PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR

Transcription

PLAN DOCUMENT AND
SUMMARY PLAN DESCRIPTION
FOR
MADONNA HEALTH PLAN
SPD Restated July 1, 2014
TABLE OF CONTENTS
INTRODUCTION ........................................................................................................................................... 1
IMPORTANT NOTICE FOR MASTECTOMY PATIENTS................................................................................ 3
PATIENT PROTECTION NOTICE ................................................................................................................. 4
ELIGIBILITY, FUNDING, EFFECTIVE DATE AND TERMINATION PROVISIONS.......................................... 5
OPEN ENROLLMENT ................................................................................................................................. 13
SCHEDULE OF BENEFITS ......................................................................................................................... 14
MEDICAL BENEFITS .................................................................................................................................. 28
UTILIZATION MANAGEMENT SERVICES .................................................................................................. 37
VISION BENEFIT ........................................................................................................................................ 41
PRESCRIPTION DRUG EXPENSE BENEFITS ........................................................................................... 42
DEFINED TERMS ....................................................................................................................................... 43
PLAN EXCLUSIONS ................................................................................................................................... 51
HOW TO SUBMIT A CLAIM......................................................................................................................... 58
YOUR RIGHT TO REVIEW OF THE PLAN'S DETERMINATION ................................................................. 60
COORDINATION OF BENEFITS ................................................................................................................. 70
THIRD PARTY RECOVERY PROVISION .................................................................................................... 73
CONTINUATION OF COVERAGE ............................................................................................................... 76
PROVIDING PROTECTED HEALTH INFORMATION TO PLAN SPONSOR ................................................ 79
GENERAL PLAN INFORMATION ................................................................................................................ 84
PREAUTHORIZATION EXHIBIT .................................................................................................................. 86
PRIVACY NOTICE ...................................................................................................................................... 87
MEDICARE PART D NOTICE...................................................................................................................... 91
MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) .......................................... 93
INTRODUCTION
This document is a description of Madonna Health Plan (the Plan). No oral interpretations can change this
Plan. The Plan described is designed to protect Plan Participants against certain catastrophic health expenses.
The Plan Administrator for the Plan is the Madonna Rehabilitation Hospital. The Plan Administrator’s duties are
more fully described in the section of this document titled “Responsibilities For Plan Administrator”.
The Claims Administrator for the Plan is Coventry Health and Life Insurance Company. The Claims
Administrator performs administrative services only with respect to the Plan (such as adjudication of claims for
benefits under the Plan). The Claims Administrator does not underwrite or insure the Plan and has no financial
responsibility for the cost of Covered Services provided under the Plan.
Coverage under the Plan will take effect for an eligible Employee and designated Dependents when the
Employee and such Dependents satisfy all the eligibility requirements of the Plan.
The Employer fully intends to maintain this Plan indefinitely. However, it reserves the right to terminate,
suspend, discontinue or amend the Plan at any time and for any reason.
Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, Deductibles,
maximums, Copayments, exclusions, limitations, definitions, eligibility and the like.
For Plan Years that begin on or after January 1, 2014, to the extent that an item or service is a covered benefit
under the Plan, the terms of the Plan shall be applied in a manner that does not discriminate against a health
care Provider who is acting within the scope of the Provider's license or other required credentials under
applicable State law. This provision does not preclude the Plan from setting limits on benefits, including cost
sharing provisions, frequency limits, or restrictions on the methods or settings in which treatments are provided
and does not require the Plan to accept all types of Providers as a Participating Provider.
Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no
coverage at all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the
Plan, such as coordination of benefits, subrogation, exclusions, timeliness of COBRA elections, utilization
review or other Utilization Management requirements, lack of Medical Necessity, lack of timely filing of claims or
lack of coverage. These provisions are explained in summary fashion in this document
The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable
for expenses incurred before coverage began or after coverage terminated. An expense for a service or supply
is incurred on the date the service or supply is furnished.
If the Plan is terminated, amended, or benefits are eliminated, the rights of Covered Persons are limited to
Covered Charges incurred before termination, amendment or elimination.
This document summarizes the Plan rights and benefits for covered Employees and their Dependents and is
divided into the following parts:
Eligibility, Funding, Effective Date and Termination. Explains eligibility for coverage under the Plan, funding
of the Plan and when the coverage takes effect and terminates.
Schedule of Benefits. Provides an outline of the Plan reimbursement formulas as well as payment limits on
certain services.
Benefit Descriptions. Explains when the benefit applies and the types of charges covered.
Utilization Management Services. Explains the methods used to curb unnecessary and excessive charges.
This part should be read carefully since each Participant is required to take action to assure that the
maximum payment levels under the Plan are paid.
Defined Terms. Defines those Plan terms that have a specific meaning.
Plan Exclusions. Shows what charges are not covered.
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Claim Provisions. Explains the rules for filing claims.
Coordination of Benefits. Shows the Plan payment order when a person is covered under more than one plan.
Third Party Recovery Provision. Explains the Plan's rights to recover payment of charges when a Covered
Person has a claim against another person because of injuries sustained.
Continuation of Coverage Option. Explains when a person's coverage under the Plan ends and the
continuation options which are available.
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IMPORTANT NOTICE FOR MASTECTOMY PATIENTS
If a Covered Person elects breast reconstruction in connection with a mastectomy, the Covered Person is
entitled to coverage under this Plan for:
·
Reconstruction of the breast on which the mastectomy was performed;
·
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
·
Prosthesis and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
Such services will be performed in a manner determined in consultation with the attending Physician and the
patient. See Medical Benefits Section for further detail regarding this coverage.
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PATIENT PROTECTION NOTICE
If this Plan generally allows for the designation of a Primary Care Physician (PCP), You have the right to
designate any PCP who participates in the Network and who is available to accept You or Your family members.
Until You make this designation the Claims Administrator may make one for You. For information on how to
select a PCP, and for a list of Participating Primary Care Physicians, contact the Claims Administrator at the
Customer Service number printed on Your ID card or visit their website at www.chcne.com.
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4
ELIGIBILITY, FUNDING, EFFECTIVE DATE
AND TERMINATION PROVISIONS
A Plan Participant should contact the Claims Administrator to obtain additional information, free of charge, about
Plan coverage of a specific benefit, particular drug, treatment, test or any other aspect of Plan benefits or
requirements.
ELIGIBILITY
Eligible Classes of Employees. All Active Full-Time Employees of the Employer.
Eligibility Requirements for Employee Coverage. A person is eligible for Employee coverage from the first
day that he or she:
(1)
is a Full-Time, Active Employee of the Employer. An Employee is considered to be Full-Time if he or
she normally works at least 40 hours in a two-week period and is on the regular payroll of the
Employer for that work.
(2)
is in a class eligible for coverage.
(3)
has satisfied the 30 day Waiting Period of Employee. Employee is eligible on the first day of the
month following 30 days of employment or on the first day of the month following change of status
resulting in the minimum hour requirement being met for current Employees.
Eligible Classes of Dependents. A Dependent is any one of the following persons:
(1)
A covered Employee’s Spouse. The term "Spouse" shall mean the person of the opposite gender
recognized as the covered Employee's husband or wife under the laws of the state where the
covered Employee lives. The Plan Administrator may require documentation proving a legal marital
relationship.
(2)
A covered Employee's Child(ren).
"Child" includes a natural Child, stepchild, adopted Child, a Child placed with the Employee for
adoption, or Children for whom the Employee is a Legal Guardian. An Employee's Child will be an
eligible Dependent until reaching the limiting age of 26, without regard to student status, marital
status, financial dependency or residency status with the Employee or any other person.
Stepchildren may be included as long as a natural parent remains married to the Employee.
The phrase "placed for adoption" refers to a Child whom the Employee intends to adopt, whether or
not the adoption has become final, who has not attained the age of 18 as of the date of such
placement for adoption. The term "placed" means the assumption and retention by such Employee
of a legal obligation for total or partial support of the Child in anticipation of adoption of the Child.
The Child must be available for adoption and the legal process must have commenced.
When the Child reaches the applicable limiting age, coverage will end on the last day of the month
following the Child's birthday.
NOTE: The Plan will provide coverage for children in accordance with Neb. Rev. Stat. § 44-7,103.
Your Child may continue coverage under the Plan once he or she reaches age twenty-six (26)
provided Your Child meets the following requirements:
-
is residing in Nebraska;
is unmarried;
is under the age of thirty (30); and,
is not covered by another health plan.
If Your Child meets these requirements and has been continuously covered under the Plan, You
may continue the Dependent’s coverage under Your Plan at an additional cost which will be
deducted from Your payroll. This continuation of coverage is allowed under Nebraska state law.
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Once Your Child’s coverage is canceled or Your Child ceases to meet the eligibility requirements.
Your Dependent will not be eligible to enroll at a later date.
(3)
A covered Employee's Qualified Dependents.
Any Child of a Plan Participant who is an alternate recipient under a Qualified Medical Child Support
Order shall be considered as having a right to Dependent coverage under this Plan. A Participant
of this Plan may obtain, without charge, a copy of the procedures governing Qualified Medical Child
Support Order (QMCSO) determinations from the Plan Administrator.
(4)
A covered Dependent Child or Qualified Dependent who reaches the limiting age and is Totally
Disabled, incapable of self-sustaining employment by reason of mental or physical handicap,
primarily dependent upon the covered Employee for support and maintenance and unmarried. The
Plan Administrator may require, at reasonable intervals, continuing proof of the Total Disability and
dependency.
The Plan Administrator reserves the right to have such Dependent examined by a Physician of the
Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity.
The Plan Administrator may require documentation proving eligibility for Dependent coverage, including birth
certificates, tax records or initiation of legal proceedings severing parental rights.
These persons are excluded as Dependents: other individuals living in the covered Employee's home, but who
are not eligible as defined; the legally separated or divorced former Spouse of the Employee; any person who is
on active duty in any military service of any country; or any Dependent of an eligible Dependent.
If a person covered under this Plan changes status from Employee to Dependent or Dependent to Employee,
and the person is covered continuously under this Plan before, during and after the change in status, credit will
be given for Deductibles and all amounts applied to maximums.
If both mother and father are Employees, their Children will be covered as Dependents of the mother or father,
but not of both.
Eligibility Requirements for Dependent Coverage. A family member of an Employee will become eligible for
Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family
member satisfies the requirements for Dependent coverage.
At any time, the Plan may require proof that a Spouse or a Child qualifies or continues to qualify as a Dependent
as defined by this Plan.
PRE-EXISTING CONDITIONS
There are no Pre-Existing Condition limitations.
FUNDING
Cost of the Plan. Madonna Rehabilitation Hospital shares the cost of Employee and Dependent coverage
under this Plan with the covered Employees.
The level of any Employee contributions is set by the Plan Administrator. The Plan Administrator reserves the
right to change the level of Employee contributions.
ENROLLMENT
Initial Enrollment: If You are not automatically enrolled in the Plan, to be covered You must elect to participate
in the Plan and elect to have Your eligible dependents covered by the Plan by completing the required
enrollment forms furnished by Your employer.
Enrollment Requirements. An Employee must enroll for coverage by filling out and signing a Benefits election
form.
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Newly Hired Employees or Newly Eligible for Benefits: Open enrollment will be allowed for new hires and
existing Employees newly eligible for benefits (changing from less than 40 hours/pay period to 40 or more
hours/pay period) and new Spouses upon family status change. Coverage will be effective the first of the month
following 30 days of employment (for new hires); and first of the month following enrollment for newly Eligible
Employees (provided the enrollment occurs within 30 days from the date of the change in scheduled hours).
Enrollment Requirements for Newborn Children.
Your newborn Child, born while You are covered under this Plan, is automatically covered from the moment of
birth until the Child is 31 days old. Coverage for the newborn will continue beyond the initial 31 days only if the
properly completed and signed enrollment form and premium is received by Coventry within 31 days of birth.
Charges for covered nursery care will be applied toward the benefits of the newborn Child. If the newborn Child
is not enrolled in this Plan on a timely basis, as defined in the section "Timely Enrollment" following this section,
there will be no payment from the Plan beyond 31 days.
Charges for covered routine Physician care will be applied toward the Plan of the Employee towards the
benefits of the newborn Child. If the newborn Child is not enrolled in this Plan on a timely basis, there will be no
payment from the Plan beyond 31 days.
If the Child is not enrolled within 31 days of birth, any future enrollment during a qualifying event will be
considered a Late Enrollment.
TIMELY OR LATE ENROLLMENT
(1)
Timely Enrollment - The enrollment will be "timely" if the completed form is received by the Claims
Administrator no later than 30 days after the person becomes eligible for the coverage, either
initially or under a Special Enrollment Period.
(2)
Late Enrollment - An enrollment is "late" if it is not made on a "timely basis" or during a Special
Enrollment Period. Late Enrollees and their Dependents who are not eligible to join the Plan during
a Special Enrollment Period may join only during open enrollment.
If an individual loses eligibility for coverage as a result of terminating employment or a general
suspension of coverage under the Plan, then upon becoming eligible again due to resumption of
employment or due to resumption of Plan coverage, only the most recent period of eligibility will be
considered for purposes of determining whether the individual is a Late Enrollee.
The time between the date a Late Enrollee first becomes eligible for enrollment under the Plan and
the first day of coverage is not treated as a Waiting Period. Coverage begins on July 1.
SPECIAL ENROLLMENT RIGHTS
Federal law provides Special Enrollment provisions under some circumstances. If an Employee is declining
enrollment for himself/herself or his/her dependents (including their Spouse) because of other health insurance
or group health plan coverage, there may be a right to enroll in this Plan if there is a loss of eligibility for that
other coverage (or if the employer stops contributing towards the other coverage). However, a request for
enrollment must be made to the Claims Administrator within 30 days after the coverage ends (or after the
employer stops contributing towards the other coverage).
In addition, in the case of a birth, marriage, adoption or placement for adoption, there may be a right to enroll in
this Plan. However, a request for enrollment must be made to the Claims Administrator within 30 days after the
birth, marriage, adoption or placement for adoption.
The Special Enrollment rules are described in more detail below. To request Special Enrollment or obtain more
detailed information of these portability provisions, contact the Plan Administrator, Madonna Rehabilitation
Hospital, 5401 South Street, Lincoln, NE, 68506.
SPECIAL ENROLLMENT PERIODS
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The Enrollment Date for anyone who enrolls under a Special Enrollment Period is the first date of coverage.
Thus, the time between the date a special enrollee first becomes eligible for enrollment under the Plan and the
first day of coverage is not treated as a Waiting Period.
If You or Your Dependents are not enrolled in a Madonna plan but are eligible to participate, You will be allowed
to enroll in the Madonna Health Plan if the following conditions are met:
(1)
You are covered by another health plan and lose it as a result of loss of eligibility, unless eligibility is
lost due to the failure of the Employee or Dependent to pay premiums on a timely basis or
termination of coverage for cause (such as making a fraudulent claim or intentional
misrepresentation of a material fact in connection with the Plan), or Your employer ceased making
contributions for the coverage; and
(2)
Coverage is requested no later than 30 days after the date the other coverage ended.
(3)
The Employee or Dependent has a loss of eligibility through a Medicaid or CHIP program and
requests coverage within sixty (60) days of termination.
(4)
The Employee or Dependent becomes eligible for a premium assistance program under Medicaid or
CHIP and requests coverage within sixty (60) days after eligibility is determined.
(Adding Other Dependents Other Than Newborns Or New Spouses Upon Family Status Change)
In the case of birth, placement for adoption or adoption of a Child, or marriage where a new Dependent is
added to the Plan during the 30-day Open Enrollment Period, additional eligible Family members may be
enrolled as Dependents of the Employee.
If the Employee or Dependent lost the other coverage as a result of the individual's failure to pay premiums or
required contributions or for cause (such as making a fraudulent claim or an intentional misrepresentation of a
material fact in connection with the plan), that individual does not have a Special Enrollment right.
ENROLLMENT OF DEPENDENT PURSUANT TO A QUALIFIED MEDICAL CHILD SUPPORT ORDER
Qualified Medical Child Support Order (“QMCSO”) means a 1) Medical Child Support Order (“MCSO”) issued by
a court or through an administrative process under state law, or 2) a National Medical Support Notice (“NMSN”)
issued by an authorized state agency, which may create or recognize the right of a Child of an eligible, retired or
disabled Employee to be covered under this Plan. Such an order or notice must be qualified and issued by a
court of competent jurisdiction for the Plan to be bound by it.
Please contact the Employer for more information regarding whether or not a Medical Child Support Order or a
National Medical Support Notice is qualified.
The Plan will enroll any alternate recipient in the Plan upon receipt of any court order or other document
(collectively “order”) which the Employer determines to be a Qualified Medical Child Support Order pursuant to
the Employer’s procedures for determining the qualified status of such orders. The Plan will enroll the alternate
recipient in the Plan in accordance with the benefit option specified in the order. If a benefit option is specified in
the order, but the Employee to whom the order relates is not enrolled in the Plan, the Employer will enroll both
the Employee and the alternate recipient in the Plan under the option specified in the order. The Employer will
deduct the Employee’s cost of the benefit option from the Employee’s compensation in accordance with the
Employer’s standard payroll practices.
If no benefit option is specified in the order, but the Employee to whom the order relates is already enrolled in
the Plan, then Employer will enroll the alternate recipient under the same option as that of the Employee and will
automatically change a Participant’s benefit election to reflect such change. If there is a change in the cost, the
Participant’s benefit election shall automatically be adjusted to reflect such change.
If no benefit option is specified in the order and the Employee to whom the order relates is not enrolled in the
Plan, the Employer will not consider the order to be a qualified order. If the Employer determines the order is not
a qualified order, it will notify the parties to the order, including the agency issuing the order if applicable, that
the order is not qualified and therefore, the Plan will not enroll the alternate recipient in the Plan until it receives
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further instructions from the issuing agency or court as to the appropriate benefit option for the alternate
recipient.
EFFECTIVE DATE
Effective Date of Employee Coverage. An Employee will be covered under this Plan as of the first day of the
month following 30 days of employment (for new hires); and first of the month following enrollment for newly
eligible employees (provided the enrollment occurs within 30 days from the date of the change in scheduled
hours), and satisfies the following:
(1)
The Eligibility Requirement.
(2)
The Active Employee Requirement.
(3)
The Enrollment Requirements of the Plan.
Active Employee Requirement.
An Employee must be an Active Employee (as defined by this Plan) for this coverage to take effect.
Effective Date of Dependent Coverage. A Dependent's coverage will take effect on the day that the Eligibility
Requirements are met; the Employee is covered under the Plan; and all Enrollment Requirements are met.
TERMINATION OF COVERAGE
When coverage under this Plan stops, Plan Participants will receive a certificate that will show the
period of Creditable Coverage under this Plan. The Plan maintains written procedures that explain how
to request this certificate. Please contact the Plan Administrator for a copy of these procedures and
further details.
The Employer or Plan has the right to rescind any coverage of the Employee and/or Dependents for
cause, making a fraudulent Claim or an intentional material misrepresentation in applying for or
obtaining coverage, or obtaining benefits under the Plan. The Employer or Plan may either void
coverage for the Employee and/or covered Dependents for the period of time coverage was in effect,
may terminate coverage as of a date to be determined at the Plan's discretion, or may immediately
terminate coverage. If coverage is to be terminated or voided retroactively for fraud or
misrepresentation, the Plan will provide at least thirty (30) days' advance written notice of such action.
The Employer will refund all contributions paid for any coverage rescinded; however, Claims paid will
be offset from this amount. The Employer reserves the right to collect additional monies if Claims are
paid in excess of the Employee's and/or Dependent's paid contributions.
Termination of Coverage of Eligible Employees and Their Dependents.
Employee coverage and Dependent coverage under this Plan will terminate at 11:59 p.m. on the first
occurrence of any of the following events:
a.
For Employee and Dependent coverage, the last day of the month in which termination or
ineligibility becomes effective;
Exceptions: A person may remain eligible for a limited time if active full-time work ceases due to Total
Disability, Employer Approved Leave of Absence or Lay-Off.
b.
On the date that any contribution required to be paid by You or on Your behalf is due and unpaid;
c.
The first day of the month immediately following the day We receive notice from You that Your
coverage is to be terminated;
d.
The date the Plan is terminated;
e.
The first day of the month immediately following the date You enter the armed forces on active duty
unless You elect to continue the Health coverage; or
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f.
The original Effective Date of Your coverage if Your coverage is rescinded due to misrepresentation
on Your application.
Continuation of Coverage. If You lose Your coverage under this health Plan due to a qualifying event, You
may continue Your coverage for a limited time. An individual covered by this health Plan on the day before a
qualifying event occurs who is either an Employee, the Employee’s Spouse, or an Employee’s Dependent Child
are eligible to continue coverage. In addition, any Child born to or placed for adoption with a covered Employee
during the period of continuation of coverage is considered as eligible to be covered under any continuation of
coverage in force at that time. The qualifying events which make a Participant eligible for continuation coverage
depend on the identity of the person covered. In all instances, a qualifying event shall be deemed to occur only if
the event would otherwise cause a loss of coverage under this health Plan.
If You are an Employee, the qualifying events which will make You eligible to continue coverage are:
1.
2.
3.
termination of service;
reduction of hours below eligibility requirements; or
when coverage ends due to reaching the allowable limits for leaves of absence as established by
the Employer.
If You are a Spouse of an Employee, the qualifying events which will make You eligible to continue coverage
are:
1.
2.
3.
the Employee's termination of service, the Employee's reduction in work hours below eligibility
requirements, or when coverage ends due to reaching the allowable limits for leave of absence as
established by the Employer.
Your divorce or legal separation from the Employee; or
the death of the Employee.
If You are a Child of an Employee, the qualifying events which will make You eligible to continue coverage
are:
1.
2.
3.
4.
the Employee's termination of service, the Employee's reduction of hours below eligibility
requirements, or when coverage for the Employee ends due to reaching the allowable limits for
leave of absence as established by the Employer;
the death of the Employee;
the divorce or legal separation of the Employee; or
a loss of coverage for You because of Your age.
In order to continue coverage, You must satisfy each of the following conditions:
1.
2.
3.
You must have experienced a qualifying event which caused You to lose coverage under this health
Plan;
within 30 days from the later of the coverage loss date or the date the continuation of coverage
election notice is provided, You must complete a continuation of coverage enrollment form and pay
Your first monthly premium in an amount to be determined from time to time by the Committee; and
pay all subsequent premium payments by the first day of the covered month and in no event later
than the last day of the covered month.
Your continuation of coverage shall terminate upon the earliest of the following dates:
1.
2.
3.
4.
5.
Rev 6.27.14
the date the Employer terminates all health Plans offered to any Employee;
the date You fail to timely pay a required monthly premium;
the date You are covered under another group health plan;
the date You are eligible for Medicare; or
twelve months from the qualifying event or 29 months from the qualifying event for qualified
Employee disability situations. Disability of the Employee may extend the 12-month period of
continuation of coverage for up to an additional 17 months for a qualifying event that is termination
of employment or reduction in hours. To qualify for the additional 17 months of continuation of
coverage, the Employee must: a) have a ruling from the Social Security Administration that he or
she became disabled prior to or within the first 60 days from the start of the continuation of
10
coverage period; and b) send the Plan a copy of the Social Security ruling letter within 60 days of
receipt and prior to the expiration of the initial 12-month continuation of coverage period.
Continuation of Dependent Child Coverage
If coverage would otherwise terminate as a result of a Dependent child reaching the Limiting Age, the
Dependent child may continue coverage for so long as the Dependent continues to meet all other eligibility
requirements. The Dependent child will be required to pay a separate premium equivalent to the premium rate
for subscriber-only coverage under this Plan. The Employer is not required to contribute to the premium for this
coverage, so the Dependent child may be responsible for the entire premium during such continuation of
coverage.
Continuation of Coverage will terminate at the end of the month in which the first of the following occurs:
(1)
the Dependent Child turns thirty (30) years of age;
(2)
the Dependent Child is married;
(3)
the Dependent Child obtains creditable coverage under another group or individual health benefit
plan;
(4)
the Dependent Child is no longer a resident of this state and is over the limiting age of 26;
(5)
the Dependent Child fails to pay Premiums or have Premiums paid on their behalf;
(6)
the Group Master Contract or Coverage of the Subscriber is terminated; or
(7)
the Member requests termination of Coverage.
Continuation of Coverage for Dependent Children attaining the Limiting Age is not available if:
(1)
the Dependent Child has other creditable coverage in force; or
(2)
the Dependent Child reached the Limiting Age prior to January 1, 2010.
You are required to notify the Employer within 30 days in case of divorce or legal separation
or when a Dependent Child ceases to be eligible.
Continuation During Periods of Employer-Certified Leave of Absence or Layoff. A person may remain
eligible for a limited time if Active, full-time work ceases due to leave of absence. This continuance will end as
follows:
For leave of absence or layoff only: the date the Employer ends the continuation.
While continued, coverage will be that which was in force on the last day worked as an Active Employee.
However, if benefits reduce for others in the class, they will also reduce for the continued person.
Continuation During Family and Medical Leave. Regardless of the established leave policies mentioned above,
this Plan shall at all times comply with the Family and Medical Leave Act of 1993 as promulgated in regulations
issued by the Department of Labor.
During any leave taken under the Family and Medical Leave Act, the Employer will maintain coverage under this
Plan on the same conditions as coverage would have been provided if the covered Employee had been
continuously employed during the entire leave period.
Contributions During Family Medical Leave (FMLA). An Employee on FMLA leave is entitled to continue
health care coverage under this Plan on the same basis as an Employee. An Employee on FMLA leave is also
entitled to make coverage changes as allowed during continuous employment, such as adding coverage for a
new Child and as otherwise provided in this Plan. If the health coverage is terminated during the FMLA leave or
the Employee chooses not to continue coverage during the FMLA leave, when the Employee returns to work,
the Employee is entitled to be reinstated at the same benefit levels and terms as before the FMLA leave and no
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11
qualification requirements (i.e. Waiting Periods, Pre-Existing Condition exclusions) may be imposed on the
benefit level and benefit terms.
