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Contract 1751
PO Box 9310 Minneapolis, MN 55440-9310 952-992-2900 February l6,2004 MEDICA City of Columbia Heights Attn: Linda MaGee 590 40th Ave. NE Columbia Heights, MN 55421 Dear Ms. MaGee, Thank you for choosing Medica! The enclosed medical Master Group Contracts (MGCs) binds Medica and City of Columbia Heights group numbers 89944 & 89945 for the contract period commencing on January 1, 2004 and expiring on December 31, 2004. To ensure appropriate .execution and continued performance under the MG~se follow the steps ~below: · Ensure the MGCs are signed and dated by an officer of~e company / · Include the contract signer's title Under the signature/ · Return one signed copy of the MGCs to me withiwS0 days - Retain the other documents for your files I / ~ \/ The MGCs will be deemed accepted by City of Cokl/umbia Heights upon the earlier of Medica's receipt of your first premium payment for this contract period or City of Columbia Heights execution of the MGCs. Please note that Medica will not accept written changes to the MGCs when they are returned to Medica. Thank you for your prompt attention.to this matter. If you have any questions, please contact me at (952) 992-2455. I appreciate your business and look forward to meeting the health care needs of your employees in the upcoming contract year. Sincerely, Janet Litwin Account Service Representative C: Britt Osterhues, Johnson-McCann Benefits- 4535 Hodgson Rd., Shoreview, MN 55126 Enclosures Medica* refers to the family of health plan businesses that includes *Medica Health Plans, Medica Health Plans of Wisconsin. *Medica Insurance Company, *Medica Self-Insured and SelectCare. *Accredited by the National Committee for Quality Assurance. 20075 11/031 An Equal Opportuniry Employer Medica Choice Select PLAN MASTER GROUP CONTRACT Employer Name: Employer Group~: Effective Date: Contract~: Amendments: CITY OF COLUMBIA HEIGHTS 89944 January 01, 2004 MCS7, BPL Number: 56741 Amendments attached as applicable for benefit package log (BPL) as listed above. ARTICLE 1 INTRODUCTION This Master Group Contract ("Contract") is entered into by and between Medica, together with its affiliate Medica Insurance Company ("MIC"), and the employer group named above ("Employer"), an employer under Minnesota law and other applicable law. This Contract includes the Eligibility Appendix, the Enrollment Appendix, the Certificate of Coverage ("Certificate") and any Amendments. This Contract is delivered in the State of Minnesota. If this Contract is purchased by Employer to provide benefits under an employee welfare benefit plan governed by the Employee Retirement Income Security Act, 29 U.S.C. 1001, et seq. ('ERISA"), this Contract is governed by ERISA and, to the extent state law applies, the laws of the State of Minnesota. If this Contract is not governed by ERISA, it is governed by the laws of the State of Minnesota. In consideration of payment of the Premiums by the Employer and payment of Copayments and Coinsurance by or for Members, Medica will provide coverage for the Benefits set forth in the Certificate' and any amendments, subject to all terms and conditions, including limitations and exclusions, in this Contract. This Contract replaces and supersedes any previous agreements between Employer and Medica relating to Benefits. Medica shall not be deemed or construed to be an employer for any purpose with respect to the administration or provision of benefits under Employer's welfare benefit plan. Medica shall not be responsible for fulfilling any duties or obligations of Employer with respect to Employer's benefit plan. The terms used in this Contract have the same meanings given those terms defined in the Certificate, unless otherwise specifically defined in this Contract. Page 1 ARTICLE 2 TERM OF CONTRACT Section 2.1 Term and Renewal. This Contract is effective from January 01,2004 ("Effective Date") to December 31, 2004 I"Expiration Date") All coverage under this Contract begins at 12:01 a.m. Central Time. At least 30 days before each Expiration Date, Medica shall notify Employer of any modifications to this Contract, including Premiums and Benefits for the next term of this Contract ("Renewal Terms"). If Employer accepts the Renewal Terms or if Employer and Medica agree on different Renewal Terms, this Contract is renewed for the additional term, unless Medica terminates this Contract pursuant to Section 2.2. Section 2.2 Termination of this Contract. Employer may terminate this Contract after at least 30 days written notice to Medica. This Contract is guaranteed renewable and will not be terminated by Medica except for the reasons and effective as stated below. Terminations for the reasons stated below require at least 30 days written notice from Medica: (a) Upon notice to an authorized representative of the Em ployer when Employer does not pay the required Premium when due, provided, however, that this Contract can be reinstated pursuant to Section 4.2; (b) On the date specified by Medica because Employer provided Medica with false information material to the execution of this Contract or to the provision of Benefits under this Contract. Medica has the right to rescind this Contract back to the effective date; (c) (d) (e) (f) (g) (h) On the date specified by Medica due to Employer's violation of the participation or contribution rules as determined by Medica; Automatically on the date Employer ceases to do business pursuant to 11 U.S.C. Chapter 7; On the date specified by Medica, after at least 90 days prior written notice to Employer, that this Contract is terminated because Medica will no longer issue this particular type of group health benefit plan within the applicable employer market; On the date specified by Medica, after at least 180 days prior written notice to the applicable state authority and Employer, that this Contract will be terminated because Medica will no longer renew or issue any employer health benefit plan within the applicable employer market; On the date specified by Medica when there is no longer any Member who resides or works in Medica's approved service area; If this Contract is made available to Employer only through one or more bona fide associations, on the date specified by Medica after Employer's membership in the association ceases. Page 2 (i) Any other reasons' or g rounds permitted by the licensing laws and regulations governing Medica. Notwithstanding the above, Medica may modify the Premium rate and/or the coverage at renewal. Nonrenewal of coverage as a result of failure of Medica and the Employer to reach agreement with respect to modifications in the Premium rate or coverage shall not be considered a failure of Medica to provide coverage on a guaranteed renewal basis. Section 2.3 Notice of Termination. Medica will notify: (a) Employer in writing if Medica terminates this Contract for any reason; (b) Subscribers in writing if Medica terminates this Contract pursuant to Section 2.2 (a), (d), (e) or (f). Employer will provide timely written notification to Subscribers in all circumstances for which Medica does not provide written notification to Subscribers. Section 2.4 Effect of Termination. In the event of termination of this Contract: (a) All Benefits under this Contract will end at 12:00 midnight Central Time on the effective date of termination. (b) Medica will not be responsible for any Claims for health services received by Members after the effective date of the termination; and (c) Employer shall be and shall remain liable to Medica for the payment of any and all Premiums that are unpaid at the time of termination. Page 3 ARTICLE 3 ENROLLMENT AND ELIGIBILITY Section 3.1 Eligibility. The Eligibility Appendix to this Contract governs who is eligible to enroll under this Contract. The eligibility conditions stated in the Eligibility Appendix are in addition to those specified in the Certifi~Jate. Section 3.2 Enrollment. The Enrollment Appendix to this Contract governs when eligible employees and eligible dependents may enroll for Benefits under this Contract, including the Initial Enrollment Period, Open Enrollment Period and any applicable Special Enrollment Periods. Employer shall conduct the Initial Enrollment Period and Open Enrollment Period. Employer shall cooperate with Medica in the event of a Special Enrollment Period. Section 3.3. Qualified Medical Child Support Orders. Employer will establish, maintain and enforce all written procedures for determining whether a child support order is a qualified medical child support order as defined by ERISA. Employer will provide Medica with notice of such determination and a copy of the order, along with an application for coverage, within the greater of 30 days after issuance of the order or the time in which Employer provides notice of its determination to the persons specified in the order. When and if Employer receives notice that the child has designated a representative, or of the existence of a legal guardian or custodial parent of the child, Employer shall promptly notify Medica of such person(s). Medica shall have no responsibility for: (i) establishing, maintaining or enforcing the procedures described above; (ii) determining whether a support order is qualified; or (iii)providing required notices to the child or the designated representative. Section 3.4. Eligibility and Enrollment Decisions. Subject to applicable law and the terms of this Contract, Employer has sole discretion to determine whether employees and their dependents are eligible to enroll for Benefits. Medica shall rely upon Employer's determination regarding an employee's and/or dependent's eligibility to enroll for Benefits. The Employer will be responsible for maintaining information verifying its continuing eligibility and the continuing eligibility of its eligible Subscribers and eligible Dependents. This information shall be provided to Medica as reasonably requested by Medica. The Employer shall also maintain written documentation of a waiver of coverage by an eligible Subscriber or eligible Dependent and provide this documentation to Medica upon reasonable request. Page 4 ARTICLE 4 PREMIUMS Section 4.1 Monthly Premiums. The monthly Premiums for this Contract are: Monthly Premium Rate Class I $364.29 (Employee Only) Class 4 $836.63 (Family) Monthly Employer Contribution Monthly Enrollee Contribution Employer shall contribute a minimum of 50% towards the single monthly premium rate. The Premiums are due on the first day of each calendar month. Employer shall pay the Premiums to Medica at the billing address stated in the Acceptance of Contract. Employer shall notify Medica in writing: (a) each month of any changes in the coverage classification of any Subscriber; and (b) within 30 days after the effective date of enrollments, terminations or other changes regarding Members. Section 4,2 Grace Period and Reinstatement. Employer has a grace period of 10 days after the due date stated in Section 4.1 to pay the monthly Premiums. If Employer fails to pay Premium, the Contract will be terminated in accordance with Section 2.2(a). This Contract will be reinstated if Employer pays all of the Premiums owed on or before the end of the grace period. In this event the Contract is not reinstated pursuant to this Section, Medica will not be responsible for any Claims for health services received by Members after the effective date of the termination. Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be calculated by Medica using the number of Subscribers in each coverage classification according to Medica's records at the time of the calculation. Em ployer may make adjustments to its payment of Premiums for any additions or terminations of Members submitted by Employer but not yet reflected in Medica's calculations. A full calendar month's Premiums shal be charged for Members whose effective date falls on or before the 15th day of that calendar month. No Premium shall be charged for Members Page 5 whose effective date falls after the 15th of that calendar month. With the exception of termination of coverage due to a Member's death, a Member's Benefits may be terminated only at the end of a calendar month and a full Premium rate for that month will apply. In the case of a Member's death, that Member's Benefits will be terminated on the date of the death. Section 4.4 Retroactive Adjustments. In accordance with applicable law, retroactive adjustments may be made for any additions, or terminations of Members or changes in coverage classifications not reflected in Medica's records at the time the monthly Premiums were calculated by Medica. However, no retroactive credit will be granted for any month in which a Member received Benefits. No retroactive adjustments to enrollment or Premium refund shall be granted for any change occurring more than 60 days prior to the date Medica received notification of the change from Employer. Regardless of the preceding, Employer shall pay a Premium for any month during which a Member received Benefits. Section 4.5 Premium Changes. Medica may change the Premiums after 30 days prior written notice to Employer on: (a) the first anniversary of the effective date of this Contract; (b) any monthly due date after the first anniversary of this Contract; or (c) any date the provisions of this Contract are amended. Section 4,6 Employer Fees. Medica may charge Employer: (a) a late payment charge in the form of a finance charge of 12% per annum for any Premiums not received by the due date; and (b) a service charge for any non-sufficient-fund check received in payment of the Premiums. ARTICLE 5 INDEMNIFICATION Medica will hold harmless and indemnify Employer against any and all claims, liabilities, damages or judgments asserted against, imposed upon or incurred by Employer, including reasonable attorney fees and costs, that arise out of Medica's grossly negligent acts or omissions in the discharge of its responsibilities to a Member. Employer will hold harmless and indemnify Medica against any and all claims, liabilities, damages or judgments asserted against, imposed upon or incurred by Medica, including reasonable attorney fees and costs, that arise out of Employer's or Employer's employees', agents', and representatives' grossly negligent acts or omissions in the discharge of its or their responsibilities under this Contract. Employer and Medica shall promptly notify the other of any potential or actual claim for which the other party may be responsible under this Article 5. Page 6 ARTICLE 6 ADMINISTRATIVE SERVICES The services necessary to administer this Contract and the Benefits provided under it will be provided in accordance with Medica's or its designee's standard administrative procedures. If Employer requests such administrative services be provided in a manner other than in accordance with these standard procedures, including requests for non-standard reports, and if Medica a§ rees to provide such non-standard administrative services, Employer shall pay for such services or reports at Medica's or its designee's then-current charges for such services or reports. ARTICLE 7 CLERICAL ERROR A Member will not be deprived of coverage under the Contract because of a clerical error. Furthermore, a Member will not be eligible for coverage beyond the scheduled termination date because of a failure to record the termination. ARTICLE 8 ERISA When this Contract is entered into by Employer to provide benefits under an employee welfare benefit plan governed by ERISA, Medica shall not be named as and shall not be the plan administrator or the named fiduciary of the employee welfare benefit plan, as those terms are used in ERISA. The parties agree that Medica has sole, final, and exclusive discretion to: (a) interpret and construe the Benefits under the Contract; (b) interpret and construe the other terms, conditions, limitations and exclusions set out in the Contract; (c) change, interpret, modify, withdraw or add Benefits without approval by Members; and (d) make factual determinations related to the Contract and the Benefits. For purposes of overall cost savings or efficiency, Medica may, in its sole discretion, provide services that would otherwise not be Benefits. The fact that Medica does so in any particular case shall not in any way be deemed to require it to do so in other similar cases. Medica may, from time to time, delegate discretionary authority to other persons or entities providing services under this Contract. ARTICLE 9 DATA OWNERSHIP AND USE Information and data acquired, developed, generated, or maintained by Medica in the course of performing under this Contract shall be Medica's sole property. Except as this Contract or applicable law requires otherwise, Medica shall have no obligation to release such information or data to Employer. Medica may, in its sole discretion, release such information or data to Employer, but only to the extent permitted by law and subject to any restrictions determined by Medica. Page 7 ARTICLE 10 CONTINUATION OF COVERAGE Medica shall provide Benefits under this Contract to those Members who are eligible to continue coverage under federal or state law. Medica will not provide any administrative duties with respect to Employer's compliance with federal or state continuation of coverage laws. All duties of the Employer, including, but not limited to, notifying Members regardi'ng federal and state law continuation rights and Premium billing and collection, remain Employer's sole responsibility. ARTICLE 11 CERTIFICATION OF QUALIFYING COVERAGE FORMS As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Medica will produce Certification of Qualifying Coverage forms for Members whose coverage under this Contract terminates. The Certification of Qualifying Coverage forms will be based on the eligibility and termination data Employer provides to Medica. Employer shall provide all necessary eligibility and termination data to Medica in accordance with Medica's data specifications. The Certification of Qualifying Coverage forms will only include periods of coverage Medica administers under this Contract. ARTICLE '12 AMENDMENTS AND ALTERATIONS Section 12.1 Standard Amendments: Except as provided in Section 12.2, amendments to this Contract are effective 30 days after Medica sends Employer a written amendment. Unless regulatory authorities direct otherwise Employer's signature will not be required. No Medica agent or broker has authority to change this Contract or to waive any of its provisions. Section 12.2 Regulatory Amendment: Medica may amend this Contract to comply with requirements of state and federal law ("Regulatory Amendment") and shall issue to Employer such Regulatory Amendment and give Employer notice of its effective date. The Regulatory Amend ment will not require Employer's consent and, unless regulatory authorities direct otherwise, Employer's signature will not be required. Any provision of this Contract that conflicts with the terms of applicable federal or state laws is deemed amended to conform to the minimum requirements of such laws. ARTICLE 13 ASSIGNMENT Neither party shall have the right to assign any of its rights and responsibilities under the Contract to any person, corporation or entity without the prior written consent of the other party; provided, however, that Medica may, without the prior written consent of the Employer, assign the Contract to any entity that controls Medica, is controlled by Medica, or is under common control with Medica. In the event of assignment, the Contract shall be binding upon the inure to the benefit of each party's successors and assigns. Page 8 ARTICLE 14 DISPUTE RESOLUTION Medica and Employer will work together in good faith to resolve any disputes under this Contract. If they are unable to resolve the disputes within 30 days following the date one party sent written notice of the dispute to the other party, and if either party wishes to pursue the dispute, it shall be submitted to binding arbitration in accordance with the rules of the American Arbitration Association ("AAA"). In no event may arbitration be initiated more than one year following the sending of written notice of the dispute. The arbitrators shall apply Minnesota substantive law to the proceeding, except to the extent federal substantive law, including ERISA, would apply to any claim. Any arbitration proceeding under this Agreement shall be conducted in Hennepin County,. Minnesota. An award may'be entered against a party who fails to appear at a duly noticed hearing. The arbitrators: (i) may construe or interpret, but shall not vary or ignore, the terms of this Agreement; (ii) shall have no authority to award any punitive or exemplary damages; and (iii) shall be bound by controlling law. A party may appeal an arbitration decision to a court of law only in accordance with applicable state arbitration laws or for de novo review of alleged errors of law or legal reasoning. The cost of arbitration shall be paid equally by the parties. In the event a third party initiates litigation involving Medica or Employer, and the party under this Contract who is involved in such third party litigation desires to bring a claim against the other party under this Agreement for indemnity or contribution, the indemnity or contribution claim may be brought in the same venue as the third party litigation, and shall not be subject to the terms of this Article 14. ARTICLE 15 TIME LIMIT ON CERTAIN DEFENSES No statement made by Employer, except a fraudulent statement, shall be used to void this Contract after it has been in force for a period of 2 years. Page 9 ARTICLE 16 RELATIONSHIP BETWEEN PARTIES The relationship between Employer and any Member is that of Employer and Subscriber, Dependent or other coverage classification as defined in this Contract. The relationship between Medica and Network Providers and the relationship between Medica and Employer are solely contractual relationships between independent contractors. Network Providers and Employer are not agents or employees of Medica. Medica and its employees are not agents or employees of Network Providers or Employer. The relationship between a Network Provider and any Member is that of provider and patient and Network Provider is solely responsible for the services provided to any Member. ARTICLE 17 EMPLOYER RECORDS Employer shall furnish Medica with all information and proofs that Medica may reasonably require with regard to any matters pertaining to this Contract. Employer will be responsible for obtaining any necessary consent from Members which allows Medica to receive a Member's protected health information (as defined in the federal privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)). Medica may at any reasonable time inspect all documents furnished to Employer by an individual in connection with the Benefits, Employer's payroll records, and