete
a Statement of Disability (Form 400-1496) which is available
from us. The Member must notify us if the total disability
ceases.
The total disability benefits specified in this section are not
available if the disability occurs after the termination of the
Member's eligibility under this Contract or the Cancellation of this
Contract.
*If this Contract is cancelled after the Member has commenced his or
her total disability period, the termination will not affect the
Member's right to total disability benefits.
- 87 -
PART SEVEN BENEFITS AFTER TERMINATION
7.1 Individual and Group Cancellation of Coverage Under This Contract
. . . (continued)
3. The Member is receiving the Supplemental Accident Benefit outlined in
Part Five 5.3. Such benefits will continue until the first of the
following occurs:
The end of ninety (90) days from the date of the accident; or
We have provided the maximum Supplemental Accident Benefit.
4. The Member is receiving the Hospice Care Benefit outlined in
Part Five 5.11. Such benefits will continue until the first of the
following occurs:
We have provided the maximum Hospice Care Benefit; or
The Member no longer requires such care or such care is not in
lieu of hospitalization.
7.2 Continuation of Employment - Nonpayment of Subscription Charges
If the Subscriber or the Group ceases to pay the Subscription Charges
required by this Contract while he or she remains employed or connected
with the Group, the coverage terminates automatically. The Terminal
Benefit of 7.1.2. will not apply.
- 88 -
PART EIGHT GENERAL PROVISIONS
8.1 Availability of Health Care
The services provided under this Contract are at all times subject to
availability of Hospital facilities and the ability of Hospitals, Hospital
employees, physicians and other providers to furnish services. We assume
no liability for conditions beyond our control which make it impossible
for services provided by this Contract to be obtained, such as:
Epidemics;
Natural disasters;
Civil disorders;
War; or
Labor dispute.
8.2 Hospitals Furnishing Care - Independent Contractors
We are not liable for any death, injury, illness or other condition
occurring to a Member while receiving care by, through or from a Health
Care Provider or Participating Hospital or other institution. Those who
furnish care or other benefits to a Member do so as independent
contractors.
8.3 Notice
Any notice this Plan is required to submit to the Group will be considered
delivered if mailed to the Group at the address appearing on the records
of the Plan. The Plan may submit notices, including individual
identification cards and descriptive benefit booklets or notifications of
modifications thereto, to covered employees by the same means. The Group
agrees to receive and promptly deliver all notices on behalf of the
covered employees.
8.4 Claim Appeal Procedure
Upon our final review and denial of a specific claim, the Plan will send
the Member an Explanation of Benefits (E.O.B.) form explaining how the
claim was processed.
89 -
PART EIGHT GENERAL PROVISIONS
8.4 Claim Appeal Procedure . . . (continued)
If the Subscriber disagrees with our denial in whole or in part, and the
Plan's Customer Service Department confirms the original denial, the
aggrieved Subscriber or his or her authorized representative must request
a formal review in writing within sixty (60) days of receipt of the E.O.B.
form. This written request must be received by us within the sixty
(60)-day period and contain the following information:
Subscriber name;
Subscriber Identification number;
Other identifying information found on the face of the E.O.B. form;
A concise statement of issues; and
Any data, document(s) or comments the Subscriber wants to have
considered.
We will notify the appealing Subscriber of our determination within sixty
(60) days following our receipt of the Subscriber's request. If special
circumstances require an extension of time, the Subscriber will be
notified of the delay and the reasons therefor. The delay will be no more
than an additional sixty (60) days. Our determination in response to an
appeal will be final in the opinion of the Plan.
8.5 Payment to Participatinp, Providers
Participating providers will seek payment solely from the Plan for the
provision of covered services, and accept such payment as full and final
payment for such services. Participating providers may seek payment from
the Member only for the following:
Services not covered by this Contract;
Deductibles;
Co-payments; and
Amounts in excess of stated benefit maximums.
- 90 -
PART NINE EMPLOYER INFORMATION
9.1 Subscription Charges and Grace Period
A. The Group shall pay to this Plan monthly the following Subscription
Charges:
For Group 828-01:
Employee $124.20
Employee and Spouse $214.38
Employee, Spouse and Children $270.21
Employee and Children $180.03
For Group 828-02 -04:
Employee $153.92
Employee and Spouse $244.10
Employee, Spouse and Children $299.94
Employee and Children $209.76
Subscription Charges are initially due in advance of the Effective
Date as stated on the first page of this Contract. Thereafter,
periodic payment(s) of Subscription Charges are due each month by the
day preceding the day of the month corresponding with said effective
date. However, a grace period of ten (10) days from each due date is
allowed to the Group for payment of any periodic payment. No
benefits are payable for claims incurred during any time period for
which Subscription Charges have not been paid.
The initial term and Subscription Charges of this Contract shall be
for twelve (12) months from its effective date as stated on the first
page and monthly thereafter, unless changed or terminated as stated
in 9.3. However, if any government imposes or changes any tax on
Plan revenue or mandates a change in benefits, the Plan may then
adjust Subscription Charges at any time to offset the effect on its
revenue.
B. After the expiration of the term of the Contract stated in 9.1.A.
above, the amount of the monthly Subscription Charges may be changed
by the Plan. The Plan shall notify the Group of any change at least
thirty (30) days before the date the change is to be effective.
Payment of the revised Subscription Charges constitutes acceptance of
the change.
- 91 -
PART NINE EMPLOYER INFORMATION
9.2 Records
A record of all employees and their dependents shall be maintained by the
Group and shall contain all information the Plan may require to administer
the provisions of the Contract. Such records shall be open for inspection
by the Plan at any reasonable time.
9.3 Termination By Group or Plan
A. By the Group
The Group may terminate this Contract at any time by giving at least
thirty (30) days' advance written notice to the Plan.
B. By the Plan
The Plan may terminate this Contract at the end of the initial term,
or at the end of any subsequent term, by giving at least thirty (30)
days advance written notice to the Group. The Plan reserves the
right to cancel the Contract at any time, by written notice as
specified above, on any monthly Subscription due date, if the Group
fails to maintain the enrollment requirements as specified or fails
to administer the provisions of the Contract.
92 -
ENDORSEMENT ONE
The Contract between CITY OF KENT . ' ALASKA,
which became effective January 1, , is hereby amended.
The purpose of this Endorsement is to amend the Subscription Charges and Grace
Period section.
PART NINE, EMPLOYER INFORMATION, 9.1. , Subscription Charges and
Grace Period, section A. , page 91, is hereby amended to read as
follows:
"A. The Group shall pay to this Plan monthly, the following
Subscription Charges:
For Group 828-01:
Employee $124.20
Employee and Spouse $214.38
Employee, Spouse and Children $270.21
Employee and Children $180.03
For Group 828-02, -04:
Employee $153.92
Employee and Spouse $244.10
Employee, Spouse and Children $299.94
Employee and Children $209.75
for a period of twelve (12) months from and after
January 1, 1988, and from month to month thereafter unless
modified as herein provided. Subscription Charges are due each
month by the day preceding the day of the month corresponding
with said effective date. However, if any government imposes or
changes any tax on Plan revenue or mandates a change in
benefits, the Plan may then adjust Subscription Charges at any
time to offset the effect on its revenue.
- 1 -
Contract No. 828-01, -02, -04 - ED1
ENDORSEMENT ONE . . . (continued)
CITY OF RENT
A grace period of ten (10) days is allowed to the Group for
payment of any periodic payment. No benefits are payable for
claims incurred during any time period for which Subscription
Charges have not been paid."
All other provisions of the Contract remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1988.
BLUE CROSS OF WASHINGTON AND ALASKA CITY OF KENT
B C.L- B Gt/
y � y
Stephen . Clark i t I e 74,,�, y�`�/
Executive Vice President
Chief Operating Officer
By
Title:
Date June 10, 1988 Date
- 2 -
Contract No. 828-01, -02, -04 - ED1
R. L. EVANS CO., INC.
401K-Pension Profit Sharing Plans I Financial&Insurance Planning
January 7, 1987
RECEIVED
Mr. Mike Webby
J A N 9 1987
City of Kent PERSONNEL DEPT,
220 4th Ave South
Kent, WA 98032
Dear Mike:
Enclosed please find the boilerplate contract changes needed for
your group. I have had this on my desk for a couple of weeks,
and wanted to send it to you for your review. These changes are
just to comply with the changes that Blue Cross has made in your
renewal packet.
If after your review you should have any questions, please feel
free to call.
Sincerely,
Douglas L. Evans / // 7
Vice-President
Employee Benefits _ AA
0-161 44,4E
Cam►'' '�-`" / �e
cvt L /12 "6e
1210 PLAZA 600 BLDG. SEATTLE,WA 98101 (206)448-7878
e
MEMORANDUM . . . . .
DATE: September 4, 1986
TO: Larry Duren
FROM: Sue Tatley
SUBJECT: CONTRACT CHANGES NEEDED FOR
GROUP NAME: CITY OF KENT
GROUP NUMBER(S) : 828, -01, -02, -04
RENEWAL DATE: l/l/87
Attached is a list of changes to update the wording and format in our group
contracts. These changes include boilerplate contract wording, various
optional contract changes to correspond with our Community-rated programs, and
Mandated Benefit Offerings. The changes applicable to the above-referenced
Group's renewal have been marked with an "X". Rate adjustments, if
appropriate, have been provided by Underwriting for optional contract
changes. It is possible that the Insurance Commissioner will require further
changes in our contracts after this memorandum is issued. This Renewal packet
does not reflect changes mandated by the Insurance Commissioner effective
l/1/87.
Please point out and explain to the broker or group the changes in contract
language relevant to the renewal, review the information contained in the
current Schedule of Eligibility, and determine if the group wants the optional
contract changes, in which case Underwriting will provide a rate adjustment,
if appropriate.
Attachment
Mkt-WA
0040/bm
CONTRACT CHANGES . . . Continued
A. BOILERPLATE CONTRACT WORDING . . . Continued
A-62 X The exclusion pertaining to Automobile Medical or No-Fault
Insurance has been rewritten to clarify the types of coverage
it excludes. The revised exclusion will read as follows:
"Motor Vehicle, Liability, or Personal Injury
Protection Insurance
Services and supplies to the extent that benefits are payable
under the terms of any automobile medical, automobile no-fault,
automobile uninsured motorist and/or underinsured motorist,
personal injury protection (PIP), commercial liability,
homeowner's policy, or other similar type of insurance or
contract."
CONTRACT CHANGES . . . Continued
A. BOILERPLATE CONTRACT CHANGES . . . Continued
A-63 X The exception pertaining to Care Received in a County, State or
U.S. Government Hospital has been revised to comply with
Federal Law (COBRA).* The revised exception will read as
follows:
"7. Care Received in a County, State or U.S. Government
Hospital
We do not provide benefits for care, services or supplies
received in a non-participating hospital owned or operated
by a county, state or federal agency, except:
for treatment of a medical emergency
(see Part One - Definitions) ; or
as otherwise required by federal law.
All services and supplies must be furnished and billed by
the hospital."
*Health care plans entered into, modified, or renewed on or
after April 7, 1986, (including self-funded plans) must provide
benefits to eligible veterans with non-service connected
disabilities for services rendered by VA facilities to the
extent that such services would be eligible had the services
not been furnished by a VA facility.
Inpatient hospital care provided after September 30, 1986, by
facilities of the uniformed services (military hospitals) to
eligible military retirees and military dependents will be
covered under your health care plan to the extent that such
care would be eligible had the care not been furnished by a
military hospital.
CONTRACT CHANGES . . . Continued
A. BOILERPLATE CONTRACT WORDING . . . Continued
A-64 X GOVERNMENTAL BENEFITS EXCLUSION - (5-1-86)
The upper age limit for Medicare secondary coverage of
"working aged" employees and spouses has been removed from the
exception pertaining to governmental programs to comply with
the Consolidated Omnibus Budget Reconciliation Act of 1986
(COBRA). A section also has been added to this exclusion to
clarify the effect of Medicare. The revised exclusion will
read as follows :
"Services and supplies for which the Member is entitled to
receive benefits from any federal, state, or governmental
program, including Medicare (even though the Member fails to
make timely application for or waives rights to such benefits),
except as otherwise required by law.
Effect of Medicare: If the employer is subject to federal
"working aged" laws, this Contract provides benefits primary
over Medicare for covered, active employees or their covered
spouses who are sixty-five (65) or older and have elected
primary coverage under this Contract. This Contract also
provides benefits primary over Medicare for covered services
for a kidney transplant or renal dialysis to the extent that
an employer-sponsored health care program is required to do so
by federal law.
In all other instances, benefits payable by Medicare will be
subtracted from total covered expenses before the benefits of
this Contract are calculated, whether or not such Medicare
benefits have been claimed."
CONTRACT CHANGES . . . Continued
A. BOILERPLATE CONTRACT WORDING . . . Continued
A-65 X Addition of Continuation of Coverage provision in compliance
with Federal Law.
Title X of the Consolidated Omnibus Budget Reconciliation Act
of 1985 (COBRA) includes a Continuation of Coverage required
related to group coverages. COBRA requires that continuation
of coverage be provided to spouses, dependents, and employees
under certain circumstances (e.g. divorce, termination of
employment, reduction in hours, etc.). Your contract will be
amended to comply with the requirements of COBRA on its renewal
date unless we are advised that your group is not affected by
this Act.
CONTRACT CHANGES . . . Continued
A. BOILERPLATE CONTRACT WORDING . . . Continued
A-66 X Please advise us of any changes to your eligibility provisions
since your last renewal (Schedule of Eligibility attached).
The Plan's policy on retroactive coverage has been revised to
provide retroactive coverage for up to 60 days instead of
12 months. Upon renewal, the Late Enrollment section of your
Schedule of Eligibility will be revised to reflect this change.
CONTRACT CHANGES . . . Continued
B. OPTIONAL CONTRACT CHANGES . . . Continued
B-27 X UTILIZATION MANAGEMENT
A new Utilization Management Program may be added to your
contract. If you elect to take this optional coverage, the
attached cost containment provisions will be incorporated in
Part Three of your contract and the Second Surgical Opinion
provisions currently in your contract will be deleted.
Z F� E+3ts F
The rate adjustment for this option isQP.l.92�t�y�y���G�37�y1L>
Note: You may increase the Inpatient Hospital Care Deductible
stated in Part Three 3.4.A. of the Inpatient Hospital
Utilization Review Program.
PART THREE PROVISIONS THAT AFFECT BENEFITS
3.4 INPATIENT HOSPITAL UTILIZATION REVIEW PROGRAM
All inpatient hospital admissions are subject to review by the Plan for
medical necessity. The review may be undertaken:
Before or during a hospital stay; or
Following discharge from the hospital.
The Plan's Inpatient Hospital Utilization Review Program includes:
A. Inpatient Hospital Care Deductible
In addition to any calendar year deductible set forth in Part 5.4. ,
Major Medical Benefits, a required one hundred dollar ($100.00)
deductible must be met for each inpatient hospital admission before
benefits for inpatient hospital care are provided. This requirement
may be waived as set forth in 3.4.B. below.
B. Preadmission Review
Preadmission Review will be conducted to determine whether, in the
reasonable opinion of the Plan, a scheduled inpatient hospital
admission is medically necessary. If Preadmission Review is not
obtained when required, the one hundred dollar ($100.00) Inpatient
Hospital Care Deductible must be satisfied. The Subscriber or
Member must initiate Preadmission Review by having his or her
physician or hospital contact the Plan.
Preadmission Review is not required and the Inpatient Hospital Care
Deductible will be waived:
For admission for obstetrical delivery or scheduled cesarean
section; or
For admission for treatment of a medical emergency; or
For admission for treatment of a medical emergency; or
For admission for treatment of an accidental bodily injury the
day of or within the next two (2) days following the accident.
For admission to a hospital located outside of the United
States of America or to a hospital located within United States
territories.
Prior to admission under all other circumstances, the Subscriber or
Member is responsible for assuring that the admitting physician
requests Preadmission Review. However, in the event appropriate
utilization review is not initiated prior to or upon admission, the
Plan will determine whether an inpatient level of care was medically
necessary at the time the claim is received by the Plan.
(See Retrospective Review described in 3.4.E. below.)
PART THREE PROVISIONS THAT AFFECT BENEFITS
3.4 INPATIENT HOSPITAL UTILIZATION REVIEW PROGRAM . . . (continued)
B. Preadmission Review . . . (continued)
Upon receipt of the request for Preadmission Review, the Plan will
determine whether, in our reasonable opinion, an inpatient level of
care is medically necessary. The Plan may, at the time Preadmission
Review is initiated for a surgical admission, recommend that the
Member obtain a second surgical opinion. The Member, the Subscriber,
the physician and the hospital will receive written notification of
our Preadmission Review determination.
Preadmission authorization is not a guarantee of payment.
Preadmission authorization means only that the Plan recognizes an
inpatient level of care is medically necessary for the condition
described by the physician.
C. Admission Review
Review upon an inpatient hospital admission may be conducted to
determine if an unscheduled admission or an admission not subject to
Preadmission Review is medically necessary.
When admission is to a Participating Hospital, that hospital will
contact the Plan for verification of medical necessity. In the event
of an admission to a hospital that does not have an agreement with
this Blue Cross Plan or a hospital outside of the service area, the
hospital may contact the Plan upon admission; otherwise, the Plan
will determine whether an inpatient level of care was medically
necessary at the time the claim is submitted to the Plan.
(See Retrospective Review described below).
D. Concurrent Review
Concurrent Review may be conducted by the Plan to determine if a
continued inpatient hospital stay is medically necessary.
If, during the Concurrent Review process, the Plan determines that
the Member no longer requires the level of care only available in an
inpatient hospital setting, written notice may be given to the
attending physician, hospital billing office, Subscriber and Member
specifying the date after which benefits for inpatient hospital
services will no longer be provided.
E. Retrospective Review
Claims for inpatient hospital admissions are subject to Retrospective
Review by the Plan. That review may result in a determination that
part, or all, of the hospital stay was not medically necessary. The
Plan may limit or exclude benefits for services which are not
medically necessary.
Payment of benefits is subject to all terms, conditions, limitations
and exclusions of this Contract. Preadmission Review, Admission
Review and Concurrent Review do not guarantee payment of benefits.
PART THREE PROVISIONS THAT AFFECT BENEFITS
3.5. INDIVIDUAL CASE MANAGEMENT
When medically necessary, cost effective services or supplies are
recommended to an Member, and benefits for those services or supplies are
limited or not included under this Contract, the Plan may, at its
discretion, decide to provide benefits for such services or supplies.
Such benefits will only be provided when the Member or someone legally
qualified and authorized to act for him or her, and the Member's
attending physician have signed a written consent specifying the terms
under which benefits for such services and supplies will be provided by
the Plan. Without such signed written consent, benefits will be limited
to those set forth in this Contract. The Group's consent will not be
required.
The Plan's decision to provide such benefits will be made on an
individual basis and will only be available to that Member subject to the
terms set forth in the written consent. Any such decision shall not be
construed to alter or change all other provisions of this Contract, nor
shall it be construed as a waiver of the Plan's right to administer this
Contract in strict accordance of its terms in other situations.
CONTRACT CHANGES . . . Continued
C. MANDATORY OFFERING OF CERTAIN COVERAGES (Washington Only)
The Washington State Legislature has passed several bills which affect
group health care plans. The bills require that certain coverages be
offered on an optional basis. The optional coverages and the
corresponding rates are described below.
C-3 X Mental Health Treatment (SSB3645 - 7/l/83)
All health carriers must offer supplemental coverage for mental
health treatment. The covered treatment must include the
services of licensed physicians, psychologists and community
mental health agencies.
Your current program already provides certain benefits for
outpatient mental health treatment, including the services of a
licensed physician or psychologist. See your contract for
details.
You now have the option of adding the services of a licensed
community mental health agency to your Major Medical outpatient
coverage for mental and nervous conditions. Such services
would be reimbursed at 50% and would also be included in the
20-visit maximum per calendar year.
The rate adjustment for this option is:
-ts
If the Group selects the optional supplemental coverage for
mental health treatment, the following Definition will be added
to the Contract:
"'Community Mental Health Agency' - An agency which is
licensed by the Washington State Department of Social and
Health Services as a Community Mental Health Agency and has
in effect a plan for quality assurance, peer review, and
supervision by a licensed physician or licensed
psychologist."
Your group previously waived this optional coverage. If we do
not receive written confirmation of your decision to add this
optional coverage by , we will conclude that
your prior decision to waive this coverage remains unchanged.
Please note that once waived, this optional coverage will not
be offered until your next renewal or, if earlier, the date you
change to another Blue Cross Program.
CONTRACT CHANGES . . . Continued
C. MANDATORY OFFERING OF CERTAIN COVERAGES Continued
C-11 X Home Health Care (SB 4787 - 7/l/84) - Basic Benefit
All health carriers must offer, as an option, home health care
coverage for up to 130 health care visits per calendar year as
an alternative to hospitalization. Services must be rendered
by a Department of Social and Health Services certified home
health care agency in conjunction with a written plan of
treatment approved by a licensed physician (M.D. or D.O.).
Covered services of a home health care agency will include
visits for medically necessary intermittent care by a
registered or licensed practical nurse, a licensed physical
therapist, a certified occupational therapist, an American
Speech and Hearing Association certified speech therapist, a
certified respiratory therapist, and a home health aide.
Covered services may include certain medically necessary
supplies provided and billed by a home health care agency such
as drugs and medicines requiring a physician's prescription,
insulin, medical supplies normally used for hospital
inpatients, and the rental of durable medical equipment.
Covered supplies are limited to a maximum benefit of $500.00
each calendar year.
The rate adjustment for this option is:
Et_t:r, dft�!--_
We would appreciate written confirmation of your decision to
add or waive this optional coverage. However, if we do not
receive written confirmation of your decision to add this
optional coverage by , we will conclude that you have
elected to waive this coverage.
Please note that once waived, this optional coverage will not
be offered until your next renewal or, if earlier, the date you
change to another Blue Cross Program.
A decision to waive this optional coverage does not prevent you
from choosing other Home Health Care coverage available through
Blue Cross of Washington and Alaska (see Part B. , Optional
Contract Changes, Home Health Care Benefit).
CONTRACT CHANGES . . . Continued
C. MANDATORY OFFERING OF CERTAIN COVERAGES . . . Continued
C-13 X Hospice Care (SB 4787 - 7/1/84) - Basic Benefit
(Only offered with a Home Health Care Benefit)
All health carriers must offer, as an option, hospice care
coverage for a six-month period as an alternative to
hospitalization for the terminally ill. Services must be
rendered by a Department of Social and Health Services
certified hospice in conjunction with a written plan of care
approved by a licensed physician (M.D. or D.O.).
Covered services of a hospice agency include visits for
intermittent care by a registered or licensed practical nurse,
a licensed physical therapist, a certified occupational
therapist, an American Speech and Hearing Association certified
speech therapist, a certified respiratory therapist, a master
of social work, and a home health aide. Such visits are
limited to a maximum benefit of $5,000.00. Also included in
the $5,000.00 maximum are certain supplies required for the
terminal illness provided and billed by a hospice agency such
as drugs and medicines requiring a physician's prescription,
insulin, medical supplies normally used for hospital
inpatients, and the rental of durable medical equipment.
In addition, benefits will be provided for up to 10 days of
inpatient care in a hospice, and up to 120 hours of respite
care in each three-month period of hospice care.
The rate adjustment for this option is:
�S
A#0
We would appreciate written confirmation of your decision to
add or waive this optional coverage. However, if we do not
receive written confirmation of your decision to add this
optional coverage by , we will conclude that you have
elected to waive this coverage.
Please note that once waived, this optional coverage will not
be offered until your next renewal or, if earlier, the date you
change to another Blue Cross Program.
CONTRACT CHANGES . . . Continued
C. MANDATORY OFFERING OF CERTAIN COVERAGES . . . Continued
C-15 X CONTINUATION OF GROUP COVERAGE PROVISION (1-1-85)
A Washington group that is not subject to Title X of the
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA),
may elect to provide a continuation of group coverage provision
for a period of up to three months for those employees and/or
their dependents whose eligibility for coverage through the
group terminates. Such individuals must self-pay subscription
charges to the group who would then submit the payment to us
with the regular monthly billing. At the end of the period of
continued coverage, group conversion is available if
application is made and subscription charges are received
within 31 days after the date coverage terminates.
We would appreciate written confirmation of your decision to
add or waive this optional coverage. However, if we do not
receive written confirmation of your decision to add this
optional coverage by , we will conclude that you
have elected to waive this coverage.
Please note that once waived, this optional coverage will not
be offered until your next renewal or, if earlier, the date you
change to another Blue Cross Program.
SCHEDULE OF ELIGIBILITY
A. Eligible Classes of Employees
The following employees of CITY OF KENT are eligible to enroll and become
covered under this Contract:
All permanent full-time active employees working a minimum of forty (40)
hours a week.
All permanent part-time active employees working a minimum of twenty-one
(21) hours a week.
A retired employee, provided such employee:
has attained age 55;
has at least 25 years of service with the employer; and
is eligible to receive a retirement benefit under the LEOFF I
Retirement Plan.
All retired disabled employees who are eligible to receive a retirement
benefit under the LEOFF I Retirement Plan.
LEOFF I Employees - Full-time active law enforcement officers or fire
fighters who were hired prior to October 1, 1977 and who were members of
the LEOFF System as defined in Sections (3) and (4), CH131, Law of 1972
1st E_. Sess. prior to October 1, 1977.
LEOFF II EMPLOYEES - Full-time active law enforcement officers or fire
fighters who were hired after October 1, 1977 and were not members of the
LEOFF System as defined in Sections (3) and (4), CH131, Law of 1972 lst
Ex. Sess. prior to October 1, 1977.
If an employee becomes permanently disabled, employer must maintain
medical insurance coverage for employee, LEOFF I only.
B. Ineligible Classes of Employees
The following employees are ineligible to enroll and become covered under
this Contract:
All temporary or seasonal employees.
Employees who are covered through GROUP HEALTH COOPERATIVE or any other
employer-sponsored Health Maintenance Organization (HPO) .
C. Effective Date of Coverage- ——
1. Employees
Employees in an eligible class shall become eligible to enroll and
have an effective date of coverage on the latest to occur of:
a. The effective date of this Contract;
b. The date the Employee enters an eligible class;
C. The first day of employment;
provided such Employee is actively at work on such coverage date.
SCHEDULE OF ELIGIBILITY . . . Continued
CITY OF RENT
C. Effective Date of Coverage . . . Continued
2. Retirees
Retirees in an eligible class will be eligible to enroll and have an
effective date of coverage on the first day of the Coverage Period
coinciding with or nest following date of retirement.
3. Dependents
Coverage for eligible dependents (other than those acquired after
the Employee's effective date) will become effective on the same
date as the Employee's coverage provided proper application has been
made. Eligible dependents are defined in Part Two 2.1.A of the
Contract.
Children of the Subscriber or spouse born while the Subscriber is
covered under this Contract are covered from date of birth. The
Subscriber must make application for coverage of the newborn infant
with in sixty (60) days from date of birth. If an additional
Subscription Charge is required, it will begin on the first of the
month following date of birth.
A spouse and children newly acquired through marriage must make
application within thirty (30) days of marriage. The effective date
of coverage for such dependents will be the first day of the
Coverage Period coinciding with or next following date of
acquisition.
Newly-acquired adopted children must be added within thirty (30)
days of the date of birth or within the child's period of probation
with the adoptive parents. Newly-acquired foster children must be
enrolled within thirty (30) days of acquisition. Enrollment of
adopted or foster children must be approved by the Plan before
coverage can begin.
Initial enrollment of the Employee and existing family members must be
made within 30 days following the Employee's date of employment or period
of probation (if any).
If an Employee is not actively at work when his/her coverage would
otherwise become effective, dependent coverage will not become effective
until the Employee's coverage becomes effective.
Eligible dependents of LEOFF I retired or retired disabled employees must
self-pay monthly Subscription Charges directly to the Group.
SCHEDULE OF ELIGIBILITY Continued
CITY OF RENT
D. Late Enrollment
Eligible Employees who are not enrolled when first eligible will be
retroactively enrolled at any later date provided application is made and
full retroactive Subscription Charges are paid by the Group on the
Employee's behalf from the later of the following:
a. the date the Employee was first eligible; or
b. retroactively twelve (12) months.
Eligible Dependents who are not enrolled when first eligible or who fail
to maintain their coverage may be enrolled only during a regular Group
Reopening which is determined by the Plan. Provided proper application
has been made, coverage will begin on the effective date of the Group's
Open Enrollment.
E. HKO Option
Employees who have elected coverage through an HMO may change coverages
and enroll under this Contract only during a regular group reopening
which is determined by the Plan.
F. Leave of Absence
In the event the employer grants an approved leave of absence to an
enrolled employee, coverage through the Group may be continued for a
period not to exceed ninety (90) days. The employer agrees to notify the
Plan on the regular monthly billing as to the employee's date of
departure on leave and will submit the monthly payment with the regular
Group remittance.
G. If a Dependent is Institutionalized on the Effective Date
If an eligible dependent is institutionalized on his or her effective
date of coverage, he or she will not receive any benefits of the Contract
until after discharge. However, this provision will. not apply to
treatment of a newborn infant born on or after the employee's effective
date of coverage.
R. Waiting Periods
Waiting periods, if any, are stated in Part Six 6.2.11 of the Contract.
SCHEDULE OF ELIGIBILITY . . . Continued
CITY OF KENT
I. Definition of Actively at Work
"Actively at work" means performing the usual duties of his/her
occupation at his/her place of employment.
J. Definition of Coverage Period
"Coverage Period" means that period for which the Group has paid, in
advance, the required Subscription Charges on behalf of eligible Members
in consideration for the benefits offered in the Contract attached hereto.
K. Deletion of Ineligible Members
The Group will promptly delete any employee or dependent who ceases to
meet the above eligibility requirements and will so notify the Plan on a
timely basis.
R. L. EVANS CO., INC.
401K-Pension Profit Sharing Plans I Financial&Insurance Planning
U t LI!!F r
1� it �jC�U
July 16 , 1986
OF KENT
Mr . Mike Webby �, �(
City of Kent
220 4th Ave S .
Kent , WA 98032-5895
Dear Mike,
In follow up to our conversation the other day regarding the
lack of the word "voluntary" in the Endorsement One to the
Blue Cross Medical contract which had previously indicated
that the Second Surgical Opinion was "Mandatory" , Betty Rohr
at Blue Cross has assured me (after checking with her
superiors) that the wording in the Endorsement One does
indeed make the Second Surgical Opinion Benefit a voluntary
one.
When you hear more from NMI regarding the Stop-loss
insurance and the possibility of placing it through
Guarantee Mutual Life, let me know so that I can pursue the
Life and AD&D quotes that I have received from them.
Sincerely,
Dougla6 Evans
Vice President
Employee Benefits
1210 PLAZA 600 BLDG. SEATTLE,WA 98101 (206)448-7878
1 R. L. M/ANS CO., INC.
401K-Pension Profit Sharing Plans/Financial&Insurance Planning
July 10 , 1986 R E % E I V E D
Mr . Mike Webby iU! "i 1986
City of Kent
220 4th Ave So . PERS;VNNE1_ 1.3EPT.
Kent , WA 98032-5895
Dear Mike,
Enclosed you will find the replacement pages for Endorsement
One to the group medical contract with Blue Cross .
These pages replace those pages in the original endorsement
that indicated that the Second Surgical Opinion Benefit was
"Mandatory" . The wording has been corrected to show this
benefit to be voluntary.
Also, during the past few weeks I have been working with
Blue Cross of WA & AK to try and determine if there will be
any changes in the medical rates next year. I think that
you can appreciate the fact that these predictions are
somewhat less than exact because Blue Cross really only has
3 months of experience to go by. The reason for this is due
to the lag time of about two months wherein claims are
incurred and when they are actually paid and show up on
experience reports .
So far this year , revenue received from the City of Kent
totals $183, 221 , claims that have been paid so far total
$120,964 . Keeping in mind that there is a reserve of two
months worth of premiums (about $60,000) for claims run out ,
this would mean that the city is running at about even on
its revenue to claims ratio. The retention for the city is
about 13% for the current size group which Blue Cross has
indicated MIGHT lead to about a 10% increase in rates next
year. Blue Cross has also indicated that they have a
sizable reserve on hand for rate stabilization and this
could be used prevent a rate increase.
At the end of September we will have a much better picture
of what if any rate changes will be necessary for next year .
If in the meantime you have any questions please call me.
I have also enclosed a copy of the experience report for the
month of .Tune for your records . I hope that your vacation
was relaxing, I 'm looking forward to taking a few days off
in August .
sincerely,
Douglas Evans
1210 PLAZA 600 BLDG. SEATTLE,WA 98101 (206)448-7878
ENDORSEMENT ONE
The Contract between the CITY OF KENT and BLUE CROSS OF WASHINGTON AND ALASKA,
which became effective January 1, 1985, is hereby amended.
