HomeMy WebLinkAboutContract 23176 ' x 819
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CITY SECRETARY
Summit Administrative
�. . TRACT N0.
o .
ervices
AUG 15 1907
THIRD PARTY ADMINISTRATOR AGREEMENT
This Third Party Administrator Agreement ("the Agreement") is by and between
Harris Methodist Texas Health Plan, Inc. d/b/a Summit Administrative Services, a
licensed Texas Third Party Administrator ("TPA") and the City of Fort Worth ("City's.
Group and TPA agree TPA will be the exclusive provider of the services described herein
on behalf of Group. The arrangement of the provisions of such services and benefits
shall be based on the statements and representations contained in this Third Party
Administrator Agreement and all exhibits attached hereto (hereinafter collectively called
the "Agreement"). Additionally, the TPA response to the Group Request for Information
(RFI) dated December 21, 1995 and the Request for Proposal (RFP) dated March 28,
1996 and other correspondence between TPA and Group concerning the RFP is hereby
incorporated by reference for all purposes. If there is any conflict between this
Agreement and the RFP or RFI responses, the various written responses to the RFI and
RFP will control.
RECITALS
WHEREAS, TPA is engaged in the business of performing certain administrative
services for self-funded health benefit plans; and
WHEREAS, the City has established a self-funded health benefits plan under
which all benefits and expenses are paid for its enrolled employees and other Covered
Persons; and
WHEREAS, the City desires to contract with TPA to provide administrative
services to it in connection with the self-funded portion of its health benefit plan;
NOW, THEREFORE, for and in consideration of the mutual terms, covenants,
and agreements set forth below, TPA and the City agree as follows:
SECTION ONE: DEFINITIONS
1.1 "Covered Person" means an employee, an employee's dependent or other
person who is entitled to benefits under the terms and conditions of the Plan.
1.2 "Plan" means the self-funded portion of the health benefit plan established by
the City to provide health benefits to its enrolled employees and other Covered
Persons.
1.3 "Plan Document" means the documents that set forth the eligibility and benefit
provisions of the Plan and provides for the payment or reimbursement of eligible
expenses.
SECTION TWO: TPA SERVICES
Agreement does not relate to, and is not applicable to, any benefits provided by the City
to any persons covered by Harris Methodist Texas Health Plan, Inc. or Harris Methodist
Health Insurance Company.
TPA will provide the following services:
2.1 Respond to inquiries from Covered Persons and providers regarding eligibility
requirements and Plan benefits.
2.2 Provide telephone access to TPA services on normal business days from 8:00
a.m. to 5:00 p.m.
2.3 Provide pre-certification for non-emergency hospital admissions and certification
for emergency hospital admissions.
2.4 Provide continuing stay and discharge planning services for Covered Persons
who*are hospital inpatients.
2.5 Provide - retrospective utilization review of all hospitalizations of Covered
Persons.
.2.6 Provide catastrophic case management services by first identifying the
catastrophic medical cases and then reviewing and continuing to monitor the
health care delivery for such patients. TPA further agrees to provide claims
notifications and to file claims in the manner required by Group's stop-loss
insurance company and to meet all other requirements imposed upon TPA by
the Group's stop-loss insurance company.
2.7 Provide utilization review and quality assurance services, including pre-
certification and certification services, for all medical services, including
psychiatric services provided under the Plan.
2.8 Receive, review, and verify the eligibility of all claims from Covered Persons.
2.9 Review claims to determine that (a) the charges are necessary and reasonable,
(b) the diagnosis is eligible for reimbursement, and (c) coverage is in force.
2.10 Assist Covered Persons in the filing and processing of claims.
2.11 Coordinate Plan benefits with other benefit plans, insurance plans, HMO's, and
other payors.
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2.12 Process and issue checks to Covered Persons or providers, as applicable under the
Plan.
2.13 Notify claimants or providers in writing of ineligible claims, indicating the reason for
the denial and pursue recovery of any claims which have been determined to have
been paid in error.
2.14 Furnish I.D. cards as approved by the Plan Administrator
2.15 Provide to the City and its designee the following monthly reports:
(a) Claims analysis by line of coverage and total;
(b) Claims list by participant;
(c) Monthly billing listing all employees and their appropriate coverage; and
(d) Provider report.
2.16 Provide to the City and its designee quarterly claims and management'
an ag ement'reports,
including contributions, income, and claims paid and expenses.
2.17 Provide the necessary data to the City and assist the City with preparation of any
regulatory reports and filing, including any reports required by ERISA(if applicable).
2.18 Perform a routine audit sampling of claims processed for the City, both paid and
denied; and provide a quarterly written report of the results to the City and its
designee. The audit will be based upon a 3-5% sampling of all claims processed
for the City.
2.19 Enforce the City's rights to reimbursement and subrogation on behalf of the City.
SECTION THREE: SERVICE FEE
3.1 The City shall pay TPA a fee of 5% of the claims paid during the previous month.
In the event, however, that the amount of claims paid by the City during a month
exceeds 120% of the amount of claims projected for that month by TPA ("the
aggregate attachment point"), TPA shall not be entitled to any fees for claims over
the aggregate attachment point. The City will pay such fees within ten (10) days of
the date that the City receives an invoice with sufficient information to allow it to
determine its liability under this Agreement.
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SECTION FOUR: REIMBURSEMENT FOR ACTUAL EXPENSES
TPA shall be entitled to reimbursement, upon request, for the actual expenses incurred as
follows:
4.1 Printed material, such as any special bulletins sent City employees, authorized by
the City or as otherwise provided herein.
4.2 Special mass mailings (benefit booklets, insurance certificates, employee status
reports, etc.) requested by the City.
4.3 Copy costs at $.15 per copy for information specifically requested by the City
beyond those necessary for TPA to carry out responsibilities under this Agreement.
SECTION FIVE: LIMITATION ON TPA AUTHORITY
The services to be provided by TPA shall be ministerial in nature and shall be
performed within the framework of policies, interpretations, rules, practices and
procedures made or established by the City. The City retains all final authority and
responsibility for the Plan and its operations. TPA is empowered to act on behalf of the
City in connection with the Plan only as expressly stated in the Agreement. TPA shall
-not have discretionary authority or discretionary controls respecting management of any
trust fund and shall not have authority to exercise control respecting management or
disposition of the assets of any trust and shall not render investment advice concerning
any money or other property of any trust fund and shall have no authority or
responsibility to do so. I
SECTION SIX: CITY DUTIES AND OBLIGATIONS
6.1 Benefit and Plan Information. The City shall provide TPA current and updated
(including all revisions or changes) information on its Plan and on all Covered
Persons in a format reasonably sufficient to enable TPA to carry out its duties
and obligations under the Agreement. The City shall notify TPA within a
reasonable period of time of any changes to such information irrespective of
whether such change is occasioned by an election to participate, an election to
terminate participation, or eligibility requirements.
6.2 Information for Audit and Management Reports. The City shall mail to TPA all
written materials necessary for TPA to complete any required monthly and/or
quarterly report, as determined by TPA, which are in the possession of the City
no later than two weeks prior to the date that such audit or report must be
submitted.
6.3 Responsibility for Funding of Plan and Payment of Claims. TPA does not insure
or underwrite the liability of the City under the Plan. The City has and retains the
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ultimate responsibility for funding of, and payment of claims under, its Plan and all
expenses incidental to such Plan. TPA shall not be required, under any
circumstances, to issue payments(s)for any Plan benefits or any other costs arising
out of the subject matter of the Agreement unless the City has previously deposited
sufficient funds in a bank account as set forth in Paragraph 7.2 to cover such
payments. TPA shall have no responsibility, risk, liability or obligation for the
funding of the Plan, or the amount of funds available to pay claims. The
responsibility and obligation for funding the Plan shall be solely and totally the
responsibility of the City.
6.4 Governmental Report and Tax Responsibility. All governmental reports including
those required in connection with the reporting and payment of Federal, state or
local taxes are the sole responsibility of the City. TPA will assist with all filings
required by State or Federal law relating to the Plan. All taxes either imposed on
the Plan or relating to the administrative services provided under the Agreement or
resulting from the benefits provided to Covered Persons are the sole responsibility
of the City.
6.5 COBRA Responsibility. TPA and the City agree management of COBRA benefits
will be in accordance with the COBRA Benefits Attachment attached hereto as
Exhibit A.
6.6 Responsibility for Determinations and Interpretations Under the Plan. The City shall
be solely responsible for determining eligibility criteria for its employees, group
members, dependents and any other persons who are eligible for benefits provided
under the Plan. TPA shall rely solely upon the City for the timely provision of
accurate eligibility information. City retains the right and responsibility to provide the
final interpretation of eligibility and bEinefit provisions held in dispute. TPA shall
assist the City in making such determinations and interpretations and shall
communicate same to the City's employees, group members, dependents and other
persons. The City shall be responsible for review of any appeals of denied claims.
6.7 Information to be Furnished by the City. The City shall furnish TPA with all
information necessary for the administration of benefits under the Plan, as TPA may
reasonably require.
SECTION SEVEN: BANKING ARRANGEMENTS
7.1 Deposits by the City to TPA's Escrow Account. The payment of all monthly
expenses relating to City's Plan will be pre-funded monthly to TPA's Texas
Commerce Claims Escrow Account at an amount approximately equal to one
hundred twenty percent (120%) of a monthly average of the most recent six month
claims payment period. This pre-funded amount will be reviewed periodically by
TPA and, if necessary, a request to adjust the amount of the pre-funding will be
made to the City whose approval will not be unreasonably withheld. The City will
be notified, in writing, by the 10th of each month of the amount needed to reimburse
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the Claims Escrow Account to maintain the agreed upon pre-funded balance. The
City shall initiate the wire transfer for such funds to the account within 48 hours of
the written notice (to fund the account). The City's funds will be deposited into an
interest earning account which interest shall be applied monthly to reduce the
amount of funds required to fund to the agreed pre-funding amount. All balances
remaining in this account upon termination of this Agreement will be returned to the
City not later than the last day of the fourth month following the date of notice of
termination of this Agreement.
7.2 Claims issued. TPA shall pay all claims from the Plan escrow account maintained
by TPA.
SECTION EIGHT: EFFECTIVE DATE AND TERM
8.1 Effective Date. The Effective Date of the Agreement is October 1, 1996.
8.2 Term. The term of the Agreement shall be for one year commencing on the
Effective Date set forth above.
8.3 Option to Renew. The City shall have the option to renew the Agreement for
four successive one-year terms, with each successive term to commence on
October 1. If the City does not notify TPA of its desire not to renew the
Agreement at least sixty (60) days prior to the conclusion of this one-year term or
any successive term, the Agreement shall be extended for a one-year tqn-n.
SECTION NINE: TERMINATION
9.1 Termination with Cause. Either party shall have the option to terminate the
Agreement for cause upon the occurrence of any of the following:
(a) Failure of the other party to cure any default under the Agreement within
thirty (30) days of receipt of written notice;
(b) Failure of the other party to comply with applicable statutory or regulatory
requirements within fifteen (15) days after receipt of written notice; or
(c) Negligence, fraud or embezzlement on the part of either party.
9.2 Effect of Termination. Upon termination of the Agreement, TPA shall continue to
process all claims that have been submitted; and,
Process all claims, with dates of service prior to the termination date, which are
submitted to TPA for adjudication for the three (3) months immediately following the
effective date of termination. At completion of the 3 month period after termination,
the two parties may mutually agree to to extend this arragement for additional thirty
day periods.
TPA shall continue to receive the service fees detailed in Section 3 of this
Agreement for any month to month extension period.
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SECTION TFK1- Pr=nnono AND FILES R
SERVICES ELATING TO ADMINISTRATIVE
10-1 TPA shall maintain all records in conjunction with the administrative services
be Performed hereunder. The City shall have the right to examine the records off
TPP-, relating to benefit payments, claims for benefits, and the issuing of draft for
payments under the Plan; provided, however, that any examination of individual
benefit payment records shall be carried out in a manner agreed to between the
City and TPA designed to protect the confidentiality of the Covered Person's
medical information. In the event of the termination of the Agreement, TPA shall
deliver the appropriate information on all claims histories, work sheets, and
claims analysis to the City; provided however, TPA shall be entitled to retain
copies of such records at its own expense. All data and records pertaining to all
transactions relating to Covered Persons are the property of the City. TPA shall
maintain all records relating to services provided pursuant to this AGreement for a
period not less than four years past the termination date of this Agreement at which
time they may be appropriately destroyed subsequent to written permission of the
City to do so.
10.2 Access to Books and Records. Until the expiration of four years after the
furnishing of services pursuant to the Agreement, TPA shall make available upon
written request of the Secretary of Health and Human Services, or any of their
duly authorized representatives, a copy of the Agreement, and those of its
books, documents and records that are necessary to certify the nature and
extent of costs incurred by TPA under the Agreement. If TPA carries out any of
the duties of the Agreement with a value Of $10,000 or more over a twelve-
month period through a subcontract with a related organization, such
subcontract must contain a clause to the effect that until the expiration of four
years after the furnishing of services under the subcontract, the related
organization shall make available upon written request of the Secretary of Health
and H'uman Services or the U.S. Comptroller General, or any of their duly
authorized representatives, the subcontract, and those of its books, documents,
and records that are necessary to certify the nature and extent of costs incurred
by TPA under the subcontract.
SECTION—ELEVEN: INDEMNIFICATION
11.1 Each party shall be liable for its own act and omissions incurred in the
performance of its specific obligations under the Agreement.
11.2 It is the intent of TPA and the City to cooperate fully with each other with respect
to any such claim or suit against either party.
11.3 TPA agrees to maintain the coverage as required by the Texas Department of
Insurance, and TPA agrees to indemnify and hold City harmless against any and
all loss, damage and expense including court costs and attorney fees including
dishonest, fraudelent or criminal acts of the TPA's employees, officers, and;agents
in performing services under the Agreement.
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11.4 It is the intention of bo ;, pab as that, without the consent of the other, neither will
in any case take any action, waive any defense, or compromise any suit which
would knowingly prejudice the other party's defense with respect to the
commission of a crime or the violation of any penal provision of any state's
insurance laws, unless required to so by law.
SECTION TWELVE: COMPLAINTS AND LITIGATION
12.1 TPA agrees to contact City immediately when a dispute emerges regarding the
rejection of any claim, denial of benefits, eligibility or coverage. If a suit arises as
a result of any rejected claim or denial of benefits, eligibility, or coverage and the
suit is subsequent to the City's having been contacted and a written decision having
been rendered regarding the matter held in dispute, the City will defend at its
expense and pay any judgment levied against the City, its officers, and/or
employees arising therefrom, unless, at the City's request, TPA agrees to defend
such claim at the City's expense or upon such other terms and conditions as the
parties shall agree upon.
SECTION THIRTEEN: GENERAL PROVISIONS
13.1 Relationship of.Parties. In performing the service herein described, TPA shall be
acting only as an independent contractor and shall not be designated or deemed
the administrator with respect to the Plan or the appropriate named fiduciary for
review of claims denials under the Plan for the purpose of the Employee
Retirement Income Security Act of 1974 or any other Federal or state law of
similar nature. TPA shall arrange for the provision of all services hereunder as
an independent contractor and not as.an officer, agent, servant or employee of
the City.
13.2 Responsibility of Parties. The City is solely responsible for its obligations under
the Plan. TPA undertakes to provide administrative services only. TPA shall use
ordinary care and reasonable diligence in the exercise of its powers and the
performance of its services, and shall not be liable for any loss unless resulting
from its negligence or willful misconduct.
13.3 Non-Appropriation of Funds. In the event no funds or insufficient funds are
appropriated and budgeted in any fiscal year for fees due pursuant to the
Agreement, the City shall notify TPA as to the prospective date on which said
funds will no longer be available. The Agreement shall be terminated on the last
day of that month in which said notice is effective without penalty or expense to
the City of any kind whatsoever, except as to the portions of fees herein agreed
upon for services rendered through the effective date of termination.
13.4 Severability. If any part, term, or provision of the Agreement shall be held void,
illegal or unenforceable, the validity of the remaining portions or provisions.shall
not be affected thereby.
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13.5 Appendices Each Appendix and Exhibit to this Agreement, including TPA's Bid
Proposal, is a part of this Agreement as if set forth as a numbered paragraph.
13.6 Notices. Any notice required or contemplated to be given pursuant to the terms
hereof shall be in writing and sent by either certified mail, return receipt
requested, postage prepaid, hand delivered or telephone to:
Summit Administrative Services
611 Ryan Plaza Drive, Suite 900
Arlington, Texas 76011-4009
Attention: John Lampton
Fax number (817) 462-6769
Legal Department
Harris Methodist Health, Inc.
6000 Western Place, Suite 340
Fort Worth, Texas 76107
Attention: Kenneth J. Kramer
and to:
The City of Fort Worth
1000 Throckmorton
Fort Worth, Texas 76102
Attention: Susan Bulla
Fax number: 871-6180
13.7 Venue and Jurisdiction. Should any action, whether real or asserted, at law or
equity, arise out of this execution, performance, attempted performance or non-
performance of the Agreement, venue for said action shall lie in Tarrant County,
Texas. The Agreement and any action in connection herewith is and shall be
governed, construed and enforced by the laws of the state of Texas.
13.8 Audit and Review. TPA's performance of services and maintenance of records
pursuant to the Agreement shall be subject to review by the City at any time.
Review will be at the sole expense of the City and upon reasonable notice during
ordinary business hours. TPA 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 the City.
13.9 Use of Name. The City shall not use the name of TPA except as authorized in
writing. TPA shall not use the name of the City except as necessary for the
performance of the Agreement and as authorized in writing. TPA shall not
perform any written or oral surveys of Covered Persons unless the City and TPA
have agreed in writing to the scope, content, method of contact, purpose and
publication of survey. Such survey shall canvass only the City's Covered
Persons, except when the survey is with enrolled members of other groups
similarly contacted. When consent is required, TPA shall contact the City's risk
manager who must agree or disagree in writing with the survey within seven
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days (7) after being contacted by TPA or such survey will be deemed acceptable
by the City.
13.10 Amendment. The Agreement shall not be modified or amended except in
writing, signed by an officer of TPA and an authorized representative of the City.
The waiver by a party of a breach or violation of any provision of the Agreement
shall not operate as, or be construed to be, a waiver of any subsequent breach
or violation thereof.
13.11 Enforceability. The invalidity or unenforceability of any terms or provisions
hereof shall not, unless otherwise specified herein, affect the validity or
enforceability of any other term or provision of the Agreement.
13.12 He_ adings. The headings contained are for convenience of reference only and
are not intended to define, limit or describe the scope or intent of any provision of
the Agreement.
13.13 Waiver. The waiver by either party of any of the terms or provisions of the
Agreement shall not be deemed to constitute a waiver of any of its other terms or
provisions. No waiver of the provisions of the Agreement shall be deemed to
constitute a continuing waiver thereof unless otherwise expressly provided
herein.
13.14 Execution in Counterparts. The Agreement may be executed in counterparts, all
of which together shall constitute one and the same instrument.
13.15 Assignment and Delegation. The Agreement shall be binding upon and inure to
the benefit of the parties hereto and their respective successors and assigns.
Neither party shall assign, subcontract or otherwise delegate its rights and
responsibilities under the Agreement without the other's prior written consent,
which consent may be withheld solely at the discretion of such party.
13.16 Performance— Guarantees. Due to the exclusive carrier status granted TPA by
this Agreement,- TPA hereby enters into the performance guarantees contained
in the Performance Guarantee Exhibit attached hereto as Exhibit B.
13.17 Wellness Initiative. TPA will offer a comprehensive Wellness Initiative for all City
employees -for the period October 1, 1996 through September 30, 1997 as
described in the Wellness Exhibit attached hereto as Exhibit C.
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IN WITNESS WHEREOF, the parties hereto executed this Agreement with the
Effective Date herein provided.
HARRIS METHODIST TEXAS CITY OF FORT WORTH
_ HEALTH PLAN, INC. d/b/a
SUMMIT ADMINISTRATIVE SERVICES
By: By:
Name: Vk Name:
Title: \- �� .�— Title:
ATTEST:
By:
ecretary
APPROVED AS TO FORM AND LEGALITY:
By:
Assistant City A ey
Date: Mi-C C--15'.5"7!t rAX,(.,--.� _
aAkjk:skk\thp1\fwseltpa.doc\111396
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EXHIBIT "A"
COBRA ATTACHMENT
City and TPA desire to further delineate the responsibilities under COBRA
between the City on one hand and TPA on the other and agree as follows:
City shall have the following COBRA responsibilities:
1 City shall provide written notice to each covered employee of his/her
COBRA rights at the time of commencement of coverage 'under the group
health plan covered by this Agreement;
2. City shall determine when a qualifying event occurs within the meaning of
COBRA when such qualifying event results in loss of coverage with
regard to:
(a) qualifying events involving: (1) the death of the covered employee,
(2) the termination or reduction of hours of a covered employee's
employment, (3) the covered employee becoming entitled to
Medicare benefits, or (4) the filing of a bankruptcy proceeding by or
against City, City shall notify TPA in writing of such qualifying
events within thirty (30) days of their occurrence when such
qualifying events would result in loss of coverage;
(b) qualifying events involving: (1) divorce or legal separation of a
covered employee from the employee's spouse, or (2) dependent
child of a covered employee ceasing to be a dependent under
applicable plan provisions upon notice by the covered employee,
City shall direct covered employee to notify TPA of such qualifying
event;
each qualified beneficiary who is disabled on the date of a
qualifying event and who has properly elected COBRA because of
a qualifying event involving termination or reduction of hours of a
covered employee's employment, City shall notify TPA, as
appropriate, within five (5) working days after City receives notice
from such qualified beneficiary of. (1) a determination under the
Social Security Act that such qualified beneficiary was disabled on
the date of the qualifying event, and (2) of a subsequent final
determination under the Social Security Act that' such qualified
beneficiary is no longer disabled;
except that the City shall rely solely upon the covered employee or the
covered dependent, as appropriate, for written notice of qualifying event if
the qualifying event is (1) divorce, (2) legal separation or (3) dependent
child(ren) becoming ineligible under the plan as such notice is required
under proposed COBRA regulations.
3. City shall provide to TPA the name, and last known address of the
qualified -beneficiary as such were reported to the City by the covered
employee whose coverage has been lost due to a qualifying event; and
4. City shall notify TPA of any information it receives which would result in
the termination of COBRA coverage for reasons other than failure to pay
premium or expiration of the maximum required period of coverage under
COBRA.
TPA shall have the following COBRA responsibilities:
1. TPA shall determine COBRA eligibility of covered employees and-their
eligible dependents in accordance with COBRA and its implementing
regulations;
2. TPA shall within fourteen (14) days of receipt of written notice from the
City of a qualifying event (other than divorce or legal separation of a
covered employee from the employee's spouse or a dependent child of
the covered employee ceasing to be a dependent) furnish each affected
qualified beneficiary written notification of the termination of regular
coverage under the health plan, together with a written recital of the rights
of such qualified beneficiary to elect continuation coverage under COBRA
and forms whereby the qualified beneficiary can elect such coverage;
3. TPA shall, in regard to. a qualifying event involving divorce or legal
separation of a covered employee from the employee's spouse or a
dependent child of the covered employee ceasing to be a dependent,
provide such notification and application within fourteen (14) days of
receipt of such notice from the covered employee or his covered
dependent of such qualifying event;
4. TPA shall determine continued eligibility for COBRA participation by
qualified beneficiaries;
5. TPA shall determine the amount of premium payment owed by a qualified
beneficiary, and the method of payment;
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6. TPA shall collect premiums from qualified beneficiaries;
7. TPA shall send notice to qualified beneficiaries of termination of COBRA
coverage;
8. TPA shall, in regard to a qualified beneficiary who is receiving COBRA
continuation coverage because of termination, or reduction of hours, of
the covered employee's employment, notify the qualified beneficiary of his
option to enroll under a conversion health plan otherwise generally
available under the City's health plan;
9. TPA shall enroll a qualified beneficiary within five (5) working days of
receipt of such beneficiary's timely filed COBRA election; and
10. TPA shall furnish to the City the appropriate reports to track the premiums
and claims of COBRA participants.
11. TPA shall make all COBRA notifications required under the Health
Insurance Portability and Accountability Act of 1996.
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EXHIBIT "B"
PERFORMANCE GUARANTEE
As part of the consideration for its serving as the Group's exclusive carrier, TPA
establishes the following performance guarantees with associated liquidated damages.
If a deficiency is identified in guarantee performance by the Group in writing, TPA will have
thirty (30) days from receipt of the written notice to address and resolve the written
deficiency. If the guaranteed performance cannot be achieved within the thirty (30) day
period, then payment of the liquidated damages will be due as specified below.
Guarantee #1
TPA guarantees a 90% overall member satisfaction. level for Covered Persons
aggregated for all product lines during each contract term year, as measured by TPA's
independent third party market research firm. Satisfaction will be measured quarterly
across all product lines and combined to obtain the yearly rate. The City will rely on reports
provided by TPA within sixty (60) days after the end of each contract term year. Interim
status reports will be provided to the City within sixty (60) days after the end of each
quarter of each contract term year.
Liquidated Damages
The liquidated damages payable are set forth in the Agreement between the Group
and the Harris Methodist Texas Health Plan,, Inc.
Guarantee #2
Consistent with the Group Minority and Women's Business Enterprises (M/WBE)
goals, City of Fort Worth Ordinance 11923 and HMHPs negotiations with the Group,
including the written responses to the RFI and RFP, SA &is,committed to the following
goal: TFA kt:t") ,�As
10% of the total contract expenditures aggregated across all Harris Metho
contracts and product lines will be direct purchases from M1WBE vendors. &AMS VPA
Awl
provide reports to the Group within sixty (60) days after the end of each contract term year.
Interim status reports will be provided to the Group within sixty (60) days after the end of
each quarter of each contract year and as soon as practicably possible.
Liquidated Damages
The liquidated damages payable are set forth in the Agreement bet ween the Group
and the Harris Methodist Texas Health Plan, Inc.
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Guarantee #3
TPA guarantees that all "clean claims" as defined below, aggregated across all
product lines, will be paid in an average of fifteen (15) days or less ("the timeliness
measure") during each contract term year.
The definition of a "clean claim" is a claim that does not require additional
information in order to process
Further, TPA guarantees 95% of all claims paid (across all product lines)will be paid
accurately (the "accuracy measure").