any other records pertinent to the Benefits under this Contract. ARTICLE '18 MEMBER RECORDS By accepting Benefits under this Contract, each Member, including Dependents, whether or not such Dependents have signed the Subscriber's application, authorizes and directs any person or institution that has provided services to the Member to furnish Medica or any of Medica's designees at any reasonable time, upon its request, any and all information and records or copies of records relating to the Benefits provided to the Member. In accordance with applicable law, Medica and any of Medica's designees shall have the right to release any and all records concerning health care services: (i) as necessary to implement and administer the terms of this Contract; or (ii) for appropriate medical review or quality assessment. Such Member information and records shall be considered confidential medical records by Medica and it designees. ARTICLE '19 NOTICE Except as provided in Article 2, notice given by Medica to an authorized representative of Employer will be deemed notice to all Members. All notices to Medica shall be sent to the address stated in the Acceptance of Contract. All notices to Employer shall be sent to the persons and addresses stated in Employer's Application. All notices to Medica and Employer shall be deemed delivered: (a) if delivered in person, on the date delivered in person; (b) if delivered by a courier, on the date stated by the courier; (c) if delivered by an express mail service, on the date stated by the mail service vendor; or Page10 (d) if delivered by United States mail, 3 business days after date of mailing. A party can change its address for receiving notices by providing the other party a written notice of the change. ARTICLE 20 COMMON LAW No language contained in the Contract constitutes a waiver of Medica's rights under common law. ACCEPTANCE OF CONTRACT This contract is deemed accepted by Employer upon the earlier of Medica's receipt of Employer's first payment of the Premium or upon Employer's execution of this Contract by its duly authorized representative. This Contract is deemed accepted by Medica upon Medica's deposit of Employer's first payment of the Premium. Such acceptance renders all terms and provisions herein binding on Medica and the Employer. #Name? MEDICA 5601 Smetana Drive Minnetonka, MN 55343 (952)992-2200 Billing Address: MN015-2838 P.O. Box 169063 Duluth, MN 55816 Mailing Address: P.O. Box 9310 Minneapolis, MN 55440 By: Tom L. Henke Title: Vice President, Commercial Sales and Account Services EMPLOYER: CITY OF COLUMBIA HEIGHTS Address: 590 40th Ave. NE Columbia Height, MN 55421 Telephone: (763) 706-3609 C orttract Signer: Title: Date: Group Contact: / Lind~/Magee Page 11 ELIGIBILITY APPENDIX Employer Name: CITY OF COLUMBIA HEIGHTS Employer Group~: 89944 Section 1 Eligibility to Enroll. A Subscriber, and his or her Dependents, as defined below, who satisfies the eligibility conditions stated in this Contract are eligible to enroll for coverage under this Contract. Any person who does not satisfy the definition of Subscriber or Dependent is not eligible for coverage under this Contract. A Subscriber and his or her Dependents must meet the eligibility requirements described below and in the entire Contract. In no event may the number of Members residing outside the Service Area exceed 10 percent of the total number of Members. If there is a conflict between the Certificate and this Eligibility Appendix, this Eligibility Appendix governs. Section 2 Subscriber Definition. The term "Subscriber" as used in the Contract will include the types of employees and conditions identified below: Applicable Waiting Periods Classifications and Effective Dates Employer Hours: Full-time em ployees working a minimum of 40 hours per week. Elected officials also. New Hires: Eligible Date of Hire Return: Date of Return Status Change: Date of Change A Subscriber who is a child entitled to receive coverage through a qualified medical child support order is not subject to any waiting periods, except to the extent that such waiting periods apply to the employee who is ordered by the qualified medical support order to provide coverage. Section 3 Dependent Definition. The term "Dependent" as used in this Contract includes the following: 1. The Subscriber's spouse 2. The following Dependent children: (a) Subscriber's unmarried natural or adopted child; (b) an unmarried child Placed For Adoption with the Subscriber; (c) a child for whom the Subscriber or the Subscriber's spouse has been appointed legal guardian, however, upon request by Medica, the Subscriber must provide satisfactory proof of dependency; Page 12 (d) Subscriber's or Subscriber's spouse's unmarried grandchild who, from the date of birth resides with and is dependent upon the Subscriber or Subscriber's spouse for support and (e) Subscriber's stepchild. A Dependent child must be under 19 years of age if s/he is not a student and must be Under 25 years of age if s/he is a student. A Dependent child is eligible as a student if s/he is enrolled full- time in a reco§nized high school, college, university, trade or vocational school. If the student is unable to a carry a full-time course load due to illness, injury, or a physical or mental disability, as documented by a Physician, full-time student status will be granted if the student carries at least 60% of a full-time course load, as determined by the educational institution. 3. The Subscriber's handicapped Dependent. The handicapped Dependent must be: (a) incapable of self-sustaining employment by reason of mental retardation, mental illness, mental disorder or physical handicap; and (b) chiefly dependent upon the Subscriber for support and maintenance. The handicapped Dependent shall be eligible for coverage as long as he or she continues to be handicapped and satisfies the requirements of (a) and (b) above, unless coverage otherwise terminates under this Contract. Medica may require annual proof of handicap and dependency. An illness will not be considered a physical handicap. A ch Id who is the subject of a qualified medical child support order is not a Dependent as defined above and may not enroll Dependents for coverage. See Section 2. Any person who does not satisfy the terms listed above will not be eligible for coverage under the Contract. Page 13 ENROLLMENT APPENDIX Employer Name: Employer Group~: CITY OF COLUMBIA HEIGHTS 89944 INITIAL ENROLLMENT "Initial Enrollment Period" is a 30 day time period starting with the date an eligible Subscriber and his or her eligible Dependents are first eligible to enroll for coverage under this Contract. An eligible Subscriber must apply within this period for coverage to begin the date he or she was first eligible to enroll. (The 30 day time period does not apply to newborn Dependents; see Special Enrollment, (item 4).) An eligible Subscriber who enrolls during the Initial Enrollment Period is accepted without application of health screening or affiliation periods. An eligible Subscriber and his/her Dependents Who do not enroll during the Initial Enrollment Period may enroll for coverage during the next Open Enrollment, any applicable Special Enrollment Periods as described be Iow. A Subscriber who is a child entitled to receive coverage through a qualified medical child support order is not subject to any Initial Enrollment Period restrictions, except as noted in the Eligibility Appendix. NOTIFICATION Subscribers must notify Employer within 30 days of the effective date of any change of address or name, addition or deletion of Dependents, or other facts identifying the Subscriber or the Subscriber's Dependents. The Employer must notify Medica within 30 days of the effective date of the MembeCs initial enrollment application, changes to the Member's name or address, or changes to enrollment, including if a Member is no longer eligible for coverage. OPEN ENROLLMENT "Open Enrollment" is a minimum 14 day period set by Employer and Medica each year during which eligible Subscribers and his or her Dependents may enroll for coverage without application of health screening or waiting periods. SPECIAL ENROLLMENT A. Special Enrollment Periods. The following "Special Enrollment Periods" are available in addition to the Initial Enrollment Period and Open Enrollment Period. A Special Enrollment period will apply to an eligible employee and Dependent if: (1) the eligible employee or Dependent: a. was covered under Qualifying Coverage at the time the eligible employee or Dependent was first eligible to enroll under the Contract, and b. declined coverage for that reason, and presents to Medica either (i) evidence of the loss of prior coverage due to loss of eligibility for that coverage, or (ii) evidence that em ployer contributions toward the prior coverage have terminated, and d. maintains Continuous Coverage, and Page14 e. requests enrollment in writing within 30 days of the date of the loss of coverage or the date the employer's contribution toward that coverage terminates; For purposes of this item: a. prior coverage does not incli~de continuation coverage required under federal law; loss of eligibility includes loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment; loss of eligibility does not include a loss due to failure of the eligible employee or Dependent to pay Premiums on a timely basis or termination of coverage for cause; (2) the eligible employee or Dependent: was covered under benefits available under (i) the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), Public Law Number 99-272, as amended, or (ii) any state continuation laws applicable to the employer or Medica, and b. declined coverage forthat reason and the eligible employee or Dependent presents to Medica evidence that the eligible employee or Dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to either failure of the eligible employee or Dependent to pay Premiums on a timely basis or for cause, and d. maintains Continuous Coverage, and e. requests enrollment in writing within 30 days of the loss of coverage; (3) (4) the Dependent is a new spouse of the Subscriber or eligible employee, provided that the marriage '~s legal, enrollment is requested in writing within 30 days of the marriage, and the eligible employee also enrolls during this Special Enrollment Period; the Dependent is a new Dependent child of the Subscriber or eligible employee, provided that enrollment is requested in writing within 30 days of the Subscriber or eligible employee acquiring the Dependent (the notification period is not limited to 30 days for newborn Dependents), and provided the eligible employee also enrolls during this Special Enrollment Period; (5) the De pendent is the spouse of the Subscriber or eligible employee through whom the Dependent child described in item #-4 above claims Dependent status and; a. that spouse is eligible for coverage; and b. is not already enrolled under the Contract; and Co enrollment is requested in writing within 30 days of the Dependent child becoming a Dependent, provided the eligible employee also enrolls during this Special Enrollment Period. Page 15 (6) the Dependents are eligible Dependent children of the Subscriber or eligible employee and enrollment ~s requested in writing within 30 days of a Dependent, as described in items #3 or #4 above becoming eligible to enroll under the coverage, provided the eligible employee also enrolls during this Special Enrollment Period. Additionally, when Employer provides Medica with notice of a qualified medical child support order and a copy of the order, Medica will provide such eligible dependent child with a Special Enrollment Period. Employer will provide Medica with such notice, along with an application for coverage, within the lesser of 30 days or the time in which Employer provides notice of its determination to the persons specified in the order. B. Effective Dates of Coverage. Coverage shall become effective: (1) in the case of paragraphs (A)(1) or (2) above, the day after the date the other coverage ended; (2) in the case of paragraph (A)(3) above, the date of the marriage; (3) in the case of paragraph (A)(4) above, the date of birth, date of adoption, or date of placement for adoption. In all other cases, the date the Subscriber acquires the Dependent child. (4) in the case of paragraph (A)(5) above, the date the Subscriber acquires the Dependent Child; and (5) in the case of (A)(6) above, the first day of the first calendar month beginning after the date the completed request for enrollment is received by Medica. (6) in the case of the qualified medical child support order, the first day of the first calendar month beginning after the date the completed request for enrollment is received by Medica. Page 16 OFF-CYCLE ENROLLMENT- NO OFF-CYCLE ENROLLMENT FOR LATE ENTRANTS WITHOUT CONTINUOUS COVERAGE An eligible Subscriber or an eligible Subscriber and his or her Dependents who do not enroll for coverage offered through Employer during the Initial Enrollment Period, the Open Enrollment Period or any applicable Special Enrollment Period will be considered Late Entrants. (1) Late Entrants who have maintained Contir~uous Coverage may enroll and coverage will be effective the first day of the month following date of approval by Medica. Continuous Coverage will be determined to have been maintained if the Late Entrant requests enrollment within 63 days after prior Qualifying Coverage ends. (2) Late Entrants who have not maintained Continuous Coverage may not enroll off-cycle. An eligible Subscriber or Dependent who: (1) does not enroll during the Initial Enrollment Period, the Open Enrollment Period or any applicable Special Enrollment period; and (2) is an enrollee of the Minnesota Comprehensive Health Association ("MCHA") at the time Medica offers or renews coverage with Employer, provided the eligible Subscriber or Dependent maintains Continuous Coverage, will not be considered a Late Entrant and will be allowed to enrolk Coverage will be effective as determined by Medica. Page 17 Medica Elect PLAN MASTER GROUP CONTRACT Employer Name: Employer Group#: Effective Date: Contrac¢: Amendments: CITY O'F COLUMBIA HEIGHTS 89945 January 01, 2004 ME7, BPL Number: 97425 Amendments attached as applicable for benefit package log (BPL) as listed above. ARTICLE 1 INTRODUCTION This Master Group Contract ("Contract") is entered into by and between Medica, together with its affiliate Medica InSurance Company ("MIC"), and the employer group named above ("Employer"), an employer under Minnesota law and other applicable law. This Contract includes the Eligibility Appendix, the Enrollment Appendix, the Certificate of Coverage ("Certificate") and any Amendments. This Contract is delivered in the State of Minnesota. If this Contract is purchased by Employer to provide benefits under an employee welfare benefit plan governed by the Employee Retirement Income Security Act, 29 U.S.C. 1001, et seq. ('ERISA"), this Contract is governed by ERISA and, to the extent state law applies, the laws of the State of Minnesota. If this 'Contract is not governed by ERISA, it is governed by the laws of the State of Minnesota. In consideration of payment of the Premiums by the Employer and payment of Copayments and Coinsurance by or for Members, Medica will provide coverage for the Benefits set forth in the Certificate and any amendments, subject to all terms and conditions, including limitations and exclusions, in this Contract. This Contract replaces and supersedes any previous agreements between Employer and Medica relating to Benefits. Medica shall not be deemed or construed to be an employer for any purpose with respect to the administration or provision of benefits under Employer's welfare benefit plan. Medica shall not be responsible for fulfilling any duties or obligations of Employer with respect to Employer's benefit plan. The terms used in this Contract have the same meanings g~ven those terms defined in the Certificate, unless otherwise specifically defined in this Contract. Page 1 ARTICLE 2 TERM OF CONTRACT Section 2.1 Term and Renewal. This Contract is effective from January 01, 2004 ("Effective Date") to December 31, 2004 ("Expiration Date") All coverage under this Contract begins at 12:01 a.m. Central Time. At least 30 days before each Expiration Date, Medica shall notify Employer of any modifications to this Contract, including Premiums and Benefits for the next term of this Contract ("Renewal Terms"). If Employer accepts the Renewal Terms or if Employer and Medica agree on different Renewal Terms this Contract is renewed for the additional term, unless Medica terminates this Contract pursuant to Section 2.2. Section 2.2 Termination of this Contract. Employer may terminate this Contract after at least 30 days written notice to Medica. This Contract is guaranteed renewable and will not be terminated by Medica except for the reasons and effective as stated below. Terminations for the reasons stated below require at least 30 days written notice from Medica: (a) Upon notice to an authorized representative of the Employer when Em ployer does not pay the required Premium when due, provided, however, that this Contract can be reinstated pursuant to Section 4.2; (b) On the date specified by Medica because Employer provided Medica with false information material to the execution of this Contract or to the provision of Benefits under this Contract. Medica has the right to rescind this Contract back to the effective date; (c) On the date specified by Medica due to Em ployer's violation of the participation or contribution rules as determined by Medica; (d) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C. Chapter 7; (e) On the date specified by Medica, after at least 90 days prior written notice to Employer, that this Contract is terminated because Medica will no longer issue this particular type of group health benefit plan within the applicable employer market; (f) On the date specified by Medica, after at least 180 days prior written notice to the applicable state authority and Employer, that this Contract will be terminated because Medica will no longer renew or issue any employer health benefit plan within the applicable employer market; (g) On the date specified by Medica when there is no longer any Member who resides or works in Medica's approved service area; (h) If this Contract is made available to Employer only through one or more bona fide associations, on the date specified by Medica after Employer's membership in the association ceases. Page 2 (i) Any other reasons or grounds permitted by the licensing laws and regulations governing Medica. Notwithstanding the above Medica may modify the Premium rate and/or the coverage at renewal. Nonrenewal of coverage as a result of failure of Medica and the Employer to reach agreement with respect to modifications in the Premium rate or coverage shall not be considered a failure of Medica to provide coverage on a guaranteed renewa basis. Section 2.3 Notice of Termination. Medica will notify: (a) Employer in writing if Medica terminates this Contract for any reason; (b) Subscribers in writing if Medica terminates this Contract pursuant to Section 2.2 (a), (d), (e) or (f). Employer will provide timely written notification to Subscribers in all circumstances for which Medica does not provide written notification to Subscribers. Section 2.4 Effect of Termination. In the event of termination of this Contract: (a) All Benefits under this Contract will end at 12:00 midnight Central Time on the effective date of termination. (b) Medica will not be responsible for any Claims for health services received by Members after the effective date of the termination; and (c) Employer shall be and shall remain liable to Medica for the payment of any and all Premiums that are unpaid at the time of termination. Page 3 ARTICLE 3 ENROLLMENT AND ELIGIBILITY Section 3.1 Eligibility. The Eligibility Appendix to this Contract governs who is eligible to enroll under this Contract. The eligibility conditions stated in the Eligibility Appendix are in addition to those specified in the CertifiCate. Section 3.2 Enrollment. The Enro ment Appendix to this Contract governs when eligible employees and eligible dependents may enroll for Benefits under this Contract, including the Initial Enrollment Period, Open Enrollment Period and any applicable Special Enrollment Periods. Employer shall conduct the Initial Enrollment Period and Open Enrollment Period. Employer shall cooperate with Medica in the event of a Special Enrollment Period. Section 3.3. Qualified Medical Child Support Orders. Employer will establish, maintain and enforce all written procedures for determining whether a child support order is a qualified medical child support order as defined by ERISA. Employer will provide Medica with notice of such determination and a copy of the order, along with an application for coverage, within the greater of 30 days after issuance of the order or the time n which Employer provides notice of its determination to the persons specified in the order. When and if Employer receives notice that the child has designated a representative, or of the existence of a legal guardian or custodial parent of the child, Employer shall promptly notify Medica of such person(s). Medica shall have no responsibility for: (i) establishing, maintaining or enforcing the procedures described above; (ii) determining whether a support order is qualified; or (iii)providing required notices to the child or the designated representative. Section 3.4. Eligibility and Enrollment Decisions. Subject to applicable law and the terms of this Contract, Employer has sole discretion to determine whether employees and their dependents are eligible to enroll for Benefits. Medica shal rely upon Employer's determination regarding an employee's and/or dependent's eligibility to enroll for Benefits. The Employer will be responsible for maintaining information verifying its continuing eligibility and the continuing eligibility of its eligible Subscribers and eligible Dependents. This information shall be provided to Medica as reasonably requested by Medica. The Employer shall also maintain written aocumentation of a waiver of coverage by an eligible Subscriber or eligible Dependent and provide this documentation to Medica upon reasonable request. Page 4 ARTICLE 4 PREMIUMS Section 4.1 Monthly Premiums. The monthly Premiums for this Contract are: Monthly Premium Rate Class 1 $327.88 (Employee Only) Class 4 $752.98 (Family) Monthly Employer Contribution Monthly Enrollee Contribution Employer shall contribute a minimum of 50% towards the single monthly premium rate. The Premiums are due on the first day of each calendar month. Employer shall pay the Premiums to Medica at the billing address stated in the Acceptance of Contract. Employer shall notify Medica in writing: (a) each month of any changes in the coverage classification of any Subscriber; and (b) within 30 days after the effective date of enrollments, terminations or other changes regarding Members. Section 4,2 Grace Period and Reinstatement, Employer has a grace period of 10 days after the due date stated in Section 4.1 to pay the monthly Premiums. If Employer fails to pay Premium, the Contract will be terminated in accordance with Section 2.2(a). This Contract will be reinstated if Employer pays all of the Premiums owed on or before the end of the grace period. In this event the Contract is not reinstated pursuant to this Section, Medica will not be responsible for any Claims for health services received by Members after the effective date of the termination. Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be calculated by Medica using the number of Subscribers in each coverage classification according to Medica's records at the time of the calculation. Employer may make adjustments to its payment of Premiums for any additions or terminations of Members submitted by Employer but not yet reflected in Medica's calculations. A full calendar month's Premiums shall be charged for Members whose effective date falls on or before the 15th day of that calendar month. No Premium shall be charged for Members Page 5 whose effective date falls after the 15th of that calendar month. With the exception of termination of coverage due to a Member's death, a Member's Benefits may be terminated only at the end of a calendar month and a full Premium rate for that month will apply. In the case of a Member's death, that Member's Benefits will be terminated on the date of the death. Section 4.4 Retroactive Adjustments~. In accordance with applicable law, retroactive adjustments may be made for any additions, or terminations of Members or changes in coverage classifications not reflected in Medica's records at the time the monthly Premiums were calculated by Medica. However, no retroactive credit will be granted for any month in which a Member received Benefits. No retroactive adjustments to enrollment or Premium refund shall be granted for any change occurring more than 60 days prior to the date Medica received notification of the change from Employer. Regardless of the preceding, Employer shall pay a Premium for any month during which a Member received Benefits. Section 4.5 Premium Changes. Medica may change the Premiums after 30 days prior writ[en notice to Employer on: (a) the first anniversary of the effective date of this Contract; (b) any monthly due date after the first anniversary of this Contract; or (c) any date the provisions of this Contract are amended. Section 4.6 Employer Fees. Medica may charge Employer: (a) a late payment charge in the form of a finance charge of 12% per annum for any Premiums not received by the due date; and (b) a service charge for any non-sufficient-fund check received in payment of the Premiums. ARTICLE 5 INDEMNIFICATION Medica will hold harmless and indemnify Employer against any and all claims, liabilities, damages or judgments asserted against, imposed upon or incurred by Employer, including reasonable attorney fees and costs, that arise out of Medica's grossly negligent acts or omissions in the discharge of its responsibilities to a Member. Employer will hold harmless and indemnify Medica against any and all claims, liabilities, damages or judgments asserted against, imposed upon or incurred by Medica, including reasonable attorney fees and costs, that arise out of Employer's or Employer's employees', agents', and representatives' grossly negligent acts or omissions in the discharge of its or their responsibilities under this Contract. Employer and Medica shall promptly notify the other of any potential or actual claim for which the other party may be responsible under this Article 5. Page 6 ARTICLE 6 ADMINISTRATIVE SERVICES The services necessary to administer this Contract and the Benefits provided under it will be provided in accordance with Medica's or its designee's standard administrative procedures. If Employer requests such administrative services be provided in a manner other than in accordance with these standard procedures, including requests for non-standard reports, and if Medica agrees to provide such non-standard administrative services, Employer shall pay for such services or reports at Medica's or its designee's then-current charges for such services or reports. ARTICLE 7 CLERICAL ERROR A Member will not be deprived of coverage under the Contract because of a clerical error. Furthermore, a Member will not be eligible for coverage beyond the scheduled termination date because of a failure to record the termination. ARTICLE 8 ERISA When this Contract is entered into by Employer to provide benefits under an employee welfare benefit plan governed by ERISA, Medica shall not be named as and shall not be the plan administrator or the named fiduciary of the employee welfare benefit plan, as those terms are used in ERISA. The parties agree that Medica has sole, final, and exclusive discretion to: (a) interpret and construe tl~e Benefits under the Contract; (b) interpret and construe the other terms, conditions, limitations and exclusions set out in the Contract; (c) change, interpret, modify, withdraw or add Benefits without approval by Members; and (d) make factual determinations related to the Contract and the Benefits. For purposes of overall cost savings or efficiency, Medica may, in its sole discretion, provide services that would otherwise not be Benefits. The fact that Medica does so in any particular case shall not in any way be deemed to require it to do so in other similar cases. Medica may, from time to time, delegate discretionary authority to other persons or entities providing services under this Contract. ARTICLE 9 DATA OWNERSHIP AND USE Information and data acquired, developed, generated, or maintained by Medica in the course of performing under this Contract shall be Medica's sole property. Except as this Contract or applicable law requires otherwise, Medica shall have no obligation to release such information or data to Employer. Medica may, in its sole discretion, release such information or data to Employer, but only to the extent permitted by law and subject to any restrictions determined by Medica. Page 7 ARTICLE 10 CONTINUATION OF COVERAGE Medica shall provide Benefits under this Contract to those Members who are eligible to continue coverage under federal or state law. Medica will not provide any administrative duties with respect to Employer's compliance with federal or state continuation of coverage laws. All duties of the Employer, including, but not limited to, notifying Members regarding federal and state law continuation rights and Premium billing and collection, remain Employer's sole responsibility. ARTICLE 11 CERTIFICATION OF QUALIFYING COVERAGE FORMS As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Medica will produce Certification of Qualifying Coverage forms for Members whose coverage under this Contract terminates. The Certification of Qualifying Coverage forms will be based on the eligibility and termination data Employer provides to Medica. Employer shall provide all necessary eligibility and termination data to Medica in accordance with Medica's data specifications. The Certification of Qualifying Coverage forms will only include periods of coverage Medica administers under this Contract. ARTICLE 12 AMENDMENTS AND ALTERATIONS Section 12.1 Standard Amendments: Except as provided in Section 12.2, amendments to this Contract are effective 30 days after Medica sends Employer a written amendment. Unless regulatory authorities direct otherwise, Employer's signature will not be required. No Medica agent or broker has authority to change this Contract or to waive any of its provisions. Section 12.2 Regulatory Amendment: Medica may amend this Contract to comply with requirements of state and federal law ("Regulatory Amendment") and shall issue to Employer such Regulatory Amendment and give Employer notice of its effective date. The Regulatory Amendment will not require Employer's consent and, unless regulatory authorities direct otherwise, Employer's signature will not be required. Any provision of this Contract that conflicts with the terms of applicable federal or state laws is deemed amended to conform to the minimum requirements of such laws. ARTICLE 13 ASSIGNMENT Neither party shall have the right to assign any of its rights and responsibilities under the Contract to any person, corporation or entity without the prior written consent of the other party; provided, however, that Medica may, without the prior written consent of the Employer, assign the Contract to any entity that controls Medica, is controlled by Medica, or is under common control with Medica. In the event of assignment, the Contract shall be binding upon the inure to the benefit of each party's successors and assigns. Page 8 ARTICLE 14 DISPUTE RESOLUTION Medica and Employer will work together in good faith to resolve any disputes under this Contract. If they are unable to resolve the disputes within 30 days following the date one party sent written notice of the dispute.to the other party, and if either party wishes to pursue the dispute, it shall be submitted to binding arbitration in accordance with the rules of the American Arbitration Association ("AAA"). In no event may arbitration be initiated more than one year following the sending of written notice of the dispute. The arbitrators shall apply Minnesota substantive law to the proceeding, except to the extent federal substantive law, including ERISA, would apply to any claim. Any arbitration proceeding under this Agreement shall be conducted in Hennepin County, Minnesota. An award may be entered against a party who fails to appear at a duly noticed hearing. The arbitrators: (i) may construe or interpret, but shall not vary or ignore, the terms of this Agreement; (ii) shall have no authority to award any punitive or exemplary damages; and (iii) shall be bound by controlling law. A party may appeal an arbitration decision to a court of law only in accordance with applicable state arbitration laws or for de novo review of alleged errors of law or legal reasoning. The cost of arbitration shall be paid equally by the parties. In the event a third party initiates litigation involving Medica or Employer, and the party under this Contract who is involved in such third party litigation desires to bring a claim against the other party under this Agreement for indemnity or contribution, the indemnity or contribution claim may be brought in the same venue as the third party litigation, and shall not be subject to the terms of this Article 14.., ARTICLE 15 TIME LIMIT ON CERTAIN DEFENSES No statement made by Employer, except a fraudulent statement, shall be used to void this Contract after it has been in force for a period of 2 years. Page 9 ARTICLE 16 RELATIONSHIP BE'I'WEEN PARTIES The relationship between Employer and any Member is that of Employer and Subscriber, Dependent or other coverage classificatibn as defined in this Contract. The relationship between Medica and Network Providers and the relationship between Medica and Employer are solely contractual relationships between independent contractors.. Network Providers and Employer are not agents or employees of Medica. Medica and its employees are not agents or employees of Network Providers or Employer. The relationship between a Network Provider and any Member is that of provider and patient and Network Provider is solely responsible for the services provided to any Member. ARTICLE 17 EMPLOYER RECORDS Employer shall furnish Medica with all information and proofs that Medica may reasonably require with regard to any matters pertaining to this Contract. Employer will be responsible for obtaining any necessary consent from Members which allows Medica to receive a Member's protected health information (as defined in the federal privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)). Medica may at any reasonable time inspect all documents furnished to Employer by an individual in connection with the Benefits, Employer's payroll records, and any other records pertinent to the Benefits under this Contract. ARTICLE 18 MEMBER RECORDS By accepting Benefits under this Contract, each Member, including Dependents, whether or not such Dependents have signed the Subscriber's application, authorizes and directs any person or institution that has provided services to the Member to furnish Medica or any of Medica's designees at any reasonable time, upon its request, any and all information and records or copies of records relating to the Benefits provided to the Member. In accordance with applicable law, Medica and any of Medica's designees shal have the right to release any and all records concerning health care services: (i) as necessary to implement and administer the terms of this Contract; or (ii) for appropriate medical review or quality assessment. Such Member information and records shall be considered confidential medical records by Medica and it designees. ARTICLE 19 NOTICE Except as provided in Article 2 notice g~ven by Medica to an authorized representative of Employer will be deemed notice to all Members. All notices to Medica shall be sent to the address stated in the Acceptance of Contract, All notices to Employer shall be sent to the persons and addresses stated in Employer's Application. All notices to Medica and Employer shall be deemed delivered: (a) if delivered in person on the date delivered in person; (b) if delivered by a courier, on the date stated by the courier; (c) if delivered by an express mail service, on the date stated by the mail service vendor; or Page 10 (d) if delivered by United States mail, 3 business days after date of mailing. A party can change its address for receiving notices by providing the other party a written notice of the change. ARTICLE 20 COMMON LAW No language contained in the Contract constitutes a waiver of Medica's rights under common law. ACCEPTANCE OF CONTRACT This contract is deemed accepted by Employer upon the earlier of Medica's receipt of Employer's first pay ment of the Premium or upon Employer's execution of this Contract by its duly authorized representative. This Contract is deemed accepted by Medica upon Medica's deposit of Employer's first payment of the Premium. Such acceptance renders all terms and provisions herein binding on Medica and the Employer. #Name? MEDICA 5601 Smetana Drive Minnetonka, MN 55343 (952)992-2200 Billing Address: MN015-2838 P.O. Box 169063 Duluth, MN 55816 Mailing Address: P.O, Box 9310 Minneapolis, MN 55440 By: Tom L. Henke Title: Vice President, Commercial Sales and Account Services EMPLOYER: CITY OF COLUMBIA HEIGHTS Address: 590 40th Ave. NE Columbia Height, MN 55421 Telephone: (763) 706-3609 Contract Signer: Title: ¢ Date: ~///~//~./,~ ¢/. ~' Group Contac¢ Li-Cf~a I~agee Page 11 ELIGIBILITY APPENDIX Employer Name: CITY OF COLUMBIA HEIGHTS Employer Groul:~: 89945 [ Section I Eligibility to Enroll. A Subs~criber, and his or her Dependents, as defined below, who satisfies the e igibility conditions stated in this Contract are eligible to enroll for coverage under this Contract. Any person who does not satisfy the definition of Subscriber or Dependent is not eligible for coverage under this Contract. A Subscriber and his or her Dependents must meet the eligibility requirements described below and in the entire Contract. In no event may the number of Members residing outside the Service Area exceed 10 percent of the total number of Members. If there is a conflict between the Certificate and this Eligibility Appendix, this Eligibility Appendix governs. Section 2 Subscriber Definition. The term "Subscriber" as used in the Contract will include the types of employees and conditions identified below: Applicable Waiting Periods Classifications and Effective Dates Employer Hours: Full-time employees working a minimum of 40 hours per week. Elected officials also. New Hires: Eligible Date of Hire Return: Date of Return Status Change: Date of Change A Subscriber who is a child entitled to receive coverage through a qualified medical child support order is not subject to any waiting periods, except to the extent that such waiting periods apply to the employee who is ordered by the qualified medical support order to provide coverage. Section 3 Dependent Definition. The term "Dependent" as used in this Contract includes the following: 1. The Subscriber's spouse 2. The following Dependent children: (a) Subscriber's unmarried natural or adopted child; (b) an unmarried child Placed For Adoption with the Subscriber; (c) a child for whom the Subscriber or the Subscriber's spouse has been appointed legal guardian, however, upon request by Medica, the Subscriber must provide satisfactory proof of dependency; Page 12 (d) Subscriber's or Subscriber's spouse's unmarried grandchild who, from the date of birth resides with and is dependent upon the Subscriber or Subscriber's spouse for support and (e) Subscriber's stepchild. A Dependent child must be under 19 years of age if s/he is not a student and must be under 25 years of age if s/he is a student. A Dependent child is eligible as a student if s/he is enrolled full- time in a recognized high school, college, university, trade or vocational school. If the student is unable to a carry a full-time course load due to illness, injury, or a physical or mental disability, as documented by a Physician, full-time student status will be granted if the student carries at least 60% of a full-time course load, as determined by the educational institution. 3. The Subscriber's handicapped Dependent. The handicapped Dependent must be: (a) incapable of self-sustaining employment by reason of mental retardation, mental illness mental disorder or physical handicap; and (b) chiefly dependent upon the Subscriber for support and maintenance. The handicapped Dependent shall be eligible for coverage as long as he or she continues to be handicapped and satisfies the requirements of (a) and (b) above, unless coverage otherwise terminates under this Contract. Medica may require annual proof of handicap and dependency. An illness will not be considered a physical handicap. A child who is the subject of a qualified medical child support order is not a Dependent as defined above and may not enroll Dependents for coverage. See Section 2. Any person who does not,satisfy the terms listed above will not be eligible for coverage under the Contract. Page13 ENROLLMENT APPENDIX Employer Name: CITY OF COLUMBIA HEIGHTS Em ployer Group¢: 89945 INITIAL ENROLLMENT "Initial Enrollment Period" is a 30 day time period starting with the date an eligible Subscriber and his or her eligible Dependents are first eligible to enroll for coverage under this Contract. An eligible Subscriber must apply within this period for coverage to begin the date he or she was first eligible to enroll. (The 30 day time period does not apply to newborn Dependents; see Special Enrollment, (item 4).) An eligible Subscriber who enrolls during the Initial Enrollment Period is accepted without application of health screening or affiliation periods. An eligible Subscriber and his/her Dependents who do not enroll during the Initial Enrollment Period may enroll for coverage during the next Open Enrollment, any applicable Special Enrollment Periods as described below. A Subscriber who is a child entitled to receive coverage through a qualified medical child support order is not subject to any Initial Enrollment Period restrictions, except as noted in the Eligibility Appendix. NOTIFICATION Subscribers must notify Employer within 30 days of the effective date of any change of address or name, addition or deletion of Dependents, or other facts identifying the Subscriber or the Subscriber's Dependents. The Employer must notify Medica within 30 days of the effective date of the Member's initial enrollment application, changes to the Member's name or address, or changes to enrollment, including if a Member is no longer eligible for coyerage. OPEN ENROLLMENT "Open Enrollment" is a minimum 14 day period set by Employer and Medica each year during which eligible Subscribers and his or her Dependents may enroll for coverage without a pplication of health screening or waiting periods. SPECIAL ENROLLMENT A. Special Enrollment Periods. The following "Special Enrollment Periods" are available in addition to the Initial Enrollment Period and Open Enrollment Period. A Special Enrollment period will apply to an eligible employee and Dependent if: (1) the eligible employee or Dependent: was covered under Qualifying Coverage at the time the eligible employee or Dependent was first eligible to enroll under the Contract, and b. declined coverage for that reason, and presents to Medica either (i) evidence of the loss of prior coverage due to loss of eligibility for that coverage, or (ii) evidence that em ployer contributions toward the prior coverage have terminated, and d. maintains Continuous Coverage, and Page 14 e. requests enrollment in writing within 30 days of the date of the loss of coverage or the date the employer's contribution toward that coverage terminates; For purposes of this item: a. prior coverage does not include continuation coverage required under federal law; loss of eligibility includes loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment; loss of eligibility does not include a loss due to failure of the eligible employee or Dependent to pay Premiums on a timely basis or termination of coverage for cause; (2) the eligible employee or Dependent: ac was covered under benefits available under (i) the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), Public Law Number 99-272, as amended, or (ii) any state continuation laws applicable to the employer or Medica, and b. declined coverage for that reason, and the eligible employee or Dependent presents to Medica evidence that the eligible employee or Dependent has exhausted, such COBRA or state continuation coverage and has not lost such coverage due to either failure of the eligible employee or Dependent to pay Premiums on a timely basis or for cause, and d. maintains Continuous Coverage, and e. requests enrollment in writing within 30 days of the loss of coverage; (3) (4) the Dependent is a new spouse of the Subscriber or eligible employee, provided that the marriage is legal, enrollment is requested in writing within 30 days of the marriage, and the eligible employee also enrolls during this Special Enrollment Period; the Dependent is a new Dependent child of the Subscriber or eligible employee, provided that enrollment is requested in writing within 30 days of the Subscriber or eli.qible employee acquiring the Dependent (the notification period is not limited to 30 days for newborn Dependents), and provided