HomeMy WebLinkAboutCAG1997-0043 - Original - Group Health Cooperative - Group Medical Coverage Agreement - 01/01/1997 f
Health
�� Cooperative
of Puget Sound
GROUP MEDICAL COVERAGE
AGREEMENT
Group Health Cooperative of Puget Sound (also referred to as "GHC" or"the Cooperative") is a non-profit health
maintenance organization furnishing health care primarily on a prepayment basis. As a direct service provider, the
Cooperative is dedicated to providing to its Members quality health care,including preventive medical services.
This Agreement states the terms of enrollment,payment and coverage under which a Group may secure GHC health
benefits. The Schedule of Benefits lists the benefits to which those enrolled under this Agreement are entitled.
Words with special meaning are capitalized. They are defined in Section I.
MEMBERS ARE ENTITLED TO COVERED SERVICES ONLY AT GHC FACILITIES AND FROM GHC
PROVIDERS,UNLESS THE MEMBER HAS BEEN REFERRED BY A GHC PRIMARY CARE PROVIDER OR
HAS RECEIVED EMERGENCY SERVICES ACCORDING TO SECTION X.I. OF THE SCHEDULE OF
BENEFITS.
Female Members may see a participating General and Family Practitioner, Physician's Assistant, Gynecologist,
Certified Nurse Midwife, Doctor of Osteopathy, Obstetrician and Advanced Registered Nurse Practitioner who
provides women's health care services directly,without a Referral from their Primary Care Provider, for medically
appropriate maternity care, covered reproductive health services, preventive care and general examinations,
gynecological care, and medically appropriate follow-up visits for the above services. If your chosen provider
diagnoses a condition that requires more extensive covered care outside the practice scope of your women's health
care provider, and requires referral to other specialists or hospitalization,you or your chosen provider must contact
your Primary Care Provider for authorization and care coordination. Women's health care services are covered as if
your Primary Care Provider had been consulted, subject to any applicable Copayments and/or Coinsurance as set
forth in the Copayments and Allowances Schedule. For more information on women's health care providers,
contact Group Health Customer Service Center.
Limited direct access to providers within GHC's defined network is also available for manipulative therapy as set
forth in Section X.B.
0036900-CO3046 4
GROUP HEALTH COOPERATIVE OF PUGET SOUND
Title: &nior Director Health Insurance Services
GROUP
By:
�Y. Y,
Title:
This Agreement will become effective January 1, 1997 and will continue
in effect until terminated as herein provided for.
PA-1133-Basic Agreement
0036900-CO3046 5
M.
GROUP MEDICAL COVERAGE
AGREEMENT
Table of Contents
I. Definitions
II. Dues,Fees and Copayments
III. Termination
IV. Continuation Coverage,Conversion,and Transfer
V. Coordination of Benefits
VI. Subrogation
VII. Grievance Procedures
VIII. Miscellaneous Provisions
IX. Enrollment and Eligibility Schedule
X. Schedule of Benefits
XI. Exclusions and Limitations
XII. Claims
• Medicare Endorsements
• Copayments and Allowances Schedule
• Dues Schedule
• Service Area Map
0036900-003046 6
a
Section I. Definitions
AGREEMENT: This Medical Coverage Agreement, including the Schedule of Benefits, Enrollment and
Eligibility Schedule, Dues Schedule, Copayments and Allowances Schedule, Service Area Map, and Medicare
endorsements.
ALLOWANCE: The maximum amount payable by GHC for certain Covered Services under this Agreement, as
set forth in the Copayments and Allowances Schedule.
COINSURANCE: An amount the Member is required to pay for Covered Services received under this Agreement,
which is a percentage of the Allowance for such services,as set forth in the Copayments and Allowances Schedule.
COPAYMENT: The specific dollar amount required to be paid by a Member for certain Covered Services under
this Agreement as set forth in the Copayments and Allowances Schedule.
COVERED SERVICES: The services and benefits to which a Member is entitled under this Agreement.
DEDUCTIBLE: A specific maximum amount paid by a Member for certain Covered Services before benefits are
payable under this Agreement. The applicable Deductible amounts are set forth in the Copayments and Allowances
Schedule.
DIRECTORY OF SERVICES: A fee-for-service schedule adopted by GHC,setting forth the fees for medical and
hospital services not covered by a GHC prepayment agreement.
EMERGENCY: The sudden,unexpected onset of a medical condition that in the reasonable judgment of a prudent
person is of such a nature that failure to render immediate care by a licensed medical provider would place the
Member's life in danger,or cause serious impairment to the Member's health.
FAMILY DEPENDENT: Any member of a Subscriber's family who meets all applicable eligibility requirements,
is enrolled hereunder,and for whom the dues prescribed in the Dues Schedule have been paid.
FAMILY UNIT: A Subscriber and all his/her Family Dependents.
GHC DESIGNATED FACILITY: A facility, not including a GHC Facility, which the GHC Board of Trustees
has specified to provide health care services to its Members. (See Service Area Map.) Designated Facilities may be
changed by GHC upon appropriate notice.
GHC FACILITY: A hospital or medical center owned and operated by Group Health Cooperative of Puget Sound.
(See Service Area Map.)
GHC MEDICARE PLAN: A plan of coverage for persons enrolled in Medicare Part A (hospital insurance) and
Part B(medical insurance), or Part B only.
GHC PRIMARY CARE PROVIDER: A provider who is employed by or contracted with GHC to provide
primary care 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 this Agreement which a Member can access without
referral. Primary Care Providers must be capable of and licensed to provide the majority of primary health care
services required by each Member.
GHC PROVIDER: The Medical Staff,Clinic Associate Staff,and Allied Health Professionals employed by GHC,
and any other health care professional with whom GHC has contracted to provide health care services to persons
enrolled under this Agreement, and who at such time is providing services which have been authorized in advance
by GHC, including, but not limited to, podiatrists, nurses, physician assistants, social workers, optometrists,
0036900-003046 7
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 RCW.
GROUP: An employer, union, welfare trust, or association which has entered into a Group Medical Coverage
Agreement with GHC.
HOSPITAL CARE: Those Medically Necessary services generally provided by acute general hospitals for
admitted patients which a GHC Provider has prescribed, directed, or authorized. Hospital care does not include
convalescent or custodial care which can, in the opinion of the GHC Provider, be provided by a nursing home or
convalescent care center.
MEDICAL CONDITION:A medical condition is a disease, an illness or an injury.
MEDICALLY NECESSARY: Required for the diagnosis or treatment of illness or injury, as determined by a
GHC Provider,and consistent with professionally recognized standards of health care.
MEDICARE: The federal health insurance program for the aged and disabled.
MEMBER: Any Subscriber or Family Dependent covered by this Agreement.
OPEN ENROLLMENT: An annual period, specified by the Group and GHC, during which an eligible person
may apply for coverage.
PRE-EXISTING CONDITION: A condition for which there has been diagnosis, treatment(including prescribed
drugs),or medical advice within the three(3)month period prior to the effective date of coverage,or a condition for
which symptoms existed within the three (3) month period prior to the date of coverage and for which a prudent
person would have ordinarily sought treatment.
REFERRAL: A written temporary referral agreement authorized in advance by a GHC Provider and approved by
GHC, which entitles a Member to receive Covered Services from a specified non-GHC health care provider.
Entitlement to such services shall not exceed the limits of the Referral and is subject to all terms and conditions of
the Referral and this Agreement.
SERVICE AREA: Clallam; Island, King, Kitsap, Lewis,Mason, Pierce, San Juan, Skagit, Snohomish, Thurston,
and Whatcom Counties,and any other areas designated by GHC. (See Service Area Map.)
SKILLED HOME HEALTH CARE: 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.
STOP LOSS: The maximum amount of Copayments,and expenses incurred and paid, during the calendar year for
Covered Services received by the Subscriber and his/her Family Dependents within the same calendar year. The
Stop Loss amount is set forth in the Copayments and Allowances Schedule.
SUBSCRIBER: A person employed by or belonging to the Group who meets all applicable eligibility
requirements, is enrolled hereunder,and for whom the dues specified in the Dues Schedule have been paid.
URGENT CONDITION: The sudden, unexpected onset of a medical condition that is of sufficient severity to
require medical treatment within twenty-four(24)hours of its onset.
USUAL,CUSTOMARY,AND REASONABLE: A term used to define the level of benefits which are payable by
GHC when expenses are incurred from a non-GHC physician or provider. Expenses are considered Usual,
Customary, and Reasonable if (1) the charges are consistent with those normally charged by the provider or
0036900-CO3046 8
w.
a
organization for the same services or supplies; and(2)the charges are within the general range of charges made by
other providers in the same geographical area for the same service or supplies.
Section 11 Dues,Fees and Copayments
A. MONTHLY DUES PAYMENTS. The Group shall submit to GHC for each Member the monthly dues set
forth in the current Dues Schedule and a verification of enrollment, on or before the due date,subject to a grace
period of ten(10)days. Dues are subject to change by GHC upon thirty(30)days written notice.
In the event the group increases enrollment at least twenty-five percent (25%) or more through acquisition or
merger,GHC reserves the right to require re-rating of the group.
B. COPAYMENTS AND COINSURANCE.
1. Copayments. At the time of service, Members shall be required to pay Copayments as set forth in the
Copayments and Allowances Schedule. Failure to pay for services and/or Copayments at the time of
service may result in a billing fee. Failure to cancel a scheduled appointment at least 24 hours prior to the
appointment may result in a billing for the value of the 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.
Total out-of-pocket Copayment expenses incurred during the same calendar year shall not exceed the
aggregate maximum amount(Stop Loss) as set forth in the Copayments and Allowances Schedule. Those
Copayment categories which apply toward the aggregate maximum amount are set forth in the Copayments
and Allowances Schedule.
If Copayments have been billed, any applicable billing fees shall not be considered in calculating total
out-of-pocket expenses for Copayments made.
2. Coinsurance. Members shall be required to pay Coinsurance for certain Covered Services as set forth in
the Copayments and Allowances Schedule.
C. SUBSCRIBER'S LIABILITY. The Subscriber is liable for (1) payment to the Group of his/her contribution
toward the monthly dues, if any; (2)payment to the Cooperative of Copayments and/or Coinsurance amounts
for Covered Services provided to the Subscriber and his/her Family Dependents,as set forth in the Copayments
and Allowances Schedule; and (3) payment to the Cooperative of any fees charged for non-Covered Services
provided to the Subscriber and his/her Family Dependents.
Payment of an amount billed and any applicable billing fee must be received within thirty (30) days of the
billing date.Amounts paid for billing fees do not apply toward the Stop Loss.
D. SELF-PAYMENTS DURING A STRIKE, LOCK-OUT, OR OTHER LABOR DISPUTE. 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 under this Agreement through payment of monthly dues
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 six(6)months after the cessation of work.
If the Group Agreement is no longer available,the Subscriber shall have the opportunity to apply for individual
Group Conversion or, if applicable, continuation coverage (see Section IV.), or an Individual and Family
Medical Coverage Agreement 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.
0036900-CO3046 9.
Section III. Termination
A. TERMINATION OF ENTIRE AGREEMENT. This Agreement may be terminated in the following
circumstances:
1. Termination on Notice. This is a guaranteed renewable contract and cannot be terminated without the
mutual approval of each of the parties except as set forth below(subsection 2.and 3.).
2. Nonpayment. Failure to make any monthly dues payment in accordance with Section II.A. shall result in
termination of this Agreement as of the due date.
3. Misrepresentation to Obtain Insurance. Group Health Cooperative may terminate this Agreement upon
written notice in the event of material misrepresentation, fraud, or omission of information in order to
obtain Group Coverage.
4. The Group may terminate this Agreement by giving thirty(30)days written notice to GHC.
B. TERMINATION OF SPECIFIC MEMBERS. This Agreement may be terminated as to a specific Member
for any of the following reasons:
1. Loss of Eligibility.If a Member no longer meets the eligibility requirements set forth in Section IX.B.,and
is not enrolled for continuation coverage as described in Section IV.A.,coverage under this Agreement will
terminate at the end of the month during which loss of eligibility occurs,unless otherwise specified by the
Group as set forth in Section IX.Enrollment and Eligibility Schedule.
2. For Cause. Coverage of a Member may be terminated upon written notice for:
a. Material misrepresentation, fraud, or omission of information in order to obtain coverage. This
includes failure to answer fully and correctly all questions contained in the application forms. In such
event,the Cooperative may,within two(2)years from the date of the application, refuse to cover any
service for a condition(s)to which such question was relevant, or may rescind or cancel the Member's
coverage upon ten(10)working days written notice.
b. Permitting the use of a GHC identification card by another person, or using another person's
identification card to obtain care to which one is not entitled.
c. Failure to comply with the rules and regulations of the Cooperative.
d. Nonpayment of charges as set forth in Section II.C.
3. Nonpayment of dues for a specific Member by the Group.
4. 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 this Agreement.
5. The Member may appeal the termination decision through GHC's grievance process as set forth in Section
VII.
C. PERSONS HOSPITALIZED ON THE DATE OF TERMINATION. A Member who is a registered bed
patient receiving Covered Services in a GHC Facility or GHC Designated Facility on the date of termination
shall continue to be eligible for Covered Services for the condition for which the Member was hospitalized,
until discharge from the facility. This continued coverage will also apply to a Member hospitalized in a
non-GHC Designated Facility as a result of an Emergency or Referral as set forth in Section XI.B.1.
D. SERVICES PROVIDED AFTER TERMINATION. Any services provided by GHC after the effective date
of termination(except those services covered under Section III.C.) shall be charged according to the Directory
0036900-003046 10
M,
K
of Services. The Subscriber shall be liable for payment of all such charges for services provided to the
Subscriber and all Family Dependents.
Section IV. Continuation Coverage, Conversion, and Transfer
A. CONTINUATION COVERAGE.
This subsection A. only applies to employer 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.
To the extent required by federal law, if the Subscriber or Family Dependent loses eligibility under this Group
Agreement, group coverage may be continued under the circumstances described below. Except as set forth in
Section IV.A.12.,.below, this provision applies only to Subscribers and Family Dependents enrolled under this
Agreement prior to the date of eligibility for continuation coverage who would otherwise lose coverage as a
result of one of the qualifying events listed below in subsections(1.),(2.),and(3.).
1. Subscribers and Family Dependents are eligible for continuation coverage for a maximum period of up to
eighteen(18)months commencing at the date that:
• The Subscriber's employment is terminated(unless terminated for gross misconduct);or
• the Subscriber experiences a reduction in work hours resulting in loss of eligibility for group benefits.
2. Family Dependents are eligible for continuation coverage for a maximum period of up to thirty-six (36)
months commencing at the date that:
• The Subscriber is divorced or legally separated;
• the Subscriber dies;
• the Subscriber becomes entitled to Medicare;or
• a Dependent child ceases to qualify as a Family Dependent under Section IX.B.2.(b)or(c).
3. A COBRA eligible beneficiary who is disabled prior to or on the date he/she loses coverage due to
termination of employment (other than for the beneficiary's gross misconduct) or reduction of hours, or
becomes disabled at any time during the first sixty (60) days of COBRA coverage, may extend his/her
coverage under COBRA from eighteen (18) months up to twenty-nine (29) months, so long as the
beneficiary provides notice of his/her Social Security disability determination within sixty (60) days of
such determination and before the end of the eighteen (18) month coverage period. Social Security
Administration certification of total disability is required. The period of extended coverage provided under
this subsection shall terminate on the first day of the first month which begins more than thirty (30) days
after the date of the Social Security Administration's final determination that the qualified beneficiary is no
longer disabled. Non-disabled dependents of a disabled Subscriber who are eligible for continuation
coverage are entitled to continue their dependent coverage for the duration of the disabled Subscriber's
disability extension.