The purpose of this Endorsement is to:
amend the definitions of Medically Necessary/Medical Necessity and Usual,
Customary and Reasonable;
amend the Institutional Care Benefit pertaining to Emergency Inpatient
Care - Non-Participating Hospital in the Service Area, Emergency
Outpatient Care - Non Participating Hospital in the Service Area, and
Skilled Nursing Facility Non-Participating in the Service Area ;
amend the Second Surgical Opinion Benefit;
amend the Major Medical Benefit pertaining to Mental, Neuropsychiatric or
Personality Disorders;
amend the Dental Care Benefit by the addition of the Pre-determination
provision;
amend the Exclusions pertaining to Services or Supplies Not Medically
Necessary and Vision Care;
amend the Exception pertaining to Cosmetic Services, Supplies and
Procedures;
delete the Exception pertaining to Nuclear Magnetic Resonance Imager; and
amend the Subscription Charges and Grace Period paragraph.
1. PART ONE, DEFINITIONS 1.1, the following definitions, pages 7 and 11,
are hereby amended to read as follows:
"MEDICALLY NECESSARY/MEDICAL NECESSITY - Indispensable in the sense
that in the reasonable opinion of this Plan, an illness, injury or
condition harmful to or threatening to the patient's life or health,
or a direct effect of such, could not have been diagnosed or relieved
without the medical service, supply or setting in question. The mere
fact that it was furnished, prescribed or approved by a physician or
other qualified provider does not in itself mean that it was
medically necessary. A medical service, supply or setting may be
medically necessary in part only."
Contract No. 00828-01-02-04-ED1
-1-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
3. PART FIVE, BENEFITS, 5.1. , BASIC BENEFITS: INSTITUTIONAL CARE,
section D. , Emergency Outpatient Care - Non-Participating Hospital In
The Service Area, paragraph 1. , When Services Are Provided and Amount
of Benefit Provided, page 28, is hereby amended to read as follows:
"D. Emergency Outpatient Care -
Non-Participating Hospital in the Service Area
1. Amount of Benefit Provided
The benefits stated in 5.1.C. are available up to the
usual, customary and reasonable charge, but only when the
condition being treated is a medical emergency."
4. PART FIVE, BENEFITS, 5.1. , BASIC BENEFITS: INSTITUTIONAL CARE,
section F., Skilled Nursing Facility - Non-Participating in the
Service Area, paragraph 1. , The Number of Days of Skilled Nursing
Care, the Services Available and Amount of Benefit Provided, page 30,
is hereby amended to read as follows:
"F. Skilled Nursing Facility Non-Participating in the Service Area
1. Amount of Benefit Provided
Benefits for the number of days stated in 5.1.E.1. and the
services stated in 5.1.E.2. are available up to the usual,
customary and reasonable charge, but only when the
condition being treated is a medical emergency."
5. PART FIVE, BENEFITS, 5.2. , BASIC BENEFITS: PROFESSIONAL SERVICES,
5.2.1. , Surgical and Medical Benefits, section H., Second Surgical
Opinion Benefit, paragraph 2. , page 43, procedure codes are revised
to read as follows:
Procedures and CPT 4 Codes:
Hysterectomy, 58150, 58180, Tonsils and adenoids, 42820
58260 thru 58270, 58275 thru 42836
& 58280 Surgery on the spine, 22555
Surgery on the knee, 27373 thru 22735 and 62295 thru
thru 27379, 27405 thru 63076
27425, 27444 thru 27447 Surgery on the heart, 33510
27487 and 27488 thru 33528, 33405, 33430
Surgery on the hip, 27130 and 93570
and 27135 Surgery on the nose, 30140
Surgery on the foot, 28080 thru 30160 and 30400 thru
thru 28299 30520"
Gallbladder surgery, 47600
thru 47620
Contract No. 00828-01-02-04-ED1
-3-
Blue Cross,.,
of Washington and Alaska
15700 Dayton Avenue North/P O. Box 327
Seattle, Washington 98111-0327
206/361-3000
May 12, 1986
Richard Evans
R. L. Evans Company, Inc.
1210 Plaza 600 Building
Seattle, Washington 98101 ;ti.,
RE: CITY OF KENT _
#00828 AND SEGMENTS
Dear Dick:
Enclosed are three copi=es of Endorsement One to the subject group's contract.
The endorsement is effective January 1, 1986.
The purpose of this Endorsement is to:
1) show the renewal rate;
2) amend the definitions of Medically Necessary/Medical Necessity and
Usual, Customary and Reasonable;
3) amend the Institutional Care Benefit pertaining to Emergency Inpatient
Care - Non-Participating Hospital in the Service Area, Emergency Outpatient
Care - Non-Participating Hospital in the Service Area, and Skilled
Nursing Facility Non-Participating in the Service Area;
4) amend the Mandatory Second Surgical Opinion Benefit;
5) amend the Major Medical Benefit pertaining to Mental, Neuropsychiatric
or Personality Disorders;
6) amend the Dental Care benefit by the addition of the Pre-determination
provision;
7) amend the Exclusions pertaining to Services or Supplies Not Medically
Necessary and Vision Care;
8) amend the Exception pertaining to Cosmetic Services, Supplies and
Procedures;
9) delete the Exception pertaining to Nuclear Magnetic Resonance Imager;
and
10) amend the Subscription Charges and Grace Period paragraph.
Please secure the appropriate signatures and have one signed copy returned
to our office by May 28, 1986.
Sincerely,
Betty Rohr
Administrative Assistant
BR:dab
Enclosure
ENDORSEMENT ONE
The Contract between the CITY OF KENT and BLUE CROSS OF WASHINGTON AND ALASKA,
which became effective January 1, 1985, is hereby amended.
The purpose of this Endorsement is to:
amend the definitions of Medically Necessary/Medical Necessity and Usual,
Customary and Reasonable;
amend the Institutional Care Benefit pertaining to Emergency Inpatient
• Care - Non-Participating Hospital in the Service Area, Emergency
Outpatient Care - Non Participating Hospital in the Service Area, and
Skilled Nursing Facility Non-Participating in the Service Area ;
1.,Z&WA0Ry -,711AI
amend the -dae4etvx* Second Surgical Opinion Benefit;
amend the Major Medical Benefit pertaining to Mental, Neuropsychiatric or
Personality Disorders;
amend the Dental Care Benefit by the addition of the Pre-determination
provision;
amend the Exclusions pertaining to Services or Supplies Not Medically
Necessary and Vision Care;
amend the Exception pertaining to Cosmetic Services, Supplies and
Procedures;
delete the Exception pertaining to Nuclear Magnetic Resonance Imager; and
amend the Subscription Charges and Grace Period paragraph.
1. PART ONE, DEFINITIONS 1.1, the following definitions, pages 7 and 11,
are hereby amended to read as follows:
"MEDICALLY NECESSARY/MEDICAL NECESSITY - Indispensable in the sense
that in the reasonable opinion of this Plan, an illness, injury or
condition harmful to or threatening to the patient's life or health,
or a direct effect of such, could not have been diagnosed or relieved
without the medical service, supply or setting in question. The mere
fact that it was furnished, prescribed or approved by a physician or
other qualified provider does not in itself mean that it was
medically necessary. A medical service, supply or setting may be
medically necessary in part only."
Contract No. 00828-01-02-04-ED1
-1-
ENDORSEMENT ONE Continued
CITY OF KENT
"USUAL, CUSTOMARY AND REASONABLE - We will take into account these
criteria in the determination of the actual amount payable for any
given service or supply:
The usual charge or fee which the provider of service most
frequently charges to the majority of patients or customers
for a similar service or medical procedure.
The charges or fees which fall within the customary range
of charges or fees in a locality for the performance of a
similar service or procedure. (In the event there are too
few providers in a given locality from which to determine a
customary range of charges or fees for a given service or
supply, the Plan will determine the amount payable based
upon the customary range of charges or fees in a wider
geographical area, such as the State in which the provider
of service is located.)
A charge which, in the reasonable opinion of the Plan, is
justified by the time required for the service, the
competency and experience of the provider, the severity of
the condition treated, and other factors required to
perform the service or provide the supply as compared with
those required for other services or supplies.
Determination of the actual amount payable for any given service or
supply is within the discretion of the Plan."
2. PART FIVE, BENEFITS, 5.1. , BASIC BENEFITS: INSTITUTIONAL CARE,
section B. , Emergency Inpatient Care - Non-Participating Hospital in
the Service Area, paragraph 1. , The Number of Inpatient Hospital
Days, the Services Available and the Amount of Benefits Provided,
page 25, is hereby amended to read as follows:
"B. Emergency Inpatient Care -
Non-Participating Hospital in the Service Area
1. Amount of Benefit Provided
Benefits for the number of inpatient hospital days stated
in 5.1.A.1. and the services stated in 5.1.A.2. are
available up to the usual, customary and reasonable charge,
but only when the condition being treated is a medical
emergency.
"
Contract No. 00828-01-02-04-ED1
-2-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
3. PART FIVE, BENEFITS, 5.1. , BASIC BENEFITS: INSTITUTIONAL CARE,
section D. , Emergency Outpatient Care - Non-Participating Hospital In
The Service Area, paragraph 1. , When Services Are Provided and Amount
of Benefit Provided, page 28, is hereby amended to read as follows:
"D. Emergency Outpatient Care -
Non-Participating Hospital in the Service Area
1. Amount of Benefit Provided
The benefits stated in 5.1.C. are available up to the
usual, customary and reasonable charge, but only when the
condition being treated is a medical emergency.
4. PART FIVE, BENEFITS, 5.1. , BASIC BENEFITS: INSTITUTIONAL CARE,
section F. , Skilled Nursing Facility - Non-Participating in the
Service Area, paragraph 1. , The Number of Days of Skilled Nursing
Care, the Services Available and Amount of Benefit Provided, page 30,
is hereby amended to read as follows:
"F. Skilled Nursing Facility Non-Participating in the Service Area
1. Amount of Benefit Provided
Benefits for the number of days stated in 5.1.E.1. and the
services stated in 5.1.E.2. are available up to the usual,
customary and reasonable charge, but only when the
condition being treated is a medical emergency.
5. PART FIVE, BENEFITS, 5.2. , BASIC BENEFITS: PROFESSIONAL SERVICE� y
5.2.1. , Surgical and Medical Benefits, section H. , _Me4da4a*y Second
Surgical Opinion, paragraph 2. , page 43> Procedure codes are revised
to read as follows:
Procedures and CPT 4 Codes:
Hysterectomy, 58150, 58180, Tonsils and adenoids, 42820
58260 thru 58270, 58275 thru 42836
& 58280 Surgery on the spine, 22555
Surgery on the knee, 27373 thru 22735 and 62295 thru
thru 27379, 27405 thru 63076
27425, 27444 thru 27447 Surgery on the heart, 33510
27487 and 27488 thru 33528, 33405, 33430
Surgery on the hip, 27130 and 93570
and 27135 Surgery on the nose, 30140
Surgery on the foot, 28080 thru 30160 and 30400 thru
thru 28299 30520"
Gallbladder surgery, 47600
thru 47620
Contract No. 00828-01-02-04-ED1
-3-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
6. PART FIVE, BENEFITS, 5.4., MAJOR MEDICAL BENEFIT, section C., Major
Medical Services and Supplies, page 57, is hereby amended to read as
follows:
15. Services for a mental, neuropsychiatric, or personality
disorder. Benefits are limited to:
a. inpatient care received during a medically necessary
hospital stay, payable at the percentages stated in Part
Five 5.4.B.1. ; and
b. a maximum of twenty (20) visits in any one calendar year
for treatment received while a Member is not confined in a
hospital, payable at fifty percent (50%) of the covered
expenses instead of the percentages stated in 5.4.B.1.
Services must be rendered by a physician or licensed
psychologist.
Benefits are subject to any applicable waiting periods as stated
in Part Six 6.2.12.
7. PART FIVE, BENEFITS, 5.6., BASIC BENEFITS: DENTAL CARE, pages 64
through 67, are hereby amended to read as follows:
"A. When Benefits Are Available
1. The Plan will provide the benefits described below for
covered services and supplies incurred in connection with
necessary dental care. Necessary dental care means, that
in the reasonable opinion of this Plan, the disease, injury
or condition cannot be diagnosed, prevented or relieved
without the dental service, treatment or supply. The mere
fact that the service or supply was approved by a qualified
provider does not in itself mean that the service or supply
constituted necessary dental care. A service or supply may
be necessary in part only. All benefits are subject to the
limitations, exceptions, and exclusions and other
provisions set forth in this Contract.
2. The Subscriber or Family Member is responsible for
furnishing to the Plan all diagnostic evaluative material,
such as study models, dental x-rays and charts, which we
may require to determine available benefits. We will not
provide benefits for those dental services which we are
unable to verify as covered services when any necessary
material is not furnished upon our request.
Contract No. 00828-01-02-04-ED1
-4-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
3. In providing benefits under this Contract we have the right
to have a dentist of our choice examine a Member. This
will be done upon our request and at our expense. Failure
to comply will result in denial of claims.
B. Alternate Benefits
The Plan will determine benefits available under this Contract
taking into account alternate procedures or services carrying
different fees which are, in the reasonable opinion of the Plan,
consistent with acceptable standards of dental practice. In all
cases where there are alternate courses of treatment carrying
different fees, the Plan will only provide benefits for the
treatment carrying the lesser fee. If the Member and the
dentist decide upon a more costly treatment, then the Member is
responsible for the additional charges beyond those for the less
costly alternate treatment and for which benefits have been
provided by the Plan.
C. Predetermination of Benefits
With respect to any proposed dental service or series of dental
services for which the total charge(s) will exceed three hundred
dollars ($300.00), the dentist may submit a predetermination
request to this Blue Cross Plan showing the treatment plan and
fees. The Plan will then review the predetermination request to
determine the estimated dental benefit under this Contract, and
notify the dentist and the Member accordingly.
If the dentist submits a treatment plan for Predetermination of
Benefits and then changes the plan, this Blue Cross Plan will
adjust its payments accordingly. If the dentist makes a major
change in the treatment plan, the dentist may submit a revised
plan.
A Predetermination of Benefits is an estimate only and not a
guarantee of coverage or payment. Benefits provided to the
Member will be subject to the specific benefits, exceptions,
exclusions, limitations and eligibility provisions set forth in
this Contract in effect at the time the services are rendered.
Contract No. 00828-01-02-04-ED1
-5-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
D. Amount of Dental Benefits Provided
Benefits are provided at the percentages specified below for all
covered dental services (subject to the usual, customary and
reasonable charge, see Part One - Definitions), rendered during
any benefit year for any Member up to a maximum benefit of one
thousand dollars ($1,000.00). A benefit year is a period of
twelve (12) consecutive months beginning on the Member's
effective date of coverage under this Contract and each period
of twelve (12) consecutive months thereafter.
During the first Benefit Year in which a Member utilizes the
Type A Dental Services listed below, the Plan shall pay toward
expenses incurred seventy (70%) percent of the amount specified
herein for the Dental Service performed, except that when a
Member utilizes such Dental Services during successive Benefit
Years, commencing with the second of such successive Benefit
Years the percentage of the amount payable by the Plan toward
such benefits shall be increased over such seventy (70%) percent
by an additional ten percent (10%) of the amount specified
herein for each successive Benefit Year until the Plan will be
paying one hundred percent (100%) of the amount specified
herein. However the percentage of the amount specified herein
that the Plan will pay toward such benefits in a Benefit Year
immediately following one or more Benefit Years in which none of
such benefits was utilized by a Member will be reduced by ten
percent 10% but not to less than seventy (70%) percent of the
amount specified herein for the service rendered.
During any Benefit Year, the Plan shall pay toward expenses
incurred for Type B Dental Services listed below, fifty percent
(50%).
E. Covered Dental Services
1. Type A Dental Services
a. Routine oral examinations (for diagnosing the oral
health of the patient and determining the dental care
required), limited to two (2) each benefit year.
b. Prophylaxis (cleaning, scaling and polishing of
teeth), limited to two (2) each benefit year.
C. Topical application of fluoride, for Members under age
twenty (20), limited to two (2) treatments each
benefit year.
d. Dental x-rays.
Contract No. 00828-01-02-04-ED1
-6-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
e. Space maintainers, for Members under age twenty (20).
f. Sealants, for Members under age fourteen (14), limited to
use on permanent teeth.
g. Simple extractions.
h. Oral surgery consisting of surgical extractions, fracture
and dislocation treatment, alveolar ridge augmentation, and
diagnosis and treatment of cysts of abscesses.
i. Fillings, consisting of silver amalgam, silicate and
plastic restorations. For other types of fillings, such as
gold foils, the allowance will be limited to what would
have been otherwise allowed for amalgam fillings.
J. Treatment of periodontal and other diseases of the gums and
tissues of the mouth.
k. Endodontic treatment.
1. Repair or recementing of crowns, inlays, bridgework or
dentures.
M. Emergency palliative treatment.
2. Type B Dental Services
a. Inlays, onlays, or the initial placement of crowns, when in
the reasonable opinion of the Plan, amalgam fillings would
not adequately restore the teeth.
b. Replacement crowns, but only when:
the existing crown was seated at least five years
prior to replacement; or
repreparation of the natural teeth is required as a
result of an accidental injury.
C. Initial installation of dentures (including adjustments
during the first six (6) month period following
installation) or fixed bridgework (including inlays and
crowns to form abutments).
Contract No. 00828-01-02-04-ED1
-7-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
d. Replacement dentures or fixed bridgework, but only when:
the existing denture or bridgework was installed at
least five years prior to replacement; or
the replacement or addition of teeth is required to
replace one or more additional teeth extracted after
initial placement; or
repreparation of the natural teeth in the existing
fixed bridgework is required as a result of an
accidental injury.
e. Relining of dentures.
F. Limitations, Exceptions and Exclusions
In addition to the Exclusions and Exceptions of Part Six, the
following limitations, exceptions and exclusions shall apply to this
benefit:
1. We provide benefits as if only one dentist provided the service
or supply if:
the Member transfers from the care of one dentist to
that of another dentist during the course of his or
her treatment; or
more than one dentist renders services for one dental
procedure.
2. Benefits for restorative or prosthetic dental services are
limited to standard techniques regardless of whether the Member
and the dentist decide:
on personalized restoration; or
to employ special techniques, such as precision
attachments.
3. Except for extractions incidental to orthodontic services, we do
not provide benefits for services or supplies related to
orthodontia (see Part One - Definitions).
4. Except for a child covered under this Contract from birth, we do
not provide benefits for the treatment of congenital
malformations.
Contract No. 00828-01-02-04-ED1
-8-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
5. We do not provide benefits for expenses incurred after
termination -of a Member's coverage under this Contract except
for prosthetic devices, crowns, or root- canals which:
were fitted, prepared, started or ordered prior to the
date of termination of the Member's coverage under
this Contract; and
were delivered to the Member, completed or seated
within thirty (30) days after the date of the
termination of the Member's coverage under this
Contract.
6. In all cases where there are, in the reasonable opinion of this
Plan, alternate courses of treatment carrying different fees,
the Plan will only provide benefits for the treatment carrying
the lesser fee.
7. This Contract must be in effect at the time the Member receives
services or supplies, except as provided in Part Five 5.6.F.5,
above.
8. We do not provide benefits for dental services received from a:
dental or medical department maintained for employees
by or on behalf of an employer; or
mutual benefit association, labor union, trustee or
similar person or group.
9. We do not provide benefits for facility charges for dental
procedures.
10. We do not provide benefits for services or supplies which:
are not customary and accepted by the dental
profession in the States of Washington or Alaska; or
are for the purpose of research; or
are experimental.
11. We do not provide benefits for dietary planning for the control
of dental caries, oral hygiene instruction and training in
preventive dental care.
12. We do not provide benefits for charges for services or supplies
for implantology (tooth implantation).
13. We do not provide benefits for charges for broken appointments.
14. We do not provide benefits for services or supplies to increase
or alter the vertical dimension.
Contract No. 00828-01-02-04-EDl
-9-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
15. We do not provide benefits for services or supplies not
necessary, in the reasonable opinion of the Plan, for proper
dental care.
16. We do not provide benefits for separate charges for study models
or casts.
17. We do not provide benefits for extra dentures or other covered
appliances, including replacements due to loss or theft.
18. We do not provide benefits for drugs and medicines, whether or
not they require a prescription.
However, benefits for prescription drugs and medicines are
provided for under the Major Medical Benefit, if available.
19. We do not provide benefits for braces, banding or retainers.
20. Dental services, supplies and treatment must be provided by a
dentist performing within the scope of his or her license.
Dental services, supplies and treatment may also be provided by
a licensed dental hygienist or other individual performing
within the scope of his or her responsibilities as allowed by
Washington or Alaska law if the treatment is rendered under the
supervision and guidance of the dentist."
8. PART SIX, EXCLUSIONS AND EXCEPTIONS, 6.1. , Exclusions, paragraph 10,
Services or Supplies Not Medically Necessary, page 73, is hereby
amended to read as follows:
"10. Services or Supplies Not Medically Necessary
Services or supplies not medically necessary, see Part One -
Definitions, even if ordered by court of law."
9. PART SIX, EXCLUSIONS AND EXCEPTIONS, 6.1. , Exclusions, paragraph 22,
Vision Care, Services or Supplies, page 75, is hereby amended to read
as follows:
"22. Vision Care, Services or Supplies
Unless stated in Part Five 5.5 - Vision Benefits, we will not
provide benefits for:
eye examinations; or
eye glasses; or
visual analysis; or
Contract No. 00828-01-02-04-EDI
-10-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
vision therapy; or
training related to muscular imbalance of the eye
(orthoptics);
services, supplies and procedures relating to altering the
refractive character of the cornea, and their results, both
direct and indirect, including but not limited to, radial
keratotomy, corneal modulation, keratomileusis, or
refractive keratoplasty; or
services of an optometrist."
10. PART SIX, EXCLUSIONS AND EXCEPTIONS, 6.2., Exceptions, paragraph 5,
Cosmetic Services, Supplies and Procedures, page 77, is hereby
amended to read as follows:
"5. Cosmetic Services, Supplies and Procedures
Services, supplies and procedures for cosmetic, plastic and
reconstructive purposes and their results, direct or indirect,
are not included benefits, except:
to repair a defect caused by an accidental injury occurring
while covered under this Contract;
to repair a dependent child's congenital anomaly;
when incidental to or following a covered surgery which
resulted from disease of the involved body part and
necessary to improve or correct the function of the
Involved body part.
for the initial reconstruction of the involved breast
following a mastectomy necessitated by disease, illness or
injury. Benefits will also be provided for all stages of
one reconstructive breast reduction on the non-diseased
breast to make it equal in size with the diseased breast
after definitive reconstructive surgery on the diseased
breast has been performed.
Below are some examples of what are not included benefits:
surgery for sagging skin of the eyelids (blepharochalasis),
face, neck, or abdomen, hips, or extremities (meloplasty,
rhytidectomy, or lipectomy);
breast enlargement, reduction or uplift procedures (except
as stated above); or
reshaping of the nose (rhinoplasty)."
11. PART SIX, EXCLUSIONS AND EXCEPTIONS, 6.2., Exceptions, paragraph 17,
Magnetic Resonance Imager, page 83, is hereby deleted in its entirety.
Contract No. 00828-01-02-04-ED1
-11-
ENDORSEMENT ONE . . . Continued
CITY OF KENT
12. PART NINE, EMPLOYER INFORMATION, 9.1. , Subscription Charges and Grace
Period, paragraph A. , page 88, is hereby amended to read as follows:
"A. The Group shall pay to this Plan monthly, the following
Subscription Charges:
For Group 00828-01:
Employee $107.07
Employee and Spouse $184.81
Employee, Spouse and Children $232.94
Employee and Children $155.20
For Group 00828-02,-04
Employee $132.69
Employee and Spouse $210.43
Employee, Spouse and Children $258.56
Employee and Children $180.82
for a period of twelve (12) months from and after January 1,
1986, and from month to month thereafter unless modified as
herein provided. Subscription Charges are due each month by the
day preceding the day of the month corresponding with said
effective date. However, if any government imposes or changes
any tag on Plan revenue or mandates a change in benefits, the
Plan may then adjust Subscription Charges at any time to offset
the effect on its revenue.
A grace period of ten (10) days is allowed to the Group for
payment of any periodic payment. No benefits are payable for
claims incurred during any time period for which Subscription
Charges have not been paid."
Contract No. 00828-01-02-04-ED1
-12-
ENDORSEMENT ONE Continued
CITY OF KENT
All other provisions of the Contract remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1986
with the exception of item 6. , which became effective- January 1, 1985.
BLUE CROSS OF WASHINGTON AND ALASKA CITY OF KENT
Patrick C. Connoll Title:
Executive Vice President
Marketing
Title:
Date A (� Date aT of!z
Contract No. 00828-01-02-04-ED1
-13-
ti R. L. EVANS CO., INC.
401K-Pension Profit Sharing Plans!Insurance&Financial Planning
i
%C'
January 2 , 1985
Mr . Mike Webby
City of Kent
220 4th Ave. South
Kent , WA 98032
Dear Mike,
Enclosed you will find a copy of the letter I received from
Stan Erickson at Blue Cross regarding the renewal rates for
the Uniform Police and Fire, and the Uniformed Police
Clerical .
If you should have any questions concerning this, please
feel free to call Dick or myself .
Sincerely,
Douglas Evans
Employee Benefits Manager
1210 PLAZA 600 BLDG. SEATTLE,WA 98101 (206)622-6937
Blue Cross `
o3 Washington and Alaska •��
15700 Dayton Avenue North/P O. Box 327
Seattle, Washington 98111-0327
206/361-3000
December 30, 1985
Mr. Doug Evans
R. L. Evans Company
1200 Plaza 600 Building
Seattle, Washington 98101
Subject: City of Kent, No. 828 and Segments
Dear Doug:
Following are the rates for the current Medical and Dental
programs for the uniformed fire and police (LEOFF 1 and 2)
employees and their dependents, and the uniformed clerical
support staff and their dependents. The LEOFF 1 and 2 employees
and their dependents are currently covered under group numbers
828-04 and -02, respectively. The police uniformed clerical
employees and their dependents are currently enrolled and are
part of group number 828-01.
1. Uniformed Fire and Police (LEOFF 1 and 2) and their
dependents
Employee Employee Employee
Plus Spouse + Plus
Medical Employee Spouse Children Children
Current Medical program,
except $25,000 Individual
Large Claims Pooling Point: $ 115.15 $ 182 .61 $ 224.38 $ 156.92
Dental
Current Dental program: $ 17.54 $ 27.82 $ 34.18 $ 23.90
2. Uniformed Police Clerical and their dependents
Medical
Current Medical program,
except $25,000 Individual
Large Claims Pooling Point: $ 89.53 $ 156.98 $ 198.75 $ 131.30
Dental
Current Dental program: $ 17.54 $ 27.82 $ 34.18 $ 23.90
The above rates are intended for a January 1, 1986 effective date
and are guaranteed in the absence of any revisions or benefit
modifications for twelve (12) months. Further, these rates are
based on the following quote assumptions :
Mr. Doug Evans December 30, 1985
R. L. Evans Company Page 2
Subject: City of Kent, No. 828 and Segments
Rates for the mandated and optional benefits for this account Is
consideration are as follows:
1. Uniformed Fire and Police (LEOFF 1 and 2)
Employee Employee Employee
Plus Spouse + Plus
Employee Spouse Children Children
New Alcoholism
(7-1-84 Benefit) ($ 1.15) ($ 1.83) ($ 2.24) ($ 1.56)
Mental Health Benefit $ .46 $ .73 $ .90 $ .63
AIM Benefit ($ 2.30) ($ 3.65) ($ 4.48) ($ 3.13)
Home Health Care Benefit $ .18 $ .18 $ .18 $ .18
Hospice Benefit $ 1.56 $ 1.56 $ 1 .56 $ 1.56
2. Uniformed Police Clerical
New Alcoholism
(7-1-84 Benefit) ($ .90) ($ 1.57) ($ 1.99) ($ 1.32)
Mental Health Benefit $ .36 $ .63 $ .80 $ .53
AIM Benefit ($ 1.79) ($ 3.14) ($ 3.98) ($ 2.63)
Home Health Care Benefit $ .18 $ .18 $ .18 $ .18
Hospice Benefit $ 1.56 $ 1 .56 $ 1.56 $ 1.56
Please let me know if you have any questions.
Sincerely,,
Stan Erickson
Account Executive
SE:cbc
Enclosure
QUOTE ASSUMPTIONS
1. January 1, 1986 effective date.
2. Our rates are firm for twelve months based on the above effective date.
3. 100% participation by employees and 75% by dependents.
4. 100% contribution on employees and partial on dependents.
5. 7 .5% level graded scale commissions.
6. Remittance of revenue on the first day which due.
7. We will not pick up any individuals who are on total disability.
8. We are duplicating the present plan of benefits as stated for Group
No. 828 and its segments.
9. Blue Cross holds reserves.
10. Medical and Dental benefits are on a packaged basis for all active
employees and 'their dependents.
11. Our quote assumes an average of 150 monthly contracts.
12. Retention of 13.0% based on the above assumptions.
13. We will credit time served under the prior carrier towards satisfaction
of the 6-month WP's.
14. We reserve the right to adjust our quoted rates if the actual contri-
bution, participation, and/or monthly contracts vary more than 10%
from those shown in our quote assumptions.
15. Evidence of insurability will be required on any dependents previously
declined coverage due to health reasons.
16. Medicare "Carve-Out" approach will apply.
17. Employees and their eligible dependents currently enrolled with Group
Health (offered on a dual choice basis) will be subject to health
statement review.
18. If the actual enrolled marital mix varies from the information provided,
we reserve the right to re-evaluate our rates.
E E+S E+S+C E+C
The assumed marital mix is as follows: 26.67% 25.93% 42.96% 4.44%
19. Our quote does not provide coverage for retirees.
,S.
a
WAIVER FORINl
IX I hereby waive, for all covered members, coverage for mental health
treatment, except as otherwise provided in my current Blue Cross
contract.
2nd signature (when legally required)
Print :.<;..; : ir4az L
Signature: �•
Title: AIJ t1 Q�N
Date:
Group name /
and number: ry o� )�LNT BLS
If you have checked the box above, you must return this signed form to 3.:.ae
Cross of Washington and Alaska, P.O. Box 327, Seattle, Washington 98111, Mail
Stop 511.
If a signed form is not received by Blue Cross by your coverage
and billing rates will be increased as indicated.
fyl
1278c
k G
RICH tMIPANY,
L.( EVANS
C INC.
ar
Plaza 600 Seattle, RVashIngton 08101 622-693
April 12, 1983
Mr. Mike Webby
City of Kent
P. 0. Box 310
Kent, Wa 98031
RE: BLUE CROSS GROUP INSURANCE
Dear Mike:
Enclosed are three copies of an endorsement, which was effective
January 1 , 1983, to your Master Group Contract.
The purpose of this endorsement is to amend the Definitions referring
to Custodial Care and a Physician and Surgeon, present new minimum/
maximum subscription charges, amend the General Provisions pertaining to
Access to Records and Continuation of Subscription Charges in the Event
of Labor Dispute.
Please sign all three copies, returning two copies to me. One copy
is to be kept with your group insurance contract.
Please call me if ,you have any questions.
Sincerely,
Barbara Fives
Enclosures
bf
0`W I ,i .'�`. 1
Pension/Profit Sharing Plans • Estate/Business Plans
g,IDORSEMGNT ONE
The Agreement between CITY OF KENT and BLUE CROSS OF WASHING'ON AND 11J1SKA,
which became effective January 1, 1982, is hereby amended.
^ihe purpose of this Endorsement is to amend the Definitions referring to
Custodial Care and a Physician and Surgeon, present new minimiun/maximum
Subscription Charges, amend the Coordination of Benefits Provision, amend t..e
General Provisions pertaining to Access to Records and Continuation of
Subscription Charges in the Event of Labor Dispute.
1. Part I, Definitions, paragraph C. , page 2, is hereby amended to read
as follows:
"C. 'Custodial Care' meads care given, in the reasonable opinion of
the Blue Cross Plan, to sustain a patient without attempting to cure or head
an illness or injury."
2. ' Part I, Definitions, paragraph N. , page 4, is hereby amended to read
as follows:
"N. 'Physician and Surgeon' and Other Providers of Service:
'Physician and Surgeon' means only one who is licensed to practice medicine
and surgery (M.D.) or osteopathy and surgery (D.O.) or Podiatry (D.P.M.) , or a
licensed psychologist, or a licensed cili.r_opractic physician (D.C.) .
Benefits wJ11 be provided for health care services performed by a registered
nurse licensed in the State of Washington if the services performed were
within the lawful scope of the nurse's license, and benefits would have been
provided if the services were performed by a licensed physician.
In the event that a dentist (D.D.S or D.M.D.) performs non-dental surgery in
the oral region (operating and cutting procedures and the treatment of
fractures and dislocations) and such services would have been covered if
performed by a physician and surgeon (M.D. or D.O.) , then such services shall
be covered when performed by a dentist.
MA828-01-02-03-04-ED1
2564A.1
ENDOt2S'EM''Ir ONE. Continued
CITY OF KENr
3. Part IV, Subscription Charges and Grace Period, paragraph A. , page 7,
is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in advance,
the following Subscription Charges:
Employee,
Employee & Spouse & Employee &
Employee Spouse Child(ren) Child(ren)
Non-Uniformed $ 83.25 $145.98 $184.83 $122.10
Uniformed 107.08 169.81 208.66 145.93
Retired Disabled 121.37 184.10 222.95 160.22
for a period of twelve (12) months from and after January 1, 1983. However,
if any government imposes or changes any tax on Plan revenue or mandates a
change in benefits, the Plan may then adjust both the minirmsum Subscription
Charges set forth above and the maximum Subscription Charges set forth below
at any time to offset the effect on its revenue.