the eligible employee also enrolls during this Special Enrollment Period; (5) the Dependent is the spouse of the Subscriber or eligible employee through whom the Dependent child described in item #4 above claims Dependent status and; a. that spouse is eligible for coverage; and b. is not already enrolled under the Contract; and enrollment is requested in writing within 30 days of the Dependent child becoming a Dependent, provided the eligible employee also enrolls during this Special Enrollment Period. Page 15 (6) the Dependents are eligible Dependent children of the Subscriber or eligible employee and enrollment is requested in writing within 30 days of a Dependent, as described in items #3 or #4 above, becoming eiigible to enroll under the coverage, provided the eligible employee also enrolls duri~qg this Special Enrollment Period. Additionally, when Employer provides Medica with notice of a qualified medical child support order and a copy of the order, Medica will provide such eligible dependent child with a Special Enrollment Period. Employer will provide Medica with such notice, along with an application for coverage, within the lesser of 30 days or the time in which Employer provides notice of its determination to the persons specified in the order. B. Effective Dates of Coverage. Coverage shall become effective: (1) in the case of paragraphs (A)(1) or (2) above, the day after the date the other coverage ended; (2) in the case of paragraph (A)(3) above, the date of the marriage; (3) in the case of paragraph (A)(4) above, the date of birth, date of adoption, or date of placement for adoption. In all other cases, the date the Subscriber acquires the Dependent child. (4) in the case of paragraph (A)(5) above, the date the Subscriber acquires the Dependent Child; and (5) in the case of (A)(6) above, the first day of the first calendar month beginning after the date the completed request for enrollment is received by Medica. (6) in the case of the qualified medical child support order, the first day of the first calendar month beginning after the date the completed request for enrollment is received by Medica. Page 16 OFF-CYCLE ENROLLMENT- NO OFF-CYCLE ENROLLMENT FOR LATE ENTRANTS WITHOUT CONTINUOUS COVERAGE An eligible Subscriber or an eligible Subscriber and his or her Dependents who do not enroll for coverage offered through Employer during the Initial Enrollment Period, the Open Enrollment Period or any applicable Special Enrollment Period will be considered Late Entrants. (1) Late Entrants who have maintained Continuous Coverage may enroll and coverage will be effective the first day of the month following date of approval by Medica. Continuous Coverage wil be determined to have been maintained if the Late Entrant requests enrollment within 63 days after prior Qualifying Coverage ends. (2) Late Entrants who have not maintained Continuous Coverage may not enroll off-cycle. An eligible Subscriber or Dependent who: (1) does not enroll during the Initial Enrollment Period, the Open Enrollment Period or any applicable Special Enrollment period; and (2) is an enrollee of the Minnesota Comprehensive Health Association ("MCHA") at the time Medica offers or renews coverage with Employer, provided the eligible Subscriber or Dependent maintains Continuous Coverage, will not be considered a Late Entrant and will be allowed to enroll. Coverage will be effective as determined by Medica. Page 17 MCS7 BPL 56741 Minneapolis/St. Paul Metro Area: (952) 945-8000 or Outside the Metro Area: 1-800-952-3455 TTY Minneapolis/St. Paul Metro Area: (952) 992-3190 or TTY Outside the Metro Area: 1-800-841-6753 Table Of Contents Table Of Contents Table Of Contents ..................................................................................................................... i Introduction ............................................................................................................................ vii To be eligible for benefits .................................................................................................. vii Definitions ........................................................................................................................ viii Language interpretation ................................................................................................... viii Acceptance of coverage ................................................................................................... viii Nondiscrimination policy ................................................................................................... viii A. Member Rights And Responsibilities ................................................................................. 1 B. How To Access Your Benefits ............................................................................................ 3 Important member information about in-network benefits ................................................... 3 Important member information about out-of-network benefits ............................................. 5 Continuity of Care .............................................................................................................. 6 Prior authorization .............................................................................................................. 7 C. How Providers Are Paid By Medica And MIC ................................................................... 10 Network providers ............................................................................................................ 10 Withhold arrangements .................................................................................................... 11 Non-network providers ..................................................................................................... 11 D= Your Out-Of-Pocket Expenses ......................................................................................... 12 Copayments, coinsurance and deductibles ...................................................................... 12 Important information about how coinsurance payments are calculated when based on retail charges ................................................................................................................... 12 Out-of-pocket maximum ................................................................................................... 14 Lifetime maximum amount ............................................................................................... 15 Out-of-Pocket Expenses .................................................................................................. 16 E= Professional Services ....................................................................................................... 17 Covered ........................................................................................................................... 17 Not covered ...................................................................................................................... 18 Office visits ....................................................................................................................... 18 Convenient/urgent care center visits ................................................................................ 18 Prenatal care services ...................................................................................................... 18 Preventive health care ...................................................................................................... 18 Allergy shots .................................................................................................................... 19 Refractive eye exams ....................................................................................................... 19 Chiropractic Services ....................................................................................................... 19 Professional sign language .............................................................................................. 19 Surgical services .............................................................................................................. 19 Services received from a physician during an emergency room visit ................................ 19 Services received from a physician during an inpatient stay ............................................. 20 Services received from a physician during an inpatient stay for prenatal care and labor and delivery ............................................................................................................................. 20 Outpatient lab, pathology and x-rays ................................................................................ 20 Other outpatient hospital services .................................................................................... 20 MCS7 (1/02) BPL 56741 Table Of Contents F= Gm Communication or interpretation services for a ventilator-dependent member ................. 20 Treatment to lighten or remove the coloration of a port wine stain .................................... 20 Diabetes self-management training and education ........................................................... 20 Neuropsychological evaluations/cognitive testing ............................................................. 20 Jm Prescription Drugs And Pharmacy Services ................................................................... 21 Formulary products .......................................................................................................... 21 Prior authorization ............................................................................................................ 22 Covered ........................................................................................................................... 22 Prescription unit ............................................................................................................... 23 Not covered ...................................................................................................................... 24 Outpatient prescription drugs ........................................................................................... 25 Emergency prescription drugs .......................................................................................... 25 Infertility prescription drugs .............................................................................................. 26 Diabetic supplies and equipment ...................................................................................... 26 Growth hormone .............................................................................................................. 26 Eligible ostomy supplies ................................................................................................... 26 Smoking cessation products ............................................................................................ 26 Mail Service Prescription Drug Program ........................................................................ 27 Formulary products .......................................................................................................... 27 Prior authorization ............................................................................................................ 27 Covered ........................................................................................................................... 28 Prescription unit ............................................................................................................... 28 Not covered ...................................................................................................................... 29 Outpatient prescription drugs ........................................................................................... 30 Oral contraceptives .......................................................................................................... 30 Infertility prescription drugs .............................................................................................. 30 Diabetic supplies and equipment ...................................................................................... 30 Eligible ostomy supplies ................................................................................................... 30 Hospital Services .............................................................................................................. 31 Newborns' and Mothers' Health Protection Act of 1996 .................................................... 31 Covered ........................................................................................................................... 31 Not covered ...................................................................................................................... 32 Outpatient services .......................................................................................................... 32 Services provided in a hospital observation room ............................................................. 32 Inpatient services ............................................................................................................. 33 Services received from a physician during an inpatient stay ............................................. 33 Ambulance Services .......................................................................................................... 34 Covered ........................................................................................................................... 34 Not covered ...................................................................................................................... 34 Ambulance services or ambulance transportation ............................................................ 35 Non-emergency licensed ambulance service ................................................................... 35 Home Health Care ............................................................................................................. 36 Covered ........................................................................................................................... 36 Not covered ...................................................................................................................... 37 Intermittent skilled care .................................................................................................... 38 Skilled physical, speech or occupational therapy .............................................................. 38 MCS7 (1/02) ii BPL 56741 Table Of Contents Home IV therapy .............................................................................................................. 38 Services received in your home from a physician ............................................................. 38 K= Outpatient Rehabilitation ................................................................................................. 39 Covered ......................................... .................................................................................. 39 Not covered ...................................................................................................................... 39 Physical therapy received outside of your home ............................................................... 40 Speech therapy received outside your home .................................................................... 40 Occupational therapy received outside of your home ....................................................... 40 L= Mental Health ..................................................................................................................... 42 Covered ........................................................................................................................... 43 Not covered ...................................................................................................................... 44 Outpatient services .......................................................................................................... 45 Inpatient services ............................................................................................................. 45 Substance Abuse ............................................................................................................. 47 Covered ........................................................................................................................... 48 Not covered ...................................................................................................................... 50 Outpatient services .......................................................................................................... 51 Inpatient services ............................................................................................................. 51 Nw Durable Medical Equipment And Prosthetics ................................................................. 52 Covered ........................................................................................................................... 52 Not covered ...................................................................................................................... 53 Durable medical equipment and certain related supplies .................................................. 53 Repair, replacement or revision of durable medical supplies ............................................ 53 Prosthetics ....................................................................................................................... 53 O= Miscellaneous Medical Supplies ..................................................................................... 55 Covered ........................................................................................................................... 55 Not covered ...................................................................................................................... 55 Blood clotting factors ........................................................................................................ 56 Dietary medical treatment of PKU .................................................................................... 56 Levonorgestrel ................................................................................................................. 56 Total parenteral nutrition .................................................................................................. 56 Pm Organ And Bone Marrow Transplant Services ............................................................... 57 Covered ........................................................................................................................... 57 Not covered ...................................................................................................................... 58 Office visits ....................................................................................................................... 59 Outpatient services .......................................................................................................... 59 Inpatient services ............................................................................................................. 60 Services received from a physician during an inpatient stay ............................................. 60 Q. Infertility Services ............................................................................................................. 61 Covered ........................................................................................................................... 61 Not covered ...................................................................................................................... 61 Office visits ....................................................................................................................... 62 Outpatient services received at a hospital ........................................................................ 62 Inpatient services ............................................................................................................. 62 iii MCS7 (1/02) BPL 56741 Table Of Contents Reconstructive And Restorative Surgery ....................................................................... 63 Covered ........................................................................................................................... 63 Not covered ...................................................................................................................... 64 Office visits ....................................................................................................................... 64 Oupatient services ........................................................................................................... 65 Inpatient services ............................................................................................................. 65 Services received from a physician during an inpatient stay ............................................. 66 S. Skilled Nursing Facility Services ..................................................................................... 67 Covered ........................................................................................................................... 67 Not covered ...................................................................................................................... 67 Daily skilled care or daily skilled rehabilitation services .................................................... 68 Skilled physical, speech or occupational therapy .............................................................. 68 Services received from a physician during an inpatient stay in a skilled nursing facility .... 69 Tm Hospice Services .............................................................................................................. 70 Covered ........................................................................................................................... 70 Not covered ...................................................................................................................... 71 Hospice services .............................................................................................................. 72 U. Temporomandibular Joint (TMJ) Disorder ...................................................................... 73 Covered ........................................................................................................................... 73 Not covered ...................................................................................................................... 73 Initial office visit for evaluation .......................................................................................... 