Both performance standards will be measured by reports generated by TPA at the
end of each contract term year, and provided to the City within sixty (60) days after the end
of the contract term year. Interim status reports will be provided to the City within sixty (60)
days after the end of each quarter of each contract term year and as soon as practicably
possible.
Liquidated Damages
The liquidated damages payable are set forth in the Agreement between the Group
and the Harris Methodist Texas Health Plan, Inc.
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Harris Methodist
gist
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THIS WELLNESS PROGRAM HAS BEEN DEVELOPED AS A VALUE ADDED FIRST YEAR
BENEFIT TO THE FLEX PLAN PROPOSAL(OPTION B). THE HARM METHODIST
HEALTH PLAN WILL UNDERWRITE THE COSTS OF THE PRO GRAM
APPLICABLE MEMBER CO PAYS). The focus of the wellness and Prevention program FOR THE
the health of employees in partnership with the City of Fort Worth. The Harris h a to improve
ability to assess the health risks of the city's employee Methodist Health Plan s
health promotion programs ty' mp o�population will enable us to provide a variety of
P at multiple intensity levels. The assessment process will enable employees to
attend programs appropriate to their readiness level to make lifestyle changes. The program focuses
include assessment,awareness building,intervention and follow up to ensure those individuals who make
lifestyle changes are supported in their efforts.As a result of these changes,Harris Methodist will look to
demonstrate increased morale,reduced sick days and leave,improved productivity,and reduced health
care costs in conjunction with the City.
• Modifiable Claims Audit CA `
The MCA (MCA) Wellness Events
that nearly performed
million doll=are associated to Monthly wellness events will focus upon the current
lifestyle related claims. The MCA demonstrates that health issues and concerns prevalent in the MCA
the City ofFort Worth has the potential to save$1.5 report and the Health RiskAssessrnent group
million dollars in claims incurred b the City's summary. As an awareness building activity,3-4
employees by addressing Y events can be scheduled at the Cxty's request, Please
including the City's top health risks see the enclosed list ofrecommended topics.
oig lack of exercise,accidents,obesity,and
smoking.. The actual amount ofrecovmy will be Wellness and Prevention
Intervenfion
dependent upon the City's support of the programs
and the employees' Programs
response and adherence i f the The intervention programs are designed to target
Programs. Please review the MCA for specifics on specific lifestyle and behavior changes based these potential cost savings. the MCA assessment. The recommended programs
• Health Risk,Assessments and Health Fairs include tobacco cessation, management,and
_ The Health Risk Assessment will provide the City iet,nutrition,and weight management programs.
with an aggregate summary report of the health ty Each Proms is associated with a member co-pay
lifestyles and key biometdc data of its employees. c�ch detnonstrates.ou the members part a
These results will direct the wellness programming mmitment with the value associated with the
program.by Providing appropriate o 1�s and
screenings to improve the health of the entire
Population- In addition.the Mammography Screening
Gusto employee will value their To increase easy accessible,mammo
customized health assessment report which will will be offered for the ladies by use of the Mobile g
explain their results and provide suggestions to
improve their overall health. The assessment process Mammography Unit and as part of the Harris
is most attractive at worksite health fairs. The health Methodist Health Plan schedule of benefits,the there
fairs provide$cr is no cost involved for this screening, The screening
blood r for eholesterol,diabetes, guidelines follow those defined
Pressure,height, de by the American
composition gad are staffed by trained medical Hit Association for women over the age of 35
Professionals. years. The unit has the flexibility to be scheduled at
various locations and times.
• Diabetes Education
The diabetes education program is designed to screen ° Prostate Screening
and educate employees at the worksite health fairs Addressing male health issues will be accomplished
and refer those at high.risk to their by focusing upon prostate cancer by use of a lab
physician. Highlights of the program include annual Prostate screening analysis for men over the age of 50
yarn
comprehensive diabetes education for diabetic health ' The screening,or PSA,can be done in
Plan members,diabetic risk factor assessement,blood conjunction with any of the wellness services and will
Plan ine testing,and is employee fa s be followed up by a registered nurse reviewing the
high risk individuals. specific follow up for information and forwarding the results to the
individual's physician.
HARRIS METHODIST HEALTH INSURANCE COMPANY
611 Ryan Plaza Drive, Suite goo
Arlington, Texas 76011-4009
8171462-78000
1-800-633-8698
GROUP ENROLLMENT AGREEMENT
This Group Enrollment Agreement is entered into by and between Harris Methodist
Health Insurance Company hereinafter called "HIC" 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 Certificate of Insurance. Group and HIC agree HIC will be the
exclusive provider of the services described herein on behalf of Group. 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
AK i hereto (hereinafter collectively called the "Agreement). Additionally, the HIC response to
the Group Request for Information (RFI) dated December 21, 1995 and the Request for
Proposal (RFP) dated March 28, 1996 and other correspondence between HIC and
Group concerning the RFP is hereby incorporated by reference for all purposes. If there
is any conflict between this Agreement and the RFP or RFI responses, the various written
responses to the RFI and RFP will 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, 1996 and continue until 12:00 A.M. Central Time, on the 30th day of
September, 1997, (the "Initial Term") unless earlier terminated as provided herein
or in the Group Health Care AgreementlSubscriber Certificate of Coverage
attached hereto as Exhibit "A" and incorporated herein by reference for all
Purposes.
3. ELIGIBILITY
To be eligible for the Group Product, the member must meet bas.ic requirements
for Group eligibility which are attached hereto, as Exhibit "B" and incorporated
herein by reference for all purposes.
EMPLOYEE CONTRIBUTIONS: .
Medical Insurance: Employee [ ] Non-Contributory [X ] Contributory
Dependent [ ] Non-Contributory [X] Contributory
EFFECTIVE DATE of coverage will be in accordance with Group eligibility rules.
WAITING PERIOD: None days 1 ] months other
4. HEALTH CARE SERVICES (BENEFITS)AND COPAYMENTS
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 "C" and incorporated herein by
reference for all purposes.
B. Prescription Drug:
X Accepted
Not Accepted
C. Serious Mental Illness Rider:
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 "D" which exhibit is 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 four (4).
successive terms of one (1) year each, unless terminated by HIC or Group
2
as provided herein or in the Group Health Care Agreement/Subscriber
Certificate of Coverage. If Group does not notify HIC 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.
For the period of the first renewal term (October 1, 1997 through September
30, 1998), HIC guarantees no rate increase from the rates specified in
Exhibit D.
Not later than ninety (90) days prior to October 1, 1998, HIC shall negotiate
and defend any increase in rates and HIC further agrees that any increase
in rates for the third year of this Agreement shall not exceed five percent
(5%) of the fully insured rates as set forth on Exhibit "D" attached hereto
and incorporated into and made a part of this Agreement.
Not later than ninety (90) days prior to October 1, 1999, HIC shall negotiate
and defend any increase in rates and HIC further agrees that any increase
in rates for the fourth year of this Agreement shall not exceed nine percent
(9%) of the fully insured rates established for the third year of the
agreement
Not later than ninety (90) days prior to October 1, 2000, HIC shall negotiate
and defend any increase in rates and HIC further agrees that any increase
in rates for the fifth year of this Agreement shall not exceed nine percent
(9%) of the fully insured rates established for the fourth year of the
agreement.
C. Premiums are due monthly on the tenth (10th) day of the month.
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" and incorporated herein by
reference for all purposes.
8. INDEMNIFICATION
HIC covenants and agrees to, and does hereby, indemnify and hold harmless and
defend Group, its officers, employees, 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
HIC's insolvency, bankruptcy or misappropriation of funds, or any negligent act,
3
ZZ
omission or malfeasance on the part of HIC, its officers, directors and employees
in the course of the administration of this Agreement.
9. AUDIT AND REVIEW
HIC's performance of services and- maintenance of records pursuant to this
Agreement shall be subject to review by Group at any time. Review will be at the
sole expense of Group and upon reasonable notice during ordinary business
hours. HIC 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 right 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 HIC 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, HIC agrees to
provide on site service to Eligible Persons during Group's regular business hours
at the Group's offices. The services to be provided include the following:
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 Group's eligibility policy and receive information from
Eligible Persons regarding changes in status
d. assist in filing claims
e. research claims processing status
4
f. assist with such other duties for Group which are acceptable to HIC
HIC acknowledges and agrees that any service representatives providing service
on behalf of HIC are employees of HIC and the Group has no responsibility or duty
to supervise, direct, compensate or control such HIC employees, and that the
doctrine of feapondent superior shall-not apply as such between HIC employees
and the Group.
13. USE OF NAME AND MEMBER SURVEYS
HIC and Group shall not use the name of the other party except as necessary for
the performance of this Agreement and as authorized in writing. HIC, its
employees, agents or subcontractors shall not perform any written or oral surveys
of Group's Eligible Persons unless Group and HIC have agreed in writing to the
scope, content, method of contact, purpose, and publication of survey. HIC shall
contact Group's designated representative who must agree or disagree in writing
with the survey within seven (7) days after being contacted by HIC or such survey
will be deemed acceptable by Group. Notwithstanding the foregoing, HIC 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
HIC 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 herein and in Section 7.0 of the Group Master
Policy/Health Care Certificate of Insurance, 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.
L
5
16. COBRA BENEFITS
Group and HIC agree management of COBRA benefits will be in accordance with
the COBRA Benefits Attachment attached hereto as Exhibit F and incorporated
herein by reference for all purposes.
17. PERFORMANCE GUARANTEES
Due to the exclusive carrier status granted HIC by this Agreement, HIC hereby
enters into the performance guarantees contained in the Performance Guarantee
Exhibit attached hereto as Exhibit G.
18. WELLNESS INITIATIVE
HIC will offer a comprehensive Wellness Initiative for all Group employees for the
period October 1, 1996 through September 30, 1997 as described in the Wellness
Exhibit attached hereto as Exhibit H.
19. ASSIGNABILITY
Neither HIC 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.
IN WITNESS WHEREOF, the undersigned have caused the Group Enrollment
n
Agreement to be executed on the day of 19-V, to be effective as
herein provided.
HARRIS METHODIST HEALTH CITY OF FORT WORTH
INSURANCE COMPANY
By: By:
Name: Name:
Title: Title:
fOOO Throckmorton
Fort Worth, Texas 761 2
FT
ATTEST:
By.
City Secretary
APPROVED AS TO FORM AND LEGALITY
By:
Assistant City mey
Date: MV-C- C-/9 5Z!2c- (,/?.P,u-:
aAkjk:skklhic\hicfwgea.doc\101096
2
CITY SECRETARY-
CONTRACT Np
-
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AUG 15 1997
PPO
GROUP ACCIDENT AND HEALTH INDEMNITY PLAN -
GROUP MASTER POLICY/CERTIFICATE OF INSURANCE
HARRIS METHODIST HEALTH INSURANCE COMPANY
601 Ryan Plaza Drive, Suite 211
Arlington, TX 76011
(817) 462-7522
1-800-356-5152
PPOLGCO1896
IMPORTANT NOTICE AVISO IMPORTANTE
To obtain information or make a complaint: Para obtener informacion o para someter una
queja:
You may call Harris Methodist Health Insurance
Company's toll-free telephone number for Usted puede Ilamar al numeeo de telefono gratis
information or to make a complaint at: de Harris Methodist Health Insurance Company
para informacion o para someter una queja al:
1-800-356-5152 1-800-356-5152
1-817-462-7522 1-817-462-7522
You may also write to Harris Methodist Health
Insurance Company at: Usted tarnbien puede escribir a Harris Methodist
Health Insurance Company:
Harris Methodist Health Harris Methodist Health
Insurance Company Insurance Company
611 Ryan Plaza Drive 611 Ryan Plaza Drive
Suite 156
Arlington, Texas 76011-4009 Suite Arlington, Texas 76011
FAX#: (817) 462-7235
FAX:#(817) 462-7235
You may write the Texas Department of Puede comunicarse con el Departamento de
Insurance to obtain information on compani(:s,
coverages, rights or complaints at: ` Seguros de Texas para obtener informacion
acerca de companias, coberturas, derechos o
1-800-252-3439 quejas al:
You may write the Texas Department of 1-800-252-3439
Insurance at:
Puede escribir al Departamento de Seguros de
Texas'Department of Insurance Texas:
P.O. Box 149104
Austin, TX 78714-9104 Texas Department of Insurance
P.O. Box 149104
FAX# (512) 475-1771
Austin, TX 78714-9104
PREMIUM OR CLAIM DISPUTES: FAX# (512) 475-1771
Should You have a dispute concerning Your
premium or about a claim, You should contact
DISPUTAS SOBRE PRIMAS O RECLAMOS:
Harris Methodist Health Insurance Comp:ny Si tiene una disputa concerniente a su prima o
first. If the dispute is not resolved, You nay a un reclamo, debe comunicarse con la
contact the Texas Department of Insurance. compania Si no se res lee la disput
puede entonces comunicarse con e,
ATTACH THIS NOTICE TO THE POLICY: departamento (TDI).
This notice is for information only and does iot
become a part or condition of the attached UNA ESTE AV1SO A SU POLIZA:
document. Este aviso es solo para proposito de
informacion y no se convierte en parte o
condicion del documento adjunto.
NOTICE.96 2
PREFERRED PROVIDER PROVISIONS
(PPO)
Your Employer has elected this PPO Option. If You or Your Dependent receive Covered Services from
a Preferred Provider, the Percentage Payable will be increased and subject to any deductibles (and
copayments) as shown in the Schedule of Benefits.
A Preferred Provider is a Hospital, Skilled Nursing Facility or any other medical or health-related service
facility, Physician, Provider or Other Health Care Practioner who has contracted with Us for the purpose
of reducing health care costs by negotiating fees.
A Non-Preferred Provider is a Hospital, Physician, Provider or Other Health Care Practitioner who has
not contracted with Us.
PPO Service Area means the geographical area in which Preferred Providers have contracted with Us
are located. The following counties are designated as Your PPO Service area:
North Central Texas: Montague, Cooke, Grayson, Jack, Wise, Denton, Collin, Palo Pinto, Parker,
Tarrant, Dallas, Rockwall, Eastland, Erath, Hood, Somervell, Johnson, Ellis,
Kaufman, Comanche, Hamilton, Bosque, Hill, Navarro, Coryell, McLennan,
Limestone, Freestone, Falls
East Texas: Delta, Rains, Leon, Fannin, Smith, Madison, Franklin, Van Zandt, Milam,
Hopkins, Wood, Polk, Hunt, Angelina, Robertson, Lamar, Gregg, San Jacinto,
Red River, Harrison, Trinity, Bowie,..Marion, Walker, Camp, Nacogdoches,
Waller, Cass, Panola, Washington, Morris, Rusk, Hardin, Titus, Sabine,'Jasper,
Anderson, San Augustine, Jefferson, Cherokee, Shelby, Liberty, Henderson,
Upshur, Newton, Houston, Brazos, Orange,Burleson, Tyler, Grimes
A list of Preferred Providers in Your PPO Service Area will be given to You at the time Your coverage
becomes effective. Any changes to this list will be provided to You not less than annually. You may
call Us during regular business hours to receive a current, up-to-date list of Preferred Providers.
When an Insured Person requires Covered Services which are not available through a Preferred Provider,
benefits for Covered Services received from Non-Preferred Providers will be paid as if the Covered
Services were received from Preferred Providers. When services are received from Preferred Providers,
We will pay benefits directly to the Preferred Provider. This will apply regardless of any other provision
in the Policy to the contrary.
When an Insured Person receives covered Emergency Care services from a Non-Preferred Provider,
those services will be paid as if they were received from a Preferred Provider. However, once the
Insured Person can be safely transferred to a Preferred Provider, he will be required to transfer to a
Preferred Provider in order to continue receiving the Preferred Provider level of benefits. If the Insured
Person chooses not to transfer, benefits will be payable at the Non-Preferred Provider level.
PPOLGCO1896 3
"TABLE OF CONTENTS
SECTION 1 `DEFINITIONS PAGE 5
SECTION 2 SCHEDULE OF BENEFITS PAGE 16
SECTION 3 -
ELIGIBILITY'RULES` PAGE 17
SECTION 4
DETERMINATION OF ORDER OF BENEFITS PAGE 25
SECTION 5
COORDINATION OF COVERAGE UNDER COBRA PAGE 29
SECTION'6 CONTINUATION/CONVERSION PROVISIONS PAGE 31
SECTION 7 -
TERMINATION OF COVERAGE PAGE 37
SECTION 8 -
PREMIUMS PAGE 40
SECTION 9 WAIVER OF RIGHTS, INDIVIDUAL PAGE 42
CERTIFICATES, REINSTATEMENT, AND
REQUIRED INFORMATION -
SECTION 10, CLAIMS PAGE 43
SECTION 11 - GENERAL PROVISIONS PAGE 45
In the Policy, use of the masculine gender automatically implies the feminine gender unless the context
clearly shows otherwise.
PPOLGCO1896 4
SECTION 1: DEFINITIONS
Some words and phrases, used in this Certificate of Insurance,are defined below. Other words and
phrases are defined where they appear. The terms defined in this Section shall, for all purposes of the
Policy, have the following meanings:
ACTIVELY AT WORK means that the Eligible Employee must be performing the usual and customary
duties of their regular employment during usual working hours on their effective date of coverage;
provided however, that if the Eligible mployee is absent from work due to vacation,,holiday, jury duty;.
or similar circumstances, not cause by injury or sickness, the Eligible Employee shall be considered
Actively at Work. p{of-Vief o1 u� or ass i9,Imen+'4ui'Hori Zed by pu Ii cy�Did� `C`�
ADMINISTRATOR means an entity designated by the Company to pay Claims and administer the
Utilization Review Program.
AGREEMENT means this Certificate of Insurance, Schedule of Benefits, Riders, Applications and any
Attachments.
AMBULATORY SURGICAL CENTER means an appropriately licensed institution or facility, either free-
standing or as part of a Hospital, with permanent facilities equipped and operated for the primary
purpose of performing surgical procedures and to which a patient is admitted and discharged from
within a twenty-four (24) hour period.
The term Ambulatory Surgical Center does not include:
1. a Facility whose primary purpose is to end pregnancies;
2. an office maintained, by a Physician for the practice of medicine; or
3. an office maintained by a Dentist for the practice of dentistry.
APPLICATION means all forms required to be completed by the Policyholder and/or the Insured..
APPROVED HEALTH CARE FACILITY OR PROGRAM means a,Facility or Program which is licensed,,
certified or otherwise authorized according to the laws of Texas to provide Covered Health Services.-
ASSIGNMENT OF BENEFITS means a written transfer of benefits payable for Covered Health Services
made by the Insured and obtained by or delivered to the Company with the Claim for benefits. The
Company will pay the benefit payment directly to the Physician or other Health Care Provider. This
written Assignment of Benefits does not relieve the Insured of any contractual responsibility to pay the
Deductible, Coinsurance, Copayments or the Out-of-Pocket Maximum.
CALENDAR YEAR means January 1, 12:01 a.m. to January 1, 12:01 a.m. of the following year..
CERTIFICATE OF INSURANCE means this insurance contract delivered by the Company to the
Policyholder who then delivers it to the Employee.
CHEMICAL DEPENDENCY means the abuse of, or psychological or physical dependence on, or-
addiction to alcohol or a controlled substance.
PPOLGCO1896 5
CHEMICAL DEPENDENCY TREATMENT CENTER means a Facility that provides a program for the
treatment of Chemical Dependency according to a written treatment plan approved and monitored by
a Physician and is also:
1. affiliated with an approved Hospital under a contractual agreement with an
established system for patient referral; or
2. accredited as a Facility by the Joint Commission on Accreditation of Hospitals;
or
3. licensed as a chemical treatment program by the Texas Commission on Alcohol
and Drug Abuse; or
4. licensed, certified, or approved as a Chemical Dependency Treatment program
or center by any other state agency having legal authority to license, certify or
approve.
CHEMICAL DEPENDENCY TREATMENT CENTER SERIES means a planned, structured and organized
program to promote chemical free status.The series may include different facilities or modalities and
is complete:
1. when the Insured is discharged on medical advice from inpatient detoxification,
inpatient rehabilitation/treatment, partial"Hospitalization or intensive outpatient;
2. when the Insured completes`a series of these levels of treatments without a
lapse in treatment; or
3. when the Insured fails to materially comply with the treatment program for
thirty (30) days.
CLAIM means written Proof of Loss due to Injury, Illness, Maternity, Mental Illness or any other
condition showing that services and/or supplies have been supplied to the Insured under the Policy.
CO-INSURANCE PERCENTAGE means the Insured's share of Covered Health Services that the Insured
must pay. All Co-Insurance Percentage amounts are listed in the Schedule of Benefits. The Co-
Insurance Percentage is the percentage of the total billed amount, up to the Reasonable and Customary
Charge, for eligible`services by a provider. The Co-Insurance Percentage applies toward the Out-Of-
Pocket Maximum.
COMPANY means Harris Methodist Health Insurance Company also referred to as We, Us or Our.
PPOLGCO1896 6
COMPLICATIONS OF PREGNANCY means conditions requiring hospital confinement (when the
pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected
by pregnancy, including, but not limited to:
1 acute nephritis;
2. nephrosis;
3. cardiac decompensation;
4. missed abortion;
5. non-elective cesarean section;
6. termination of ectopic pregnancy;
7. spontaneous termination of pregnancy when a viable birth is not possible due to stage
of fetal development; and
8. similar medical and surgical conditions of comparable severity.
Complications of Pregnancy do not include:
1. false labor;
2. occasional spotting;
3. Physician prescribed rest during pregnancy;
4. morning sickness;
5. hyperemesis gravidarum;
6. pre-eclampsia;
7. elective cesarean section; and
8. similar conditions associated with the management of a difficult pregnancy but not
constituting a nosologically distinct Complication of Pregnancy.
CONGENITAL ANOMALY means a defective development or formation of a`part of the body which is
learned to have been present and discovered within the first three (3) months following birth.
CONTRACT means the Group Policy, Individual Enrollment Application, Group Enrollment Agreement
and any applicable amendments, addenda and/or Riders attached to the Policy.
CONTROLLED_SUBSTANCE means either a toxic inhalant or any substance designated as a Controlled
Substance in the Chapter 481, Health and Safety Code (Health and Safety Code, Section 481.002(5)).
COPAYMENT CHARGE means the charge which the Insured is required to pay for certain Covered
Health Services and supplies provided under this Contract. The insured is responsible at the time of
service for the payment of any Copayment Charge directly to the Provider of the Covered Health
Services.
COSMETIC SURGERY means surgery that is primarily for the purpose of improving appearance and
does not, other than incidentally, corrector improve a functional I impairment.
COVERED HEALTH SERVICES means those Medically Necessary services, supplies, or benefits
described in the Comprehensive Major Medical Benefits section of the Policy or any Rider provided
under the terms and conditions of the Policy.
CRISIS STABILIZATION UNIT means a 244-hour residential program licensed or certified as a Crisis
Stabilization Unit or Facility, that provides intensive supervision and highly structured activities to
persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe
proportions.
PPOLGCO1896 7
CUSTODIAL CARE means services and supplies furnished to the Insured to train or help in activities
of daily living, such as bathing, feeding, dressing, walking, and taking`oral medicine. Custodial Care
also means services and supplies, such as dressing changes and catheter care, which can safely and
adequately supplied by persons other than licensed health care professionals. Custodial Care also
means care that ambulatory patients customarily provide for themselves, such as ostomy care,
measuring and recording urine and blood sugar levels, and administering insulin. The Administrator
and/or an independent medical review will decide if a service or treatment is Custodial Care.
DENTIST means one licensed by the Texas E tate Board of Dental Examiners or licensed and qualified
to provide dental surgery, treatment,or care under the laws of the state or other jurisdiction in which
treatment is received.
DEPENDENT means the Employee's legal spouse, or unmarried children including foster child, step
child, grandchild, adopted child, all of who meet the eligibility`requirements for coverage under the
Policy. This does not include any active member in the armed forces of any country.
DESIGNATED MEDICAL CONVERSION CARRIER means the insurance company contracted by the
Company to provide conversion/continuation of the Policy.
DOMICILIARY CARE: refers to Custodial CE re as defined above.
DURABLE MEDICAL EQUIPMENT means equipment that is:
1. Medically Necessary;
2. _ made for and mainly used in the treatment of an Injury or Illness;
3. not primarily and customarliv used for'a non-medical purpose;
4. made to withstand prolonge d use and suited for use in the home; and -
5. not for altering air quality or temperature or for exercise or training (including,
but'notlimited to, air conditicners humidifiers, dehumidifiers, purifiers, exercise
bicycles, whirlpool baths, sun lamps, heat lamps or heating pads).'
EDUCATIONAL means that the primary'purpose of the service or supply is to provide the Insured
person with any of the following:
1. training in actvities`of daily living;
2. instruction in scholastic skill3 such as reading and writing,
3. preparation for an occupation; or
4. treatment for learning disabilities.
Training in the activities of daily living does not include training directly related to treatment of an
Illness or Injury that resulted in a loss of a previously demonstrated'ability to perform those activities.
EFFECTIVE DATE means:
1. with respect to the Policy, -:he date stated as the Effective Date on the face
page of the Policy; and
2. with respect to any Insurec, the date the Insured is first covered under the
Policy.
ELIGIBLE EMPLOYEE means an individual r✓ho is Actively at Work and who satisfies the eligibility
criteria established by the Employer and the Company and defined in the Policy.
PPOLGCO1896 8
EMERGENCY CARE means bona fide emergency services provided after the sudden onset of a medical'
condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that
the absence of immediate medical attention, could be expected to result in:
1. placing the patient's health in serious jeopardy;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.
EVIDENCE OF INSURABILITY means the Company's medical information application the Insured;
completed when applying for coverage during a time other than the Open Enrollment Period and/or
Initial Enrollment Period. This application could include medical records and a physical examination_
EXPERIMENTAL or INVESTIGATIVE PROCEDURE means that HMHIC determines that one or more of
the following is true:
1. The service or supply is under study or in clinical trial to evaluate its toxicity,
safety or efficacy for a particular diagnosis or set of indications. Clinical trials
include but are not limited to phase 1, 11 and III clinical trials.
2. The prevailing opinion within the appropriate specialty of the United States
medical profession is that the service or supply needs further evaluation for the
particular diagnosis or set of indications before it is used outside clinical trials
or other research settings.
