HomeMy WebLinkAboutContract 18668 CITY SE-0RUARY
ADMINISTRATIVE SERVICES ONLY
AGREEMENT
BY AND BETWEEN
SANUS TEXAS HEALTH PLAN, INC.
AND
THE CITY OF FORT WORTH
Sw,
TABLE OF CONTENT'S
ASO AGREEMENT
Page
ADMINISTRATIVE SERVICES ONLY AGREEMENT . . . . . . . . . . . . . . . . . 1
APPENDICES
A Defined Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1
B Services Provided By Santis . . . . . . . . . . . . . . . . . . . . . . . . . B-1
C Plan Funding Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-1
D Fixed Administrative Charges . . . . . . . . . . . . . . . . . . . . . . . . D-1
E Medical Program Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . E-1
F Indemnification Agreement . . . . . . . . . . . . . . . . . . . . . . . . . F-1
EXHIBITS
1 - Part A Group Membership Service Agreement as
Administered by Santis Texas Health Plan . . . . . . . . . . . . 1A-1
1 - Part A
(Cont'd) Schedule of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 1A-57
1 - Part B Major Medical Employer Certification . . . . . . . . . . . . . . 1B-1
2 - Part A Group Membership Service Agreement as
Administered by Sanus Texas Health Plan . . . . . . . . . . . . 2A-1
2 - Part A
(Cont'd) Schedule of Benefits 2A-2
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LGkwASO+/F1V•TOC.DTF791
TABLE OF CONTENTS (Cont'd)
Page
EXHIBM (Cont'd)
3 - Part A Group Membership Service Agreement as
Administered by Santis Texas Health Plan . . . . . . . . . . . . 3A-1
3 - Part A
(Cont'd) Schedule of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 3A-2
3 - Part B Major Medical Employer Certification . . . . . . . . . . . . . . 3B-1
4 Health Benefit Plan for Employees of the City of Fort Worth 4-1
LG\m,ASO-,'FW-TOC.DTF791 111 �4r.
ADMUSISTRATIVE SERVICES ONLY (ASO) AGREEMENT
This AGREEMENT is entered into by and between Sanus Texas Health
Plan, Inc. (Sanus) , a corporation organized under the laws of the
State of Texas with its principal office at 8600 Freeport Parkway,
Irving, Texas, 75063 , and the City of Fort Worth (Employer) with
its principal office at 1000 Throckmorton, Fort Worth, Texas. This
Agreement shall take effect as provided in Paragraph 26.
WHEREAS, Sanus provides contractual and administrative arrangements
and systems to implement self-funded employer health benefit plans,
and
WHEREAS, Employer desires to retain Sanus to provide Administrative
Services Only for Employer's self-funded Benefit Plan, as described
herein, and
WHEREAS, Sanus is willing and able to provide such services;
NOW, THEREFORE, in consideration of the mutual promises herein, and
intending to be legally bound hereby, the parties agree as follows:
1. Recitals: The WHEREAS paragraphs of this Agreement are deemed
to be incorporated as though fully rewritten._,_-.__,__
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2 . Definitions: For purposes of this Agreement, the following l
definitions shall apply:
(a) "Administrative Services Only" (ASO) means that Sanus
undertakes to act only as independent contractor for
Employer in providing services for the administration of
Employer's Benefit Plan, and does not agree to act in any
other capacity;
(b) "Benefit Plan" means the self-funded health benefits plan
adopted by Employer. Part A of the Benefit Plan provides
benefits for Enrollees who choose the Managed Care
program; Part B provides benefits for Enrollees who elect
at the time of service not to use or who are ineligible
to use the Managed Care Program. A true copy of the High
Option Benefit Plan is attached as Exhibit 1; a true copy
of the Low Option Benefit Plan is attached as Exhibit 2 ;
a true copy of the Low Option OOSA Only (out-of-service
area for retired enrollees) Benefit Plan is attached as
Exhibit 3 ;
(c) "Defined Area" with respect to Part A, means the area
described in Appendix A, within which Participating
Providers (Hospitals, Physicians and Other Health Care
LGVwASO+/FW-AG.DTFIAt -2-
Professionals) are available to provide health care
services to Enrollees;
(d) "Enrollee" means a person covered under the Employer' s
Benefit Plan, either actively-at-work as an "Active
Enrollee" or retired from active employment as a "Retired
Enrollee" ;
(e) "Health Care Management Services" means those services
provided by Sanus as described in Appendix B;
(f) "Hospital" , with respect to Part A, means a licensed
public or private hospital that is bound by contract to
provide inpatient medical and health care to Covered
V,
Persons pursuant to an agreement between Sanus and
Hospital ;
(g) "Other Health Care Professional" , with respect to Part A,
means a person or institution other than Physician or
Hospital who or which is licensed or otherwise authorized
to provide medical or health care and who or which is
bound by contract to provide medical or health care to
Covered Persons pursuant to an agreement between Sanus
and such person or institution;
s I V
k,
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(h) "Physician" , with respect to Part A, means a medical
practitioner who is licensed by the State having
jurisdiction and who is bound by contract to provide
medical care to Covered Persons pursuant to an agreement
between Sanus and such medical practitioner;
(i) "Participating Provider" , with respect to Part A, means
a Physician or Hospital or Other Health Care Professional
who or which has agreed to accept alternative rates of
payment for health care services provided to Enrollees;
(j ) "Participating Provider Network" , with respect to Part A,
means the group of Participating Providers.
3 . Sanus Representations: Sanus represents (i) that it has
contracted with Physicians, Hospitals and Other Health Care
Professionals, to constitute a Participating Provider Network,
(ii) that it provides administrative systems necessary for the
effective operation of the network and (iii) that such
Participating Providers and such systems will be available to
Enrollees, as set forth herein, in connection with Part A of
the Benefit Plan. Sanus further represents that it has
arrangements and administrative systems and procedures for
administering Parts A and B of the Benefit Plan.
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4 . Employer Representation: Employer represents that it has
established a Benefit Plan and that a true copy of the Benefit
Plan is attached as Exhibit 1, Exhibit 2 , and Exhibit 3 .
Employer shall not change the terms or benefits of the Benefit
Plan without prior notice to and acceptance by Sanus.
Employer further represents that it has established or will
establish a Plan Funding Account to pay claims for benefits,
to provide payments to Participating Providers and to pay
charges due Sanus. The Plan Funding Account shall also be
used, and shall be adequate for the purpose, to pay premium
for specific and aggregate reinsurance, if the Employer so
provides. The Plan Funding Account shall be maintained and
administered as described in Appendix C.
5. Retention of Sanus: Employer retains Sanus to provide
Administrative Services Only. A description of the services
is set forth as Appendix B.
6. Relationship of Parties: In performing the services
herein described, Sanus shall be acting only as independent
contractor and shall not be designated or deemed the
administrator with respect to the Plan or the appropriate
named fiduciary for review of claim denials under the Plan for
the purpose of the Employee Retirement Income Security Act of
1974 or any other Federal or state law of similar nature.
Sanus shall arrange for the provision of all services
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hereunder as an independent contractor and not as an officer,
l
agent, servant or employee of Employer. Sanus shall have the
exclusive control of, and exclusive right to control, the
details of the administration of this Agreement. Sanus agrees
to assist Employer in its responsibility for compliance with
all requirements imposed by Federal or State authorities upon
Employers who have established health benefit plans. Employer
agrees to accept Sanus ' decision, with respect to the benefit
provisions administered by Sanus, on the monetary amount of
Plan Benefits for which Employer is responsible. However, if
the Employer determines that the Plan provisions have been
misinterpreted and so informs Sanus in writing, all claims
reported after delivering of such writing shall be processed
and paid in accordance with Employer' s instructions. Any
claims that, in the judgement of Sanus, are doubtful or
partially or wholly deniable shall be referred to Employer's
designee for determination. Employer shall be responsible for
review of appealed claims.
7. Responsibility of Parties: Employer is solely responsible for
its obligations under the Benefit Plan. Sanus undertakes to
provide Administrative Services Only. Sanus shall not be
liable for the payment of benefits under this Plan. Sanus
shall use ordinary care and reasonable diligence in the
exercise of its powers and the performance of its services,
LGUavASO+/FWAG.DTF691 —6— (D
and shall not be liable for any loss unless resulting from its
negligence or willful misconduct.
8 . Information to be Furnished by Emplover: Employer shall
furnish Sanus with all information necessary for the
administration of benefits under the Benefit Plan, as Sanus
may reasonably require.
9. Administration Charges: The charges to Employer for the
performance of the services described herein by Sanus shall be
paid whether or not there is any unresolved dispute claimed by
either party and shall be as described in Appendix D.
10. Term: With regard to Active Employees, this Agreement shall
be for an initial period beginning on the Effective Date and
ending at midnight on the September 30th next following the
Effective Date, and shall continue thereafter for subsequent
contract year terms until terminated pursuant to Paragraphs
12, 13 and 14 . With regard to Retirees, this Agreement shall
be for an initial period beginning January 1, 1991 and shall
be subject to all other terms and conditions set forth in the
previous sentence.
11. Renewal: Either party may decline to renew at the end of any
term by giving the other party sixty (60) days advance written
notice.
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12 . Termination Without Cause: Either party may terminate this
Agreement, without cause, upon one hundred twenty (120) days
advance written notice to the other.
13 . Termination With Cause: Either party shall each have the
additional option to terminate this Agreement for cause, upon
thirty (30) days prior written notice following the occurrence
of any of the following events:
(a) Failure of the other party to comply with any provision
of this Agreement thirty (30) days after receipt of
written notice;
(b) Failure of the other party to comply with applicable
statutory or regulatory requirements fifteen (15) days
after receipt of written notice;
(c) Negligence, fraud or embezzlement on the part of the
other party as deemed to have occurred in the notifying
party' s sole judgement.
14 . Effect of Termination: Upon termination, Sanus shall complete
processing all claims for benefits under the Benefit Plan and
shall receive a fee of 6% of claims payable as reimbursement
for expenses incurred and paid after termination or incurred
prior to termination but not paid until after the date of
termination, subject to the provisions of Appendix E. Such
fee shall be due and payable thirty (30) days from date of
invoicing by Sanus.
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15. Records: All data and records pertaining to all Enrollee
transactions are the property of Employer which Sanus shall
maintain, at its principal office, under the Benefit Plan for
the term of this Agreement and six (6) years thereafter unless
otherwise requested by Employer in writing.
16. Complaints and Litigation: Employer and Sanus shall promptly
notify the other of any complaint to or from any state or
Federal regulatory authority of which each party becomes aware
in connection with any transaction covered by this Agreement.
Such notices shall be addressed as set forth in Paragraph 23
of this Agreement. If a suit arises under any rejected claim,
Employer will defend at its expense and pay any judgement
arising therefrom, unless, at Employer's request, Sanus agrees
to defend such claim at Employer's expense or upon such other
terms and conditions as the parties shall agree upon.
17. Venue and Jurisdiction: Should any action, whether real or
asserted, at law or equity, arise out of the execution,
performance, attempted performance or non-performance of this
Agreement, venue for said action shall lie in Tarrant County,
Texas. This Agreement and any action in connection herewith
is and shall be governed, construed and enforced by the laws
of the State of Texas.
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18 . Audit and Review: Sanus ' performance of services and
maintenance of records pursuant to this Agreement shall be
subject to review by Employer at any time. Review will be at
the sole expense of Employer and upon reasonable notice during
ordinary business hours. Sanus will provide any reports and
data with respect to the performance of services as may be
necessary from time to time upon thirty (30) days prior
written request by Employer.
19 . Use of Name: Employer shall not use the name of Sanus except
as authorized in writing.
20. Amendment: This Agreement shall not be modified or amended
except in writing, signed by an officer of Sanus and Employer.
The waiver by a party of a breach or violation of any
provision of this Agreement shall not operate as, or be
construed to be, a waiver of any subsequent breach or
violation thereof.
21. Assignment: Any unauthorized or purported assignment or
delegation of any of Sanus ' rights or duties hereunder,
without the prior written consent of Employer on an assignment
form, shall be void and constitute a breach of this Agreement.
This Agreement shall be binding upon the parties, their
successors and assigns. Employer agrees not to unreasonably
withhold consent to the assignment of this Agreement. In the
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event that Employer cannot agree to such assignment, Employer
k shall be permitted to terminate this Agreement with one
hundred twenty (120) days prior written notice to Sanus and
without penalty.
22 . Severability: If any part, term, or provision of this
Agreement shall be held void, illegal or unenforceable, the
validity of the remaining portions or provisions shall not be
affected thereby.
23 . Waiver: The failure of either party to insist upon the
performance of any term or provision of this Agreement or to
exercise any right herein conferred shall not be construed as
a waiver or relinquishment to any extent of that party's to
assert or rely upon any such term or right on any future
occasion.
24 . Appendices: Each Appendix and Exhibit to this Agreement is a
part of this Agreement as if set forth as a numbered
paragraph.
25. Notices: Any notice required to be given pursuant to the
terms hereof shall be sent by certified mail, return receipt
requested, postage prepaid to:
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SANUS TEXAS HEALTH PLAN, INC.
8600 Freeport Parkway
Suite 3040
Irving, Texas 75063
Attention: Executive Director
and to:
CITY OF FORT WORTH
1000 Throckmorton
Fort Worth, Texas 76102
Attention: Risk Manager
26. Effective Date: The Effective Date of the initial term of
this Agreement shall be construed as October 1, 1990 as such
Agreement relates to the Benefit Plan extended to Active
Enrollees and as January 1, 1991 as such Agreement relates to
the Benefit Plan extended to Retired Enrollees. The Effective
Date of subsequent terms shall be construed as the next
following October 1st for all Enrollees. 0
27 . Indemnification: An Indemnification Agreement is set forth
hereto in Appendix F.
28. Enrollment Period: The Enrollment Period shall be from
September 1, 1990 to October 15, 1990 for Active Enrollees and
from October 15, 1990 to December 31, 1990 for Retired
Enrollees.
29. Non-Appropriation of Funds - In the event no funds or
insufficient funds are appropriated and budgeted in any fiscal
year for fees due pursuant to this Agreement, Employer shall
LGVwASO+/FW-AG.O?F691 -12-
notify Sanus as to the prospective date on which said funds
will no longer be available; this Agreement shall be
terminated on the last day of that month in which said notice
is effective without penalty or expense to Employer of any
kind whatsoever, except as to the portions of fees herein
agreed upon for services rendered through the effective date
of termination.
30. The Table of Contents annexed hereto lists all documents
comprising the entire Agreement between Sanus and Employer,
including this ASO document and all appendices and exhibits.
IN WITNESS WHEREOF, and as duly authorized, th paxtil�s hereto
execute this Agreement with the Effective Date he i n
g provided.
CITY OF FORT WORTH SANDS TEXAS HEALTH PLAN, INC.
BY: OLI"— BY
TITLE: �` �� TITLE:
DATE: DATE:—
AT� T/
City Secretary
APPROVED AS TO FORM AND LEGALITY:
City Attorney Date
Co riu''1 rization
Lc�nso+/MAGMU691 —13— Date
APPENDIX A
DEFINED AREA
This Appendix sets forth the Defined Area in which Participating
Providers are available for service to Enrollees:
The entire Counties of: Collin, Cooke, Dallas, Delta,
Denton, Ellis, Fannin, Grayson,
Hood, Hopkins, Hunt, Johnson,
K
Kaufman, Parker, Rains, Rockwall,
Somervell, Tarrant and Wise; and
that portion of Palo Pinto County
which includes the incorporated city
of Mineral Wells.
.,- LG\r.ASO+/FW-A.DTF591 A_]
ZD. APPENDIX B
HEALTH CARE MANAGEMENT
SERVICES PROVIDED BY SANDS
Sanus shall provide the following services with respect to the
Benefit Plan:
1. Determine the amount necessary, on a monthly basis, to
enable Employer to fund the Benefit Plan and notify
Employer of the minimum balance required in the Plan
Funding Account.
2 . Process all claims for Benefits, all payments to
Providers and authorized charges by Sanus.
3 . Maintain and make available to Enrollees & dependents the
participating provider network and compensate providers
in accordance with established procedures.
4 . Provide Utilization Review and Quality Assurance programs
in connection with the managed health care benefit
provisions generally as follows:
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B-1
Utilization Review (UR) : Maintain a program requiring
n,
Participating Providers to participate in a utilization
review procedure that includes (a) pre-admission review
and certification, (b) concurrent review or length of
stay certification and/or discharge planning, (c) second
surgical opinion and (d) retrospective review. The
program shall be operated for the purpose of examining
the cost and economic appropriateness of utilizing
medical and health resources, to identify variances from
previously established and professionally recognized
norms and to attempt to correct variances where
appropriate.
Quality Assurance (QA) : Maintain a Quality Assurance av ,
program designed to assure that medical services,
including treatment of illnesses and injuries, will be
provided in a manner assuring availability of adequate
physicians and other health care providers, specialty
care and facilities.
5. Maintain in computerized form a roster of Participating
Providers containing names, ID numbers, addresses and
such other information as Employer may reasonably require
and shall update the roster monthly to record additions,
terminations and other changes.
LG4wAS0+/FW-B.DTF591 B-2 0
6. Furnish to Employer Booklets and/or Certificates of
Coverage for distribution to Enrollees describing
benefits available.
7 . Prepare and deliver I.D. cards to Employer for use by
Enrollees .
8 . Notify claimants of rejected claims and the reasons
therefor.
9 . Investigate claims as necessary.
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APPENDIX C
PLAN FUNDING ACCOUNT
1. Employer shall guarantee that sufficient funds are available
so as to enable Employer to wire transfer monies as required
herein or so as to permit Sanus to draft from Employer's Plan
Funding Account as established for purpose and as permitted
herein, amounts required for: (a) payment of Fixed Administra-
tive Charges, as set forth in Appendix D annexed hereto, (b)
payment of Medical Program Costs as set forth in Appendix E
annexed hereto and (c) monthly payment, on behalf of
Enrollees, of (i) the Primary Care Physicians, Mental
Health/Chemical Dependency Providers, Clinics and Medical
10 Laboratory capitation expenses ("Fixed Medical Expenses") ,
(ii) the fee-for-service expenses including major medical
expenses from Physicians, Hospitals and Other Health Care
Professionals ("Fee-For-Service Medical Charges") . Employer
shall accept Sanus ' determination as to amounts payable to
providers and for payment of Plan Benefits. Payment of Plan
benefits may be suspended in the event that Employer fails to
wire transfer monies as required herein or if Sanus is unable
to access funds as permitted hereto.
2 . Charges made by the depository in connection with the
operation of the Plan Funding Account ("Bank Account Charges")
shall be the responsibility of the Employer.
LGUwASO+/FW-C.DrrF691 C-1
3 . Service charges to the Employer for services performed by
Sanus (Fixed Administrative Charges and Medical Program Costs)
shall be as set forth in Appendix D and Appendix E
respectively.
4 . Monies required to reimburse Sanus for Fixed Medical Expenses
and Fee-For-Service Medical Charges shall be payable by
Employer each month of the contract term, commencing in
December 1990 for costs attributable to Active Enrollees and
commencing in March 1991 for costs attributable to Retired
Enrollees.
a. Upon Sanus ' determination of actual monies due for Fixed
Medical Expenses, Sanus will notify Employer, via
M k.
telefax, of the dollar amount owed. Employer agrees to
compensate Sanus, by wire transfer of funds to the
appropriate account as determined by Sanus, on or before
the next business day following receipt of such
notification.
b. At intervals compatible with Sanus' usual and customary
business practice for payment of claims, Sanus will
determine the actual dollar amount of Fee-For-Service
Medical Charges incurred by Sanus on Employer' s behalf
and will notify Employer of said dollar amount owed by
Employer via telefax. In the event that said dollar
LG4wASO+/FW-C.DTF691 C-2
amount is two hundred fifty thousand dollars
($250, 000. 00) or less, Sanus will draft said amount from
Employer' s Plan Funding Account on the next business day
following Sanus ' notification to Employer of the actual
dollar amount due and payable. If such dollar amount
exceeds two hundred and fifty thousand dollars
($250, 000. 00) , Employer agrees to reimburse Sanus such
amount on the next business day following notification of
the amount due and payable by wire transfer of funds to
the appropriate account as determined by Sanus.
5. Employer acknowledges that Fee-For-Services Medical Charges
incurred during the contract term yet payable by Sanus after
the termination date of this Agreement remain the financial
responsibility of Employer irrespective of the termination of
this Agreement. Employer agrees to compensate Sanus for such
Fee-For-Service Medical Charges as set forth in Paragraph 4
above, and subject to the provisions of Appendix E.
6. If Employer and Sanus determine that Sanus has paid claims for
services not covered under the Benefits Plan, the amount of
any such claims shall be refunded by Sanus to Employer within
thirty (30) days of request of refund by Employer.
LG4wAS0+/FW-C.DTFfAI C-3
APPENDIX D
FIXED ADMINISTRATIVE CHARGES
1. The Fixed Administrative Charge attributable to Active
Enrollees and payable by Employer for services performed by
Sanus under this Agreement for the initial twelve-month term
shall be $209 , 100. 33 per month. The Fixed Administrative
Charges attributable to Retired Enrollees and payable by
Employer for services performed by Sanus under this Agreement
for the initial nine month term shall be $61, 646. 00 per month,
based on an enrollment of sixteen hundred (1, 600) or less
retirees. Each five percent (5%) increase in the number of
Retired Enrollees will result in a five percent (5%) increase
in the Fixed Administrative Charges attributable to and
payable for Retired Enrollees for that month in which such
increased enrollment is realized and all subsequent months in
which the increase continues. Employer agrees to wire
transfer, into the appropriate account as designated by Sanus,
on the first working day of each month the total amount of
Fixed Administrative Charges for all Enrollees due Sanus for
that month, as set forth herein and pursuant to the terms and
conditions of Appendix C. No further notification regarding
such payment shall be required of either party.
LGvwAW+/Fv-o.urT-69i a-t
APPENDIX E
MEDICAL PROGRAM COSTS
Medical Program Costs are the costs of the Fee for Service Medical Charges and Fixed
Medical Expenses provided to all Enrollees and their dependents under this Agreement.
I. Medical Program Costs shall be paid by Employer via wire
transfer of funds into the appropriate account as designated
by Sanus on the second working day of each of the first three
months of the initial term, namely, October, November and
December, 1990 for Active Enrollees and January, February, and
March 1991 for Retired Enrollees. Employer agrees to notify
Sanus via telefax of the exact dollar amount due and payable
based on enrollment for each of those months on the first
working day of those months. Medical Program Costs shall be
payable at the rate set forth herein for each person who is an
"Enrolled Employee" , as determined by Sanus, as of the first
day of that month for which said payment applies. For
purposes of this Appendix E and the ASO Agreement to which it
is attached, "Enrolled Employee" means any person, either
Actively-at-Work or Retired, who is deemed by Employer to be
a participant in the Benefit Plan issued by Employer and for
whom Sanus provides Administrative Services Only.
u,-%mASo+/ASV-E NV691 E-I
II . Monies payable as Medical Program Costs on a monthly basis for
the first three months of the initial contract term as defined
herein and for the first three months of any subsequent
contract terms shall be wire transferred to Sanus and be equal
to the aggregate amount of the rates set forth below payable
for each Employee and his dependents at that rate which
reflects the option level under which said Employee and his
Dependents were eligible to receive health care benefits for
the month in which said payment applies.
III. The rates to be used to determine Medical Program Costs, as
permitted herein, shall be as follows:
High Option Benefit Plan
Active Retired
Enrollee Enrollee
Employee $103 .98 $159 . 34
• Spouse 355. 08 369 .89
• Children 310. 18 329 . 78
• Family 426. 13 409 . 99
Low Option Benefit Plan
Active Retired
Enrollee Enrollee
Employee $ 80. 80 $120. 98
• Spouse 291.81 291.25
• Children 254 . 08 258. 82
• Family 351. 52 323 . 68
LG%rwAc0+/FW4EMIF691 F-2 QJ
Low Option OOSA Only Benefit Plan
(Out-of-Service Area Retired Enrollees)
Retired
Enrollee
Employee $120. 98
• Spouse 291. 25
• Children 258 . 82
• Family 323 . 68
IV. For months four through twelve of the initial contract year
and of any subsequent contract years, Sanus will calculate the
anticipated Medical Program Costs for that month based on actual
enrollment for that month and at the rates set forth above. Such
calculation will determine the Employer's monthly liability unit.
The result of that calculation, when added to the actual
Medical Program Costs paid in months one through three, equates the
Employer's aggregate maximum liability for the contract term,
excluding fixed Administrative Expenses and the additional
administrative fee equal to 6% of all Fee-for-Service Medical
Charges incurred during the contract term but paid after the
termination of this Agreement in the event this Agreement is not
renewed for the October 1, 1991 term.
The reconciliation of all Medical Program costs with actual
medical expenses, including Fee-For-Service Charges and Fixed
Medical Expenses, shall be continual throughout the term of this
LG%twA90+/Fv4EureG 1 E-3
Agreement. Sanus will provide periodic reports to Employer of the
status of the aggregate maximum liability limit. To the extent
that Sanus has not received payment for claims paid above the
monthly liability limit but within the Employer' s annual liability,
Employer will remit payment during the reconciliation period.
within one hundred twenty (120) days after the end of each contract
term, Sanus will provide to Employer a reconciliation statement
reflecting monies due either party, if any. Said monies are to be
paid by the owing party within thirty (30) days of receipt of the
reconciliation statement.
r
u.%mASo+Mv-FLD7T*w1 E4
APPENDIX F
INDEMNIFICATION AGREEMENT
I . A. Each party shall be liable for its own acts and omissions
incurred in the performance of its specific obligations
under this Agreement.
B. The Employer shall be responsible for the payment of all
taxes imposed in relation to the Employer' s Benefit Plan
including any taxes which may be imposed upon the fees
actually received by Sanus for services provided pursuant
to this Agreement.
C. It is the intent of Sanus and Employer to cooperate fully
with each other with respect to any such claim or suit
against Sanus or Employer.
II. Sanus agrees to maintain blanket bond coverage with a limited
liability in an amount satisfactory to Employer and in
reasonable proportion to the dollar amount and volume of
benefit payments paid and administered to indemnify and hold
the Employer harmless against any and all loss, damage and
expense including court costs and attorney fees resulting from
or arising out of dishonest, fraudulent or criminal acts of
F
.� LG\r-ASO+/FW-F.DTF591 F-1
Sanus ' employees, officers and agents in performing services
under the Agreement.
III. It is the intention of both parties that, without the consent
of the other, neither will in any case take any action, waive
any defense, or compromise any suit which would knowingly
prejudice the other party' s defense with respect to the
commission of a crime or the violation of any penal provision
of any state' s insurance laws, unless required to so by law.
LG\mASO+/FW-F.DTF591 F-?
EXHIBIT 1
PART A
GROUP MEMBERSHIP SERVICE AGREEMENT
AS ADMINISTERED BY
SANUS TEXAS HEALTH PLAN
Your Employer certifies that, subject to the terms and conditions
of the Benefit Plan and, more particularly, to the terms and
conditions of this Part A, you are covered for the benefits
described herein.
The following terms and provisions apply to the Managed Health Care
Benefits Option (Part A) of the Benefit Plan:
Following are the terms and provisions of Employer' s Health Benefit
Plan:
I. DEFINITIONS
Except as expressly otherwise provided or unless the context
otherwise requires, the following words and phrases used in
this Part A shall have the following meanings:
LGVwAS0+/FWIAZrF691 1A-1
1. "Actively at Work" means that an Eligible Employee must
be performing usual and customary duties of his regular
employment during his usual working hours on his
Effective Date of coverage; provided, however, that if
the Eligible Employee is absent from work due to
vacation, holiday, jury duty or other similar
circumstances not caused by injury or illness, such
employee shall be considered "Actively at Work" .
2 . "Agreement" means the Administrative Services only
contract executed by and between Employer and Sanus,
including all appendices and exhibits hereto.
3 . "Ambulatory Surgical Center" means a non-hospital center
which provides ambulatory surgical services and which is
properly licensed as such by the State of Texas.
4 . "Application" means the forms prescribed by Employer
which each Employee shall, on his own behalf and on
behalf of his Dependents, be required to complete and
submit to Employer for the purpose of enrolling himself
and such Dependents for coverage hereunder.
5. "Copayment" means the fee set forth in Part A to be paid
by Enrollees at the time of service directly to
LG4wASO+/F W-I A.OTF691 1A-2
Physicians, Hospitals or other Health Professionals in
connection with the services set forth in Part A.
6. "Covered Services" means only the medical care, services
and supplies rendered under the following conditions :
a. provided, directed or authorized by the Enrollee ' s
Participating Primary Care Physician, except in the
case of a Medical Emergency, as defined by the
Plan,
b. prescribed by a doctor for the therapeutic
treatment of injury, sickness or pregnancy,
C. deemed Medically Necessary and appropriate in type,
level setting, and length of service by the Plan,
d. rendered in accordance with generally accepted
medical practice and professionally recognized
standards,
e. not generally considered to be experimental ,
investigational, or which are performed for
research purposes, and
f. services which are specifically included and not
excluded or limited or not specifically excluded by
the Plan.
7. "Custodial Care" means that care which is marked by or
given to watching and protecting rather than seeking to
cure; or (2) care which is not a necessary part of
LG\mASO+/FW-I A.DTF691 1A-3
medical treatment for recovery; or (3) care comprised of
services and supplies that are provided primarily to ,
assist in the activities of daily living.
8. "Deductible" means the expense set forth in Part A, which
the Enrollee is required to pay directly to the
Physicians, Hospitals, or other Health Care Providers in
connection with Covered Services, before receipt of
Covered Services.
9. "Defined Area" means the area, described in Appendix A,
within which Participating Hospitals, Physicians and
Providers are available to provide health care services
to Enrollees. ID
10. "Dependent" means an Eligible Dependent who has been
enrolled under the Plan and for whom the appropriate
contribution payments required have been received by
Employer.
11. "Domiciliary Care" means that care provided for persons
so disabled or infirm as to be unable to live
independently.
12 . "Effective Date" means the effective date of an
Enrollee 's coverage.
LG\mASO+/FW I A.DTF691 1A-4
13 . "Eligible Dependent" means an Eligible Employee ' s spouse
'4) or child who meets the dependent eligibility
requirements set forth in Section II.A of this Part A.
14. "Eligible Employee" means an individual who meets the
eligibility requirements set forth in Section II.A of
this Part A.
15. "Emergency Care" means bona fide emergency services
provided after the sudden onset of a medical condition
manifesting itself by acute symptoms of sufficient
severity, including severe pain, such that the absence of
immediate medical attention could reasonably be expected
to result in:
I
a. placing the patient 's health in serious jeopardy;
b. serious impairment to bodily functions; or
C. serious dysfunction of any bodily organ or part.
16. "Enrollee" means a person covered under the Benefit Plan.
17. "Enrollment Period" means the period announced by the
Employer during which Eligible Employees and Eligible
Dependents may elect to enroll under this Part A or
terminate their enrollment in this Plan.
ti'- LGN wASO+/FWIA.DTF691 1A-5
18 . "Free Standing Surgical Center" shall have the same F_
meaning as Ambulatory Surgical Center. `
19 . "Health Professional" means dentists, nurses,
audiologists, podiatrists, osteopaths, optometrists,
physician's assistants, clinical psychologists, social
workers, pharmacists, nutritionists, physical therapists,
speech therapists, and other professionals engaged in the
delivery of health services who are licensed, practice
under an institutional license, are certified or practice
under the authority of a Physician or legally constituted
professional association, or other authority consistent
with the laws of the State of Texas.
20. "Hospital" means
a. An institution which is operated pursuant to state
law and is primarily engaged in providing, on an
inpatient and outpatient basis, for the medical
care and treatment of sick and injured persons
through medical, diagnostic, major and minor
surgical services, all of which services must be
provided on its premises under the supervision of a
staff of Physicians and with twenty-four hour a day
registered nursing service, or
LGkwASO+/FW-IA.O?F691 1A-6 0
b. An institution not meeting all of the foregoing
requirements but which meets state licensing
requirements and is accredited as a Hospital by the
Joint Commission on Accreditation of Healthcare
Organizations.
In no event shall the term "Hospital" include a
convalescent nursing home or any institution or part
thereof which is used principally as a convalescent
facility, rest facility, nursing facility, facility for
the aged or extended care facility, intermediate care
facility, skilled nursing facility or facility primarily
for rehabilitative services; the term "Hospital" shall,
pursuant to Chapter 3 , Texas Insurance Code, Article
� . 3 .72 , include treatment in a residential treatment center
for children and adolescents and treatment provided by a
crisis stabilization unit.
21. "Medical Director" means the licensed physician in the
full or part time employ of Sanus and/or such other
licensed physician as the Medical Director may designate,
who shall be responsible for monitoring the quality of
medical care rendered to Enrollees.
22 . "Medical Emergency" means a medical condition so
classified by the Medical Director and which manifests
;k
a -z= LG4wAS0+/FWIA.DTF691 1A-7
itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of 40
immediate medical attention could reasonably be expected
to result in (a) placing the patient' s health in serious
jeopardy; or (b) serious impairment to bodily functions;
or (c) serious dysfunction of any bodily organ or part.
23 . "Medically Necessary" means medical or surgical treatment
of an illness or injury at the appropriate level of care
in accordance with accepted medical standards and Plan
requirements as approved by the Plan ' s review committees
for professional and technical practice and the Sanus
Medical Director.
24. "Medicare" means Title XVIII of the Social Security Act 3
and regulations thereunder.
25. "Non-Participating Physician" means a physician who is
not a Participating Physician.
26. "Out-Patient Emergency Care Center" means a non-hospital
center which provides ambulatory medical, surgical and/or
emergency services.
27 . "Participating Chemical Dependency Treatment Facility"
means a facility which provides a program for the
MmASO+/F W-1 A.DTF691 1A-8 4��y�;.
treatment of alcohol or drug dependency pursuant to a
written treatment plan approved and monitored by a
Physician and which has contracted with Sanus to provide
such program to Enrollee and which facility is also:
a. affiliated with a Hospital under a contractual
arrangement with an established system for patient
referral ; or
b. accredited as such a facility by the Joint
Commission on Accreditation of Healthcare
Organizations; or
C. licensed as a chemical dependency treatment program
by the Texas Commission on Alcohol and Drug Abuse;
or
d. licensed, certified or approved as a chemical
dependency treatment program or center by any other
state agency having a legal authority to so
license, certify or approve.
28. "Participating Facility" means a facility properly
licensed by the appropriate regulatory and licensing
authorities of the State of Texas which has contracted
with Sanus to provide services to Enrollees, and which
facilities shall include hospitals, alcohol and drug
dependency treatment facilities, out-patient emergency
� Lc\mAso+/Fw-I A.DTF691 1A-9
care centers, ambulatory surgical centers and other
t
facilities of similar purpose.
29 . "Participating Hospital" means a Hospital (as defined in
subparagraph 19 of this Section) which has contracted
with Sanus to provide the inpatient and outpatient
services set forth in Section II.A and II.D (or, if
applicable to Section III) of the Schedule of Benefits.
30. "Participating Out-Patient Emergency Care Center" means
a non-hospital center which has contracted with Sanus to
provide ambulatory medical, surgical and/or emergency
services to Enrollees.
31. "Participating Physician" means any Physician who has
contracted with Sanus to provide care to Enrollee(s) .
32 . "Participating Primary Care Physician" means with respect
to each Enrollee, the Participating Physician engaged in
the practice of family practice, general medicine,
internal medicine or pediatrics, who is designated in
accordance with Sanus policies as the Physician having
primary responsibility for coordinating such Enrollee' s
medical care, providing initial and primary care to
Enrollees, maintaining the continuity of such Enrollee ' s
care and initiating referral for specialist care.
LG\rwA50+/FW 1 A.DTF691 1A-10
33 . "Participating Specialist Physician" means any Physician
x. who has contracted with Sanus to provide specialist care
to Enrollees covered under this Agreement upon referral
of a Participating Primary Care Physician (or upon
referral of another Participating Specialist Physician
with the concurrence of the responsible Participating
Primary Care Physician) .
34 . "Participating Urgent Care Center" shall have the same
meaning as Participating Out-Patient Emergency Care
Center.
35. "Physician" means anyone licensed by the State of Texas
to practice as a Physician within the scope of his
�. license.
36. "Plan" means the Employer' s self-funded comprehensive
health care services plan, administered by Sanus acting
as an independent contractor and as covered by this
Agreement.
37 . "Primarily Dependent" means a dependent receiving more
than fifty percent (50%) of his support from the
Enrollee, residing with Enrollee or Enrollee's present or
former spouse, meeting the requirements to be claimed as
a dependent on the Enrollee' s federal income tax return
^�'. Mr.ASO+/FW-IA.DTF691 1A-11
and being a dependent unmarried natural child, foster
child, stepchild, legally adopted child or child under ,.
Enrollee ' s legal guardianship or conservatorship and
residing with Enrollee or Enrollee ' s present or former
spouse.