74 Office Visit ........................................................................................................................ 74 Outpatient services .......................................................................................................... 74 Physical therapy received outside of your home ..................... ; ......................................... 74 Inpatient services ............................................................................................................. 75 Services received from a physician or dentist during an inpatient stay ............................. 75 TMJ splints and adjustments ............................................................................................ 75 V= Medical-Related Dental Services ..................................................................................... 76 Covered ........................................................................................................................... 76 Not covered ...................................................................................................................... 77 Charges for medical facilities and general anethesia services .......................................... 78 Orthodontia related to cleft lip and palate ......................................................................... 78 Accident-related dental services ....................................................................................... 79 Oral surgery ..................................................................................................................... 79 W= Emergency Services From Non-Network Providers ...................................................... 80 Covered ........................................................................................................................... 80 Not covered ...................................................................................................................... 80 Emergency services ......................................................................................................... 81 Ambulance service or ambulance transportation .............................................................. 81 X= Referrals To Non-Network Providers ............................................................................... 82 What you must do ............................................................................................................ 82 What Medica will do ......................................................................................................... 83 Y. Harmful Use Of Medical Services .................................................................................... 84 When this section applies ................................................................................................. 84 MCS7 (1/02) iv BPL 56741 Table Of Contents Z. Exclusions ......................................................................................................................... 85 How To Submit A Claim ................................................................................................. 89 Claims for benefits from network providers ....................................................................... 89 Claims for benefits from non-network providers ................................................................ 89 Claims for services provided outside the United States .................................................... 90 Time limits ........................................................................................................................ 90 BB. Coordination Of Benefits ............................................................................................... 91 Applicability ...................................................................................................................... 91 Definitions that apply to this section ................................................................................. 91 Order of benefit determination rules ................................................................................. 93 Effect on the benefits of this plan ..................................................................................... 95 Right to receive and release needed information .............................................................. 96 Facility of payment ........................................................................................................... 97 Right of recovery .............................................................................................................. 97 CC. Right Of Recovery .......................................................................................................... 98 DD. Eligibility And Enrollment ............................................................................................ 100 Who can enroll ............................................................................................................... 100 Extending a child's eligibility ........................................................................................... 100 Qualified Medical Child Support Order (QMCSO) ........................................................... 101 How to enroll .................................................................................................................. 101 Notification ..................................................................................................................... 102 Initial enrollment ............................................................................................................. 102 Open enrollment ............................................................................................................. 102 Special enrollment .......................................................................................................... 103 Late enrollment .............................................................................................................. 104 The date your coverage begins ...................................................................................... 105 EE. Ending Coverage .......................................................................................................... 106 When coverage ends ..................................................................................................... 106 FF. Continuation .................................................................................................................. 109 Your right to continue coverage under state law ............................................................. 109 Your right to continue coverage under federal law .......................................................... 114 GG. Conversion ................................................................................................................... 120 Overview ........................................................................................................................ 120 What you must do .......................................................................................................... 121 What the employer must do ........................................................................................... 121 HH. Complaints ................................................................................................................... 122 First level of review ........................................................................................................ 122 Second level of review ................................................................................................... 124 External review ............................................................................................................... 125 Civil action ...................................................................................................................... 125 II. General Provisions .......................................................................................................... 126 V MCS7 (1/02) BPL 56741 Table Of Contents Definitions ............................................................................................................................ 128 MCS7 (1/02) -' vi BPL 56741 Introduction Introduction Medica Health Plans (Medica), together with its affiliate, Medica Insurance Company (MIC), offers Medica Choice Select. Medica provides coverage for your in-network benefits and MIC provides coverage for your out-of-network benefits. This Certificate of Coverage (this certificate) describes health services that are eligible for coverage and the procedures you must follow to obtain benefits. Because many provisions are interrelated, you should read this certificate in its entirety. Reviewing just one or two sections may not give you a complete understanding of the coverage described. The most specific and appropriate section will apply for those benefits related to the treatment of a specific condition. Members are subject to all terms and conditions of the Contract and health services must be medically necessary. Medica and MIC may arrange for various persons or entities to provide administrative services on their behalf, including claims processing and utilization management services. To ensure efficient administration of your benefits, you must cooperate with them in the performance of their responsibilities. The employer is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by applicable law. To be eligible for benefits Each time you receive health services, you must: 1. Confirm with Medica that your provider is a network provider with Medica Choice Select to be eligible for in-network benefits; 2. Identify yourself as a Medica Choice Select member; and 3. Present your Medica Choice Select identification card. (If you do not show your Medica Choice Select identification card, providers have no way of knowing that you are a Medica Choice Select member and you may receive a bill for health services or be required to pay at the time you receive health services.) However, possession and vii MCS7 (1/02) BPL 56741 Introduction use of a Medica Choice Select identification card does not necessarily guarantee coverage. Definitions Many words in this certificate have specific meanings. These words are identified in each section and defined in Definitions (at the end of this certificate). Language interpretation Language interpretation services will be provided upon request, as needed in connection with the interpretation of this certificate. If you would like to request language interpretation services, please call Customer Service at one of the telephone numbers listed inside the front cover. If this certificate is translated into another language or an alternative communication format is used, this written English version governs all coverage decisions. Acceptance of coverage This certificate is not a legal contract between you and Medica. It is simply an explanation of the benefits covered under the Contract between Medica and the employer. By accepting the health care coverage described in this certificate, you, on behalf of yourself and any dependents enrolled under the Contract, authorize the following: 1. The use of a social security number for purpose of identification; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and complete. You understand and agree that any omissions or incorrect statements knowingly made by you in connection with your enrollment under the Contract may invalidate your coverage. Nondiscrimination policy Medica and MIC's policy is to treat all persons alike, without distinctions based on race, color, creed, religion, national origin, gender, marital status, status MCS7 (1/02) viii BPL 56741 Introduction with regard to public assistance, disability, sexual orientation, age or any other classification protected by law. If you have questions, call Customer Service at one of the telephone numbers listed inside the front cover. ix MCS7 (1/02) BPL 56741 Member Rights And Responsibilities A. Member Rights And Responsibilities Member bill of rights As a member of Medica Choice Select, you have the right to: 1. Available and accessible services, including emergency services (defined in this certificate) 24 hours a day, seven days a week; 2. Information about your health condition, appropriate or medically necessary treatment options and risks, regardless of cost or benefit coverage, so you can make an informed choice about your health care; 3. Participate with providers in decision-making regarding your health care, including the right to refuse treatment recommended to you by Medica or any provider; 4. Be treated with respect and recognition of your dignity, and privacy of your medical and financial records maintained by Medica or any network provider in accordance with existing law; 5. Contact Medica and Minnesota's Commissioner of Health to file a complaint about issues related to in- network benefits, or Minnesota's Commissioner of Commerce to file a complaint about issues related to out-of-network benefits (see Complaints). You may begin a legal proceeding if you have a problem with Medica or any provider; 6. Receive information about Medica, its services, its practitioners and providers, and members' rights and responsibilities. Member responsibilities To increase the likelihood of maintaining good health and to ensure that the best quality care is received, it is important that you take an active role in your health care by: 1. Establishing a relationship with a network provider before becoming ill, as this allows for continuity of care; 2. Providing the necessary information to health care professionals needed to determine the appropriate care. This objective is best obtained when you share: MCS7 (1/02) BPL 56741 Member Rights And Responsibilities a. Information about lifestyle practices; and b. Personal and family health history; 3. Following the instructions given by those providing health care; 4. Practicing self-cars by knowing: a. How to recognize common health problems and what to do when they occur; b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; 5. Practicing preventive health cars by: a. Having the appropriate tests, exams and immunizations recommended for your gender and age as described in this certificate; and b. Engaging in healthy lifestyle choices (such as exercise, proper diet and rest). MOS7 (1/02) 2 BPL 56741 How To Access Your Benefits B. How To Access Your Benefits 1. Important member information about in-network benefits The information below describes your covered health services and the procedures you must follow to obtain in-network benefits. Benefits Medica will cover health services and supplies as in-network benefits only if they are provided by network providers or are authorized by Medica. Prior authorization may be required from Medica for certain in-network benefits. This certificate fully defines your benefits and describes procedures you must follow to obtain in-network benefits. Decisions about coverage are based on appropriateness of care and service to the member. Medica does not reward providers for denying care, nor does Medica encourage inappropriate utilization of services. Referrals Certain health services are covered only upon referral; read this certificate carefully for referral requirements. All referrals to non-network providers and certain types of network providers must be prior authorized by Medica to be eligible for coverage at your highest level of benefits. Emergency services Emergency services from non-network providers will be covered as in-network benefits only if you follow required procedures. This certificate explains these procedures and the covered health services associated with emergency care. Providers Enrolling in Medica Choice Select does not guarantee that a particular provider (in the Medica network provider directory) will remain a network provider or provide you with health services. When a provider no longer participates with Medica, you must choose to receive health services from 3 MCS7 (1/02) BPL 56741 How To Access Your Benefits network providers to continue to be eligible for in- network benefits. Exclusions Certain health services are not covered. Read this certificate for a detailed explanation of all exclusions. Mental health and substance abuse Medica's designated mental health and substance abuse provider will arrange your mental health and substance abuse benefits. Medica's designated mental health and substance abuse provider uses a limited network of hospitals for the provision of mental health and substance abuse benefits. Continuation/conversion You may continue coverage or convert to an individual conversion plan under certain circumstances. See Continuation and Conversion for additional information. Cancellation Your coverage may be canceled only under certain conditions. This certificate describes all reasons for cancellation of coverage. See Ending Coverage for additional information. Newborn coverage Your dependent newborn is covered from birth, but only if health services are provided by a network provider or authorized by Medica. Certain services are covered only upon referral. If additional premium is required, Medica is entitled to all premiums due from the time of the infant's birth until the time you notify Medica of the birth. Medica may withhold payment for any health benefits for the newborn infant until any premium you owe is paid. For more information, see Eligibility And Enrollment. Prescription drugs and medical equipment Enrolling in Medica does not guarantee that a particular prescription drug or piece of medical equipment will continue to be covered, even if the drug or equipment is covered at the start of the calendar year. MCS7 (1/02) 4 BPL 56741 How To Access Your Benefits = Important member information about out-of network benefits The information below describes your covered health services and the procedures you must follow to obtain out-of-network benefits. Benefits MIC pays out-of-network benefits for eligible health services received from non-network providers. Prior authorization may be required from MIC for certain out-of-network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out-of-network benefits. In addition to the benefits described in this certificate, MIC may authorize more efficient methods of providing services. Emergency services received from (and prior authorized referrals to) non-network providers are covered as in-network benefits and are not considered out-of-network benefits (provided you follow proper procedures). Some benefits are provided only as in-network benefits. Read this certificate for a detailed explanation of in-network and out-of-network benefits. Be aware that if you choose to use out-of-network benefits, you may have to pay more than if you use in-network benefits. The charges billed by your non-network provider may exceed the non-network provider reimbursement amount, leaving a balance for you to pay in addition to any applicable copayment, coinsurance and deductible amount. The difference will not be applied to the out-of- pocket maximum amount described in Your Out-Of- Pocket Expenses. Decisions about coverage are made based on appropriateness of care and service to the member. Medica does not reward providers for denying care, nor does Medica encourage inappropriate utilization of services. Lifetime maximum amount Out-of-network benefits are subject to a lifetime maximum amount payable by MIC. See Your Out- Of-Pocket Expenses for a detailed explanation of the lifetime maximum amount. · - 5 MCS7 (1/02) BPL 56741 How To Access Your Benefits Exclusions Some health services, such as preventive care (described in Professional Services), are not covered when received from or under the direction of non-network providers. Read this certificate for a detailed explanation of exclusions. Claims When you use non-network providers, you will be responsible for filing claims in order to be reimbursed for the non-network provider reimbursement amount. See How To Submit A Claim for details. 