We will determine if this item (2) is true based on:
a. published reports in authoritative medical literature; and
b. regulations, reports, publications and evaluations issued by government
agencies such as the Agency for Health Care Agreement and Research,
the National Institutes of Health and the FDA.
3. In the case of a drug, a device or other supply,that is subject to FDA approval:
a. it does not have FDA approval; or
b. it has FDA approval only under its Treatment Investigation New Drug
Regulation or a similar regulation;
C. it has FDA approval, but is being used as an indication or at a dosage'
that is not accepted off-label use. Unlabeled uses of FDA-approved
drugs are not considered experimental or investigational'if they are
determined to be:
(1) included in one or more of the following medical compendia:
the American Medical Association Drug` Evaluations, the
American Hospital Formulary Service Drug Information, and the
United, States Pharmacopoeia Drug Information and other
authoritative compendia as identified from time to time by the
Secretary of Health and Human Services, or
(2) can be established based on ,supportive clinical evidence in
peer-reviewed medical publications.
4. The provider's institutional review board acknowledges that the use of the
service or supply is experimental or investigational and subject to that board's
approval.
PPOLGCO1896 9
5. Research protocols indicate that the service or supply is experimental or
investigational. This item 4 applies for protocols used by the Member's
provider as well as for protocols used by other providers studying substantially
the same service or supply.
FACILITY means a health care or residential treatment center licensed by the state in which it operates
to provide medical inpatient, residential, day treatment, partial hospitalization or outpatient care. Facility
also means a treatment center for the diagnosis and/or treatment of Chemical Dependency or Mental
Illness.
FAMILY means Employee and the Employee's Dependents who are covered under the Policy.
FDA means The Food and Drug Administration, an agency of the United States government.
HEALTHCARE PROVIDER (other than a Physician or a Hospital)means a Doctor of Podiatric Medicine,
Doctor of Optometry, Doctor of Chiropractic, Licensed Dentist, Licensed Audiologist, Licensed Speech-
Language Pathologist, Licensed Master Social Worker, Licensed 'Dietitian, Licensed Professional
Counselor, Psychologist, Licensed Marriage' and Family Therapist,` Licenses Chemical Dependency
Counselor, Licensed Hearing Aid Fitter and Dispenser, Licensed Psychological Associate. Health Care
Provider also means other licensed medical practioners'or who are furnishing or providing any Covered
Health Services under a license, certificate, or other legal authorization issued or granted under the
laws of this state.
HMHIC means Harris Methodist Health Insurance Company.
HOME HEALTH AGENCY means an agency or organization' that is duly licensed to provide skilled
nursing services and'other therapeutic services in the home.
HOSPICE means an institution or Facility that provides a coordinated plan of inpatient and outpatient
home care for a Terminally III Patient and his Family. It operates as a unit or program that only admits
Terminally III Patients; and is separate from any other Facility. However, it may be affiliated with a
Hospital or Home Health Care Agency. "Terminally III Patient" means an Insured who does not have
a reasonable prospect for cure and who has a life expectancy of six months or less. The attending
Physician must certify that the Insured is a Terminally III Patient.
HOSPITAL means a licensed public or private'institution as defined by the Texas Hospital Licensing
Law,Texas Civil Statutes, Article 4437f, or by the Texas Mental Health Code, 88,Texas Civil Statutes,
Article 5547-88.
HOSPITAL CONFINEMENT means being registered and confined as a resident bed patient in a Hospital
on the recommendation of a Physician.
HOSPITAL SERVICES means those covered acute-care services furnished and billed by a Hospital.
INDIVIDUAL TREATMENT PLAN means a 'program with specific attainable goals and objective
appropriate to both the patient and the treatment modality of the program.
INITIAL ENROLLMENT PERIOD means a time specified by the Policyholder and the Company during
which Insured may apply for enrollment for Insured and Insured's Eligible Dependents without providing
Evidence of Insurability.
PPOLGCO1896 10
INPATIENT means registered and confined as a resident bed patient in a Hospital on the.
recommendation of a Physician.
ILLNESS means a sickness, disease, bodily disorder or infirmity that are first manifested after the Policy
Effective Date and while the Policy is in force.
INJURY means accidental bodily injury sustained by an Insured person that is the direct cause of a loss
independent of disease or bodily infirmity and occurs after the Policy Effective Date.
IN-NETWORK means services that are given by Providers that are under contract with HMHIC to
provide benefits to Covered Persons and their Eligible Dependents. The In-Network option is based on
a health care delivery system known as a Preferred Provider Organization (PPO). This type of plan is
designed to encourage Covered Persons to seek cost-efficient health care services. The PPO Plan
provides financial incentives to You, if You purchase needed health care services through'appointed
medical Facilities and Physicians. When You use these Preferred Providers, Your Out-Of-Pocket
expenses, Deductibles and Copayments are reduced. If You do not use a Preferred Provider, Your Out-
Of-Pocket costs increase.
INSURED means an Employee or his Dependent who is covered and entitled to benefits under thel
Policy.
MAMMOGRAPHY means the X-ray examination of the breast using equipment dedicated specifically
for Mammography including the x-ray tube, filter,compression device, screens, films, and cassettes,
with an average radiation exposure delivery of less than one (1) rad mid-breast, with two (2)' views of
each breast.
MATERNITY means ante/postpartum care, childbirth, or early involuntary termination of pregnancy for
the Insured.
MEDICAL CARE means furnishing those services defined as the practice of medicine in the Medical:
Practice Act of Texas,Texas Civil Statutes, Article 4495b.
MEDICAL DIRECTOR means the licensed Physician,designated by Harris Methodist Health Insurance-
Company and/or such other Physicians as the Medical Director may designate with'the prior approval
of Harris Methodist Health Insurance Company. This Physician is'responsible for supervising`the
delivery of medical service to Insured's and for monitoring the quality of medical care rendered to
Insureds.
MEDICALLY NECESSARY means the Covered Health Services prescribed by the Physician, Provider,
or other Health Care Practioner to diagnose or treat an Injury or Illness and is known to be safe and
effective in accordance with the accepted standards of medical practice within the medical community
in the area where services are rendered. Such services`must be:
1. performed in the least costly setting available where the services and
treatments can be safely and appropriately provided;
2. not provided primarily for the convenience of the Insured, the Insured's
Physician, or the Facility providing the service;
3. consistent with professionally recognized standards of care with respect to
quality, frequency and duration;
4. not primarily Educational, Experimental or Investigative; and
5. consistent with the Insured's symptoms, diagnosis or treatment.
PPOLGCO1896 11
An Insured can use the appeals process under Section 12, Appeals Procedures to resolve a dispute
regarding medical necessity.
MEDICARE means Title XVIII (Health Insurance for the Aged and Disabled) of the United States Social
Security Act, as added by the Social Security Amendments of 1965 as now or subsequently amended.
MENTAL HEALTH SERVICES means those services and supplies covered under the Policy for the
diagnosis and treatment of Mental Illness.
MENTAL ILLNESS means a physical or mental condition having`an emotional or psychological origin,
diagnosed by a Physician or a licensed clinical`psychologist as in the Diagnostic and Statistics Manual
III - Revised.
MONTH means a period of time beginning and ending with the same 'date each Calendar Month'. If a
succeeding month has no such date, the last day of the month will be used.
NEUROMUSCULAR-SKELETAL DISORDERS means mis-alignments of skeletal structures and muscular
weaknesses, imbalance and disorders related to the spinal cord,neck and joints. The Physician must
document and prove, through x-rays and/or bodily function limitations, all disorders.
NON-PARTICIPATING PROVIDER means any health care provider who is not contracted with the
Company.
NURSE PRACTIONER means a person who is licensed or certified to practice as a Nurse Practioner and
who:
1. is licensed by the board of nursing as a registered nurse (RN); and
2. has completed a program approved by the state for the preparation.of Nurse
Practioners.
OPEN ENROLLMENT PERIOD means a time after the Initial Enrollment Period, usually once a-year, as
specified in the Policyholder's Application and 'decided periodically by the Company and the
Policyholder. Insured and Insured's Eligible Dependents may enroll during this period-without providing
an Evidence of Insurability to the Company.
ORGAN TRANSPLANT means the harvesting of solid and/or non-solid' organs, glands or tissues
(including bone marrow, bone marrow stem cells, pancreas, and cornea) from one individuate and
reintroducing that organ, tissue or gland into that same or another individual.
OUT-OF-NETWORK means a traditional fee-for-service plan. You are responsible for properly filing
Claims. You are also responsible for insuring that the Utilization Review Department is contacted when
Pre-certification is necessary.
PARTICIPATING PROVIDER means a Hospital Provider, institutional Provider, Physician, or an
organization of Physicians who has contracted with the Company to provide services and treatment
to Insured under the Policy. These Participating Providers signed an agreement with the Company to
accept the Usual, Customary and Reasonable Charge and to file claims on Insured's behalf.
PPOLGCO1896 12
-- PARTICIPANT EMPLOYER means any employer, sole proprietorship, partnership, corporation or firm
which:
1. - is a subsidiary of or associated with the Policyholder and is under common
control
2. by written mutual agreement between the Policyholder and the Company, has
been included under the Policy; and
3. has not been removed according to any of the Policy terms.
The Employer may act for all Participant Employers in all Policy matters. Every act, or agreement made,
between the Company and the Employer, or notice given to the Company,.or to the Employer by the
other one, or by the Administrator for the Company, will be binding on all the Participant Employers.
PHYSICIAN means, with respect to any Medical Care and service, a person:
1. certified or licensed, under the laws of the state where treatment is provided;
qualified for the medical or surgical service for which Claim is made; and
practicing within the scope of certification or licensure; and
2. any other Health Care Provider or allied practitioner if, and as, mandated by
state law.
This term Physician does not include: an intern; or a person in training.
POLICY means the document, the Application, and any subsequent amendment or endorsement which
the Company issues to the Policyholder.
POLICYHOLDER means the Employer or entity shown on the face page of the Policy who has
purchased, for its Eligible Employees, the Policy from Harris Methodist Health Insurance Company. If
the Policyholder (including any Participant Policyholder) is a partnership or a sole proprietorship, each
of its partners, or the sole proprietor, is considered an Employee, for Policy purposes. However, the
person must be actively working on a full-time basis (at least 30 hours per week).
PREMIUM or PREMIUMS means money paid monthly to the Company by the Policyholder in order for
an Insured to receive services and benefits under he Policy.
PRE-EXISTING CONDITION means any disease or p yslcal condition which the Insured received medical
advice or treatment for during the continuou sip--4 ) month period before the effective date of
coverage. Pre-Existing Conditions are not covered under the Policy for the first twelve(12) months
after the effective date of coverage.
PRIOR PLAN means the group health plan, provided by the Policyholder immediately prior to the Plan
provided by Harris Methodist Health Insurance Company.
PSYCHIATRIC DAY TREATMENT means a mental health Facility which provides treatment for
individuals suffering from acute mental and nervous disorders. Treatment is provided in a structured
psychiatric program using individualized treatment plans with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program. The program is clinically
supervised by a Doctor of Medicine, who is certified in psychiatry by the American Board of Psychiatry
and Neurology.
PPOLGCO1896 13
QUALIFIED INDIVIDUAL means:
1. a postmenopausal woman who is not receiving estrogen replacement therapy;
2. an individual with:
a. vertebral abnormalities;
b. primary hyperparathyroidism; or
C. a history of bone fractures; or
3. an individual who is:
a. receiving long-term glucocorticoid therapy; or
b. being monitored to assess the response to or efficacy of an
approved osteoporosis drug therapy.
RECONSTRUCTIVE SURGERY means all required'Medically Necessary services provided by or under
the direction of a Physician in a Physician's office, Hospital, or other Approved Health Care Facility or
Program and is necessary to:
1. correct a Congenital Anomalk/;
2. restore normal physiological'`unctioning following an accident, Injury, disease
or surgery; or
3. reconstruct the breast(s) following Medically Necessary- partial or total
mastectomy. In order for the Insured to qualify for breast reconstruction, the
Reconstructive Surgery must occur within twelve (12) months from the initial
date of the partial or total mastectomy which required Reconstructive Surgery.
Breast augmentation, correction of breast asymmetry and cosmetic breast
procedures are not a Covered Health Service.
REPLACED POLICY means a similar health benefits policy or plan which was issued to the Policyholder
and is being replaced by the Policy.
RESIDENTIAL TREATMENT CENTER for chi dren and adolescents means a'child-care institution that
provides residential care and treatment for ernotionally disturbed children and adolescents. The center
is accredited as`a Residential Treatment Cen-:6r by the Council on Accreditation, the Joint Commission
on Accreditation of Hospitals, or the Amerit:an Association'of Psychiatric Services for Children.
RIDER means an attachment to the Policy entitled "Rider" and describes medical benefits that may be
purchased through the Company for an additional Premium.
SEMI-PRIVATE ACCOMMODATION means two or more beds per room'in a Hospital, Skilled Nursing
Facility or other Approved Health Care Facility or Program. The semi-private bed room charge is the
maximum allowable toward private room accommodations. The Company will pay charges for a private
room only if use of a private room is Medically Necessary.
SICKNESS means an Illness of an Insured,including"Complications of Pregnancy." Sickness does not
include` any Illness or Injury for which bE nefits are provided under any workers' compensation,
occupational disease, Employer's liability or similar statute.
PPOLGCO[896 14
SKILLED NURSING FACILITY or EXTENDED CARE FACILITY means an institution which:
1. is accredited under one program of the Joint Commission on Accreditation of
Health Care Organizations as a Skilled Nursing Facility or is recognized by
Medicare as an Extended Care Facility;
2. furnishes room and board and 24-hour-a-day skilled nursing care by, or under
the supervision of, a registered nurse (RN); and
3. is not a clinic, a rest Facility, a home for the aged, a place for drug addicts or
alcoholics, or a place for Custodial Care.
USUAL, REASONABLE, and CUSTOMARY CHARGE, with respect to Covered Health Services, means
the lower of:
1. the Provider's usual charge for furnishing the treatment, service, supply or
surgery; or
2. the charge decided by the Administrator to be the general rate charged by
others who render or furnish treatments, services or supplies to persons:
a. who reside in the same area as the Provider; and
b. whose Illness or Injury is comparable in nature and severity.
The Administrator will decide the Usual, Reasonable, and Customary Charge for a treatment, service,
supply or surgery that is unusual or provided by only some Providers in the area. The Administrator will
consider factors such as:
1. complexity;
2. degree of skill needed;
3. type of specialist required;
4. range of services or supplies provided by a Facility; and
5. the prevailing charge in other areas.
The term "area" means a city, a county or any greater area which is necessary to obtain a
representative cross section of providers.
YOU or YOUR means the Covered Insured and his Eligible Dependents.
PPOLGCO1896 15
SECTION 2: SCHEDULE OF BENEFITS
(SEE ATTACHED)
PPOLGC01896 16
SECTION 3: ELIGIBILITY RULES
ELIGIBLE EMPLOYEES
Eligible Employee means an individual who is Actively at Work and continues to satisfy the eligibility
criteria established by the Policyholder and the Company, and as defined in the Policy.
EFFECTIVE DATE OF EMPLOYEE'S COVERAGE
An Employee's coverage under the Policy becomes effective on the later of:
1. the Effective Date of the Policy; or
2. the date the Employee qualifies for coverage. _
:There is no coverage if, on the Effective Date described in this section, the Employee is confined for
Medical Care or treatment in any institution. Coverage becomes effective on the next day following
the Employee's final release by the Physician from all confinement.
MULTIPLE COVERAGE
An Employee is not eligible for multiple coverage even if the Employee is connected with more than
one Participant.Employer. If the Employee is considered an Employee of more than one Participant
Employer, the Employee is only eligible to be covered under one Participant Employer. A person who
is eligible as an Employee under the Policy may not be insured as a Dependent. No_person is eligible
as a Dependent of more than one Employee.
ELIGIBLE DEPENDENTS
"Dependent or Eligible Dependent" means the Employee's:
1. legal spouse; and/or
2. : __ unmarried children less than age 19 including:
a. a natural born child, an adopted child, a child waiting for adoption,
stepchild or a child who resides with the Insured in a customary parent-
child relationship;
b. grandchild, upon payment of premium, who is Dependent for purposes
of federal income taxes; a.3
C. a child who is a full-time student under the age 25;
d. a child who is disabled to such an extent as to be dependent upon the
Insured for care or support;
e. newborn coverage will be automatic for the first thirty-one (31) days
following birth of the Insured's newborn child and will terminate on the
thirty-second (32) day. To continue coverage beyond the thirty-one
(31) days,the Insured must notify the Company in writing within thirty-
one (31) days of birth and pay the required premium within that thirty-,
one (31) day period or a period consistent with the next billing cycle.
If the Insured notifies the Company after the thirty-one (31) day period,
the newborn child will become effective in accordance with the
provisions for Late Enrollees.
PPOLGCO1896 17
3. Court Ordered Coverage for a Dependent
If a court has ordered the Insured to provide coverage for a spouse or
minor child, coverage will be automatic for the first thirty-one (31) days
following the date on which the court order is issued. To continue
coverage beyond thirty-one (31) days, the Insured must notify the
Company and pay the required premium within that thirty-one (31) day
period. If the Insured notifies the Company after the thirty-one (31)
day period, the Dependents coverage will become effective in
accordance with the provisions for Late Enrollees.
EFFECTIVE DATE OF DEPENDENT COVERAGE -
Coverage under the Policy for Dependents, except newborn children, becomes'effective on the later
of:
1. the date Employee's coverage becomes effective; or
2. on the date the Employee acquires Eligible Dependents.
To obtain'coverage under the Policy for Dependents,'the Employee 'must'notify the Company, in
writing, within thirty-one (31) days of acquiring Eligible Dependents.` There is no coverage if, on the
Effective Date described in this section,the Dependent is confined for Medical Care or treatment in any
institution. Coverage`becomes effective on the next day following the Dependent's final release by
the Physician from all confinement.
NEWBORN CHILDREN
A Newborn Child means a child from the moment of birth through thirty-one (31)days olds .A Newborn
Child born to an Employee or to any Dependent, while insured under the Policy and while the Policy
is in force, is covered under the Policy as a Dependent child for the first thirty-one (3 1) days from the
moment of birth. Continued coverage beyond the first thirty-one (31) days depends upon::
1'. the enrollment of the newborn child as a covered Dependent (no
Evidence of Insurability is required)'within'the first thirty-one (31) days
from the date of birth; and
2. the payment of applicable Premiums'-beginning from the date of birth within
thirty-one (3 1) days.
ADOPTED'CHILDREN -
If an Employee adopts a child'while insured under the Policy, the child is covered from the time the
Employee is a party in a legal action to adopt the child.
GRANDCHILDREN
Any children of the Employee or the spouse's children`are covered if the children are the Employee 's
Dependents for federal income tax purposes.
ENROLLMENT
An Employee can apply for coverage under the Policy during an Initial Enrollment, Open Enrollment or
Late Enrollment Period.
PPOLGCO1896 18
INITIAL ENROLLMENT PERIOD
An Employee and the Employee's eligible Dependents are entitled to coverage under the Policy if the
Employee applies during the Initial Enrollment Period. The Employee must submit a properly completed
Application to the Policyholder and list themselves and their eligible, Dependents on the Enrollment
Application. The Company will not require an Evidence of Insurability, medical history, or physical
examination during the Initial Enrollment period if the Policyholder has provided continuous medical
coverage under a Replaced Policy. if the Policyholder did not have medical_coverage under another
policy immediately prior to the Initial Enrollment Period,the Company may require an Insured to provide
an Evidence of Insurability iA ac.L,o(Jance_WiK av%J SIA)evi" fio Policyholc��'s e1�9i7oi)��}�r
cri 4eri a. S.e.t_61K in Exln 6l
OPEN ENROLLMENT PERIOD
The Employee may apply for coverage under the Policy after the Initial Enrollment Period for themselves
or their eligible Dependents during the time designated by their. Employer and HMHIC as the Open
Enrollment Period. The Employee must submit`a properly completed Application to the Policyholder and
list themselves and their eligible Dependents on the Enrollment Application. If the Employee satisfies
the eligibility requirements and the Policyholder pays the applicable Premium,the Employee and eligible
Dependents are covered on the first day of the next month'after the;Employee applies for coverage.
LATE ENROLLMENT
Other than during Initial and Open Enrollment Periods, an Employee may apply for coverage for
themselves or their eligible Dependents within thirty-one .(31) days after they are eligible. The
Employee must-submit a properly completed Application to the Policyholder. The Company will
approve the Employee's Application for coverage if the Employee satisfies the eligibility requirements
and the Policyholder pays the applicable Premium. The Employee or his eligible Dependents are covered
under the Policy effective on the first day of the next month after the Company approves the
Employee's Application or the first day of the next month after the Employee satisfies any waiting or
probationary periods established by the Policyholder.
The Company may require an Evidence of Insurability, medical history, or physical_examination during
alate enrollment. The Company may deny the Employee's Application if the Employee or his eligible
Dependents do not provide a satisfactory Evidence of Insurability.
The Employee may waive coverage under the Policy during his Initial Enrollment or Open Enrollment
Period because the Employee is covered under his spouse's health plan. The Employee may apply,for
coverage later, however, the Company will approve the Employee's Application only during:
a. any Open Enrollment Period; or
b. the first thirty-one (31) days after the spouse's health plan has ended,
and he submits an Evidence of Insurability.
EFFECTIVE DATE OF COVERAGE
Coverage for the Employee and his eligible Dependents is effective if the Employee provides a properly
completed Application to the Company, the Company approves the Application and the Policyholder
pays the premium to the Company. Coverage under the Policy becomes effective on the later of:
1. the date the Policy takes effect;
2. on the first day of the next month following the end of the Initial Enrollment
Period;
PPOLGCO[896 19
3. as otherwise specified in the Policy; or
4. as follows:
a. When the Employee provides an Application to the Company after the
Policy's effective,datE, coverage is in effect on the first day of the next
month following the c ate the Company approves the Application based
on the Evidence of Insurability.
b. Coverage is in effect at birth for newborn children for thirty;one,(31)
days. Coverage will c)ntinue if the newborn is eligible, enrolled by the
Employee,and all Pre-niums due are paid within thirty..-one (3,1) days of
the newborn's birth.
C. When the Employe: completes an Application during .the Open
Enrollment Period, coverage is effective on the first_day of the next
month following the Open Enrollment period, unless the Policyholder
and the Company have agreed to a different arrangement. ;
d. The Employee may apply for Dependent coverage after the initial thirty-,,,_
one-(31) day period expires after they become eligible. However,
Evidence of Insurability is required and coverage is not guaranteed.. If
the Company approves the Application,,coverage is not effective until
the first day of the n.xt month following the Company's approval.
NOTIFICATION OF ELIGIBILITY CHANGE
1. Any person who does not satisfy the eligibility requirements is not covered by
the Policy and has no right to any of the benefits provided under the Policy.
2.` The Policyholder'and/or the Employee must notify the Company within thirty-
one'(31)`days of any change in status that affects a change in eligibility. This
includes notification of his Dependent's ability to meet eligibility criteria.
HOW BENEFITS ARE PAID-
The Company will pay benefits at the Co-Insurance Percentage, after any applicable Deductible, as
shown in the Schedule of Benefits.: All bene-:its are subject to the Definitions, Benefit Limitations, and
General Exclusions listed in the Policy. When a single charge is made fora series of services, each
service shares a proportion of the total charg.. Benefits for some services are subject to the Utilization
Review Program.
DEDUCTIBLE
The Deductible is the total amount in cove red medical expenses that each Insured must pay each
Calendar Year before the Company will pa,1 any benefits. After each Insured pays the Deductible
amount, the Company will pay benefits for Covered Health Services at the Co-Insurance Percentage
rate shown in the Schedule of Benefits. All services which require a Deductible amount are listed in
the Schedule of Benefits. The Deductible d.)es not apply toward the Out-of-Pocket Maximum. If the
Insured was covered under the Policyhold-,r's Prior Plan on the Effective Date of the Policy, any
covered charges which were:
1. provided under the Prior Plan;
2. provided during the ninety (90) day period immediately prior to the Effective
Date of the Policy; and
3. credited toward the Insureds Cash Deductible under the Prior Plan;
will also be applied toward the Insured's Cash Deductible under the Policy. The Policyholder is
responsible to provide this information to tl-a Company or to the Company's Administrator.
PPOLGCO1896 20
CO-INSURANCE PERCENTAGE
The Co-Insurance Percentage is the Insured's share of a covered medical expense, not including the-
Deductible, that the Insured must pay. All Co-Insurance Percentage amounts are listed in the Schedule
of Benefits. It is a percentage of the Usual,`Reasonable, and Customary charge. Co-Insurance
Percentage applies toward the Out-of-Pocket Maximum. If the Insured was covered under the:
Policyholder's Prior Plan on the Effective Date of the Policy, any Covered Health Services which were:
1. provided under the Prior Plan;
2. provided during the ninety (90) day period immediately prior to the Effective
Date of the Policy; and
3. credited toward Insured's Co-Insurance Percentage under the Prior Plan;
will also be credited toward Insured's Co-Insurance Percentage under the Policy. The Policyholder is
responsible to provide this information to the Company'or to the Company's Administrator.
OUT-OF-POCKET MAXIMUM
The Out-of-Pocket Maximum is the total amount that the Insured must pay each Calendar`Year before.
the Company pays benefits at 100% up to the Usual, Reasonable, and Customary charge. The Co
Insurance Percentage counts toward the Out-of-Pocket Maximum. All Out-of-Pocket Maximum,
amounts are listed in the Schedule of Benefits. Out-of-Pocket Maximum does not include:
1. Deductibles;
2. any amount over Usual, Reasonable and Customary`Charges;
3. charges for services not covered`by the Policy; and
4. the Failure to Pre-Certify Penalty.
If the Insured was covered under the Policyholder's Prior Plan on the`Effective Date of the Policy,any,
covered expenses which were:
1. provided under the Prior Plan;
2. provided during the 90-day period immediately prior to the Effective Date of the
Policy; and
3. credited toward Insured's Out-of-Pocket Maximum under the Prior Plan;
will also be credited toward the Insured's Out-of-Pocket Maximum under the Policy.' The Policyholder
is responsible to provide this information to the Company or to the Company's Administrator.