4. In the event the group has retirees,the Subscriber who is a retiree or the spouse or Dependent of a retiree,
may continue coverage hereunder if the Subscriber and /or Family Dependent would otherwise lose
coverage hereunder within one year of the date a proceeding under Title 11 of the United States Code is
commenced with respect to the Group. Coverage under this Section IV.A.4.,continues only upon payment
of applicable monthly charges to the Group at the time specified by the Group.The terms and conditions of
this coverage are governed by COBRA.
5. If an individual enrolled for continuation coverage experiences a second qualifying event as set forth in
subsection (2.) above, continuation coverage may be extended for up to thirty-six (36)months, beginning
from the date of the first qualifying event. Where the Subscriber becomes entitled to Medicare,the period
0036900-CO3046 11
of continuation coverage for Family Dependents as a result of the Subscriber's Medicare entitlement or any
later event described in Section IV.A.2. above shall extend up to a maximum of thirty-six (36) months
from the date the Subscriber becomes entitled to Medicare.
6. In addition to the conditions set forth in Section III. Termination,continuation coverage may be terminated
prior to the prescribed period set forth in subsections(1.),(2.),and(3.)above if-
there is a failure to make timely payment of any monthly dues required under this Agreement;
• the Member becomes covered under any other group health plan, unless such plan contains an
exclusion or limitation on coverage for any pre-existing condition which may apply to the Member;
• the Member becomes enrolled under Medicare;
• the employer ceases to maintain any group health plan;or
• the Member is no longer disabled as determined by the Social Security Administration.
7. In the event a child is born to, or is placed with the covered Subscriber for adoption, during a period of
COBRA continuation coverage,such child will also be considered a qualifted beneficiary.
8. Notice. The Group is responsible for assuring compliance with COBRA and that Members are given
timely notice of their continuation coverage option. The Group is also responsible for notifying GHC in a
timely fashion of the election to continue coverage and the applicable coverage period.
The Subscriber or Family Dependent must notify the Group,or plan administrator, if any, within sixty(60)
days following a divorce, legal separation, or when an enrolled dependent child no longer meets the
eligibility requirements set forth in Section IX.B.2., or within sixty (60) days following the date coverage
ends in accordance with the termination provisions under this Agreement,whichever is later.
9. Application. Written application for continuation coverage must be made within sixty (60) days of the
termination date of coverage, or the date that the Member receives specific notice of his/her right to
continuation coverage, whichever is later. For the purposes of this Agreement, "receives" means that
written notice was mailed by the Group to the Member's most recent address as recorded with the Group.
No lapse in coverage prior to continuation coverage is permitted, except as provided above. The
application shall be deemed by GHC to include all Family Dependents eligible for continuation coverage
unless specifically stated otherwise.A physical examination or statement of health is not required.
10. Monthly Dues. Monthly dues must be paid directly to the Group. The Group is responsible for submitting
such dues with its regular monthly dues payment to GHC.
Payment of the initial dues payment, which includes the period from the election retroactive to the
qualifying event, and any regular dues payment that becomes due prior to the initial dues payment date,for
continuation coverage under COBRA is due forty-five(45)days after the date of the election. Subsequent
dues payments are due on a monthly basis. Dues for persons extending COBRA coverage from eighteen
(18) months to twenty-nine (29) months because of total disability may be charged at one hundred fifty
percent(150%)of the Group's dues rate that would otherwise apply to them.
11. Group Conversion. In addition to Group Conversion rights as set forth in Section IV.B.,the Subscriber or
Family Dependent enrolled for continuation coverage is entitled to convert to GHC's Group Conversion
Plan within a 180-day period prior to termination of continuation coverage, if his/her coverage under this
Agreement is terminated for any reason other than nonpayment or cause. See Section IV.B.2. GHC Group
Conversion Plan-Application.
12. Open Enrollment and Adding Dependents. To the extent required under COBRA, a qualified
beneficiary under COBRA may add Family Dependents during the Group's Open Enrollment period and
newly eligible persons according to the procedures specified in Section IX.A.
0036900-CO3046 12
B. GHC GROUP CONVERSION PLAN.
1. Eligibility.Any Subscriber or Family Dependent is entitled to convert to GHC's Group Conversion Plan if
his/her coverage under this Agreement is terminated for any reason other than cause. (See Section III.13.2.)
Following termination of marriage or death of the Subscriber, all Family Dependents are entitled to make
such a conversion.
2. Application. Application for conversion must be made within thirty-one (31) days following termination
under this Agreement. Coverage under the GHC Group Conversion Plan is subject to all terms and
conditions of such plan, including dues payment..A physical examination or statement of health is not
required for enrollment in the Group Conversion Plan.
Section V. Coordination of Benefits
A. BENEFITS SUBJECT TO THIS PROVISION: As described in subsection H., benefits provided under this
Agreement do not duplicate other group coverage for medical care or treatment. If a Member is entitled to
receive benefits or services for medical care or treatment under another individual, group or governmental plan,
GHC may recover the reasonable cash value of services provided under this Agreement so that benefits and
services under all plans do not exceed one hundred percent(100%)of allowable expenses(except copayments,
coinsurances and deductibles)as set forth in this section.
B. PLAN:The definition of a"Plan" includes the following sources of benefits or services:
1. Group or blanket disability insurance policies and health care service contractor and health maintenance
organization group agreements, issued by insurers, health care service contractors and health maintenance
organizations;
2. Labor-management trusteed plans, labor organization plans, employer organization plans or employee
benefit organization plans;
3. Governmental programs;and
4. Coverage required or provided by any statute.The term"Plan"shall be construed separately with respect to
each policy, agreement or other arrangement for benefits or services, and separately with respect to the
respective portions of any such policy,agreement or other arrangement which do and which do not reserve
the right to take the benefits or services of other policies, agreements or other arrangements into
consideration in determining benefits.
C. ALLOWABLE EXPENSE: "Allowable Expense" means any necessary, reasonable and customary items of
expense at least a portion of which is covered under at least one of the Plans covering the person for whom the
claim is made.When a Plan provides benefits in the form of services rather than cash payments,the reasonable
cash value of each service rendered shall be considered as both an Allowable Expense and a benefit paid.
D. CLAIM DETERMINATION PERIOD: "Claim Determination Period" means a period beginning with any
January 1 and ending with the next following December 31 except that the first Claim Determination Period
with respect to any person shall begin on the effective date of coverage under this Agreement with respect to
such person and end on the following December 31. In no event will a Claim Determination Period for any
person extend beyond the last day on which such a person is covered under this Agreement.
E. RIGHT TO RECEIVE AND RELEASE INFORMATION: For the purpose of determining the applicability
of and implementing this provision and any provision of similar purpose in any other Plan, the Cooperative
may,with such consent as may be necessary,release to or obtain from any other insurer,organization or person
any information,with respect to any person which the insurer considers necessary for such purpose.Any person
0036900-CO3046 13
claiming benefits under this Agreement shall furnish to the Cooperative the information necessary for such
purpose.
F. FACILITY OF PAYMENT: Whenever coverage which should have been provided under this Agreement in
accordance with this provision has been provided or paid for under any other Plan,the Cooperative shall have
the right, exercisable alone and in its sole discretion,to pay over to any Plan making such other payments any
amounts it shall determine to be warranted in order to satisfy the intent of this provision, and amounts so paid
shall be considered to be coverage or benefits paid under this Agreement and, to the extent of such payments,
the Cooperative shall be fully discharged from liability under this Agreement.
G. RIGHT OF RECOVERY: Whenever benefits have been provided by the Cooperative with respect to
Allowable Expenses in total amount, at any time, in excess of the maximum amount of payment necessary at
that time to satisfy the intent of this provision, the Cooperative shall have the right to recover the reasonable
cash value of such benefits,to the extent of such excess, from one or more of the following, as the Cooperative
shall determine: any persons to or for or with respect to whom such benefits were provided, any other insurers,
any service plans or any other organization or other Plans.
H. EFFECT ON BENEFITS:
1. This provision shall apply in determining the benefits for a person covered under this Agreement for a
particular Claim Determination Period if, for the Allowable Expenses incurred as to such person during
such period,the sum of:
a. The reasonable cash value of the benefits that would be provided under the Agreement in the absence
of this provision,and
b. The benefits that would be payable under all other Plans in the absence therein or provisions of similar
purpose to this provision would exceed such Allowable Expenses.
2. As to any Claim Determination Period with respect to which this provision is applicable, the reasonable
cash value of the benefits provided under this Agreement in the absence of this provision for the Allowable
Expenses incurred as to such person during such Claim Determination Period shall be reduced to the extent
necessary so that the sum of the reasonable cash value of benefits and all benefits payable for such
Allowable Expenses under all other Plans,except as provided in subparagraph(3)of this Section, shall not
exceed the total of such Allowable Expenses. Benefits payable under another Plan include benefits that
would have been payable had a claim been duly made therefor. In determining liability under this
paragraph,the Plan is not required, and will not take into consideration, deductibles, copayments, or other
cost-sharing provisions.
3. If
a. another Plan which is involved in subparagraph (2) of this Section and which contains a provision
coordinating its benefits with those of this Agreement would, according to its rules, determine its
benefits after the benefits of this Plan have been determined;and
b. the rules set forth in subparagraph (4) of this Section would require this Agreement to determine its
benefits before such other Plan,then the benefits of such other Plan will be ignored for the purposes of
determining the benefits under this Agreement.
4. For the purposes of subparagraph (3) of this Section, the rules establishing the order of benefit
determination are:
a. The benefits of a Plan which covers the person on whose expenses a claim is based other than as a
dependent shall be determined before the benefits of a Plan which covers such person as a dependent.
14
0036900-003046
b. In the case that a dependent is covered under both parents'medical Plan,the benefits of the Plan of the
parent whose birthday falls earlier in the year are determined before those of the Plan of a parent
whose birthday falls later in the year. This birthdate will refer only to the month and day,not the year
in which a person was born. If both parents have the same birthday, the benefits of the Plan which
covered the parent longer are determined before those that covered the other parent for a shorter period
of time,except that in the case of a person for whom claim is made as a dependent child,
i. when the parents are separated or divorced and the parent with custody of the child has not
remarried,the benefits of a Plan which covers the child as a dependent of the parent with custody
of the child will be determined before the benefits of a Plan which covers the child as a dependent
of the parent without custody;and
ii. when the parents are divorced and the parent with custody of the child has remarried,the benefits
of a Plan which covers the child as a dependent of the parent with custody shall be determined
before the benefits of a Plan which covers that child as a dependent of the stepparent, and the
benefits of a Plan which covers that child as a dependent of the stepparent will be determined
before the benefits of a Plan which covers that child as a dependent of the parent without custody.
Notwithstanding items (i) and (ii) above, if there is a court decree which would otherwise establish
financial responsibility for the medical, dental or other health care expenses with respect to the child,
the benefits of a Plan which covers the child as a dependent of the parent with such financial
responsibility shall be determined before the benefits of any other Plan which cover the child as a
dependent child.
c. When rules(a)and(b)do not establish an order of benefit determination,the benefits of a Plan which
has covered the person on whose expenses claim is based for the longer period of time shall be
determined before the benefits of a Plan which has covered such person the shorter period of time,
provided that:
i. The benefits of a Plan covering the person on whose expenses claim is based as a laid off or
retired employee, or dependent of such person shall be determined after the benefits of any other
Plan covering such person as an employee, other than a laid off or retired employee,or dependent
of such person;and
ii. If either Plan does not have a provision regarding laid off or retired employees, which results in
each Plan determining its benefits after the other,then the provisions of(i)of this subsection shall
not apply.
d. If none of the above rules determines the order of benefits, the benefits of the Plan which covered an
employee or Subscriber for the longer period of time shall be determined before those of the Plan
which covered that person for the shorter time period.
5. When this provision operates to reduce the total amount of benefits otherwise to be provided to a person
covered under this Agreement during any Claim Determination Period, the reasonable cash value of each
benefit that would be provided in the absence of this provision shall be reduced proportionately, and such
reduced amount shall be charged against any applicable benefit limit of this Agreement.
Section VI. Subrogation
"Injured person" under this section means a Member covered by this Agreement who sustains compensable injury.
"GHC's medical expenses" means the expense incurred and the reasonable value of the services provided by the
Cooperative for the care or treatment of the injury sustained.
If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability against
the third party, GHC shall have the right to recover from the third party GHC's medical expenses. This right is
commonly referred to as "subrogation."GHC shall be subrogated to and may enforce all rights of the injured person
0036900-CO3046 15
to the extent of GHC's medical expenses. GHC's equitable and contractual rights of subrogation are limited(only as
required)by Washington law.
The injured person and his or her agents must cooperate fully with GHC in its efforts to collect GHC's medical
expenses. This cooperation shall include supplying GHC with information about any defendants and/or insurers
related to the injured person's claim. The injured person and his or her agents shall permit GHC,at GHC's option,to
associate with the injured party or to intervene in any action filed against any third party.The injured person and his
or her agents shall do nothing to prejudice GHC's subrogation rights. The injured person shall not settle a claim
without protecting GHC's interest.
GHC shall be subrogated to and may enforce all rights of the injured person to the extent of its medical expense.
GHC's right of subrogation shall be limited to the excess of the amount required to fully compensate the injured
person for the loss sustained. Full compensation shall be measured on an objective, case-by-case basis, but is
subject to a presumption that a settlement which does not exhaust the third parry's reachable assets is full
compensation to the injured person. If the Member fails to cooperate fully with GHC in recovery of medical
expenses as described above,the Member shall be responsible for reimbursing GHC for such medical expenses.
GHC shall not pay any attorney's fees or collection costs to attorneys representing the injured person where it has
retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a written fee
agreement signed by GHC prior to any collection efforts. When reasonable collection costs have been incurred with
GHC's prior written agreement, to recover GHC's medical expenses, there shall be an equitable apportionment of
such collection costs between GHC and the injured person subject to a maximum responsibility of GHC equal to
one-third of the amount recovered on behalf of GHC.
Section VII Grievance Procedures
The Member Services Program is designed to help a Member resolve formal complaints and concerns about medical
and business service. GHC will record,research,and respond in a timely manner to a Member's concern.A concern
should initially be registered at the Member's area medical center. If not satisfied, the Member should then contact
the regional Member Services Department, which will arrange for review by appropriate Medical Staff,
management,and/or GHC consumers.
For grievances following denial of claims for experimental/investigational procedures,see Section XI.A.
Section VIII Miscellaneous Provision
A. DISSEMINATION OF INFORMATION. The Group is responsible for disseminating to Subscribers written
information concerning this Agreement which is provided by the Cooperative.
B. IDENTIFICATION CARDS. The Cooperative will furnish cards, for identification only, to all persons
enrolled under this Agreement.
C. ADMINISTRATION OF AGREEMENT. GHC may adopt reasonable policies and procedures to help in the
administration of this Agreement.
D. MODIFICATION OF AGREEMENT. Except as required by Washington state law,this Agreement may not
be modified without agreement between both parties..