3. Continuity of Care In certain situations, you have a right to continuity of care. If Medica terminates its contract with your current primary care provider, specialist or hospital without cause, you may be eligible to continue care with that provider at the in- network benefit level. If you are a new Medica member as a result of your employer changing health plans and your current primary care provider, specialist or hospital is not a network provider, you may be eligible to continue care with that provider at the in-network benefit level. This applies only if your provider agrees to comply with Medica's prior authorization requirements, provide Medica with all necessary medical information related to your care, and accept as payment in full the lesser of Medica's network provider reimbursement or the provider's customary charge for the service. This does not apply when Medica terminates a provider's contract for cause. Upon request, Medica will authorize continuity of care for up to 120 days as described in a. and b. above for the following conditions: an acute condition; a life-threatening mental or physical illness; pregnancy beyond the first trimester of pregnancy; MCS7 (1/02) 6 BPL 56741 How To Access Your Benefits m . a physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year, or can be expected to result in death; or a disabling or chronic condition that is in an acute phase. Authorization to continue to receive services from your current primary care provider, specialist or hospital may extend to the remainder of your life if a physician certifies that your life expectancy is 180 days or less. Upon request, Medica will authorize continuity of care for up to 120 days as described in a. and b. above in the following situations: · if you are receiving culturally appropriate services and Medica does not have a network provider who has special expertise in the delivery of those culturally appropriate services within the time and distance requirements defined in Minnesota law; or · if you do not speak English and Medica does not have a network provider who can communicate with you, either directly or through an interpreter, within the time and distance requirements defined in Minnesota law. Medica may require medical records or other supporting documentation from your provider to review your request, and will consider each request on a case-by-case basis. If Medica authorizes your request to continue care with your current provider, Medica will explain how continuity of care will be provided. After that time, your services or treatment will need to be transitioned to a network provider to continue to be eligible for in-network benefits. If your request is denied, Medica will explain the criteria used to make its decision. Prior authorization Prior authorization from Medica may be required before you receive certain services or supplies in order to determine whether a particular service or supply is medically necessary and a benefit. Medica uses written procedures and criteria when reviewing your request for prior authorization. MCS7 (1/02) BPL 56741 How To Access Your Benefits To request prior authorization for a service or supply, either you, someone on your behalf or your attending provider must call Medica. Some of the services that may require prior authorization from Medica include: Reconstructive or restorative surgery; Temporomandibular joint disorder or craniomandibular disorder; Organ and bone marrow transplant; Home health care; Medical supplies and durable medical equipment; Outpatient surgical procedures; Skilled nursing facility services; and In-network benefits for services from non- network providers. When you, someone on your behalf or your attending provider calls, the following information may be required: Name and telephone number of the provider who is making the request; Name, telephone number, address and type of specialty of the provider to whom you are being referred, if applicable; Services being requested and the date those services are to be rendered (if scheduled); · Specific information related to your condition (for example, a letter of medical necessity from your provider); · Other applicable member information (i.e., Medica member number). MCS7 (1/02) '~ 8 BPL 56741 How To Access Your Benefits Medica will review your request and provide a response to you and your attending provider within 10 business days from the date your request was received, provided all information reasonably necessary to make a decision has been made available to Medica. Medica will inform both you and your provider of Medica's decision within 72 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function. If Medica does not approve your request for prior authorization, you have the right to appeal Medica's decision as described in Complaints. If Medica fails to respond within the required timeframe, benefits will be covered as otherwise described in this certificate. MCS7 (1/02) BPL 56741 How Providers Are Paid By Medica And MIC C. How Providers Are Paid By Medica And MIC This section describes how Medica and MIC generally pay providers for health services. Network providers Network providers are paid using various types of contractual arrangements, which are intended to promote the delivery of health care in a cost efficient and effective manner. These arrangements are not intended to affect your access to health care. These payment methods may include: 1. A fee-for-service method, such as per service or percentage of charges; or A risk-sharing arrangement, such as an amount per day, per stay, per episode, per case, per period of illness, per member or per service with targeted outcome. The methods by which specific network providers are paid may change from time to time. Methods also vary by network provider. The primary method of payment under Medica Choice Select is fee-for-service. Fee-for-service payment means that Medica pays the network provider a fee for each service provided. If the payment is per service, the network provider's payment is determined according to a set fee schedule. The amount the network provider receives is the lesser of the fee schedule or what the network provider would have otherwise billed. If the payment is percentage of charges, the network provider's payment is a set percentage of the provider's charge. The amount paid to the network provider, less any applicable copayment, coinsurance or deductible, is considered to be payment in full. MCS7 (1/02) 10 BPL 56741 How Providers Are Paid By Medica And MIC Risk-sharing payment means that Medica pays the network provider a specific amount for a particular unit of service, such as an amount per day, an amount per stay, an amount per episode, an amount per case, an amount per period of illness, an amount per member, or an amount per service with targeted outcome. If the amount paid is less than the cost of providing or arranging for a member's health services, the network provider may bear some of the shortfall. If the amount paid to the network provider is more than the cost of providing or arranging a member's health services, the network provider may keep some of the excess. Withhold arrangements For some network providers paid on a fee-for-service basis, including most network physicians and clinics, Medica holds back some of the payment. This is sometimes referred to as a physician contingency reserve or holdback. The withhold amount generally will not exceed 15 percent of the fee schedule amount. In general, Medica does not hold back a portion of network hospitals' fee for service payments. However, when it does, the withhold amount will not usually exceed 5 percent of the fee schedule amount. Network providers may earn the withhold amount based on Medica's financial performance as determined by Medica's Board of Directors and/or certain performance standards identified in the network provider's contract including, but not limited to, quality and utilization. Based on individual measures, the percentage of the withhold amount paid, if any, can vary among network providers. Non-network providers When a service from a non-network provider is covered, the non-network provider is paid a fee for each covered service that is provided. This payment may be less than the charges billed by the non-network provider. If this happens, you are responsible for paying the difference. 11 MCS7 (1/02) BPL 56741 Your Out-Of-Pocket Expenses D. Your Out-Of-Pocket Expenses This section describes the expenses that are your responsibility to pay. commonly called out-of-pocket expenses. You are responsible for paying the cost of a service that is not medically necessary or a benefit even if the following occurs: 1. A provider performs, prescribes or recommends the service; or 2. The service is the only treatment available; or 3. You request and receive the service even though your provider does not recommend it. (Your network provider is required to inform you or in some instances provide a waiver for you to sign.) To verify coverage before receiving a particular service or supply, call Customer Service at one of the telephone numbers listed inside the front cover. · Most in-network benefits are covered at 80 percent. Most out-of-network benefits are covered at 80 percent of the non-network provider reimbursement amount after you pay a deductible amount for yourself or your family. These expenses are Copayments, coinsurance and deductibles For in-network benefits, you must pay the following: 1. Any applicable copayment or coinsurance as described in this certificate. 2. Any charge that is not covered under the Contract. IMPORTANT INFORMATION ABOUT HOW COINSURANCE PA YMENTS ARE CALCULA TED WHEN BASED ON RETAIL CHARGES Following is an explanation of how Medica's payments to network providers are determined when the member coinsurance is based on the provider's retail charge, MCS7 (1/02) 12 BPL 56741 Your Out-Of-Pocket Expenses but Medica has negotiated a discount with the network provider. Because Minnesota statutes authorize Medica to negotiate discounts with medical providers, the amount Medica actually pays a provider may be a discounted amount (i.e., "wholesale"). When a member is asked to pay coinsurance based on the provider's retail charge in these instances, the amount that Medica pays the provider is as described under either 1. or 2. below. The amount that Medica pays the provider is the difference between the wholesale amount that the provider has agreed to accept and what the member pays as coinsurance (based on the "retail" charge). For example, if a network provider charges $100 for a particular benefit (i.e., retail), and the member is responsible to pay a 20 pement coinsurance based on the provider's retail charge, the member must pay $20 (20 percent of the retail charge). Medica, however, may have negotiated a discount with the provider; for example, a wholesale charge of $60. Less the $20 member coinsurance, Medica would pay the network provider $40, instead of paying 80 percent of the retail charge ($80). The amount that Medica pays the provider is a "per episode" amount agreed upon by Medica and the provider. This amount might not change based on what the member pays as coinsurance. You may obtain a written Explanation of Benefits (EOB) regarding any claim by calling Customer Service at one of the telephone numbers listed inside the front cover to request one. For out-of-network benefits, you must pay the following: 1. Any applicable coPayment, coinsurance or deductible as described in this certificate. However, a family deductible also applies. When members in a family unit (a subscriber and his or her dependents) have together paid the family deductible for benefits received during any calendar year (as described in the Out-of-Pocket Expenses table in this section), then all members of the family 13 MCS7 (1/02) BPL 56741 Your Out-Of-Pocket Expenses unit are considered to have satisfied their deductible for that calendar year. Any charge that exceeds the non-network provider reimbursement amount. This means you are required to pay the difference between what MIC pays to the provider (which is less any copayment, coinsurance or deductible) and what the provider bills you. To inquire about the non-network provider reimbursement amount for a particular procedure, call Customer Service at one of the telephone numbers listed inside the front cover. When you call, you will need to provide the following: The CPT (Current Procedural Terminology) code for the procedure (ask your non-network provider for this); and The name and location of the non-network provider. Customer Service will provide you with an estimate of the non-network provider reimbursement amount based on the information provided at the time of your inquiry. The actual amount paid will be based on the information received at the time the claim is submitted and subject to all applicable benefit provisions, exclusions and limitations, including but not limited to copayments, coinsurance and deductible. 3. Any charge that is not covered under the Contract. Out-of-pocket maximum The out-of-pocket maximum is an accumulation of copayments, coinsurance and deductible only. Unless otherwise specified, you will not be required to pay more than the out-of-pocket maximum of copayments, coinsurance and/or deductible, as described in the Out- of-Pocket Expenses table in this section, for benefits received during any calendar year. MCS7 (1/02) 14 BPL 56741 Your Out-Of-Pocket Expenses After you satisfy the out-of-pocket maximum, all other eligible services received during the rest of the calendar year will be covered at 100 pement, except for any charge not covered by Medica or charge in excess of the non-network provider reimbursement amount. In addition, a family out-of-pocket maximum also applies to your in-network benefits. When any members in a family unit (the subscriber and his or her dependents) have together satisfied the family in- network benefits, out-of-pocket maximum of copayments and/or coinsurance (see the Out-of-Pocket Expenses table in this section) for in-network benefits received during any calendar year, then all members of the family unit are considered to have satisfied the in- network benefits family out-of-pocket maximum for that calendar year. Lifetime maximum amount The lifetime maximum amount payable per member for out-of-network benefits under the Contract and for out- of-network benefits under any other Medica contract offered through the same employer is described in the Out-of-Pocket Expenses table in this section. You should monitor the amount paid for out-of-network benefits and contact Medica when you are close to reaching your lifetime maximum amount. 15 MCS7 (1/02) BPL 56741 Your Out-Of-Pocket Expenses Out-of-Pocket Expenses Copayment or coinsurance Deductible Per member Per family Out-of-pocket maximum For copayments, coinsurance and deductible Per member Per family Lifetime maximum amount payable per member See specific benefit for applicable copayment or coinsurance. A deductible does not apply to in-network benefits. $30O $900 $1,200 $2,400 Unlimited $3,000 Out-of-pocket maximum does not apply. Refer to the per member out-of- pocket maximum above. $1,000,000 Applies to all benefits you receive under this or any future Medica contract that has a lifetime maximum benefit MCS7 (1/02) BPL 56741 16 Professional Services E. Professional Services This section describes coverage for professional services received from or directed by a physician. Covered For benefits and the amounts you pay, see the table in this section. In-network benefits apply to: 1. Professional services received from a network provider; Professional services for testing and treatment of a sexually transmitted disease and testing for AIDS and other HIV-related conditions received from a network provider or a non-network provider; 3. Family planning services, for the voluntary planning of the conception and bearing of children, received from a network provider or a non-network provider. Out-of-network benefits apply to professional services received from a non-network provider. In addition to the deductible and copayment or coinsurance, you will be responsible for any charges in excess of the non-network provider reimbursement amount. The most specific and appropriate section of this certificate will apply for professional services related to the treatment of a specific condition. For example, benefits for infertility services are described in Infertility Services. -' 17 MCS7 (1/02) BPL 56741 Professional Services Not covered Mental health or substance abuse services, except as described in Mental Health and Substance Abuse. 1. Office visits $15/visit 2. Convenient/urgent care center $15/visit visits 3. Prenatal care services received Nothing from a physician during an office visit or an outpatient hospital visit Preventive health care (Please note: This only applies when there is no existing condition or no complaint about your health, regardless of the reasons that you scheduled your office visit.) Health education and health supervision services provided during an office visit (including evaluation and follow-up) Child health supervision services, including well-baby care c. Immunizations Nothing Nothing Nothing 20% coinsurance For emergency services from non-network providers, refer to Emergency Services From Non-Network Providers. 20% coinsurance for non- emergency services received from non- network providers. 20% coinsurance No coverage 20% coinsurance 20% coinsurance MCS7 (1/02) BPL 56741 18 Professional Services d. Early disease detection services including physicals e. Routine screening procedures for cancer Allergy shots Refractive eye exams Chiropractic services to diagnose and to treat, by manual manipulation or certain therapies, neuromusculoskeletal conditions related to the spine or joint Professional sign language interpreter services in a physician's office (Call Customer Service to arrange such services.) Surgical services (as defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit 10. Services received from a physician during an emergency room visit Nothing Nothing Nothing Nothing $15/visit Nothing $15/visit Nothing No coverage 20% coinsurance 20% coinsurance No coverage 20% coinsurance. Coverage is limited to 15 visits per calendar year. This visit limitation applies whether or not your deductible has been met. No coverage 20% coinsurance For emergency services from non-network providers, see Emergency Services From Non-Network Providers. 20% coinsurance for non- emergency services provided in a non- network hospital emergency room. 19 MCS7 (1/02) BPL 56741 Professional Services 11. Services received from a physician during an inpatient stay 12. Services received from a physician during an inpatient stay for prenatal care and labor and delivery 13. Outpatient lab, pathology and x-rays 14. Other outpatient hospital or ambulatory surgical center services received from a physician 15. Up to 120 hours of communication or interpretation services for a ventilator- dependent member (Services must be received from a professional personal care assistant or private duty nurse during an inpatient stay.) 16. Treatment to lighten or remove the coloration of a port wine stain 17. Diabetes self-management training and education, including medical nutrition therapy, received from a provider in a program consistent with national educational standards (as established by the American Diabetes Association) 18. Neuropsychological evaluations/cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury Nothing Nothing Nothing Nothing Nothing $15/visit $15/visit $15/visit 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance MCS7 (1/02) BPL 56741 2O Prescription Drugs And Pharmacy Services F. Prescription Drugs And Pharmacy Services This section describes coverage for prescription drugs and supplies received from a pharmacy. For purposes of this section, the word supplies means eligible diabetic equipment and supplies, ostomy supplies and smoking cessation products. Formulary products The Medica drug formulary (formulary) identifies prescription drugs and supplies that are preferred by Medica for dispensing to members. Where appropriate, the formulary includes generic equivalents of brand name prescription drugs and supplies. The formulary and appropriate use guidelines are periodically reviewed and modified by Medica. This may mean that a brand name formulary prescription drug or supply may become non-formulary when an appropriate generic equivalent becomes available. Your pharmacist will dispense the generic equivalent of prescription drugs or supplies according to the formulary. Network providers, network pharmacies and members have access to Medica's drug formulary. Medica's appropriate use guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturer's packaging guidelines and clinical publications. Only prescription drugs and supplies on Medica's formulary are eligible for in-network benefits under this certificate. 21 MCS7 (1/02) BPL 56741 Prescription Drugs And Pharmacy Services Your physician may request that Medica make an exception to allow the formulary copayment or coinsurance for a non-formulary prescription drug. Medica will work with your physician to determine if an exception is appropriate for your medical condition. Exceptions to the formulary can include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the formulary or you change health plans. Prior authorization Certain prescription drugs and supplies require prior authorization. The provider who prescribes the prescription drug or supply initiates prior authorization. Network providers, including network pharmacies, are given a list of formulary prescription drugs and supplies that require prior authorization. If prior authorization is not obtained, you are required to pay the cost of the products and submit a paper claim with supporting documentation. Covered For benefits and the amounts you pay, see the table in this section. · In-network benefits apply to: A prescription drug prescribed by a network provider authorized to prescribe the prescription drug and received at a network pharmacy; and Prescription drugs for family planning services or the treatment of sexually transmitted diseases when prescribed by or received from either a network or a non-network provider; and Diabetic equipment and supplies and eligible ostomy supplies (described in this section) when received from a network pharmacy or a network durable medical equipment provider (You must provide the name of your network provider to the network pharmacist or durable medical equipment provider.); and 4. Prescription drugs prescribed by non-network providers when: MCS7 (1/02) 22 BPL 56741 Prescription Drugs And Pharmacy Services a network provider refers you to a non- network provider because services are not available from network providers, and prior authorization is obtained from Medica as described in Referrals To Non-Network Providers, and prescription drugs are prescribed by the non- network provider authorized to prescribe the prescription drugs and received at a network pharmacy; and Smoking cessation products (described in this section) when prescribed by a network provider authorized to prescribe the product and received at a network pharmacy. You must provide the name of your network provider to the network pharmacist. Out-of-network benefits apply to: A prescription drug prescribed by a non-network provider authorized to prescribe the prescription drug or received at a non-network pharmacy; and Diabetic equipment and supplies and eligible ostomy supplies (described in this section) when received from a non-network pharmacy or a non- network durable medical equipment provider; and 3. There is no coverage under out-of-network benefits for smoking cessation products. In addition to the deductible and copayment or coinsurance described for out-of-network benefits, you are responsible for any charges in excess of the non-network provider reimbursement amount. Prescription unit Prescription drugs and supplies will not be dispensed in excess of one prescription unit. However, when you have used 80 pement of your prescription, you may refill your prescription before your refill date (which is generally seven days before your refill date). 23 MCS7 (1/02) BPL 56741 Prescription Drugs And Pharmacy Services 1. For prescription drugs, one prescription unit is equal to: Up to a 31-consecutive-day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines); b. Up to a 31-day supply per type of insulin; or c. A one-cycle supply of oral contraceptives. For diabetic supplies, one prescription unit is equal to the greater of: Up to a 31-consecutive-day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines); or b. 100 units. For eligible ostomy supplies, one prescription unit is equal to up to a 31-consecutive-day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines). For smoking cessation products, coverage is limited to nicotine patches, nicotine gum and Zyban. One prescription unit is equal to up to a 30- consecutive-day supply of nicotine patches or nicotine gum orZyban (unless limited by the drug manufacturer's packaging) as determined by the manufacturer's dosing instructions for appropriate use. Not covered These prescription drugs and supplies are not covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the pharmacy as a member. (Medica will notify you before enforcement of this provision.) Medications available over-the-counter (OTC) that by federal or state law do not require a prescription order or refill and any medication that is equivalent MCS7 (1/02) 24 BPL 56741 Prescription Drugs And Pharmacy Services to an OTC medication (except as described in this section). 