MAXIMUM BENEFIT
Maximum Benefit is the total amount of Major Medical Benefits payable at any time under the Policy
each Calendar Year, even if the Insured coverage is interrupted, terminated` and subsequently
reinstated. The Maximum Benefit amount is listed in the Schedule of Benefits. The Maximum Benefit
payable for Major Medical Benefits under the Policy includes all benefits paid under the Policy. Any-
unused portions of the Maximum Benefit are only payable for expenses incurred while the Insured is.
eligible for coverage:
1. while the Policy is in force; or
2. under the extended benefits provision of the Policy.
PPOLGCO[896 21
COMMON ACCIDENT
If two or more covered Family,members are injured in the same accident, only one individual Deductible
will apply. This covers all of the combined Family expenses due to that accident during that Calendar
Year.
FAMILY DEDUCTIBLE
When the Family members covered by this Policy meet the Family Deductible limit noted in the Policy
Specifications, no further Deductible will apply to other insured Family members for the remainder of
the Calendar Year.
PRE-EXISTING CONDITIONS
Pre-Existing Conditions are covered 12 months after the Effective Date of the Policy. However,this
waiting period will not apply to an Insured who was covered under the Policyholder's Prior Plan on the
Effective Date of the Policy. The Company gives the Insured credit for the time he was covered under
the Prior Plan, if the previous coverage was continuous to a date not more than sixty (60) days prior
to the-Effective;Date of the Policy coverage, exclusive of any applicable waiting period under the
Policy.
SUBROGATION
Subrogation seeks to shift the expense for injuries suffered by You to those responsible for causing
them. If You are injured by an act or omission of a third party, and if that party is later determined to
be liable for the cost of medical, surgical, and Hospital care furnished to You because of that act or
omission, You will be liable to HMHIC for all expenses incurred because of the actor omission to the
extent that benefits are paid by HMHIC. HMHIC will be Subrogated to, and may enforce Your rights
against, the third party for those expenses. In accepting this_Agreement, You assign to HMHIC all
rights and Claims against the third party for those expenses. By the assignment, HMHIC will have the
right to enforce Claims for those expenses. HMHIC will also have the following rights:
1. to compromise Claims for our reimbursement;`
2. to begin and prosecute any legal proceeding; and
3. to pursue judgements through,collection.
These rights can be executed in HMHIC's or Your name.
You cannot settle, compromise, or release a Claim for expenses against a third party unless:
1. the rights of HMHIC are expressly preserved in the settlement, compromise,or
release;
2. HMHIC's Claim is paid in full; or
3. HMHIC has given a written waiver of Claim after notice.
Any settlement, compromise, or release by You in favor of a'third party that violates this section will
include the full amount due to HMHIC. You will therefore be liable to HMHIC up to the amount of the
settlement, compromise, or release paid by HMHIC.
You shall execute a formal, written injury report that outlines pertinent information'about the negligent
party and his/her insurance carrier(s). This report will assist HMHIC in recovering the reasonable value
of any Benefits provided directly by HMHIC. It will also assist in recovering the actual costs.paid by
PPOLGCO1896 22
HMHIC under this Agreement for injuries, ailments, and diseases caused by a third party, together with
any associated costs of recovery.
You shall give HMHIC timely, written notice of the beginning of any legal proceeding against a third
party. You shall also give timely, written notice of any proposed settlement, compromise, or release
of Claims against a third party. Upon notice, HMHIC will have the right to participate or intervene in
the proceedings. You and HMHIC will be bound by the result of legal proceedings of which You were
given notice and an opportunity to participate. HMHIC will not be bound by any agreement to which
it is not a party, when the agreement provides that payment to You by a third party does not include
any amount of medical expenses. This section does not confer any Benefit on any person or entity
other than HMHIC and You.
You hereby agree to execute any further assignments that, in the judgement'of HMHIC, may be
necessary to enforce this section, or to protect.HMHIC's rights under this section. You shall cooperate
with HMHIC to effect settlements subject to this section.
NON-DUPLICATION
The benefits under the Policy are not designed to duplicate any benefits the Insured is entitled to under
Workers' Compensation Insurance or laws. The Insured will reimburse the Company all the money the
Insured received under Workers' Compensation Insurance or laws for any Covered Health Services paid
for by the Company for job related injuries. The Insured must complete and provide to the Company
any consents, releases, assignments and other documents requested by the Company in order to obtain
or assure reimbursement.
PAYMENTS TO THE TEXAS DEPARTMENT OF HUMAN SERVICES '
If legally notified, the Company must pay any benefits for the Employee's Dependent child to the Texas
Department of Human Services, if the Agency is paying benefits on behalf of his Dependent child under
Chapter 31 or Chapter 32, Human Resources Code.
PAYMENT TO THE STATE
If legally notified, the Company must pay the Texas Department of Human Resources for the actual
cost of medical expenses the department pays through medical assistance fora Insured under the
Policy, if the Insured is entitled to payment for the Covered Health Services.
EFFECTS OF MEDICARE ON THE BENEFITS OF THE POLICY
Harris Methodist Health Insurance Company is the Primary Plan and Medicare is the Secondary Plan:
1. for the Employee if Actively at Work, age 65 or older, and eligible for Part A of
Medicare; or
2. for the Employee's Dependent spouse, age 65 or older, and eligible for Part A
of Medicare;
provided the Employer or Participant Employer employed 20 or more employees on a typical business
day the preceding Calendar Year.
Harris Methodist Health Insurance Company is also the Primary Plan and Medicare is the Secondary
Plan for the Employee or Employee's Dependent if the Employee is Actively at Work, under age 65, and
the Employee or his Dependents are eligible for Medicare benefits:
PPOLGCO1896 23
1. solely due to End Stage Renal Disease (ESRD) and is within the first eighteen
(18) months of ESRD care; or
2. is disabled, as defined by the Social Security Administration;
provided the Employer or any one Participant Employer employed 100 or more employees on a typical
business day during the preceding Calendar Year. In all other instances, Medicare is the Primary Plan
and Harris Methodist Health Insurance Company is the Secondary Plan.
1. If the Employee eligible for Medicare chooses Medicare as his Primary coverage
Plan, his coverage under Harris Methodist Health Insurance Company Policy will
automatically end.
2. When Medicare is the Primary Plan and Harris Methodist`Health Insurance
Company is the Secondary Plan,Medicare (Parts A and B) will be considered
a Plan for the purposes of Coordination of Benefits. The Secondary Plan will
coordinate benefits with Medicare whether or not Employee or his Dependents
are actually receiving Medicare benefits.
OPTIONS UNDER MEDICARE COVERAGE
1. If the Employee is 65 or older, he may reject coverage under the Policy._This
rejection must be in writing and sent to the Company's Administrator. Benefits
end when the Company receives the notice.
2. If the Employee is eligible for Medicare and rejects, in writing, the coverage
under the Policy, the Policy, will automatically end for Employee's covered
spouse, regardless of the age of Employee's covered spouse.
3. If only the Employee's covered spouse rejects, in writing, coverage under the
Policy, then the Policy will end-for Employee's' covered spouse but not the
Employee.
4. If either Employee or Employee's covered spouse reapplies for coverage and,
if the Employee pays a part of the Premium, the Employee and all eligible
Dependents are required to submit Evidence of Insurability to the Company.
The Employee's spouse is not eligible to submit an Application unless the
Employee is currently covered or reapplying for coverage and the spouse must
provide an Evidence of Insurability.
PPOLGC01896 24
SECTION-4: DETERMINATION OF ORDER OF BENEFITS
APPLICABILITY
The Coordination of Benefits (COB) provision applies under This Plan when the Insured has healthcare
coverage under more than one health Plan. Plan and This Plan are defined below. This Policy provision.
will only apply for the duration of the Employee's employment.
If this COB provision applies,,the order of benefit determination rules should be looked at first. Those
rules determine whether the Benefits of This Plan are determined before'or after those of another Plan.
The benefits of This Plan:
1. will not be reduced when This Plan determines its benefits before another Plan;
but
2. may be reduced when another Plan determines its benefits first.
DEFINITIONS:
PLAN is any of these which provides benefits or services for, or because of,medical or dental care or
treatment:
1. Group insurance or group-type coverage, whether insured or uninsured. This
includes prepayment, group practice or individual practice coverage. It also
includes coverage other than school accident-type coverage.
2. Coverage under a government plan, or coverage required or provided by law.
This does not include a state plan under Medicaid (Title XIX, Grants to States
for Medical Assistance Programs, of the United States Social'Security Act, as
amended).
Each contract or other arrangement for coverage under 1 or 2 is a separate Plan. Also, if an
arrangement has two parts and COB rules apply only,to one of the two, each of the parts is a separate
Plan.
THIS PLAN is the part of the Policy that provides benefits for health care expenses.
PRIMARY PLAN/SECONDARY PLAN: The order of benefit determination rules state whether This Plan
is a Primary Plan or Secondary Plan covering the person.
When This Plan is a Primary Plan, its benefits are determined before those of the other plan and without
considering the other plan's benefits.
When This Plan is a Secondary Plan, its benefits are determined after those of the other plan and may
be reduced because of the other plan's benefits.
When there are more than two plans covering the person, This Plan may be a Primary Plan as to one
or more other plans, and may be a Secondary Plan as to a different plan or plans.
ALLOWABLE EXPENSE means a Medically Necessary, Reasonable and Customary item of expense for
health care; when the item of expense is covered at least in part by'one'or more plans covering the
insured for whom claim is made.
PPOLGCO1896 25
The difference between the cost of a private hospital room and the cost of a semi-private hospital room
is not considered an Allowable Expense under the above definition unless the patient's stay in a private
room is Medically Necessary either in terms of generally accepted medical practice, or as specifically
defined in the plan.
When a plan provides benefits in the form of services, the reasonable cash value of each service
rendered will be considered both an Allowable Expense and a benefit paid.
When benefits are reduced under a Primary Plan because an insured person does not comply with the
plan provisions, the amount of such reduction will not be considered an Allowable Expense. Examples
of such provisions are those related to second surgical opinions or precertification`of admissions or
services.
CLAIM DETERMINATION PERIOD means a calendar year. However, it does'not include any part of'a
year during which an Insured has no coverage under This Plan, or any part of a year before the date
this COB provision or a similar provision takes effect.
ORDER OF BENEFIT DETERMINATION RULES
General
When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan which
has its benefits determined after those of the other plan, unless:
1. the other Plan has rules coordinating its benefits with those of This Plan; and
2. both those rules and This Plan's rules require that This Plan's benefits be
determined before those of the other plan.
Rules
This Plan determines its order of benefits using the first of the following rules which applies:
1. Non-Dependent/Dependent-The benefits of the plan which covers the Insured
as an Employee are determined before those of the Plan which covers the
Insured as a Dependent. Except that, if the Insured is also a;.Medicare
beneficiary, and as a result of the rule established by Title XVlll of the Social
Security Act and implementing regulations, Medicare is:
a. secondary to the Plan covering the Insured as a Dependent; and
b._ primary to the Plan covering the Insured as other than a Dependent
(e.g. a retired employee);
then the benefits of the Plan covering the Insured as a Dependent are
determined before those of the Plan covering that Insured'as other than a
Dependent.
2. Dependent Child/Parents Not' Separated or Divorced - Except as stated in
Paragraph 3 below, when This Plan and another Plan cover the same child as
a Dependent of different persons, called parents:
a. The benefits of the plan of the parent whose birthday falls earlier in a
year are determined before those of the plan of the parent whose
birthday falls later in that year; but
PPOLGCO1896 26
b. If both parents have the same birthday, the benefits-of the plan which
covered one parent longer are determined before those of the Plan
which covered the other parent for a shorter period of time.
However, if the other Plan does not have the rule described in (a.) immediately
above, but instead has a rule based on gender of the parent, and if, as a result,
the plans do not agree on the order of benefits,the rule in the other Plan will
determine the order of benefits.
3. Dependent Child/Separated or Divorced - If two or more Plans cover an Insured
as a Dependent child of divorced or separated parents, benefits for the child are
determined in this order:
a. first, the Plan of the parent with custody of the child; then
b. the Plan of the spouse of the parent with custody; and
C. finally,,the Plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the parents
is responsible for the health care expense of the child, and the entity'obligated
to pay or provide the benefits of the plan of that parent has actual knowledge
of those terms, the benefits of that plan are determined first.' The Plan of the
other parent will be the Secondary Plan. This paragraph does not.apply with
respect to any Claim, Determination Period or Plan Year during which any
benefits are actually paid or provided before the entity'has that actual
knowledge.
4. Joint Custody - If the specific terms of a court decree state that the parents
shall share joint custody, without stating that one of the parents is responsible
for the health care expenses of the child, the plans covering the child,will
follow the order of benefit determination'rules outlined in Paragraph 2.
5. Active/Inactive Employee - The benefits of a plan which covers an Insured as
an Employee who is neither laid off nor retired are determined before those of
a Plan which covers the Insured as a laid off or retired Employee. The same
would hold true if an Insured is a Dependent of a person covered as a retiree
and an Employee. If the other Plan does not have this rule, and if, as a result,
the plans do not agree on the order of benefits, this Rule 5 is ignored.
6. Continuation Coverage - If an Insured whose coverage is provided under a right
of continuation pursuant to federal or state law also is covered under'another "
plan, the following shall be the order of benefit determination:
a. first, the benefits of a Plan covering the Insured as an Employee, (or as
the Insured's Dependent);
b. second, the benefits under the continuation coverage.
If the other Plan does not have the rule described above, and if, as a result, the plans do not
agree on the order of benefits, this rule is ignored.
7. Longer/Shorter Length of Coverage - If none of the above rules determine the
order of benefits, the benefits of the Plan which covered an Employee longer
are determined before those of the Plan which covered the Insured for the`
shorter term.
PPOLGCO1896 27
EFFECT ON THE BENEFITS OF THIS PLAN:
When This Section Armlies
This section applies when This Plan is the Secondary Plan in`accordance with the order of benefits
determination outlined above. In that event, the benefits'of This Plan may be reduced under this
section.
Reduction in This Plan's Benefits
The benefits of This Plan will be reduced when the sum of:
1. the benefits that would be payable for the Allowable Expense under This Plan
in the absence`of this COB provision; and
2. the benefits that would be payable for the Allowable Expense under-the other
plans, in the absence of provisions with a purpose° like that of this COB
provision, whether or not claim is made; exceeds those Allowable Expenses in
a`Claim Determination Period. In that case, the benefits of This Plan will be
reduced so that they and the benefits'payable under the other Plans do not
total more than those'Allowable Expenses.
When the benefits'of This Plan are reduced as described'above, each benefit is reduced in proportion.
It is then charged against any applicable benefit limit of This Plan.
RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION:
Certain facts are heeded to apply these COB rules.` The Company has the right to decide which facts
are needed. The Company may get`needed facts from or give them to any other organization or
person. The Company need not tell, or get the consent of, any person to do this. Each person
claiming benefits under This Plan must give us any facts needed to pay the claim.'
FACILITY OF PAYMENT:
A payment made under another plan may include an amount which should have been paid under This
Plan. If it does, the Company may pay that amount to the organization which made that payment.
That amount will then be treated as through it were a benefit paid under This Plan. We will not have
to pay that amount again. ` The term "payment made" includes providing"benefits in the form of
services, in which case "payment made" means reasonable cash value of the benefits provided in the
form of services.
RIGHT TO RECOVERY:
If the amount of the payments made by the Company is more than the Company should have paid
under this COB provision, the Company may recover the excess from one or more of:
1. the persons we have paid or for whom we have paid;
2. insurance companies; or
3. other organizations.
The "amount of the payments made" includes the reasonable cash value of any benefits provided in
the form of services.
PPOLGCO1896 28
SECTION 5: CONTINUATION OF COVERAGE
UNDER COBRA
An Employee and his Dependents may continue major medical coverage under the Harris Methodist
Health Insurance Company Policy if insurance would otherwise end due to a Qualifying Event. The
medical coverage that is continued is the same as the major medical coverage under the Policy, had
the Policy remained in forcer Continuation of coverage for the Employee and his Dependents under the
Consolidated Omnibus Budget Reconciliation Act (COBRA) is available if the Policyholder has twenty
(20) or more employees on a typical business day in the previous Calendar Year. The Employer is
required to-notify the Employee and his Dependents of their COBRA continuation privileges under the
Policy. The Employee and his Dependents have sixty(60) days after the notification to accept
coverage or lose all rights to benefits.
QUALIFYING EVENT means one of`the'following circumstances which would 'otherwise end the
Employee's or his Dependent's insurance in the absence of this provision:
1. Employee's Employment ends, other than for gross misconduct;
2. Employee's work hours are reduced;
3. , Employee's death;
4. Employee's entitlement to Medicare;
5. Employee's divorce; or
6. - Employee's child is no longer an Eligible Dependent under the Policy's
definition.
NOTIFICATION
It is the Policyholder's responsibility to inform the Employee or his Dependents of their rights under the
continuation of coverage provision under' COBRA. It is the Employee's responsibility to notify the
Company, in'writing, within sixty (60) days of any of the following Qualifying Events:
1. Employee's divorce; or
2. Employee's child is no longer an Eligible Dependent under the Policy's
definition.
The Employee or his Dependent must provide written notification within sixty (60) days after the later
of:
1. the date of the Qualifying Event;
2. the date the Dependent would lose coverage due to the Qualifying Event; or
3. the date Social Security determines the Employee or his Dependent is disabled.
ELECTION PERIOD
The Employee or his Dependent may continue coverage within sixty (60) days after the later of:
1. the date the Employee or his Dependent would lose coverage due to a
Qualifying Event; or '
2. the date the Employee or his Dependent receives notice of his rights under the
continuation provision.
PPOLGCO1896 29
The Employee or his Dependent must reque 3t continuation of coverage on the form supplied by the
Company. Benefits will continue provided:
1. the Employee or his Dependent properly completes the form and returns it to
the Company within sixty (60) days after the Company notifies the Employee
or his Dependent; and
2. the Employee or his Dependent pays the required Premium to the Policyholder
within forty-five (45)days after either of them returns the form to the Company
and the Policyholder pays the premium to the Company,
The Premium is the total amount of Premium paid by both the Employee and the Policyholder for
coverage under the Policy, plus an additional 2% administrative fee. If either the Employee or his
Dependent is disabled, and the term of cov,-rage has been increased from eighteen(18) months to
thirty-six (36) months, the Premium may be increased for the last eleven (11) months of coverage to
150% of the total Premium. The amount of the Premium paid by either the Employee or his Dependent
may increase if the Premium charged by the Company increases:
DURATION OF CONTINUATION OF COVERAGE
Normally, the Company provides continuation of coverage under COBRA up to eighteen (18) months
for any individual covered under the Policy the day before a Qualifying Event. The Company will
provide continuation of coverage up to twenty-nine (29) months if the Employee or his Dependent is
determined under Title 11 or XVI of the Social_Security Act to be disabled at the time of the Qualifying
Event. The Employee or Dependent continuation of coverage under COBRA begins on the date that
coverage under the Policy would otherwise ,nd because of a Qualifying Event.
The Company provides continuation of coverage under COBRA up to thirty-six (36) months for the:
1. Employee's surviving spouse and his Dependent children after he dies;
2. ' Employee's separated or divorced spouse including the Employee's spouse's
Dependent children;
3. Employee's spouse and his Dependent children if he elects,Medicare as primary
coverage; or
4. Employee's Dependent child whose coverage would otherwise end because the
child has ceased to be an eli,iible Dependent as defined in the Policy.
The Company may end the continuation of coverage prior to expiration of the mentioned time periods
if the:
1. Policyholder ends its employe welfare health benefit plans;
2. Employee or his Dependent fails to make timely;payments of any charges or
Premiums required;
3. Employee or his Dependent becomes covered by another group health benefit
plan with no exclusion or limitation for Pre-Existing Conditions;
4. Employee or his Dependent becomes entitled to Medicare benefits; or
5. lifetime Maximum Benefit under the Policy is reached.
If the Employee or his Dependent become:3 covered under another group health policy, coverage
provided under the continuation policy is secondary to coverage under the other group health policy.
The coverage provided under the continuatio i policy is primary for any Pre-Existing Conditions that are
not covered under the new policy. If the Employee or his Dependents are hospitalized when coverage
under the Policy ends, expenses for that confinement will be paid by the Company.
PPOLGCO1896 30
CONTINUATION/CONVERSION PRIVILEGE
When Employee's or his Dependent's,COBRA coverage ends ,because the4 maximum time limit has
expired, he or his Dependent may apply for a continuation/conversion policy. The Employee or his
Dependent must apply in writing to the Company within thirty-one (31) days ,after his or his:
Dependent's COBRA coverage ends.
The Employee or his Dependents are not required to submit an Evidence of Insurability, however, the.
Pre-Existing Condition provision contained in the continuation/conversion policy will apply. Any waiting]
period that applied toward the Pre-Existing Condition provision under the COBRA policy will: count
toward the waiting period under the continuation/conversion policy.
r,
PPOLGCO1896 31
SECTION 6: CONTINUATION/CONVERSION PROVISIONS
An Insured Person whose coverage terminates shall have the right to conversion or continuation under
the Policy as outlined below. In order to be eligible for this option,the Insured Person must:
1. have been continuously covered under the 'Policy 'for at least three (3)
consecutive months immediately prior to termination (or under any policy
providing similar benefits which it replaced); and
2. have had coverage terminated for any reason other than involuntary termination
for cause.
There is no right to continuation/conversion if:
1. the termination of coverage occurred because You failed to pay any required
premium; or
2. any discontinued group coverage was replaced by similar group coverage within thirty-
one (31) days of the discontinuance; or
3. the Insured Person is or could be covered by Medicare; or
4. the Insured Person has similar benefits under another group or individual health
plan, whether insured or uninsured;
5. the Insured Person is eligible for similar benefits under another group plan,
whether insured or uninsured; or
6. similar benefits are provided for or available to the Insured Person under any
state or federal law.
Written application and payment of the first premium for either conversion or continuation must be
made within thirty-one (31) days after the date coverage terminates or within thirty-one (31) after the
Insured Person has given the required notice.
No evidence of insurability is required for either continuation or conversion. Each Insured Person may
select one of the following options:
OPTION 1
A conversion policy providing the similar coverage and benefits as provided under the Group Policy.
If this option is selected, lifetime maximums shall be computed from the initial effective date under the
Group Plan.
OPTION-2
A conversion policy with lesser coverage and benefits. If this option is selected, lifetime maximums
will be computed from the effective date of the conversion policy. A conversion policy will be effective
on the day after termination of coverage under the policy. The Insured Person will be given credit for
any satisfaction under this Policy of waiting periods or limitations for any Preexisting Condition.
PPOLGCO1896 32
OPTION 3
Continuation of coverage under the group Plan. If this option is selected, continuation will be permitted:
for a maximum of six (6) months. The Premium rate will be 102% of the Group Premium. The
Premium will be payable in advance to the Employer or Group Policyholder on a monthly basis_
Continuation of the Policy may not terminate until the earliest of:
1.'` six months after the date Option 3 is chosen;
2. the date the Insured fails to make timely'Premium payments;
3. the date on which the Insured is or could be covered under Medicare;
4. the date on which the Insured is covered for similar benefits under another
group or individual policy;
5. the date on which the Insured is eligible for similar benefits under another group
plan; or
6. the date on which similar benefits are provided for or available to the Insured
under any state or federal`law. -
If the Policy terminates in its entirety before the end of the continuation period, the Insured Person"s.
coverage will continue until the time other wise specified.
ADDITIONAL CONTINUATION/CONVERSION FOR CERTAIN DEPENDENTS
If coverage terminates as the result of an Employees's death, retirement or divorce, a Insured'
Dependent's coverage can continue. The Dependent must have been covered under the plan for at
least one (1) year, unless the Dependent is an infant under one (1) year of age. Continuation does not
require Evidence of Insurability.
Continuation is not available:
1. when coverage terminates due to cancellation of the Policy; or
2, when premium payments are not made in a timely manner.
Continuation ends at the earliest of:
1. " three (3) years after the date that coverage would have ended;
2. failure to make required premium payments;
3. the Dependent becoming eligible for coverage under any other group Plan
providing similar benefits;
4. the Policy is cancelled.
NOTIFICATION REQUIREMENTS
The Dependent must notify the Employer/Policyholder within fifteen (15) days of the Employee's`death,.
retirement or divorce. The Employer/Policyholder will within five (5) working days provide written
notice to the Dependent of the right to continue coverage,`and will send the 'election'form and
instructions for premium payment.
Within sixty+(60) days after the Employee's death, retirement, or divorce, the Dependent must give
written'notice to the Employer/Policyholder of the desire to'exercise the right of continuation or the
option expires. Coverage remains in effect during the sixty-day (60-day) period, provided the premium
is paid.
PPOLGCO1896 33
Any Dependent qualifying for continuation of coverage under this provision may elect a converted
policy instead of such continuation of group insurance. If the Dependent has elected continuation
under this provision, the Dependent will have the option of a conversion coverage at the end of the
maximum continuation period.-All conversion provisions described above in Option (1), and Option (2)
will apply.
CONVERSION PREMIUM
1. The initial Premium at the time of conversion for any converted policy issued
will be determined as follows:
a. In accordance`with the HMHIC's table of Premium rates for coverage
that was provided under the Group'Policy or Plan; and
b. based on the type of converted policy and the coverage provided by
the converted policy.'
2. The initial;Premium at the time of conversion may be based on the age at issue
of the conversion policy and the geographic location of each person to be
covered and the type of converted policy however, the premium for the same
coverage and benefits under a converted policy may not exceed 200% of the
premium determined under subsection 1 (a) and (b) of this section.
3. For all policies converted for twelve (12) months or more, renewal premiums
will be based on the pooled experience of all such policies'_with,:credibility
applied. The credibility of pooled policies will be based on sound actuarial
principles and practices. A certification that the resulting premiums are
reasonable in relation to benefits provided will be submitted to the department
by each June 1, 1997.
4. All rates for individual conversion policies will be submitted to the department
in accordance with the requirements of Insurance Code, Article 3.42, and
Subchapter A of this Chapter 3 of this title (relating to Requirements for Filing
Policy Forms, Riders, Amendments, and Endorsements for Life, Accident and
Health Insurance and Annuities). The department may request documentation
related to the premium rates and/or actuarial information for any conversion
policy as permitted by Subchapter A of Chapter 3 of this title.