Continuation due to disability: Disability of the employee may extend the 12 month period of continuation of
coverage for up to an additional 17 months for a qualifying event that is termination of employment or reduction
in hours. To qualify for the additional 17 months of continuation coverage, the employee must:
(a)
have a ruling from the Social Security Administration that he or she became disabled prior to or
within the first 60 days from the start on the continuation of coverage period; and
(b)
send the Plan a copy of the Social Security ruling letter within 60 days of receipt and prior to the
expiration of the initial 12 month continuation of coverage period.
While continued, coverage will be that which was in force on the last day worked as an Active Employee.
However, if benefits reduce for others in the class, they will also reduce for the continued person.
Contributions During Total Disability. To continue coverage while on Total Disability, Employees must make
contributions on behalf of themselves and their covered Dependents. Contact
the Employer for details.
Rehiring a Terminated Employee. A terminated Employee who is rehired will be treated as a new hire and be
required to satisfy all Eligibility and Enrollment requirements.
Employees on Military Leave. Employees going into or returning from military service may elect to continue
Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act (USERRA)
under the following circumstances. These rights apply only to Employees and their Dependents covered under
the Plan immediately before leaving for military service.
(1)
The maximum period of coverage of a person and the person's Dependents under such an election
shall be the lesser of:
(a)
The 24 month period beginning on the date on which the person's absence begins; or
(b)
The day after the date on which the person was required to apply for or return to a position
of employment and fails to do so.
(2)
A person who elects to continue health plan coverage must pay up to 102% of the full contribution
under the Plan, except a person on active duty for 30 days or less cannot be required to pay more
than the Employee's share, if any, for the coverage.
(3)
An exclusion or Waiting Period may not be imposed in connection with the reinstatement of
coverage upon reemployment if one would not have been imposed had coverage not been
terminated because of service. However, an exclusion or Waiting Period may be imposed for
coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been
incurred in, or aggravated during, the performance of uniformed service.
If You wish to elect this coverage or obtain more detailed information, contact the Plan Administrator Madonna
Rehabilitation Hospital. You may also have continuation rights under COBRA. In general, You must meet the
same requirements for electing USERRA coverage as are required under COBRA continuation coverage
requirements. Coverage elected under these circumstances is concurrent not cumulative. The Employee may
elect USERRA continuation coverage for the Employee and their Dependents. Only the Employee has election
rights. Dependents do not have any independent right to elect USERRA health plan continuation.
Rev 6.27.14
12
OPEN ENROLLMENT PERIOD
OPEN ENROLLMENT
During the annual open enrollment period, Employees and their Dependents who are Late Enrollees will be able
to enroll in the Plan.
Benefit choices for Late Enrollees made during the open enrollment period will become effective July 1.
Plan Participants will receive detailed information regarding open enrollment from their Employer.
Rev 6.27.14
13
SCHEDULE OF BENEFITS
Verification of Eligibility: 1-800-288-3343
Call this number to verify eligibility for Plan benefits before the charge is incurred.
MEDICAL BENEFITS
All benefits described in this Schedule are subject to the exclusions and limitations described more fully herein
including, but not limited to, the Plan Administrator's determination that: care and treatment is Medically
Necessary; that charges are within the Maximum Allowable amount; that services, supplies and care are not
Experimental and/or Investigational. The meanings of these capitalized terms are in the Defined Terms section
of this document.
Please see the Utilization Management section in this booklet for additional details. Certain services
must be Preauthorized or reimbursement from the Plan may be reduced.
The Plan utilizes a Claims Administrator to administer many of the benefits described in this document. The
Claims Administrator is:
Coventry Health and Life Insurance Company
15950 West Dodge Road
Omaha, NE 68118
(800) 288-3343
www.chcnebraska.com
The Plan is a plan which contains a Preferred Provider Organization (PPO).
This Plan has entered into an agreement with certain Hospitals, Physicians and other health care Providers,
which are called Network Providers. Because these Network Providers have agreed to charge reduced fees to
persons covered under the Plan, the Plan can afford to reimburse a higher percentage of their fees.
Therefore, when a Covered Person uses a Network Provider, that Covered Person will receive a higher
payment from the Plan than when a Non-Network Provider is used. It is the Covered Person's choice as to
which Provider to use.
Under the following circumstances, the higher In-Network payment will be made for certain Non-Network
services:
·
If a Covered Person has no choice of Network Providers in the specialty that the Covered Person is
seeking within the PPO service area.
·
If a Covered Person is out of the PPO service area and has a Medical Emergency requiring immediate
care.
·
If a Covered Person receives Physician or anesthesia services by a Non-Network Provider at an
In-Network facility.
If You utilize Non-Network Providers, this Plan provides benefits only for Covered Charges that are equal to or
less than the Allowable Charge. YOU ARE RESPONSIBLE FOR ANY AMOUNTS OVER THE ALLOWABLE
CHARGE.
Additional information about this option, as well as a list of Network Providers, will be given to Plan Participants,
at no cost, and updated as needed. The most current listing of Network Providers is available online at
www.chcnebraska.com.
Please note: Coinsurance and other payments to Network Providers may be based on an approved rate
schedule, but a Network Provider's compensation ultimately is determined on the basis of each particular
Network Provider’s agreement with the Claims Administrator and may be an amount less than the approved
rate. The Claims Administrator may receive a retrospective discount or rebate from a Network Provider or
vendor related to the volume of services, supplies, equipment or pharmaceuticals purchased by persons
Rev 6.27.14
14
enrolled in health care plans offered or administered by the Claims Administrator and its affiliates. Neither the
Plan nor the Covered Person shall share in such retrospective volume-based discounts or rebates, except as
provided for under the context of the fees the Plan pays to the Claims Administrator for its services.
Deductibles/Copayments payable by Plan Participants
Deductibles/Copayments are dollar amounts that the Covered Person must pay before the Plan pays.
A Deductible is an amount of money that is paid once a Benefit Year per Covered Person. Typically, there is
one Deductible amount per Plan and it must be paid before any money is paid by the Plan for any Covered
Charges. Each January 1st, a new Deductible amount is required.
A Copayment is the amount of money that is paid each time a particular service is used. Typically, there may be
Copayments on some services and other services will not have any Copayments.
Rev 6.27.14
15
PPO
Schedule of Benefits
Madonna Rehabilitation Hospital
Low Option Basic Plan
(No Wellness Health Screen Completed)
Member Responsibility
In-Network
Out-of-Network**
“Benefit Year” means a Calendar Year, which is the period of twelve (12) consecutive months commencing on January
1st and continuing through December 31st of that year.
Benefits
Deductible (Per Benefit Year)
· Individual Deductible
· Family Deductible
$1,900
$3,800
Coinsurance at Madonna Rehabilitation Hospital
(excluding Physician services)
Deductible waived,
10%
Coinsurance Other Providers
40%
20%
Out-of-Pocket Maximum (Per Benefit Year)
The Out-of-Pocket Maximum includes Deductible, Coinsurance, and
Copayments except for Rx Copayments.
$6,900
$3,500
· Individual
$13,800
$7,000
· Family
Maximum Lifetime Benefit
(while covered under the Health Plan)
Unlimited
NOTE: In-Network and Out-of-Network Deductible and Out-of-Pocket Maximum are combined. Visit
limits are combined for both In-Network and Out-of-Network.
Covered Services
In-Network
Out-of-Network
Preventive Services (Adult and Child)
For services billed as routine including physicals, laboratory, well-baby
care, well-child care, well-woman care, mammograms, prostate cancer
$0 Copayment
Deductible then
screening, colon cancer screening, diabetes screening, certain
Coinsurance
osteoporosis screenings, behavioral health screening, lactation support
and counseling, tobacco use screening and interventions, routine eye
exams and refractions, flu shots, and adult and childhood
immunizations.
Note: The above is not a complete listing of covered preventive
services. Additional preventive care shall be provided as required by
applicable law, except for contraceptive coverage. For a current listing
of preventive care services please access the following government
website:
· www.HealthCare.gov/center/regulations/prevention.html and
· http://www.cdc.gov/vaccines/acip/index.html
Physician Office Services
Primary Care Physician (PCP) Office Visit*
including:
· Convenient Care Clinic
$40 Copayment
$40 Copayment, then
Coinsurance after
Deductible
Specialist Physician Office Visit *
$50 Copayment
$50 Copayment, then
Coinsurance after
Deductible
Rev 6.27.14
16
In-Network
Out-of-Network
Covered Services
Surgery performed in Physician’s office
Deductible then
Coinsurance
Deductible then
Coinsurance
X-ray and Laboratory Services
Deductible then
Coinsurance
Deductible then
Coinsurance
Allergy Injections
Deductible then
Coinsurance
Deductible then
Coinsurance
Allergy Testing
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
$40 Copayment
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Same benefit as
In-Network
Deductible then
Coinsurance
Same benefit as
In-Network
Inpatient Hospital care, including semi-private room & board, acute
Inpatient care, acute rehabilitation care, intensive / coronary care,
maternity care, x-ray, laboratory, professional services and other facility
and ancillary charges
Therapies-Inpatient and Outpatient
Speech Therapy
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Occupational Therapy
Deductible then
Coinsurance
Deductible then
Coinsurance
Physical Therapy
Deductible then
Coinsurance
Deductible then
Coinsurance
Cardiac/Pulmonary Rehabilitation
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Maternity Services
Includes prenatal, delivery and postnatal Physician services and office
visits. For Hospital charges related to delivery or other Inpatient
Hospital care, refer to Member Responsibility for “Inpatient Hospital.”
Urgent Care Facility
· Services performed at an Urgent Care Facility
·
Professional services
Outpatient Facility
· Services performed at a Hospital or Free-Standing Facility
· Professional services
Emergency Services
Hospital Emergency Room
Ambulance
Inpatient Hospital Services
Chiropractic Care
Coverage for up to 50 visits per Benefit Year
Rev 6.27.14
17
In-Network
Out-of-Network
Covered Services
Other Services
Nursing Facility/Nursing Care
· Coverage up to 60 days per Benefit Year
Home Health Care
· Coverage up to 100 visits per Benefit Year
Hospice Care
· Inpatient
· Outpatient
· Bereavement
Durable Medical Equipment (DME)
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Not Covered
Prosthetic Devices
Transitional Rehabilitation/Habilitation Program
Transplant Services
Must be performed at a Coventry Transplant Network Facility approved
by Us
Outpatient Prescription Drugs-Administered by MedTrak
Retail (30-day supply)
· Generic Drugs
· Preferred Formulary Brand Drugs
· Non-Formulary Brand Drugs
$15 Copayment
$55 Copayment
$75 Copayment
Mail-Order or Performance 90 Retail Pharmacy (90-day supply)
· Generic Drugs
Specialty Drugs (30-day supply)
NOTE: All Specialty Drugs require Prior Authorization by the PBM. If
Prior Authorization is granted, the Specialty Drug must be obtained
through the PBM’s Specialty Drug Program in order for Benefits to be
paid.
$35 Copayment
$110 Copayment
$150 Copayment
$100 Copayment
Mental Disorder, Substance-Related Disorder Services and/or
Biologically Based Mental Illness Coverage
· Office Visit Services
$50 Copayment
$50 Copayment, then
Coinsurance after
Deductible
Same as Medical
Benefits
Same as Medical
Benefits
Deductible then
Coinsurance
Same Benefit as
In-Network
· All Other Services
Jaw Joint Disorder Treatment
* Primary Care Physicians (“PCP”) generally include those Physicians who practice in the specialties of Family
Practice, Internal Medicine, General Practice, OB/GYN or Pediatrics. If You are not sure if a Physician is a PCP,
Rev 6.27.14
18
please contact the Customer Service Number on the back of Your ID card. If You receive a service from a PCP,
Your PCP Member Responsibility will apply. If You receive this service from a Specialist, Your Specialist benefit
will apply.
**When receiving services from Non-Participating Providers, payment for Covered Services is limited to the lesser of
the billed charge, or the Out-of-Network Allowable Amount, less applicable Copayment, Coinsurance and/or
Deductibles. Please refer to the Summary Plan Description for additional details.
Only services and treatments that meet the Plan’s “Medical Necessity” criteria and are listed in the Plan as a
Covered Service are covered. Services and treatments listed under the Plan’s Exclusions and Limitations Section
are not covered. Even though Your Provider may recommend a procedure, service or prescription, they may not
always meet the Plan’s Medical Necessity criteria. You should refer to the Summary Plan Description for further
details on “Medical Necessity,” “Covered Services” and “Exclusions and Limitations.”
You must insure that any required Prior Authorization has been obtained. You may incur financial penalty or
reduction in benefits of 20% of the Out-of-Network benefit if You do not receive Prior Authorization for a planned
Hospitalization or elective surgery. Before You receive certain services, supplies or procedures, You or Your
Physician must request any necessary Prior Authorization. If You choose to have requested services performed
even though the Plan is unable to certify the Medical Necessity of the services, You are responsible for the
charges.
If You are unaware if a service requires Prior Authorization, contact Coventry at the Customer Service phone
number listed on the back of Your ID card prior to receiving care.
Rev 6.27.14
19
PPO
Low Option Enhanced Plan
(Wellness Health Screen Completed)
In-Network
Out-of-Network**
Benefits
$1,500
$3,000
Deductible waived,
10%
40%
20%
$6,900
$3,200
· Individual
$13,800
$6,400
· Family
Unlimited
Covered Services
In-Network
Out-of-Network
$0 Copayment
Deductible then
Coinsurance
immunizations.
website:
including:
$35 Copayment
$35 Copayment, then
Coinsurance after
Deductible
$45 Copayment
$45 Copayment, then
Coinsurance after
Deductible
Rev 6.27.14
20
In-Network
Out-of-Network
Covered Services
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Allergy Injections
Deductible then
Coinsurance
Deductible then
Coinsurance
Allergy Testing
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
$35 Copayment
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Same benefit as
In-Network
Deductible then
Coinsurance
Same benefit as
In-Network
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Physical Therapy
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Maternity Services
Includes prenatal, delivery and postnatal Physician services and office
visits. For Hospital charges related to delivery or other Inpatient
Hospital care, refer to Member Responsibility for “Inpatient Hospital.”
·
Outpatient Facility
Emergency Services
Ambulance
Speech Therapy
Chiropractic Care
Rev 6.27.14
21
In-Network
Out-of-Network
Covered Services
Other Services
Deductible then
Coinsurance
Deductible then
Coinsurance
Home Health Care
Deductible then
Coinsurance
Deductible then
Coinsurance
Hospice Care
· Inpatient
· Outpatient
· Bereavement
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Not Covered
Prosthetic Devices
Transplant Services
by Us
· Generic Drugs
$15 Copayment
$55 Copayment
$75 Copayment
· Generic Drugs
$35 Copayment
$110 Copayment
$150 Copayment
paid.
·
· Office Visit Services
· All Other Services
·
$100 Copayment
$45 Copayment
$45 Copayment, then
Coinsurance after
Deductible
Same as Medical
Benefits
Deductible then
Coinsurance
Same as Medical
Benefits
Same Benefit as
In-Network
will apply.
Rev 6.27.14
22
charges.
Rev 6.27.14
23
PPO
High Option Enhanced Plan
(Wellness Health Screen Completed)
In-Network
Out-of-Network**
Benefits
$900
$1,800
Deductible waived,
10%
40%
20%
$5,400
$2,500
· Individual
$10,800
$5,000
· Family
Unlimited
Covered Services
In-Network
Out-of-Network
$0 Copayment
Deductible then
Coinsurance
immunizations.
website:
including:
$35 Copayment
$35 Copayment, then
Coinsurance after
Deductible
$45 Copayment
$45 Copayment, then
Coinsurance after
Deductible
Rev 6.27.14
24
In-Network
Out-of-Network
Covered Services
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Allergy Injections
Deductible then
Coinsurance
Deductible then
Coinsurance
Allergy Testing
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
$35 Copayment
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Same benefit as
In-Network
Deductible then
Coinsurance
Same benefit as
In-Network
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Maternity Services
·
Outpatient Facility
Emergency Services
Ambulance
Speech Therapy
Physical Therapy
Rev 6.27.14
25
In-Network
Out-of-Network
Covered Services
Chiropractic Care
Other Services
Home Health Care
Hospice Care
· Inpatient
· Outpatient
Bereavement Benefits
Prosthetic Devices
Transplant Services
by Us
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Deductible then
Coinsurance
Not Covered
$15 Copayment
$55 Copayment
$75 Copayment
· Generic Drugs
· Generic Drugs
$35 Copayment
$110 Copayment
$150 Copayment
paid.
$100 Copayment
·
Office Visit Services
·
All Other Services
Rev 6.27.14
26
$45 Copayment
$45 Copayment, then
Coinsurance after
Deductible
Same as Medical
Benefits
Same as Medical
Benefits
Deductible then
Coinsurance
Same Benefit as
In-Network
will apply.
charges.
Rev 6.27.14
27
MEDICAL BENEFITS
Medical Benefits apply when Covered Charges are incurred by a Covered Person for care of an Injury or
Sickness and while the person is covered for these benefits under the Plan. Certain services may require
Preauthorization from the Claims Administrator. Please refer to the Preauthorization Exhibit for a listing of these
services.
DEDUCTIBLE
Deductible Amount. This is an amount of Covered Charges for which no benefits will be paid. Before benefits
can be paid in a Calendar Year a Covered Person must meet the Deductible shown in the Schedule of Benefits.
Deductible Three Month Carryover. Covered Charges incurred in, and applied toward the Deductible in
October, November and December will be applied toward the Deductible in the next Benefit Year.
Family Unit Limit. When the maximum amount shown in the Schedule of Benefits has been incurred by two or
more members of a Family Unit toward their Calendar Year Deductibles, the Deductibles of all members of that
Family Unit will be considered satisfied for that year.
COPAYMENT
A Copayment is the amount of money that is paid each time a particular Covered service is used. Typically,
there may be Copayments on some services and other services will not have any Copayments.
BENEFIT PAYMENT
Each Benefit Year, benefits will be paid for the Covered Charges of a Covered Person that are in excess of the
Deductible and any Copayments. Payment will be made at the rate shown under reimbursement rate in the
Schedule of Benefits. No benefits will be paid in excess of the Maximum Benefit Amount or any listed limit of the
Plan.
OUT-OF-POCKET MAXIMUM
Covered Charges are payable at the percentages shown each Benefit Year until the out-of-pocket maximum
shown in the Schedule of Benefits is reached. Then, Covered Charges incurred by a Covered Person will be
payable at 100% (except for the charges excluded) for the rest of the Benefit Year.
When a Family Unit reaches the out-of-pocket maximum, Covered Charges for that Family Unit will be payable
at 100% of the Allowable Charge without any Coinsurance for the remainder of the Benefit Year. The amount of
the Out-of-Pocket Maximum is listed in the Schedule of Benefits. Even if You reach the Out-of-Pocket
Maximum, a Non-Network Provider may require You to pay amounts in excess of the Allowable Charge.
Amounts above the Allowable Charge which You pay to Non-Network Providers do not count toward Your Outof-Pocket Maximum.
The following expenses do not apply toward the Out-of-Pocket Maximum: utilization review penalties; charges
in excess of the Plan limitations; non-Covered Services; and charges in excess of the Allowable Charge .
MAXIMUM BENEFIT AMOUNT
Any Maximum Benefit Amount is shown in the Schedule of Benefits, when applicable. It is the total amount of
benefits that will be paid for certain services under the Plan for all Covered Charges incurred by a Covered
Person.
The Maximum Benefit Amount for Essential Health Benefits will not apply in Plan Years beginning on or after
January 1, 2014.
Rev 6.27.14
28
COVERED CHARGES
Covered Charges are the Maximum Allowable Charges that are incurred for the following items of service and
supply. These charges are subject to the benefit limits, exclusions and other provisions of this Plan. A charge is
incurred on the date that the service or supply is performed or furnished.
(1)
Hospital Care. The medical services and supplies furnished by a Hospital or Ambulatory Surgical
Center or a Birthing Center. Covered Charges for room and board will be payable as shown in the
Schedule of Benefits. After 23 observation hours, a confinement will be considered an Inpatient
confinement.
Room charges made by a Hospital having only private rooms will be paid at 80% of the average
private room rate.
Specialized care units. Such as intensive care or cardiac care units.
(2)
Coverage of Pregnancy. Charges for the care and treatment of Pregnancy are covered the same
as any other Sickness for a covered Employee or covered Dependent.
Group health plans generally may not, under Federal law, restrict benefits for any Hospital length of
stay in connection with childbirth for the mother or newborn Child to less than 48 hours following a
vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally
does not prohibit the mother's or newborn's attending Provider, after consulting with the mother,
from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In
any case, plans and issuers may not, under Federal law, require that a Provider obtain authorization
from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
(3)
Skilled Nursing Facility Care. The room and board and nursing care furnished by a Skilled
Nursing Facility will be payable if and when Skilled Nursing Care is determined to be Medically
Necessary by the Claims Administrator. Custodial care, respite care, rest cures, domiciliary, or
convalescent care are not covered. Preauthorization is required from the Claims Administrator.
Covered charges for a Covered Person's care in these facilities are payable as described in the
Schedule of Benefits.
(4)
Physician Care. The professional services of a Physician for surgical or medical services.
(5)
Home Health Care Services and Supplies. Charges for home health care services and supplies
are covered only for care and treatment of an Injury or Sickness. The diagnosis, care and treatment
must be certified by the attending Physician and be contained in a Home Health Care Plan.
A home health care visit will be considered a periodic visit by either a nurse or therapist, as the case
may be.
Benefit payment for nursing, home health and therapy services is subject to the Home Health Care
limit shown in the Schedule of Benefits.
(6)
Hospice Care Services and Supplies. Charges for hospice care services and supplies are
covered only when the attending Physician has diagnosed the Covered Person's condition as being
terminal, determined that the person is not expected to live more than six months and placed the
person under a Hospice Care Plan. Inpatient hospice respite care is covered for up to five (5) days
in a six (6) month period.
Covered charges for Hospice Care are payable as described in the Schedule of Benefits.
(7)
Other Medical Services and Supplies. These services and supplies not otherwise included in the
items above are covered as follows:
(a)
Rev 6.27.14
Local Medically Necessary professional land or air ambulance service. A charge for this
item will be a Covered Charge only if the service is to the nearest Hospital or Skilled
29
Nursing Facility where necessary treatment can be provided unless the Claims
Administrator finds a longer trip was Medically Necessary.
(b)
Anesthetic; oxygen; blood and blood derivatives that are not donated or replaced;
intravenous injections and solutions. Administration of these items is included.
Hospital services and general anesthesia for procedures are covered when determined to
be Medically Necessary for a Member who is under the age of eight (8), is severely
disabled, or has a medical condition, and requires admission to a Hospital or Outpatient
surgery facility and general anesthesia for dental care treatment. Preauthorization of
Hospitalization and anesthesia should not be construed as Preauthorization and payment of
dental care incident to the Hospitalization and anesthesia benefits.
(c)
Autism spectrum disorder, including overage for the screening, diagnosis, and treatment
of autism spectrum disorder in an individual under twenty-one (21) years of age is covered
in accordance with the requirements of Neb. Rev. Stat. § 44-7,104 effective July 1, 2015.
(d)
Blood. When medically necessary and is not replaced by or for the Covered Person,
including;
· Blood and plasma processing fees.
· Costs associated with drawing, preparation, and storage of Member’s blood, blood
plasma, or blood derivatives for use by the Member. Charges incurred in connection
with the treatment of routine bleeding episodes associated with hemophilia and other
congenital bleeding disorders. Covered charges include the purchase of blood products
and blood infusion equipment required for home treatment of routine bleeding episodes
associated with hemophilia and other congenital bleeding disorders when the home
treatment program is under the supervision of the state-approved hemophilia treatment
center.
(e)
Breast pumps are covered as follows:
1.
Purchase of a manual breast pump or a standard dual electric breast pump (E0603)
is covered under Preventive Care Services for all women who choose to breast
feed. An electric breast pump must be purchased from a Durable Medical
Equipment Provider and the Covered Person must have a prescription from her
treating Physician. Coverage includes lactation support and counseling by a
trained Provider during Pregnancy and/or in the postpartum period.
2.
Supplies necessary for the use of a breast pump, such as tubing (A4281) and an
adapter (A4282) are covered, as needed, at no cost to You when purchased from
an In-Network Durable Medical Equipment Provider.
(f)
Breast reductions are covered if determined to be Medically Necessary.
(g)
Cardiac rehabilitation is covered according to the coverage guidelines used by the Claims
Administrator. Coverage includes Phase I and Phase II. Phase III cardiac rehabilitation
services are not covered.
(h)
Radiation or chemotherapy and treatment with radioactive substances. The materials and
services of technicians are included. Coverage is limited to a phase III clinical trials and
must be approved by the National Cancer Institute and the Claims Administrator.
(i)
Clinical Trials. Coverage is limited to the routine patient cost of a qualified individual, and
as defined under the Patient Protection and Affordable Care Act of 2010.
A “qualified individual” is defined under the law as an individual who is enrolled or
participating in a health plan or coverage and who is eligible to participate in an approved
clinical trial according to the trial protocol with respect to treatment of cancer or another lifethreatening disease or condition. To be a qualified individual, there is an additional
requirement that a determination be made that the individual’s participation in the approved
clinical trial is appropriate to treat the disease or condition. That determination can be made
Rev 6.27.14
30
based on the referring health care professional’s conclusion or based on the provision of
medical and scientific information by the individual.
The term “routine patient costs” is also defined for purposes of these new federal
requirements. With some important exceptions, routine patient costs generally include all
items and services consistent with the coverage provided under the plan (or coverage) for a
qualified individual (viz. for treatment of cancer or another life threatening disease or
condition) who is not enrolled in a clinical trial. However, costs associated with the following
are excluded from that definition, and the plan or issuer is not required under federal law to
pay for the following:
1.
2.
3.
The cost of the investigational item, device or service.
The cost of items and services provided solely to satisfy data collection and
analysis needs and that are not used in direct clinical management.
The cost for a service that is clearly inconsistent with widely accepted and
established standards of care for a particular diagnosis.
The term “approved clinical trial” is defined in the statute as a phase I, phase II, phase III, or
phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment
of cancer or other life-threatening disease or condition and is one of the following:
1.
2.
3.
A federally funded or approved trial.
A clinical trial conducted under an FDA investigational new drug application.
A drug trial that is exempt from the requirement of an FDA investigational new drug
application.
Limitations and Exclusions:
1.