E. Group Health Cooperative reserves the right to construe the provisions of this Medical Coverage Agreement,
and to determine any and all questions pertaining to benefit entitlement and coverage.
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.
0036900-003046 16
h_ p'::►
F. INDEMNIFICATION. GHC agrees to indemnify and hold the Group harmless against all claims, damages,
losses, and expenses, including reasonable attorney's fees, arising out of GHC's failure to perform or negligent
performances of its express obligations under the Group Medical Coverage Agreement. GHC further agrees to
indemnify and hold the Group harmless against claims, damages, losses or expenses, including reasonable
attorney's fees, for injury or damage caused to any person which is the result of or is alleged to be the result of
the failure to provide or the negligent provision of medical services or supplies specified under this contract by
any health care provider who is employed by, is an agent of or who has a direct contractual relationship with
GHC.Provided,however,that the Group notifies GHC in writing promptly of any such claims,that it will assist
GHC (at GHC's expense) in the defense of same, and that GHC has the right to direct and arrange the defense
of the case.
The foregoing shall not in any way be construed as applying to any claim, demand or loss arising out of
negligent acts or omissions of the Group, its agents, officers or employees, or failure by the Group to cant'out
any of its responsibilities under this Agreement.
G. The Medical Coverage Agreement is entered into and governed by the laws of Washington State, except as
otherwise pre-empted by ERISA and other Federal laws.
Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or mental handicaps in
its employment practices and services.
Section IX Enrollment and Efildbilify Schedule
A. ENROLLMENT
1. Application for Enrollment. Application for enrollment shall be made on an application form furnished
and approved by GHC. No person shall be enrolled or dues accepted until this completed application has
been received and approved by GHC.The Group is responsible for submitting completed application forms
to GHC.
a. Newly Eligible Persons. Newly eligible Subscribers may make written application for enrolhment to
the Group within thirty-one (31) days of eligibility. If the Subscriber wishes to enroll his/her eligible
Dependents,application must be made during this same thirty-one(31)day period.
Written application for enrollment for a newly dependent person, other than a newborn or newborn
adopted child,must be made to the Group within thirty-one(31)days after the dependency occurs.
A Subscriber's newborn child shall be automatically enrolled when born:
i. at a GHC Facility or GHC Designated Facility;or
ii. at a non-GHC Facility due to an Emergency,provided that all the requirements of Section X.I. of
this Agreement are met, including notification of GHC by way of the GHC Notification Line
within twenty-four (24) hours following inpatient admission, or as soon thereafter as medically
possible.
GHC shall provide notice of such enrollment to the Subscriber and the Group. It is the Subscriber's
responsibility to complete and submit a revised application form to the Group. If the Subscriber does
not want the newborn child enrolled, he/she must notify GHC within sixty (60) days of the date of
birth.
If subsequent to enrollment it is discovered that the newborn child is not eligible or if the Group does
not initiate dues payments on or before sixty(60)days from the date of birth, GHC shall disenroll the
child retroactive to the effective date of coverage.
0036900-003046 17
Children who are born in a non-GHC Facility on a nonemergency basis will not be automatically
enrolled. In the event there is a change in the monthly dues payment as a result of the addition of a
newborn child,the Subscriber must make written application for enrollment to the Group within sixty
(60)days following the date of birth.
In the event there is a change in the monthly dues payment as a result of the addition of an adoptive
child,including adopted newborns,the Subscriber must make written application for enrollment within
sixty (60) days from the day that the child is physically placed with the Subscriber for the purpose of
adoption and the Subscriber assumes financial responsibility for the medical expenses of the child.
b. If the spouse and/or eligible Family Dependents of a GHC Subscriber loses eligibility under a
comparable medical plan they may be added to the GHC Subscriber's plan.There must be no more than
a three (3) month lapse of coverage between plans, and application must be made prior to the
expiration of this three(3)month period.
c. Open Enrollment. A person not enrolled as a Subscriber or Family Dependent when newly eligible,
as described above,may make written application during the Group's Open Enrollment period.
2. Limitation on Enrollment. This Agreement will be open for application as set forth in Section IX.A.I.
GHC may limit enrollment, establish quotas, or set priorities for acceptance of new applications if it
determines that its capacity, in relation to its total enrollment, is not adequate to provide services to
additional persons.
3. Effective Date of Enrollment.
a. Provided application is made as set forth in Section IX.A.I.a. (above),enrollment for a newly eligible
Subscriber and listed Dependents will begin on the date of hire.
Subscribers who return to work from a leave without pay status within ninety (90) days, shall be
eligible for enrollment on the first of the month following their date of return to work.
Enrollment for newly dependent persons, other than newborns and adopted children,will begin on the
first(1st)of the month following application.
Provided newborns are enrolled as specified in Section IX.A.I.a. (above),enrollment is effective from
the date of birth.
For adopted children, enrollment is effective from the date that the adopted child is physically placed
with the Subscriber for the purpose of adoption and the Subscriber has assumed financial
responsibility for the medical expenses of the child.
b. Persons Hospitalized on Effective Date. If a person, other than a newborn or adoptive child, is
confined in a hospital on the date enrollment would otherwise become effective, the effective date of
enrollment for the person(s)hospitalized will not begin until discharge from the facility.
4. Effective Date of Services and Benefits. Services provided to Enrollees, including newborns and adoptive
children, are subject to all terms and conditions of the Group Agreement including the requirement that all
services must be received at a GHC or GHC Designated Facility under the medical management of a GHC
physician unless the Enrollee has been Referred by a GHC physician or has received Emergency services
according to Section X.I.
B. ELIGIBILITY
In order to be accepted for enrollment and continuing coverage under the Group Agreement, individuals must
meet all applicable requirements set forth below.The Group is responsible for determining eligibility.
0036900-CO3046 18
t.
Subscribers and Family Dependents must reside in the GHC Service Area(as defined in Section I.) in order to
be eligible for enrollment under this Agreement, except for temporary residency outside the Service area for
purposes of attending school, court-ordered coverage for Dependents, or when approved in advance by GHC,
other unique family arrangements. All non-urgent/emergent care must be provided at GHC Facilities or GHC
Designated Facilities.
1. Subscribers.Bona fide employees and LEOFF II employees who are employed on a regularly scheduled
basis of not less than twenty(20)hours per week shall be eligible for enrollment.
Elected officials and council members shall be eligible for enrollment.
LEOFF I employees will not be covered under this plan.
2. Family Dependents.The Subscriber may enroll any of the following:
a. The Subscriber's legal spouse;
b. Unmarried dependent children who are under the age of twenty-one (21), provided they reside
regularly with the Subscriber or are chiefly dependent on the Subscriber for support and maintenance,
provided proof of such dependency is furnished to GHC.
"Children" means the children of the Subscriber including adopted children, stepchildren, foster
children, 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.
c. Enrollment may be extended past the limiting age for an unmarried person enrolled as a Family
Dependent on his/her twenty-first(21st)birthday if:
i. the Dependent is a full-time registered student at an accredited secondary school, college, or
university and under the age of twenty-three(23);or
ii. the Dependent is totally incapable of self-sustaining employment because of a developmental
disability or a physical handicap incurred prior to attainment of the limiting age as set forth in
Section IX.B.2.b., or prior to attainment of the student limiting age as set forth in Section
IX.B.2.c., 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 the Cooperative upon request, but not more
frequently than annually after the two(2)year period following the Dependent's attainment of the
limiting age.
d. Dependents of LEOFF I employees are eligible for coverage under this contract.
e. Temporary Coverage for Ineligible Newborns. A child born to a covered Member which does not
otherwise qualify as an eligible dependent as set forth in this section will be entitled to the benefits set
forth in Section X. from birth through three (3) weeks of age. After three (3) weeks of age, no
benefits are available unless the newborn child qualifies as a Dependent and is enrolled under this
Agreement. All contract provisions, limitations, and exclusions will apply except Section IV.
Continuation of Coverage,Conversion,and Transfer.
In regard to temporary coverage, continuation of coverage benefits set forth in Section IV. will not
apply.
0036900-003046 19
Ineligible Persons.GHC reserves the right to refuse enrollment to any person whose coverage under the Group
Agreement or any other Medical Coverage Agreement issued by Group Health Cooperative of Puget Sound has
been terminated for cause.
C. CONTINUATION OF ENROLLMENT
While on a group approved leave of absence, the Subscriber and listed Dependents will continue to receive
services and benefits under this Agreement for up to one hundred eighty(180)days,provided the employer or
Group continues to remit dues to GHC for the Subscriber and such Dependents.
While on a group approved leave of absence the Subscriber and listed Dependents can continue to be covered
under this Agreement, provided they remain eligible for coverage, such leave is in compliance with the
employer's established leave of absence policy consistently applied to all employees, the employer's leave
policy is in compliance with the Family and Medical Leave Act when applicable, and the employer or Group
continues to remit dues for the Subscriber and Dependents to the Cooperative.
D. PERSONS ENTITLED TO, OR ELIGIBLE TO PURCHASE MEDICARE. Except as deemed by federal
regulations, all Members entitled to, or eligible to purchase Medicare must be enrolled in the GHC Medicare
Plan upon such entitlement or eligibility. A condition of coverage under the GHC Medicare Plan requires that a
Member be continuously fully qualified and enrolled fro the hospital(Part A)and medical(Part B)benefits, or
Part B only, available from the Social Security Administration, and sign any papers that may be required by
GHC or Medicare. Subscribers and covered dependents who are eligible for Medicare (as set forth below)
must,effective the date that Medicare would become the primary payor,enroll in Medicare Parts A &B, and
must participate in GHC's Medicare Plan. For purposes of this section, an individual shall be deemed
eligible for Medicare when he or she has the option to receive part A Medicare benefits, irrespective of
whether the individual elects to enroll in Part B coverage under the federal regulations. All applicable
provisions of the GHC Medicare Plan are fully set forth in the Medicare Endorsement(s) attached to this
Agreement.
E. PERSONS AGE SIXTY-FIVE (65) OR OLDER WHO ARE NOT ENTITLED TO, OR ELIGIBLE TO
PURCHASE MEDICARE. Upon reaching age sixty-five (65), if not entitled to, or eligible to purchase
Medicare, Members may continue coverage under this Agreement upon payment of the applicable dues as set
forth in the Dues Schedule.
Section X. Schedule Of Benefits
Subject to all provisions of this Group Medical Coverage Agreement, including the Copayments and
Allowances Schedule, Members are entitled to receive the benefits and services that are Medically Necessary
for the treatment of a Medical Condition as determined by GHC's Medical Director or his/her designee,and
as described in this Schedule of Benefits.
A. HOSPITAL CARE
Hospital care is provided when approved by a GHC Provider,limited to the following services:
1. Room and board,including private room when prescribed,and general nursing services.
2. Hospital services(including use of operating room, anesthesia, oxygen,x-ray,laboratory,and radiotherapy
services).
3. As a cost-effective alternative in lieu of otherwise covered, Medically Necessary hospitalization or other
covered, Medically Necessary institutional care, alternative care arrangements may be covered.
0036900-CO3046 20
Alternative care arrangements in lieu of covered hospital or other institutional care must be determined
appropriate and Medically Necessary based upon the patient's medical condition. Such determination of
medical appropriateness and necessity,and authorization of coverage must be made in advance by GHC.
For additional coverage,see Section X.E. Skilled Home Health Care Services and Section X.F.Hospice.
For Skilled Nursing benefits other than as set forth in this Section,see Section xB.
4. Drugs and medications which are listed as covered in the GHC Drug Formulary(approved drug list).
5. Special duty nursing(when prescribed as Medically Necessary).
If a Member is hospitalized in a non-GHC Facility,GHC reserves the right to require transfer of the Member to
a GHC Facility, upon consultation with a GHC Provider. If the Member refuses to transfer to a GHC Facility,
all further costs incurred during the hospitalization are the responsibility of the Member.
B. MEDICAL AND SURGICAL CARE
Medical and surgical services are provided,limited to the following,when prescribed by a GHC Provider:
1. Surgical services.
2. Diagnostic x-ray,nuclear medicine,ultrasound,and laboratory services.
3. Family planning counseling services.
4. Hearing examinations to determine hearing loss.
5. Blood derivatives and the administration of blood and blood derivatives. The cost of blood is not covered.
6. Preventative services for health maintenance, including routine mammography screening, physical
examinations in accordance with criteria established by GHC for the detection of disease, and
immunizations and vaccinations which are listed as covered in the GHC Drug Formulary (approved drug
list). A fee may be charged for health education programs.
7. Radiation therapy services.
8. The following services are covered by GHC when performed by a GHC Provider or GHC oral surgeon:
reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or cysts of the jaw,
cheeks,lips,tongue,gums,roof and floor of the mouth;and incision of salivary glands and ducts.
9. Nonexperimental implants,limited to the following:cardiac devices,artificial joints,and intraocular lenses.
Artificial or mechanical hearts are excluded.
10. Respiratory therapy.
11. Dietary formula for the treatment of phenylketonuria (PKU) when determined Medically Necessary by
GHC's Medical Director, or his/her designee. Coverage for this formula is not subject to a Pre-existing
Conditions waiting period,if any.
Outpatient total parenteral nutritional therapy, when Medically Necessary and in accordance with medical
criteria as established by GHC, is covered including supplies necessary for its administration. Outpatient
enteral therapy is excluded.
0036900-003046 21
l W�
Dietary formulas and special diets, except for treatment of phenylketonuria (PKU) and total parenteral
nutritional therapy as set forth above,are excluded.
12. Visits by GHC Providers(including consultations and second opinions by a GHC Provider) in the hospital
or office.
13. Routine eye examinations and refractions are covered, limited to once every twelve (12) months, except
when Medically Necessary. Services for routine eye examinations must be received at a GHC Facility and
in accordance with GHC medical criteria in order to be covered.
Evaluations and surgical procedures to correct refractions which are not related to eye pathology are not
covered. Complications related to such surgery are also excluded.
Contact lens fittings and related examinations are not covered except as set forth below. Contact lens
examinations and fittings for eye pathology are provided in full. When dispensed through GHC Facilities,
one contact lens per diseased eye in lieu of an intraocular lens, including exam and fitting, is covered for
Members following cataract surgery performed by a GHC Provider, provided the Member has been
continuously covered by GHC since such surgery. Replacement of a covered contact lens will be provided
only when needed due to change in the Member's medical condition but may be replaced only one time
within any twelve(12)month period.
14. Maternity care,including care for complications of pregnancy and prenatal and postpartum visits.
Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary as
determined by GHC's Medical Director,or his/her designee.
Hospitalization and delivery services and voluntary (not medically indicated and non-therapeutic)
termination of pregnancy are not covered unless indicated in the next paragraph of this section.
Additional Maternity Care Services
Hospitalization and delivery, including home births for low risk pregnancies when approved in advance
and provided by a GHC Provider, is covered.
Voluntary (not medically indicated and nontherapeutic) or involuntary termination of pregnancy is
covered.
15. Transplants. When authorized as medically appropriate by GHC's Medical Director or his/her designee,
and in accordance with criteria established by the Cooperative, for heart, heart-lung, single lung, double
lung, kidney, simultaneous pancreas/kidney, cornea, bone marrow, and liver transplants, limited to the
following:
• evaluation testing to determine recipient candidacy;
• transplantation, limited to costs for the surgery and hospitalization related to the transplant, and
medications;and
• follow-up services for specialty visits,re-hospitalization,and maintenance medications.