38 . "Provider" means any Health Professional, Hospital,
Chemical Dependency Treatment Facility, Out-Patient
Emergency Care Center or other facility which has
contracted with Sanus to provide services to Members
covered under this Plan.
39 . "Sanus" means Sanus Texas Health Plan, Inc. , the entity
designated by Employer to provide contractual
arrangements and administrative systems to implement the
Plan.
40. "Schedule of Benefits" means the schedule provided in
conjunction with enrollment in this Plan and made a part
hereof, which sets forth the benefits and services that
Employer shall make available to Enrollees.
41. "Semi-Private" means a room in a Hospital or Skilled
Nursing Facility containing two (2) to four (4) beds
and/or classified as semi-private by such Hospital or
Skilled Nursing Facility.
LG\.-ASO+/FW-I A.DTF691 1A-12
42 . "Skilled Nursing Facility" means an institution or part
, thereof, licensed by state or local law, that is
accredited as an extended care facility by the Joint
Commission on Accreditation of Healthcare Organizations
or is recognized as a skilled nursing facility by the
Secretary of the Department of Health and Human Services
under Title XVIII of the Social Security Act, as amended.
43 . "Urgent Care" shall have the same meaning as Medical
Emergency.
44 . "Urgent Care Center" shall have the same meaning as Out-
Patient Emergency Care Center.
( II. ELIGIBILITY; EFFECTIVE DATE OF COVERAGE
A. Eligibility
1. To be eligible to enroll, an Employee must be:
a. Eligible under eligibility criteria established by
the Employer, and
b. Entitled on his or her own to participate in the
medical and hospital care benefits arranged by the
Employer.
LG1-ASO+1FW.1 A.DTF691 1A-13
2 . To be eligible to enroll as a Dependent, a person must
be:
a. The spouse of an Enrolled employee, or
b. A dependent unmarried natural child, foster child,
stepchild, legally adopted child or child under
Enrollee's legal guardianship or custodianship,
residing with Enrollee or with Enrollee 's present
or former spouse who is:
(1) under nineteen (19) years of age, or
(2) under twenty-three (23) years of age,
Primarily Dependent on the Enrollee for
financial support and attending a state
accredited college or university, trade or
secondary school on a full time basis, which
has, in writing, verified said attendance.
C. A dependent unmarried natural child, foster child,
stepchild, legally adopted child, or child under
Enrollee's legal guardianship, residing with
Enrollee or with Enrollee's present or former
spouse, who is nineteen (19) years of age or older
but incapable of self-sustaining employment because
LG\fWASO+/FWIA.=691 1A-14
of mental retardation or physical handicap
commenced prior to age nineteen (19) (or commenced
prior to age twenty-three (23) if such child was
attending a recognized college or university, trade
or secondary school on a full time basis when such
incapacity occurred) and Primarily Dependent upon
the Enrollee for support and maintenance. Such
dependent child must have been enrolled at all
times under the Employer's benefit plan either
prior to attaining nineteen (19) years of age or
twenty-three (23) years of age under the conditions
of the previous sentence. Enrollee shall give
Employer proof of such incapacity and dependency
within thirty-one (31) days before the dependent
child' s attainment of the limiting age and from
time to time thereafter as Employer deems
appropriate.
d. Maternity care benefits will be extended to an
Enrollee's unmarried Dependent child. No benefits
are provided for the infant child of the Enrollee ' s
unmarried Dependent child unless the infant child
of the unmarried Dependent is otherwise eligible
for coverage by Enrollee. If such infant child is
eligible for coverage by the Enrollee, such
coverage will be available as described in Section
p Lcw Aso+IFv-1 A.DTF691 1A-15
II .A of this Agreement, provided appropriate
notices and premiums have been timely.
B. When an Enrollee's Coverage Becomes Effective
1. During the Employer's Enrollment Period: Each Eligible
Employee who applies for enrollment in the Plan by
submitting an Application during an Enrollment Period
shall become an Enrollee on the Effective Date, provided
such Employee is Actively at Work and meets Employer's
eligibility criteria on that date, otherwise it will
begin the first day this requirement is met.
2. Other Than During the Employer's Enrollment Period: Each
Eligible Employee who first meets the eligibility
requirements of Section II.A other than during the
Employer' s Enrollment Period may enroll within thirty-one
(31) days of meeting such requirements by submitting an
Application, provided that such employee has completed
one (1) month of continuous service and that such
Employee must be Actively at Work on such day, otherwise
coverage shall begin the first day these requirements is
met.
LGkwAS0+/FW-IA.DTF691 1A-16
3 . An otherwise eligible employee who is: (a) not Actively-
r
at-Work on the Effective Date of the group enrollment due
to the fact that he/she is confined in a hospital or
other medical institution or confined at home; and (b)
who was a covered individual under the Sanus insured
product as of September 30, 1990 shall be considered
eligible on October 1, 1991. Retirees who are otherwise
eligible but are afforded extension of benefits under
Aetna until December 31, 1991 shall become eligible under
this Plan effective January 1, 1992 .
C. When Dependent Coverage Becomes Effective
For the purposes of this Section, the following words and
phrases shall have the following meaning:
"Confined in a Hospital or Other Medical
Institution" means that a person is a patient
and/or undergoing medical care or treatment in a
Hospital, nursing home, or other medical
institution.
"Confined at Home" means that a person is
undergoing medical care. or treatment in his home
and/or has a condition, due to an illness, injury
or congenital deformity, which restricts the
Lc\mAs0+1ew-1 A.rnFwi 1A-17
patient ' s ability to leave his home without the aid
of a supporting device, or monitoring equipment, or
without the aid of another person.
1. On Date Enrollee Becomes Covered: An Eligible Dependent
for whom the Enrollee has applied for membership in the
Plan by submitting an Application shall become covered
under the Plan as a Dependent, subject to the preexisting
condition rider of the Plan, on the Effective Date,
provided that any Dependent Confined at Home or Confined
in a Hospital or Other Medical Institution on the day
that person would otherwise become covered will become
covered on the first day such Dependent is not confined.
No Dependent can be covered before the date the Employee
becomes covered. If the Employee or Retiree did not
become covered solely because he did not meet the
Actively-at-Work requirement stated in Section II.B, his
eligible Dependents who otherwise meet all requirements
will become covered on either (1) the day the Employee
becomes covered after having met the Actively-at-Work
requirement or (2) the day on which the Retiree's
continuation of coverage benefits expire as stated in
Section II.B. 3 , whichever occurs first.
2. Newly Acquired Dependents; Dependents First Becoming
Eligible Other Than During an Enrollment Period:
LOkwA50+/FW-IA.DW691 1A-18
a. A newly acquired Eligible Dependent other than a
newborn child, and an Eligible Dependent who first
meets the eligibility requirements of Section II.A
other than during an Enrollment Period and has an
Application submitted on his behalf within thirty-
one (31) days of meeting such requirements shall be
covered as of the first day on which he meets such
requirements, subject to the preexisting condition
Amendment of the Plan, provided that any Dependent
Confined at Home or Confined in a Hospital or Other
Medical Institution on the day that person would
otherwise become covered will become covered on the
first day such Dependent is not confined.
b. Newborn children of an Enrollee and/or an of
Enrollee's spouse shall be covered under the Plan
for an initial period of thirty-one (31) days from
the date of birth, and shall continue to be so
covered after that time only if, prior to the
expiration of such thirty-one (31) day period,
Enrollee notifies Employer with an Application
submitted for such newborn child.
C. A newly adopted child, including a newborn, shall
be covered under the Plan as if he were a newly
acquired Eligible Dependent. The thirty-one (31)
..,`i LG\wAS0+/FW-IA.DTF691 1A-19
day period for submission of an Application shall
commence on the earlier of the date upon which such
child commences residence with the Enrollee or when
the adoption becomes legal, and coverage shall
begin on such earlier date provided the Application
is submitted on a timely basis.
D. Coverage on Effective Date
In the event an employee or dependent has satisfied the
eligibility conditions in Section II of this Agreement on
the date that coverage under this Plan becomes effective,
such person shall, as of that date, be covered under the
Employer's Plan. The Plan shall not cover, or otherwise
be liable for services rendered prior to the Effective
Date or for such confinement or services not covered
under this Plan, including those services covered under
Extended Benefits coverage of any other health plan as
described in Section II.A.
E. Change of Eligibility Criteria
Requirements for participation in medical and hospital
care benefits arranged by the Employer are considerations
material to the provision of benefits. Any change in
LGVwASO+/FW-IA.DTF691 1A-20
such requirements is under the exclusive control of the
Employer, subject to Sanus ' prior written consent.
III. TERMINATION OF COVERAGE OF ENROLLEES FOR CAUSE
A. Termination of Enrollee
1. The coverage of any Enrollee who ceases to be
eligible under Section II.A shall terminate thirty-
one (31) days after the date such eligibility
ceases. This paragraph also applies to a Dependent
of an Enrollee who lost his eligibility, for what-
ever reason, including the death of the Enrollee.
Indefinite suspension shall not be considered as a
�) termination of employment for group health benefit
payment purposes only, and such payment shall be
the sole responsibility of the Enrollee.
2 . For coverage purposes, an Enrollee 's employment
will be considered to terminate when the Enrollee
is no longer actively engaged in work the number of
hours required by the Employer to be eligible for
coverage under this plan.
3 . If any payment for group health benefits, Copayment
and/or required payroll deduction, if any, is not
LG\rwASO+/FW-IA.DTF691 1A-21
paid in a timely manner by or on behalf of any
Enrollee, coverage may be canceled after not less
than a thirty (30) day written notice to the
Enrollee by the Employer or Sanus.
4 . Fraud or misrepresentation by Enrollee will cause
coverage to be canceled after not less than a
fifteen (15) day written notice to the Enrollee by
the Employer or Sanus.
5. Failure of an Enrollee to meet eligibility
requirements may cause coverage to be canceled
immediately, subject to the continuation of
coverage and conversion provisions.
6. Failure of the Enrollee and Participating
Physician to establish a satisfactory Patient-
physician relationship may cause coverage to be
terminated, if it is shown that Sanus has, in
good faith, provided the Enrollee with the prior
written notice as required below and the op-
portunity to select an alternative Participating
Physician. The Enrollee shall be notified in
writing at least sixty (60) days in advance that
the Patient-physician relationship is considered
to be unsatisfactory by Sanus; Sanus must
LG4mA5O+/F W-I A.DTF691 1A-22 '
specify the changes that are necessary in order
to avoid termination. If the Enrollee has
failed to make such changes, coverage may be
canceled at the end of the sixty (60) days.
7 . Refusal of an Enrollee to accept recommended
procedures or treatment as described in Section
V.A may cause the Enrollee's coverage to be
terminated after not less than a sixty (60) day
written notice, so as to allow sufficient time
for the Enrollee to elect and consult with
another Participating Physician or Participant
Provider.
IV. SPECIAL REQUIREMENTS FOR MEMBERS COVERED UNDER MEDICARE
A. Employer coverage under the Plan shall be primary when
an Enrollee age 65 or older is enrolled in Medicare
and is employed by the Employer. Employer coverage
shall be primary for the spouse of an Enrollee who is
employed by the Employer when such spouse is a
Dependent, is enrolled in Medicare and is age 65 or
older.
B. The Plan shall be primary as compared to Medicare, for
a period of not less than nine (9) months and not
LG4wAS0+/flV-IA.D7'F691 1A-23
greater than twelve (12) months for Enrollees who have
become entitled to Medicare solely on the basis of end
stage renal disease. Said twelve (12) month period
begins with the earlier of: (1) the month in which a
regular course of dialysis is initiated; or (2) in the
case of an individual who receives a kidney
transplant, the first month in which the individual
became entitled to Medicare.
C. When an Enrollee is entitled in Part A and/or Part B
or Medicare and Medicare is the primary insurer,
Employer' s Plan shall pay on behalf of such Enrollee
all Medicare deductible and co-insurance payments.
The Enrollee shall remain liable, however, on a carve-
out basis, for the Copayments and deductibles set
forth in the Schedule of Benefits in the event that
such Copayments and deductibles are less than the
Medicare deductibles and required Medicare coinsurance
payments.
V. REFUSAL TO ACCEPT TREATMENT: EXCESSIVE TREATMENT
A. Certain Enrollees may, for personal reasons, refuse to
accept procedures or treatment recommended by a
Participating Physician and/or Provider. The
Participating Physician and/or Provider may regard
LG'rwASO+/FW I A.OTF691 1A-24
such refusal to accept their recommendations as
incompatible with the continuation of their Physician-
patient and/or Provider-patient relationship and as
obstructing the provision of proper medical care. If
an Enrollee refuses to accept such recommended
treatment or procedure and the Participating Physician
and/or Provider believes that no professionally
acceptable alternative treatment or procedure exists,
such Enrollee shall be so advised in writing. If the
Enrollee still refuses to accept the recommended
treatment or procedure, then the Enrollee may be
terminated in accordance with Sections III.A. 6 and
III.A. 7 .
B. If two (2) or more Participating Physicians who have
rendered care to an Enrollee inform the Employer that
the Enrollee is receiving health services or
prescription medications in a manner or in a quantity
which is not Medically Necessary or not medically
beneficial, the Enrollee may be required by Sanus to
select a single Participating Primary Care Physician
(hereafter referred to as a "Coordinating Health Plan
Physician") and a single Participating Pharmacy for
the provision and coordination of all future health
services.
/ LG\mASO+/FW-IA.DrF691 1A-25
If the Enrollee fails to select a Coordinating Health
Plan Physician and a single Participating Pharmacy
within thirty (30) days of written notice by Sanus of
the need to do so, the Employer shall designate a
Coordinating Health Plan Physician and a Participating
Pharmacy for the Enrollee.
Following selection or designation of a Coordinating
Health Plan Physician for an Enrollee, coverage for
health services shall be contingent upon each health
service being provided by or through written referral
of the Coordinating Health Plan Physician for that
Enrollee.
VI. PAYMENT REQUIREMENTS
1. The required payments, if any, from Enrollees for the
services and benefits made available hereunder are in
the Schedule of Benefits.
2 . Copayments are due and payable to the Physician and/or
Provider at the time a service is delivered. The
maximum amount of Copayment for Plan Benefits in any
calendar year will not exceed the amounts specified in
the Schedule of Benefits. It is the Enrollee' s
responsibility to retain receipts and to notify the
LGVWASO+1FW-IA.DTF691 1A-26 Q
Employer upon attaining the Copayment limit so that
additional services will be provided without a
Copayment charge.
3 . Any premium payments required for newborn children who
meet the requirements of Section II.C(2) (b) shall be
initially payable on or before the first day of the
month next following the month in which the
application required under Section 11.C(2) (b) is
submitted to the Employer. Such initial payments
shall be retroactive to the first day of the month in
which such child' s date of birth occurred.
Thereafter, all payments with respect to such newborn
child, shall be made as otherwise required hereunder.
VII. IDENTIFICATION CARDS
A. Employer shall issue identification cards for the
Enrollees.
B. Possession of an I.D. card confers no rights to
services or other benefits. The holder of the card
and the name on the card must be the same and the
holder of the card must be, in fact, an Enrollee on
whose behalf all applicable charges have actually been
paid. Any person receiving services or other benefits
��"
LG\rwASO+/FW-I A.UrF691 1A-27
to which he is not entitled through use of an
identification card or otherwise, shall be chargeable
therefor at the actual cost of services rendered. If
any Enrollee permits the use of his identification
card by an other person, such card may be recalled and
invalidated, and all rights of such Enrollee may be
terminated (see Section III.A) .
VIII. TERM AND AMENDMENT OF AGREEMENT
A. Term
This Plan shall be effective October 1, 1990 and shall
remain in effect until September 30, 1991. Employer
may terminate this Plan upon one hundred twenty (120)
days prior written notice to Sanus and without consent
of Enrollees.
B. Amendment
1. This Plan may be amended at any time, without
the consent of the Enrollees, or any other
person having a beneficial interest in it. Any
such amendment shall be without prejudice to any
claim arising prior to the date of such
amendment.
LG\i.AS0+1FW-1A.UrF691 1A-28
2 . Employer may alter or revise the terms of this
! Plan, subject to Sanus ' prior consent as
guarantor of this Plan. The alteration or
revision shall become effective and shall be
implemented by Sanus on the date contained in
Employer' s notice.
IX. HEALTH CARE SERVICES
A. Benefits and Services
1. Employer will arrange for the provision of the
benefits and services in the Schedule of
( Benefits in accordance with the procedures and
subject to the limitations and exclusions
specified in the Plan and this Agreement.
2 . Unless referred in writing by a Participating
Primary Care Physician (or by a Participating
Specialist Physician with the concurrence of the
responsible Participating Primary Care
Physician) , and except in cases of Medical
Emergency, benefits and services set forth in
Section II of the Schedule of Benefits that are
rendered by a Participating Physician other than
k
LGVWASO+/FW I A.DTF691 1A-29
a Participating Primary Care Physician shall not
be covered. 01-
3 . Unless previously authorized in writing by a
Participating Physician and by the Medical
Director and except in cases of Medical
Emergency, all benefits and services set forth
in Section II of the Schedule of Benefits shall
be available and covered only when provided by a
Participating Physician, Participating Hospital
or by another Provider under contract with Sanus
to provide health care services to Enrollees.
4 . In cases of Medical Emergency, Enrollees shall
be entitled to the benefits and services set
forth in Section III of the Schedule of
Benefits.
5. Regardless of the foregoing, an eligible covered
Enrollee and/or his eligible covered dependents
who elect coverage under Exhibit 1 or Exhibit
III of this Plan may at all times use the major
medical benefits as set out in Part B of those
Exhibits.
LG4wAS0+IFlN-IA.DTF691 1A-30 0
B. Benefits and Services Excluded from Coverage
y
Enrollees shall not be entitled to the benefits and
services described in Section IV of the Schedule of
Benefits.
X. LIMITATIONS
The rights of Enrollees and obligations of Employer,
Participating Physicians, Participating Hospitals and
Providers are subject to the following limitations:
A. Major Disaster or Epidemic
In the event of any major disaster or epidemic that
would severely limit the ability of Participating
Physicians, Providers and/or Hospitals to provide
health care services on a timely basis, Participating
Physicians, Participating Hospitals and Providers
shall, in good faith, use their best efforts to render
the benefits and services covered insofar as practical
according to their best judgement and within the
limitation of such facilities and personnel as are
then available. If Sanus, Participating Physicians,
Participating Hospitals and Providers shall have, in
good faith, used their best efforts to render benefits
LGVwASO+/F W-1 A.DTF691 1A-31
and services in the aforesaid manner, they shall have
,hM'1
no further liability or obligation for delay or 1
failure to provide such benefits and services due to
a shortage of available facilities or personnel
resulting from such disaster or epidemic.
Regardless of the foregoing, an eligible covered
Enrollee and/or his eligible covered dependents who
elect coverage under Exhibit 1 or Exhibit III of this
Plan may at all times use the major medical benefits
as set out in Part B of those Exhibits.
B. Circumstances Beyond The Control of Employer, Sanus,
Participating Physician or Provider
In the event that, due to circumstances not reasonably
within the control of Employer, Sanus, Participating
Physicians or Providers, such as the complete or
partial destruction of facilities because of war,
riot, civil insurrection, or the disability of a
significant number of Participating Physicians or
Providers, or similar causes, the rendering of
benefits and services covered hereunder is delayed or
rendered impractical, Employer, Sanus, Participating
Physicians or Providers shall not have any liability
or obligation on account of such delay or such failure
LG\mASO+/FW-IA.UrF691 1A-32
to provide such benefits and services if they shall
have, in good faith, used their best efforts to render
the benefits and services covered insofar as practical
according to their best judgement and within the
limitation of such facilities and personnel as are
then available.
Regardless of the foregoing, an eligible covered
Enrollee and/or his eligible covered dependents who
elect coverage under Exhibit 1 or Exhibit III of this
Plan may at all times use the major medical benefits
as set out in Part B of those Exhibits.
ga, C. Limitations as Set Out in the Schedule of Benefits
The benefits provided are also limited by the limitations
and exclusions as set out in the Schedule of Benefits.
D. Non-Covered Services
The Employer shall not be responsible for the
reimbursement for services or treatment of complications
that result from any non-covered service, procedure or
treatment. Employer shall not be responsible for
prescription drugs and/or medications related to any non-
covered service, procedure or treatment.
c
.f LGVwASO+/FWIA.DT'F691
1A-33
XI. CLAIM PROVISION
A. Reimbursement of Claims Paid by Enrollees
It is not anticipated that an Enrollee will make payment,
other than the Copayments and Deductibles required
hereunder, to any other person or institution providing
benefits and services which are covered under this Plan;
provided, if the Enrollee furnishes to Employer written
proof that he has made payment to such person or
institution with respect to benefits and services covered
under this Plan, payment with respect to said services
will be paid to the Enrollee, but without prejudice to
Employer' s right to seek recovery of any payment made by
it before receipt of such evidence. Claims must be in
writing but need not be in any particular form. A letter
accompanied by invoices describing the services provided
will normally be sufficient.
B. Proof of Claim
If a charge (other than as specified in paragraph C
below) is made to an Enrollee for any benefits and
services which are covered under this Plan, written
proof of such charge must be furnished to the Employer
LGVwASO+/F W-I A.DTF691 1A-34
within six (6) months after the performance of the
service.
C. Pharmaceutical Services
Where this Plan provides coverage for outpatient
prescription drugs subject to certain deductibles, it
is the Enrollee' s responsibility to retain receipts
for covered drug payments. Any claim for
reimbursement must be made in writing to Employer and
accompanied by the relevant receipt within six (6)
months following the end of the calendar year in which
the covered expense is incurred.
r�
D. Emergency Care Services
Payment or reimbursement of Emergency Care services
(see Schedule of Benefits Section III for a
description of covered Emergency Care services)
provided by Physicians, Hospitals or Health
Professionals that have not contracted with Sanus to
provide services under the Plan, whether inside or
outside the Defined Area, will be on a fee-for-service
basis subject to a maximum allowable fee, and subject
to Copayments, Deductibles and exclusions set out in
1
r;�
LGVWASO+4W-I A.DTF691 1A-35
the Plan, as well as the following additional
y
conditions:
1. The Enrollee and Provider must notify the Plan
or his Participating Primary Care Physician of
his condition and the service arrangements
within forty-eight (48) hours after the onset of
the Medical Emergency and receive authorization
for continued services, if indicated. If the
Enrollee ' s physical condition does not permit
such notification within the prescribed time, he
must make the notification as soon as it is
reasonably possible to do so.
2 . The claim for reimbursement must be made in
writing within sixty (60) days of the onset of
the Medical Emergency and for which payment is
requested, accompanied by invoices or other
appropriate evidence of payment.
E. Failure to Furnish Proof of Claim
Failure to furnish proof within the required time
established in paragraphs B and C of this Section
shall not invalidate or reduce any claim if it was not
reasonably possible to give proof within such time,
LG4wAS0+iFw-IA.rn'F691 1A-36
provided such proof is furnished as soon as reasonably
possible. All such charges will be paid within sixty
(60) days of receipt of written proof covering the
occurrence, character and extent of the event for
which claim is made unless the Enrollee is notified of
the need for a longer time pursuant to paragraph G of
this section.
F. Examination
Employer, or its designee, at its own expense, shall
have the right to examine the person whose sickness or
injury is the basis of a claim when and so often as it
may reasonably require during the pendency of the
r.
claim.
Such examination shall be made by a physician
similarly situated with regard to education,
credentials and training. In the case of major
medical benefits, such examination shall be by a non-
participating physician with similar education,
credentials and training.
Y"
LG4wAS0+/FW-IA.DTF691 1A-37
G. Action on Claims
Claims will be acted on within sixty (60) days unless
the Enrollee is notified of the need for a longer
time. If a claim is denied, a written notice will
contain the reason for the denial.
If the Enrollee is notified of the need for a longer
time to act upon the claim, Employer shall use due
diligence to act upon the claim within two hundred
seventy days (270) of the date of submission of the
claim.
H. Review
If a claim is denied, an Enrollee may obtain a review
of the denial through written request to Employer.
1. No action at law or equity shall be brought
under this Section against Employer: (i) prior
to the expiration of the sixty (60) day period
immediately following the date on which written
proof of the charge or loss upon which the
action is brought has, in accordance with the
provisions of this Section, been furnished to
Employer; or (ii) later than four (4) years
LG4wASO+/FW-1A.DTF691 1A-38
after the expiration of the period of time in
y: which such proof of charge or loss is required
under this Section to be furnished to Employer.
2 . No liability shall be imposed upon Employer
other than for the benefits and services
specifically covered hereunder.
XII. COORDINATION OF BENEFITS AND SUBROGATION
If any benefits to which an Enrollee is entitled under this
Plan are also covered under any other Health Care Plan, the
benefits payable under another Health Care Plan include the
benefits that would have been payable had a claim been duly
f Y
made therefor. This provision does not apply to individual
coverage or Medicaid.
A. For purposes of this Section only, the following words
and phrases shall have the following meanings:
1. "Allowable Expenses" means any necessary,
reasonable and customary item of expense at
least a portion of which is covered under at
least one of the Health Care Plans covering the
person for whom claim is made. When a Health
Care Plan (including this Plan) provides
LGVwASO+FW-IA.DTF691 1A-39
benefits in the form of services, the reasonable
cash value of each service rendered shall be
deemed to be both an Allowable Expense and a
benefit paid.
2 . "Health Care Plan" means any of the following
(including this Plan) which provide benefits or
services for, or by reason of, medical care or
treatment:
a. Coverage under government programs,
including Medicare, required or provided by
any statute unless coordination of benefits
with any such program is forbidden by law.
b. Group coverage, including automobile
insurance, individual coverage or any other
arrangement of coverage for individuals in
a group, whether on an insured or uninsured
basis, including any prepayment coverage,
group practice basis or individual practice
coverage and any coverage for students
which is sponsored by or provided through,
a school or other educational institution
above the high school level.
LGVWA5O+/FW-I A.DTF691 1A-40
The term "Health Care Plan" shall be
construed separately with respect to:
(i) Each policy, contract or other
arrangement for benefits or services.
(ii) That portion of any such policy,
contract or other arrangement which
reserves the right to take the
benefits of other Health Care Plans
into consideration in determining its
benefits and that portion which does
not.
"'2
B. Employer shall have the right to coordinate benefits
between this Plan and any other Health Care Plan
covering the Enrollee.
The rules establishing the order of benefit
determination between this Plan and any other Health
Care Plan covering the Enrollee on whose behalf a
claim is made are as follows:
1. The benefits of a Health Care Plan which does
not have a "coordination of benefits with other
`+�-.J LG\r.ASO+TWIA.DTF691 1A-41
health plans" provision shall , in all cases, be
determined before the benefits of this Plan.
2 . If, according to the rules set forth in
Paragraph C of this Section, the benefits of
another Health Care Plan that contains a
provision coordinating its benefits with this
Plan before the benefits of this Plan have been
determined, the benefits of such other Health
Care Plan will be considered before the
determination of benefits under this Plan.
C. Rules establishing the order of benefit determination
as to an Enrollee's claim for the purposes of
Paragraph B of this Section are as follows:
1. The benefits of a plan which covers the person
on whose expenses claim is based other than as a
dependent shall be determined before the
benefits of a plan which covers such person as a
dependent.
2 . The benefits of a plan which covers the person
on whose expenses claim is based as a dependent
of a person whose date of birth, excluding year
of birth, occurs earlier in a calendar year,
MmASO+/FW-IA.DTF691 1A-42
shall be determined before the benefits of a
plan which covers such person as a dependent of
a person whose date of birth, excluding year of
birth, occurs later in a calendar year. In the
event that both persons have the same birth
date, the Plan covering the person with the
earlier birth year shall be considered primary.
If either plan does not have the provision of
this paragraph regarding dependents, which
results either in each plan determining its
benefits before the other, or each plan
determining its benefits after the other, the
provisions of this Paragraph shall not apply,
and the rule set forth in the plan which does
' not have the provisions of this Paragraph shall
determine the order of benefits; except that in
the case of a person for whom claim is made as a
dependent child:
W When the parents are divorced and the
parent with custody of the child has not
remarried, the benefits of a plan which
covers the child as a dependent of the
parent with custody of the child will be
determined before the benefits of a plan
which covers the child as a dependent of
the parent without custody.
LG\rwASO+fM-I A.OrIF691 1A-43
When the parents are divorced and the
parent with custody of the child has
remarried, the benefits of a plan which
covers the child as a dependent of the
parent with custody shall be determined
before the benefits of a plan which covers
that child as a dependent of the step-
parent, and the benefits of a plan which
covers that child as a dependent of the
step-parent will be determined before the
benefits of a plan which covers the child
as a dependent of the parent without
custody.
Notwithstanding Subparagraphs (i) and (ii)
of this Paragraph, when the parents are
divorced and there is a court decree which
would otherwise establish financial
responsibility for the medical, dental, or
other health care expenses with respect to
the child, the benefits of a plan which
covers the child as a dependent of the
parent with such financial responsibility
shall be determined before the benefits of
any other plan which covers the child as a
dependent child.
LG4wASO+/FWIA.DTF691 1A-44
3 . When paragraphs (1) and (2) do not establish an
order of benefits determination, the benefits of
a plan which has covered the person on whose
expenses claim is based for the longer period of
time shall be determined before the benefits of
a plan which has covered such person the shorter
period of time, except that:
(i) The benefits of a plan covering the person
on whose expenses claim is based as a laid-
off or Retiree or as the dependent of such
person shall be determined after the
benefits of any other plan covering such
person as an Enrollee other than as a laid-
off or Retiree or a dependent of such
person; and,
(ii) if either plan does not have a provision
regarding laid-off or Retiree and, as a
result, each plan determines its benefits
after the other, then the provisions of
subparagraph (i) of this paragraph do not
apply.
D. When any benefits are available as primary benefits to
an Enrollee under Medicare, Medicare will be
LG\mASO+/FW-I A.DTF691 1A-45
determined first and benefits available under this y
Plan, if any, will be reduced accordingly.
E. If an Enrollee who has enrolled under this Plan is
entitled to inpatient benefits under another contract
or policy of insurance due to inpatient care which
began while the Enrollee was enrolled under a
previously held policy, the Employer will pay, subject
to Copayments under this plan, the difference between
entitlements under this Plan and entitlement under the
other contract or policy of insurance.
F. Benefits which are provided directly through a
specified provider of an employer shall in all cases
be provided before the benefits of this Plan.
G. Services and benefits for military service connected
disabilities for which an Enrollee is legally entitled
and for which facilities are reasonably available,
shall in all cases be provided before the benefits of
this Plan.
H. For purposes of Section XII, the Employer may, subject
to applicable confidentiality requirements set forth
in this Plan, release to or obtain from any insurance
company or other organization necessary information
LG\mASO+/FW-I A.DTF69I 1A-46
under this provision. Any Enrollee claiming benefits
as�
J under this Plan must furnish to the Employer all
information deemed necessary by it to implement this
provision.
I. None of the above rules as to coordination of benefits
will serve as a barrier to the Enrollee first
receiving direct health services arranged by the
Employer which are covered under this Plan except as
specifically stated in Paragraph G of this Section.
J. Whenever payments have been made by the Employer with
respect to Allowable Expenses in a total amount, at
$ 0. any time, in excess of 100% of the amount of payment
necessary at that time to satisfy the intent of this
Section XII, the Employer shall have the right to
recover such payment, to the extent of such excess,
from among one or more of the following as the
Employer shall determine: any person or persons to,
or for, or with respect to whom, such payments were
made; any insurance company or companies; or any other
organization or organizations to which such payments
were made.
LGVwASO+/FW I A.DTF691 1A-47
K. Workers ' Compensation
All sums payable for benefits available pursuant to
workers' compensation shall not be reimbursable under
this Agreement.
L. Enrollee' s Cooperation (Medicare)
Each Enrollee shall complete and submit to the
Employer or its designee, such consents, releases,
assignments and other documents as may be requested by
the Employer in order to obtain or assure
reimbursement under Medicare. Any Enrollee who fails
to enroll under Part B and, if eligible, Part A of the
Medicare program, will be liable for the amount of
funds the Employer would have received had Member so
enrolled.
M. Acts of Third Parties (Subrogation)
Plan services shall be provided to an Enrollee due to
the act or omission of another person. However, if
the Enrollee is entitled to a recovery from any third-
party with respect to those services such Enrollee
shall agree in writing:
LG4wAS0+/FlV-1 A.vrFbal 1A-48
1. To reimburse Employer to the extent of the usual
and customary charge that would have been
charged to the injured Enrollee for health care
services hereunder if the Enrollee were not
covered under this Plan. Such reimbursement
must be made immediately upon collection of
damages for hospital or medical expenses by the
Enrollee whether by action at law, settlement or
otherwise.
2 . To provide Employer with a lien against any
third party recovery for hospital or medical
expenses to the extent of the usual and
customary charge that would have been charged to
the Enrollee for health care services in the
absence of coverage under this Plan. Such lien
may be filed with the person whose act caused
the injury, such person's agent or the court.
N. Facility of Payment
Whenever payments which should have been made under
the Employer's coverage in accordance with this
provision have been made under any other Health Care
Plan, the Employer shall have the right, exercisable
in its sole discretion, to pay over to an organization
LG\ewASO+/FW-IA.DTF69I 1A-49
making such other payments any amounts it shall
determine to be warranted in order to satisfy the
intent of this Section XII. Accounts so paid by the
Employer shall be deemed to be benefits paid under the
Employer' s coverage, and to the extent of such
payment, the Employer shall be fully discharged from
liability under this Plan.
O. Disclosure
Each Enrollee agrees to disclose to the Employer at
the time of enrollment, at the time of receipt of
services and benefits, and from time to time as
requested by the Employer, Social Security number,
birth date, employment, and the existence of other
Health Care Plan coverage, in regard to which the
identity of the carrier and the group through whom
provided will be furnished by the Enrollee.
XIII. OPTION TO CONTINUE GROUP COVERAGE, CONVERSION
PRIVILEGE AND TRANSFER
A. If, under the provisions of Title X of the
Consolidated Omnibus Budget Reconciliation Act of
1985, Public Law 99-272 ("COBRA") , any Enrollee is
granted the right to continuation of coverage beyond
LG\mASO+/FW I A.DrCF691 1A-50
the date his coverage would otherwise terminate, or,
if COBRA is inapplicable and the provisions of an
applicable state statute grants such Enrollee similar
rights to continuation of coverage, this Plan shall be
deemed to allow continuation of coverage to the extent
necessary to comply with the provisions of the
applicable statute. Contact Employer for verification
of eligibility and procedures to follow.
B. Conversion
If the coverage of any Enrollee terminates for any
reason other than those set forth in Section III.A,
then such Enrollee may convert his membership to
individual membership without furnishing evidence of
insurability. No Enrollee shall be allowed to convert
if Enrollee's termination results from the Employer's
withdrawal from this Plan. In order to obtain
individual membership, any Enrollee eligible to
convert his membership must continue to reside in the
Defined Areal submit a completed application for
conversion to Employer within thirty-one (31) days
after the date of termination and submit premium
payments required by Employer under such membership.
The effective date of such individual membership shall
�JLGVwASO+/FW-I A.DTF691 1A-51
be the next day following the Termination Date of the
Enrollee 's coverage under this Agreement.
C. Transfer of Residence
1. Transfer within the Defined Area - If an
Enrollee changes his primary residence within
the Defined Area, he must notify Sanus within
thirty (30) days of such change.
2 . Transfer outside the Defined Area - If an
Enrollee changes his primary residence outside
the Defined Area, such change shall result in
loss of eligibility.
XIV. MISCELLANEOUS
A. Pronouns
Masculine pronouns used in this Plan shall include
both masculine and feminine genders.
B. Records and Information
1. Information from medical records of Enrollees
and information received from Physicians or
Providers or Facilities incident to the
Physician-patient, Provider-patient or Facility-
LG\mASO+IFW-IA.DTF691 1A-52
patient relationship shall be kept confidential .
The information, except as reasonably necessary
in connection with the administration of this
Plan, or as required by law, may not be
disclosed without the consent of Enrollees.
2 . For the purposes of administering this Plan
(including, without limitation, Section XII
hereof) , the Employer or its designee may, to
the extent legally allowable and without further
consent of or notice to any Enrollee, release to
or obtain from any insurance company or other
organization or person any information, with
respect to any person, which Employer deems to
be necessary for such purposes. Any person
claiming benefits under this Plan shall furnish
to Employer such information as may be necessary
to implement Section XII hereof.
3 . Prior to admission as an inpatient for elective
hospitalization or for same day surgery, the
Participating Primary Care Physician must obtain
pre-admission certification from Sanus.
C. Notices
LG4wASO+/FWIA.DTF69I 1A-53
Any notice under this Plan may be given by United
States Mail, postage prepaid, addressed as follows: t,
If to Sanus:
Sanus Texas Health Plan
8600 Freeport Parkway, Suite 3040
Irving, Texas 75063
Attn: Executive Director
If to Employer:
City of Fort Worth
1000 Trockmorton
Fort Worth, Texas
Attn: Risk Manager
If to Enrollee:
The latest address provided by the Enrollee on
forms actually delivered to Employer.
