HomeMy WebLinkAboutHR13-107 - Original - Group Health Cooperative - Group Medical Coverage Agreement - 01/01/2013 T ecords M eme
KEN Wws Hincron Document
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office. All portions are to be completed.
If you have questions, please contact City Clerk's Office.
vendor Name: Gi--�ou t-1 L-T-H C. 00r�t..fZPr j IV i�
Vendor Number:
ID Edwards Number
Contract Number: `1 d
This is assigned by City Clerk's Office�
Project Name: ,�a I� 'C-0IvTRAc_1
Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment Xcontract
❑ Other:
Contract Effective Date: —( - ao 13 Termination Date: 1 cc� -31 -a013
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
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Contract Manager: (--per t�(L Department:
Detail: (i.e. address, location, parcel number, tax id, etc.):
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0
GroupHealth®
Group Health Cooperative
Contracts and Coverage
PO BOX 34589
Seattle, WA 98124-1589
Enclosed is the 2013 Group Health Cooperative medical coverage agreement.
Benefit or contract provisions that you or Group Health might have requested or
negotiated during the renewal process are included in the enclosed medical coverage
agreement.
If you have any questions about this information or your new contract, please call your
Marketing account executive:
Seattle (206) 448-4140 or toll free in WA 1-800-542-6312
Tacoma (253) 383-6226 or toll free in WA 1-800-854-5322
Eastern WA/NorthID (509)459-9100 or toll free in WA 1-800-497-2210
Central WA (509) 783-3484 or toll free in WA 1-800-458-5450
We appreciate your business.
Sincerely,
Contract Administration
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GroupHeaith®
Group Medical Coverage Agreement
Group Health Cooperative ( Group Health )is a nonprofit health maintenance organization,duly registered under
the laws of the State of Washington,furnishing health care coverage on a prepayment basis The Group identified
below wishes to purchase such coverage This medical coverage agreement("Agreement')sets forth the terms
under which that coverage will be provided,including the rights and responsibilities of the contracting parties,
requirements for enrollment and eligibility,and benefits to which those enrolled under this Agreement are entitled.
The Group medical coverage agreement between Group Health and the Group consists of the following.
• Signed Group Master Application
• Premium Schedule
• Standard Provisions
• Benefits Booklet
City of Kent,#0036900
This Agreement will continue in effect until terminated or renewed as herein provided for and is effective
January 1,2013
CA-188813 1
Standard Provisions
1. Group Health agrees to provide benefits as set forth in the attached Benefits Booklet to enrollees of the
Group.
2. Monthly Premium Payments.
For the initial term of this Agreement,the Group shall submit to Group Health for each Member the monthly
premiums set forth in the current Premium Schedule and a verification of enrollment Payment must be received
on or before the due date and is subject to a grace period of 10 days Premiums are subject to change by Group
Health upon 30 days written notice Premium rates will be revised as a part of the annual renewal process
In the event the Group increases or decreases enrollment at least 25%or more, Group Health reserves the right
to require re-rating of the Group
3. Dissemination of Information.
Unless the Group has accepted responsibility to do so,Group Health will disseminate information describing
benefits set forth in the Benefits Booklet attached to this Agreement
4. Identification Cards.
Group Health will furnish cards,for identification purposes only,to all Members enrolled under this
Agreement.
5. Administration of Agreement.
Group Health may adopt reasonable policies and procedures to help in the administration of this Agreement.
This may include,but is not limited to,policies or procedures pertaining to benefit entitlement and coverage
determinations
6. Modification of Agreement.
Except as required by federal and Washington State law,this Agreement may not be modified without
agreement between both parties
No oral statement of any person shall modify or otherwise affect the benefits,limitations and exclusions of this
Agreement,convey or void any coverage,increase or reduce any benefits under this Agreement or be used in
the prosecution or defense of a claim under this Agreement
7. Indemnification.
Group Health agrees to indemnify and hold the Group harmless against all claims,damages,losses and
expenses,including reasonable attorney's fees,arising out of Group Health's failure to perform,negligent
performance or willful misconduct of its directors,officers,employees and agents of their express obligations
under this Agreement.
The Group agrees to indemnify and hold Group Health harmless against all claims,damages,losses and
expenses,including reasonable attorney's fees,arising out of the Group's failure to perform,negligent
performances or willful misconduct of its directors,officers,employees and agents of their express obligations
under this Agreement
The indemnifying party shall give the other party prompt notice of any claim covered by this section and
provide reasonable assistance(at its expense) The indemnifying party shall have the right and duty to assume
the control of the defense thereof with counsel reasonably acceptable to the other party Either party may take
part in the defense at its own expense after the other party assumes the control thereof
8. Compliance With Law.
The Group and Group Health shall comply with all applicable state and federal laws and regulations in
performance of this Agreement.
C34613-0036900 2
This Agreement is entered into and governed by the laws of Washington State,except as otherwise pre-empted
by ERISA and other federal laws
9. Governmental Approval.
If Group Health has not received any necessary government approval by the date when notice is required under
this Agreement,Group Health will notify the Group of any changes once governmental approval has been
received Group Health may amend this Agreement by giving notice to the Group upon receipt of government
approved rates,benefits,limitations,exclusions or other provisions,in which case such rates,benefits,
limitations,exclusions or provisions will go into effect as required by the governmental agency All
amendments are deemed accepted by the Group unless the Group gives Group Health written notice of non-
acceptance within 30 days after receipt of amendment, in which event this Agreement and all rights to services
and other benefits terminate the first of the month following 30 days after receipt of non-acceptance
10. Confidentiality.
Each party acknowledges that performance of its obligations under this Agreement may involve access to and
disclosure of data,procedures,materials,lists,systems and information,including medical records,employee
benefits information,employee addresses, social security numbers,e-mail addresses,phone numbers and other
confidential information regarding the Group's employees(collectively the"information") The information
shall be kept strictly confidential and shall not be disclosed to any third party other than (i)representatives of
the receiving party(as permitted by applicable state and federal law)who have a need to know such information
in order to perform the services required of such party pursuant to this Agreement,or for the proper
management and administration of the receiving party,provided that such representatives are informed of the
confidentiality provisions of this Agreement and agree to abide by them,(u)pursuant to court order or(in)to a
designated public official or agency pursuant to the requirements of federal,state or local law, statute,rule or
regulation The disclosing party will provide the other party with prompt notice of any request the disclosing
party receives to disclose information pursuant to applicable legal requirements,so that the other party may
object to the request and/or seek an appropriate protective order against such request Each party shall maintain
the confidentiality of medical records and confidential patient and employee information as required by
applicable law
11. Arbitration.
Any dispute,controversy or difference between Group Health and the Group arising out of or relating to this
Agreement,or the breach thereof,shall be settled by arbitration in Seattle,Washington in accordance with the
Commercial Arbitration Rules of the American Arbitration Association,and judgment on the award rendered by
the arbitrator(s)may be entered in any court having jurisdiction thereof Except as may be required by law,
neither party nor arbitrator may disclose the existence,content or results of any arbitration hereunder without
the prior written consent of both parties
12. HIPAA.
Definition of Terms.Terms used,but not otherwise defined,in this section shall have the same meaning as
those terms have in the Health Insurance Portability and Accountability Act of 1996("HIPAA")
Transactions Accepted.Group Health will accept Standard Transactions,pursuant to HIPAA, if the Group
elects to transmit such transactions The Group shall ensure that all Standard Transactions transmitted to Group
Health by the Group or the Group's business associates are in compliance with HIPAA standards for electronic
transactions The Group shall indemnify Group Health for any breach of this section by the Group
13. Termination of Entire Agreement.
This is a guaranteed renewable Agreement and cannot be terminated without the mutual approval of each of the
parties,except to the circumstances set forth below
a. Nonpayment or Non-Acceptance of Premium.Failure to make any monthly premium payment or
contribution in accordance with Subsection 2 above shall result in termination of this Agreement as of the
premium due date The Group's failure to accept the revised premiums provided as part of the annual
renewal process shall be considered nonpayment and result in non-renewal of this Agreement The Group
C34613-0036900 3
may terminate this Agreement upon 15 days written notice of premium increase,as set forth in Subsection
2 above
b. Misrepresentation.Group Health may rescind or terminate this Agreement upon written notice in the
event that intentional misrepresentation,fraud or omission of information was used in order to obtain
Group coverage Either party may terminate this Agreement in the event of intentional misrepresentation,
fraud or omission of information by the other party in performance of its responsibilities under this
Agreement
c. Underwriting Guidelines.Group Health may terminate this Agreement in the event the Group no longer
meets underwriting guidelines established by Group Health that were in effect at the time the Group was
accepted
d. Federal or State Law Group Health may terminate this Agreement in the event there is a change in
federal or state law that no longer permits the continued offering of the coverage described in this
Agreement
14. Withdrawal or Cessation of Services.
a. Group Health may determine to withdraw from a Service Area or from a segment of its Service Area after
Group Health has demonstrated to the Washington State Office of the Insurance Commissioner that Group
Health's clinical,financial or administrative capacity to service the covered Members would be exceeded
b. Group Health may determine to cease to offer the Group's current plan and replace the plan with another
plan offered to all covered Members within that line of business that includes all of the health care services
covered under the replaced plan and does not significantly limit access to the services covered under the
replaced plan Group Health may also allow unrestricted conversion to a fully comparable Group Health
product
Group Health will provide written notice to each covered Member of the discontinuation or non-renewal of the
plan at least 90 days prior to discontinuation.
15. Limitation on Enrollment.
The Agreement will be open for applications for enrollment as described in the group master application.
Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health may
limit enrollment,establish quotas or set priorities for acceptance of new applications if it determines that Group
Health's capacity,in relation to its total enrollment, is not adequate to provide services to additional persons
C34613-0036900 4
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GroupHealth®
Group Health Cooperative
2013 Benefits Booklet
CA-1888a13,CA-3873,CA-224413,CA-3929,CA-381613,CA-370813,CA-3921
C346130036900
1
Table of Contents
I. Introduction...................................................................................................................................................4
H. How Covered Services Work........................................................................................................................4
AAccessing Care ... ...... . ............ ..... .... . ....................... ... .............. . .....................4
B Administration of the Benefits Booklet............................................................................................ .. .5
C. Confidentiality . ....................... . .......... . ..... ........................................ ......... . ....... ..................5
D. Modification of the Benefits Booklet....... ................................................. ....................................5
E. Nondiscrimination ....... ..........................................................................................5
F. Pre-existing Condition Waiting Period.................. .............................................................................5
GPreauthorizatron...... .............. ............ ... . ... ............................. .... .. ........5
H Recommended Treatment................. .. ....... ..... . ..............I..... .. ....... .. .. ..... ............6
I. Second Opinions .......................... .......... ................................ . .... .. ........ ...... ....6
J. Unusual Circumstances.... ... ........................................... .. .................................................. .............6
KUtilization Management .. .... .. .................... ........... I...................... . . . ................6
III. Financial Responsibilities.............................................................................................................................6
A Premium . .................... ...... ..... .........6
. . . . .... .. ... .. . . .. . . .
B. Financial Responsibilities for Covered Services . .. ... .. ........ . ............ .. ..........6
C. Financial Responsibilities for Non-Covered Services... . . ................................. . ..............7
IV. Benefits Details..............................................................................................................................................8
AnnualDeductible....... ..... ........... .. .................................. . . ....................... . . . .8
Coinsurance . .............................. . . .................................................................................. .... . .... ...8
LifetimeMaximum......................................... ..... .................................... ........ .... . ........... ........ 8
Out-of-pocket Limit............................. .............................. . ................... 8
Pre-existing Condition Waiting Period.... . ........................... . .... ................ .... 8
Acupuncture... . . . ............................... . . .. .. ............................ ....9
AllergyServices.............................................................................................................................................9
Ambulance........................ ............ ........ .................................. .. ............................. ........9
Cancer Screening and Diagnostic Services........ . .. . .................. ............................. .... .9
Chemical Dependency .. . ..................................... . .. ...... .. 9
Circumcision .................................................................................... ....................................................10
Dental Services and Dental Anesthesia......... . .................... . ........ ............................... ...............11
Devices,Equipment and Supplies(for home use) . .. ..... ... ......................................... . ... ............. .11
Diabetic Education,Equipment and Pharmacy Supplies............................. . ................ ... ........ ......... 12
Diagnostic Laboratory and Radiology.. ..... . .. ... .................................................................12
Drugs-Outpatient Prescription ................... . ............ .. . ............... .. .............. 12
EmergencyServices ............ ... . .. . .......................................................................14
Hearing Examinations and Hearing Aids . .............................................................................................14
HomeHealth Care .... ................. . ... . .................................. . .......................15
Hospice ...... .. ... ... .. 15
....... . .. . . ..... .... ......