If during the twelve (12) month period following January 1, 1983, the incurred
claims, retention plus any losses outstanding as of December 31, 1982, exceed
the total charges shown above, the Group shall pay to this Blue Cross Plan an
amount up to this cumulative loss, plus applicable retention, but not to
exceed the amount that would have been paid had the monthly Subscription
Charges during this period been as follows:
Employee,
Employee & Spouse & Employee &
Employee Spouse Child(ren) Child(ren)
Non-Uniformed $ 95.74 $167.88 $212.55 $140.41
Uniformed 123.14 195.28 293.95 167.81
Retired Disabled 139.57 211.71 256.38 184.24
This Blue Cross Plan shall bill the-Group for any additional Subscription
• Charges as soon as practical after the end of the twelve (12) month period.
The Group shall remit the amount of such charges within fifteen (15) days
after the date of such billing. If the remittance is not received by our Plan
by the fifteenth day, a late charge will be made. The late charge will be the
prevailing charge of the three (3) month U.S. Treasury Bills plus 2%.
At the end of said twelve (12) months, the provisions of this Agreement shall
continue from month to month unless modified or terminated as herein provided."
-2-
MA828-01-02-03-04-ED1
2564A.2
ENDORSEMENT ONE. . . Continued
CITY OF KENT
4. Part VII.C. , Coordination of Benefits, page 33, item 2.a. , concerning
the definition of a Program is amended by the deletion of the last paragraph,
pertaining to excess benef Hs.
5. Part VII.C. , Coordination of Benefits, pagee 35, paragraph 3.c. , is
amended to read as follows:
"c. When this provision operates to reduce the total amount of
benefits otherwise payable as to a Member covered under this Program during
any Claim Determination Period, each benefit that would be payable in the
absence of this provision shall be reduced proportionately, and the amount
reduced will be applied toward any Allowable Expense incurred during a Claim
Determination Period. The Member shall not be entitled to benefits in excess
of the total maximum benefits of the Program during the Claim Determination
Period."
6. Part X, General Provisions, paragraph B. , Access to Records, page 40,
is hereby amended to read as follows:
. "B. RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION - When a
Member applies for benefits under this Agreement, he or she authorizes health
care providers to release to us information and records about services that
have been given. Also, the Member authorizes any person, organization or
insurance company to furnish to or to obtain from us any information regarding
his or her benefits. If a Member does not authorize access to his or her
records, benefits will riot be provided."
7. Part X, General Provisions, paragraph Q. , Continuation of
Subscription Charges in the Event of Labor Dispute, page 42, is hereby amended
to read as follows:
"Q. CONTINUATION OF SUBSCRIPTION CHARGES IN THE EVENT OF LABOR
DISPUTE - In the event that a Subscriber's compensation or wage is suspended
or terminated by the group as a result of a strike, lockout, or other labor
dispute, the Subscriber may pay the subscription charges, subject to the terms
of Part IV, directly to the Group for a period not exceeding six months from
the date of such suspension or termination. When the Subscriber's
compensation or wage is so suspended or terminated, the Subscriber shall be
notified immediately by the Group, in writing, by mail addressed to the
address last on record with the Group, that the Subscriber may pay
subscription charges to the Group as they are due as provided in this
section. If at the end of said six-month period the benefits of this
Agreement are no longer available, the Subscriber shall be entitled to
transfer to Group Conversion coverage subject to the terms of Part VIII of
this Agreement."
-3-
MA828-01-02-03-04-ED1
2564A.3
ENDORSEMENT ONE. Continued
CITY OF KENT
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1983.
BLUE CROSS OF VASHINGTON AND ALASKA CITY OF KENT
By By
Joseph Hunt Ti le:Michael R. Webb
r Vice President Assistant to t e City
of External Affairs Administrator
Date } i c__ 1 5 Date
-4-
MA828-01-02-03-04-ED1
2564A.4
ENDOPSDUiT TWO
The Agreement between CITY OF KENT and BLUE CROSS or WASHING'FON AND ALASKA,
which became effective January 1, 1982, is hereby amended.
This Endorsement clarifies the exclusion for Workers' Compensation.
Part VII, Exclusions, Exceptions and Limitations, paragraph A.l. , page 29,
is hereby amended to read as follows:
"l. a. For those Non-Uniformed (#828-01) and LEOFF II (#828-02)
employees: Any condition, ailment or injury for which the Member is entitled
to receive benefits in whole or in part under occupational coverage
voluntarily obtained by the employer required by state or federal workers'
compensation acts, employer liability acts, or other legislative acts
providing compensation for work-incurred injuries, or service rendered in a
hospital owned or operated by a state or U.S. governmental agency even though
that Member fails to make timely application therefor or waives his or her
rights to such benefits.
b. LFF I employees of Groups #828-03 (Retired or Di
BJ sabled)
and #828-04 covered under the Law Enforcement and Firefighters Act of 1969
will be covered under this Agreement for (i) non-occupational injuries and
(ii) injuries connected with their occupation as policemen or firemen as
employees of the Group, notwithstanding Part VII.A.l.a. of this Agreement."
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is March 1, 1983.
BLUE CROSS OF WASHING`ION AND ALASKA
^7
By
Patrick C. Connoll
Senior Vice President
Marketing
Date
MA828-01-02-03-04-ED2
0076c.1
ENDORSEMENT THREE
The Agreement between CITY OF KENT and BLUE CROSS OF WASHINGTON AND ALASKA,
which became effective January 1, 1982, is hereby amended.
The purpose of this Endorsement is to present new Subscription Charges; add
additional Hospital Inpatient Benefits; amend the Institutional Care Benefit
pertaining to preadmission tests; amend the Supplemental Accident Benefit to
include a licensed physical therapist; amend the Dental Benefits by deleting
time limitations on certain procedures; amend the Major Medical Benefit to
include a licensed physical therapist; add additional Major Medical Benefits;
amend the Major Medical Exception pertaining to Neuropsychiatric, Mental or
Personality Disorders; amend the Exclusions pertaining to Cosmetic Surgery,
Sex Transformations, and Sexual Dysfunctions or Inadequacies; add an Exclusion
pertaining to Governmental Benefits; amend the Coordination of Benefits
Provision; and amend the Schedule of Eligibility.
1. Part IV, Subscription Charges and Grace Period, as amended in Item 3
of Endorsement One, is hereby further amended to read as follows:
"A. Minimum/Maximum Subscri tion Char es and Grace Period
1. Definitions
Effective Date: January 1, 1984
Contract Period: January 1, 1984 through December 31,
1984
Incurred Claims: The sum of (1) the claims paid during
• the contract period and (2) the reserves for unpaid and
unreported claims liabilities at the end of the contract
period, less the reserves for unpaid and unreported
claims liabilities at the beginning of the contract
period.
Minimum Subscription Charges* (monthly):
Non Uniformed Employees, Segment 828-01:
Employee $101.70
Employee and Spouse $178.32
Employee, Spouse and Children $225.78
Employee and Children $149.16
MA828-01/-02/-03/-04-ED3
ENDORSEMENT THREE Continued
CITY OF KENT
LEOFF II Employees, Segment 828-02:
Employee $130.81
Employee and Spouse $207.43
Employee, Spouse and Children $254.89
Employee and Children $178.27
Retired/Disabled Employees, Segment 828-03:
Employee $148.26
Employee and Spouse $224.88
Employee, Spouse and Children $272.34
Employee and Children $195.72
LEOFF I Employees, Segment 828-04:
Employee $130.81
Employee and Spouse $207.43
Employee, Spouse and Children $254.89
Employee and Children $178.27
Maximum Subscription Charges* (monthly) :
Non-Uniformed Employees, Segment 828-01:
Employee $116.96
Employee and Spouse $205.08
Employee, Spouse and Children $259.65
Employee and Children $171.53
LEOFF II Employees, Segment 828-02:
Employee $150.43
Employee and Spouse $238.55
Employee, Spouse and Children $293.12
Employee and Children $205.00
Retired/Disabled Employees, Segment 828-03:
Employee $170.50
Employee and Spouse $258.62
Employee, Spouse and Children $313.19
Employee and Children $225.07
LEOFF I Employees, Segment 828-04:
Employee $150.43
Employee and Spouse $238.55
Employee, Spouse and Children $293.12
Employee and Children $205.00
MA828-01/-02/-03/-04-ED3
-2-
ENDORSEMENT THREE . . . Continued
CITY OF KENT
*If, however, any government imposes or changes any tax on
Plan revenue or mandates a change in benefits, the Plan may
then adjust both the minimum subscription charges and
maximum subscription charges at any time to offset the
effect on its revenue.
2. Periodic Payments
The Group shall pay to this Blue Cross Plan monthly, in
advance, the minimum subscription charges for the contract
period. At the end of the contract period, the tpinimum
subscription charges stated in this Endorsement will
terminate.
A grace period of ten (10) days is allowed to the Group for
payment of any periodic payment. No benefits are payable
for claims incurred during any time period for which
Subscription Charges have not been paid.
3. Settlement
At the end of the contract period, this Blue Cross Plan
shall perform its customary final settlement and identify
the revenue produced by the minimum subscription charges,
the incurred claims, the retention, any losses outstanding
as of the date immediately preceding the effective date,
and the cumulative gain/(loss) position.
If the cumulative position thus identified is a cumulative
loss, the Group shall pay to this Blue Cross Plan an amount
equal to the cumulative loss. However, the sum of the
amount of such payment by the Group and the revenue
produced by the minimum subscription charges shall not
exceed the amount which would have resulted had the maximum
subscription charges been paid throughout the contract
period.
This Blue Cross Plan shall bill the Group for any
additional amount due us as soon as practical after the end
of the contract period.
The Group shall remit the amount of such charges within
fifteen (15) days after the date of such billing. If the
remittance is not received by our Plan by the fifteenth
day, a late charge will be made. The late charge will be
the annual interest rate determined by the prevailing
charge of a three (3)-month U.S. Treasury Bill at the time
the billing is rendered plus 2%.
MA828-01/-02/-03/-04-ED3 - 3 -
ENDORSEMENT THREE . . . Continued
CITY OF KENT
4. Contract Termination
If the contract terminates on a date earlier than the last
day of the contract period, such date shall be considered
the end of the contract period and an interim settlement
will be performed. If, on such date, the cumulative
position is a cumulative loss, the Group shall pay to this
Blue Cross Plan an amount equal to such cumulative loss.
However, the sum of the amount of such payment by the Group
and the revenue produced by the minimum subscription
charges shall not exceed the amount which would have
resulted had the maximum subscription charges been paid
from the beginning of the contract period through such
date. A final settlement will be performed when sufficient
time has elapsed for processing the runout of all claims,
usually a period of not less than twelve months. The
remittance procedures specified above would apply."
2. Part VI, Benefits, is hereby amended by the addition of the following:
"A. Hospital Care - Inpatient
1. The Blue Cross Plan shall furnish to each Member, subject
to the provisions of Part VII and the limitations of paragraphs 2 and 3 below,
the following items of Hospital Care:
a. Daily Hospital Services in a room of two (2) or more
beds.
If a private room is occupied, the hospital's most
prevalent charge for accommodations of a room of two (2) beds will be allowed
against the charge for the private room; any charge above this allowance shall
be paid by the Member. When a Member is confined in a hospital having private
room accommodations only, the Plan shall determine the amount of eligible
expense to be allowed hereunder.
Use of an intensive care unit (includes coronary and
constant care units). Services in an intensive care unit include nursing
services provided by hospital employees as a regular hospital service. In no
event will benefits be provided for any other room accommodations "reserved"
for the Member during the period that the Member is confined in an intensive
care unit.
b. Use of operating, recovery, isolation, cystoscopic and
cast rooms.
- 4 -
MA828-01/-02/-03/-04-ED3
ENDORSEMENT THREE Continued
CITY OF RENT
C. Anesthetic supplies and use of hospital anesthetic
equipment. Administration of anesthesia when administered by a hospital
employee as a regular hospital service.
d. Casts, splints and surgical dressings.
e. X-ray and radium therapy.
f. Oxygen and all drugs and medicines listed and
accepted in the "United States Pharmacopoeia", "National Formulary" or drugs
approved for use as listed in "AMA Drug Evaluations" published by the American
Medical Association, at the time hospitalization is required and which are
prescribed and used during the furnishing of hospital care.
g. Administration and cost of blood, blood plasma and
blood derivatives."
3. Part VI.A. , Hospital Care, Inpatient, paragraph l.h. , page 9, is
hereby amended to read as follows:
"h. The following services only when furnished and billed by the
hospital in connection with an illness or accident requiring bed care and
treatment, and necessitating these services for treatment of the condition:
Laboratory Examinations*
Electrocardiograms*
X-Ray Examinations*
Physiotherapy and Hydrotherapy
*These services shall be considered inpatient services if
rendered in the outpatient department of a hospital within seventy-two (72)
hours of admission to such hospital, provided such tests are related to the
condition for which the Member is admitted."
4. Part VI.I., Supplemental Accident Benefit, paragraph l.g. , page 18,
is hereby amended to read as follows:
"g. Services of a physician and surgeon, or a licensed or
registered physical therapist, in connection with physical therapy treatments,
other than one who ordinarily resides in the Subscriber's home or who is
related to the Subscriber by blood or marriage."
5. Part VI.J. , Dental Benefit, paragraph 2.a. , subparagraphs (1) - (4),
page 20, are hereby amended to read as follows:
"(1) oral -Examinations.
(2) Dental X-rays as required.
(3) Topical fluoride application.
(4) Prophylaxis, including cleaning, scaling and polishing."
MA828-01/-02/-03/-04-ED3 - 5 -
ENDORSEMENT THREE Continued
CITY OF KENT
6. Part VI.J. , Dental Benefits, is hereby amended by the deletion of
paragraphs 5.e. and 5.1. , page 23.
7. Part VIA. , Major Medical Benefit, paragraph l.b.(7) , page 25, is
hereby amended to read as follows:
"(7) Services of a licensed physician and surgeon, or a licensed or
registered physical therapist, in connection with physical therapy treatments,
other than one who ordinarily resides in the Subscriber's home or who is
related to the Subscriber by blood or marriage."
8. Part VI. , K. , Major Medical Benefits, paragraph l.b. , page 25, is
hereby amended by the addition of the following:
"(9) Licensed ambulance service, which is certified as medically
necessary by the attending physician, to the nearest facility equipped to
render treatment of the condition of the Member. This method of
transportation will be provided only when the use of other means of
transportation would endanger the life or safety of the Member.
(10) Drugs or medicines directly related to the treatment of an
illness or injury and requiring a written prescription and dispensed by a
licensed pharmacist or licensed physician and surgeon.
(11) Artificial limbs or eyes, casts, splints, trusses, braces,
crutches, and other similar durable medical appliances, and also the rental of
a wheelchair, hospital-type bed, iron lung or other similar durable medical
mechanical equipment required for treatment. The Plan may, at its option,
purchase such durable medical mechanical equipment for the Member, in lieu of
rental. These supplies will be limited to those reasonably required by
standard treatment practices as a result of illness, disease or injury.
The term "durable medical equipment shall mean equipment
which: (i) can withstand repeated use. (An exception to this would be
certain consumable medical supplies); (ii) is primarily and customarily used to
serve a medical purpose; (iii) is generally not useful to a person in the
absence of illness or injury; and (iv) is ordered and/or prescribed by a
physician."
(12) Blood transfusions, including the cost of blood and blood
derivatives."
MA828-01/-02/-03/-04-ED3 - 6 -
ENDORSEMENT THREE . . . Continued
CITY OF KENT
9. Part VIA. , Major Medical Benefits, is hereby amended by the
addition of the following:
"2. Benefits
Upon receipt of due notice and proof that the Member shall have
incurred expense for Major Medical Benefits, benefits will be provided as
follows:
a. Such expense must be incurred on or after the Member's
effective date of coverage hereunder, or, in the event the Member is
hospitalized on such effective date, such expense must be incurred subsequent
to the date of discharge from the hospital. An expense will be considered to
have been incurred on the date that the individual received the services for
which the charge is made.
b. Payment for such services shall be based upon charges not
exceeding the usual, customary and reasonable charges or fees for such
services, as defined in Part I.S."
10. Part VIA. , Major Medical Benefits, paragraph 3.b. , page 27, is
hereby amended to read as follows:
"b. Neuropsychiatric, mental or personality disorders unless
hospitalized or as specifically provided in paragraph 2.d above."
11. Part VII.A. , Exclusions, Exceptions and Limitations, paragraph 12. ,
page 30, is hereby amended to read as follows:
"12. Services, supplies or procedures for cosmetic, plastic or
reconstructive purposes and complications thereof unless they are required to
treat injuries received in an accident, or for correction of functional
disorders, or for the initial reconstruction of the involved breast following
a mastectomy necessitated by disease, illness or injury. These include, but
are not limited to:
a. surgery for sagging skin of the eyelids
(blepharochalasis), face, neck or abdomen, hips or extremities (meloplasty,
rhytidectomy, or lipectomy) ;
b. breast enlargement, reduction or uplift procedures;
C. reshaping of the nose (rhinoplasty)."
MA828-01/-02/-03/-04-ED3 - 7
ENDORSEMENT THREE . . . Continued
CITY OF KENT
12. Part VII.A. , Exclusions, Exceptions and Limitations, paragraph 14,
page 30, is hereby deleted in its entirety.
13. Part VII.A. , Exclusions, Exceptions and Limitations, page 31, is
hereby amended by the addition of the following:
"22. Services and supplies or drugs for sex transformations.
23. Services, supplies and procedures for reproductive and sexual
disorders and defects, whether or not the consequence of illness, disease or
injury, including but not limited to the following conditions and procedures:
impotency; frigidity; or artificial insemination and in-vitro fertilization."
14. Part VII.A. , Exclusions, Exceptions and Limitations, page 31, is
hereby amended by the addition of the following:
"24. Any care for which benefits are available (or would be
available if this Agreement were not in existence) under any plan or program
of a government or governmental body, including Medicare, even though you may
waive your right to such benefits, except that this Agreement will provide
benefits before Medicare under the following circumstances:
a) covered expenses for a kidney transplant or renal dialysis
treatment in accordance with PL 97-35, the Omnibus
Reconciliation Act of 1981, but only to the extent that an
employer-sponsored program is required to be primary by
such Act; or
b) covered expenses for an active employee age 65 through 69,
and his or her covered spouse, who is also age 65 through
69, in accordance with PL 97-248, the Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA) and the corresponding
regulations of the Equal Employment Opportunity Commission,
but only to the extent that an employer-sponsored program
is required to be primary by such Act and regulations.
A governmental program established for its own civilian
employees and their dependents is not subject to this exclusion."
MA828-01/-02/-03/-04-ED3 - 8 -
ENDORSEMENT THREE . . . Continued
CITY OF KENT
15. Part VII.C. , Coordination of Benefits, item 2.a., page 33, concerning
the definition of a Program, is hereby amended to read as follows:
"2. Definitions
a. Program means the following sources of benefits which will
be recognized for coordination of benefits purposes:
(1) Group or blanket disability insurance or health care
program issued by insurers, health care services contractors and health
maintenance organizations;
(2) Labor-management trustee plans, labor organization
plans, employer organization plans or employee benefit organization plans;
(3) Governmental programs, including Medicare;
(4) Coverage required or provided by any statute;
(5) Group student coverage provided or sponsored by a
school or other educational institution which includes medical benefits for
illness or disease.
The term "Program" will be separately understood to mean
each program which does or which does not provide for coordination of
benefits. Each portion of a program which separately states whether it is or
is not subject to this provision will also be determined to mean a separate
"Program."
MA828-01/-02/-03/-04-ED3 - 9 -
ENDORSEMENT THREE . . . Continued
CITY OF KENT
16. The Schedule of Eligibility is hereby amended to read as follows:
"SCHEDULE OF ELIGIBILITY
A. Definition of Eligible Classes of Employees
The following employees of CITY OF KENT are eligible to enroll
and become covered under this Agreement:
All permanent full-time salaried employees working a minimum of
forty (40) hours a week.
All permanent part-time hourly employees working a minimum of
twenty-one (21) hours a week.
All retired employees who have at least twenty-five (25) years
of service with the employer and are eligible to receive a
retirement benefit under the LEOFF I Retirement Plan.
All retired disabled employees who are eligible to receive a
retirement benefit under the LEOFF I Retirement Plan.
LEOFF I Employees - Full-time law enforcement officers or fire
fighters who were hired prior to October 1, 1977 and who were
members of the LEOFF System as defined in Sections (3) and (4) ,
CH131, Law of 1972 1st Ex. Sess.
LEOFF II Employees - Full-time law enforcement officers or fire
fighters who were hired after October 1, 1977 and were not
members of the LEOFF System as defined in Sections (3) and (4) ,
CH131, Law of 1972 1st Ex. Sess. prior to October 1, 1977.
B. Definition of Ineligible Classes of Employees
The following employees are ineligible to enroll and become
covered under this Agreement:
All temporary or seasonal employees.
Employees working less than twenty-one (21) hours a week.
Employees who are covered through GROUP HEALTH COOPERATIVE or
any other employer-sponsored Health Maintenance Organization
(HMO).
MA828-01/-02/-03/-04-ED3 - 10 -
ENDORSEMENT THREE Continued
CITY OF KENT
C. Definition of Eligibility for Eligible Classes of Employees
Active employees in an eligible class, as defined above, will be
eligible to enroll and have an effective date of coverage as of
date of employment, providing such employee is actively at work
on such coverage date.
Active employees working less than twenty-one (21) hours per
week will be eligible to enroll and have an effective date of
coverage as of the date their employment status meets minimum
eligibility requirements, providing such employee is actively at
work on such coverage date.
Retired employees, as defined above, will be eligible on the
first of the month or next following date of retirement.
Retired disabled employees, as defined above, will be eligible on
the first of the month or next following date of retirement.
D. Definition of Eligibility for Eligible Dependents
Eligible dependents' coverage will become effective on the same
date as the employee's coverage providing proper application has
been made.
Eligible dependents of LEOFF I retired or retired disabled
employees must self-pay monthly Subscription Charges directly to
the Group.
Eligible dependents are the employee's spouse. and unmarried
children from birth to twenty-three (23) years of age, as defined
in Part I.E. of the Agreement.
Newly-acquired dependents of an eligible employee must be
enrolled within thirty (30) days of acquisition. The effective
date of coverage for such dependents will be the first day of the
Coverage Period next following acquisition.
Children of the Subscriber or spouse born while the Subscriber is
covered under this Agreement are covered from date of birth. The
Subscriber must make application for coverage of the newborn
infant within sixty (60) days from date of birth. If an
additional Subscription Charge is required, it will begin on the
first billing date following date of birth.
MA828-01/-02/-03/-04-ED3
ENDORSEMENT THREE . . . Continued
CITY OF KENT
E. Late Enrollment
Eligible employees who are not enrolled when first eligible may
be retroactively enrolled at any later date not to exceed a
maximum of twelve (12) months provided full retroactive
Subscription Charges are paid by the Group on the Employee's
behalf.
Eligible dependents who are not enrolled when first eligible may
be enrolled only during a regular Group Reopening which is
determined by the Plan. Providing proper application has been
made, coverage will begin on the effective date of the Group's
Open Enrollment.
F. HMO Option
In the event the employer offers alternative coverage through an
HMO to eligible classes of employees as defined, employees who
have elected the HMO option may change coverages and enroll under
this Agreement only during a regular group reopening which is
determined by the Plan.
G. Leave of Absence
In the event the employer grants an approved leave of absence to
an enrolled employee, coverage through the Group may be continued
for a period not to exceed ninety (90) days. The employer agrees
to notify the Plan on the regular monthly billing as to the
employee's date of departure on leave and will submit the monthly
payment with the regular Group remittance.
H. If a Member is Institutionalized on the Effective Date
If the employee or eligible dependent is institutionalized on his
or her effective date of coverage, he or she will not receive any
benefits of the Agreement until after discharge. However, this
provision will not apply to treatment of a newborn infant born on
or after the employee's effective date of coverage.
I. Definition of Actively At Work
"Actively at work" means performing the usual duties of his/her
occupation at his/her place of employment. When the effective
date falls on other than a regularly scheduled day of work for an
employee, the employee's effective date will be on such effective
date if the employee is actively at work on the first regularly
scheduled work day following the effective date. An employee on
vacation authorized by the employer on his/her effective date
will be considered actively at work.
MA828-01/-02/-03/-04-ED3 - 12 -
ENDORSEMENT THREE . . . Continued
CITY OF KENT
J. Definition of Coverage Period
"Coverage Period" means that period for which the Group has
paid, in advance, the required Subscription Charges on behalf of
eligible Members in consideration for the benefits offered in
the Agreement attached hereto.
K. Deletion of Ineligible Members
The Group will promptly delete any employee or dependent who
ceases to meet the above eligibility requirements and will so
notify the Plan on a timely basis."
All other provisions of the Agreement remain unchanged except as specifically
provided herein. Items 2, 5, 6, 8, 9, and 10 of this Endorsement are
effective January 1, 1982; the remaining items in this Endorsement are
effective January 1, 1984.
BLUE CROSS OF WASHINGTON AND ALASKA CITY OF KENT
By By
Patrick C. Connoll At,e: Assistant to e
Senior Vice President City Adminis ator
Marketing
Date By
Title:
By
Title:
MA828-01/-02/-03/-04-ED3 - 13 -
• 1 , -,CHA D L. EVANS
CO 1 PANY, C.
r-
1610 Plaza 600 Seattle, Washington 98101 622-6937
October 30, 1981
Mr. Mike Webby
CITY OF KENT
P.O. Box 310
Kent, Washington 98031
Dear Mike:
RE: Blue Cross Medical Contract
Per my telephone call to Peggy this morning, I am enclosing the Blue
Cross experience report for the period January 1, 1981 through
September 30, 1981. During this period of time, you have incurred a
net loss of $80,505.73 which brings the cumulative loss todate to
$53,518.73.
The experience and inflation is catching up to us. The renewal action
is scheduled for January 1, 1982; and the renewal calculations, which
have been modified due to the existence of some larger claims, indicate
the need for a rate adjustment of 35.4%•
A comparison of current and renewal rates is as follows:
Employee
Employee Spouse & Employee
Employee & Spouse Children & Children
1828-01 (Non Uniformed Employees)
Current Rates 51.76 90.76 114.91 75.91
Renewal Rates 70.06 122.84 155.53 102.75
#828-02 (Uniformed Employees)
Current Rates 66.58 105.58 129.73 90•?3
Renewal Rates 90.11 142.89 175.58 122.80
#828-03 (Retired-Disabled, LEOFF Employees)
Current Rates 75.47 114.47 138.62 99.62
Renewal Rates 102.14 154.92 187.61 134.83
CONSULTANTS
Pension/Profit Sharing Plans • Estate/Business Plans
RICHA�D L. (EVANS
COMPANY, INC.
1510 Plaza 600 Seattle, Washington 98101 622-6937
January 22, 1981
REk:o-y.�4VED
CITY CLERK
CITY OF KENT
Mr, Mike Webby 'JAN 2 8
City of Kent
P.O. Box 310
Kent, Washington 93031
Dear Mike:
Please find enclosed two copies of Endorsement Nine to the Master
Agreement for your Blue Cross group plan.
Would you please sign and return one completed copy to Cindy Swanson,
Marketing Services Coordinator, Blue Cross, P.O. Box 327 Seattle,
Washington 98111. Keep the other copy for ,your file. With kindest
regards,
Sincerely,
Richard L. Evans, C.L.U.
RLE:RM
Enclosure
0NS( t.l I
Pension/Profit Sharing Plans • Estate/Business Plans
ENDORSEMENT NINE
The Agreement between CITY OF = and BLUE CROSS OF WASHINGI'ON AND MASK ,
which begone effective December 1, 1973, is hereby amended.
The purpose of this Endorsement is to present new Subscription Charges,
delete terminal maternity, amend an existing dental Limitation, and add
the orthognathic surgery benefit.
1. Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A. , page 5, is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in
advance, the following Subscription Charges:
EMPLOYEE EMPLOYEE EMPLOYEE, EMPLOYEE &
& SPOUSE SPOUSE & CHILD(REN)
CHILD(FEN)
Non-Uniformed $51.76 $ 90.76 $114.91 $75.91
Uniformed $66.58 $105.58 $129.73 $90.73
Retired Disabled $75.47 $114.47 $138.62 $99.62
for a period of twelve (12) months from and after January 1, 1981, and
frcan month to month thereafter unless modified as herein provided."
2. Part VI, J. , Major Medical Benefit, paragraph 4.b. , page 31,
is hereby deleted in its entirety.
3. Part VI, J. , Major Medical Benefit, paragraph 4.c. , page 31,
is hereby amended with the deletion of the reference to 4.b.
4. Part VI, I. , Dental Benefits, Limitations, paragraph 4.b. ,
page 24, is hereby amended to read as follows:
"b. Dental services for congenital malformations (except for
Members continuously covered by this Plan from birth) , dental services
primarily for cosmetic or esthetic purposes, or for dental implants."
MA828-ED9
ENDORSEMENT NINE . . . Continued
City of Kent
S. Part VII, Limitations, page 33, paragraph A.18. , as amended
in Endorsement Eight, is hereby further amended to read as follows:
"18. Services, supplies or treatment for cosmetic, plastic
or reconstructive purposes and complications thereof, unless they are
required to treat injuries received in an accident or for correction
of functional disorders. This includes, but is not limited to:
a. a surgery for sagging skin of the eyelids
(blepharochalasis) , face (meloplasty or rhytidectomy) , neck or abdomen;
b. breast or hip enlargement or reduction procedures;
C. reshaping of the nose (rhinoplasty) ."
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1981..
BLUE CROSS OF �NIASHINGTON AND ALASKA CITY OF KENT
By ByrjoKn (�
M. Hopkins Ti le: , ,c
Vice President - Marketing au&ht'j
Date GL / By
Title:
MA828-ED9 -2-
sr ,Z Alea
_ I ,
r
f
I
f
Blue Cross
•�' of Washington and Alaska
c
Group Contract
for
Health Care Benefits
i
i
BLUE O'RO SS OF WASHINV=3 AND iUASKA
(herein called the Blue Cross Plan or the Plan)
15700 Dayton Avenue :3crt.h
P. 0. Box 327
Seattle, Washington 98111
APPLICATION
for
GROUP HEALTH CAREE
ASR=NT
Application is hereby made to this Blue Cross Plan for a Group Health Care
Agreement in the form attached hereto, the provisions of which are to be made
available to all eligible classes of Employees as defined in the attached
Schedule of Eligibility.
'Ihe Applicant, in the event this Application is accepted and the Group Health
Care Agreement is issued, agrees to the methods and practices outlined in the
Agreement relative to submission of monthly Subscription Charges and information
as may be required for the Plan to adequately administer its obligations.
Coverage under the Agreement shall be effective at 12:01 a.m., on the _ first
day of Tanl,a�, , 19 82 , at Seattle, tashington and such coverage small
continue until terminated in accordance with the Agreement.
The Applicant agrees to promptly deliver to all covere employees the individual
identification cards, descriptive booklets and all notices received from the
Blue Cross Plan. If the Applicant fails to distribute such information to tre
employees and the Blue Cross Plan becomes liable for claims by virtue of enployee
reliance on a superseded booklet, the Applicant agrees to reil;burse the Blue
Cross Plan for such liability.
Applicant's
Address CITY OF KF N T
(Applicant)
P. 0. BOX 310
220 South 4th Avenue
Kent Washington 980311'
BY
Title:
By
(Date) Ti—le:
MA828-01-02-03
BLUE UOSS OF WASHINGTON P-l" ` ALA F.A
(A Non-Profit Health Care Corporation approved as a.
Blue Cross Plan, herein called the Blue Cross Plan
or the Plan)
In consideration of the Application made by
CIly OF K=
(herein called the Group)
a copy of which is attached hereto arx.Y made parr of this Agreement, and in
consideration of payments to be made by the Group of the Subscription Charges as
herein provided,
TES BLUE CPOSS PLAN HEREBY AGREES '10 PPDVIDE
the benefits herein describe3 for the term of this Agreement, as specified in
Part III, commencing at 1_2:01 a.m. , at Seattle, Washington on January 1 1982 .
The Subscription Charges shall be due and payable by the Group in advance of
the effective date of this Agreement and thereafter as provided herein. This
Agreement is issued and delivered in the State of Washin -on and i.s
governed by the laws thereof and is subject to the teiHs and conditions recited
on the subsequent pages hereof, which are a part of this Agreement, as if re-
cited over the signature hereto affixed.
IN WITNESS IN-HEREOF, this Blue Cross Plan has caused this Agreement to be signed
this day of ' v;k , 19
Josef E. Hunt
Senior Vice President
of External Affairs
MA828-01-02-03
PART I UFFIt1I'1'IJ��3
A. "Agreement" mans (i) the hppiicat.ion for Group Health Care Agree-
ment, (ii) this Agreement between the Group and this Blue Cross Plan, (iii)
any endorsements, addenda or riders now attached or hereinafter issued by tthe
Plan and (iv) the notices of election (application cards) of the Subscribers
indicating their participation in the coverage provided 'hereunder.
