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HomeMy WebLinkAboutContract 18752 CITY SECRETS t WHIRAGI 4OM3 HARRIS HEALTH PLAN, INC. 1300 Summit Avenue, Suite 300 Fort Worth, Texas 76102 817/878-5800 1-800-633-8598 GROUP ENROLLMENT AGREEMENT This Group Enrollment Agreement is entered into by and between Harris Health Plan, Inc. , hereinafter called "Harris Health" and the City of Fort Worth, hereinafter called "Group" for the purpose of making available to Eligible Persons and their Eligible Dependents (as defined in Section 3 below) certain prepaid health care services under a Group Health Care Agreement/Subscriber Certificate of Coverage, providing both a high benefit option ("High Plan") and a low benefit option ("Low Plan") issued by Harris Health. The arrangement of the provisions of such services and benefits shall be based on the statements and representations contained in this Group Enrollment Agreement and all exhibits attached hereto (hereinafter collectively called the "Agreement") . Additionally the bid - proposal from Harris Health to Group dated April 26, 1991 ("Bid Proposal") is hereby incorporated by reference. If there is any conflict between this Agreement and the Bid Proposal, this Agreement shall control. 1. GROUP Group Name: City of Fort Worth Address: 1000 Throckmorton City: Fort Worth State: Texas Zip Code: 76102 2 . GROUP EFFECTIVE DATE AND INITIAL TERM This Agreement shall be effective 12: 01 A.M. , Central Time, on the 1st day of October, 1991 and continue until 12:00 A.M. Central Time, on the ' 30th day of September, 1992, (the "Initial Term") unless earlier terminated as provided herein or in the Group Health Care Agreement/Subscriber Certificate of Coverage attached hereto as Exhibit "A" . 3 . ELIGIBILITY Any person and/or his/her dependents shall be eligible for coverage under the Agreement if they meet the eligibility requirements for coverage as specified in Section 3.1 and Section 3.2 of the Group Health Care Agreement/Subscriber Certificate of Coverage or as listed on Exhibit "B" attached hereto, as amended from time to time. -Contract Authorization Date 4. HEALTH CARE SERVICES (BENEFITS) AND COVAYMENTS Eligible Persons and Eligible Dependents of Group are entitled to Health Care Services and Benefits as follows: A. Basic Health Care Services: Basic Health Care Services shall be those as described in the Schedules of Benefits attached hereto as Exhibit "Cot (for the High Plan) and Exhibit IIC-111 (for the Low Plan) B. Prescription Drug: X Accepted Not Accepted 5. COVERAGE BASIS X Contributory Non-Contributory 6. SCHEDULE OF RATES AND RENEWAL OPTIONS A. Group agrees to pay premiums pursuant to the rate schedules attached hereto as Exhibit I'D" (for the High Plan) , Exhibit I'D-111 (for the Low Plan) and Exhibit I'D-211 (for both the High and Low Plans with an expanded tier for retirees with Medicare coverages with split eligibility) , which exhibits are hereby incorporated by reference and made a part of this Agreement for all purposes. B. This Agreement shall be renewed, at the option. of Group, for three (3) successive terms of one (1) year each, unless terminated by Harris Health or Group as provided herein or in the Group Health Care Agreement/Subscriber Certificate of Coverage. If Group does not notify Harris Health of its desire not to renew this Agreement at least sixty (60) days prior to the conclusion of the initial one-year term or any successive one-year term, this Agreement shall be extended for an additional one-year term. If Group provides Harris Health with Group's written notice of intent to renew this Agreement not later than ninety (90) calendar days prior to October 1, 1992, Four Hundred Sixty-Five Thousand Dollars ($465,000.00) of premium due and payable to Harris Health shall be credited to Group in the eleventh (11th) month of the first year of this Agreement and shall be deferred for receipt by Harris Health and paid by Group in twelve equal monthly installments of Thirty-Eight Thousand Seven -2- Hundred Fifty Dollars ($38,750. 00) each, commencing October 1, 1992 and continuing on the first (1st) day of each calendar month thereafter through September 30, 1993 or by such other method as may be mutually acceptable by both Group and Harris Health. Not later than ninety (90) days prior to October 1, 1992, Harris Health shall negotiate and defend any increase in rates and Harris Health further agrees that any increase in rates for the second year of this Agreement shall not exceed twelve and one-half percent (12.5%) of the fully insured rates as set forth on Exhibits "D", "D-111, and "D-2" attached hereto and incorporated into and made a part of this Agreement. If. Group renews this Agreement for a third year for a period from October 1, 1993 through September 30, 1994, Harris Health agrees to negotiate and defend any increase in rates and further agrees that the rates for such period shall be set by using the Group's actual recorded paid claims attributable to the preceding year under the High and Low plans, which paid claims shall be trended forward using an annual inflation factor not greater than twelve and one-half percent (12 .50) . Group agrees to notify Harris Health in writing of its intent to renew this Agreement for a third year no later than ninety (90) days prior to October 1, 1993. 7. IN-VITRO WAIVER Group acknowledges that it has been presented and has declined coverage for in-vitro fertilization. Group agrees to execute and deliver to Health Plan the In-Vitro Fertilization Rider attached hereto as Exhibit "E" . 8. INDEMNIFICATION Harris Health covenants and agrees to, and does hereby, indemnify and hold harmless and defend Group, its agents and representatives, from and against any and all suits, claims, liabilities, expenses and damages to any and all persons or property, whether real or asserted, arising out of or in connection with Harris Health's insolvency, bankruptcy or misappropriation of funds, or any negligent act, omission or malfeasance on the part of Harris Health, its officers, directors and employees in the course of the administration of this Agreement. 9. AUDIT AND REVIEW Harris Health's performance of services and maintenance of records pursuant to this Agreement shall be subject to -3- review by Group at any time. Review will be at the sole expense of Group and upon reasonable notice during ordinary business hours. Harris Health 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 Group. 10. 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. 11. NON-APPROPRIATION OF FUNDS In the event no funds or insufficient funds are appropriated and budgeted in any fiscal year for payments due pursuant to this Agreement, Group shall notify Harris Health 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 Group of any kind whatsoever, except as to the portions of the payment herein agreed upon for services rendered through the effective date of termination. 12. ON-SITE ASSISTANCE Throughout the term of this Agreement, and any renewals thereof, Harris Health agrees to provide two (2) claims representatives on site during Group's regular business hours at the Group's offices to provide the following services: a. prepare notices required under the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA") upon receipt of notice from Group that a qualifying event has occurred and such COBRA notice should be provided b. explain Health Plan benefits C. provide copy of City's eligibility policy and receive information from Eligible Persons regarding changes in status d. assist in filing claims e. research claims processing status f. assist with permissible changes of primary care physicians 9- assist with such other duties for Group which are acceptable to Harris Health -4- Harris Health acknowledges and agrees that the claims representatives referenced above are employees of Harris Health and the Group has no responsibility or duty to supervise, direct, compensate or control such Harris Health employees. 13 . USE OF NAME AND MEMBER SURVEYS Group shall not use the name of Harris Health except as authorized in writing. Harris Health shall not use the name of Group except as necessary for the performance of this Agreement and as authorized in writing. Harris Health, its employees, agents or subcontractors shall not perform any written or oral surveys of Group's Eligible Persons unless Group and Harris Health have agreed in writing to the scope, content, method of contact, purpose, and publication of survey. Harris Health shall contact Group's risk manager who must agree or disagree in writing with the survey within seven (7) days after being contacted by Harris Health or such survey will be deemed acceptable by Group. Notwithstanding the foregoing, Harris Health shall have the right to canvass Group's Eligible Persons at any time when surveying all enrolled members of the Health Plan. 14. INDEPENDENT CONTRACTOR Harris Health shall perform or arrange for the provision of all services hereunder as an independent contractor and not as an officer, agent, servant or employee of Group. 15. TERMINATION WITH CAUSE In addition to the rights set forth in Section 4. 0 of the Group Health Care Agreement/Subscriber Certificate of Coverage, at any time, either party shall 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 provisions 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. Fraud or embezzlement on the part of the other party. -5- IN WITNESS WHEREOF, the undersigned have caused the Group Enrollment Agreement to be executed on the 7-y'"`day of 19 ql , to be effective as herein provided. HARRIS HEALTH PLAN, INC. By: Title: ATTES CITY OF FORT WORTH By: (� City Secretary Charles Bos ell Title: Assistant City Manager Address: 1000 Throckmorton Fort Worth, Texas 76102 APPROVED AS TO FORM AND LEGALITY By: City Attorney Date: LKG/skk ' HMO:Ft-Worth.GEA -6- HARRIS HEALTH PLAN, INC. 1300 Summit Avenue, Suite 300 Fort Worth, Texas 76102 AMENDMENT TO GROUP HEALTH CARE AGREEMENT/ SUBSCRIBER CERTIFICATE OF COVERAGE In accordance with Section 12 of the Group Health Care Agreement/ Subscriber Certificate of Coverage (the "Agreement") between Harris Health Plan, Inc. ("Harris Health") and The City of Fort Worth (the "Group") , the Agreement is hereby amended to reflect the changes indicated below. All other terms and conditions of the Agreement, not otherwise affected by any other provision of any document comprising the contract between Harris Health and the Group, are unchanged. 1. Section 1. , Subsection 1, line 2 is amended to add the following phrase after the word "employment" and before the word "during": "or other duty assignment authorized by Group" 2. Section 1. , Subsection 25 is amended to read as follows: 1125. GROUP shall mean collectively the contracting employer and all affiliated organizations of the employer whose employees are on The City of Fort Worth's payroll to which this Agreement is issued and through which as agent for Subscriber and not for Harris Health, Subscriber and Dependents become entitled to the benefits as set forth on the Schedule of Benefits. " . 3 . Section 1. , Subsection 51 is amended to delete the reference to "Attachment B11 and substituting the reference to "Exhibits C and C-1 attached to the Group Enrollment Agreement". 4. Section 1. , Subsection 53 is amended to read as follows: 1153. Service Area shall mean the geographic area as set forth herein". 5.. Section,, 3 . , Subsection 3.2 is amended by replacing all references to "twenty-five (25) years of age" with the language "twenty-three (23) years of age" . 6. Section 3. , Subsection 3 .2, the last sentence of said paragraph regarding maternity care benefits is amended by deleting the last sentence and replacing it with the following sentence: "Eligibility for the infant of an unmarried Dependent is set by Group's eligibility criteria as set forth in Exhibit "B" to the Group Enrollment Agreement". 7. Section 3 . , Subsection 3.7 is amended by adding the following language to the end of the paragraph: "and subject to Group's eligibility criteria as set forth within Exhibit "B" of the Group enrollment Agreement" . 8. Section 4. , Subsection 4.1. 1, line 6, the fourth (4th) sentence beginning with the word "Interest" is deleted in its entirety and the following sentence substituted therefore: "Interest on late payments from the dates such premiums were due may be charged at a rate equal to one percent (1%) per month. A payment shall be due on the tenth (10th) day of each calendar month and late if not paid thirty (30) days thereafter" . 9. Section 4, Subsection 4. 1. 1, second paragraph is amended by deleting the last sentence in its entirety. 10. Section 4. , Subsection 4.2.3i line 5 is amended by adding the following language after the word "misrepresentation": "was made or discovered" . 11. Section 4. , Subsection 4. 2.4 is amended by adding the following language at the end of the paragraph as follows: "is discovered" . 12 . Section 4. , Subsection 4.2 .7, the first paragraph is amended to read as follows: "If the Member and the Participating Physician fail to establish a satisfactory patient-physician relationship and if it is shown that Harris Health has, in good faith, provided the Member with reasonable opportunities to select an alternative Participating Physician, the Member shall be notified in writing at least thirty (30) days in advance that Harris Health considers the patient-physician relationship to be unsatisfactory and specifies the changes that are necessary in order to avoid termination. If Member fails to make such changes, coverage may be cancelled at the end of thirty (30) days". -2- 13 . Section 4. , Subsection 4.6, line 2 is amended to insert the word "below" prior to the word "definition" . 14. Section 5. , Subsection 5. 1 is amended by deleting on line 2 the -words "the first (1) day" and substituting the words "the tenth (10th) day". 15. Section 5. , Subsection 5.1 is amended by deleting the second sentence in its entirety. 16. Section 5. , Subsection 5.2, line 5 is amended to read as follows: " . . .not made arrangements for medical care or paid benefits for the ineligible person but in no such event shall such prepayments. . . 