Hospital-Inpatient and Outpatient..................... . ...............................................................................17
Infertility(including sterility) ............................... .. .. ....................................................................17
Manipulative Therapy ....... ..... ... ......... ... ........I...........I . .. 18
Maternityand Pregnancy.. .................................... ........... .................... .......................................... 18
MentalHealth .......................................................................................................................... .. 18
Naturopathy. ................ . ......... ............ ........... .. .. ........... 20
C34613-0036900 2
Newborn Services....................................... ................... ...... .. .... .. .. .........20
Nutritional Counseling. ................. . . .... ...... ...... .. ......... . . .. ...................... ....... ...20
Nutritional Therapy. ................................................ ........... . . ............ ..........20
Obesity Related Services ......................... ................ ...... ..... . ...... . .... .....21
On the Job Injuries or Illnesses................................. ... ...... ... ... 21
Oncology .. ........................ . ... . . .. ... ............. ............ . . . ................ . .21
Optical (vision)... ... . .. ..... ..... ........... .......... ........ . ............................ . . .. .. 22
OralSurgery .................. .. ..... .. ... . .... .. ........ ... ................ 22
Outpatient Services ....... .... . . ... ....... ..... ..............................23
Plastic and Reconstructive Surgery...................................... ........... . . ............ . 23
Podiatry . .............................. 23
Preventive Services. .... . ....... ... ..... .. . . ........ ........ .. .... .. ......... . ... .... 23
Rehabilitation(massage,occupational,physical and speech therapy)and Neurodevelopmental Therapy 24
Sexual Dysfunction . . .. . .......... . ....... ...... 25
Skilled Nursing Facility.. ..... ........................................... ............. . . ....... ...... . 25
Sterilization ............................... .. ....... . ... ... ............................................................... 25
Temporomandibular Joint(TMJ) ........ ......... . ...................... . .. ............................. 26
Tobacco Cessation ... .. .... .... .. ... . .... 26
Transplants ....................................................... ... .......... ... 27
UrgentCare ... ........ ................................................. . .. ...................... 27
V. General Exclusions......................................................................................................................................27
VI. Eligibility,Enrollment and Termination...................................................................................................29
A Eligibility . ... .... . . .. .... .. 29
B Application for Enrollment....................... ............ .. .......................................... . . 30
C When Coverage Begins . . ..... ..... . ...... ... .......... . . 31
D Eligibility for Medicare.. .. .. ... ...... ........ .. ...... ........ .................. ..........32
E. Termination of Coverage ... . ..... . .. . . ......................... .... .32
F. Continuation of Inpatient Services ....... . . . .. .. ... .. .............................. ... . ......... 33
G Continuation of Coverage Options ................ . . ............................................. ..... 33
VII. Complaints and Appeals.............................................................................................................................34
A Complaint Process ...................... . .. . ...... . . ... .... ... .............34
B Appeals Process ............... . ... .......I.... ..... .... ....... ..... ....... 35
VIII. Claims...........................................................................................................................................................36
IX. Coordination of Benefits.............................................................................................................................37
Definitions ...... ..... ... 37
Order of Benefit Determination Rules .. .......... ... .. ............ .................... . 39
Effect on the Benefits of this Plan ... .... ....... . .................. .... 40
Right to Receive and Release Needed Information ............. ....... 40
Facilityof Payment..... ....................................................... .. . ..................................40
Right of Recovery . ............... . ........ ........................ ....... .. 41
Effect of Medicare ..... . ...... 41
X. Subrogation and Reimbursement Rights..................................................................................................41
XI. Definitions....................................................................................................................................................42
C34613-0036900 3
Group Health believes this plan is a"grandfathered health plan"under the Patient Protection and Affordable Care
Act of 2010.Questions regarding this status may be directed to Group Health Customer Service at toll-free 1-888-
901-4636 Members may also contact the Employee Benefits Security Administration,U S Department of Labor at
toll-free 1-866-444-3272 or www dol aov/ebsa/healthreform.
I. Introduction
This Benefits Booklet is a statement of benefits,exclusions and other provisions as set forth in the Group medical
coverage agreement between Group Health Cooperative("Group Health")and the Group The benefits were
approved by the Group who contracts with Group Health for health care coverage This Benefits Booklet is not the
Group medical coverage agreement itself In the event of a conflict between the Group medical coverage agreement
and the benefits booklet,the benefits booklet language will govern
The provisions of the Benefits Booklet must be considered together to fully understand the benefits available under
the Benefits Booklet Words with special meaning are capitalized and are defined in Section XI
Contact Customer Service at 206-901-4636 or toll-free 1-888-901-4636 for benefits questions
I. R*6vered S "ice Work
A. Accessing Care.
1. Members are entitled to Covered Services from the following:
Members are entitled to Covered Services only at Network Facilities and from Network Providers,except
for Emergency services and care pursuant to a Preauthorization
A listing of Network Personal Physicians,specialists,women's health care providers and Group Health-
designated Specialists is available by contacting Customer Service or accessing the Group Health website
at www ehc ore
2. Primary Care Provider Services.
Group Health recommends that Members select a Network Personal Physician when enrolling One
personal physician may be selected for an entire family,or a different personal physician may be selected
for each family member Select or change Network Personal Physicians by contacting Customer Service or
accessing the Group Health website at www ehc org The change will be made within 24 hours of the
receipt of the request if the selected physician's caseload permits.
In the case that the Member's personal physician no longer participates in Group Health's network,the
Member will be provided access to the personal physician for up to 60 days following a written notice
offering the Member a selection of new personal physicians from which to choose.
3. Specialty Care Provider Services.
Unless otherwise indicated in Section II.or Section IV.,Preauthorization is required for specialty care and
specialists that are not Group Health-designated Specialists and are not providing care at facilities owned
and operated by Group Health.
Group Health-designated Specialist.
Members may make appointments with Group Health-designated Specialists at facilities owned and
operated by Group Health without Preauthorization The following specialty care areas are available from
Group Health-designated Specialists allergy,audiology,cardiology, chemical dependency,
chiropractic/manipulative therapy,dermatology,gastroenterology,general surgery,hospice,manipulative
therapy,mental health,nephrology,neurology,obstetrics and gynecology,occupational medicine,
oncology/hematology,ophthalmology,optometry,orthopedics,otolaryngology(ear,nose and throat),
physical therapy, smoking cessation, speech/language and learning services and urology.
C34613-0036900 4
4. Hospital Services.
Non-Emergency inpatient hospital services require Preauthorization Refer to Section IV for more
information about hospital services
5. Emergency Services.
Emergency services at a Network Facility or non-Network Facility are covered Members must notify
Group Health by way of the Group Health Emergency notification line within 24 hours of any admission,
or as soon thereafter as medically possible Coverage for Emergency services at a non-Network Facility is
limited to the Allowed Amount Refer to Section IV for more information about Emergency services
6. Urgent Care.
Inside the Group Health Service Area,urgent care is covered at a Group Health medical center,Group
Health urgent care center or Network Provider's office Outside the Group Health Service Area,urgent care
is covered at any medical facility Refer to Section IV for more information about urgent care.
7. Women's Health Care Direct Access Providers.
Female Members may see a general and family practitioner,physician's assistant,gynecologist,certified
nurse midwife, licensed midwife,doctor of osteopathy,pediatrician,obstetrician or advance registered
nurse practitioner who is contracted by Group Health to provide women's health care services directly,
without Preauthorization,for Medically Necessary maternity care,covered reproductive health sery ices,
preventive services(well care)and general examinations,gynecological care and follow-up visits for the
above services Women's health care services are covered as if the Member's Network Personal Physician
had been consulted,subject to any applicable Cost Shares If the Member's women's health care provider
diagnoses a condition that requires other specialists or hospitalization,the Member or her chosen provider
must obtain Preauthorization in accordance with applicable Group Health requirements
B. Administration of the Benefits Booklet.
Group Health may adopt reasonable policies and procedures to administer the Benefits Booklet This may
include,but is not limited to,policies or procedures pertaining to benefit entitlement and coverage
determinations.
C. Confidentiality.
Group Health is required by federal and state law to maintain the privacy of Member personal and health
information Group Health is required to provide notice of how Group Health may use and disclose personal
and health information held by Group Health The Notice of Privacy Practices is distributed to Members and is
available in Group Health medical centers,at www¢hc ora,or upon request from Customer Service
D. Modification of the Benefits Booklet.
No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of the
Benefits Booklet,convey or void any coverage,increase or reduce any benefits under the Benefits Booklet or be
used in the prosecution or defense of a claim under the Benefits Booklet
E. Nondiscrimination.
Group Health does not discriminate on the basis of physical or mental disabilities in its employment practices
and services Group Health will not refuse to enroll or terminate a Member's coverage on the basis of age,sex,
race,religion,occupation or health status
F. Pre-existing Condition Waiting Period.
Pre-existing conditions are covered with no waiting period A pre-existing condition is a condition for which
there has been diagnosis,treatment or medical advice within the 3 month period prior to the effective date of
coverage
G. Preauthorization.
Covered Services may require Preauthorization Refer to Section IV for more information Group Health
recommends that the provider requests Preauthorization Members may also contact Customer Service
Preauthorization requests are reviewed and approved based on Medical Necessity,eligibility and benefits.
C34613-0036900 5
a
H. Recommended Treatment.
Group Health's medical director will determine the necessity,nature and extent of treatment to be covered in
each individual case and the judgment,made in good faith,will be final Members have the right to participate
in decisions regarding their health care A Member may refuse any recommended treatment or diagnostic plan
to the extent permitted by law Members who obtain care not recommended by Group Health's medical director
do so with the full understanding that Group Health has no obligation for the cost,or liability for the outcome,
of such care Coverage decisions may be appealed
I. Second Opinions.
The Member may access,upon request,a second opinion from a Network Provider regarding a medical
diagnosis or treatment plan The Member may request Preauthorization or may visit a Group Health-designated
Specialist for a second opinion When requested or indicated,second opinions are provided by Network
Providers and are covered with Preauthorization,or when obtained from a Group Health-designated Specialist.
Coverage is determined by the Member's Benefits Booklet,therefore,coverage for the second opinion does not
imply that the services or treatments recommended will be covered Preauthorization for a second opinion does
not imply that Group Health will authorize the Member to return to the physician providing the second opinion
for any additional treatment Services,drugs and devices prescribed or recommended as a result of the
consultation are not covered unless included as covered under the Benefits Booklet
J. Unusual Circumstances.
In the event of unusual circumstances such as a major disaster,epidemic,military action,civil disorder,labor
disputes or similar causes,Group Health will not be liable for administering coverage beyond the limitations of
available personnel and facilities
In the event of unusual circumstances such as those described above,Group Health will make a good faith
effort to arrange for Covered Services through available Network Facilities and personnel Group Health shall
have no other liability or obligation if Covered Services are delayed or unavailable due to unusual
circumstances
K. Utilization Management.
All benefits are limited to Covered Services that are Medically Necessary and set forth in the Benefits Booklet.
Group Health may review a Member's medical records for the purpose of verifying delivery and coverage of
services and items Based on a prospective,concurrent or retrospective review,Group Health may deny
coverage if,in its determination,such services are not Medically Necessary and,in the case of services provided
by non-Network Providers,within the Allowed Amount Such determination shall be based on established
clinical criteria
Group Health will not deny coverage retroactively for services with Preauthorization and which have already
been provided to the Member
rI. Financial Responsibilities
A. Premium.
The Subscriber is liable for payment to the Group of his/her contribution toward the monthly premium,if any.
B. Financial Responsibilities for Covered Services.
The Subscriber is liable for payment of the following Cost Shares for Covered Services provided to the
Subscriber and his/her Dependents Payment of an amount billed must be received within 30 days of the billing
date Charges will be for the lesser of the Cost Shares for the Covered Service or the actual charge for that
service Cost Shares will not exceed the actual charge for that service
1. Annual Deductible.
Covered Services may be subject to an annual Deductible Charges subject to the annual Deductible shall
be borne by the Subscriber during each year until the annual Deductible is met Covered Services must be
C34613-0036900 6
received from a Network Provider at a Network Facility,unless the Member has received Preauthorization
or has received Emergency services
There is an individual annual Deductible amount for each Member and a maximum aggregate annual
Deductible amount for each Family Unit Once the aggregate annual Deductible amount is reached for a
Family Unit in a calendar year,the individual annual Deductibles are also deemed reached for each
Member during that same calendar year
Individual Annual Deductible Carryover.Under this Benefits Booklet,charges from the last 3 months of
the prior year which were applied toward the individual annual Deductible will also apply to the current
year individual annual Deductible The individual annual Deductible carryover will apply only when
expenses incurred have been paid in full The aggregate Family Unit Deductible does not carry over into
the next year
2. Coinsurance.
a Plan Coinsurance.
After the applicable annual Deductible is satisfied,Members may be required to pay Plan Coinsurance
for Covered Services
b Benefit-speciffe Coinsurance.
A benefit-specific coinsurance may apply to some Covered Services.Covered Services that are subject
to the benefit-specific coinsurance are not subject to the Plan Coinsurance.
3. Copayments.
Members shall be required to pay applicable Copayments at the time of service.Payment of a Copayment
does not exclude the possibility of an additional billing if the service is determined to be a non-Covered
Service or if other Cost Shares apply
4. Out-of-pocket Limit.
Out-of-pocket Expenses which apply toward the Out-of-pocket Limit are set forth in Section IV.Total Out-
of-pocket Expenses incurred during the same calendar year shall not exceed the Out-of-pocket Limit
C. Financial Responsibilities for Non-Covered Services.
The cost of non-Covered Services and supplies is the responsibility of the Member The Subscriber is liable for
payment of any fees charged for non-Covered Services provided to the Subscriber and his/her Dependents at the
time of service Payment of an amount billed must be received within 30 days of the billing date
C34613-0036900 7
IV. Benefits Details
Benefits are subject to all provisions of the Benefits Booklet.Members are entitled only to receive benefits and
services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as
determined by Group Health's medical director and as described herein All Covered Services are subject to case
management and utilization management at the discretion of Group Health
Annual Deductible Member pays$0 per Member or$0 per Family Unit per calendar year
Coinsurance Plan Coinsurance: Member pays nothing
Benefit-specific Coinsurance:A benefit-specific coinsurance may apply to some Covered
Services
Lifetime Maximum No Lifetime Maximum on covered Essential Health Benefits
Out-of-pocket Limit Limited to an aggregate maximum of$2,000 per Member or$4,000 per Family Unit per
calendar year
The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: Ambulance
coinsurance/Copayment,diagnostic laboratory and radiology Copayment,Emergency
services Copayment,hospital inpatient Copayment,hospital outpatient Copayment,
outpatient services Copayment,oral chemotherapy Copayment
The following expenses do not apply to the Out-of-pocket Limit: Benefit-specific
coinsurances,prescription drug Copayment,premiums,charges for services in excess of
benefit level,charges in excess of Allowed Amount,charges for non-Covered Services
Pre-existing Condition No pre-existing condition waiting period
Waiting Period
C34613-0036900 g
Acupuncture
Acupuncture needle treatment. Member pays$10 Copayment
Limited to 8 visits per medical diagnosis per calendar year.