5. HMHIC is required to substantiate with actuarial data the rate for any converted
policy providing the same coverage and benefits with a premium rate of 200%
of the premium determined under subsection 1. (a) and (b) of this section. The
premium charged for converted policies 'must' be determined using sound
actuarial principles, and the relationship of benefits to premiums paid must be
reasonable, subject to the maximum 200% cap.
MINIMUM STANDARDS FOR BENEFITS FOR OTHER CONVERSION POLICIES
No insurer will issue any other conversion policy in this state unless it meets the following minimum
standards:
1. Hospital or Surgical Expense Coverage. Subject to the provisions and
conditions` of these sections, if the Group Health' Benefit Plan from which
conversion is made insures the Employee, or Dependent for basic hospital or
surgicai expense insurance, any ,converted policy must provide coverage and
benefits on an expense incurred basis under a plan meeting the requirements
of the Lesser In-Hospital Conversion Policy Benefit Package:found in Article
3.520 of this title. Provisions of the converted policy may not be less favorable
than the prototype provisions for covered services and benefits.
PPOLGCO1896 34
2.` Major Medical Coverage. If'the"Group Health Benefit Plan from which
conversion is made' insures the Employee or Dependent for major medical
insurance, any converted policy must provide coverage and benefits on an
expense-incurred basis under a plan meeting the requirements of the Basic
Conversion Policy Benefit Package found in Article 3.520 of this title.
Provisions of the converted policy may not be less favorable than the;prototype
provisions for covered services and benefits.
MINIMUM STANDARDS FOR CONVERSION POLICY PROVISIONS AND REQUIREMENTS FOR
CONVERSION POLICIES
1. A conversion policy will provide for the addition of newborn children and
children for whom a court or administrative order has mandated coverage. The
policy may provide that such coverage terminates when the converted person's
coverage terminates.
2. A conversion policy may not reduce benefits when benefits are being provided
under the Texas Medical Assistance Act of 1967,as amended.
3. A conversion policy may not exclude any condition as a pre-existing condition
of any Insured Person unless the condition was excluded under the Group
coverage from which the Employee or Dependent is converting. Any condition
excluded under that Policy may be excluded under the conversion policy only
until such time as the condition would have been covered'under'the Group
Policy had the coverage remained in force.
4 An individual or Group conversion` policy, subject to the subchapter, may
provide that the insurer may refuse to renew the policy or coverage of any
person insured under the policy only for reasons outlined in Article'3.513 of
this title (relating to Minimum Standards for Renewability of Conversion
Policies).
5. Any Group conversion policy must contain the following:
a. a provision that the trust"policy will not be terminated by either the
`trustee or the insurer until such time as no certificate holders remain
covered under the policy; and
b. a provision prohibiting any unilateral'change in the terms'of coverage.
LIFETIME MAXIMUMS AND BENEFITS CALCULATIONS; DEDUCTIBLE AND CO-INSURANCE CREDIT
1. The lifetime maximum under a conversion policy providing the same or similar
coverage and benefits will be computed from the initial date of the Employee's
or Dependent's effective date under the preceding Group coverage. This will
apply equally in the calculation of lifetime maximum dollar limits or durational
limits.
2. The lifetime maximum under a conversion policy providing lesser coverage and
benefits will be computed from the Effective Date of the Employee's or
Dependent's conversion coverage. This will apply equally in the calculation of
lifetime maximum dollar limits or durational limits.
PPOLGCO1896 35
3. When conversion is being made to a policy of same or similar coverage and
benefits, the insurer will give credit under the conversion policy for any portion
of the deductible and any amounts attributed to an Insured's Out-of-Pocket
Maximums which were met during the policy year in which conversion was
made.
4. When conversion is being ma3e to a policy of lesser coverage and benefits, the
insurer will calculate deductibles and co-insurance 'maximums` from the
Effective Date of the conversion coverage.
MINIMUM STANDARDS FOR RENEWABILITY OF CONVERSION POLICIES
A converted policy may provide that the insurer may refuse to renew the policy or the coverage of any
person insured under the policy only for the following reasons:
1. the converted person is covered for similar benefits by another hospital,
surgical, medical, or major inedical expense insurance policy or hospital or
medical service subscriber contract or medical practice or other prepayment
plan, or by any other health or program;
2. the converted person is eligible for similar benefits under any arrangement of
coverage for individuals in a group,I whether on an insured or self-funded basis;
3. similar benefits are provid:d for or available to the person under the
requirements of any state or federal law;
4. the converted person fails to provide information as requested by the Company
prior to any premium due date in order to establish the existence of coverage
as outlined in paragraphs 1 of this subsection;
5. fraud or material misrepresentation' in applying for any benefits under the
conversion policy;
6. the Insured Person is eligible for coverage under Medicare (Title XVIII of the
United States Social Security Act as added by the Social Security Amendments
of 1965 or as later amended 3r superseded) or under any other state or federal
law (except the Texas Medical Assistance Act of 1967;as amended) providing
for benefits similar to those provided by the conversion policy; or
7. any other reason which has received specific prior approval by the
Commissioner of Insurance:
MINIMUM STANDARDS FOR CONTINUATION OF COVERAGE
1. For those persons who elect continuation, coverage may not terminate until the
earliest of the following dates:
a. six (6) months after :he date the election is made;
b. the date on which fai'ure to make timely payments would terminate the
coverage;
C. the date on which the Group policy terminates in its entirety;
PPOLGCO1896 36
d. the date on which`the covered`person is or could be covered under
Medicare;
e. the date on which the covered person is covered for similar benefits by
another hospital, medical, surgical, or major medical expense insurance
policy or hospital or medical service subscriber contract or medical
practice or other prepayment plan or by any other plan or program;
f. the date which the covered person is eligible for similar benefits
whether or not covered therefor under any arrangement of coverage for
individuals in a group, whether an insured or uninsured basis; or
g. the date on which similar benefits are provided for or available to such
person, pursuant to Or in accordance with the requirements of any
state or federal law.
2. Any insurer providing continuation of group coverage in accordance with
Insurance Code, Article 3.51-6, 1(d)(3)(13)(1) in lieu of conversion will not be
relieved of its obligation to provide benefits in the event of policy termination.
A conversion privilege will be available to all Insureds including those insureds
affected during the six (6) month continuation period 'unless the insurer
provides for the continuation of the coverage beyond the policy termination
date to fulfill the continuation obligations.
3. Any insured person who has elected to continue-group coverage under
applicable`federal or state law' will be included under any group plan which
replaces the existing group plan. Coverage under the replacing policy must be
continued until the completion of the continuation period.
PPOLGCO1896 37
SECTION 7: TERMINATION OF COVERAGE
EMPLOYEE AND DEPENDENT
RENEWABILITY OF COVERAGE
The Company will renew this policy for any Employer at the option of the Employer, except for:
1. nonpayment of a premium as required by the terms of the policy;
-2. fraud or misrepresentation of a material fact by the Employer; or
3. noncompliance with any provision of this policy.
However, the Company may elect to refuse to renew all of these Policies. If the Company elects to
refuse to renew all of these Policies, the Company will notify the Employer not later than one-hundred
and eighty (180) days before the date on which this Policy will end.
TERMINATION OF EMPLOYEE COVERAGE
Except as provided under the EXTENDED BENEFITS provision of the MAJOR MEDICAL BENEFITS and
under CONTINUATION OF COVERAGE, the Employee's coverage under the Policy will end on the first
of the following:
1. the date the Policy ends;
2. the date the Maximum Benefit amount under the Policy has been paid to or on
the Employee's behalf;
3. the date the Employee is no longer employed by the Policyholder or by a
Participant Policyholder or is no longer an Eligible Employee
4. the last day of the period for which premium payments have been paid to the
Company, on the Employee's behalf;
5. the date the Employee enters the active service of any military of any country
on a full-time active duty basis for other than scheduled drills or other military
training not exceeding one (1) month in any calendar year;
6. the date the Employee is no longer Actively at Work, except in the event he is
absent due to Illness or Injury or authorized leave of absence, Actively at Work
will terminate on a later date determined by the Policyholder; or
7. the date of the Employee's death.
TERMINATION OF DEPENDENT COVERAGE
Except as provided below or under the EXTENDED BENEFITS provision of the MAJOR MEDICAL
BENEFITS and under CONTINUATION OF COVERAGE, the Dependent's coverage under Harris
Methodist Health Insurance Company will end on the first of the following:
1. the date the Policy ends;
2. the date the Maximum Benefit amount under the Policy has been paid to or on ,
the Dependent's behalf;
3. the date the Employee's coverage under the Policy ends;
4. the date the Employee's spouse or child no longer satisfies the Policy's
definition of an Eligible Dependent;
5. the last day of the period for which Premium payments have been paid to the
Company, on the Employee's or the Employee's Dependent's behalf; or
PPOLGCO1896 38
6. the date the Employee's Dependent enters active service of any military of any,
country on a full-time active duty basis for other then scheduled drills or other
training not exceeding one (1) month in any calendar year.
If the Dependent attempts, through deceit, to obtain coverage and/or benefits for himself or for another
person that otherwise would not be provided or payable, the Dependent's =coverage will terminate
automatically, without notice, and the Dependent will not be entitled to the Conversion Privilege of the
Policy.
TERMINATION OF THE POLICY -
The Policyholder must pay all Premiums due for the period the Policy was in force when the Policy
ends.
TERMINATION BY THE POLICYHOLDER
The Policyholder may end the Policy by giving written notice to the Administrator. The Administrator
must receive the notice thirty (30) days before the termination date.
TERMINATION BY THE COMPANY
The Company reserves the right to end the Policy if any of the following occurs:
1. The Policyholder fails to promptly,furnish any information that the Company
requested or fails to perform its duties contained in the Policy,in good faith.
The Company will provide thirty (30) days written notice of termination.
2. The Policy has been in effect for at least twelve (12) months and the Company
provides thirty (30) days notice of termination.
3. If the Policyholder fails to pay the required Premiums to the Company within
the thirty-one (31) day Grace Period, the Policy will terminate on the last day
of the month in which Premiums were paid.
HANDICAPPED OR INCAPACITATED CHILD
Coverage under the Policy may continue for an unmarried or incapacitated child after the Dependent
reaches the limiting age if:
1. on the date the Dependent reaches the limiting age, the child cannot work
because of mental retardation or physical handicap;
2. the Dependent became incapacitated before reaching the limiting age;
3. the Dependent is chiefly dependent on Insured for support and maintenance;
and
4. a medical expense insurance policy, as described in the CONVERSION RIGHTS
section, has not been issued to the Dependent.
If the Company denies a Claim because the Dependent reached the limiting,age, it is Employee's
responsibility to prove to the Administrator that the Dependent is still handicapped.
PPOLGCO1896 39
The Company or the Administrator has the rights
1. to require proof of the Dependent's incapacity; and
2. to have its own Physician examine the Dependent, at its own expense, during
the term of the incapacity. The Company can require the examination more
than once a year during the first two years and once a year thereafter.
Coverage for a handicapped or incapacitated Dependent may continue until the first of the following:
1. the date the incapacity ends;
2. the date the Employee refuses to submit proof of the Dependent continues to
be incapacitated;
3. the date the Employee refuses to allow the Company's Physician to examine
the Dependent; or
4. the date the Dependent's coverage under the Policy;ends for, any reason other
than reaching the limiting age.
EXTENSION OF BENEFITS
If the Insured is Totally Disabled on the date the Policy ends, his coverage under the Policy is extended
for Covered Health Services provided for the treatment of the Illness or Injury which caused the
disability. Benefits are extended if:
1. premiums continue to be paid by the Policyholder;
2. the Covered Health Services'would have been covered under the Policy, had
the Policy not ended;'`
3. the Insured remains Totally Disabled on the date each Covered Health Service
is provided; and
4. the Insured is under the care of a Physician for the disability.
The Company pays benefits subject to the same Policy maximums, limitations and exclusions that were
in effect for the Insured on the date the Policy ended. Benefits are extended until the first of the
following dates:
1. the date the Maximum Benefit amount under the Policy has been paid to or on
behalf of the Insured;
2. the date the Insured is no longer Totally Disabled; or
3. the last day of a three (3) month period during which benefits have been
extended under the provision.
TOTAL DISABILITY or TOTALLY DISABLED`means that because of an Illness or Injury:
1. the Employee or Spouse is completely unable to perform all of the substantial
and material duties and functions of his occupation and any other gainful
occupation in which the Employee or Spouse earns substantially the same
compensation earned prior to the disability; or
2. the Dependent is confined as a bed patient in a hospital.
Exception: Newborn children are not subject to the Total Disability provision.
The Policy provides extension of benefits for the course of treatment or dental procedures that were
authorized and began, in connection with a specific accident or Illness, while the Policy was in effect.
The dental procedures must be provided within ninety (90) days after the patient's coverage ends.
PPOLGC01896 40
SECTION 8: PREMIUMS
PREMIUM CALCULATIONS
The Policyholder must pay the initial and subsequent Premiums to the Company on or before the due
date. The Company has the right to change the initial Premium to reflect the actual number, age or
class of Employees on the Effective Date of the Policy. The Policyholder will 'mail the Premium
payment to the Administrator.
The rate required for a"newly acquired Eligible Dependent will be payable initially when the required
Application is submitted to HMHIC. Thereafter, all payments with respect to such new Eligible
Dependent shall be made as otherwise required in this Agreement.
Any payments required for newborn children who meet the requirements of this Agreement will be
initially payable to HMHIC on or before the first day of the month following the month in which the
required notification is submitted to HMHIC. All payments then made for the newborn will be made
as otherwise required in this Agreement.
PREMIUM CHANGES
the Polieyholder at least thiFty ene (31) days PFieF written Fietiee when
- Date;
of Employees; e
liability HFideF the Pek.•
PaYS PFeFs.-im Employee and- he is RQ 1GROBF eligible7mthe Gempany Will Fefund t amount
Employee was met eligible, th
t
the G9FAPaRy of the Employee's or Dependgnt's i"affNk)�_ �j ch-6
NON-CONTRIBUTORY COVERAGE
If the coverage basis is "Non-Contributory", the Policyholder agrees to pay on each payment due date,
the sum of the HMHIC rate for the coverage then provided under this Agreement. The Group premium
for the coverage provided by HMHIC under this Agreement will be determined by the applicable rate
then in effect and the number of Insured's at the monthly intervals established by HMHIC.
PPOLGCO1896 41
CONTRIBUTORY COVERAGE
If the coverage basis is "Contributory", the Policyholder agrees to pay on each payment due date, that
part of the HMHIC rate for coverage then provided under this Agreement. The Policyholder will permit
Insured's to pay their contributory portion of such rate through payroll deduction." Procedures for
implementing payroll deductions for the Insured's portion of such rate will be the same as those utilized
for any Alternative.Health Benefit Plan. if thy; Policyholder does not have an Alternative Health Benefit
Plan, the procedures will solely be those as agreed to,in writing, between the Policyholder and HMHIC.
The Group premiums for the coverage provided by HMHIC under this Agreement will be determined by
the applicable rate then in effect and the number of Insured's at the monthly intervals`established by
HMHIC. The Policyholder will offer HMHIC to all Eligible Employees on contribution-related terms that
are no less favorable than those of any Alte►native Health Benefit Plan that,may be available through
the Policyholder. The Policyholder will not change its contributions during the term of this Agreement
unless the change is approved, in writing, by HMHIC before it is carried out. If, however, the
Policyholder contributions to any Alternative Health Benefit Plan are increased during the term of this
Agreement,the Policyholder agrees to also increase contributions to HMHIC. This increase will become
effective with the first monthly payment following the increase.
PPOLGCO1896 42
1
SECTION 9: WAIVER OF RIGHTS, INDIVIDUAL CERTIFICATES,
REINSTATEMENT, AND REQUIRED INFORMATION
WAIVER OF RIGHTS
If the Company failed to enforce a provision of the Policy earlier, it does not lose:the right to enforce:
that provision later. The Company's failure to enforce one provision does not affect the Company's:
ability to enforce any other Policy provision.
INDIVIDUAL CERTIFICATES
The Company'issues to the Policyholder, for delivery to each Employee, individual 'certificates of
coverage. The certificate will describe the benefits that each Employee is entitled to and to whom the
Company will pay the benefits.
REINSTATEMENT
HMHIC will reinstate the insurance if it ended because the Eligible Employee was no I i���rA�a,nd'ti e�.
Eligible Employee returns within six,(6) consecutive months after the last day of being.Weprwlse,,
if the Eligible Employee's coverage lapsed due to non-payment of premium or voluntary cancellation„
he will not be eligible to apply for coverage until the next Open Enrollment Period as established by the.
Employer/Policyholder and HMHIC.
If the Policyholder pays its delinquent payments to HMHIC within fifteen (15) days of termination;.
HMHIC may reinstate the Policyholder without requiring a new Group Enrollment Agreement. However,
HMHIC reserves the right to refuse to reinstate the Policyholder by refunding,within five (5) business,
days, all payments made by the Policyholder after the date of termination.:
REQUIRED INFORMATION
The Policyholder will furnish the Company all information necessary to calculate the Premium and`all!
other information that the Company may require. Failure of the Policyholder to furnish the information
will not invalidate any insurance, nor will it continue any insurance beyond the last day of coverage.
The Company has the right to examine any records of the Policyholder,'any person, company or
organization which may effect the Premiums and benefits of the Policy.
The Company's right to examine any records exists:
1. during the time the Policy is in force; or
2. until the Company pays the last Claim.
In addition, HMHIC will, to the extent legally allowable and without further consent of or notice to You;;
release to"or get from any insurance company, or other organization, or person any information about
You that HMHIC sees as necessary. When claiming benefits, You must furnish HMHIC the information!
necessary to carry out this Agreement.
PPOLGCO1896 43
SECTION 10: CLAIMS_
PROOF OF LOSS REQUIREMENTS - PARTICIPATING PROVIDERS
An Insured does not need to file a claim form when services or supplies are rendered by a Participating
Provider of the Company.
NOTICE OF CLAIM
An Insured must give written notice of Claim to the Administrator within twenty (20) days after a
covered,loss occurs. Notice will include the Employee's name,,Certificate of Coverage number, the
name of the Insured on whose behalf the claim is being submitted, and the nature and extent of the
loss. Failure to give Notice of Claim to the Administrator within twenty (20) days will not invalidate
or reduce any Claim if the Insured can prove he gave Notice of Claim as soon as it was reasonably
possible.
CLAIM FORMS
When the Administrator receives the Notice of Claim, it will send the Insured the Claim Forms. If the
Claim Forms are not sent to Insured within fifteen (15) days after the Administrator receives the Notice
of Claim, he may file a Claim by submitting written Proof of Loss within ninety (90)'days. -
PROOF OF LOSS
Written Proof of Loss must be given to the Administrator,within ninety (90) days after the date of loss.
Proof of Loss must include the nature and extent of the loss. The Insured must provide any information
pertaining to the Claim, such as original bills or Explanation of Benefits.
The Administrator will not reduce or deny a Claim because the Insured did not furnish a Proof of Loss
within ninety (90) days, if proof is furnished as soon as reasonably possible. The Administrator will
not accept any Proof of Loss, except if he is legally unable to furnish one, after one (1) year from the
time it was required.
TIME OF PAYMENT OF CLAIMS
Unless additional information is needed, the Administrator will pay*the Claims within sixty (60) days
after it receives a proper and complete written Proof of Loss. The Administrator will provide written
acknowledgment of the Claim within fifteen (15) business days after it receives the Proof of Loss. The
Administrator will mail a request to the Insured for any additional items, statements and forms that it
believes is required to process the Proof of Loss.
APPEAL PROCEDURES
The Administrator will either pay or deny the Claim no later than fifteen (15) business days after it
receives all items, statements, and forms requested from the Insured. If the Administrator notifies
Insured that the claim will be paid, it must pay the Claim within five (5) business days after the Insured
is notified.
If the Administrator is unable to either pay or deny the Claim within fifteen (15) business days after
the Administrator receives all the information, the Administrator will mail a notice to Insured within
fifteen (15) business days and include the reasons why the Administrator needs more time.
Under any circumstances, the Administrator must either pay or deny the Claim within forty-five (45)
business days after it notifies the Insured it received the Proof of Loss. If the Administrator delays
PPOLGCO1896 44
Claim payment for more than sixty (60) days after it receives all the items, statements or forms
requested from the Insured, the Administrator will pay him, in addition to the amount of the Claim,
18% per year.
If a Claim is denied, either in whole or in part, the Insured will receive a written explanation. The
Insured may appeal the denial through the Company's Administrator.- The appeal must be in writing
and mailed to the Administrator within sixty (60) days after the Insured is notified that a Claim is
denied.
The Insured has the right to read all relevant documents that were used to deny the Claim and provide
any information to the Administrator that he believes supports the Claim. The Administrator will notify
the Insured of its decision within thirty (30) days after it receives the appeal
If the Administrator denies the appeal,the Insured may request that the dispute be resolved through
mediation or binding arbitration. The Insured cannot sue the Company to resolve matters submitted
to arbitration. The Insured pays 10% and the Company pays 90% of the cost for the arbitration. The
arbitration will be conducted according to the Texas Arbitration Act.
PAYMENT OF BENEFITS
The Company will pay all benefits to the Insured, to his designated Beneficiary or Beneficiaries, or to
his estate, unless the Insured assigns benefits to another person. The Insured must-provide the written
Assignment of Benefits to the Company by the time Proof of Loss is filed.The Administrator will pay
the party-it determines is entitled to the payment if the Insured is not legally capable of giving'a valid
receipt for payment of benefits, or there is no legal guardian. Payment made in good faith under this
provision will release the Administrator and the Company from their obligation.
PPOLGCO1896 45
SECTION 11: GENERAL PROVISIONS
ENTIRE CONTRACT: A copy of the Policyholder's Application, any individual Applications, and any
amendments, riders, or endorsements attached to the Policy constitutes the entire contract of
insurance. All statements, made by the Policyholder or by the Employee, ;are considered
representations and not warranties.
The Policy cannot be amended or changed without the permission of both the Policyholder and the
Company. No change is valid unless it is made through an endorsement to the Policy, or by an
amendment-or rider signed by an authorized Company Representative, and agreed to by the
Policyholder. Each Employee and any other individuals referred to in the Policy are bound by any
change that is made.
GRACE PERIOD: After payment of the first Premium, the Policyholder is entitled to a.Grace Period of
thirty-one (31) days to pay any subsequent Premiums due. The Policy will remain in force during the
Grace Period unless the Company receives written notice of cancellation from the Policyholder in
advance of the date of cancellation and in accordance with the terms of the Policy. The Policyholder
must pay the Company the Premium due for the time period the Policy was in force during the Grace
Period. V
PREMIUMS: The Policyholder must:pay all Premiums to the Company on or before the due date or
during the Grace Period designated in the Policy., The Policyholder remains liable for all premiums not
paid before termination. Interest on late payments maybe_charged beginning at the end of the Grace
Period at a rate of�� r. Unpaid interest will be due when the Policyholder receives
notification from HMHIC.
INCONTESTABILITY: Except'for non-payment of Premiums, the validity of the Policy shall not be
contested after it has been in force for two (2) years from the date of issue. The Company will not
use a statement, except for a fraudulent misstatement, made by an Insured to contest the validity of
the Insured person's insurance unless the Employee wrote and signed the statement. The Company
must provide a copy of all documents it uses to contest the Policy to the Insured or to his Estate.
TIME LIMIT ON CERTAIN DEFENSES: The Company will not contest the Policy or deny a Claim
because of a statement made by an Insured while covered under the Policy if:
1. the Policy has been in force for at least two years prior to the contest; and
2. the Insured was alive during the two (2) years the Policy was in force.
NEW EMPLOYEE: The Policyholder may add new Employees according to the Eligibility Rules section
of the Policy.
ELIGIBILITY: The Company can require an Eligible Employee or Dependent to furnish an Evidence of
Insurability as a condition to part or all of the coverage.
CONFIDENTIALITY OF MEDICAL RECORDS: The Insured must authorize the release of all medical
information requested by the Company or the Company's Administrator. The Company or the
Company's Administrator agrees to maintain and preserve the confidentiality of all medical information.
The Company may supply medical information to its Utilization Review Agent, a peer review committee
or governmental agency. The Company will pay a reasonable fee for any medical information that it
requests. The Company can deny the Claim if the Insured refuses to authorize a release of the medical
information requested by the Company.
MISSTATEMENT OF AGE: When the Insured's age has been misstated, the Company will provide the
amount of insurance for the correct age. The Company will change the amount of Premium so that
the Company receives the correct Premium for the true age.
PPOLGCO1896 46
PHYSICAL EXAMINATION: The Company reserves the right to choose a Physician to examine any
Insured whose condition, Illness or Injury is the basis of a Claim. All examinations are at the
Company's expense. The Company's right may be exercised when and as often as it may require
during the investigation of a Claim. The Company will deny the claim if the Employee refuses to be
examined.
AUTOPSY: The Company can request that an autopsy be performed on any deceased Insured whose
condition, Illness or Injury is the basis of a Claim. The Company's right exists only where not
prohibited by law.
LEGAL ACTION: The Company has sixty (60) days to pay a Claim from the date the Company receives
it and the Insured must wait sixty (60) days before he can sue the Company to recover benefits.
However, the Insured has up to three (3) years to sue the Company from the time he mailed the Claim
to the Company.
CONFORMITY WITH STATE STATUTE: Any provision of the Policy which, on its Effective Date,
conflicts with the state laws where the Policy was issued or delivered, is amended to meet the
minimum requirements of the law.
CLERICAL ERRORS: Clerical Errors or delays in record keeping:
1. will not deny coverage that otherwise would have been issued;
2. will not continue coverage that otherwise would have ended;
3. will not extend, provide, or create coverage that does not exist under the
Policy; and
4. may require a change in Premium.
RECOVERY OF PAYMENTS: The Company will deduct from any benefits payable under the Policy the
amount of any payment which has been made:
1. in error;
2. based on a misstatement contained in a proof of loss;
3. based on a misstatement made to obtain coverage under the Policy within two
(2) years after the date the Insured's coverage begins; or
4. on behalf of an ineligible person.
AGENCY RELATIONSHIP: Nothing in the Policy establishes that the Policyholder is an agent of the
Company. The Policyholder is an agent of the Employee. The relationship between HMHIC and the
Policyholder is that of independent contracting entities. Neither the Policyholder nor You is the Agent
of HMHIC. HMHIC is not the employee or agent of the Policyholder or You.