11 17. Section 6. , Subsection 6.5, the first paragraph, line 3 is amended to delete the first two words "this charge" and to insert the words "a claim". Line 4 is amended to delete the reference to "three (3) years" and to substitute the reference to "four (4) years" . 18. Section 7. , Subsection 7.3. 1, line 11 is amended to delete the word "child" and to substitute the word "parent". 19. Section 12 . , Subsection 12 .3 is deleted in its entirety. 20. Section 13 . , Subsection 13 .2, the second paragraph, line 3 is amended to delete the reference to "person" and substitute the word "Member". 21. Section 13, Subsection 13.4 is amended by adding the following sentence to the end of the paragraph: "Neither Harris Health nor Group shall assign, subcontract or otherwise delegate its rights and responsibilities under this Agreement without the other's prior written consent, which consent may be withheld solely at the discretion of such party." 22 . Section 13 . , Subsection 13. 19 is amended to substitute the following address for Harris Health: 111300 Summit Avenue, Suite 300 Fort Worth, Texas 7610211 -3- EXECUTED ON THIS A day of �C�'�Q UY\�Lv- , 1991. ATTEST: CITY OF FORT WORTH By: Cit ecretary Marles BcYswell Assistant City Manager APPROVED AS TO FORM AND LEGALITY: By: X"-/— It /'o 4" City Attorney Date: g—zo --%l HARRIS HEALTH PLAN, INC. By: - Nam j�aba t� �rv� Title: LKG/skk HMO:Amend.GHA -4- ACTIVE EMPLOYEES FAX: September 4, 1991 ELIGIBILITY These are eligibility rules for active employees and their spouses and dependents for participation in the City's group health insurance program. These rules may be amended from time to time. Please contact the Risk Management Department for the latest revision of this information. Employees I. Must be permanent employees occupying positions budgeted for at least halftime (0.5.A.P.) or working in a full-time position (1.0.A.P.) at least twenty hours per week on a regular basis. 2. Employees whose insurance coverage initially becomes effective on or after October 1, 1991 are eligible to enroll only in the Health Maintenance Organization Plan(s) offered. 3. In order to continue eligibility, employees must remain current with the biweekly contribution required to effect the employee's choice of coverage. Failure to do so will result in loss of coverage for the employee and his/her dependents. 4. An employee's and his eligible dependents' coverage becomes effective after the employee has completed one (1) month of continuous service and will remain in effect for thirty-one (31) days after termination of employment. 5. Employees who choose NOT to participate in the City's group health insurance program may waive participation. The employee will be required to sign a waiver of coverage to do so and will not be allowed to enroll in the City's program until the next open enrollment period. Such enrollment will be subject to any conditions then in effect for new employees. 6 If an employee waives coverage and re-enrolls at any future point, he/she and his/her eligible dependents will be subject to any limitations or exclusions then in effect, including, but not limited to, limitations or exclusions for pre-existing conditions. Dependents I. To be eligible to enroll as a dependent, a person must be: a. the spouse of an enrollment employee, or b. a dependent, unmarried natural child, foster child, stepchild, legally adopted child or child under the enrollee's legal guardianship or custodianship, residing with the enrolle or with the enrolle present or former spouse who is: I. under nineteen (19) years of age, or 2. under twenty-three (23) years of age, primarily dependent on the enrolle for financial support and attending a state accredited college, 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 the enrollee's legal guardianship or custodianship, residing with the enrollee or with the enrollee's present or former spouse, who is nineteen (19) years of age or older but incapable of self-sustaining employment because 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 enrolleed at all times under the City'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 the City proof of such incapacity and dependency within thirty-one (31) days before the dependent child's attainment of the limiting age and from the time to time thereafter as the City 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 a child of the unmarried dependent is otherwise eligible for coverage by Enrollee. If an infant child is eligible for coverage by the Enrollee, such coverage will be available as described above provided appropriate notices and contribution payments have been timely. 2. Coverage takes effect for dependents as follows: a. No dependent coverage can be covered before the date the employee becomes covered. b. A newly acquired eligible dependent other than a newborn child shall be covered as of the first day on which he meets all applicable eligibility requirements, subject to any limitations and/or exclusions then in effect, including, but not limited to, pre-existing conditions provided that any dependent confined at home or confined in a hospital or confined in any other medical institution on the day that person would otherwise become covered will become covered on the first day such dependent is not confined. C. Employee's eligible spouses and/or other dependents who lose coverage due to the spouse's or former spouse's loss of employment due to employment or carrier discontinuation of group coverage will be allowed to enroll in the City's plan within thirty-one (31) days of such loss of coverage subject to the following conditions: 1. proof of loss of employment and/or coverage must be verified 2. the spouse and/or other dependents eligible for participation in the City's plan must have been enrolled through the spouse's or former spouse's group plan at the time of loss of coverage. 3. the spouse and/or other eligible dependents will be subject to any exclusions or limitations then in effect, including, but not limited to, pre-existing conditions. d. Newborn children of an Enrollee and/or of an Enrollee's spouse shall be covered 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 the Risk Management Department with an application submitted for such newborn child. e. A newly adopted child, including a newborn, shall be covered as if he were a newly acquired eligible dependent. The thirty-one (31) 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 the earlier date provided the application is submitted on a timely basis. f. If approved evidence of insurability (medical questionnaire, etc) is required for participation of dependents in the City's plan, the dependent wi 11 NOT be added to the City's payrol 1 deduction for covered members until the completed form is returned to the Risk Management Department. ETIREES FAX: September 9, 1991 ELIGIBILITY I. Persons who have retired as either regular or disability and are receiving pension disbursements from the Retirement System. These persons have the option to participate in the City's group health insurance program for retired employees. Persons hired after October, 1988 will be required to participate in the cost of their group health insurance cost (at the then-current quoted retiree premium cost) based on the following schedule: Years of City Will Pay. Retiree Will Pay Service Of Basic Coverage Of Basic Coverage 0-5 NO ELIGIBILITY BEYOND COBRA 6-15 33% 67% + optional additional coverage 16-25 67% 33% + optional additional coverage 25+ 100% 0% + optional additional coverage Persons hired before October, 1988 will have afforded to them at least one group health insurance option which requires no cost participation for their own basic coverage. Benefits above the basic coverage are paid at the retiree's full cost. Payment for dependent coverage to be at the rate adopted by the City Council during budget deliberations. Effective immediately. No additional adverse effect to persons currently so defined. If a retired person opts not to participate in the City's plan, he/she will not be eligible to rejoin the plan in the future. 2. Persons who resign/retire and who remained vested in the City's pension program, but who have not yet begun to receive distributions (Rule of 65 or other). Persons vested in the Retirement System who have not yet begun taking distribution of pension benefits must pay 100% of the cost of their coverage and that of their eligible dependents at the premium rate for active employees until the earlier of such time as : (1) they do begin receiving distribution or (2) they reach 65 years of age at which time the City will participate in the cost of their group health insurance according to the provisions of #1 above. If a vested person opts not to participate in the City's plan, he/she will not be eligible to rejoin the plan in the future. Effectively immediately. This one WILL have an effect on the three (e) persons currently enrolled. 3. Persons who take an actuarial reduction in pension benefits to retire early. Persons who have retired and are taking an actuarial reduction in pension disbursements are eligible to participate in the City's group health insurance plan under the same provisions as #1 above. 4. The surviving spouses and other dependents of persons described above. The surviving dependents of City former employees/retirees are subject to the same eligibilit criteria as that of the former employee/retiree, and in order to assert that eligibility, must have been a participant of the plan at the time of the retiree's death. Dependents must be covered under the City's group health insurance program at the time of the employee's retirement (or at the time of separation of employment, remaining vested) in order to be eligible for continued coverage through the City's group health insurance program for retired employees. Surviving dependents will be required to pay a contribution as set annually. If a surviving dependent opts not to participate in the City's plan, he/she will not be eligible to rejoin the plan in the future. METHOD OF PAYMENT Retirees who participate in the cost of their own insurance and who pay for eligible dependent coverage authorize deductions for the required participation through deductions from their monthly pension checks. Retirees whose monthly pension checks are insufficient to pay the premium must arrange a payment plan with the Risk Management Department to make supplemental payments to maintain the desired coverage. Arrangements are to be made for quarterly payments in advance. In cases of extreme hardship, supplemental payment monthly in advance may be granted. If a retired employee falls into arrears in required contributions, he/she will be notified and will be allowed to correct the arrearage. If the arrearage continues 45 days after notification, coverage of dependents will be terminated and the retiree's health benefits reduced to the "no cost participation required" level of benefits. SCHEDULE OF BENEFITS PLAN 1-5 HARRIS HEALTH PLAN, INC. Health Maintenance Organization 1325 Pennsylvania Avenue, #450 Fort Worth, Texas 76104 800/633-8598 I. OBTAINING HEALTH CARE SERVICES Each Subscriber and his Dependent Members are entitled to receive the services and benefits set forth in this Schedule which are Medically Necessary and obtained in accordance with the provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage. A. Upon enrollment, each Member shall choose (or the Subscriber shall choose on behalf of his Dependents) a Primary Care Physician. If the Member fails to choose a Primary Care Physician, the Health Plan shall assign a Primary Care Physician for the Member. The names and addresses of the Primary Care Physician from which the Member may choose shall be provided to each Subscriber upon enrollment. Services are provided or coverage arrangements are available twenty-four (24) hours per day, seven (7) days a week by calling the telephone number provided for the Primary Care Physician. B. A Member may change their Primary Care Physician by contacting the Health Plan Member Services Department at the address or telephone number specified above. The change will become effective on a date designated by the Health Plan. C. All health care services, except those resulting from a Medical Emergency, are to be performed, prescribed, arranged, directed or authorized by the Primary Care Physician selected by the Member. When care by a Specialist Physician is necessary, the Primary Care Physician shall coordinate the referral to a Participating Specialist Physician. No referral is necessary for an annual well woman exam. If a required speciality is not represented in the Health Plan, a referral may be made to a Non-Participating Provider. All such non-emergency referrals must be authorized by the Health Plan before services are obtained. Any Member may obtain additional information as to how medical services are obtained by contacting the Health Plan at the address specified above. D. Except in cases of a Medical Emergency, or as a result of special prior approval by the Health Plan as specified above, only those services provided by a Participating Provider shall be covered under this Schedule of Benefits. E. All services and benefits are subject to any stated Copayment amounts, limitations, and exclusions described in this Schedule of Benefits. F. This Schedule of Benefits may be supplemented by additional benefit Riders if included with this Group Health Care Agreement/Subscriber Certificate of Coverage. P1-5-989 II. PHYSICIAN SERVICES B Required* Benefits Comment Physician Office visits, adult health $5.00/Visit assessments, routine physical examinations, well child care, and;:health education for diagnosis, care and treatment of illness or injury. Annual well woman examination. $5.00/Visit Physician visits after office hours. $5.00/Vis.it Home health visits. No Copayment Hearing, vision, and speech screening $5.00/Visit provided by Primary Care Physician to determine the need for correction. Allergy diagnosis, testing and treatment; serum $5.00/Visit is not covered. Administered