Additional visits are covered with Preauthorization
Exclusions:Herbal supplements,any services not within the scope of the practitioner's licensure
Allergy Services
Allergy testing,serum and injections Member pays$10 Copayment
Ambulance
Emergency ground or air transport to any facility. Member pays 20%ambulance coinsurance
Non-Emergency ground or air interfacility transfer to or from Member pays 20%ambulance coinsurance
a Network Facility when initiated by Group Health
Hospital-to-hospital ground transfers:No charge,
Member pays nothing
Cancer Screening and Diagnostic Services
Routine cancer screening covered as Preventive Services in Member pays$10 Copayment
accordance with the well care schedule established by Group
Health and the Patient Protection and Affordable Care Act of
2010 The well care schedule is available in Group Health
medical centers,at vvluw ahe org,or upon request from
Customer Service See Preventive Services for additional
information
Diagnostic laboratory and diagnostic services for cancer See No charge,Member pays nothing
Diagnostic Laboratory and Radiology Services for additional
information Preventive diagnostic laboratory/services are
covered as Preventive Services
Chemical Dependency
Chemical dependency services including inpatient Residential Hospital-Inpatient:No charge,Member pays
Treatment,diagnostic evaluation and education,organized nothing
individual and group counseling, and/or prescription drugs
unless excluded under the Benefits Booklet. Outpatient Services: Member pays$10 Copayment
Chemical dependency means an illness characterized by a
physiological or psychological dependency,or both,on a
C34613-0036900 9
controlled substance and/or alcoholic beverages,and where
the user's health is substantially impaired or endangered or
his/her social or economic function is substantially disrupted
For the purposes of this section,the definition of Medically
Necessary shall be expanded to include those services
necessary to treat a chemical dependency condition that is
having a clinically significant impact on a Member's
emotional,social,medical and/or occupational functioning.
Chemical dependency services must be provided at a Group
Health-approved treatment facility or treatment program.
Court-ordered chemical dependency treatment shall be
covered only if determined to be Medically Necessary
Non-Emergency inpatient hospital services require
Preauthorization
Acute chemical withdrawal(detoxification)services for Emergency Services Network Facility: Member
alcoholism and drug abuse "Acute chemical withdrawal" pays$75 Copayment
means withdrawal of alcohol and/or drugs from a Member for
whom consequences of abstinence are so severe that they Emergency Services Non-Network Facility:
require medical/nursing assistance in a hospital setting,which Member pays$125 Copayment
is needed immediately to prevent serious impairment to the
Member's health Hospital-Inpatient: No charge;Member pays
nothing
Coverage for acute chemical withdrawal(detoxification)is
provided without Preauthorization Members must notify
Group Health by way of the Group Health Emergency
notification line within 24 hours of any admission,or as soon
thereafter as medically possible
Group Health reserves the right to require transfer of the
Member to a Network Facility/program upon consultation
between a Network Provider and the attending physician If
the Member refuses transfer to a Network Facility/program,
all further costs incurred during the hospitalization are the
responsibility of the Member
Circumcision
Circumcision. Hospital-Inpatient:No charge,Member pays
nothing
Non-Emergency inpatient hospital services require
Preauthorization. Hospital-Outpatient: Member pays$10
Copayment
Outpatient Services:Member pays$10 Copayment
C34613-0036900 10
Dental Services and Dental Anesthesia
Dental services including accidental injury to natural teeth Not covered,Member pays 100%of all charges
Group Health's medical director will determine whether the
care or treatment required is within the category of Oral
Surgery or Dental Services
General anesthesia services and related facility charges for Hospital-Inpatient: No charge,Member pays
dental procedures for Members who are under 7 years of age, nothing
or are physically or developmentally disabled or have a
Medical Condition where the Member's health would be put Hospital-Outpatient:Member pays$10
at risk if the dental procedure were performed in a dentist's Copayment
office
General anesthesia services for dental procedures require
Preauthorization
Exclusions:Dentist's or oral surgeon's fees,dental care,surgery,services and appliances,including treatment of
accidental injury to natural teeth,reconstructive surgery to the jaw in preparation for dental implants,dental implants,
periodontal surgery, any other dental service not specifically listed as covered
Devices,Equipment and Supplies(for home use)
• Durable medical equipment Equipment which can Member pays 20%benefit-specific coinsurance
withstand repeated use,is primarily and customarily used
to serve a medical purpose,is useful only in the presence
of an illness or injury and is used in the Member's home
Durable medical equipment includes hospital beds,
wheelchairs,walkers,crutches,canes,blood glucose
monitors,external insulin pumps(including related
supplies such as tubing,syringe cartridges,cannulae and
inserters),oxygen and oxygen equipment,and
therapeutic shoes,modifications and shoe inserts for
severe diabetic foot disease Group Health will determine
if equipment is made available on a rental or purchase
basis
• Orthopedic appliances Items attached to an impaired
body segment for the purpose of protecting the segment
or assisting in restoration or improvement of its function
• Ostomy supplies Supplies for the removal of bodily
secretions or waste through an artificial opening
• Post-mastectomy bras limited to 2 ever} 6 months
• Prosthetic devices Items which replace all or part of an
external body part,or function thereof
When provided in lieu of hospitalization,benefits will be the
greater of benefits available for devices,equipment and
supplies,home health or hospitalization See Hospice for
durable medical equipment provided in a hospice setting
Devices,equipment and supplies including repair,adjustment
C34613-0036900 11
or replacement of appliances and equipment require
Preauthorization
Exclusions: Arch supports,including custom shoe modifications or inserts and their fittings,orthopedic shoes that are
not attached to an appliance,take-home dressings and supplies following hospitalization,supplies,dressings,
appliances,devices or services not specifically listed as covered above, same as or similar equipment already in the
Member's possession,replacement or repair due to loss,theft,breakage from willful damage,neglect or wrongful use,
or due to personal preference
Diabetic Education,Equipment and Pharmacy Supplies
Diabetic education and training. Member pays$10 Copayment
Diabetic equipment.Blood glucose monitors and external Member pays 20%benefit-specific coinsurance
insulin pumps(including related supplies such as tubing,
syringe cartridges,cannulae and inserters),and therapeutic
shoes,modifications and shoe inserts for severe diabetic foot
disease See Devices,Equipment and Supplies for additional
information
Diabetic pharmacy supplies-Insulin,lancets,lancet devices, Generic drugs listed in the GHO drug formulary
needles,insulin syringes,insulin pens,pen needles,glucagon (Tier 1): Member pays$10 Copayment
emergency kits,prescriptive oral agents and blood glucose
test strips for a supply of 30 days or less See Drugs— Brand name drugs listed in the GHO drug
Outpatient Prescription for additional pharmacy information. formulary(Tier 2):Member pays$10 Copayment
Certain brand name insulin drugs will be covered at the
generic level Non-formulary generic and brand name drugs
(Tier 3):Not covered,Member pays 100%of all
Charges
Diagnostic Laboratory and Radiology
Diagnostic x-ray,nuclear medicine,ultrasound and laboratory No charge,Member pays nothing
services.
Services received as part of an emergency visit are covered as
Emergency Services.
High end radiology imaging services such as CT,MR and
PET require Preauthorization except when associated with
Emergency services or inpatient services
Drugs-Outpatient Prescription
Prescription drugs,supplies and devices for a supply of 30 Generic drugs listed in the GHO drug formulary
days or less including diabetic pharmacy supplies(insulin, (Tier 1)•Member pays$10 Copayment
lancets,lancet devices,needles,insulin syringes,insulin pens,
pen needles and blood glucose test strips),contraceptive Brand name drugs listed in the GHO drug
drugs and devices,mental health drugs and self-administered formulary(Tier 2):Member pays$10 Copayment
C34613-0036900 12
mlectables All drugs,supplies and devices must be for
Covered Services Non-formulary generic and brand name drugs
(Tier 3):Not covered,Member pays 100%of all
All drugs,supplies and devices must be obtained at a Group charges
Health-designated pharmacy except for drugs dispensed for
Emergency services
Prescription drug Cost Shares are payable at the time of
delivery Certain brand name insulin drugs are covered at the
generic drug Cost Share.
Injections administered by a professional in a clinical setting. Member pays$10 Copayment
Over-the-counter drugs. Not covered,Member pays 100%of all charges
Mail order drugs dispensed through the Group Health- Member pays the prescription drug Cost Share for
designated mad order service each 30 day supply or less
Prescription drugs are drugs which have been approved by the Food and Drug Administration(FDA)and which can,
under federal or state law,be dispensed only pursuant to a prescription order These drugs, including off-label use of
FDA-approved drugs(provided that such use is documented to be effective in one of the standard reference
compendia,a majority of well-designed clinical trials published in peer-reviewed medical literature document
improved efficacy or safety of the agent over standard therapies,or over placebo if no standard therapies exist,or by
the federal secretary of Health and Human Services)are covered "Standard reference compendia"means the
American Hospital Formulary Service—Drug Information,the American Medical Association Drug Evaluation,the
United States Pharmacopoeia—Drug Information,or other authoritative compendia as identified from time to time by
the federal secretary of Health and Human Services "Peer-reviewed medical literature"means scientific studies
printed in health care journals or other publications in which original manuscripts are published only after having been
critically reviewed for scientific accuracy,validity and reliability by unbiased independent experts Peer-reviewed
medical literature does not include in-house publications of pharmaceutical manufacturing companies
The Group Health drug formulary is a list of preferred pharmaceutical products,supplies and devices developed and
maintained by Group Health Generic drugs are dispensed whenever available A generic drug is a drug that is the
pharmaceutical equivalent to one or more brand name drugs Such generic drugs have been approved by the Food and
Drug Administration as meeting the same standards of safety,purity, strength and effectiveness as the brand name
drug Brand name drugs are dispensed if there is not a generic equivalent In the event the Member elects to purchase
a brand-name drug instead of the generic equivalent(if available),and it is not Medically Necessary,the Member is
responsible for paying the difference in cost in addition to the prescription drug Cost Share.
Drug coverage is subject to utilization management that includes Preauthorization,step therapy,limits on drug
quantity or days supply and prevention of overutdization,underutilization,therapeutic duplication,drug-drug
interactions,incorrect drug dosage,drug-allergy contraindications and clinical abuse misuse of drugs
The Member's Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure
safe and effective pharmacy services,and to guarantee Members' right to know what drugs are covered and the
coverage limitations Members who would like more information about the drug coverage policies,or have a question
or concern about their pharmacy benefit,may contact Group Health at 206-901-4636 or toll-free 1-888-901-4636 or
by accessing the Group Health website at www¢hc org
Members who would like to know more about their rights under the law,or think any services received while enrolled
may not conform to the terms of the Benefits Booklet,may contact the Washington State Office of Insurance
Commissioner at toll-free 1-800-562-6900 Members who have a concern about the pharmacists or pharmacies
serving them may call the Washington State Department of Health at toll-free 1-800-525-0127
C34613-0036900 13
Prescription Drug Coverage and Medicare: This benefit,for purposes of creditable coverage,is actuarially equal to
or greater than the Medicare Part D prescription drug benefit Members who are also eligible for Medicare Part D can
remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a
Medicare Part D plan at a later date A Member who discontinues coverage must meet eligibility requirements in
order to re-enroll
Exclusions: Over-the-counter drugs,supplies and devices not requiring a prescription under state law or regulations,
drugs and injections for anticipated illness while traveling,drugs and injections for cosmetic purposes,vitamins,
including most prescription vitamins,replacement of lost or stolen drugs or devices,administration of excluded drugs
and injectables,drugs used in the treatment of sexual dysfunction disorders
Emergency Services
Emergency services at a Network Facility or non-Network Network Facility:Member pays$75 Copayment
Facility See Section XI for a definition of Emergency
Non-Network Facility:Member pays$125
Members must notify Group Health by way of the Group Copayment
Health Emergency notification line within 24 hours of any
admission,or as soon thereafter as medically possible.
If a Member is admitted as an inpatient directly from a
Network Facility emergency department,any Emergency
services Copayment is waived Coverage is subject to the
hospital services Cost Share.
If two or more Members in the same Family Unit require
Emergency services as a result of the same accident,coverage
for all Members will be subject to only one Emergency
services Copayment
If a Member is hospitalized in a non-Network Facility,Group
Health reserves the right to require transfer of the Member to
a Network Facility upon consultation between a Network
Provider and the attending physician If the Member refuses
to transfer to a Network Facility or does not notify Group
Health within 24 hours following admission,all further costs
incurred during the hospitalization are the responsibility of
the Member.
Follow-up care which is a direct result of the Emergency must
be received from a Network Provider,unless Preauthorization
is obtained for such follow-up care from a non-Network
Provider
Hearing Examinations and Hearing Aids
Hearing examinations to determine hearing loss Member pays$10 Copayment
Hearing aids including hearing aid examinations Not covered;Member pays 100%of all charges
Exclusions:Hearing devices and hearing aids,including related examinations
C34613-0036900 14
Home Health Care
Home health care when the following criteria are met No charge,Member pays nothing
• The Member is unable to leave home due to his/her
health problem or illness Unwillingness to travel and/or
arrange for transportation does not constitute inability to
leave the home
• The Member requires intermittent skilled home health
care,as described below
• Group Health's medical director determines that such
services are Medically Necessary and are most
appropriately rendered in the Member's home
Covered Services for home health care may include the
following when rendered pursuant to a Group Health-
approved home health care plan of treatment nursing care;
restorative physical,occupational,respiratory and speech
therapy,durable medical equipment and medical social
worker and limited home health aide services
Home health services are covered on an intermittent basis in
the Member's home "Intermittent'means care that is to be
rendered because of a medically predictable recurring need
for skilled home health care "Skilled home health care"
means reasonable and necessary care for the treatment of an
illness or injury which requires the skill of a nurse or
therapist,based on the complexity of the service and the
condition of the patient and which is performed directly by an
appropriately licensed professional provider.
Home health care requires Preauthorization.