High dose chemotherapy and stem cell (obtained from the peripheral blood or marrow as medically
appropriate) support is covered when authorized as medically appropriate by GHC's Medical Director, or
his/her designee.
Transportation expenses,except as set forth under Section X.M. of this Agreement,and living expenses are
excluded.
0036900-CO3046 22
Donor costs for a covered organ recipient are covered,limited to procurement center fees,travel costs for a
surgical team,excision fees,and matching tests. GHC shall exclude coverage for donor costs to the extent
that the donor costs are reimbursable by the organ donor's insurance.
Except for children who have been continuously enrolled at GHC since birth, coverage for all transplants
and any related services, items, and drugs shall be excluded until such time as the Member has been
continuously enrolled under this Agreement, or any prior GHC Medical Coverage Agreement, for twelve
(12) consecutive months without any lapse in coverage, unless the Member requires a transplant as the
result of a condition which had a sudden unexpected onset after the Member's effective date of coverage.
16. Self-referrals for manipulative therapy of the spine and extremities by GHC Providers are covered up to a
maximum of 10 visits per calendar year,subject to the office visit Copayment.
The medical necessity for manipulative therapy must meet GHC protocol.
17. Medical and surgical services and related hospital charges, including orthognathic (jaw) surgery for the
treatment of temporomandibular joint (TMJ) disorders, are covered as set forth in the Copayments and
Allowances Schedule when determined to be Medically Necessary and referred in advance by GHC. Such
disorders may exhibit themselves in the form of pain, infection,disease, difficulty in speaking,or difficulty
in chewing or swallowing food. TMJ appliances are covered as set forth under orthopedic appliances
(Section X.H.1.).
Orthognathic (jaw)surgery,radiology services and TMJ specialist services, including fitting/adjustment of
splints,is subject to the benefit limit set forth in the Copayments and Allowances Schedule.
The following services including related hospitalizations,are excluded regardless of origin or cause:
• orthognathic(jaw)surgery in the absence of a TMJ diagnosis,
• treatment for cosmetic purposes,and
• all dental services(except as noted above), including orthodontic therapy.
18. When authorized as medically appropriate by GHC's Medical Director, or his/her designee, and in
accordance with criteria established by the Cooperative, treatment of growth disorders by growth
hormones.
Growth hormone treatment shall be excluded until such time as the Member has been continuously
enrolled under this Agreement or any prior GHC Medical Coverage Agreement for twelve(12)consecutive
months without any lapse in coverage.
19. Pre-existing conditions are covered in the same manner as any other illness.
20. Skilled Nursing Facility care in a GHC-approved skilled nursing facility up to a maximum of thirty (30)
days per condition when full-time skilled nursing care is necessary in the opinion of the attending GHC
Provider.
When prescribed by a GHC Provider, such care may include board and room; general nursing care; drugs,
biologicals, supplies, and equipment ordinarily provided or arranged by a skilled nursing facility; and
short-term physical therapy,occupational therapy,and restorative speech therapy.
Excluded from coverage are personal comfort items such as telephone and television; and rest cures,
custodial,domiciliary or convalescent care.
C. CHENUCAL DEPENDENCY TREATMENT
0036900-003046 23
Subject to all terms and conditions of this Agreement, care is provided as set forth below at a GHC Facility,
GHC Designated Facility, or GHC-approved treatment facility, subject to the Benefit Period Allowance and
Lifetime Maximum Benefit as described below and as shown in the Copayments and Allowances Schedule.
1. Chemical Dependency Treatment Services.
a. All alcoholism and/or drug abuse treatment services must be: (1) provided at a facility as described
above and must be authorized in advance, except for acute chemical withdrawal as described in
Section X.C.2.b.; and (2) deemed Medically Necessary by GHC's ADAPT Director or his/her
designee. Chemical dependency treatment may include the following services received on an inpatient
or outpatient basis: diagnostic evaluation and education, organized individual and group counseling,
detoxification services,and prescription drugs and medicines.
b. Court-ordered treatment shall be provided only if determined to be Medically Necessary by GHC's
ADAPT Director or his/her designee.
2. Emergency Care.
a. Coverage for medical Emergencies incident to the abuse of alcohol and/or drugs is subject to the
Emergency care benefit as set forth in Section X.L.
b. Coverage for acute chemical withdrawal is provided without prior approval. If a Member is
hospitalized in a non-GHC Designated Facility, coverage is subject to payment of the Deductible
shown in the Copayments and Allowances Schedule, and notification of GHC by way of the GHC
Notification Line within twenty-four(24)hours following inpatient admission, or as soon thereafter as
medically possible. Furthermore, if a Member is hospitalized in a non-GHC Designated Facility, GHC
reserves the right to require transfer of the Member to a GHC Facility upon consultation with a GHC
Provider. If the Member refuses transfer to a GHC Facility, all further costs incurred during the
hospitalization are the responsibility of the Member.
For the purpose of this section, "acute chemical withdrawal"means withdrawal of alcohol and/or drugs
from a person for whom consequences of abstinence are so severe as to require medical/nursing
assistance in a hospital setting, and which is needed immediately to prevent serious impairment to the
Member's health.
3. Benefit Period and Benefit Period Allowance.
a. Benefit Period. For the purpose of this section, "Benefit Period" shall mean a twenty-four (24)
consecutive calendar month period during which the Member is eligible to receive covered chemical
dependency treatment services as set forth in this section. The first Benefit Period shall begin on the
first day the Member receives covered chemical dependency services under this or any other group
insurance, health care service contractor, health maintenance organization, self-insured plan or any
combination thereof, hereinafter referred to as "group plans," and shall continue for twenty-four (24)
consecutive calendar months, provided that coverage under this Agreement remains in force. All
subsequent Benefit Periods thereafter will begin on the first day Covered Services are received after
expiration of the previous twenty-four(24)month Benefit Period.
b. Benefit Period Allowance. The maximum allowance available for any Benefit Period shall be the
total of all chemical dependency benefits provided and payments made for chemical dependency
treatment under any group plan(s), not to exceed the Benefit Period Allowance shown in the
Copayments and Allowances Schedule during the Member's Benefit Period.
4. Lifetime Maximum Benefit.
0036900-CO3046 24
z
Chemical dependency services are not covered after the Member has reached his/her Lifetime Maximum
Benefit amount as shown in the Copayments and Allowances Schedule. All such benefits provided or
payments made by:
a. GHC under any GHC Group Medical Coverage Agreement,plus
b. all amounts paid on an individual's behalf under any carrier or plan maintained by the Group,
including self-insured plans,shall be applied toward this Lifetime Maximum Benefit amount.
Any Deductibles or Copayments which may be borne by the Member under the terms of this Agreement shall
not be applied toward the Benefit Period Allowance or Lifetime Maximum Benefit.
In regard to this section, the Benefit Period(s), Benefit Period Allowance(s), and Lifetime Maximum Benefit
shall include only alcoholism treatment services received on or after January 1, 1987 and alcoholism and/or
drug abuse services received on or after January 1, 1988.
D. PLASTIC AND RECONSTRUCTIVE SERVICES are covered:
1. to correct'a congenital disease or congenital anomaly as determined by a GHC Provider; or to correct a
Medical Condition following an injury or incidental to surgery covered by GHC which has produced a
major effect on the Member's appearance,provided:
• the Member has been continuously enrolled with GHC since the date of such injury or surgery;and
• when in the opinion of a GHC Provider, such services can reasonably be expected to correct the
condition.
In the case of a congenital condition which affects appearance,an anomaly will be considered to exist if the
Member's appearance resulting from such condition is not within the range of normal human variation.
Complications of noncovered surgical services are excluded.
2. for reconstructive surgery and associated procedures following a mastectomy provided Members are
medically suitable candidates,as determined by GHC's Medical Director, or his/her designee,regardless of
when the mastectomy was performed. Internal breast prostheses required incident to the surgery will be
provided.
A Member will be covered for all stages of one reconstructive breast reduction on the nondiseased breast to
make it equivalent in size with the diseased breast after definitive reconstructive surgery on the diseased
breast has been performed.
3. for women who have not undergone breast reconstruction,external breast prostheses following mastectomy
and post-mastectomy bras limited to one external breast prosthesis per diseased breast every two years,and
two post-mastectomy bras every six (6) months, up to four (4) in any twelve (12) consecutive month
period. Coverage for post-mastectomy bras is subject to the Coinsurance as set forth in the Copayments
and Allowances Schedule.
E. HOME HEALTH CARE SERVICES, as set forth in this section, shall be provided by GHC Home Health
Services or by a GHC-authorized home health agency when Referred in advance by a GHC Provider for
Members who meet the following criteria:
1. The Member is unable to leave home due to his or her health problem or illness (unwillingness to travel
and/or arrange for transportation does not constitute inability to leave the home);
2. the Member requires intermittent Skilled Home Health Care services,as described below;and
0036900-003046 25
Y.
3. a GHC Provider has determined 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 prescribed by a GHC Provider and
when rendered pursuant to an approved home health care plan of treatment: nursing care, physical therapy,
occupational therapy, respiratory therapy, restorative speech therapy, and medical social worker and limited
home health aide services. Home health services are provided 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 services.
Excluded are: custodial care and maintenance care, private duty or continuous nursing care in the Member's
home,housekeeping or meal services, care in any nursing home or convalescent facility, any care provided by
or for a member of the patient's family, and any other services rendered in the home which are not specifically
listed as covered under this Agreement.
F. HOSPICE
It is understood and agreed that the following fully sets forth the eligibility requirements and Covered Services
for a Member who elects to receive services through GHC's Hospice Program. Members who elect to receive
GHC Hospice Services do so in lieu of curative treatment for their terminal illness for the period that
they are in the GHC Hospice Program.
Hospice Program
1. Eligibility.Hospice Services, as set forth below, shall be provided to Members for as long as the following
criteria are met:
a. A GHC Provider has determined that the Member's illness is terminal and life expectancy is six (6)
months or less;
b. the Member has chosen a palliative treatment focus (emphasizing comfort and supportive services
rather than treatment aimed at curing the Member's terminal illness);
c. the Member has elected in writing to receive hospice care through GHC's Hospice Program;
d. the Member has available a primary care person who will be responsible for the Member's home care;
and
e. a GHC Provider and GHC's Hospice Director determine that the Member's illness can be appropriately
managed in the home.
2. Hospice care shall be defined as a coordinated program of palliative and supportive care for dying persons
by an interdisciplinary team of professionals and volunteers centering primarily in the Member's home.
3. Covered Services. Hospice services may include the following as prescribed by a GHC Provider and
rendered pursuant to an approved hospice plan of treatment:
a. Home Services
i. 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, and limited services by a Home Health Aide under the supervision of a
Registered Nurse.
ii. One period of continuous care service per Member in the Member's home when prescribed by a
GHC Provider, as set forth in this paragraph. A continuous care period is defined as "skilled
nursing care provided in the home during a period of crisis in order to maintain the terminally ill
patient 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
0036900-CO3046 26
Registered Nurse. Continuous care is provided for four(4)or more hours per day for a period not
to exceed five (5) days, or a total of seventy-two (72) hours, whichever first occurs. Continuous
care is covered only when a GHC Provider determines that the Member would otherwise require
hospitalization in an acute care facility.
b. Inpatient Hospice Services shall be provided in a facility designated by GHC's Hospice Program
when Medically Necessary and authorized in advance by a GHC Provider and GHC's Hospice
Program. Inpatient hospice services shall be provided according to the provisions set forth in Section
X.of this Agreement.
4. Hospice Exclusions:All services not specifically listed as covered in this section including:
a. Financial or legal counseling services.
b. Housekeeping or meal services.
c. Custodial or maintenance care in the home or on an inpatient basis.
d. Services not specifically listed as covered by this Medical Coverage Agreement.
e. Any services provided by members of the patient's family.
f. All other exclusions listed in Section XI., Exclusions and Limitations of this Medical Coverage
Agreement,apply.
G. REHABILITATION SERVICES are covered as set forth in this section, limited to the following: physical
therapy; occupational therapy; and speech therapy to restore function following illness, injury, or surgery.
Services are subject to all terms,conditions,and limitations of this Agreement,including the following:
I. All services must be provided at GHC or a GHC-approved rehabilitation facility and must be prescribed
and provided by a GHC-approved rehabilitation team that may include medical,nursing,physical therapy,
occupational therapy and speech therapy providers.
2. The Member must be referred for rehabilitation services in advance by a GHC Provider.
3. Services are limited to those necessary to restore or improve functional abilities when physical,
sensori-perceptual and/or communication impairment exists due to injury or illness. Such services are
provided only when GHC's Medical Director, or his/her designee, determines that significant, measurable
improvement to the Member's condition can be expected within a sixty(60)day period as a consequence of
intervention by covered therapy services described in paragraph one(1)above.
4. Coverage for inpatient and outpatient services is limited to the allowance set forth in the Copayments and
Allowances Schedule.
Services excluded under this benefit include the following: specialty rehabilitation programs not provided by
GHC; long-term rehabilitation programs; physical therapy, occupational therapy, and speech therapy services
when such services are available (whether application is made or not) through governmental programs;
programs offered by public school districts; therapy for degenerative or static conditions when the expected
outcome is primarily to maintain the Member's level of functioning(except for neurodevelopmental therapies);
implementation of home maintenance programs; programs for treatment of learning problems; any other
treatment not considered Medically Necessary by GHC;any services not specifically included as covered in this
Section;and any services that are excluded under Section XI.
Neurodevelopmental Therapies for Children Age Six (6) and Under. When determined to be Medically
Necessary by GHC's Medical Director, or his/her designee,physical therapy, occupational therapy, and speech
therapy services for the restoration and improvement of function for neurodevelopmentally disabled children
age six (6) and under shall be covered. Coverage includes maintenance of a covered Member in cases where
significant deterioration in the Member's condition would result without the services. Coverage for inpatient
and outpatient services is limited to the allowance set forth in the Copayments and Allowances Schedule.
0036900-003046 27
Services excluded under this benefit include: specialty rehabilitation programs; long-term rehabilitation
programs;physical therapy,occupational therapy,and speech therapy services when such services are available
(whether application is made or not) through governmental programs; programs offered by public school
districts; except as set forth above, therapy for degenerative or static conditions when the expected outcome is
primarily to maintain the Member's level of functioning; implementation of home maintenance programs; any
treatment not considered Medically Necessary;any services not specifically included as covered in this Section;
and any services that are excluded under Section XI.
H. APPLIANCES,DEVICES AND SUPPLIES
1. Orthopedic Appliances. When Medically Necessary, orthopedic appliances, which are attached to an
impaired body segment for the purpose of protecting the segment or assisting in restoration or
improvement of its function, are covered. Medically Necessary repair, adjustment or replacement of an
orthopedic appliance is covered when authorized in advance by a GHC Provider. Covered Services are
subject to the Coinsurance set forth in the Copayments and Allowances Schedule. Excluded are arch
supports; orthopedic shoes that are not attached to an appliance; or any orthopedic appliances that are not
listed as covered in GHC's Orthopedic Appliance Formulary.
2. Ostomy Supplies.Ostomy supplies necessary for the removal of bodily secretions or waste are covered.
3. Oxygen and Oxygen Equipment. When medical criteria as established by GHC are met, and upon
Referral,oxygen and oxygen equipment for home use is covered.