drugs, medications, dressings,: $5.00/Visit splints, and casts. Diagnostic services, laboratory tests, and No Copayment x-rays. Immunizations and injections. No Copayment Surgery, anesthesia, and treatments performed in $5.00/Visit the physician's office, '`surgery center, or hospital. All physician fees while a Member is No Copayment hospitalized. Only one Copayment will be required for covered services performed or furnished on same date of service by the same Provider. This Copayment will be the higher of all listed Copayments'. P1-5-989-1 III. HOSPITAL SERVICES (Continued) OUTPATIENT HOSPITAL SERVICES: 1 Surgery. $5.00/Procedure 2. Therapeutic radiation treatment. No Copayment 3. Inhalation therapy. No Copayment 4. Diagnostic testing, laboratory, and No Copayment x-ray. IV. EMERGENCY CARE SERVICES In cases of a Medical Emergency, Member is entitled to the benefits and services set forth in this Schedule of Benefits and in this Agreement even if the services are not received from Participating Providers. Member is entitled to receive these 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 placing the patient's health in serious jeopardy, serious impairment' to bodily functions or serious dysfunction of any bodily organ or part. If not -authorized by the Member's Primary Care Physician, all treatment for such services will be reviewed retrospectively by the Health Plan Medical Director or his designee to determine whether an acute condition or situation indicated ;immediate emergency care to be appropriate. If upon review, the Health Plan Medical Director or his 'designee determines that no need for emergency care existed, the Member will be responsible for payment of all charges incurred for such care. WITHIN THE SERVICE AREA Emergency Care Services must be obtained or authorized through the Primary Care Physician who provides the Member with twenty-four (24) hours a day, seven (7) days a week access to call coverage to assist the Member in -obtaining Emergency Care Services. At the time of a Medical Emergency, the Member or someone acting on behalf of the Member, shall make every reasonable effort to contact the Member's Primary Care Physician for advice. If it is not reasonably possible to contact the Primary Care Physician at the time (such as that of a life or limb threatening emergency), the Member shall seek care from a Participating Hospital or Participating Emergency Center: If it is not reasonable to use a Participating Facility due to life threatening conditions or if taken to a non-participating facility under conditions over which the Member had no control , the Member or someone acting P1-5-989-3 V. FAMILY PLANNING SERVICES Family Planning Services will be available to Members on a voluntary basis. Covered services are _limited to the use of Participating , Providers and will include history, physical examination, related laboratory tests; medical supervision in -accordance with generally , accepted medical ; practice; information and counseling on contraception, including advice or prescription for a contraceptive method; education, including education on the ;prevention of venereal disease; and voluntary sterilization after appropriate counseling. Required Benefits Comment Physician office visits including related $5.00/Visit testing, education and counseling. Fitting and dispensing of IUD and diaphragms. $5.00/Visit Tubal ligation. $5.00/Visit Vasectomy. $5.00/Visit VI. INFERTILITY SERVICES Infertility services will be available to Members on a voluntary basis. Artificial insemination and diagnostic -services to determine the cause of infertility will be provided from Participating Providers and Participating Facilities. Excluded from services to treat infertility- are those services described in "Exclusions". Section , XIX, Number 22 of this Schedule of Benefits. Required Benefits Copayment Physician office visits for diagnosis, $5.00/Visit non-psychiatric counseling, artificial - insemination, and sperm count. Endometrial biopsy, hysterosalpingography $5.00/Visit and diagnostic laparoscopy. P2-5-989-5 VIII. MENTAL HEALTH SERVICES (Continued) INPATIENT MENTAL HEALTH SERVICES: When determined to be Medically Necessary by Participating Physician and by the Health Plan'Medical Director or his designee, the Member shall be entitled to evaluation, 'crisis ' intervention, treatment or any combination thereof for acute conditions at'' a 'Participating ' Facility. Services must represent treatment for conditions'which in the judgement of Participating Providers can substantially benefit from treatment, and requires inpatient treatment. If in the 'judgment of Participating Providers, treatment in a psychiatric day treatment program is appropriate, only such benefit will be authorized by the Health Plan. Chronic mental health conditions and long-term treatment are not covered. Required Benefits Copayment Inpatient hospitalization for up to thirty (30) No Copayment inpatient days per Calendar Year. Psychiatric Day Treatment Facility, Crisis No Copayment Stabilization Unit or Residential Treatment Center for Children and Adolescents for up to sixty (60) days per Calendar Year. Treatment in such facilities will be limited to sixty (60) days of care such that one (1) day of care shall be equal to one-half (112) day of inpatient care. IX. REHABILITATION SERVICES Member shall be entitled to receive short-term inpatient or outpatient physical or occupational therapy rehabilitation services from a Participating Provider for conditions which. in the judgment of Participating Physicians are Medically 'Necessary, subject to significant improvement through short-term treatment, and authorized by the Health Plan before services are obtained. Short-term treatment is defined as up to sixty (60) days per episode, and shall be provided on an 'outpatient basis only. Short-term rehabilitation services on an inpatient basis or in a' skilled nursing facility will be provided only if other non-rehabilitation medical services are required by the Member. Required Benefits Comment Hospital, home health agency, or other "$3.0ONisit-OP provider for restorative treatment subject to No Copayment-Inpatient short-term clinical improvement, and limited to sixty (60) days per episode. Long-term or maintenance services are not covered. P1-5-989-7 XIII. SKILLED NURSING FACILITY SERVICES Member is entitled to receive services in a Participating Skilled Nursing Facility for medical conditions which in the judgement of a Participating Physician is subject to significant clinical improvement and require services of such appropriate level of care. Services in a Skilled Nursing facility may be provided in lieu of hospitalization (either in lieu of admission or upon discharge from inpatient care) as Medically Necessary °based on acuity of services and patient condition, , are limited to sixty .(60) days per Calendar Year, and include Participating Physician services only. Required Benefits Comment .Room, board, medications and supplies while No Copayment confined in-a Skilled Nursing Facility as part of a short-term recovery or rehabilitation program. Physician visits while confined to No Copayment Skilled Nursing Facility. XIV. PROSTHETIC MEDICAL APPLIANCES Member shall be entitled to prosthetic medical -services-or medical appliances if they are Medically Necessary, with authorization from the Health Plan, and received from Participating Providers. While the Member is covered under this Agreement, initial prostheses are provided when required due to illness or injury. ' Replacement is provided only when marked physical changes occur which require replacement, and is not provided for items which wear out due to normal usage. Required Benefits Comment Internal prosthetic appliances including No Copayment internal cardiac pacemakers, and minor devices such as screws, wire mesh, nails, and artificial joints. External prosthetic appliances including $10.00/Appliance artificial arms, legs, above or below knee or elbow prostheses; eyes, lenses, external cardiac pacemaker; terminal devices such as hand or hook; rigid or semi-rigid immobilizing devices such as arm, leg, neck or back braces; and ordinary splints, and crutches. P1-5-989-9 XVIII. LIMITATIONS The following services are limited as described below: 1. Any "service, supply, or treatment which is not provided, ordered, performed, prescribed, directed, referred, arranged, authorized . or approved by the Member's Primary Care Physician, or the Health Plan Medical Director or his designee, except for Emergency Care Services as described in this Schedule of Benefits, will not be covered. 2. Services by physicians, facilities or other providers, who are not Participating Providers, except for Emergency Care Services as described in this Schedule- of Benefits, or unless requested and authorized in advance in writing by the Health Plan Medical Director or his designee, will not be covered. 3. Care and treatment of the teeth or gums, except for oral surgery for tumors or injuries to the jaw bone or surrounding tissue, is limited to the initial stabilization of acute accidental trauma to sound, natural teeth when provided within thirty (30) days of the accident. 4. Coverage for vision examinations is limited to conditions which require examination to diagnose injury or illness. 5. The benefit for durable medical equipment is limited to either the total rental cost or the purchase price of such equipment, whichever is less, as determined and authorized in advance by the Health Plan Medical Director or his designee. The Health Plan will authorize use of durable medical equipment no less than every three (3) months, and shall have no liability or responsibility for repair or replacement of equipment lost' or damaged. 6. Care and treatment provided in non-participating hospital owned or operated by federal, state, county or city government is limited to the care for the condition which the law requires to be treated or provided in a public facility. 7. - The purchase or fitting of eye glasses or contact lens or advice on their care, is limited to the initial set of eye glasses, contact lens, or lens implant required following cataract surgery, repair of congenital defect or as required by an accidental injury to the Member. 8. Coverage for reconstructive surgery is limited to surgery necessary to repair a functional disorder resulting from disease, injury, or congenital defect. 9. Any normal delivery for the Member which occurs outside the Service Area, ' and is within thirty (30) days of the delivery date, as specified by a Participating Physician, will not qualify as Emergency Care Services' benefits described in this Schedule of Benefits. P1-5-989-11 XIX. EXCLUSIONS (Continued) 6. Charges related to services for military or service connected conditions for which the Member is legally entitled, and for which appropriate facilities are reasonably available to the Member. 7 Charges related to occupational injury or illness or conditions covered under Worker's Compensation. 8. Charges related to homemaker, chore or similar services and health care services primarily for rest, custodial, respite, domiciliary, or convalescent care. 9. Charges related to reports, evaluations, or physical examinations (not Medically Necessary) not required for health reasons, including but not limited to, reports for employment, insurance, camp, adoption, travel, or government licenses. 10. Charges related to drugs or medicines, prescription or non-prescription, provided to the Member while' he or she is not an _%patient, unless specifically provided by Rider to this Schedule of Benefits. 11. Charges related to experimental drugs or substances not approved by the FDA for other than FDA approved indications; and drugs labeled 01Caution - limited by Federal Law to investigational use": 12. Charges related to formulas, dietary supplements, or special diets provided to the Member on an outpatient basis. ` 13. Charges related to vision care, including but not limited to, examination for eye glasses; refraction, dispensing, or fitting of eye glass frames and lenses; all types of 'contact lens; eye exercises and visual training; and orthoptics except as otherwise specified in Section XVIII, Number 7 of this Schedule of Benefits; or for services to determine the need for vision correction as described in "Limitations", Section XVIII, Number 4 of this Schedule. 14. Charges related to radial keratotomy or other radial keratoplasties, and all costs associated with such surgery. 15. Charges related to hearing aids, batteries, and examinations for fitting thereof unless specifically provided by Rider to this Schedule of Benefits. 16. Charges related to the care and treatment of the feet unless such services are Medically Necessary. Exclusions include routine foot care, such as removal of corns, calluses, or the trimming of nails; treatment for flat feet; orthotics arch supports; or custom fitted braces and splints. P1-5-989-13 9 . XIX. EXCLUSIONS (Continued) 25. Charges related to mental health services for psychiatric conditions which are determined by the Health Plan Medical Director or his designee, to be chronic or organic in nature, and which will not substantially benefit from short-term evaluation, crisis intervention and stabilization, or short-term treatment. 26. Charges related to court ordered testing, and special reports not directly related to medical treatment. 27. Charges related to services for the treatment of mental retardation and mental deficiency. 28. Charges related to employment, vocational, or marriage counseling; behavioral training; remedial education, including evaluation and treatment of learning and developmental disabilities and minimal brain dysfunction; or attention deficit therapy. 29. Charges related to services for chronic intractable pain provided by a pain control center; acupuncture,- naturopathy, and hynotherapy; holistic or _homeopathic care, including drugs; and ecological or environmental medicine. 