3. Replacement of a prescription drug or supply due to loss, damage or theft. 4. Appetite suppressants. 5. Smoking cessation products or services (except as described in this section). 6. Prescription drugs and supplies that are not prescribed by a provider acting within their scope of licensure. 7. Homeopathic medicine. 8. For in-network benefits, prescription drugs and supplies not on Medica's formulary. Outpatient prescription drugs other than those described below Up to a 24-hour supply of emergency prescription drugs received from a hospital or convenient/urgent care center 20% coinsurance with a minimum copayment of $10 and a maximum copayment of $25 per prescription unit or refill Nothing $25 or 40% coinsurance (whichever is greater) per prescription unit or refill See Emergency Services From Non-Network Providers. 25 MCS7 (1/02) BPL 56741 Prescription Drugs And Pharmacy Services 3. Infertility prescription drugs 4. Diabetic supplies and equipment Growth hormone when appropriately prescribed by a physician, for the treatment of a demonstrated growth hormone deficiency 6. Eligible ostomy supplies Smoking cessation products limited to nicotine replacement therapy (nicotine patch and nicotine gum only) and Zyban. Coverage is limited to an annual maximum benefit of up to six prescription units for Zyban, two prescription units for nicotine patches, and up to three prescription units for nicotine gum. This annual limit is calculated each calendar year. 20% coinsurance per prescription unit or refill 20% coinsurance per prescription unit or refill 20% coinsurance per prescription unit or refill Due to limited distribution by the manufacturer, growth hormone is not available through all network pharmacies. 20% coinsurance per prescription unit or refill 20% coinsurance. Coverage is limited to an annual maximum benefit of up to six prescription units for Zyban, two prescription units for nicotine patches, and up to three prescription units for nicotine gum. This annual limit is calculated each calendar year. $25 or 40% coinsurance (whichever is greater) per prescription unit or refill 40% coinsurance per prescription unit or refill 40% coinsurance per prescription unit or refill 40% coinsurance per prescription unit or refill No coverage MCS7 (1/02) BPL 56741 26 Mail Service Prescription Drug Program Mail Service Prescription Drug Program This section describes coverage for proscription drugs and supplies received from the designated mail service proscription drug program when prescribed as described in this section. For purposes of this section, the word supplies means certain eligible diabetic equipment and supplies and ostomy supplies. Formulary products The Medica drug formulary (formulary) identifies prescription drugs and supplies that are preferred by Medica for dispensing to members. Whero appropriate, the formulary includes generic equivalents of brand name prescription drugs and supplies. The formulary and appropriate use guidelines are periodically reviewed and modified by Medica. This may mean that a brand name formulary prescription drug or supply may become non-formulary when an appropriate generic equivalent becomes available. The designated mail service prescription drug program will dispense the generic equivalent of prescription drugs or supplies according to the formulary. The designated mail service prescription drug program and members have access to Medica's drug formulary. Medica's appropriate use guidelines are based on FDA approval, manufacturor's packaging guidelines and clinical publications. Only prescription drugs and supplies on Medica's formulary are eligible for in-network benefits under this certificate. Prior authorization Certain prescription drugs and supplies roquiro prior authorization. The provider who proscribes the proscription drug or supply initiates prior authorization. Network providers and the designated mail service prescription drug program aro given a list of formulary prescription drugs and supplies that requiro prior authorization. 27 MCS7 (1/02) BPL 56741 Mail Service Prescription Drug Program If prior authorization is not obtained, you are required to pay the cost of the products and submit a paper claim with supporting documentation. Covered Benefits apply to the following when received from the designated mail service prescription drug program: A prescription drug prescribed by a network provider authorized to prescribe the prescription drug; and Prescription drugs for family planning services or the treatment of sexually transmitted diseases when prescribed by either a network or a non- network provider; and Diabetic equipment and supplies, and eligible ostomy supplies (described in this section). (You must provide the name of your network provider to the designated mail service prescription drug program.) Prescription unit Prescription drugs and supplies will not be dispensed in excess of one prescription unit. However, when you have used 80 percent of your prescription, you may refill your prescription before your refill date (which is generally 21 days before your refill date). 1. For prescription drugs, one prescription unit is equal to: Up to a 93-consecutive-day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines); b. Up to a 93-day supply per type of insulin; or c. A one-cycle supply of oral contraceptives. 2. For diabetic equipment and supplies, one prescription unit is equal to the greater of: MCS7 (1/02) 28 BPL 56741 Mail Service Prescription Drug Program Up to a 93-consecutive-day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines); or b. 100 units. For eligible ostomy supplies, one prescription unit is equal to up to a 93-consecutive-day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines). Not covered These prescription drugs and supplies are not covered: Any amount above what Medica would have paid when you fail to identify yourself to the designated mail service prescription drug program as a member. (Medica will notify you before enforcement of this provision.) Medications available over the counter (OTC) that by federal or state law do not require a prescription order or refill and any medication that is equivalent to an OTC medication (except as described in Prescription Drugs And Pharmacy Services). 3. Replacement of a prescription drug or supply due to loss, damage or theft. 4. Appetite suppressants. Smoking cessation products or services (except as described in Prescription Drugs And Pharmacy Services). Prescription drugs and supplies that are not prescribed by a provider acting within their scope of licensure. 7. Homeopathic medicine. 8. For in-network benefits, prescription drugs and supplies not on Medica's formulary. 29 MCS7 (1/02) BPL 56741 Mail Service Prescription Drug Program Outpatient prescription drugs other than those described below 2. Oral contraceptives 3. Infertility prescription drugs 4. Diabetic supplies and equipment 5. Eligible ostomy supplies 20% coinsurance with a minimum copayment of $20 and a maximum copayment of $50 per prescription unit or refill 20% coinsurance with a minimum copayment of $20 and a maximum copayment of $50 per prescription unit or refill 20% coinsurance per prescription unit or refill 20% coinsurance per prescription unit or refill 20% coinsurance per prescription unit or refill MCS7 (1/02) BPL 56741 30 Hospital Services H. Hospital Services This section describes coverage for use of hospital and ambulatory surgical center services. physician must direct care. Newborns' and Mothers' Health Protection Act of 1996 Generally, Medica may not restrict benefits for any hospital stay in connection with childbirth for the mother or newborn child member to less than 48 hours following a vaginal delivery (or less than 96 hours following a cesarean section). However, federal law generally does not prohibit the mother or newborn child member's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any case, Medica may not require a provider to obtain prior authorization from Medica for a length of stay of 48 hours or less (or 96 hours, as applicable). Covered For benefits and the amounts you pay, see the table in this section. In-network benefits apply to hospital services received from a network hospital or ambulatory surgical center. Out-of-network benefits apply to hospital services received from a non-network hospital or ambulatory surgical center. In addition to the deductible and copayment or coinsurance described for out-of- network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. A 31 MCS7 (1/02) BPL 56741 Hospital Services Not covered Admission to another hospital is not covered when care for your condition is available at the network hospital where you were first admitted. = Outpatient services a. Services provided in a hospital emergency room b. Outpatient lab, pathology and x-rays c. Maternity labor and delivery services d. Prenatal care services e. Other outpatient services Other outpatient hospital and ambulatory surgical center services received from a physician Services provided in a hospital observation room $60/visit. However, if you are admitted for an inpatient stay to the same hospital within 24 hours for the same condition treated in the emergency room, this copayment will not apply. Nothing $15/visit Nothing $15/visit Nothing $15/visit. However, if you are admitted for an inpatient stay to the same hospital within 24 hours for the same condition treated in the observation room, this copayment will not apply. For emergency services from non-network providers, see Emergency Services From Non-Network Providers. 20% coinsurance for non-emergency services provided in a non- network hospital emergency room. 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance MCS7 (1/02) BPL 56741 · ' 32 Hospital Services Inpatient services, including inpatient maternity labor and delivery services: Semi-private room and board in a hospital A private room is covered only for conditions of preeclampsia, radium implants, contagion or immunosuppression that require isolation. Services received from a physician during an inpatient stay Nothing Nothing 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of- network benefits described in this certificate. This day limitation applies whether or not the deductible has been met. 20% coinsurance 33 MCS7 (1/02) BPL 56741 Ambulance Services I. Ambulance Services This section desCribes coverage for ambulance transportation and related services received for covered medical and medical-related dental services (as described in this certificate). Covered For benefits and the amounts you pay, see the table in this section. For non-emergency licensed ambulance services described in number 2. in the table in this section: In-network benefits apply to ambulance services arranged through a physician and received from a network provider. Out-of-network benefits apply to ambulance services arranged through a physician and received from a non-network provider (except as described in number 1. in the table in this section). In addition to the deductible and copayment or coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. Not covered These services, supplies and associated expenses are not covered: Ambulance transportation to another hospital when care for your condition is available at the network hospital where you were first admitted. 2. Non-emergency ambulance transportation services (except as described in this section). MC$7 (1/02) 34 BPL 56741 Ambulance Services Ambulance services or ambulance transportation to the nearest hospital for an emergency Non-emergency licensed ambulance service that is arranged through an attending physician, as follows: a. Transportation from hospital to hospital when: Care for your condition is not available at the hospital where you were first admitted; or ii. Required by Medica b. Transportation from hospital to skilled nursing facility 20% coinsurance 20% coinsurance 20% coinsurance See Emergency Services From Non-Network Providers. 20% coinsurance 20% coinsurance 35 MCS7 (1/02) BPL 56741 Home Health Care J. Home Health Care This section describes coverage for home health care. Home health care must be directed by a physician and received from a home health care agency authorized by the laws of the state in which treatment is received. Such services will be eligible for coverage if they are provided through Medica's managed care procedures. Covered For benefits and the amounts you pay, see the table in this section. As described under numbers 1. and 2. in the table in this section, Medica considers you homebound when it is medically contraindicated for you to leave your home (i.e., when leaving your home would directly and negatively affect your physical health). A dependent child may still be considered "confined to home" when attending school where life support specialized equipment and help are available. Benefits covered under numbers 1. and 2. in the table in this section are limited to a combined maximum of 56 hours of care per week. In-network benefits apply to home health care services ordered or prescribed by a physician and received from a network home health care agency. Out-of-network benefits apply to home health care services that are ordered or prescribed by a physician and received from a non-network home health care agency. In addition to the deductible and copayment or coinsurance described for out-of- network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. Please note. Your place of residence is where you make your home. This may be your own dwelling, a relative's home, an apartment complex that provides assisted living services or some other type of institution. However, an institution will not be considered your home if it is a hospital or skilled nursing facility. MCS7 (1/02) 36 BPL 56741 Home Health Care Not covered These services, supplies and associated expenses are not covered: 1. Companion, homemaker and personal care services. 2. Services provided by a member of your family. 3. Custodial care and other nonskilled services. Home health care and supplies for ventilator- dependent members unless a skilled nursing facility bed is not available. 5. Physical, speech or occupational therapy provided in your home for convenience. 6. Services provided in your home when you are not homebound. 7. Services primarily educational in nature. 8. Vocational and job rehabilitation. 9. Recreational therapy. 10. Self.care and self-help training (non-medical). 11. Health clubs. 12. Disposable supplies and appliances, except as described in this certificate. 13. Correction of speech impediments (stuttering or lisps) and assistance in the development of verbal clarity. 14. Voice training and voice therapy. 15. Outpatient rehabilitation services when no medical diagnosis is present. 37 MCS7 (1/02) BPL 56741 Home Health Care Intermittent skilled care when you are homebound, provided by or supervised by a registered nurse Skilled physical, speech or occupational therapy when you are homebound Home IV therapy Services received in your home from a physician 20% coinsurance except you pay nothing for high- risk prenatal care services 20% coinsurance Nothing Nothing 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance MCS7 (1/02) BPL 56741 38 Outpatient Rehabilitation K. Outpatient Rehabilitation This section describes coverage for both professional and outpatient health care facility services. A physician must direct your care. Co vere d For benefits and the amounts you pay, see the table in this section. In-network benefits apply to outpatient rehabilitation services arranged through a network physician and received from a network physical therapist, a network occupational therapist, a network speech therapist or a network physician. Out-of-network benefits apply to outpatient rehabilitation services arranged through a non- network physician and received from a non-network physical therapist, a non-network occupational therapist, a non-network speech therapist or a non- network physician. In addition to the deductible and copayment or coinsurance described for out-of- network benefits, you are responsible for any charges in excess of the non-network provider reimbursement amount. Not covered These services, supplies and associated expenses are not covered: 1. Services primarily educational in nature. 2. Vocational and job rehabilitation. 3. Recreational therapy. 4. Self-care and self-help training (non-medical). 5. Health clubs. 39 MCS7 (1/02) BPL 56741 Outpatient Rehabilitation 6. Correction of speech impediments (stuttering or lisps) and assistance in the development of verbal clarity. 7. Voice training and voice therapy. 8. Outpatient rehabilitation services when no medical diagnosis is present. 1. Physical therapy received $15/visit outside of your home Speech therapy received outside of your home a. Initial speech therapy Nothing evaluation to determine if speech is impaired due to a medical illness or injury, or congenital or developmental conditions that have delayed speech development b. Speech therapy when $15/visit speech is impaired due to a medical illness or injury, or congenital or developmental conditions that have delayed speech development Occupational therapy received outside of your home a. Initial occupational therapy Nothing evaluation to determine if physical function is impaired due to a medical illness or injury or congenital or developmental conditions that have delayed motor development 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance MCS7 (1/02) 40 BPL 56741 Outpatient Rehabilitation Occupational therapy when physical function is impaired due to a medical illness or injury or congenital or developmental conditions that have delayed motor development $15/visit 20% coinsurance 41 MCS7 (1/02) BPL 56741 Mental Health L. Mental Health This section describes coverage for services to diagnose and treat mental disorders listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. For purposes of this section: 1. Outpatient services include: a. Evaluations and diagnostic services. b. Therapeutic services including psychiatric services. Relationship and family counseling services. Intensive outpatient programs, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (this may also include services such as day treatment programs). Treatment for a minor, including family therapy. Treatment of serious or persistent disorders. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD). Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. 2. Inpatient services include: a. Semi-private room and board. Partial program. (This may be in a freestanding facility or hospital based. Active treatment is provided through specialized programming with medical/psychological intervention and supervision during program hours.) c. Attending psychiatric services. d. Hospital or facility-based professional services. MCS7 (1/02) 42 BPL 56741 Mental Health e. Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. (Refer to numbers 2.a., b., c. and d. in the table in this section to determine your benefits.) f. Residential services. (Refer to numbers 2.a., b. and c. in the table in this section to determine your benefits.) Covered For benefits and the amounts you pay, see the table in this section. For in-network benefits: Medica's designated mental health and substance abuse provider arranges in-network mental health benefits. Medica's designated mental health and substance abuse provider will refer you to other mental health providers only if network providers cannot provide the services you require. If you require hospitalization, Medica's designated mental health and substance abuse provider will refer you to one of its hospital providers (Medica and Medica's designated mental health and substance abuse provider hospital networks are different). Notify Medica's designated mental health and substance abuse provider as soon as reasonably possible after receiving any emergency mental health inpatient services. Call Medica's designated mental health and substance abuse provider at: 1-800-848-8327 or TTY: 1-800-543-7162. = Second opinions from a qualified provider are covered under in-network benefits only if Medica's designated mental health and substance abuse provider determines that no treatment is necessary. Medica's designated mental health and substance abuse provider will consider the second opinion but is not required to accept it. 43 MCS7 (1/02) BPL 56741 Mental Health For out-of-network benefits: Mental health services from a non-network provider listed below will be eligible for coverage under out-of-network benefits. Emergency mental health services are eligible for coverage under in-network benefits. You must receive services directly from or at any of the following non-network providers to obtain out-of-network benefits: a. Licensed psychiatrist b. Licensed consulting psychologist c. Licensed psychologist d. Certified clinical nurse specialist in psychiatric and mental health nursing e. Licensed mental health clinic f. Licensed residential treatment center g. Licensed independent clinical social worker h. Licensed marriage and family therapists i. A hospital that provides mental health services Not covered These services, supplies and associated expenses are not covered: 1. Services for mental disorders not listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. 2. Services from a network provider for a condition that cannot be improved with treatment. Services, care or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. 4. Relationship counseling beyond initial evaluation and brief intervention services. MCS7 (1/02) 44 BPL 56741 Mental Health Services beyond the initial evaluation to diagnose mental retardation or learning disabilities. Telephone consultations. Services, including room and board charges, provided by mental health providers who are not licensed to practice independently or substance abuse providers who are not certified, such as services received at a halfway house or therapeutic group home, except for outpatient mental health services that are specifically described in this section. Services to assist in activities of daily living that do not seek to cure and are performed regularly as a part of a routine or schedule. 