2.
3.
4.
5.
The decision to enroll a Covered Person into a clinical trial will be made by the
Covered Person and his/her Physician. Preauthorization is required by the Plan;
Any non-health care services that a Covered Person may require in conjunction
with the clinical trial (e.g. transportation, lodging, Custodial Care) are excluded;
Administrative costs (data analysis and collection, record keeping, etc.) associated
with managing the clinical trial are excluded;
Investigational drug(s) or devices are excluded; and
Non-Investigational treatment (i.e. cosmetic surgery, Custodial Care) are excluded.
Definitions:
·
·
·
·
Rev 6.27.14
Phase I Clinical Trials: Uncontrolled studies that involve initial introduction of an
Investigational new drug into humans. These studies are designed to determine
the metabolic and pharmacological actions of the drug, dose-related side effects,
and possible information on effectiveness.
Phase II Clinical Trials: Early studies meant to obtain preliminary data on the
effectiveness of the drug(s) in treatment for a specific disease or condition. They
are conducted in a relatively small number of patients, usually less than a few
hundred. Some are randomized, controlled, or comparative trials. Most are “singlearm” (i.e., no comparative group or control group).
Phase III Clinical Trials: Expanded, randomized, controlled or comparative studies
performed after preliminary evidence suggesting effectiveness of the Investigational
drug(s) has been obtained in Phase II trials. These studies usually include several
hundred to one thousand people or more.
Phase IV Clinical Trials: Final Phase study conducted after a new treatment or
procedure has been marketed and is in wide use. Information is collected
regarding the safety, efficacy and long-term effects of the new treatment or
procedure.
(j)
Cochlear Implants: Covered if determined to be Medically Necessary. Requires prior
authorization.
(k)
Initial contact lenses and/or glasses required following cataract surgery.
31
(l)
Diabetes treatment and counseling is covered for in-person outpatient self-management
training and education, including medical nutritional therapy required for the treatment of
insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin
using diabetes. This coverage is provided if: (i) prescribed by a Provider legally authorized
to prescribe such services under law and (ii) provided by a Provider who is a certified,
registered, or licensed health care professional.
Diabetes supplies including insulin pumps and insulin pump supplies for the treatment of
insulin dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin
using diabetes are provided if prescribed by a Provider legally authorized to prescribe such
items under law.
The Plan will provide coverage for diabetes in accordance with Neb. Rev. Stat. § 44-790.
(m)
Peritoneal Dialysis and Hemodialysis.
(n)
Rental of durable medical or surgical equipment if deemed Medically Necessary. These
items may be bought rather than rented, with the cost not to exceed the fair market value of
the equipment at the time of purchase, but only if agreed to in advance by the Claims
Administrator.
Benefit includes ostomy supplies, oxygen and respiratory equipment.
Equipment rental for Negative Pressure Wound Therapy is covered under the durable
medical equipment benefit and does not apply to the benefit maximum.
Orthotics are covered under this benefit. Covered orthotic devices must, (i) be a device
added to the body to stabilize or immobilize a body part, prevent deformity or assist with
function; and (ii) be semi-rigid and correct a diagnosed musculoskeletal malalignment of a
weakened or diseased body part; or (iii) be rigid or semi-rigid and stop or limit motion of a
weak or diseased body part. Foot orthotics are not covered.
Benefit payment for durable medical equipment and medical supplies is provided as stated
in the Schedule of Benefits.
(o)
Family health planning. Contraceptives are not covered under the Plan.
(p)
Infertility is the inability to conceive after one year of intercourse without contraception.
Diagnostic services to establish and identify the cause of infertility are covered.
(q)
Medically Necessary services for care and treatment of jaw joint conditions, including
Temporomandibular Joint syndrome.
Coverage for diagnosis and treatment of Temporomandibular Joint Disorder (TMD) and
Craniomandibular Disorder (CMD) including:
·
·
·
·
·
·
Rev 6.27.14
Health history (medical and/or dental) pertinent to symptoms
Clinical examination related to the presenting symptoms
Imaging procedures, provided that radiographs must be diagnostic for
Temporomandibular Disorders (TMD) and/or Craniomandibular Disorder(s) (CMD)
Conventional diagnostic and therapeutic injections
Physical medicine and physiotherapy, which shall include:
· Ultrasound
· Diathermy
· High-Voltage Galvanic Stimulation
· Transcutaneous Nerve Stimulation
Surgery on the Temporomandibular Joint which includes, but is not limited to,
arthrotomy and diagnostic arthroscopy. All other surgeries are excluded.
32
(r)
Laboratory tests are covered when obtained at the office of a Physician or through a
laboratory.
(s)
Maternity including obstetrical care, prenatal, delivery and postpartum care, in an Inpatient
setting and/or a home visit or visits in accordance with the medical criteria prepared by the
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists is covered. A nurse midwife may provide obstetrical care. Obstetrical care
does not include services for childbirth performed in a home setting.
(t)
A Medical Emergency is a sudden onset of a medical condition that manifests itself by
symptoms of sufficient severity, including severe pain, that the absence of immediate
medical attention could reasonably be expected by a Prudent Layperson to result in (i)
serious jeopardy to the mental or physical health of the Member; (ii) danger of serious
impairment of the Member’s bodily functions; (iii) serious dysfunction of any of the
Member’s bodily organs; or (iv) in the case of a pregnant woman, serious jeopardy to the
health of the fetus. Screening and stabilization services provided in a Hospital emergency
room for a Medical Emergency may be received from either Participating or NonParticipating Providers.
A Prudent Layperson is someone without medical training who draws on his or her practical
experience when making a decision regarding whether emergency medical treatment is
needed. A Prudent Layperson will be considered to have acted “reasonably” if other
similarly situated Laypersons would have believed, on the basis of observation of the
medical symptoms at hand, that emergency medical treatment was necessary.
The Claims Administrator reviews all information and documentation with respect to these
claims in accordance with established medical criteria and guidelines. If this review results
in the determination that the Member did not experience a Medical Emergency, the Member
may be responsible for the entire bill. Claims resulting from a Medical Emergency are
eligible for payment at the In-Network level of benefits. If a claim is denied or paid at the
Out-of-Network benefit level when You believe a Medical Emergency existed, contact the
Customer Service Department. The Claims Administrator reviews all information and
documentation with respect to these claims in accordance with established medical criteria
and guidelines. If this review results in the determination that the Member did not
experience a Medical Emergency, the Member may be responsible for the entire bill. If a
claim is denied when You believe a Medical Emergency existed, contact the Customer
Service Department.
(u)
Treatment of Mental Disorders and Substance Abuse. Covered Charges for care,
supplies and treatment of Mental Disorders and Substance Abuse will be covered.
(v)
Injury to or care of mouth, teeth and gums. Charges for Injury to or care of the mouth,
teeth, gums and alveolar processes will be Covered Charges under Medical Benefits only if
that care is for the following oral surgical procedures:
Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth.
Emergency repair due to Injury to sound natural teeth, when such repair occurs within sixty
(60) days of the Injury. Emergency stabilization may consist of: control of hemorrhage,
treatment of fractures, maintenance of airway, control of pain, and return to basic function.
No additional coverage will be allowed until a comprehensive treatment plan is provided.
Treatment performed that is not deemed “emergency” will not be covered. The time limit for
treatment to be performed shall not exceed six (6) months, unless written approval is
received from the Claims Administrator. In certain situations, two or more dental treatment
alternatives may produce comparable results. When alternative options may be utilized, the
least costly method will be eligible for coverage. If, after review in accordance with
established medical and dental guidelines, the services received were not Medical
Necessary, coverage under the Plan may be denied. Coverage is not provided for injuries
that occur while in the act of chewing or biting, or for cosmetic treatment or surgery
performed mainly to improve appearance.
Rev 6.27.14
33
Surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor and
roof of the mouth.
Excision of benign bony growths of the jaw and hard palate.
External incision and drainage of cellulitis.
Incision of sensory sinuses, salivary glands or ducts.
Excision of partial or completely bony impacted third molars. Partially impacted or soft
tissue removal of third molars is not covered. Anesthesia services rendered in connection
with the covered removal of impacted teeth are also covered if performed by a person
licensed to do so.
No charge will be covered under Medical Benefits for dental and oral surgical procedures
involving orthodontic care of the teeth, periodontal disease and preparing the mouth for the
fitting of or continued use of dentures.
The Plan will provide benefits required for Children who are under 8 years of age or who
are developmentally disabled as required by Neb. Rev. Stat. § 44-798.
(w)
Occupational therapy by a licensed occupational therapist. Therapy must be ordered by a
Physician, result from an Injury or Sickness and improve a body function. Covered Charges
do not include recreational programs, maintenance therapy or supplies used in occupational
therapy.
(x)
Organ transplant limits. Services related to Medically Necessary organ transplants are
covered when approved by the Claims Administrator and performed at a Coventry
Transplant Network Participating facility approved by the Claims Administrator. Charges
otherwise covered under the Plan that are incurred for the care and treatment due to an
organ or tissue (including bone marrow) transplant are subject to these limits:
The transplant must be performed to replace an organ or tissue.
Charges for obtaining donor organs or tissues are Covered Charges under the Plan when
the recipient is a Covered Person. When the donor has medical coverage, his or her plan
will pay first. The benefits under this Plan will be reduced by those payable under the
donor's plan. Donor charges include those for:
(i)
evaluating the organ or tissue;
(ii)
removing the organ or tissue from the donor; and
(iii)
transportation of the organ or tissue from within the United States and Canada to
the place where the transplant is to take place.
Travel for Transplant Services. Travel expenses for Covered Persons and living donors
are covered according to the Plan transplant travel benefit. Details of the transplant travel
benefit will be provided upon request and at any time transplant Services are authorized.
Transplant services rendered by a Provider not in the Coventry Transplant Network.
The Plan uses a transplant Network. Facilities in this Network are contracted to perform
specific transplant services. Transplant services rendered by a Provider not in the Coventry
Transplant Network are not covered. Specifically, even if the transplant services are
rendered by a Network Provider, unless such Network Provider is also a Coventry
Transplant Network Participating Facility, there is no coverage for such services. The Plan
reserves the right to require a Covered Person to obtain services from a contracted
Provider who may be outside of the Network service area if the services are to be covered
by the Plan.
Rev 6.27.14
34
(y)
Orthotic appliances are covered and will accrue toward the Durable Medical Equipment
benefit. Covered orthotic devices must, (i) be a device added to the body to stabilize or
immobilize a body part, prevent deformity or assist with function; and (ii) be semi-rigid and
correct a diagnosed musculoskeletal malalignment of a weakened or diseased body part; or
(iii) be rigid or semi-rigid and stop or limit motion of a weak or diseased body part. Foot
orthotics are not covered.
(z)
Physical therapy by a licensed physical therapist. The therapy must be in accord with a
Physician's exact orders as to type, frequency and duration and for conditions which are
subject to significant improvement through short-term therapy.
(aa)
Routine Preventive Care Services. Covered Charges under Medical Benefits are payable
for routine preventive care as described in the Schedule of Benefits. Routine preventive
care is care by a Physician that is not for an Injury or Sickness. Additional preventive care
shall be provided as required by applicable law. A current listing of Preventive Care
Services can be accessed at the Claims Administrators website or at
http://www.healthcare.gov/law/about/provisions/services/lists.html
Preventive Care Services do not include any service or benefit intended to treat an existing
Illness, Injury, or condition.
(ab)
The initial purchase, fitting and repair of fitted prosthetic devices which replace body parts.
(ac)
Reconstructive surgery. Reconstructive surgery or procedures when performed to correct
deformity caused by disease, trauma, or a previous therapeutic process that is considered a
Covered Service. In the event a Member is undergoing a multi-stage reconstruction or
fulfilling a specific waiting period that is medically indicated, then the Provider must submit a
treatment plan for approval.
Pursuant to the Women’s Health and Cancer Rights Act, if a Member elects reconstructive
surgery in connection with a mastectomy, the Plan will provide benefits for:
(i)
(ii)
(iii)
Reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction of the other breast to produce a symmetrical
appearance;
Prostheses limited to two (2) per Benefit Year, and physical complications at all
stages of mastectomy, including lymphedemas;
Such services shall be performed in a manner determined in consultation with the attending
Physician and the patient.
Additionally, the Plan provides benefits in connection with reconstructive breast surgery for:
(i)
(ii)
Rev 6.27.14
Nipple and areola reconstruction.
Medical complications resulting from the rupture of the prostheses/implant, and
appropriate treatment, including removal of the prostheses/implant, upon
Preauthorization.
(ad)
Speech therapy by a licensed speech therapist. Therapy must be ordered by a Physician
and follow either: (i) surgery for correction of a congenital condition of the oral cavity, throat
or nasal complex (other than a frenectomy) of a person; or (ii) an Injury.
(ae)
Spinal Manipulation/Chiropractic services by a health care Provider acting within the
scope of his or her license.
(af)
Sterilization procedures. Surgical sterilization or reversal of sterilization is not covered.
(ag)
Surgical dressings, casts and other devices used in the reduction of fractures and
dislocations.
(ah)
Termination of pregnancy is not covered.
35
(ai)
Coverage for a Transitional Rehabilitation/Habilitation Program will be payable if
services are determined to be Medically Necessary by the Plan Administrator. Covered
Changes for a Covered Person’s care are payable as described in the Schedule of Benefits.
(aj)
Treatment of Morbid Obesity through gastric bypass surgery or other methods recognized
by the National Institutes of Health as effective for the long term reversal of Morbid Obesity
is not covered.
Dietary supplements and programs for weight reduction are not covered. Also not covered
are medical or psychiatric services, office visit and associated charges for the following
procedures: “mini” gastric bypass, gastric balloons, jejunal bypasses, gastroplasty, and
bilopancreatic diversion with duodenal switch (BPD-DS).
Counseling and Prescription Drugs may be covered if Medically Necessary as prescribed
by a Doctor to treat the condition of obesity. Precertification of these services must take
place before You begin treatment. You or Your Physician must contact Coventry to
make sure You qualify for these benefits. Food supplements, nutritional supplements,
vitamins, and educational books and materials would not be covered.
(ak)
Coverage of Well Newborn Nursery/Physician Care.
Charges for Routine Nursery Care. Routine well newborn nursery care is care while the
newborn is Hospital-confined after birth and includes room, board and other normal care for
which a Hospital makes a charge.
This coverage is only provided if the newborn Child is an eligible Dependent and a parent
(1) is a Covered Person who was covered under the Plan at the time of the birth, or (2)
enrolls himself or herself (as well as the newborn Child if required) in accordance with the
Special Enrollment provisions with coverage effective as of the date of birth.
The benefit is limited to Maximum Allowable Charges for nursery care for the newborn Child
while Hospital confined as a result of the Child's birth.
Charges for covered routine nursery care will be applied toward the Plan of the newborn
Child.
Group health plans generally may not, under Federal law, restrict benefits for any Hospital
length of stay in connection with childbirth for the mother or newborn Child to less than 48
hours following a vaginal delivery, or less than 96 hours following a cesarean section.
However, Federal law generally does not prohibit the mother's or newborn's attending
Provider, after consulting with the mother, from discharging the mother or her newborn
earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not,
under Federal law, require that a Provider obtain authorization from the plan or the issuer
for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Charges for Routine Physician Care. The benefit is limited to the Maximum Allowable
Charges made by a Physician for the newborn Child while Hospital confined as a result of
the Child's birth.
Charges for covered routine nursery care including newborn hearing test will be applied
toward the Plan of the newborn Child.
Rev 6.27.14
36
UTILIZATION MANAGEMENT SERVICES
Preauthorization
Please refer to the Employee ID card for the Preauthorization and Customer Service phone numbers.
When a Covered Person receives care from a Network Provider, the Provider is responsible for
following the Utilization Management policies and procedures. If a Covered Person receives care from a
Non-Network Provider, the Covered Person must comply with all of the policies and procedures of the
Utilization Management Program.
When a Covered Person receives care or intends to receive care from a Non-Network Provider, the Covered
Person or family member must call the number on the Plan ID card to receive certification of certain services in
order for those services to be covered under this Plan. This call is recommended to be made at least ten (10)
days in advance of services being rendered to allow enough time for the review process to occur. If there is an
emergency admission to a Medical Care Facility, the Covered Person or someone on the Covered Person’s
behalf such as a family member, the Medical Care Facility or attending Physician, must contact the Claims
Administrator within 48 hours or the first business day after the admission.
General Policies
Under all circumstances, the attending Physician bears the ultimate responsibility for the medical decisions
regarding treatment of Covered Persons.
Covered Persons will incur an additional financial penalty as stated in the Schedule of Benefits when using a
Non-Network Provider if the Covered Person fails to call the Claims Administrator prior to an elective admission
or outpatient surgery or procedure or, in the event of a Medical Emergency, within forty-eight (48) hours after the
date of the Medical Emergency or as soon as reasonably possible.
If the Covered Person does not receive authorization prior to service being rendered, as explained in
this section, the benefit payment will be reduced by 20%. Note if the services are determined not to be
Medically Necessary or otherwise not covered, there will be no benefit payment under the Plan.
The Claims Administrator will determine the number of days of Medical Care Facility confinement or use of other
listed medical services authorized for payment.
If a Covered Person requests services which are not Medically Necessary having full knowledge that such
services were not authorized for payment, then the Covered Person will be responsible for all charges for
services incurred and not authorized.
If a Covered Person is admitted to an Out-of-Network Medical Facility prior to the date authorized by the Claims
Administrator, unless it is an emergency admission, then the Covered Person is responsible for all charges
related to the unauthorized days.
If the Claims Administrator authorizes an admission to an Out-of-Network facility, outpatient surgery or
procedure based on information later determined to be incorrect and the authorized services are not Medically
Necessary or a Covered Service, payment will be denied for charges incurred for those services.
The financial penalty stated in the Schedule of Benefits will be waived in an emergency situation if the Covered
Person’s medical condition prohibits contacting the Claims Administrator within the designated time frame.
A Covered Person has the right to appeal any Utilization Management Program payment decision according to
the Complaint and Appeal Procedures.
OBTAINING PREAUTHORIZATION FOR VISITS TO OUT-OF-NETWORK PROVIDERS
If a Physician feels that there is a need for a Covered Person to be seen by a Physician or other medical
Provider who does not participate in the network and that the services may be eligible for coverage under the
Plan, then the Physician must submit medical information to the Claims Administrator prior to the Covered
Person receiving services. Retroactive requests for consideration of coverage will not be considered.
Covered Services from an Out-of-Network Provider are preauthorized by the Claims Administrator for InRev 6.27.14
37
Network benefits only when the Claims Administrator does not have an In-Network Provider who can provide
the service. The Physician must submit evidence that Participating Plan Providers are unable to perform the
requested services. The Claims Administrator has the right to determine where the services can be provided for
coverage when an In-Network Provider cannot render the service.
A Covered Person has the right to appeal any Utilization Management Program payment decision according to
the Complaint and Appeal Procedures.
UTILIZATION REVIEW
Utilization review is a program designed to help insure that all Covered Persons receive necessary and
appropriate health care while avoiding unnecessary expenses.
The program consists of:
(a)
Preauthorization of the Medical Necessity for the following non-emergency services before
Medical and/or Surgical services are provided:
Refer to the Preauthorization Exhibit at the end of this document.
The attending Physician does not have to obtain Preauthorization from the Plan for prescribing a
maternity length of stay that is 48 hours or less for a vaginal delivery or 96 hours or less for a
cesarean delivery.
Note: The services above must be Preauthorized or reimbursement from the Plan may be
reduced. TO PREAUTHORIZE MEDICAL SERVICES CALL 1-800-471-0240 EXTENSION 7718
AND 1-866-860-7476 TO PREAUTHORIZE MENTAL HEALTH AND SUBSTANCE ABUSE
TREATMENT.
(b)
Retrospective review of the Medical Necessity of the listed services provided on an
emergency basis;
(c)
Concurrent review, based on the admitting diagnosis, of the listed services requested by the
attending Physician; and
(d)
Certification of services and planning for discharge from a Medical Care Facility or
cessation of medical treatment.
The purpose of the program is to determine what charges may be eligible for payment by the Plan. This
program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the
attending Physician or other health care Provider.
If a particular course of treatment or medical service is not certified, it means that either the Plan will not pay for
the charges or the Plan will not consider that course of treatment as appropriate for the maximum
reimbursement under the Plan. The patient is urged to find out why there is a discrepancy between what was
requested and what was certified before incurring charges.
The attending Physician does not have to obtain Preauthorization from the Plan for prescribing a maternity
length of stay that is 48 hours or less for a vaginal delivery or 96 hours or less for a cesarean delivery.
In order to maximize Plan reimbursements, please read the following provisions carefully.
Here's how the program works.
Pre-Service Requests for benefits (requests for benefits that require Preauthorization and are for services that
have not yet been provided).
To make a pre-service request for benefits that will be provided by a Non-Network Provider, the Covered Person
or the Non-Network Provider on the Covered Person’s behalf should contact the Claims Administrator’s
Customer Service and provide the following information:
Rev 6.27.14
38
-
The name of the patient and relationship to the covered Employee,
The name, Social Security number and address of the covered Employee,
The name of the Employer,
The name and telephone number of the attending Physician,
The name of the Medical Care Facility, proposed date of admission, and proposed length of stay,
The diagnosis and/or type of surgery, and
The proposed rendering of listed medical services.
Within five (5) days after the Claims Administrator receives the request, it will notify the Covered Person or NonNetwork Provider of any additional information needed by the Plan to make its determination. The Claims
Administrator will make its decision and notify the Covered Person within 15 days after it receives the request
for benefits.
A Covered Person may make an Urgent Care Request for benefits by contacting the Claims Administrator.
Urgent Care Requests for Benefits (requests for benefits related to services that the health care Provider
believes places the Covered Person’s life, health or ability to regain maximum function in immediate jeopardy, or
for care that the treating Physician determines is urgent, or determines that a delay would subject the Covered
Person to severe pain that could not be adequately managed without the treatment requested).
For Urgent Care Requests, the Claims Administrator will make its decision and notify the Covered Person of that
decision as quickly as possible, taking into account medical exigencies, but in no event later than 72 hours after
it receives the request. In some cases, the Covered Person or the Provider may not have provided the Claims
Administrator with sufficient information to make a decision. If this is the case, the Claims Administrator, within
24 hours after it has received the request, will notify the Covered Person of the additional information that it
needs to make a determination. The Claims Administrator will give the Covered Person a reasonable amount of
time, at least 48 hours, to provide the information. The Claims Administrator will make its decision within the
earlier of: 48 hours after it receives the information, or within 48 hours of the time it gave the Covered Person to
provide the additional information.
Concurrent Care Benefit Determinations
If a Covered Person is undergoing an approved course of treatment, and the Claims Administrator determines
that the number or course of the treatment should be reduced or terminated, the Claims Administrator will inform
the Covered Person of its decision before the end of the approved course of treatment, so that the Covered
Person has sufficient time to appeal the decision to reduce or limit the treatment.
Notifications of Benefit Determinations
If the Claims Administrator denies a request for services in whole or in part, it will provide the Covered Person
with a written explanation of the decision, including the specific reason that the request was denied, the Plan
provision on which the denial was based, a description of any additional information that may be submitted and
why the information is necessary, and a description of the appeal procedures.
Preauthorization
In the event of a non-emergency Hospital admission, the Claims Administrator must be contacted prior to the
scheduled Hospital admission or outpatient surgery or procedure. This call is recommended to be made ten
(10) days prior to the procedure to allow enough time for the review process to occur.
If a Covered Person is being treated by a Network Provider, it is the responsibility of the attending Network
Provider to contact the Claims Administrator.
If the Covered Person is being treated by a Non-Network Provider, it is the Covered Person’s responsibility to
contact the Claims Administrator. If the Claims Administrator is not contacted and the admission is in a NonNetwork Hospital, a financial penalty as stated in the Schedule of Benefits will be deducted from any benefits
payable for a claim for a Medically Necessary Hospitalization or outpatient surgery or procedure. If the
admission is in a Network Hospital, the financial penalty stated in the Schedule of Benefits will be deducted from
any benefits payable to the Provider, or from any benefits payable for the entire claim if the Covered Person did
not present his/her ID card to the Network Hospital. If the Claims Administrator does not receive prior
notification, and review of the claim indicates the Hospitalization or outpatient surgery or procedure is not
Medically Necessary, payment of the claim will be denied.
Rev 6.27.14
39
Admission/Continued Stay Review
In the event of an emergency Hospitalization or outpatient surgery or procedure, the Claims Administrator must
be contacted within 48 hours after the Medical Emergency or as soon as reasonably possible following the
receipt of the services.
If the Covered Person is being treated by a Network Provider, it is the responsibility of the attending Network
Provider to contact the Claims Administrator.
If the Covered Person is being treated by a Non-Network Provider, it is the Covered Person’s responsibility to
contact the Claims Administrator. A friend or relative, the attending Physician, the Hospital, or anyone a
Covered Person designates may contact the Claims Administrator.
If the Claims Administrator was contacted by the Covered Person or the Network Provider and the emergency
admission was not Medically Necessary, the services will be denied.
In the event that a Covered Person wants to stay in the Hospital longer than authorized by the Claims
Administrator, no further benefits will be provided.
CASE MANAGEMENT
Complex Case Management. Coventry Health and Life Insurance Company strives for the early identification
and effective management of selected members for whom intensive management can be expected to improve
the quality of care and reduce overall medical expenses. The Complex Case Management Program offers
special assistance to members with serious and complex, long-term medical needs and promotes quality of care
to reduce the likelihood of extended, more costly health care. The Program identifies serious and complex
medical conditions as ones that are persistent and substantially disabling or life-threatening and that require
treatments and services across a variety of domains of care to ensure the best possible outcome for each
unique member. Long-term medical needs are those that are more chronic than and acute and can be
expected to require extended use of health care resources.
Complex Case management is a collaborative process which assesses, plans, implements, coordinates,
monitors, and evaluates options and services to meet an individual member’s health care needs through
communication and available resources to promote quality, cost-effective outcomes.
Note: Case Management is a voluntary service. There are no reductions of benefits or penalties if the
patient and family choose not to participate.
Each treatment plan is individually tailored to a specific patient and should not be seen as appropriate
or recommended for any other patient, even one with the same diagnosis.