4. Nasal CPAP Device. When Medically Necessary, the purchase of a nasal CPAP device, and the initial
purchase of associated supplies, is covered. The initial one-month rental of the device prior to purchase,
which is required to establish compliance, is also covered. Medically Necessary repair or replacement of a
nasal CPAP device is covered when authorized in advance by a GHC Provider. Covered Services are
subject to the Coinsurance as set forth in the Copayments and Allowances Schedule. Coverage for
replacement of supplies is excluded.
Replacement or repair of appliances, devices and supplies that are due to loss, breakage from willful damage,
neglect or wrongful use,or due to personal preference are excluded.
I. TOBACCO CESSATION. When provided through GHC, services related to tobacco cessation are covered,
limited to:
1. participation in one individual and/or group program per calendar year;
2. educational materials;and
3. one course of nicotine replacement therapy per calendar year, provided the Member is actively
participating in the Group Health Free and Clear Program.
Covered Services are subject to the Allowances set forth in the Copayments and Allowances Schedule.
J. LEGEND (PRESCRIPTION) DRUGS AND MEDICINES FOR OUTPATIENT USE as prescribed by a
GHC Provider for conditions covered by this Agreement, 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).
All drugs, supplies, medicines, and devices must be obtained at a GHC pharmacy. The prescription drug
copayment as set forth in the Copayments and Allowances Schedule applies to each 30-day supply.
Copayments for single and multiple 30-day supplies of a given prescription are payable at the time of delivery.
0036900-CO3046 28
A . I hk
"Standard reference compendia" means the American Hospital Formulary Service-Drug Information; the
American Medical 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 healthcare 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.
Excluded are: over-the-counter drugs, medicines, and devices not requiring a prescription under state law or
regulations; dietary formulas and special diets, except as set forth in Section X.B.; contraceptive drugs and
devices and their fitting unless otherwise noted in this section; medicines and injections for anticipated illness
while traveling; and any other drugs, medicines and injections not listed as covered in the GHC Drug
Formulary(approved drug list).
The Member will be charged for mailing drugs, medicines or devices, and replacing lost or stolen drugs,
medicines or devices.
K. MENTAL HEALTH CARE SERVICES
1. Outpatient Services.Mental health care services are provided on an outpatient basis at GHC in individual,
family, couple, and group therapy formats. Services provided place priority on restoring social and
occupational functioning,such as evaluation,crisis intervention,managed psychotherapy, intermittent care,
psychological testing, and consultation services. The length and type of the treatment program and the
frequency and modality of visits shall be determined by the Director of GHC's Mental Health Service, or
his/her designee.
Coverage for each Member is provided according to the Outpatient Mental Health Care Allowance set
forth in the Copayments and Allowances Schedule. Psychiatric medical services including medical
management and medications are covered as set forth in Sections X.B. and X.J. All individual, family,
couple, and group visits of one and one-half (1-1/2) hours or less are regarded as one full visit per
individual. A missed appointment will be considered a "visit" unless GHC's Mental Health Service is
notified at least twenty-four(24)hours in advance of a scheduled session.
2. Inpatient Services. Usual, Customary, and Reasonable charges for services described in this section,
including psychiatric Emergencies resulting in inpatient services, shall be covered to the maximum benefit
as set forth in the Copayments and Allowances Schedule. This benefit shall include coverage for acute
treatment and stabilization of psychiatric emergencies in GHC-approved hospitals. When medically
indicated, outpatient electro-convulsive therapy (ECT) is covered in lieu of inpatient services. Payment of
bills incurred at non-GHC facilities shall exclude any charges that would otherwise be excluded for
hospitalization within a GHC Facility.
When authorized in advance by the Director of GHC's Mental Health Service, or his/her designee, partial
hospitalization and outpatient electro-convulsive therapy programs are covered subject to the maximum
inpatient benefit limit described in the Copayments and Allowances Schedule. Every two (2) partial
hospitalization days or two (2) electro-convulsive therapy treatments are equivalent to one inpatient
hospital day.The total maximum annual benefit under this section shall not exceed the number of inpatient
days described in the Copayments and Allowances Schedule.
Subject to the maximum Inpatient Mental Health Care Allowance as set forth in the Copayments and
Allowances Schedule, services provided under involuntary commitment statutes shall be covered at
facilities approved by GHC. Services for any court-ordered treatment program beyond the seventy-two
(72)hours shall be covered only if determined to be Medically Necessary by the Director of GHC's Mental
Health Service,or his/her designee.
0036900-CO3046 29
Coverage for voluntary/involuntary Emergency inpatient psychiatric services is subject to the Emergency
care benefit as set forth in Section X.L., including the twenty-four (24) hour notification and transfer
provisions. All other voluntary psychiatric care must be authorized in advance by the Director of GHC's
Mental Health Service,or his/her designee;the facility must be approved by the Cooperative.All voluntary
care not authorized in advance by GHC's Mental Health Service is not covered.
3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services.Covered
Services are limited to those considered to be Medically Necessary by the Director of GHC's Mental Health
Service, or his/her designee. Covered Services are limited to those provided for covered conditions for
which, in the opinion of the Director of GHC's Mental Health Service,or his/her designee, improvement or
stabilization can be expected.
Partial hospitalization programs and electro-convulsive therapy are covered only under subsection K.2.
(Inpatient Services).
Excluded are all forms of extensive psychotherapy; day treatment; custodial care; treatment of sexual
disorders; specialty programs for mental health therapy which are not provided by GHC; court-ordered
treatment which is not specifically described above; or any other services not specifically listed as covered
in this section.All other provisions,exclusions and limitations under this Agreement also apply.
L. EMERGENCY/URGENT CARE
Emergency Care(See Section I.for a definition of Emergency):
1. At a GHC Facility or GHC Designated Facility. GHC will cover Emergency care for all Covered
Services as set forth in the Copayments and Allowances Schedule.
2. At a Non-GHC Designated Facility. Usual, Customary, and Reasonable charges for Emergency care for
Covered Services are covered subject to:
a. payment of the Emergency Care Deductible shown in the Copayments and Allowances Schedule;
and
b. notification of GHC by way of the GHC Notification Line within twenty-four (24) hours
following inpatient admission,or as soon thereafter as medically possible.
Outpatient medications prescribed by a non-GHC Provider are excluded.
3. Waiver of Emergency Care Copayment/Deductible.
a. Waiver for Multiple Injury Accident. If two or more members of the Family Unit require
Emergency care as a result of the same accident, only one Emergency Care Copayment/Deductible
will apply.
b. Emergencies Resulting in an Inpatient Admission. If the Member is admitted to a GHC or GHC
Designated Facility directly from the emergency room, the Emergency Care Copayment is waived.
However,the first day's Hospital Care Copayment,if any,will be charged.
4. Transfer and Follow-up Care.If a Member is hospitalized in a non-GHC Facility,GHC reserves the right
to require transfer of the Member to a GHC Facility, upon consultation with a GHC Provider. If the
Member refuses to transfer to a GHC Facility, 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 obtained at GHC,unless a GHC Provider
has authorized such follow-up care in advance.
Urgent Care(See Section I.for a definition of Urgent Condition):
0036900-CO3046 30
5. Urgent Care. Care for Urgent Conditions received inside the GHC Service Area is covered only at GHC
medical centers, GHC urgent care clinics, or network providers' offices. Urgent care received at any
hospital emergency department is not covered unless authorized in advance by a GHC Provider.
M. AMBULANCE SERVICES are covered as set forth below,provided that the service is authorized in advance
by a GHC Provider or meets the definition of an Emergency.(See Section I.)
1. Emergency Transport to a GHC Facility,GHC Designated Facility,or non-GHC Designated Facility.
Each Emergency is covered as set forth in the Copayments and Allowances Schedule.
2. GHC-Initiated Transfers.GHC-initiated non-emergent transfers to or from a GHC Facility is covered.
Section XI Exclusions and Limitations
A. EXCLUSIONS
1. Blood for transfusions.
2. Unless otherwise noted as covered in Sections X.B., X.D., X.H., and X.J., corrective appliances and
artificial aids including: eyeglasses; contact lenses, including services related to their fitting; prosthetic
devices; diabetic supplies including insulin pumps;hearing aids and examinations in connection therewith;
take-home dressings and supplies following hospitalization; or any other supplies, dressings, appliances,
devices or services which are not for the specific treatment of disease or injury, or not specifically listed as
covered in Section X.
3. Cosmetic services, including treatment for complications of cosmetic surgery, except as provided in
Section X.D.
4. Convalescent or custodial care,including skilled nursing facility care,unless otherwise noted in Section X.
5. Durable medical equipment such as hospital beds, wheelchairs, and walk-aids, except while in the hospital
or as set forth in Section X.B.or X.H.
6. Services rendered as a result of work-incurred injuries,illnesses or conditions.
7. Those parts of an examination and associated reports and immunizations required for employment(unless
otherwise noted in Section X.B.), immigration, license, or insurance purposes that are not deemed
Medically Necessary by GHC for early detection of disease.
8. Procedures,services,and supplies related to sex transformations.
9. Regardless of origin or cause, diagnostic testing and medical treatment of sterility, infertility, and sexual
dysfunction,unless otherwise noted in Section X.B.
10. Services of practitioners whose licensing category is not represented by GHC Medical Personnel, unless
otherwise noted in Section X.B.
11. Services directly related to obesity,except for nutritional counseling provided by GHC staff.
12. Any services to the extent benefits are available to the Member 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: (1) medical coverage, medical "no fault" coverage,
Personal Injury Protection coverage, or similar medical coverage contained in said policy; and/or (2)
uninsured motorist or underinsured motorist 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,
0036900-CO3046 31
comes within the policy definition of insured, is a third-party donee beneficiary under the terms of the
policy,or otherwise has the right to receive benefits under the policy.
The Member and his or her agents must cooperate fully with GHC in its efforts to enforce this exclusion.
This cooperation shall include supplying GHC with information about any available insurance coverage.
The Member and his or her agents shall permit GHC at GHC'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 or her agents shall
do nothing to prejudice GHC's right to enforce this exclusion.
GHC shall not enforce this exclusion as to coverage available under uninsured motorist or underinsured
motorist coverage until the Member has been made whole, unless the Member fails to cooperate fully with
GHC as described above. In the event the Member fails to cooperate fully, the Member shall be
responsible for reimbursing GHC for such medical expenses.
GHC shall not pay any attorneys' fees or collection costs to attorneys representing the injured person where
it has retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a
written fee agreement signed by GHC prior to any collection efforts.
13. Services or supplies not specifically listed as covered in the Schedule of Benefits.
14. Voluntary (not medically indicated and nontherapeutic) termination of pregnancy, unless otherwise noted
in Section X.B.
15. The cost of services and supplies resulting from a Member's loss of or willful damage to covered
appliances, devices, supplies, and materials provided by GHC for the treatment of disease, injury, or
illness.
16. Routine circumcision,including newborn circumcision,which is not considered Medically Necessary.
17. Orthoptic(eye training)therapy.
18. Specialty treatment programs that are not provided by GHC including weight reduction, rehabilitation, and
"behavior modification programs."
19. Services required as a result of war,whether declared or not declared.
20. Nontherapeutic sterilization (unless otherwise noted in Section X.B.) and procedures and services to
reverse a therapeutic or nontherapeutic sterilization.
21. Dental care, surgery, services, and appliances, including: treatment of accidental injury to natural teeth,
reconstructive surgery to the jaw incident to denture wear, periodontal surgery, and any other dental
services not specifically listed as covered in Section X. The Cooperative's Medical Director, or his/her
designee, will determine whether the care or treatment required is within the category of dental care or
service.
If a GHC Provider determines that an unrelated medical condition requires that a Member be hospitalized
for a dental procedure which is normally done in a dentist's office, GHC will cover associated hospital and
anesthesia costs at a GHC or GHC Designated Facility. GHC will not cover the dentist's or oral surgeon's
fees.
22. Drugs, medicines, and injections, except as set forth in Section X.J. Any exclusion of drugs, medicines,
and injections, including those not listed as covered in the GHC Drug Formulary(approved drug list),will
also exclude their administration.
0036900-003046 32
23. Investigational or experimental treatment, including medical and surgical services, drugs, devices and
biological products, until formally approved by GHC for medical coverage. GHC's determination shall be
made in accordance with criteria for determining investigational status as established by GHC as generally
outlined below. Specific indications and methods of use shall be considered in GHC's review of evidence
provided by evaluations of national medical associations, consensus panels, and/or other technological
evaluations, including the scientific quality of such supporting evidence and rationale. Any investigational
or experimental treatment, including medical and surgical services, drugs, devices and biological products
not meeting GHC's determination pursuant to its criteria as outlined below are excluded.
a. Investigational or experimental drugs, devices and biological products until clinical trials have been
completed and approved by the U.S. Food and Drug Administration (FDA) as being safe and
efficacious for general marketing and permission has been granted by the FDA for commercial
distribution;
b. there is sufficient scientific evidence in published medical literature to permit conclusions concerning
the effect of the treatment on health outcomes;
c. there is conclusive evidence in published peer-reviewed medical literature that the treatment will result
in a demonstrable benefit for the particular injury, disease or condition in question, and that the
benefits are not outweighed by risks;
d. evidence that the new treatment is as safe and effective as all existing conventional treatment
alternatives;and
e. that treatment will satisfy(c)and(d)outside of a research setting.
Appeals regarding denial of coverage must be submitted to your regional Member Services Department,or
to GHC's Contracts and Coverage Department at 1730 Minor Avenue, Suite 1910, Seattle, WA 98101.
GHC will respond in writing within twenty(20)working days of the receipt of a fully documented request.
24. Mental health care, except as specifically provided in Section X.K.
25. See coverage for pre-existing conditions under Section X.B.
B. LIMITATIONS
1. Conditions and Extent of Coverage. ALL SERVICES AND BENEFITS UNDER THIS
AGREEMENT MUST BE PROVIDED BY GHC MEDICAL PERSONNEL AT A GHC FACILITY
UNLESS:
a. The Member has received a Referral from a GHC physician.
b. The Member has received Emergency services according to Section X.L.
2. Recommended Treatment. The Cooperative's Medical Director or his/her designee will determine the
necessity,nature,and extent of treatment to be provided 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
recommended treatment or diagnostic plan to the extent permitted by law. In such case, GHC shall have no
further obligation to provide the care in question. Members who seek other sources of care because of such
a disagreement do so with the full understanding that GHC has no obligation for the cost,or liability for the
outcome,of such care.
3. Major Disaster or Epidemic. In the event of a major disaster or epidemic, GHC Medical Personnel will
provide Covered Services according to their best judgment,within the limitations of available facilities and
personnel. The Cooperative has no liability for delay or failure to provide or arrange Covered Services to
the extent facilities or personnel are unavailable due to a major disaster or epidemic.
0036900-003046 33
4. Unusual Circumstances. If the provision of Covered Services is delayed or rendered impossible due to
unusual circumstances such as complete or partial destruction of facilities, military action, civil disorder,
labor disputes, or similar causes, GHC shall provide or arrange for services that, in the reasonable opinion
of GHC's Medical Director, or his/her designee, are emergent or urgently needed. In regard to nonurgent
and routine services, GHC shall make a good faith effort to provide services through its then-available
facilities and personnel. GHC shall have the option to defer or reschedule services that are not urgent or
routine while its facilities and services are so affected.In no case shall the Cooperative have any liability or
obligation on account of delay or failure to provide or arrange such services.