Exclusions:Private duty or continuous nursing care in the Member's home,housekeeping or meal services,any care
provided by or for a family member,any other services rendered in the home which do not meet the definition of
skilled home health care above
Hospice
Hospice care in lieu of curative treatment for terminal illness No charge,Member pays nothing
when the following criteria are met
• A physician has determined that the Member's illness is
terminal and life expectancy is 6 months or less
• The Member has chosen a palliative treatment focus
(emphasizing comfort and supportive services rather than
treatment aimed at curing the Members terminal illness)
• The Member has elected in writing to receive hospice
care through a hospice program
• The Member has available a primary care person who
will be responsible for the Member's home care
• A physician and the hospice agency have determined that
the Member's illness can be appropriately managed in
the home
C34613-0036900 15
Hospice care shall mean a coordinated program of palliative
and supportive care for dying Members by an
interdisciplinary team of professionals and volunteers
centering primarily in the Member's home
Care may include the following as prescribed by a physician
and rendered pursuant to a Group Health-approved hospice
plan of treatment
Home Services. Intermittent care by a hospice
interdisciplinary team which may include services by a
physician,nurse,medical social worker,physical therapist,
speech therapist,occupational therapist,respiratory therapist,
limited services by a home health aide under the supervision
of registered nurse and homemaker services
Continuous care services in the Member's home when
prescribed by a physician "Continuous care"means skilled
nursing care provided in the home during a period of crisis in
order to maintain the terminally ill Member at home
Continuous care may be provided for pain or symptom
management by a registered nurse,licensed practical nurse or
home health aide under the supervision of a registered nurse
Continuous care is covered up to 24 hours per day during
periods of crisis Continuous care is covered only when a
physician determines that the Member would otherwise
require hospitalization in an acute care facility
Inpatient Hospice Services.For short-term care,inpatient
hospice services are covered with Preauthorization
Inpatient respite care is covered for a maximum of 5
consecutive days per occurrence in order to continue care for
the Member in the temporary absence of the Member's
primary care giver(s).
Other covered hospice services may include the following:
• Drugs and biologicals that are used primarily for the
relief of pain and symptom management
• Medical appliances and supplies primarily for the relief
of pain and symptom management
• Durable medical equipment.
• Counseling services for the Member and his/her primary
care-giver(s)
• Bereavement counseling services for the family.
Hospice care requires Preauthorization.
Exclusions:Financial or legal counseling services,meal services,any services provided by family members
C34613-0036900 16
Hospital-Inpatient and Outpatient
The following inpatient medical and surgical services are Hospital-Inpatient:No charge,Member pays
covered nothing
• Room and board,including private room when
prescribed,and general nursing services Hospital-Outpatient:Member pays$10
• Hospital services(including use of operating room, Copayment
anesthesia,oxygen,x-ray,laboratory and radiotherapy
services)
• Drugs and medications administered during confinement
• Medical implants
• Acute chemical withdrawal(detoxification).
Outpatient hospital includes ambulatory surgical centers.
Alternative care arrangements may be covered as a cost-
effective alternative in lieu of otherwise covered Medically
Necessary hospitalization or other Medically Necessary
institutional care Alternative care arrangements in lieu of
covered hospital or other institutional care must be
determined to be appropriate and Medically Necessary based
upon the Member's Medical Condition Such care is covered
to the same extent the replaced Hospital Care is covered
Alternative care arrangements require Preauthorization
Members receiving the following nonscheduled services are
required to notify Group Health by way of the Group Health
Emergency Notification Line within 24 hours following any
admission,or as soon thereafter as medically possible acute
chemical withdrawal(detoxification)services,Emergency
psychiatric services,Emergency services,labor and delivery
and inpatient admissions needed for treatment of Urgent
Conditions that cannot reasonably be delayed until
Preauthorization can be obtained.
Coverage for Emergency services in a non-Network Facility
and subsequent transfer to a Network Facility is set forth in
Emergency Services
Non-Emergency inpatient hospital services require
Preauthorization
Exclusions:Take home drugs,dressings and supplies following hospitalization, internally implanted insulin pumps,
artificial hearts,artificial larynx and any other implantable device that have not been approved by Group Health's
medical director
Infertility(including sterility)
General counseling and diagnostic services Not covered,Member pays 100%of all charges
Specific diagnostic services,treatment and prescription drugs Not covered,Member pays 100%of all charges
C34613-0036900 17
Exclusions: Diagnostic testing and medical treatment of sterility and infertility regardless of origin or cause,all
charges and related services for donor materials,all forms of artificial intervention including artificial insemination
and in-vitro fertilization,surrogacy
Manipulative Therapy
Manipulative therapy of the spine and extremities when in Member pays$10 Copayment
accordance with Group Health clinical criteria,limited to a
combined total of 10 visits per calendar year.
Exclusions: Supportive care rendered primarily to maintain the level of correction already achieved,care rendered
primarily for the convenience of the Member,care rendered on a non-acute,asymptomatic basis,charges for any other
services that do not meet Group Health clinical criteria as Medically Necessary
Maternity and Pregnancy
Maternity care and pregnancy services, including care for Hospital-Inpatient:No charge,Member pays
complications of pregnancy and prenatal and postpartum care nothing
Delivery and associated Hospital Care,including home births Hospital-Outpatient: Member pays$10
and birthing centers Copayment
Members must notify Group Health by way of the Group Outpatient Services:Member pays$10 Copayment
Health Emergency notification line within 24 hours of any
admission,or as soon thereafter as medically possible The
Member's physician,in consultation with the Member,will
determine the Member's length of inpatient stay following
delivery.
Prenatal testing for the detection of congenital and heritable
disorders when Medically Necessary as determined by Group
Health's medical director and in accordance with Board of
Health standards for screening and diagnostic tests during
pregnancy
Termination of pregnancy. Hospital-Inpatient:No charge,Member pays
nothing
Non-Emergency inpatient hospital services require
Preauthorization Hospital-Outpatient: Member pays$10
Copayment
Outpatient Services:Member pays$10 Copayment
Exclusions:Birthing tubs;genetic testing of non-Members for the detection of congenital and heritable disorders;
fetal ultrasound in the absence of medical indications
Mental Health
Mental health services,limited to when the reduction or Hospital-Inpatient:No charge,Member pays
removal of acute clinical symptoms or stabilization can be nothing
C34613-0036900 18
expected given the most clinically appropriate level of mental
health care intervention as determined by Group Health's Hospital-Outpatient:Member pays$10
medical director Treatment may utilize psychiatric, Copayment
psychological and/or psychotherapy services to achieve these
objectives Outpatient Services:Member pays$10 Copayment
Mental health services including medical management and
prescriptions are covered the same as for any other condition.
Applied behavioral analysis(ABA)therapy,limited to
outpatient treatment of an autism spectrum disorder as
diagnosed and prescribed by a neurologist,pediatric
neurologist,developmental pediatrician,psychologist or
psychiatrist experienced in the diagnosis and treatment of
autism Documented diagnostic assessments,individualized
treatment plans and progress evaluations are required
Outpatient electro-convulsive therapy treatment is covered
subject to the hospital-outpatient Cost Share
Services for any involuntary court-ordered treatment program
beyond 72 hours shall be covered only if determined to be
Medically Necessary by Group Health's medical director
Services provided under involuntary commitment statutes are
covered only at Group Health-approved facilities.
Coverage for voluntary/involuntary Emergency inpatient
psychiatric services is subject to the Emergency services
benefit Coverage for services incurred at non-Network
Facilities shall exclude any charges that would otherwise be
excluded for hospitalization within aNetwork Facility
Members must notify Group Health by way of the Group
Health Emergency notification line within 24 hours of any
admission,or as soon thereafter as medically possible
Mental health services are limited to the services rendered by
a physician(licensed under RCW 18 71 and RCW 18 57),a
psychologist(licensed under RCW 18 93),a community
mental health agency licensed by the Washington State
Department of Social and Health Services(pursuant to RCW
71.24),a master's level therapist(licensed under RCW
18 225 090),an advance practice psychiatric nurse(licensed
under RCW 18 79)or,in the case of non-Washington State
providers,those providers meeting equivalent licensing and
certification requirements established in the state where the
provider's practice is located
Inpatient mental health services must be provided at a
hospital or facility that Group Health has approved
specifically for the treatment of mental or nervous disorders
Non-Emergency inpatient hospital services require
Preauthonzation
C34613-0036900 19
Exclusions: Inpatient Residential Treatment services. learning,communication and motor skills disorders, academic
or career counseling,sexual and identity disorders,personal growth or relationship enhancement,assessment and
treatment services that are primarily vocational and academic,court-ordered or forensic treatment,including reports
and summaries,not considered Medically Necessary, work or school ordered assessment and treatment not considered
Medically Necessary,counseling for overeating,specialty treatment programs such as"behavior modification
programs",relationship counseling or phase of life problems(V code only diagnoses),custodial care
Naturopathy
Naturopathy Member pays$10 Copayment
Limited to 3 visits per medical diagnosis per calendar year
Additional visits are covered with Preauthorization.
Laboratory and radiology services are covered only when
obtained through a Network Facility
Exclusions:Herbal supplements, nutritional supplements;any services not within the scope of the practitioner's
licensure
Newborn Services
Newborn services are covered the same as for any other Hospital-Inpatient: No charge,Member pays
condition Any Cost Share for newborn services is separate nothing
from that of the mother.
During the baby's initial hospital stay while the birth
Preventive services for newborns are covered under mother and baby are both confined,any applicable
Preventive Services Deductible and Copayment for the newborn are
See Section VLA 3.for information about temporary waived
coverage for newborns Hospital-Outpatient:Member pays$10
Copayment
Outpatient Services:Member pays$10 Copayment
Nutritional Counseling
Nutritional counseling. Member pays$10 Copayment
Exclusions:Nutritional supplements,weight loss programs,pre and post bariatric surgery nutritional counseling
Nutritional Therapy
Dietary formula for the treatment of phenylketonuria(PKU) No charge,Member pays nothing
C34613-0036900 20
Enteral therapy(elemental formulas)for malabsorption. Member pays 20%benefit-specific coinsurance
Necessary equipment and supplies for the administration of
enteral therapy are covered as Devices,Equipment and
Supplies.
Parenteral therapy(total parenteral nutrition) No charge,Member pays nothing
Necessary equipment and supplies for the administration of
parenteral therapy are covered as Devices,Equipment and
Supplies
Exclusions:Any other dietary formulas or medical foods;coral nutritional supplements, special diets,prepared
foods/meals and formula for access problems
Obesity Related Services
Banatric surgery and related hospitalizations when Group Hospital-Inpatient:No charge,Member pays
Health criteria are met. nothing
Obesity Related Services require Preauthonzation Hospital-Outpatient:Member pays$10
Copayment
Outpatient Services:Member pays$10 Copayment
Exclusions: Obesity treatment and treatment for morbid obesity including any medical services,drugs or supplies,
regardless of co-morbidities,specialty treatment programs such as weight reduction,medications and related
physician visits for medication monitoring,pre and post banatnc surgery nutritional counseling
On the Job Injuries or Illnesses
On the lob injuries or illnesses Hospital-Inpatient:Not covered,Member pays
100%of all charges
Hospital-Outpatient:Not covered.Member pays
100%of all charges
Outpatient Services:Not covered;Member pays
100%of all charges
Exclusions:Confinement,treatment or service that results from an illness or injury arising out of or in the course of
any employment for wage or profit including injuries, illnesses or conditions incurred as a result of self-employment
Oncology
Radiation therapy,chemotherapy,oral chemotherapy. Member pays$10 Copayment
C34613-0036900 21
Formulary oral chemotherapy:
Generic drugs listed in the GHO drug formulary
(Tier 1): Member pays$10 Copayment
Brand name drugs listed in the GHO drug
formulary(Tier 2):Member pays$10 Copayment
Non-formulary generic and brand name drugs
(Tier 3):Not covered,Member pays 100%of all
charges
Optical(vision)
Routine eye examinations and refractions,limited to once Routine Exams: Member pays$10 Copayment
every 12 months.
Exams for Eye Pathology: Member pays$10
Eye and contact lens examinations for eye pathology and to Copayment
monitor Medical Conditions,as often as Medically
Necessary
Contact lenses for eye pathology. Frames and Lenses: Not covered;Member pays
100%of all charges
One contact lens per diseased eye in lieu of an intraocular
lens is covered following cataract surgery provided the Contact Lenses for Eye Pathology: No charge;
Member has been continuously covered by Group Health Member pays nothing
since such surgery Replacement of lenses for eye pathology,
including following cataract surgery, is covered only once
within a 12 month period and only when needed due to a
change in the Member's prescnption.
Exclusions:Eyeglasses;contact lenses,contact lens evaluations,fittings and examinations not related to eye
pathology;orthoptic therapy(i a eye training),evaluations and surgical procedures to correct refractions not related
to eye pathology and complications related to such procedures
Oral Surgery
Reduction of a fracture or dislocation of the law or facial Hospital-Inpatient:No charge,Member pays
bones,excision of tumors or non-dental cysts ofthejaw, nothing
cheeks,lips,tongue,gums,roof and floor of the mouth,and
incision of salivary glands and ducts Hospital-Outpatient:Member pays$10
Copayment
Group Health's medical director will determine whether the
care or treatment required is within the category of Oral Outpatient Services:Member pays$10 Copayment
Surgery or Dental Services
Oral surgery requires Preauthorization
Exclusions: Care or repair of teeth or dental structures of any type,tooth extractions or impacted teeth, services
related to malocclusion, services to correct the misalignment or malposition of teeth, any other services to the mouth,
facial bones or teeth which are not medical in nature
C34613-0036900 22
Outpatient Services
Covered outpatient medical and surgical services in a Member pays$10 Copayment
provider's office
See Hospital-Inpatient and Outpatient for outpatient hospital
medical and surgical services,including ambulatory surgical
centers
Plastic and Reconstructive Surgery
Plastic and reconstructive services Hospital-Inpatient:No charge,Member pays
• Correction of a congenital disease or congenital anomaly nothing
A congenital anomaly is considered to exist if the
Member's appearance resulting from such condition is Hospital-Outpatient:Member pays$10
not within the range of normal human variation. Copayment
• Correction of Medical Condition following an injury or
resulting from surgery covered by Group Health which Outpatient Services: Member pays$10 Copayment
has produced a major effect on the Member's
appearance,when in the opinion of Group Health's
medical director such services can reasonably be
expected to correct the condition
• Reconstructive surgery and associated procedures,
including internal breast prostheses,following a
mastectomy,regardless of when the mastectomy was
performed Members are covered for all stages of
reconstruction on the non-diseased breast to make it
equivalent in size with the diseased breast Complications
of covered mastectomy services,including lymphedemas,
are covered
Plastic and reconstructive surgery requires Preauthorization.