D. Assignment by Enrollee
The benefits to an Enrollee under this Plan are
personal to the Enrollee and are not assignable or
otherwise transferable.
E. Authority
Any alteration or revision to this Plan or the
attached schedule of Benefits must be in writing,
agreed to by Sanus, and signed by an officer of the
Employer to be valid. No other person has the
authority to change this Plan or to waive any of its
provisions.
LG\mASO+tFW 1 A.DTF691 1A-54
F. Plan Documents
Employer will make this Group Membership Service
Agreement available for review by Enrollees upon
request and a provide copy of the applicable Schedule
of Benefits to each Enrollee.
G. List of Providers of Services
Sanus will provide to the Employer for dissemination
to Enrollees, a list of Participating Physicians,
Participating Hospitals, Participating Chemical
Dependency Treatment Facilities, and other Providers
who have contracted with Sanus to provide the services
and benefits covered by this Plan.
H. Furnishing Information
Any person claiming or who may claim benefits under
this Plan shall facilitate the access of or furnish to
Employer such information as may be necessary to
implement this Plan, and Employer may release or
obtain such information as needed to implement the
provisions of the Plan.
\JS
,. +' LG\MASO+/FWIA.DrrF691 1A-55
I . Independent Contractors
1. The relationship between Sanus, Employer, and
Facilities is that of independent contractors.
Facilities are not agents or employees of Sanus
or Employer nor is Sanus or any employee of
Sanus or Employer an employee or agent of any
Facility. Facilities shall maintain the
Facility-patient relationship with Enrollees and
shall be the only parties responsible to
Enrollees for the services that they provide.
2 . The relationship between Sanus and, Employer,
Enrollees and Physicians and other Health
Professionals is that of independent
contractors. Physicians and Health Profes-
sionals are not agents or employees of Employer
or Sanus, nor is Employer or Sanus or any
employee of Employer or Sanus an employee or
agent of any Physician or Health Professional.
Physicians and Health Professionals shall
maintain the Physician-patient or Health
Professional-patient relationship with
Enrollees.
LG4wAS0+/F1V-1 A.m'F691 1A-56
EXHIBIT 1
PART A (Cont'd)
SCHEDULE OF BENEFITS
Enrollees are entitled to receive the services and benefits set
forth in this Schedule of Benefits which are Medically Necessary
and are provided, ordered, prescribed or authorized by the
Enrollee's Participating Primary Care Physician subject to the
limitations, exclusions, Copayments and deductibles specified.
I. ROUTINE MEDICAL AND HEALTH SERVICES, WHEN COVERED
Except in the case of a Medical Emergency, services are covered
only under the following conditions:
A. Each Enrollee must select a Participating Primary Care
Physician, from the directory, who will be responsible
for the Enrollee's health needs, including coordination
of out-of-area services and specialist referrals.
B. To be covered under the Plan, all services must be
provided, directed or authorized by the Enrollee ' s
Participating Primary Care Physician at a Participating
Facility. When the Enrollee requires care by another
Participating Physician, Participating Hospital,
Participating Chemical Dependency Treatment Facility or
other Participating Health Professional, the Enrollee ' s
t �� LG\rwASOCF-SB1.DTF691 1A-57
Participating Primary Care Physician will make a written
referral to such Participating Physician, Participating
Hospital, Participating Chemical Dependency Treatment
Facility or Participating Health Professional . The only
exception is the well-woman examination provided for in
Section II. B (1) (a) , or as otherwise expressly provided.
The Plan will not pay for visits to any Physicians,
Hospitals, chemical dependency treatment facilities or
Health Professionals that have not been authorized in
writing by the Enrollee's Participating Primary Care
Physician and, when appropriate, approved in advance by
the Plan. The Enrollee' s Participating Primary Care
Physician will be responsible for reviewing, coordinating
and following up on any specialty or hospital course of
treatment.
C. The Enrollee's Participating Primary Care Physician may
make referrals only to Participating Physicians,
Participating Hospitals, Participating Chemical
Dependency Treatment Facilities and other Participating
Health Professionals who have signed participating
provider agreements with Sanus. The Enrollee' s
Participating Primary Care Physician may make referrals
to Non-Participating Physicians and Non-Participating
Hospitals and Health Professionals when such services
cannot be provided by another Participating Provider.
LGVwASOCF-SB I.DTF691 1A-58
Such referrals must be in writing and approved in advance
by Sanus as the administrator of the Plan.
D. Participating Specialist Physicians may make further
referrals to other Physicians, Hospitals, Participating
Chemical Dependency Treatment Facilities and Health
Professionals. In each case, they must receive the
concurrence of the Enrollee's Participating Primary Care
Physician and follow the same referral procedures set out
in paragraphs B and C above.
E. When a Participating Physician determines that an
Enrollee requires admission to a Participating Hospital,
the physician must obtain pre-certification from the
P' Plan. Length of stay will be determined by medical
necessity and monitored to assure that appropriate care
is rendered in the appropriate setting.
', LG\mASOCF-SBI.DTF691 1A-59
II. ROUTINE MEDICAL BENEFITS, HEALTH BENEFITS AND COPAYMENTS:
Services Required Copayments
A. OUTPATIENT SERVICES
1. Office visits for diagnosis and $5 per visit.
treatment of illness or injury.
a. Laboratory services. None in lab facility.
b. Diagnostic and therapeutic None in radiology
radiological services in facility.
support of other covered
benefits and services.
C. Surgical procedures in a $5 per visit.
Participating Physician's
office. (See Section
II.C( 1) ) .
d. Administered drugs, $5 per visit.
medications, injectibles,
biologicals, fluids,
radioactive materials,
dressings, casts, and
crutches; splints and
braces which are used for
urgent or emergency
treatment. (See Sections
IV.W and IV.Y)
e. Obstetrical care, including $5 per visit.
pre-natal and post-natal
services.
2. Medically Necessary short-term $5 per visit.
outpatient rehabilitation
(i.e. , physical therapy)
services for acute conditions
which are recommended by the
Enrollee' s Participating
Primary Care Physician and
approved in advance by the
Plan. The acute condition must
be subject to significant
improvement through short-term
therapy. Short-term is defined
as up to sixty (60) consecutive
LGVwAS0CF48I.DfF691 1A-60
services Required Copayments
days per medical condition,
including treatment received as
an inpatient under Section
II.D(2) . The total of
outpatient and inpatient
rehabilitative services shall
not exceed sixty (60)
consecutive days per medical
condition, beginning with the
first date of treatment.
3 . Medically necessary outpatient $25 for each surgery in
or same day surgery services, a Hospital outpatient
including anesthesia, which are unit, day surgery unit
recommended by the Enrollee's or Ambulatory Surgical
Participating Primary Care Center. (See Section
Physician and approved in
advance by the Plan. The Plan
reserves the right to obtain a
second opinion by a Physician
1 of its own choosing.
4 . Participating Physician $5 for each physician
services rendered in an home visit.
Enrollee's home.
5. Allergy testing by a $25 per testing visit.
Participating SANUS allergy $5 per visit (all
specialist. (Allergy others)
injections and serum are not
covered. )
6. Mental health services (non- $25 for each 50 minute
chronic acute conditions only; visit.
see Section IV.Q) . When
recommended by the Enrollee's
Participating Primary Care
Physician and approved in
advance by the Plan, up to
twenty (20) fifty (50) minute
office visits per calendar year
to a participating
psychiatrist, participating
psychologist or participating
mental health professional are
�: ) LG1rwAS0CF-SBI.DTF691 1A-61
j�
Services Required Copayments
provided for evaluation or
crisis intervention mental
health services.
7. Chemical Dependency - Necessary $5 per visit. (No
outpatient treatment for Copayment for aftercare
Chemical Dependency is provided maintenance visits)
on the same basis and is
subject to the same limita-
tions, exclusions and
Copayments as treatment for
physical illness generally.
All treatment must be
recommended by the Enrollee's
Participating Primary Care
Physician and pre-authorized by
the Plan, and all care must be
provided by a Participating
Chemical Dependency Treatment
Facility.
B. PREVENTIVE HEALTH SERVICES
1. Periodic health assessments, None.
pediatric well-baby care and
routine immunizations when
deemed Medically Necessary by
the Enrollee's Participating
Primary Care Physician. The
schedule and extent of such
health assessments shall be
determined by the Enrollee's
Participating Primary Care
Physician. Immunizations are
given and covered in accordance
with accepted medical practice
for certain common communicable
diseases including diphtheria,
pertussis, measles, mumps,
rubella, poliomyelitis and
tetanus.
2 . Annual Well Woman-Exam. Female None.
Enrollees may elect to have a
gynecological and related
LG\mASOCF-SB1.DTF691 1A-62
FServices Required Copayments
examination, including Pap
smear, performed once every
twelve (12) months by the
Enrollee's Participating
Primary Care Physician or any
Sanus Participating
Obstetrician/Gynecologist or
Gynecologist offering such
examination.
NOTE: No Participating Primary
Care Physician referral
is needed for this exam.
However, referrals are
still required for other
gynecological
procedures.
3 . Routine vision, speech and None.
hearing screening through 17
-'' years of age to determine the
need for correction; not to
include refraction eye exams,
testing or fitting for hearing
aids.
C. FAMILY PLANNING
1. Family planning services on a $5 per visit plus: IUD
voluntary basis to include $25 for insertion or
history, physical examination, removal ; Diaphragm $25 ;
related laboratory tests and Vasectomy $25; Elective
medical supervision in tubal ligation $25 ;
accordance with generally (See Section II.A( 3 ) )
accepted medical practice;
information and counseling on
contraception, including advice
on or prescription for a
contraceptive method.
2 . Infertility services on a $5 per visit.
voluntary basis. Diagnostic 50% for each artificial
testing services to determine insemination service.
the cause of infertility are
covered. Artificial
LGU-ASOCF-SBLDTF691 1A-63
Services Required Copayments
insemination (patient's
spouse's sperm only) is
covered. All infertility
services require pre-
certification from the Plan.
(See Section IV.N)
D. INPATIENT SERVICES
Medically Necessary Inpatient Hospital Services. An
Enrollee is entitled to receive the inpatient hospital
services set forth in this Section, subject to all
definitions, terms and conditions in this Plan and its
attachments. Except as otherwise provided in Section III,
these services will be available only in the Defined Area
and only if performed, prescribed, arranged for, directed or
authorized by the Enrollee's Participating Primary Care
Physician at a Participating Facility. All non-emergency
hospitalization must be approved in advance by the Plan.
The Plan reserves the right to obtain a second opinion by a
Physician of its own choosing.
1. Inpatient hospital services Medical or surgical :
are those provided by $100 per admission.
Participating Hospitals within Obstetrical (including
the Defined Area. Inpatient Therapeutic abortions)
hospital services for the Mother: $100
treatment of illness or injury Child: $100
including but not limited to:
semi-private room and board;
special diets when Medically
0 LG\mAS0CF-SBI.DTF691 1A-64
Y
Services Required Copayments
Necessary; use of operating
room and related facilities;
special care unit and services;
x-ray, laboratory and other
diagnostic tests; drugs,
medications, biologicals,
anesthesia and oxygen services;
physical therapy, radiation
therapy and inhalation therapy;
and administration of whole
blood or blood products. (See
Section IV.K) . Special duty
nursing shall be provided only
when Medically Necessary (i.e. ,
in the absence of an intensive
care unit) , when recommended by
the Enrollee' s Participating
Primary Care Physician and
approved in advance by the
Plan. Private room coverage
shall be provided only in cases
of medical necessity (i.e. ,
isolation due to infectious
diseases) . The Enrollee may
elect private room
accommodations for other than
the above stated reason. In
such cases, the Enrollee is
responsible for the direct
payment of the difference to
the Hospital.
NOTE: Following discharge by
the Physician
responsible for the
Enrollee' s care while
the Enrollee is
hospitalized, an
Enrollee remaining in
the Hospital beyond the
Hospital 's discharge
time is responsible for
direct payment of
additional charges to
the Hospital. The Plan
+� LG�-ASOCF-SB L UU691 1A-65
services Required Copayments
is not responsible or
financially liable for
such additional
payments.
2. Rehabilitation Services. $100 per admission.
Medically Necessary short-term
inpatient rehabilitation (i.e. ,
physical therapy) services at a
Participating Facility for
acute conditions which are
recommended by the Enrollee's
Participating Primary Care
Physician and approved in
advance by the Plan. This
acute condition must be subject
to significant improvement
through short-term therapy.
Short-term is defined as up to
sixty (60) consecutive days per
medical condition which
includes services received as
an outpatient under section
II.A(2) . Such services shall
not be approved on an inpatient
basis unless other acute
medical care is to be provided.
The total of inpatient and
outpatient rehabilitative
services shall not exceed sixty
(60) consecutive days per
medical condition, beginning
with the first date of
treatment.
3 . Inpatient services in a $25 per day.
Participating Skilled Nursing
Facility. When recommended by
a Participating Primary Care
Physician and approved in
advance by the Plan, an
Enrollee shall be able to
receive short-term inpatient
treatment at a participating
Skilled Nursing Facility when
LG\rwASOCF-SBLUrF691 1A-66
Services Required Copayments
acute care hospitalization is
not appropriate.
NOTE: Skilled nursing care is
not covered when
provided for conditions
of senile deterioration,
Alzheimer's Disease,
mental retardation or
mental illness. Private
duty nursing services,
private room accommoda-
tions, personal or
comfort items and other
articles not specifi-
cally necessary for
treatment of illness or
injury are excluded.
Short-term is defined as
up to sixty (60) days
per medical condition.
4 . Chemical Dependency. Necessary $100 per admission.
inpatient care and treatment
for Chemical Dependency is
provided on the same basis and
subject to the same
limitations, exclusions and
Copayments as treatment for
physical illness generally.
All treatment must be
recommended by the Enrollee ' s
Participating Primary Care
Physician and pre-authorized by
the Plan and all care must be
provided by a Participating
Chemical Dependency Treatment
Facility.
E. OTHER SERVICES
1. Home Health Care Services. $5 per visit.
Medically necessary home health
care services are available
�j only in the Defined Area when
LG1rwAS0CF•SBLUU691 1A-67
I)
services Required Copayments
provided by a Sanus
participating home health care
agency, and are specifically
limited to short-term
intermittent skilled visits.
Such services must be
recommended by the Enrollee 's
Participating Primary Care
Physician and approved in
advance by the Plan. Short-
term is defined as up to sixty
(60) consecutive days per
medical condition, beginning on
the date when the first such
visit occurs.
2 . Emergency Services:
a. Hospital Emergency Room. $40 Copayment for each
visit. (Charge waived
if admission occurs at" b'
the time of emergency
room visit) .
b. Outpatient Emergency Care $15 Copayment for each
Center visit.
C. Physician offices operating $15 Copayment for each
after hours as emergency visit.
centers, office visits to a
Physician outside normal
office hours or urgent
visits to a Physician
covering for the Enrollee's
Participating Primary Care
Physician.
d. Emergency ambulance None.
service.
3 . Ambulance Services. Medically None.
Necessary ambulance service to
the nearest medical facility
capable of providing Emergency
Care, or Medically Necessary
LG\MASOCF•SB I.DTF691 1A-68
Services Required Copayments
non-emergency ambulance service
when authorized in advance by
the Plan.
4 . Prosthetic Devices. Initial None.
external standard prosthetic
medical appliances and limbs
are covered are: when due to
an acute illness or injury.
External prosthetic appliances
which are covered are:
artificial arms, legs, eyes or
permanent lenses; above or
below knee or elbow prostheses;
external cardiac pacemaker; and
terminal devices such as hand
or hook. Internal prosthetic
devices covered are: permanent
aids and supports for defective
parts of the body such as
prosthetic cardiac valves,
internal pacemakers and minor
devices such as screw nails,
sutures and wire mesh. All
other prosthetic medical
appliances, including items
described in Section IV, are
excluded. In questions of
medical necessity, a second
opinion may be requested by the
Plan and is binding. (See
Sections IV.CC, IV.DD, and
IV.EE)
5. Blood and Blood Products. None.
Administration only. (See
Section IV.K)
6. Dental Services
a. Short-term, limited dental None.
services for the following
which result from an
accidental non-occupational
} trauma or injury to
v
LG\mASOCF-SB 1.DTF691 1A-69
Services Required Copayments `i
healthy, natural teeth:
Initial care and short-term
treatment (up to 60
consecutive days) is
covered provided (1) such
accident occurred and
services are performed
during the term of coverage
hereunder, (2) the Enrollee
seeks initial treatment
within forty-eight (48)
hours of such accidental
trauma or injury, and (3)
all subsequent treatment
after such initial
emergency treatment is
authorized by the
Enrollee 's Participating
Primary Care Physician,
approved in advance by the
Plan and performed by a
participating dentist.
Injuries sustained by
reason of mastication
(i.e. , chewing or biting
down) are excluded.
b. Treatment of fracture, dis-
location or malignant
tumors of the jaw is
provided on the same basis
and is subject to the same
limitations, exclusions and
Copayments as for physical
illness generally.
7. Temporomandibular Joint Subject to the
Syndrome Benefits. Medically applicable Copayments
Necessary (non-dental, non- specified in Section
cosmetic) diagnostic and/or II.
surgical treatment of the
temporomandibular (jaw or
craniomandibular) joint. Such
surgical treatment (including
arthroscopy) will be covered
LGkwASOCF-SBI.DrrF691 1A-70
Services Required Copayments
provided it is Medically
Necessary, recommended by the
Enrollee's Participating
Primary Care Physician and
approved in advance by the
Plan. The Plan reserves the
right to obtain a second
opinion by a physician of its
own choosing. Benefits are not
provided under this Section for
dental treatments, services or
supplies including, but not
limited to orthodontics,
splints, positioners, dental x-
rays, extraction of teeth, and
selective grinding of the
teeth. (See Section IV) .
a
`4," LG\r.ASOCF-SB1.DTF691 1A-71
III . EMERGENCY AND URGENT SERVICES
A. IN GENERAL
1. Emergency care services must be secured by the
Enrollee immediately after the onset of the medical
condition, or as soon thereafter as is possible, but
not later than twenty-four (24) hours after the
first appearance of symptoms of illness or forty-
eight (48) hours after an accident. Heart attacks,
cardiovascular accidents, poisoning, loss of
consciousness or respiration, convulsions, severe
bleeding and broken bones are examples of true
Medical Emergencies.
2 . Emergency and urgent services are subject to the
Plan' s retrospective review for determination of
whether an acute condition or incident requiring
immediate, emergency or urgent care existed. If the
Plan determines that no need for emergency or urgent
care existed, the Enrollee will be responsible for
payment of all charges incurred for such care,
subject to Employer's complaint resolution
procedure.
B. WITHIN THE DEFINED AREA
Inside the Defined Area, the Enrollee, or someone acting
MmASOCF-SB1.DTF691 1A-72
on behalf of the Enrollee, is required to contact the
Enrollee ' s Participating Primary Care Physician for
advice. If it is not reasonably possible to contact the
Enrollee 's Participating Primary Care Physician at the
time (such as that of a life threatening emergency) , the
Enrollee, or someone acting on behalf of the Enrollee,
shall notify the Plan within forty-eight (48) hours of
the emergency, or if not possible within forty-eight
(48) hours, as soon as it is reasonably possible. Upon
receipt of notification, the Plan will coordinate the
transfer of the patient to the care of the Enrollee ' s
Participating Primary Care Physician when medically
prudent to do so.
Coverage for treatment for Medical Emergencies within
the Defined Area by non-participating providers is
limited to the care required before the Enrollee can,
without medically harmful or injurious consequences, be
treated by a Participating Physician or Participating
Hospital.
C. OUTSIDE THE DEFINED AREA
Services are available while outside the Defined Area
provided that such Services are of an emergency or
urgent nature and cannot be postponed until the Enrollee
�= 1A-73
LG�rwASOCF-SB I.D'I-F691
is able to return to the Defined Area to obtain
treatment from a Participating Physician. All
continuing or follow-up treatment shall be provided only
within the Defined Area and shall be subject to all the
provisions of this Plan.
To constitute a covered out-of-area service, the Plan
must make the following determinations:
1. onset of the acute illness or injury must have
been sudden and unexpected;
2 . the Enrollee must not have been able to return to
the Defined Area to receive treatment from the
Enrollee's Participating Primary Care Physician;
3 . the treatment must have been Medically Necessary.
The Plan shall pay the Enrollee or arrange to pay the
Non-Participating Hospital (s) or Non-Participating
Physician(s) directly. The payment shall be at the
prevailing rate, subject to any required Copayments.
Covered services include ambulance transportation,
provided it is Medically Necessary and appropriate.
At the time of the emergency, the Enrollee, or someone
LG\mASOCF•SB1.DTF691 1A-74
acting on behalf of the Enrollee, shall make every
reasonable effort to notify the Plan. If it is not
reasonably possible to notify the Plan at that time, the
Enrollee, or someone acting on behalf of the Enrollee,
shall notify the Plan within forty-eight (48) hours of
the onset of the emergency treatment or, if not
possible, as soon as it is reasonably possible. Upon
notification, the Plan will coordinate the transfer of
the patient to the care of the Participating Primary
Care Physician within the Defined Area when medically
prudent to do so.
IV. LIMITATIONS AND EXCLUSIONS FROM COVERAGE
The following services and supplies, and the cost thereof,
are excluded from coverage under this Plan unless
specifically included by a Plan Amendment.
A. Private room accommodations and special duty nursing
except as provided in Section II.D(1) or unlimited
hospital care except when deemed by the Plan to be
appropriate for an acute level of inpatient care.
B. Any service given without a prior written referral from
the Enrollee 's Participating Primary Care Physician,
except as otherwise permitted in Sections I, II or III
of this Schedule of Benefits, including annual well-
�, -, LG\mASOCF-SBI.DTF691 1A-75
woman examinations (see Section II . B(1) (a) ) .
C. Treatment or evaluations required by third persons,
including but not limited to those for: school,
employment, flight clearance, summer camp, insurance or
court ordered.
D. No payments will be made for outpatient services
received in Federal facilities or for any items or
services provided in any institutions operated by any
state government or agency when the Enrollee has no
legal obligation to pay for such items or services.
Inpatient hospital care costs incurred on behalf of U.S.
Armed Forces retirees and dependents in governmental or }inn
military service-connected facilities will only be
covered by the Plan if such services are preauthorized
by the Plan in accordance with this Schedule of Benefits
and all deductible or Copayment amounts thereunder are
paid by the Enrollee.
E. Care which an Enrollee receives from or through the
United States Government or any of its corporations,
agencies or bureaus, or from or through any State,
County, City or any political subdivision thereof,
unless a charge is customarily made and services were
provided in accordance with the provisions of Sections
LGV-ASOCF-SBI.DTF691 1A-76
II.A-II .E.
F. Cosmetic or surgical procedures are excluded except
reconstructive surgery necessary to repair a functional
disorder as a result of disease, injury or congenital
defect. Such exclusions include, but are not limited to
surgical excision or reformation of any sagging skin on
any part of the body including, but not limited to the
eyelids, face, neck, abdomen, arms, legs or buttocks;
any services performed in connection with the
enlargement, reduction, implantation or change in
appearance of a portion of the body including, but not
limited to, the breasts, face, lips, jaw, chin, nose,
ears or genitals; hair transplantation; chemical face
peels or abrasion of the skin; electrolysis
depilitation; or any other surgical or non-surgical
procedures which are primarily for cosmetic purposes.
The Plan reserves the right to secure a second opinion
by a physician of its own choosing with respect to any
case involving cosmetic or reconstructive surgery.
G. Dental services and dental prostheses including dentures
are excluded, except as covered in Section II.E(6) .
Maxillary and mandibular osteotomies for shortening or
lengthening of the jaw are excluded. Benefits for
Medically Necessary diagnosis and/or surgical treatment
a
�_,,., LG4wASOCF-SBI.I7I-F691 1A-77
of temporomandibular joint syndrome are strictly limited
to those provided in Section II .E(7) . All other
hospitalization, anesthesiology or other services
relating to dental work are excluded.
H. Custodial, respite or domiciliary care.
I. Services and appliances for the correction of vision
deficiencies including, but not limited to, special
procedures such as orthoptics, vision training, vision
therapy or radial keratotomy.
J. Personal comfort and convenience items or services
including, but not limited to, care kits provided on
admission to a hospital, TV's and telephones. ��
K. Whole blood or blood components and any related
replacement fees.
L. Surgery or other procedures, treatments or services for
obesity including, but not limited to, gastric
intestinal bypass surgery.
M. Sex change surgery including medical or psychological
counseling and hormonal therapy in preparation or
subsequent to any such surgery.
LG\m ASOCF-SB 1.UrF691 1A-78
N. Reversal of voluntary sterilization, gamete intra-
`. fallopian transfer, any fees relating to donor sperm,
menotropins (e.g. , pergonal) or related drug therapy,
surrogate parenting fees and in-vitro fertilization.
O. Acupuncture, naturopathy and hypnotherapy.
P. Inpatient mental health. Treatment for mental
retardation, mental deficiency, or other forms of senile
deterioration, such as Alzheimer's Disease.
Q. Outpatient mental health services for chronic conditions
including, but not limited to, treatment for mental
retardation, mental deficiency or other forms of senile
deterioration, such as Alzheimer's Disease.
R. Heart transplants and all organ transplants, except
Medically Necessary kidney transplants, corneal
transplants, and liver transplants for children with
biliary atresia. All donor expenses are excluded.
S. Bone marrow transplants, except for aplastic anemia,
leukemia, severe combined immunodeficiency disease, and
Wiskott-Aldrich syndrome. All donor expenses are
excluded.
LG\mASGCF-SB 1.DTF691
1A-79
T. Any procedure or treatment that is deemed by the Plan to 0>
be experimental or any procedure, medication or "
treatment that is used for a non-FDA approved
indication.
U. Care for conditions that federal, state or local law
requires to be treated in a public facility, or while in
the custody of legal authorities.
V. Services payable under workers ' compensation, black lung
benefits or a government program to the extent that such
services are covered under workers ' compensation or
similar laws.
W. Routine foot care such as hygienic yg nic care. Treatment for
flat feet, removal of corns or calluses; corrective
orthopedic shoes, arch supports, orthotics.
X. All splints and braces not used for urgent or emergency
treatment including, but not limited to, those used for
preventive purposes.
Y. All durable medical equipment.
Z. Consumables or disposable supplies purchased by the
Enrollee on an outpatient basis, or purchased by or
0_1
LG4wASOCF-SBI.DTF691 1A-80
given to the Enrollee upon discharge from a Hospital
including, but not limited to, sheaths, bags, elastic
garments, syringes, needles, blood or urine testing
supplies, ostomy bags, home testing kits, vitamins,
dietary supplements and/or replacements, non-rigid
appliances and supplies.
AA. Occupational and educational testing and therapy.
BB. Long-term rehabilitation therapy. Long--;term means
treatment in excess of sixty (60) consecutive calendar
days per illness or event.
CC. Replacement, repair or routine periodic maintenance of
prosthetic devices.
DD. Mechanical organ replacement devices (including, but not
limited to, artificial heart) .
EE. All prostheses not covered under Section II.E.4
(including, but not limited to, penile prostheses) and
services associated with the insertion of any excluded
prosthetic device.
FF. Speech and hearing therapy, including hearing aids.
"v... LG\wAS0CF-SBIMU691 1A-81
GG. Outpatient prescription drugs and hospital discharge or
take home drugs, except where specifically covered by
Amendment to the Plan.
HH. Charges for pregnancy and subsequent delivery, including
cesarean sections which are planned or scheduled or
performed only because of previous cesarean section,
which occur outside of the Defined Area and within
thirty (30) days of the due date specified by the
Enrollee' s Sanus participating attending physician.
However, Complications of Pregnancy, as defined below,
will be covered as any other illness.
For the purpose of this limitation, "Complications of
Pregnancy" means: (1) conditions requiring hospital
confinement (when the pregnancy is not terminated) ,
whose diagnoses are distinct from pregnancy but are
adversely affected by pregnancy or are caused by
pregnancy, such as acute nephritis, nephrosis, cardiac
decompensation, missed abortion, and similar medical and
surgical conditions of comparable severity, but shall
not include false labor, occasional spotting, physician
prescribed rest during the period of pregnancy, morning
sickness, hyperemesis gravidarum, pre-eclampsia, and
similar conditions associated with the management of a
difficult pregnancy not constituting a nosologically
LG\mAS0CF-SBI.DTF691 1A-82
distinct complication of pregnancy; and (2) non-elective
cesarean section (emergency/urgent, except as specified
above) , termination of ectopic pregnancy, and
spontaneous termination of pregnancy, occurring during a
period of gestation in which a viable birth is not
possible.
II. All anti-smoking treatment and programs including, but
not limited to, tobacco abuse and smoking cessation
programs.
V. MAXIMUM COPAYMENTS
The maximum amount of Copayment for the Basic Plan Benefits
covered by this Schedule of Benefits in any calendar year
will not exceed $650 for any Enrollee, or $1, 500 for a
covered Enrollee and his Dependents. The maximum amount of
Copayments for each calendar year shall be determined by
applying Copayments relating to Basic Plan Benefits only,
and shall not take into account any Copayments pertaining to
any Plan Amendment.
LG\rwASOCF-SBI.DTF691 1A-83
EXHIBIT 1
PART A (Cont' d)
PLAN AMENDMENT
PRESCRIPTION DRUGS
The benefits described in this Amendment are added to Part A of
the Plan. All provisions of Part A of the Plan apply to this
Amendment, except as modified herein.
The Copayments described in this Amendment do not apply toward
fulfillment of the maximum Enrollee Copayment limit per year
specified in the Plan.
A. Definitions
1. "Prescription Drugs" means any drugs and/or medications
that require a prescription written by a duly licensed
physician or dentist.
2 . "Designated Mail Service Pharmacy" means Express
Scripts, P.O. Box 27667 , St. Louis, MO. 63146.
3 . "Participating Pharmacy" means a pharmacy, other than
the Designated Mail Service Pharmacy, that has
contracted with SANUS to provide Prescription Drugs to
Enrollees covered under the Plan as hereby amended.
4 . "Brand Name Prescription Drug" means the unique trade
name which a manufacturer assigns to a Prescription Drug
and which, when dispensed, can only be the Prescription
LG\mASGCF-SBI.DTF691 1A-84
Drug bearing such manufacturer ' s trade name.
5. "Generically Equivalent Prescription Drug" means a
Prescription Drug which is pharmaceutically equivalent
and therapeutically equivalent to a Brand Name
Prescription Drug.
B. In General
1. Enrollees will be provided with Generically Equivalent
Prescription Drugs by the Designated Mail Service
Pharmacy or a Participating Pharmacy when permitted by
the licensed Physician or Dentist and by state law.
2 . Enrollees will utilize the services of the Designated
Mail Service Pharmacy by mailing the prescription or
refill ordered by a Participating Physician or
Participating Dentist in a pre-addressed envelope to:
Express Scripts
P.O. Box 27667
St. Louis, MO 63146
3 . Use of the Designated Mail Service Pharmacy is at the
Enrollee's option.
4 . Except in cases of Medical Emergency occurring outside
of the Defined Area and except to the extent that an
Enrollee has not yet fulfilled his deductible, an
Enrollee must obtain a prescription from a Participating
Physician or Participating Dentist and have it filled by
a Participating Pharmacy or the Designated Mail Service
Pharmacy. Participating Pharmacies are listed in the
/ LG\,-ASOCF-SBI.DTF691 1A-85
directory provided to Enrollees by SANDS .
,,7
C. Covered Items t
1. Federal legend Prescription Drugs and Prescription Drugs
which may only be dispensed by written prescription
under state law.
2 . Compounded medications of which at least one ingredient
is a prescription legend drug and which is provided for
a Food and Drug Administration ("FDA") approved
indication.
3 . Injectable insulin and insulin syringes.
4 . Oral contraceptives, diaphragms, and cervical caps.
D. Non-Covered Items
1. Drugs and medications, except insulin, which do not
require a prescription whether or not a prescription has
been obtained.
2 . Prescriptions written prior to the effective date of
coverage.
3 . Experimental or investigational drugs including
compounded medications which are not provided for an FDA
approved indication.
4 . Therapeutic devices or appliances, including hypodermic
needles, syringes (other than insulin syringes) , support
garments and other non-medical substances, regardless of
their intended use.
5. Blood and blood products.
6. Contraceptive devices (other than oral contraceptives,
LG\mAS0CF-SB1.L7FF691 1A-86 (D
diaphragms, and cervical caps) .
7 . Prescriptions which an eligible Enrollee is entitled to
receive without charge from any workers ' compensation
laws from any municipal, state or federal program.
8. Blood or urine testing devices including, but not
limited to, clinitest, acetest, and dextrostix.
9. Medications used to suppress appetite (e.g. diet
medication) .
10. Antismoking aids (e.g. nicorette gum) .
11. Injectables other than injectable insulin.
12 . Drugs and medications prescribed for a cosmetic purpose,
including, but not limited to, topic minoxidil or Retin
A.
13. Allergy sera and allergy testing materials.
14 . Prescriptions filled at or by non-Participating
Pharmacies, except in cases of Medical Emergency
occurring outside of the Defined Area.
15. Prescriptions written by a non-Participating Physician
(except in cases of Medical Emergency occurring outside
of the Defined Area) .
16. Hemophile M, Factor VIII or any other blood product or
derivative.
E. Copayments
1. There are no Copayments required of the Enrollee when
using the Designated Mail Service Pharmacy to obtain the
quantity of Prescription Drugs specified in Paragraph
'' LG�-ASOCF-SBLDTF691 1A-87
G. 1 of this Amendment.
2 . There is a two dollar ($2 . 00) Copayment, payable to
Express Scripts, required for each prescription or
refill ordered from the Designated Mail Service Pharmacy
to obtain the quantity of Prescription Drugs specified
in Paragraph G.2 of this Amendment.
3 . There is a two dollar ($2 . 00) Copayment required for
each prescription or refill when the Enrollee obtains
covered Generically Equivalent Prescription Drugs from a
Participating Pharmacy, after meeting the deductible.
4 . There is a seven dollar ($7. 00) Copayment required for
each prescription or refill when the Enrollee obtains
covered Brand Name Prescription Drugs from a
Participating Pharmacy, after meeting the deductible.
F. Deductibles
There is a seventy-five dollar ($75. 00) deductible per
Enrollee per calendar year, which must be met on non-mail
service prescriptions prior to an Enrollee ' s receipt of
benefits from a Participating Pharmacy under this Amendment.
To obtain such benefits, an Enrollee must submit itemized
bills equaling the amount of the deductible and containing
the information set forth in items #1, 2, 3 and 4 of Paragraph
H of this Amendment. Upon such submission, an Enrollee will
receive an identification card reflecting that the
deductible has been met.
LG4wASOCF-SBI.DTF691 1A-88
G. Limitations
1. An Enrollee may obtain up to a 34-day supply or 100
units, whichever is less, of a Prescription Drug from a
Participating Pharmacy or the Designated Mail Service
Pharmacy.
2 . The Enrollee may, at his sole option, obtain a 90-day
supply or 300 units, whichever is less, of a
Prescription Drug from the Designated Mail Service
Pharmacy, provided Enrollee pays the Copayment specified
in Paragraph E.2 of this Amendment to the Designated
Mail Service Pharmacy.
H. Enrollee Reimbursement Rules
If a Medical Emergency occurs outside the Defined Area and
the Enrollee incurs expenses for Prescription Drugs, an
gk
itemized bill should be submitted by the Enrollee to the
Plan for reimbursement. The itemized bill must contain the
following information:
1. The name of the drug.
2 . The date and quantity purchased.
3 . The name of the authorizing licensed physician or
dentist.
4 . The name of the person for whom it was prescribed.
a LG\mASOCF-SBLDTF691 1A-89
EXHIBIT 1
PART A (Cont'd)
PLAN AMENDMENT
INPATIENT MENTAL HEALTH
The benefits described in this Amendment are added to Part A of
the Plan. All provisions of Part A of the Plan apply to this
Amendment, except as modified herein.
1. In General
A. Enrollees shall be entitled to additional mental health
care benefits for evaluation, crisis intervention
treatment or any combination thereof for Acute
Conditions when such evaluation, crisis intervention or
treatment is recommended by a Participating Primary Care
Physician, approved in advance by the Medical Director
and precertified by the Employer or Employer's Designee.
B. These services rendered must be based on an Individual
Treatment Plan.
C. Providers of services must be licensed by the
appropriate state agency or board to provide these
services.
D. The total benefit is limited to any combination of the
following, not to exceed thirty (30) treatment days per
calendar year.
1. As an inpatient in an authorized SANUS participating
LG\rwASOCF-SBI.DTF691 1A-90
psychiatric facility, one (1) inpatient day equals
one (1) treatment day; or
2 . As a day care patient in an authorized SANDS
participating psychiatric facility, one (1) day care
day equals one-half (1/2) treatment day; or
3 . As an inpatient in an authorized SANUS Participating
Crisis Stabilization Unit, one (1) inpatient day
equals one-half (1/2) treatment day; or
4 . As an inpatient in an authorized SANDS Participating
Residential Treatment Center for Children and
Adolescents, one (1) inpatient day equals one-half
(1/2) treatment day.