Section MI. Claims
Members must submit claims for reimbursement of Covered Services to GHC within sixty(60) days of the service
date, or as soon thereafter as is reasonably possible. In no event, except in the absence of legal capacity, shall a
claim be accepted later than one (1) year from the service date. This section applies to Covered Services received
under Section X.L.and X.M.,or services for which the Member has received a Referral from a GHC physician.
0036900-CO3046 34
M.
Medicare
Endorsement
For Persons Covered by Parts A and B of Medicare
THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL REMAIN IN EFFECT
EXCEPT AS MODIFIED BY THE ADDITION OF THE PROVISIONS, EXCLUSIONS, AND LIMITATIONS
CONTAINED IN THIS MEDICARE ENDORSEMENT. IN NO EVENT SHALL THE BENEFITS UNDER THIS
ENDORSEMENT DUPLICATE THE BENEFITS UNDER THE GROUP MEDICAL COVERAGE
AGREEMENT. THE HIGHER LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THIS GROUP
MEDICAL COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL AND HOSPITAL BENEFITS
ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED, AND REFERRED TO AS
"MEDICARE." THE BENEFITS AND EXCLUSIONS DESCRIBED IN THIS ENDORSEMENT APPLY ONLY
TO MEMBERS WHO ARE COVERED UNDER BOTH PART A AND PART B OF MEDICARE.
Except as defined by Federal Regulations,all Members entitled to, or eligible to purchase Medicare must transfer to
the GHC Medicare Plan upon such entitlement or eligibility. A condition of enrollment under the GHC Medicare
Plan requires that a Member be continuously enrolled for the hospital (Part A) and medical (Part B) benefits
available from the Social Security Administration, and sign any papers that may be required by GHC or Medicare.
For additional information,the Member may refer to"The Medicare Handbook,"which can be obtained from your
local Social Security office.
NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC FACILITIES
UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE MEMBER HAS RECEIVED
EMERGENCY OR URGENTLY NEEDED SERVICES ACCORDING TO SECTION V.D. OF THIS MEDICARE
ENDORSEMENT.
Those enrolled under GHC's Medicare plan, as set forth in this Endorsement,all Copayments are waived except the
prescription drug Copayment.
This Endorsement does not constitute a Medicare supplemental contract.
Section I DEFINITIONS
CUSTODIAL CARE: Care that is primarily for the purpose of meeting personal needs and could be provided by
persons without professional skills or training. Custodial Care includes help in walking, bathing, dressing, eating,
and taking medicine.
EMERGENCY SERVICES(Medicare defined): Inpatient or outpatient services that are rendered immediately by
an appropriate non-GHC provider because of an injury or sudden illness, and for which the time required to reach
GHC or a GHC Designated Facility would risk permanent damage to the Member's health.
HEALTH CARE FINANCING ADMINISTRATION (HCFA): The federal agency that administers the
Medicare program.
MEDICARE: The federal health insurance program for the aged and disabled.
MEDICARE GUIDELINES: Coverage rules and policies established by the Health Care Financing Administration
(HCFA),a federal agency.
MEDICARE HANDBOOK (Titled "The Medicare Handbook"): A pamphlet published by the Health Care
Financing Administration, which provides an easy-to-read explanation of Medicare benefits, and can be obtained
from your local Social Security office,or your Washington State Part B carrier's office.
0036900-CO3046 35
PERMANENT MOVE: An uninterrupted absence of more than ninety(90)days from GHC's Service Area.
REFERRAL: A written temporary referral agreement authorized in advance by a GHC physician and formally
approved in advance through GHC's Medicare medical coverage approval process,that entitles a Member to receive
Covered Services from a specified non-GHC health care provider. Entitlement to such services shall not exceed the
limits of the Referral and is subject to all terms and conditions of the Referral and this Agreement.
SERVICE AREA: The geographic area comprised of Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit,
Snohomish,Thurston,and Whatcom Counties,and any other areas designated by GHC and approved by the Health
Care Financing Administration. (See Service Area Map.)
SKILLED NURSING FACILITY: A Medicare certified and licensed facility, as defined in Medicare regulations,
primarily engaged in providing skilled nursing care or rehabilitation and related services for which Medicare pays
benefits or qualifies to receive such approval.
URGENTLY NEEDED SERVICES (Medicare defined): Services needed in order to prevent a serious
deterioration of the Member's health due to an unforeseen illness or injury while temporarily absent from GHC's
Service Area,and which cannot be delayed until the Member returns to the Service Area.
USUAL,CUSTOMARY,AND REASONABLE: A term used to define the level of benefits which are payable by
GHC when expenses are incurred from a non-GHC physician or provider. Expenses are considered Usual,
Customary and Reasonable if (1) the charges are consistent with those normally charged by the provider or
organization for the same services or supplies; and(2)the charges are within the general range of charges made by
other providers in the same geographical area for the same services or supplies.
Section II TERMINATION
Enrollment under the GHC Medicare Plan for a specific Member,may be terminated in the circumstances set forth
below.
Until such time as a Member's termination of enrollment is effective, neither GHC nor Medicare shall pay for
services provided at non-GHC Facilities unless the Member has been Referred by GHC or the Member has received
Emergency or Urgently Needed Services according to Section V.D. of this Medicare Endorsement.
A. Termination of Specific Members.
1. Loss of Medicare Part B Entitlement.If the Health Care Financing Administration(HCFA)advises GHC
that a Member's entitlement to Medicare coverage no longer exists, or the Member voluntarily terminates
Medicare enrollment, enrollment under the GHC Medicare Plan shall terminate the first of the month as
specified by HCFA.
2. Change of Permanent Residence Outside GHC's Service Area. If a Member makes a Permanent Move
as set forth in Section I. of this Medicare Endorsement, enrollment shall terminate the first day of the
month following the month in which GHC receives notification of such move.
3. For Cause.Enrollment may be terminated upon written notice for:
a. Knowingly providing fraudulent information to obtain coverage. In such event, GHC may rescind or
cancel enrollment upon ten(10)working days'written notice.
b. Permitting the use of a GHC identification card by another person.
c. Failure to comply with the rules and regulations of GHC including disruptive, unruly, abusive or
uncooperative conduct.
Such termination shall be subject to review and approval by HCFA.
0036900-CO3046 36
B. Persons Hospitalized on the Date of Termination. A Member who is a registered bed patient receiving
Covered Services in a GHC Facility or GHC Designated Facility on the date of termination shall continue
to receive covered inpatient services, until discharge from the facility. This continued coverage will also
apply to a Member hospitalized in a Medicare-certified non-GHC Designated Facility as a result of
Emergency or Urgently Needed Services or Referral as set forth in Section VI.B. of this Medicare
Endorsement.
C. Services Provided After Termination. Any services provided by GHC after the effective date of
termination (except those services covered under Section II.B. of this Medicare Endorsement) shall be
charged according to the Directory of Services. The Subscriber shall be liable for payment of all such
charges for services provided to the Subscriber and all Family Dependents.
Section III, SUBROGATION
"Injured person"under this section means a Member covered by this Agreement who sustains compensable injury.
"GHC's medical expense"means the expense incurred by GHC for the care or treatment of the injury sustained.
If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability against
the third party,GHC shall have the right to recover its cost of providing benefits to the injured person(subrogation)
from the third party as set forth in this Agreement and in compliance with Medicare regulations and guidelines.
GHC shall be subrogated to and may enforce all rights of the injured person to the extent of its medical expense.
After Medicare laws and regulations mandating recovery of Medicare payments have been satisfied, the
Cooperative's right of subrogation shall be limited to the excess of the amount required to fully compensate the
injured person for the loss sustained.Full compensation shall be measured on an objective,case-by-case basis,but is
subject to a presumption that a settlement which does not exhaust the third parry's reachable assets is full
compensation to the injured person.
The injured person and his or her agents must cooperate fully with GHC in its efforts to collect GHC's medical
expenses. This cooperation shall include, but is not limited to, supplying GHC with information about any
defendants and/or insurers related to the injured person's claim.The injured person and his or her agents shall permit
GHC,at GHC's option,to associate with the injured party or to intervene in any action filed against any third party.
The injured person and his or her agents shall do nothing to prejudice GHC's subrogation rights. The injured person
shall not settle a claim without protecting GHC's interest.
GHC shall not pay any attorney's fees or collection costs to attorneys representing the injured person where it has
retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a written fee
agreement signed by GHC prior to any collection efforts.When reasonable collection costs have been incurred,with
GHC's prior written agreement, to recover GHC's medical expenses, there shall be an equitable apportionment of
such collection costs between GHC and the injured person subject to a maximum responsibility of GHC equal to
one-third of the amount recovered on behalf of GHC.
This provision does not apply to occupationally incurred disease,sickness,and/or injury.
Section IV, GRIEVANCE PROCEDURES
A. GHC Member Services Program.
The Member Services Program is designed to help a Member resolve formal complaints and concerns about
medical and business service. GHC will record, resea� and respond in a timely manner to a Membees
concern. A concern should be registered initially at th. Member's area medical center. If not satisfied, the
Member should then contact the regional Member Services Department, which will arrange for review by
appropriate medical staff,management and/or GHC consumers.
B. Reconsideration of Claims.
0036900-003046 37
i Asa
If GHC denies a request for payment of a claim, or declines to provide services which the Member believes should
be provided, the Member may file a request for reconsideration with GHC or a Social Security Administration
office. The request must be filed in writing within sixty (60) days of GHC's written notice of denial unless an
extension is specifically approved. If GHC does not overturn the denial in full, it will be referred by GHC to the
Health Care Financing Administration for reconsideration.
Section V. SCHEDULE OF BENEFITS
All benefits and services listed in this Schedule of Benefits:
• are subject to all provisions of this Agreement and Medicare Endorsement;
• must be approved in advance by GHC except for Emergency and Urgently Needed Services as set forth in
Section V.D.of this Medicare Endorsement;and
• must meet Medicare guidelines and limitations unless otherwise specified.
The booklet, "The Medicare Handbook" provides additional information about Medicare benefits, and can be
obtained from your local Social Security office,or your Washington State Part B carrier's office.
A. Skilled Nursing Facility. Upon Referral and following a Medicare-certified three (3) day hospital stay, GHC
will cover up to one hundred (100) days of care in a Skilled Nursing Facility, in accordance with Medicare
Guidelines,when Medically Necessary,as determined by GHC's Medical Director,or his/her designee.
B. Hospice.
Members with Part A and Part B of Medicare who elect to receive Medicare-covered hospice services may
select.any Medicare-certified hospice program. Members who elect to receive services from the GHC Hospice
Program are entitled to hospice services as provided under the Medicare Hospice Program. Members who elect
to receive hospice services do so in lieu of curative treatment for their terminal illness for the period that
they are in the hospice program. To receive hospice services,the Member is required to sign the Hospice
Election Form.
Covered Services.In addition to the hospice services provided under the Group Medical Coverage Agreement,
the following hospice services shall be provided:
1. Home Services
Continuous care services per Member in the Member's home when prescribed by a GHC physician, as set
forth in this paragraph. Continuous care is defined as "skilled nursing care provided in the home during a
period of crisis in order to maintain the terminally ill patient 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 may be provided up to twenty-four (24)
hours per day during periods of crisis. Continuous care is covered only when a GHC physician determines
that the Member otherwise would require hospitalization in an acute care facility.
2. Inpatient Hospice Services for short-term care shall be provided through a Medicare-certified Hospice
Program when Medically Necessary, and authorized in advance by a GHC physician. Respite care is
covered for a maximum of five (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).
3. Other hospice services may include the following:
a. drugs and biologicals that are used primarily for the relief of pain and symptom management;
b. medical appliances and supplies primarily for the relief of pain and symptom management;
c. counseling services for the Member and his/her primary care-giver(s);and
0036900-CO3046 38
d. bereavement counseling services for the family.
C. Mental Health Care,Alcoholism and Drug Abuse Treatment Services.
1. Outpatient mental health, alcoholism and substance abuse treatment services are covered for each
Member in accordance with Medicare Guidelines.
2. Inpatient mental health care services are covered in full up to a 190-day lifetime benefit when such
services are provided in a Medicare-certified mental health facility.
Inpatient alcoholism and drug abuse treatment services are covered in full when such services are
provided in a hospital-based treatment center.
3. Coverage for Medical Emergencies incident to alcoholism and drug abuse or for acute alcoholism or drug
abuse, including acute detoxification, is provided as set forth in Section V.D. of this Medicare
Endorsement.
D. Emergency/Urgently Needed Services. When an Emergency meets the Medicare definition for Emergency or
Urgently Needed Services as defined in Section I.of this Medicare Endorsement, services are covered.
D1. Out Of The Service Area Non-Emergent and/or Non-Urgently Needed Care. Non-Emergent and/or non-
urgently needed care will be covered outside GHC's defined Service Area, up to a maximum of$2,000.00
(GHC's Service Area is defined in Section I. of this Agreement). Coverage under this benefit does NOT
include coverage of prescription drugs.
Services, as noted in this section, are available to Members traveling outside GHC's defined Service Area,
except when traveling primarily for the purpose of seeking medical care.
The services received under this benefit are subject to all limitations set forth in this Agreement.
All Medicare non-covered expenses, including hospital inpatient deductibles and inpatient and outpatient
Coinsurances,are the responsibility of the Member.
E. Medicare Ambulance Benefit. Medically Necessary ambulance transportation to or from a hospital or Skilled
Nursing Facility is covered in full only if transportation by any other vehicle could endanger the patient's health
and the ambulance,equipment,and personnel meet Medicare requirements.
F. Medical and Surgical Care. The following medical and surgical services are covered when prescribed by
GHC Medical Personnel,Medicare requirements are met:
1. Eye examinations and treatment for eye pathology.
Evaluations and surgical procedures to correct refractions which are not related to eye pathology are not
covered. Complications related to such surgery are also excluded.
2. One pair of eyeglasses or contact lenses, including examination and fitting, following cataract surgery, are
covered subject to UCR charges when required to replace the natural lens of the eye. Covered eyeglasses
and contact lenses must be dispensed through GHC Facilities. Replacements will be provided when needed
due to change in the Member's medical condition or when deemed appropriate by a GHC physician.
3. Blood,blood derivatives, and their administration.
4. 'Maternity and pregnancy-related services,including visits before and after birth; involuntary termination of
pregnancy;and care for any other complication of pregnancy.
0036900-CO3046 39
5. Organ transplants, limited to heart, kidney, cornea, bone marrow, and liver, when established criteria are
met.
6. Physician calls (including consultations and second opinions by a GHC physician) in the hospital, office,
home,Skilled Nursing Facility,nursing home,or convalescent center.
7. Restorative physical,occupational,and speech therapy following illness,injury,or surgery.
8. Immunizations and vaccinations that are listed as covered in the GHC Drug Formulary(approved drug list)
or approved by Medicare.
9. Services related to dysfunction of the jaw. When Referred by a GHC physician, evaluation and treatment
by a GHC-approved temporomandibular joint(TMJ)care provider.
All TMJ appliances,other than the occlusal splint and its fitting,are excluded.
Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when the dysfunction is
related to malocclusion or when TMJ services are needed due to dental work performed. All such services
and related hospitalization, including orthodontic therapy and orthognathic (jaw) surgery, are excluded
regardless of origin or cause.