B. "Approved Alconolism 'Treatment Facility" means an institution
whicn nas been approved as an AlcoholiCrn Treatment Facility by the State of
Washington in accoraance witn RCW or as a facility primarily
engaged in the treatment of alcoholism and licensed or approved as such oy
the State in wnicn the facility is located.
C. "Custodial care" means the provision of room ana hoard, with or
without routine nursing care, training in personal hygiene and other corms
of self care, or supervisory care Try a aoctor for a person wno is mentally
or physically disabled as the result of retarded development or cocky
infirmity, ana who is not under specific medical, surgical or psychiatric
treatment to reduce the aisability to the extent necessary to enable such
person to live outside an institution providing medical care.
D. "Effective date" is the date on whicn the Member's coverage
becomes effective under this agreement. This date is established by and
appears on the records of the Plan.
JE. "Family ivemoer" or "Dependent" is the Subscriber's spouse or
any child of either or both under twenty-tnree (23) years of age if unmarried
and dependent within the meaning of tine Internal Revenue Code of the United
,States and listed on the application completed :Yy the Subscriber, except
that eligibility may be continues for any unmarried child enrolled under
this Agreement wno attains aqe twenty-three (23) and is incapable of self-
sustaining employ,�yient by reason of develoaiental disability or physical nandi.-
cap and is chiefly dependent on the Subscricx--r for support and maintenance.
Proof of such incapacity and depenaency must De furnisned to this Biue Cross
Plan cy the Subscriber within thirty-one (31) days of the child's attainment
of age twenty-three (23) and periodically thereafter as the Plan ;nay require.
Upon notice by the Subscriber, Family memcers may be aaded under tnis Agreement
as they becoire eligible in accordance with the regulations of the Plan.
Family members shall cease to be covered under the following circtumstancesc
1. A child wno ceases to meet the eligibility requirements set forth
above.
2. A spouse upon entry of decree of divorce.
3. A covered. spouse or covered children or both upon the death of the
Subscriber.
Coverage will terminate on the last day of the period for which Subscription
Charges have been paid, following a cnange in status.
-2-
PART I CEFINITIOIS . . . Continued
F. "Legally operated Hospital" mans an institution operated in accord-
ance with the laws of the jurisdiction in which it is located pertaining
to institutions identified as hospitals and which, for compensation from its
patients and on an inpatient basis, is primarily engaged in providing diag-
nostic and therapeutic facilities for surgical. end medical diagnosis, treat-
ment and care of injured and sick person-, by or under the supervision of a
staff of licensed physicians and surgeons, and which continuously provides
twenty-four (24) hours a day nursing :service by registered graduate nurses.
It shall specifically exclude any institution which is primarily a place of
rest, a place for the aged, a nursing home, a convalescent home, or a
facility operated by the Federal aivernment or any agency thereof.
G. "Medically Necessary/Medical Necessity" means indispensable in
the sense that, in the reasonable opinion of this Plan, an illness, injury or
condition han-nful or threatening to the patient's life or health, or a direct
effect of such, could not have been diagnosed or relieved without the medical
service or supply in question. The mere fact that it was furnished, pre-
scribed or approved by a physician or other qualified provider does not in
itself mean that it was medically necessary. A medical service or- supply may
be medically necessary in part only.
H. "Medicare" means the program established by Title I of Public
Law 89-97 (79 Statutes 286-343) , which Title I contains a new Title XVIII
of the Social Security_ Act %-Alich is cited ,is the .Iealth Insurance For `one
Agea Act.
I. "Member" is a Subscriber or eligible Family Member.
J. "Neuropsychiatric, mental or personality disorder" shall mean
only those conditions listed in the International Classification of Diseases
as psychoses, neuroses, personality disorders, and other rion psychotic mental
disorders.
Benefits will not be provided for services rendered for learning disabilities;
marital, family, sexual or other counseling or training services; custodial
care; services rendered after a court ordered admission or for services
not medically necessary.
K. "Participating Dentist" is a dentist who, at the time services are
rendered, has an agreement in effect with this Blue Cross Plan to furnish
dental services to Members.
-3-
PART I E FINITIONS . . . Continued
L. "Participating Hospital" is a Legally c_.-=rated Hospital. or other
institution Vjaich, at the time of admission to such hospital under the terms
of this Agreement, has an agency agreement in effect with the Blue Cross
Plan to furnish hospital care to h1r{::>ers, and has been accepted and approved
by the Blue Cross Board of Directors. A list of rarticipating Hospitals is
available on request, such list being subject to change at the option of the
Plan.
"Non--Participating- Hospital" is a legally operated hospital which
does not have a contract in effect with the Blur. Cross Plan to furnish hospital
care to Members.
M. "Participating Skilled Nursing Facility" means a facility which,
at the time of admission to such facility under the terms of the Agreement,
has an agency agreement in effect with this Blue Cross Plan to furnish certain
services to Members, and has been accepted and approved by the Blue Cross
Board of Directors. A list of Participating Skilled Nursing Facilities is
available on request, such list being subject to change at the option of the
Plan.
N. "Physician and Surgeon" and Other Providers of Service: "Physician
and Surgeon" means only one who is licensed to practice medicine and surgery
(M.D. ) or osteopathy and surgery (D.O. ) or Podiatry (D.P.M.) or a licensed
psychologist or a licensed chiropractic physician. (D.C.) .
Benefits will be provided for health care services performed by a registered
nurse licensed in the State of Washington if the services performed were within
the lawful scope of the nurse's license, and benefits would have been provided
if the services were performed by a licensed physician.
In the event that a dentist (D.D.S. or D.M.D. ) performs non-dental surgery in
the oral region (operating and cutting procedures and the treatment of fractures
and dislocations) and such services would have been covered if performed by a
physician and surgeon (M.D. or D.O.) , then such services shall be covered when
performed by a dentist.
0. "Pre-existing condition" mans a condition for which symptoms
existed which would ordinarily cause a prudent person to seek medical diagnosis,
care or treatment, or for which medical advice was given or treatment was
recc mm--nded for or received by the Member, during the five (5) years iminy--di_ately
preceding the Me_mber's effective date.
P. "Service area' shall mean the states of Washington (except Clark
County) and Alaska.
Q. "Subscribes` or "Employee" is the individual whose application has
been accepted by this Blue Cross Plan and in whose name the Identification
Card is issued.
R. "Subscription Charges" shall mean the monthly rates established by
the Plan as consideration for the services and benefits offered by this
Agreement to a Subscriber and covered Family Members.
SMA5B/21
-4-
PAS I Lis iNITIMS Continued
S. "Usual, customary and reasonable." The Plan will take into
consideration the following criteria in the determination for the actual
amount payable for any given service or supply:
`Ihe usual chard e or fee which t'r;e provider or service most frequently charges
to the majority of patients or customers fcr a similar service or medical
procedure;
The charges or fees which fall within the custcnary range of charges or fees
in a locality for the performance of a si-nilar service or procedure; (in the
event there are too few providers in any given locality from which to deter-mine
a custa-nary range of charges or fees for a given service or supply, the Plan
will determine the armurt payable based upon the customary range of charges or
fees in a wider geographical area such as the state in which the provider of
service is located.)
Unusual circumstances or can; lications requiring additional time, skill and
experience in connection with a particular service or procedure.
Cetermination of the actual amount payable for any given service or supply is
within the discretion of the Plan. Except for the charges of a Participating
Eentist, chames or fees in excess of the usual, customary arrd reasonable
charges or fees as determined by the Plan shall be the responsibilit-y of the
Membe r.
SMA6A/18
-5-
PART II.. TFR IS OF FjWLLMENT AND ELIGIMLITY
A. h-very Subscriber ar- Fa;nily Member n the classifications
set forth in the attached Schedule of Eligibility shall be eligible for
coverage in accordance with the provisions cf this Agreement.
B. The Group s"all n;aintain a record of Subscribers included for
coverage hereunder, containing for each Subscriber arti F.�nily meii-hers, if
any, such information as the Blue Cross Plan may require in connection
with the administration of the agreement. Such records shall be open for
inspection by the Plan at any reasonable time.
PART III TEMS AND TERIINATICN OF AGIIEFIIENT
A. The initial tern of this Agreement shall be for twelve (12)
:rionth(s) from its effective date. At the end of said Wel10 I.2)
month(s) , the term of this jygrearent shall be monthly thereafter, unless
modified or terminated as herein provided.
B. This Agreement ;nay be terminated at any time by the Group by
giving written notice to the Blue Cross Plan at least thirty (30) days in
advance of such termination. This Agreement may be terminated by the
Blue Cross Plan at the end of the initial term, or at the erxi of any
subsequent term, ul:on giving :written notice to the Group at least thirty
(30) days in advance of such termination.
-6-
Sry 4/3
PART IV SUBSCRIPTION CHARGES AND GLACE PERIOD
A. The Group shall pay to the Blue Cross Plan monthly, in advance,
the following Subscription Charges:
EMPLOYEE EMPLOYEE EMPLOYEE, EMPLOYEE &
& SPOLF3E SPOUSE & CHILD(REN)
CIJILD(REN)
Non-Uniformed $ 70.06 $122.84 $155.53 $102.75
Uniformed $ 90.11 $142.89 $175.58 $122.80
Retired Disabled $102.14 $154.92 $187.61 $134.83
11he Subscription Charges specified above shall remain in effect
for the term of this Agreement as specified in Part III. However, if any
government imposes or changes any tax on Plan revenue or mandates a change in
benefits, the Plan may then adjust Subscription Charges at any time to offset
the effect on its revenue.
A grace period of ten (10) days, however, is allowed to the Group
for payment of any periodic payment. In the event the Agreement terminates
for any reason, the Group shall be liable for any Subscription Charges due
the Plan for any time this Agreement is in force during a grace period.
B. After the expiration of the term of the Agreement specified in
Part III, the amount of said monthly Subscription Charges may be changed by
the Plan, provided however, that the Plan shall notify the Group of any
change at least thirty (30) days in advance of the date the change is to
be effective. Payment of the revised Subscription Charges shall constitute
acceptance of the change.
C. Upon failure to pay the Subscription Charges on behalf of any
Member, the rights of the Member under this Agrent shall be terminated,
except as provided in Part IX of this Agreement, until said Member shall have
been reinstated pursuant to the provisions of eligibility as defined herein.
-7-
PArd V CaMI -L Ul41T.,R MUCH ENS'JUTU;'lUt-M, CARE WILL, BE FURIUSIiL'D
A. [R)spital, Skilled Nursing I'acility and Alcohol.iam Treatment Facil-
ity Care - (institutional Care)
Institutional care ;where covered under this Agreer;iert ;gill tx' pro-
vided to the extent medically necessary for disabilities arising fro,:, illness
or injury. A 11ember must be under constant care and treatment of a physician
and surgeon to be eligible for inpatient benefits. The Plan provides benefits
only for the nor7;ial period of inpatient convale_,ce:ice, follaaing surgery or
other acute illness. It does not provide benefits for convalescent care cohere
the necessity for definitive medical treaty;ent no lamer exists or the acute
care provided by such institution is no longer necessary. Admission to such
institution, whether inp-at-ient or outpatient, must be subsequent to the effec-
tive 'date of coverage hereunder.
B. Care (within the Service Area
1. If a Member receives inpatient or outpatient care in a Partic-
ipating Iospital, or inpatient care in a Participating Ski-lied Nursing Facil-
ity or Approved Alcoholism Treatment Facility, benefits will be provided in
accordance with the provisions of this Agreement.
2. If a Member receives inpatient or outpatient care in a 113n-
Participating Hospital for a covered condition that is life-endangering,
occurs suddenly and unexpectedly and rewires immediate medical attention,
the Plan will pay eighty percent (80%) of the hospital's usual, customary
and reasonable charge for services rendered in connection with such medical
eiergency and covered by this Agreement.
3. If a Member receives inpatient or outpatient care in a Ibn-
Participating Hospital or inpatient care in a ,'bn-Participating Skilled
Nursing Facility or Non-Approved Alcoholismm Treatment Facility, that is not
for a cory.]ition that is life--endangering, occurs suddenly and unexpectedly
and requires immediate medical attention, benefits of this Agreement will not
apply.
C. Care Outside the Service Area
In the case of accidental injury or illness requiring hospitaliza-
tion in any Legally Operated Hospital in areas other than that served by this
Blue Cross Plan, the Member shall be entitled to benefits as indicated in
paragraph 1 or 2 below (with the days of care provided under either paragraph
being counted against the total number of days of care available under this
Agreement) .
1. If covered inpatient services provided in a Member Hospital of
another Blue Cross Plan, benefits will be provided through the Inter-Plan
Service Benefit Bank (a reciprocal service arranger:�-_nt between Blue Cross
Plans) ; or
2. If covered services are provided in a non-r,�,ber Legally Cper.-
ated Hospital or in the outpatient department of a Mer�>er iospital, benefits
will be provided in accordance with the provisioi-L,; entitled "Ilbspital Care" as
def ined under Part VI.A and B.
-8-
PART VI BLNEI'ITS
A. Hospital Care -- Inpatient Continued
h. The fo1_lo:;ing services only w i--n furnished and billed
by the hospital in connection with an iiln,7--ss oL' accident requiring hed
care aril treatment, and necessitating th,i e services for treat.,e.nt. of the
condition:
Laboratory 1"xaminations*
Electr ocard iograiis"
X-I:cay E crmi_nati.ons*
Physiotherapy and Ilydrothcrapy
*These services shall b,3 considered inpatient services
if rendered in the outpatient dep--.);_t:nent of a hos;-)ital
within ti,enty-four ( 24) h az s of a ;mission to such
hospital, provided such tests are related to the condition
for which the Member is &KJmi.tted,
2. The foregoing hospital Services shall be furnished to each
Meibber up to an aggregate of 365 days for each hospital confincment,
provided ho,;evcr, that days of care shall not exceed an agrtrerjLite of 120
each calendar year for neuropsychiatric, :n ;rlt.al or personality disorders,
alcoholic, or drug addiction. Successive hospital confinements shall be
deemed to be continuous and to constitutc a si;xlle hospital con- i_n(m nt
for puLl)oses of this Agrecinent if discharc,,e frc�ii and readmission to a
hospital shall occur within a ninety (90) day p�-,rio:1; provided ho�-rever,
a. that any subsequent confinctnent where the Subscriber
is the patient shall be considered as a ne-a Period of confi.nL'nent if
acceptable evidenc(- is furnished to the Blue C�mss Plan that the Subscriber
shall have returned to active work on a full-ti;,ie basis follcraing the previous
conf inaiient.
b. should reaclnission to a hospital be required as a
result of accidental injury occurring during tl,e ninety (90) Clay period
referred to above, such read,nission shall. constitute a new confinement.
-9-
PART VI BENEFITS
B. hospital. Care -- Outpatient
1. The Blue Cross Plan shall furnish to the Member the services
listed in paragraphs b through h of Part VI.A.1 above, in the outpatient
department of a Participating Hospital, for treatment of accidental injury.
All such treatment must be rendered within seven (7) days after the occurrence
of such injury and be performed in connection with such injury.
2. The Member shall be entitled to the services listed in
paragraphs b through h of Part VI.A.1 above, furnished in the outpatient
department of a Participating Hospital in connection with (i) surgical
treatment requiring the use of operating rocta facilities and (ii) x-ray and
radium therapy treatments, and (iii) chemotherapy for the treatment of malig-
nancies only.
3. The Member shall be entitled to the services listed in
paragraphs b through h of Part VI.A.1 above, furnished in connection with a
life-endarr,ering illness that occurs suddenly and une. .-cted].y and requires
immediate medical attention. Such medical emergencies include heart attacKs,
cardio-vascular accidents, poisonings, loss of consciousness or respiration,
convulsions and such other acute conditions as may be determined to be
medical emergencies by the Plan.
4. Exclusion
In addition to the Exclusions, Exceptions and Limitations of
Part VII, this hospital outpatient benefit does not include the services of
a physician.
SMA4B/13
-10-
PART VI BE EF1TS Con.tinuc�d
C. Skilled Nursing Service
"Skilled Nursing Service" must include c'ii_rec,t medical supervision
of the treatment provided each ;eimi er and must include nursing service under
the supervision of a Registered Nul-se, plus other therapeutic_ services .
This service is designed to serve the Ianber who does not need the canprehen-
sive service of the acute facility, yet is not at a point in the illness
or disability which would allow care in a facility offering lesser services.
1. Benefits
a. When receiving Skilled Nursing Service in a Participating
Skilled Nursing Facility, the Plan shall furnish to each Merriber the following
items of Skilled Nursing Service for confinam nts coaRencing on or after the
Menber's effective date of coverage uncer this .greumant:
(1) Skilled Nursing Service in a room of two (2) or
more beds.
(2) The cost of items (a) through (f) below consistent
with and related to the admitting diagnosis, -.hen prescribed by the attending
physician and when ordinarily furnished and billed by a Participating Skilled
Nursing Facility.
(a) Ilse of special treatment rooms.
(b) Routine laboratory examinations .
(c) Physical, occupational or speech therapy
treatments.
(d) Oxygen and other gas therapy.
(e) Drugs, biologicals and solutions used
while the Mye-n er is in such facility.
(f) Gauze, cotton, fabrics, solutions, plaster
and other materials used in dressings and casts.
b. Each day of care in a Participating Skilled Nursing
Facility will be charged as one-half (1./2) day of fbspital Care against
the maximum benefit period as specified in part VI.A.2.
C. In case of accidental injury or illness requiring
Confinement in a Skilled Nursing Facility in areas other than that served
by this Blue Goss Plan, the N,eirber will b- entitled to the benefits provided
hereunder.
-11-
PAFa VI BENEFITS . . . continued
c. Skilled Nursing Service . . . . Continued
2. Exclusions
In addition to the Exclusions, Exceptions and L unitatiolls
of Part vII, benefits will not be provided hereunder when care received
by the Member:
a. consists principally of custodial or domiciliary
care, or
b. consists principally of care for senile deterioration;
for mental deficiency or mental retardation; or for mental illness.
-12-
PAFT VI BITS Continued
D. Alcoholism Treatrmnt Facility Benefit
1. When intensive alcoholism treatment services are rendered to
a Member in an approved Alcoholism Treatment Facility► the Plan shall pay
fcr ti:e
eighty percent (80%) of the usual, custan-ary and reasonable charges
treatment received until one thousand dollars ($1,000.00) has bin paid
toward expenses incurred during any calendar year. The foregoing benefit,
mission to sure facility occurs on or after
will be provided only when ad
the Member's effective date of coverage and services provided are furnish..3
and billed by such facility. Each day of care shall be charged as one day
of Hospital Care against the maximum benefit period specsfled in Fart VI.A•2
of this Agreement.
2. If a Member is confined in a Participating Hospital, whether
or not it is an Approved Alcoholism Treatrent Facility, he or she shall be
entitled to the benefits provided under Part VI.A Of this Agreement.
-13-
PART VI :BENSFI"'s . . . rcn4tin.c:u
E. Professional Medical. Benefits
1. upon receipt of due ;notice and proof that the Member has
incurred expense for the fol.laArxl :services rendered by a physician and
surgeon in connection with an illness or injury, the Blue Cross Plan will pay
for such services up to ti:e usual, cust-co.ary and reasonable crarge or fee for
such services in the canmun ity in which the services are rendered, subject to
the provisions of Part VII.
a. Professional services of a physician and surgeon for
surgical services (operative and cutting procedures for the treatinent of
disease and injury, and the treatment of fractures and dislocations) and
services of an assistant surgeon for major surgery.
If more than one surgical procedure is f-erformed, benefits will be provided
as follais:
(1) at different tines due to entirely unrelated causes,
benefits will be provided for each procedure;
(2) at the same time in the sane operative area, benefits
will be provided only for the procedure with the largest allowance;
(3) at tine same time in different operative areas, fail
benefits will be pror,.,ided for the procedure with the largest allowance plus
one-half (1/2) of the allowance for each additional procedure.
b. Physician's hospital visits (limited to one (1) visit per
day) while a Member receives hospital services and benefits hereunder as a
registered bed patient and for each visit by a physician (limited to one (1)
visit per day) when the Member is confined to a Participating Skilled Nursing
Facility and is eligible for skilled nursirx; service. Such medical benefits
will not be payable during confinement preceding or following any surgical
operation or treatment of any injury or condition for which benefits are
provided under paragraph l.a above.
C. Professional services of a physician anesthesiologist when
the Member is confined in a hospital and is eligible for Hospital Care and
surgical benefits. Such medical benefits will not be payable when such
services are rendered by the operating surgeon or when anesthesia is admin-
istered by a hospital employee.
d. Professional consultation services (opinion or advice
provided in the evaluation and/or treatraent of a patient's illness or accident)
rendered by a physician and surgeon during the period the Member is confined
in a hospital and eligible for Hospital Care. Such services must be requested
by the attending physician arx3 surgeon.
e. Professional services of a physician and surgeon for
radiotherapy treatments.
2. The professional services liste-J, above must be rendered to the
Kauber on or after his effective date of coverage under this Agreement, or, in
the event the Member is hospitalized on such effective date, su:h services
must be rendered subsequr`nt to the date of discharge frari the hospital.
SMASB/l 1 -14
PART VI B EN-1]F1 T S . . . .
F. Hospital Out!_�-Itiellt cle,--lic'-al 13el-'ef
is treate6 a physician and surgeon in the
outpatient department off: a participating v0sj4rai and is cntitled to
benefits under Part VI.3.3, the Flue Criss pInn will y: y for exponses
all trea"Ll""er"t
�-)-nal) -e fee for
incurred up to tie usual, custaOarY aly-' ' ea:
renderc-A by the attending physician aM s,.,r:gc(Dtj in connection with e,.wh
medical c7argency. EID benefits will no provided for treaMent for which
benefits are provided under Part VIZ of this Weement-
-15-
PART VI BENEFITS . Continued
G. Diagnostic X-Ray and Laboratory Benefits
1. In non--hospitalized cases, the Blue Cross Plan will pay up to
usual, customary and reasonable charges, as defined in Part I.S, for expenses
incurred by the member for diagnostic x-ray and laboratory examinations ordered by
a physician and surgeon for treatment of illness or injury as follais:
a. For each accident, up to $100.00 .
b. For illness, up to an aggregate of $ 100.00 _ in any calendar
year.
2. Exclusions
In addition to the Exclusions, Exceptions and Limitations of Part
VII, no Diagnostic X-Ray and Laboratory Benefits will be provided for dental or
eye examinations and treatments; neuropsychtatric, mental or personality disorders;
or for routine physical examinations.
-16-
PART VI BENEFITS . . . Continued
H. Ambulance Benefits
The Blue Cross Plan will pay expenses incurred by the Member for
licensed ambulance transportation to a hospital, up to an aggregate of
$50.00 for each accident or for each hospital confinement.
-17-
PAW` VL BENEFITS Continued
1_. Supplemental Accident Benefit
1. Tree Blue Cross Plan shall pay, subject to the limitations a!:d
exclusions expressed herein, the usual, customary and reasonable charges,
as defined, for the followi r?g services vA-:en rendered to the Member who
requires care as the result of an accident, up to a total of three hundred
dollars ($300.00) for each accident, in addition to the benefits set forth
elsewhere in this Agreement:
a. Services furnished and billed by a Legally operated Hospital,
except as follows:
(1) Services of a persona nature, such as charges for
radio, telephone, guest trays and the like.
(2) Private roan charges exceeding the hospital' s most
prevalent charge for accarnnodations in a roan of tti o (2) or mere beds. When
a Member is confined in a hospital having private roan accaumodations only,
the Plan shall determine the amount of eligible expense to be allowed herE--
under.
b. Medical or surgical care by a physician other than one who
ordinarily resides in the Subscriber' s home or is related to the Subscriber by
blood or marriage.
If more than one surgical procedure is performed, benefits
will be provided as follows:
(1) at different times due to entirely unrelated causes,
benefits will be provided for each procedure;
(2) at the sane time in the same operative area, benefits
will be provided only for the procedure with the largest allowance;
(3) at the same time in different operative areas, full
benefits will be provided for the procedure with the largest allcwa.nce plus
one-half (1/2) of the allowance for each additional procedure.
c. Necessary laborator-1 and x-ray examinations.
d. Professional nursing service of a registered professional
nurse, other than one who ordinarily resides in the Subscriber' s home or
who is related to the Subscriber by blood or marriage. Such service must be
acute nursing service ordered by a physician and surgeon.
e. Professional services rendered by a physician and surgeon
or doctor of dental surgery for treatment of a fractured jaw, or other
accidental injury to natural teeth provided that the injury occurs while the
patient is covered hereunder.
f. Anesthetic supplies and administration of anesthesia by cui
anesthetist.
g. Services of a physician and surgeon, or a registered physical
therapist, in connection with physical therapy treatments, other than one
who ordinarily resides in the Subscriber' s home or who is related to the
Subscriber by blood or marriage.
SMA3B/3 -18-
PART VI BE,1VFk 1I'S . . utn' in.:ed
1. Strpplement.al A.ccxdenr:. I�enefit.
h. Licensed ambulance sj�rvice which is certified as medically
necessary by the attending physician to the nearest facility equipped to
render treatment of t.,e condition of L.ie ti:el,lber `This method of trar-isportation
will be p-ovide-d only when the use of other means of transportation would
endanger the life or safe-ty of the Member.
i. Drugs or medicines directly related to the treatment of an
injury and reluiring a written prescription and dispensed by a licensed
pharmacist or physician anJ surgeon.
J•
Artificial limbs or eyes, casts, splints, trusses, braces,
crutches and other similar durable medical, appliances and also the rental of a
wheelchair, hospital.--type bed, iron lung or other similar durable medical
mechanical equipment required for treatment. The Plan may, at its option,
purchase such durable medical mechanical ecuipmer,t for the Member, in lieu of
rental. These supplies will be limited to those reasonably required by
standard treatment practices as a result of injury occurring while the Member
is covered hereunder.
The term "durable medical equipment" shall mean equipment
which: (i) can withstand repeated use. (,An exception to this would be
certain consumable medical supplies; (ii) is primarily and customarily used to
serve a medical purpose; (iii) is generally not useful to a person in the
absence of illness or injury; and (iv) is ordered and/or prescribed by a
physician.
k. Blood transfusions, including cost of blood and blood
derivatives.
2. In addition to the Exclusions, Exceptions and Limitations of
Part VII, no benefits will be provided under this Supplemental Accident
Benefit for:
a. Any services or supplies other than those specifically
set forth above.
b. Benefits payable under other provisions of this Agreement.
C. Expenses for treatment received more than three (3) months
after date of accident.
d. Any injury sustained prior to the Member's effective date
of coverage hereunder.
e. Disease or infection (except infection occurring as a result
of an accidental cut or wound) .
f. Dentistry, except as specifically provided in paragraph
l.e above; eye refractions or the fitting of eye glasses; food poisoning.
Termination of a Member's participation under this Agreement
shall not invalidate or reduce any clai:,r under this Sulx?lemental Accident
Benefit in connection with an accident that occurred prior to such termination.
SMAIA/16
-19-
PART VI BENEFITS . . . Continued
J. Dental Benefits
1. Definitions
a. "Benefit Year" as used in this Part VI J, means that
12-month period following the effective date; of coverage of a i-nber on this
Dental Benefit, and each 12-month period thereafter.
b. "Dental Services" means those dental services for which
benefits are provided under this Part VI
C. "Dentist" means any dentist duly licensed to practice
his profession.
2. Benefits
Subject to the limitations, exclusions, exceptions and
other terms and conditions of this Agrec4nent, not inconsistent herewith,
benefits to the extent hereinafter set forth shall be provided to ',4--mbers
for the services set forth belay when rendered by a Dentist while the
Member is covered hereunder.
a. Basic benefits consisting of:
(1) Oral examinations, limited to two (2) each
benefit year.
(2) Dental X-rays as rewired.
(3) Topical fluoride application, for members under
age twenty (20) .
(4) Prophylaxis, including cleaning, scaling and
polishing, limited to two (2) each benefit year.
(5) Repair of dentures and bridges.
(6) Palliative emergency treatment.
(7) Fillings consisting of silver amalgam, silicate
and plastic restorations. For other types of fillings, such as gold foils,
the allowance will be limited to what would otherwise have been allowed for
an amalgam restoration.
(8) Extractions.
(9) Endodontics, including pulpotomy, pulp capping
and root canal treatment.
(10) Space Maintainers.
(11) Oral surgery consisting of fracture and dislo-
cation treatment, diagnosis and treatment of cyst and abscess.
(12) Apicoectcxny.
SMAW2
_ 20-
pAEU VI Ba4EFITS . . . Continued
J. Dental Benefits . Continued
(13) riodontic services consisting of surgical
it ido curettage, gingivecta:ry and gingivoplasty,
periodontic examination, g - lastic surgery,
osseous surgery inciudiryg flap entry and closure, mucogif)gvivo p
management of acute infection arxi oral. lesions-
b. prosthetic Dental Services consisting Of:
(1) Inlays aril a-1 ays.
(2) Crowns.
(3) Bridges, fixed and removable.
(4) Dentures, full and partial, except that:
(a) Benefits for denture replacement shall not be
provided for:
(i) Any denture -replacement made less than
ered
five years after a denture
oYplaleme�'yoaen precreUlacementnt emadevneces�aryor✓`,'
under this Part VI �, (
reason of the loss or theft of a denture, and
(b) If, in the construction of a denture, the
employ
Member and the Dentist decde to personalized
ar da drprocedures,tthe benefits
special techniques as opposed
under this Agreement shall be limited to tile standard procedures for
prosthetic services-
C. The dental benefits available under this Part VI J
will be provided prior to any dental benefits which may be available under
other provisions of this Agreer;'ent.
3. Amount of Benefits Payable
Benefits provided under this Part VI J _ for Dental
r
Services shall oe as follows but
servics rend�edn alowlce of on during�any BenefittYeasand
dollars (*1,000) for all Dental
for any Member:
-21-
sMAW 3
PAW VI BENEFITS . . . Continued
J. Dental Benefits . . . Continued
a. Basic Dental Services
During the first Benefit Year in which a Member utilizes
the Basic Dental Services listed in paragraph 2.a above, the Plan shall pay
toward expenses incurred seventy percent (70`' * of the amount specified in
paragraph 3.a for the Dental Service performed, except that when a Menem
utilizes such Dental Services during successive Benefit Years, comrea cing with
the second of such successive Benefit Years the percentage of the amount
payable by the Plan toward such benefits shall be increased over such seventy
percent (70%) * by an additional ten percent (10%) * of the amount specified in
paragraph 3.a for each successive Benefit Year until the Plan will be paying
one hundred percent (100%) * of the amount specified in paragraph 3.a. However,
the percentage of the amount specified ion paragraph 3.a that the Plan will pay
toward such benefits in a Benefit Year -bmediately following one or more Benefit
Years in which none of such benefits was utilized by a Member will be reduced
by 10%*, but not to less than 70%* of the arum specified in paragraph 3.a for
the service rendered.
b. Prosthetic Dental Services
During any Benefit Year, the Plan shall pay toward
expenses incurred for the Prosthetic Dental Services listed in paragraph
2.b above:
Any Benefit Year . . . . . . . . . . . . . . 50%*
*Limited to these percentages; (i) of the Dentist's charge
or (ii) of usual, customary and reasonable charges as defined in Part I. S
of the Agreement, whichever is less.
4. Conditions Under Which Benefits Are Payable
a. Participating Dentist
The Subscriber will be- responsible to the Participating
Dentist for the difference, if any, between the amount payable by the Plan as
provided in paragraph 3 above and the usual, custorlary and reasonable fee or
the Dentist's charges, whichever is less. Tt.,e Subscriber will not be respens ble
for charges in excess of the usual, custamary and reasonable fee.
b. Non-Participating Dentist
The Subscriber will be responsible to the non-participating
Dentist for the difference, if any, between tiro �munt payable by the Plan as
provided in paragraph 3 above, and one hurxlred percent (100%) of the non--partici-
pating Dentist's charges.
C. This Blue Cross Plan shall, at its own expense and by a
Dentist of its own choice, have the right and opportunity to physically ex-mine
any Wm ber with respect to the Dental Services provided hereunder upon req.lest.
SMALL/4
-22-
PART VI BENEFITS . . . Continued
J. Dental Benefits . Continued
5. Exclusions, Exceptions an-d Lunitat..i_or::
In addition to the E-Xclusions; Exceptions and Limitati0 of
Part VI I of the Agrer�<<ent, the Blue 'C OSS Plan st L:=.1 not be rc uiz-c<a
furnish any benefits under this Part %TI J. fOY
a. Dental services rendered fro.n a dental or med-cal
department maintained by or on behalf of an u,i'�jl.oy?7; a. rurtual ;x.nefit
association, labor_ union, trustee or si�ni-lar pc',.:`r: or gr oop.
b. Dental services for corrgc-nit:al r-alforr!ations (except for
Members continuously coverod by this Plan i_can bird:) , d ntal s`r.-lices pri-
marily for cosmetic or esthetic purposes, or for dental implants.