2. Definitions
A. "Acute Conditions" means situations in which the
Enrollee has a serious mental illness which
substantially impairs such Enrollee' s thought,
perception of reality, emotional process or judgement or
grossly impairs behavior as manifested by recent
disturbed behavior.
B. "Day Care" means treatment of the Enrollee in an
authorized SANUS participating psychiatric facility on a
day-to-day basis with release of the patient at the
conclusion of the treatment day, and in which no
overnight stay is involved.
` � LG\IWASOCF-SBI.DTF691 1A-91
C. "Crisis Stabilization Unit" means a 24-hour residential
program that is usually short-term in nature and that
provides intensive supervision and highly structured
activities to persons who are demonstrating an acute
demonstrable psychiatric crisis of moderate to severe
proportions.
D. "Residential Treatment Center for Children and
Adolescents" means a child-care institution that
provides residential care and treatment for emotionally
disturbed children and adolescents and that is
accredited as a residential treatment center by the
Council on Accreditation, the Joint Commission on
Accreditation of Healthcare Organizations, or the
American Association of Psychiatric Services for
Children.
E. "Individual Treatment Plan" means a treatment plan with
specific attainable goals and objectives appropriate to
both the patient and the treatment modality of the
program.
3 . Limitations
A. Mental health services for the following diagnosed
conditions are excluded: Chronic psychosis, Alzheimer's
Disease, intractable personality disorders, mental
retardation, psychiatric therapy on court order or as a
condition of parole or probation, and chronic organic
brain syndrome.
LG\mAS0CF•SBI.DTF691 1A-92
B. The benefits described in this Amendment are available
when:
1. They are recommended by the Participating Primary
Care Physician, approved in advance by the Medical
Director and precertified by the Employer or the
Employer's designee; and
2 . The Enrollee does not refuse to accept recommended
procedures or treatment; and
3 . They are provided in an authorized SANDS
participating psychiatric hospital, psychiatric
facility, Crisis Stabilization Unit or Residential
Treatment Center for Children and Adolescents and by
a Participating Provider; and
4. The Enrollee continues to meet the SANUS criteria
for continued benefits under this Amendment; and
5. The Enrollee has not reached the total benefit
described in Section 1.D of this Amendment.
C. Benefits for a Residential Treatment Center for Children
and Adolescents or a Crisis Stabilization Unit are
available only for Acute Conditions which would
otherwise necessitate confinement in an authorized SANUS
participating psychiatric hospital or psychiatric
facility.
4 . Exclusions
Benefits will not be allowed under this Amendment if
treatment is provided by a non-participating provider or
' ! ' LG\rwASOCF-SBI.L7rF691 1A-93
non-participating hospital, facility, Crisis Stabilization
Unit, or Residential Treatment Center for Children and
Adolescents or by a Participating Facility that is not an
authorized SANDS participating psychiatric facility.
5. Copayments
A. A twenty percent (20%) Copayment shall be paid by the
Enrollee for all services under this Amendment.
B. The Copayments described in this Amendment do not apply
toward fulfillment of the maximum Enrollee cost limit
per calendar year specified in the Plan.
LGVwASOCF-SBI.DTF691 1A-94
EXHIBIT 1
4) PART A (Cont'd)
PLAN AMENDMENT
DURABLE MEDICAL EQUIPMENT
The benefits described in this Amendment are added to Part A of
the Plan subject to the limitations and Copayments described
herein. All provisions of Part A of the Plan apply to this
Amendment, except as modified herein.
When determined to be medically necessary by a Participating
Primary Care Physician and pre-approved by the Medical Director,
Enrollees shall be entitled to the rental or purchase of Durable
Medical Equipment (initial placement only) ; rental or purchase
will be determined by Employer or Employer' s designee.
"Durable Medical Equipment" means equipment which can withstand
repeated use, is primarily and customarily used to serve a
medical purpose, generally is not useful to a person in the
absence of a sickness or injury, is appropriate and used in the
home, may be used by more than one person, and does not require
an individual prescription for construction. All services and
devices must be obtained through a Plan participating provider.
Some examples include, but are not limited to, a standard
wheelchair, crutches, walkers, orthopedic tractions, hospital
Mx.AS0CF-SBI.DTF69I 1A-95
beds, oxygen, bedside commodes, suction machines, etc. (lengthy
list maintained - HCFA Coverages Issue Manual) .
The following items are among, but not limited to, those
excluded: deluxe equipment such as motor driven wheelchairs and
beds; comfort items; bedboards; bathtub lifts; over bed tables;
air purifiers; disposable supplies; elastic stockings; sauna
baths; repair, replacement or maintenance of durable medical
equipment; exercise equipment; stethoscopes and
sphygmomanometers; orthopedic shoes; arch supports; dentures;
experimental or research items. In no event will prosthetic
devices or artificial limbs be covered under this Amendment.
HEARING AIDS
Part A of this Plan will cover medically necessary diagnosis of
hearing deficiencies including audiometry and initial placement
of necessary hearing aid device(s) .
Part A of this Plan will also cover one (1) audiogram per year,
if needed; one cleaning of the hearing device per year; and,
replacement of the hearing device every four (4) years* if
medically indicated. Replacement for loss, damage or for
functional defects are not covered.
All services and devices must be approved in advance by the
LGVwASOCF-SB1.DTF691 1A-96 �• :�.
Medical Director and must be obtained through a Participating
Provider.
* Note: There are some cases of rapid deterioration of
hearing loss which will necessitate hearing device
replacement sooner than the four (4) year period and
will be considered on an individual basis with prior
approval from the Medical Director.
LG4wASOCF-SBI.DTF691 1A-97
EXHIBIT 1
PART A (Cont'd) mow'
PLAN AMENDMENT
PRE-EXISTING CONDITIONS
The Copayments payable by an Enrollee as described in Part A of
the Plan are subject to the limitations described herein.
A. Definitions
"Pre-existing Condition" means any medical condition known
by the Enrollee to have existed or for which diagnosis was
made or treatment received within the three (3) months
immediately preceding the Enrollee's effective date of
coverage under the Plan. A medical condition has been S
"diagnosed" if its existence has been identified or
recognized by a Physician or other Health Professional. A
medical condition has been "treated" if any services of a
Physician or other Health Professional have been received
with respect thereto, including, but not limited to, office
visits or consultations, Hospital treatment, laboratory
services, X-rays or the dispensing of prescription
medication or refills.
B. In addition to any other Copayment required under the Plan,
each Enrollee with a Pre-existing Condition shall be
required to pay an additional Copayment equal to a total of
LG\r.ASOCF-SBI.DTF691 1A-98
fifty percent (50%) of the cost of Treatment (which shall
include all applicable Copayments specified in the Schedule
of Benefits for such Treatment) with respect to such Pre-
existing Condition until such time as the Enrollee has been
continuously enrolled for a period of twelve (12) months
under this Plan and/or under another Plan with Sanus
immediately preceding this Plan; provided that any
uninterrupted and consecutive-day hospitalization begun
prior to the expiration of said twelve (12) month period
shall be deemed to be a continuous confinement subject to
the aforesaid Pre-existing Condition Copayments.
C. The maximum amount of additional Copayment for a Pre-
existing Condition during this twelve (12) month period will
not exceed $800 for any such Enrollee or Dependent or $3, 000
total for such Enrollee and his Dependents. Copayments
payable pursuant to Section B of this Amendment shall not be
included in, and are in addition to, the maximum amount of
Copayment for Part A Benefits.
-'
-99
LG�xwASOCF-SBI.DTF691 1A
EXHIBIT 1
PART B
MAJOR MEDICAL
EMPLOYER CERTIFICATION
Your Employer certifies that, subject to the terms and conditions
of the Benefit Plan, and, more particularly, to the terms and
conditions of this Part B, you are also covered for the benefits
described in this Part.
When you and your dependents, if any, are enrolled under Part A,
you and your dependents will also be covered under Part B.
Benefits are not payable under Part B for services and supplies for
which you received benefits under Part A.
Percentage Payments* by your Employer and the applicable
Deductibles under Part B are as follows:
Percentage Employer pays 80%
Individual Deductible $200
Family Deductible $600
Individual Out of Pocket Limit $1, 500
Family Out of Pocket Limit $4, 500
* The Percentage Employer pays for certain SPECIAL BENEFITS is
50%.
Mi-ASO+(FW-I B.Dn691 1B-1
I . Definitions: Except as otherwise expressly provided or unless
the context otherwise requires, the following words and
phrases used in this Part B shall have the following meanings:
1. "AMBULATORY SURGICAL CENTER" means a legally operated
institution which is primarily operated to provide
facilities for performing surgery, and which has:
a. Permanent operating rooms and all medical equipment
necessary for surgery.
b. A medical staff including registered nurses for
patient care.
The term "ambulatory surgical center" does not include a
private office or clinic of one or more doctors.
2 . "BASIC BENEFITS" means the coverage for you or your
dependents, if any, provided under Part A.
3 . "DOCTOR" means a licensed physician, osteopath, dentist,
chiropractor, chiropodist, optometrist, podiatrist,
audiologist, speech - language pathologist, certified
social worker-advanced clinical practitioner, licensed
dietician, or other licensed practitioner of healing art,
if the following conditions are met:
LG\r.AS0+/FW-1 B.DPF691 1B-2
a. the practitioner' s services fall within the scope
of his or her license or certification.
b. in the case of services of a certified social
worker-advanced clinical practitioner, the services
are direct, diagnostic, preventive, or clinical ;
are provided to a person whose functioning is
threatened or affected by social or psychological
stress or health impairment; and are professionally
recommended by a doctor of medicine or doctor of
osteopathy.
C. in the case of services of a licensed dietician,
the services are related to an injury or illness
covered by the Plan; and are rofessionall
P Y
recommended by a doctor of medicine or doctor of
osteopathy whose treatment or examination for the
injury or illness would be a Covered Expense.
The term "doctor" includes a Christian Science
Practitioner currently listed in the Christian Science
Journal.
4 . "EMERGENCY CONFINEMENT" means a hospital confinement due
to an Emergency Illness or accidental injury that, unless
treated at once on an inpatient basis, would jeopardize
LG\mASO+/FW-I B.DTF691 1B-3
the family member' s life, or cause serious damage or
impairment to the family member' s bodily functions.
5. "HOME HEALTH AGENCY" means an agency which is primarily
engaged in furnishing home nursing care and other
therapeutic services for persons recovering from a
sickness or injury, and which is:
a. Qualified for payment under the federal Medicare
program; or
b. Established and operated under applicable state law.
6. "HOSPITAL" means a legally operated institution which is
primarily engaged in providing medical services for
resident patients, and which has:
a. Permanent facilities for diagnosis and major
surgery.
b. Continuous nursing service by registered nurses.
C. Continuous supervision by a staff of doctors.
However, the major surgery requirement does not apply to
a hospital which primarily treats mental illness or
LG\rwASO+/FW-I B.DTF691 1 B-4
yy chronic diseases. The term "hospital" includes a
; l Christian Science sanatorium, but does not include a
nursing home, a rest home or a place for care of the
aged, or drug addicts. It also includes:
(1) A state-approved institution engaged in treating
alcoholism and drug addiction for inpatient
treatment, ordered by a doctor.
(2) A Psychiatric Day Treatment Facility which (a) is a
legally accredited health facility, (b) provides
treatment for acute mental and nervous disorders,
and (c) has a structured program using
individualized treatment plans that are clinically
supervised by a certified psychiatrist.
(3) A Residential Treatment Center for Children and
Adolescents is a facility for child care which:
(a) provides residential care and treatment for
emotionally disturbed children and adolescents; and
(b) is accredited as such by the Council on
Accreditation, the Joint Commission on
Accreditation of Hospitals, or the American
Association for Psychiatric Services for Children.
L�M1 LG1rv-ASO+/FW-IB.DTF691 1B-5
(4) A Crisis Stabilization Unit is a 24-hour
residential program which: (a) is usually short-
term in nature; and (b) provides intensive
supervision and highly structured activities to
persons who display an acute demonstrable
psychiatric crisis of moderate-to-severe
proportions.
(5) An Individual Treatment Plan is a plan of treatment
of a serious mental illness which has specific
attainable goals and objectives appropriate to both
the patient and the method of treatment.
7. "MEDICAL CARE" means medical services and supplies kr
furnished or ordered by a doctor which are necessary for
diagnosing or treating an injury, a sickness, a mental
disorder or a pregnancy.
8. "NURSING HOME" means a legally operated institution (or
a distinct part of a hospital) which is engaged in
providing convalescent services for sick or injured
resident patients and which has:
a. Continuous nursing service under the full-time
supervision of a doctor or a registered nurse.
Lc\mAs0+mow-1a.Dn691 1B-6
b. The services of a doctor available under an
established agreement.
C. Clinical records for all patients.
The term "nursing home" does not include a rest home or
a place for care of the aged, alcoholics or drug addicts.
9. "PAURsm*/Prior Authorization Utilization Review" means
the process by which NYL evaluates the number of days of
hospital confinement, if any, required for the care or
treatment of a family member's condition.
PAURsm is obtained as follows:
a. A request for PAURsm must be made to New York Life
by the family member or attending doctor. When
required to be written, this request must be on a
form satisfactory to New York Life and completed by
the family member's attending doctor. Except for
an Emergency Confinement, the request must be sent
to New York Life at least ten (10) working days
before the family member enters the hospital as an
inpatient.
• PAURsm is a service mark of New York Life Insurance Company(NYL)for its hospital utilization review program.
LGVwASO+/FW-I B.DTF691 1B-7
1
b. For EMERGENCY CONFINEMENT, a telephone request must
be made by the attending doctor to NYL within 48
hours after confinement starts. The telephone
request must be followed by a written request prior
to discharge.
A late request by the attending doctor will be
accepted if it is not reasonably possible to submit
the request during the above time frame.
C. PAURsm determination will be made within three (3)
working days after NYL receives the written
request, and written notification of this
determination will be sent to the attending doctor,
hospital and family member. For EMERGENCY
CONFINEMENT, the attending doctor and hospital will
be notified of the PAUR determination.
d. The attending doctor or family member may at any
time ask NYL to:
(1) re-evaluate the PAURsm determination; or
(2) extend the number of days of confinement
authorized in this determination.
LG\rwAS0+/FlV-1 B.DTF691 1B-8
Any PAURsm functions may be performed on our behalf by a
third party we select.
10. "USUAL OR PREVAILING CHARGES" means the lesser of:
a. The charge usually made by the provider for the
services or supplies furnished; or
b. The charge most other providers with the same
training in the same locality would make for those
or comparable services or supplies, as determined
by New York Life.
11. "WE" means the Employer.
In this Part, "he", "him", and "himself" mean a person of either
sex unless the context requires that the word mean only a male.
WHO IS ELIGIBLE FOR COVERAGE AND WHEN DOES COVERAGE BEGIN?
No employee shall become covered under Part B for himself or his
dependents, if any, unless (a) he is covered or simultaneously
becomes covered under Part A and (b) , with respect to coverage for
dependents, enrolls his dependents for coverage under Part A.
LG1rwASO+/FW.1 B.DTF691 1B-9
Any child born while the parent is covered will become a covered
dependent at the moment of birth. If the employee did not elect
dependents ' coverage before the child' s birth, coverage on the
child will cease at the end of the 31st day after its birth unless
during such 31 days the employee gives the Employer a written
request to make payroll deductions, if any, toward the cost of
dependents ' coverage.
WHEN DOES COVERAGE END?
Coverage ends on the day the employee ceases to be covered for Part
A benefits.
WHEN SHOULD A CHANGE IN FAMILY STATUS BE REPORTED?
The employer should be contacted promptly when any event occurs
that could affect a dependent' s eligibility for coverage. Some
examples are: change in marital status, birth of a child and
change in a child's student status. A delay could result in not
having coverage which would otherwise be provided.
Benefits will be payable under Part B if an employee or dependent
incurs medical expenses due to an injury, a sickness, a mental
disorder or a pregnancy. There is a deductible for each person.
LG\mASO+/FW-1B.DTF691 1B-10
WHAT IS THE DEDUCTIBLE?
The deductible is an amount of a person's covered expenses in a
calendar year for which no benefits will be paid. It applies to
all kinds of covered expenses.
WHAT IS PAID BY YOUR EMPLOYER?
We will pay a percentage of most covered expenses in excess of the
deductible. This percentage is indicated after Percentage We Pay
on the Employer Certification. However, for a few covered expenses
a reduced rate of 50%, after the deductible, will be paid. (See
1B-1) .
ARE PAYMENTS MADE FOR PRE-EXISTING CONDITIONS?
Covered expenses due to a pre-existing condition are covered on the
same basis as for other conditions. However, no benefits are
payable until one of the requirements of the DO WE PAY FOR PRE-
EXISTING CONDITIONS is satisfied.
WHAT ARE COVERED EXPENSES?
Covered expenses are usual or prevailing charges for a broad range
of medical services and supplies.
18-11
J "" LG\mAS0+/Fw•1a.M691
WHAT EXPENSES ARE NOT COVERED?
Some medical expenses are covered only under certain conditions.
Others are not covered at all.
DOES OTHER COVERAGE AFFECT BENEFITS?
Yes. Benefits may be reduced by similar benefits of other group
type plans or Medicare. See DUPLICATE BENEFITS.
WHAT IS THE DEDUCTIBLE?
Individual Deductible
An employee must pay an amount in each calendar year of each
FAMILY MEMBER'S Covered Expenses before benefits become payable.
This amount is the amount indicated after Individual Deductible on
the Employer Certification.
Family Deductible
An employee does not have to pay more than the Family Deductible
amount for all family members combined. After that, each family
member's deductible will be considered paid for that year.
LG\ewASO+/F W-I B.DTF691 1B-12
The Family Deductible amount is the amount indicated after the
Family Deductible on the Employer Certification.
"Family Member" means the employee or any of his covered eligible
dependents under the Plan.
WHAT DOES THE EMPLOYER PAY?
After the employee pays the Deductible, we will pay a percentage of
the Covered Expenses for the rest of the calendar year. This
percentage is indicated after Percentage We Pay on the Employer
Certification. The employee will have to pay the percentage of
such Covered Expenses which we do not pay. This is also true for
each family member.
Are There Exceptions To This?
There are some Covered Expenses for which we pay only 50%. These
are described under SPECIAL BENEFITS.
Is There A Limit On What An Employee Pays?
Individual Limit
Aside from the Deductible, an employee does not have to pay more
than the amount indicated after Individual Out-Of-Pocket Limit on
' a*� LG\r.ASO+/FWIB.DTF691 1B-13
the Employer Certification for Covered Expenses for himself and/or
a family member during a calendar year. For the rest of that year,
we will pay 100% of Covered Expenses for the employee and/or that
family member, except as stated under SPECIAL BENEFITS.
Family Limit
Aside from the Deductible, an employee does not have to pay more
than the amount indicated after Family Out-Of-Pocket Limit on the
Employer Certification for Covered Expenses of all family members
combined during a calendar year. For the rest of that year, we
will pay 100% of Covered Expenses for all family members whose
Deductible has been paid, except as stated under SPECIAL BENEFITS.
Is There A Maximum Benefit?
There is no limit on the amount of benefits we will pay for a
family member's Covered Expenses while the family member is covered
under this Plan, except for mental disorders and nursing services.
The limits for these benefits are stated below.
LG\rwASO+/FW-1 B.DU691 1B-14
SPECIAL BENEFITS
What Do We Pay For Mental Disorders?
We will pay an Employee's and/or a family member' s Covered Expenses
due to mental, nervous and emotional disorders as described below.
Doctor Services and Other Outpatient Services
BENEFITS--After the Deductible is paid, we will pay 50% of Covered
Expenses for doctor services and other outpatient services due to
these disorders for the rest of the calendar year.
COVERED EXPENSES--Covered Expenses for doctor services and other
outpatient services due to these disorders include charges up to
$50 for each of the first 20 visits in a calendar year. After
that, such services are not covered. However, Covered Expenses do
not include charges for more than one visit in any day or charges
for services not personally performed by a doctor. The term
"doctor" includes a licensed or certified psychologist. The
maximum number of visits described above will be reduced by the
number of visits for which you receive BASIC BENEFITS in the same
calendar year.
LG4wASO+/FW I B.DTF691 1B-15
Inpatient Hospital Services
DOCTOR SERVICES AND BENEFITS--After the Deductible is paid, we will
pay 50% of doctor services and other inpatient hospital services
due to these disorders for 30 days of confinement in a calendar
year. After that, such services are not covered.
The maximum number of days described above will be reduced by the
number of days for which an employee received BASIC BENEFITS in the
same calendar year.
Psychiatric Day Treatment Facility
BENEFITS--After the Deductible is paid, we will pay Covered
Expenses for doctor services and other services by a PSYCHIATRIC
DAY TREATMENT FACILITY due to mental, nervous and emotional
disorders. See--DEFINITIONS for an explanation of Psychiatric Day
Treatment Facility under "Hospital" .
COVERED EXPENSES--Covered Expenses for doctor services and other
services by a Psychiatric Day Treatment Facility will be 50% of the
Inpatient Hospital Services Benefit described above.
LG4avA50+/Fw-IB.1TF691 1B-16
Alternative Mental Health Treatment
BENEFITS--After the Deductible is paid, we will pay Covered
Expenses for doctor services and other services by a RESIDENTIAL
DAY TREATMENT FACILITY FOR CHILDREN AND ADOLESCENTS or a CRISIS
STABILIZATION UNIT if the following conditions are met:
(a) An employee or a covered dependent has a serious mental
illness which: (i) substantially impairs the person' s
thought, perception of reality, emotional process, or
judgement or grossly impairs behavior as shown by recent
disturbed behavior, and (ii) would require inpatient services
by a hospital in the absence of a Residential Treatment Center
for Children and Adolescents or Crisis Stabilization Unit
Facility.
(b) The services rendered by such a facility are based on an
INDIVIDUAL TREATMENT PLAN; and
(c) The providers of those services are licensed by the
appropriate state agency or board to do so.
See DEFINITIONS for explanations of Residential Treatment Center
for Children and Adolescents, Crisis Stabilization Unit, and
Individual Treatment Plan, all under "Hospital" .
"" LG\mAS0+/FW-IB.DTF691 1B-17
COVERED EXPENSES--Covered Expenses for Alternative Mental Health
P.
Treatment will be 50% of the Inpatient Hospital Services Benefit
described above.
Limit On What You Pay
The 100% payment rate after the Out-Of-Pocket Limit is reached does
not apply to Covered Expenses for mental disorders.
Lifetime Maximum Benefit
The maximum we will pay for all Covered Expenses due to these
disorders is $30, 000. This maximum amount will be reduced by the
amounts received under BASIC BENEFITS.
SPECIAL BENEFITS
What Do We Pay For Nursing Services?
We will pay a family member's Covered Expenses for nursing services
as described below:
BENEFITS--After the Deductible is paid, we will pay:
50% of Covered Expenses for nursing services, including those
provided while confined in a hospital . However, we will pay
MmASO+/FW.IB.DTF691 1B-18
no more than $2 , 500 in benefits for nursing services in a
' calendar year.
LIMIT ON WHAT AN EMPLOYEE PAYS--The 100% payment rate after the
Out-Of-Pocket Limit is reached does not apply to Covered Expenses
for nursing services.
COVERED EXPENSES--Covered Expenses for nursing services include
charges by a registered nurse or a licensed practical nurse.
Covered Expenses do not include:
Charges by the same nurse for more than one eight hour
shift during any day.
- Charges by a nurse who resides in the family member' s
home or is related to the family member by blood or
marriage.
- Charges for custodial care.
The maximum calendar year amount described above will be reduced by
amounts received under BASIC BENEFITS in the same calendar year.
DO WE PAY FOR PRE-EXISTING CONDITIONS?
For persons not covered under the prior plan (See 1B-38) , we will
pay for Covered Expenses due to a PRE-EXISTING CONDITION on the
same basis as for other conditions, but only after the earliest of:
\"'� l LG\rwASO+/FW-1B.DTF691 1B-19
( 1) The day the family member has not received any medical advice
or treatment for the pre-existing condition for twelve (12)
consecutive months;
(2) The day upon which a two year period has elapsed after the
family member' s coverage date; or
(3) The day the pre-existing condition qualifies for full benefits
under Part A.
Until the family member has met one of the above, we will not pay
for Covered Expenses due to the pre-existing condition.
"Pre-existing Condition" means any injury, sickness, mental
disorder, pregnancy,p g y, or related illness for which a family member
has consulted a doctor, received any medical services or supplies,
or taken any medication during the three months immediately before
becoming covered under this Part B.
DO WE PAY FOR PREGNANCY?
We will pay for a family member' s Covered Expenses due to
pregnancy, childbirth or a related medical condition on the same
basis as for a sickness. Covered Expenses include COMPLICATIONS OF
PREGNANCY, as described below. However, we will not pay any
LG4wAS0+/FW 1 B.DTF691 1B-20
expenses incurred in connection with voluntary abortions. See WHAT
� EXPENSES ARE NOT COVERED?
Covered Expenses include the charge normally made by the hospital,
excluding doctor charges, for routine services furnished to a baby
during the first 5 days after its birth or before the mother is
discharged from the hospital, if earlier.
"COMPLICATIONS OF PREGNANCY" means:
(A) conditions, requiring hospital confinement (when the pregnancy
is not terminated) , whose diagnoses are distinct from
pregnancy but are adversely affected by pregnancy or are
caused by pregnancy, such as acute nephritis, nephrosis,
�1
cardiac decompensation, missed abortion, and similar medical
and surgical conditions of comparable severity, and
(B) non-elective cesarean section, termination of ectopic
pregnancy, and spontaneous termination of pregnancy, occurring
during a period of gestation in which a viable birth is not
possible.
' LG VwAS0+/FW.1 B.DTF691 1B-21
WHAT ARE COVERED EXPENSES?
Covered Expenses are USUAL OR PREVAILING CHARGES for the necessary
MEDICAL CARE set forth below. Such charges will be covered if they
are incurred by a family member while covered under Part B.
Not all expenses are covered. See WHAT EXPENSES ARE NOT COVERED?
HOSPITAL SERVICES--Charges by a HOSPITAL for inpatient services
excluding the first $500 of such charges per confinement if PRIOR
AUTHORIZATION UTILIZATION REVIEW is not requested. See DEFINITIONS
for an explanation of what PRIOR AUTHORIZATION UTILIZATION REVIEW
is and how it is requested. Also, see SPECIAL BENEFITS for
inpatient hospital services due to mental disorders.
Private room charges are covered up to the hospital 's regular daily
semi-private room rate. However, this limit will not apply if
confinement in a private room is required because of a contagious
disease. Charges by a hospital for outpatient services are also
covered.
If a family member is admitted to a hospital on a Friday or a
Saturday, hospital charges incurred on the day of admission and on
the following day, if a Saturday, are not covered. This does not
apply if surgery is performed within 24 hours of the admission or
the admission is due to emergency illness or accident. Two or more
LGMwASO+/FW-1 B.D7'F691 1B-22
hospital confinements due to related causes will count as one
period of hospital confinement unless separated by at least 14
days.
DOCTOR SERVICES--Charges by a DOCTOR. See SPECIAL BENEFITS for
Covered Expenses due to mental disorders.
NURSING SERVICES--See SPECIAL BENEFITS for these Covered Expenses.
LAB SERVICES--Charges for diagnostic x-ray and lab tests.
ANESTHETICS--Charges for anesthetics and their administration.
MEDICAL SUPPLIES--Charges for: blood or blood plasma not donated
or replaced; prosthetic appliances, splints, crutches and braces;
oxygen; and rental of durable equipment of a medical or surgical
nature. This equipment is limited to hospital beds, wheel chairs,
respirators and cardiac monitors.
TRANSPORTATION SERVICES--Charges for local ambulance service.
Charges for railroad or regularly scheduled airline service for one
trip per year within the United States or Canada by a covered
employee or covered dependent requiring transportation for the
purpose of receiving medical treatment. These services must be in
connection with the transport of that family member to and from the
nearest hospital where the family member has been or will be
LG4wASO+/FW-1 B.DTF691 1B-23
confined for necessary medical care. However, the confinement
requirement does not apply when transportation to a hospital is
necessary because of an accidental injury.
PHYSIOTHERAPY--Charges by a licensed or certified physiotherapist.
SPEECH OR HEARING LOSS--Charges for treatment of loss or impairment
of speech or hearing.
CHEMICAL DEPENDENCY SERVICES--Charges by a state approved
institution that is primarily engaged in treating chemical
dependency for inpatient, residential or non-residential treatment
programs, ordered by a doctor.
EMERGENCY CARE--Charges for bona fide emergency services after the
sudden onset of a medical condition which (a) manifests itself by
severe pain and other acute symptoms of sufficient severity and (b)
leads to the reasonable expectation that, absent immediate medical
attention, the condition would result in:
(1) placing the patient's health in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
LG\mASO+(F W-1 B.Dn691 1B-24
NURSING HOME SERVICES--Charges by a Nursing Home up to the home ' s
regular daily semi-private rate for 100 days of confinement in a
calendar year. Such confinement must be certified, in writing, by
the attending physician, prior to the confinement. The physician
must certify that:
(1) the confinement is medically necessary,
(2) the treatment to be provided is non-custodial, and
(3) the confinement is in lieu of a hospital confinement.
Care required solely for assistance with normal daily activities,
such as dressing, feeding, and ambulation is custodial. The
maximum number of days described above will be reduced by the
number of days for which you receive BASIC BENEFITS in the same
ZJcalendar year.
MAMMOGRAPHY--Charges for an annual mammography and screening for
the presence of occult breast cancer for females who are age 35 or
older.
HOME CARE SERVICES--Charges by a hospital or a HOME HEALTH AGENCY
for up to 100 home care visits in a 12 month period. The visits
must begin within 14 days after a hospital or nursing home stay.
This requirement will not apply if a doctor certifies that the home
care is in lieu of a confinement. Up to 4 consecutive hours of
home health services provided by a home health aide will be
: LGVwASO+/FW-IB.UTF691 1B-25
considered one home care visit. Home Care Services include:
physical, occupational , speech or respiratory therapy; the service
of a home health aide under the supervision of a registered nurse;
and the furnishing of medical equipment and medical supplies other
than drugs and medicines. Charges for custodial care are not
covered.
The maximum number of visits described above will be reduced by the
number of visits for which you receive BASIC BENEFITS in the same
12 month period.
AMBULATORY SURGICAL CENTER SERVICES--Charges by an AMBULATORY
SURGICAL CENTER for surgical services.
WHAT EXPENSES ARE NOT COVERED?
The following charges are not covered or are covered only to the
extent stated.
OCCUPATIONAL INJURY--Charges due to an on the job injury are not
covered. However, this exclusion will not apply if the law does
not permit a family member' s employer (or his family member) to
obtain coverage for the family member under a Workers ' Compensation
Act or similar act. Nor will it apply if the law permits but does
not require a family member who is a partner or an individual
LGUavASO+mow-1B.D7'FQ91 1B-26
proprietor to have coverage under a Workers ' Compensation Act or
` similar act and that person does not have such coverage.
OCCUPATIONAL SICKNESS--Charges due to any sickness which would
entitle the family member to benefits under a Workers ' Compensation
Act or similar act are not covered.
GOVERNMENT SERVICES--Charges for medical care furnished by or paid
for by any government or government agency are not covered.
Charges for medical care are not covered if the family member would
not have been required to pay for the services in the absence of
insurance for medical care. However, this exclusion will not
apply:
(a) to charges which the state in which the Family member resides
is entitled to as a reimbursement under its Medicaid Law; or
(b) to charges which a hospital facility makes for care or a
family member who is not indigent, and which that facility
normally makes and collects from each patient who is not and
indigent; or
(c) to charges for treatment while in a tax-supported institution
due to mental illness, mental retardation, or both.
,t, ! MmASO+/FW1B.0?F691 1B-27
SERVICES FOR WHICH PAYMENT IS NOT REQUIRED--Charges for medical
�y
care are not covered if the family member would not have been
required to pay for the services in the absence of insurance for
medical care.
COSMETIC SURGERY AND TREATMENT--Charges in connection with surgery,
medication or any other type of treatment primarily for the
purposes of improving appearance, including hair restoration, are
not covered. However, this exclusion does not apply if the
surgery, medication or treatment is due to injuries sustained in an
accident which takes place while covered under the Plan's Major
Medical insurance. Nor will it apply to a congenital malformation
of a child who became covered under the Plan's Major Medical
insurance at birth.
Few
FOOT CARE--Charges for the following are not covered: treatment of
weak, strained or flat feet; instability or imbalance of the feet;
orthopedic shoes and other supportive devices. Also, charges for
cutting, removal or treatment of corns, calluses, bunions or
toenails are not covered unless needed because of diabetes or other
similar disease.
CUSTODIAL CARE--Charges for custodial care are not covered.
ROUTINE PHYSICAL EXAMINATIONS--Charges for routine physical
examinations are not covered.
LG\mASO+/FW-1 B.DTF691 1B-28
PRESCRIPTION DRUGS--Charges for prescription drugs are covered in
excess of the deductible at eighty percent (80%) of the cost of the
drugs up to the annual maximum out-of-pocket expense. Thereafter,
such costs are covered at 100%. Such charges may be applied to
satisfy either the annual Plan deductible or the annual maximum
out-of-pocket expense.
IMMUNIZATIONS--Charges for immunizations are not covered.
HEARING CARE--Charges for hearing aids or their fitting are not
covered.
OVERSEAS BUSINESS TRAVEL--Charges for medical care furnished during
a business trip outside the United States and Canada are covered
,5
1
yy only during the first 60 days of the trip.
WAR CONDITIONS--Charges due to an injury, a sickness or a mental,
nervous or emotional disorder arising out of war, or an act of war,
are not covered.
DENTAL SERVICES--Charges for treatment of the teeth are not covered
except for treatment of natural teeth injured in an accident which
takes place while the family member is covered under Part B.
Charges for any such treatment rendered more than one year after
the accident are not covered. Charges for surgery due to
periodontal disease are not covered. Charges for treatment of the
-N,1 LGV.ASO+/FW-1B.DTF691 1B-29
teeth due to a congenital malformation of a child who became
covered under Part B at birth are covered.
VISION CARE--Charges for eye tests are not covered unless due to a
sickness or an injury. Also not covered are charges for: eye
glasses or their fitting; and radial keratotomies or similar
surgery done to treat myopia.
SERVICES BY RELATIVES--Charges for medical care furnished by any of
the following persons: the family member's spouse, parent, child,
grandparent, brother, sister or parent-in-law are not covered.
INPATIENT HOSPITAL SERVICES--Charges by a HOSPITAL for inpatient
services for the first $500 per confinement are not covered if ID
Prior Authorization Utilization Review is not requested for that
confinement.
If a family member is admitted to a hospital on a Friday or a
Saturday, hospital charges incurred on the day of admission and on
the following day, if a Saturday, are not covered. This does not
apply if surgery is performed within 24 hours of the admission if
the admission is due to emergency illness or accident.
BODY DISTORTION--Charges for detecting and correcting body
distortion are not covered except as set forth below. "Body
MrwASO+/FW-IB.DTF691 1B-30
distortion" means structural imbalance, distortion, or incomplete
00 or partial dislocation in the human body:
(a) which interferes with the human nerves; and
(b) which is due to or related to distortion, misalignment or
incomplete or partial dislocation of or in the vertebral
column.
However, charges by a doctor for detecting or correcting body
distortion will be covered up to $500 in a calendar year.
BASIC BENEFITS--Charges for which you received BASIC BENEFITS are
k4
not covered.
JAW JOINT DISORDERS--Charges due to treatment for any jaw joint
disorders including temporalmandibular joint syndrome and
craniomandibular disorders, or other conditions of the joint
linking the jaw bone and skull and the complex of muscles, nerves
and other tissues related to that joint. However, charges due to
treatment for any jaw joint disorder will be covered up to a
maximum of $1, 500 in a calendar year.
INFERTILITY--Charges made for procedures which promote fertility
are not covered: these include, but are not limited to, hormone
therapy, artificial insemination, in-vitro fertilization, embryo
' LGVwASo+/FW-1a.DTF691 1B-31
transfer and Gamete Intra-Fallopian Transfer (GIFT) ; and reversal
of surgical sterilizations.
STERILIZATIONS--Charges made in connection with sterilizations are
not covered.
VOLUNTARY ABORTIONS--Charges for services furnished in connection
with voluntary abortions are not covered.
HOW DO OTHER GROUP TYPE PLANS AFFECT BENEFITS?
If a person has medical coverage under a "GROUP TYPE PLAN"
(excluding school student insurance) , we will coordinate our
benefits with those of that plan. One plan is primary. One plan
is secondary. The primary plan pays regular benefits in full . The
secondary plan pays a reduced amount which, when added to the
benefits paid by the primary plan, will equal 100% of ALLOWABLE
EXPENSES.
"ALLOWABLE EXPENSE" means the usual or prevailing charge of an item
of care at least part of which is covered by one of the plans.