30. Charges related to durable medical equipment, unless described in this Schedule of Benefits, excluded items include: (a) deluxe equipment, such as motor driven wheel chairs and beds, except when such deluxe features are necessary for the effective treatment of the patient's condition in order for the patient to operate the equipment himself/herself; (b) items not primarily medical in nature or for the patient's comfort and convenience, such as bed boards, bathtub lifts, over-bed tables, adjust-a-bed, and telephone arms; (c) physician's equipment such as stethoscope and sphygmomanometer; (d) disposable supplies; (e) exercise equipment such as exercycles and enrollment in health or athletic clubs; (f) self-help devices not primarily medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (g) corrective orthopedic shoes and arch supports; (h) supplies or equipment for common household use, such as but not limited to, air purifiers, central or unit air conditioners, water purifiers, allergenic pillows or mattresses, and water beds; and (i) items deemed to be experimental or research equipment as determined by the Health Plan. The Health Plan will authorize use of durable medical equipment no less than every three (3) months, and shall have no liability or responsibility for repair or replacement of equipment lost or damaged. 31. Charges related to prosthetic medical appliances, unless described in this Schedule of Benefits, excluded items include: (a) dentures, hearing aids unless provided by Rider, and contact lens; (b) medical supplies such as elastic stockings, garter belts, arch supports, corsets, and corrective orthopedic shoes; (c) items deemed to be experimental or research devices as determined by the Health Plan; and (d) replacement, repair, and routine maintenance of covered appliances or braces unless surgically implanted, or replacement required due to a marked change in physical growth or physical requirements. P1-5-989-15 SCHEDULE OF BENEFITS PLAN 10 HARRIS HEALTH PLAN, INC. Health Maintenance Organization 1325 Pennsylvania Avenue, #450 Fort Worth, Texas 76104 800/633-8598 I. OBTAINING HEALTH CARE SERVICES Each Subscriber and his Dependent Members are entitled to receive the services and benefits set forth in this Schedule which are Medically Necessary and obtained in accordance with the provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage. A. Upon enrollment, each Member shall choose (or the Subscriber shall choose on behalf of his Dependents) a Primary Care Physician. If the Member fails to choose a Primary Care Physician, the Health Plan shall assign a Primary Care Physician for the Member. The names and addresses of the Primary Care Physician from which the Member may choose shall be provided to each Subscriber upon enrollment. Services are provided or coverage arrangements are available twenty-four (24) hours per day, seven (7) days a week by calling the telephone number provided for the Primary Care Physician. B. A Member may change their Primary Care Physician by contacting the Health Plan Member Services Department at the address or telephone number specified above. The change will become effective on a date designated by the Health Plan. C. All health care services, except those resulting from a Medical Emergency, are to be performed, prescribed, arranged, directed or authorized by the Primary Care Physician selected by the Member. When care by a Specialist Physician is necessary, the Primary Care Physician shall coordinate the referral to a Participating Specialist Physician. No referral is necessary for an annual well woman exam. If a required speciality is not represented in the Health Plan, a referral may be made to a Non-Participating Provider. All such non-emergency referrals must be authorized by the Health Plan before services are obtained. Any Member may obtain additional information as to how medical services are obtained by contacting the Health Plan at the address specified above. D. Except in cases of a Medical Emergency, or as a result of special prior approval by the Health Plan as specified above, only those services provided by a Participating Provider shall be covered under this Schedule of Benefits. E. All services and benefits are subject to any stated Copayment amounts, limitations, and exclusions described in this Schedule of Benefits. F. This Schedule of Benefits may be supplemented by additional benefit Riders if included with this Group Health Care Agreement/Subscriber Certificate of Coverage. P10-989 II. PHYSICIAN SERVICES Required* Benefits Comment Physician Office visits, adult health $10.00/Visit assessments, routine physical examinations,` well child care, and health education for diagnosis, care and treatment of illness or injury. Annual well woman examination. $10.00/Visit Physician visits after office hours. $25.00/Visit Home health visits. $10.00/Visit Hearing, `vision,' and speech screening $10.00/Visit provided by Primary Care Physician to determine_ the need for correction. Allergy diagnosis, testing and treatment; serum $10.00/Visit is not covered. Administered drugs, medications, dressings, $10.00/Visit splints, and casts. Diagnostic services, laboratory tests, and No Copayment x-rays. Immunizations and injections. No Copayment Surgery, anesthesia, and treatments performed in $10.00/Visit the physician's office, surgery center, or hospital. All physician fees while a Member is No Copayment hospitalized. Hospital Emergency ,Room visits or urgent 20% care center. * Only one Copayment will be required for covered services performed or furnished on same date of service by the same Provider. This Copayment will be the higher of all listed Copayments. _ P10-989-1 III. HOSPITAL SERVICES (Continued) OUTPATIENT HOSPITAL SERVICES: ` 1. Surgery. $10.00/Procedure 2. Therapeutic radiation treatment. No Copayment 3. Inhalation therapy. No Copayment 4. Diagnostic testing, laboratory, and No Copayment x-ray: IV. EMERGENCY CARE SERVICES In cases of a Medical Emergency, Member is entitled to the benefits and services set forth in this Schedule of Benefits and in this Agreement, even if the services are not received from Participating Providers. Member is entitled to receive these 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 placing the patient's health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. If not authorized, by the Member's Primary Care Physician, all treatment for such services will be reviewed retrospectively by the Health Plan Medical Director or his designee to determine whether an acute: condition_ or situation indicated immediate emergency care to be appropriate. If upon review, the Health Plan Medical Director or his designee determines that no need for emergency care existed the Member, will be responsible for payment of all charges incurred for such care. WITHIN THE SERVICE AREA Emergency Care ;Services must be obtained or authorized through the Primary Care Physician who provides the Member with twenty-four (24) hours a day, seven (7) days a week access to call coverage to assist the Member in obtaining Emergency Care Services. At the time of a Medical Emergency, the Member or someone acting on behalf of, the Member, shall make= every reasonable effort to contact the Member's Primary 'Care Physician for advice. If it is not reasonably possible to contact the Primary Care Physician at the time (such as that of a life or limb threatening emergency), the Member shall seek care from a Participating Hospital or Participating Emergency Center. If it is not reasonable to use a Participating Facility due to life threatening conditions or if taken to a non-participating_;facility under conditions over which the Member had no control, the Member or someone acting P10-989-3 V. FAMILY PLANNING SERVICES Family Planning Services will be available to Members on a -voluntary basis. Covered services are limited to the use of Participating Providers and will include history, physical examination, related laboratory 'tests'; medical supervision in accordance with generally accepted medical practice; information and counseling on contraception, including advice or prescription for a contraceptive method; education, including education on the prevention of .venereal disease; and voluntary sterilization=after-appropriate counseling. Required Benefits Copayment Physician office visits including related $10.00/Visit testing, education and counseling. Fitting and dispensing of IUD and diaphragms. $10.00/Visit Tubal ligation. $10.00/Visit Vasectomy. _ _____ $10.00/Visit VI. INFERTILITY SERVICES Infertility services will be -available to Members on a voluntary basis. Artificial insemination and diagnostic services to determine the cause of infertility will be provided from Participating Providers and Participating Facilities. Excluded from services to treat infertility are those services described in "Exclusions". Section XIX, Number 22 of this Schedule of Benefits. Required Benefits Copayment Physician office visits for diagnosis,, $10.00/Visit non-psychiatric counseling, artificial insemination, and sperm count. Endometrial biopsy, hysterosalpingography $10.00/Visit and diagnostic laparoscopy. P10-989-5 VIII. MENTAL. HEALTH SERVICES (Continued) INPATIENT MENTAL HEALTH SERVICES: When determined to be Medically Necessary by Participating Physician and by the Health Plan Medical Director or his designee, the Member shall be entitled to evaluation, crisis intervention, treatment or any combination thereof for acute conditions. at a Participating Facility. Services must represent treatment for conditions which in the judgement of °Participating Providers can substantially benefit from treatment, and requires inpatient treatment. If in the judgment of Participating Providers, treatment in a psychiatric day treatment program is appropriate, only such benefit will ;be=authorized by the Health Plan. Chronic mental health conditions and long-term treatment are not covered. Benefits Required Copayment Inpatient hospitalization for up to thirty (30) 20% inpatient days per Calendar Year. Psychiatric Day Treatment Facility, Crisis 20% Stabilization Unit or Residential Treatment Center for Children and Adolescents for up to sixty (60) days, per Calendar Year. Treatment in such facilities will be limited to sixty (60) days of care such that one (1) day of care shall be equal to one-half (112) day of inpatient care. IX. REHABILITATION SERVICES Member --shall be entitled to receive short-term inpatient or outpatient physical or occupational therapy rehabilitation services from a Participating Provider for conditions which in the judgment of Participating Physicians are Medically Necessary, subject to-significant improvement ; through short-term treatment, and authorized by the Health Plan before services are obtained. Short-term treatment is defined as up to sixty (60) days per episode, and shall be provided on an outpatient basis only. Short-term rehabilitation services on an inpatient basis or in a skilled nursing facility will be provided only if other non-rehabilitation medical services are required by the Member. Required Benefits Copayment Hospital , home health agency, or other $3.00/Visit-OP provider for restorative treatment subject to 20%-Inpatient short-term clinical improvement, and limited to sixty (60) days per episode. Long-term or maintenance services are not covered. P10-989-7 XIII. SKILLED NURSING FACILITY SERVICES Member is entitled to receive services in a Participating Skilled Nursing Facility for medical conditions., which in the judgement of a Participating Physician is subject to significant clinical improvement and require services of such appropriate level of care. Services in a Skilled Nursing Facility may be 'provided in lieu of hospitalization ,(either in lieu of admission or upon discharge from inpatient care) as Medically Necessary based on <acuity, of services and patient condition, are limited to 'sixty (60) days per Calendar Year, and include Participating Physician services only. Required Benefits Copayment Room, 'board, medications and supplies while 20% confined in a Skilled Nursing Facility as part of a short-term recovery or rehabilitation program. Physician visits while confined to No Copayment Skilled Nursing Facility. XIV. PROSTHETIC MMICAL APPLIANCES Member shall be entitled to prosthetic medical services or medical appliances if they are Medically Necessary, with authorization from the 'Health Plan, and received from Participating Providers. While the Member is covered:under this Agreement, initial prostheses are provided when required due to :illness or injury. Replacement is provided only when marked physical changes occur which require replacement, and is not provided for items which wear out due to normal usage. Required Benefits Comment Internal prosthetic appliances including 20% internal cardiac pacemakers, and minor devices such as screws, wire mesh, nails, and artificial joints. External prosthetic appliances including $10.00/Appliance artificial arms, legs, above or below knee or elbow prostheses; eyes, lenses, external cardiac pacemaker; terminal devices such as hand or hook; rigid or semi-rigid immobilizing devices such as arm, leg, neck or back braces; and ordinary splints, and crutches. P10-989-9 XVIII. LIMITATIONS The following services are limited as described below: 1. Any -service, supply, or treatment which is not provided, ordered, performed, prescribed, directed, referred, arranged, authorized or approved by the Member's Primary Care Physician, or the Health Plan Medical Director or his designee, except for Emergency Care Services as ,described in this Schedule of Benefits, will not be covered. 2. Services by physicians, facilities or other providers, who are not Participating Providers, except for Emergency Care Services as described in this Schedule of Benefits, or unless requested and authorized in advance in writing by the Health Plan Medical Director or his designee, will not be covered. 3. Care and treatment of the teeth or gums, except for oral surgery for tumors or injuries to the jaw bone or surrounding tissue, is limited to the initial stabilization of acute accidental trauma to sound, natural teeth when provided within thirty (30) days of the accident. 