Rev 6.27.14
40
VISION BENEFIT
A summary of the benefits and Your payment responsibility are shown on the Schedule of Benefits included with
this Plan Document and Summary Plan Description.
This section describes coverage for services for routine vision care. This includes refractive eye exams/vision
exams even if they are billed with a medical diagnosis. Coverage for diseases and injuries of the eye is
described in the Medical Benefits section of this Summary Plan Description.
What is covered
Complete refractive eye examinations, to include exams for the wearing of glasses, daily wear or extended wear
hard or soft lenses and specialty lens exams. This benefit is subject to a maximum as stated in the Schedule of
Benefits included with this Plan Document and Summary Plan Description. Your payment responsibility is also
shown in the Schedule of Benefits. Vision care savings are available through EyeMed Vision Care (Plan ID
number 9240177 Select Plan D, Non-Voluntary Enrollment Discounted Exam and a Defined Materials Discount).
Call 866-211-2417 or visit www.eyemedvisioncare.com for more information or to locate a Provider.
Rev 6.27.14
41
PRESCRIPTION DRUG EXPENSE BENEFITS
Prescription Drugs are covered under the Pharmacy Benefit Manager (PBM). The Plan has contracted with a
MedTrak pharmacy network to provide You with covered Drugs. Prescriptions can be purchased at a
discounted price at Participating Network Pharmacies. Members must present their medical identification card
at the time of purchase to receive the discounted price.
MedTrak will automatically charge You the contracted price or the pharmacy’s best price, whichever is less.
You pay for the prescription at the time of purchase, and MedTrak will submit the resulting claim to the Claim
Supervisor.
If You use a pharmacy that is not in the Participating Network, You will pay the usual cost of the prescription and
then You must submit the claim to MedTrak. Forms will be available from the Human Resource Department, or
You may access the form at www.medtrakservices.com under Member Services, Member Claim Form.
Specialty Drug Program. This Plan utilizes a mandatory Specialty Drug program administered by a Pharmacy
Benefit Manager (PBM). All Specialty Drugs require prior authorization by the PBM. If prior authorization is
granted, the Specialty Drug must be obtained through the PBM’s Specialty Drug program in order for benefits to
be paid.
A Specialty Drug will be excluded from coverage if:
a.
b.
prior authorization is not granted by the PBM; or
the Specialty Drug is dispensed by a Physician or pharmacy that is not participating in the
Specialty Drug program.
Questions about the mandatory Specialty Drug program should be directed to the PBM. Information about the
PBM, including the phone number, is listed on Your ID card.
Covered Drugs do not include:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
o.
p.
q.
Rev 6.27.14
Non-legend over the counter drugs other than Insulin and Meclizine.
Topical Minoxidil (Rogaine) preparations whether commercially prepared or compounded.
Diabetic alcohol swabs.
Therapeutic supplies, devices or appliances, including support garments, and other nonmedicinal substances except those listed above.
Experimental or Investigational Drugs.
Human Growth Hormones.
Covered Prescription medications, which are not self-administered or are administered in a
Hospital, long term care facility or other Inpatient setting.
Charges for the administration or injection of any Drug.
Prescription Drugs or medicines covered under any Worker’s compensation law or similar laws
or any Municipal, State or Federal program, even if the patient chooses not to claim such
Benefits.
Refills of covered Drugs, which exceed the number of, refills the prescription order calls for, or
refills after one (1) year from the original date.
Smoking Deterrents (including over the counter smoking deterrents and nicotine patches).
All Fluoride Preparations.
All Vitamin Preparations (excluding Prenatal).
All over the counter medications.
Vitamin A Derivatives for dermatological/cosmetic use (i.e. Retin A, Renova).
Anti-Obesity Drugs.
Cosmetic Drugs.
All Drugs for the treatment of impotency (i.e. Viagra).
42
DEFINED TERMS
The following terms have special meanings and when used in this Plan will be capitalized.
Active Employee is an Employee who is on the regular payroll of the Employer and who has begun to perform
the duties of his or her job with the Employer on a full-time basis. The term “Active Employee” does not include
independent contractors, temporary employees or part-time employees.
Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery, has a
staff of Physicians, has continuous Physician and nursing care by registered nurses (R.N.s) and does not
provide for overnight stays.
Authorized Prescriber means any:
· licensed dentist,
· licensed Physician,
· licensed podiatrist,
· certified nurse midwife to the extent permitted by applicable law,
· certified nurse practitioner to the extent permitted by applicable law, or
Benefit Year is January 1 to December 31st.
Birthing Center means any freestanding health facility, place, professional office or institution which is not a
Hospital or in a Hospital, where births occur in a home-like atmosphere. This facility must be licensed and
operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the facility is
located.
The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide
care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed
nurse-midwife; and have a written agreement with a Hospital in the same locality for immediate acceptance of
patients who develop complications or require pre- or post-delivery confinement.
Calendar Year means January 1st through December 31st of the same year.
Claims Administrator is Coventry Health and Life Insurance Company.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
Coinsurance means the percentage stated in the Schedule of Medical Benefits if any, that You must pay to the
Network or Non-Network Provider. The Plan calculates Coinsurance based on the negotiated rate between the
Claims Administrator and the Network Provider.
Copayment means the flat dollar amount as specified in the Schedule of Medical Benefits that will be charged
to the Covered Person by the Network or Non-Network Provider.
Cosmetic Services and Surgery means plastic or reconstructive surgery: (i) from which no significant
improvements in physiologic function could be reasonably expected; or (ii) that does not meaningfully promote
the proper function of the body or prevent or treat illness or disease; or (iii) done primarily to improve the
appearance or diminish an undesired appearance of any portion of the body.
Covered Charge(s) means those Medically Necessary services or supplies that are covered under this Plan.
Covered Person is any Employee or Dependent who is covered under this Plan.
Creditable Coverage includes most health coverage, such as coverage under a group health plan (including
COBRA continuation coverage), HMO membership, an individual health insurance policy, Medicaid, Medicare or
public health plans.
Creditable Coverage does not include coverage consisting solely of dental or vision benefits.
Creditable Coverage does not include coverage that was in place before a significant break of coverage of 63
days or more. With respect to the Trade Act of 2002, when determining whether a significant break in coverage
Rev 6.27.14
43
has occurred, the period between the trade related coverage loss and the start of the special second COBRA
election period under the Trade Act, does not count.
Custodial Care is care (including Room and Board needed to provide that care) that is given principally for
personal hygiene or for assistance in daily activities and can, according to generally accepted medical
standards, be performed by persons who have no medical training. Examples of Custodial Care are help in
walking and getting out of bed; assistance in bathing, dressing, feeding; or supervision over medication which
could normally be self-administered.
Deductible means the amount of money that is paid once a Calendar Year per Covered Person. Typically,
there is one Deductible amount per Plan and it must be paid before any money is paid by the Plan for any
Covered Charges.
Durable Medical Equipment means equipment which (a) can withstand repeated use, (b) is primarily and
customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of an Illness
or Injury and (d) is appropriate for use in the home.
Employee means any person employed by the Employer whose customary scheduled weekly employment is
not less than twenty (20) hours. An Employee is an individual whom the Employer treats as its common-law
Employee and who is performing services for the Employer for wages, salary, or other remuneration as
evidenced by the Employer’s withholding taxes from such compensation; provided, however, that an
independent Contractor, a Leased Employee, or a Contractor’s Employee (or other individual) who is
reclassified as a common-law Employee on a retroactive basis will not be treated as having been an Employee
for purposes of the Plan for any period prior to the date that he or she is so reclassified. An independent
Contractor, a Contractor’s Employee, a Leased Employee, and a Person Not Offered Participation shall not be
considered an Employee hereunder. An “Independent Contractor” is a person who is classified by the Employer
as an independent contractor, as evidenced by its failure to withhold taxes from his or her compensation, even if
the individual really is the Employer’s common-law Employee.
A Contractor’s Employee is a person working for a company providing goods or services, including temporary
Employee services, to the Employer whom the Employer does not regard to be its common-law Employee, as
evidenced by its failure to withhold taxes from his or her compensation, even if the individual really is the
Employer’s common-law Employee. A “Leased Employee” means a leased Employee within the meaning of
Internal Revenue Code Section 414(n). A “Person Not Offered Participation” means a person to whom the
Employer did not extend the opportunity of participating in the Plan and who agreed orally or in writing to such
Non-Participant status.
Employer means Madonna Rehabilitation Hospital, the “Sponsoring Employer,” The Madonna Foundation, and
any other Employer who shall adopt this Plan with the prior consent of the Board of Directors of the Sponsoring
Employer (The Madonna Foundation and any other such adopting Employer being hereafter described as a
“Participating Employer”).
Participating Employers. With the consent of the Board of Directors of Madonna Rehabilitation Hospital, a
Participating Employer may adopt this Plan and participate herein by a properly executed document(s)
evidencing its intent to do so. Unless the context of the Plan clearly indicates to the contrary, the word Employer
includes each Participating Employer as related to its adoption of the Plan.
The Participating Employers irrevocably delegate to the Sponsoring Employer the right, power and authority to
amend this Plan and consent to any such amendment by the Sponsoring Employer without further execution or
adoption thereof. If any Participating Employer Adopts an amendment to this Plan without the joinder thereof of
the Sponsoring Employer, the Participating Employer is deemed to have adopted its own Plan. No such
amendment is effective with respect to the Sponsoring Employer or any other Participating Employer.
Enrollment Date is the first day of coverage or, if there is a Waiting Period, the first day of the Waiting Period.
Essential Health Benefits include, to the extent they are covered under the Plan, ambulatory patient services;
Emergency Services; Hospitalization; maternity and newborn care; Mental Health and substance use disorder
services, including behavioral health treatment; Prescription Drugs; rehabilitative and habilitative services and
devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric
services, including oral and vision care.
Rev 6.27.14
44
Experimental and/or Investigational applies to treatment, procedure, drugs or drug usage, facility or facility
usage, equipment or equipment usage, device or device usage, or supplies that are not generally and widely
accepted by experts as shown by (or in) articles published in at least two existing peer-reviewed evidence based
medical or scientific literature, accepted by Medicare or any competent federal government body. Drugs are
also considered Experimental or Investigational if they are not commercially available for purchase or are not
approved by the U.S. Food and Drug Administration for Your specific condition or for general use, or if they are
used for a purpose other than that for which approved, including off-label usage of drugs. The Plan
Administrator must make an independent evaluation of the Experimental/non-Experimental standings of specific
technologies guided by a reasonable interpretation of Plan provisions. Decisions will be made in good faith and
rendered following a detailed factual background investigation of the claim and the proposed treatment. A
decision by the Plan Administrator will be final and binding on the Plan. A decision is not a determination of the
medical appropriateness of the treatment, but only on the scope of Plan coverage. The Plan Administrator will
be guided by the following principles and when any one of these principles applies, the Plan Administrator will
consider the drug, device, medical treatment, or procedure Experimental or Investigational:
1. if the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug
Administration and approval for marketing has not been given at the time the drug or device is
furnished;
2. if the drug, device, medical treatment or procedure, or the patient-informed consent document utilized
with the drug, device, treatment or procedure, was reviewed and approved by the treating facility’s
Institutional Review Board or other body serving a similar function, or if federal law requires such
review or approval;
3. if reliable evidence shows that the drug, device, medical treatment or procedure is the subject of
ongoing phase I or phase II clinical trials, is the research, Experimental, study of Investigational arm of
ongoing phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose,
its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or
diagnosis; or
4. if reliable evidence shows that the prevailing opinion among experts regarding the drug, device,
medical treatment or procedure is that further studies or clinical trials are necessary to determine its
maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard
means of treatment or diagnosis.
Notwithstanding the foregoing, the following will not be excluded from coverage as Experimental or
Investigational:
5. any drug or combination of drugs on the basis that the drug or combination of drugs has not been
approved by the Federal Food and Drug Administration for the treatment of another specified type of
cancer if (a) the drug or combination if drugs is recognized for treatment of the other specific type of
cancer in the United States Pharmacopeia-Drug Information and the drug or combination of drugs is
approved for sale by the Federal Food and Drug Administration or (b) the drug or combination of drugs
is recognized for treatment of the other specific type of cancer in medical literature and the drug or
combination of drugs is approved for sale by the Federal Food and Drug Administration.
6. any drug or combination of drugs on the basis that the drug or combination of drugs has not been
approved by the Federal Food and Drug Administration for the treatment of human immunodeficiency
virus or acquired immunodeficiency syndrome if (a) the drug or combination of drugs is recognized for
treatment of human immunodeficiency virus or acquired immunodeficiency syndrome in the United
States Pharmacopeia-Drug Information and the drug or combination of drugs is approved for sale by
the Federal Food and Drug Administration or (b) the drug or combination of drugs is recognized for
treatment of human immunodeficiency virus or acquired immunodeficiency syndrome in medical
literature and the drug or combination of drugs is approved for sale by the Federal Food and Drug
Administration.
Paragraphs 5 and 6 will be interpreted in accordance with Neb. Rev. Stat. § 44-788.
The Claims Administrator must make an independent evaluation of the experimental/non-experimental
standings of specific technologies. The Claims Administrator shall be guided by a reasonable interpretation of
Plan provisions. The decisions shall be made in good faith and rendered following a detailed factual background
investigation of the claim and the proposed treatment. The decision of the Claims Administrator will be final and
binding on the Plan.
Rev 6.27.14
45
Family Unit is the covered Employee and the family members who are covered as Dependents under the Plan.
FMLA means Family and Medical Leave Act of 1993, as amended.
Genetic Information means information about genes, gene products and inherited characteristics that may
derive from an individual or a family member. This includes information regarding carrier status and information
derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical
examinations, family histories and direct analysis of genes or chromosomes.
Home Health Care Agency is an organization that meets all of these tests: its main function is to provide Home
Health Care Services and Supplies; it is federally certified as a Home Health Care Agency; and it is licensed by
the state in which it is located, if licensing is required.
Home Health Care Plan must meet these tests: it must be a formal written plan made by the Covered Person’s
attending Physician which is reviewed at least every 30 days; it must state the diagnosis; it must certify that the
Home Health Care is in place of Hospital confinement; and it must specify the type and extent of Home Health
Care required for the treatment of the Covered Person.
Home Health Care Services and Supplies include: part-time or intermittent nursing care by or under the
supervision of a registered nurse (R.N.); part-time or intermittent home health aide services provided through a
Home Health Care Agency (this does not include general housekeeping services); physical, occupational and
speech therapy; medical supplies; and laboratory services by or on behalf of the Hospital.
Hospice Agency is an organization where its main function is to provide Hospice Care Services and Supplies
and it is licensed by the state in which it is located, if licensing is required.
Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice Agency
and supervised by a Physician.
Hospice Care Services and Supplies are those provided through a Hospice Agency and under a Hospice
Care Plan and include Inpatient care in a Hospice Unit or other licensed facility, home care, and family
counseling during the bereavement period.
Hospice Unit is a facility or separate Hospital Unit, that provides treatment under a Hospice Care Plan and
admits at least two unrelated persons who are expected to die within six months.
Hospital means:
1.
an institution constituted, licensed and operated in accordance with the law pertaining to
Hospitals, which maintains on its premises all the facilities necessary to provide for the diagnosis
and medical and surgical treatment of Injury or Sickness and which provides such treatment for
compensation, by or under the supervision of Doctors on an Inpatient basis with continuous twentyfour (24) hour nursing service by Licensed Registered Nurses;
2.
an institution which is licensed and operated in accordance with the state laws pertaining to
osteopathic Hospitals, free standing surgical facilities, birthing centers, a place for alcoholics, drug
addicts or rehabilitation centers and which is accredited by any nationally recognized accrediting
program;
3.
a certified accredited rehabilitation facility (CARF); and
4.
For purposes of Serious Mental Illness, “Hospital” includes any institution, facility, place or
building, not licensed as a Hospital, described in Neb. Rev. Stat. § 71-2017.01 which is used to
provide for a period exceeding twenty-four consecutive hours accommodation, board, and advice,
counseling, diagnosis, treatment, care or services primarily or exclusively to persons residing or
confined in the institution, facility, place, or building who are afflicted with a mental disease,
disorder, or disability and any other licensed institution or facility authorized in section 71-2017.01
that provides a program for the treatment of a Mental Health condition pursuant to a written plan.
Illness means a bodily disorder, disease, physical sickness or Mental Disorder. Illness includes Pregnancy,
childbirth, miscarriage or complications of Pregnancy.
Rev 6.27.14
46
Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to
sustain a successful pregnancy.
Injury means an accidental physical Injury to the body caused by unexpected external means.
Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within a
Hospital solely for the care and treatment of patients who are critically ill. This also includes what is referred to
as a "coronary care unit" or an "acute care unit." It has: facilities for special nursing care not available in regular
rooms and wards of the Hospital; special life saving equipment which is immediately available at all times; at
least two beds for the accommodation of the critically ill; and at least one registered nurse (R.N.) in continuous
and constant attendance 24 hours a day.
Legal Guardian means a person recognized by a court of law as having the duty of taking care of the person
and managing the property and rights of a minor Child.
Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations. Lifetime is
understood to mean while covered under this Plan. Under no circumstances does Lifetime mean during the
Lifetime of the Covered Person.
Maximum Allowable Charge is the maximum amount covered under this Plan for approved Covered Charges
of Non-Network Providers. This rate will be derived from either a Medicare based fee schedule or a percent of
billed charges as determined by the Claims Administrator, based on the following:
·
Non-Network Rate/Out-of-Network Rate (ONR): the Maximum Allowable Amount is equivalent to the
current Medicare fee schedule, or diagnosis group rate, as applicable, for the services and supplies
rendered, taking into account the appropriate Medicare geographic adjustments. If there is no corresponding
Medicare rate for the particular service, the Plan will pay the amount that the Plan would have paid if the
Non-Participating Provider furnishing the services were a Provider contracting with the Claims Administrator.
The Maximum Allowable Amount for Emergency Services received from Non-Participating Providers will be
the same as the In-Network Rate. It is from this amount that any Deductible, Copayments and Coinsurance
are deducted before payment is issued.
·
In-Network: The amount determined by the Claims Administrator that it will pay for a Covered Service.
Allowable Charge is the amount that a Network Provider has agreed to accept as payment in full pursuant to
its agreement with the Claims Administrator.
Medical Care Facility means a Hospital, a facility that treats one or more specific ailments or any type of Skilled
Nursing Facility.
Medical Emergency means the sudden and acute onset of a medical condition manifesting itself by symptoms
of sufficient severity (including pain) such as a prudent person, with an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result in
·
·
·
serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of
the woman or her unborn Child, or
serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part.
Some examples of a Medical Emergency include but are not limited to:
·
·
·
·
·
·
·
·
Rev 6.27.14
Broken bone;
Chest pain;
Seizures or convulsions;
Severe or Unusual Bleeding;
Severe burns;
Suspected poisoning;
Trouble breathing;
Vaginal bleeding during Pregnancy.
47
Medically Necessary means those services, supplies, equipment and facilities charges that are not expressly
excluded under this Plan and determined by the Claims Administrator to be:
(i)
Medically appropriate, so that expected health benefits (such as, but not limited to, increased life
expectancy, improved functional capacity, prevention of complications, relief of pain) materially
exceed the expected health risks;
(ii)
Necessary to meet the Covered Person’s health, improve physiological function and required for a
reason other than improving appearance;
(iii)
Rendered in the most cost-efficient manner and setting appropriate for the delivery of the health
service;
(iv)
Consistent in type, frequency and duration of treatment with scientifically-based guidelines of
national medical research, professional medical specialty organizations or governmental agencies
that are generally accepted as national authorities on the services, supplies, equipment or facilities
for which coverage is requested;
(v)
Consistent with the diagnosis of the condition at issue;
(vi)
Required for reasons other than the Covered Person’s comfort or the comfort and convenience of
the Physician or Medical Facility; and
(vii)
Not Experimental or Investigational as determined by the Claims Administrator.
All of these criteria must be met; merely because a Physician recommends or approves certain care does not
mean that it is Medically Necessary.
The Claims Administrator has the discretionary authority to decide whether care or treatment is Medically
Necessary.
Medicare is the Health Insurance For The Aged and Disabled program under Title XVIII of the Social Security
Act, as amended.
Mental Disorder means any disease or condition, regardless of whether the cause is organic, that is classified
as a Mental Disorder in the current edition of International Classification of Diseases, published by the U.S.
Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual
of Mental Disorders, published by the American Psychiatric Association.
Member is any individual who meets the eligibility requirements of the Plan and is enrolled for coverage under
the Plan.
Morbid Obesity means (i) a weight that is at least 100 pounds over or twice the ideal weight for frame, age,
height, and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI)
equal to or greater than 35 kilograms per meter squared with co-morbidity or coexisting medical conditions such
as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter
squared without such co-morbidity. As used herein, BMI equals weight in kilograms divided by height in meters
squared.
Narrow Therapeutic Index. A drug is said to have a narrow therapeutic index when small variances in a
Participant’s blood levels can change the effectiveness or toxicity of the drug. Safe and effective use of these
drugs requires careful dosage adjustment and patient monitoring, regardless of whether the generic or brand
name product is used.
Network Provider, Network Hospital, Network Physician, or Other Network Health Care Provider means
any health care Provider that has entered into an agreement with the Claims Administrator to furnish covered
services to Covered Persons.
No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining
fault in connection with automobile accidents.
Outpatient Care and/or Services is treatment including services, supplies and medicines provided and used at
a Hospital under the direction of a Physician to a person not admitted as a registered bed patient; or services
Rev 6.27.14
48
rendered in a Physician's office, laboratory or X-ray facility, an Ambulatory Surgical Center, or the patient's
home.
Out-of-Pocket Maximum means the limit on the amount a covered Employee and covered Dependents must
pay out of their pocket for specified Covered Charges in a Benefit Year.
Partial Hospitalization is an outpatient program specifically designed for the diagnosis or active treatment of a
Mental Disorder or Substance Abuse when there is reasonable expectation for improvement or when it is
necessary to maintain a patient's functional level and prevent relapse; this program shall be administered in a
psychiatric facility which is accredited by the Joint Commission on Accreditation of Health Care Organizations
and shall be licensed to provide partial Hospitalization services, if required, by the state in which the facility is
providing these services. Treatment lasts less than 24 hours, but more than four hours, a day and no charge is
made for room and board.
Participant is any Employee or Dependent who is covered under this Plan.
Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor
of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor, Licensed
Professional Physical Therapist, Master of Social Work (M.S.W.), Midwife, Occupational Therapist,
Physiotherapist, Psychiatrist, Psychologist (Ph.D.), Speech Language Pathologist and any other practitioner of
the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his
or her license.
Plan means the Madonna Health Plan as herein set forth and as from time to time amended.
Plan Administrator means Madonna Rehabilitation Hospital.
Plan Year means the period from July 1 to June 30.
Pregnancy is childbirth and conditions associated with Pregnancy, including complications.
Sickness is for a covered Employee and covered Dependents: Illness, disease, or Pregnancy.
Significant Break in Coverage is a break in coverage of 63 days or more. Waiting periods do not count
towards a Significant Break in Coverage.
Skilled Nursing Facility is a facility that fully meets all of these tests:
(1)
It is licensed to provide professional nursing services on an Inpatient basis to persons convalescing
from Injury or Sickness. The service must be rendered by a registered nurse (R.N.) or by a licensed
practical nurse (L.P.N.) under the direction of a registered nurse. Services to help restore patients to
self-care in essential daily living activities must be provided.
(2)
Its services are provided for compensation and under the full-time supervision of a Physician.
(3)
It provides 24 hour per day nursing services by licensed nurses, under the direction of a full-time
registered nurse.
(4)
It maintains a complete medical record on each patient.
(5)
It has an effective utilization review plan.
(6)
It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mental
retardates, Custodial or educational care or care of Mental Disorders.
(7)
It is approved and licensed by Medicare.
This term also applies to charges incurred in a facility referring to itself as an extended care facility,
convalescent nursing home, rehabilitation Hospital, long-term acute care facility or any other similar
nomenclature.
Rev 6.27.14
49
Spinal Manipulation/Chiropractic Care means skeletal adjustments, manipulation or other treatment in
connection with the detection and correction by manual or mechanical means of structural imbalance or
subluxation in the human body. Such treatment is done by a Physician to remove nerve interference resulting
from, or related to, distortion, misalignment or subluxation of, or in, the vertebral column.
Substance Abuse is regular excessive compulsive drinking of alcohol and/or physical habitual dependence on
drugs. This does not include dependence on tobacco and ordinary caffeine-containing drinks.
Temporomandibular Joint (TMJ) syndrome is the treatment of jaw joint disorders including conditions of
structures linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the
temporomandibular joint. Care and treatment shall include, but are not limited to orthodontics, crowns, inlays,
physical therapy and any appliance that is attached to or rests on the teeth.
Total Disability (Totally Disabled) means in the case of an Employee, the complete inability to
perform any and every duty of his or her occupation or of a similar occupation for which the person is
reasonably capable due to education and training, as a result of Injury or Sickness. A covered
Employee with such a Total Disability will be considered a Disabled Employee. In the case of a
Dependent, the complete inability as a result of Injury or Sickness to perform the normal activities of a
person of like age and sex in good health.
Transitional Rehabilitation/Habilitation Program is a program that provides:
1.
Setting for members to care for themselves in a home-like surrounding or simulated environment;
2.
Supervision is available on 24/7 basis;
3.
Therapeutic rehabilitation activities 8 to 10 hours a day such as speech, neuropsychological, physical,
occupational, vocational and recreational therapies;
4.
Group education, exercise and holistic offerings;
5.
Nursing services; and
6.
Functional rehabilitation and development of independent living skills.
We means the Employer as set forth in this Plan.
You/Your means any person who is covered under the Plan as (1) an Employee, (2) a Disabled Employee, or
(3) a Dependent, subject to the terms of this Plan.
Rev 6.27.14
50
PLAN EXCLUSIONS
The services, supplies, equipment, facilities and related charges listed below are excluded from payment under
this Plan unless covered under an amendment to this Plan. Covered Persons may contact the Claims
Administrator Customer Services Department to assist in determining whether their benefit or payment has been
extended by an amendment or notice of material modification.