C. Appliances or restorations necessary to increase
vertical dimensions or restore the occlusion.
d. Services rendered by a Dentist b:-yarjd the scope of
his license.
e. Topical. fluoride applications after the Member attains
age twenty (20) .
f. Dental services to the extent that charges for such
services exceed the charge that would have been made -and actually collected
if no coverage existed hercun<ler or for whic:, the merr?xr incurs no charge.
g. orthodontic services, except for extractions incidental.
thereto.
h. In the event a Member transfers from the care of one
Dentist to that of another Dentist during the course of treatment, or if
more than one Dentist renders services for one dental procedure, the Plan
shall be liable for not more than the ar?ount it would have been la-able for
had but one Dentist rendered the service.
i. In all cases in which there are optional techniques
of treatment carrying different fees, the Plan shall be liable hereunder
only for the treatment carrying the lesser fee.
j. Prosthetic services or devices (including bridges arA
craans) started prior to the date the Mel,ber_ became covered under this
Part VI J .
k. Expenses incurred after termination of coverage except
expenses for prosthetic devices which were fitted and ordered prior to terMln-
ation and were delivered to the Member within thirty (30) days after the date
of termination.
1. Benefits are not provided for r Kore than two (2) oral
examinations nor for more than tc-x) (2) prophylaxes (including cleaning,
scaling and polishing) each Benefit Year.
-23-
SMAlA/5
PIPHr Ili BENEFITS . . Continued
K. Major Medical Benefit
1. Definitions
a. The term "Deductible Ariount" shall mean the first
$50.00 of expense incurred for Major Medical Benefits for which each
person covered hereunder shall be responsible. Tne Deductible Ammunt
shall be applied in the following manner:
(1) The Deductible Amount shall be applied to Major
Medical Benefits incurred in each calendar year by each IMEnber.
(2) In no event shall any family unit be required to
satisfy more than an aggregate of in Iductible Amount ,
during a calendar year. Once the �'1 5L_(la____ maximum deductible is
satisfied, all Members of that faiily shall be deemed to have satisfied
their deductible for that calendar year..
(3) if two or more Members shall suffer bodily
injury as a result of the same accident, only one Deductible Amount shall
be applied to all Major Medical Benefits incurred as the result of said
accident during the year in which the accident occurs.
(4) Any expense for Major Medical Benefits incurred
in the last calendar quarter of the year and applied against the Dc-�duc-
tible Amount for that year shall be carried fon,rard to apply against the
Eeductible Amount for the ensuing year. 'Where the expense carried for-
ward to the ensuing year under this sub-section (4) shall be in connection
with the same accident resulting in bodily injury to t<,ro or more Members
covered hereunder, the Major Medical Benefits incurred by all said
Members in the ensuing calendar year as the result of said accident shall
be subject to only the one Deductible Amount.
(5) The Blue Cross Plan shall select at all times in
the application of sub-section (1) , (2) , ( 3) or (4) above, the sub-section
which shall provide the greatest total payment by the Plan to all Members
covered hereunder.
b. The term "Major Medical Benefits," as used in this
Agreement, means only those services and supplies listed below and only
to the extent that they are not furnished by the Blue Cross Plan under
other provisions of this Agreement. To be eligible for Major !Medical
Benefits, it is required that such be medically necessary and furnished
in connection with the diagnosis or treatment of an illness, disease or
accidental bodily injury, and be authorized by a licensed physician and
surgeon and for only as long as such authorization is given.
-24-
PAI2 `I Ba7EFITS . . . Continued
K. Major. Medical Benefits . . . . Continued
(1) Services furnished and billed by a Legally operated
Hospital, except as follows:
(a) Services of a personal nature, such as charges
for radio, telephone, guest trays and the like.
(b) Private room charges exceeding the hospital' s
most prevalent charge for accomrbdations in a roan of two (2) or more beds,
except �en a Member is confined in a hospital having private roan accomr-o3a-
tions only, the Plan shall determine the amount of additional eligible expense
to be included hereunder.
(2) Professional services rendered by a licensed
physician other than one who ordinarily resides in the Subscriber' s home or is
related to the Subscriber by blood or marriage.
If more than one surgical procedure is performed,
benefits will be provided as follows:
(a) at different tunes due to entirely unrelated
causes, benefits will be provided for each procedure;
(b) at the same time in the same operative area,
benefits will be provided only for the procedure with the largest allowance;
(c) at the same time in different operative areas,
full benefits will be provided for the procedure with the largest allowance
plus one-half (1/2) of the allowance for each additional procedure.
(3), Professional services rendered by a licensed physician
and surgeon or doctor of dental surgery for treatment of a fractured jaw
or other accidental injury to natural teeth provided that the injury occurs
while the patient is covered hereunder. Such services will be covered only
during the twelve (12) months' period immediately following the date of
injury.
(4) Professional nursing, service of a registered pro-
fessional nurse, other than one who ordinarily resides in the Subscriber' s
hone or who is related to the Subscriber by blood or marriage. Such service
must be acute nursing service ordered by a physician and surgeon.
by an anesthetist. (5) Anesthetic supplies and administration of anesthesia
(6) X-ray, radium and radioactive isotope therapy.
(7) Services of a licensed physician and surgeon, or a
registered physical therapist, in connection with physical therapy treatments,
other than one who ordinarily resides in the Subscriber' s homme or who is
related to the Subscriber by blood or marriage.
(8) Diagnostic X-ray and laboratory services required
for treatment of illness or accident.
SMA5B/13
-25-
PART VI BENEFITS . . . Continued
K. Major Medical Benefits . . . Cbntinnued
C. If the expense incurred for Major Medical Benefit:
exceeds the Deductible Pmo.szt as set forth in paragraph l.a above, payment
will be made by the Plan for (i) eighty percent (80%) of such excess until
$2,000.00 have been paid for expenses incurred during any
calendar year on behalf of any Member and (ii) one hundred percent (10j%)
of the amount of all other covered expenses incurred on behalf of such
Member during the remainder of such calendar year.
After fifty thousand dollars ($50,000.00) have been
paid under this Major Medical Benefit for a Member, payment will be made by
the Plan for one hundred percent (100%) of Major Medical expenses for that
Member, without further requirements of a Deductible amount or co-insurance,
up to a lifetime maximum of 250,000.00
The portion of a Member's benefit which has been paid
by the Plan up to 000 per calendar year, will be
automatically restored without requiring action on the part of the Member.
Such restored amounts will be added to the S2
lifetime maximum.
d. With respect to charges incurred while the Member is not
confined as a bed patient in a hospital in connection with a neuropsychiatric,
mental or personality disorder, benefits will be available subject to the
following limitations:
(1) The payment by the plan shall be fifty percent
(50%) of eligible expenses instead of the percentages stated in paragragh
2.c above;
(2) Benefits shall be paid for a maximum of twenty
(20) visits in any one calendar year; and
(3) Such services must be rendered by a physician and
surgeon licensed to practice medicine, or by a licensed psychologist. Benefits
are not payable for marital, sexual or family counsel.ing.
SMA/lA/21 -26-
PART VI BENEFITS Continued
K. Major Medical Benefit . . . . Continued
3. Exclusions, Exceptions and Limitations
In addition to the Exclusions, Exceptions and Limitations of
Part VII, no benefits will be provided under this Major Medical Benefit
for:
a. Any of the foregoing services or supplies to the extent
that they are furnished by the Blue Cross Plan under the other provisions
of this Pgreement or Endorsements thereto.
b. Neuropsychiatric, mental or personality disorders, except
as specifically provided in paragraph 2.d above.
c. Any services or supplies not specifically listed herein
as covered benefits.
-27-
PART VI BEIFFITS . . . Continued
K. Major Medical Benefit . . . Continued
4. Termination of Coverage and Cancellation of the Agreement
a. Total Disability
If a Member is toi_ally disabled and being treated by a
licensed physician for the condition causing the disability on the date of
his or her termination, and within ninety (90) days tiere.after furnishes this
Blue Cross Plan with proof acceptable to the Pl«n of that disability, he or
she shall receive all the benefits under tr,is 1,Iajor m`�dical Benefits section
payable solely for the condition causing the disability. Such benefits will
be provided for a period after termination equal to the number of months the
Member was covered hereunder up to a maximtr,7 of (12) months or until the max-
imum benefits have been paid, whichever occurs first.
b. Cancellation of the Agreement
ne terminal I'lajor medical benefits specified in para-
graph 4.a above will not be available to memo--rs covered under this Agreement
at the time of cancellation of the F�qreement.
-28-
PAIU VI I EXCLUSIONS, EXC=IONS AND LIP lI TATIONS
A. The Blue Cross Plan shall not be required to furnish any ervic:Ps
or benefits for:
1. a. Any condition, ailment or injury for which the Merc er
entitled to receive beriefi_cs in whole or i11 part i_uider occupational co�,'7er_age
voluntarily obtained by the eri-q-,)loyer, required by state or fed• ral �,nrkers'
compensation acts, employer liability acts, or other legislative acts pro,.=idi.g
COITpeensation .for work-incurred injuries, or service rendered :in a h--,s_pital
owned or operated by a state or U.S. gover_rmi--ntal agency even though that
Member fails to make timely application therefor or waives his or her right.,
to such benefits.
b. Those employees covered under the Law Enforcement
officers and Firefighters Act of 1969 will be covered under this
Agreement for (i) non--occupational injuries and (ii) injun-ies
connected with their occupation as policemen or fi_renen as employees
of the Group, notwithstanding Part VII.A.1.a of this Agreement.
2. X-ray, laboratory and pathological services, and machine
diagnostic tests not related to a specific illness or injury or a definitive
set of syriptoms.
3. Hospitalization primarily for diagnostic studies, physical
examinations or checkups, medical evaluations or observation, when Hospital
Care would not have otherwise been required.
4. Care for extraction of teeth or other dental procedures, as w11
as dental examinations, except as provided in Par . . The Plan wi_11
t VI J.
provide. Hospital Care only for cases where adequate treatment cannot be
provided without the use of hospital facilities and where there is an under-
lying medical condition that necessitates hospitalization.
5. Any services furnished by an institution which is primarily a
place of rest, a place for the aged, a nursing home, a convalescent home or
any institution of like character, except as specifically provided in Part
VI.C, or for convalescent or custodial services regardless of where such
services are rendered, or that portion of any hospital confinement begirming
on the day that such confinement develops into primarily convalescent or
custodial care.
6. Any hospital confincment in a hospital that is not a Partici-
pating Hospital, except as specifically provided in Part V and the supplElTentac l
Accident Benefit and the Major Medical Benefit outlined in Part VI.
7. Conditions caused by or arising out of an act of war, armed
invasion or aggression.
8. Treatment for obesity, including surgery and complications
thereof.
-29-
PAW VI EXCIMIOtZ, EXCEPTIONS AND r,IMrrNfIONS . . . Continued
9. Any services or supplies for which no charge is made or which
would not have been made if this Agreenne-:t were not in effect nor for
services or supplies for which the �imbbeer would not be legally liable if
this Agreement were not in effect.
10. Admissions or treatnent primarily for rehabilitative care
(including, but not limited to, speech and occupational therapy) . Further,
when the type of care rendered during a continuous period of hospital
confinement develops into primarily rehabilitative care, that portion of
the stay beginning on the day of such development is not covered under
this Agreement.
11. Routine foot-care procedures such as the trimming of nails,
corns or calluses, fallen arches or other symptomatic complaints of the
feet, impression casting for prosthetics and appliances including
prescriptions therefor and routine hygienic care.
12. Services, supplies or treatment for cosmetic, plastic or recon-
structive purposes and campiications thereof, unless they are required to
treat injuries received in an accident or for correction of functional dis-
orders. These include, but are not limited to:
a. a surgery for sagging skin of the eyelids (blepharochalasis) ,
face (meloplasty or rhytidectomy) , neck or abdomen;
b. breast or hip enlargement or reduction procedures;
C. reshaping of the nose (rhinoplasty) ;
13. Services or procedures which are not customary and accepted by the
medical profession generally, and services or procedures which are experimental
or for the purpose of research.
14. Services or supplies related to sex transformations or sexual
misfunctions or inadequacies.
15. Services or supplies not medically necessary for treatment of
disease, illness, or injury; marital, sexual or family counseling.
16. Visual analysis, therapy, or training related to muscular
imbalance of the eye; orthoptics.
17. Treatment designed primarily to provide a change in environment
or a controlled environment (milieu therapy) .
-30-
PART VII EXCLUSIONS, EXCEPTIONS AND LIMITATIONS . . . Continued
18. Physical examinations or tests, including screening examinations,
not connected with the care and treatment of an actual illness, disease, Ln1 .
or pregnancy; eye lenses, eye refractions or eye examinations for die correction
of vision or fitting of glasses (except as provided herein) ; or the furnishing
or replacement of hearing aids.
19. Well baby care, including physical examinations, except hospital
infant nursery care for the newborn infant while the mother is hospitalized
and receiving maternity benefits.
20. Upper or lower jaw augmentation or reduction procedures (ortho-
gnathic surgery) , except for Members continuously covered by this Plan from
date of birth.
21. Any charges or fees of a provider which are in excess of the
'usual, custanary and reasonable' charges or fees. (See Part I, Definitions. )
-31-
PART VII EXCLUSIONS, EXCEPTIONS AND LIMITATIONS . . . Continued
B. In the event that a Member enrolled hereunder has been covered
by a prior Certificate or Agreement with this Blue Cross Plan, which is
replaced by this Agreement, the following specific provision will apply:
1. If a Member is admitted to a hospital within ninety (90) days
after discharge from the last previous hospitalization, the nintlber. of days of
care furnished under the prior Certificate or Agreement for the last hospital
confinement shall be deducted from the days of care available under this
Agreement, provided, however, that this paragraph shall not be applied in
connection with:
a. hospitalization of a Subscriber who shall have returned
to active work on a full time basis following last previous hospital confine-
ment, or
b. hospitalization of a Member required as a result of
accidental injury.
2. If a Member is confined in a hospital while covered under
the prior Certificate or Agreement and remains continuously confined past the
effective date of coverage under this Agreement, the benefits of the prior
Certificate or Agreement will apply until the date of discharge.
-32-
PARr VI EXCLUSIONS, EXCEPTIONS AND LIMITIT=NS . . . continued
C. Coordination of Benefits
1. Benefits Subiect To This Provision
All of the benefits provided under this Contract are subject
to these provisions.
2. Definitions
a. program means the fol3owi.ng sources of benefits which
will be recognized for coordination of benefits purposes:
(1) Group or blanket disability insurance or health
care program issued by insurers, health care services contractors and health
maintenance organizations;
(2) Labor-management ttzustee plans, labor organization
plans, employer organization plans or employee benefit organization plans;
(3) Governmental programs, including Medicare;
(4) Coverage required or provided by any statute;
(5) Group student coverage provided or sponsored
by a school or other educational institution which includes medical benefits
for illness or disease.
The term "Program" will be separately understood to
mean each policy which does or which does not provide for coordination of
benefits. Each portion of a policy which separately states whether it is or
is not subject to this provision will also be determined to mean a separate
"Program."
The Member will not be entitled to benefits from this
Plan in excess of those which he or she would have been entitled to if this
Coordination of Benefits provision were not inclL.y3ed.
b. Allowable Expense means any necessary, reasonable and
customary item of expense at least a portion of which is covered by at least
one of the Programs covering, the Member for whom the claim is made. When a
Program provides benefits in the form of services rather than cash payments,
the reasonable cash value of the service wil+. be considered as both an
allowable expense and a benefit paid.
C. Claim Determination Period means a Calendar Year.
SMA7B/20
-33-
PAT VII EXCLUSIONS, EXCEPTIONS AND LDIITATIONS . . . continued
C. Coordination of Benefits . . . (Continued)
3. Effect On Benefits
Coordination of Benefits canes into effect when a Member
has health care coverage under more than one Program. if, in the absence of
this provision, the suva of the benefits available under this Program and the
benefits available under all other programs covering the Member would be
greater than the total amount of Allowable Expenses incurred by that Member
during the Claim Determination Period, the Progranis involved will coordinate
their benefits according to this provision.
In order to coordinate benefits, it must be determined which
Program will be responsible for providing benefits first. Such Program is
determined to be "Primary." The Primary Program is responsible for paying
available Program benefits as if the coordination of benefits provision did
not exist. The remaining Programs are determined to be "Secondary." The
Secondary Program will reduce the benefits that �nuld have been paid in
the absence of this provision, so that the sum of the benefits paid by all the
Programs covering the person will not exceed the total amount of Allohable
Expenses incurred. Benefits payable under another Program include the benefits
that would have been payable whether or not a claim was actually submitted
to the Program.
The following rules will apply in determining which Program
will be Primary:
a. A Program which does not provide for coordination of
benefits will always be Primary over a Program which includes a coordination
of benefits provision.
b. When a Member is covered by more than one Program and
each Program involved includes this provision, the following rules shall apply
in determining which Program is Primary:
(1) The Program which covers the Member as other
than a dependent shall be Primary over the Program which covers the Member as
a dependent. However, if this Blue Cross Plan covers the Member as a retired
person, it shall be Secondary to any other Program which covers the Member.
(2) The Program which covers the Member as the depen-
dent of a male person will be Primary over the Program which covers the Member
as the dependent. of a female person. However, if the Member is a dependent
child and the parents of the child are separated or divorced, the following
rules will apply:
SMA7B/21
-34-
PART VI EXCLUSIONS, L>:CEI7fIONS AND LIMIT:'1MNS . . . continued
C. Coordination of Benefits . . . . (continued)
3. Effect On Benefits . . . . (continued)
(a) If the parent with custa:ly of the child
has not remarried, the Program which covers Cho child as a dependent of the
parent with custody of the child will be Primary over the Program vihich covers
the child as a dependent of the parent without custo:ly.
(b) If the parent c-jith custody has remarried,
the Program which covers the child as the dep2.ncient of the parent with cust
ody
will be Primary over the Program which cover:, the child as the dependent of a
step-parent. Also, the Progran which covers the child as the dependent of the
step-parent will be Primary over a Program which covers the child as a dei�endent
of the parent without custody.
(c) If there is a court decree which establishes
financial responsibility for the health care exixenses of the child, this will
take precedence over (a) and (b) , above. In this case, the Program which
covers the child as the dependent of the parent with such financial responsi
bility will be primary over any other Program which covers the child as
a dependent.
(3) When rules (1) or (2) do not determine which
Program has responsibility for I�_imary paymt,-It of benef i_ts, the Program w'rrich
has covered the member for the longer perial of tisre will be Primary over
the Program which has covered the ijamh,er for the shorter period of time.
C. Men this provision operates to reduce the total amount
of benefits otherwise payable as to a mk-mber covered under this PLa,rau during
any Claim Determination Period, each benefit that would be payable in the
absence of this provision shall. !7>e reduced proportionately, and such reduced
amount shall be charged against any applicable benefit limit of this Program.
4. Determination of other Coverage
This Plan will not be required to determine the existence
or extent of any other group coverage. 7iie benefits payable under this
Program shall be affected by coordination of benefits only to the extent that
other Program information is supplied to the Plan by the the other
group, the provider of setvices, or any otlier organization or person.
5. Facility of Payment.
Whenever payments which should have been made under: this
Program in accordance with this provision have been made under any ache-
Program, the Plan shall have the right, exercisable alone and in its sole
discretion, to pay over to any Program making such other_ payments any amounts
it shall determine to be warranted in order to satisfy the intent of this
provision, and amounts so paid shall be considered benefits paid under
this Program and, to the extent of such payments, the Plan shall be fully
discharged from liability under this Program.
SMT,,7B/22
-35-
PART V!I Continued
C. Coordination o-f Rene-HtE;
6. Right of r"-'r"C"'er",
V,11-enever Pa%7-1cntS for covered c-,,-,r-,,7ices have !Deeci male by
17,ixi-�-�un ariour�t Of -pa,vrent
this Blue Cross Pi-:al,, :;aidpa%r ents
;. - ic- interit of thl.-S to \"1"07,
necessaly to satisf:- "'��paid, the Plan shall 1-aVc the to recover such (--xc..3ssive - - is E-Cvl
t s ',��re 173,30, Or
any I�K--rsons to, Or for, wid, rcs,�O-ct '-0 -)n!-- -tions or pers(
from any Insurance Ca-1-c a n-Y Or any OtL�1-,�'r 0 1:('
-36-
PART' VIII CONVERSION PRIVILEGE
If the Subscriber ceases to be employed or connected with the Group
through which he or she has been covered under this Agreement, or if a
Family Member ceases to be eligible according to the criteria outlined in
Part I.E, coverage shall terminate automatically witrout notice at the
end of the period for which Subscription Charges have been paid. If.,
however, Subscription Charges have been paid through the Group for at
least one (1) month, and the Subscriber or Family Member, as the case may
be, wishes to maintain continuous coverage, application must be made to
the Blue Cross Plan within thirty (30) days of the date on which coverage
terminates.
Upon receipt by the Plan of such application and the required
Subscription Charges within such thirty (30) day period, a certificate
will be issued which shall be of the type and class of direct payment
certificate then being generally issued by the Plan.
However, should the subscriber remain in the employ of the Group
and elect to terminate coverage under this Agreement, neither the Sub-
scriber nor any of his Family Members will be entitled to apply for such
certificate.
-37-
PART IX TERMINATION OF COVFHRAGE AND CF�I7�E; LAi�IO�� OF TiiF A�1T�IEirI
A. Termination of Member's Coverage While Agreement Remains in Effect:
Coverage of any Member under this Agrea,ient shall terminate auto-
matically upon termination of his or her eligia)ili ty to participate i.ux;er the
Agreement. The follaeing benefit provisions shall apply with respect to the
Member's termination:
1. Hospitalization
Should a Member be confined in a I-R)spital, Skilled Nursing
Facility or Alcoholism 'Treatment Facility and entitled to services and bene-
fits provided in Part VI on ti;e termination date of his or her coverage, such
services and benefits shall continue until the Member (i) is discharged from
the hospital, Skilled Nursing Facility or Alceholian Treatment Facility, (ii)
no longer requires such care or (iii) has been provided with maximum benefits
hereunder, ulAchever occurs first.
2. Supplemental Accident Benefit
Should a Member be receiving benefits under the Supplemental
Accident Benefit outlined in Part VI on the termination date of his or her
coverage, such benefits shall continue (i) three months from tine date of the
accident or (ii) until exhaustion of the benefits available, whichever occurs
first.
3. Total Disability
In the event the Member is totally disabled at date of termi-
nation, see Part VI, Major Medical. Benefit.
-38-
PART IX TMMINATION OF COVERAGE AND CANCELLATION Or rME AGREINENT . . . Continued
B. Termination of Coverage While Subscriber Remains with Group
If the Subscriber: or the Croup ceases to pay the Subscription
Charges of this Agreement while such Subscriber remains employed or connected
with the Group, the individual coverage of such Subscriber, including cover-
age of Family Members, shall terminate automatically and shall be of no
further force and effect. The provisions of paragraph A.3 above and the
Group Conversion privilege specified in Part VIII will not apply in this
case.
C. Cancellation of the Agreement.
Coverage of any Member under this Agreement shall terminate auto-
matically upon cancellation of the Agreement. The terminal benefits speci-
fied in paragraph A.3 above and the Group Conversion privilege specified in
Part VIII will not be available to Members covered under this Agreement at
the time of cancellation.
-39-
PAR L X k.,
A. SUBROSATIOIl - To the extent of any amot:nts paid by this Blue Cross
Plan to or for a Member on account of services made necessary by an injury
to or condition of his or tier person, it shall be subrogat.ed to his or her
rights against any third party liable for the injury or condition. The Plan
shall, however, not be obligated to pay for such services unless and until
the Member, or someone legally qualified and authorized to act for him or her,
prccmises in writing to:
1. include those amounts in any claim he or she makes against a
third party for the injury or condition;
2. repay the Plan those amounts to the extent that the proceeds of
the Member's recovery fran a settlement with a third party by reason of such
an injury or condition exceed his or her ao1 portion of the total loss, pro-
rating any attorneys' fees incurred in the recovery; and
3. cooperate fully with the Plan in asserting its rights under
this Contract, to supply us with any and all information and execute any and
all instruments we reasonably need for that purpose.
B. RIGHT TO RECEIVE AND RELEASE NECESS.- Y INFOR14ATION --- Wien a Member
applies for benefits under this Contract, he or she authorizes health care
providers to release to us information and records alout services that have
been given. Also, the Member authorizes any person, organization or insurance
company to furnish to or to obtain from us any information regarding his or
her benefits. If a Member does not authorize access to his or her records,
benefits will not be provided.
C. TRANSFER OF BENEFITS; ASSIGNMENT, CA.RNISHMENr AND A=hCE MFNT - A11
rights to benefits under this Agreement are personal and available only to the
Member. They may not be transferred to anyone else.
No benefits or other rights arising in favor of the Member under
this Agreement are assignable or subject to garnishment or attachment by
creditors. This Plan is not obligated by any attempted or purported assignment,
garnishment or attachment. In paying under this Agreement for services or
supplies to a member, the Plan may, at its option, remit.funds to the Ma_mber,
the provider of the services or supplies, the Group, other carrier, or jointly
to any of these. Remittance as aforesaid in rood faith shall discharge the
Plan's obligation to the extent of the remittance amount so that it will riot
be liable to anyone aggrieved by its selection of payee.
D. CHANCES TO AGREEMENT - No agent of the Blue Cross Plan is autho-
rized to change the form or content of this Agreement in any mariner other
than by Endorsement issued to form a part hereof and over the signature of
an officer of this Blue Cross Plan.
E. EVIDENCE OF MEDICAL NECESSITY - The Blue Cross Plan shall be enti-
tled to require that there be submitted by or on behalf of any Member receiv-
ing benefits under this Agreement, a certificate of medical necessity fraa
such persons or organizations as it may deem apprcpr_iate in a manner arks at
such time satisfactory to the Plan. No Member stall be entitled to the con-
tinuation of any benefit whatsoever under this Agreement unless, if requested,
such certificate has been provided and, subject to review by a medical review
board, substantiates the medical necessity for continued care. Such certif-
icate shall not be requested by the Plan more frequently than at ten (10) day
intervals.
SMAI B/2 2
-4 0-
PART X GENERAL PROVI S IONS . Continued
F. HOSPITALS-INDEPENDENT COI?rQACIIIWS -a The hospitals furnishing Hospi-
tal Care or other benefits to the Muiber do so as independent contractors with
,the Blue Cross Plan, and the Plan shall not be linable for any claim or demand
on account of damages arising out of or in any manner connected with any in-
juries suffered by the Member while receiving care in any hospital.
G. CON1RACT LIABILITY - The full extent of liability under this Agreement
and benefits conferred hereunder including recovery under any claim of breach,
shall be 1 imi ted to the actual cost of hospital and medical services as pro-
vided herein and shall specifically exclude any claim for general damages
including alleged "pain, suffering or mental anguish."
H. TERMINATICN OF AQZEEIIENT --• This Blue Cross Plan reserves the right
to terminate this Agree;iient at any time the Group through which the Subscriber
is enrolled fails to meet the Group enrol.Lme.nt require-orients of the Plan.
I. TIME LIMIT ON FILING CLAIMS — This Blue Cross Plan shall not be
required to furnish any benefits under this Agreement unless request for such
benefits is made within ninety (90) days after crrmmencertent of the service
giving rise to the benefits or within thirty (30) days after such services
cease, whichever is later, unless it is not reasonably possible to make such
request within such time limitation, but in no event shall benefits be allowed
if notice of claims is made beyond one (1) year fran the date on which ex-
penses were incurred.
6\ben services are rendered by a person or organization having a con-
tract with the Blue Cross Plan to provide such service, the requirement of
notice shall be waived.
J. VENUE — Any and all suits or legal proceedings of any kind whatso-
ever, as may be brought against this Blue Cross Plan by a Member, or brought
by anyone claiming any right against the Plan as deriving frcm or through a
Member's rights under this Agreement, must be filed within fifteen (15)
months of the date that the service giving rise to such suit or legal pro-
ceedings was rendered or within fifteen (15) months of the date this Blue
Crass Plan denies in uniting rights claimed under this Agreement. I\b suits
or legal proceedings to enforce a Member's rights under this Agreement shall
be brought anywhere except in the State of Washington or a State in which
the Member resides or is employed.
Any and all suits or legal proceedings brought by this Blue Cross
Plan against a Member shall be filed within tl:e appropriate statutory period
of limitation and in all such suits or legal prcceediixls venue may lie, at
the option of the Plan, in King County, State of Washington, provided how-
ever, that where the suit or legal proceeding is brolx;ht against a Member who
is a resident of the State of Alaska, it must be filed in the Third Judicial
District, Anchorage, State of Alaska.
-41-
PART X GENERAL PAOVISIONS . . . Continued
K. EPIDEMICS-PLIBLIC DISASTERS - The services provided under this
Agreement are at all times subject to the availability of hospital fac
ties and the ability of hospitals, hospital employees, physicians and
surgeons, ar-O other providers, to furnish such services. The Blue Cross Plan
shall assume no liability for epidemic, public disaster, or other conditions
beyond its control which make it impossible for, the services provided by this
Agreement to be obtained.
L. AGREEMENT MUST BE EFFECTIVE - Except as specifically provided for
in Part %7IK .4 and Part IX, this Agreement must be in effect at the time
services are rendered to the Member.
M. NOTICE - Any notice required of this Blue Cross Plan hereunder shall
be deemed to be sufficient if mailed to the Subscriber or to the Group,
as the Plan may elect, at the address appearing on the records of the Plan;
and, if required of the Subscriber, if mailed to the principal office of this
Blue Cross Plan in Seattle, aashington.
N. VESTED RIGHTS - Except as specifically provided in Part VI. K .4 and
Part IX, this Agreement confers no rights which continue beyond the date
of termination, and consequently, no rights conferred by this Agreement shall,
in any way, be deemed vested. No Member subject to such termination shall
be entitled to any benefits or payments conferred by this Agreement for
any services, treatrent, medical attention or care rendered after the date
of termination.
O. RIGHT OF RECOVERY -- This Plan will have the right, upon demand, to
recover overpayments or payments obtained through fraud, error, mistake, or
payments made in excess of the maximum amount necessary to satisfy the intent
of the Coordination of Benefits provision in Part VII, C, made to other
insurers, any service plans, any other organization, or on behalf of a Member
or someone who is not eligible to receive benefits. If reimbursement is not
made, such over.-payments or payments will be deducted froze future claims.
P. DENTIST CHARGES - Any payment required of the Blue Cross Plan under
this Agreement may, at the discretion of the Plan, be made to the Dentist
furnishing the service or to the Subscriber, or to the Dentist and the Subscriber
jointly.
Q. 0ONrI1\RATION OF SUBSCRIPTION CHARGES IN THE EVENT OF LABOR DISPUTE -
In the event that a Subscriber's compensation or wage is suspended or terni-
nated by the group as a result of a strike, lockout, or other labor dispute,
the Subscriber may pay the subscription charges, subject to the terms of
Part IV, directly to the Plan for a period not exceeding six months frcm the
date of such suspension or termination. Fhren ti-.e Subscriber's compensation
or wage is so suspended or terminated, the Subscriber shall be notified
immediately by the Group, in writing, by mail addressed to the address last
on record with the Grasp, that the Subscriber may pay subscription charges
to the Plan as they are due as provided in this section. If at the end of
said six-month period the benefits of this Agreement are no longer available,
the Subscriber shall be entitled to transfer to Group Conversion coverage,
subject to the terms of Part VIII of this Agreement.
-42-
SMA5A/2 4
SCF`F 'Jj I :,T_GIB! CITY
All permanent full tires erployees vx)rki_ng a mcini.m).un of. twenty (20) ho�zrs a. week
will be eligible to enroll and t-eccxne covered on the date of hires.
Eligible dependents' coverage will become effective on the same date as the
enployee's coverage providing proper application has been made. Eligible dependents
are the employee's spouse and un-narri ed children from birth to twenty-three (23)
years of age.
Newly acquired dependents of an eligible employe, nast be enrolled within thirty
(30) days of acquisition. Coverage for such dependents will c ormerce on the
first billing date following acquisition or in the case of a newborn, from the
date of birth.
Eligible employees and dependents who are not enrolled when first eligible
may be enrolled at any later date only if full subscription charges are paid
from the first date of eligibility.
In the event the enployer_ grants an approved leave of absence to an enrolled
employee, coverage througli the Group may be continued for a period not to
exceed ninety (90) days. The er�?lcyer agrees to notify the Plan on the regular
monthly billing as to the employee's date of departure on leave and will sulxmit
the monthly payment with the regular Group remittance.
The Group will promptly delete any employee or dependent who ceases to meet
the above eligibility requirements and will so notify the Plan on a timely
basis.
ENDORSEMENT TEN
The Agreement between CITY OF KENT which �� effective
and BLUE C iS OF VaSjiINC-Ia1 AND ALASKA, amended-
The
1, 19"73 is hereby
The purpose of thi:3 Endorsement is to add the definition of Participating
Dentist to the Agr�-ement and outline the method of payment which these
dentists have agreed to accept.
1. part I, Definitions, is hereby amended by the addition of the
following:
"Participating Dentist" is a dentist who, at the time services
are rendered, has an agreement in effect with this Blue Cross Plan to furnish
dental services to Members."
2. part I, Definitions, is further a*nc'-nded by changing the last
sentence of the definition of "Usual, Customary and Reasonable" to read:
"Except for the charges of a Participating Dentist, charges or fees
in excess of the usual, custcniary and reasonable charges or fees as determined
by the Plan shall be the responsibility of the Member."
3. The AgrEement is hereby amended by the addition of the following
General Provision:
"Conditions Under Which. Benefits Are Payable
1. Participating Dentist
The Subscriber will be responsible to the Participating Dentist
for the difference, if any, between the amount payable by the Plan and the
usual, custcmary and reasonable charges. The Subscriber will rot be responsible
for charges in excess of the usual, custcmary and reasonable fee.