POLICIES ISSUED UNDER A COLLECTIVE BARGAINING AGREEMENT: If the Premium for the Policy is
paid in whole or in part by an Policyholder according to the terms of a collective bargaining agreement,
the Policy may remain in effect for the Employees covered by the Policy who are involved in a labor
dispute. The Policy will remain in force during a strike by the Employees if the Premiums are paid. All
Employees covered under the Policy on the date of the strike must continue to pay their individual
contribution and also pay the Policyholder's contribution for the duration of the strike. The Policy will
end six (6) months after the first day of the strike, if the employees have not returned to work.
PPOLGCO1896 47
ATY OF FORT WORTH,, TEXAS
" RISK MANAGEMENT DEPARTMENT
EMPLOYEE OMBUDSMAN
1000 THROCKMORTON STREET
FORT WORTH,TEXAS 76102
March 10, 1994 -
To: ALL EMPLOYEES WITH GROUP MEDICAL BENEFITS
From: Susan Bulla, Director a/ _
Risk Management Department
Subject: Eligibility rules
The attachment to this memo details the rules for eligibility for
those of you with group medical benefits conferred through the
City of Fort Worth and your eligible dependents. These
eligibility rules have been recently amended to accommodate
changes in Texas State Law, and they determine who may
participate in the City' s group health program. Please review
these carefully and keep this information with your materials
regarding your group medical benefits.
If you have any questions regarding this information please
contact Ann Bracey at 871-7787.
r -
C
L
}
Fort Worth All-America City
AII•Ameda City
d'. A child of an Enrollee's unmarried dependent child. No benefits are
provided for the infant child of the Enrollee's unmarried dependent`
child unless the infant child of the unmarried dependent is otherwise
eligible for coverage by Enrollee. If' "such infant 'child is eligible for
coverage by the Enrollee, such coverage will be available as described
above provided appropriate notices and contribution payments have been
timely.
2. Coverage takes effect for dependents as follows:
a. No dependent can be covered before the date the Enrollee becomes cov-
ered.
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 con-
fined 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. Enrollee's eligible spouse and/or other dependents who lose coverage due
to the spouse's or former spouse's loss of coverage due to involuntary
loss of employment or involuntary reduction in hours or employer 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
only if the Enrollee has current coverage on him/herself and 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
Revised February 21, 1994
period-for submission-of, an appl- cation- 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 depen-
dent will NOT be added to the 'City's payroll deduction for covered
members until the completed form is returned to the Risk Management
Department.
Revised February 21, 1994
ACTIVE EMPLOYEES
ELIGIBILITY
These are eligibility rules for active. employees and their spouses and depen-
dents for participation in the City's group health benefits program. 1 These '
rules may be amended from time to time. Please contact the Risk Management
Department for the latest revision of this information.
Employees
1. Must be permanent employees occupying positions budgeted for at least
half-time (0.5 A.P.)_or working in a full-time position (1.0 A.P. )'aIt least
twenty hours per week on a regular basis.
2. Employees whose 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' 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 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; HMO coverage only available if the
employee lives in the managed care service area and the loss of coverage
entirely if he/she lives out of_the service area; and any other eligibility
changes which may be imposed from time to time.
7. The value of any benefits or services provided by the City's plan(s) shall
be coordinated with any group plan or coverage under governmental programs,
including Medicare, to assure that the covered person receives coverage
Revised February 21, 1994
Y
while avoiding double recovery.
8. Services and benefits for military service connected disabilities for which
the covered person is legally entitled and for which facilities are reason
ably ;available,. shall .in all cases be provided before the benefits of the
City's plan(s).
Dependents
1. To be eligible to enroll as a dependent, a person must be:
a. the spouse of an enrolled employee or the surviving, unmarried spouse of
a police officer or firefighter who has`died`a violent death in the line
of duty who is not eligible for coverage through any group medical
benefit plan nor Medicare, or-
b. a dependent, unmarried natural child, foster child, stepchild, legally
" adopted `child 'or 'child'"under the Enrollee's legal guardianship or custo-
dianship, 'residing with the Enrollee or with the Enrollee's present or
former spouse who is:
1. under `nineteen (19) years of age, or under 21 years of age if a
surviving dependent of a police officer or firefighter who has died a
violent death in the line of duty who is not eligible for coverage`
through any group medical benefit plan, or
2. 'under `twenty-three (23) years of age, primarily dependent on the
Enrollee 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, or
c.' a dependent, unmarried natural child, foster child, stepchild, legally `
adopted child or child 'under the Enrollee's' legal guardianship or custo-
dianship, 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 an a full-time basis when such
incapacity occurred) and primarily dependent upon the Enrollee for
support and maintenance. Such dependent child must have been enrolled
at all times under the 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 fr= time to time
thereafter as the City deems''appropriate, or
Revised February 21, 1994
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ELIC3I8Xt,I1 Y fAXs �r 9, iggi
1• Persons 'at* have retired as either
Pension disbursements from ' ragvTa. y disability and ar•c� reco1vin9
the Retir�nt SystQ0.
These persons have the 221tM to
insurance program for rOtired in the City's group health
Persons hired after October, 1988 kilt be required-to art
of their group health insurance cost at
Premiurs cost) based on the follokin s� then-current p Pauotin the cost
9 schedule: quoted retiree
Y �r City Nil1 P
jc Retired Will pay
1 •25 679 67z + optional additional coverage
26+% 10QX 33% ♦ optional additional coverage
OX + optional additional coveraga
j Persons hired before Qctobar Y
group health insurance option which requires no cost a
`9W will have afforded to theta at least one
.i own basic coverage. Benefits above the basic p rticiPation for their
retirees full cost. P. for de encient coverarege are
adopted by the City Council during p 9 to be paid thetrate '
g budget deliberations.
f Efrective tnmedtatalY- No additional adverse
To def fined, v rse etfect to
pflrson= currently
If a reteligible red person opts not to participate to
not be to re,�oin the plan in the fututhe Cityts
. , Plan, he/she will
�• Persons who rest
' program, but Oho onlretire and who remained vested in
f other ve not yet begun to receive distributions City s pension
(Rule of 65 or
Persons vested in the Retirement Systea
distribution of pension benefits must who have not
and that of their eligible dependents at the h eco ' Yet begun coverage
employees until the earlier of such tine as cost of their coverage
distribution-or 2 m rate for
Participate in they reach 65 years of a (l� they do begin receivi
t e a n
Provisions cost of their grou 9 t which time the City
of #1 above. P .health Insurance ecCOrdin wily
� g to the
iVI 49
o J=JJr ivt rt-Wl-1 r rr t /
Oil OtOIJ Y. J
X5:34 EMERGERCY'MANAGEMERT FAX Nu_ bYiNIMU __ r. ua
If a vested person opts. not to participate in the City's plan, hefshe Will
not be, eligible to retain the plan -in the future.
Eff0ctivaly .•immediately. This one WILL haw an effec on the tfrMe t ,e
parsons currently enrolled. C
3• Persons Who taRe on actuarial reduction in
Pension benefit: to retire early.
Persons vhO have retired and are taking an act unri$1 reduction in pension
disbursements are eligible to participate in is City's group health
Insurance plan under the sari provisions as fi above.
4. The sur lvtng spouses and voter dependents of
• persons described above. _
The surviving dependents of City former employees/retirees are s to
the same gL� criteria as that of the former employee/retreesand
in order to assert that eligibility. must have been a participant of the P Tan
at the time of the retiree's death. Dependents must be covered u rorthe
City's grou health insurance program at the time of the
retirement �or at the time of separation of em to remaining Vested)employees
in order to be eligible for continued coverage t��gh r�City' , group
health insurance program for retired employees. P
Sur
yivtn de endents will be required to
9 p 4 Pay a contribution as set annually.
If a survivin dependent opts not to participate in the City,s la►n
Kill not be e iHible to re,3ofn the plan in the future. plant he/she
Retirees who participate in the cost of their own insurance and '
eligible dependent coverage authorize deductions for the ho pay for
Participation through deductions from their monthly equired
Whose monthly pension checks are insufficient to y pension checks. Retirees
a Payment plan with the Risk Management DepartmenChtormake srtuwst arrange
payments to maintain the desired covers e. pplemental
quarterly payrr�ants in advance. g Arrangements are to be made for
Payment monthly in advance nay be anted o Iextreme hardship, of Dental
arrears in required contribution=, he/she will ebierendot��ieodyeand Tvtll into
al lowed to correct the-arrearage. If the arrearage continues 4a days after
notification coverage of dependents vfll be terminated and be
health benefits reduced to the "no cost participation required"} benefits.
q level of
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Harris Methodist Health Insurance Company
Preferred Provider Organization
(PPO)
SCHEDULE OF BENEFITS
CITY OF FORT WORTH
601 Ryan Plaza Drive,Suite 156
Arlington,Texas 76011
1-800-373-9781
(817)462-7881
PPOLG-SCH-96
CFW
WELCOME TO HMHIC'S PPO
Harris Methodist Health Insurance Company(HMHIC)has contracted with Providers of medical care to develop
Preferred Provider:Organization (PPO). The contracted Providers are considered preferred or In-Network
_'roviders. They are listed in BNIHIC's PPO Provider Directory. This Schedule of Benefits describes your health
care Benefits both In-and Out-of-Network.
In-Nelhvork
n-Network services are health care services provided by Facilities and Physicians that are under contract with
rlarris Methodist Health Insurance Company to provide Benefits to You and Your Eligible Dependents. The PPO
is designed to encourage you to seek health care services in a cost-efficient manner.
n general, this means that the PPO Plan has financial incentives for You if You purchase needed health care
services through designated medical Facilities and Physicians. When You use preferred,or In Network,Providers,
-(our out-of-pocket expenses,Deductibles,and Copayments are substantially reduced. If you do not use a preferred
'rovider,your out-of-pocket costs will be increased.
)ut-of-Network
This is a traditional fee-for-service health plan. You will be responsible for larger portion of Your health care
osts if you use an Out-of-Network Provider.
b.
'POLG-SCH-96 1 CFW
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OBTAINING HEALTH CARE SERVICES
You and Your Eligible Dependents are entitled to receive the services and Benefits in this Schedule of Benefits that
are Medically Necessary and received according to the Certificate of Insurance.
A. The Utilization Review Department determines the Medical Necessity of services. You are responsible for
notifying the Utilization Review Department(UR)for the services listed below. The UR phone number is
(817)462-6666 or 1-800-299-1789. Services that are not Medically Necessary or not a covered benefit will
not be paid by HMHIC. You and Your Physician must decide on your medical care. The Utilization
Review Department only determines the Medical Necessity of a service.
Benefits are reduced by 50%if You(Out-of Network)or Your Physician(In-Network)do not call UR before
receiving the services listed below. The penalty applies to each Confinement,surgical procedure,diagnostic
procedure,or Treatment Plan.
Within five working days before receiving the following services, You are required to call UR for
authorization for:
• Inpatient admissions(including pregnancy)
• Outpatient surgery where the procedure requires an operating room or surgical setting
(except endoscopes,sterilization,and biopsies)
• Inpatient Chemical Dependency treatment
• Home intravenous therapy
• Physical and occupational therapy
• Durable Medical Equipment and prosthetics
• Home nursing services
• Skilled Nursing Facility services
• Outpatient mental or Nervous Disorder services
• Hearing aids,if Coverage is included as a Rider
Other office procedures requiring Precertification are:
• Laser procedures, Thallium stress tests, Cystoscopies, Chorionicvilli sampling,
Amniocentesis,LEEPILETZ procedures,and D&C
• Arteriogram,Aortogram,Myelogram,and Lumbar Puncture
B. Emergency Care Benefits are available for any emergency condition that requires treatment. Emergency
Care Benefits will be paid as if you received the services from an In-Network HMHIC Provider.
Emergency Care is bona-fide emergency services provided after the sudden onset of a medical condition
manifesting itself by acute symptoms of sufficient severity, including severe pain, where 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.
PPOLG-SCFI-96 2 CFW
t
You must submit Your own Claim forms for all medical bills for services received from Out-Of Network
Providers. The Claims office address is 601 Ryan Plaza Drive,Suite 156,Arlington,Texas 76011. Benefits
are based on the Usual,Reasonable,and Customary charges established by HMHIC. The Benefits are set
according to the Claims provisions outlined in the Certificate of Insurance. You will get an explanation of
Benefits (EOB) summary that explains the amounts`paid by HMHIC and the amounts that are your
responsibility.
7. All services and Benefits are subject to the Usual, Reasonable, and Customary Charges and any stated
Copayment amounts,Limitations,and Exclusions described in this Schedule of Benefits.
E. Any Copayment expressed as a percentage of total charges or a flat amount will mean the stated percentage
of the amount paid to the medical Provider by HMHIC.
F. This Schedule of Benefits may be supplemented by additional Benefit Riders if they are included with the
Certificate of Insurance: -
;J. The relationship between HMHIC and the Group is that of independent contracting entities. Providers are
not agents or employees of HMHIC,nor is HMHIC an employee or agent of any Provider. Providers will
maintain the Physician-patient or professional-patient relationship with You and will be the only parties
responsible to You for the services provided.' Neither HMHIC nor any employee of HMHIC will practice;
medicine. HMHIC will in no way supervise the practice of medicine by any Provider. HMHIC will not,
in any manner,supervise,regulate,or interfere with the usual professional relationships between You and
a Provider.
H. The following Calendar-Year Deductible must be met for all Benefits and Riders from January 1 through
December 31. The Deductible applies to all covered services unless otherwise noted.
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I` Individual Calendar-Year Deductible $200 $300
Family Calendar-Year Deductible $600 $900
i. Any services limited in daily or dollar maximums count toward both In-Network and Out-of Network
Benefits.
�. A Pre-Existing provision applies to all new employees,uninsured existing employees,and their Dependents.
Pre-Existing Conditions are any medical condition treated or diagnosed within the six months immediately
preceding your Effective Date of Coverage under this Plan. A medical condition has been diagnosed if its
existence is identified or recognized by a Physician or other health professional. A medical condition has
been treated if any services of a Physician or other health professional have been received for the condition,
including,but not limited to,office visits or consultations,Hospital treatment,laboratory services,X-rays,
or the dispensing of prescription medication or refills.
The Pre-Existing Condition limitation will not apply to an Insured Person who was continuously covered
for a minimum of 12 months by a health benefit plan that was in effect up to a date not more than 60 days
before the Effective Date of coverage under the Policy,excluding any Waiting Peridd.
No benefits will be payable under this Plan for any condition for which medical advice or treatment was
received during the six months preceding the effective date of coverage until You have been covered under
this Plan for 12 consecutive months.
PPOLG-SCH-96 3 CFW
COPAYMENT MAXIMUM
The maximum annual Copayments for covered Benefits will not exceed the following in a Calendar Year:
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Individual Calendar-Year Out-of-Pocket Maximum $2,000 $3,000
(excluding Deductible)
Family Calendar-Year Out-of-Pocket Maximum $4,000 $6,000
(excluding Deductible)
When you reach the out-of-pocket maximums shown above,HMHIC will cover 100%of the Usual,Reasonable,
and Customary Charges for any more Covered Health Care Services you incur during that Calendar Year. Benefits
payable will,continue to be subject the Policy's conditions,Limitations,Benefit maximums,Exclusions,and the
Failure to Precertify-Penalty.
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Lifetime Benefit Maximum No Lifetime Limit No Lifetime Limit
PPOLG-SCH-96 4 CFW
"HYSICIAN SERVICES
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(I Physician office visits 100%after 70%after Calendar-
$15 Copayment Year Deductible:
Adult health assessments,routine physical examinations, 100%after 70%after Calendar-
IIwell-child care,and health education for the diagnosis, $15 Copayment Year Deductible
care,and treatment of illness or injury provided by a
Physician
(I Medically accepted Bone Mass Measurement for 100%after 70%after Calendar-
Qualified Individuals for detection of low bone mass and $15 Copayment Year Deductible
to determine the person's risk of osteoporosis and
fractures associated with osteoporosis
Preventive Care(Includes annual well-woman 100%after 70%after Calendar-
examination,childhood immunizations,low-dose $15 Copayment Year Deductible
IImammography for females 35 and older,colorectal
screening,prostate cancer screening,and vision/hearing
screening for children under 19)
IIPhysician office visits after hours 100%after 70%after Calendar-
' $30 Copayment Year Deductible
II Home visits 100%after 70%after Calendar-
$15 Copayment Year Deductible
allergy diagnosis and/or testing and serum
80%after Calendar- 70%after Calendar-
Year Deductible Year Deductible
administered drugs,medications,dressings,splints,and 80%after Calendar- 70%after Calendar-
I' :asts Year Deductible Year Deductible
Diagnostic services,laboratory tests,and x-rays 100%after 70%after Calendar-
;per test) $15 Copayment Year Deductible
IIUltrasound,MR-I, CAT,and non-routine laboratory tests 100%after 70%after Calendar-
(per test) $30 Copayment Year Deductible
surgery and/or anesthesia performed in the Physician's 80%after Calendar- 70%after Calendar-
office or Outpatient setting(per procedure) Year Deductible Year Deductible
X11 Physician fees,including anesthesia,while You are 80%after Calendar- 70%after Calendar-
_ospitalized Year Deductible Year Deductible
II
MOLL-SCH-96 g CFW
r+
For maternity services,You are entitled to receive medical,surgical,and Hospital care from Physicians and other Providers:
• During the term of the pregnancy, upon delivery, and during the postpartum period for normal
delivery;
• For miscarriages and involuntary termination of pregnancy;and
• For Complications of Pregnancy.
Charges related to medical services connected with the home delivery of a newborn and the services of mid-wives,
unless provided as Emergency Care Services,are not covered.
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.:..,f:c:........<.s..s.: .. sy?4.: :¢:.:: .: x..rN ...::.......:.:.rz::.y:•.<.. :•r.>.. _
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Physician services for maternity care including delivery, 80%after Calendar- 70%after Calendar
Hospital visits,and anesthesia Year Deductible Year Deductible
Inpatient Physician care for eligible newborn 80%after Calendar- 70%
after Calendar-
Year Deductible Year Deductible
PPOLG-SCH-96
6
CFW '
IOSPITAL SERVICES
You are entitled to receive Medically Necessary Hospital services,subject to all definitions,terms,and conditions
f the Agreement andithis Schedule of Benefits. If You choose to remain in the Hospital beyond the period that is
Qedically Necessary(as determined by Your Physician and the HMHIC Utilization Review Department),You will
be responsible to the Hospital for non-Medically Necessary services. You must'notify the Utilization Review
Department if Your stay is extended beyond the authorized time.
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Inpatient Hospital Charges
Semi-private room,private if Medically Necessary,and 80%after Calendar- 70%o after Calendar-
all services and medical supplies related to Inpatient Year Deductible Year Deductible
treatment(per admission)
i
+ ,II Outpatient Hospital Charges
(Including Ambulatory Facilities)
Surgery,Therapeutic radiation treatment,Inhalation 80%after Calendar 70%after Calendar-
therapy,All other hospital services Year Deductible Year Deductible
=" Diagnostic testing,laboratory,and x-rays '100%after 70%after Calendar-
(per test) $30 Copayment Year Deductible
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)LO-SCH-96
7 CFW
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EMERGENCY CARE SERVICES
Emergency Care Benefits are available for any emergency condition that requires treatment. Emergency Care
Benefits will be paid as if the Services were received from an In-Network HMHIC Provider. Emergency Care is
bona-fide emergency services provided after the sudden onset of a medical condition manifesting itself by acute
symptoms of sufficient severity,including severe pain,where the absence of immediate medical attention could'
reasonably be expected to result in placing Your health in serious jeopardy,serious impairment to bodily functions
or serious dysfunction of any bodily organ or part.
At the time of a Medical Emergency,You or someone acting for You should make every reasonable effort to contact'
the Utilization Review Department. If it is not possible to contact the Utilization Review Department,;You shoule .
seek care immediately. -
At the time of a Medical Emergency that results in a Hospital admission,You or someone acting for You should
notify the Utilization Review Department within 24 hours or as soon as possible. Upon notification,the Utilization
Review Department will evaluate the need for the continuation of Hospital services.
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Hospital emergency room and urgent care center ” 100%o'after$50 Copayment I
services
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Physician fees in emergency room - 100%after$25 Copayment
AMBULANCE SERVICES
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Land and air ambulance services for Medically Necessary Emergency $50 Copayment
Care Services
PPOLG-SCH-96 8 CFw
FAMILY PLANNING SERVICES
Family Planning Services will be available to You voluntarily. Covered services will include:
• History,physical examination,and related laboratory tests;
• Medical supervision according to generally accepted medical practice;
- • Information and counseling on contraception,including advice or prescription for contraceptive
method;
• Education,including education on the prevention of venereal disease;and
o Voluntary sterilization after proper counseling.
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�;�'�j'��" '�" o\ x.:; >:cY�i`3''k�� ��,,r�Yab"�4 .�``• y:�:g�%%' �4�am�- .j h $`sa. '� s�:n`�;•„�,
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Physician office visits,including related testing, 100%after 70%after Calendar-
education and counseling;fitting and dispensing of IUD $15 Copayment Year Deductible
and diaphragm
Tubal.ligation;vasectomy 80%after Calendar- 70%after Calendar-
Year Deductible Year Deductible
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PPOLG-SCH-96 9 CFW
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CHEMICAL DEPENDENCY SERVICES
You are entitled to all necessary care and treatment for Chemical Dependency as if it is any other physical illness.
Coverage is limited to a lifetime maximum of three separate series of treatments. Diagnosis and treatment for
Chemical Dependency will include detoxification and/or rehabilitation on an Inpatient or Outpatient basis, as
determined to be Medically Necessary by a Physician. All treatment is subject to the same Limitations,Exclusions,
and Copayments that apply to the covered services of any other physical illness.
Note: Inpatient Chemical Dependency treatment requires Precertification by the Utilization Review Department.
A series of treatments is a planned,structured,and organized program to promote a chemical-free status that may
include different Facilities or modalities and is complete when:
• You are discharged on medical advice from Inpatient detoxification,;Inpatient rehabilitation/treatment,
partial hospitalization,or intensive Outpatient treatment;or
• You have received a series of these levels of treatments without a lapse in treatment;or
• You have failed to materially comply with the treatment program for 30 days.
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Office visits 100%after 70%after Calendar-
$15 Copayment Year Deductible
Necessary Inpatient care and treatment for detoxification 80%after Calendar- 60%after Calendar-
and/or rehabilitation from Chemical Dependency Year Deductible Year Deductible
Intensive Outpatient or partial hospitalization 100%after 70%after Calendar-
$30 Copayment Year Deductible
PPOLG-SCH-96 10 CFW
IENTAL HEALTH SERVICES
Outpatient Mental Health Services:
_'ou are entitled to receive 30 office visits per Calendar Year for evaluation,crisis intervention,and stabilization,
and for Outpatient therapy in support of the evaluation or crisis intervention. The 30-visit maximum may include
idividual,couple,or family visits.
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z.�..,y:;.>::�e.... ,?... p.w.�.:. ... , .: .. ..:�.��: :�'�•,�:�"y�i� .,":'+.�•- .:a?.y::r,�,sw� ,> Viz•\2rr„ z�5k
"F�: .may.(, p,. ,:: • y,y�[>>' 3.?�3 :c,� . y.'�� �1:�1.q ¢ K.t;
k#[k,rr: ..,.y�..:.dk:'3R.gY.•^r.�'�., '��..+�' �!�F.i'�jY .t"k<S.v ��� k :3.� ,.:h'{:::. '�� ..t4 �n3'�,,� �'A y' '4� 4 r.r[.
..wYs;? ,kf;:3: .y,aFZ.:: ?�<s:c yuvr?� ;x,.;,�v.�`Cd,d> 3.::y;,,:no•^^' .ya§�fl,.y:.�:A`�.• h3'fSf;:.c.::.:,'. .z... :.:<: .yey,:rti'�.:yF"s'3,.nti'%€:hi,•+:.0
u,��•�;<%: ;>::��r <>.:.*:Y'•, ,,3 w i:r...�..�z$sfj 3y,.,.... ,c .a.:g;: ^i�� 3[dk[: y,:. .(���,.� A••:s}>�%
,t< :zu..� fskx.[ 'ds ?,5:§<, •,.;z:Fl;::. •Y3#n�["� .,,d':c}s,�>k : c,�`." p :..�:F
, ,.,.. ,.,>:.:3GS3�y:3 c:�.i?::.,.....�.0: .::.;;.}... 33•: Y�`C ........yh�.[H..,,cy..Y..:v:,,n?::.:::y..... .:.^,r3::,,::y.., ..�,
( Lifetime Mental Health Maximum Benefit $40,000 $20,000
Outpatient office visits for crisis intervention and 100%after 70%o after Calendar-
I) treatment $15 Copayment Year Deductible
Tupatient Mental Health Services:
When determined to be Medically Necessary by the Utilization Review Department,You are entitled to evaluation,
crisis intervention, treatment, or any combination of these for acute conditions. Only treatment at the most
ppropriate level of care,as determined by the Utilization Review Department,will be authorized.
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Lifetime Mental Health Maximum Benefit $40,000 $20,000
Inpatient hospitalization for up to 30 Inpatient days per 80%after Calendar- 70%after Calendar-
IICalendar Year Year Deductible Year Deductible
I) Psychiatric Day Treatment Facility,Crisis Stabilization 80%after Calendar- 70%after Calendar-
Unit,or Residential Treatment Center for Children and Year Deductible Year Deductible
Adolescents for up to 30 days per Calendar Year.
Treatment in such Facilities is limited to 30 days of care
(I where one day of Outpatient care is equal to one-half
day of Inpatient care
POLG—SCH-96 I I CFW
1:
REHABILITATION SERVICES
The following is a summary of Benefits available to You and Your Dependents under the Harris Methodist Health
Insurance Company.
You are entitled to receive short-term inpatient or outpatient physical,occupational,or speech therapy rehabilitation
services that are Medically Necessary. Services can be received for conditions subject to significant improvement
through Short-Term Treatment. Services must be authorized by the Utilization Review Department before they are
received. Treatment is limited to a combined maximum of 60 visits per medical episode. Rehabilitation services
on an Inpatient basis or in a Skilled Nursing Facility will be authorized only if other non-rehabilitation medical
services also are required by Your medical condition.