This Plan does not cover the following items:
1. Any service or supply that is not Medically Necessary;
2. Any service or supply that is not a Covered Charge or that is directly or indirectly a result of receiving a
non-Covered Charge;
3. Any service or supply for which a Covered Person has no financial liability or that was provided at no
charge;
4. Procedures and treatments that this Plan determines, in its sole and absolute discretion, to be
Experimental or Investigational;
5. Reconstruction or delayed procedures except as specified in the Schedule of Benefits and, in the case
of traumatic injury, when a significant anatomical or functional improvement can be anticipated;
6. Any services to the extent that payment for such services is, by law, covered by any governmental
agency as a primary plan;
7. Charges resulting from Your failure to appropriately cancel a scheduled appointment;
8. Court-ordered services or services that are a condition of probation or parole, to the extent permitted by
law.
9. Drugs, treatments, services or supplies which are considered Investigational because they do not meet
generally accepted standards for medical practice in the United States or which are not deemed
Medically Necessary. This includes any related confinement, treatment, service or supply.
For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:
(1)
Abortion. For an abortion, that is, directly intended termination of Pregnancy before viability, is
never permitted nor is the directly intended destruction of a viable fetus. Every procedure whose
sole immediate effect is the termination of Pregnancy before viability is an abortion, which, in its
moral context, includes the interval between conception and implantation of the embryo.
Catholic Hospitals are not to provide abortion services based upon the principle of material
cooperation.
Operations, treatments, and medication, which do not directly intend termination of Pregnancy
but which have as their purpose the cure of a proportionately serious pathological condition of
the mother, are permitted when they cannot be safely postponed until the fetus is viable, even
though they may or will result in the death of the fetus. If the fetus is not certainly dead, it should
be baptized.
(2)
Acupressure.
(3)
Acupuncture.
(4)
Autopsy.
(5)
Behavior modification.
(6)
Biofeedback.
(7)
Bionic Devices (microprocessor controlled prosthetics) to include, but not limited to, C-Leg.
Rev 6.27.14
51
(8)
The drawing, preparation and storage of umbilical cord blood is not covered.
(9)
Braces and supports needed for athletic participation or employment.
(10) Clinical Trials, unless required by Section 2709 of the Public Health Service Act.
(11)
Clothing or shoes of any type, including but not limited to orthopedic shoes, Children’s
corrective shoes, shoes used in conjunction with leg braces, and shoe inserts except for inserts
and shoes for Participants with diabetes or peripheral vascular disease;
(12) Complications of non-covered treatments. Care, services or treatment required as a result of
complications from a treatment not covered under the Plan are not covered.
(13) Contraceptive Substances or devices (unless used for medically necessary non-contraceptive
uses).
(14) Corrective Appliances that do not require prescription specifications and/or are used primarily
for recreational sports.
(15) Cosmetic Services and Surgery and the complications incurred as a result of those services
and surgeries.
(16) Custodial care. Services or supplies provided mainly as a rest cure, maintenance or Custodial
Care.
(17) Repair and maintenance of Durable Medical Equipment and Corrective Appliances:
(a) Repair and maintenance for routine servicing such as testing, cleaning, regulating and
checking of equipment is not covered except as specified in the Schedule of Benefits.
(b) Except as specified in the Schedule of Benefits, repair coverage is limited to: (a)
adjustment required by wear or by condition change when prescribed by a Participating
Provider; and (b) repairs necessary to make the equipment/appliance serviceable unless
the repair costs exceed the cost of the equipment/appliance.
(18) Except as specified in the Schedule of Benefits, replacement coverage for Durable Medical
Equipment or Corrective Appliances is limited to once every two (2) years for irreparable
damage and/or normal wear, or a significant change in medical condition. Replacement
resulting from malicious damage, culpable neglect, or wrongful disposition of the equipment or
device on the part of the Participant is NOT covered.
(19) Educational or vocational testing and therapy services, including but not limited to cognitive
therapy, physical therapy, occupational therapy, and speech therapy for developmental delay,
school-related problems, apraxic disorders (unless caused by accident or episodic illness),
stuttering, autism spectrum disorder except as outlined under the Medical Benefits Section,
speech delay, articulation disorder, functional dysphonia, services for educational or vocational
testing or training, and or other disturbance or speech problems resulting from psychoneurotic
or personality disorders. Services for special education, counseling or care for learning
deficiencies or behavioral problems, whether or not associated with a manifest mental disorder,
long-term therapy and long-term pulmonary therapy are not covered.
(20) Elective home delivery for childbirth.
(21) Replacement supplies for electric breast pumps for comfort and convenience are not covered.
These include caps for breast pump bottle (A4283), breast shield and splash protector (A4284),
polycarbonate bottles (A4285), locking ring for breast pump (A4286) and milk storage products.
The Plan does not cover other breastfeeding supplies such as maternity bras, nursing pads,
additional bottles, and other supplies. Also excluded from coverage is the rental of a heavy
duty, Hospital grade electric pump and purchase of necessary supplies.
Rev 6.27.14
52
(22) Equipment or services primarily used for use in altering air quality or temperature.
(23) Equipment primarily used for non-medical purposes.
(24) Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is
in excess of the Allowable Charge.
(25) Exercise programs and equipment. Exercise programs for treatment of any condition, except
for Physician-supervised cardiac rehabilitation, occupational or physical therapy covered by this
Plan.
(26) Experimental or Investigational, or not Medically Necessary. For drugs, treatments, services
or supplies which are considered Investigational because they do not meet generally accepted
standards for medical practice in the United States or which are not deemed Medically
Necessary. This includes any related confinement, treatment, service or supplies.
For Plan Years beginning on or after January 1, 2014, this exclusion shall not apply to the extent
that the charge is for a qualified individual who is a Participant in an approved clinical trial with
respect to the treatment of cancer or another life-threatening disease or condition. The Plan
shall not deny, limit or impose additional conditions on routine patient costs for items and
services furnished in connection with participation in the clinical trial. However, this provision
does not require the Plan to pay charges for services or supplies that are not otherwise Covered
Charges (including, without limitation, charges which the qualified individual would not be
required to pay in the absence of this coverage) or prohibit the Plan from imposing all applicable
cost sharing and reasonable cost management provisions. For these purposes, a qualified
individual is a Covered Person who is eligible to participate in an approved clinical trial
according to the trial protocol with respect to the treatment of cancer or another life-threatening
disease or condition, and either: (1) the referring health care professional is a Participating
Provider and has concluded that the individual's participation in such trial would be appropriate;
or (2) the Covered Person provides medical and scientific information establishing that the
individual's participation in such trial would be appropriate. This paragraph will be interpreted in
accordance with the coverage for Clinical Trials described in Section 7(i) above.
(27) Eye exercises and therapy.
(28) Eye care. Radial keratotomy or other eye surgery to correct refractive disorders. Also, lenses for
the eyes and exams for their fitting. This exclusion does not apply to aphakic patients and soft
lenses or sclera shells intended for use as corneal bandages.
(29) Failure to provide information. Failure to provide any additional documentation or information
as may be requested by the Claims Administrator may result in no coverage.
(30) Food or food supplements, tube feeding, medical foods, vitamins or other nutritional and overthe-counter electrolyte supplements.
(31) Foot care. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or
bunions (except open cutting operations), and treatment of corns, calluses or toenails (unless
needed in treatment of a metabolic or peripheral-vascular disease) and determined to be
Medically Necessary.
(32) Foreign travel. Care, treatment or supplies out of the U.S. if travel is for the sole purpose of
obtaining medical services.
(33) Genetic counseling and genetic studies that are not required for diagnosis or treatment of
genetic abnormalities according to Plan guidelines.
(34) Government coverage. Care, treatment or supplies furnished by a program or agency funded
by any government. This does not apply to Medicaid or when otherwise prohibited by law.
(35) Growth hormones, unless Medically Necessary.
(36) Habilitative services that are not Medically Necessary, do not meet the medical criteria of the
Rev 6.27.14
53
Claims Administrator or that are determined to be long term care where no significant
improvement in the Plan Participant’s condition is expected, are not covered; provided that the
Plan will provide habilitative services that are similar in scope, amount and duration to benefits
covered for rehabilitative services. The Plan will provide habilitative services to the extent
required by Section 2709 of the Public Health Services Act and guidance issued pursuant
thereto.
(37) Hair analysis and hair transplants.
(38) Hair loss. Care and treatment for hair loss including wigs, hair transplants or any drug that
promises hair growth, whether or not prescribed by a Physician, except for wigs after
chemotherapy or radiation.
(39) Hearing aids and exams. Charges for services or supplies in connection with hearing aids or
exams for their fitting, except as may be covered under the well adult or well Child sections of
this Plan.
(40) Home services to help meet personal/family/domestic needs. Homemaker services, home
health aide services, custodial care, respite care and private duty nursing are not covered.
(41) Hospital employees. Professional services billed by a Physician or nurse who is an employee
of a Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service.
(42) Hypnotherapy.
(43) Illegal acts. Charges for services received as a result of Injury or Sickness occurring directly or
indirectly, as a result of a Serious Illegal Act, or a riot or public disturbance. For purposes of this
exclusion, the term "Serious Illegal Act" shall mean any act or series of acts that, if prosecuted
as a criminal offense, a sentence to a term of imprisonment in excess of one year could be
imposed. It is not necessary that criminal charges be filed, or, if filed, that a conviction result, or
that a sentence of imprisonment for a term in excess of one year be imposed for this exclusion
to apply. Proof beyond a reasonable doubt is not required. This exclusion does not apply if the
Injury or Sickness resulted from an act of domestic violence or a medical (including both
physical and Mental Health) condition.
(44) Immunizations, physical exams and vaccinations for travel or employment, insurance,
governmental licensing, school, camp, adoption, marriage, athletic participation or those ordered
by a third party.
(45) Impotence. Care, treatment, services, supplies such as sexual aids, vacuum devices and penile
implants or medication in connection with treatment for impotence, unless as the result of illness
or injury.
(46) Infertility. Care, supplies, medications, services and treatment for infertility, except for
diagnostic services rendered for infertility evaluation.
(47) Marital or relationship counseling; family counseling; vocational or employment counseling;
and sex therapy. Care and treatment for any of these types of counseling.
(48) Medical Equipment, appliances, devices and supplies. Coverage does not include benefits
for medical equipment, appliances, devices and supplies that have both a therapeutic and nontherapeutic use. These include: elastic or leather braces or supports; cranial helmets; splints;
canes; traction apparatus; cervical collars; corsets; batteries and battery chargers; exercise
equipment; office chairs; equipment or services for use in altering air quality or temperature
including, but not limited to, air conditioners, filters, humidifiers, dehumidifiers, bed liners, and
mattress covers; other special supplies, appliances, and equipment such as sun or heat lamps,
whirlpool baths, and heating pads; rental or purchase of TENS units; personal hygiene, comfort,
and convenience items including but not limited to grab/tub bars, tub benches, telephone,
television, guest meals and accommodations, take home medications, and supplies; home
improvement items, including but not limited to, escalators, elevators, ramps, stair glides or
Rev 6.27.14
54
emergency alert equipment; and expenses incurred at a health spa, gym or similar facility. An
office visit for the purpose of fitting for a non-covered device or supply is not covered.
(49) Milieu therapy, the treatment of mental disorder or maladjustment by making substantial
changes in a patient's immediate life circumstances and environment in a way that will enhance
the effectiveness of other forms of therapy is not covered. Also known as “situation therapy”.
(50) Napropathic services provided by a practitioner of Naprapathy (a "Naprapath") are not
covered. Naprapathy is a system of treatment by manipulation of connective tissue and
adjoining structures and by dietary measures that is held to facilitate the recuperative and
regenerative processes of the body.
(51) Newborn home deliveries.
(52) No charge. Care and treatment or portions of charges for care or treatment for which there
would not have been a charge if no coverage had been in force.
(53) Non-compliance. All charges in connection with treatments or medications where the patient
either is in non-compliance with or is discharged from a Hospital or Skilled Nursing Facility
against medical advice.
(54) Non-emergency Hospital admissions. Care and treatment billed by a Hospital for non-Medical
Emergency admissions on a Friday or a Saturday. This does not apply if surgery is performed
within 24 hours of admission.
(55) Non-medical expenses such as preparing medical reports, itemized bills or charges for mailing;
for training, educational instructions or materials, even if the are performed or prescribed by a
Physician; for legal fees and expenses incurred in obtaining medical treatment.
(56) No Physician recommendation. Care, treatment, services or supplies not recommended and
approved by a Physician; or treatment, services or supplies when the Covered Person is not
under the regular care of a Physician. Regular care means ongoing medical supervision or
treatment which is appropriate care for the Injury or Sickness.
(57) Not specified as covered. Non-traditional medical services, treatments and supplies which are
not specified as covered under this Plan.
(58) Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any
case, a part of the treatment plan for another Sickness, except as stated in the Medical Benefits
section. Specifically excluded are charges for gastric balloons, “mini” gastric bypass, stapling
and intestinal bypass, bilopancreatic diversion with duodenal switch (BPD-DS), gastroplasty and
lap band surgery, including reversals. Medically Necessary non-surgical charges for Morbid
Obesity will be covered.
(59) Occupational. Care and treatment of an Injury or Sickness that is occupational -- that is, arises
from work for wage or profit including self-employment; provided the employer provides, or is
required to provide workers’ compensation or similar type coverage for such services.
(60) Oral Surgery: required as part of an orthodontic treatment program, required for correction of
an occlusal defect, encompassing orthoganathic or prognathic surgical procedures.
(61) Orthotics. Charges in connection with orthotics, heel lifts, and arch supports. Foot orthotics are
not covered.
(62) Orthodontia and related services.
(63) Out-of-Network: Charges in excess of the Maximum Allowable Amount. Out-of-Network:
Except as otherwise stated in this Plan Document, services are not covered Out-of-Network.
When Out-of-Network services are authorized by the Plan, charges in excess of the Maximum
Allowable Amount are not covered.
Rev 6.27.14
55
(64) Over-the-counter supplies which do not require a prescription such as ACE wraps, elastic
supports, splints, Band-Aids, antibiotic creams, Vita lights, magnetic mats and orthotics.
(65) Personal comfort items. Personal comfort items or other equipment, such as, but not limited
to, air conditioners, air-purification units, humidifiers, electric heating units, orthopedic
mattresses, blood pressure instruments, scales, elastic bandages or stockings, nonprescription
drugs and medicines, television and telephone, and first-aid supplies and non-Hospital
adjustable beds.
(66) Plan design exclusions. Charges excluded by the Plan design as mentioned in this document.
(67) Private Inpatient room, unless Medically Necessary or if a semi-private room is unavailable.
(68) Psychiatric evaluation or therapy when related to judicial or administrative proceedings or
orders, when employer requested, or when required for school.
(69) Relative giving services. Professional services performed by a person who ordinarily resides
in the Covered Person's home or is related to the Covered Person as a Spouse, parent, Child,
brother or sister, whether the relationship is by blood or exists in law.
(70) Replacement braces. Replacement of braces of the leg, arm, back, neck, or artificial arms or
legs, unless there is sufficient change in the Covered Person's physical condition to make the
original device no longer functional.
(71) Charges related to robotics assistance during surgery are not covered.
(72) Services before or after coverage. Care, treatment or supplies for which a charge was
incurred before a person was covered under this Plan or after coverage ceased under this Plan.
(73) Services that are not authorized when authorization is required.
(74) Sex changes. Care, services or treatment for non-congenital transsexualism, gender dysphoria
or sexual reassignment or change. This exclusion includes medications, implants, hormone
therapy, surgery, medical or psychiatric treatment.
(75) Sleep disorders. Care and treatment for sleep disorders unless deemed Medically Necessary.
(76) Smoking cessation. Care and treatment for smoking cessation programs, including smoking
deterrent patches, except as may be covered under the preventive services section of this plan.
(77) Sports medicine treatment plans, surgery, Corrective Appliances, or artificial aids primarily
intended to enhance athletic functions.
(78) Jobst stockings, elastic hose and graduated compression (TED) hose.
(79) Surgery performed solely to address psychological or emotional factors.
(80) Surgical sterilization or surgical sterilization reversal. Care and treatment for sterilization or
reversal of surgical sterilization.
(81) Surrogate motherhood services and supplies, including, but not limited to, all services and
supplies relating to the conception and Pregnancy of a Covered Person acting as a surrogate
mother.
(82) Testicular implants.
(83) Therapy. The following types of habilitated therapy are not covered, although this list is not
meant to be exclusive;
a. Physical or Occupational Therapy for the purpose of behavioral modification or for
improving performance in school or sports.
Rev 6.27.14
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b. Occupational Therapy for the purpose of treating sensory hypersensitivity.
c. Sensory Integration Therapy.
(84) Treatment of drug abuse or alcoholism when not rendered according to a written treatment
plan approved and monitored by a licensed psychologist.
(85) Treatment of drug abuse or alcoholism provided by halfway houses, boot camps and
wilderness programs.
(86) Transplant services, screening tests, and any related conditions or complications related to
organ donation when a Covered Person is donating organ or tissue to a non-Covered Person.
(87) Except as otherwise Preauthorized by this Plan, transplant services and all related services
and supplies when received from any Provider not designated by this Plan as a participating
Coventry Transplant Network facility.
(88) Travel or accommodations. Charges for travel or accommodations, whether or not
recommended by a Physician, except for ambulance charges and transplant travel services
defined as a Covered Charges.
(89) Treatment of mental retardation, unless covered as a biologically-based mental illness.
(90) Treatment of teeth, the nerves or roots of the teeth (excepted as stated under “Covered
Services”) or for the repair or replacement of a denture.
(91) Vocational Therapy.
(92) War. Any loss that is due to a declared or undeclared act of war.
(93) Work hardening programs. Charges for or in connection if an Illness or Injury for which the
Employee or Dependent is entitled to benefits under any Workers’ Compensation or similar law.
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57
HOW TO SUBMIT A CLAIM
Benefits under this Plan shall be paid only if the Claims Administrator decides in its discretion that a
Covered Person is entitled to them.
Claims for services rendered by Out-of-Network Providers that qualify as Benefits should be sent to:
Coventry Health Care of Nebraska, Inc.
Claims Department
P. O. Box 7705
London, Kentucky 40742
1-800-288-3343
If a charge is made to a Participant for any service that is reimbursable under this Plan, written proof of such
charge shall include an itemized statement and diagnosis and must be submitted to Health Plan within fifteen (15)
months after the delivery of the service. Such services must have been provided in accordance with the Plan's
utilization management and Preauthorization policies and procedures. Failure to furnish such documentation
within the specified period shall invalidate or reduce any such claim unless for good reason, as determined by the
Plan, it was not possible to submit the claim within the specified period, provided such proof is produced in a timely
basis.
The Plan may make payment to the person or institution providing the services, or at the Plan's discretion may
make payment directly to the Covered Employee. However, if the Covered Employee furnishes evidence
satisfactory to the Plan that payment has been made to such person or institution for the service covered,
reimbursement will be made to the Covered Employee after deducting any payment made by the Plan before
receipt of such evidence. The Plan will reimburse up to the Out-of-Network Rate for services rendered.
The Plan at its own expense shall have the right to require that a Participant whose sickness or injury is the basis
of a claim under this Summary Plan Description, be examined by a Network Physician or other Health Care
Provider of the Plan’s choosing when and as often as the Plan may reasonably require.
No legal action for reimbursement of a claim for payment for services may be initiated prior to the exhaustion of the
Plan's appeals procedures. No legal action for reimbursement of a claim for payment for services may be initiated
more than three (3) years after the expiration of the date of service of the claim at issue.
WHEN CLAIMS SHOULD BE FILED
Claims should be filed with the Claims Administrator within fifteen (15) months of the date charges for the
service were incurred. Benefits are based on the Plan's provisions at the time the charges were incurred. Claims
filed later than that date may be declined or reduced unless:
(a)
it's not reasonably possible to submit the claim in that time; and
(b)
the claim is submitted within fifteen (15) months from the date incurred. This fifteen (15)
month period will not apply when the person is not legally capable of submitting the claim.
The Claims Administrator will determine if enough information has been submitted to enable proper
consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the
right to have a Plan Participant seek a second medical opinion.
A request for Plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair
review. If a claim is wholly or partially denied, the Claims Administrator will furnish the Plan Participant with a
written notice of this denial. This written notice will be provided within 90 days after receipt of the claim. The
written notice will contain the following information:
Rev 6.27.14
(a)
the specific reason or reasons for the denial;
(b)
specific reference to those Plan provisions on which the denial is based;
(c)
a description of any additional information or material necessary to correct the claim and an
explanation of why such material or information is necessary; and
58
(d)
appropriate information as to the steps to be taken if a Plan Participant wishes to submit the
claim for review.
A Plan Participant will be notified within 90 days of receipt of the claim as to the acceptance or denial of a claim
and if not notified within 90 days, the claim shall be deemed denied.
If special circumstances require an extension of time for processing the claim, the Claims Administrator shall
send written notice of the extension to the Plan Participant. The extension notice will indicate the special
circumstances requiring the extension of time and the date by which the Plan expects to render the final
decision on the claim. In no event will the extension exceed a period of 90 days from the end of the initial 90-day
period.
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59
YOUR RIGHT TO REVIEW OF THE PLAN’S DETERMINATION
The following is a description of how the Plan processes Claims for benefits and reviews the Appeal of any
Claim that is denied. The terms used in this section are defined below.
A "Claim" is defined as any request for a Plan benefit, made by a claimant or by an authorized representative on
behalf of a claimant, which complies with the Plan's reasonable procedure for filing Claims and making benefit
Claims determinations. For purposes of this Section, an authorized representative may pursue a Claim on
behalf of a claimant.
A "Claim" includes a request for a determination of an individual's eligibility to participate in the Plan, except for
purposes of the External Review Process described below.
If a Claim is denied, in whole or in part, or if Plan coverage is rescinded retroactively for fraud or intentional
misrepresentation, the denial is known as an "Adverse Benefit Determination."
A claimant has the right to request a review of an Adverse Benefit Determination. This request is an "Appeal." If
the Claim is denied at the end of the Appeal process, as described below, the Plan's final decision is known as a
"Final Adverse Benefit Determination." If the claimant receives notice of a Final Adverse Benefit Determination,
the claimant then has the right to request an independent external review. The External Review procedures are
described below.
A claimant must follow all Claims and Appeal procedures both internal and external, before he or she can file a
lawsuit. If a lawsuit is brought, it must be filed within 2 years after the final determination of the External
Review Process.
Any of the authority and responsibilities of the Plan Administrator under the Claims and Appeal Procedures or
the External Review Process, including the discretionary authority to interpret the terms of the Plan, may be
delegated to a third party. If You have any questions regarding these procedures, please contact the Plan
Administrator.
There are different kinds of Claims and each one has a specific timetable for each step in the review process.
Upon receipt of the Claim, the Plan Administrator must decide whether to approve or deny the Claim. The time
periods are discussed under the Notice to claimant of Adverse Benefit Determination section below. Decisions
will be made within a reasonable period of time appropriate to the circumstances, but within the maximum time
periods listed in the below. Unless otherwise noted, "days" means calendar days.
The definitions of the types of Claims are as follows:
Urgent Care Claim
A Claim involving Urgent Care is any Claim for medical care or treatment where the Plan conditions receipt of
benefits, in whole or in part, on approval in advance of obtaining the care or treatment, and using the timetable
for a non-Urgent Care determination could seriously jeopardize the life or health of the claimant; or the ability of
the claimant to regain maximum function; or in the opinion of the attending or consulting Physician, would
subject the claimant to severe pain that could not be adequately managed without the care or treatment that is
the subject of the Claim.
A Physician with knowledge of the claimant's medical condition may determine if a Claim is one involving Urgent
Care. If there is no such Physician, an individual acting on behalf of the Plan applying the judgment of a prudent
layperson who possesses an average knowledge of health and medicine may make the determination.
If there is an Adverse Benefit Determination on a Claim involving Urgent Care, a request for an expedited
Appeal may be submitted orally or in writing by the claimant. All necessary information, including the Plan's
benefit determination on review, may be transmitted between the Plan and the claimant by telephone, facsimile,
or other similarly expeditious method. Alternatively, the claimant may request an expedited review under the
External Review Process if he or she has filed a request for an Urgent Care Internal Review.
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60
Concurrent Care Claims
A Concurrent Care Claim is a special type of Claim that arises if the Plan informs a claimant that benefits for a
course of treatment that has been previously approved for a period of time or number of treatments is to be
reduced or eliminated. In that case, the Plan must notify the claimant sufficiently in advance of the effective date
of the reduction or elimination of treatment to allow the claimant to file an Appeal. This rule does not apply if
benefits are reduced or eliminated due to Plan amendment or termination. A similar process applies for Claims
based on a rescission of coverage for fraud or misrepresentation.
Pre-Service Claim
A Pre-Service Claim means any Claim for a benefit under this Plan where the Plan conditions receipt of the
benefit, in whole or in part, on approval in advance of obtaining medical care. These are, for example, Claims
subject to pre-certification. Please see the Cost Management section of this booklet for further information about
Pre-Service Claims.
If a claimant fails to follow the Plan’s procedures for filing a Pre-Service Claim, the Plan Administrator will notify
the claimant of the failure and the proper procedures that he or she must follow in order to file a Claim. The
Plan Administrator will provide this notice as soon as possible, but not later than 5 days (72 hours in the case of
an Urgent Care Claim) following the failure. The notification may be oral, unless the claimant requests written
notification.
Post-Service Claim
A Post-Service Claim means any Claim for a Plan benefit that is not a Claim involving Urgent Care or a PreService Claim; in other words, a Claim that is a request for payment under the Plan for medical services already
received by the claimant.
Notice to claimant of Adverse Benefit Determinations
If a Claim is denied in whole or in part, the denial is considered to be an Adverse Benefit Determination. Except
with Urgent Care Claims, when the notification may be oral followed by written or electronic notification within 3
days of the oral notification, the Plan Administrator or its designee shall provide written or electronic notification
of the Adverse Benefit Determination.