When our plan is secondary, any deductible or copayment amount or
percentage charged and unpaid by the primary plan will be an
Allowable Expense; our Plan' s deductible and copayment amounts
remain applicable to the balance of Allowable Expenses unpaid by
the primary plan.
LGV.ASO+/FW-I B.DTF691 1B-32
"GROUP TYPE PLAN" means a plan of insurance (other than a plan
providing BASIC BENEFITS) , which:
(a) is provided through a group policy or contract, or individual
policies or contracts to classes of employees or members
defined by conditions pertaining to employment or membership;
(b) provides coverage only because of the covered person ' s
membership in or in connection with the particular
organization or group; it does not provide coverage to the
general public;
(c) is sponsored by an employer, union or association which also
arranges for bulk payment of premiums or subscription charges;
and
(d) provides benefits similar to, but not necessarily identical
with, this plan's benefits for medical charges.
A plan that does not coordinate with other plans is always the
primary plan. If both plans coordinate, the primary plan is
determined as described below.
(a) The Plan which covers the patient as an employee, rather than
as a dependent, is primary.
,_' LG\mAS0+/FW-1B.Dn691 1B-33
(b) If both plans cover the patient as a dependent child, the
following will determine which plan is primary:
(i) If the child' s parents are living together, the primary
plan will be the Plan of the parent whose birthday occurs
earlier in the calendar year, except that:
If either parent's plan does not have this rule for
determining which plan is primary, the Plan without
this rule shall determine which plan is primary.
(ii) If the child's parents are divorced, the primary plan
will be the Plan of the parent with the custody of the
child, except that:
When the parents are divorced and the parent with
custody of the child has not remarried, the
benefits of the Plan which covers the child as a
dependent of the parent with custody of the child
will be determined before the benefits of a Plan
which covers the child as a dependent of the parent
without custody.
When the parents are divorced and the parent with
custody of the child has remarried, the benefits of
a Plan which covers the child as a dependent of the
LG\mASO+/FW-1 B.DTF691 1B-34
parent with custody, shall be determined before the
benefits of a Plan which covers that child as a
dependent of the stepparent, and the benefits of a
Plan which covers the child as dependent of the
stepparent will be determined before the benefits
of a Plan which covers that child as dependent of
the parent without custody.
Notwithstanding (i) and (ii) above, if there is a
court decree which would otherwise establish
financial responsibility for the medical, dental or
other health care expenses with respect to the
child, the benefits of a Plan which covers the
child as a dependent of the
p parent with such
financial responsibility shall be determined before
the benefits of any other Plan which covers the
child as a dependent child.
(c) If neither (a) nor (b) applies, the primary plan will be
the Plan which has covered the patient for the longer
period of time, except that:
(i) If the coverage of one plan is based on present
employment, and the coverage of the other plan is
based on prior employment, the primary plan will be
the Plan which is based on present employment; and
LG\mASO+/Flip•1 B.DTF691 1B-35
(ii) If either plan issued in another state and does not
have the rule in (c) (i) for determining which plan
is primary, and as a result both plans will be
considered secondary, then the (c) (i) rule will not
apply.
HOW DOES MEDICARE AFFECT BENEFITS?
1. We will pay this Plan's benefits for you without regard to
Medicare if you are eligible to apply for Medicare because of
age and are eligible for this Plan's benefits as an active
employee.
2. We will pay this Plan's benefits for your spouse without
regard to Medicare if:
(a) You are eligible for this Plan 's benefits as an active
employee; and
(b) Your spouse is a family member under this Plan, is not
eligible to apply for benefits under another group type
as an active employee, and is eligible to apply for
Medicare because of age.
3 . If your spouse is eligible to apply for benefits under another
"GROUP TYPE PLAN" as an active employee, but all the other
LGVwASO+/FW I B.DTF691 1B-36
requirements of item 2 . above are met, we will coordinate our
coverage as stated above under HOW DO OTHER GROUP TYPE PLANS
AFFECT BENEFITS? If any expenses are unpaid after the group
type plan pays its benefits as the primary plan and we pay our
benefits as the secondary plan, a claim should be made to
Medicare for those expenses.
4 . If you and/or your spouse are eligible for this Plan' s
benefits as a retired employee and in all other cases, we will
pay benefits as follows:
(a) For types of expenses covered by both this Plan and
Medicare, we will reduce our benefits so that our
benefits plus Medicare benefits equal 100% of Allowable
Expenses, excluding applicable copayments and
deductibles. When a person is eligible to apply for
benefits under Medicare or another group type plan as an
employee, we will first adjust this Plan' s benefits for
Medicare as if the person had full Medicare coverage
(Part A and Part B) ; we will do so even if the person has
not enrolled for Medicare or applied for its benefits.
Then we will coordinate with the other plan's benefits.
But we will not in any event pay for hospital room and
board charges in excess of the regular semi-private room
rate.
l% LG4wAS0+/FW-1 B.DTF691 1B-37
(b) For types of expenses covered by this Plan, but not
covered by Medicare, we will pay the Plan' s regular '
benefits.
THIS SECTION ONLY APPLIES TO PERSONS COVERED UNDER THE
EMPLOYER'S PLAN ON THE DAY BEFORE THIS PLAN TOOK EFFECT. THE
MAIN PURPOSE IS TO AVOID GAPS IN COVERAGE THAT MIGHT OTHERWISE
OCCUR BECAUSE OF THE CHANGE IN PLANS. IT ALSO PREVENTS
DUPLICATE CLAIM PAYMENTS.
"The Prior Plan" means the Employer's Plan which (a) was in
effect on the day before the Employer adopted this plan, (b)
was terminated for all the Employer's employees, and (c) was
replaced by this Plan.
HOW DOES THE PRIOR PLAN AFFECT BENEFITS?
This Plan's benefits will not duplicate the prior plan's benefits.
We will reduce the benefits for a claim by any benefits that would
be payable under the prior plan's extended benefit provisions for
that same claim if the EFFECT OF PRIOR PLAN COVERAGE section had
not been included.
LGMwASO+/Fw-1 B.DTF691 1B-38
WHAT ARE THE BENEFITS FOR PERSONS COVERED UNDER THE PRIOR PLAN?
If any employee met all of the "WHO IS ELIGIBLE FOR COVERAGE"
requirements on the day this Plan took effect, that employee will
be covered for pre-existing conditions as described below. Each
dependent who met the "WHO IS ELIGIBLE FOR COVERAGE?" requirements
on such day are also covered for this Plan's benefits except that
benefits for a pre-existing condition will be described below. The
"WHO IS ELIGIBLE FOR COVERAGE AND WHEN DOES COVERAGE BEGIN"
requirements are described on page 1B-10.
WHAT ARE THE BENEFITS FOR PERSONS COVERED UNDER THE PRIOR PLAN FOR
PRE-EXISTING CONDITIONS?
Benefits for pre-existing conditions will be as described below for
persons covered under the prior plan. The "DO WE PAY FOR PRE-
EXISTING CONDITIONS?" provision in Part B does not apply to such
persons.
Benefits for any pre-existing condition will be the amount of this
Plan's benefits.
"PRE-EXISTING CONDITION" means an injury, sickness, mental
disorder, pregnancy or related illness for which a person has
consulted a doctor, received any medical services or supplies or
LGVwASO+/F W.I B.DTF691
-• 1B-39
taken any medication during the three months immediately before
becoming covered under Part B of this Plan. p
WHAT ARE THE BENEFITS FOR PERSONS WHO FAILED TO MEET THE "WHO IS
ELIGIBLE FOR COVERAGE?" REQUIREMENTS WHEN THIS PLAN TOOK EFFECT?
If, on the day this Plan took effect, an employee failed to meet
all of the "WHO IS ELIGIBLE FOR COVERAGE?" requirements, no Part B
benefits are payable.
After an employee has met all of the "WHO IS ELIGIBLE FOR
COVERAGE?" requirements, the employee will become covered for this
Plan's Part B benefits as described under "WHAT ARE THE BENEFITS
FOR PERSONS COVERED UNDER THE PRIOR PLAN?" .
WILL A NEW PART B DEDUCTIBLE HAVE TO BE MET?
A new Part B deductible for this Plan must be met. However,
charges applied toward the prior Plan' s deductible which were
incurred during the calendar year in which this Plan took effect
will count toward meeting this Plan's deductible for that year.
SHOULD RECORDS OF EXPENSES BE KEPT?
An employee should save all bills and receipts for medical
expenses. We need them as proof of claim.
LG\mASO+IFWK i 6.DrrF691 1B-40
1 HOW TO FILE A CLAIM FOR PART B BENEFITS?
1
An employee should obtain a claim form from the Employer.
WHEN SHOULD CLAIMS BE SUBMITTED?
When an employee has a claim, he should promptly submit the
completed claim form and any bills or receipts. We have the right
to reject claims submitted more than 180 days after the loss. A
late claim might be accepted if it was not reasonably possible to
submit the claims during the 180 days.
HOW WILL BENEFITS BE PAID?
Benefits will be paid after we receive proof of claim. They will
be paid as directed on the claim form.
All benefits must be paid no more than 60 days after receipt of
proof. No legal action can be brought if payment is not received
prior to the expiration of 60 days after proof of loss has been
filed and no such action shall be brought at all unless brought
within four (4) years from the expiration of 60 days within which
Proof of Loss is required.
FcVwAso+/Fw-I H.DTF691 1B-41
MAY WE REQUIRE ADDITIONAL PROOF OF CLAIMS?
Yes. For example, before paying benefits, we may have a non-
participating physician with similar education, credentials and
training whom we select examine the patient.
RIGHT OF SUBROGATION
When we pay benefits for Covered Expenses incurred due to the
injury, sickness or mental disorder of a family member:
1. We shall be subrogated, to the extent of such payment, to all
of the family members ' rights of recovery against any third
party because of such injury, sickness, or disorder; and,
k
2 . The family member shall: (a) sign and deliver to us all
necessary papers and do whatever else is necessary to secure
such rights; and (b) do nothing to prejudice such rights
without our written consent.
We may elect not to exercise such rights with respect to a
particular claim or family member.
WHEN DOES COVERAGE UNDER PART B END?
Coverage will end on the day the employee ceases to be covered for
Part A benefits.
MmASO+/F W-1 B.DTF691 1B-42 0
CONTINUANCE OF COVERAGE
May Coverage Be Continued After It Would Otherwise End?
Contact your Employer to determine if the coverage may be
continued.
FACILITY OF PAYMENT
Payment may be made to any person(s) , other than the employee, or
to an institution, if in the Employer's opinion: (a) the employee
is legally not able to give valid receipt for any payment due him;
and (b) the persons) or institution receiving such payment has
been caring for or supporting the employee.
Such payments will continue until claim is made by a duly appointed
guardian or committee of the employee.
Lc\mas0+1FW-1B.M691 1B-43
EXHIBIT 2
PART A
GROUP MEMBERSHIP SERVICE AGREEMENT
AS ADMINISTERED BY
SANUS TEXAS HEALTH PLAN
Your Employer certifies that, subject to the terms and conditions
of the Benefit Plan and, more particularly, to the terms and
conditions of this Part A, you are covered for the benefits
described herein.
� d
This Exhibit is subject to the terms and conditions of the Group
Membership Service Agreement as set forth in Exhibit I, Part A,
pages 1A-1 to 1A-50 herein.
LG\MASO+/FW:A.DTF691 2A-1
EXHIBIT 2
PART A (Cont'd) {
SCHEDULE OF BENEFITS
Enrollees are entitled to receive the services and benefits set
forth in this Schedule of Benefits which are Medically Necessary
and are provided, ordered, prescribed or authorized by the
Enrollee's Participating Primary Care Physician subject to the
limitations, exclusions, Copayments and deductibles specified.
I. ROUTINE MEDICAL AND HEALTH SERVICES . WHEN COVERED
Except in the case of a Medical Emergency, services are
covered only under the following conditions:
A. Each Enrollee must select a Participating Primary Care
Physician, from the directory, who will be responsible
for the Enrollee's health needs, including coordination
of out-of-area services and specialist referrals.
B. To be covered under the Plan, all services must be
provided, directed or authorized by the Enrollee's
Participating Primary Care Physician at a Participating
Facility. When the Enrollee requires care by another
Participating Physician, Participating Hospital ,
LG\mAS0CF-SB2.DTF691 2A-2 �
Participating Chemical Dependency Treatment Facility or
other Participating Health Professional, the Enrollee ' s
Participating Primary Care Physician will make a written
referral to such Participating Physician, Participating
Hospital, Participating Chemical Dependency Treatment
Facility or Participating Health Professional. The only
exception is the well-woman examination provided for in
Section II.B (1) (a) , or as otherwise expressly provided.
The Plan will not pay for visits to any Physicians,
Hospitals, chemical dependency treatment facilities or
Health Professionals that have not been authorized in
writing by the Enrollee' s Participating Primary Care
Physician and, when appropriate, approved in advance by
the Plan. The Enrollee 's Participating Primary Care
Physician will be responsible for reviewing, coordinating
and following up on any specialty or hospital course of
treatment.
C. The Enrollee's Participating Primary Care Physician may
make referrals only to Participating Physicians,
Participating Hospitals, Participating Chemical
Dependency Treatment Facilities and other Participating
Health Professionals who have signed participating
provider agreements with Sanus. The Enrollee 's
Participating Primary Care Physician may make referrals
to Non-Participating Physicians and Non-Participating
:' LGkwAS0CF-SB2.DTF691 2pl-3
Hospitals and Health Professionals when such services
cannot be provided by another Participating Provider
Such referrals must be in writing and approved in advance
by Sanus as the administrator of the Plan.
D. Participating Specialist Physicians may make further
referrals to other Physicians, Hospitals, Participating
Chemical Dependency Treatment Facilities and Health
Professionals. In each case, they must receive the
concurrence of the Enrollee's Participating Primary Care
Physician and follow the same referral procedures set out
in paragraphs B and C above.
E. When a Participating Physician determines that an
Enrollee requires admission to a Participating Hospital,
the physician must obtain precertification from the Plan.
Length of stay will be determined by medical necessity
and monitored to assure that appropriate care is rendered
in the appropriate setting.
LG\mASOCFSB2.DTF691 2A-4
II. ROUTINE MEDICAL BENEFITS, HEALTH BENEFITS AND COPAYMENTS:
Services Required Copayments
A. OUTPATIENT SERVICES
1. Office visits for diagnosis and $10 per visit.
treatment of illness or injury.
a. Laboratory services. None in lab facility.
b. Diagnostic and therapeutic None in radiology
radiological services in facility.
support of other covered
benefits and services.
C. Surgical procedures in a $10 per visit.
Participating Physician's
office. (See Section
II.C( 1) ) .
d. Administered drugs, $10 per visit.
medications, injectibles,
biologicals, fluids,
radioactive materials,
dressings, casts, and
crutches; splints and
braces which are used for
urgent or emergency
treatment. (See Sections
IV.W and IV.Y)
e. Obstetrical care, including $10 per visit.
pre-natal and post-natal
services.
2 . Medically Necessary short-term $10 per visit.
outpatient rehabilitation
(i.e. , physical therapy)
services for acute conditions
which are recommended by the
Enrollee 's Participating
Primary Care Physician and
approved in advance by the
Plan. The acute condition must
be subject to significant
improvement through short-term
therapy. Short-term is defined
as up to sixty (60) consecutive
LGVwAS0CF-S82.DTF691 2A-5
services Required Copayments
days per medical condition,
including treatment received as
an inpatient under Section
II.D(2) . The total of
outpatient and inpatient
rehabilitative services shall
not exceed sixty (60)
consecutive days per medical
condition, beginning with the
first date of treatment.
3 . Medically necessary outpatient $175 for each surgery
or same day surgery services, in a Hospital
including anesthesia, which are outpatient unit, day
recommended by the Enrollee' s surgery unit or
Participating Primary Care Ambulatory Surgical
Physician and approved in Center. (See Section
advance by the Plan. The Plan II.C(1) ) .
reserves the right to obtain a
second opinion by a Physician
of its own choosing.
4 . Participating Physician $10 for each physician
services rendered in an home visit.
Enrollee's home.
5. Allergy testing by a $25 per testing visit.
Participating SANDS allergy $10 per visit (all
specialist. (Allergy others)
injections and serum are not
covered. )
6. Mental health services (non- $25 for each 50 minute
chronic acute conditions only; visit.
see Section IV.Q) . When
recommended by the Enrollee's
Participating Primary Care
Physician and approved in
advance by the Plan, up to
twenty (20) fifty (50) minute
office visits per calendar year
to a participating
psychiatrist, participating
psychologist or participating
LGkwASOCF-SB2.DTF691 2A-6
services Required Copayments
mental health professional are
provided for evaluation or
crisis intervention mental
health services.
7 . Chemical Dependency - Necessary $10 per visit. (No
outpatient treatment for Copayment for aftercare
Chemical Dependency is provided maintenance visits)
on the same basis and is
subject to the same limita-
tions, exclusions and
Copayments as treatment for
physical illness generally.
All treatment must be
recommended by the Enrollee 's
Participating Primary Care
Physician and pre-authorized by
the Plan and all care must be
provided by a Participating
Chemical Dependency Treatment
- Facility.
B. PREVENTIVE HEALTH SERVICES
1. Periodic health assessments, None.
pediatric well-baby care and
routine immunizations when
deemed Medically Necessary by
the Enrollee's Participating
Primary Care Physician. The
schedule and extent of such
health assessments shall be
determined by the Enrollee's
Participating Primary Care
Physician. Immunizations are
given and covered in accordance
with accepted medical practice
for certain common communicable
diseases including diphtheria,
pertussis, measles, mumps,
rubella, poliomyelitis and
tetanus.
LGVwASOCF-SB2.DTF691 2A-7
Services Required Copayments
2 . Annual Well Woman-Exam. Female None.
Enrollees may elect to have a
gynecological and related
examination, including Pap
smear, performed once every
twelve (12) months by the
Enrollee's Participating
Primary Care Physician or any
Sanus Participating
Obstetrician/Gynecologist or
Gynecologist offering such
examination.
NOTE: No Participating Primary
Care Physician referral
is needed for this exam.
However, referrals are
still required for other
gynecological
procedures.
3 . Routine vision, speech and None.
hearing screening through 17
years of age to determine the
need for correction; not to
include refraction eye exams,
testing or fitting for hearing
aids.
C. FAMILY PLANNING
1. Family planning services on a $10 per visit plus: IUD
voluntary basis to include $25 for insertion or
history, physical examination, removal; Diaphragm $25;
related laboratory tests and Vasectomy $25; Elective
medical supervision in tubal ligation $25;
accordance with generally (See Section II.A(3 ) )
accepted medical practice;
information and counseling on
contraception, including advice
on or prescription for a
contraceptive method.
LG\mAS0CF•SB2.M691 2A-8
'r
Services Required Copayments
2 . Infertility services on a $10 per visit.
voluntary basis. Diagnostic 50% for each artificial
testing services to determine insemination service.
the cause of infertility are
covered. Artificial
insemination (patient's
spouse's sperm only) is
covered. All infertility
services require pre-certifi-
cation from the Plan. (See
Section IV.N)
D. INPATIENT SERVICES
Medically Necessary Inpatient Hospital Services. An
Enrollee is entitled to receive the inpatient hospital
services set forth in this Section, subject to all
definitions, terms and conditions in this Plan and its
attachments. Except as otherwise provided in Section III,
these services will be available only in the Defined Area
and only if performed, prescribed, arranged for, directed or
authorized by the Enrollee's Participating Primary Care
Physician at a Participating Facility. All non-emergency
hospitalization must be approved in advance by the Plan.
The Plan reserves the right to obtain a second opinion by a
Physician of its own choosing.
1. Inpatient hospital services Medical or Surgical :
are those provided by $275 per admission.
Participating Hospitals within Obstetrical (including
the Defined Area. Inpatient Therapeutic abortions)
. ,, LG\mAS0CF-SB2.OFF691 2A-9
Services Required Copayments f
hospital services for the Mother: $275
treatment of illness or injury Child: $275
including but not limited to:
semi-private room and board;
special diets when Medically
Necessary; use of operating
room and related facilities;
special care unit and services;
x-ray, laboratory and other
diagnostic tests; drugs,
medications, biologicals,
anesthesia and oxygen services;
physical therapy, radiation
therapy and inhalation therapy;
and administration of whole
blood or blood products. (See
Section IV.K) . Special duty
nursing shall be provided only
when Medically Necessary (i.e. ,
in the absence of an intensive
care unit) , when recommended by
the Enrollee's Participating
Primary Care Physician and
approved in advance by the
Plan. Private room coverage
shall be provided only in cases
of medical necessity (i.e. ,
isolation due to infectious
diseases) . The Enrollee may
elect private room
accommodations for other than
the above stated reason. In
such cases, the Enrollee is
responsible for the direct
payment of the difference to
the Hospital .
NOTE: Following discharge by
the Physician
responsible for the
Enrollee's care while
the Enrollee is
hospitalized, an
Enrollee remaining in
LGkwASOCF-SB2.M691 2A-10
Services Required Copayments
the Hospital beyond the
Hospital 's discharge
time is responsible for
direct payment of
additional charges to
the Hospital. The Plan
is not responsible or
financially liable for
such additional
payments.
2 . Rehabilitation Services. $275 per admission.
Medically Necessary short-term
inpatient rehabilitation (i.e. ,
physical therapy) services at a
Participating Facility for
acute conditions which are
recommended by the Enrollee 's
Participating Primary Care
Physician and approved in
advance by the Plan. This
acute condition must be subject
to significant improvement
through short-term therapy.
Short-term is defined as up to
sixty (60) consecutive days per
medical condition which
includes services received as
an outpatient under Section
II.A(2) . Such services shall
not be approved on an inpatient
basis unless other acute
medical care is to be provided.
The total of inpatient and
outpatient rehabilitative
services shall not exceed sixty
(60) consecutive days per
medical condition, beginning
with the first date of
treatment.
3 . Inpatient services in a $25 per day.
Participating Skilled Nursing
`� LGVwASOCF-S82.DTF691 2A-11
services Required Copayments
Facility. When recommended by
a Participating Primary Care
Physician and approved in
advance by the Plan, an
Enrollee shall be able to
receive short-term inpatient
treatment at a participating
Skilled Nursing Facility when
acute care hospitalization is
not appropriate.
NOTE: Skilled nursing care is
not covered when
provided for conditions
of senile deterioration,
Alzheimer's Disease,
mental retardation or
mental illness. Private
duty nursing services,
private room accommoda-
tions, personal or
comfort items and other
articles not specifi-
cally necessary for
treatment of illness or
injury are excluded.
Short-term is defined as
up to sixty (60) days
per medical condition.
4 . Chemical Dependency. Necessary $275 per admission.
inpatient care and treatment
for Chemical Dependency is
provided on the same basis and
subject to the same
limitations, exclusions and
Copayments as treatment for
physical illness generally.
All treatment must be
recommended by the Enrollee's
Participating Primary Care
Physician and pre-authorized by
the Plan, and all care must be
provided by a Participating
LGVwASOCF-SB2.DTF691 2A-12
Services Required Copayments
Chemical Dependency Treatment
Facility.
E. OTHER SERVICES
1. Home Health Care Services. $10 per visit.
Medically necessary home health
care services are available
only in the Defined Area when
provided by a Sanus
participating home health care
agency, and are specifically
limited to short-term
intermittent skilled visits.
Such services must be
recommended by the Enrollee's
Participating Primary Care
Physician and approved in
advance by the Plan. Short-
term is defined as up to sixty
ED (60) consecutive days per
medical condition, beginning on
the date when the first such
visit occurs.
2 . Emergency Services:
a. Hospital Emergency Room. $40 Copayment for each
visit. (Charge waived
if admission occurs at
the time of emergency
room visit) .
b. Outpatient Emergency Care $20 Copayment for each
Center visit.
C. Physician offices operating $20 Copayment for each
after hours as emergency visit.
centers, office visits to a
Physician outside normal
office hours or urgent
visits to a Physician
covering for the Enrollee's
- LG\rwAS0CF-SB2.DTF69I 2A-13
t
:y'
Services Required Co a '
qu p yments
Participating Primary Care
Physician.
d. Emergency ambulance None.
service.
3 . Ambulance Services. Medically None.
Necessary ambulance service to
the nearest medical facility
capable of providing Emergency
Care, or Medically Necessary
non-emergency ambulance service
when authorized in advance by
the Plan.
4 . Prosthetic Devices. Initial None.
external standard prosthetic
medical appliances and limbs
are covered when due to an
acute illness or injury.
External prosthetic appliances
which are covered are:
artificial arms, legs, eyes or
permanent lenses; above or
below knee or elbow prostheses;
external cardiac pacemaker; and
terminal devices such as hand
or hook. Internal prosthetic
devices are covered are:
permanent aids and supports for
defective parts of the body
such as prosthetic cardiac
valves, internal pacemakers and
minor devices such as screw
nails, sutures and wire mesh.
All other prosthetic medical
appliances, including items
described in Section IV, are
excluded. In questions of
medical necessity, a second
opinion may be requested by the
Plan and is binding. (See
Sections IV.BB, IV.CC, and
IV.DD)
LGV.ASOCF-SB2.DW691 2A-14 (
1,
0MM" Services Required Copayments
5. Blood and Blood Products. None.
Administration only. (See
Section IV.K)
6. Dental Services
a. Short-term, limited dental None.
services for the following
which result from an
accidental non-occupational
trauma or injury to
healthy, natural teeth:
Initial care and short-term
treatment (up to 60
consecutive days) is
covered provided (1) such
accident occurred and
services are performed
during the term of coverage
hereunder, (2) the Enrollee
seeks initial treatment
within forty-eight (48)
hours of such accidental
trauma or injury, and (3)
all subsequent treatment
after such initial
emergency treatment is
authorized by the
Enrollee's Participating
Primary Care Physician,
approved in advance by the
Plan and performed by a
participating dentist.
Injuries sustained by
reason of mastication
(i.e. , chewing or biting
down) are excluded.
b. Treatment of fracture, dis-
location or malignant
tumors of the jaw is
provided on the same basis
and is subject to the same
limitations, exclusions and
,,`) LG1i-ASGCF-SB2.DTF691 2A-15
Services Required Copayments
Copayments as for physical
illness generally.
7. Temporomandibular Joint Subject to the
Syndrome Benefits. Medically applicable Copayments
Necessary (non-dental, non- specified in Section
cosmetic) diagnostic and/or II.
surgical treatment of the
temporomandibular (jaw or
craniomandibular) joint. Such
surgical treatment (including
arthroscopy) will be covered
provided it is Medically
Necessary, recommended by the
Enrollee's Participating
Primary Care Physician and
approved in advance by the
Plan. The Plan reserves the
right to obtain a second
opinion by a physician of its
own choosing. Benefits are not 5
provided under this Section for
dental treatments, services or
supplies including, but not
limited to orthodontics,
splints, positioners, dental x-
rays, extraction of teeth, and
selective grinding of the
teeth. (See Section IV) .
LG\mASOCFSB2.UfF691 2A-16
III . EMERGENCY AND URGENT SERVICES
A. IN GENERAL
1. Emergency care services must be secured by the
Enrollee immediately after the onset of the medical
condition, or as soon thereafter as is possible, but
not later than twenty-four (24) hours after the first
appearance of symptoms of illness or forty-eight (48)
hours after an accident. Heart attacks,
cardiovascular accidents, poisoning, loss of
consciousness or respiration, convulsions, severe
bleeding and broken bones are examples of true Medical
Emergencies.
2 . Emergency and urgent services are subject to the
Plan's retrospective review for determination of
whether an acute condition or incident requiring
immediate, emergency or urgent care existed. If the
Plan determines that no need for emergency or urgent
care existed, the Enrollee will be responsible for
payment of all charges incurred for such care, subject
to Employer' s complaint resolution procedure.
B. WITHIN THE DEFINED AREA
Inside the Defined Area, the Enrollee, or someone acting
on behalf of the Enrollee, is required to contact the
Enrollee's Participating Primary Care Physician for
?'l, LG\mASOCF•SB2.DTF691 2A-17
advice. If it is not reasonably possible to contact the
Enrollee ' s Participating Primary Care Physician at the
time (such as that of a life threatening emergency) , the
Enrollee, or someone acting on behalf of the Enrollee,
shall notify the Plan within forty-eight (48) hours of the
emergency, or if not possible within forty-eight (48)
hours, as soon as it is reasonably possible. Upon receipt
of notification, the Plan will coordinate the transfer of
the patient to the care of the Enrollee's Participating
Primary Care Physician when medically prudent to do so.
Coverage for treatment for Medical Emergencies within the
Defined Area by non-participating providers is limited to
the care required before the Enrollee can, without
medically harmful or injurious consequences, be treated by
a Participating Physician or Participating Hospital.
C. OUTSIDE THE DEFINED AREA
Services are available while outside the Defined Area
provided that such Services are of an emergency or urgent
nature and cannot be postponed until the Enrollee is able
to return to the Defined Area to obtain treatment from a
Participating Physician. All continuing or follow-up
treatment shall be provided only within the Defined Area
and shall be subject to all the provisions of this Plan.
To constitute a covered out-of-area service, the Plan must
make the following determinations:
LGVwASOCF-SB2.DIF691 2A-18 ✓ :,
1. onset of the acute illness or injury must have
been sudden and unexpected;
2 . the Enrollee must not have been able to return to
the Defined Area to receive treatment from the
Enrollee's Participating Primary Care Physician;
3 . the treatment must have been Medically Necessary.
The Plan shall pay the Enrollee or arrange to pay the Non-
Participating Hospital (s) or Non-Participating
Physician(s) directly. The payment shall be at the
prevailing rate, subject to any required Copayments.
(!k,D#
Covered services include ambulance transportation,
provided it is Medically Necessary and appropriate.
At the time of the emergency, the Enrollee, or someone
acting on behalf of the Enrollee, shall make every
reasonable effort to notify the Plan. If it is not
reasonably possible to notify the Plan at that time, the
Enrollee, or someone acting on behalf of the Enrollee,
shall notify the Plan within forty-eight (48) hours of the
onset of the emergency treatment or, if not possible, as
soon as it is reasonably possible. Upon notification, the
Plan will coordinate the transfer of the patient to the
� MmASOCF•SBIDTF691 2A-19
1
care of the Participating Primary Care Physician within
the Defined Area when medically prudent to do so. =
IV. LIMITATIONS AND EXCLUSIONS FROM COVERAGE
The following services and supplies, and the cost thereof, are
excluded from coverage under this Plan unless specifically
included by a Plan Amendment.
A. Private room accommodations and special duty nursing
except as provided in Section II.D(1) or unlimited
hospital care except when deemed by the Plan to be
appropriate for an acute level of inpatient care.
B. Any service given without a prior written referral from
the Enrollee's Participating Primary Care Physician,
except as otherwise permitted in Sections I, II or III of
this Schedule of Benefits, including annual well-woman
examinations (see Section II.B(1) (a) ) .
C. Treatment or evaluations required by third persons,
including but not limited to those for: school,
employment, flight clearance, summer camp, insurance or
court ordered.
D. No payments will be made for outpatient services received
LG4wASOCF-SB2.DrrF691 2A-20
01
in Federal facilities or for any items or services
provided in any institutions operated by any state
government or agency when the Enrollee has no legal
obligation to pay for such items or services. Inpatient
hospital care costs incurred on behalf of U.S. Armed
Forces retirees and dependents in governmental or military
service-connected facilities will only be covered by the
Plan if such services are preauthorized by the Plan in
accordance with this Schedule of Benefits and all
deductible or Copayment amounts thereunder are paid by the
Enrollee.
E. Care which an Enrollee receives from or through the United
States Government or any of its corporations, agencies or
bureaus, or from or through any State, County, City or any
political subdivision thereof, unless a charge is
customarily made and services were provided in accordance
with the provisions of Sections II.A-II.E.
F. Cosmetic or surgical procedures are excluded except
reconstructive surgery necessary to repair a functional
disorder as a result of disease, injury or congenital
defect. Such exclusions include, but are not limited to
surgical excision or reformation of any sagging skin on
any part of the body including, but not limited to the
eyelids, face, neck, abdomen, arms, legs or buttocks; any
LG\r.ASOCF-SH2.MF691 2A-21
services performed in connection with the enlargement,
reduction, implantation or change in appearance of a
portion of the body including, but not limited to, the
breasts, face, lips, jaw, chin, nose, ears or genitals;
hair transplantation; chemical face peels or abrasion- of
the skin; electrolysis depilitation; or any other surgical
or non-surgical procedures which are primarily for
cosmetic purposes. The Plan reserves the right to secure
a second opinion by a physician of its own choosing with
respect to any case involving cosmetic or reconstructive
surgery.
G. Dental services and dental prostheses including dentures
are excluded, except as covered in Section II.E(6) .
Maxillary and mandibular osteotomies for shortening or
lengthening of the jaw are excluded. Benefits for
Medically Necessary diagnosis and/or surgical treatment of
temporomandibular joint syndrome are strictly limited to
those provided in Section II.E(7) . All other
hospitalization, anesthesiology or other services relating
to dental work are excluded.
H. Custodial, respite or domiciliary care.
I. Services and appliances for the correction of vision
deficiencies including, but not limited to, special
LGVwASOCF•SB2.DTF691 2A-22 Q
procedures such as orthoptics, vision training, vision
therapy or radial keratotomy.
J. Personal comfort and convenience items or services
including, but not limited to, care kits provided on
admission to a hospital, TV's and telephones.
K. Whole blood or blood components and any related
replacement fees.
L. Surgery or other procedures, treatments or services for
obesity including, but not limited to, gastric intestinal
bypass surgery.
MY.
p M. Sex change surgery including medical or psychological
counseling and hormonal therapy in preparation or
subsequent to any such surgery.
N. Reversal of voluntary sterilization, gamete intra-
fallopian transfer, any fees relating to donor sperm,
menotropins (e.g. , pergonal) or related drug therapy,
surrogate parenting fees and in-vitro fertilization.
O. Acupuncture, naturopathy and hypnotherapy.
P. Inpatient mental health. Treatment for mental
°.'� LG4wASOCFSB2.DTF691 2A-23
retardation, mental deficiency, or other forms of senile
deterioration, such as Alzheimer' s Disease.
Q. Outpatient mental health services for chronic conditions
including, but not limited to, treatment for mental
retardation, mental deficiency or other forms of senile
deterioration, such as Alzheimer' s Disease.
R. Heart transplants and all organ transplants, except
Medically Necessary kidney transplants, corneal
transplants, and liver transplants for children with
biliary atresia. All donor expenses are excluded.
S. Bone marrow transplants, except for aplastic anemia,
leukemia, severe combined immunodeficiency disease, and
Wiskott-Aldrich syndrome. All donor expenses are excluded.
T. Any procedure or treatment that is deemed by the Plan to
be experimental or any procedure, medication or treatment
that is used for a non-FDA approved indication.
U. Care for conditions that federal, state or local law
requires to be treated in a public facility, or while in
the custody of legal authorities.
V. Services payable under Workers ' Compensation, black lung
LG\rwASOCF-SB2.DTF691 2A-24
benefits or a government program to the extent that such
services are covered under Workers ' Compensation or
similar laws.
W. Routine foot care such as hygienic care. Treatment for
flat feet, removal of corns or calluses; corrective
orthopedic shoes, arch supports, orthotics.
X. All splints and braces not used for urgent or emergency
treatment including, but not limited to, those used for
preventive purposes.
Y. All durable medical equipment.
Z . Consumables or disposable supplies purchased by the
Enrollee on an outpatient basis, or purchased by or given
to the Enrollee upon discharge from a Hospital including,
but not limited to, sheaths, bags, elastic garments,
syringes, needles, blood or urine testing supplies, ostomy
bags, home testing kits, vitamins, dietary supplements
and/or replacements, non-rigid appliances and supplies.
AA. Occupational and educational testing and therapy.
BB. Long-term rehabilitation therapy. Long-term means
treatment in excess of sixty (60) consecutive calendar
41' LG\mAS0CF-SB2.DTF691 2A-25
r
days per illness or event.
CC. Replacement, repair or routine periodic maintenance of
prosthetic devices.
DD. Mechanical organ replacement devices (including, but not
limited to, artificial heart) .
EE. All prostheses not covered under Section II.E. 4
(including, but not limited to, penile prostheses) and
services associated with the insertion of any excluded
prosthetic device.
FF. Speech and hearing therapy, including hearing aids.
GG. Outpatient prescription drugs and hospital discharge or
take home drugs, except where specifically covered by
Amendment to the Plan.