Exclusions: Cosmetic services including treatment for complications resulting from cosmetic surgery;cosmetic
surgery,complications of non-Covered Services
Podiatry
Medically Necessary foot care Member pays$10 Copayment
Exclusions:Routine foot care except in the presence of a non-related Medical Condition affecting the lower limbs
Preventive Services
Preventive services in accordance with the well care schedule Member pays$10 Copayment
established by Group Health and the Patient Protection and
Affordable Care Act of 2010 The well care schedule is
available in Group Health medical centers,at www ehc ore,
or upon request from Customer Service
C34613-0036900 23
Preventive services include,but are not limited to,well adult
and well child physical examinations,immunizations and
vaccinations,pap smears,routine mammography screening
and routine prostate/colorectal cancer screening
Services provided during a preventive services visit, including
laboratory services,which are not in accordance with the
Group Health well care schedule are subject to Cost Shares.
Eye refractions are not included under preventive services.
Exclusions: Those parts of an examination and associated reports and immunizations required for employment,
immigration,license,travel or insurance purposes that are not deemed Medically Necessary by Group Health for early
detection of disease,diagnostic services
Rehabilitation(massage,occupational,physical and
speech therapy)and Neurodevelopmental Therapy
Rehabilitation services to restore function following illness, Hospital-Inpatient:No charge,Member pays
injury or surgery,limited to the following restorative nothing
therapies occupational therapy,physical therapy,massage
therapy and speech therapy Services are limited to those Outpatient Services:Member pays$10 Copayment
necessary to restore or improve functional abilities when
physical,Benson-perceptual and/or communication
impairment exists due to injury,illness or surgery Outpatient
services require a prescription or order from a physician that
reflects a written plan of care to restore function,and must be
provided by a rehabilitation team that may include a
physician,nurse,physical therapist,occupational therapist,
massage therapist or speech therapist
Neurodevelopmental therapy for neurodevelopmentally
disabled children under the age of 7 to restore or improve
function including maintenance in cases where significant
deterioration in the child's condition would result without the
services,limited to the following therapies occupational
therapy,physical therapy and speech therapy.
Limited to a combined total of 60 inpatient days and 60
outpatient visits per calendar year for all Rehabilitation and
Neurodevelopmental Therapy services.
Non-Emergency inpatient hospital services and massage
therapy require Preauthorization
Exclusions: Specialty treatment programs such as cardiac rehabilitation;inpatient Residential Treatment services,
specialty rehabilitation programs including"behavior modification programs",long-term rehabilitation programs,
therapy for degenerative or static conditions when the expected outcome is primarily to maintain the Member's level
of functioning(except as described for neurodevelopmental therapy),recreational,life-enhancing,relaxation or
palliative therapy,implementation of home maintenance programs,programs for treatment of learning problems
C34613-0036900 24
Sexual Dysfunction
Sexual dysfunction services Not covered,Member pays 100%of all charges
Exclusions: Diagnostic testing and medical treatment of sexual dysfunction regardless of origin or cause,devices,
equipment and supplies for the treatment of sexual dysfunction
Skilled Nursing Facility
Skilled nursing care in a Group Health approved skilled No charge,Member pays nothing
nursing facility when full-time skilled nursing care is
necessary in the opinion of the attending physician, limited to
a combined total of 30 days per condition per calendar year.
Care may include room and board,general nursing care;
drugs,biologicals,supplies and equipment ordinarily
provided or arranged by a skilled nursing facility,and short-
term restorative occupational therapy,physical therapy and
speech therapy.
Skilled nursing care in a skilled nursing facility requires
Preauthorization
Exclusions:Personal comfort items such as telephone and television,rest cures,domiciliary or Convalescent Care
Sterilization
Female sterilization procedures Hospital-Inpatient: No charge,Member pays
nothing
Non-Emergency inpatient hospital services require
Preauthorization Hospital-Outpatient: Member pays$10
Copayment
Outpatient Services: Member pays$10
Copayment
Vasectomy. Hospital-Inpatient:No charge,Member pays
nothing
Non-Emergency inpatient hospital services require
Preauthorization Hospital-Outpatient: Member pays$10
Copayment
Outpatient Services: Member pays$10 Copayment
Exclusions:Procedures and services to reverse a sterilization
C34613-0036900 25
Temporomandibular Joint(TMJ)
Medical and surgical services and related hospital charges for TMJ services limited to an Allowance of$1,000 per
the treatment of temporomandibular Joint(TMJ)disorders Member per calendar year,up to$5,000 per Member
per lifetime
The following services are subject to the benefit limits
• Orthoenathic surgery for the treatment of TMJ disorders. After Allowance-Not covered,Member pays 100%
• Radiology services of all charges
• TMJ specialist services.
• Fitting/adjustment of splints Hospital-Inpatient:No charge;Member pays
nothing
Non-Emergency inpatient hospital services require
Preauthorization. Hospital-Outpatient:Member pays$10
Copayment
Outpatient Services:Member pays$10 Copayment
TMJ appliances See Devices,Equipment and Supplies for Member pays 20%benefit-specific coinsurance
additional information
Exclusions: Treatment for cosmetic purposes,bite blocks, dental services including orthodontic therapy,any
orthognathic(law)surgery in the absence of a diagnosis of TMJ,severe obstructive sleep apnea or congenital
anomaly,hospitalizations related to these exclusions
Tobacco Cessation
Individual/group counseling and educational materials Group Health-designated tobacco cessation
program:No charge,Member pays nothing
Other outpatient services:Member pays$10
Copayment
Approved pharmacy products See Drugs—Outpatient Group Health-designated tobacco cessation
Prescription for additional pharmacy information program:No charge,Member pays nothing when
prescribed as part of the Group Health-designated
tobacco cessation program and dispensed through the
Group Health-designated mail order service
Other approved pharmacy products: Generic
drugs listed in the GHO drug formulary(Tier 1):
Member pays$10 Copayment
Brand name drugs listed in the GHO drug
formulary(Tier 2):Member pays$10 Copayment
Non-formulary generic and brand name drugs
(Tier 3):Not covered.Member pays 100%of all
charges
C34613-0036900 26
Transplants
Transplant services,including heart,heart-lung,single lung, Hospital-Inpatient:No charge,Member pays
double lung,kidney,pancreas, cornea,intestinal/multi- nothing
visceral,liver transplants,and bone marrow and stem cell
support(obtained from allogeneu or autologous peripheral Hospital-Outpatient:Member pays$10
blood or marrow)with associated high dose chemotherapy Copayment
Services are limited to the following- Outpatient Services: Member pays$10 Copayment
• Inpatient and outpatient medical expenses for evaluation
testing to determine recipient candidacy,donor matching
tests,hospital charges,procurement center fees,
professional fees,travel costs for a surgical team and
excision fees Donor costs for a covered organ recipient
are limited to procurement center fees,travel costs for a
surgical team and excision fees
• Follow-up services for specialty visits
• Rehospitalization
• Maintenance medications during an inpatient stay
Transplant services require Preauthorization.
Exclusions:Donor costs to the extent that they are reimbursable by the organ donor's insurance,treatment of donor
complications,living expenses,transportation expenses except as covered as Ambulance Services
Urgent Care
Inside the Group Health Service Area,urgent care is covered Network Emergency Department: Member pays
at a Group Health medical center,Group Health urgent care $75 Copayment
center or Network Provider's office
Network Urgent Care Center: Member pays$10
Outside the Group Health Service Area,urgent care is Copayment
covered at any medical facility
Network Provider's Office: Member pays$10
See Section XI for a definition of Urgent Condition Copayment
Outside the Group Health Service Area: Member
pays$125 Copayment
V. General Exclusions
In addition to exclusions listed throughout the Benefits Booklet,the following are not covered
1. Services or supplies not specifically listed as covered in the Benefits Booklet.
2 Follow-up services or complications related to non-Covered Services
3. Services or supplies for which no charge is made,or for which a charge would not have been made if the
Member had no health care coverage or for which the Member is not liable, services provided by a family
member
C34613-0036900 27
4. Convalescent Care.
5. Any services to the extent benefits are"available"to the Member as defined herein under the terms of any
vehicle,homeowner's,property or other insurance policy,except for individual or group health insurance,
whether the Member asserts a claim or not,pursuant to medical coverage,medical"no fault"coverage,personal
injury protection coverage or similar medical coverage contained in said policy For the purpose of this
exclusion,benefits shall be deemed to be"available"to the Member if the Member is a named insured,comes
within the policy definition of insured,or otherwise has the right to receive benefits under the policy
The Member and his/her agents must cooperate fully with Group Health in its efforts to enforce this exclusion.
This cooperation shall include supplying Group Health with information about,or related to,the cause of injury
or illness or the availability of other coverage The Member and his/her agent shall permit Group Health,at
Group Health's option,to associate with the Member or to intervene in any action filed against any party related
to the injury The Member and his/her agents shall do nothing to prejudice Group Health's right to enforce this
exclusion Failure to fully cooperate,including withholding information regarding the cause of injury or illness
or other coverage may result in denial of claims and the Member shall be responsible for reimbursing Group
Health for expenses incurred and the value of the benefits provided by Group Health under this Benefits
Booklet for the care or treatment of the injury or illness sustained by the Member
If this Benefits Booklet is not subject to ERISA and reasonable collections costs(attorney fees and costs)have
been incurred by an attorney for the injured person in connection with obtaining recovery under underinsured or
uninsured motor coverage,under certain conditions Group Health will not enforce this exclusion until a
reduction from benefits"available"to the Member is made by the amount of an equitable apportionment of
such collection costs between Group Health and the injured person This reduction is made only if each of the
following conditions has been met (i)Group Health receives a list of the fees and associated costs before
settlement and(u)the injured person's attorney's actions were reasonable and necessary to secure recovery
6. Services or care needed for injuries or conditions resulting from active or reserve military service,whether such
injuries or conditions result from war or otherwise This exclusion will not apply to conditions or injuries
resulting from previous military service unless the condition has been determined by the U.S.Secretary of
Veterans Affairs to be a condition or injury incurred during a period of active duty Further,this exclusion will
not be interpreted to interfere with or preclude coordination of benefits under Tri-Care
7. Services provided by government agencies,except as required by federal or state law.
8. Services covered by the national health plan of any other country.
9. Experimental or investigational services.
Group Health consults with Group Health's medical director and then uses the criteria described below to
decide if a particular service is experimental or investigational.
a. A service is considered experimental or investigational for a Member's condition if any of the following
statements apply to it at the time the service is or will be provided to the Member.
1) The service cannot be legally marketed in the United States without the approval of the Food and Drug
Administration("FDA")and such approval has not been granted
2) The service is the subject of a current new drug or new device application on file with the FDA
3) The service is provided as part of a Phase 1 or Phase II clinical trial,as the experimental or research
arm of a Phase III clinical trial,or in any other manner that is intended to evaluate the safety,toxicity
or efficacy of the service
4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the
service's safety,toxicity or efficacy as among its objectives
5) The service is under continued scientific testing and research concerning the safety,toxicity or efficacy
of services
C34613-0036900 28
6) The service is provided pursuant to informed consent documents that describe the service as
experimental or investigational,or in other terms that indicate that the service is being evaluated for its
safety,toxicity or efficacy
7) The prevailing opinion among experts,as expressed in the published authoritative medical or scientific
literature, is that(1)the use of such service should be substantially confined to research settings,or(2)
further research is necessary to determine the safety,toxicity or efficacy of the service
b. The following sources of information will be exclusively relied upon to determine whether a service is
experimental or investigational
1) The Member's medical records
2) The written protocol(s)or other document(s)pursuant to which the service has been or will be
provided
3) Any consent document(s)the Member or Member's representative has executed or will be asked to
execute,to receive the service
4) The files and records of the Institutional Review Board(IRB)or similar body that approves or reviews
research at the institution where the service has been or will be provided,and other information
concerning the authority or actions of the IRB or similar body
5) The published authoritative medical or scientific literature regarding the service,as applied to the
Member's illness or injury
6) Regulations,records,applications and any other documents or actions issued by,filed with or taken by,
the FDA or other agencies within the United States Department of Health and Human Services,or any
state agency performing similar functions
Appeals regarding Group Health denial of coverage can be submitted to the Member Appeal Department,or to
Group Health's medical director at P O Box 34593, Seattle,WA 98124-1593
10 Hypnotherapy and all services related to hypnotherapy
11. Directed umbilical cord blood donations
12 Genetic testing and related services,unless determined Medically Necessary by Group Health's medical
director and in accordance with Board of Health standards for screening and diagnostic tests,or specifically
provided in Section IV.Testing for non-Members is also excluded.
13. Autopsy and associated expenses
14. Services and supplies related to sexual reassignment surgery,such as sex change operations or transformations
and procedures or treatments designed to alter physical characteristics.
. Eligibility}Enrollment and Termination
A. Eligibility.
In order to be accepted for enrollment and continuing coverage,individuals must meet any eligibility
requirements imposed by the Group,reside or work in the Service Area and meet all applicable requirements set
forth below,except for temporary residency outside the Service Area for purposes of attending school,court-
ordered coverage for Dependents or other unique family arrangements,when approved in advance by Group
Health Group Health has the right to verify eligibility
1. Subscribers.
Bona fide employees as established and enforced by the Group shall be eligible for enrollment Please
contact the Group for more information
2. Dependents.
The Subscriber may also enroll the following.