In the case of an Urgent Care Claim, the Plan Administrator or its designee will notify the claimant as soon as
possibile, taking into account the medical exigencies, but not later than 72 hours after receipt of the Claim but
the Plan. If the Plan Administrator needs additional information to determine whether, or to what extent, benefits
are covered or payable under the Plan, it shall notify the claimant as soon as possible, but not later than 24
hours after receipt of the Claim by the Plan of the specific information necessary to complete the Claim. The
claimant will have at least 48 hours to provide the information. The Plan Administrator shall notify the claimant
of the Plan’s benefit determination as soon as possible, but not later than 48 hours after the earlier of the Plan’s
receipt of the specified information or the end of the period afforded the claimant to provide the specified
additional information.
In the case of a Concurrent Care Claim, the Plan Administrator or its designee will notify the claimant sufficiently
in advance of a reduction or termination to allow the claimant to Appeal and obtain a determination on review
before the benefit is reduced or terminated. Any request by a claimant to extend the course of treatment
beyond the period of time or number of treatments that is a Claim involving Urgent Care shall be decided as
soon as possible, taking into account the medical exigencies within 24 hours after receipt of the Claim, provided
that such Claim is made at least 24 hours prior to the expiration of the prescribed period of time or number of
treatments. If the course of treatment involves Urgent Care, it shall be treated as an Urgent Care Appeal.
In the case of a Pre-Service Claim, the Plan Administrator or its designee will notify the claimant not later than
15 days after receipt of the Claim. The Plan Administrator may determine that matters beyond its control require
additional time for processing the Claim. It can extend the response period up to an additional 15 days. To do
so, it must notify the claimant in writing before the end of the initial 15-day period. The notice of extension must
set forth the matters beyond its control that cause the delay and must contain the date by which the Plan
Administrator expects to render a decision. If the Plan Administrator requests the extension because the
claimant has failed to submit the information necessary to decide the Claim, the notice of extension will describe
the required information. The claimant will have at least 45 days from receipt of the notice to provide the
Rev 6.27.14
61
specified information. The time period for the Plan Administrator to make the benefit determination shall be
tolled from the date of the notification of the extension until the date on which the claimant responds to to the
request for additional information.
In the case of a Post-Service Claim, the Plan Administrator or its designee will notify the claimant not later than
30 days after receipt of the Claim. The Plan Administrator may determine that matters beyond its control require
additional time for processing the Claim. It can extend the repsonse period for up to an additional 15 days. To
do so, it must notify the claimant in writing before the end of the initial 30-day period. The notice of extension
must set forth the matters beyond its control that cause the delay and must contain the date by which the Plan
Administrator expects to render a decision. If the Plan Administrator requests the extension because the
claimant has failed to submit the information necessary to decide the Claim, the notice of extension will describe
the required information. The claimant will have at least 45 days from receipt of the notice to provide the
specified information. The time period for the Plan Administrator to make the benefit determination shall be
tolled from the date of the notification of the extension until the date on which the claimant responds to to the
request for additional information.
The notice will state in a manner calculated to be understood by the claimant:
(1)
Information sufficient to allow the claimant to identify the Claim involved (including the date of
service, the healthcare Provider, the Claim amount (if applicable), and a statement describing the
availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment
code and its corresponding meaning).
(2)
The specific reason or reasons for the adverse determination, including the denial code and its
corresponding meaning, and a description of the Plan's standard, if any, that was used in denying
the Claim.
(3)
Reference to the specific Plan provisions on which the determination was based.
(4)
A description of any additional material or information necessary for the claimant to perfect the
Claim and an explanation of why such material or information is necessary.
(5)
A description of the Plan's internal and external Appeal procedures. This description will include
information on how to initiate the Appeal and the time limits applicable to such procedures. It will
include a statement of the claimant’s right to bring a civil action under state law following a Final
Adverse Benefit Determination.
(6)
If the Adverse Benefit Determination was based on an internal rule, guideline, protocol, or other
similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge. If
this is not practical, a statement will be included that such a rule, guideline, protocol, or criterion was
relied upon in making the Adverse Benefit Determination and a copy will be provided free of charge
to the claimant upon request.
(7)
If the Adverse Benefit Determination is based on the Medical Necessity or Experimental or
Investigational treatment or similar exclusion or limit, an explanation of the scientific or clinical
judgment for the determination, applying the terms of the Plan to the claimant's medical
circumstances, will be provided. If this is not practical, a statement will be included that such
explanation will be provided free of charge, upon request.
(8)
If the Adverse Benefit Determination relates to a Claim involving Urgent Care, a description of the
expedited review process applicable to such Claims.
(9)
Information about the availability of and contact information for, any applicable office of health
insurance consumer assistance or ombudsman established under applicable federal law to assist
individuals with the internal Claims and Appeals and external review process.
Non-Urgent Care Internal Appeal Process
A claimant may request a review of a Non-Urgent Care Claim according to the procedure set forth below. The
Non-Urgent Care Internal Appeal process provides for 2 levels of Appeal.
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62
First Level Internal Appeal Process (Non-Urgent)
When a claimant receives notification of an Adverse Benefit Determination, he or she has 180 days following
receipt of the notification in which to file a written request for an Appeal. A claimant may submit written
comments, documents, records, and other information relating to the Appeal. The Plan Administrator or its
designee will also provide the claimant reasonable access to and copies of information relevant to his or her
Claim for benefits. Applicable regulations define the information relevant to a Claim for benefits. It will provide
these materials upon request free of charge. The period of time within which a benefit determination on Appeal
is required to be made shall begin at the time an Appeal is filed in writing in accordance with the procedures of
the Plan. The time begins without regard to whether all the necessary information accompanies the filing.
The Appeal should be submitted in writing to the following:
Attention: Appeal Department
15950 West Dodge Rd
Omaha, NE 68118
The Plan Administrator or its designee will consider all comments, documents, records, and other information
submitted by the claimant relating to the Claim. This includes information not submitted or considered in the
initial benefit determination. The Appeal review will not afford deference to the initial Adverse Benefit
Determination. It will be conducted by an appropriate administrator of the Plan who is neither the individual who
made the Adverse Benefit Determination that is the subject of the Appeal, nor the subordinate of such individual.
If the Appeal involves medical judgment, the Plan Administrator or its designee will consult with a health care
professional who has appropriate training and experience in the relevant filed of medicine. The health care
professional will not be the individual who was consulted in connection with the initial Adverse Benefit
Determination, nor his or her subordinate. If the Plan Administrator or its designee obtains advice from a
medical or vocational expert in connection with the Adverse Benefit Determination, it will provide the name of
such expert, whether or not it relied on his or her advice.
The Appeal review will be completed and written notification will be sent to the claimant within the following time
periods:
·
·
Pre-service Appeal – 15 calendar days after the date on which the Appeal is filed.
Post-service Appeal – 30 calendar days after the date on which the Appeal is filed.
This notification will state the following in a manner calculated to be understood by the claimant:
(1)
(2)
The specific reason or reasons for the Adverse Benefit Determination, including the denial code and
its corresponding meaning, and a description of the Plan's standard, if any, that was used in
denying the Claim. In the case of a notice of final internal Adverse Benefit Determination, this
description will include a discussion of the decision.
(3)
(4)
information on how to initiate the Appeal and the time limits applicable to such procedures. This will
include a statement of the claimant’s right to bring a civil action under state law following a Final
(5)
A statement that the claimant is entitled to receive, upon request and free of charge, reasonable
access to, and copies of, all documents, records, and other information relevant to the Claim.
Applicable regulations define the information relevant to a Claim for benefits.
(6)
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63
(7)
(8)
The following statement: “You and Your Plan may have other voluntary alternative dispute
resolution options, such as mediation. One way to find out what may be available is to contact Your
State insurance regulatory agency.”
(9)
Second Level Internal Appeal Process (Non-Urgent)
If a claimant receives an Adverse Benefit Determination from the First Level Internal Appeal, he or she may
Appeal the denial of the Claim. The claimant has 180 days following receipt of the notification of the First Level
Internal Appeal in which to file a written request for a Second Level Internal Appeal. A claimant may submit
written comments, documents, records, and other information.
The Appeal should be submitted in writing as follows:
Attention: Health Plan Committee
5401 South Street
Lincoln, NE 68506
The claimant should include any issues, comments and documents he or she thinks will allow the Appeal to be
decided favorably. The claimant may request a personal appearance before the Plan Committee. The request
should be made in the claimant’s Appeal.
The Plan Committee will provide the claimant reasonable access to and copies of information relevant to his or
her Claim for benefits. Applicable regulations define the information relevant to a Claim for benefits. The Plan
Committee will provide these materials upon request free of charge. The period of time within which a benefit
determination on Appeal is required to be made shall begin at the time an Appeal is filed in writing in
accordance with the procedures of the Plan. The time begins without regard to whether all the necessary
information accompanies the filing.
The Plan Committee will consider all comments, documents, records, and other information submitted by the
claimant relating to the Claim. This includes information not submitted or considered in the prior benefit
determinations. The Plan Committee will not afford deference to the prior Adverse Benefit Determinations. The
Plan Committee is an appropriate administrator of the Plan which is neither an individual who made the prior
Adverse Benefit Determinations, nor the subordinate of such individual. If the Appeal involves medical judgment,
the Plan Committee will consult with a health care professional who has appropriate training and experience in
the relevant field of medicine. The health care professional will not be the individual who was consulted in
connection with the prior Adverse Benefit Determinations, nor his or her subordinate. If the Plan Committee
obtains advice from a medical or vocational expert in connection with the Appeal, it will provide the name of
Before the Plan Committee issues its Final Adverse Benefit Determination based on a new or additional
rationale or new or additional information or records, it must provide the claimant, free of charge, with a copy of
the rationale or new or additional information or records. The Plan Committee must provide the rationale or
additional information or records as soon as possible and sufficiently in advance of the time within which a final
determination on Appeal is required to allow the claimant time to respond.
The Appeal review will be completed and written notification will be sent to the claimant within the following
periods:
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64
·
·
Pre-service Appeal – 15 calendar days after the date on which the Appeal is filed.
Post-service Appeal – 30 calendar days after the date on which the Appeal is filed.
This notification will contain the information set forth in paragraphs (1) – (9) that was provided to the claimant
following the First Level Internal Appeal.
If the Plan Committee denies the Claim, the claimant may seek further review using the External Review
Process described below.
No action in law or in equity may be brought against the Plan or any officer, employee, director or fiduciary of
the Plan, or any other party, by the claimant or his or her covered Dependents with respect to the Plan or any
benefits claimed under the Plan without full and complete compliance with the Claims and Appeals procedures
set forth in this Plan. If a lawsuit is brought, it must be filed within 2 years after the earlier of the final
determination on Appeal or final determination of an External Appeal.
Urgent Care Internal Appeal Process
A claimant may request an expedited review of a Claim by providing the Plan with clinical rationale and facts to
support the request. The Urgent Care Internal Appeal process provides for 2 levels of Appeal. All necessary
information, including the Plan’s benefit determination on review, shall be transmitted between the Plan and the
claimant by telephone, facsimile, or other available similarly expeditious method.
First Level Internal Appeal Process (Urgent)
When a claimant receives notification of an Adverse Benefit Determination, he or she has 180 days following
receipt of the notification in which to file a written request for an Appeal. A claimant may submit written
comments, documents, records, and other information relating to the Appeal. The Plan Administrator or its
designee will also provide the claimant reasonable access to and copies of information relevant to his or her
Claim for benefits. Applicable regulations define the information relevant to a Claim for benefits. It will provide
these materials upon request free of charge. The period of time within which a benefit determination on Appeal
is required to be made shall begin at the time an Appeal is filed in writing in accordance with the procedures of
the Plan. The time begins is without regard to whether all the necessary information accompanies the filing.
The Appeal should be submitted orally or in writing as follows:
Telephone: (402) 995-7000 ext. 7718 or (800) 471-0240
Facsimile: (866) 769-2399
Attention: Appeal Department
15950 West Dodge Rd
Omaha, NE 68118
The Plan Administrator or its designee will consider all comments, documents, records, and other information
submitted by the claimant relating to the Claim. This includes information not submitted or considered in the
initial benefit determination. The Appeal review will not afford deference to the initial Adverse Benefit
Determination. It will be conducted by an appropriate administrator of the Plan who is neither the individual who
made the Adverse Benefit Determination, nor a subordinate of that individual.
If the Appeal involves medical judgment, the Plan Administrator or its designee will consult with a health care
professional who has appropriate training and experience in the relevant field of medicine. The health care
professional will not be the individual who was consulted in connection with the Initial Adverse Benefit
Determination, nor his or her subordinate. If the Plan Administrator or its designee obtains advice from a
medical or vocational expert in connection with the Adverse Benefit Determination, it will provide the name of
If the Appeal of a Claim is denied, in whole or in part, the Plan Administrator or its designee shall provide written
notification of the Adverse Benefit Determination on Appeal. The Appeal review will be completed and written
notification will be sent to the claimant as soon as possible, taking into account the medical exigencies, but not
later than 72 hours of the filing of the Appeal for the Urgent Care Claim. The notice will state the following in a
manner calculated to be understood by the claimant:
Rev 6.27.14
65
(1)
(2)
The specific reason or reasons for the adverse determination, including the denial code and its
corresponding meaning, and a description of the Plan's standard, if any, that was used in denying
the Claim. In the case of a notice of final internal Adverse Benefit Determination, this description
will include a discussion of the decision.
(3)
(4)
information on how to initiate the Appeal and the time limits applicable to such procedures. It will
include a statement of the claimant's right to bring a civil action under state law following a final
(5)
A statement that the claimant is entitled to receive, upon request and free of charge, reasonable
access to, and copies of, all documents, records, and other information relevant to the Claim.
Applicable regulations define information relevant to a Claim for benefits.
(6)
(7)
(8)
The following statement: “You and Your Plan may have other voluntary alternative dispute
resolution options, such as mediation. One way to find out what may be available is to contact Your
State insurance regulatory agency.”
(9)
Second Level Internal Appeal Process (Urgent)
If a claimant receives an Adverse Benefit Determination from the First Level Internal Appeal, he or she may
Appeal the denial of the Claim. The Claimant has 180 days following receipt of the notification of the First Level
Internal Appeal in which to file a written request for a Second Level Internal Appeal. A claimant may submit
written comments, documents, records, and other information.
The Appeal should be submitted in writing as follows:
5401 South Street
Lincoln, NE 68506
The Plan Committee will also provide the claimant reasonable access to and copies of information relevant to
his or her Claim for benefits. Applicable regulations define the information relevant to a Claim for benefits. The
Plan Committee will provide these materials upon request free of charge. The period of time within which a
benefit determination on Appeal is required to be made shall begin at the time an Appeal is filed in writing in
accordance with the procedures of the Plan. The time begins without regard to whether all the necessary
information accompanies the filing.
Rev 6.27.14
66
The Plan Committee will consider all comments, documents, records, and other information submitted by the
claimant relating to the Claim. This includes information not submitted or considered in the prior benefit
determinations. The Plan Committee will not afford deference to the prior Adverse Benefit Determinations. The
Plan Committee is an appropriate administrator of the Plan which is neither the individual who made the prior
Adverse Benefit Determinations, nor the subordinate of such individual. If the Appeal involves medical judgment,
the Plan Committee will consult with a health care professional who has appropriate training and experience in
the relevant field of medicine. The health care professional will not be the individual who was consulted in
connection with the prior Adverse Benefit Determinations, nor his or her subordinate. If the Plan Committee
obtains advice from a medical or vocational expert in connection with the Appeal, it will provide the name of
Before the Plan Committee issues its Final Adverse Benefit Determination based on a new or additional
rationale or new or additional information or records, it must provide the claimant, free of charge, with a copy of
the rationale or new or additional information or records. The Plan Committee must provide the rationale or
additional information or records as soon as possible and sufficiently in advance of the time within which a final
determination on Appeal is required to allow the claimant time to respond.
If the Appeal of a Claim is denied, in whole or in part, the Plan Administrator or its designee shall provide written
notification of the Adverse Benefit Determination on Appeal. The Appeal review will be completed and written
notification shall be sent to the claimant as soon as possible, taking into account the medical exigencies, but not
later than 72 hours of the filing of the Appeal for the Urgent Care Claim. This notification will contain the
information set forth in paragraphs (1) – (9) that was provided to the claimant following the First Level Internal
Appeal.
If the Plan Committee denies the Claim, the claimant may seek further review using the External Review
Process described below.
set forth in this Plan. If a lawsuit is brought, it must be filed within 2 years after the final determination of
an External Appeal.
External Review Process
If a claimant receives a Final Adverse Benefit Determination under the Plan's Internal Claims and Appeals
Procedures, he or she may request that the Claim be reviewed under the Plan's External Review Process. The
claimant’s request for External Review will be decided according to Treasury Regulation § 54.9815-2719T and
any subsequent guidance issued by the IRS, the terms of which are incorporated by reference to the extent
required. A claimant may not seek External Review of a denial, reduction, termination, or other decision not to
provide a payment for a benefit based on a determination that a Participant or beneficiary fails to meet the
requirements for eligibility under the terms of the Plan. This request must be filed in writing within 4 months after
receipt of the Final Adverse Benefit Determination.
Within 5 business days after receipt of request for External Review, the Plan Administrator or its designee will
determine whether the Claim is eligible for review under the External Review process. This determination is
based on whether:
(1)
The claimant is or was covered under the Plan at the time the Claim was made or incurred;
(2)
The denial relates to the claimant's failure to meet the Plan's eligibility requirements;
(3)
The claimant has exhausted the Plan's Internal Claims and Appeal Procedures; and
(4)
The claimant has provided all the information required to process an External Review.
Within 1 business day after completion of this preliminary review, the Plan Administrator or its designee will
provide written notification to the claimant of whether the Claim is eligible for External Review.
Rev 6.27.14
67
Unless provided otherwise in guidance issued by the Secretary of Treasury, with respect to Claims for which
External Review has not been initiated before September 20, 2011, the External Review Process applies only to
the following:
(1)
An Adverse Benefit Determination by the Plan that involves medical judgment (including, but not
limited to, those based on the Plan’s requirements for medical necessity, appropriateness, health
care setting, level of care, or effectiveness of a covered benefit; or its determination that a treatment
is experimental or investigational), as determined by the external reviewer; and
(2)
A rescission of coverage (whether or not the rescission has any effect on any particular benefit at
that time).
If the request for review is complete but not eligible for External Review, the Plan Administrator or its designee
will notify the claimant of the reasons for its ineligibility. The notice will include contact information for the United
States Department of Labor Employee Benefits Security Administration at its toll free number (866) 444-3272.
If the request is not complete, the notice will describe the information needed to complete it. The claimant will
have 48 hours or until the last day of the 4 month filing period, whichever is later, to submit the additional
information.
If the request is eligible for External Review, the Plan will assign it to a qualified independent review organization
("IRO"). The IRO is responsible for notifying the claimant, in writing, that the request for External Review has
been accepted. The notice should include a statement that the claimant may submit in writing, within 10
business days, additional information the IRO must consider when conducting the review. The IRO will share
this information with the Plan. The Plan may consider this information and decide to reverse its denial of the
Claim. If the denial is reversed, the Plan will notify the claimant in writing and the External Review Process will
end.
If the Plan does not reverse the denial, the IRO will make its decision on the basis of its review of all of the
information in the record, as well as additional information where appropriate and available, such as:
(1)
The claimant's medical records;
(2)
The attending health care professional's recommendation;
(3)
Reports from appropriate health care professionals and other documents submitted by the Plan or
issuer, claimant, or the claimant's treating Provider;
(4)
The terms of the Plan;
(5)
Appropriate practice guidelines;
(6)
Any applicable clinical review criteria developed and used by the Plan; and
(7)
The opinion of the IRO's clinical reviewer.
The IRO must provide written notice to the Plan and the claimant of its final decision within 45 days after the
IRO receives the request for the External Review. The IRO's decision notice must contain:
(1)
A general description of the reason for the External Review, including information sufficient to
identify the Claim;
(2)
The date the IRO received the assignment to conduct the review, the date the external review was
conducted, and the date of the IRO's decision;
(3)
References to the evidence or documentation, including the evidence-based standards, the IRO
considered in reaching its decision;
(4)
A discussion of the principal reason(s) for the IRO's decision, including what applicable, if any,
evidence-based standards were a basis for its decision;
Rev 6.27.14
68
(5)
The rationale for the IRO’s decision;
(6)
A statement that the determination is binding and that judicial review may be available to the
claimant; and
(7)
Contact information for any applicable office of health insurance consumer assistance or
ombudsman established under the PPACA.
The decision of the IRO is binding on the Plan, as well as the claimant, except to the extent other remedies are
available under State or Federal law. The Plan will provide any benefits (including making payment on the
Claim) pursuant to the final External Review decision without delay, regardless of whether the Plan intends to
seek judicial review of the External Review decision and unless or until there is a judicial decision otherwise.
Generally, a claimant must exhaust the Plan's Claims and Appeal Procedures in order to be eligible for the
External Review process. However, in some cases the Plan provides for an expedited External Review if:
(1)
The claimant receives an Adverse Benefit Determination that involves a medical condition for which
the time for completion of the Plan's internal Claims and Appeal Procedures would seriously
jeopardize the claimant's life or health or ability to regain maximum function and the claimant has
filed a request for an expedited internal review; or
(2)
The claimant receives a Final Adverse Benefit Determination that involves a medical condition
where the time for completion of a standard External Review process would seriously jeopardize the
claimant's life or health or the claimant's ability to regain maximum function, or if the Final Adverse
Benefit Determination concerns an admission, availability of care, continued stay, or health care
item or service for which the claimant received emergency services, but has not been discharged
from a facility.
Immediately upon receipt of a request for expedited External Review, the Plan must determine and notify the
claimant whether the request satisfies the requirements for expedited review, including the eligibility
requirements for External Review listed above. If the request qualifies for expedited review, it will be assigned to
an IRO. The IRO must make its determination and provide a notice of the decision as expeditiously as the
claimant's medical condition or circumstances require, but in no event more than 72 hours after the IRO
receives the request for an expedited External Review. If the original notice of its decision is not in writing, the
IRO must provide written confirmation of the decision within 48 hours to both the claimant and the Plan.
set forth in this Plan. If a lawsuit is brought, it must be filed within 2 years after the earlier of the final
determination on Appeal or final determination of an External Appeal.
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COORDINATION OF BENEFITS
Coordination of the benefit plans. Coordination of benefits sets out rules for the order of payment of Covered
Charges when two or more plans -- including Medicare -- are paying. When a Covered Person is covered by this
Plan and another plan, or the Covered Person's Spouse is covered by this Plan and by another plan or the
couple's Covered Children are covered under two or more plans, the plans will coordinate benefits when a claim
is received.
The plan that pays first according to the rules will pay as if there were no other plan involved. The secondary
and subsequent plans will pay the balance due up to 100% of the total Allowable Charges.
Benefit plan. This provision will coordinate the medical benefits of a benefit plan. The term benefit plan means
this Plan or any one of the following plans:
(1)
Group or group-type plans, including franchise or blanket benefit plans.
(2)
Blue Cross and Blue Shield group plans.
(3)
Group practice and other group prepayment plans.
(4)
Federal government plans or programs. This includes Medicare.
(5)
Other plans required or provided by law. This does not include Medicaid or any benefit plan like it
that, by its terms, does not allow coordination.
(6)
No Fault Auto Insurance, by whatever name it is called, when not prohibited by law.
Allowable Charge. For a charge to be allowable it must be within the Maximum Allowable Charge and at least
part of it must be covered under this Plan.
In the case of HMO (Health Maintenance Organization) or other In-Network only plans: This Plan will not
consider any charges in excess of what an HMO or network Provider has agreed to accept as payment in full.
Also, when an HMO or network plan is primary and the Covered Person does not use an HMO or network
Provider, this Plan will not consider as an Allowable Charge any charge that would have been covered by the
HMO or network plan had the Covered Person used the services of an HMO or network Provider.
In the case of service type plans where services are provided as benefits, the reasonable cash value of each
service will be the Allowable Charge.
Automobile limitations. When medical payments are available under vehicle insurance, the Plan shall pay
excess benefits only, without reimbursement for vehicle plan Deductibles. This Plan shall always be considered
the secondary carrier regardless of the individual's election under PIP (personal injury protection) coverage with
the auto carrier.
Benefit plan payment order. When two or more plans provide benefits for the same Allowable Charge, benefit
payment will follow these rules:
(1)
Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a
provision will be considered after those without one.
(2)
Plans with a coordination provision will pay their benefits up to the Allowable Charge:
Rev 6.27.14
(a)
The benefits of the plan which covers the person directly (that is, as an employee, member
or subscriber) ("Plan A") are determined before those of the plan which covers the person
as a dependent ("Plan B").
(b)
The benefits of a benefit plan which covers a person as an Employee who is neither laid off
nor retired are determined before those of a benefit plan which covers that person as a
laid-off or Retired Employee. The benefits of a benefit plan which covers a person as a
Dependent of an Employee who is neither laid off nor retired are determined before those of
a benefit plan which covers a person as a Dependent of a laid off or Retired Employee. If
70
the other benefit plan does not have this rule, and if, as a result, the plans do not agree on
the order of benefits, this rule does not apply.
(c)
The benefits of a benefit plan which covers a person as an Employee who is neither laid off
nor retired or a Dependent of an Employee who is neither laid off nor retired are determined
before those of a plan which covers the person as a COBRA beneficiary.
(d)
When a Child is covered as a Dependent and the parents are not separated or divorced,
these rules will apply:
(e)
(f)
(i)
The benefits of the benefit plan of the parent whose birthday falls earlier in a year
are determined before those of the benefit plan of the parent whose birthday falls
later in that year;
(ii)
If both parents have the same birthday, the benefits of the benefit plan which has
covered the parent for the longer time are determined before those of the benefit
plan which covers the other parent.
When a Child's parents are divorced or legally separated, these rules will apply:
(i)
This rule applies when the parent with custody of the Child has not remarried. The
benefit plan of the parent with custody will be considered before the benefit plan of
the parent without custody.
(ii)
This rule applies when the parent with custody of the Child has remarried. The
benefit plan of the parent with custody will be considered first. The benefit plan of
the stepparent that covers the Child as a Dependent will be considered next. The
benefit plan of the parent without custody will be considered last.
(iii)
This rule will be in place of items (i) and (ii) above when it applies. A court decree
may state which parent is financially responsible for medical and dental benefits of
the Child. In this case, the benefit plan of that parent will be considered before other
plans that cover the Child as a Dependent.