4. _ Coverage for vision examinations is limited to conditions which require examination to diagnose injury or illness. 5. The benefit for durable medical equipment is limited to either the total rental cost or the purchase price of such equipment, whichever is less, as determined and authorized in advance by the Health Plan Medical Director or his designee. The Health Plan will authorize use of durable medical equipment no less than every three (3) months, and shall have no liability or responsibility for repair or replacement of equipment lost r or damaged. 5. Care- and treatment provided in non-participating hospital owned or operated by federal, state, county or city government is limited to the care for the condition which the law requires to be treated or provided in a public facility. 7. The purchase or fitting of eye glasses or contact lens or advice on their care, is limited to the initial set of eye glasses, contact lens, or lens implant required following cataract surgery, repair of congenital defect or as required by an accidental injury to the Member. 8. Coverage for reconstructive surgery is limited to surgery necessary to repair a functional disorder resulting from disease, injury, or congenital defect. P10-989-11 XIX. EXCLUSIONS (Continued) 5. Charges related to services rendered by a person who 'resides in a Member's home, or by an immediate relative of the Member. 6. Charges related to services for military or 'service connected conditions for 'which the Member is `legally entitled, and for which appropriate facilities are reasonably available to the Member. 7. Charges related to occupational injury or illness or conditions covered under Worker's Compensation. B. Charges related to homemaker, chore or similar services and health care services primarily for rest, custodial, respite, domiciliary, or convalescent care. 9. Charges related to reports, evaluations, or physical examinations (not Medically Necessary) not required for health reasons, including but not limited to, reports for employment, insurance, camp, adoption, travel , or government licenses. 10." Charges related to drugs or medicines, prescription or non-prescription, provided to the Member while he or she is not an inpatient, unless specifically provided by Rider to this Schedule of Benefits. 11. Charges related to experimental drugs or substances not approved by the FDA for other than FDA approved indications; and drugs labeled "Caution - limited by Federal Law to investigational use". 12. Charges related to formulas, dietary supplements, or special diets provided to the Member on an outpatient basis. 13. Charges related to vision care, including but not limited to, examination for eye glasses; refraction, dispensing, or fitting of eye glass 'frames and lenses; all types of contact lens; eye exercises and visual training; and orthoptics; except as otherwise specified in Section XVIII, Number 4 of this Schedule of Benefits. 14. Charges related to radial keratotomy or other radial keratoplasties, and all costs associated with such surgery. 15. Charges related to hearing aids, batteries, and examinations for fitting thereof unless specifically provided by Rider to this Schedule of Benefits. PIO-989-13 XIX. EXCLUSIONS (Continued) 24. Charges related to medical and hospital care for an infant of an unmarried Dependent. 25. Charges related to mental health services for psychiatric conditions which are determined by the Health Plan Medical Director or his designee, to be chronic or organic in nature, and which will not substantially benefit from short-term evaluation, crisis intervention and stabilization, or short-term treatment. 26. Charges related to court ordered testing, and special reports not directly related to medical treatment. 27. Charges related to services for the treatment of mental retardation and mental deficiency. 28. Charge's related - to -employment, vocational, or marriage counseling; behavioral training; remedial education, including evaluation and treatment of learning and developmental disabilities and minimal brain dysfunction; or attention deficit therapy. 29. Charges related to any inpatient or outpatient rehabilitation for treatment of drug or substance abuse, unless specifically provided by Rider to this Schedule. 30. Charges related to services for chronic intractable pain provided by a pain control center, acupuncture, naturopathy, and hynotherapy; holistic or homeopathic care, including drugs; and ecological or environmental medicine. 31. Charges , related to durable medical equipment, unless described in this Schedule of Benefits, excluded items include: (a) deluxe equipment, such as motor driven wheel chairs and beds, except when such deluxe features are necessary for the effective treatment of the patient's condition in order for the patient to operate the equipment himself/herself;_ (b) items not primarily medical in nature or for the patient's comfort and convenience, such as bed boards, bathtub lifts, over-bed tables, adjust-a-bed, and telephone arms; (c) physician's equipment such as stethoscope and sphygmomanometer; (d) disposable supplies; (e) exercise equipment such as exercycles and enrollment in health or athletic clubs; (f) self-help devices not primarily medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (g) corrective orthopedic shoes and arch supports; (h) supplies or equipment for common household use, such as but not limited to, air purifiers, central or unit air conditioners, water purifiers, allergenic pillows or mattresses, and water beds; and (i) items deemed to be experimental or research equipment as determined by the Health Plan. The Health Plan will authorize use of durable medical equipment no less than every three (3) months, and shall have no liability or responsibility for repair or replacement of equipment lost or damaged. P10-989-15 Rates Retiree' Retiree' Who is NOT Who is High Ootion Active Medicare Medicare Employee Eligible Eligible Employee Only $162.56 $310.53 Employee + Spouse $443.63 $236.42 Employee + Child(ren) $393.37 $435.05 $236.42 Family, inc employee $523.98 $435.26 $242.95 $745.49 Surviving Spouse $361.16 Surviving Children) $310.53 $118.21 Surviving Family $124.74 $124.74 $435.26 $242.95 r 'Available only to retirees who reside in the Health Plan service area. f p Ex H iT " D 255:tfw3 last r®vtsad/prtntad 04/26/91 11:35 am Rates Retiree' Retirees Who is NOT Who is Active Medicare Medicare Low Ootion Employee Eligible Eligible Employee Only $135.47 $235.79 $110.00 Employee + Spouse $369.69 $471.58 $220.00 Employee + Child(ren) $327.81 $341.05 $215.68 Family, inc employee $436.64 $576.84 $325.26 Surviving Spouse $235.79 $110.00 Surviving Child(ren) $105.26 $105.26 Surviving Family $341.05 $215.68 i 1 'Available only to retirees who reside in the Health Plan service area. XE- Oi L - 1 , 255:nt«3 — = last revised/printed 04/26/92 11:35 am i High Low 0 tion Option Retiree Only (Medicare) 118.21 11.0.00 Retiree Only (Non-Medicare) 310.53 235.79 Retiree & Spouse (One Medicare) 428.74 345.79 Retiree & Spouse (Both Medicare) 236.42 220.00 Retiree & Spouse (Neither Medicare) 621.05 471.58 Retiree & Children (Medicare) 242.95 215.68 Retiree & Children (Non-Medicare) 435.26 341.05 Retiree & Family (No Medicare) 745.79 576.84 Retiree & Family (One Medicare) 553.47 451.05 Retiree & Family (Two Medicare) 361.16 325.26 Surviving Spouse (Medicare) 118.21 110.00 Surviving Spouse (Non-Medicare) 310.53 235.79 Surviving Children 124.74 105.26 Surviving Family (Medicare) 242.95 215.68 Surviving Family (Non-Medicare) 435.26 341.05 L xH ie a a f• IN-VITRO FERTILIZATION RIDER FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT/ SUBSCRIBER CERTIFICATE OF COVERAGE 1.0 INTRODUCTION In consideration for the timely payment of premiums, and all other terms and conditions of the Group Healthcare Agreement/Subscriber Certificate of Coverage ("Agreement"), it is agreed that the benefits of this Rider, together with the terms and conditions of this Rider, shall be added to Agreement as issued if this Rider is accepted by the Group. 2.0 BENEFITS For the purpose of this Rider, outpatient expenses arising from in-vitro fertilization procedures for the Subscriber or the Subscriber's spouse, the following conditions shall apply: o The fertilization or attempt at fertilization of the Member's oocytes is made only with the Member's spouse's sperm. o The Member and the Member's spouse have a history of infertility of at least five continuous years duration; or the infertility is associated with one or more of the following medical conditions: a. endometriosis; b. exposure in utero to diethylstilbestrol (DES); c. blockage of, or surgical removal of, one or both fallopian tubes (non-voluntary); or d. oligospermia. o The Member has been unable to attain a successful pregnancy through any less costly applicable infertility treatments for which benefits are available under the Plan. o The in-vitro fertilization procedures are performed at a medical facility that conforms to the American College of Obstetric and Gynecology guidelines for in-vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in-vitro fertilization. o Benefits for in-vitro fertilization procedures shall be provided to the same extent as the benefits for other pregnancy-related procedures under the Plan. 3.0 ELIGIBILITY Benefits under this Rider are available to the Subscriber and the Subscriber's spouse. Benefits provide no conversion privileges or benefit continuity for Members when such persons are no longer entitled to Group benefits as set forth in Agreement to which this Rider is issued. 4.0 LIMITATIONS Benefits shall be provided only if recommended by a Harris Health Primary or Harris Health Speciality Physician and have received prior written approval from the Harris Health Medical Director or his designee. - IVF188-1 £'_Y#1131 T "e ACCEPTED: Group By: Authorized Representative Date: REJECTED: ATTEST: CITY OF FORT WORTH By: City Sec;e� ary Charles Boswell, Assistant City Manager APPROVED AS TO FORM AND LEGALITY aJ By: /"v City Attorney Date: HARRIS HEALTH PLAN, INC. By: Titi Page 10.0 Member Complaint Resulution Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 10.1 Complaint.Resolution Process . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . .. . . . . . . . . . . . . . 21 10.2 Complaint Resolution Appeal Process . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . 22 11.0 Health Care Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . .. . ... . . . . . . . . . . . . . 22 11.1 Benefits and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . 22 12.0 Term and Amendment of Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 12.1 Term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 12.2 Amendment . . . . . . . . . . . . . . . . . . . . . . . . . . . . I. . . . . . . . . . . . .* . . . . . . . . . . . . . . . . . 23 12.3 Change of Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . 23 13.0 Miscellaneous Provisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 13.1 Use of Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 13.2 Records and Information . . . . . 23 13.3 Information from Group .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . 23 13.4 Assignment . . . . . . . . . . . . . . . . . . . .I . ... . . . . . . . . .. . . . . . .. . ... . . . . . . . . 24 13.5 Authority. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Governing Law... . . . . . . . . . ... . . ; . . . . . . .. . . . . . . . . . . . . 24 13.6 . . . . . . . . . . . . . . . . . 13.7 Incorporation by Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . ... . . . . . . . . . 24 13.8 Entire Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... . . . . . . . . . . . . . . . 24 13.9 Information to Member . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . ... . 24 13.10 Uniform Rules. .1 . . . . . . . . . .. . . . .. . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . ... . . . 24 13.11 Calculation of Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . 24 13.12 Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Severability . . . 13.13 . . . . . ... . . . . . . . . . . . . . . . . . . i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 . . . ... . . . . . . . . . . . . . . . . . ... . . . . . . 13.14 Venue . . . . . . . . . . .. . . . . .... . . . . . . . . . . . . . . 24 13.15 Waiver of Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. I., . . . . . . . . . . 25 13.16 Headings . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . 25 13..17 Notice of Certain Events . . . I. . . . . . . . . . ... . . . . . . . . . . .. . . . . . . . ... . . . . . . . . . . . . . 25 13.18 Notice of Termination . . . . . . . . . I . . . . . . . . . .I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 13.19 Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Attachment A Service Area Attachment B Schedule of Benefits. GA-8B9-2 ment B,which is not covered by premiums payable hereunder, and which must be paid by Members directly to the person or entity providing the service when the service as set forth in the Schedule dire y P Y p g of Benefits is received. 13. COURSE OF TREATMENT shall mean that period of time represented by an inpatient hospital admission and related discharge during which time treatment has been received by a Member or that period of time authorized by a Participating Physician and/or Harris Health as necessary to com- plete a cycle of treatment and subsequently provide a medical release to the. Member. 14. CRISIS STABILIZATION UNIT shall mean a twenty-four(24)hour residential program, licensed by Texas Department of Mental Health and Mental Retardation;that is usually short-term in nature and that pro- vides intensive supervision and highly structured activities to persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe proportions. 15. 'CUSTODIAL CARE shall mean 1)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 medical treatment or recovery; or 3) care comprised of services and supplies that are primarily provided to assist in the activities of daily living. 16. DEPENDENT shall mean an Eligible Dependent who has satisfied the eligibility and participation requirements specified in this Agreement. 