C34613-0036900 29
a. The Subscriber's legal spouse.
b The Subscriber's state-registered domestic partner(as required by Washington state law)or if
specifically included as eligible by the Group,the Subscriber's non-state registered domestic partner
c. Children who are under the age of 26.
"Children"means the children of the Subscriber,spouse or eligible domestic partner,including adopted
children,stepchildren,children for whom the Subscriber has a qualified court order to provide
coverage and any other children for whom the Subscriber is the legal guardian.
Eligibility may be extended past the Dependent's limiting age as set forth above if the Dependent is
totally incapable of self-sustaining employment because of a developmental or physical disability
incurred prior to attainment of the limiting age,and is chiefly dependent upon the Subscriber for
support and maintenance Enrollment for such a Dependent may be continued for the duration of the
continuous total incapacity,provided enrollment does not terminate for any other reason Medical
proof of incapacity and proof of financial dependency must be furnished to Group Health upon request,
but not more frequently than annually after the 2 year period following the Dependent's attainment of
the limiting age
3. Temporary Coverage for Newborns.
When a Member gives birth,the newborn is entitled to the benefits set forth in the Benefits Booklet from
birth through 3 weeks of age All provisions,limitations and exclusions will apply except Subsections F.
and G After 3 weeks of age, no benefits are available unless the newborn child qualifies as a Dependent
and is enrolled
B. Application for Enrollment.
Application for enrollment must be made on an application approved by Group Health The Group is
responsible for submitting completed applications to Group Health
Group Health reserves the right to refuse enrollment to any person whose coverage under any medical coverage
agreement issued by Group Health Options,Inc or Group Health Cooperative has been terminated for cause
1. Newly Eligible Subscribers.
Newly eligible Subscribers and their Dependents may apply for enrollment in writing to the Group within
31 days of becoming eligible.
2. New Dependents.
A written application for enrollment of a newly dependent person,other than a newborn or adopted child,
must be made to the Group within 31 days after the dependency occurs
A written application for enrollment of a newborn child must be made to the Group within 60 days
following the date of birth when there is a change in the monthly premium payment as a result of the
additional Dependent
A written application for enrollment of an adoptive child must be made to the Group within 60 days from
PP P P Y
the day the child is placed with the Subscriber for the purpose of adoption or the Subscriber assumes total
or partial financial support of the child if there is a change in the monthly premium payment as a result of
the additional Dependent
When there is no change in the monthly premium payment,it is strongly advised that the Subscriber enroll
the newborn or newly adoptive child as a Dependent with the Group to avoid delays in the payment of
claims
C34613-0036900 30
3. Open Enrollment.
Group Health will allow enrollment of Subscribers and Dependents who did not enroll when newly eligible
as described above during a limited period of time specified by the Group and Group Health
4. Special Enrollment.
a Group Health will allow special enrollment for persons•
1) Who initially declined enrollment when otherwise eligible because such persons had other health
care coverage and have had such other coverage terminated due to one of the following events
• Cessation of employer contributions
• Exhaustion of COBRA continuation coverage
• Loss of eligibility,except for loss of eligibility for cause
2) Who initially declined enrollment when otherwise eligible because such persons had other health
care coverage and who have had such other coverage exhausted because such person reached a
lifetime maximum limit
Group Health or the Group may require confirmation that when initially offered coverage such persons
submitted a written statement declining because of other coverage.Application for coverage must be
made within 31 days of the termination of previous coverage
b Group Health will allow special enrollment for individuals who are eligible to be a Subscriber and
his/her Dependents in the event one of the following occurs
1) Man iage.Application for coverage must be made within 31 days of the date of marriage
2) Birth Application for coverage for the Subscriber and Dependents other than the newborn child
must be made within 60 days of the date of birth
3) Adoption or placement for adoption Application for coverage for the Subscriber and Dependents
other than the adopted child must be made within 60 days of the adoption or placement for
adoption.
4) Eligibility for medical assistance,provided such person is otherwise eligible for coverage under
this Benefits Booklet,when approved and requested in advance by the Department of Social and
Health Services(DSHS) The request for special enrollment must be made within 60 days of
DSHS's determination that enrollment would be cost-effective
5) Coverage under a Medicaid or CHIP plan is terminated as a result of loss of eligibility for such
coverage Application for coverage must be made within 60 days of the date of termination under
Medicaid or CHIP
6) Applicable federal or state law or regulation otherwise provides for special enrollment
C. When Coverage Begins.
1. Effective Date of Enrollment.
• Enrollment for a newly eligible Subscriber and listed Dependents is effective on the date eligibility
requirements are met,provided the Subscriber's application has been submitted to and approved by
Group Health Please contact the Group for more information
• Enrollment for a newly dependent person other than a newborn or adoptive child, is effective on the
date eligibility requirements are met Please contact the Group for more information.
• Enrollment for newborns is effective from the date of birth
• Enrollment for adoptive children is effective from the date that the adoptive child is placed with the
Subscriber for the purpose of adoption or the Subscriber assumes total or partial financial support of
the child
2. Commencement of Benefits for Persons Hospitalized on Effective Date.
Members who are admitted to an inpatient facility prior to their enrollment will receive covered benefits
beginning on their effective date,as set forth in Subsection C 1 above If a Member is hospitalized in a
non-Network Facility,Group Health reserves the right to require transfer of the Member to a Network
Facility The Member will be transferred when a Network Provider,in consultation with the attending
C34613-0036900 31
physician,determines that the Member is medically stable to do so If the Member refuses to transfer to a
Network Facility,all further costs incurred during the hospitalization are the responsibility of the Member
D. Eligibility for Medicare.
An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare
benefits Medicare secondary payer regulations and guidelines will determine primary/secondary payer status
for individuals covered by Medicare
The Group is responsible for providing the Member with necessary information regarding Tax Equity and
Fiscal Responsibility Act of 1982(TEFRA)eligibility and the selection process,if applicable If a Member is
eligible for Medicare,he/she has the option of maintaining both Medicare Parts A and B while continuing
coverage under this Benefits Booklet Coverage between this Benefits Booklet and Medicare will be
coordinated as outlined in Section [X.
The Group is also responsible for providing Group Health with a prospective timely notice of Members'
ineligibility for Medicare Advantage coverage under the Group,as well as providing a prospective notice to its
Members alerting them of the termination event In the event the Group does not obtain Medicare Advantage
coverage,the loss of Medicare drug coverage,other coverage options that may be available to the Member,and
the possibility of late enrollment penalties if the Member does not apply for Medicare coverage within the
required timeframe will also need to be provided
E. Termination of Coverage.
The Subscriber shall be liable for payment of all charges for services and items provided to the Subscriber and
all Dependents after the effective date of termination
1. Termination of Specific Members.
Individual Member coverage may be terminated for any of the following reasons:
a Loss of Eligibility If a Member no longer meets the eligibility requirements and is not enrolled for
continuation coverage as described in Subsection G.below,coverage will terminate at the end of the
month during which the loss of eligibility occurs,unless otherwise specified by the Group
b. For Cause In the event of termination for cause,Group Health reserves the right to pursue all civil
remedies allowable under federal and state law for the collection of claims,losses or other damages.
Coverage of a Member may be terminated upon 10 working days written notice for
1 ) Material misrepresentation,fraud or omission of information in order to obtain coverage.
2.) Permitting the use of a Group Health identification card or number by another person,or using
another Member's identification card or number to obtain care to which a person is not entitled.
c. Premium Payments Nonpayment of premiums or contribution for a specific Member by the Group.
Individual Member coverage may be retroactively terminated upon 30 days written notice and only in the
case of fraud or intentional misrepresentation of a material fact,or as otherwise allowed under applicable
law or regulation Notwithstanding the foregoing,Group Health reserves the right to retroactively terminate
coverage for nonpayment of premiums or contributions by the Group as described above
In no event will a Member be terminated solely on the basis of their physical or mental condition provided
they meet all other eligibility requirements set forth in the Benefits Booklet
Any Member may appeal a termination decision through Group Health's appeals process.
2. Certificate of Creditable Coverage.
Unless the Group has chosen to accept this responsibility,a certificate of creditable coverage(which
provides information regarding the Member's length of coverage)will be issued automatically upon
termination of coverage,and may also be obtained upon request
C34613-0036900 32
F. Continuation of Inpatient Services.
A Member who is receiving Covered Services in a hospital on the date of termination shall continue to be
eligible for Covered Services while an inpatient for the condition which the Member was hospitalized,until one
of the following events occurs
• According to Group Health clinical criteria,it is no longer Medically Necessary for the Member to be an
inpatient at the facility
• The remaining benefits available for the hospitalization are exhausted,regardless of whether a new
calendar year begins
• The Member becomes covered under another agreement with a group health plan that provides benefits for
the hospitalization
• The Member becomes enrolled under an agreement with another carrier that provides benefits for the
hospitalization
This provision will not apply if the Member is covered under another agreement that provides benefits for the
hospitalization at the time coverage would terminate,except as set forth in this section,or if the Member is
eligible for COBRA continuation coverage as set forth in Subsection G below
G. Continuation of Coverage Options.
1. Continuation Option.
A Member no longer eligible for coverage(except in the event of termination for cause,as set forth in
Subsection E)may continue coverage for a period of up to 3 months subject to notification to and self-
payment of premiums to the Group This provision will not apply if the Member is eligible for the
continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) This continuation option is not available if the Group no longer has active employees or
otherwise terminates
2. Leave of Absence.
While on a Group approved leave of absence,the Subscriber and listed Dependents can continue to be
covered provided that
• They remain eligible for coverage,as set forth in Subsection A,
• Such leave is in compliance with the Group's established leave of absence policy that is consistently
applied to all employees,
• The Group's leave of absence policy is in compliance with the Family and Medical Leave Act when
applicable,and
• The Group continues to remit premiums for the Subscriber and Dependents to Group Health.
3. Self-Payments During Labor Disputes.
In the event of suspension or termination of employee compensation due to a strike,lock-out or other labor
dispute,a Subscriber may continue uninterrupted coverage through payment of monthly premiums directly
to the Group Coverage may be continued for the lesser of the term of the strike,lock-out or other labor
dispute,or for 6 months after the cessation of work
If coverage under the Benefits Booklet is no longer available,the Subscriber shall have the opportunity to
apply for an individual Group Health group conversion plan or,if applicable,continuation coverage(see
Subsection 4 below),or an individual and family plan at the duly approved rates
The Group is responsible for immediately notifying each affected Subscriber of his/her rights of self-
payment under this provision
4. Continuation Coverage Under Federal Law.
C34613-0036900 33
1
This section applies only to Groups who must offer continuation coverage under the applicable provisions
of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended,and only applies
to grant continuation of coverage rights to the extent required by federal law.
Upon loss of eligibility,continuation of Group coverage may be available to a Member for a limited time
after the Member would otherwise lose eligibility,if required by COBRA The Group shall inform
Members of the COBRA election process and how much the Member will be required to pay directly to the
Group.
Continuation coverage under COBRA will terminate when a Member becomes covered by Medicare or
obtains other group coverage,and as set forth under Subsection E
5. Group Health Group Conversion Plan.
Members whose eligibility for coverage,including continuation coverage,is terminated for any reason
other than cause,as set forth in Subsection E,and who are not eligible for Medicare or covered by another
group health plan,may convert to an individual Group Health group conversion plan If coverage under the
Benefits Booklet terminates,any Member covered at termination may convert to a Group Health group
conversion plan,unless he/she is eligible to obtain other group health coverage within 31 days of the
termination
An application for conversion must be made within 31 days following termination of coverage or within 31
days from the date notice of the termination of coverage is received,whichever is later.A physical
examination or statement of health is not required for enrollment in a Group Health group conversion plan
By exercising group conversion rights,the Member may waive guaranteed issue and pre-existing condition
waiver rights under Federal regulations
Persons wishing to purchase Group Health's individual and family coverage should contact Group Health
plaints and Appeals - 1 1
The processes to express a complaint and to appeal a Group Health denial of benefits are set forth below The
complaint process is available for a Member to express dissatisfaction about customer service or the quality or
availability of a health service The appeals process is available for a Member to seek reconsideration of an adverse
benefit determination(action) Adverse benefit determination(action)means any of the following a denial,
reduction,or termination of,or a failure to provide or make payment(in whole or in part)for,a benefit,including
any such denial,reduction,termination,or failure to provide or make payment that is based on a determination of a
Member's eligibility to participate in a plan
A. Complaint Process.
Step 1:The Member should contact the person involved,explain his/her concerns and what he/she would like
to have done to resolve the problem The Member should be specific and make his/her position clear.
Step 2: If the Member is not satisfied,or if he/she prefers not to talk with the person involved,the Member
should call the department head or the manager of the medical center or department where he/she is having a
problem That person will investigate the Member's concerns Most concerns can be resolved in this way
Step 3:If the Member is still not satisfied,he/she should call Customer Service at 206-901-4636 or toll-free
1-888-901-4636 Most concerns are handled by phone within a few days In some cases the Member will be
asked to write down his/her concerns and state what he/she thinks would be a fair resolution to the problem A
Customer Service Representative or Member Quality of Care Coordinator will investigate the Member's
concern by consulting with involved staff and their supervisors,and reviewing pertinent records,relevant plan
policies and the Member Rights and Responsibilities statement This process can take up to 30 days to resolve
after receipt of the Member's written statement
C34613-0036900 34
If the Member is dissatisfied with the resolution of the complaint,he/she may contact the Member Quality of
Care Coordinator or Customer Service
B. Appeals Process.
1. Initial Appeal
If the Member or the Member's legal representative wishes to appeal a Group Health decision to deny,
modify,reduce or terminate coverage of or payment for health care services,he/she must submit a request
for an appeal either orally or in writing to Group Health's Member Appeal Department,specifying why
he/she disagrees with the decision The appeal must be submitted within 180 days of the dental notice
he/she received Appeals should be directed to Group Health's Member Appeal Department,P O Box
34593, Seattle.WA 98124-1593,toll-free 1-866-458-5479
A party not involved in the initial coverage determination and not a subordinate of the party making the
initial coverage determination will review the appeal request Group Health will then notify the Member of
its determination or need for an extension of time within 14 days of receiving the request for appeal Under
no circumstances will the review timeframe exceed 30 days without the Member's written permission
There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using
the standard appeal review process will seriously jeopardize the Member's life,health or ability to regain
maximum function or subject the Member to severe pain that cannot be managed adequately without the
requested care or treatment The Member can request an expedited/urgent appeal in writing to the above
address,or by calling Group Health's Member Appeal Department toll-free 1-866-458-5479 The nature of
the patient's condition will be evaluated by a physician and if the request is not accepted as urgent,the
member will be notified in writing of the decision not to expedite and given a description on how to grieve
the decision If the request is made by the treating physician who believes the member's condition meets
the definition of expedited,the request will be processed as expedited
The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours
after receipt of sufficient information to determine whether,or to what extent,benefits are covered or
payable For expedited/urgent appeals,the Member has the right to request an appeal through Group
Health's Member Appeal Department and a review by an independent review organization concurrently.