(iv)
If the specific terms of the court decree state that the parents shall share joint
custody, without stating that one of the parents is responsible for the health care
expenses of the Child, the plans covering the Child shall follow the order of benefit
determination rules outlined above when a Child is covered as a Dependent and
the parents are not separated or divorced.
(v)
For parents who were never married to each other, the rules apply as set out above
as long as paternity has been established.
If there is still a conflict after these rules have been applied, the benefit plan which has
covered the patient for the longer time will be considered first. When there is a conflict in
coordination of benefit rules, the Plan will never pay more than 50% of Allowable Charges
when paying secondary.
(3)
Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare is to
be the primary payer, this Plan will base its payment upon benefits that would have been paid by
Medicare under Parts A, B and D, regardless of whether or not the person was enrolled under any
of these parts.
(4)
If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will
pay first and this Plan will pay second.
Claims determination period. Benefits will be coordinated on a Calendar Year basis. This is called the claims
determination period.
Right to receive or release necessary information. To make this provision work, this Plan may give or obtain
needed information from another insurer or any other organization or person. This information may be given or
Rev 6.27.14
71
obtained without the consent of or notice to any other person. A Covered Person will give this Plan the
information it asks for about other plans and their payment of Allowable Charges.
Facility of payment. This Plan may repay other plans for benefits paid that the Plan Administrator determines it
should have paid. That repayment will count as a valid payment under this Plan.
Right of recovery. This Plan may pay benefits that should be paid by another benefit plan. In this case this
Plan may recover the amount paid from the other benefit plan or the Covered Person. That repayment will count
as a valid payment under the other benefit plan.
Further, this Plan may pay benefits that are later found to be greater than the Allowable Charge. In this case,
this Plan may recover the amount of the overpayment from the source to which it was paid.
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72
THIRD PARTY RECOVERY PROVISION
RIGHT OF SUBROGATION AND REIMBURSEMENT
The benefits payable hereunder as a result of any injuries which give rise to a claim by any Participant,
beneficiary or any other covered person, hereinafter individually and collectively “Participant”, against a third
party tortfeasor or against any person or entity as the result of the actions of a third party are excluded from
coverage under this plan. This Plan also does not provide benefits to the extent that there is other coverage
under non-group medical payments (including auto) or medical expense type coverage to the extent of that
coverage. However, this Plan will provide benefits, otherwise payable under this Plan, to or on behalf of said
Participant only on the following terms and conditions:
1.
In the event that benefits are provided under this Plan, the Plan shall be subrogated to all of the
Participant’s (the term Participant includes any person receiving benefits hereunder including all
dependents) rights of recovery against any person or organization to the extent of the benefits provided.
The Participant shall execute and deliver instruments and papers and do whatever else is necessary to
secure such rights. The Participant shall do nothing after loss to prejudice such rights. The Participant
hereby agrees to cooperate with the Plan and/or any representatives of the Plan in completing such
forms and in giving such information surrounding any accident as the Plan or its representatives deem
necessary to fully investigate the incident.
2.
The Plan is also granted a right of reimbursement from the proceeds of any recovery whether by
settlement, judgment, or otherwise. This right of reimbursement is cumulative with and not exclusive of
the subrogation right granted in paragraph 1, but only to the extent of the benefits provided by the Plan.
3.
The Plan, by providing benefits hereunder, is hereby granted a lien on the proceeds of any settlement,
judgment or other payment intended for, payable to, or received by the Participant or his/her
representatives, and the Participant hereby consents to said lien and agrees to take whatever steps are
necessary to help the company secure said lien. The Participant agrees that said lien shall constitute a
charge upon the proceeds of any recovery and the Plan shall be entitled to assert security interest
thereon. By the acceptance of benefits under the Plan, the Participant and his/her representatives
agree to hold the proceeds of any settlement in trust for the benefit of the Plan to the extent of 100% of
all benefits paid on behalf of the Participant.
4.
By accepting benefits hereunder, the Participant hereby grants a lien and assigns to the Plan an amount
equal to the benefits paid against any recovery made by or on behalf of the Participant. This
assignment is binding on any attorney who represents the Participant whether or not an agent of the
Participant and on any insurance company or other financially responsible party against whom a
Participant may have a claim provided said attorney, insurance carriers or others have been notified by
the Plan or its agents.
5.
The subrogation and reimbursement rights and liens apply to any recoveries made by the Participant as
a result of the injuries sustained, including but not limited to the following:
Rev 6.27.14
a.
Payments made directly by the third party tortfeasor, or any insurance company on
behalf of the third party tortfeasor, or any other payments on behalf of the third party
tortfeasor.
b.
Any payments or settlements or judgment or arbitration awards paid by any insurance
company under an uninsured or underinsured motorist coverage, whether on behalf of
a Participant or other person.
c.
Any other payments from any source designed or intended to compensate a Participant
for injuries sustained as the result of negligence or alleged negligence of a third party.
d.
Any worker’s compensation award or settlement.
e.
Any recovery made pursuant to no-fault insurance.
f.
Any medical payments made as a result of such coverage in any automobile or
homeowners insurance policy.
73
This section will be interpreted in accordance with Neb. Rev. Stat. § 44-3,159.
6.
No adult Participant hereunder may assign any rights that it may have to recover medical expenses
from any tortfeasor or other person or entity to any minor Child or Children of said adult Participant
without the prior express written consent of the Plan. The Plan’s right to recover (whether by
subrogation or reimbursement) shall apply to decedents’, minors’, and incompetent or disabled persons’
settlements or recoveries.
7.
No Participant shall make any settlement, which specifically reduces or excludes, or attempts to reduce
or exclude the benefits provided by the Plan.
8.
The Plan’s right of recovery shall be a prior lien against any proceeds recovered by the Participant,
which right shall not be defeated nor reduced by the application of any so-called “Made-Whole
Doctrine”, “Rimes Doctrine”, or any other such doctrine purporting to defeat the Plan’s recovery rights by
allocating the proceeds exclusively to non-medical expense damages.
9.
No Participant hereunder shall incur any expenses on behalf of the Plan in pursuit of the Plan’s rights
hereunder, specifically, no court costs nor attorneys fees may be deducted from the Plan’s recovery
without the prior express written consent of the Plan. This right shall not be defeated by any so-called
“Fund Doctrine”, or “Common Fund Doctrine”, or “Attorney’s Fund Doctrine”.
10.
The Plan shall recover the full amount of benefits provided hereunder without regard to any claim of
fault on the part of any Participant, whether under comparative negligence or otherwise.
11.
The benefits under this Plan are secondary to any coverage under no-fault or similar insurance.
In the event that a Participant shall fail or refuse to honor its obligations hereunder, then the Plan shall be
entitled to recover any costs incurred in enforcing the terms hereof including but not limited to attorney’s fees,
litigation, court costs, and other expenses. The Plan shall also be entitled to offset the reimbursement obligation
against any entitlement to future medical benefits hereunder until the Participant has fully complied with his
reimbursement obligations hereunder, regardless of how those future medical benefits are incurred.
By acceptance of benefits under the Plan, the Participant agrees that a breach hereof would cause irreparable
and substantial harm and that no adequate remedy at law would exist. Further, the Plan shall be entitled to
invoke such equitable remedies as may be necessary to enforce the terms of the Plan, including, but not limited
to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as
injunctive relief.
Defined terms: "Covered Person" means anyone covered under the Plan, including minor dependents.
"Recover," "Recovered," "Recovery" or "Recoveries" means all monies paid to the Covered Person by way of
judgment, settlement, or otherwise to compensate for all losses caused by the Injury or Sickness, whether or not
said losses reflect medical or dental charges covered by the Plan. "Recoveries" further includes, but is not
limited to, recoveries for medical or dental expenses, attorneys' fees, costs and expenses, pain and suffering,
loss of consortium, wrongful death, lost wages and any other recovery of any form of damages or compensation
whatsoever.
"Refund" means repayment to the Plan for medical or dental benefits that it has paid toward care and treatment
of the Injury or Sickness.
"Subrogation" means the Plan's right to pursue and place a lien upon the Covered Person's claims for medical
or dental charges against the other person.
"Third Party" means any Third Party including another person or a business entity.
Recovery from another plan under which the Covered Person is covered. This right of Refund also applies
when a Covered Person Recovers under an uninsured or underinsured motorist plan (which will be treated as
Third Party coverage when reimbursement or Subrogation is in order), homeowner's plan, renter's plan, medical
malpractice plan or any liability plan.
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74
Rights of Plan Administrator. The Plan Administrator has a right to request reports on and approve of all
settlements.
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75
CONTINUATION OF COVERAGE
If You lose Your coverage under this health Plan due to a qualifying event, You may continue Your coverage for
a limited time. An individual covered by this health Plan on the day before a qualifying event occurs who is either
an Employee, the Employee’s Spouse, or an Employee’s Dependent Child are eligible to continue coverage. In
addition, any Child born to or placed for adoption with a covered Employee during the period of continuation of
coverage is considered as eligible to be covered under any continuation of coverage in force at that time. The
qualifying events which make a Participant eligible for continuation coverage depend on the identity of the
person covered. In all instances, a qualifying event shall be deemed to occur only if the event would otherwise
cause a loss of coverage under this health Plan.
If You are an Employee, the qualifying events which will make You eligible to continue coverage are:
1.
termination of service;
2.
reduction of hours below eligibility requirements; or
3.
when coverage ends due to reaching the allowable limits for leaves of absence as established by
the Employer.
If You are a Spouse of an Employee, the qualifying events which will make You eligible to continue coverage
are:
1.
the Employee's termination of service, the Employee's reduction in work hours below eligibility
requirements, or when coverage ends due to reaching the allowable limits for leave of absence as
established by the Employer.
2.
Your divorce or legal separation from the Employee; or
3.
the death of the Employee.
If You are a Child of an Employee, the qualifying events which will make You eligible to continue coverage are:
1.
the Employee's termination of service, the Employee's reduction of hours below eligibility
requirements, or when coverage for the Employee ends due to reaching the allowable limits for
leave of absence as established by the Employer;
2.
the death of the Employee;
3.
the divorce or legal separation of the Employee; or
4.
a loss of coverage for You because of Your age.
In order to continue coverage, You must satisfy each of the following conditions:
1.
You must have experienced a qualifying event which caused You to lose coverage under
health Plan;
2.
within 30 days from the later of the coverage loss date or the date the continuation of coverage
election notice is provided, You must complete a continuation of coverage enrollment form and pay
Your first monthly premium in an amount to be determined from time to time by the Committee; and
3.
pay all subsequent premium payments by the first day of the covered month and in no event later
than the last day of the covered month.
Your continuation of coverage shall terminate upon the earliest of the following dates:
1.
the date the Employer terminates all health Plans offered to any Employee;
2.
the date You fail to timely pay a required monthly premium;
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76
this
3.
the date You are covered under another group health plan;
4.
the date You are eligible for Medicare; or
5.
twelve months from the qualifying event or 29 months from the qualifying event for qualified
Employee disability situations. Disability of the Employee may extend the 12-month period of
continuation of coverage for up to an additional 17 months for a qualifying event that is termination
of employment or reduction in hours. To qualify for the additional 17 months of continuation of
coverage, the Employee must: a) have a ruling from the Social Security Administration that he or
she became disabled prior to or within the first 60 days from the start of the continuation of
coverage period; and b) send the Plan a copy of the Social Security ruling letter within 60 days of
receipt and prior to the expiration of the initial 12-month continuation of coverage period.
You are required to notify the Employer within 30 days in case of divorce or legal separation or when a
Dependent Child ceases to be eligible.
GENERAL PROVISIONS
A. Governing Law. The Plan is established in the State of Nebraska. To the extent federal law does not apply,
any questions arising under the Plan shall be determined under the laws of the State of Nebraska.
B. Interpretation. We have the discretionary authority to construe the terms of the Plan and to determine all
questions that arise under it. Such power includes, for example, the administrative discretion necessary to
determine whether an individual meets the Plan's written eligibility requirements, or to interpret any other term
contained in this Plan Document. Further, to the extent that any Plan benefit is subject to a determination of
Medical Necessity, usualness or the like, We will make that factual determination. Our interpretations and
determinations are binding on all Employees, Retired Employees, Dependents and their beneficiaries.
C. Alienation. No benefits under this Plan may be assigned, or be subject to anticipation, garnishment,
attachment, execution, or levy of any kind, or be liable for Your debts or obligations, except that You may
authorize benefits to a Provider of medical services or supplies. We may direct that benefits under this Plan be
paid directly to the Provider of the benefits or to both You and the Provider of benefits in whatever manner We
authorize.
If a person who is entitled to receive a payment under the Plan is, in our opinion, incapable of giving a valid
receipt for the payment and if no guardian has been appointed for that person, We may make the payment to
the person or persons who in our opinion have assumed the obligations of caring for the person on whose
behalf the payment is made.
Notwithstanding the foregoing, this Plan will honor any assignment of rights made by or on behalf of a
Participant or a beneficiary of the Participant as required by Medicaid, that is, a state plan for medical assistance
approved under Title XIX of the Social Security Act. In addition, to the extent that Medicaid makes payments
which this Plan has a legal liability to make, this Plan will reimburse Medicaid for those payments, but only to the
extent it is required to do so by state statute.
D. Termination and Amendment. Although We intend to continue the Plan indefinitely, We
reserve the right to amend or even terminate the Plan. Any amendment to the Plan will be in writing. We
may delegate to the Committee by corporate resolution the power to amend the Plan and may revoke that
delegation.
E. General Information. The Plan is funded through Employer and Employee contributions, except that selfpayment by Employees or Dependents to maintain their coverage is required in some circumstances. The Plan
records are maintained on the basis of a fiscal year ending June 30. The Employer's tax identification number is
47-0439599 and the Plan's number is 506.
F. Agent for Service of Process. The Employer is the agent for service of process for the Plan. The
Employer's address and telephone number is 5401 South Street, Lincoln, Nebraska 68506, (402) 483-9588.
G. Gender and Number. In the construction of this Plan the masculine shall include the feminine and the
singular the plural in all cases where those meanings would be appropriate.
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77
H. Plan Not in Place of Workers' Compensation. This Plan is not in place of and does not affect any
requirement for coverage by Workers' Compensation insurance.
I. Committee. The duties of the Employer relating to the administration and operation of the Plan shall be solely
controlled and managed by a committee (the "Committee") of not less than three (3) individuals, the sole
purpose of which is the administration of this Plan. Members of the Committee will consist of persons who are
employed by, or who are directors of the Employer. The members of this Committee will be directly accountable
to, and serve at the pleasure of, the Employer's board of directors.
The Employer agrees to indemnify, defend and hold harmless the members of the Committee from and against
any and all claims, causes of action, loss, damage or expense arising out of their acts or omissions while
serving on such Committee, so long as such acts or omissions occur through the exercise of good faith.
The Committee so appointed shall meet with such frequency as it determines is necessary in order to fulfill the
committee's duties, but in any event at least annually. The Committee shall select from its members a Chairman
who shall be responsible for calling and conducting the meetings and executing documents on behalf of the
Committee, and where authorized by the Employer's board of directors, on behalf of the Employer. The
Committee shall also select from its members a Secretary who shall take and keep minutes of the Committee's
action. The Secretary of the Committee may certify to appropriate parties copies of minutes and other action
taken by the Committee. Any party dealing with the Employer may rely upon documents signed by the Chairman
or Secretary as the official actions of the Committee.
J. Committee Powers. The Committee shall have all powers necessary to administer the Plan, including
without limitation, powers:
1)
To maintain complete and accurate records of all Plan transactions, contributions and
distributions;
2)
To adopt rules of procedure and regulations necessary for the proper and efficient administration of
the Plan. All rules and decisions of the Committee shall be uniformly and consistently applied to all
Participants in similar circumstances;
3)
To enforce the terms of the Plan and rules and regulations the Committee adopts;
4)
To interpret the Plan as provided in Article IX, Section B.
5)
To furnish Participants, upon request, with information which Participants may require for tax or
other purposes;
6)
To employ agents, attorneys, accountants or other persons (who also may be employed by or
represent the Employer) for such purposes as the Committee considers necessary or
desirable in connection with its duties hereunder;
7)
To apply for and take all steps as may be necessary to secure insurance contracts with one or more
insurers as and when required by the Employer, and pay or coordinate payment between the
insurance company or companies and the Employer any and all premiums as and when such
premiums become due;
8)
To perform any and all other acts necessary or appropriate for the proper management and
administration of the Plan.
K. Effective Date. The Effective Date of this Plan is July 1, 2009. It is effective for Plan Participants, Eligible
Employees and individuals continuing coverage under the plan on or after that date.
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78
PROVIDING PROTECTED HEALTH INFORMATION TO PLAN SPONSOR
A. Permitted Uses and Disclosure of Summary Health Information. The Plan (or a health insurance issuer
or HMO with respect to the Plan) may disclose Summary Health Information to Madonna Rehabilitation Hospital
(the “Plan Sponsor”), provided the Plan Sponsor requests the Summary Health Information for the purpose of:
a.
Obtaining premium bids from health plans for providing health insurance coverage under the
Plan; or
b.
Modifying, amending, or terminating the Plan.
B. Certification of Plan Sponsor. The Plan (or a health insurance issuer or HMO with respect to the Plan) shall
disclose Protected Health Information (“PHI”) to the Plan Sponsor only upon receipt of a certification by the Plan
Sponsor that the Plan has been amended to incorporate the provisions of 45 CFR § 164.504(f)(2)(ii), and that
the Plan Sponsor agrees to the conditions of disclosure set forth in Section C of this Article. The Plan shall not
disclose and may not permit a health insurance issuer or HMO to disclose PHI to the Plan Sponsor as otherwise
permitted herein unless the statement required by 45 CFR § 164.520(b)(1)(iii)(C) is included in the appropriate
notice.
C. Conditions of Disclosure. The Plan Sponsor agrees that with respect to any PHI disclosed to it by the Plan,
a health insurance issuer or an HMO, the Plan Sponsor shall:
a.
Not use or further disclose the PHI other than as permitted or required by the Plan documents or as
required by law.
b.
Ensure that any agents, including a subcontractor, to whom it provides PHI received from the
Plan, agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to
such PHI, and ensure that any agents, including a subcontractor, agree to implement reasonable
and appropriate security measures to protect and safeguard Electronic PHI.
c.
Not use or disclose the PHI for employment related actions and decisions or in connection with any
other benefit or employee benefit plan of the Plan Sponsor.
d.
Report to the Plan any use or disclosure of the information that is inconsistent with the uses or
disclosures provided for of which it becomes aware.
e.
Make available PHI in accordance with 45 CFR § 164.524.
f.
Make available PHI for amendment and incorporate any amendments to PHI in accordance with 45
CFR § 164.526.
g.
Make available the information required to provide an accounting of disclosures in accordance with
45 CFR § 164.528.
h.
Make its internal practices, books, and records relating to the use and disclosure of PHI received
from the Plan available to the Secretary of Health and Human Services for purposes of determining
compliance by the Plan with Subpart E of 45 CFR § 164.
i.
If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor maintains in any
form and retain no copies of such PHI when no longer needed for the purpose for which disclosure
was made, except that, if such return or destruction is not feasible, limit further uses and disclosures
to those purposes that make the return or destruction of the information infeasible.
j.
Ensure that the adequate separation between Plan and Plan Sponsor, required in 45 CFR §
164.504(f)(2)(iii), is established.
D. Adequate Separation Between Plan and Plan Sponsor. The Plan Sponsor shall only allow those persons
identified in Exhibit “A” attached hereto, and incorporated herein, to be given access to the PHI to be disclosed.
These specified persons shall only have access to and use of PHI to the extent necessary to perform the Plan
Administration Functions that the Plan Sponsor performs for the Plan. The Plan Sponsor shall ensure that this
separation is supported by reasonable and appropriate security measures. In the event that any of these
Rev 6.27.14
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specified persons do not comply with the provisions of this Article, that person, if an Employee of the Plan
Sponsor, shall be subject to disciplinary action by the Plan Sponsor for noncompliance pursuant to the Plan
Sponsor’s Employee discipline and termination procedures. If that person is a non-employee, the Plan Sponsor
shall take appropriate action with the entity involved, to ensure that appropriate discipline or sanctions are
imposed and that non-compliance does not recur.
E. Permitted and Non-permitted Uses and Disclosure of Protected Health Information. Unless otherwise
permitted by law, and subject to obtaining a written certification pursuant to Section B of this Article, the Plan
may disclose PHI to the Plan Sponsor, provided the Plan Sponsor uses or discloses such PHI only for the
purpose of carrying out Plan Administration Functions that the Plan Sponsor performs for the Plan, consistent
with the provisions of Section C of this Article. Notwithstanding the provisions of this Article to the contrary, in no
event shall the Plan Sponsor be permitted to use or disclose PHI in a manner that is inconsistent with 45 CFR §
164.504(f). The Plan may not permit a health insurance issuer or HMO with respect to the Plan to disclose PHI
to the Plan Sponsor except as permitted by 45 CFR § 164.504(f).
The Plan may not disclose PHI to the Plan Sponsor for the purpose of employment-related actions or decisions
or in connection with any other benefit or employee benefit plan of the Plan Sponsor.
F. Information Regarding Participation. Notwithstanding Section E of this Article, the Plan, or a health
insurance issuer or HMO with respect to the Plan, may disclose to the Plan Sponsor information on whether an
individual is participating in the Plan, or is enrolled in or has disenrolled from a health insurance issuer or HMO
offered by the Plan.
G. Definitions. The following definitions apply for purposes of this Article:
a. Covered Entity means:
i. a Health Plan;
ii. a health care clearing house; or
iii. a health care Provider who transmits any Health Information in electronic form in connection with
the transmission of information between two parties to carry out financial or administrative activities
related to health care.
b. Health Information means: any information, whether oral or recorded in any form or medium, that:
i.
is created or received by a health care Provider, health plan, public health authority, employer, life
insurer, school or university, or health care clearing house; and
ii.
relates to the past, present or future physical or Mental Health or condition of an individual; the
provision of health care to an individual; or the past, present or future payment for the provision of
health care to an individual.
c. Health Plan means: an individual or group plan that provides or pays the cost of medical care (as
defined in Section 2791(a)(2) of the Public Health Service Act, 42 U.S.C. § 300gg-91(a)(2)).
d. Individually Identifiable Health Information means: a subset of Health Information including
demographic information collected from an individual, and which:
i.
is created or received by a health care Provider, Health Plan, employer, or health care clearing
house; and
ii.
relates to the past, present, or future physical or Mental Health or condition of an individual; the
provision of health care to an individual; or the past, present, or future payment for the provision of
health care to an individual; and
(1) that identifies the individual; or
(2) with respect to which there is a reasonable basis to believe the information can be used to
identify the individual.
e. Plan Administration Functions means: administration functions performed by the Plan
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80
Sponsor on behalf of the Plan, excluding functions performed by the Plan Sponsor in
connection with any other benefit or benefit plan of the Plan Sponsor.
f. Protected Health Information (PHI) means: Individually Identifiable Health Information:
i.
Except as provided in paragraph ii below that is:
(1) transmitted by electronic media;
(2) maintained in any media described in the definition of electronic media at 42 CFR § 162.103;
or
(3) transmitted or maintained in any other form or medium.
ii.
Protected Health Information excludes Individually Identifiable Health Information in:
(1) Education records covered by the Family Educational Rights and Privacy Act, as amended,
20 U.S. C. § 1232g;
(2) Records described at 20 U.S.C. § 1232g(a)(4)(B)(iv); and
(3) Employment records held by a Covered Entity in its role as employer.
g. Summary Health Information means: information that:
i.
Summarizes the claims history, claims expenses or type of claims experienced by individuals for
whom a plan sponsor has provided health benefits under a Health Plan; and
ii.
From which the information described at 42 CFR § 164.514(b)(2)(i) has been deleted, except that
the geographic information described in 42 CFR § 164.514(b)(2)(i)(B) need only be aggregated to
the level of a five digit zip code.
Exhibit “A”
1. Madonna Rehabilitation Hospital Human Resources staff, including the Director Human Resources, Human
Resources Manager, Benefits Specialist, and Human Resources Specialist. Other Human Resources staff may
come into contact with a Participant’s PHI and other information as part of his or her job duties and in the
communication process to or by Human Resources.
2. Madonna Rehabilitation Hospital Accounting and Finance and staff, including Accounting and Finance by
Coventry and/or HR or other parties regarding Participants with potential and actual reinsurance claims for
financial purposes, the budget Cost Accounting Specialist and Accountant II Affiliate Accounting. Others in
Accounting may have access to the Plan records area but will not use or work with the information unless
requested to do so by an authorized party. Accounting and Finance are responsible for financial administration
of Health Plans, monitoring of the Plan’s claims activity, and funding of the Plan Accounts, as well as historical
Plan financial records retention.
3. Madonna Rehabilitation Hospital Plan Committee (Chief Operations Officer, Director Human Resources, and
Human Resources Manager), and, upon request by the Plan Committee, other Madonna executives and their
executive assistants or secretaries as necessary, for purposes of assisting the Plan Committee review Plan
benefits, Participant Plan appeals, and overall Plan operations.
4. Madonna Rehabilitation Hospital Chief Financial Officer, as necessary as part of the financial review process
of Madonna’s Health Plans, normally resulting from large claims which have potential for reinsurance
reimbursement.
5. Madonna Rehabilitation Hospital Chief Executive Officer, as necessary as part of the financial review of Plan
activity.
6. Madonna Rehabilitation Hospital designated Madonna individual, for purposes of health care operations,
including quality assessment and improvement activities, establishment and administration of a wellness
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program in effort to reduce or contain costs under the Plan, or establishment and administration of other
employee benefit programs directly related to employee health claims.
7. Coventry Participants claims are typically submitted directly by health Providers to Coventry. When
Participants request assistance with claims and follow-up is needed with Coventry, PHI will be used or disclosed
as necessary. Coventry also may request medical records from health care Providers for purposes of claims
processing.
8. MedTrak Pharmacy Benefit Management. If Madonna finds it necessary, it may enter into an agreement with
MedTrak to review health claims activity in conjunction with prescription claims in order to provide an analysis of
the interrelationship between prescription expenses and other plan claims in order to provide recommendations
on alternative treatment, Participant education, or plan benefits. When Participants request assistance with
claims status and follow-up is needed with Coventry, PHI may be used and/or disclosed as necessary.