17. DOMICILIARY CARE shall mean that care provided for persons so disabled or infirm as to be unable to live independently. 18. EFFECTIVE DATE shall mean the effective date of coverage for Eligible Persons and Eligible Dependents pursuant to the terms of this Agreement. 19. ELIGIBLE.DEPENDENT,shall mean an individual as defined in Section 3.2 of this Agreement. 20. ELIGIBLE PERSON shall mean an individual as defined'in Section 3.1 of this Agreement. 21. EMERGENCY CARE shall mean 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 placing the patients health in serious jeopardy; serious impairment to bodily functions; or serious dysfunc- tion to any bodily organ or part. 22. EVIDENCE OF INSURABILITY shall mean that an Eligible Person or Eligible:Dependent verifies that they were.enrolled for the preceeding twelve(12)months in a group or individual plan providing benefits for medical,surgical and hospital expenses; or completes the Evidence of Insurability form and pro- vides timely any additional documentation of health status as required by.Harris Health. Such infor- mation shall be reviewed by Harris Health and the Eligible Person or Eligible Dependent shall be notified regarding their eligiblity for participation in Harris Health. 23. EXCLUSION shall mean those specific conditions or causes for which coverage by Harris Health is entirely excluded. 24. FDA shall mean the Food and Drug Administration, an agency of the United States government. 25. GROUP shall mean collectively the contracting employer and all affiliated organizations of the employer as set forth in Attachment A annexed hereto and made a part hereof,to which this Agreement is issued and through which as agent for Subscriber and not for Harris Health, Subscriber and Dependents become entitled to the benefits as set forth in the Schedule of Benfits. 26. GROUP EFFECTIVE DATE shall mean the date specified as such in the Group Enrollment Agreement. 27. GROUP ENROLLMENT AGREEMENT shall mean that agreement which'Sr executed between Harris Health and Group for the purpose of making available to Eligible Persons and Eligible Dependents of Group those benefits and services which are described in the Group Health Care Agreement/ Subscriber Certificate of Coverage. Such Group Enrollment Agreement shall identify the Group, Group Effective Date, eligibility requirements, rates, and covered benefits. 28. HARRIS HEALTH shall mean Harris Health Plan, Inc., a Texas not-for-profit corporation organized as a Health Maintenance Organization (HMO) and licensed by the Texas State Board of Insurance. 29. HEALTH PLAN shall mean the Health Maintenance Organization operated by Harris Health d/b/a Harris Methodist Health Plan. GA-889-4 Schedule of Benefits and described in this Agreement. 43. OPEN ENROLLMENT PERIOD shall mean a period of at least thirty (30) days during each twelve (12)consecutive months when Eligible Persons may elect to change from the Alternative Health Benefit Plan to Harris Health or from Harris Health to the Alternative Health Benefit Plan. 44. PARTICIPATING PHYSICIAN shall mean any Physician who has contracted with Harris Health to provide to Members the services as set forth in the Schedule of Benefits and described in this Agreement. 45. PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency, Laboratory, Minor Emergency Center, Chemical Dependency Treatment Center, Psychiatric Day Treament facility or other provider or entity which has contracted with Harris Health to provide to Members the services as set forth in the Schedule of Benefits and described in this Agreement. 46. PSYCHIATRIC DAY TREATMENT FACILITY shall mean a mental health facility which provides treat- ment for individuals suffering from acute mental and nervous disorders in a structured psychiatric pro- gram utilizing individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program and that is clinically supervised by a j Physician who is certified in Psychiatry by the American Board of Psychiatry and Neurology.The facility shall be licensed by the State of Texas, accredited by the Program for Psychiatric Facilities, or its suc- cessor, of the Joint Commission on Accreditation of Health Care Organizations, and shall have con- tracted with Harris Health to provide to Members the mental health services as set forth in the Schedule of Benefits and described in this Agreement. 47. PHYSICIAN shall mean any individual (other than a hospital resident or intern) who is fully licensed and qualified to practice within the scope of the license under the law of the jurisdiction in which treat- ment is received. 48. PRIMARY PHYSICIAN shall mean, with respect to each Member, those Participating Physicians who are designated by Harris Health and identified in writing to Members as Physicians having primary responsibility for coordinating such Member's medical care, providing initial and primary care to Members, maintaining the continuity of such Member's care and initiating referrals for specialist care. 49. RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS shall mean a child- care institution that provides residential care and treatment for emotionally disturbed children and adolescents, licensed by Texas Department of Mental Health and Mental Retardation, and that is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Health Care Organizations or the American Association of Psychiatric Services for Children. 50. RIDER shall mean a Schedule provided with this Agreement, and made a part hereof, which sets forth additional benefits and services made available by Harris Health by amending this Schedule of Benefits. 51. SCHEDULE OF BENEFITS shall mean the schedule annexed hereto as Attachment B and made a part hereof which sets forth the benefits and services that Harris Health shall make available to Members. 52. SEMI-PRIVATE shall mean the charges made by a Member Hospital for a room containing two (2) or more beds. 53. SERVICE AREA shall mean the geographic area as set forth and annexed hereto as Attachment A. 54. SHORT TERM shall mean a course of treatment lasting thirty (30) days or less. 55. SPECIALIST PHYSICIAN shall mean any Physician who has contracted with Harris Health to provide specialist care to Members upon referral of a Primary Physician or upon referral of another Specialist Physician with the concurrence of the responsible Primary Physician. 56, SKILLED NURSING FACILITY shall mean 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 Health Care Organizations, or is recognized as a Skilled Nursing Facility by the Department of Health and Human Services under Title XVIII of the Social Security Act (Medicare), as amended. 57. SUBSCRIBER shall mean an Eligible Person who has satisfied the eligibility and participation require- ments specified in this Agreement. 58. TOXIC INHALANT shall mean as volatile chemical under Chapter 323, Acts of the 68th Legislature, Regular Session, 1983 (Article 4476-13a, Vernon's Texas Civil Statutes), or abusable glue or aerosol GA-889-6 Section 2.0 GROUP`AND AFFILIATED ORGANIZATIONS 2.1 ORGANIZATIONS,INCLUDED UNDER THIS AGREEMENT The Group and its affiliated organizations are included under this Agreement. Affiliated organiza- tions include all those organizations which are subsidiary to or affiliated with the Group and located within the Service Area of Harris Health. 2.2 CHANGE OF AFFILIATED ORGANIZATIONS The Group hall notify Harris Health, in writing, when an affiliated organization ceases to be a subsidiary of, or affiliated with,the Group. When an organization ceases to be a subsidiary of, or affiliated with, the Group, it shall cease to be an included organization. Therefore, this Agreement shall terminate on the date of such cessation with respect to all Eligible Persons,of that organization, except for those persons who on the next day are employees of another affiliated organization and thus Eligible Persons under this Agreement. Section 3.0 ELIGIBILITY AND EFFECTIVE DATE 3.1 ELIGIBLE PERSONS To be eligible to enroll as a Subscriber, a person must reside in the Service Area and be an Eligible Person as follows: ® In the employment of the Group or a bona fide Member of the Group; 'and/or° ® Eligible under the eligibility criteria established by the Group; and i ® Entitled on his or her own behalf to participate in the medical and hospital care benefits arranged.,by the Group. 3.2 ELIGIBLE DEPENDENTS ' , To be eligible to 'enroll as a Dependent; a person must reside in the Service Area and be: The legal spouse of,a Subscriber; A dependent unmarried natural child, foster child, stepchild., legally adopted child or child under Subscriber's,court appointed legal guardianship, residing with Subscriber or with Subscriber's present or former:spouse in the Service-Area who is (a) under nineteen '(19) years of age, or (b) under twenty-five (25) years of age and primarily dependent on the Subscriber for,financial support and attending an accredited college or university, trade or secondary school,on a full-time basis; which has, in writing,,verified said attendance or; . ® A dependent unmarried natural child, foster child, stepchild, legally adopted child, or child under Subscriber's court appointed legal guardianship, residing with Subscriber or with Subscriber's present or former spouse in the Service area who is nineteen (19) years of age or older but incapable of self-sustaining employment because of mental retardation or physical handicapwhich commenced prior to age nineteen;(19) (or commenced prior to age twenty-five (25) 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 Subscriber for support and maintenance. Such dependent child must have been a Member either prior to attaining nineteen (19) years of age or twenty-five,(25),years of age under,the conditions of the previous sentence. Subscriber shall furnish Harris Health 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 Harris Health deems appropriate, but not more frequently than annually. ® Maternity care benefits will;be extended to an unmarried Dependent Child. No benefits are provided for;the infant of an unmarried Dependent. GA-889-8 Dependent,then such Eligible Person or Eligible Dependent shall have to document Evidence of Insurability as required;by Harris Health. 3.8 NOTIFICATION OF INELIGIBILITY A condition of participation in Harris Health is Subscriber's agreement to notify Harris Health of any changes in status that affect Subscriber or the ability of the Subscriber's Dependents to meet the eligibility criteria set forth in this Section. 3.9 CLERICAL ERROR Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due to clerical error, to record or report an Eligible Person or Eligible Dependent to Harris Health. if an Application had been completed and submitted to Group as required under the terms of this Agreement by or on behalf of such Eligible Person or Eligible Dependent and that the premium applicable to such coverage had been received by Harris Health. Section 4.0 GROUP AND MEMBER TERMINATION, CONTINUATION OF BENEFITS AND CONVERSION 4.1 TERMINATION OF GROUP 4.1.1 Default in Payment of Premium If Group fails to pay to Harris Health the premium payable hereunder on or before the thirty-first (31) calendar day after such payment is due, this Agreement may be terminated by Harris Health and all benefits and services shall cease at the end of such thirty-one (31) day grace period. Group may be held liable for the cost of all benefits and services provided to Member by Harris Health during the grace period. Group shall remain liable for all premiums (and any interest accrued thereon) not paid prior to termination. Interest on late payments from the date such premiums were due may be charged at a rate equal to eighteen percent(18%) per year. Unpaid interest shall be due and payable upon notice thereof to Group from Harris Health. If Group remits its delinquent payments to Harris Health within fifteen (15) days of a termination date, Harris Health may reinstate Group without requiring a new Group Enrollment Agreement. However, Harris Health reserves the right to refuse to reinstate by refunding within five(5) business days all payments made by Group after the date of termination. 4.1.2. Upon Notification This Agreement may be terminated by either Harris Health or Group upon written notice to the other party at least sixty(60) days prior to the end of the Contract Year. Such termination shall occur at midnight on the day preceeding the end of the Contract Year. In the event that Harris Health terminates this Agreement, any Member who is a registered bed patient in a Hospital on the date of termination shall receive coverage for all hospital services for that hospital confinement or until a determination is made by the Medical Director that inpatient care is no longer medically indicated, whichever occurs first. 4.2 TERMINATION OF MEMBER— FOR CAUSE 4.2.1 Default in Payment of Copayments If any required Copayment is not paid timely by or on behalf of Member, pursuant to the terms of this Agreement, such Member's entitlement to benefits may be terminated not less than sixty-one(61) days after the date such Copayment was due. 4.2.2 Default in Payment of Premium If any premium contributions due from Member are not paid timely by or on behalf of Member, such Member's entitlement to benefits may be terminated not less than thirty-one(31)days after the date such premium was due. 4.2.3 Misrepresentation If any Subscriber should make a fraudulent statement or provide any material misrepresentation of fact by or on behalf of such Subscriber or Dependent on an Application or Evidence of Insurability form, Harris Health shall have the right to terminate the Member's coverage under this Agreement without any further liability or obligation to such Member. Such Subscriber's entitlement to benefits may be terminated not less than sixty-one (61) days after such misrepresentation. If a Member corrects inaccurate•informa- tion furnished to Harris Health, and Harris Health has not relied upon such incorrect information to its GA-889-10 If a Member ceases to be a resident of the Service Area as defined by Harris Health, eligibility to participate in Harris Health shall automatically terminate as of the date on which the Member ceased to be a resident of the Service Area, except as may be required by State and Federal regulations for COBRA participants. Such Member shall be eligible to convert to an Individual Hospital and Surgical Express Policy as specified in Section 4.6.2 4.4 LIABILITY UPON TERMINATION At the effective date of any termination of a Member's coverage under this Agreement any payments received on account of such Member applicable to periods after the effective date of the termination of coverage,:plus amounts due to such Member for claims reimbursement , if any, less any amount due to Harris Health'or which must be paid by Harris Health on behalf of such Member, shall be refunded to the appropriate party within thirty-one (31) days. Harris Health and Group shall thereafter have no further liability'or responsibility to such Member except as may be specifically provided in Section 4.1.2 of this Agreement. 