If the Member requests an appeal of a Group Health decision denying benefits for care currently being
received,Group Health will continue to provide coverage for the disputed benefit pending the outcome of
the appeal If the Group Health determination stands,the Member may be responsible for the cost of
coverage received during the review period
The U S Department of Health and Human Services has designated the Washington State Office of the
Insurance Commissioner's Consumer Protection Division as the health insurance consumer ombudsman.
The Consumer Protection Division Office can be reached by mail at Washington State Insurance
Commissioner,Consumer Protection Division,P O Box 40256,Olympia,WA 98504-0256 or at toll-free
1-800-562-6900 More information about requesting assistance from the Consumer Protection Division
Office can be found at httn//www insurance via eov/consumers/health/anoeal/Table-of-Contents shim
2. Next Level of Appeal
If the Member is not satisfied with the decision regarding a Group Health denial of benefits,or if Group
Health fails to adhere to the requirements of the appeals process,the Member may request a second level
review by an external independent review organization as set forth under Subsection a below The Member
may also choose to pursue a voluntary review by an appeal committee prior to requesting a review by an
independent review organization as set forth under Subsection b below The voluntary(optional)appeal
committee review is not a required step in the appeals process
a. Request a review by an independent review organization.An independent review organization is not
legally affiliated or controlled by Group Health Once a decision is made through an independent
C34613-0036900 35
review organization,the decision is final and cannot be appealed through Group Health *if the
independent review organization overturns Group Health's coverage decision,Group Health will
promptly comply and notify the Member
A request for a review by an independent review organization must be made within 180 days after the
date of the initial appeal decision notice Group Health will prov ide the independent review
organization all of the Member's case information within 3 business days from the date of the request.
The Member has 5 business days,from the date the Member received notice that the appeal was sent to
an IRO,to submit in writing,directly to the IRO,any additional information to be considered in the
review
The Member may request an expeditedlurgent external review if the decision regarding a Group
Health denial of benefits concerns an admission,availability of care,continued stay,or health care
service for which the Member received Emergency services but has not been discharged from a
facility,or involves a medical condition for which the standard external review time frame of 45 days
would seriously jeopardize the life or health of the Member orjeopardize the Member's ability to
regain maximum function The independent review organization must make its decision to uphold or
reverse the decision and notify the Member and Group Health of the determination as promptly as
possible but within not more than 72 hours after the receipt of the request for expedited/urgent external
review if the notice is not in writing,the independent review organization must provide written
confirmation of the decision within 48 hours after the date of the notice of the decision.
For claims involving experimental or investigational treatments,Group Health member appeal
employees must ensure that adequate clinical and scientific experience and protocols are taken into
account as part of the external review process
The decision of the independent review organization is binding unless other remedies are available
under state or federal law Group Health must provide benefits,including making payment on a claim,
pursuant to the final external review decision without delay,regardless of whether Group Health
intends to seek judicial review of the external review decision,and unless or until there is a judicial
decision changing the final determination
b. Request a voluntary(optional)hearing by the Group Health appeal committee.
The voluntary appeal committee hearing is an informal process The hearing will be conducted within
30 working days of the Member's request and notification of the appeal committee's decision will be
mailed to the Member within 5 working days of the hearing
Members electing the voluntary appeal committee maintain their right to appeal further to an
independent review organization as set forth in Subsection a above.
Review by the voluntary appeal committee is not available if the appeal request is for an experimental
or investigational exclusion or limitation.
A request for a hearing by the appeal committee must be made within 30 days after the date of the
initial appeal decision notice The request can be mailed to Group Health's Member Appeal
Department,P O Box 34593,Seattle,WA 98124-1593 *
*If the Member's health plan is governed by the Employee Retirement Income Security Act,known as"ERISA"
(most employment related health plans,other than those sponsored by governmental entities or churches—ask
employer about plan),the Member has the right to file a lawsuit under Section 502(a)of ERISA to recover benefits
due to the Member under the plan at any point after completion of the initial appeal process Members may have
other legal rights and remedies available under state or federal law
VIII. Claims aft
C34613-0036900 36
Claims for benefits may be made before or after services are obtained Group Health recommends that the provider
requests Preauthorization To make a claim for benefits,a Member must contact Customer Service,or submit a
claim for reimbursement as described below Other inquiries,such as asking a health care provider about care or
coverage,or submitting a prescription to a pharmacy,will not be considered a claim for benefits
If a Member receives a bill for services the Member believes are covered,the Member must,within 90 days of the
date of service,or as soon thereafter as reasonably possible,either(1)contact Customer Service to make a claim or
(2)pay the bill and submit a claim for reimbursement of Covered Services to Group Health,P O Box 34585,
Seattle,WA 98124-1585 In no event,except in the absence of legal capacity,shall a claim be accepted later than 1
year from the date of service
Group Health will generally process claims for benefits within the following timeframes after Group Health receives
the claims
• Pre-service claims—within 15 days
• Claims involving urgently needed care—within 72 hours.
• Concurrent care claims—within 24 hours
• Post-service claims—within 30 days
Timeframes for pre-service and post-service claims can be extended by Group Health for up to an additional 15
days Members will be notified in writing of such extension prior to the expiration of the initial timeframe
,jX. Coordination of Benefits -
The coordination of benefits(COB)provision applies when a Member has health care coverage under more than one
plan Plan is defined below.
The order of benefit determination rules govern the order in which each plan will pay a claim for benefits.The plan
that pays first is called the primary plan The primary plan must pay benefits according to its policy terms without
regard to the possibility that another plan may cover some expenses The plan that pays after the primary plan is the
secondary plan In no event will a secondary plan be required to pay an amount in excess of its maximum benefit
plus accrued savings.
If the Member is covered by more than one health benefit plan,the Member or the Member's provider should file all
the Member's claims with each plan at the same time If Medicare is the Member's primary plan,Medicare may
submit the Member's claims to the Member's secondary carrier
Definitions.
A A plan is any of the following that provides benefits or services for medical or dental care or treatment If
separate contracts are used to provide coordinated coverage for Members of a Group,the separate contracts
are considered parts of the same plan and there is no COB among those separate contracts However,if
COB rules do not apply to all contracts,or to all benefits in the same contract,the contract or benefit to
which COB does not apply is treated as a separate plan
1. Plan includes group,individual or blanket disability insurance contracts and group or individual
contracts issued by health care service contractors or health maintenance organizations(HMO),closed
panel plans or other forms of group coverage,medical care components of long term care contracts,
such as skilled nursing care,and Medicare or any other federal governmental plan,as permitted by
law
C34613-0036900 37
2 Plan does not include hospital indemnity or fixed payment coverage or other fixed indemnity or fixed
payment coverage,accident only coverage, specified disease or specified accident coverage, limited
benefit health coverage,as defined by state law, school accident type coverage,benefits for non-
medical components of long-term care policies,automobile insurance policies required by statute to
provide medical benefits, Medicare supplement policies,Medicaid coverage,or coverage under other
federal governmental plans, unless permitted by law.
Each contract for coverage under Subsection 1.or 2 is a separate plan If a plan has two parts and COB
rules apply only to one of the two,each of the parts is treated as a separate plan
B. This plan means,in a COB provision,the part of the contract providing the health care benefits to which
the COB provision applies and which may be reduced because of the benefits of other plans Any other part
of the contract providing health care benefits is separate from this plan A contract may apply one COB
provision to certain benefits,such as dental benefits,coordinating only with similar benefits,and may apply
another COB provision to coordinate other benefits
C. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan
when the Member has health care coverage under more than one plan
When this plan is primary,it determines payment for its benefits first before those of any other plan without
considering any other plan's benefits When this plan is secondary,it determines its benefits after those of
another plan and must make payment in an amount so that,when combined with the amount paid by the
primary plan,the total benefits paid or provided by all plans for the claim equal 100%of the total allowable
expense for that claim This means that when this plan is secondary,it must pay the amount which, when
combined with what the primary plan paid,totals 100%of the allowable expense In addition,if this plan is
secondary, it must calculate its savings(its amount paid subtracted from the amount it would have paid had
it been the primary plan)and record these savings as a benefit reserve for the covered Member This
reserve must be used by the secondary plan to pay any allowable expenses not otherwise paid,that are
incurred by the covered person during the claim determination period
D. Allowable Expense Allowable expense is a health care expense,coinsurance or copayments and without
reduction for any applicable deductible,that is covered at least in part by any plan covering the person
When a plan provides benefits in the form of services,the reasonable cash value of each service will be
considered an allowable expense and a benefit paid An expense that is not covered by any plan covering
the Member is not an allowable expense.
The following are examples of expenses that are not allowable expenses:
1. The difference between the cost of a semi-private hospital room and a private hospital room is not an
allowable expense,unless one of the plans provides coverage for private hospital room expenses.
2. If a Member is covered by two or more plans that compute their benefit payments on the basis of usual
and customary fees or relative value schedule reimbursement method or other similar reimbursement
method,any amount in excess of the highest reimbursement amount for a specific benefit is not an
allowable expense.
3. If a Member is covered by two or more plans that provide benefits or services on the basis of
negotiated fees,an amount in excess of the highest of the negotiated fees is not an allowable expense
4. An expense or a portion of an expense that is not covered by any of the plans covering the person is
not an allowable expense
E. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services
through a panel of providers who are primarily employed by the plan,and that excludes coverage for
services provided by other providers,except in cases of Emergency or referral by a panel member
C34613-0036900 38
F. Custodial parent is the parent awarded custody by a court decree or,in the absence of a court decree,is the
parent with whom the child resides more than one half of the calendar year excluding any temporary
visitation
Order of Benefit Determination Rules.
When a Member is covered by two or more plans,the rules for determining the order of benefit payments are as
follows.
A The primary plan pays or provides its benefits according to its terms of coverage and without regard to the
benefits under any other plan
B. Except as provided below(subsection 2),a plan that does not contain a coordination of benefits provision
that is consistent with this chapter is always primary unless the provisions of both plans state that the
complying plan is primary
Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a
basic package of benefits and provides that this supplementary coverage is excess to any other parts of the
plan provided by the contract holder Examples include major medical coverages that are superimposed
over hospital and surgical benefits,and insurance type coverages that are written in connection with a
closed panel plan to provide out-of-network benefits
C. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits ,
only when it is secondary to that other plan
D. Each plan determines its order of benefits using the first of the following rules that apply
1. Non-Dependent or Dependent The plan that covers the Member other than as a Dependent,for
example as an employee,member,policyholder, Subscriber or retiree is the primary plan and the plan
that covers the Member as a Dependent is the secondary plan However.if the person is a Medicare
beneficiary and,as a result of federal law, Medicare is secondary to the plan covering the Member as a
Dependent,and primary to the plan covering the Member as other than a Dependent(e g,a retired
employee),then the order of benefits between the two plans is reversed so that the plan covering the
Member as an employee,member,policyholder,Subscriber or retiree is the secondary plan and the
other plan is the primary plan
2. Dependent child covered under more than one plan Unless there is a court decree stating otherwise,
when a dependent child is covered by more than one plan the order of benefits is determined as
follows
a) For a dependent child whose parents are married or are living together,whether or not they have
ever been married
• The plan of the parent whose birthday falls earlier in the calendar year is the primary plan,or
• If both parents have the same birthday,the plan that has covered the parent the longest is the
primary plan
b) For a dependent child whose parents are divorced or separated or not living together,whether or
not they have ever been married
t If a court decree states that one of the parents is responsible for the dependent child's health
care expenses or health care coverage and the plan of that parent has actual knowledge of
those terms,that plan is primary This rule applies to claim determination periods
commencing after the plan is given notice of the court decree,
ii. If a court decree states one parent is to assume primary financial responsibility for the
dependent child but does not mention responsibility for health care expenses,the plan of the
parent assuming financial responsibility is primary,
iii If a court decree states that both parents are responsible for the dependent child's health care
expenses or health care coverage,the provisions of a)above determine the order of benefits;
C34613-0036900 39
iv. If a court decree states that the parents have joint custody without specifying that one parent
has responsibility for the health care expenses or health care coverage of the dependent child,
the provisions of Subsection a)above determine the order of benefits,or
v. If there is no court decree allocating responsibility for the dependent child's health care
expenses or health care coverage,the order of benefits for the child are as follows
• The plan covering the custodial parent,first,
• The plan covering the spouse of the custodial parent,second,
• The plan covering the non-custodial parent,third,and then
• The plan covering the spouse of the non-custodial parent,last
c) For a dependent child covered under more than one plan of individuals who are not the parents of
the child,the provisions of Subsection a)or b)above determine the order of benefits as if those
individuals were the parents of the child.
3. Active employee or retired or laid-off employee The plan that covers a Member as an active
employee,that is,an employee who is neither laid off nor retired,is the primary plan The plan
covering that same Member as a retired or laid off employee is the secondary plan The same would
hold true if a Member is a Dependent of an active employee and that same Member is a Dependent of a
retired or laid-off employee If the other plan does not have this rule,and as a result,the plans do not
agree on the order of benefits,this rule is ignored This rule does not apply if the rule under Section a.
can determine the order of benefits.