9. Coventry (PPO network). Claims are typically submitted directly by health Providers to Coventry Health Care
for payment. When Participants request assistance with claims follow-up and interaction is necessary with
Coventry, MedTrak, and/or other parties, PHI may be used and/or disclosed as necessary by Human Resources
or others in order to research and resolve questions and issues.
10. The Reinsurance Carrier. Information is used and/or disclosed by those with access to this information as
necessary for purposes of enrollment and/or insurance claims, which have potential for reimbursement to the
Plan as a result of the amount of the claims incurred during the Plan Year. PHI is also used and/or disclosed by
Coventry and/or Madonna with The Reinsurance Carrier for purposes of renewing the reinsurance policy and
establishing premium rates.
11. Cline, Williams, Wright, Johnson & Oldfather, L.L.P. and other legal counsel of Madonna. This includes
Madonna’s internal General Counsel for assistance with Plan operations, including Plan interpretation and legal
and other action related to claims activity. Upon request by the Plan Committee or General Counsel, the
Credentialing Contract Review Specialist for purposes of assisting General Counsel with subrogation claims
correspondence and/or health plans contracts.
12. Off-Site Storage Facility. Historical benefit Plan and other related documents and information is stored at an
off-site storage facility. Documents stored at this location are maintained in a confidential manner with only
authorized parties having access to the documents. If records or documents are needed from this location, upon
receipt of authorization from Madonna, records will be pulled and delivered to Madonna. Only parties authorized
to use and/or disclose PHI for authorized purposes will request and/or use documents or information from this
storage facility.
13. Health Care Providers. When Madonna is contacted by a Participant or health care Provider regarding
claims activity and status of payments, Madonna may need to use or disclose PHI to assist or answer questions
relative to claims activity.
14. Madonna Rehabilitation Hospital Corporate Compliance Committee, the members of which are responsible
for ensuring resolution of issues and investigating complaints related to HIPAA. In so doing, the Corporate
Compliance Committee members may use or disclose PHI as necessary in the course of their duties.
15. Insurance Companies and Specialists/Consultants including SilverStone Group may use or disclose PHI to
consulting health care Providers, insurance companies and plan consultants including SilverStone Group for
purposes of claims processing, case management, general operations or to obtain bids for reinsurance or
prescription programs.
16. Workers’ Compensation and Madonna Employee Health, for purposes of coordination with Madonna’s
Health Plans or in order to comply with laws, regulations and processing and/or coordination of claims related to
Workers’ Compensation.
17. As Required by Law or Public Health Authorities, to respond to a court order, subpoena, warrant, summons
or similar legal process for judicial and administrative proceedings and to assist law enforcement officials in their
duties. The Center for Medicare and Medicaid Services is an example of a public entity which requires periodic
reporting of information regarding Health Plan participation.
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18. Participants, Participant’s Family Members and Personal Representatives, who may request assistance and
information regarding Participant claims. Such persons often desire assistance by Human Resources in
resolving or clarifying claims issues. In doing so, PHI will be used or disclosed as necessary.
SECURITY REQUIREMENTS
A. Certification of Plan Sponsor. The certification of Madonna Rehabilitation Hospital (the “Plan Sponsor”)
required pursuant to Article X, paragraph B of the Plan (the HIPAA Privacy Amendment) shall also certify that
the Plan Sponsor will comply with the Security Standards as set forth at 45 CFR Parts 160, 162, and 164 (the
“Security Rule”).
B. Conditions of Disclosure. The Plan Sponsor agrees that with respect to any PHI, as defined in Article X,
paragraph G.f of the Plan (the HIPAA Privacy Amendment), disclosed to it by the Plan, a health insurance issuer
or an HMO, the Plan Sponsor shall:
1. Ensure that any business partner to whom it provides PHI received from the Plan, agrees to the same
privacy and security restrictions and conditions that apply to the Plan Sponsor with respect to such PHI.
2. Report to the Plan any security incident as that term is defined in 45 CFR §164.304.
3. Ensure that electronic “firewalls” are in place to secure electronic PHI.
4. Implement reasonable and appropriate safeguards for electronic PHI as defined in 45 CFR §164.103,
created, received, maintained, or submitted to or by the Plan Sponsor on behalf of the Plan, in
accordance with the Security Rule.
CONTRIBUTIONS
A. Employee/Employer Contributions. The Employer will pay a portion of the cost of coverage for Eligible
Employees. Eligible Employees must pay a portion of the cost of coverage for their Dependents, if coverage for
Dependents is elected. The Plan Sponsor will determine from time to time the cost of coverage and designate
the portion of the cost that must be paid by the Eligible Employee on behalf of themselves and their covered
Dependent(s), if applicable.
B. Contributions During Family Medical Leave (FMLA). An Employee on FMLA leave is entitled to continue
health care coverage under this Plan on the same basis as an Employee. An Employee on FMLA leave is also
entitled to make coverage changes as allowed during continuous employment, such as adding coverage for a
new Child and as otherwise provided in this Plan. If the health coverage is terminated during the FMLA leave or
the Employee chooses not to continue coverage during the FMLA leave, when the Employee returns to work,
the Employee is entitled to be reinstated at the same benefit levels and terms as before the FMLA leave and no
qualification requirements (i.e. Waiting Periods, Pre-Existing Condition exclusions) may be imposed on the
benefit level and benefit terms.
If an Employee fails to return from FMLA leave after the allowed leave period has expired and such failure is
due to reasons other than continuation, recurrence or onset of a serious health condition that would entitle an
Employee to such leave, or due to other circumstances beyond the Employee’s control, the Employer may
recover the contribution that was paid for maintaining the Employee’s Health Plan coverage during any period of
said (unpaid) leave.
C. Contributions During Total Disability. To continue coverage while on Total Disability, Employees must
make contributions on behalf of themselves and their covered Dependents. Contact the Employer for details.
Rev 6.27.14
83
GENERAL PLAN INFORMATION
TYPE OF ADMINISTRATION
The Plan is a self-funded group health Plan and the administration is provided through a Third Party Claims
Administrator. The funding for the benefits is derived from the funds of the Employer and contributions made by
covered Employees. The Plan is not insured.
PLAN NAME
Madonna Health Plan
TAX ID NUMBER: 47-0439599
PLAN EFFECTIVE DATE: July 1, 2009; Restated July 1, 2014
PLAN YEAR ENDS: June 30
EMPLOYER INFORMATION
5401 South Street
Lincoln, NE 68506
PLAN ADMINISTRATOR
5401 South Street
Lincoln, NE 68506
CLAIMS ADMINISTRATOR
For Claims:
P.O. Box 7705
London, KY 40742
1-800-288-3343
For Other Inquiries:
Madonna Health Plan
5401 South Street
Lincoln, NE 68506
Rev 6.27.14
84
Rev 6.27.14
85
PREAUTHORIZATION EXHIBIT
COVENTRY HEALTH CARE OF NEBRASKA
Preauthorization is the process for authorizing the non-emergency use of facilities and other health services
before care is provided. Certain services MUST be preauthorized. Prior authorization is completed to determine
medical necessity of the services and is not a confirmation that the services are a covered benefit or that the
member is eligible under the plan. Eligibility and benefits are determined at the time the claims are processed.
Many services do not require prior authorization, however, it should not be assumed that those services are
covered under Your benefit plan. Some services may be excluded from coverage, may be experimental or
investigational, cosmetic, custodial or otherwise not covered under the plan. If You have questions regarding
whether a service is covered under Your benefit plan, please call customer services at the number provided on
Your ID card.
In most cases the prior authorization will be completed by the Provider if they are an In-Network, Participating
Provider. You are responsible for obtaining the prior authorization for services provided by Out-ofNetwork, Non-Participating Providers.
SERVICES REQUIRING PREAUTHORIZATION
·
·
·
·
·
All Hospital admissions, including observations
All Inpatient Mental Health and substance abuse treatment
All admissions to Skilled Nursing Facilities or Inpatient Specialty care programs
Transplants
Initial review for non-surgical obesity services
TO PRIOR AUTHORIZE MEDICAL SERVICES CALL THE NUMBERS LISTED ON YOUR ID CARD.
Rev 6.27.14
86
Madonna Rehabilitation Hospital · 5401 South Street · Lincoln, Nebraska 68506
Effective: April 14, 2004, updated effective July 1, 2012
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (“Notice”) describes the privacy practices of the following Employee health
Plans (“the Plans”): Madonna Health Plan; Madonna Rehabilitation Hospital Group Dental Plan; and Madonna
Rehabilitation Hospital Health Care Flexible Spending Account Plan. The Plans are sponsored by Madonna
Rehabilitation Hospital as Sponsoring Employer. The Madonna Foundation is a Participating Employer in the
Plans. Each of the Plans is required to protect the privacy of Your health information. The Plans are an
organized health care arrangement and may share Your health information as needed for treatment or payment
purposes. They may also share Your information for the health care operations of their organized health care
arrangement.
In this Notice, “Your health information” means the health information maintained by one or more of the Plans
about plan Participants or their family Members. “Your health information” may include information that
identifies You or a family Member and that relates to the individual’s physical or Mental Health. It includes
information about a diagnosis or treatment. It also includes insurance information and health care claims and
payment information.
This joint Notice is provided to You to comply with the federal privacy regulations known as HIPAA and covers
all health information maintained by the Plans listed above. It describes how the Plans may use and disclose
Your health information. It also describes Your rights and the Plans’ responsibilities about uses or disclosures
of Your health information.
Your Health Information Rights. You have the following rights about Your health information:
Right to Request Restrictions. You have the right to request limits on how the Plans use or disclose Your
health information for payment, treatment, or health care operations. You may also request limits on disclosures
to a family Member or friend who is involved with Your care or payment for Your care. We are not required to
comply with a requested restriction unless: (1) Your request is to restrict disclosures to health plans; (2) Your
request only limits disclosures made for the purpose of carrying out payment or health care operations; (3) the
request only limits disclosures relating to health care items or services for which You, or another person on Your
behalf other than the health plan, have paid for out of pocket in full; and (4) the disclosure is not otherwise
required by law. To request a restriction, send Your request in writing to the Plan Committee, Attention: Benefits
Specialist, Madonna Rehabilitation Hospital, 5401 South Street, Lincoln, Nebraska 68506. In Your request, tell
us (1) what information You want to limit; (2) whether You want to limit use, disclosure or both; and (3) to whom
the limits should apply.
Right to Access. Except for certain types of records, You have the right to review and copy Your health
information. In some circumstances You may have the right to receive this information in an electronic copy
sent to an entity or individual You have clearly, specifically, and conspicuously designated. If You would like to
review and copy this information, please submit Your request in writing to the Plan Committee as listed above.
Right to Request Amendments. You have the right to request a change to Your health information if You
believe the information is inaccurate or incomplete. You must provide a reason that supports Your request.
Requests must be in writing and sent to the Plan Committee. The Plans are not required to change Your health
information. If Your request is denied, the Plans will provide You with information about the decision.
Right to Confidential Communications. You have the right to ask that the Plans communicate with You
confidentially about Your health information in certain ways or at certain locations. To request confidential
communications, please make Your request in writing to the Plan Committee. Your request must say how or
where You wish to be contacted. The Plans will accommodate all reasonable requests as determined by the
Rev 6.27.14
87
Plan Committee.
Right to an Accounting. You have the right to ask for an accounting or list of certain disclosures the Plans or
their business associates may make of Your health information that were for reasons other than treatment,
payment, or health care operations. In some circumstances, You may have the right to receive an accounting of
disclosures, for the last three years, which were made for treatment, payment or healthcare operations
purposes. Your request for an accounting of disclosures should be made in writing to the Plan Committee.
Right to Receive Notification of Certain Breaches. You have the right to be notified by us if Your information
is improperly used or disclosed. Generally, You will be notified about an improper use or disclosure of Your
information if: (1) it was not secured by encryption or other means that follow federal standards, (2) Your
information was accessed, disclosed, or used in violation of federal laws, and (3) the access, disclosure, or use
poses a significant risk of harm to Your reputation, could cause harm to You financially, or otherwise. This
notification will contain important information about the breach and where You can obtain further information.
In addition to these rights, You have a right to receive a paper copy of this Notice of Privacy Practices upon
request.
Plan Responsibilities. The Plans are required to:
·
·
·
Protect the privacy of Your health information according to the law’s requirements;
Provide You with a current copy of this Notice of Privacy Practices upon request; and
Follow the Notice of Privacy Practices currently in effect.
How the Plans May Use or Disclose Your Health Information without Your Authorization. The Plans may
use or disclose Your health information without Your authorization as generally described below:
For Treatment Purposes. For example, if one of Your health care Providers requests health information from a
Plan, the Plan may provide that information to the Provider for Your care.
For Payment Activities. The payment activities of the Plans include, but are not limited to the following:
Determining eligibility for plan benefits, obtaining premiums, arranging to pay for treatment or services provided,
processing claims, coordinating benefits, and determining if a Plan is responsible for paying benefits. For
example, payment functions by a Plan may include uses or disclosures of Your health information to determine
if health care services You received are covered by a Plan, whether the services were Medically Necessary, or
to assist You or a family Member with claims follow-up.
For Health Care Operations. The Plans may use or disclose Your health information for Plan administration.
The Plans may disclose Your health information to other persons or entities, known as “business associates,”
who provide services to the Plans, such as third-party administrators, re-insurers, off-site storage facilities,
software vendors, attorneys, accountants, insurance companies, or other consultants. Examples of the Plans’
health care operations include: (a) Arranging for medical review, legal services, audit services, and fraud and
abuse detection programs; (b) premium rating, and other activities related to plan coverage; (c) conducting
quality assessment and improvement activities; (d) submitting claims for stop-loss coverage; (e) analyzing
claims data to assist in adding new benefits or changing the Plans; (f) general data analysis for the plans; and
(g) business planning, management, and general administration.
To You, Your Family, or Your Representatives. The Plans may use or disclose Your health information to
You or to a Member of Your family, or to another relative or close friend who is directly involved in Your health
care or payment for Your care. This often occurs when You request claims follow-up assistance. The Plans
may also disclose Your health information to Your personal representative designated by law, such as a legal
guardian, health care power of attorney, or the personal representative of Your estate.
Plan Sponsor. The Plans may disclose Your health information to the Plans’ Sponsor, Madonna Rehabilitation
Hospital, to its Plan Committee, and to the Madonna Employees who carry out the administrative functions of
the Plans. The Plan Sponsor is required to protect the health information provided and cannot use or disclose
the health information for any employment-related decisions, for any other Employee benefit determinations
without Your authorization, or in any other manner not permitted by law.
For Health-Related Benefits or Services. The Plans may use or disclose Your health information to provide
You information about benefits available under the Plans that apply to You. The Plans may also contact You
Rev 6.27.14
88
about treatment alternatives or other health-related benefits and services that may be of interest to You.
As Required by Law. The Plans may use or disclose Your health information as required by state or federal
law.
Public Health Activities. As required or permitted by law, the Plans may disclose Your health information to
public health authorities. Examples include notifying public health authorities or others about communicable
diseases, injuries, or disabilities, and suspected cases of child abuse or neglect, or domestic violence. The
Plans may also disclose Your health information to Employers to help them comply with their duties under laws
related to workplace injuries or workplace medical surveillance.
Health Oversight Activities. The Plans may disclose Your health information to health oversight agencies for
audits, investigations, inspections, licensure activities, and other proceedings related to supervision of the health
care system.
To Avert a Serious Threat to Health or Safety. As required by law, the Plans may disclose Your health
information to help avert a serious threat to another person’s health or safety. The Plans may also disclose
Your health information to disaster relief agencies for purposes of coordinating with them disclosures to notify or
locate Your family Members, a personal representative, or another person responsible for Your care and to
provide information about Your location, general condition, or death.
Judicial and Administrative Proceedings. The Plans may disclose Your health information in response to a
subpoena, court order, discovery request, or other lawful process as part of an administrative or judicial
proceeding.
Law Enforcement. As required or permitted by law, the Plans may disclose Your health information to a law
enforcement official. Examples include responding to a court order, subpoena, warrant, summons or similar
process, helping identify or locate a suspect, fugitive, material witness, or missing person, answering inquiries
about a victim of a crime, or about a death the Plans believe may be the result of criminal conduct, or reporting a
crime under certain circumstances.
National Security and Intelligence Activities. The Plans may disclose Your health information to federal
officials for military, national security, and protective services for the President and others. If You are an inmate
in a correctional institution, the Plans may disclose Your health information to that institution or to a law
enforcement official having custody of You if necessary for Your health or the health and safety of other
individuals.
Workers’ Compensation. The Plans may disclose Your health information as necessary to comply with
workers’ compensation or similar laws.
Deceased Persons. The Plans may use or disclose the health information of deceased persons to coroners,
medical examiners, or funeral directors to enable them to carry out their duties or as permitted by law.
Organ or Tissue Donation. The Plan may release Your health information as needed to organizations that
procure organ, eye, or tissue donations for transplantation to facilitate organ or tissue donation or
transplantation.
Research. The Plans may use Your health information for research if certain requirements are met.
Other uses or disclosures of Your health information not generally described by this Notice or permitted by law
will only be made with Your written authorization. You may revoke Your authorization in writing, at any time. If
You revoke Your authorization, the Plans will no longer use or disclose Your health information for the reasons
covered by the authorization. Please understand that the Plans cannot retrieve previously disclosed
information.
This Notice may be changed at any time. If a revised Notice is issued, it will be effective for all health
information the Plans maintain for any of the Plans. Whenever this Notice is changed, a copy of the revised
Notice will be provided to You as required by law. The Notice will include its version number and effective date.
Rev 6.27.14
89
Until that time, the Plans will follow the most current version of this Notice.
For More Information or to Report a Concern.
If You have a question about this Notice or would like additional information about the privacy practices of the
Plans, please contact Madonna’s Privacy Officer at (402) 489-7102, Ext. 6501. You may also write to the
Privacy Officer at the following address: Privacy Officer, Madonna Rehabilitation Hospital, 5401 South Street,
Lincoln, Nebraska 68506.
If You believe that Your privacy rights have been violated or not adequately addressed, You may file a complaint
in writing with the Corporate Compliance Officer, Madonna Rehabilitation Hospital, 5401 South Street, Lincoln,
Nebraska 68506 or with the Secretary of the U.S. Department of Health and Human Services. Complaints
submitted to the Corporate Compliance Officer may be filed using Madonna Rehabilitation Hospital’s Corporate
Compliance Form CC001, which is available in Madonna Rehabilitation Hospital’s Purchasing Department or on
the Intranet in the Forms Section. Individuals who wish to remain anonymous in submitting a complaint may call
the Corporate Compliance Hotline at (402) 483-9472. The Plans will not retaliate against You or penalize You in
any way for making a complaint.
Rev 6.27.14
90
MEDICARE PART D NOTICE
Important Notice from the Madonna Health Plan with Coventry
About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where You can find it. This notice has information about Your
current Prescription Drug coverage with the Madonna Health Plan with Coventry and about Your options
under Medicare’s Prescription Drug coverage. This information can help You decide whether or not You want
to join a Medicare drug plan. If You are considering joining, You should compare Your current coverage,
including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare
Prescription Drug coverage in Your area. Information about where You can get help to make decisions about
Your Prescription Drug coverage is at the end of this notice.
There are two important things You need to know about Your current coverage and Medicare’s
Prescription Drug coverage:
1. Medicare Prescription Drug coverage became available in 2006 to everyone with Medicare. You can
get this coverage if You join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan
(like an HMO or PPO) that offers Prescription Drug coverage. All Medicare drug plans provide at
least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a
higher monthly premium.
2. Madonna Rehabilitation Hospital has determined that the Prescription Drug coverage offered by the
Madonna Health Plan with Coventry is, on average for all plan Participants, expected to pay out as
much as standard Medicare Prescription Drug coverage pays and is therefore considered Creditable
Coverage. Because Your existing coverage is Creditable Coverage, You can keep this coverage and
not pay a higher premium (a penalty) if You later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when You first become eligible for Medicare and each year from October
15th to December 7th.
However, if You lose Your current creditable Prescription Drug coverage, through no fault of Your own, You will
also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If You decide to join a Medicare drug plan, Your current Madonna health plan coverage will not be affected.
You can retain Your existing coverage and choose not to enroll in a Part D plan. If You elect Medicare Part D
coverage, this plan will coordinate with Part D coverage.
If You do decide to join a Medicare drug plan and drop Your current Madonna Health Plan coverage, be aware
that You and Your Dependents may not be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if You drop or lose Your current coverage with the Madonna Health Plan with
Coventry and don’t join a Medicare drug plan within 63 continuous days after Your current coverage ends, You
may pay a higher premium (a penalty) to join a Medicare drug plan later.
If You go 63 continuous days or longer without creditable Prescription Drug coverage, Your monthly premium
may go up by at least 1% of the Medicare base beneficiary premium per month for every month that You did not
have that coverage. For example, if You go nineteen months without creditable coverage, Your premium may
consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this
higher premium (a penalty) as long as You have Medicare Prescription Drug coverage. In addition, You may
have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get
Rev 6.27.14
91
it before the next period You can join a Medicare drug plan, and if this coverage through Madonna Rehabilitation
Hospital changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer Prescription Drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted
directly by Medicare drug plans.
For more information about Medicare Prescription Drug coverage:
· Visit www.medicare.gov
· Call Your State Health Insurance Assistance Program (see the inside back cover of Your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
· Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If You have limited income and resources, extra help paying for Medicare Prescription Drug coverage is
available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or
call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If You decide to join one of the Medicare drug plans,
You may be required to provide a copy of this notice when You join to show whether or not You have
maintained creditable coverage and, therefore, whether or not You are required to pay a higher premium
(a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
Rev 6.27.14
5/1/13
Wendy Charlton, Benefits Specialist
5401 South Street, Lincoln, NE 68516
(402)413-4336
92
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If You or Your children are eligible for Medicaid or CHIP and You are eligible for health coverage from Your
employer, Your State may have a premium assistance program that can help pay for coverage. These States
use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also
have access to health insurance through their employer. If You or Your children are not eligible for Medicaid or
CHIP, You will not be eligible for these premium assistance programs.
If You or Your dependents are already enrolled in Medicaid or CHIP and You live in a State listed below, You
can contact Your State Medicaid or CHIP office to find out if premium assistance is available.
If You or Your dependents are NOT currently enrolled in Medicaid or CHIP, and You think You or any of Your
dependents might be eligible for either of these programs, You can contact Your State Medicaid or CHIP office
or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If You qualify, You can ask the
State if it has a program that might help You pay the premiums for an employer-sponsored plan.
Once it is determined that You or Your dependents are eligible for premium assistance under Medicaid or CHIP,
as well as eligible under Your employer plan, Your employer must permit You to enroll in Your employer plan if
You are not already enrolled. This is called a “special enrollment” opportunity, and You must request
coverage within 60 days of being determined eligible for premium assistance. If You have questions about
enrolling in Your employer plan, You can contact the Department of Labor electronically at
www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272).
If You live in one of the following States, You may be eligible for assistance paying Your employer
health plan premiums. The following list of States is current as of January 31, 2014. You should contact
Your State for further information on eligibility –
ALABAMA – Medicaid
COLORADO – Medicaid
Website: http://www.medicaid.alabama.gov
Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447
Medicaid Phone (In state): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
ALASKA – Medicaid
Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA – CHIP
FLORIDA – Medicaid
Website: http://www.azahcccs.gov/applicants
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
Phone (Outside of Maricopa County): 1-877-764-5437
Phone (Maricopa County): 602-417-5437
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
Rev 6.27.14
93
IDAHO – Medicaid
MONTANA – Medicaid
Medicaid Website:
http:/healthandwelfare.idaho.gov/Medical/Medicaid/Pre
miumAssistance/tabid/1510/Default.aspx
Website:
http://medicaidProvider.hhs.mt.gov/clientpages/
clientindex.shtml
Medicaid Phone: 1-800-926-2588
Phone: 1-800-694-3084
INDIANA – Medicaid
NEBRASKA – Medicaid
Website: http://www.in.gov/fssa
Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949
Phone: 1-800-383-4278
IOWA – Medicaid
NEVADA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 1-800-635-2570
Phone: 603-271-5218
NEW JERSEY – Medicaid and CHIP
LOUISIANA – Medicaid
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
Medicaid Phone: 609-631-2392
MAINE – Medicaid
CHIP Website: http://www.njfamilycare.org/index.html
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
CHIP Phone: 1-800-701-0710
Phone: 1-800-977-6740
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
NEW YORK – Medicaid
Website: http://www.mass.gov/MassHealth
Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-462-1120
Phone: 1-800-541-2831
Rev 6.27.14
94
MINNESOTA – Medicaid
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Website: http://www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI – Medicaid
NORTH DAKOTA – Medicaid
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/
Website:
http://www.dss.mo.gov/mhd/Participants/pages/hipp.ht
m
Phone: 1-800-755-2604
Phone: 573-751-2005
OKLAHOMA – Medicaid and CHIP
UTAH – Medicaid and CHIP
Website: http://health.utah.gov/upp
Website: http://www.insureoklahoma.org
Phone: 1-866-435-7414
Phone: 1-888-365-3742
OREGON – Medicaid and CHIP
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-250-8427
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
VIRGINIA – Medicaid and CHIP
Medicaid Website: http://www.dmas.virginia.gov/rcpHIPP.htm
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND – Medicaid
WASHINGTON – Medicaid
Website: www.ohhs.ri.gov
Website:
http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 401-462-5300
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
SOUTH CAROLINA – Medicaid
Website: http://www.scdhhs.gov
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
Phone: 1-888-549-0820
Rev 6.27.14
95
SOUTH DAKOTA - Medicaid
WISCONSIN – Medicaid
Website: http://www.badgercareplus.org/pubs/p10095.htm
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Phone: 1-800-362-3002
TEXAS – Medicaid
WYOMING – Medicaid
Website: https://www.gethipptexas.com/
Website:
http://health.wyo.gov/healthcarefin/equalitycare
Phone: 1-800-440-0493
Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2014, or for more
information on special enrollment rights, You can contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
Rev 6.27.14
96

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