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... ..:::. ...:a.v , :. Y9r}. :..: .: :.... .vv..:,,v:::,;:.,r:c`,`.b'.`%:^:;::.:..,. ..,Y .0 v.Y'. ,:4�5:: ::.5i•+t+:ti` ”:{;k
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.v.l FCc. h,,: .,>C,4 � i>R. '43 v:'<:k"> `�:Ey}0•F_ .'+:2kx'x;.>�c:,:.
:.>... :� yla...,�N>.:., m:S:.,::..,:>:.,:.. .:s.`c<x;>.:•>x...=.k<,.':.:::.;:>:.a".v4>:: >3;f;� ��iXk.t. •: ::.#�.,
Calendar-Year Maximum Benefit $20,000 $10,000
Hospital,home health agency,or other Provider for 80%after Calendar- - 70%after Calendar
restorative treatment subject to clinical improvement. Year Deductible Year Deductible
Limited to a combined maximum of 60 visits per
medical episode
Physical,Occupational,or Speech Therapy. Limited to 80%after Calendar- 70%after Calendar
-
a combined maximum of 60 days per medical episode Year Deductible Year Deductible
Long-term or maintenance services Not Covered' Not Covered
PPOLG-SCH-96 12 CFW
IDNEY DIALYSIS SERVICES
you are entitled to services and Benefits provided for kidney dialysis upon prior authorization from the Utilization
-view Department. Kidney dialysis services will only be provided if Your Physician determines that the services
represent the preferred method of treatment and if You satisfy the criteria for the service involved. Coverage will
be coordinated for You if You are eligible for Coverage under the Medicare provisions for end-stage renal disease.
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IIInpatient or Outpatient Hospital,or outpatient kidney "780%after alendar- 70%o after Calendar-
dialysis center;Home dialysis(continuous ambulatory uctible Year Deductible'
peritoneal dialysis)including equipment,training,
IIsolutions,coils,drugs,and surgical supplies
POLG-SCH-96 13 CFW
6
HOME HEALTH CARE AND HOSPICE
You are entitled to receive home health care and hospice services according to a Treatment Plan approved by the
Utilization Review Department. Treatment is provided only for:
• those medical conditions subject to clinical improvement through Short-Term Treatment;
• recovery or rehabilitation of illness or injury;or
• treatment of terminal illness.
Short-Term Treatment is a plan of care established,approved in writing,and reviewed at least every two months
by the attending Physician and certified by the attending Physician as necessary for medical purposes. Benefits will
be payable for you for 60(sixty)visits in any Calendar Year. ,Excluded Benefits include Custodial Care and'
Benefits provided by a person who resides in your home,or is a member of your family. A visit by a Home Health"
Agency representative is one home health visit. Four hours of home health aid service is also:one home health visit.
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Physical,Occupational,Speech,or Respiratory therapy, 80%after Calendar- 70%after Calendar-
intravenous solutions,Home health aide services and Year Deductible Year Deductible
skilled nursing care. Limited to 60(sixty)visits per
Calendar Year
Hospice(home health service only)Limited to sixty(60) 80%after Calendar- 70%after Calendar-
visits per Calendar Year Year Deductible Year Deductible
PPOLG-SCH-96 14 CFW
"KILLED NURSING SERVICES
.,u are entitled to receive services in a Skilled Nursing Facility for medical conditions that,in the judgement of
the Utilization Review Department,are subject to significant clinical improvement.-The condition must require
vices that can only be provided at that level of care. Services in a Skilled Nursing Facility may be provided
tead of hospitalization(either instead of admission or upon discharge from inpatient care)as Medically Necessary
based on the acuity of the services and your condition. Services are limited to 60(sixty)days per Calendar Year.
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„<:3;.< :;,c����`:. ,;;s;:,::.�. s`.n, ,�.,•; •r U,�,::».,;,.:,..o-;: %?w ��.r :;62.4� s.:u�o:.:2,.:v''... �,.>:s.: �n�£:....::::�..
<.<,sx• .,.&i�s.. :*c; :.,e.. �k,. ,�.:.�.. .;x<�>',4. .,�»;,sa? :>rs�r<r, r, �: •a'�`'•,' �.•c�....
>:.�•>.,:<sst;.. s<.:c::.:s=ss•s r��7�'<�`3•%?k`>�:°}:>�: %`3 r.. .z,:
(.<:�?� f$.eD.J:'r i,�+s':`�:u'S.::oX'f•�ws�:2.;SS'.�n.: +t:/!:; ,t..: � X. .�;
�) �'oom,board,medications,and supplies while confined 80% after Calendar- 70%after Calendar-
in a Skilled Nursing Facility as part of a short-term Year Deductible Year Deductible
�covery or rehabilitation program;Physician visits
(I chile confined to Skilled Nursing Facility. Limited to
60(sixty)days per Calendar Year
)LG-SCH-96 15 CFW
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PROSTHETIC MEDICAL APPLIANCES
You are entitled to prosthetic medical services or medical appliances if Medically Necessary,with authorizatir--
from the Utilization Review Department. While You are covered under the Agreement, initial prostheses z
provided when required due to illness or injury. Replacement is provided only when marked physical changes occur
that require,replacement. Replacement is not provided for items that wear out due to normal usage.
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».,;'9,t.',r r,"�{'za. aL ..sc „T. T^+' �za�r3 ..brc. .;. .£;•».ak.:n>.:!'�'„��:rsT�i�2” ,r
..:!,�:.. rq.x3nu: C:. ii...$<;i'�;'�:::n::.>:...;:>..:........:....:... .....:. .;:. .,,.. '�"'a"•.''::.',."n r ,.'?..>v:'. >.•�2+
::,�io:<•::....c.::�ca;.xa:..dx.�.,.:.:...:...: :....s;:...,y, ....,.E:...,......,....,.zc....,...:... .E t.,�:.�.» <. ...:...c?'.r;. �ii�t;..z�?c..
....,u:.:....,,..a"�`>..;XS....c:,>..,�...i....,x,`.rN._,...,o .::c:.,>»f..<..'>:�';::>..>^,:! .€,=t�3>�#?F:��
Maximum Benefit per Calendar Year $3,000` $1,500
Internal and external prosthetic appliances and 80%after Calendar 70%after Calendar-
applicable hardware Year Deductible Year Deductible
DURABLE MEDICAL EQUIPMENT
You are entitled to Benefits for certain Durable Medical Equipment as prescribed by a Physician, with prior
authorization from the Utilization Review Department. Durable Medical Equipment must:
• be able to withstand repeated use;
• primarily and customarily serve a medical purpose;
• generally not be useful in the absence of illness or injury;
• be required by a Physician's order;and
• be appropriate for use in the home.
At its option, HT&HC may rent or purchase approved equipment. HMIUC has the right of possession of th.
equipment. HMHIC has no liability or responsibility for repair or replacement of lost or damaged equipment.
Equipment not considered Durable Medical Equipment is described in this Schedule of Benefits.
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Maximum Benefit per Calendar Year $3,000 $1,500
Rental or purchase of medical equipment 80%after Calendar- 70%after Calendar- II
Year Deductible Year Deductible
PPOLG-SCH-96 16 CF
3RGAN TRANSPLANTS
You are entitled to Benefits for-certain Organ Transplants. If Medically Necessary and authorized by HMHIC,
TIMHIC will cover:
• kidney transplants
• cornea transplants
• liver transplants
• pancreas transplants
• bone marrow transplants-
• heart transplants
• lung transplants
• any combination of these covered transplants
3enefits for covered transplants,as specified in this section,are provided to the extent that benefits are available
ander this policy with the following exceptions:
• Medical costs associated with organ procurement(the removal of an organ for a covered transplant)
for a Member are limited to a maximum Benefit of$20,000 for the recipient and donor;
• The donors' transportation costs are not covered;
• Charges related to experimental organ,tissue, or artificial organ transplants'(except as otherwise
specified in this section)are excluded;
• Services provided to You for the donation of any organ or element of the body are not covered;and
• Reimbursement for the medical expenses of a live donor are provided to the extent that Benefits
remain available after all Benefits have been provided for You as the recipient.
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Maximum Benefit per Calendar Year for organ $20,000 $10,000
procurement
(, Organ Transplant Services 80%after Calendar- 60%after Calendar-
Year Deductible Year Deductible
'POLG-SCH-96 17 CFW
V
LIMITED DENTAL SERVICES
You are entitled to services for the initial stabilization of acute accidental,non-occupational injury to sound,natural
teeth with prior authorization by the Utilization Review Department. Services must be provided within thirty(3(
days of the accident on an Outpatient basis only. Limitations and Exclusions for dental services are described i..
this Schedule of Benefits.
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Initial stabilization of acute accidental,non-occupational 80%after Calendar- 60%after Calendar- I)
injury to sound,natural teeth provided within thirty(30) Year Deductible Year Deductible
days of the accident on an Outpatient basis;Medically
Necessary diagnostic and/or surgical treatment of the I)
Temporomandibular Joint
Maximum Benefit per Calendar Year, $2,000 $1,000
PPOLG-SCH-96 18 CFN
LIMITATIONS
The following services are limited as described below:
1. Care and treatment of the teeth or gums, except oral surgery for tumors or injuries to the jaw bone or
surrounding tissue,is limited to the initial stabilization of acute accidental,non-occupational injury to sound,
natural teeth. Services must be provided within 30(thirty)days of the accident on an Outpatient basis only.
2. Coverage for vision examinations is limited to conditions that require examination to diagnose injury or
illness,unless covered by a Rider attached to this Schedule of Benefits.
3. The Benefit for Durable Medical Equipment is limited to the total rental cost or the purchase price of the
equipment..,The decision must be authorized in advance by the HMHIC Medical Director or his or her
designee. HMH1C has no liability or responsibility for repair or replacement of lost or damaged'equipment.
4. Care and treatment provided in a Hospital owned or operated by the federal government is limited to care
for conditions that the law requires be treated or provided in a public Facility.
5. The purchase or fitting of eye glasses or contact lenses,or advice on their care,'is limited to the initial set
of eye glasses,contact lenses,or lens implants required following cataract surgery,the repair of a congenital
defect,or as required by an accidental injury.
" 5. Coverage for reconstructive surgery is limited to surgery necessary to repair a functional disorder resulting
from disease or injury(except congenital defect).Reconstructive surgery for Congenital Defects will be
covered. Supply or replacement of internal breast protheses is covered only if the initial surgery was a result
of injury or disease.
?. Coverage for the treatment of the temporomandibular(jaw or craniomandibular)joint is limited to Medically
Necessary diagnostic services and/or surgical treatment. Charges related to dental services for this condition
are not covered.
3. Replacement and repair of prosthetic medical appliances are covered if the prosthesis is surgically implanted
or needs replacement due to a marked change in physical growth or requirements or malfunction of the
device.
�. The purchase of an external breast prosthesis and any associated garments is limited to the purchase of the
initial prosthesis and bra following mastectomy without reconstruction.
'POLG-SCH-96 19 CFW
EXCLUSIONS
The following services and supplies, and their costs, are excluded from Coverage under this Agreement, unless
specifically added by a Rider to this Schedule of Benefits.
1. Charges exceeding the Usual,Reasonable,and Customary amounts determined by HMHIC.
2. Charges related to any service or treatment that You would not be legally required to pay, except foi
Medicaid.
3. Charges related to personal,convenience,or comfort items such as personal kits provided on admission'tc
a Hospital,television,telephone,newborn photographs,guest meals,birth announcements,and other related
articles that are not for the specific treatment of illness or injury.
4. Charges related to transportation,except charges related to land and air ambulance services for Medically
Necessary Emergency Care Services described in this Schedule of Benefits.
5. Charges related to a private Hospital room and/or private duty nursing,unless determined to be Medically
Necessary and authorized by HMHIC's Utilization Review Department.
6. Charges related to services delivered by a person who resides in Your home,or by any of Your immediate
relatives.
7. Charges related to services for military-or service-connected conditions for which You are legally entitled
and for which proper Facilities are available to You. :..
8. Charges related to occupational injury or illness or conditions covered under Worker's Compensation or a
similar law:
9. Charges for health care services primarily for rest,Custodial,respite,Domiciliary,or convalescent care.
10. Charges related to reports,evaluations,or physical examinations not Medically Necessary. Excluded items
include reports for employment,insurance,camp,adoption,travel,or government licenses.
11. Charges related to drugs or medicines,prescription or non-prescription,provided,to You while You are not
an Inpatient,unless specifically added by a Rider to this Schedule of Benefits. ;
12. Charges related to experimental drugs or substances not approved by the FDA for other than FDA-approved
indications. Drugs labeled"Caution-limited by Federal Law to investigational use" are also excluded.
13. Charges related to formulas,dietary supplements,or special diets provided to You on an Outpatient basis.
14. Charges related to vision care. Excluded services include: 1) examination for eye glasses;2)refraction,
dispensing,or fitting of eye glass frames and lenses;3)all types of contact lenses;4)eye exercise and visual
training; and 5) orthoptics. This Exclusion applies except-as otherwise specified in this Schedule of
Benefits.
15. Charges related to radial keratotomy or other radial keratoplasties.
PPOLG-SCH-96 20 CFW
Charges related to hearing aids,batteries,and examinations for their fitting.
17. Charges related to the routine care and treatment of the feet. Exclusions include,but are not limited to: any
arch supports,orthopedic shoes,support hose,or similar type devices/appliances regardless of intended use.
Also excluded are: 1)removal of warts,coms,or calluses;2)the cutting and trimming of toenails;and 3)
foot care for flat feet,fallen arches,and chronic foot strain,in the absence of severe systemic disease.
Charges related to dental care,except as otherwise specified in this Schedule of Benefits. This includes:
1)services related to the care,filling,removal,or replacement of teeth;2)treatment of diseases of the teeth
or gums;3)extraction of wisdom teeth;4)malocclusion or malposition of the teeth and jaws(mandibular
hyperplasia/hypoplasia);5)professional services or anesthesia related to or required for the sole purpose of
dental care;6)Hospital care;7)Inpatient or Outpatient surgery required for any dental care;8)prescription
drugs for dental treatment;9)dental x-rays; 10)dentures;and l l)dental appliances or prostheses.
Charges related to surgical procedures and other care associated with the treatment of obesity,regardless
of medical or psychological conditions. This includes the treatment of a complication of a surgical
r procedure for obesity. Excluded procedures include,but are not limited to: 1)intestinal or stomach bypass
surgery;2)gastric stapling;3)wiring of the jaw;4)insertion of gastric balloons;or 5)similar treatments.
Also excluded are prescription drugs for obesity.
Charges related to transsexual surgery,including medical or psychological counseling or hormonal therapy
before or after any such surgery.
Charges related to services for cosmetic surgery or reconstructive surgery,except as otherwise specified in
. this Schedule of Benefits. Cosmetic surgery Exclusions include,but are not limited to: 1)rhinoplasty;2)
scar revisions;3)prosthetic penile implants 4)surgical revision or reformation of any sagging skin on any
part of the body, relating to the eye lids,face,neck, abdomen, arms, legs, or buttocks; 5) liposuction
procedures; 6) any services performed in connection,with the enlargement, reduction, implantation,,or
appearance of any portion of the body described as the breast,face,lips,jaw,chin,nose,ears,or genitals;
7) hair transplantation; 8) chemical face peels or abrasions of the skin;9) removal;of tattoos; and 10)
electrolysis depilation.
22. Charges related to reduction mammoplasty,unless determined to be Medically Necessary by the HMHIC
Medical Director or his or her designee.
23. Charges related to the reversal of surgically performed sterilization or resterilization after such a surgery.
Charges related to amniocentesis,ultrasound,or any other procedure performed solely to determine the sex
of a fetus.
Charges related to mental health services for psychiatric conditions that are not Medically Necessary in
nature(as determined by HMHIC)and are beyond the maximum days allowed by HMHIC.
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.
1.G-SCH-96 21 CFW
F''
28. Charges related to: 1)employment,vocational,or marriage counseling;2)behavioral training;3)remedia
education,including evaluation and treatment of learning and developmental disabilities and minimal brain
dysfunction; or 4) attention deficit therapy. Benefits for the necessary care and treatment of loss or
impairment of speech or hearing are also excluded,unless added by Rider to this Schedule of Benefits.''
29. Charges related to services for chronic intractable pain provided by a pain control center. Also excluded
are: 1)acupuncture,naturopathy,and hypnotherapy;2)holistic or homeopathic care, including drugs;ane
3)ecological or environmental medicine.
30. Charges related to"Durable Medical Equipment,unless described in this Schedule of Benefits. Excluded
items include: 1)deluxe equipment,such as motor-driven wheel chairs and beds possessing features of an
aesthetic nature,or features of a medical nature that are not required by the patient's condition;2)items not
primarily medical in nature or for the patient's comfort and convenience,such as bed boards,'bathtub'lifts,
aver-bed tables, adjust-a-beds, and telephone arms; 3) Physician's equipment such as stethoscopes and
sphygmomanometers;4)exercise equipment such as exercycles and enrollment in health or athletic clubs;
5)self-help devices not primarily medical in nature,such as sauna or whirlpool baths,chairs,and elevators;
6)corrective orthopedic shoes and arch supports;7)supplies or equipment for common`household use,"such
as air purifiers,central or unit air conditioners,water purifiers,allergenic pillows or mattresses,and water
beds;and 8)research equipment or items thought to be experimental(as determined by HMHIC). HMHIC
has no liability or responsibility for repair or replacement of lost or damaged Durable Medical Equipment.
31. ('harges related to prosthetic medical appliances,except as specified in this Schedule'of Benefits. Excluded
items include: 1)aids,appliances,or supplies that possess features not required by the patient's condition;
2) items that are not primarily medical in nature;3)self-help devices;4)items primarily for the patient's
comfort or convenience;5)items for common household use;6)research equipment;7)routine maintenance-.
of airy external device,appliance,equipment,or supply;or 8)equipment deemed experimental by HMHIC
including,but not limited to corrective orthopedic shoes,arch supports,or foot orthotics,dentures,contact
lenses,and wigs or hair pieces. Repairs deemed cosmetic by HMHIC are also excluded.
32. Charges related to medical supplies,aids,and appliances except as otherwise specified in this Schedule of
Benefits. Excluded items include: consumables,disposable supplies,sheaths,bags,gloves,cervical collars,
elastic stockings,stethoscopes,blood pressure units,traction apparatus,slings, electrical nerve stimulation
devices,wigs or hair pieces,dressings,testing supplies,syringes,home testing kits,disposable diapers or
incontinent supplies,and over-the-counter medications.
33. Charges related to Inpatient'or Outpatient long-term neuromuscular or occupational therapy, or other
rehabilitation services in excess of the maximum allowed by this Schedule of Benefits.
34. Charges related to recreational,educational,or sleep therapy,and any related diagnostic testing,except as
provided by the Hospital as part of an approved Inpatient hospitalization.
35. Charges related to structural changes to a house or vehicle.
36. Charges related to any medical,surgical,or health care procedure or treatment held to be experimental or
investigational at the time the procedure or treatment is performed. HMHIC will use findings and
assessments of national medical associations,professional societies and organizations, and any proper
technological body established by any state or federal government or similar entity to determine the
Coverage and/or effectiveness of the procedure or treatment.
PPOLG-SCIP)b 22 CFW;<
OUTPATIENT PRESCRIPTION DRUG RIDER
FOR USE ONLY WITH HMHIC GROUP HEALTH CARE AGREEMENT
HARRIS METHODIST HEALTH INSURANCE COMPANY
601 RYAN PLAZA DRIVE,SUITE 156
ARLINGTON,TX 76011
1-800-373-9781
(817),462-7881
1.0 INTRODUCTION
In consideration for the timely payment of premiums, and all other terms and conditions of the Group Health Policy
("Agreement"),it is agreed that the benefits of this Rider,together with the terms and conditions of this Rider,are added to
the Agreement as issued.
Benefits under this Rider are available to the Covered Person as identified in the Agreement. In addition to the Prescription,
the Covered Person will present his/her BM IIC Identification Card to the licensed pharmacy. The Covered Person must
be covered under the Agreement and eligible to receive benefits at the time the Prescription is filled or refilled.
Benefits for outpatient prescription drugs provided through this Rider are subject to the definitions,conditions,exclusions,
and provisions of the Agreement to which this Rider is attached. Prescriptions and/or medications that represent a
replacement of a previous prescription and/or medication that was lost,spilled,stolen,or otherwise misplaced is not covered.,
2.0 DEFINITIONS
Brand Name Drug means a drug that has no generic equivalent or a drug that is the innovator or original formulation for
which a generic equivalent form exists.
Coinsurance Percentage or Copayment means the amount you are required to pay the Participating Pharmacy for
dispensing or refilling a Prescription
Covered Drug means those drugs prescribed by a Physician and which,under Federal or State law,can be dispensed only
pursuant to a Prescription or is a compound prescription that contains at least one legend ingredient or insulin.
Covered Person means either the Employee or any eligible Dependents covered under the Agreement.
Generic Drug means a drug that is both pharmaceutically and therapeutically equivalent to the drug prescribed.
Heritable Disease means an inherited disease that may result in mental or physical retardation or death.
Physician means anyone licensed to practice medicine.
PKU(Phenylketonuria)means an inherited condition that may cause severe mental retardation if not treated.
Prescription Drug means only those Medically Necessary drugs and medications that are prescribed by a Physician,that
legally require a prescription,and that are obtained from a licensed pharmacy.
Prescription Medication means a drug that can,under Federal or State law,be dispensed only pursuant to a Prescription,
or that is a compounded prescription or insulin.
Prescription means the authorization for Prescription Medication issued by a Physician who is duly licensed to make such
an authorization in the ordinary course of his or her professional practice.
Usual,Reasonable,and Customary Charges means the amount that Company determines to be the charge for dispensing
a Prescription Medication to the general public.
:)LGRX7-96 1
m
a
3.0 PHARMACY BENEFITS
Any benefit provided under this Rider will not be eligible as a'Covered Charge under any other provision of the Policy.
When submitting a claim, the Covered Person must provide an itemized prescription, a completed claim form, and
prescription receipt from the pharmacist. The receipt must include the National Drug Code for the prescription medicatior
dispensed.
After the Covered Person pays the Calendar-Year Deductible,l IIvIHIC will pay its share for covered health services for
prescription drugs prescribed by a Physician and dispensed by a`licensed pharmacy for treatment of injury or sickness.
Policy Maximum Benefit,per Covered Person Unlimited
Pharmacy Benefit Calendar-Year Deductible,for out-of-network coverage,per Covered Person_ $50
Copayments and Coinsurance:Retail
A copayment/coinsurance percentage or the contracted rate,whichever is less,is taken for each new prescription or refill
for each thirty(3 0)day supply.
Generic Drugs _
In-Network 100%after a$10 Copayment
Out-of-Network 70%
Brand-Name Drugs
In-Network 100%after a$20 Copayment
Out-of-Network 70%
In-network copayments do not apply toward the out-of-network deductible. In the event that a Brand-Name Drug is
dispensed at your or your physician's request when a Generic Drug is available,you will pay the cost difference between
the two drugs plus the appropriate generic copayment. Copayments,coinsurance,deductibles,and cost differences do not
apply to your calendar-year out-of-pocket maximum
Covered Items
When prescribed by a Physician and dispensed at a licensed pharmacy to a Covered Person,covered health services include:
• Any Federal Legend Drugs that includes the legend'"Caution, federal law prohibits dispensing without
prescription"
• Any drug that must be dispensed by prescription according to state or federal law
• Injectable insulin,insulin syringes,urine and blood glucose strips,and lancets
• PKU and other Heritable Disease supplements
o Compound prescriptions,if the compound contains a legend drug in a therapeutic amount
Covered Refills
Refills are covered if:
® Allowed by law
• Authorized by a Physician
• Dispensed by licensed pharmacy
• The Covered Person remains eligible for the benefit
• 75%of the medication must be consumed,based on the dosage'instructions of the physician
provided the refills are dispensed within twelve(12)months of the initial prescription date.
PPOLGRX7-96 2
Covered Quantities
Prescribed covered quantities include up to a maximum of a thirty(30)day supply for each new covered prescription or
refill. The Covered Person must pay 100 percent of the Usual,Reasonable,and Customary Charge for any amount of a
covered prescription exceeding covered quantities,including lost or misplaced medications.
The quantity of prescription drugs dispensed pursuant to a Prescription or refill will not exceed that amount required for
thirty(30)consecutive days and are limited to:
■ Up to three(3)vials of insulin
® Up to eight(8)fluid ounces of a liquid medication,except for liquid potassium supplement
■ Up to three(3)ounces net weight of ointment,cream;or gel except vaginal medication,which will be limited to
one(1)tube
K Up to two(2)manufacturer's smallest standard package size of a nasal or oral inhaler
0 One(1)vial containing up to fifteen(15)milliliters of any otic or ophthalmic product
a One(1)month supply of oral contraceptives
4.0 MAIL ORDER BENEFITS(for maintenance medication)
The benefits for mail order prescription drugs provided under this Rider are available for maintenance drugs and medicines
that are dispensed according to a Prescription for your outpatient use. Mail-order prescriptions must be prescribed by a
provider and dispensed by a Participating mail order Pharmacy.
Schedule of Benefits
The Participating Mail Order Pharmacy Provider will furnish up to a ninety(90)-day supply of a Covered Drug for a
Copayment of
■ 100%after a$16 Copayment for each new prescription and/or refill of a Generic Drug;or
® 100%after a$30 Copayment for each new prescription and/or refill of a Brand Name Drug.
Exclusions
In addition to the exclusions described in Section 5.0,the following exclusions apply to the Mail Order Pharmacy benefit:
s Fluorides
® Drugs requiring refrigeration
Covered Quantities
Prescribed covered quantities include the lesser of the prescribed amount or a ninety(90)-day supply for each new covered
prescription or refill. You must pay 100%for any amount of a covered prescription exceeding covered quantities,including
lost or misplaced medications.
a Covered Refills
Refills are covered if:
■ Allowed by law
M Authorized by a Physician
■ Dispensed by a licensed pharmacy
■ The Covered Person remains eligible for the benefit
■ 75%of the medication must be consumed,based on the dosage instructions of the physician
provided the refills are dispensed within twelve(12)months of the initial prescription date.
s.