HH. Charges for pregnancy and subsequent delivery, including
cesarean sections which are planned or scheduled or
performed only because of previous cesarean section, which
occur outside of the Defined Area and within thirty (30)
days of the due date specified by the Enrollee's Sanus
participating attending physician. However, Complications
of Pregnancy, as defined below, will be covered as any
LG\mAS0CF-se2.DrF691 2A-26
other illness.
j�
For the purpose of this limitation, "Complications of
Pregnancy" means: (1) conditions requiring hospital
confinement (when the pregnancy is not terminated) , whose
diagnoses are distinct from pregnancy but are adversely
affected by pregnancy or are caused by pregnancy, such as
acute nephritis, nephrosis, cardiac decompensation, missed
abortion, and similar medical and surgical conditions of
comparable severity, but shall not include false labor,
occasional spotting, physician prescribed rest during the
period of pregnancy, morning sickness, hyperemesis
gravidarum, pre-eclampsia, and similar conditions
associated with the management of a difficult pregnancy
not constituting a nosologically distinct complication of
pregnancy; and (2) non-elective cesarean section
(emergency/urgent, except as specified above) , termination
of ectopic pregnancy, and spontaneous termination of
pregnancy, occurring during a period of gestation in which
a viable birth is not possible.
II. All anti-smoking treatment and programs including, but not
limited to, tobacco abuse and smoking cessation programs.
V. MAXIMUM COPAYMENTS
'`� MrwASOCF-SBIUM91 2A-27
The maximum amount of Copayment for the Basic Plan Benefits
covered by this Schedule of Benefits in any calendar year will
not exceed $650 for any Enrollee, or $1, 500 for a covered
employee and his Dependents. The maximum amount of Copayments
for each calendar year shall be determined by applying
Copayments relating to Basic Plan Benefits only, and shall not
take into account any Copayments pertaining to any Plan
Amendment.
look
MrWASOCFSBIE TF691 2A-28 ,' "'
EXHIBIT 2
PART A (Cont' d)
PLAN AMENDMENT
PRESCRIPTION DRUGS
The benefits described in this Amendment are added to Part A of the
Plan. All provisions of Part A of the Plan apply to this
Amendment, except as modified herein.
The Copayments described in this Amendment do not apply toward
fulfillment of the maximum Enrollee Copayment limit per year
specified in the Plan.
A. Definitions
1. "Prescription Drugs" means any drugs and/or medications
that require a prescription written by a duly licensed
physician or dentist.
2 . "Designated Mail Service Pharmacy" means Express Scripts,
P.O. Box 27667, St. Louis, MO. 63146.
3 . "Participating Pharmacy" means a pharmacy, other than the
Designated Mail Service Pharmacy, that has contracted with
SANUS to provide Prescription Drugs to Enrollees covered
under the Plan as hereby amended.
4 . "Brand Name Prescription Drug" means the unique trade name
which a manufacturer assigns to a Prescription Drug and
which, when dispensed, can only be the Prescription Drug
" _�� MiwASOCF-SBIDTF691 2A-29
bearing such manufacturer' s trade name.
5. "Generically Equivalent Prescription Drug" means a
Prescription Drug which is pharmaceutically equivalent and
therapeutically equivalent to a Brand Name Prescription
Drug.
B. In General
1. Enrollees will be provided with Generically Equivalent
Prescription Drugs by the Designated Mail Service Pharmacy
or a Participating Pharmacy when permitted by the licensed
Physician or Dentist and by state law.
2 . Enrollees will utilize the services of the Designated Mail
Service Pharmacy by mailing the prescription or refill
ordered by a Participating Physician or Participating
Dentist in a pre-addressed envelope to:
Express Scripts
P.O. Box 27667
St. Louis, MO 63146
3 . Use of the Designated Mail Service Pharmacy is at the
Enrollee's option.
4 . Except in cases of Medical Emergency occurring outside of
the Defined Area and except to the extent that an Enrollee
has not yet fulfilled his deductible, an Enrollee must
obtain a prescription from a Participating Physician or
Participating Dentist and have it filled by a
Participating Pharmacy or the Designated Mail Service
Pharmacy. Participating Pharmacies are listed in the
LG\rwASOCF-SB2.UTF691 2A-30
directory provided to Enrollees by SANDS.
C. Covered Items
1. Federal legend Prescription Drugs and Prescription Drugs
which may only be dispensed by written prescription under
state law.
2 . Compounded medications of which at least one ingredient is
a prescription legend drug and which is provided for a
Food and Drug Administration ("FDA") approved indication.
3 . Injectable insulin and insulin syringes.
4 . Oral contraceptives, diaphragms, and cervical caps.
D. Non-Covered Items
1. Drugs and medications, except insulin, which do not
require a prescription whether or not a prescription has
been obtained.
2 . Prescriptions written prior to the effective date of
coverage.
3 . Experimental or investigational drugs including compounded
medications which are not provided for an FDA approved
indication.
4 . Therapeutic devices or appliances, including hypodermic
needles, syringes (other than insulin syringes) , support
garments and other non-medical substances, regardless of
their intended use.
5. Blood and blood products.
6. Contraceptive devices (other than oral contraceptives,
diaphragms, and cervical caps) .
.� LG\rwASOCF-SB2.DrrF691 2A-31
7 . Prescriptions which an eligible Enrollee is entitled to
receive without charge from any Workers ' Compensation laws
from any municipal, state or federal program.
8 . Blood or urine testing devices including, but not limited
to clinitest, acetest, and dextrostix.
9. Medications used to suppress appetite (e.g. diet
medication) .
10. Antismoking aids (e.g. nicorette gum) .
11. Injectables other than injectable insulin.
12. Drugs and medications prescribed for a cosmetic purpose,
including, but not limited to, topic minoxidil or Retin A.
13 . Allergy sera and allergy testing materials.
14 . Prescriptions filled at or by non-Participating
Pharmacies, except in cases of Medical Emergency occurring
outside of the Defined Area.
15. Prescriptions written by a non-Participating Physician
(except in cases of Medical Emergency occurring outside of
the Defined Area) .
16. Hemofil M, Factor VIII or any other blood product or
derivative.
E. Copayments
1. There are no Copayments required of the Enrollee when
using the Designated Mail Service Pharmacy to obtain the
quantity of Prescription Drugs specified in Paragraph G. 1
of this Amendment.
2 . There is a two dollar ($2 . 00) Copayment, payable to
LG\mASOCF-SB2.DTF691 2A-32
Express Scripts, required for each prescription or refill
ordered from the Designated Mail Service Pharmacy to
obtain the quantity of Prescription Drugs specified in
Paragraph G. 2 of this Amendment.
3 . There is a two dollar ($2 . 00) Copayment required for each
prescription or refill when the Enrollee obtains covered
Generically Equivalent Prescription Drugs from a
Participating Pharmacy, after meeting deductible.
4 . There is a seven dollar ($7. 00) Copayment required for
each prescription or refill when the Enrollee obtains
covered Brand Name Prescription Drugs from a Participating
Pharmacy, after meeting the deductible.
F. Deductibles
There is a seventy-five dollar ($75. 00) deductible per
Enrollee per calendar year, which must be met on non-mail
service prescriptions prior to an Enrollee 's receipt of
benefits from a Participating Pharmacy under this Amendment.
To obtain such benefits, an Enrollee must submit itemized
bills equaling the amount of the deductible and containing the
information set forth in items #1, 2 , 3 and 4 of Paragraph H of
this Amendment. Upon such submission, an Enrollee will
receive an identification card reflecting that the deductible
has been met.
G. Limitations
1. An Enrollee may obtain up to a 34-day supply or 100 units,
whichever is less, of a Prescription Drug from a
. ' .\ LGVwASOCF-SB2.DTF691 2A-33
Participating Pharmacy or the Designated Mail Service
Pharmacy.
2 . The Enrollee may, at his sole option, obtain a 90-day
supply or 300 units, whichever is less, of a Prescription
Drug from the Designated Mail Service Pharmacy, provided
Enrollee pays the Copayment specified in Paragraph E. 2 of
this Amendment to the Designated Mail Service Pharmacy.
H. Enrollee Reimbursement Rules
If a Medical Emergency occurs outside the Defined Area and the
Enrollee incurs expenses for Prescription Drugs, an itemized
bill should be submitted by the Enrollee to the Plan for
reimbursement. The itemized bill must contain the following
information:
1. The name of the drug.
3,
2 . The date and quantity purchased.
3 . The name of the authorizing licensed physician or dentist.
4 . The name of the person for whom it was prescribed.
LGkwASOCF-SB2.LTFF691 2A-34
D
aa EXHIBIT 2
i PART A (Cont'd)
PLAN AMENDMENT
INPATIENT MENTAL HEALTH
The benefits described in this Amendment are added to Part A of the
Plan. All provisions of Part A of the Plan apply to this
Amendment, except as modified herein.
1. In General
A. Enrollees shall be entitled to additional mental health
care benefits for evaluation, crisis intervention
treatment or any combination thereof for Acute Conditions
when such evaluation, crisis intervention or treatment is
recommended by a Participating Primary Care Physician,
approved in advance by the Medical Director and
precertified by the Employer or Employer's Designee.
B. These services rendered must be based on an Individual
Treatment Plan.
C. Providers of services must be licensed by the appropriate
state agency or board to provide these services.
D. The total benefit is limited to any combination of the
following, not to exceed thirty (30) treatment days per
calendar year.
1. As an inpatient in an authorized SANUS participating
psychiatric facility, one (1) inpatient day equals
one (1) treatment day; or
LG\mASOCFSB2.M69j 2A-35
2 . As a day care patient in an authorized SANDS
participating psychiatric facility, one (1) day care
day equals one-half (1/2) treatment day; or
3 . As an inpatient in an authorized SANDS Participating
Crisis Stabilization Unit, one (1) inpatient day
equals one-half (1/2) treatment day; or
4 . As an inpatient in an authorized SANDS Participating
Residential Treatment Center for Children and
Adolescents, one (1) inpatient day equals one-half
(1/2) treatment day.
2 . Definitions
A. "Acute Conditions" means situations in which the Enrollee
has a serious mental illness which substantially impairs
such Enrollee 's thought, perception of reality, emotional
process or judgement or grossly impairs behavior as
manifested by recent disturbed behavior.
B. "Day Care" means treatment of the Enrollee in an
authorized SANUS participating psychiatric facility on a
day-to-day basis with release of the patient at the
conclusion of the treatment day, and in which no overnight
stay is involved.
C. "Crisis Stabilization Unit" means a 24-hour residential
program that is usually short-term in nature and that
provides intensive supervision and highly structured
activities to persons who are demonstrating an acute
LG\m-ASOCF•SB2.DPF691 2A-36
demonstrable psychiatric crisis of moderate to severe
proportions.
D. "Residential Treatment Center for Children and
Adolescents" means a child-care institution that provides
residential care and treatment for emotionally disturbed
children and adolescents and that is accredited as a
residential treatment center by the Council on
Accreditation, the Joint Commission on Accreditation of
Healthcare Organizations, or the American Association of
Psychiatric services for Children.
E. "Individual Treatment Plan" means a treatment plan with
specific attainable goals and objectives appropriate to
both the patient and the treatment modality of the
program.
3 . Limitations
A. Mental health services for the following diagnosed
conditions are excluded: Chronic psychosis, Alzheimer' s
Disease, intractable personality disorders, mental
retardation, psychiatric therapy on court order or as a
condition of parole or probation, and chronic organic
brain syndrome.
B. The benefits described in this Amendment are available
when:
1. They are recommended by the Participating Primary Care
Physician, approved in advance by the Medical Director
and precertified by the Employer or the Employer's
MmASOCF•SBIM69I 2A-37
designee.
2 . The Enrollee does not refuse to accept recommended
procedures or treatment; and
3 . They are provided in an authorized SANDS participating
psychiatric hospital, psychiatric facility, Crisis
Stabilization Unit or Residential Treatment Center for
Children and Adolescents and by a Participating
Provider; and
4. The Enrollee continues to meet the SANUS criteria for
continued benefits under this Amendment; and
5. The Enrollee has not reached the total benefit
described in Section 1.D of this Amendment.
C. Benefits for a Residential Treatment Center for Children
and Adolescents or a Crisis Stabilization Unit are
available only for Acute Conditions which would otherwise
necessitate confinement in an authorized SANUS
participating psychiatric hospital or psychiatric
facility.
4 . Exclusions
Benefits will not be allowed under this Amendment if treatment
is provided by a non-participating provider or non-
participating hospital, facility, Crisis Stabilization Unit,
or Residential Treatment Center for Children and Adolescents
or by a Participating Facility that is not an authorized SANUS
participating psychiatric facility.
5. Copayments
LG4wASOCF•SB2.DIP691 2A-38
A. A fifty percent (50%) Copayment shall be paid by the
Enrollee for all services under this Amendment.
B. The Copayments described in this Amendment do not apply
toward fulfillment of the maximum Enrollee cost limit per
calendar year specified in the Plan.
LG\rwASOCF-SB2.M691 2A-39
EXHIBIT 2
PART A (Cont'd) J
PLAN AMENDMENT
DURABLE MEDICAL EQUIP14ENT
The benefits described in this Amendment are added to Part A of the
Plan subject to the limitations and Copayments described herein.
All provisions of Part A of the Plan apply to this Amendment,
except as modified herein.
When determined to be medically necessary by a Participating
Primary Care Physician and pre-approved by the Medical Director,
Enrollees shall be entitled to the rental or purchase of Durable
Medical Equipment (initial placement only) ; rental or purchase will
be determined by Employer or Employer' s designee.
"Durable Medical Equipment" means equipment which can withstand
repeated use, is primarily and customarily used to serve a medical
purpose, generally is not useful to a person in the absence of a
sickness or injury, is appropriate and used in the home, may be
used by more than one person, and does not require an individual
prescription for construction. All services and devices must be
obtained through a Plan participating provider.
Some examples include, but are not limited to, be a standard
wheelchair, crutches, walkers, orthopedic tractions, hospital beds,
LG4wASOCF-SB2.DTF691 2A-40
oxygen, bedside commodes, suction machines, etc. (lengthy list
maintained - HCFA Coverages Issue Manual) .
The following items are among, but not limited to, those excluded:
deluxe equipment such as motor driven wheelchairs and beds; comfort
items; bedboards; bathtub lifts; over bed tables; air purifiers;
disposable supplies; elastic stockings; sauna baths; repair,
replacement or maintenance of durable medical equipment; exercise
equipment; stethoscopes and sphygmomanometers; orthopedic shoes;
arch supports; dentures; experimental or research items. In no
event will prosthetic devices or artificial limbs be covered under
this Amendment.
HEARING AIDS
{
Part A of this Plan will cover medically necessary diagnosis of
hearing deficiencies including audiometry and initial placement of
necessary hearing aid device(s) .
Part A of this Plan will also cover one (1) audiogram per year, if
needed; one cleaning of the hearing device per year; and,
replacement of the hearing device every four (4) years* if
medically indicated. Replacement for loss, damage or for
functional defects are not covered.
All services and devices must be approved in advance by the Medical
LG\i-ASOCF-ss2.M691 2A-41
4
Director and must be obtained through a Participating Provider.
*Note: There are some cases of rapid deterioration of hearing
loss which will necessitate hearing device
replacement sooner than the four (4) year period and
will be considered on an individual basis with prior
approval from the Medical Director.
LG\mASOCF-SB2.=691 2A-42
EXHIBIT 2
PART A (Copt 1 d)
PLAN AMENDMENT
PRE-EXISTING CONDITIONS
The Copayments payable by an Enrollee as described in Part A of the
Plan are subject to the limitations described herein.
A. Definitions
"Pre-existing Condition" means any medical condition known by
the Enrollee to have existed or for which diagnosis was made
or treatment received within the three (3) months immediately
preceding the Enrollee 's effective date of coverage under the
1fa '"s
Plan. A medical condition has been "diagnosed" if its
existence has been identified or recognized by a Physician or
other Health Professional. A medical condition has been
"treated" if any services of a Physician or other Health
Professional have been received with respect thereto,
including, but not limited to, office visits or consultations,
Hospital treatment, laboratory services, X-rays or the
dispensing of prescription medication or refills.
B. In addition to any other Copayment required under the Plan,
each Enrollee with a Pre-existing Condition shall be required
to pay an additional Copayment equal to a total of fifty
LG\rwASOCFSB2.DTF691 2A-43
percent (50%) of the cost of Treatment (which shall include
all applicable Copayments specified in the Schedule of
Benefits for such Treatment) with respect to such Pre-existing
Condition until such time as the Enrollee has been
continuously enrolled for a period of twelve (12) months under
this Plan and/or under another Plan with Sanus immediately
proceeding this Plan; provided that any uninterrupted and
consecutive-day hospitalization begun prior to the expiration
of said twelve (12) month period shall be deemed to be a
continuous confinement subject to the aforesaid Pre-existing
Condition Copayments.
C. The maximum amount of additional Copayment for a Pre-existing
Condition during this twelve (12) month period will not exceed
$800 for any such Enrollee or Dependent or $3 , 000 total for
such Enrollee and his Dependents. Copayments payable pursuant
to Section B of this Amendment shall not be included in, and
are in addition to, the maximum amount of Copayment for Part
A Benefits.
LG4wASOCF•SB2.DTF691 2A-44
EXHIBIT 3
PART A
GROUP MEMBERSHIP SERVICE AGREEMENT
AS ADMINISTERED BY
SANUS TEXAS HEALTH PLAN
Your Employer certifies that, subject to the terms and conditions
of the Benefit Plan and, more particularly, to the terms and
conditions of this Part A, you are covered for the benefits
described herein.
This Exhibit is subject to the terms and conditions of the Group
Membership Service Agreement as set forth in Exhibit I, Part A,
pages 1A-1 to 1A-50 herein.
�'�
LG4-ASO+/FW-3A.DTF691 3A-1
EXHIBIT 3 i
PART A (Cont'd)
SCHEDULE OF BENEFITS
Enrollees are entitled to receive the services and benefits set
forth in this Schedule of Benefits which are Medically Necessary
and are provided, ordered, prescribed or authorized by the
Enrollee's Participating Primary Care Physician subject to the
limitations, exclusions, Copayments and deductibles specified.
I. ROUTINE MEDICAL AND HEALTH SERVICES , WHEN COVERED
Except in the case of a Medical Emergency, services are
covered only under the following conditions:
A. Each Enrollee must select a Participating Primary Care
Physician, from the directory, who will be responsible
for the Enrollee's health needs, including coordination
of out-of-area services and specialist referrals.
B. To be covered under the Plan, all services must be
provided, directed or authorized by the Enrollee ' s
Participating Primary Care Physician at a Participating
Facility. When the Enrollee requires care by another
LG\YW ASOCF-SB3.DfF691 3A-2
Participating Physician, Participating Hospital ,
Participating Chemical Dependency Treatment Facility or
other Participating Health Professional, the Enrollee 's
Participating Primary Care Physician will make a written
referral to such Participating Physician, Participating
Hospital, Participating Chemical Dependency Treatment
Facility or Participating Health Professional. The only
exception is the well-woman examination provided for in
Section II.B (1) (a) , or as otherwise expressly provided.
The Plan will not pay for visits to any Physicians,
Hospitals, chemical dependency treatment facilities or
Health Professionals that have not been authorized in
writing by the Enrollee 's Participating Primary Care
1
Physician and, when appropriate, approved in advance by
the Plan. The Enrollee 's Participating Primary Care
Physician will be responsible for reviewing, coordinating
and following up on any specialty or hospital course of
treatment.
C. The Enrollee's Participating Primary Care Physician may
make referrals only to Participating Physicians,
Participating Hospitals, Participating Chemical
Dependency Treatment Facilities and other Participating
Health Professionals who have signed participating
provider agreements with Sanus. The Enrollee ' s
Participating Primary Care Physician may make referrals
�. , LG\r.ASOCF-SB3.DTF691 3A-3
to Non-Participating Physicians and Non-Participating
Hospitals and Health Professionals when such services
cannot be provided by another Participating Provider.
Such referrals must be in writing and approved in advance
by Sanus as the administrator of the Plan.
D. Participating Specialist Physicians may make further
referrals to other Physicians, Hospitals, Participating
Chemical Dependency Treatment Facilities and Health
Professionals. In each case, they must receive the
concurrence of the Enrollee 's Participating Primary Care
Physician and follow the same referral procedures set out
in paragraphs B and C above.
E. When a Participating Physician determines that an
Enrollee requires admission to a Participating Hospital,
the physician must obtain precertification from the Plan.
Length of stay will be determined by medical necessity
and monitored to assure that appropriate care is rendered
in the appropriate setting.
MmASOU-SBIUM91 3A-4
II. ROUTINE MEDICAL BENEFITS, HEALTH BENEFITS AND COPAYMENTS:
Ila
Services Required Copayments
A. OUTPATIENT SERVICES
1. Office visits for diagnosis and $10 per visit.
treatment of illness or injury.
a. Laboratory services. None in lab facility.
b. Diagnostic and therapeutic None in radiology
radiological services in facility.
support of other covered
benefits and services.
C. Surgical procedures in a $10 per visit.
Participating Physician's
office. (See Section
II.C(1) ) .
d. Administered drugs, $10 per visit.
medications, injectibles,
biologicals, fluids,
radioactive materials,
dressings, casts, and
crutches; splints and
braces which are used for
urgent or emergency
treatment. (See Sections
IV.W and IV.Y)
e. Obstetrical care, including $10 per visit.
pre-natal and post-natal
services.
2 . Medically Necessary short-term $10 per visit.
outpatient rehabilitation
(i.e. , physical therapy)
services for acute conditions
which are recommended by the
Enrollee's Participating
Primary Care Physician and
approved in advance by the
Plan. The acute condition must
be subject to significant
improvement through short-term
therapy. Short-term is defined
as up to sixty (60) consecutive
LG\mASOCF•SB3.DTF691 3A-5
T
Services Required Copayments
days per medical condition,
including treatment received as
an inpatient under Section
II.D(2) . The total of
outpatient and inpatient
rehabilitative services shall
not exceed sixty (60)
consecutive days per medical
condition, beginning with the
first date of treatment.
3 . Medically necessary outpatient $175 for each surgery
or same day surgery services, in a Hospital
including anesthesia, which are outpatient unit, day
recommended by the Enrollee 's surgery unit or
Participating Primary Care Ambulatory Surgical
Physician and approved in Center. (See Section
advance by the Plan. The Plan II.C(1) ) .
reserves the right to obtain a
second opinion by a Physician
of its own choosing.
4 . Participating Physician $10 for each physician
services rendered in an home visit.
Enrollee's home.
5. Allergy testing by a $25 per testing visit.
Participating SANDS allergy $10 per visit (all
specialist. (Allergy others)
injections and serum are not
covered. )
6. Mental health services (non- $25 for each 50 minute
chronic acute conditions only; visit.
see Section IV.Q) . When
recommended by the Enrollee's
Participating Primary Care
Physician and approved in
advance by the Plan, up to
twenty (20) fifty (50) minute
office visits per calendar year
to a participating
psychiatrist, participating
psychologist or participating
LG4wASOCFSB3.=691 3A-6
Services Required Copayments
mental health professional are
provided for evaluation or
crisis intervention mental
health services.
7. Chemical Dependency - Necessary $10 per visit. (No
outpatient treatment for Copayment for aftercare
Chemical Dependency is provided maintenance visits)
on the same basis and is
subject to the same limita-
tions, exclusions and
Copayments as treatment for
physical illness generally.
All treatment must be
recommended by the Enrollee' s
Participating Primary Care
Physician and pre-authorized by
the Plan, and all care must be
provided by a Participating
Chemical Dependency Treatment
' Facility.
B. PREVENTIVE HEALTH SERVICES
1. Periodic health assessments, None.
pediatric well-baby care and
routine immunizations when
deemed Medically Necessary by
the Enrollee' s Participating
Primary Care Physician. The
schedule and extent of such
health assessments shall be
determined by the Enrollee' s
Participating Primary Care
Physician. Immunizations are
given and covered in accordance
with accepted medical practice
for certain common communicable
diseases including diphtheria,
pertussis, measles, mumps,
rubella, poliomyelitis and
tetanus.
-`� LGVwASOCF-SB3.DTF691 3A-7
F`
services Required Copayments
2 . Annual Well Woman-Exam. Female None.
Enrollees may elect to have a
gynecological and related
examination, including Pap
smear, performed once every
twelve (12) months by the
Enrollee's Participating
Primary Care Physician or any
Sanus Participating
Obstetrician/Gynecologist or
Gynecologist offering such
examination.
NOTE: No Participating Primary
Care Physician referral
is needed for this exam.
However, referrals are
still required for other
gynecological
procedures.
3 . Routine vision, speech and None.
hearing screening through 17
years of age to determine the
need for correction; not to
include refraction eye exams,
testing or fitting for hearing
aids.
C. FAMILY PLANNING
1. Family planning services on a $10 per visit plus: IUD
voluntary basis to include $25 for insertion or
history, physical examination, removal; Diaphragm $25;
related laboratory tests and Vasectomy $25; Elective
medical supervision in tubal ligation $25;
accordance with generally (See Section II.A( 3 ) )
accepted medical practice;
information and counseling on
contraception, including advice
on or prescription for a
contraceptive method.
LGVwASOCF-SB3.DTF691 3A-8
services Required Copayments
2 . Infertility services on a $10 per visit.
voluntary basis. Diagnostic 50% for each artificial
testing services to determine insemination service.
the cause of infertility are
covered. Artificial
insemination (patient's
spouse's sperm only) is
covered. All infertility
services require pre-certifi-
cation from the Plan. (See
Section IV.N)
D. INPATIENT SERVICES
Medically Necessary Inpatient Hospital Services. An
Enrollee is entitled to receive the inpatient hospital
services set forth in this Section, subject to all
1t`F definitions, terms and conditions in this Plan and its
attachments. Except as otherwise provided in Section III,
these services will be available only in the Defined Area
and only if performed, prescribed, arranged for, directed or
authorized by the Enrollee's Participating Primary Care
Physician at a Participating Facility. All non-emergency
hospitalization must be approved in advance by the Plan.
The Plan reserves the right to obtain a second opinion by a
Physician of its own choosing.
1. Inpatient hospital services Medical or Surgical:
are those provided by $275 per admission.
Participating Hospitals within Obstetrical (including
the Defined Area. Inpatient Therapeutic abortions)
hospital services for the Mother: $275
* LG\mASOCFSB3.UU691 3A-9
Services Required Copayments
treatment of illness or injury Child: $275
including but not limited to:
semi-private room and board;
special diets when Medically
Necessary; use of operating
room and related facilities;
special care unit and services;
x-ray, laboratory and other
diagnostic tests; drugs,
medications, biologicals,
anesthesia and oxygen services;
physical therapy, radiation
therapy and inhalation therapy;
and administration of whole
blood or blood products. (See
Section IV.K) . Special duty
nursing shall be provided only
when Medically Necessary (i.e. ,
in the absence of an intensive
care unit) , when recommended by
the Enrollee's Participating'
Primary Care Physician and
approved in advance by the
Plan. Private room coverage
shall be provided only in cases
of medical necessity (i.e. ,
isolation due to infectious
diseases) . The Enrollee may
elect private room
accommodations for other than
the above stated reason. In
such cases, the Enrollee is
responsible for the direct
payment of the difference to
the Hospital.
NOTE: Following discharge by
the Physician
responsible for the
Enrollee's care while
the Enrollee is
hospitalized, an
Enrollee remaining in
the Hospital beyond the
LGVwASOCFSB3.DTF691 3A-10
Services Required Copayments
Hospital 's discharge
time is responsible for
direct payment of
additional charges to
the Hospital. The Plan
is not responsible or
financially liable for
such additional
payments.
2 . Rehabilitation Services. $275 per admission.
Medically Necessary short-term
inpatient rehabilitation (i.e. ,
physical therapy) services at a
Participating Facility for
acute conditions which are
recommended by the Enrollee 's
Participating Primary Care
Physician and approved in
MPI advance by the Plan. This
acute condition must be subject
to significant improvement
through short-term therapy.
Short-term is defined as up to
sixty (60) consecutive days per
medical condition which
includes services received as
an outpatient under Section
II.A(2) . Such services shall
not be approved on an inpatient
basis unless other acute
medical care is to be provided.
The total of inpatient and
outpatient rehabilitative
services shall not exceed sixty
(60) consecutive days per
medical condition, beginning
with the first date of
treatment.
3 . Inpatient services in a $25 per day.
Participating Skilled Nursing
Facility. When recommended by
MmASOCF-SBIUrF691 3A-11
r
Services Required Copayments
a Participating Primary Care
Physician and approved in
advance by the Plan, an
Enrollee shall be able to
receive short-term inpatient
treatment at a participating
Skilled Nursing Facility when
acute care hospitalization is
not appropriate.
NOTE: Skilled nursing care is
not covered when
provided for conditions
of senile deterioration,
Alzheimer's Disease,
mental retardation or
mental illness. Private
duty nursing services,
private room accommoda-
tions, personal or
comfort items and other ,
articles not specifi-
cally necessary for
treatment of illness or
injury are excluded.
Short-term is defined as
up to sixty (60) days
per medical condition.
4. Chemical Dependency. Necessary $275 per admission.
inpatient care and treatment
for Chemical Dependency is
provided on the same basis and
subject to the same
limitations, exclusions and
Copayments as treatment for
physical illness generally.
All treatment must be
recommended by the Enrollee's
Participating Primary Care
Physician and pre-authorized by
the Plan, and all care must be
provided by a Participating
Chemical Dependency Treatment
MrWASOCFSBIUM691 3A-12
Services Required Copayments
Facility.
E. OTHER SERVICES
1. Home Health Care Services. $10 per visit.
Medically necessary home health
care services are available
only in the Defined Area when
provided by a Sanus
participating home health care
agency, and are specifically
limited to short-term
intermittent skilled visits.
Such services must be
recommended by the Enrollee's
Participating Primary Care
Physician and approved in
advance by the Plan. Short-
term is defined as up to sixty
(60) consecutive days per
F medical condition, beginning on
the date when the first such
visit occurs.
2 . Emergency Services:
a. Hospital Emergency Room. $40 Copayment for each
visit. (Charge waived
if admission occurs at
the time of emergency
room visit) .
b. Outpatient Emergency Care $20 Copayment for each
Center visit.
C. Physician offices operating $20 Copayment for each
after hours as emergency visit.
centers, office visit to a
Physician outside normal
office hours or urgent
visits to a Physician
covering for the Enrollee's
Participating Primary Care
Physician.
/;'.� LG\rwASOCF-SB3.Dn691 3A-13
Services Required Copayments
d. Emergency ambulance None.
service.
3 . Ambulance Services. Medically None.
Necessary ambulance service to
the nearest medical facility
capable of providing Emergency
Care, or Medically Necessary
non-emergency ambulance service
when authorized in advance by
the Plan.
4 . Prosthetic Devices. Initial None.
external standard prosthetic
medical appliances and limbs
are covered when due to an
acute illness or injury.
External prosthetic appliances
which are covered are:
artificial arms, legs, eyes or
permanent lenses; above or
below knee or elbow prostheses;
external cardiac pacemaker; and
terminal devices such as hand
or hook. Internal prosthetic
devices covered are: permanent
aids and supports for defective
parts of the body such as
prosthetic cardiac valves,
internal pacemakers and minor
devices such as screw nails,
sutures and wire mesh. All
other prosthetic medical
appliances, including items
described in Section IV, are
excluded. In questions of
medical necessity, a second
opinion may be requested by the
Plan and is binding. (See
Sections IV.BB, IV.CC, and
IV.DD)
5. Blood and Blood Products. None.
Administration only. (See
LG4wASOCF-SB3.DTF691 3A-14
Services Required Copayments
Section IV.K)
6. Dental Services
a. Short-term, limited dental None.
services for the following
which result from an
accidental non-occupational
trauma or injury to
healthy, natural teeth:
Initial care and short-term
treatment (up to 60
consecutive days) is
covered provided (1) such
accident occurred and
services are performed
during the term of coverage
hereunder, (2) the Enrollee
seeks initial treatment
within forty-eight (48)
hours of such accidental
trauma or injury, and (3)
all subsequent treatment
after such initial
emergency treatment is
authorized by the
Enrollee's Participating
Primary Care Physician,
approved in advance by the
Plan and performed by a
participating dentist.
Injuries sustained by
reason of mastication
(i.e. , chewing or biting
down) are excluded.
b. Treatment of fracture, dis-
location or malignant
tumors of the jaw is
provided on the same basis
and is subject to the same
limitations, exclusions and
Copayments as for physical
illness generally.
` LGVwASOCF•SB3.M691 3A-15
t<
Services Required Copayments
7 . Temporomandibular Joint Subject to the
Syndrome Benefits. Medically applicable Copayments
Necessary (non-dental, non- specified in Section
cosmetic) diagnostic and/or II.
surgical treatment of the
temporomandibular (jaw or
craniomandibular) joint. Such
surgical treatment (including
arthroscopy) will be covered
provided it is Medically
Necessary, recommended by the
Enrollee's Participating
Primary Care Physician and
approved in advance by the
Plan. The Plan reserves the
right to obtain a second
opinion by a physician of its
own choosing. Benefits are not
provided under this Section for
dental treatments, services or
supplies including, but not
limited to orthodontics,
splints, positioners, dental x-
rays, extraction of teeth, and
selective grinding of the
teeth. (See Section IV) .
LG\mASOCF-SB3.DTF691 3A-16
III . EMERGENCY AND URGENT SERVICES
A. IN GENERAL
1. Emergency care services must be secured by the
Enrollee immediately after the onset of the medical
condition, or as soon thereafter as is possible, but
not later than twenty-four (24) hours after the first
appearance of symptoms of illness or forty-eight (48)
hours after an accident. Heart attacks,
cardiovascular accidents, poisoning, loss of
consciousness or respiration, convulsions, severe
bleeding and broken bones are examples of true Medical
Emergencies.
2. Emergency and urgent services are subject to the
Plan's retrospective review for determination of
- whether an acute condition or incident requiring
immediate, emergency or urgent care existed. If the
Plan determines that no need for emergency or urgent
care existed, the Enrollee will be responsible for
payment of all charges incurred for such care, subject
to Employer's complaint resolution procedure.
B. WITHIN THE DEFINED AREA
Inside the Defined Area, the Enrollee, or someone acting
on behalf of the Enrollee, is required to contact the
Enrollee's Participating Primary Care Physician for
"= LG4wASOCF-SB3.DTF691 3A-17
advice. If it is not reasonably possible to contact the AOIL
Enrollee 's Participating Primary Care Physician at the
time (such as that of a life threatening emergency) , the
Enrollee, or someone acting on behalf of the Enrollee,
shall notify the Plan within forty-eight (48) hours of the
emergency, or if not possible within forty-eight (48)
hours, as soon as it is reasonably possible. Upon receipt
of notification, the Plan will coordinate the transfer of
the patient to the care of the Enrollee ' s Participating
Primary Care Physician when medically prudent to do so.
Coverage for treatment for Medical Emergencies within the
Defined Area by non-participating providers is limited to
the care required before the Enrollee can, without
medically harmful or injurious consequences, be treated by
a Participating Physician or Participating Hospital .
C. OUTSIDE THE DEFINED AREA
Services are available while outside the Defined Area
provided that such Services are of an emergency or urgent
nature and cannot be postponed until the Enrollee is able
to return to the Defined Area to obtain treatment from a
Participating Physician. All continuing or follow-up
treatment shall be provided only within the Defined Area
and shall be subject to all the provisions of this Plan.
LG\mAS0CF-SB3.Dn691 3A-18
r,k.,
To constitute a covered out-of-area service, the Plan must
make the following determinations:
1. onset of the acute illness or injury must have
been sudden and unexpected;
2 . the Enrollee must not have been able to return to
the Defined Area to receive treatment from the
Enrollee's Participating Primary Care Physician;
3 . the treatment must have been Medically Necessary.
The Plan shall pay the Enrollee or arrange to pay the Non-
Participating Hospital (s) or Non-Participating
Physician(s) directly. The payment shall be at the
prevailing rate, subject to any required Copayments.
Covered services include ambulance transportation,
provided it is Medically Necessary and appropriate.
At the time of the emergency, the Enrollee, or someone
acting on behalf of the Enrollee, shall make every
reasonable effort to notify the Plan. If it is not
reasonably possible to notify the Plan at that time, the
Enrollee, or someone acting on behalf of the Enrollee,
shall notify the Plan within forty-eight (48) hours of the
onset of the emergency treatment or, if not possible, as
~:� LGVwASOCF-SB3.DTF691 3A-19
soon as it is reasonably possible. Upon notification, the
Plan will coordinate the transfer of the patient to the
care of the Participating Primary Care Physician within
the Defined Area when medically prudent to do so.
IV. LIMITATIONS AND EXCLUSIONS FROM COVERAGE
The following services and supplies, and the cost thereof, are
excluded from coverage under this Plan unless specifically
included by a Plan Amendment.
A. Private room accommodations and special duty nursing
except as provided in Section II.D(1) or unlimited
hospital care except when deemed by the Plan to be
appropriate for an acute level of inpatient care.
B. Any service given without a prior written referral from
the Enrollee's Participating Primary Care Physician,
except as otherwise permitted in Sections I, II or III of
this Schedule of Benefits, including annual well-woman
examinations (see Section II.B(1) (a) ) .
C. Treatment or evaluations required by third persons,
including but not limited to those for: school,
employment, flight clearance, summer camp, insurance or
court ordered.