4.5 CONTINUATION OF COVERAGE If a Member's coverage ends, such coverage may qualify to be continued in one of the following ways: • it may be extended under the Extension of Medical Benfits provisions, if the Member is Hospital Confined when this Agreement terminates; or • it may be continued under the Optional Continuation of Coverage provisions; or • it may be converted to an individual plan of medical coverage as described in the Conversion provisions: If, under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272 ("COBRA"), any Member is granted the right to continuation of coverage beyond the date his coverage would otherwise terminate, or, if COBRA is inapplicable and the provisions of an appli- cation state statute grants such Member similar rights to continuation of coverage, this Agreement shall be deemed to allow continuation of coverage to the extent necessary to comply with the provisions of the applicable statute. Contact the employer for verification of eligibility and procedures to follow. 4.5.1 Extension of Medical Benefits Harris Health shall continue to provide medical services if this Agreement terminates under Sec- tion 4.1.2 while a Member is confined in a Hospital or Skilled Nursing Facility. Services will be provided only for the same injury or sickness which caused the Member to be confined. This continued coverage will end on the earlier of: (1)the date the confinement is no longer Medically Necessary; or (2) the date the Member reaches any_limits under the Group Contract for the provisions of services; or (3) the date the Member becomes eligible for similar coverage under another plan. 4.6 CONVERSION PRIVILEGE If a Member has been covered by this Agreement for at least three(3)consecutive months or covered as a newborn from the date of birth and meets the definition of a person eligible for conversion, Member may enroll in an individual plan with a defined Schedule of Benefits available to conversion Members only under the terms and conditions of this Agreement. ELIGIBILITY TO CONVERT A Member whose coverage under this Agreement is terminated in accordance with the Termina- tion provisions may convert if the coverage is not ending for one of the following reasons: • Termination of this Agremeent; • Failure to pay any required copayment amounts; • Termination for cause; • Coverage under another individual or group health policy, plan or contract; • Eligibility for Medicare; • Eligibility or coverage for similar hospital,medical or surgical benefits under a state or federal law. A covered Dependent whose coverage is terminated under this Agreement may also convert if GA-889-12 and the number of Members at the monthly intervals established by Harris Health. Group shall offer Harris Health to all Subscribers of Group on terms no less favorable with respect to the Group contribution than those applicable to any Alternative Health Benefit Plan as may be available . through the Group.The Group contributions shall not be changed during the term of this Agreement unless such change is prior approved, in writing, by Harris Health. If, however, Group contribution to the Alter- native Health Benefit Plan as may available through the Group is increased during the term of this Agree- ment, Group agrees to also increase contribution to Harris Health effective the first monthly payment due following such increase. 5.2 NOTIFICATION BY GROUP Group shall forward completed Applications and any Evidence of Insurability form(s)to Harris Health within ten (10) business days of their receipt from Eligible Persons. In the event Group fails to notify Harris Health of the ineligibility of any person for whom the Group has made the monthly prepayment required pursuant to this Agreement, then, such prepayment shall be credited to Group only if Harris Health has not made arrangements for or paid benefits for the ineligible person but in no event shall such prepay- ment be credited subsequent to thirty (30) days after the date such person became ineligible. 5.3 COPAYMENTS All Copayments, as specified in the Schedule of Benefits, are due and payable at the time a service is provided. The maximum amount of Copayment in any Contract Year shall not exceed the maximum specified in the Schedule of Benefits. It is the Subscriber's responsibility to retain receipts and to notify Harris Health upon attaining the Copayment limit so that additional services can be provided without a Copayment charge. i Section 6.0 CLAIM_PROVISIONS 6.1 CHARGES PAID BY MEMBERS It is not anticipated that a Member shall make payments, other than the Copayments asset forth in the Schedule of Benefits, for benefits and covered services under this Agreement. However, if a pay- meet is made by a Member then a written description of such services, accompanied by evidence of pay- _ ment by the Member must be provided to Harris Health within sixty (60) days after the performance of the service. Failure to furnish such proof within the required time shall not invalidate nor reduce any claim, if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible. If the Member provides evidence that he has made such payment, payment shall j be paid to the Member but without prejudice to Harris Health's right to seek recovery of any payment made by it before receipt of such evidence. 6.2 MEDICAL EMERGENCY Medical Emergency services which are covered under this Agreement but are not received from Participating Providers shall be reimbursed subject to the Copayments in the Schedule of Benefits. Harris Health reserves the right to deny a claim for reimbursement of services received from a Hospital emergency department or a Minor Emergency Center, if it is determined by Harris Health that such services were not obtained pursuant to the terms of this Agreement or if a Medical Emergency did not exist at the time services were received by the Member. 6.3 ACTION ON CLAIM All claims for reimbursement shall be finalized by Harris Health within sixty(60) days of receipt of written documentation describing the occurrence, character and extent of the event for which the claim is made, unless the Member is notified of the need for a longer time. If a claim is denied, written notice GA-889-14 Group 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. 7.2 DETERMINATION OF BENEFITS This provision shall apply in determining the benefits payable for the Allowable Expenses incur- red by a Member during a Claim Determination Period. The term Coordinated Plan shall be construed separately with respect to each policy, contract, or other arrangement for benefits or services and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the right to take the benefits or services of other Coordinated Plans into consideration in determining its benefits and that portion which does not. Whenever the sum of the benefits that would be payable under this Agreement in the absence of this provision, and the benefits that would be payable under all Coordinated Plans in the absence thereof or amendments of similar purpose to this provision would exceed the Allowable Expenses,then the following j shall apply: ® The benefits that would be payable under this Agreement shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all Coordinated Plans shall not exceed the total payable under this Agreement. Benefits payable under a Coordinated Plan include the benefits that would have been payable had claim been duly made therefor. If a Coordinated Plan would, according to its rules, determine its benefits after the benefits payable under this agreement have been`determined, and the rules as described in Section 7.3 would require payment under this Agreement to be determined before the Coordinated Plan,then the benefits of the Coordinated Plan shall not be included for the purpose of determining the benefits under this Agreement. 7.3 ORDER OF BENEFIT DETERMINATION The rules establishing the order of benefit determination shall be as follows: The benefits of a Coordinated Plan without a coordination of benefits provision (or a non- duplication provision of similar intent)shall be determined before the benefits of this Agreement. ® The benefits of a Coordinated Plan which covers the Member other than as a dependent shall be determined before the benefits of a Coordinated Plan which covers such person as a dependent. ® The benefits of a Coordinated Plan which covers the Member as a dependent child of a person whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be deter- mined 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. If a Coordinated Plan does not have the provisions of this paragraph regarding dependents, which results either in each Coordinated Plan determining its benefits before the other or in each Coordinated Plan deter- mining its benefits after the other, the provisions of this paragraph shall not apply, and the rule set forth in the Coordinated Plan which does not have the provisions of this paragraph shall deter- mine the order of benefit determination unless Section 7.3.1 shall apply. ® If the rules provided above or the rules provided in Section 7.3.1 do not establish an order of benefit determination, then the benefits of a Coordinated Plan which has covered the Member for whom the claim is made for the longer period of time shall be determined before the benefits of a Coordinated Plan which has covered such Member for the shorter period of time except as follows: — The benefits of a Coordinated Plan covering the Member as a laid-off or retired employee or as the dependent of such Member shall be determined after the benefits of a Coordinated Plan covering such person as a Member other than as a laid-off or retired employee or depen- dent of such person. — If a Coordinated Plan does not have a provision regarding laid-off or retired employees, and, as a result, such Coordinated Plan determines its benefits after the Coordinated Plan with GA-889-16 The employer will provide Subscriber with a choice to elect one of these options at least one month before becoming age 65. All new Employees age 65 or older will be offered these options when hired. If Option 1 is chosen, Subscriber's rights under this Agreement will be subject to the same requirements as for an Employee or Dependent who is under age 65. There are two categories of persons eligible for Medicare.The calculation and payment of benefits by this Agreement differs for each category. Category 1 Medicare Eligibles are: 1. Actively working covered Employees age 65 or older who choose Option 1; 2. The age 65 or older covered spouses of actively working covered Employees age 65 or older who choose Option 1; j 3. Age 65 or older covered spouses of actively working covered Employees who are underage 65; 4. Actively working covered Employees of employers with 100 or more Employees and their Covered Dependents who are entitled to Medicare by reason of disability other than End Stage Renal Disease (ESRD); and 5. Covered individuals entitled to Medicare solely on the basis of ESRD during a period of up to 12 months after the individual has been determined eligible for ESRD benefits. Category 2 Medicare Eligibles are: 1. Retired employees and their spouses; 2. Covered Employees of employers with less than 100 Employees and their covered Dependents who are entitled to Medicare by reason of a disability other than ESRD; and 3. Covered individuals entitled to Medicare solely on basis of ESRD for more than 12 months after the individual has been determined eligible for ESRD benefits. Calculation and Provision of Services: - For Members in Category 1, services are provided by this Agreement without regard to any benefits provided by Medicare. Medicare will then determine its benefits. For Members in Category 2, services are provided by the Group Agreement.Harris Health shall then have the right to recover the full amount of all Medicare benefits the Member is entitled to receive,'whether or not the Member is'actually enrolled for them.The Member should authorize payment of Medicare benefits directly to Harris Health for services rendered. If the Member does not authorize direct payment, he or she is responsible to Harris Health for the reasonable value of the services rendered.The Member is also responsible to Harris Health for the reasonable value of all Group Agreement services reimbursable by Medicare if the Member is not enrolled for all benefits he or she is entitled to receive. 7.5 RIGHT TO RECEIVE AND RELEASE INFORMATION For purposes of administering the provisions of this Section, Harris Health may, without further con- sent of, or notice to any Member, release to or obtain from any healthcare plan, insurance company or other person or organization, any information with respect to any Member which it deems to be reasonably necessary for such purposes, if permitted by law. Any Member receiving services or claiming benefits under this Agreement shall furnish to Harris Health all information deemed necessary by Harris Health to imple- ment this Section 7.0. 