2. Non-Participating Dentist
The Subscriber will be responsible to the non-participating
Dentist for the difference, if any, between the amount payable by the Plan
and one hundred percent (100%) of the non-participating Dentist's charges.,,
4. The General Provision Section of the Agreement is further amended
by the addition of the following:
"Dental Charges - Any payment for dental services required of the
Blue Cross plan and this Agreement may, at the discretion of the Plan, be
made to the Dentist furnishing the service, or to the Subscriber or to the
Dentist and the Subscriber jointly."
MA828-ED10
EbWRSEt= TEN Contl ued
5. The Exclusions, Exceptions and Limitations section of the
Preement is hereby amended by the addition of the following exclusion:
"Any charges or fees of a provider which are in excess of the
'usual, custcanary -and reasonable charges or fees. (See Part I, Definitions.) "
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is July 1, 1981.
BLUE CROSS OF WA.SHIJX=z AND ALASKA CITY OF KENT
;By By
,}Joseph E. Hunt Title:
Senior Vice President
of External Affairs
Date �jiG,( c.�t.�.'
i '!
By
Title:
MA828-ED10 -2.-
2 81979
RICHA D L. VANS SP `
CO PANY, C.
1
� Y
1510 PLAZA 600 SEATTLE, WA. 98101
622-6937
September 26, 1979
Mr. Dick Cushing
City of Kent
P.O. Box 310
Kent, Washington 98031
Dear Dick:
RE: Blue Cross Group #00828
Enclosed are two copies of Endorsement #7 to the Blue Cross
Agreement held by your firm.
Please retain one copy for your files. The other copy should
be signed and returned to:
Jack Littlemore
Blue Cross of Washington & Alaska
P.O. Box 327
Seattle, Washington 98111
If you have any questions, please give us a call.
With kindest regards,
Sincerely,
Richard L. Evans, C.L.U.
ift
Enclosures
C0NSi71;PANTS
PENSION/PROFIT SHARING PLANS • ESTATE/BUSINESS PLANS
f
R
RICHAI, ,D IAEVANS ,( �
COMPANY, INC.
1510 PLAZA 600 � SEATTLE, WA. 98101
622 6937
[larch 9, 1979
Y
Mr. Gerald M. Winkle,
Finance & Personnel z
CITY OF KENT
P.O. Box 310 '
Kent, Washington 98031
Dear Jerry:
As you are aware, expenses for maternity must be covered in the same
manner as expenses for any other medical condition, effective April 30,
1979.
Blue Cross is proposing that this benefit be added to all their groups
on April 30th with a rate change on May 1 , 1979. This benefit would
include coverage of all employees and dependents.
The following are the rates necessary for this benefit:
Employee
Employee + Spouse Employee
Employee + Spouse + Child(ren) + Child(ren)
$ .32 $3.50 $3.82 $ .64
Please let me know if you have any questions regarding this proposed
benefit change.
In addition, I am enclosing Policy Amendment No. 6 from the Standard
Insurance Company which supersedes Amendment No 5 stating that a person
is eligible for insurance if he has established eligibility under
Washington Law Enforcement Officers and Firefighters' Retirement
System, Plan I . Please sign the original and one copy, retain the
original and return the copy to Standard Insurance Company at:
United Airlines Building, Suite 990
6th & Virginia Street
Seattle, Washington 98101
With kindest regards,
Sincerely,
Richard L. Evans, C.L.U.
P,LE:ift
Enclosures (2)
PFNSION i Pr?r lF:,T -Oh'I71r.;:_. n•,-
l �? RICHA L. k�7
ANS
RECEIVED
CO aNY,
1
1510 PLAZA 600 SEATTLE, WA. 98101
622-6937
January 10, 1979
+i
I
Mr. Jerry Winkle
Finance & Personnel Director
City of Kent
Kent, Washington 98031
Dear Jerry:
Enclosed are two copies of Endorsement Six to the Master Contract
for your Blue Cross contract. As you and I mentioned, some of
the Uniformed rates were changed by 1� at the request of Pat Henderson
and it would be greatly appreciated if you would sign both copies and
return the one marked in red directly to Jack Littlemore, Account
Executive, at 15700 Dayton Avenue North/P.O. Box 327, Seattle,
Washington 98111.
I certainly appreciated having lunch with you late in December and
hope we can do it again soon.
With kindest regards,
Sincerely,
Richard L. Evans, C.L.U.
RLE:co
Enclosure
PENSION PROFIT SHARING PLANS • ESTATE/BUSINESS PLANS
.ICI-TAT,D !-,. EVANS
CO--hPANY, �,NC.
1510 PLAZA 600 SFATTLE, WA. 98101
622-6937
February 27, 1978
Mr. Gerald Winkle
Finance & Personnel
CITY OF KENT ^ �'
P.O. Box 310
Kent, Washington 98031 /
Dear Jerry:
Enclosed are two copies of Endorsement 5 to the Master Agreement held
through Blue Cross. Would you please sign the Endorsement in the
proper place, keep one copy, and return one copy to:
Jack Littlemore, Account Executive
Blue Cross of Washington
P.O. Box 327
Seattle, Washington 98111 .
I would like to explain that there is a slight change in our Account
Executive, since Mr. Records was doing absolutely nothing on your
account nor much on any of the other accounts that he was assigned to
us to service for those firms and businesses over 100 lives. He finally
screwed the whole thing up approximately a. week ago on a Public Utility
District and, at that time, we asked for his removel from all of our
accounts which Blue Cross quickly did do.
Mr. Jack Littlemore is a long time Blue Cross employee, having been
with them over 15 years. He worked his way up through the Underwriting
Department and will be an excellent addition to our accounts since he
can better assist us in the rate making area since he served in that
area previously.
If you have any questions, please don't hesitate to call or write.
With kindest regards,
S-ncerely, ,
Richard L. Evans, C.L.U.
RLE:id
Enclosures
CITY CLERK
1975
ENDORSEMENT ONE R E M Y E D
The Agreement between CITY OF KENT and BLUE CROSS, WASHINGTON-
ALASKA INC. , which became effective on December 1, 1973, is hereby
amended.
The purpose of this Endorsement is to expand the definition of physician
and surgeon to include Chiropractor, to present new Subscription Charges,
to modify Conditions Under Which Hospital Care Will Be Furnished and to
modify General Provisions pertaining to subrogation and venue.
1. Part I, Definitions, paragraph F, page 3, is hereby amended to read
as follows:
"F. A "physician and surgeon" means only one who is licensed to practice
medicine and surgery (M. D. ), osteopathy and surgery (D. O.), podiatry
(D. P. M. ) or Chiropractor (D. C. ).
In the event that a dentist (D. D. S. or D. M. D. ) performs oral surgical
services (operative and cutting procedures for the treatment of disease
and injury and the treatment of fractures and dislocations) and such
services would have been covered if performed by a physician and
surgeon (M. D. or D. O. ), then such services shall be covered when
performed by a dentist.
Benefits will not be provided for general dental services such as
extractions, (including full mouth extractions), prosthesis, orthodontia,
operative restorations, fillings, medical or surgical treatment of dental
caries or gingivitis. "
2. Part IV, Subscription Charges and Schedule of Periodic Payments, paragraph
A, page 5, is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in advance, the
following Subscription Charges:
Employee:
Non-Uniformed . . . . . . . . . . $29. 48
Uniformed . . . . . . . . . . . . . 37. 99
Retired or Disabled Uniformed 43. 09
Dependent:
Spouse . . . . . . . . . . . . . . .$20. 74
Spouse and Children) . . . . . . . 34. 39
Child(ren) . . . . . . . . . . . . 13. 65
for a period of one (1) month from and after December 1, 1974,
and from month to month thereafter unless modified as herein
provided. "
MA828-ED 1
ENDORSEMENT ONE . . . Continued
3. Part V, Conditions Under Which Hospital Care Will Be Furnished, page
6, is hereby modified to read as follows:
"A. Hospital Care Within the Service Area
1, Hospital Care will be provided to the extent medically necessary
for disabilities arising froni illness or injury, or for obstetrical
care, only while suc'_i Member is necessarily confined as a
registered bed patient in a Participating Hospital and only when
admission to the hospital was subsequent to the effective date
of covereage hereunder,
2. If a Member receives inpatient or outpatient- care in a non-participat
hospital for a covered condition that is life-endangering, occurs
suddenly and unexpectedly and requires immediate medical
attention, the Blue Cross Plan will pay eighty percent (80%0)
of the hospital's usual, customary and reasonable charge
for services covered by this Agreement.
3. If a Member receives inpatient or outpatient care in a
non-participating hospital that is not for a condition that is
life-endangering, occurs suddenly and unexpectedly and requires
immediate medical attention, benefits of this Agreement will
not apply,
B. Hospital Care Outside the Service Area
In case of accidental injury or illness requiring hospitalization
in any Licensed General Hospital in areas other than that served by
this Blue Cross Plan, the Member shall be entitled to benefits
.as indicated in paragraph 1 or 2 below (with the days of care
provided under either paragraph being counted against the total
number of days of care available under this Agreement). Such
hospital care shall be provided only to the extent medically
necessary while the Member is a registered bed patient under the
care ,of a physician and surgeon, and only when admission to the
hospital was subsequent to the effective date of covereage hereunder.
1. If covered inpatient services are provided in a Member Hospital
of another Blue Cross Plan, benefits will be provided through the
Inter-Plan Service Benefit Bank (a reciprocal service arrangement
between Blue Cross Plans); or
2. If covered services are provided in a non-member Licensed
General Hospital or in the outpatient department of a Member
Hospital, benefits will be provided in accordance with the
provisions entitled "Hospital Care" as herein defined under
!) Part VI. A and B. "
i
f '
i
i
ENDORSEMENT ONE . . . Continued
4. Part VII, Limitations, page 33, is hereby amended by the addition of
the following paragraph 12:
12. Services or procedures which are not customary and accepted by
the medical profession generally, and services or procedures which
are experimental or for the purpose of research. "
5. Part X, General Provisions, paragraph A, page 39 is hereby modified
to read as follows:
A. In the event that this Blue Cross Play: provides benefits for any
condition or injury for which a third party is liable, the Plan shall
be subrogated to the rights of the individual entitled to the benefits
of this Agreerent to the extent of any benefits that the Plan shall
pay or be liable for. In the event that any claim or action is made
or instituted by the individual entitled to the benefits of this
Agreement on account of such third-party liability, the amount
which the Blue Cross Plan pays or may be liable for shall be
included in any such claim or action. Any sums collected by or on
behalf of the Member or the Member's estate by legal action or
settlement, as a result of an incident for which benefits are provided,
shall be payable to the Blue Cross Plan, When attorneys' fees
and legal expenses have been actually incurred by the Member or
the Member's estate to recover sums which benefit both the Mernber
and the Blue Cross Plan, whether incurred in an action for damages
or otherwise, there shall be a pro rata apportionment of such
attorneys fees and legal expenses directly and solely attributable
to the collection of such suns as are payable to the Blue Cross
Plan. The individual covered under this Agreement shall fully
cooperate with the Plan and shall take such action, furnish such
information and assistance, and shall execute such assignments and
other instrurnents as the Plan may request in order to facilitate
enforcement of the rights of the Plan hereunder, and shall take
no action which prejudices the rights and interests of the Plan
hereunder. "
6. Part X, General Provisions, paragraph K, page 40, regarding venue,
is amended to extend the period in which any and all suits or legal
proceedings of any kind must be filed from twelve (12) to fifteen (15)
months of the date that the service was rendered.
-3-
ENDORSEMENT ONE . . . Continued
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is December 1,
1974.
BLUE CROSS, WASHINGTON-
ALASKA INC. CITY OF KENT
BY By
George ay and Title:
Vice P esid nt - arketingL,rc
J
Date 40jele By
Title:
-4-
I ��
I
ENDORSEMENT NINt
The Agreement between CITY OF KENT and BLUE CROSS OF WASHINGTION AND ALASKA,
which became effective December 1, 1973, is hereby amended.
The purpose of this Endorsement is to present new Subscription Charges,
delete terminal maternity, amend an existing dental Limitation, and add
the orthognathic surgery benefit.
1. Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A. , page 5, is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in
advance, the following Subscription Charges:
EMPLOYEE EMPLOYEE EMPLOYEE, EMPLOYEE &
& SPOUSE SPOUSE & CHILD(REN)
CHILD(REN)
Non-Uniformed $51.76 $ 90.76 $114.91 $75.91
Uniformed $66.58 $105.58 $129.73 $90.73
Retired Disabled $75.47 $114.47 $138.62 $99.62
for a period of twelve (12) months from and after January 1, 1981, and
from month to month thereafter unless modified as herein provided."
2. Part VI, J. , Major Medical Benefit, paragraph 4.b. , page 31,
is hereby deleted in its entirety.
3. Part VI, J. , Major Medical Benefit, paragraph 4.c. , page 31,
is hereby amended with the deletion of the reference to 4.b.
4. Part vI, I. , Dental Benefits, Limitations, paragraph 4.b. ,
page 24, is hereby amended to read as follows:
"b. Dental services for congenital malformations (except for
M ambers continuously covered by this Plan from birth) , dental services
primarily for cosmetic or esthetic purposes, or for dental implants."
r1A828-ED9
ENMRSEMENT NINE . . . Continued
City of Kent
5. Part VII, Limitations, page 33, paragraph A.18. , as amended
in Endorsement Eight, is hereby further amended to read as follows:
1118. Services, supplies or treatment for cosmetic, plastic
or reconstructive purposes and complications thereof, unless they are
required to treat Injuries received in an accident or for correction
of functional disorders. This includes, but is not limited to:
a. a surgery for sagging skin of the eyelids
(blepharochalasis) , face (meloplasty or rhytidectomy) , neck or abdcrnen;
b. breast or hip enlargement or reduction procedures;
C. reshaping of the nose (rhinoplasty) ."
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1981.
BLUE CROSS OF WASHINGMN AND ALASKA CITY OF KENT
B
Gi?"a y c�
, hn M. Hopkins Ti le:
Vice President - Marketing b, Av-j cz;&t
Date BY- —
Title:
eLEAbN EXECUTE AND 1jI';'1'UHN THIS COPY 'ru
BLUE CROSS. WASHINGTON-ALASKA INC.
MA828-ED9 -2-
ENDORSEMENT EIGHT
The Agreement between CITY OF KENT and BLUE CROSS OF WASHINGTON
AND ALASKA, which became effective December 1 , 1973 , is hereby
amended.
The purpose of this Endorsement is to add the definition of
Medically Necessary/Medical Necessity , present new Subscrip-
tion Charges and clarify the existing exclusion relating to
cosmetic surgery.
1. Part I , Definitions , is hereby amended with the
addition of the following paragraph :
"Medically Necessary/Medical Necessity" means indis-
pensable in the sense that , in the reasonable opinion of this
Plan, an illness , injury or condition harmful or threatening
to the patient ' s life or health , or a direct effect of such ,
could not have been diagnosed or relieved without the medical
service or supply in question. The mere fact that it was furn-
ished, prescribed or approved by a physician or other qualified
provider does not in itself mean that it was medically necessary.
A medical service or supply may be medically necessary in part
only.
2 . Part IV , Subscription Charges and Schedule of Periodic
Payments , paragraph A. , page 5 , is hereby amended to read as
follows :
"A. The Group shall pay to the Blue Cross Plan monthly,
in advance the following Subscription Charges .
Employee Employee Employee , Employee
9 Spouse Spouse 9 8 Child ren)
Child(ren)
Non-Unifomed $51 . 66 $ 90 . 56 $114 . 01 $75 . 71
Uniformed $66 . 48 $105 . 38 $129 . 43 $90 . 53
Retired Disabled $75 . 37 $114 . 27 $138 . 32 $99 . 42
for a period of twelve (12) months from and after January 1 ,
1980 and from month to month thereafter unless modified as
herein provided. "
3 . Part VII , Limitations , A. 7 . , page 33 , is amended to
read as follows :
"7 . Treatment for obesity , including surgery and
complications thereof. "
4. Part VII , Limitations , page 33 , is further amended
with the addition of A. 18 . , which reads as follows :
MA828-ED8
ENDORSEMENT EIGHT . . . Continued
1118 . Services , supplies or treatment for cosmetic,
plastic or reconstructive purposes and complications thereof,
unless they are required to treat injuies received in an
accident . This includes , but is not limited to:
a. a surgery for sagging skin of the eyelids
(blepharochalasis ) , face (.meloplasty or rhytidectomy) , neck or
abdomen;
b. breast or hip enlargement or reduction
procedures ;
C. reshaping of the nose (rhinoplasty) ;
d. upper or lower jaw augmentation or reduction
procedures (orthognathic surgery) ; and
e . treatment for conditions relating to teeth
or to the jaw or gums supporting the teeth, if these conditions :
(1) exist at or from birth (.congenital
anomalies ) , except in the case of an infant covered on this
Agreement from birth , or
anomalies ) . " (2 ) arise after birth (developmental
All other provisions of this Agreement remain unchanged except
as specifically provided herein. The effective date of this
Endorsement is January 1 , 1980 .
BLUE CROSS OF WASHINGTON CITY OF KENT
AND ALASKA
By B
d.. y
J it M. Hopkins Title :
Vice President - Marketing
Date /Lc�:� ! !NO By
-- Title :
MA828-ED8 -2-
ENDORSEMENT SEVEN
The Agreement between CITY OF = and BLUE CROSS OF VQASHIDUf,0N AND ALASKA,
which became effective December 1, 1973, is hereby amended.
The purpose of this Endorsement is to present new Subscription Charges,
include maternity as any other condition for all Members and amend the
leave of absence.
1. Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A. , page 5, is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in advance,
the following Subscription Charges:
Employee Employee Employee, Employee
& Spouse Spouse & & Child(ren)
Child(ren)
Nor-Uniformed $ 59.72 $104.69 $132.50 $ 87.53
Uniformed $ 76.86 $121.83 $149.64 $104.67
Retired Disabled $ 87.13 $132.10 $159.91 $114.94
for a period of twelve (12) months from and after May 1,: 1979 and from month
to month thereafter unless modified as herein provided."
2. Effective for deliveries or other pregnancy terminations on or after
April 29, 1979, the full benefits of this Agreement will be available to all
Members without the requirement that conception occur while covered on this
Agreement. The dollar limits applicable to maternity benefits will no longer
apply. Hospital infant nursery care will be provided for the newborn child
while the mother is hospitalized.
3. The separate $800.00 deductible amount required for Major Medical
maternity benefits will no longer apply. Any amounts paid by the Member on or
after April 29, 1979 shall apply toward her regular Major Medical deductible
amount for the calendar year. When this deductible is satisfied, she will be
covered for maternity benefits at the same co-insurance as other conditions.
4. Any exclusions or limitations in this Agreement relating to pregnancy
will not apply on or after April 29, 1979.
5. The Member must transfer without lapse of coverage to Group Conversion
or another individual program with this Blue Cross Plan when she leaves the
Group in order to be eligible for the basic maternity benefits of this program
for a pregnancy existing while she is covered hereunder.
MA828-ED7
Emopsa= SEVEN Continued
6. The reference in the Schedule of Eligibility to a sixty (60) day
approved leave of absence, is hereby changed to ninety (90) days.
7. Dependent daughters are eligible for maternity benefits on the same
basis outlined in paragraphs 2 through 5 above.
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date for paragraphs 2 through 7 is April 29, 1979
and paragraph 1 is effective May 1, 1979.
BLUE CROSS OF WASHING ON AND ALASKA CITY OF KENT
y
By
L
By
John M. Hopkins Title:
Vice President - Marketing
Date ����� �� 1�1� By Title:
-2-
ENDORSEMENT SIX
The Agreement between CITY OF KENT and BLUE CROSS OF WASHINGI'ON AND
ALASKA, which became effective December 1, 1973, is hereby amended.
Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A. , page 5, is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in advance,
the following Subscription Charges:
Employee Employee Employee, Employee
& Spouse Spouse & & Children)
Child(ren)
Non-Uniformed $ 59.40 $101.19 $128.68 $ 86.89
Uniformed $ 76.54 $118.33 $145.82 $104.03
Retired Disabled $ 86.81 $128.60 $156.09 $114.30
for a period of twelve (12) months from and after January 1, 1979 and from
month to month thereafter unless modified as herein provided."
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1979.
BLUE CROSS OF WASHINCI'ON AND ALASKA CITY OF KENT
B � By
X T og
John M. Hopkins Title: Isabe K.
Vice President - Marketing Mayor
Date By
Title:
MA828-ED6
i
ENDORSElIP-417 FIVE
The Agreement between CITY OF = and BLUE CROSS, WAS=GTON-ALASKA INC. ,
which became effective December 1, 1973, is hereby amended.
1. Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A. page 5, is hereby amended as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in
advance, the following Subscription Charges:
Employee Employee Employee Employee &
& Spouse Spouse & Child(ren)
Child(ren)
Nan-Uniformed $ 52.94 $ 90.19 $114.69 $ 77.44
Uniformed $ 68.22 $105.47 $129.97 $ 92.72
Retired Disabled $ 77.37 $114.62 $139.12 $101.87
for a period of twelve(12) months from and after January 1, 1973 and from month
to month thereafter unless modified as herein provided."
2. Part VII, Limitations, page 33, .is hereby amended to read as
follows:
"1 7. Treatment in an institution designed primarily to provide
a change in environment or a controlled environment (milieu therapy) ."
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1978.
MUE =S, WASHIN=-ALASKA INC. CITY OF1T
r,
John M. Hopkins itle:
Vice President - Marketing
Date `� ri C c�c� -2 �� ���� By4itie:
MA828-ED5
ENDORSEMENT FOUR
The Agreement between CITY OF KENT and BLUE CROSS, WASHINGTON-ALASKA
INC., which became effective December 1, 1973, is hereby amended.
Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A, page 5, is hereby amended as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in
advance, the following Subscription Charges:
Employee:
Non-Uniformed . . . . . . . . . $47.91
Uniformed . . . . . . . . . . . $61.74
Retired or Disabled Uniformed $70.02
Dependent:
Spouse. . . . . . . . $33.71
Spouse $ Child(ren) . . . . . . $55.88
Child(ren) . . . . . . . . . . . $22.18
for a period of twelve (12) months from and after January 1, 1977
and from month to month thereafter unless modified as herein provided.
If during the twelve (12) month period following January 1,
1977, the incurred claims plus retention exceed the total Subscription
Charges set forth above, the Group shall pay to the Blue Cross Plan
an amount not to exceed the amount that would have been paid had the
monthly Subscription Charges during this period have been:
Employee:
Non-Uniformed . . . . . . . . . $50.71
Uniformed . . . . . . . . . . . $65.35
Retired or Disabled Uniformed $74.11
Dependent:
Spouse. . . . . . . . . . . . . $35.68
Spouse & Child(ren) . . . . . . $59.15
Child(ren) . . . . . . . . . . . $23.47
MA828-ED4
ENDORSEMENT FOUR . . . Continued
The Blue Cross Plan shall bill the Group for such additional
Subscription Charges as soon as practical after January 1, 1978, and
the Group shall remit the amount of such charges within sixty (60)
days after the date of such billing."
All other provisions of the Agreement remain unchanged except as
specifically provided herein. The effective date of this Endorsement
is January 1, 1977.
BLUE CROSS, WASHINGTON-ALASKA INC. CITY OF KENT
J
By. By
George o Title:
Senior ce resident
Marketing and Community Relations
1 �
Date 477 By
�� Title: �_
ENDORSEMENT THREE
The Agreement between CITY OF KENT and BLUE CROSS, WASHINGTON-ALASKA INC. ,
which became effective December 1, 1973, is hereby amended.
The purpose of this Endorsement is to present new Subscription Charges and
to add Alcoholism Treatment Facility Benefit.
1. Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A, page 5, is hereby amended to read as follows :
"A. The Group shall pay to the Blue Cross Plan monthly, in advance,
the following Subscription Charges:
Employee:
Non-Uniformed $36.85
Uniformed 62.78
Retired or Disabled Uniformed 53.86
Dependent:
Spouse $25.93
Spouse and Child(ren) 42.99
Children) 17.06
for a period of twelve (12) months from and after January 1,
1976, and from month to month thereafter unless modified as
herein provided."
2. Part VI, Benefits, page 31, is hereby amended by the addition of the
following paragraph K:
"K. Alcoholism Treatment Facility Benefit
1. Definitions
An "Approved Alcoholism Treatment Facility" means an
institution which has been approved as an Alcoholism Treatment
Facility by the State of Washington in accordance with RCW
70.96A.020(2) or as a facility primarily engaged in the
treatment of alcoholism and licensed or approved as such by
the State in which the facility is located.
2. Benefits
a. The Plan shall provide or pay for the services or an
approved Alcoholism Treatment Facility in• accordance
MA828-ED3
ENDORSEMENT THREE . . . Continued
with the provisions of this paragraph 2, when admission
to such institution occurs on or after the Member's
effective date of coverage and services provided are
furnished and billed by such institution. Each day of
care shall be charged as one day of Hospital Care against
the maximum benefit period as specified in Part VI.A.2
of this Agreement.
b. When intensive alcoholism treatment services are
.rendered to a Member in or by an Approved Alcoholism
Treatment Facility with which this Blue Cross Plan does
not have an agreement, the Plan shall pay eighty percent
(80%) of the usual, customary and reasonable charges for
the treatment received, up to one thousand dollars
($1,000) in any calendar year.
C. If the Member is confined in a Participating Hospital,
whether or not it is an Approved Alcoholism Treatment
Facility, he or she shall be entitled to the benefits
provided under Part VI .A of this Agreement."
3. Part VII, Limitations, page 33, is hereby amended by the addition of the
following paragraphs:
1113. X-ray, laboratory, and pathological services, and machine
diagnostic tests not related to a specific illness or injury
or a definitive set of symptoms.
14. Services or supplies related to sex transformations or sexual
misfunctions or inadequacies.
15. Services or supplies not medically necessary for treatment of
disease, illness or injury.
16. Visual analysis, therapy, or training relating to muscular
imbalance of the eye; orthoptics."
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is January 1, 1976.
BLUE CROSS, WASHINGTON-ALASKA INC. CITY OF KENT
By By
George R s' nd
Vice Pr den - Marketingl' ti:��
Date 64 wa a,Z. �lG 71 BY
—�'�`—" Title:
-2-
ENDORSEMENT TWO
The Agreement between CITY OF KENT and BLUE CROSS, WASHINGTON-ALASKA INC. ,
which became effective on December 1, 1973, is hereby amended.
The purpose of this Endorsement is to present new Subscription Charges and
a plan to pay such charges plus any additional expenses for incurred claims
and retention which may accrue up to the maximum amount specified herein.
Part IV, Subscription Charges and Schedule of Periodic Payments,
paragraph A, page 5, is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in advance,
the following Subscription Charges:
1. For the Dental Benefit described in Part VI.I, page 20:
Employee:
Non-Uniformed. . . . . . . . . . . $ 7. 17
Uniformed. . . . . . . . . . . . . 9.29
Retired or Disabled Uniformed . . . 10.55
Dependent:
Spouse . . . . . . . . . . . . . $ 4. 12
Spouse and Child(ren) . . . . . . 7.91
Child(ren) . . . . . . . . . . . 3.79
for a period of one (1) month from and after December 1, 1974
and from month to month thereafter unless modified as herein
provided.
2. For all benefits described in Part VI except the Dental
Benefit:
Employee:
Non-Uniformed . . . . . . . . . . . $22.31
Uniformed . . . . . . . . . . . . . 28.70
Retired or Disabled Uniformed . . . 32.54
Dependent:
Spouse . . . . . . . . . . . . . . . $16.62
Spouse and Child(ren) . . . . . . . 26.48
Children) . . . . . . . . . . . . 9.86
MA828-ED2
ENDORSEMENT TWO . . . Continued
for a period of thirteen (13) months from and after December. 1,
1974 and from month to month thereafter unless modified as
herein provided."
3. If during the seven (7) month period, June 1 through December
31, 1975, the incurred claims plus retention exceed an amount
produced by the Subscription Charges set forth in paragraph A.2
above, the Group shall pay to the Plan such excess, but in
no event more than the amount that would have been paid had the
monthly Subscription Charges for all benefits except the Dental
Benefit during this period been:
Employee:
Non-Uniformed . . . . . . . . . . . . . .$27.32
Uniformed . . . . . . . . . . . . . . . . 35. 15
Retired or Disabled Uniformed . . . . . . 39.85
Dependent:
Spouse . . . . . . . . . . $20.36
Spouse and Child(ren) . . . . . . . . . 32.44
Children . . . . . . . . . . . . . . . . 12.08
The Plan shall bill the Group for such loss as soon as practical
after December 31, 1975, and the Group shall remit the amount
of such loss within sixty (60) days after the date of such
billing.
This Endorsement is effective December 1, 1974 and supersedes item 2 of Endorse-
ment One. All other provisions of the Agreement remain unchanged except as
specifically provided herein.
BLUE CROSS, WASHINGTON-ALASKA INC. CITY OF KENT
.f
BY By
George Ti
on Title;i Vice Pe - Marketing6 1
r
Date BY
Title:
-2-
ENDORSEMENT ONE
The Agreement between CITY OF KENT and BLUE CROSS, WASHINGTON-
ALASKA INC. , which became effective on December 1, 1973, is hereby
amended.
The purpose of this Endorsement is to expand the definition of physician
and surgeon to include Chiropractor, to present new Subscription Charges,
to modify Conditions Under Which Hospital Care Will Be Furnished and to
modify General Provisions pertaining to subrogation and venue.
1. Part I, Definitions, paragraph F, page 3, is hereby amended to read
as follows:
"F. A "physician and surgeon" means only one who is licensed to practice
medicine and surgery (M. D. ), osteopathy and surgery (D. O.), podiatry
(D. P. M. ) or Chiropractor (D. C. ).
In the event that a dentist (D, D. S. or D. M. D. ) performs oral surgical
services (operative and cutting procedures for the treatment of disease
and injury and the treatment of fractures and dislocations) and such
services would have been covered if performed by a physician and
surgeon (M. D. or D. O. ), then such services shall be covered when
performed by a dentist.
Benefits will not be provided for general dental services such as
extractions, (including full mouth extractions), prosthesis, orthodontia,
operative restorations, fillings, medical or surgical treatment of dental
caries or gingivitis. "
2. Part IV, Subscription Charges and Schedule of Periodic Payments, paragraph
A, page 5, is hereby amended to read as follows:
"A. The Group shall pay to the Blue Cross Plan monthly, in advance, the
following Subscription Charges:
Employee:
Non-Uniformed . . . . . . . . . . $29. 48
Uniformed . . . . . . . . . . . . . 37. 99
Retired or Disabled Uniformed . 43. 09
Dependent:
Spouse . . . . . . . . . . . . . . .$20. 74
Spouse and Child(ren) . . . . . . . 34. 39
Child(ren) . . . . . . . . . . . . . 13. 65
for a period of one (1) month from and after December 1, 1974,
and from month to month thereafter unless modified as herein
provided. "
MA828-ED 1
ENDORSEMENT ONE . . . Continued
3, Part V, Conditions Under Which Hospital Care Will Be Furnished, page
6, is hereby modified to read as follows:
"A. Hospital Care Within the Service Area
1. Hospital Care will be provided to the extent medically necessary
for disabilities arising from illness or injury, or for obstetriQal
care, only while such Member is necessarily confined as a
registered bed patient in a Participating Hospital and only when
admission to the hospital was subsequent to the effective date
of covereage hereunder.
2. If a Member receives inpatient or outpatient care in a non-participatinsi
hospital for a covered condition that is life-endangering, occurs
suddenly and unexpectedly and requires immediate medical
attention, the Blue Cross Plan will pay eighty percent (80/o)
of the hospital's usual, customary and reasonable charge
for services covered by this Agreement,
3, If a Member receives inpatient or outpatient care in a
non-participating hospital that is not for a condition that is
life-endangering, occurs suddenly and unexpectedly and requires
immediate medical attention, benefits of this Agreement will
not apply,
B. Hospital Care Outside the Service Area
In case of accidental injury or illness requiring hospitalization
in any Licensed General Hospital in areas other than that served bv_
this Blue Cross Plan, the Member shall be entitled to benefits
.as indicated in paragraph 1 or 2 below (with the days of care
provided under either paragraph being counted against the total
number of days of care available under this Agreement). Such
hospital care shall be provided only to the extent medically
necessary while the Member is a registered bed patient under the
care.of a physician and surgeon, and only when admission to the
hospital was subsequent to the effective date of covereage hereunder.