4. COBRA or State Continuation Coverage If a Member whose coverage is provided under COBRA or
under a right of continuation provided by state or other federal law is covered under another plan,the
plan covering the Member as an employee,member,Subscriber or retiree or covering the Member as a
Dependent of an employee,member, Subscriber or retiree is the primary plan and the COBRA or state
or other federal continuation coverage is the secondary plan If the other plan does not have this rule,
and as a result,the plans do not agree on the order of benefits,this rule is ignored This rule does not
apply if the rule under Section D 1 can determine the order of benefits.
5 Longer or shorter length of coverage The plan that covered the Member as an employee, member,
Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter
period of time is the secondary plan
6. If the preceding rules do not determine the order of benefits,the allowable expenses must be shared
equally between the plans meeting the definition of plan In addition,this plan will not pay more than it
would have paid had it been the primary plan.
Effect on the Benefits of this Plan.
When this plan is secondary,it must make payment in an amount so that, when combined with the amount paid
by the primary plan,the total benefits paid or provided by all plans for the claim equal one hundred percent of
the total allowable expense for that claim However, in no event shall the secondary plan be required to pay an
amount in excess of its maximum benefit plus accrued savings In no event should the Member be responsible
for a deductible amount greater than the highest of the two deductibles
Right to Receive and Release Needed Information.
Certain facts about health care coverage and services are needed to apply these COB rules and to determine
benefits payable under this plan and other plans Group Health may get the facts it needs from or give them to
other organizations or persons for the purpose of applying these rules and determining benefits payable under
this plan and other plans covering the Member claiming benefits Group Health need not tell,or get the consent
of,any Member to do this Each Member claiming benefits under this plan must give Group Health any facts it
needs to apply those rules and determine benefits payable
Facility of Payment.
If payments that should have been made under this plan are made by another plan, Group Health has the right,
at its discretion,to remit to the other plan the amount it determines appropriate to satisfy the intent of this
C34613-0036900 40
provision The amounts paid to the other plan are considered benefits paid under this plan.To the extent of such
payments,Group Health is fully discharged from Lability under this plan
Right of Recovery.
Group Health has the right to recover excess payment whenever it has paid allowable expenses in excess of the
maximum amount of payment necessary to satisfy the intent of this provision Group Health may recover excess
payment from any person to whom or for whom payment was made or any other issuers or plans.
Questions about Coordination of Benefits9 Contact the State Insurance Department
Effect of Medicare.
Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status,
and will be adjudicated by Group Health asset forth in this section W hen Medicare,Part A and Part B or Part
C are primary.Medicare's allowable amount is the highest allowable expense
When a Network Provider renders care to a Member who is eligible for Medicare benefits,and Medicare is
deemed to be the primary bill payer under Medicare secondary payer guidelines and regulations, Group Health
will seek Medicare reimbursement for all Medicare covered services
X. Subrogation and Reimbursement Rights
The benefits under this Benefits Booklet will be available to a Member for injury or illness caused by another party,
subject to the exclusions and limitations of this Benefits Booklet If Group Health provides benefits under this
Benefits Booklet for the treatment of the injury or illness, Group Health will be subrogated to any rights that the
Member may have to recover compensation or damages related to the injury or illness and the Member shall
reimburse Group Health for all benefits provided.from any amounts the Member received or is entitled to receive
from any source on account of such injury or illness,whether by suit,settlement or otherwise This section more
fully describes Group Health's subrogation and reimbursement rights
"Injured Person" under this section means a Member covered by the Benefits Booklet who sustains an injury or
illness and any spouse,dependent or other person or entity that may recover on behalf of such Member including the
estate of the Member and,if the Member is a minor,the guardian or parent of the Member When referred to in this
section. "Group Health's Medical Expenses"means the expenses incurred and the value of the benefits provided by
Group Health under this Benefits Booklet for the care or treatment of the injury or illness sustained by the Injured
Person
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal liability against the third
party and/or payment by the third party to the Injured Person and/or a settlement between the third party and the
Injured Person,Group Health shall have the right to recover Group Health's Medical Expenses from any source
available to the Injured Person as a result of the events causing the injury,including but not limited to funds
available through applicable third party liability coverage and uninsured/underinsured motorist coverage This right
is commonly referred to as"subrogation"Group Health shall be subrogated to and may enforce all rights of the
Injured Person to the full extent of Group Health's Medical Expenses
Group Health's subrogation and reimbursement rights shall be limited to the excess of the amount required to fully
compensate the injured Person for the loss sustained,including general damages
Subject to the above provisions,if the Injured Person is entitled to or does receive money from any source as a result
of the events causing the injury or illness,including but not limited to any liability insurance or
uninsured/underinsured motorist funds,Group Health's Medical Expenses are secondary,not primary
The Injured Person and his/her agents shall cooperate fully with Group Health in its efforts to collect Group Health's
Medical Expenses This cooperation includes,but is not limited to, supplying Group Health with information about
the cause of injury or illness,any potentially liable third parties,defendants and/or insurers related to the Injured
Person's claim and informing Group Health of any settlement or other payments relating to the Injured Person's
injury The Injured Person and his/her agents shall permit Group Health,at Group Health's option,to associate with
C34613-0036900 41
the Injured Person or to intervene in any legal,quasi-legal,agency or any other action or claim filed If the Injured
Person takes no action to recover money from any source,then the Injured Person agrees to allow Group Health to
initiate its own direct action for reimbursement or subrogation
The Injured Person and his/her agents shall do nothing to prejudice Group Health's subrogation and reimbursement
rights The Injured Person shall promptly notify Group Health of any tentative settlement with a third party and shall
not settle a claim without protecting Group Health's interest If the Injured Person fails to cooperate fully with
Group Health in recovery of Group Health's Medical Expenses,the Injured Person shall be responsible for directly
reimbursing Group Health for 100%of Group Health's Medical Expenses.
To the extent that the Injured Person recovers funds from any source that may serve to compensate for medical
injuries or medical expenses,the Injured Person agrees to hold such monies in trust or in a separate identifiable
account until Group Health's subrogation and reimbursement rights are fully determined and that Group Health has
an equitable lien over such monies to the full extent of Group Health's Medical Expenses and/or the Injured Person
agrees to serve as constructive trustee over the monies to the extent of Group Health's Medical Expenses
If this Benefits Booklet is not subject to ERISA and reasonable collections costs have been incurred by an attorney
for the Injured Person in connection with obtaining recovery,under certain conditions Group Health will reduce the
amount of reimbursement to Group Health by the amount of an equitable apportionment of such collection costs
between Group Health and the Injured Person.This reduction will be made only if each of the following conditions
has been met (i)Group Health receives a list of the fees and associated costs before settlement and(u)the Injured
Person's attorney's actions were reasonable and necessary to secure recovery.
If this Benefits Booklet is subject to ERISA and reasonable collections costs have been incurred by the Injured
Person for the benefit of Group Health,under special circumstances,the Injured Person may request and Group
Health may agree to reduce the amount of reimbursement to Group Health by an amount for reasonable and
necessary attorney's fees and costs incurred by the Injured Person on behalf of and for the benefit of Group Health,
but only if such amount is agreed to in writing by Group Health prior to settlement or recovery.
To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA,
implementation of this section shall be deemed a part of claims administration and Group Health shall therefore
have discretion to interpret its terms
%1. Definitions i ._ u _°
x � m
Allowance The maximum amount payable by Group Health for certain Covered Services.
Allowed Amount A term used to define the level of benefits which are payable by Group Health when
expenses are incurred from a non-Network Provider Expenses are considered an
Allowed Amount if the charges are consistent with those normally charged to others by
the provider or organization for the same services or supplies,and the charges are within
the general range of charges made by other providers in the same geographical area for
the same services or supplies Members shall be required to pay any difference between
a non-Network Provider's charge for services and the Allowed Amount
Benefits Booklet The Benefits Booklet is a statement of benefits,exclusions and other provisions as set
forth in the Group medical coverage agreement between Group Health and the Group
Convalescent Care Convalescent Care is non-skilled personal care and care provided solely to assist with
daily living activities Members are considered under Convalescent Care/custodial care
while in a nursing home,adult family home,assisted living facility or in a personal
home
Copayment The specific dollar amount a Member is required to pay at the time of service for certain
C34613-0036900 42
Covered Services
Cost Share The portion of the cost of Covered Services for which the Member is liable Cost Share
includes Copayments,comsurances and Deductibles.
Covered Services The services for which a Member is entitled to coverage in the Benefits Booklet
Deductible A specific amount a Member is required to pay for certain Covered Services before
benefits are payable
Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements,
is enrolled hereunder and for whom the premium has been paid
Emergency The emergent and acute onset of a symptom or symptoms,including severe pain,that
would lead a prudent lay person acting reasonably to believe that a health condition
exists that requires immediate medical attention,if failure to provide medical attention
would result in serious impairment to bodily function or serious dysfunction of a bodily
organ or part or would place the Member's health,or if the Member is pregnant,the
health of her unborn child,in senousjeopardy.
Essential Health Benefits set forth under the Patient Protection and Affordable Care Act of 2010,
Benefits including the categories of ambulatory patient services,Emergency services,
hospitalization, maternity and newborn care,mental health and substance use disorder
services,including behavioral health treatment,prescription drugs,rehabilitative and
habilitative services and devices,laboratory services,preventive and wellness services
and chronic disease management and pediatric services,including oral and vision care
Family Unit A Subscriber and all his/her Dependents
Group An employer,union,welfare trust or bona-fide association which has entered into a
Group medical coverage agreement with Group Health
Group Health- A specialist specifically identified by Group Health
designated Specialist
Hospital Care Those Medically Necessary services generally provided by acute general hospitals for
admitted patients
Medical Condition A disease,illness or injury.
Medically Necessary Appropriate and clinically necessary services,as determined by Group Health's medical
director according to generally accepted principles of good medical practice,which are
rendered to a Member for the diagnosis,care or treatment of a Medical Condition and
which meet the standards set forth below In order to be Medically Necessary,services
and supplies must meet the following requirements (a)are not solely for the
convenience of the Member,his/her family or the provider of the services or supplies,
(b)are the most appropriate level of service or supply which can be safely provided to
the Member,(c)are for the diagnosis or treatment of an actual or existing Medical
Condition unless being provided under Group Health's schedule for preventive services,
(d)are not for recreational,life-enhancing,relaxation or palliative therapy,except for
treatment of terminal conditions,(e)are appropriate and consistent with the diagnosis
and which, in accordance with accepted medical standards in the State of Washington,
could not have been omitted without adversely affecting the Member's condition or the
quality of health services rendered,(f)as to inpatient care, could not have been provided
C34613-0036900 43
s
a
ti
i
in a provider's office,the outpatient department of a hospital or a non-residential facility
without affecting the Member's condition or quality of health services rendered,(g)are
not primarily for research and data accumulation,and(h)are not experimental or
investigational The length and type of the treatment program and the frequency and
modality of visits covered shall be determined by Group Health's medical director. In
addition to being medically necessary,to be covered,services and supplies must be
otherwise included as a Covered Service and not excluded from coverage
Medicare The federal health insurance program for the aged and disabled
Member Any enrolled Subscriber or Dependent.
Network Facility A facility(hospital,medical center or health care center)owned,operated or otherwise
designated by Group Health,or with whom Group Health has contracted to provide
health care services to Members.
Network Personal A provider who is employed by or contracted with Group Health to provide primary care
Physician services to Members and is selected by each Member to provide or arrange for the
provision of all non-emergent Covered Services,except for services set forth in the
Benefits Booklet which a Member can access without Preauthorization Network
Personal Physicians must be capable of and licensed to provide the majority of primary
health care services required by each Member
Network Provider The medical staff,clinic associate staff and allied health professionals employed by
Group Health,and any other health care professional or provider with whom Group
Health has contracted to provide health care services to Members, including,but not
limited to physicians,podiatrists, nurses,physician assistants,social workers,
optometrists,psychologists physical therapists and other professionals engaged in the
delivery of healthcare services who are licensed or certified to practice in accordance
with Title 18 Revised Code of Washington
Out-of-pocket Expenses Those Cost Shares aid b the Subscriber or Member for Covered Services which are
Po Pe P Y
applied to the Out-of-pocket Limit
Out-of-pocket Limit The maximum amount of Out-of-pocket Expenses incurred and paid during the calendar
year for Covered Services received by the Subscriber and his/her Dependents within the
same calendar year The Out-of-pocket Expenses which apply toward the Out-of-pocket
Limit are set forth in Section IV
Plan Coinsurance The percentage amount the Member is required to pay for Covered Services received.A
coinsurance percentage not identified as Plan Coinsurance is a benefit-specific
coinsurance
Preauthorization An approval by Group Health that entitles a Member to receive Covered Services from a
specified health care provider Services shall not exceed the limits of the
Preauthorization and are subject to all terms and conditions of the Benefits Booklet
Members who have a complex or serious medical or psychiatric condition may receive a
standing Preauthonzation for specialty care provider services
Residential Treatment A term used to define facility-based treatment,which includes 24 hours per day,7 days
per week rehabilitation Residential Treatment services are provided in a facility
specifically licensed in the state where it practices as a residential treatment center.
Residential treatment centers provide active treatment of patients in a controlled
C34613-0036900 44
environment requiring at least weekly physician visits and offering treatment by a multi-
disciplinary team of licensed professionals
Service Area Washington counties of Benton,Columbia,Franklin,Island,King,Kitsap,Kittitas,
Lewis,Mason,Pierce, San Juan,Skagit,Snohomish,Spokane,Thurston,Walla Walla,
Whatcom,Whitman and Yakima,Idaho counties of Kootenai and Latah,and any other
areas designated by Group Health
Subscriber A person employed by or belonging to the Group who meets all applicable eligibility
requirements,is enrolled and for whom the premium has been paid
Urgent Condition The sudden,unexpected onset of a Medical Condition that is of sufficient severity to
require medical treatment within 24 hours of its onset
C34613-0036900 45