LGVwASOCFSB3.ErrF691 3A-20
s'
D. No payments will be made for outpatient services received
in Federal facilities or for any items or services
provided in any institutions operated by any state
government or agency when the Enrollee has no legal
obligation to pay for such items or services. Inpatient
hospital care costs incurred on behalf of U.S. Armed
Forces retirees and dependents in governmental or military
service-connected facilities will only be covered by the
Plan if such services are preauthorized by the Plan in
accordance with this Schedule of Benefits and all
deductible or Copayment amounts thereunder are paid by the
Enrollee.
E. Care which an Enrollee receives from or through the United
States Government or any of its corporations, agencies or
bureaus, or from or through any State, County, City or any
political subdivision thereof, unless a charge is
customarily made and services were provided in accordance
with the provisions of Sections II.A-II.E.
F. Cosmetic or surgical procedures are excluded except
reconstructive surgery necessary to repair a functional
disorder as a result of disease, injury or congenital
defect. Such exclusions include, but are not limited to
surgical excision or reformation of any sagging skin on
any part of the body including, but not limited to the
LG4wASOCFSB3.DU691 3A-21
eyelids, face, neck, abdomen, arms, legs or buttocks ; any
services performed in connection with the enlargement,
reduction, implantation or change in appearance of a
portion of the body including, but not limited to, the
breasts, face, lips, jaw, chin, nose, ears or genitals;
hair transplantation; chemical face peels or abrasion of
the skin; electrolysis depilitation; or any other surgical
or non-surgical procedures which are primarily for
cosmetic purposes. The Plan reserves the right to secure
a second opinion by a physician of its own choosing with
respect to any case involving cosmetic or reconstructive
surgery.
G. Dental services and dental prostheses including dentures
are excluded, except as covered in Section II.E(6) .
Maxillary and mandibular osteotomies for shortening or
lengthening of the jaw are excluded. Benefits for
Medically Necessary diagnosis and/or surgical treatment of
temporomandibular joint syndrome are strictly limited to
those provided in Section II.E(7) . All other
hospitalization, anesthesiology or other services relating
to dental work are excluded.
H. Custodial, respite or domiciliary care.
LGVwASOCF-SB3.DTF691 3A-22
I . Services and appliances for the correction of vision
c, deficiencies including, but not limited to, special
procedures such as orthoptics, vision training, vision
therapy or radial keratotomy.
J. Personal comfort and convenience items or services
including, but not limited to, care kits provided on
admission to a hospital, TV's and telephones.
K. Whole blood or blood components and any related
replacement fees.
L. Surgery or other procedures, treatments or services for
obesity including, but not limited to, gastric intestinal
bypass surgery.
M. Sex change surgery including medical or psychological
counseling and hormonal therapy in preparation or
subsequent to any such surgery.
N. Reversal of voluntary sterilization, gamete intra-
fallopian transfer, any fees relating to donor sperm,
menotropins (e.g. , pergonal) or related drug therapy,
surrogate parenting fees and in-vitro fertilization.
O. Acupuncture, naturopathy and hypnotherapy.
LG\mASOCF-SB3.DrrF691 3A-23
��r
P. Inpatient mental health. Treatment for mental
retardation, mental deficiency, or other forms of senile
deterioration, such as Alzheimer' s Disease.
Q. Outpatient mental health services for chronic conditions
including, but not limited to, treatment for mental
retardation, mental deficiency or other forms of senile
deterioration, such as Alzheimer's Disease.
R. Heart transplants and all organ transplants, except
Medically Necessary kidney transplants, corneal
transplants, and liver transplants for children with
biliary atresia. All donor expenses are excluded.
S. Bone marrow transplants, except for aplastic anemia,
leukemia, severe combined immunodeficiency disease, and
Wiskott-Aldrich syndrome. All donor expenses are
excluded.
T. Any procedure or treatment that is deemed by the Plan to
be experimental or any procedure, medication or treatment
that is used for a non-FDA approved indication.
U. Care for conditions that federal, state or local law
requires to be treated in a public facility, or while in
LGVwASOCF-SB3.UiF691 3A-24
the custody of legal authorities.
V. Services payable under Workers ' Compensation, black lung
benefits or a government program to the extent that such
services are covered under Workers ' Compensation or
similar laws.
W. Routine foot care such as hygienic care. Treatment for
flat feet, removal of corns or calluses; corrective
orthopedic shoes, arch supports, orthotics.
X. All splints and braces not used for urgent or emergency
treatment including, but not limited to, those used for
preventive purposes.
Y. All durable medical equipment.
Z . Consumables or disposable supplies purchased by the
Enrollee on an outpatient basis, or purchased by or given
to the Enrollee upon discharge from a Hospital including,
but not limited to, sheaths, bags, elastic garments,
syringes, needles, blood or urine testing supplies, ostomy
bags, home testing kits, vitamins, dietary supplements
and/or replacements, non-rigid appliances and supplies .
AA. Occupational and educational testing and therapy.
LG\MAS0CF•SB3.DTF691 3A-25
BB. Long-term rehabilitation therapy. Long-term means
treatment in excess of sixty (60) consecutive calendar
days per illness or event.
CC. Replacement, repair or routine periodic maintenance of
prosthetic devices.
DD. Mechanical organ replacement devices (including, but not
limited to, artificial heart) .
EE. All prostheses not covered under Section II.E. 4
(including, but not limited to, penile prostheses) and
services associated with the insertion of any excluded
prosthetic device.
FF. Speech and hearing therapy, including hearing aids.
GG. Outpatient prescription drugs and hospital discharge or
take home drugs, except where specifically covered by
Amendment to the Plan.
HH. Charges for pregnancy and subsequent delivery, including
cesarean sections which are planned or scheduled or
performed only because of previous cesarean section, which
occur outside of the Defined Area and within thirty (30)
days of the due date specified by the Enrollee' s Sanus
LG\r.ASOCF-SB3.DrrF691 3A-26
participating attending physician. However, Complications
of Pregnancy, as defined below, will be covered as any
other illness.
For the purpose of this limitation, "Complications of
Pregnancy" means: (1) conditions requiring hospital
confinement (when the pregnancy is not terminated) , whose
diagnoses are distinct from pregnancy but are adversely
affected by pregnancy or are caused by pregnancy, such as
acute nephritis, nephrosis, cardiac decompensation, missed
abortion, and similar medical and surgical conditions of
comparable severity, but shall not include false labor,
occasional spotting, physician prescribed rest during the
period of pregnancy, morning sickness, hyperemesis
F+s
ravidarum
g pre-eclampsia, and similar conditions
associated with the management of a difficult pregnancy
not constituting a nosologically distinct complication of
pregnancy; and (2) non-elective cesarean section
(emergency/urgent, except as specified above) , termination
of ectopic pregnancy, and spontaneous termination of
pregnancy, occurring during a period of gestation in which
a viable birth is not possible.
II. All anti-smoking treatment and programs including, but not
limited to, tobacco abuse and smoking cessation programs.
LG\mASOCF-SB3.DTF691 3A-27
V. MAXIMUM COPAYMENTS 77")f
The maximum amount of Copayment for the Basic Plan Benefits
covered by this Schedule of Benefits in any calendar year will
not exceed $650 for any Enrollee, or $1, 500 for a covered
Enrollee and his Dependents. The maximum amount of Copayments
for each calendar year shall be determined by applying
Copayments relating to Basic Plan Benefits only, and shall not
take into account any Copayments pertaining to any Plan
Amendment.
LGVwASOCF-SB3.DTF691 3A-28
h
EXHIBIT 3
PART A (Cont' d)
PLAN AMENDMENT
PRESCRIPTION DRUGS
The benefits described in this Amendment are added to Part A of the
Plan. All provisions of Part A of the Plan apply to this
Amendment, except as modified herein.
The Copayments described in this Amendment do not apply toward
fulfillment of the maximum Enrollee Copayment limit per year
specified in the Plan.
A. Definitions
1. "Prescription Drugs" means any drugs and/or medications
that require a prescription written by a duly licensed
physician or dentist.
2. "Designated Mail Service Pharmacy" means Express Scripts,
P.O. Box 27667, St. Louis, MO. 63146.
3 . "Participating Pharmacy" means a pharmacy, other than the
Designated Mail Service Pharmacy, that has contracted with
SANUS to provide Prescription Drugs to Enrollees covered
under the Plan as hereby amended.
4 . "Brand Name Prescription Drug" means the unique trade name
which a manufacturer assigns to a Prescription Drug and
which, when dispensed, can only be the Prescription Drug
LG\rwASOCF-SB3.DTF691 3A-29
k.
bearing such manufacturer' s trade name.
5. "Generically Equivalent Prescription Drug" means a
Prescription Drug which is pharmaceutically equivalent and
therapeutically equivalent to a Brand Name Prescription
Drug.
B. In General
1. Enrollees will be provided with Generically Equivalent
Prescription Drugs by the Designated Mail Service Pharmacy
or a Participating Pharmacy when permitted by the licensed
Physician or Dentist and by state law.
2 . Enrollees will utilize the services of the Designated Mail
Service Pharmacy by mailing the prescription or refill
ordered by a Participating Physician or Participating
Dentist in a pre-addressed envelope to:
Express Scripts
P.O. Box 27667
St. Louis, MO 63146
3 . Use of the Designated Mail Service Pharmacy is at the
Enrollee 's option.
4 . Except in cases of Medical Emergency occurring outside of
the Defined Area and except to the extent that an Enrollee
has not yet fulfilled his deductible, an Enrollee must
obtain a prescription from a Participating Physician or
Participating Dentist and have it filled by a
Participating Pharmacy or the Designated Mail Service
Pharmacy. Participating Pharmacies are listed in the
MMASOCF-SBIDTF691 3A-30
directory provided to Enrollees by SANUS.
C. Covered Items
1. Federal legend Prescription Drugs and Prescription Drugs
which may only be dispensed by written prescription under
state law.
2 . Compounded medications of which at least one ingredient is
a prescription legend .drug and which is provided for a
Food and Drug Administration ("FDA") approved indication.
3 . Injectable insulin and insulin syringes.
4 . Oral contraceptives, diaphragms, and cervical caps.
D. Non-Covered Items
1. Drugs and medications, except insulin, which do not
require a prescription whether or not a prescription has
been obtained.
2 . Prescriptions written prior to the effective date of
coverage.
3 . Experimental or investigational drugs including compounded
medications which are not provided for an FDA approved
indication.
4. Therapeutic devices or appliances, including hypodermic
needles, syringes (other than insulin syringes) , support
garments and other non-medical substances, regardless of
their intended use.
5. Blood and blood products.
6. Contraceptive devices (other than oral contraceptives,
diaphragms, and cervical caps) .
a
LG\r.ASOCF-SB3.DTF691 3A-31
7 . Prescriptions which an eligible Enrollee is entitled to
receive without charge from any Workers ' Compensation laws
from any municipal, state or federal program.
8 . Blood or urine testing devices including, but not limited
to clinitest, acetest, and dextrostix.
9. Medications used to suppress appetite (e.g. diet
medication) .
10. Antismoking aids (e.g. nicorette gum) .
11. Injectables other than injectable insulin.
12 . Drugs and medications prescribed for a cosmetic purpose,
including, but not limited to, topic minoxidil or Retin A.
13 . Allergy sera and allergy testing materials.
14 . Prescriptions filled at or by non-Participating
Pharmacies, except in cases of Medical Emergency occurring
outside of the Defined Area.
15. Prescriptions written by a non-Participating Physician
(except in cases of Medical Emergency occurring outside of
the Defined Area) .
16. Hemofil M, Factor VIII or any other blood product or
derivative.
E. Copayments
1. There are no Copayments required of the Enrollee when
using the Designated Mail Service Pharmacy to obtain the
quantity of Prescription Drugs specified in Paragraph G. 1
of this Amendment.
2 . There is a two dollar ($2 . 00) Copayment, payable to
LG\rwASOCF-SB3.DTF691 3A-32
Express Scripts, required for each prescription or refill
ordered from the Designated Mail Service Pharmacy to
obtain the quantity of Prescription Drugs specified in
Paragraph G. 2 of this Amendment.
3 . There is a two dollar ($2 . 00) Copayment required for each
prescription or refill when the Enrollee obtains covered
Generically Equivalent Prescription Drugs from a
Participating Pharmacy, after meeting the deductible.
4. There is a seven dollar ($7 . 00) Copayment required for
each prescription or refill when the Enrollee obtains
covered Brand Name Prescription Drugs from a Participating
Pharmacy, after meeting the deductible.
F. Deductibles
There is a seventy-five dollar ($75. 00) deductible per
Enrollee per calendar year, which must be met on non-mail
service prescriptions prior to an Enrollee' s receipt of
benefits from a Participating Pharmacy under this Amendment.
To obtain such benefits, an Enrollee must submit itemized
bills equaling the amount of the deductible and containing the
information set forth in items #1, 2 , 3 and 4 of Paragraph H of
this Amendment. Upon such submission, an Enrollee will
receive an identification card reflecting that the deductible
has been met.
G. Limitations
1. An Enrollee may obtain up to a 34-day supply or 100 units,
whichever is less, of a Prescription Drug from a
�� LG\MASOCFSB3.DTF691 3A-33
Participating Pharmacy or the Designated Mail Service
Pharmacy.
2 . The Enrollee may, at his sole option, obtain a 90-day
supply or 300 units, whichever is less, of a Prescription
Drug from the Designated Mail Service Pharmacy, provided
Enrollee pays the Copayment specified in Paragraph E. 2 of
this Amendment to the Designated Mail Service Pharmacy.
H. Enrollee Reimbursement Rules
If a Medical Emergency occurs outside the Defined Area and the
Enrollee incurs expenses for Prescription Drugs, an itemized
bill should be submitted by the Enrollee to the Plan for
reimbursement. The itemized bill must contain the following
information:
1. The name of the drug.
t.;
2. The date and quantity purchased.
3 . The name of the authorizing licensed physician or dentist.
4 . The name of the person for whom it was prescribed.
LGV.ASOCF•se3.UrF691 3A-34 ,�;,:
EXHIBIT 3
VPART A (Coot' d)
PLAN AMENDMENT
INPATIENT MENTAL HEALTH
The benefits described in this Amendment are added to Part A of the
Plan. All provisions of Part A of the Plan apply to this
Amendment, except as modified herein.
1. In General
A. Enrollees shall be entitled to additional mental health
care benefits for evaluation, crisis intervention
treatment or any combination thereof for Acute Conditions
when such evaluation, crisis intervention or treatment is
recommended by a Participating Primary Care Physician,
approved in advance by the Medical Director and
precertified by the Employer or Employer's Designee.
B. These services rendered must be based on an Individual
Treatment Plan.
C. Providers of services must be licensed by the appropriate
state agency or board to provide these services.
D. The total benefit is limited to any combination of the
following, not to exceed thirty (30) treatment days per
calendar year.
1. As an inpatient in an authorized SANDS participating
psychiatric facility, one (1) inpatient day equals
one (1) treatment day; or
LG'r-ASOCF-SBIDTF691 3A-35
2 . As a day care patient in an authorized SANUS
participating psychiatric facility, one (1) day care
day equals one-half (1/2) treatment day; or
3 . As an inpatient in an authorized SANUS Participating
Crisis Stabilization Unit, one (1) inpatient day
equals one-half (1/2) treatment day; or
4 . As an inpatient in an authorized SANUS Participating
Residential Treatment Center for Children and
Adolescents, one (1) inpatient day equals one-half
(1/2) treatment day.
2. Definitions
A. "Acute Conditions" means situations in which the Enrollee
has a serious mental illness which substantially impairs
such Enrollee' s thought, perception of reality, emotional
process or judgement or grossly impairs behavior as
manifested by recent disturbed behavior.
B. "Day Care" means treatment of the Enrollee in an
authorized SANUS participating psychiatric facility on a
day-to-day basis with release of the patient at the
conclusion of the treatment day, and in which no overnight
stay is involved.
C. "Crisis Stabilization Unit" means a 24-hour residential
program that is usually short-term in nature and that
provides intensive supervision and highly structured
LG\mASOCF-SB3.DTF691 3A-36
activities to persons who are demonstrating an acute
demonstrable psychiatric crisis of moderate to severe
proportions.
D. "Residential Treatment Center for Children and
Adolescents" means a child-care institution that provides
residential care and treatment for emotionally disturbed
children and adolescents and that is accredited as a
residential treatment center by the Council on
Accreditation, the Joint Commission on Accreditation of
Healthcare Organizations, or the American Association of
Psychiatric Services for Children.
E. "Individual Treatment Plan" means a treatment plan with
specific attainable goals and objectives appropriate to
both the patient and the treatment modality of the
program.
3 . Limitations
A. Mental health services for the following diagnosed
conditions are excluded: Chronic psychosis, Alzheimer's
Disease, intractable personality disorders, mental
retardation, psychiatric therapy on court order or as a
condition of parole or probation, and chronic organic
brain syndrome.
B. The benefits described in this Amendment are available
when:
1. They are recommended by the Participating Primary Care
Physician, approved in advance by the Medical Director
_ LG\twASOCF•SB3.DTF691 3A-37
�t
and precertified by the Employer or the Employer' s
designee; and
2 . The Enrollee does not refuse to accept recommended
procedures or treatment; and
3 . They are provided in an authorized SANDS participating
psychiatric hospital, psychiatric facility, Crisis
Stabilization Unit or Residential Treatment Center for
Children and Adolescents and by a Participating
Provider; and
4 . The Enrollee continues to meet the SANUS criteria for
continued benefits under this Amendment; and
5. The Enrollee has not reached the total benefit
described in Section 1.D of this Amendment.
C. Benefits for a Residential Treatment Center for Children
and Adolescents or a Crisis Stabilization Unit are
available only for Acute Conditions which would otherwise
necessitate confinement in an authorized SANUS
participating psychiatric hospital or psychiatric
facility.
4 . Exclusions
Benefits will not be allowed under this Amendment if treatment
is provided by a non-participating provider or non-
participating hospital, facility, Crisis Stabilization Unit,
or Residential Treatment Center for Children and Adolescents
or by a Participating Facility that is not an authorized SANUS
participating psychiatric facility.
LGU.vA50CF-SB3.DriF691 3A-38
s
5. Copayments
A. A fifty percent (50%) Copayment shall be paid by the
Enrollee for all services under this Amendment.
B. The Copayments described in this Amendment do not apply
toward fulfillment of the maximum Enrollee cost limit per
calendar year specified in the Plan.
LGVwASOCF-SB3.DTF691 3A-39
vy-r
EXHIBIT 3
PART A (font'd) '
PLAN AMENDMENT
DURABLE MEDICAL EQUIPMENT
The benefits described in this Amendment are added to Part A of the
Plan subject to the limitations and Copayments described herein.
All provisions of Part A of the Plan apply to this Amendment,
except as modified herein.
When determined to be medically necessary by a Participating
Primary Care Physician and pre-approved by the Medical Director,
Enrollees shall be entitled to the rental or purchase of Durable
Medical Equipment (initial placement only) ; rental or purchase will
be determined by Employer or Employer' s designee.
"Durable Medical Equipment" means equipment which can withstand
repeated use, is primarily and customarily used to serve a medical
purpose, generally is not useful to a person in the absence of a
sickness or injury, is appropriate and used in the home, may be
used by more than one person, and does not require an individual
prescription for construction. All services and devices must be
obtained through a Plan participating provider.
Some examples include, but are not limited to, a standard
wheelchair, crutches, walkers, orthopedic tractions, hospital beds,
LG\mASOCFSE3.1TF691 3A-40
oxygen, bedside commodes, suction machines, etc. (lengthy list
- � maintained - HCFA Coverages Issue Manual) .
The following items are among, but not limited to, those excluded:
deluxe equipment such as motor driven wheelchairs and beds; comfort
items; bedboards; bathtub lifts; over bed tables; air purifiers;
disposable supplies; elastic stockings; sauna baths; repair,
replacement or maintenance of durable medical equipment; exercise
equipment; stethoscopes and sphygmomanometers; orthopedic shoes;
arch supports; dentures; experimental or research items. In no
event will prosthetic devices or artificial limbs be covered under
this Amendment.
HEARING AIDS
Part A of this Plan will cover medically necessary diagnosis of
hearing deficiencies including audiometry and initial placement of
necessary hearing aid device(s) .
Part A of this Plan will also cover one (1) audiogram per year, if
needed; one cleaning of the hearing device per year; and,
replacement of the hearing device every four (4) years* if
medically indicated. Replacement for loss, damage or for
functional defects are not covered.
LG4wASOCFSB3.DTF691 3A-41
i
All services and devices must be approved in advance by the Medical
Director and must be obtained through a Participating Provider.
*Note: There are some cases of rapid deterioration of hearing
loss which will necessitate hearing device
replacement sooner than the four (4) year period and
will be considered on an individual basis with prior
approval from the Medical Director.
LG\twASOCFSB3.DTF69I 3A-42
EXHIBIT 3
PART A (font'd)
PLAN AMENDMENT
PRE-EXISTING CONDITIONS
The Copayments payable by an Enrollee as described in Part A of the
Plan are subject to the limitations described herein.
A. Definitions
"Pre-existing Condition" means any medical condition known by
the Enrollee to have existed or for which diagnosis was made
or treatment received within the three (3) months immediately
preceding the Enrollee' s effective date of coverage under the
Plan. A medical condition has been "diagnosed" if its
existence has been identified or recognized by a Physician or
other Health Professional . A medical condition has been
"treated" if any services of a Physician or other Health
Professional have been received with respect thereto,
including, but not limited to, office visits or consultations,
Hospital treatment, laboratory services, X-rays or the
dispensing of prescription medication or refills.
B. In addition to any other Copayment required under the Plan,
each Enrollee with a Pre-existing Condition shall be required
to pay an additional Copayment equal to a total of fifty
percent (50%) of the cost of Treatment (which shall include
all applicable Copayments specified in the Schedule of
Benefits for such Treatment) with respect to such Pre-existing
LG4wASOCFSB3.UrF691 3A-43
Condition until such time as the Enrollee has been
continuously enrolled for a period of twelve (12) months under
this Plan and/or under another Plan with Sanus immediately
preceding this Plan; provided that any uninterrupted and
consecutive-day hospitalization begun prior to the expiration
of said twelve (12) month period shall be deemed to be a
continuous confinement subject to the aforesaid Pre-existing
Condition Copayments.
C. The maximum amount of additional Copayment for a Pre-existing
Condition during this twelve (12) month period will not exceed
$800 for any such Enrollee or Dependent or $3 , 000 total for
such Enrollee and his Dependents. Copayments payable pursuant
to Section B of this Amendment shall not be included in, and
are in addition to, the maximum amount of Copayment for Part
A Benefits.
LG\-ASOCFSB3.DTF691 3A-44
EXHIBIT 3
PART B
MAJOR MEDICAL
EMPLOYER CERTIFICATION
Your Employer certifies that, subject to the terms and conditions
of the Benefit Plan, and, more particularly, to the terms and
conditions of this Part B, you are also covered for the benefits
described in this Part.
When you and your dependents, if any, are enrolled under Part A,
you and your dependents will also be covered under Part B.
1
Benefits are not payable under Part B for services and supplies for
which you received benefits under Part A.
Percentage Payments by your Employer and the applicable Deductibles
under Part B are as follows:
Percentage Employer pays 80%
Individual Deductible $400
Family Deductible $1200
Individual Out of Pocket Limit $5, 000
Family Out of Pocket Limit $15, 000
* The Percentage Employer pays for certain SPECIAL BENEFITS is
50%.
`:y LG\mAS0+/FW-3B.DTF691 3B-1
I . Definitions: Except as otherwise expressly provided or unless
the context otherwise requires, the following words and
phrases used in this Part B shall have the following meanings:
1. "AMBULATORY SURGICAL CENTER" means a legally operated
institution which is primarily operated to provide
facilities for performing surgery, and which has:
a. Permanent operating rooms and all medical equipment
necessary for surgery.
b. A medical staff including registered nurses for
patient care.
The term "ambulatory surgical center" does not include a
private office or clinic of one or more doctors.
2 . "BASIC BENEFITS" means the coverage for you or your
dependents, if any, provided under Part A.
3 . "DOCTOR" means a licensed physician, osteopath, dentist,
chiropractor, chiropodist, optometrist, podiatrist,
audiologist, speech - language pathologist, certified
social worker-advanced clinical practitioner, licensed
dietician, or other licensed practitioner of healing art,
if the following conditions are met:
r'v i
LG\mASO+/FW-3B.D7'F691 3B-2
a. the practitioner' s services fall within the scope
. of his or her license or certification.
b. in the case of services of a certified social
worker-advanced clinical practitioner, the services
are direct, diagnostic, preventive, or clinical ;
are provided to a person whose functioning is
threatened or affected by social or psychological
stress or health impairment; and are professionally
recommended by a doctor of medicine or doctor of
osteopathy.
C. in the case of services of a licensed dietician,
the services are related to an injury or illness
covered by the Plan; and are professionally
recommended by a doctor of medicine or doctor of
osteopathy whose treatment or examination for the
injury or illness would be a Covered Expense.
The term "doctor" includes a Christian Science
Practitioner currently listed in the Christian Science
Journal.
4 . "EMERGENCY CONFINEMENT" means a hospital confinement due
to an Emergency Illness or accidental injury that, unless
treated at once on an inpatient basis, would jeopardize
'w. MmASO+/FW-3B.DTF691 3B-3
the family member' s life, or cause serious damage or
impairment to the family member's bodily functions.
5. "HOME HEALTH AGENCY" means an agency which is primarily
engaged in furnishing home nursing care and other
therapeutic services for persons recovering from a
sickness or injury, and which is:
a. Qualified for payment under the federal Medicare
program; or
b. Established and operated under applicable state law.
6. "HOSPITAL" means a legally operated institution which is
primarily engaged in providing medical services for
resident patients, and which has:
a. Permanent facilities for diagnosis and major
surgery.
b. Continuous nursing service by registered nurses.
C. Continuous supervision by a staff of doctors.
However, the major surgery requirement does not apply to
a hospital which primarily treats mental illness or
LG4wAS0+/FW-3B.DTF691 3B-4
chronic diseases. The term "hospital" includes a
Christian Science sanatorium, but does not include a
nursing home, a rest home or a place for care of the
aged, or drug addicts. It also includes:
(1) A state-approved institution engaged in treating
alcoholism and drug addiction for inpatient
treatment, ordered by a doctor.
(2) A Psychiatric Day Treatment Facility which (a) is a
legally accredited health facility, (b) provides
treatment for acute mental and nervous disorders,
and (c) has a structured program using
individualized treatment plans that are clinically
h
supervised by a certified psychiatrist.
(3) A Residential Treatment Center for Children and
Adolescents is a facility for child care which:
(a) provides residential care and treatment for
emotionally disturbed children and adolescents; and
(b) is accredited as such by the Council on
Accreditation, the Joint Commission on
Accreditation of Hospitals, or the American
Association for Psychiatric Services for Children.
`N
! LG\mASO+/FW-3B.UrF691 3B-5
(4) A Crisis Stabilization Unit is a 24-hour
residential program which: (a) is usually short-
term in nature; and (b) provides intensive
supervision and highly structured activities to
persons who display an acute demonstrable
psychiatric crisis of moderate-to-severe
proportions.
(5) An Individual Treatment Plan is a plan of treatment
of a serious mental illness which has specific
attainable goals and objectives appropriate to both
the patient and the method of treatment.
7. "MEDICAL CARE" means medical services and supplies
furnished or ordered by a doctor which are necessary for
diagnosing or treating an injury, a sickness, a mental
disorder or a pregnancy.
8 . "NURSING HOME" means a legally operated institution (or
a distinct part of a hospital) which is engaged in
providing convalescent services for sick or injured
resident patients and which has:
a. Continuous nursing service under the full-time
supervision of a doctor or a registered nurse.
LG4wAS0+iFW3B.D"CF69] 3B-6
` +'
b. The services of a doctor available under an
established agreement.
C. Clinical records for all patients.
The term "nursing home" does not include a rest home or
a place for care of the aged, alcoholics or drug addicts.
9. "PAURsm*/Prior Authorization Utilization Review" means
the process by which NYL evaluates the number of days of
hospital confinement, if any, required for the care or
treatment of a family member's condition.
PAURsm is obtained as follows:
a. A request for PAURsm must be made to New York Life
by the family member or attending doctor. When
required to be written, this request must be on a
form satisfactory to New York Life and completed by
the family member' s attending doctor. Except for
an Emergency Confinement, the request must be sent
to New York Life at least ten (10) working days
before the family member enters the hospital as an
inpatient.
PAURsm is a service mark of New York Life Insurance Company(NYL) for its hospital utilization review program.
`�:,: LG\MASO+/FW-38.DTF691 3B-7
b. For EMERGENCY CONFINEMENT, a telephone request must
be made by the attending doctor to NYL within 48
hours after confinement starts. The telephone
request must be followed by a written request prior
to discharge.
A late request by the attending doctor will be
accepted if it is not reasonably possible to submit
the request during the above time frame.
C. PAURsm determination will be made within three (3)
working days after NYL receives the written
request, and written notification of this
determination will be sent to the attending doctor,
hospital and family member. For EMERGENCY
CONFINEMENT, the attending doctor and hospital will
be notified of the PAUR determination.
d. The attending doctor or family member may at any
time ask NYL to:
(1) re-evaluate the PAURsm determination; or
(2) extend the number of days of confinement
authorized in this determination.
LGVwASO+/FW-3B.DTF691 3B-8
Any PAURsm functions may be performed on our behalf by a
third party we select.
10. "USUAL OR PREVAILING CHARGES" means the lesser of:
a. The charge usually made by the provider for the
services or supplies furnished; or
b. The charge most other providers with the same
training in the same locality would make for those
or comparable services or supplies, as determined
by New York Life.
11. "WE" means the Employer.
In this Part, "he", "him", and "himself" mean a person of either
sex unless the context requires that the word mean only a male.
WHO IS ELIGIBLE FOR COVERAGE AND WHEN DOES COVERAGE BEGIN?
No employee shall become covered under Part B for himself or his
dependents, if any, unless (a) he is covered or simultaneously
becomes covered under Part A and (b) , with respect to coverage for
dependents, enrolls his dependents for coverage under Part A.
LG\-ASO+/FW-3B.DCF691 3B-9
Any child born while the parent is covered will become a covered
dependent at the moment of birth. If the employee did not elect pw
dependents ' coverage before the child's birth, coverage on the
child will cease at the end of the 31st day after its birth unless
during such 31 days the employee gives the Employer a written
request to make payroll deductions, if any, toward the cost of
dependents ' coverage.
WHEN DOES COVERAGE END?
Coverage ends on the day the employee ceases to be covered for Part
A benefits.
WHEN SHOULD A CHANGE IN FAMILY STATUS BE REPORTED?
The employer should be contacted promptly when any event occurs
that could affect a dependent 's eligibility for coverage. Some
examples are: change in marital status, birth of a child and
change in a child's student status. A delay could result in not
having coverage which would otherwise be provided.
Benefits will be payable under Part B if an employee or dependent
incurs medical expenses due to an injury, a sickness, a mental
disorder or a pregnancy. There is a deductible for each person.
LGV-ASO+/FW-38.DTF691 3B-10
WHAT IS THE DEDUCTIBLE?
The deductible is an amount of a person's covered expenses in a
calendar year for which no benefits will be paid. It applies to
all kinds of covered expenses.
WHAT IS PAID BY YOUR EMPLOYER?
We will pay a percentage of most covered expenses in excess of the
deductible. This percentage is indicated after Percentage We Pay
on the Employer Certification. However, for a few covered expenses
a reduced rate of 50%, after the deductible, will be paid. (See
1B-1) .
ARE PAYMENTS MADE FOR PRE-EXISTING CONDITIONS?
Covered expenses due to a pre-existing condition are covered on the
same basis as for other conditions. However, no benefits are
payable until one of the requirements of the DO WE PAY FOR PRE-
EXISTING CONDITIONS is satisfied.
WHAT ARE COVERED EXPENSES?
Covered expenses are usual or prevailing charges for a broad range
of medical services and supplies.
�, LG\rwA50+/FW3B.DTF691 3B-11
WHAT EXPENSES ARE NOT COVERED?
Some medical expenses are covered only under certain conditions.
Others are not covered at all .
DOES OTHER COVERAGE AFFECT BENEFITS?
Yes. Benefits may be reduced by similar benefits of other group
type plans or Medicare. See DUPLICATE BENEFITS.
WHAT IS THE DEDUCTIBLE?
Individual Deductible
An employee must pay an amount in each calendar year of each
FAMILY MEMBER'S Covered Expenses before benefits become payable.
This amount is the amount indicated after Individual Deductible on
the Employer Certification.
Family Deductible
An employee does not have to pay more than the Family Deductible
amount for all family members combined. After that, each family
member's deductible will be considered paid for that year.
LG\mASO+/FW-3B.DTF691 3B-12 {
The Family Deductible amount is the amount indicated after the
x
Family Deductible on the Employer Certification.
"Family Member" means the employee or any of his covered eligible
dependents under the Plan.
WHAT DOES THE EMPLOYER PAY?
After the employee pays the Deductible, we will pay a percentage of
the Covered Expenses for the rest of the calendar year. This
percentage is indicated after Percentage We Pay on the Employer
Certification. The employee will have to pay the percentage of
such Covered Expenses which we do not pay. This is also true for
each family member.
may,
Are There Exceptions To This?
There are some Covered Expenses for which we pay only 50%. These
are described under SPECIAL BENEFITS.
Is There A Limit On What An Employee Pays?
Individual Limit
Aside from the Deductible, an employee does not have to pay more
than the amount indicated after Individual Out-Of-Pocket Limit on
y ,� LGUwASO+/Fw-3B.DIT691 3B-13
the Employer Certification for Covered Expenses for himself and/or
a family member during a calendar year. For the rest of that year,
we will pay 100% of Covered Expenses for the employee and/or that
family member, except as stated under SPECIAL BENEFITS.
Family Limit
Aside from the Deductible, an employee does not have to pay more
than the amount indicated after Family Out-Of-Pocket Limit on the
Employer Certification for Covered Expenses of all family members
combined during a calendar year. For the rest of that year, we
will pay 100% of Covered Expenses for all family members whose
Deductible has been paid, except as stated under SPECIAL BENEFITS.
Is There A Maximum Benefit?
There is no limit on the amount of benefits we will pay for a
family member's Covered Expenses while the family member is covered
under this Plan, except for mental disorders and nursing services.
The limits for these benefits are stated below.
i
LG\rwASO+/FW3B.DCF691 3B-14
SPECIAL BENEFITS
What Do We Pay For Mental Disorders?
We will pay an Employee 's and/or a family member' s Covered Expenses
due to mental, nervous and emotional disorders as described below.
Doctor Services and Other Outpatient Services
BENEFITS--After the Deductible is paid, we will pay 50% of Covered
Expenses for doctor services and other outpatient services due to
these disorders for the rest of the calendar year.
COVERED EXPENSES--Covered Expenses for doctor services and other
outpatient services due to these disorders include charges up to
$50 for each of the first 20 visits in a calendar year. After
that, such services are not covered. However, Covered Expenses do
not include charges for more than one visit in any day or charges
for services not personally performed by a doctor. The term
"doctor" includes a licensed or certified psychologist. The
maximum number of visits described above will be reduced by the
number of visits for which you receive BASIC BENEFITS in the same
calendar year.
t '
i.GVwAs0+mow-3B.DTF691 3B-15
Inpatient Hospital Services
DOCTOR SERVICES AND BENEFITS--After the Deductible is paid, we will
pay 50% of doctor services and other inpatient hospital services
due to these disorders for 30 days of confinement in a calendar
year. After that, such services are not covered.
The maximum number of days described above will be reduced by the
number of days for which an employee received BASIC BENEFITS in the
same calendar year.
Psychiatric Day Treatment Facility
BENEFITS--After the Deductible is paid, we will pay Covered
Expenses for doctor services and other services by a PSYCHIATRIC
DAY TREATMENT FACILITY due to mental, nervous and emotional
disorders. See--DEFINITIONS for an explanation of Psychiatric Day
Treatment Facility under "Hospital".
COVERED EXPENSES--Covered Expenses for doctor services and other
services by a Psychiatric Day Treatment Facility will be 50% of the
Inpatient Hospital Services Benefit described above.
LG4wASO+/FW-38.DTF69I 3B-16
Alternative Mental Health Treatment
WT
BENEFITS--After the Deductible is paid, we will pay Covered
Expenses for doctor services and other services by a RESIDENTIAL
DAY TREATMENT FACILITY FOR CHILDREN AND ADOLESCENTS or a CRISIS
STABILIZATION UNIT if the following conditions are met:
(a) An employee or a covered dependent has a serious mental
illness which: (i) substantially impairs the person' s
thought, perception of reality, emotional process, or
judgement or grossly impairs behavior as shown by recent
disturbed behavior, and (ii) would require inpatient services
by a hospital in the absence of a Residential Treatment Center
for Children and Adolescents or Crisis Stabilization Unit
Facility.
(b) The services rendered by such a facility are based on an
INDIVIDUAL TREATMENT PLAN; and
(c) The providers of those services are licensed by the
appropriate state agency or board to do so.
See DEFINITIONS for explanations of Residential Treatment Center
for Children and Adolescents, Crisis Stabilization Unit, and
Individual Treatment Plan, all under "Hospital" .