1. If covered inpatient services are provided in a Member Hospital
of another Blue Cross Plan, benefits will be provided through the
Inter-Plan Service Benefit Bank (a reciprocal service arrangement
between Blue Cross Plans); or
2. If covered services are provided in a non-member Licensed
General Hospital or in the outpatient department of a Member
Hospital, benefits will be provided in accordance with the
provisions entitled ''Hospital Care" as herein defined under
Part VI. A and B. "
-2-
ENDORSEMENT ONE Continued
4. Part VII, Limitations, page 33, is hereby amended by the addition of
the following paragraph 12:
12. Services or procedures which are not customary and accepted by
the medical profession generally, and services or procedures which
are experimental or for the purpose of research. "
5. Part X, General Provisions, paragraph A, page 39 is hereby modified
to read as follows:
A. In the event that this Blue Cross Plan provides benefits for any
condition or injury for which a third party is liable, the Plan shall
be subrogated to the rights of the individual entitled to the benefits
of this Agreement to the extent of any benefits that the Plan shall
pay or be liable for. In the event that any claim or action is made
or instituted by the individual entitled to the benefits of this
Agreement on account of such third-party liability, the amount
which the Blue Cross Plan pays or may be liable for shall be
included in any such claim or action. Any sums collected by or on
behalf of the Member or the Member's estate by legal action or
settlement, as a result of an incident for which benefits are provided,
shall be payable to the Blue Cross Plan. When attorneys' fees
and legal expenses have been actually incurred by the Member or
the Member's estate to recover sums which benefit both the Member
and the Blue Cross Plan, whether incurred in an action for damages
or otherwise, there shall be a pro rates apportionment of such
attorneys.fees and legal expenses directly and solely attributable
to the collection of such sums as are payable to the Blue Cross
Plan. The individual covered under this Agreement shall fully
cooperate with the Plan and shall take such action, furnish such
information and assistance, and shall execute such assignments and
other instruments as the Plan may request in order to facilitate
enforcement of the rights of the Plan hereunder, and shall take
no action which prejudices the rights and interests of the Plan
hereunder. "
6. Part X, General Provisions, paragraph K, page 40, regarding venue,
is amended to extend the period in which any and all suits or legal
proceedings of any kind must be filed from twelve (12) to fifteen (15)
months of the date that the service was rendered.
-3-
ENDORSEMENT ONE . . . Continued
All other provisions of the Agreement remain unchanged except as specifically
provided herein. The effective date of this Endorsement is December 1,
1974.
BLUE CROSS, WASHINGTON-
ALASKA INC. CITY OF KENT
ByZ By 1
eorge ay and Title:
Vice P esid nt - arketing
Date x .
Title.
i
-4-
BLUE CROSS, ti!'1vi lVV x vW.1 iJASi.f♦ INC.
(herein called the Blue Cross Plan or tho Plan)
601- L'roadr:ay
P.O. Iox 327
Seattle, 11ashington 98111
APPLICATION
for
GROUP HOSPITAL SERVICE
AND PROFESSIONAL BENEFIT AGREEiNLI NT
Application is hereby made to this Blue Cross Plan for a Group Hospital Service
and Professional Benefit Agreement .in the form attached hereto, the provisions
of which are to be made available to all eligible classes of Employees as
defined in the attached Schedule of Eligibility.
The Applicant, in the event this Application is accepted and the Group Hospital
Service and Professional Benefit Agreement is issued, agrees to the methods and
practices outlined in the Agreement relative to submission of monthly Subscription
Charges and information as may be rcqu:i."rci for the Plan to adequately administer
its obligations .
Coverage under the Agreement shall be effective at 12:01 a.m. , Standard Time, on
the first day of 7 at tt Dc�ce3n �E:r , 19 13 , �;.� 5c;a��l.e,
"UsHyngLuH and Such coverage shall continue until terminated in accordance with
the Agreement.
The Applicant agrees to deliver to its covered Employees, individual Identifica-
tion Cards and descriptive booklets furnished by the Blue Cross Plan . "Ile
Applicant agrees to receive, on behalf of its covered Employees, all notices
delivered by the Plan and to forward such notices to such Employees.
The Applicant agrees at all times to forward to this Blue Cross Plan written
notice of termination a minimum of thirty days in advance of such termination.
Applicant's
Address CITY OF KF,NT
P. O. Box 310 (Applicant)
220 South 4th Avenue J+
Kent. Washington 98031
BY lf , 5�
By _
Title:
MAR 0 71974
(Date) Title:
MA828
� r i
BLUE CROSS, WASHINGTON-ALASKA INC.
(A Non-Profit Health Care Corporation approved as
a Blue Cross Plan, herein called the Blue Cross Plan
or the Plan)
In consideration of the Application made by
CITY OF KENT
(herein called the Group)
a copy of which is attached hereto and made part of this Agreement , and
in consideration of payments to be made b)r the Group of the Subscription
Charges as herein provided.
T1IE BLUE CROSS PLAN HEREBY AGREES TO PROVIDE
the benefits hnrnin described for the _four_te_cn__ 14 ____ month period
commencing at 12:01 a.m. , Standard Time, at Seattle, Washington on
_ December 1,_ 1973 , and from month to month thereafter, un-
less this Agreement: is modified or terminated as provided herein. The
Subscription Charges shall be due and payable by the Group in advance
of the effective date of this Agreement and thereafter as provided
herein. This Agreement is, issued and delivered in the State of
Washington __ and is governed by the laws thereof and is subject to
the terms and conditions recited on the subsequent pages hereof, which
are a part of this Agreement, as if recited over the signature hereto
affixed.
IN WITNESS I'MEREOF, this Blue Cross la 1 has caused this Agreement to
be signed this _�/ '* day of 19 .
r
Georg-e rRVxY i and
Vice Pesi cnt -,. Marketing
PART I DEFINITIONS
A. ' A "Subscriber" or "Employee" is the individual ,those application has been
accepted by this Blue Cross Plan and in whose name the Identification Card is
issued.
B. An eligible "Family Member." or "Dependent" is the Subscriber's spouse or
any child of either or both under twenty--three (23) years of age if unmarried
and dependent within tale meaning of tie Internal Revenue. Code of the United
States and listed on the application completed by the Subscriber, except that
eligibility may be continued for any unmarried child enrolled under this
Agreement vho attains age twenty-threo (23) and :is incapable of self-sustaining
employment by reason of mental retardation or l-hysic:al handicap and is chiefly
dependent upon the Subscriber for support and maintenance. Proof of such
incapacity and dependency gust be furnished to the Plan by the Subscriber within
thirty-one (31) days of the child's attainment of age twenty-three (23) and
periodically thereafter as the Plan may require. Upon notice by the Subscriber,
Family Members may be added under this Agreement a.s they become eligible in
accordance with the regulations of the Dian.
Family Members shall cease to be covered under the following circumstances:
1. A child who ceases to meet the eligibility requirements set forth above
applicable to such children.
2. A spouse upon entry of decree of divorce.
3. A covered spouse and/or children upon the death of the Subscriber.
Coverage will terminate on the first monthly anniversary of the Subscriber's
effective date following a change in status .
In order to maintain continuous coverage, the spouse or child must apply to the
Blue Cross Plan within dirty (30) days of the date on i,-Bich coverage terminates .
Upon receipt by the Plan of such application and tile, required subscription
charges within such thirty (30) day period, a certificate will be issued which
shall be of the type and class of direct payment certificate then being generally
issued by this Blue Cross Plan.
C. A "Member" is a Subscriber or eligible Family Member.
D. A "Licensed General hospital" is an institution operated in accordance with
the laws of the jurisidiction in which it is located pertaining to institutions
identified as General fIospitals and which, for compollsation from its patients
and on an inpatient basis , is primarily engaged in provi_d:ing diagnostic and
therapeutic facilities for surgical and medical. diagnosis, treatment and care of
injured and sick persons by or underr the supervisi.on of a staff of licensed
physicians and surgeons , and which cunt-i_nuously provides twenty-four (24) hours
a day nursing services by registered professional nurses.
_2_
PART I DEN,NITIONS . . Continued
It shall specifically exclude any instit:uti.on which :is prima.r:i.ly a place of nest,
a place for the aged, a place for drug addicts or alcoholics, a place primarily
for treatment of tuberculosis or dental cond_i_tiors, a nursing home, a convales-
cent home, or a facility operated by the Federal or State Government or any
agency thereof.
F. A ''Participating hospital" is a Licensed Genera-1 hospital or other institu-
tion which, at .the time of admission to such hospital under the terms of this
Agreement, has a contract in effect with the Elio Cross Plan to furnish hospital
care to Members, and has been accepted and approved by the Blue Cross Board of
Directors . A list of Participating hospitals is available on request, such list
being subject to change at the option of the plan .
F. A "physician and surgeon" means only one who is licensed to practice
medicine and surgery (M.D.) or osteopathy and surgery P.O.) or podiatry (D.P.M.) .
In the event that a dentist (D.D.S. or U.M.D. ) performs oral surgical services
(operative and cutting procedures for the treatment of disease and injury and the
treatment of fractures and dislocations) and such services would have been
covered if performed by a physician and surpcon (M.D. or D .O.) , then such serv-
ices shall be covered when performed by a dentist .
G. The "effective date" is the date on which the Member's coverage becomes
effective under this Agreement. This date is established by and appears on the
records of the Plan.
H. "Agreement" means this Agreement between the Group and this Blue Cross Plan
and shall include any attached Indorsements or Riders, and the notices of
election (application cards) of the Subscribers indicating their participation
in the coverage provided hereunder.
I. "Medicare" means the program established by Title I of .Public Law 89-97
(79 Statutes 286-343) , which Title I contains a new 'Title XVIII of the Social
Security Act which is cited as the Health Insurance For Ilse Aged Act.
-3-
PART II TERMS OF ENROLLMENT
Ever), Subscriber within the classifications set forth in the attached Schedule
of Eligibility shall be eligible for coverage. for himself and his Family Nicmbers
in accordance with the provisions of the Schedule of Eligibility.
PART III RECORDS
The Group shall mainta-in a record of Subscribers included for coverage here-
under, containing for each Subscriber and his Family Alembers, if any, such
information as the Blue Cross Plan may require :in connection with the
administration of the Agreement . Such records shall be open for inspection
by the Plan at any reasonable time .
-4-
PART IV SUBSCRIPTION CHARGES AND
SCHEDULE OF PERIODIC PAYINEWS
A. The Group shall pay to the Blue Cross Plan monthly, in advance, the
following Subscription Charges :
Employee: /
Non-Uniformed . . . . . . . . . . . $28. 93
Uniformed. . . . . . . . . . . . . . 37. 44
Retired or Disabled Uniformed 42. 54
Dependent:
Spouse $20. 39
Spouse and Children) . . . . . . . . 33 79
Children) . . . . . . . . . . . . . . 13, 40
for a period of fourteen 14 months from and after the date this
Agreement is effective arrd r!�mOnth to month thereafter unless modified as
herein provided.
B. The amount of said monthly Subscription Charges may be changed by
the Plan, provided, however, that the Plan shall notify the Group of any change
at least thirty (30) days in advance of the date the change :is to be effoc-ri.ve.
Payments of the reViS(-d 5,71)S(-rii,t4_nn Ch r�nc s'.
change. i�,us �t
i- acceptance Of �..c
C. Upon failure to pay the Subscription Charges on behalf of any Member,
the rights of the IMember under this a.grecnient shall be terminated until said
Member shall have been reinstated pursuant to the provisions of eligibility as
defined in the Schedule Of ,Eligibility attached.
It is provided, however, that such termination shall not affect the right to
Hospital Care or surgical-medical benefits provided hereunder in connection
with a hospital stay that has commenced prior to such termination.
In the event the Member is totally disablod at date of termination, see
Part VI ,J 4, a.
A grace period of ten (10) days, however, is allowed to the Group for payr!rent
of any periodic payment. In the event the Agreement terminates for any reason,
the Group shall be liable for any Subscription Chargcs due the Plan for any
time this Agreement is in force during a grace period.
-5-
PART V CONDITIONS UNDER WHICH HOSPITAL CARE
WILL BE FUltNISIIi:D
A. Hospital Care will be provided to the extent medically necessary for
disabilities arising from illness or injury, or for obstetrical care, only
while the Member is uncler the care of a physician and surgeon and only while
such Member is necessarily confined as a registered bed -patient in a Partici-
pating Hospital and only when admission to the hospital was subsequent to the
effective date of coverage Iiercunder.
B. In case of accidental injury or illness requiring hospitalization in
any Licensed General hospital in areas other thLji that served by this Blue
Cross Plan, the Member shall be entitled to bcnefi.ts as indicated in paragraph 1
or 2 below (With the days of care provided under either part graph being counted
against the total nu)nber of days of care av«-i1 .bJe under this Agreement)
1. If covered inpatient services are provided in a Member Hospital
of another Blue Cross flan, bcncfits will be provided through
the Inter-Plan Service 13; ne-Ci t 1>,ink (a reciprocal service
arrangement between Blue Cross Plans) ; or
2. If covered services are provided i-n a non-member Licensed
General Ilospi-Uil or in the out.p,it i cnt department of a Member
Hospital , benefits %•:i_l l he provi.cic`d in accordance 1;,ith the
pr0,'1 ; `-' 'i _� +''� rc:�' as iiE 1'C .ui dC -Llned.
J.�Q�tJ eil�l�.ll.l.! li\/.:J li.l ttl J. L<1
PART VI BENEFITS
A. Hospital Care - Inpatio nt
1. The Blue Cross Plan shall furnish to each Member, subject to
the limitations of paragraph 2 below, the following items of Hospital Care:
a. Daily Hospital Service in a room of two (2) or more beds .
If a private room is occupied, the hospital's most prevalent charge for
accommodations of a room of two (2) beds w:i.11 be allowed against the charge
for the private room; any charge above this allOwance shall be paid by the
Member. When a Member :is confined in a hospital having private room accommo-
dations only, the Plan shall determine the amount eligible expense to be
allowed hereunder.
Use of an intensive care unit (includes coronary and constant care units .
Services in an :intensive care unit include nursing services provided by
hospital employees as a regular hospital service . In no event will benefits
be provided for any other room accommodations "reserved" for the Member
during the period that the Member is confined in an intensive care unit.
b. Use of operating, recovery, delivery, isolation, cystos-
copic and cast rooms .
C. Anesthetic supplies and use of hospital anesthetic
equipment . Administration of anesthesia when administered by a hospital
employee as a regular hospital service.
d. Casts, splints, and surgical dressings .
e. X-ray and radium therapy.
f. Oxygen. and all drugs and medicines listed and accepted
in the "United States Pharmacopeia," ",National Formulary" or the "Now and
Non-Official Remedies" as published by the American Medical Association, at
the time hospitalization is rendered and which are prescribed and used during
the furnishing of hospital care.
g. Administration of blood and blood derivatives, but not
including the cost of blood and blood derivatives .
-7-
PART VI BENEFITS . . . Continued
A. Hospital Care - Inpatient Continued
h. The follo�"ing se.rvi.ccs only r;hen furnished and billed by
the hospital. in connection with all illness or a-ccidcent requiring bed care and
treatment, necessitating these services for treatment of the condition:
Laboratory Examinations h
Electrocardiograms
X-Ray Examinations
Physiotherapy and Hydrotherapy
* These services shall be considered inpatient: services
if rendered in the oui.pat .ent department of a hospital
Within twenty-four (24) hours of admission to such
hospital , provided such tests arc related to the
condition for which the Ner,iber is admitted.
2. The foregoing Hospital Services shall, be furnished to each
Member up to an aggregate of 365 days Tor eaach hospital confinement,
provided however, that, days of ccare s1�a-11 not exceed an aggrcgat 0 of 120
each calendar year for nervous end 1;���ntal ci�r,_di. ri_ons; alcoholism or drug
addiction. Successive lospital canf_iner;eiits sh 111 be deemed to be cont:inuoUs
and to coiis}'l1_7)t(? a Si ' 10 }1pc1,iYa1 rnn (iT1C'l.".C:;.` l i OSeS Ci �14
b
if discharge from and readmission to a hospital shall occur within a ninety
(90) day period; provided, however,
a. that any subsequent coil f I'll en,cnt sahere the Subscriber is
the patient shall be considered as a now period of confinement if acceptable
evidence is furnished to the Plan that tho Subscriber shall have returned to
active titork on a full.-time basis following his previous confinement .
b. should readmission to ,! hospital be required as a result
of accidental injury occurring during the ninot:y (90) day period referred to
above, such reachnission shall constitute a nc;a confinement .
-8-
PART VI BENEFITS . . . Continued
A. Hospital Care - - Inpatient: . . . Continued
3. The term "obstetrical care" as used herein means Hospital Care
furnished for conditions arising from childbirth delivery or any conditions
arising from pregnancy during the period of pregnancy and within forty-five
(45) days following termination of pregnancy, excepting ectopi.c pregnancy.
This Blue Cross Plan shall furnish obstetrical care only to the Subscriber or
spouse providing pregnancy has its inception white she is covered hereunder
and providing further that, from inception of pr.cnaancy, she has been continu-
ously enrolled until date of delivery. Pregnancy is considered to have
commi,enced nine (9) months before its termination, unless a different commence-
ment date is established by the Plan based upon is physician and surgeon 's
written statement to the Plan.
Obstetrical care will he furnished for each pregnancy, including infant
nursery care, not to exceed the hospitol 's actual charges, as follows :
a. For other than Cesarean Section.: The Plan will pay up
to a maximum of t; 250. 00
b. For Cesarean Section : The Plan will pay up to a maximum
of $ 400. 00
4. For infants born on 'or after the Subscriber's effective date
of coverage, all benefits specified in this Agroomcnt will be available from
date of birth when necessary treatment results from prematurity, illness,
injury, congenital defects or neonatal emergencies .
- 9-
PART VI BENEFITS . . . Continued
B. Hospital Care - - Outpatient
1 . The Blue Cross Plan shall furnish to the I•Ieiribor the services
listed in paragraphs b through h of Part VI .A.1 above, :in the outpatient
department of a Participating hospital. during (i) first: treatment for
accidental injury and (ii) the twenty four (2.4) Hour period following such
first treatment for accidental injury. All such treatment must be rendered
within seven (7) days after the occurrence of such injury and be performed
in connection with such injury.
2. The Member shall be entitled to the services listed in
paragraphs b through b of Part VI .A.1 above, furnished in the outpatient
department of a Participating hospital in connection with (i) surgical
treatment requiring the use of operating room facilities and (ii) X-ray and
radium therapy treatments .
3. The P•hanber shall be entitled to the services listed in
paragraphs b through h of Part VI .A.1_ above, furnished in connection with a
life-endangering illness that occurs suddenly and unexpectedly and requires
inm)ediate medical attention. Such medical em rgencies include heart attacks,
cardio-vascular accidents, poisonings, loss of consciousness oy respiration,
convulsions and such other acute cond-i.t _ois as nmy be datermi7iej to be
medical emergencies by the Plan.
10-
PART -VI BENEFITS . . . Continued
C. Extended Care Facility Benefit
I. Definitions
a. "Participating Extended Care Facility" means a facility
iahich, at the time of admission to such facility under the terms of this
Agreement, has an agency agreement in effect with the Blue Cross Plan to
furnish certain services to Members, and has been accepted and approved by
the Blue Cross Board of Directors . A list of Participating Extended Care
Facilities is available on request, such last being subject to change at theoption of the Plan.
b . "Extended Care" is an extension of certain hospital
services to be provided within either the hospital organization or in another
type of health care facility. Such service must include direct medical
supervision of the treatment provided each patient and must include nursing
service under the supervision of a Registered Nurse, plus other therapeutic
services . This service is designed to serve the patient i,:lio no longer needs
the comprehensive service of the acute facility, yet who is not at a point
in his illness or disability tehich t�ould allot hi.,.1 co return hope or be cared
for in a facility offering lesser services.
2 . Benefits
a. When receiving Extended Care in a Participating Extended
Care Facility, the Plan shall furnish to each ;,icmber the following items of
Extended Care for confi.nen.ents conu;c:acing on or• after the Member's effective
date of coverage under this Agreement:
(1) Extended care in a room of two or more beds .
(2) The cost of items a through f below consistent with
and related to the admitting diaTnosi_s, when pr.cscribed by the attending
physician and when ordinarily furnished and billed by a Participating Extended
Care Facility.
(a) Use of special treatment rooms .
(b) Routine laboratory examinations .
(c) Physical. , occupational or speech therapy
treat,_-ients .
(d) Oxygen and other gas therapy.
- 11-
PART VI BENEFITS Continued
C. Extended Care Facility Benefit Continued
(e) Drugs, biologicals and solutions used while
the Member is in such facility,
(f) Gauze, cotton, fabrics, solutions, plaster
and other materials used in dressings and casts .
b, Each day of care in a Participating Extended Care Facility
will be charged as one day of Hospital Care against the maximum benefit period
as specified in this Agreement .
C. In case of accidental injury or :illness requiring confine-
ment in an Extended Care Facility in areas other than that served by this Blue
Cross Plan, the Member will be entitled to the benefits provided .hereunder. .
3. General Limitations
In addition to the Limitations of Part VII, benefits will not
be provided hereunder when care received by the Hember:
a. consists Principally of custodial or domiciliary care, or
b, Consists y"n"Pa l ly Or care for C(?Tl> deterioration; for
mental deficiency or mental retardation; or for mental illness .
- lz-
PART VI BENEFITS . . . Continued
D. ' Professional Medical Benefits
1. Upon receipt of due notice and proof that the Member has
incurred expense for the following services rendered by a physician and surgeon
in connection with an illness or injury, the Blue Cross Plan will pay for such
services up to the usual , customary and reasonable charge or fee for such
services in the conv,unity in which the services are rendered. -
For the purpose of this Agreement, the Plan will take into
consideration the following criteria in determining what constitutes a usual ,
customary and reasonable charge or fee:
The usual charge or fee which the provider of service
most frequently charges to the majority of his patients or customers for a
similar service or medical. procedure;
The charges or fees which fall within the customary range
of charges or fees in a locality for the performance of a similar service or
medical procedure;
Unusual circumstances or complications requiring additional
time, skill and experience in connection with a particular service or procedure.
The determination of the actual amount payable for any given
service or supply is within the sole discretion of this Blue Cross Plan.
Charges or fees in excess of the usual , customary and reasonable charge or fee
as determined by the Plan shall be the responsibility of the Member.
a. Professional services of a physician and surgeon for surgical
services (operative and cutting procedures for the treatment of disease and
injury, and the treatment of fractures and dislocations) and services of
assistant surgeon for major surgery.
b. Physician's hospital visits (limited to one visit per day)
while a Member receives hospital services and benefits hereunder as a regis-
tered bed patient and for each visit by a physician (limited to one visit per day)
when the Member is confined to a Participating Extended Care Facility and is
eligible for extended care. Such medical benefits will not be payable during
confinement preceding or following any surgical operation or treatment of any
injury or condition for which benefits are provided under paragraph l .a above,
nor will they be provided for pregnancy or any condition resulting therefrom.
- 13-
PART VI BENEFITS . . . Continued
D. Professional Medical Benefits . . . Continued
C. Professional services of a physician anesthesiologist when
the Member is confined in a hospital and is eligible for Hospital Care and
surgical benefits. Such nccdical benefits haill not be payable when such services
are rendered by the operating surgeon or when anesthesia is administered by a
hospital employee, No benefits r,,ill be provided during hospitalization for
normal delivery.
d. Professional consultation services (opinion or advice
provided in the evaluation and/or treatment of a patient's illness) rend.cred by
a physician and surgeon during the period the }";ember" is conf:i_llod in a hospital
and eligible for hospital Care. Such services hust be requcsted by the attending
physician and surgeon.
e. Professional services of a physician and surgeon for
radiotherapy treatments.
f. Surgical-obstetrical Benefits will be available only to the
Subscriber or spouse pra;acting pregnancy tins its inccpt:ion while she is covered
hereunder a.nd providing further th-t-, ftorh inception. of pregnanccy, slrc has been
continuously enrolled until datc of del:ivory. Pre "'n<ncy is C.urhsidered to have
cOIlmenced Dille months before its teluihinatIon, unless a dlfferont coin'--,nCer[erlt
date is established by the Plan based upon a phy:,:lcian and surgeon's l:ritterl
statement to the Plan.
2. The professional services listed <�bovc must. be rendered to the
Hember on or after iris of fcctive date of coven 1e ',Hider this Agreemn',mt, or, in
the event the Member is hospitalized on such eff ec.i:ive date, such services must
be rendered subsequen-c to the date of d.ischzhx•ge frojil the. hospital.
- 14-
PART VI BENEFITS Continued
E. Outpatient Medical Benefit
When a Member is treated by a physician and surgeon in the outpatient
department of a Participating hospital and is entitled to benefits under
Part VI. B.3, the Blue Cross Plan will pay for expenses incurred up to the usual ,
customary, and reasonable fee for all treatment rendered by the attending physi-
cian and surgeon in connection with each medical emergency. No benefits will be
provided for treatment for which benefits are provided under Part VI.D above .
- 15-
PART VI BENEFITS . . . Continued
K Diagnostic X-Ray and Laboratory Benefits
In non-hospitalized cases, the Blue Cross Plan will pay for
expenses incurred by the Member for diagnostic X-ray and laboratory examina-
tions ordered by a physician and surgeon for treatment of illness or injury
as follows :
1. For each accident, up to $ 100. 00
2, For illness , up to an aggregate of $ 100. 00 in any
calendar year.
In addition to the Limitations of Part VII , no diagnostic X-Ray and Laboratory
Benefits will be provided for conditions arising from pregnancy, dental or eye
examinations and treatments, mental or nervous conditions, or for routine
physical examinations .
- 1b-
PART VI BENEFITS . . . Continued
G. Ambulance Benefits
Blue Cross will pay expenses incurred by the Member for licensed
ambulance transportation to a hospital, up to an aggregate of $50. 00 _
for each accident or for each hospital confinement. No ambulance benefits
shall be provided for any condition arising from pregnancy.
- 17-
7
PART VI .BENEFITS Continued
H. Supplemental Accident Benefit
1. The Blue Cross Plan will pay to or for the account of the
Member who requires care as a result of an accident, the usual , customary and
reasonable fee or charge for the following services up to a total of $300 .00
for each accident in addition to the benefits provided in this Agreement :
a. Services furnished and billed by a Licensed General
Hospital , except as follows :
(1) Services of a personal. nature, such as charges for
radio, telephone, guest trays and the like .
(2) Private room charges exceeding the hospital 's most
prevalent charge for accommodations in a room of two (2) or more beds . When
a Member is confined in a hospital having private room accommnodations only,
the Plan shall determine the amount of eligibic expense to be allowed
hereunder.
b. Medical or surgical care by a physician and surgeon.
C. Necessary laboratory and X-ray examinations .
n t-- ,,At P -r;
- �'�' 1�.b-�.VJ-11�a 1/1 V l .J J1 VIliAr nur sc for as 1lJll�,'
as the attending physician and surgeon will cerLify such services to be
medically necessary.
e. Professional services rendered by a physician and surgeon
or doctor of dental surgery for treatment of a fractured jaw, or other
accidental injury to natural, teeth provided that the injury occurs while the
patient is covered hereunder.
f. Anesthetic supplies and administration of anesthesia
by an anesthetist.
g. Services of a physician and surgeon, or a registered
physical therapist, in connection with physical therapy treatments, other
than one who ordinarily resides in the Subscriber's home or who is related
to the Subscriber by blood or marriage.
h. Services of a licensed ambulance company for local
ambulance service to or from a hospital.
i . Drugs or medicines directly related to the treatment of
an injury and requiring a written prescription and dispensed by a licensed
pharmacist or physician and surgeon.
- i8-
PART VI BENEFITS . . . Continued
H. Supplemental Accident Benefit . . . Continued
j . Artificial. limbs or eyes, casts, splints, trusses,
braces, crutches and other similar appliances , and also the rental of a
wheel chair, hospital-type bed, iron lung or other similar mechanical
equipment required for treatment . The Plan may, at its option, purchase
such mechanical equipment for the Member_ , in lieu of rental . These supplies
will be limited to those reasonably required by standard treatment practices
as a result of injury occurring while the Mci-kor is covered hereunder.
k. Blood transfusions, including cost of blood and blood
derivatives, to the extent that such blood and blood derivatives are not
replaced by voluntary donors .
2. In addition to the Limitations of Part VII, no benefits will
be provided under this Supplemental Accident Benefit for:
a. Any services or supplies other than those specifically
set forth above .
b. Benefits payable under other provisions of this Agreement .
C. Care for any injury arising out of the Member's occupation .
d. Expenses for treatment received more than ninety (90)
days after date of accident.
e. Any injury sustained prior to the Member's effective date
of coverage hereunder.
f. Disease or infection (except infection occurring as a
result of an accidental cut or wound) .
g. Dentistry, except as specifically provided in paragraph
l.e above; eye refractions or the fitting of eye glasses; food poisoning or
intentionally self-inflicted injuries .
h . The cost of blood and blood derivatives to the extent that
such blood and blood derivatives are replaced by voluntary donors .
Termination of a Member's participation under this Agreement
shall not invalidate or reduce any claim under this Supplemental Accident
Benefit in connection with an accident that occurred prior to such termination.
- 19
PART VI BENEFITS . . . Continued
I. Dental Benefit
1 . Definitions
a. "Dentist" means any dentist duly licensed
to practice his profession.
b. "Dental Services" means those dental. services for i%hich
benefits are provided under Part VI I of this Agreement.
C. "Benefit Year" as used in this Agreement means that 12-
month period following the effective date of coverage of a Member hereunder
and each 12-month period thereafter.
2 . Benefits
Subject to the limitations, exclusions and other terms and
conditions of this Agreement, not inconsistent hereieith, benefits to the
extent hereinafter set fort!) shall be. provided to Members for the services
set forth below when rendercd by a 1)enti_st !,.Bile the 1,11ember is covered
hereunder.
a. Basic benefits consisting of:
.(1) Oral Examination.
(2) Periapical and bitei•aing X-rays as required.
(3) Topical fluoride application .
(4) Prophylaxis, including c1_caning, scaling and polishing.
(S) Repair of dentures and bridges .
(6) Palliative emergency treatment.
(7) Fillings consisting of silver a.nialgam, silicate and
plastic restorations . For other types of 1:i11=ir?gs, such as gold, the allowance
will. be limited to what would otherwise have been allowed for an analgam
restoration.
(8) Extractions .
(9) Endodontics, including; pulpotomy, pulp capping and
root canal treatment.
(10) Space Maintainers .
-20-
PART VI BENEFITS Continued
• Dental Benefit Continued
(11) Oral surgery consisting of fracture and dislocation
treatment, diagnosis and treatment of cyst and abscess .
(12) Apicoectomy.
(13) Periodontic services consisting of surgical perio-
dontic examination, gingival curettage, gingive.cLomy and gingivoplasty,
osseus surgery including flap entry and closure, mucogingivoplastic surgery,
management of acute infection and oral lesions.
b . Prosthetic Services, if the ?Member is covered under this
Agreement when these Dental Services are actually rendered, consisting of:
(1) Inlays .
(2) Croirns .
(3) Bridges, fixed and removable .
(4) Dentures, full and partial except that (a) benefits
for full denture replacement shall not be provided for (i) any denture
replacement made less than five years after a deiIture pl.acei;ient or replacement
whether covered or not under this Agreement, or (ii) any dent-,_3rc 1eplace,,,,-IIt
made necessary by reason of the loss or theft of a. denture, and (b) if, in the
construction of a denture, the Member acid the Dentist decide on personalized
restoration or to employ special techniques as opposed to standard procedures,
the benefits provided under this Agreement sliai.l be limited to the standard
procedures for prosthetic services .
C. The dental benefits available under this Part VI I
will be provided prior to any dental benefits which may be available under
other provisions of this Agreement.
-21 -
PART VI BENEFITS . . . Continued
I. Dental Benefit Continued
3. Amount of Benefits Payable
Subject to the provisions concerning amounts payable by the
Blue Cross Plan as hereinafter set forth in paragraph b below, benefits
provided under this Agreement for Dental Services shall be as follows, but
not to exceed an allowance of $1, 000, 00 for all Dental Services rendered
during any Benefit Year for any Member:
a. For Dental Services rendered by a Dentist, an amount
equal to a percentage of his usual charge as provided in paragraph b below
for the Dental Services, provided such charge is not in excess of the usual,
customary and reasonable charge for the Dental Services in the area where
the services are rendered, as determined by the Plan, subject to the
following considerations:
The usual fee is the fee which the individual. dentist
most frequently charges to the majority of his patients for a similar dental
service.
The customary fees are those fees which fall within
the customary range of fees charged in a locality by most dentists of similar
training and experience for the performance of a similar dental service. '
A charge is reasonable when it meets the usual and
customary criteria, or it may be reasonable if, in the opinion of an approp-
riate professional review committee, it merits special consideration based on
unusual circumstances or medical complications requiring additional time,
skill and experience in connection with a particular dental service.
The determination of the actual amount payable for a given
Dental Service is within the sole discretion of this Blue Cross Plan. Charges
in excess of the usual, customary and reasonable fee as determined by the Plan
shall be the responsibility of the Member.
b. Amount payable by the Blue Cross Plan
(1 ) Basic Dental Services: During the first Benefit Year
in which a Member utilizes the Basic Dental Services listed in paragraph 2.a
above, the Plan shall pay toward expenses incurred seventy percent (700) of
the amount specified in paragrapn 3.a for the Dental Service performed, except
that when a Member utilizes such Dental Services during successive Benefit
Years, commencing with the second of such successive Benefit Years, the
percentage of the amount payable by the Plan toward such benefits shall be
increased over such seventy percent (700) by an additional ten percent (100)
of the amount specified in paragraph 3.a for each successive Benefit Year until
the Plan will be paying one hundred percent: (100') of the amount specified in
paragraph 3.a. However, the percentage of the amount specified in paragraph 3.a
-22-
PART VI BENEFITS Continued
I. Dental Benefit . . Continued
that the Plan will pay toward such benefits in a Benefit Year immediately
following one or more Benefit Years in which none of such benefits was
utilized by a Member will be reduced by 10%, but not to less than 70% of the
amount specified in paragraph 3.a for the service rendered.