(See Section X.B.17. of the Group Medical Coverage Agreement for Covered Services not meeting
Medicare guidelines).
10. Chiropractic care limited to spinal manipulations. Excluded are any other diagnostic or therapeutic
services,including x-rays,furnished by a chiropractor.Members who receive their primary care in portions
of the GHC Service Area where GHC-designated licensed practitioners are available must utilize GHC's
designated providers in order to be covered.
11. Podiatric care. Services are covered when all Medicare criteria are met and when authorized in advance by
your Primary Care Provider. Excluded is treatment of flat feet or other misalignments of the feet;removal
of corns and calluses; and routine foot care such as hygienic care, except in the presence of a nonrelated
medical condition affecting the lower limbs. Members who receive their primary care in portions of the
GHC Service Area where GHC designated licensed practitioners are available must utilize GHC's
designated providers in order to be covered.
12. Home intravenous(IV)drug therapy services.
13. Routine eye examinations and refractions, limited to once every twenty-four (24) months, except when
Medically Necessary. Services for routine eye examinations must be received at a GHC Facility and in
accordance with GHC medical criteria in order to be covered and are not subject to Medicare requirements.
Lenses. One pair of standard glass single vision, lenticular, or nonblended bifocal or trifocal lenses, or
contact lenses,will be covered subject to UCR charges once every twenty-four(24)months, and replaced
as specified below,when received at a GHC facility and in accordance with GHC medical criteria.
Frames. An Allowance of up to$100 per Member once every 24 months will be provided for frames.
Replacements. Lens replacement for any reason (including loss, breakage or change in prescription) will
be provided not more often than once every 24 months.
Replacement of frames will be provided subject to the frames Allowance set forth above not more often
than once every 24 months.
0036900-003046 40
14. Hearing examinations to determine hearing loss. Hearing aids,including examinations and fitting,must be
received at a GHC Facility and are covered up to a maximum of$250 per Member once every 24 months.
G. Prosthetic Devices, such as cardiac devices, intraocular lenses, artificial joints, breast prostheses, artificial
eyes, and braces, are covered. Excluded are: orthopedic shoes unless they are part of leg braces; dental
plates or other dental devices;and experimental devices.
H. Medical/Surgical Supplies, such as casts, splints, post-surgical dressings, and ostomy supplies, are
covered.
I. Rental or Purchase of Durable Medical Equipment,such as oxygen and oxygen equipment,wheelchairs
and other walk-aids,and hospital beds,is covered.
J. Respite Care.
1. Eligibility. Respite care is provided to chronically dependent persons for reasonable and necessary
in-home services,provided that such services are:
a. authorized in advance by a GHC physician;
b. provided by GHC Community Health Services or by a GHC-approved agency;and
c. that the Member has incurred no less than the equivalent of$6,870.00 in expenses for Medicare
Part B Covered Services during the calendar year in which respite benefits are to be provided.
2. Covered Services. Covered respite care services are provided up to a maximum of eighty (80) hours
for the twelve (12) month period following the date all eligibility requirements are met. Covered
respite services are limited to the following:
a. Services of a homemaker or home health aide;
b. Personal care services;and
c. Nursing care provided by a licensed professional nurse.
"Chronically dependent persons" under this section means persons who live with a voluntary care-giver;
are dependent upon the care-giver for assistance with at least two activities of daily living, such as eating,
bathing, dressing, toileting, or transferring in and out of a bed or chair; and who meet the eligibility
requirements described above.
Section VI EXCLUSIONS AND LIMITATIONS
A. Exclusions.
1. Investigational procedures, including medical and surgical services, drugs and devices until formally
approved by Medicare unless specifically provided herein (See Section XI.A.23. in the Group Medical
Coverage Agreement).
2. Supportive devices for the feet.
3. Services directly related to obesity except as provided by Medicare.
4. Services or supplies not specifically listed as covered by Medicare or GHC.
B. Limitations.
Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS V.17.10. AND V.F.11., ALL
SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL
PERSONNEL AT A GHC OR GHC DESIGNATED FACILITY UNLESS:
0036900-CO3046 41
At
1. the Member has received a Referral from GHC, including formal advance approval through GHC's
Medicare medical coverage approval process,or
2. the Member has received Emergency or Urgently Needed Services as defined in Section I. and as set forth
in Section V.D.of this Medicare Endorsement.
Section VII CLAIMS PROCEDURE
Claims for services or supplies and explanation of Medicare benefits for services or supplies from providers other
than Group Health Cooperative should be sent to: Medicare Claims, Group Health Cooperative of Puget Sound. If
you must receive Emergency or Urgently Needed Services from a non-GHC provider, be sure to show your GHC
I.D.card and your red,white,and blue Medicare card.
A. The Member must file claims for services rendered during the first nine (9) months of a calendar year by
December 31 of the following calendar year.
B. The Member must file claims for services rendered in the last three(3)months of a calendar year the same
as if the services had been furnished in the subsequent calendar year. The time limit on filing claims for
services furnished in the last three (3)months of the calendar year is December 31 of the second calendar
year following the calendar year in which the services were rendered.
See "The Medicare Handbook" for additional information regarding filing claims, which can be obtained
from your local Social Security office, or your Washington State Part B carrier's office, or call 1-800-772-
1213.
GHC may obtain information which it deems necessary concerning the medical care and hospitalization for
which payment is requested.
0036900-003046 42
Medicare
Endorsement
For Persons Covered by Part B only of Medicare
THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL REMAIN IN EFFECT
EXCEPT AS MODIFIED BY THE ADDITION OF THE PROVISIONS, EXCLUSIONS AND LIMITATIONS
CONTAINED IN THIS MEDICARE ENDORSEMENT. IN NO EVENT SHALL THE BENEFITS UNDER THIS
ENDORSEMENT DUPLICATE THE BENEFITS UNDER THE GROUP MEDICAL COVERAGE
AGREEMENT. THE HIGHER LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THIS GROUP
MEDICAL COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL BENEFITS ESTABLISHED
BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED, AND REFERRED TO AS "MEDICARE."
THE BENEFITS AND EXCLUSIONS DESCRIBED IN THIS ENDORSEMENT APPLY ONLY TO MEMBERS
WHO ARE COVERED UNDER PART B ONLY OF MEDICARE.
Except as defined by Federal Regulations,all Members entitled to, or eligible to purchase Medicare must transfer to
the GHC Medicare Plan upon such entitlement or eligibility. A condition of enrollment under the GHC Medicare
Plan requires that a Member be continuously enrolled for medical (Part B) benefits available from the Social
Security Administration,and sign any papers that may be required by GHC or Medicare. For additional information,
the Member may refer to "The Medicare Handbook," which can be obtained form your local Social Security
office.
NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC FACILITIES
UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE MEMBER HAS RECEIVED
EMERGENCY OR URGENTLY NEEDED SERVICES ACCORDING TO SECTION V.C. OF THIS MEDICARE
ENDORSEMENT.
Those enrolled under GHC's Medicare plan,as set forth in this Endorsement, all Copayments are waived except the
prescription drug Copayment.
This Endorsement does not constitute a Medicare supplemental contract.
Section I. DEFINITIONS
CUSTODIAL CARE: Care that is primarily for the purpose of meeting personal needs and could be provided by
persons without professional skills or training. Custodial Care includes help in walking, bathing, dressing, eating,
and taking medicine.
EMERGENCY SERVICES (Medicare defined): Medicare Part B services that are rendered immediately by an
appropriate non-GHC provider because of an injury or sudden illness,and for which the time required to reach GHC
or a GHC Designated Facility would risk permanent damage to the Member's health.
HEALTH CARE FINANCING ADMINISTRATION (HCFA): The federal agency that administers the
Medicare program.
MEDICARE: The federal health insurance program for the aged and disabled.
MEDICARE GUIDELINES: Coverage rules and policies established by the Health Care Financing Administration
(HCFA),a federal agency.
MEDICARE HANDBOOK (Titled "The Medicare Handbook"): A pamphlet published by the Health Care
Financing Administration, which provides an easy-to-read explanation of Medicare benefits, and can be obtained
from your local Social Security office,or your Washington State Part B carrier's office.
0036900-CO3046 43
1
PERMANENT MOVE: An uninterrupted absence of more than ninety(90)days from GHC's Service Area.
REFERRAL: A written temporary referral agreement authorized in advance by a GHC physician and formally
approved in advance through GHC's Medicare medical coverage approval process,that entitles a Member to receive
Covered Services from a specified non-GHC health care provider.Entitlement to such services shall not exceed the
limits of the Referral and is subject to all terms and conditions of the Referral and this Agreement.
SERVICE AREA: The geographic area comprised of Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit,
Snohomish,Thurston, and Whatcom Counties, and any other areas designated by GHC and approved by the Health
Care Financing Administration.(See Service Area Map.)
URGENTLY NEEDED SERVICES (Medicare defined): Medicare Part B services needed in order to prevent a
serious deterioration of the Member's health due to an unforeseen illness or injury while temporarily absent from
GHC's Service Area,and which cannot be delayed until the Member returns to the Service Area.
USUAL,CUSTOMARY,AND REASONABLE: A term used to define the level of benefits which are payable by
GHC when expenses are incurred from a non-GHC physician or provider. Expenses are considered Usual,
Customary and Reasonable if (1) the charges are consistent with those normally charged by the provider or
organization for the same services or supplies;and(2)the charges are within the general range of charges made by
other providers in the same geographical area for the same services or supplies.
Section II. TERMINATION
Enrollment under the GHC Medicare Plan for a specific Member,may be terminated in the circumstances set forth
below.
Until such time as a Member's termination of enrollment is effective, neither GHC nor Medicare shall pay for
services provided at non-GHC Facilities unless the Member has been Referred by GHC or the Member has received
Emergency or Urgently Needed Services according to Section V.C. of this Medicare Endorsement.
A. Termination of Specific Members.
1. Loss of Part B Medicare Entitlement.If the Health Care Financing Administration(HCFA)advises GHC
that a Member's entitlement to Medicare coverage no longer exists, or the Member voluntarily terminates
Medicare Part B enrollment, enrollment under the GHC Medicare Plan shall terminate the first of the
month as specified by HCFA.
2. Change of Permanent Residence Outside GHC's Service Area. If a Member makes a Permanent Move
as set forth in Section I. of this Medicare Endorsement, enrollment shall terminate the first day of the
month following the month in which GHC receives notification of such move.
3. For Cause.Enrollment may be terminated upon written notice for:
a. Knowingly providing fraudulent information to obtain coverage. In such event, GHC may rescind or
cancel enrollment upon ten(10)working days'written notice.
b. Permitting the use of a GHC identification card by another person.
c. Failure to comply with the rules and regulations of GHC including disruptive, unruly, abusive or
uncooperative conduct.
Such termination shall be subject to review and approval by HCFA.
Section III SUBROGATION
0036900-CO3046 44
"Injured person" under this section means a Member covered by this Agreement who sustains compensable injury.
"GHC's medical expense"means the expense incurred by GHC for the care or treatment of the injury sustained.
If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability against
the third party, GHC shall have the right to recover its cost of providing benefits to the injured person (subrogation)
from the third party as set forth in this Agreement and in compliance with Medicare regulations and guidelines.
GHC shall be subrogated to and may enforce all rights of the injured person to the extent of its medical expense.
After Medicare laws and regulations mandating recovery of Medicare payments have been satisfied, the
Cooperative's right of subrogation shall be limited to the excess of the amount required to fully compensate the
injured person for the loss sustained.Full compensation shall be measured on an objective,case-by-case basis,but is
subject to a presumption that a settlement which does not exhaust the third parry's reachable assets is full
compensation to the injured person.
The injured person and his or her agents must cooperate fully with GHC in its efforts to collect GHC's medical
expenses. This cooperation shall include, but is not limited to, supplying GHC with information about any
defendants and/or insurers related to the injured person's claim. The injured person and his or her agents shall permit
GHC, at GHC's option,to associate with the injured party or to intervene in any action filed against any third party.
The injured person and his or her agents shall do nothing to prejudice Gf!:--'s subrogation rights. The injured person
shall not settle a claim without protecting GHC's interest.
GHC shall not pay any attorney's fees or collection costs to attorneys representing the injured person where it has
retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a written fee
agreement signed by GHC prior to any collection efforts.When reasonable collection costs have been incurred,with
GHC's prior written agreement, to recover GHC's medical expenses, there shall be an equitable apportionment of
such collection costs between GHC and the injured person subject to a maximum responsibility of GHC equal to
one-third of the amount recovered on behalf of GHC.
This provision does not apply to occupationally incurred disease,sickness,and/or injury.
Section IV GRIEVANCE PROCEDURES
A. GHC Member Services Program.
The Member Services Program is designed to help a Member resolve formal complaints and concerns about
medical and business service. GHC will record, research, and respond in a timely manner to a Member's
concern. A concern should be registered initially at the Member's area medical center. If not satisfied, the
Member should then contact the regional Member Services Department, which will arrange for review by
appropriate medical staff,management and/or GHC consumers.
B. Reconsideration of Claims.
If GHC denies a request for payment of a claim, or declines to provide services which the Member believes
should be provided, the Member may file a request for reconsideration with GHC or a Social Security
Administration office. The request must be filed in writing within sixty (60) days of GHC's written notice of
denial unless an extension is specifically approved. If GHC does not overturn the denial in full, it will be
referred by GHC to the Health Care Financing Administration for reconsideration.
Section V. SCHEDULE OF BENEFITS
All benefits and services listed in this Schedule of Benefits:
• are subject to all provisions of this Agreement and Medicare Endorsement;
• must be approved in advance by GHC except for Emergency and Urgently Needed Services as set forth in
Section V.C.of this Medicare Endorsement;and
0036900-003046 45
• must meet Medicare guidelines and limitations unless otherwise specified.
The booklet, "The Medicare Handbook" provides additional information about Medicare benefits, and can be
obtained from your local Social Security office.
A. Hospice.
It is understood and agreed that the following fully sets forth Covered Services for a Member with Part B
Medicare only who elects to receive hospice services.Members who elect to receive hospice services do so in
lieu of curative treatment for their terminal illness for the period that they are in the hospice program.
To receive hospice services,the Member is required to sign the Hospice Election Form.
Covered Services.Hospice services may include the following as prescribed by a GHC physician and rendered
pursuant to an approved hospice plan of treatment:
1. Home Services
Continuous care services per Member in the Member's home when prescribed by a GHC physician, as set
forth in this paragraph. Continuous care is defined as "skilled nursing care provided in the home during a
period of crisis in order to maintain the terminally ill patient 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 may be provided up to twenty-four (24)
hours per day during periods of crisis. Continuous care is covered only when a GHC physician determines
that the Member otherwise would require hospitalization in an acute care facility.
2. Inpatient Hospice Services for short-term care shall be provided in a facility designated by GHC's
Hospice Program when Medically Necessary and authorized in advance by a GHC physician and GHC's
Hospice Program. Respite care is covered for a maximum of five (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).
3. Other hospice services may include the following:
a. drugs and biologicals that are used primarily for the relief of pain and symptom management;
b. medical appliances and supplies primarily for the relief of pain and symptom management;
c. counseling services for the Member and his/her primary care-giver(s);and
d. bereavement counseling services for the family.
B. Outpatient Mental Health Care, Alcoholism and Drug Abuse Treatment Services are covered for each
Member in accordance with Medicare Guidelines.