LG\rwASO+/FW3B.DTF691 3B-17
COVERED EXPENSES--Covered Expenses for Alternative Mental Health
Treatment will be 50% of the Inpatient Hospital Services Benefit
described above.
Limit On What You Pay
The 100% payment rate after the Out-Of-Pocket Limit is reached does
not apply to Covered Expenses for mental disorders.
Lifetime Maximum Benefit
The maximum we will pay for all Covered Expenses due to these
disorders is $30, 000. This maximum amount will be reduced by the
amounts received under BASIC BENEFITS.
t4�yF.
SPECIAL BENEFITS
What Do We Pay For Nursing Services?
We will pay a family member's Covered Expenses for nursing services
as described below:
BENEFITS--After the Deductible is paid, we will pay:
50% of Covered Expenses for nursing services, including those
provided while confined in a hospital. However, we will pay
LG4wASO+/F W-3B.DTF691 3B-18
no more than $2 , 500 in benefits for nursing services in a
calendar year.
LIMIT ON WHAT AN EMPLOYEE PAYS--The 100% payment rate after the
Out-Of-Pocket Limit is reached does not apply to Covered Expenses
for nursing services.
COVERED EXPENSES--Covered Expenses for nursing services include
charges by a registered nurse or a licensed practical nurse.
Covered Expenses do not include:
Charges by the same nurse for more than one eight hour
shift during any day.
Charges by a nurse who resides in the family member's
��. home or is related to the family member by blood or
marriage.
- Charges for custodial care.
The maximum calendar year amount described above will be reduced by
amounts received under BASIC BENEFITS in the same calendar year.
DO WE PAY FOR PRE-EXISTING CONDITIONS?
For persons not covered under the prior plan (See 1B-38) , we will
pay for Covered Expenses due to a PRE-EXISTING CONDITION on the
same basis as for other conditions, but only after the earliest of:
LGVwASO+/FW-38.DTF691 3B-19
(1) The day the family member has not received any medical advice
or treatment for the pre-existing condition for twelve (12)
consecutive months;
(2) The day upon which a two year period has elapsed after the
family member's coverage date; or
(3) The day the pre-existing condition qualifies for full benefits
under Part A.
Until the family member has met one of the above, we will not pay
for Covered Expenses due to the pre-existing condition.
"Pre-existing Condition" means any injury, sickness, mental
disorder, pregnancy, or related illness for which a family member
has consulted a doctor, received any medical services or supplies,
or taken any medication during the three months immediately before
becoming covered under this Part B.
DO WE PAY FOR PREGNANCY?
We will pay for a family member's Covered Expenses due to
pregnancy, childbirth or a related medical condition on the same
basis as for a sickness. Covered Expenses include COMPLICATIONS OF
PREGNANCY, as described below. However, we will not pay any
LG\MASO+/FW-3B.UFF691 3B-20 �
expenses incurred in connection with voluntary abortions . See WHAT
EXPENSES ARE NOT COVERED?
Covered Expenses include the charge normally made by the hospital ,
excluding doctor charges, for routine services furnished to a baby
during the first 5 days after its birth or before the mother is
discharged from the hospital, if earlier.
"COMPLICATIONS OF PREGNANCY" means:
(A) conditions, requiring hospital confinement (when the pregnancy
is not terminated) , whose diagnoses are Idistinct from
pregnancy but are adversely affected by pregnancy or are
caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical
and surgical conditions of comparable severity, and
(B) non-elective cesarean section, termination of ectopic
pregnancy, and spontaneous termination of pregnancy, occurring
during a period of gestation in which a viable birth is not
possible.
`�-� LG\mASO+/FW3B.DTF691 3B-21
WHAT ARE COVERED EXPENSES?
Covered Expenses are USUAL OR PREVAILING CHARGES for the necessary
MEDICAL CARE set forth below. Such charges will be covered if they
are incurred by a family member while covered under Part B.
Not all expenses are covered. See WHAT EXPENSES ARE NOT COVERED?
HOSPITAL SERVICES--Charges by a HOSPITAL for inpatient services
excluding the first $500 of such charges per confinement if PRIOR
AUTHORIZATION UTILIZATION REVIEW is not requested. See DEFINITIONS
for an explanation of what PRIOR AUTHORIZATION UTILIZATION REVIEW
is and how it is requested. Also, see SPECIAL BENEFITS for
inpatient hospital services due to mental disorders.
Private room charges are covered up to the hospital 's regular daily
semi-private room rate. However, this limit will not apply if
confinement in a private room is required because of a contagious
disease. Charges by a hospital for outpatient services are also
covered.
If a family member is admitted to a hospital on a Friday or a
Saturday, hospital charges incurred on the day of admission and on
the following day, if a Saturday, are not covered. This does not
apply if surgery is performed within 24 hours of the admission or
the admission is due to emergency illness or accident. Two or more
W\mAs0+/FW-3B.M691 3B-22
hospital confinements due to related causes will count as one
period of hospital confinement unless separated by at least 14
days.
DOCTOR SERVICES--Charges by a DOCTOR. See SPECIAL BENEFITS for
Covered Expenses due to mental disorders.
NURSING SERVICES--See SPECIAL BENEFITS for these Covered Expenses.
LAB SERVICES--Charges for diagnostic x-ray and lab tests.
ANESTHETICS--Charges for anesthetics and their administration.
MEDICAL SUPPLIES--Charges for: blood or blood plasma not donated
or replaced; prosthetic appliances, splints, crutches and braces;
oxygen; and rental of durable equipment of a medical or surgical
nature. This equipment is limited to hospital beds, wheel chairs,
respirators and cardiac monitors.
TRANSPORTATION SERVICES--Charges for local ambulance service.
Charges for railroad or regularly scheduled airline service for one
trip per year within the United States or Canada by a covered
employee or covered dependent requiring transportation for the
purpose of receiving medical treatment. These services must be in
connection with the transport of that family member to and from the
nearest hospital where the family member has been or will be
LGVwASO+PW3B.DTF691 3 B-2 3
'j
confined for necessary medical care. However, the confinement
requirement does not apply when transportation to a hospital is
necessary because of an accidental injury.
PHYSIOTHERAPY--Charges by a licensed or certified physiotherapist.
SPEECH OR HEARING LOSS--Charges for treatment of loss or impairment
of speech or hearing.
CHEMICAL DEPENDENCY SERVICES--Charges by a state approved
institution that is primarily engaged in treating chemical
dependency for inpatient, residential or non-residential treatment
programs, ordered by a doctor.
EMERGENCY CARE--Charges for bona fide emergency services after the
sudden onset of a medical condition which (a) manifests itself by
severe pain and other acute symptoms of sufficient severity and (b)
leads to the reasonable expectation that, absent immediate medical
attention, the condition would result in:
(1) placing the patient's health in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
LG4wAS0+/FlV-3B.D7'F691 3B-24
NURSING HOME SERVICES--Charges by a Nursing Home up to the home ' s
regular daily semi-private rate for 100 days of confinement in a
calendar year. Such confinement must be certified, in writing, by
the attending physician, prior to the confinement. The physician
must certify that:
(1) the confinement is medically necessary,
(2) the treatment to be provided is non-custodial, and
(3) the confinement is in lieu of a hospital confinement.
Care required solely for assistance with normal daily activities,
such as dressing, feeding, and ambulation is custodial . The
maximum number of days described above will be reduced by the
number of days for which you receive BASIC BENEFITS in the same
t calendar year.
MAMMOGRAPHY--Charges for an annual mammography and screening for
the presence of occult breast cancer for females who are age 35 or
older.
HOME CARE SERVICES--Charges by a hospital or a HOME HEALTH AGENCY
for up to 100 home care visits in a 12 month period. The visits
must begin within 14 days after a hospital or nursing home stay.
This requirement will not apply if a doctor certifies that the home
care is in lieu of a confinement. Up to 4 consecutive hours of
home health services provided by a home health aide will be
LGI.-ASO+/FW-3B.DrrF691 3B-25
considered one home care visit. Home Care Services include:
physical, occupational, speech or respiratory therapy; the service
of a home health aide under the supervision of a registered nurse;
and the furnishing of medical equipment and medical supplies other
than drugs and medicines. Charges for custodial care are not
covered.
The maximum number of visits described above will be reduced by the
number of visits for which you receive BASIC BENEFITS in the same
12 month period.
AMBULATORY SURGICAL CENTER SERVICES--Charges by an AMBULATORY
SURGICAL CENTER for surgical services.
WHAT EXPENSES ARE NOT COVERED?
The following charges are not covered or are covered only to the
extent stated.
OCCUPATIONAL INJURY--Charges due to an on the job injury are not
covered. However, this exclusion will not apply if the law does
not permit a family member's employer (or his family member) to
obtain coverage for the family member under a Workers ' Compensation
Act or similar act. Nor will it apply if the law permits but does
not require a family member who is a partner or an individual
LG4wASO+iFW-3B.DTF691 3B-26
proprietor to have coverage under a Workers ' Compensation Act or
similar act and that person does not have such coverage.
OCCUPATIONAL SICKNESS--Charges due to any sickness which would
entitle the family member to benefits under a Workers ' Compensation
Act or similar act are not covered.
GOVERNMENT SERVICES--Charges for medical care furnished by or paid
for by any government or government agency are not covered.
Charges for medical care are not covered if the family member would
not have been required to pay for the services in the absence of
insurance for medical care. However, this exclusion will not
apply:
. (a) to charges which the state in which the Family member resides
is entitled to as a reimbursement under its Medicaid Law; or
(b) to charges which a hospital facility makes for care or a
family member who is not indigent, and which that facility
normally makes and collects from each patient who is not and
indigent; or
(c) to charges for treatment while in a tax-supported institution
due to mental illness, mental retardation, or both.
Y Lc4wAW+/Pw-3a.UU691 3B-27
SERVICES FOR WHICH PAYMENT IS NOT REQUIRED--Charges for medical
care are not covered if the family member would not have been
required to pay for the services in the absence of insurance for
medical care.
COSMETIC SURGERY AND TREATMENT--Charges in connection with surgery,
medication or any other type of treatment primarily for the
purposes of improving appearance, including hair restoration, are
not covered. However, this exclusion does not apply if the
surgery, medication or treatment is due to injuries sustained in an
accident which takes place while covered under the Plan's Major
Medical insurance. Nor will it apply to a congenital malformation
of a child who became covered under the Plan's Major Medical
insurance at birth.
FOOT CARE--Charges for the following are not covered: treatment of
weak, strained or flat feet; instability or imbalance of the feet;
orthopedic shoes and other supportive devices. Also, charges for
cutting, removal or treatment of corns, calluses, bunions or
toenails are not covered unless needed because of diabetes or other
similar disease.
CUSTODIAL CARE--Charges for custodial care are not covered.
ROUTINE PHYSICAL EXAMINATIONS--Charges for routine physical
examinations are not covered.
M wASO+/FW-3B.DTF691 3B-28
PRESCRIPTION DRUGS--Charges for prescription drugs are covered in
v excess of the deductible at eighty percent (80%) of the cost of the
drugs up to the annual maximum out-of-pocket expense. Thereafter,
such costs are covered at 100%. Such charges may be applied to
satisfy either the annual Plan deductible or the annual maximum
out-of-pocket expense.
IMMUNIZATIONS--Charges for immunizations are not covered.
HEARING CARE--Charges for hearing aids or their fitting are not
covered.
OVERSEAS BUSINESS TRAVEL--Charges for medical care furnished during
a business trip outside the United States and Canada are covered
` only during the first 60 days of the trip.
WAR CONDITIONS--Charges due to an injury, a sickness or a mental,
nervous or emotional disorder arising out of war, or an act of war,
are not covered.
DENTAL SERVICES--Charges for treatment of the teeth are not covered
except for treatment of natural teeth injured in an accident which
takes place while the family member is covered under Part B.
Charges for any such treatment rendered more than one year after
the accident are not covered. Charges for surgery due to
periodontal disease are not covered. Charges for treatment of the
' ' LGkwASO+/FW-3B.DTF691 3B-29
teeth due to a congenital malformation of a child who became
covered under Part B at birth are covered.
VISION CARE--Charges for eye tests are not covered unless due to a
sickness or an injury. Also not covered are charges for: eye
glasses or their fitting; and radial keratotomies or similar
surgery done to treat myopia.
SERVICES BY RELATIVES--Charges for medical care furnished by any of
the following persons: the family member' s spouse, parent, child,
grandparent, brother, sister or parent-in-law are not covered.
INPATIENT HOSPITAL SERVICES--Charges by a HOSPITAL for inpatient
services for the first $500 per confinement are not covered if
Prior Authorization Utilization Review is not requested for that
r'
confinement.
If a family member is admitted to a hospital on a Friday or a
Saturday, hospital charges incurred on the day of admission and on
the following day, if a Saturday, are not covered. This does not
apply if surgery is performed within 24 hours of the admission if
the admission is due to emergency illness or accident.
BODY DISTORTION--Charges for detecting and correcting body
distortion are not covered except as set forth below. "Body
LG\mAS0+/FW3B.Dn69I 3B-30
distortion" means structural imbalance, distortion, or incomplete
or partial dislocation in the human body:
(a) which interferes with the human nerves; and
(b) which is due to or related to distortion, misalignment or
incomplete or partial dislocation of or in the vertebral
column.
However, charges by a doctor for detecting or correcting body
distortion will be covered up to $500 in a calendar year.
BASIC BENEFITS--Charges for which you received BASIC BENEFITS are
not covered.
r
JAW JOINT DISORDERS--Charges due to treatment for any jaw joint
disorders including temporalmandibular joint syndrome and
craniomandibular disorders, or other conditions of the joint
linking the jaw bone and skull and the complex of muscles, nerves
and other tissues related to that joint. However, charges due to
treatment for any jaw joint disorder will be covered up to a
maximum of $1, 500 in a calendar year.
INFERTILITY--Charges made for procedures which promote fertility
are not covered: these include, but are not limited to, hormone
therapy, artificial insemination, in-vitro fertilization, embryo
" MmASO+1FW-3B.D'TF691 3B-31
transfer and Gamete Intra-Fallopian Transfer (GIFT) ; and reversal
of surgical sterilizations.
STERILIZATIONS--Charges made in connection with sterilizations are
not covered.
VOLUNTARY ABORTIONS--Charges for services furnished in connection
with voluntary abortions are not covered.
HOW DO OTHER GROUP TYPE PLANS AFFECT BENEFITS?
If a person has medical coverage under a "GROUP TYPE PLAN"
(excluding school student insurance) , we will coordinate our
benefits with those of that plan. One plan is primary. One plan
is secondary. The primary plan pays regular benefits in full. The
secondary plan pays a reduced amount which, when added to the
benefits paid by the primary plan, will equal 100% of ALLOWABLE
EXPENSES.
"ALLOWABLE EXPENSE" means the usual or prevailing charge of an item
of care at least part of which is covered by one of the plans.
When our plan is secondary, any deductible or copayment amount or
percentage charged and unpaid by the primary plan will be an
Allowable Expense; our Plan ' s deductible and copayment amounts
remain applicable to the balance of Allowable Expenses unpaid by
the primary plan.
LG\rwASO+/FW-3B.DTF691 3B-32 K
"GROUP TYPE PLAN" means a plan of insurance (other than a plan
providing BASIC BENEFITS) , which:
(a) is provided through a group policy or contract, or individual
policies or contracts to classes of employees or members
defined by conditions pertaining to employment or membership;
(b) provides coverage only because of the covered person' s
membership in or in connection with the particular
organization or group; it does not provide coverage to the
general public;
(c) is sponsored by an employer, union or association which also
arranges for bulk payment of premiums or subscription charges;
and
(d) provides benefits similar to, but not necessarily identical
with, this plan's benefits for medical charges.
A plan that does not coordinate with other plans is always the
primary plan. If both plans coordinate, the primary plan is
determined as described below:
(a) The Plan which covers the patient as an employee, rather than
as a dependent, is primary.
LGVwASO+/FW-3B.DTF691 3B-33
(b) If both plans cover the patient as a dependent child, the
following will determine which plan is primary: ;>
(i) If the child' s parents are living together, the primary
plan will be the Plan of the parent whose birthday occurs
earlier in the calendar year, except that:
If either parent' s plan does not have this rule for
determining which plan is primary, the Plan without
this rule shall determine which plan is primary.
If the child's parents are divorced, the primary plan
will be the Plan of the parent with the custody of the
child, except that:
When the parents are divorced and the parent with
custody of the child has not remarried, the
benefits of the Plan which covers the child as a
dependent of the parent with custody of the child
will be determined before the benefits of a Plan
which covers the child as a dependent of the parent
without custody.
When the parents are divorced and the parent with
custody of the child has remarried, the benefits of
a Plan which covers the child as a dependent of the
LG4a,AS0+/FW-3B.D?F691 3B-34
t;.
parent with custody, shall be determined before the
benefits of a Plan which covers that child as a
dependent of the stepparent, and the benefits of a
Plan which covers the child as dependent of the
stepparent will be determined before the benefits
of a Plan which covers that child as dependent of
the parent without custody.
Notwithstanding (i) and (ii) above, if there is a
court decree which would otherwise establish
financial responsibility for the medical, dental or
other health care expenses with respect to the
child, the benefits of a Plan which covers the
child as a dependent of the parent with such
financial responsibility shall be determined before
the benefits of any other Plan which covers the
child as a dependent child.
(c) If neither (a) nor (b) applies, the primary plan will be
the Plan which has covered the patient for the longer
period of time, except that:
(i) If the coverage of one plan is based on present
employment, and the coverage of the other plan is
based on prior employment, the primary plan will be
the Plan which is based on present employment; and
`: LG4wASO+/FW-3B.DTF691 3B-35
(ii) If either plan issued in another state and does not
have the rule in c 5
( ) (i) for determining which plan
is primary, and as a result both plans will be
considered secondary, then the (c) (i) rule will not
apply.
HOW DOES MEDICARE AFFECT BENEFITS?
1. We will pay this Plan's benefits for you without regard to
Medicare if you are eligible to apply for Medicare because of
age and are eligible for this Plan's benefits as an active
employee.
2 . We will pay this Plan' s benefits for your spouse without
regard to Medicare if:
(a) You are eligible for this Plan's benefits as an active
employee; and
(b) Your spouse is a family member under this Plan, is not
eligible to apply for benefits under another group type
as an active employee, and is eligible to apply for
Medicare because of age.
3 . If your spouse is eligible to apply for benefits under another
"GROUP TYPE PLAN" as an active employee, but all the other
LG4wASO+/FW-3B.DTF691 3B-36
requirements of item 2 . above are met, we will coordinate our
coverage as stated above under HOW DO OTHER GROUP TYPE PLANS
AFFECT BENEFITS? If any expenses are unpaid after the group
type plan pays its benefits as the primary plan and we pay our
benefits as the secondary plan, a claim should be made to
Medicare for those expenses.
4 . If you and/or your spouse are eligible for this Plan's
benefits as a retired employee and in all other cases, we will
pay benefits as follows:
(a) For types of expenses covered by both this Plan and
Medicare, we will reduce our benefits so that our
benefits plus Medicare benefits equal 100% of Allowable
'i Expenses, excluding applicable copayments and
deductibles. When a person is eligible to apply for
benefits under Medicare or another group type plan as an
employee, we will first adjust this Plan' s benefits for
Medicare as if the person had full Medicare coverage
(Part A and Part B) ; we will do so even if the person has
not enrolled for Medicare or applied for its benefits.
Then we will coordinate with the other plan's benefits.
But we will not in any event pay for hospital room and
board charges in excess of the regular semi-private room
rate.
LG\rwASO+/FW-3B.UrF691 3B-37
(b) For types of expenses covered by this Plan, but not
covered by Medicare, we will pay the Plan ' s regular
benefits.
THIS SECTION ONLY APPLIES TO PERSONS COVERED UNDER THE
EMPLOYER'S PLAN ON THE DAY BEFORE THIS PLAN TOOK EFFECT. THE
MAIN PURPOSE IS TO AVOID GAPS IN COVERAGE THAT MIGHT OTHERWISE
OCCUR BECAUSE OF THE CHANGE IN PLANS. IT ALSO PREVENTS
DUPLICATE CLAIM PAYMENTS.
"The Prior Plan" means the Employer's Plan which (a) was in
effect on the day before the Employer adopted this plan, (b)
was terminated for all the Employer's employees, and (c) was
replaced by this Plan.
HOW DOES THE PRIOR PLAN AFFECT BENEFITS?
This Plan's benefits will not duplicate the prior plan's benefits.
We will reduce the benefits for a claim by any benefits that would
be payable under the prior plan's extended benefit provisions for
that same claim if the EFFECT OF PRIOR PLAN COVERAGE section had
not been included.
LG4wAS0+/FW-38.vrF6v1 3B-38 �`
WHAT ARE THE BENEFITS FOR PERSONS COVERED UNDER THE PRIOR PLAN?
1
If any employee met all of the "WHO IS ELIGIBLE FOR COVERAGE"
requirements on the day this Plan took effect, that employee will
be covered for pre-existing conditions as described below. Each
dependent who met the "WHO IS ELIGIBLE FOR COVERAGE?" requirements
on such day are also covered for this Plan's benefits except that
benefits for a pre-existing condition will be described below. The
"WHO IS ELIGIBLE FOR COVERAGE AND WHEN DOES COVERAGE BEGIN"
requirements are described on page 3B-10.
WHAT ARE THE BENEFITS FOR PERSONS COVERED UNDER THE PRIOR PLAN FOR
PRE-EXISTING CONDITIONS?
Benefits for pre-existing conditions will be as described below for
persons covered under the prior plan. The "DO WE PAY FOR PRE-
EXISTING CONDITIONS?" provision in Part B does not apply to such
persons.
Benefits for any pre-existing condition will be the amount of this
Plan's benefits.
"PRE-EXISTING CONDITION" means an injury, sickness, mental
disorder, pregnancy or related illness for which a person has
consulted a doctor, received any medical services or supplies or
LG\mASO+/Ew-38.Dn691 3B-39
taken any medication during the three months immediately before
becoming covered under Part B of this Plan.
WHAT ARE THE BENEFITS FOR PERSONS WHO FAILED TO MEET THE "WHO IS
ELIGIBLE FOR COVERAGE?" REQUIREMENTS WHEN THIS PLAN TOOK EFFECT?
If, on the day this Plan took effect, an employee failed to meet
all of the "WHO IS ELIGIBLE FOR COVERAGE?" requirements, no Part B
benefits are payable.
After an employee has met all of the "WHO IS ELIGIBLE FOR
COVERAGE?" requirements, the employee will become covered for this
Plan's Part B benefits as described under "WHAT ARE THE BENEFITS
FOR PERSONS COVERED UNDER THE PRIOR PLAN?" .
WILL A NEW PART B DEDUCTIBLE HAVE TO BE MET?
A new Part B deductible for this Plan must be met. However,
charges applied toward the prior Plan's deductible which were
incurred during the calendar year in which this Plan took effect
will count toward meeting this Plan's deductible for that year.
SHOULD RECORDS OF EXPENSES BE KEPT?
An employee should save all bills and receipts for medical
expenses. We need them as proof of claim.
MmASO+/FW-3B.DTF691 3B-40
HOW TO FILE A CLAIM FOR PART B BENEFITS?
y
An employee should obtain a claim form from the Employer.
WHEN SHOULD CLAIMS BE SUBMITTED?
When an employee has a claim, he should promptly submit the
completed claim form and any bills or receipts. We have the right
to reject claims submitted more than 180 days after the loss. A
late claim might be accepted if it was not reasonably possible to
submit the claims during the 180 days.
HOW WILL BENEFITS BE PAID?
Benefits will be paid after we receive proof of claim. They will
be paid as directed on the claim form.
All benefits must be paid no more than 60 days after receipt of
proof. No legal action can be brought if payment is not received
prior to the expiration of 60 days after proof of loss has been
filed and no such action shall be brought at all unless brought
within four (4) years from the expiration of 60 days within which
Proof of Loss is required.
;.� LG\rwAW+/FW-3B.DTF691 3B-41
MAY WE REQUIRE ADDITIONAL PROOF OF CLAIMS?
Yes. For example, before paying benefits, we may have a non-
participating physician with similar education, credentials and
training whom we select examine the patient.
RIGHT OF SUBROGATION
When we pay benefits for Covered Expenses incurred due to the
injury, sickness or mental disorder of a family member:
1. We shall be subrogated, to the extent of such payment, to all
of the family members' rights of recovery against any third
party because of such injury, sickness, or disorder; and,
i
2 . The family member shall: (a) sign and deliver to us all
necessary papers and do whatever else is necessary to secure
such rights; and (b) do nothing to prejudice such rights
without our written consent.
We may elect not to exercise such rights with respect to a
particular claim or family member.
WHEN DOES COVERAGE UNDER PART B END?
Coverage will end on the day the employee ceases to be covered for
Part A benefits.
LG4wASO+/FW-3B.M691 3B-42
CONTINUANCE OF COVERAGE
May Coverage Be Continued After It Would Otherwise End?
Contact your Employer to determine if the coverage may be
continued.
FACILITY OF PAYMENT
Payment may be made to any person(s) , other than the employee, or
to an institution, if in the Employer's opinion: (a) the employee
is legally not able to give valid receipt for any payment due him;
and (b) the person(s) or institution receiving such payment has
been caring for or supporting the employee.
Such payments will continue until claim is made by a duly appointed
guardian or committee of the employee.
',, r, LG\mASO+/FW-3B.DTF691 3B-43
EXHIBIT 4
HEALTH BENEFIT PLAN
(The "Plan")
FOR EMPLOYEES OF THE
CITY OF FORT WORTH
("Employer")
Employer has established the Plan described herein for its eligible
employees, retirees and their eligible dependents.
The Plan offers Enrollees a Managed Health Care Option with minimal
copayments and deductibles when a network of participating
providers is used and alternative benefits with higher copayments
and deductibles when non-network providers are elected.
~- Part A has the provisions applicable to the Managed Health Care
Part of the Plan for Enrollees who choose the services of
Participating Hospitals, Physicians and Other Health Care
Professionals in a Defined Area.
Part B has the provisions applicable to the Major Medical Employer
Certification, the Plan for Covered Persons who elect, at the time
health care services are obtained, not to use Participating
Providers.
Coverages are provided by the Employer on a self-funded basis.
Sanus has been retained to provide certain Administrative Services
.� LG4wASO+/FW 4.pTF691 4-1
in connection with the Plan. Sanus provides Administrative
Services Only to the Employer and acts as independent contractor of
Employer, not as an insurer or guarantor.
Eligible employees, retirees and their eligible dependents who
become Enrollees will be entitled to receive the benefits of the
Plan subject to the provisions of the Plan. The Plan Year shall
start on the effective date and shall end twelve months thereafter,
unless the Plan is terminated.
The Plan shall remain in effect until terminated by the Employer.
The Employer may terminate the Plan at any time or may amend the
Plan and/or any Schedule of Benefits at any time, without the
consent of the Enrollees or any other person having a beneficial
interest in it. Any such termination or amendment shall be without
prejudice to a claim arising prior to the date of such termination
or amendment.
The Effective Date of the Plan shall be October 1, 1990.
IN WITNESS WHEREOF, and as duly authorized, the parties hereto
execute this Agreement with the Effective Date herein provided.
CITY OF FORT WORTH SANUS TEXAS HEALTH PLAN, INC.
BY: 0 BY:
TITLE: TITLE:
DATE: DATE:_
LGVwASO+/FW4.DTF691 4-2
City of Fort Worth, Texas _ -`
Mayor and Council CommunicaildA `
DATE REFERENCE SUBJECT: PROFESSIONAL SERVICES AGREEMENT PAGE
NUMBER
11-27-90 C-12626 WITH SANUS TEXAS HEALTH PLAN, INC., FOR Iof 3
RETIREE GROUP HFAITH INSURANCE SERVICES
RECOMMENDATION:
It is recommended that the City Council authorize the City Manager:
1. To enter into a professional services agreement with Sanu____TQxas__Hea_lth_
_ Plan, Inc. , (SANUS) for management of the City' s medical insurance
program of benefits for retired employees and their dependents, as
summarized in Attachments A and B, for the period January 1, 1991
through September 30, 1991 for a fee of $554,814;
2. To notify the Aetna Life and Casualty Company of termination of the
City's current agreement with Aetna for administration of the retiree
group health insurance program effective December 31, 1990; and,
3. To notify ThriftDrug of the termination of the current agreement with
ThriftDrug for mail-order pharmacy service effective December 31, 1990.
DISCUSSION:
On August 14, 1990, the City Council approved a professional services
agreement with SANUS to administer the City's group health insurance program
for its active employees and their eligible dependents (M&C G-8762). At the
direction of the City Council Insurance Committee, the City' s consultant for
group health insurance matters, Asset Protection Agency, Inc. (APA), requested
proposals for administration of the retiree group health insurance program
from its current administrator, Aetna Life and Casualty Company, and SANUS.
At the October 23, 1990 meeting of the City Council Insurance Committee, APA
recommended SANUS to serve as the administrator for a nine-month period
beginning January 1, 1991, after discussion of the proposals. Acting upon the
recommendation of its consultant, the City Council Insurance Committee
instructed City staff to pursue an agreement with SANUS to administer a
comparable program for its retired employees and their eligible dependents.
BENEFIT FEATURES:
The recommended program will have benefit features similar to the program for
active employees. (See Attachment A.) The City will contribute a fixed
amount toward the financing of the program, with the balance to be funded by
retiree contributions; the program for active employees is funded in the same
manner. Retirees may select the following options: (1) "in-network" benefits
(low option) at no cost to them and lower cost for their dependents; (2)
"out-of-network" benefits (low option) for only those retirees who live too
far from the service area to access "in-network" benefits, at no cost to the
retiree and lower cost for their dependents; or (3) combined "in-network/
out-of-network" benefits (high option) which imposes a cost to cover retirees
and a higher contrib. ti ost for their dependents. (See Attachment B) .
tia
DATE REFERENCE SUBJECT: PROFESSIONAL SERVICES PAGE
NUMBER
11-27-90 C-12626
AGREEMENT WITH SANUS TEXAS HEALTH
I - -
INSURANCE SERVICES
The major benefit difference between the retiree program and that of the
active employees is that the retiree program has a "Medicare carve out"
component. The proposed plan will secondarily cover Medicare eligible
retirees and their dependents for covered expenses up to the City' s plan
limits after coordination with Medicare parts A and B. For those retirees
who are not eligible for Medicare, the City' s plan is primary.
It is estimated that approximately 10% to 15% of the retirees are eligible
for Part B of Medicare coverage, but have not yet enrolled as it was not
relevant under the City' s previous plan. The next Medicare open enrollment
period begins in January, 1991 for coverage effective on July 1, 1991. The
actuarial assumptions underlying the cost of the City' s proposed retiree
group health plan for January - September, 1991 assumed a January 1, 1991
implementation date for the full Medicare carve-out provisions of this plan;
however, it will be July 1, 1991 before the entire cost savings of the
Medicare carve-out may be implemented. Therefore, the retiree health
program may be underfunded as a result of the delay in full Medicare
care-out implementation. The amount of the shortfall is difficult to
determine precisely as it depends upon the actual number of persons
affected, their potential claims, and their selection of high or low option
City group health insurance coverages. The shortfall is, however, estimated
to be less than $100,000 for the six month period.
COST:
Where the retiree chooses the "in-network" benefits (low option) or
"out-of-network" benefits (low option) for those living too far out of the
service area, a retiree' s own health care coverage will continue to be
provided at no cost and the cost to cover retiree dependents will remain the
same. (See Attachment B.) If the retiree chooses combined "in-network/
out-of network" benefits (high option), the retiree who covers him/herself
only will be required to pay thirty-six dollars ($36) per month for this
coverage. Costs of high option dependent coverage will also increase. (See
Attachment B.)
Under its contract with the City, SANUS will render managed care services
that will include, but not be limited to, claims review and assessment,
pre-certification for scheduled hospital stays, utilization review and large
case management including identification of home health care alternatives,
certification of physicians and other providers available under the network,
education and information services, and claims payment. The SANUS staff
located on-site in the Insurance Office will also be available to assist
retirees and their families with their insurance needs.
A stand-alone optional dental plan also will be made available to retirees
through the Sanus Dental Plan of Texas, Inc. The City will not contribute
to the cost of this plan, nor does it do so for active employees and their
dependents.
J
DATE REFERENCE SUBJECT PROFESSIONAL SERVICES PAGE
NUMBER
11-27-90 C-12626 AGREEMENT WITH SANUS TEXAS HEALTH 3 0, 3
PI ANT INC-, FLk RETIREE GROUP HFALTH
INSURANCE SERVICES
FINANCING:
Sufficient funds to support the Sanus Texas Health Plan, Inc. contract in the
amount of $554,814 are available in the Health Insurance Fund FE85, Account
539120, Center 0158570, Retiree Insurance Administrative Costs. Revenue from
retiree contributions to help fund the plan will be based on the options
selected by the retirees and their eligible dependents.
RAM:u
15Sanus
A§IP�'?dt'�;.ia 64'
r2kri ..0
of
SUBMITTED FOR THE
\ CITY MANAGER'S DISPOSITION BY COUNCIL: PROCESSED BY
/1 OFFICE BY: Ruth Ann McKinney 6125 ❑ APPROVED
ORIGINATING ❑ OTHER (DESCRIBE)
DEPARTMENT HEAD: Susan Bul la 8513 CITY SECRETARY
FOR ADDITIONAL INFORM ON Bul la 8513
CONTACT: DATE
."ASfI:N fILE.i L/ Citi Y Fort Worth, rfey _. s
ACCOUNTIN4.2 Mayor and Council Communication
LI
TRANSPORTATIONIPUBC WO
"MR AWAIMSTRAIMON i REFERENCE SUBJECT:
PAGE
NUMBER PROFESSIONAL SERVICES AGREEM NT
8-14-90 G-8762 WITH SANUS TEXAS HEALTH PLAN, I C.1 0f
RECOMMENDATION
_ It is recommended that the City of Fort Worth enter into a
profession&l services agreement with Sanus Texas Health Plan,
Inc. f-or management of the City's medical insurance program of
benefits 'f_or active employees and their dependents summarized in
Attar ment_A. Sanus Texas Health Plan, Inc. will provide the
managed care services outlined below for the 1990-91 fiscal year
for- a- fee -of $2,509, 204.
DISCUSSION
For the past 21 months, the City of Fort Worth has had a contract
with Sanus/New York Life for its medical benefits program for
active employees and their dependents . That program was a fully
insured program with premium rates established by the company. -
The managed care/dual option program provided by Sanus/New York
Life has resulted in the City's experiencing less drastic cost
increases than many other employers in our area. Staff and the
Council Insurance Committee have reviewed the status of our
current program and recommend a modified approach to our
insurance program for the 1990-91 fiscal year.
In implementing the Council direction given at the January
retreat to pass any cost increases along to employees at this
time, the staff and Committee have developed a high/low option
program. For the same cost they are paying now, employees can
enroll in the Sanus HMO which has a "network" of physicians and
other providers . Employees who wish to maintain a choice of
using either network providers or their own physician of choice
can select the high-option program. They will pay the increased
cost of this program. Costs of the high and low option program
with a comparison to present costs are shown on Attachment B.
Under its contract with the City, Sanus Texas Health Plan, Inc.
will render managed care services that will include but not be
limited to: claims review and assessment , pre-certification for
scheduled hospital stays , utilization review and large case
management including identification of home health care
alternatives , certification of physicians and other providers
available under the network, education and information services
and claims payment .
OFFICIAL EQr-0,7O
CITY SEC,q[TARy
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DATE REFERENCE SUBJECT: PAGE
NUMBER PROFESSIONAL SERVICES AGREEMENT WITH
2 of 2
8-14-90 G-8762 SANUS TEXAS HEALTH PLAN, INC.
A stand-alone optional dental plan also will be made available to
employees through Sanus Dental Plan of Texas , Inc . The City will
not contribute to the cost of this plan.
To improve our joint educational efforts and shorten response
time to information requests , Sanus will establish and staff an
on-site office in the Risk Management area.
FINANCING
Funds to support the Sanus Texas Health Plan, Inc. contract in
the amount of $2 , 509,204 are included in the City Manager's
recommended budget with an additional amount included to cover
estimated claims costs in the amount of $15,099,245 . Revenue
from employee contributions will be dependent on the options
selected.
It is staff 's recommendation that any claims savings realized
during the 1990-91 fiscal year be dedicated to offsetting any
cost increases the following year. -
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APPROVED BY
CITY. COUNCIL
E
t AUG 14 1190
1,3t'!S«zetWV of the
o
SUBMITTED FOR THE DISPOSITION BY COUNCIL: PROCESSED BY
OIFFICEABYGER'S Ruth Ann McKinney 6125 ❑ APPROVED
❑ OTHER (DESCRIBE)
ORIGINATING
DEPARTMENT HEAD: Ruth Ann McKinney 6125 CITY SECRETARY
FOR ADDITIONAL INFORMATION
CONTACT: Ruth Ann McKinney 6125 DATE