C2.) Prosthetic Dental Services: During any Benefit Year
in which the Member utilizes the Prosthetic Dental Services listed in paragraph
2.b above, the Plan shall pay toward expenses incurred up to fifty percent
(50 0) of the amount specified in paragraph 3.a.
(3.) The Subscriber will be responsible to the Dentist for
the difference, if any, between the amount payable by the Plan as provided in
this paragraph b and one hundred percent (100 0) of the amount specified in
paragraph a above.
c. , Any payment required of the Plan under this Agreement may,
at the sole discretion of the Plan, be made to the Dentist or other person or
organization furnishing the service giving rise to the payment, or to the
Subscriber., or to such person or organization and the Subscriber jointly.
d. This Blue Cross Plan shall , at its own expense and by a
Dentist of :its own choice, have the right and opportunity to physically
examine any Member with -respect to the Dental Services provided hereunder
upon request. `
e. A Treatment Plan shall be submitted when required by the
regulations of the Blue Cross Plan. 11,hcn a Treatment Plan is required for any
of the Dental Services described herein, such Treatment Plan must be submitted
to the Blue Cross Plan prior to the performance by the Dentist of any such
Dental Services . Treatment Plan means a written report showing the recom-
mended treatment of any dental disease, defect or injury for a. Member
prepared by a Dentist as a result of any examination made by such Dentist,
while coverage under this Agreement is in effect- for. the Member.
-23-
PART VI BENEFITS Continued
I. Dental Benefit Continued
4. Limitations
In addition to the Limitations of Part VII, the Blue Cross Plan
shall not be required to furnish any benefits under this Agreement for:
a. Dental services received from a dental or medical depart-
ment maintained by or on behalf of an employer, a mutual benefit association,
labor union, trustee or similar person or group .
b. Dental services for congenital malformations; primarily
for cosmetic or esthetic purposes; or for dental implants .
C. Appliances or restorations necessary to increase vertical
dimensions or restore the occlusion.
d. Services rendered by a Dentist beyond the scope of his
license.
e. Dental. services to the extent that charges for such services
exceed the charge that would have been made and actually collected if no
coverage existed hereunder or for which the Rlember incurs no charge .
f. Orthodontic services, except for extractions incidental
thereto .
g. In the event a Member transfers from the care of one Dentist
to that of another Dentist during the course of treatment, or if more than one
Dentist renders services for one dental procedure, the Plan shall be liable for
not more than the amount it would have been liable for had but one Dentist
rendered the service .
h. In all cases in which there are optional techniques of
treatment carrying different fees, the Plan shall be liable hereunder only for
the treatment carrying the lesser fee.
i . Prosthetic services or devices (including bridges and
crowns) started prior to the date the Member became covered under this Agreement .
j . Expenses incurred after tormination of coverage except
expenses for prosthetic devices which were fitted and ordered prior to termina-
tion and were delivered to the Member within thirty (30) days after the date of
termination.
-24-
PART VI BENEFITS . . . Continued
J. Major Medical Benefit
1. Definitions
a. "Legally Operated Hospital" means an institution operated
in accordance with the laws of the jurisdiction in which it is located
pertaining to institutions identified as hospitals and which, for compensation
from its patients and on an inpatient basis , is primarily engaged in providing
diagnostic and therapeutic facilities for surgical and medical diagnosis,
treatment and care of injured and sick persons by or under the supervision of
a staff of licensed phys-icians and surgeons, and which continuously provides
tl,enty-four Hours a day nursing service by registered graduate nurses. It
shall specifically exclude any institution which is primarily a place of rest,
a place for the aged, a nursing home, a convalescent home, or a facility
operated by the Federal. Government or any agency thereof.
b. The term "Major Medical Benefits," as used in this Agree-
ment, means only those services and supplies listed below and only to the
extent that they are not furnished by the Blue Cross Plan under other
provisions of this Agreement or Endorsements thereto. To be eligible for
Major Medical Benefits, it is required that such be medically necessary and
furnished in connection with the diagnosis or treatment of an illness, and
or accidental bodily injury, and be authorized by a licensed physician and
surgeon and for only as long as such authorization is given.
(1) Cervices f„r„, ,,,..� ,. , , L__ ,
ulii,�s�i�,u uiiu U.'L1.J_0d by a Legally Vpura.LeCl
Hospital, except as follows :
(a) Services of a personal nature, such. as charges
for radio, telephone, guest trays and the like.
(b) Private room charges exceeding the hospital 's
most prevalent charge for accommodations in a room of two (2) or more beds,
except when a Member is confined in a hospital having private room accommoda-
tions only, the Plan shall determine the amount. of additional eligible expense
to be included hereunder.
and surgeon. (2) Professional services rendered by a licensed physician
-25-
PART VIA BENEFITS . . . Continued
J. Major Medical Benefit Continued
(3) Professional services rendered by a licensed physician
and surgeon, or doctor of dental surgery for treatment of a fractured jaw or
other accidental injury to natural teeth provided that the injury occurs while
the patient is covered hereunder. Such services will he covered only during
the twelve (12) months ' period immediately following the date of injury.
(4) Professional nursing service of a registered profes-
sional nurse, other than one who ordinarily resides in the Subscriber's home
or who is related to the Subscriber by blood or marriage.
(5) Anesthetic supplies and administration of anesthesia
by anesthetist.
(6) X-ray, radium and radioactive isotope therapy.
(7) Services of a licensed physician and surgeon, or a
registered physical therapist, in connection with physical therapy treatments,
other than one who ordinarily resides in the Subscriber's home or who is
related to the Subscriber by blood or marriage .
(8) Di-agnostic X-ray and laboratory services required for
treatment of illness or accident.
t ^(9) Services of a licensed ambulance company for local
WIr�u ancc s-c Vice t franc r 1ho ss ultal
l Ul Ufl V Vl 1 Vllt u 1VJ
(10) Drugs or medicines directly related to the treatment
of an illness or injury and requiring a written prescription and dispensed by
a licensed pharmacist or licensed physician and surgeon.
(11) Artificial limbs or eyes, casts, splints, trusses,
braces, crutches, and other similar appliances, and also the rental of a
wheel chair- , hospital-type bed, iron lung or other similar mechanical equip-
ment required for treatment. The Plan may, at its option, purchase such.
mechanical equipment for the ?Member, in lieu of rental. These supplies will
be limited to those reasonably required by standard treatment practices as a
result of illness, disease or injury occurring while the Member is covered
hereunder.
(12) Blood transfusions , including cost of blood and blood
derivatives to the extent that such blood and blood derivatives are not
replaced by voluntary donors .
-26-
PART VI BENEFITS Continuer
J. Major Medical Benefit . Continued
C. The term "Deductible Amount" shall mean the first $50. 00
of expense incurred for Major Medical Benefits for which each person covered
hereunder shall be responsible. The Deductible Amount shall be applied in the
following manner:
(1) The Deductible Amount shall be applied to Major
Medical Benefits incurred -in each calendar year by each Member.
(2) In no event shall any family unit be required to
satisfy more than an aggregate of $150. 00 in Deductible Amounts during a
calendar year. Once the $150. 00 maximum deductible is satisfied, all Members
of that family unit shall be deemed to have satisfied their deductible for
that calendar year.
(3) If_ two or more Members shall suffer bodily injury as
a result of the same accident, only one Deductible Amount shall be applied to
all Major Medical Benefits incurred as the result of said accident during the
year in which the accident occurs .
(4) Any expense for Major Medical Benefits incurred in
the last calendar quarter of the year and applied against the Deductible
Amount for that year shall be carried forward to apply against the Deductible
Amount for the ensuing year. Where the expense carried forward to the
ensuing year under this sub-section (4) shall be :in connection with the same
accident resulting in bodily injury to two or more i-iembers covered hereunder,
the Major Medical Benefits incurred by all said Members in the ensuing
calendar year as the result of said accident shall be subject to only the one
Deductible Amount.
(5) The Blue Cross Plan shall select at all times in the
application of sub-sections (1) , (2) , (3) or (4) above, the sub-section which.
shall provide the greatest total payment by the Plan to all Members covered
hereunder.
2. Benefits
Upon receipt of due notice and proof that the Member shall have
incurred expense for Major Medical Benefits, benefits will be pxoyi.ded as.
follows:
a. Such expense must be incurred on or after the Member's
effective .date of coverage hereunder, or, in the event the Mciiiber is hospi-
talized on such effective date, such expense must be incurred subsequent to
the date of discharge from the hospital . An expense will be considered to
have been incurred on the date that the individual received the services for
which the charge is made .
-27-
PART VI BENEFITS . . . Continued
J. Major Medical Benefit Continued
b. Payment for such services shall be based upon charges not exceeding
the usual, customary and reasonable charges or fees for such services in the community.
For the purpose of this Agreement, the Blue Cross Plan will take into consideration
the following criteria in determining what constitutes a usual, customary and reasonable
charge or fee:
The usual charge or fee which the provider of service most frequently charges
to the majority of his patients or customers for a similar service or medical procedure;-
The charges or fees which fall within the customary range of charges or fees in
a locality for the performance of a similar service or medical procedure;
Unusual circumstances or complications requiring additional time, skill and
experience in connection with a particular service or procedure.
The determination of the actual amount payable for any given service or supply is
within the sole discretion of this Blue Cross Plan. Charles or fees in excess of
the usual, customary and reasonable charge, or. No as detcrmined by the Plan shall
be the responsibility of the Member.
c. If the expense incurred for Major Medical Benefits exceeds the
Deductible Amount as set forth above, payment will be made by the Plan for (i) eighty
percent (80%) of such excess until $2,000 have bcup paid for expenses incurred during
any calendar year on behalf of any Member and (ii.) one hu.nOred percent (100%) of the
amount of all other covered expenses incurred on behalf of such Member during the
remainder of such calendar year. The maximum amount of Major Medical Benefits payable
shall not exceed an aggregate: amount of $50,000 for all conditions during the lifetime
of each Member. At the end of every calendar year, that portion of a HeNber's maximari
amount for any illness, disease or injury up to 0,000 which has been paid in benefits
by the Plan will be automatically restored without action on the part of the Member.
Such restored amounts are subject to the deductible cmount and percentage payment as
heretofore defined. If the Vember is eligible for benefits under the Terminal Benefits
Provision, such Automatic Restoration shall not apply.
After exhaustion of the fifty thousand dollar ( +50,000) maximum
Major Medical Benefit, as specified above, padncnt: will be glade. by the Plan for one
hundred percent (100%) of Major Medical expenses, without: further requirement of a
Deductible Amount or co-insurance, up to a lifetime maximum of two hundred and fifty
thousand dollars (S�250,000) .
d. The Member who has received at least $1,000.00 of benefits
hereunder may apply for reinstatement of maximum benefits by furnishing evidence
of good health satisfactory to this Blue Cross Plan .
-28-
PART VJ ' B131,1ET l TS . . . Conti_nued
J. Major Aled i cal Benefit Continued
e. If, as a result of pregnancy, resulting childbirth or
infant nursery care, expense for Alajor Afed:ical Benefits is incurred in excess
of $800.00, the Plan will provide benefits as indicated inparagraph 2 .c above,
for the 14ajor Helical Benefits :incurred exceeding $800,00, Such benefits will
be provided only if the SubscWher or spouse is covered hereunder when
pregnancy has :its :inception, and provided further that, from inception of
pregnancy, she has been continuously unrolled until- date-of delivery. The
maternity benefits paid under paragraphs W 3 and It of this fart VI
shall he credited against the $800 .00 Nmount required for such
pregnancies.
f. Benefits will be payable with respect to charges incurred
in connection with any nervous or mental condition while the Member is not
confined as a becl patient in a hospital , subject to the following:
(1) The pay711e11t by the Plan shall be fifty percent (5O%)
of eligible expenses instead of the percentages stated in paragraph 2.c above.
(2) Benefits shall be paid for a maximum of twenty (20)
visits in any and ca-lendar year; and
(3) Such psychiatric services must be rendered by a
physician and surgeon licensed to practice medicine (other than one whose
license limits his practice to one or more specified fields) .
Q 9-
PART VI BENEFITS . . . Continued
J, Major Medical. Benefit . . Continued
3. Exclusions and Limitations
In addition to the Limitations of Part VII, no benefits will
be provided under this Major Medical Benefit for:
a. Any of the foregoing services or supplies to the extent
that they are furnished by the Blue Cross Plan under the other provisions of
this Agreement or Endorsements thereto.
b. Mental, psychoneurotic and personality disorders, unless
hospitalized or as specifically provided in paragraph 2 .f above.
C. Any services or supplies not specifically listed herein
as covered benefits .
d. Any services or supplies furnished in connection with
any condition arising from pregnancy or resulting childbirth, including all
complications thereof, prenatal or postnatal care, or for routine care of a
newborn infant, except as provided under paragraph 2.e above.
e. Physical examinations or tests, including screening
examinations, not connected with the care and treatment of an actual illness,
disease or injury; dental treatment (except as otherwise provided herein) or
dental examinations; eye glasses, eye refractions or cyc examinations for the
correction Of vision or fitting Of Plasses - or I-he ftirtii china nr
of hearing aids .
f. The cost of blood and blood derivatives to the extent that
such blood and blood derivatives are replaced by voluntary donors.
-30-
1
PART VI BENEFITS Continued
J. Major Medical Benefit Continued
4. Termination and Terminal Benefits
a. Except as otherwise provided in paragraph c below, should
a Member be totally disabled at the date of termination of coverage hereunder
and be wider treatment by a licensed physician and surgeon, all benefits of
this Major Medical Benefit section , as heretofore defined, shall be furnished
for a period equal to the number of months the Member was covered hereunder
up to a maximum of twelve (12) consecutive months after termination of coverage
or until the maximum amount of benefits has been paid, as heretofore defined,
whicliever occurs first . Such benefits shall be furnished solely in connection
with the condition causing such total disability and only during the continua-
tion -of such total disability. Proof of such disability and the continuation
thereof shall be furnished to the- Blue Cross Plan within 90 days after the
date .of termination of coverage hereunder.
b. A Subscriber or spouse covered hereunder shall continue to
be eligible for the benefits specified in paragraph 2 .e above except as stated
in paragraph c below, providing pregnancy had its inception while the mother
was covered hereunder, for a period not to exceed nine (9) months following
the date of termination of coverage hereunder.
C. If a Subscriber is required to pay the whole, or any part,
of the Subscription Charges ,required under the terms of the Agreement, and if
such Subscriber ceases to pay such charges while lie remains employed or con-
nected with the group through which he became eligible to make application
under this Agreement, the individual coverage of such Subscriber, including
coverage of his Pamily Members, shall terminate automatically and shall be of
no further force and effect, notwithstanding the provisions of paragraphs a
and b above.
-31 -
PART VI LIMITATIOTS
A. The Blue Cross Plan shall not be required 10 furnish any items of
Hospital Care, surgical or medical benefits, other than those set forth above,
nor to furnish such Ilosp .t.al Care, surgical or medical benefits for:
1 . Any condition or a:ilr,r:nt, or :injury in respoct of which the
Member is entitled to receive benefits in whole or in part under occupational
coverage voluntarily obtained by the employer or required by State or Federal
Workmen's Compensation or Liability Laws or the United States, or services
rendered in a hospital owned or operated by a State or U. S. Governmental
Agency, even though the Member waives his YIght to such benefits .
2. Ilospi.ta.li.zation primarily for diagnostic studies, when Hospital
Care Mould not have oth.crwise Wen ruquired, except as provided under the
Major madi.cal. Benefit outlined in Part VI .
3. Care for extraction of teeth, or other dcnt.a.l procedures , except
that the Plan will pxov.ide Hospital Care only for cases whore a-dequate treat-
ment caDnot be provided without, the use of hospital facilities and where there
is an underlying medical condition that nccessi sites hospitalization , or as
specifically provided in the Major Medical and Dental Benefits in Part V1.
4 . Any services furnished by an institution which is primarily a
place of rest, a place for the aged, a nurnW3 home, a convalescent home or
any institution of like character, or for ['.n n P I n cr"Pi_ or rn f od l services
regardless of where such services are rendered, or that portion of any hospital
confinement beginning on the day that such conf:inamunt dcvelops into primarily
convalescent or custodial care . Custodial care is defined as the provision of
room and board, with or without routine nursing care, training, and persona-1
hygiene and other forms of self care or staj!c:r visory cayc by a doctor for a
person who is mentally or physically disablul as the result of retarded
development or body infirmity, and who is not under specific medical , surgical
or psychiatric treatment to reduce his disphi_lity to the extent necessary to
enable him to live outside an in.stitutioa_a providing medical care .
S. Any hospital confinement in a hospital that is not a. Partici-
pating Hospital , except as specifically p ov_ided in Part V, the Supplemental
Accident. Benefit and Major Medical Benefit outlined in Past VI.
- 32-
PART VII LIMITATIONS Continued
6. Conditions caused by or arising out of an .act of war, armed
invasion or agression.
7. Treatment for obesity; services performed for cosmetic purposes,
unless performed for correction of functional disorders or as a result of an
accidental :injury while the Member is covered hereunder.
8. Any services or supplies for which no charge is made or which
would not have been made if this Agreement were not in effect nor for services
or supplies for which the Alember would. not: be legally liable if this Agreement
were not in effect.
9. Admissions or treatment primarily for rehabilitative care
(includi.ng, but not limited to, speech and occupational. therapy) . Further,
when the type of care rendered during a continuous period of hospital- confine-
ment develops into primarily rehabi.lita.tive care, that portion of the stay
beginning on the day of such development is not covered Luider this Agreement.
10. Routine foot-care procedures such as the trimming of nails,
corns or calluses , fallen arches or other symptomatic complaints of the feet,
impression casting for prosthetics and appliances including prescriptions
therefor and routine hygienic care.
11. Pregnancy and any conditions resulti.nl; therefrom, except
ectopic pregnancy and as specifically provided herein.
- 33-
PART VII LIMITATIONS . . . Continued
B. In the event that a Member enrolled hereunder has been covered by
a prior Certificate or Agreement i;ith this Bluc Cross Plan, which is replaced
by this Agreement , the following specific provisions will apply:
1. The provisions of the prior Certificate or Agreement relating
to benefits for obstetrical care (if any) that %-,,ere in effect at the time of
inception of pregnancy, shall. be applied.
2. If a Momber is admitted to a hospital for other than obstetrical
care within ninety (90) days after discharge from the last previous hospital-
ization, the number of days of care furni.slied under the prior Certificate or
Agreement for the last lospital confinement shall he deducted from the days of
care available under this Agreement, provided, liowever, that this paragraph
shall not be applied in connection with:
a. hospitalization of a Subscriber who shall have returned to
active work on a full brie basis following last previous hospital confinement,
or
b. hospitalization of a Member required as a result of
accidental injury .
a ��
3. if a 1�ZAi ber i.c_. ;.�onf�.ned 1-ii u }io Jl:itai. iihilc Vo,vcrod u--dor he
prior Certificate or Agreement and remains continuously confined on past the
effective date of coverage under this Agreement, the benefits of the prior
Certificate or Agreement will apply until date of discharge.
C. In the event that a Member enrolled hereunder has been covered by a
prior Certificate or Agreement of another Blue Cross Plan which is replaced by
this Agreement, the provision of this Blue Cross Plan's Group Conversion
Certificate relating to benefits for obstetrical care shall be applied in
connection with any pregnancy that had its inception while the mother was
covered under the prior Certificate or Agreement.
-34-
PART' VII LIMITATIONS . . . Continued
D. Coordination of Benefits Provision
All of the benefits provided under this Agreement are subject to the
following provisions and limitations.
1. Definitions
a. "Program" means any plan, contract or policy providing
benefits or services for or by reason of hospital , surgical. , or medical care
or treatment , which benefits or services are provided by any group type
program, plan or policy toward the cost of which any employer or other
organization shall have contributed, riade payroll deduction, or otherwise
collected Subscription Charges; or any progra,), plan or policy supported
solely or largely by taxes or othe-rwi.se provided by or through any action of
any government, including iledicare .
b. "This Agreement" means the contract between the Blue Cross
Plan and the Group, of which this provision is a part . To the extent legally
possible, it shall Have the same meaning as Program.
C. "Covered Services" means any necessary, reasonable and
customary items of hospital or medical_ expense incurred, where. at least a
portion of said incurred expense is covered under one or more of the plans
COVer171p he, Member fnr t.hom c1:a.?m 1S :'1'3de Or Ser'd7.Ce
legally possible, "covered services" shall be synonymous with allowable
expense.
d. "Claim Determination Period" is a period beginning with
any January lst and ending at 12 :00 o'clock midnight on the next succeeding
December 31st, or that portion of such period during which the Member was
covered under this Agreement.
2. Effect on Benefits
a. For any claims determination period to which this provi-
sion is applicable, the services due and the benefits that would be payable
wider this Agreement in the absence of this provision for the allowable
expenses incurred during such claim determination period shall be reduced to
the extent necessary so that the sum of (i_) such reduced benefits and (ii)
all the benefits payable for such allowable expenses under all other programs
shall not exceed 100 per cent of Covered Services under all programs .
- 35-
PAP:I' 'VII LIMITATIONS . . . Continued
D. Coordination of Benefits Provision Continued
b . The services due or the benefits payable under this
Agreement shall be reduced in accordance with the foregoing paragraph a, when
the Member's other program:
(1) does not contain a coordination of benefits provision,
or.
(2) the other program has a coordination of benefits
provision and
(a) this Agreement covers the P•lember as a dependent
while the other program covers him as an employee, or
(b) this Agreement covers the individual as the
child of a female Subscriber while the other program covers him as the child
of a male employee; or
(c) this Agreement covers the individual as a
Subscriber while the other program covers him as an employee, and the other
program has covered him for a longer period of time .
In no event shall. the Member be entitled to benefits from
the Blue Cross Plan in excess of those to which lie would have been entitled in
the absence of this Coordination of Benefits Provision .
C. The Blue Cross Plan shall not be required to determine the
existence of any program, or the benefits payable under any program, when
computing the services or benefits due any Member covered under this Agreement.
The services due or the benefits payable under this Agreement shall be
affected only to the extent that other program information is supplied by the
Group, the Member, any supplier of covered services hereunder, or any other
organization or person.
d. When a program provides benefits in the form of services
rather than cash payments , the reasonable cash value of each service rendered
shall be deemed to be both a covered service and a benefit paid. The reason-
able cash value of any services provided to the covered individual by any
service organization shall be deemed an expense incurred by said individual ,
and the liability of this Plan under this Agreement will be reduced accordingl}
- 36-
PART -VII LIMITATIONS Continued
D. Coordination of Benefits Provision Continued
C. 10ien this provision operates to reduce the total amount
of benefits otherwise payable as to a Membex• covered under this Agreement
during any Claim Determination Period, each benefit that would be payable in
the absence of this provision shall be reduced proportionately, and such
reduced amount shall be charged against any applicable benefit limit of this
Agreement.
3. Facility of Payment
Whenever payments which should have been made under this
Agreement in accordance herewith have been made under any other programs, this
Blue Cross Plan shall have the right, exercisable alone and in its sole
discretion, to pay over to any orga.niza.tions malting such other payments, any
amounts it shall detcrriine -to be warranted -in order to satisfy the intent of
this provision. Any amolmts so paid shall be deemed to be benefits paid tinder
this Agreement and to t1le. extent of such payments , this Plan shall be fully
discharged from liability under this Agreement .
4. Right of Recovery
1`,%enever payments for coverer] Seri i cos have been made by t hi s
Blue Cross Plan and said payments exceed the max.i.mum amount of payment neces-
sary to satisfy the i7ltent of t11is provision, irrespective of to whom paid,
the Plaid shall have the right to recover such excessive amounts .from any
persons to, or for, or with respect to whom such payments were made, or from
any Insurance Company, or any other organizations or persons .
5. Right to Receive and Release Necessary Information
For the purpose of implementing this provision and in the
interest thereof, this Plan may release or obtain any information deemed to
be necessary with respect to any person claiming benefits under this Agreement.
Such information may be released or obtained without the consent of, or notice
to, the N"ember or any other person or organization . Any Member shall furnish
the Plan such information as may be necessary to implement this provision.
-37-
PART VIII CONVERSION PRIVILEGE
If the Subscriber ceases to be emp7oycd or connected with the
Group through which he has been covered under this Agroono.nt, coverage shall
terminate automatically wi.thout. notice. If, however. , Subscription Charges
Have been paid through the Group for at least: one (1) month, and the
Subscriber wishes to maintain continuous coverage, he must apply to the Blue
Cross Plan within thirty (30) days of term:i_ns t:ion of eriployraent. Upon receipt
by the Plan of such application and the rcqui-red subscription charges within
Such thirty (30) day period, a certificate will be _issued which shall be of
the, type and class of direct paMnt certificate then being generally issued
by the Plan. Iloweve_t•, should the Subscriber remain in the employ of the
Group and elect to terminate this Agreement , he will not be entitled to apply
for such certificate .
PART I FREE CIIOICE OF PARTICIPATING HOSPITAL
AND KFTENDING PHSICIAIN
A. Nothing contained in this Agreement shall in any way or manner
restrict or interfere wit% the right of any individual entitled to Hospital
Care hereuKer to select: the Participating Hospital or to make free choice
Of his
atten "" phys"c"Ps and sur!", who shOlf be a mc1 bey of or acceptable
to, the Mending;�i nn staff f l .. - i. t. ...
� 1y�� -� __ "=.0 i:,��liuhi.;iii:�it Of iall`' 11iiS}iJ_Lctl 1J7 which Sd1U IIOSp1-Cal
services are to be rendered.
B. Payment under this Agreement for services rendered by a physician
and surgeon shall not be construed as regulating in any way the fees which
the physician and surgeon may charge for his services .
Any payment required of the Blue Cross Plain under this Agreement
may, at the sole discretion of the Plan, be trade to the physician or other
person or Organization furnishing the service tivinl rise to the payment , or
to the Subscriber, or to such person or organization and the Subscriber jointly.
-38-
PART X GENERAL PROVISIONS
A. In the event that this Blue Cross Plan provides benefits for any
condition or injury for which a third party is liable, the Plan shall be
subrogated to the rights of the individual entitled to the benefits of this
Agreement to the extent of any benefits that the Plan shall pay or be liable
for. In the event that any claim or action is made or instituted by the
individual entitled to the benefits of this Agreement on account of such
third-party liability, the amount which the Bluc Cross Plan pays or may be
liable for shall be included in any such claim or action and, in the event
of settlement of such claim or action, the Plan shall be rci_mbursed any amount
that it has paid on account of its obligations under this Agreement. The
individual covered under this Agreement shall fully cooperate with the Plan
and shall take such action, furnish such information and assistance, and shall
execute such assignments and other instruricnts as the Plan may request in
order to facilitate enforcement of the rights of the Plan hereunder, and shall
take no action which prejudices the rights and interests of the Plan hereunder. .
B. This Agreement is not in lieu of and does not affect any requirement
of coverage by Workmen's Compensation Insurance.
C. Each member consents to and authorizes an attending physician and
surgeon or hospital to permit the examination and copying of any portion of
his hospital or medical record requested by the Blue Cross Plan in connection
with processing a claim.
D. All rights to benefits of this Agreement are personal and are
available only to Members . The right to hospital Care, or other benefits may
not be transferred, assigned or be subject to attachment.
E. No agent of the Blue Cross Plan is authorized to change the form or
content of this Agreement in any manner other than by Endorsement issued to
form a part hereof and over' the signature of a Blue Cross officer.
F. The Blue Cross Plan shall be entitled to require that there be
submitted by or on behalf of any Member receiving benefits under this Agreement,
a certificate of medical necessity from such persons or organizations as it may
deem appropriate in a manner and at such time satisfactory t.o the Plan. No
Member shall be entitled to the continuation of any benefit whatsoever under
this Agreement unless, if requested, such certificate has been provided and,
subject to review by a medical review board, substantiates the medical neces-
sity for continued care. Such certificate shall not be requested by the Plan
more frequently than at ten (10) day intervals .
G. The hospitals furnishing hospital Care or other benefits to the Member
do so as independent contractors with the Blue Cross Plan, and the Plan shall not
be liable for any claim or demand on account 'of damages arising out of or in any
manner connected with any injuries suffered by the Member while receiving care in
any hospital .
-39-
PART X GENERAL PROVISIONS Continued
H. The full extent of liability under this Agreement and benefits
conferred hereunder including recovery under any claim of breach, shall be
limited to the actual cost of hospital_ and medical services as provided
herein and shall specifically exclude any claim for general. damages including
alleged "pain, suffering or mental anguish ."
I. . This Blue Cross Plan reserves the right to terminate this Agreement
at any time the Group through which the Subscriber is enrolled fails .to meet
the Group enrollment requirements of the Plan.
J. This Blue Cross Plan shall not be required to furnish any benefits
under this Agreement unless request for such benefits is made within ninety
(90) days after cormiencerxrit of the service giving rise to the benefits or
within thirty (30) days after such services cease, i.hichever is later, unless
it is not reasonably possible to make such request within such time limitation,
but in no event shall benefits be allowed if notice of claims is made beyond
one (1) year from the date on which expenses were incurred.
When services are rendered by a person or organization having a
contract faith the Blue Cross Plan to provide such service, the requirement of
notice shall be waived.
K. Any and all suits or legal proceedings of any kind whatsoever, as
may be broul"ht agaiiijt c]iis M ue Cross Plan by a Nember, or brought by anyone
claiming any right against the Plan as deri.vi_ng from or through a Member's
rights under this Agreement, must be filed within twelve (12) months of -the
date that the service giving rise to such suit or. legal proceeding was
rendered and ,past be filed in king County, State of Washington, provided
however, that where the person filing such suit or legal proceeding is a
resident: of the State of Alaska, such suit or legal proceeding must be filed
in the Third Judicial District, Anchorage, State of Alaska. Any and all suits
or legal proceedings brought by this Blue Cross Plan against a Hember shall be
filed within the appropriate statutory period of limitation and in all such
suits or legal proceedings venue may lie , at the option of the Plan, in King
County, State of Washington, provided hor:ever, that where the suit or legal
proceeding is brought against a Member who is a resident of the State of
Alaska, it must be filed in the Third Judicial District, Anchorage, State of
. Alaska. Any and all suits or legal proceedings brought by the Plan against
a third party or third parties pursuant to any subrogation rights which the
Plan has under the Agreement herein, may be filed at any time within the
appropriate statutory period of limitation in such cases .
-40-
PART X GENERAL PROVISIONS . . . Continued
L. The services provided under this Agreement are at all times subject
to the availability of hospital facilities and the ability of hospitals,
hospital employees, and physicians and surgeons to provide such services.
The Blue Cross Plan shall assume no liability for epidemic, public disaster,
or other conditions beyond its control which make it impossible for the services
provided by this Agreement to be obtained.
M. Except for as specifically provided herein, this Agreement or any
Endorsements thereto, mast be in effect at the time services are rendered to
the Member.
N. Any notice required of this Blue Cross Plan hereunder shall be deemed
to be sufficient if mailed to the Subscriber or to the Group, as the Plan may
elect, at the address appearing on the records of the Plan; and, if required
of the Subscriber, if mailed to the principal office of this Blue Cross Plan in
Seattle, Washington.
0. No person by virtue of this Agreement shall acquire or have any
vested right whatever to any services or benefits, or payment on account of
any services or benefits, of any kind, rendered after the date this Agreement
is terminated. Except as specifically provided herein, termination of this
Agreement as to any Member for any reason shall completely end all obligations
of the Blue Cross Plan to provide him any services or benefits, or payments on
a�Gniint Of any s.rl'1Ce� }J�n f1tS ar.. �-t a , r + "
J _ , reilde red c..l�-�.i 1. I "il Vl 1.l:riil-L l.tvll,
whether or not the Member may then be receiving treatment, or may thereafter
be in need of treatment for an illness, injury or physical disability incurred
or treated while this Agreement was in effect.
-41-
SCHEDULE OF ELIGIBILITY
Ali
All full time permanent employees, working a minimum of twenty-five
(25) hours a week and who have made application prior to the initial
effective date of this program, will be covered as of December 1, 1973.
All full time permanent employees working a minimum of twenty-five
(25) hours a week, hired after December 1, 1973, will be eligible to
enroll and become effective immediately upon attaining full time
employment.
Eligible dependents' coverage will become effective on the same date
as the employee's coverage providing proper application has been made.
Eligible dependents are the employee's spouse and unmarried children
from birth to twenty-three (23) years of age.
Newly acquired dependents of an eligible employee must be enrolled
within thirty (30) days of acquisition. Coverage for such dependents
will commence on the first billing date following acquisition or in the
case of a newborn, from the date of birth.
Eligible dependents who are not enrolled when first eligible may be
enrolled during regular group reopening periods which are determined
by the Plan.
In the event the employer grants an approved leave of absence to an
enrolled employee, coverage through the Group may be continued for a
period not to exceed sixty (60) days. The employer agrees to notify
the Plan on the regular monthly billing as to the employee's date
of departure on leave and will submit his monthly payment with the
regular Group remittance.
The Group will promptly delete any employee or dependent who ceases
to meet the above eligibility requirements and will so notify the Plan
an a timely basis.