C. Outpatient Emergency/Urgently Needed Services. When an Emergency meets the Medicare definition for
Emergency or Urgently Needed Services as defined in Section 1. of this Medicare Endorsement, services are
covered in full:
C1. Out Of The Service Area Non-Emergent and/or Non-Urgently Needed Care. Non-Emergent and/or non-
urgently needed care will be covered outside GHC's defined Service Area, up to a maximum of$2,000.00
(GHC's Service Area is defined in Section I. of this Agreement). Coverage under this benefit does NOT
include coverage of prescription drugs.
Services, as noted in this section,are available to Members traveling outside GHC's defined Service Area,
except when traveling primarily for the purpose of seeking medical care.
The services received under this benefit are subject to all limitations set forth in this Agreement.
0036900-CO3046 46
r, s
All Medicare non-covered expenses including hospital inpatient deductibles and inpatient and outpatient
coinsurances are the responsibility of the Member.
D. Medicare Ambulance Benefit.Medically Necessary ambulance transportation to or from a hospital or Skilled
Nursing Facility is covered in full only if transportation by any other vehicle could endanger the patient's health
and the ambulance,equipment,and personnel meet Medicare requirements.
E. Medical and Surgical Care. The following medical and surgical services are covered when prescribed by
GHC Medical Personnel,Medicare requirements are met:
1. Eye examinations and treatment for eye pathology.
Evaluations and surgical procedures to correct refractions which are not related to eye pathology are not
covered. Complications related to such surgery are also excluded.
2. One pair of eyeglasses or contact lenses, including examination and fitting, following cataract surgery, are
covered subject to UCR charges when required to replace the natural lens of the eye. Covered eyeglasses
and contact lenses must be dispensed through GHC Facilities.Replacements will be provided when needed
due to change in the Member's medical condition or when deemed appropriate by a GHC physician.
3. Blood,blood derivatives,and their administration.
4. Maternity and pregnancy-related services,including visits before and after birth;involuntary termination of
pregnancy;and care for any other complication of pregnancy.
5. Organ transplants, limited to heart, kidney, cornea, bone marrow, and liver, when established criteria are
met.
6. Physician calls (including consultations and second opinions by a GHC physician) in the hospital, office,
home, Skilled Nursing Facility,nursing home,or convalescent center.
7. Restorative physical,occupational,and speech therapy following illness,injury,or surgery.
8. Immunizations and vaccinations that are listed as covered in the GHC Drug Formulary(approved drug list)
or approved by Medicare.
9. Services related to dysfunction of the jaw. When Referred by a GHC physician, evaluation and treatment
by a GHC-approved temporomandibular joint(TMJ)care provider.
All TMJ appliances,other than the occlusal splint and its fitting,are excluded.
Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when the dysfunction is
related to malocclusion or when TMJ services are needed due to dental work performed. All such services
and related hospitalization, including orthodontic therapy and orthognathic (jaw) surgery, are excluded
regardless of origin or cause.
(See Section X.B.17. of the Group Medical Coverage Agreement for Covered Services not meeting
Medicare guidelines).
10. Chiropractic care limited to spinal manipulations. Excluded are any other diagnostic or therapeutic
services,including x-rays,furnished by a chiropractor.Members who receive their primary care in portions
of the GHC Service Area where GHC-designated licensed practitioners are available must utilize GHC's
designated providers in order to be covered.
0036900-003046 47
L c " ►
11. Podiatric care. Services are covered when all Medicare criteria are met and when authorized in advance by
your Primary Care Provider. Excluded is treatment of flat feet or other misalignments of the feet;removal
of corns and calluses; and routine foot care such as hygienic care, except in the presence of a nonrelated
medical condition affecting the lower limbs. Members who receive their primary care in portions of the
GHC Service Area where GHC designated licensed practitioners are available must utilize GHC's
designated providers in order to be covered.
12. Home intravenous(1V)drug therapy services.
13. Routine eye examinations and refractions, limited to once every twenty-four (24) months, except when
Medically Necessary. Services for routine eye examinations must be received at a GHC Facility and in
accordance with GHC medical criteria in order to be covered and are not subject to Medicare requirements.
Lenses. One pair of standard glass single vision, lenticular, or nonblended bifocal or trifocal lenses, or
contact lenses,will be covered subject to UCR charges once every twenty-four(24) months, and replaced
as specified below,when received at a GHC facility and in accordance with GHC medical criteria.
Frames. An Allowance of up to $100 per Member once every twenty-four(24)months will be provided
for frames.
Replacements. Lens replacement for any reason (including loss, breakage or change in prescription)will
be provided not more often than once every 24 months.
Replacement of frames will be provided subject to the frames Allowance set forth above not more often
than once every 24 months.
14. Hearing examinations to determine hearing loss. Hearing aids, including examinations and fitting,must be
received at a GHC Facility and are covered up to a maximum of$250 per Member once every 24 months.
F. Prosthetic Devices,such as cardiac devices,intraocular lenses,artificial joints,breast prostheses,artificial eyes,
and braces,are covered.Excluded are: orthopedic shoes unless they are part of leg braces;dental plates or other
dental devices;and experimental devices.
G. Medical/Surgical Supplies,such as casts,splints,post-surgical dressings,and ostomy supplies,are covered.
H. Rental or Purchase of Durable Medical Equipment,such as oxygen and oxygen equipment,wheelchairs and
other walk-aids,and hospital beds,is covered.
I. Respite Care.
1. Eligibility. Respite care is provided to chronically dependent persons for reasonable and necessary
in-home services,provided that such services are:
a. authorized in advance by a GHC physician;
b. provided by GHC Community Health Services or by a GHC-approved agency;and
c. that the Member has incurred no less than the equivalent of$6,870.00 in expenses for Medicare Part B
Covered Services during the calendar year in which respite benefits are to be provided.
2. Covered Services. Covered respite care services are provided up to a maximum of eighty (80) hours for
the twelve (12) month period following the date all eligibility requirements are met. Covered respite
services are limited to the following:
a. Services of a homemaker or home health aide;
b. Personal care services;and
c. Nursing care provided by a licensed professional nurse.
0036900-003046 48
"Chronically dependent persons" under this section means persons who live with a voluntary care-giver;
are dependent upon the care-giver for assistance with at least two activities of daily living, such as eating,
bathing, dressing, toileting, or transferring in and out of a bed or chair; and who meet the eligibility
requirements described above.
Section VI. EXCLUSIONS AND LIMITATIONS
A. Exclusions.
1. Investigational procedures, including medical and surgical services, drugs and devices until formally
approved by Medicare unless specifically provided herein (See Section XI.A.10. in the Group Medical
Coverage Agreement).
2. Supportive devices for the feet.
3. Services directly related to obesity except as provided by Medicare.
4. Services or supplies not specifically listed as covered by Medicare or GHC.
B. Limitations.
Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS V.E.10. AND V.E.I L, ALL
SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE PROVIDED BY GHC MEDICAL
PERSONNEL AT A GHC OR GHC DESIGNATED FACILITY UNLESS:
1. the Member has received a Referral from GHC, including formal advance approval through GHC's
Medicare medical coverage approval process,or
2. the Member has received outpatient Emergency or Urgently Needed Services as defined in Section I. and
as set forth in Section V.C. of this Medicare Endorsement.
Section VII. CLAIMS PROCEDURE
Claims for services or supplies and explanation of Medicare benefits for services or supplies from providers other
than Group Health Cooperative should be sent to: Medicare Claims, Group Health Cooperative of Puget Sound. If
you must receive Emergency or Urgently Needed Services from a non-GHC provider, be sure to show your GHC
I.D. card and your red,white,and blue Medicare card.
A. The Member must file claims for services rendered during the first nine (9) months of a calendar year by
December 31 of the following calendar year.
B. The Member must file claims for services rendered in the last three(3)months of a calendar year the same as if
the services had been furnished in the subsequent calendar year. The time limit on filing claims for services
furnished in the last three(3)months of the calendar year is December 31 of the second calendar year following
the calendar year in which the services were rendered.
See "The Medicare Handbook" for additional information regarding filing claims, which can be obtained from
your local Social Security office,or your Washington State Part B carrier's office.
GHC may obtain information which it deems necessary concerning the medical care and hospitalization for
which payment is requested.
0036900-CO3046 49
COPAYMENTS AND ALLOWANCES SCHEDULE
The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the Group
Medical Coverage Agreement.
STOP LOSS:
Total out-of-pocket Copayment expenses for the following Covered Services:
Limited to an aggregate maximum of$750 per Member and$1,500 per family per calendar year.
• Outpatient Services
• Emergency Care at a GHC or GHC Designated Facility
INPATIENT HOSPITAL SERVICES:
HOSPITAL CARE: All inpatient medical and surgical hospital care services are subject to the stated Copayment.
• Chemical dependency treatment(see benefit limits under Chemical Dependency section of the Copayments and
Allowances Schedule)
• Rehabilitation Services. Inpatient physical, occupational and restorative speech therapy services combined,
including services for neurodevelopmentally disabled children age six (6) and under, plus associated hospital
services for the purpose of rehabilitation is covered up to 60 days per condition per calendar year.
• Pregnancy-related complications prior to delivery
• Other pregnancy-related services
No Copayment. Covered in full.
OUTPATIENT SERVICES: Diagnostic radiology and laboratory services and administration of injections
including covered immunizations and vaccinations are not subject to the outpatient Copayment. All other outpatient
medical and surgical services are subject to the stated Copayment.
• Medical and surgical care
• Office visits,including consultations
• Outpatient surgery
• Physical examinations,including well-child care and routine mammography screening
• Radiation therapy and chemotherapy
• Family planning counseling
• Audiological testing
• Routine eye exam/refraction;contact lens exams and fitting for eye pathology
• Chemical dependency treatment(see benefit limits under Chemical Dependency section of the Copayments and
Allowances Schedule)
• Prenatal and postpartum visits and prenatal testing
• Pregnancy-related services
• Outpatient physical, occupational and restorative speech therapy services combined, including services for
neurodevelopmentally disabled children age six (6) and under are covered up to 60 visits per condition per
calendar year
$5 Copayment per visit per Member.
0036900-CO3046 50
CHEMICAL DEPENDENCY:
• Benefit Period Allowance
$5,000 maximum per Member per any 24 consecutive calendar month period
• Lifetime Maximum Benefit
$10,000 per Member
TOBACCO CESSATION:
• Individual/Group Sessions
Covered at 50%of the total charges. Coinsurance does not apply to Stop Loss.
• Nicotine replacement therapy
Covered subject to the Outpatient Prescription Drug Copayment for each(30)day supply or less of a prescription or
refill when provided at GHC Facilities and prescribed by a GHC Provider. Copayment does not apply to Stop Loss.
PRESCRIPTION DRUGS - OUTPATIENT: Drugs and medicines (including injectables) which require a
prescription when provided at GHC Facilities and prescribed by a GHC Provider for a supply of thirty(30)days or
less of an outpatient prescription or refill is subject to the stated Copayment.
Covered subject to the lesser of GHC's charge or a$5 Copayment. Copayment does not apply to Stop Loss.
MENTAL HEALTH CARE:
• Outpatient Services
Twenty (20) visits covered per Member per calendar year subject to $20 Copayment per individual/family/couple
session and$10 per Member per group session;no coverage thereafter.
• Inpatient Services
Coverage Allowance up to 12 days at 80%per Member per calendar year at a GHC-approved mental health care
facility when authorized in advance by GHC.
Total expenses,Copayments and Coinsurance paid for mental health treatment do not apply to Stop Loss.
EMERGENCY CARE: All emergency care services are subject to the stated Copayment.
• At a GHC or GHC Designated Facility
$50 Copayment per Emergency visit per Member. Copayment is waived if Member is admitted directly from the
Emergency department.
• At a non-GHC Designated Facility
0036900-CO3046 51
$100 Deductible per Emergency visit per Member. Emergency Deductible does not apply to Stop Loss.
AMBULANCE SERVICES:
• Transport to a GHC Facility,GHC Designated Facility,or non-GHC Designated Facility.
Covered at 80%. Coinsurance amount does not apply to Stop Loss.
• Transfer to a GHC or GHC Designated Facility
No Copayment.
ORTHOPEDIC APPLIAN
• Orthopedic appliances when prescribed by a GHC Provider and listed as covered in the Orthopedic Appliance
Formulary.
Covered Services are subject to a 50%Coinsurance. Coinsurance amount does not apply to Stop Loss.
NASAL CPAP DEVICE:
• Nasal CPAP device when Medically Necessary and authorized in advance by GHC.
Covered Services are subject to a 50%Coinsurance. Coinsurance amount does not apply to Stop Loss.
POST-MASTECTOMY BRAS:
Covered Services are subject to a 50%Coinsurance. Coinsurance amount does not apply to Stop Loss.
TEMPORO ANDIB n AR JOINT(TMi1 SERVICES
• Inpatient and outpatient TMJ services when Medically Necessary and authorized by GHC.
$1,000 maximum per Member per calendar year
• Lifetime Maximum Benefit
$5,000 per Member
SKILLED iR IN FACILITY-
0 Care in a GHC-approved skilled nursing facility
Coverage allowance up to thirty(30)days per condition per Member.
PA-1133 -Basic Agreement
0036900-CO3046 52
PA-1117-Service Area Map
CA-174-Medicare A&B
CA-175-Medicare B Only
CA-66-M&A
DA420-MT-A
CA-18-PEC(0)
CA-573-IM-U
CA-61 -SN-A
0036900-003046 53
Dues Schedule
Fo For to Group Medical Coverage Agreement with: GROUP # 00369
KENT, CITY OF
This schedule reflects Group Health Cooperative monthly dues effective January 1, 1997
and guaranteed to January 1, 1998.
MONTHLY HEALTH CARE DUES
.............................................................. $157.94 per month
Subscriber only.......................... .. $353.38 per month
Subscriber and Spouse...........................................................................
Subscriber-and Child(ren)............................................
............................. $318.53 per month
Subscriber and Family ""'
......... $505.90 per month
....................... $195.44 per month
Spouse only....................................................................... $160.59 per month
..............
Children) only.................................................................... $356.04 per month
Spouse and Child rem
COPAYMENT PROVISION
The following copayments apply to this plan. See Group Medical Coverage Agreement for
benefit details.
$5 Outpatient/Office Visit
$5 Outpatient Prescription Drugs
$0 Inpatient Co-pay
$50 Emergency Room
0 Month Pre-existing Condition
BILLING INFORMATION
Dues must be remitted on a calendar month basis on or before the first day of the coverage
month for which they become payable. Each remittance must be accompanied by a list of
subscribers for whom such dues are paid.
9.0 percent(9%) of each months medical dues for each member and each family enrollee, as
scheduled above, is the budgeted prepaymen
t for cost of all pharmaceuticals and prescription
to be dispersed on written orders of the Group Health Cooperative Medical Staff for the next
fiscal year under coverage of your medical coverage agreement
Group Health Cooperative of Puget Sound does not discriminate on the basis of physical or
mental handicaps in its employment practices or services.
BILLING INFORMATION, Continued
Regardless of the effective date of enrollment for a Subscriber and Family
Dependents, the Group will not be required to submit dues* to the Cooperative
for the month of enrollment, and these Enrollees will appear on the subsequent
month's billing at the regular charge. When the Subscriber's enrollment
terminates, the group will submit the full amount of dues to the Cooperative
regardless of the specific date of termination for that month.
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