OLGRX7-96 3
c
5.0 EXCLUSIONS
There is no benefit provided under this Rider for:
■ Contraceptive devices other than diaphragms and cervical caps
■ Devices of any type,even though they may require a Prescription,including,but not limited to,artificial appliances,
therapeutic or prosthetic devices,appliances,supports or other non-medical products
E Medical supplies except those specifically listed in this Rider as covered items
■ Injectable drugs(except insulin),immunization agents,allergy and biological sera
■ Compounded Prescription Drugs intended for injectable use and medications not used for an FDA approved
indication
■ PrescriptionDrugs produced from blood,blood plasma and blood products,derivatives,Hemofil M,Factor VIII,
and synthetic blood products
■ Experimental or investigational drugs
■ Fertility medications
■ Appetite suppressants
■ Drugs which by Federal and/or State Law do not require a prescription,except for insulin,PKU,and other heritable
disease supplements -
■ Drugs consumed in an inpatient or other institutional care setting
■ Nutritional or dietary supplements or formulas,even when required by a Prescription other than prescription
required vitamins
■ Drugs intended for use in a Physician's office or clinical setting
■ Prescription Drugs for cosmetic conditions not covered such as Retin-A (for patients over the age of 25),
Minoxidil,etc.
■ Smoking cessation patches,gum,and other such aids
■ Anabolic steroids -
■ Drug infusion/metering devices
■ Growth hormones
■ Administration or injection of any drugs or medications,except as specified as a basic benefit in Group Health
Policy
■ Prescription Drugs or medications taken by or administered to the Covered Person while they are a patient in an
in-patient facility or similar institution that.operates or allows to be operated on its premises a facility for dispensing
pharmaceuticals
■ Prescription Drugs which have an over-the-counter equivalent,even if written on a Prescription
PPOLGRX7-96 4
SERIOUS MENTAL HEALTH RIDER
FOR USE ONLY WITH IIMIIIC GROUP HEALTH CARE AGREEMENT
[HARRIS METHODIST HEALTH INSURANCE COMPANY
601 RYAN PLAZA DRIVE,SUITE 156
ARLINGTON,TX 76011
1-800-373-9781
(817)462-7881]
WRODUCTION
In consideration for the timely payment of premiums, and all other terms and conditions of the Group Health Care
Agreement/Subscriber Certificate of Insurance C Agreement'D,it is agreed that the benefits of this Rider,together with the terms
id conditions of this Rider,shall be added to the Agreement as issued if this Rider is accepted by the Group.
DEFINITIONS
enefits for Serious Mental Illness provided through this Rider will be subject to the provisions and definitions of the Agreement
which this Rider is a part. Serious Mental Illness will mean the following psychiatric illnesses as defined by the American
Psychiatric Association in the Diagnostic and Statistical Manual(DSM)III-R:
Schizophrenia
Paranoid and other psychotic disorders
® Bipolar disorders(mixed,manic,and depressive)
Major depressive disorders(single episode or recurrent)
Schizo-affective disorders(bipolar or depressive)
BENEFITS
ental Health services provided for Serious Mental Illness shall be provided subject to the same limitations, exclusions,
• Copayments,Coinsurance and Deductibles as applied to covered services or any other physical illness.
KCLUSIONS
Charges related to mental health services for psychiatric conditions determined by the HMHIC Medical Director or his designee
not qualifying for coverage under this Rider will be subject to the same limitations,exclusions,and copaymertts or coinsurance
applied to mental health services listed in the Schedule of Benefits of which this Rider is a part.
LIMITATIONS
:rvices must be obtained according to HMHIC Utilization Review guidelines.
c ELIGIBILITY
:nefits under this Rider are available to You and Your Dependents as identified in the Agreement.
i.
MG-SW-96
CITY OF FORT WORTH
PPO
PLAN YEAR 1996-97
(EFFECTIVE OCTOBER 1, 1996)
ACTIVE EMPLOYEES PPO
SINGLE $135.27
EMPLOYEE & SPOUSE' $369.12
EMPLOYEE & CHILDREN $327.31
FAMILY
$435.97
RETIREES(MEDICARE) PPO
RETIREES(1) $114.22
RETIREES(2) $114.22
RETIREE & SPOUSE (A) $349.65
RETIREE & SPOUSE (H) $228.45
RETIREES & CHILDREN (C) $219.33
FAMILY (B) $454.75
FAM I LY (G) $333.54
SURVIVING SPOUSE(D) $114.22
SURVIVING FAMILY(E) $340.52
SURVIVING CHILDREN(F) $105.10
RETIREES(NON MEDICARE)
RETIREES(1) $235.43
RETIREES(2) $235.43
RETIREE & SPOUSE (A) $470.85
RETIREE & SPOUSE (H)
RETIREES & CHILDREN (C) $340.52
FAMILY (B) $575.95
FAM I LY (G)
SURVIVING SPOUJSE(D) $235.43
r. SURVIVING FAMILY(E) $340.52
SURVIVING CHILDREN(F) $105.10
la..
f:
Li �� •r�„
IN-VITRO FERTILIZATION BENEFITS WAIVER
FOR USE ONLY WITH TEXAS GROUP HEALTH CARE AGREEMENT/
r,
SUBSCRIBER CERTIFICATE OF INSURANCE
Coverage for benefits for in-vitro fertilization procedures is hereby rejected by the
Group.
This amendment shall be added to the Agreement, and is applicable to Subscribers
and Dependents as identified in Agreement.
REJECTED:
Group HARRIS METHODIST HEALTH
F
INSURANCE COMPANY
By: By.
Authorized Representative uthorized Representative
c
-
Date: Dater
3 -
{
A - -
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3
PPOLGIVFW896
3
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EXHIBIT "Ff)
COBRA RESPONSIBILITIES
Group and HIC desire to further delineate the responsibilities under COBRA
between the Group on one hand and HIC on the other and agree as follows:
Group shall have the following COBRA responsibilities:
1 Group shall provide written notice to each covered employee of his/her
COBRA rights at the time of commencement of coverage under the group
health plan covered by this Agreement;
2. Group shall determine when a qualifying event occurs within the meaning
of COBRA when such qualifying event results in loss of coverage with
regard to:
(a) qualifying events involving: (1) the death of the covered employee,
(2) the termination or reduction of hours of a covered employee's
employment, (3) the covered employee becoming entitled to
Medicare benefits, or (4) the filing of a bankruptcy proceeding by or
against Group, Group shall notify HIC in writing of such qualifying
events within thirty (30) days of their occurrence- when such
qualifying events would result in loss of coverage;
(b) qualifying events involving: '(1) divorce or legal separation of a
covered employee from the employee's spouse, or (2) dependent
child of a covered employee ceasing to be a dependent under
applicable plan provisions upon notice by the covered employee,
Group shall direct covered employee to notify HIC of such
qualifying event;
a.
(c) each qualified beneficiary who is disabled on the date of a
qualifying event and who has properly elected COBRA because of
a qualifying event involving termination or reduction of hours of a
covered employee's employment, Group shall notify HIC, as
appropriate, within five (5) working days after Group receives notice
from such qualified beneficiary of.- (1) a determination under the
Social Security Act that such qualified beneficiary was disabled on
the date of the qualifying event, and (2) of a subsequent final
determination under the Social Security Act that such qualified
beneficiary is no longer disabled;
except that the Group shall rely solely upon the covered employee or the
covered dependent, as appropriate, for written notice of qualifying event if
the qualifying event is (1) divorce, (2) legal separation or (3) dependent
children) becoming ineligible under the plan as such notice is required
under proposed COBRA regulations.
3. Group shall provide to HIC the name, and last known address of the
qualified beneficiary as such were reported to the Group by the covered
employee whose coverage has been lost due to a qualifying event; and
4. Group shall notify HIC of any information it receives which would result in
the termination of COBRA coverage for reasons other than failure to pay
premium or expiration of the maximum required period of coverage under
COBRA.
HIC shall have the following COBRA responsibilities:
1. HIC shall determine COBRA eligibility of covered employees and their
eligible dependents in accordance with COBRA and its implementing
regulations;
2. HIC shall within fourteen (14) days of receipt of written notice from the
Group of a qualifying event (other than divorce or legal separation of a
covered employee from the employee's spouse or a dependent child of
the covered employee ceasing to be a dependent) furnish each affected
qualified beneficiary written notification of the termination of regular
coverage under the health plan, together with a written recital of the rights
of such qualified beneficiary to elect continuation coverage under COBRA
and forms whereby the qualified beneficiary can elect such coverage;
3. HIC shall, in regard to a qualifying event involving divorce or legal
separation of a covered employee from the employee's spouse or a
dependent child of the covered employee ceasing to be a dependent,
provide such notification and application within fourteen (14) days of
receipt of such notice from the covered employee or his covered
dependent of such.qualifying event;
4. HIC shall determine continued eligibility for COBRA participation by
qualified beneficiaries;
5. HIC shall determine the amount of premium payment owed by P qualified
beneficiary, and the method of payment;
6. HIC shall-collect premiums from qualified beneficiaries;
9
7. HIC shall send notice to qualified beneficiaries of termination of COBRA
coverage;
8. HIC shall, in regard to a qualified beneficiary who is receiving COBRA
continuation coverage because of termination, or reduction of hours, of
the covered employee's employment, notify the qualified beneficiary of his
option to enroll under a conversion health plan otherwise generally
available under the Group's health plan;
9. HIC shall enroll a qualified beneficiary within five (5) working days of
receipt of such beneficiary's timely filed COBRA election; and
10. HIC shall furnish to the Group the appropriate reports to track the
premiums and claims of COBRA participants.
11. HMHP shall make all COBRA notifications required under the Health and
Insurance Portability and Accountability Act of 1996.
10
e.
EXHIBIT "G"
PERFORMANCE GUARANTEE
As part of the consideration for its serving as the Group's exclusive carrier, HIC
establishes the following performance guarantees with associated liquidated damages.
If a deficiency is identified in guarantee performance by the Group in writing, HIC will
have thirty (30) days from receipt of the written notice to address and resolve the written
deficiency. If the guaranteed performance cannot be achieved within the thirty (30) day
period, then payment of the liquidated damages will be due as specified below.
Guarantee#1
HIC guarantees a 90% overall member satisfaction level for the City of Fort
Worth Members, aggregated for all product lines during each contract term year, as
measured by HIC's independent third party market research firm. Satisfaction will be
measured quarterly across all product lines and combined to obtain the yearly rate. The
Group will rely on reports provided by HIC within sixty (60) days after the end of each
contract term year. Interim status reports will be provided to the Group within sixty (60)
days after the end of each quarter of each contract term year.
Liquidated Damages
The liquidated damages payable are set forth in the Agreement between the
Group and the Harris Methodist Texas Health Plan, Inc.
Guarantee#2
Consistent with the Group Minority and Women's Business Enterprises (M\WBE)
goals, City of Fort Worth Ordinance 11923, and HIC's negotiations with the Group,
including the written responses to the RFI and RFP, HIC is committed to the following
goals:
2a. 10% of the total contract expenditures will be direct purchases from
MXWBE vendors and 20% of the number of individual health care
providers will be minority or women providers.
2b. HIC agrees to meet no less than every six months with representatives of
the Inter and Intragovernmental Committee of the City Council,
representatives of the Doctors for Excellence, a designee of the City
Manager and a designee of the Chief Executive Officer of the HIC to
review HIC's progress in addressing minority participation concerns with
an annual report to the City Council; such meetings shall continue until the
City Council, at its sole discretion changes the frequency and/or reporting
requirements imposed herein.
2c' Harris Methodist Select, at the direction of HIC, will submit to a semi-
annual review by the Group's M\WBE office to evaluate and document
both progress and good faith efforts in the implementation of Harris
Methodist Select's Affirmative Action Policy.
2d. HIC guarantees Harris Methodist Select will appoint minority physicians to
the key committees reporting to the Harris Methodist Select Board of
Trustees. Those committees include the Finance, Selections, Utilization
Management, Quality Improvement and OBIGYN Contracting committees.
Liquidated Damages
The liquidated damages payable. are set forth in the Agreement between the
Group and the Harris Methodist Texas Health Plan, Inc.
Guarantee #3
Operational performance is crucial to member satisfaction. Timely claims
payment and claims payment accuracy are key components of operational
performance. HIC guarantees that all "clean claims" as defined below, aggregated
across all product lines, will be paid in an average of 15 days or less ("the timeliness
measure") during each contract term year.
The definition of a "clean claim" is a claim that does not require additional.
information in order to process.
Further, HIC guarantees 95% of all claims paid (across all product lines) will be
paid accurately (the "accuracy measure").
Both performance standards will be measured by reports generated by HIC at
the end of each contract term year, and provided to the Group within sixty (60) days
after the end of the contract term year. Interim status reports will be provided to the
Group within sixty (60) days after the end of each quarter of each contract term year.
Liquidated Damages
The liquidated damages payable are set forth in the Agreement between the
Group and the Harris Methodist Texas Health Plan, Inc.
12
® Harris Methodist
I or'Forf�ort�'W@1i ess'�rograin�roposaY"""""""""'
THIS WELLNESS PROGRAM HAS BEEN DEVELOPED AS A VALUE ADDED FIRST YEAR
BENEFIT TO THE FLEX PLAN PROPOSAL(OPTION B). THE HARRIS METHODIST
HEALTH PLAN WILL UNDERVVRITE THE COSTS OF THE PROGRAM(EXCEPT FOR'THE
APPLIAPPLICABLE MEMBER CO-PAYS)', The focus of the wellness and prevention program is to improve
CABLE
health of employees in partnership with the City of Fort Worth. The Harris Methodist Health plan's
ability to assess the health risks of the city's employee population will enable us to provide a variety of
health promotion programs at multiple intensity levels. The assessment process will enable employees to
attend programs appropriate to their readiness level to make lifestyle changes. The program focuses
include assessment,awareness building,intervention and follow up to ensure those individuals who make
lifestyle changes are supported in their efforts.As a result of these changes,Harris Methodist will look to
demonstrate increased morale,reduced sick days and leave,improved productivity,and reduced health
care costs in conjunction with the City.
• Modifiable Claims Audit(MCA) Monthly Wellness Events
The.MCA performed for the City has demonstrated Monthly wellness events will focus upon the current
that nearly$5.0 million dollars are associated to health issues and concerns prevalent in the MCA
lifestyle related claims. The MCA demonstrates that report and the Health Risk Assessment group
the City of Fort Worth has the potential to save$1.5 summary. As an awareness building activity,3-0
million dollars in claims incurred by the City's events can be scheduled at the City's request. Please
employees by addressing the City's top health risks see the enclosed list of recommended topics.
including lack of exercise,accidents,obesity,and
smoking.. The actual amount ofrecovery will be • Wellness and Prevention Intervention
dependent upon the City's support ofthe programs programs
and the employees'response and adherence to the The intervention programs are designed to target
programs. Please review the MCA for specifics on specific lifestyle and behavior changes based upon
`. these potential cost savings. the MCA assessment. The recommended programs
inglude tobacco cessation,stress management,and
• Health Risk Assessments and Health Fairs diet,nutrition,and weight management programs.
The Health Risk Assessment will provide the City Each program is associated with a member co-pay
with an aggregate summary report of the health which demonstrates on the members part a
lifestyles and key biometdc data of its employees. commitment with the value associated with the
These results will direct the wellness programming program
initiative by providing appropriate programs and
screenings to improve the health of the entire • Mammography Screening
Population- In addition,the employee will value their To increase easy accessible,mammography screening
customized hearth assessment report which will will be offered for the ladies by use of the Mobile
i° explain their results and provide suggestions to Mammography Unit and as part of the Harris
improve their overall health. The assessment process Methodist Health Plan schedule of benefits,the there
is most attractive at worksite health fairs. The health is no cost involved for this screening. The screening
fairs provide screening for cholesterol,diabetes, guidelines follow those defined by the American
blood pressure,height,weight,and body fat Heart Association for women over the age of 35
composition and are staffed by trained medical years. The unit has the flexibility to be scheduled at
Professionals. various locations and times.
L
• Diabetes Education = Prostate Screening
r The diabetes education program is designed to screen Addressing male health issues will be accomplished
and educate employees at the worksite health fairs by focusing upon prostate cancer by use of a lab
and refer those at high risk to their primary care prostate screening analysis for men over the age of 50
Physician. Highlights of the program include annual years. The screening,or PSA,can be done in
t comprehensive diabetes education for diabetic health conjunction with any of the wellness services and will
k_. plan members,diabetic risk factor assessement,blood be followed up by a registered nurse reviewing the
gluscose testing,and employee specific follow up for information and forwarding the results to the
1 high risk individuals. individual's physician.
9
E
if
Ca ® .Fort{ ®rtk. extu
®r a d °r [ omm nic ti n
DAIS `•.. RSFERENCS NUIdBSR LOG NAME PAGE
08/08/96, 4 -45574 VISED 15HARR1 1 of 3
suBjEcT.= .CONTRACT WITH-HARRIS'METHODIST TEXAS HEALTH PLAN, INC.,d/b/a.HARRIS
METHODIST.HEALTH' PLAN �HARRI&METHODIST HEALTH INSURANCE COMPANY,
-'HARRIS :METHODIST TEXAS:HEALTHPL.AN INC., d/b/a SUMMIT ADMINISTRATIVE
SERVICES FOR GROUP:MEDIC4L_BENEFITS FOR EMPLOYEES AND RETIREES AND
JOHN'ALDEN RISKWANAGEMENT SERVICES FOR•STOP.LOSS INSURANCE FOR
SELF-FUNDED BENEFITS.:
RECOMMENDATION:-
It is Kecommendedthatthe City Council,isb�eckto sufficient.fundsheing appropnatedKm`the City
'� .,.biadgef=ifors�fiscal=year°1996=97tfo{payfoGol�gations incurred:under ahe proposed contracts,
au'thotize,the Ci Manager:to execute1afone year contract (with .four consecutive options-to,
tY
rer'ewfiorfour additional one:yearterms)for}group medical benefits and services for employees;
retirees and their eligible dependents,�wth
7R Harris Methodist ealth:'Plan foams F6' balth;maintenanceArganizatidh HMO) benefits,
a 2 Harps Methodist—Health—Insurance.Company for`insured preferred provider organization
7(13120) benefits, and
Summit Administrative
Services, Inc , to administer the City's self-funded indemnity type
medical.benefits>atfive percent�(5°IQ)�of claims`.expense;'and n :-
ON
. 4 { John:Alden Risk= Management FSer'vices to provide stop loss insurance (specific and
:: ,
_> gregate) on=a:per-enrollee premium for=stop-loss insurance on self-funded:benefits for a
otal:annual progranm-cost estimated to be $ 22;::600,000.The,City's cost for the program.
�rl� Wu is estitnatedto ire —PToximately�$16;000,000' Employee and retiree contributions' and the
h balance of the —'cost.
bISCUSSION
The:;City'Jinal contract:renewal.option with'Harris ,Methodist Health Plan, Inc., and•:'Summit
a:::Administrative %Services to':provide;:group Ymedical. benefits and administrative 'services to
employees, retirees, and their eligible dependents ex-pires September 30, 1996. Likewise, the
City's::policy for stop loss insurance for"its se1f4dnded.indemnity-type,benefits with John--Alden_
Risk:Management Services expires
In the' early fall of .1995, City staff initiate d'a -process to solicit proposals from carriers and
administrators to provide group medical benefits for a:contract period to begin October 1 '1996.
The City Council's Inter and Intragovernmental Committee and the: Employee and -Retiree
Insurance and Benefits Committees have been involved in this process at several key points.
All interested carriers and/or administrators were invited to submit information regarding their
firms' abilities to offer services in response to the City's Request for Information in December,
1995. Eight firms responded and were invited to submit proposals due March 28; 1996. Six
firms responded to this original solicitation. .Three proposers responded with revised proposals
Printed on Recyded Paper
>CZty o Fort worth,
Mayor and Council Communication
DATE REFERENCE NUMBER LOG NAME . ` PAGE
08/08/96 C-15574 VISED 15HARRI 3 of 3
SUBJECT CONTRACT WITH HARRIS METHODIST TEXAS HEALTH PLAN, INC., d/b/a HARRIS
METHODIST HEALTH PLAN, HARRIS METHODIST HEALTH INSURANCE COMPANY,
HARRIS-METHODIST TEXAS HEALTH PLAN; INC., d/b/a SUMMIT ADMINISTRATIVE
SERVICES FOR_,GROUP MEDICAL BENEFITS FOR EMPLOYEES.AND RETIREES AND
JOHN ALDEN�RISK:;.MANAGEMENT SERVICES FOR STOP LOSS INSURANCE-FOR
SELF-FUNDED-BENEFITS
FISCAL INFORMATION/CERTIFICATION:
The Director of Fiscal St:rvices certifies that the money requiredffor obligations in the 1996-97 ,
Fiscal Year will beinciuded�m the City Manager's Proposed Bdget �antl4thatthe contract will
include a fiscal funding out clause which will allow for terrnmatton without penalty if the City
Council were not to approp.p.p.;t funds for this purpose.
1
***ADD A PROVISION. THAT CITY COUNCIL- APPROVAL; OF THIS CONTRACT, IS CON-
TINGENT UPON 'ALL, CONT=RACT' PERFORMANCE GUARANTE'EA; ENALTIES, AS OFFERED B.
HARRIS IN ITS `LETTER�OF 4AUGUST 8, 1996. -THAT LETTER rSP,ECIFIES THAT ANY
PENALTIES WHICH MAY' BE--'OWED ARE TO BE PAYABLE AT aTHE;.END OF EACH CONTRAC.
YEAR OR AT CONTRACT .TERMINATION, WHICHEVER',COMES; FIRST 'AND UPON CONTRAC- "
TUAL AGREEMENT BY :HARRIS TO MEET NO LESS :THAT, <EIERY S:IX zMONTHS WITH RE .
PRESENTATIVES.,'OF THE'--I`NTER AND INTRAGOVERNMENTAL;�;,COMMITTE OF THE CITY
COUNCIL; REPRESENI•ATIYES OF THE DOCTORS FOR' EXC_ELLENCE.;: A DESIGNEE OF" TH
CITY MANAGER AND" Af�D $IGNEE OF THE CHIEF EXECUTIYE='OFFICER OF THE HARRIS
METHODIST HEAf$Tti1P"LA " Tfl "REVIEW HARRIS=' PROGRESS� N �ADDRESS3NG' MINORITY
PARTICIPATION'C U E S;'W:ITH AN ANNUAL 'REPORT �TO �LHE�CITY' COUNGIL, SUCH
MEETINGS` TO_,CONTINUE� UNTIL THE CITY .COUNCIL:, ATITS' SOLE i)ISCRETION
CHANGES THE F:REQUENCYAND/OR REPORTING REQUIREMENTS'`IMPOSED HEREIN"
Submitted for City 1Vlanage;'s` =FUND ACCOUNT CENTE CITY SECRETARY
Office by:
Charles Boswell 8511
Originating Department Head: j Af M. 0 r;
�^i �L
Susan Bulla 8513 (from) .
FE85 534740 0158520 . -$ 194,312.00
For Additional Information FE85 534730 0158520 $7,518,562.00. ,
Contact: FE85 534770 0158520 $8,272,212100 �� �oN
Ci1C R �.
FE85 534730 0158540 $2,832,467:00 "G�tp�cfi.Falc� �
FE85 534770 0158540 $2,167,255.00
Susan Bulla 8513 FE85 534740 0158540 $1,615,192.00
****SEE ABOVE
`,t,.- Printed on Recycied Paper
ATTACHMENT 1
Monthly Premium Costs for the 1996-97 Fiscal Year
HMO Flea PPO
Active Employees P10 Pi-5
Employee $122.72 $147.25 $135.27
Employee and Spouse $334.87 $401.85 $369.12
Employee and Child $296.94 $356.32 $327.31
Employee and Family $395.52 $474.63 $435.97
Medicare Eligible Retirees Plan M
Retiree $103.63 $114.22
Retiree and Spouse(1) $317.21 $388.36 $349.65 ,
Retiree and Spouse(2) $207.25 $228.45
Retiree and Child $198.98 $220.07 $219.33
Retiree and Family(1) $412.55 $501.07 $454.75
J Retiree and Family(2) $302.60 -$327.14 $333.54
Surviving Spouse $103.63 $114.22
Surviving Child(ren) $ 95.35 $112.98 $105.10
Surviving Family $308.93 $394.00 $340.52
Non-Medicare Eligible Retirees'
Retiree $213.58 $281.27- $235.43
Retiree and Spouse $427.16. $562.56 $470.85
Retiree and Child $308.93 $394.27 $340.52
Retiree and Family $522.51 $675.28 $575.95
Surviving Spouse $21158 $281.27 $235.43
Surviving Children) $95.35 $112.98 $105.10
Surviving Family $308.93 $394.00 $340.52
�J� a 322
CITY SECRETARY
Letter of Agreement CONTRACT NO.
The purpose of this agreement is to formalize the specific responsibilities of each of the two parties
herein known as the City of Fort Worth and Harris Methodist Health Plan(HMHP)in regards to the
administration of required activities for the Health Insurance Portability and Accountability Act
(HIPAA).
1. HMHP agrees to issue the HIPAA Creditable Coverage Certificates within fourteen days:
a) After notice of any event which results in termination of coverage however such notice is
obtained.
b) Of the request of the appropriate parties,including the City of Fort Worth,to provide such
certificate for an individual whose coverage terminated within the prior twenty-four(24)
months. City agrees to notify Harris within four(4)days any individual request received.
2. The City of Fort Worth retains the responsibility for providing HMHP with timely notifications
(within four days of City's awareness of same) of employee and/or dependent terminations from
health plan coverage, except for those occassions where terminations are automatic, ie, dependent
reaching maximum age, etc.
3. IMP also agrees to provide a written monthly summary report to the City of Fort Worth which
identifies individuals for which a certificate of coverage was provided.
4. This agreement is for the timeframe of June 1, 1997 through September 30, 1997. Throughout
the course of this agreement there will be no administrative fees due from the City of Fort Worth to
IMH' for fulfillment for the above identified actions.
5. It is understood that prior to September 30, 1997,a new agreement will be negotiated for the next
twelve(12)months which will include a provision for an administrative fee to be paid by the City
4.
of Fort Worth to HMHP as compensation for the administration associated witli RM A A.
054FUAL GRECOED
Harris Methodist Texas Health Plan,Inc. City of Fort Worth C, U MCNEAff
d/b/a Health Methodist Health Plan
B �1 �vt-/ By
Ark
Name C A — P,%3 Name
Title 9 � Title
4-j—�L.
CI—/JJ�7� APPROVED AS TO DORM A LEGALITY:
Contract Authorization
0 Assistant Cit y t bar ney��"
Date