7.6 ` FACILITY OF PAYMENT Whenever payments which should have been made by Harris Health in accordance with this Section have been made by a Coordinated Plan, Harris Health shall have the right, exercisable alone and in its sole discretion, to authorize payment to the Coordinated Plan making such payments any amounts Har- ris Health shall determine to be warranted in order to satisfy the intent of this Section, and amounts when so paid shall be deemed to be benefits under this Agreement, and,to the extent of such payments, Harris Health shall be fully discharged from liability under this Agreement. 7.7 RIGHT OF RECOVERY Whenever payments have been made by Harris Health with respect to Allowable Expenses in a total amount which is, at any time, in excess of the maximum amount of payment necessary at that time GA-889-18 i in no way supervise the practice of medicine by any Participating Provider hereunder, nor shall Harris Health in any manner supervise, regulate or interfere with the usu sal -vela- tionships between a Participating Provider and a Member. ® The relationship between Harris Health,the Group and any Member is that of independent con- tracting entities. Neither the Group nor any Member is the agent or employee of Harris Health, and-Harris'Health is not the employee or agent of the Group or any Member. Neither the Group or any Member shall be liable for any acts or omissions of Harris Health;its agents or employees, any Physician,any Hospital, or any other person ororganization in which Harris Health has made, or hereafter shall make arrangements for the performance of''services under this Agreement. 8.2 LIMITATION ON LIABILITY Harris Health does not guarantee by this Agreement that any Participating Provider shall perform or properly perform such contracts;the only obligation of Harris Health in the event of breach of such contract by any Participating Provider shall be, upon request,to use its best efforts to procurethe needed services from another provider. Harris Health shall not be liable to a Member for any act of ommission,or commis- sion on the part of any Participating Provider. ! 8.3 REFUSAL TO ACCEPT TREATMENT/EXCESSIVE;TREATMENT 'Members may,for reasons personal to themselves, refuse to accept services or complete a Course of Treatment as recommended by a Participating Physician.,Participating,Physicians shall use their best efforts to render all necessary and appropriate professional services in a manner compatible with the Member's wishes, insofar as this can be done consistently with such Participating Physician's judgment as to the requirements of proper medical-practice. If a Member refuses to complete a recommended Course of,Treatment, and the Participating Physi clan believes that no professionally acceptable alternative exists, such member shall be so advised. If upon j being so`advised, the Member still refuses to follow the recommended treatment or procedure, then the Member shall be given no further treatment for the condition, and neither he Participating Physician,nor Harris Health shall have any further responsibility to provide care for such condition. A Member may appeal a withdrawal of treatment under this provision through the Member Complaint Resolution Procedure as described in Section 10.0 of this Agreement. If two(2)or more Participating Physicians who have rendered care to a Member inform Harris Health that the Member is receiving health services or prescription medications in a manner or in a quantity which is not medically necessary or not medically beneficial, the Member may be required by Harris Health to select a single Participating Primary Physician(hereafter,referred to as a "Coordinating Health Plan Physi- cian") and a single Participating Pharmacy, if Pharmacy benefits are available to Member, for the provi- sion and coordination of all future health services. If the Member fails to voluntarily select a Coordinating Health Plan Physician and a single Participating Pharmacy within thirty(30)days of written notice by Harris Health of the need to do so,_Harris Health shall designate a Coordinating Health Plan Physician and/or a'Participating Pharmacy'for the Member. Following selection or designationof a Coordinating Health Plan Physician for a Member, coverage of.health services set forth on this-Agreement shall be contingent upon each health service being pro- vided by or through written referral to the Coordinating Health Plan Physician for that Member. If, after sixty (60) days from initial notification by Harris Health, the Member is not in compliance with this Section, the Member may be terminated by Harris Health under Section 4.2.7. Section 9.0 EXCLUSIONS ON SERVICE RESPONSIBILITIES The rights of Members and obligations of Participating Providers under this Agreement are sub- ject to the exclusions as specified below. 9.1 MAJOR DISASTER OR EPIDEMIC In the event of any major disaster or epidemic that would severely limit the availability of Participating Providers to provide healthcare services on a timely basis, Participating Providers shall, in good faith, use their best efforts to render the benefits and services covered insofar as practical according to their best judgment and within the limitation of such facilities and personnel as are then available. If Harris Health and Participating Providers shall, in good faith, have used their best efforts to provide or make arrangements GA-889-20 i services, medical personnel or facilities, such other individuals on the Ad Hoc Review Committee shall be Participating Physicians. Within fifteen (15) business days of receipt of the request for a review, Harris Health shall respond, in writing, to inform the Member of the decision or resolution of the complaint by the Ad Hoc Review Committee. 10.1.2 Notification By Review Committee If the original complaint involved a physician-patient relationship, the written response of the Ad Hoc Review Committee shall inform the Member that he has the option, at his discretion, to submit the complaint to the mediation service maintained by the Tarrant County Medical Society, and that such media- tion shall usually be concluded'within a thirty (30) day to sixty (60) day time period. The notice shall in- form the Member that participation in the mediation process is voluntary and that mediation recommen- dations are non-binding on both parties. As part of their contractual obligation to comply with the Health Plan rules and regulations, Participating Physicians must cooperate with the Tarrant County Medical Society mediation service. 10.2 COMPLAINT RESOLUTION APPEAL PROCESS If a member is not satisfied with the decision of the Ad Hoc Review Committee, or the Tarrant County Medical Society mediation service, the Member may request an additional review by Harris Health. The Member must file a request for review within fifteen (15) business days of receipt of the decision of the Ad Hoc Review Committee or the mediation service. Upon receipt of a request for a review, Harris Health shall forward the review request and a complete record of the complaint history to the Medical Director and to Harris Health. After reviewing the complaint records, Harris Health shall convene an Ad Hoc Appeal Committee composed of Harris Health,the Medical Director and at least two other individuals not involved in the initial j investigation of the complaint. In the case of a complaint concerning medical treatment or services, medical personnnel or facilities, such other individuals on the Ad Hoc Appeal Committee shall be Participating Physicians. Within fifteen(15) business days of receipt of the request for a review, Harris Health shall respond, in writing,to inform the Member of the decision or resolution of the complaint by the Ad Hoc Appeal Com- mittee. If all parties involved in the complaint agree,'the complaint response of the Ad Hoc Appeal Com- mittee shall be final and binding on all parties: i Section 11.0 HEALTH CARE SERVICES 11.1 Benefits and Services i Harris'Health agrees to arrange for the provision of the benefits and services in the Schedule of Benefits and/or Riders, in accordance with the procedures and subject to the limitations and exclusions specified in such Schedule of Benefits and/or Riders and in this Agreement. I Unless referred in writing by a Participating Primary Physician(or by a Participating Specialist Physi- cian), and except in cases of Medical Emergency, benefits and services set forth in the Limitations and Exclusions Section of the Schedule of Benefits or any Riders that are rendered by a Participating Physi- cian other than a Participating Primary Physician shall not be covered. All hospital admissions must be authorized by Harris Health, and the Member's condition or required services must be such that treatment can be rendered only in a hospital setting. Harris Health and the Participating Physician may decide to provide Medically Necessary services on an outpatient basis or in an outpatient surgery unit. The use of alternative levels of care, such as outpatient hospital or home care, will be encouraged where possible based on Member condition and treatment. 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 the Schedule of Benefits and any Riders shall be available and covered only when provided by a Participating Physician, Participating Hospital or by another Provider under contract with Harris Health to provide healthcare services to Members. All charges related to services and supplies incurred prior to the Member's effective date, or after the Member's termination date of coverage under this Agreement shall not be covered. GA-889-22 I 13.4 ASSIGNMENT The benefits to a Member under this Agreement are specific to the Member and are not assignable or otherwise transferable. 13.5 AUTHORITY Any alterations or revisions to this Agreement shall not be valid unless evidenced by written amend- ment which has been signed by Group and by an officer of Harris,Health and attached to:the affected document. No other person has the authority to change this Agreement or to waive any of its provisions. 13.6 GOVERNING LAW This Agreement is executed and is to be performed in all respects in accordance with all federal' and Texas state laws applicable to Health Maintenance Organizations and all other applicable,Texas state laws or regulations. j 13.7 INCORPORATION BY REFERENCE The Schedule of Benefits, Group Enrollment Agreement, Applications, any optional-'Riders,''any'' Attachments, and any amendments to any of the foregoing, form a part of this Agreement as if fully incor- porated herein. Any direct conflict or ambiguity of this Agreement shall be resolved under terms most favorable to the'Member.' 13.8 ENTIRE AGREEMENT This Agreement constitutes the entire understanding betweeri Harris Health and Group. 13.9 INFORMATION TO MEMBER Upon execution of this Agreement, Harris Health sihall`provide to each Subscriber a copy of this Agreement and-an Identification Card. Such delivery shall be accomplished by mailing postage paid,to. the latest address furnished to Harris Health or bydelivery from a representative of Harris Health or Group to Subscriber. 13.10 UNIFORM RULES In the administration of Harris Health, this Agreement shall be applied uniformly to all Members similarly situated. 13.11 CALCULATION OF TIME In determining time periods within which an event or action is to take place for purposes of Harris Health, no fraction of a day shall be considered, and any act, the performance of which would fall on a Saturday, Sunday, holiday or other non-business day, may be performed on the next following business day. 13.12 EVIDENCE I Evidence required of any Member of Harris Health may be by certificate, affidavit, document, or other information which the person acting on it considers pertinent and reliable, and signed, made or presented by the proper party or parties. 13.13 SEVERABILITY If any provision of this Agreement shall be held invalid or illegal, the rest of this Agreement shall remain in full force and effect and shall be construed in accordance with the intentions of the parties as manifested by all provisions hereof including those which shall have been held invalid and illegal. Further- more, in lieu of any provision hereof which is found to be illegal, invalid or unenforceable, there shall be added hereto a provision as similar in terms to such illegal, invalid or uninforceable provision as may be possible and be legal, valid and enforceable without materially changing the purpose and intent of this Agreement. 13.14 VENUE The parties hereby expressly agree that this Agreement is executed and shall be performable in Tarrant County, Texas, and venue of any disputes, claims, or lawsuits arising hereunder shall be in the said Tarrant County. GA-889-24 HARRIS HEALTH SERVik.,-t AREA The Harris Health Service Area includes all four- teen(14)counties Central Texas. d parts of five(5)counties in North wichue " OKLAHOMA ' The following fourteen(14)counties are included in the Service Area: Bosque Hill Aroher elny Montague Lmm�r lira son Fermin Comanche Hood i " Cooke Y Dallas Johnson Denton Limestone Erath. Somervell � Freestone Tarrant Young 7ec1 Wise coum tl,m Hs,pFim Hamilton Wise 15 Denton In the following five (5) counties zip codes are t t 9 ;Ruek Remy included as specified in the Service Area: Tarrant Dallas ��� Parker COUNTY ZIP CODES Stephens PttloPmto 4 5 " Knurman �' Coryell 76512 12 1 3 Van Zand� 76525 76528 Hood 76538 Eesanna Johnson Ellis 76566 Erath c& 8 14 76580 13 S°0���� Henderson -Ellis 76064 Bosque Hill Navarro 76065 Comanche r Anderson Montague 76230 76239 Hamilton Freestone x 76251 Limestone 76270 10 Navarro 75110 Coryell w 76639 x Lalls Leon 75153 76679 �Snn Saba L mpasas Belle Robertsan 76681 Sam Parker 76008 76020 76066 1. All Saints Cityview Hospital 76074 2. All Saints Episcopal Hospital 76076 3. Arlington Memorial Hospital 76082 4. Campbell Memorial Hospital 76086 5. Cook-Ft. Worth Children's Medical Center 76090 6. Decatur Community Hospital 7. Harris Methodist Fort Worth 8. Harris Methodist Glen Rose 9. Harris Methodist H-E-B 10. Harris Methodist Mexia 11. Harris Methodist Northwest 12. Harris Methodist Southwest 13. Harris Methodist Stephenville 14. Walls Regional Hospital 15. Bridgeport Hospital