1. Outpatient services $1 O/visit-group $15/visit-individual 20% coinsurance Inpatient services a. Semi-private room and board Nothing b. Hospital or facility-based Nothing professional services c. Attending psychiatrist Nothing services 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of- network benefits described in this certificate. This day limitation applies whether or not the deductible has been met. 20% coinsurance 20% coinsurance 45 MCS7 (1/02) BPL 56741 Mental Health d. Partial program Nothing 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of- network benefits described in this certificate, This day limitation applies whether or not the deductible has been met, MCS7 (1/02) BPL 56741 46 Substance Abuse M. Substance Abuse This section describes coverage for the diagnosis and primary treatment of substance abuse disorders listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders. For purposes of this section: 1. Outpatient services include: a. Evaluations, diagnostic and primary treatment. Intensive outpatient programs, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting. Services, care or treatment for a member that has been placed in the Minnesota Department of Corrections' custody following a conviction for a first-degree driving while impaired offense; to be eligible, such services, care or treatment must be required and provided by the Minnesota Department of Corrections. (Refer to numbers 1 .a. and b. in the table in this section to determine your benefits.) Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician, licensed psychologist, licensed alcohol and drug dependency counselor or a certified chemical dependency assessor and that includes an individual treatment plan. (Refer to numbers 1 .a. and b. in the table in this section to determine your benefits.) 2. Inpatient services include: a. Semi-private room and board. b. Attending physician services. c. Hospital or facility-based professional services. Services, care or treatment for a member that has been placed in the Minnesota Department of Corrections' custody following a conviction for a first-degree driving while impaired offense; to be eligible, such services, care or treatment must be required and provided by the Minnesota 47 MCS7 (1/02) BPL 56741 Substance Abuse Department of Corrections. (Refer to numbers 2.a., b. and c. in the table in this section to determine your benefits.) Partial program. (This may be in a freestanding facility or hospital based. Active treatment is provided through specialized programming with medical/psychological intervention and supervision during program hours. Partial program may include lodging.) (Refer to numbers 2.a., b. and c. in the table in this section to determine your benefits.) Residential services. (Refer to numbers 2.a., b. and c. in the table in this section to determine your benefits.) Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician, licensed psychologist, licensed alcohol and drug dependency counselor or a certified chemical dependency assessor and that includes an individual treatment plan. (Refer to numbers 2.a., b. and c. in the table in this section to determine your benefits.) Covered For benefits and the amounts you pay, see the table in this section. · For in-network benefits: Medica's designated mental health and substance abuse provider arranges in-network substance abuse benefits. Medica's designated mental health and substance abuse provider will refer you to other substance abuse providers only if network providers cannot provide the services you require. If you require hospitalization, Medica's designated mental health and substance abuse provider will refer you to one of its hospital providers (Medica and Medica's designated mental health and substance abuse provider hospital networks are different). In-network benefits will apply to services, care or treatment for a member that has been placed in the Minnesota Department of Corrections' MCS7 (1/02) BPL 56741 48 = custody following a conviction for a first-degree driving while impaired offense. To be eligible, such services, care or treatment must be required and provided by the Minnesota Department of Corrections. Notify Medica's designated mental health and substance abuse provider as soon as reasonably possible after receiving any emergency substance abuse inpatient services. Call Medica's designated mental health and substance abuse provider at 1-800-848-8327 or TTY: 1-800-543-7162. Second opinions from a qualified provider are covered under in-network benefits only if Medica's designated mental health and substance abuse provider determines that no treatment is necessary. Medica's designated mental health and substance abuse provider will consider the second opinion but is not required to accept lt. For out-of-network benefits: Substance abuse services from a non-network provider listed below will be eligible for coverage under out-of-network benefits. Emergency substance abuse services are eligible for coverage under in-network benefits, 2, You must receive services directly from or at any of the following non-network providers to obtain out-of-network benefits: a. Licensed psychiatrist b. Licensed consulting psychologist c. Licensed psychologist d. Certified clinical nurse specialist in psychiatric and mental health nursing e. Licensed chemical dependency clinic f. Licensed residential treatment center g. A hospital that provides substance abuse services 49 Substance Abuse MCS7 (1/02) BPL 56741 Substance Abuse Not covered These services, supplies and associated expenses are not covered: 1. Services for substance abuse disorders not listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. 2. Services from a network provider for a condition that cannot be improved with treatment. Services, care or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received. 5. Services beyond the primary treatment of substance abuse. Methadone or Cyclazocine maintenance or their equivalents. 7. Telephone consultations. Services, including room and board charges, provided by mental health providers who are not licensed to practice independently or substance abuse providers who are not certified, such as services received at a halfway house or therapeutic group home, except for outpatient substance abuse services that are specifically described in this section. Services to assist in activities of daily living that do not seek to cure and are performed regularly as a part of a routine or schedule. MOS7 (1/02) 50 BPL 56741 Substance Abuse Outpatient services a. Evaluations, diagnostic and primary treatment services $1 O/visit-group $15/visit-individual 20% coinsurance b. Intensive outpatient programs Inpatient services: a. Semi-private room and board b= Hospital or facility-based professional services c. Attending physician services $15/day Nothing Nothing Nothing 20% coinsurance 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of- network benefits described in this certificate. This day limitation applies whether or not the deductible has been met. 20% coinsurance 20% coinsurance 51 MCS7 (1/02) BPL 56741 Durable Medical Equipment And Prosthetics N. Durable Medical Equipment And Prosthetics This section describes coverage for durable medical equipment and certain related supplies and prosthetics. Covered For benefits and the amounts you pay, see the table in this section. Medica covers only a limited selection of durable medical equipment and certain related supplies that meet the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. To request a list of Medica's eligible durable medical equipment and certain related supplies, call Customer Service at one of the telephone numbers listed inside the front cover. Medica determines if durable medical equipment will be pumhased or rented. Medica's approval of rental of durable medical equipment is limited to a specific period of time. To request approval for an extension of the rental period, call Customer Service at one of the telephone numbers listed inside the front cover. In-network benefits apply to durable medical equipment and certain related supplies, prosthetic services prescribed by a physician and received from a network durable medical equipment provider, and hearing aids as described in number 4. in the table in this section when prescribed by a physician and received from a network hearing aid vendor. To request a list of network durable medical equipment providers and hearing aid vendors, call Customer Service at one of the telephone numbers listed inside the front cover. Out-of-network benefits apply to durable medical equipment and certain related supplies and prosthetic services prescribed by a physician and received from a non-network provider. In addition to the deductible and copayment or coinsurance described for out-of-network benefits, you are responsible for charges in excess of the non- network provider reimbursement amount. MCS7 (1/02) 52 BPL 56741 Durable Medical Equipment And Prosthetics Not covered These services, supplies and associated expenses are not covered: Durable medical equipment and supplies, prosthetics and appliances not on the Medica eligible list. 2. Charges in excess of the Medica standard model of durable medical equipment or prosthetics. 3. Repair, replacement or revision of durable medical equipment and prosthetics, except when made necessary by normal wear and use. 4. Duplicate durable medical equipment and prosthetics. Durable medical equipment and certain related supplies Repair, replacement or revision of durable medical equipment made necessary by normal wear and use Prosthetics: a. Initial pumhase of breast prostheses b. Initial pumhase of artificial limbs and eyes c. Scalp hair prostheses due to alopecia areata 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance of the first $437.50 and 100% of any amount over $437.50. Medica pays up to $350. This is calculated each calendar year. 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance of the first $437.50 and 100% of any amount over $437.50. Medica pays up to $350. This is calculated each calendar year. The deductible does not apply. 53 MCS7 (1/02) BPL 56741 Durable Medical Equipment And Prosthetics d. Repair, replacement or 20% coinsurance revision of artificial limbs, eyes and breast prostheses made necessary by normal wear and use Hearing aids for members 18 years of age and younger for hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures. 20% coinsurance. Limited to one hearing aid per ear every three years. Related services must be prescribed by a physician and hearing aids must be received from a network hearing aid vendor. 20% coinsurance No coverage MCS7 (1/02) BPL 56741 Miscellaneous Medical Supplies O. Miscellaneous Medical Supplies This section describes coverage for miscellaneous medical supplies prescribed by a physician. Medica covers only a limited selection of miscellaneous medical supplies that meet the criteria established by Medica. Some items ordered by a physician, even if medically necessary, may not be covered. Covered For benefits and the amounts you pay, see the table in this section. In-network benefits apply to miscellaneous medical supplies received from a network provider. In- network benefits also apply to levonorgestrel (e.g., Norplant) services received from either a network or non-network provider. Out-of-network benefits apply to miscellaneous medical supplies received from a non-network provider. In addition to the deductible and copayment or coinsurance described for out-of- network benefits, you are responsible for any charges in excess of the non-network provider reimbursement amount. Not covered Other disposable supplies and appliances, except as described in this certificate. 55 MOS7 (1/02) BPL 56741 Miscellaneous Medical Supplies Blood clotting factors Dietary medical treatment of phenylketonuria (PKU) Levonorgestrel (e.g., Norplant); limited to one implant every three years 4. Total parenteral nutrition 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance Refer to in-network benefits. 20% coinsurance MCS7 (1/02) BPL 56741 56 Organ And Bone Marrow Transplant Services P. Organ And Bone Marrow Transplant Services This section describes coverage for certain organ and bone marrow transplant services. Services must be provided under the direction of a physician and received at a transplant facility. This section also describes benefits for professional, hospital and ambulatory surgical center services. Coverage is provided for certain types of organ transplants and related services (including organ acquisition and procurement) and for certain bone marrow transplant services that are medically necessary, appropriate for the diagnosis, without contraindications and non-investigative. Covered Medica uses specific medical criteria to determine benefits for organ and bone marrow transplant services. Because medical technology is constantly changing, Medica reserves the right to review and update these medical criteria. Benefits for each individual member will be determined based on the clinical circumstances of the member according to Medica's medical criteria. Coverage is provided for the following human organ transplants, if appropriate, under Medica's medical criteria policies and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous and syngeneic bone marrow. The preceding is not a comprehensive list of eligible organ and bone marrow transplant services. · In-network benefits apply to transplant services provided by a network provider and received at a designated transplant facility. A designated transplant facility means a hospital that has entered into a separate contract with Medica to provide certain transplant-related health services to members receiving transplants. Once evaluated and listed as a potential recipient at a designated transplant facility, you must remain with that facility, unless it is medically necessary for your transplant to be rendered elsewhere. You cannot be listed at more than one facility. If you independently choose to be listed at additional facilities, any charges for services they provide will not be covered under the Contract. 57 MCS7 (1/02) BPL 56741 Organ And Bone Marrow Transplant Services For in-network benefits, Medica requires that all pre-transplant, transplant and post-transplant services, from the time of the initial evaluation through no more than one year after the date of the transplant, be received at one designated transplant facility (that you select from among the list of transplant facilities Medica provides). Based on the type of transplant you receive, Medica will determine the specific time period medically necessary for these services. Out-of-network benefits apply to organ and bone marrow transplant services provided by or at either of the following: 1. A non-network provider; or 2. A non-designated transplant facility In addition to the deductible and copayment or coinsurance described for out-of-network benefits, you are responsible for any charges in excess of the non-network provider reimbursement amount. Not covered These services, supplies and associated expenses are not covered: 1. Organ and bone marrow transplant services except as described in this section. Supplies and services related to transplants that would not be authorized by Medica under the medical criteria referenced in this section. 3. Chemotherapy, radiation therapy, drugs or any therapy used to damage the bone marrow and related to transplants that would not be authorized by Medica under the medical criteria referenced in this section. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. Islet cell transplants except for autologous islet cell transplants associated with pancreatectomy. Services required to meet the patient selection criteria for the authorized transplant procedure. This includes treatment of nicotine or caffeine addiction, services and related expenses for weight loss programs, nutritional supplements, appetite MCS7 (1/02) " 58 BPL 56741 Organ And Bone Marrow Transplant Services suppressants and supplies of a similar nature otherwise not covered under the Contract. 7. Mechanical, artificial or non-human organ implants or transplants and related services that would not be authorized by Medica under the medical criteria referenced in this section. 8. Transplants and related services that are investigative. 9. Private collection and storage of umbilical cord blood for directed use. Office visits $15/visit Outpatient services a. Professional services i. Surgical services (as $15/visit defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit ii. Outpatient lab, pathology Nothing and x-rays iii. Other outpatient hospital Nothing services received from a physician b. Hospital and ambulatory surgical center services i. Outpatient lab, pathology Nothing and x-rays 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance ii. Other outpatient hospital $15/visit services 20% coinsurance 59 MCS7 (1/02) BPL 56741 Organ And Bone Marrow Transplant Services 3. Inpatient services Nothing 4. Services received from a Nothing physician during an inpatient stay 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all out-of-network inpatient benefits described in this certificate. This day limitation applies whether or not the deductible has been met. 20% coinsurance MCS7 (1/02) 60 BPL 56741 Infertility Services Q. Infertility Services This section describes coverage for the diagnosis and treatment of infertility in connection with the voluntary planning of conceiving a child. Coverage includes benefits for professional, hospital and ambulatory surgical center services. Infertility treatment must be received from or under the direction of a physician. Covered For benefits and the amounts you pay, see the table in this section. For a diagnosis of infertility, up to six cycles of artificial inseminations are covered per attempted pregnancy. Benefits renew after a confirmed pregnancy. · In-networkbenefits apply to: 1. Infertility treatment services received from a network provider; and 2. Services for the diagnosis of infertility received from a network or non-network provider. Out-of-network benefits apply to infertility treatment services received from a non-network provider. You are responsible for any charges in excess of the non-network provider reimbursement amount. This is in addition to the deductible and copayment or coinsurance described for out-of-network benefits. Not covered These services, supplies and associated expenses are not covered: 1. Drugs for self-administration when dispensed by a physician. 2. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 3. More than six cycles of artificial insemination per confirmed pregnancy. 61 MCS7 (1/02) BPL 56741 Infertility Services 4. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 5. Sperm banking. 6. Adoption. 7. Donor sperm. 8. Embryo and egg storage. 9. Sensorineural integration. 1. Office visits including.any 20% coinsurance services provided and drugs administered during such visits 2. Outpatient services received at a 20% coinsurance hospital 3. Inpatient services 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all out-of-network inpatient benefits described in this certificate. This day limitation applies whether or not the deductible has been met. MCS7 (1/02) 62 BPL 56741 Reconstructive And Restorative Surgery R. Reconstructive And Restorative Surgery This section describes coverage for professional, hospital and ambulatory surgical center services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative surgery services must be medically necessary and not cosmetic. Covered For benefits and the amounts you pay, see the table in this section. In-network benefits apply to reconstructive and restorative surgery services received from a network provider. Out-of-network benefits apply to reconstructive and restorative surgery services received from a non- network provider. In addition to the deductible and copayment or coinsurance described for out-of- network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. 63 MCS7 (1/02) BPL 56741 Reconstructive And Restorative Surgery Not covered These services, supplies and associated expenses are not covered: Revision of blemishes on skin surfaces and scars (including scar excisions) primarily for cosmetic purposes, unless otherwise covered in Professional Services. 2. Repair of a pierced body part and surgical repair of bald spots or loss of hair. Repairs to teeth, including any other dental procedures or treatment, whether the dental treatment is needed because of a primary dental problem or as a manifestation of a medical treatment or condition. 4. Services and procedures primarily for cosmetic purposes. 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. 6. Hair transplants. 1. Office visits 20% coinsurance 20% coinsurance MCS7 (1/02) 64 BPL 56741 Reconstructive And Restorative Surgery 2. Outpatient services a. Professional services Surgical services (as defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit ii. Outpatient lab, pathology and x-rays iii. Other outpatient hospital or ambulatory surgical center services received from a physician b. Hospital and ambulatory surgical center services i. Outpatient lab, pathology and x-rays ii. Other outpatient hospital and ambulatory surgical center services 3. Inpatient services 20% coinsurance Nothing 20% coinsurance Nothing 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all out-of-network inpatient benefits described in this certificate. This day limitation applies whether or not the deductible has been met. 65 MOS7 (1/02) BPL 56741 Reconstructive And Restorative Surgery 4. Services received from a 20% coinsurance physician during an inpatient stay 20% coinsurance MCS7 (1/02) 66 BPL 56741 Skilled Nursing Facility Services S. Skilled Nursing Facility Services This section describes coverage for use of skilled nursing facility services. Care must be provided under the direction of a physician. Skilled nursing facility services are eligible for coverage only if they are provided through Medica's managed care procedures. Covered For benefits and the amounts you pay, see the table in this section. In-network benefits apply to skilled nursing facility services arranged through a physician and received from a network skilled nursing facility. Out-of-network benefits apply to skilled nursing facility services arranged through a physician and received from a non-network skilled nursing facility. In addition to the deductible and copayment or coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. For purposes of this section, room and board includes coverage of health services and supplies. Not covered These services, supplies and associated expenses are not covered: 1. Custodial care and other non-skilled services. 2. Self-care or serf-help training (non-medical). 3. Private room, except for conditions of preeclampsia, radium implants, contagion or immunosuppression that require isolation. · ' 67 MCS7 (1/02) BPL 56741 Skilled Nursing Facility Services 4. Services primarily educational in nature. 5. Vocational and job rehabilitation. 6. Recreational therapy. 7. Health clubs. 8. Correction of speech impediments (stuttering or lisps) and assistance in the development of verbal clarity. 9. Voice training and voice therapy. 10. Outpatient rehabilitation services when no medical diagnosis is present. 1. Daily skilled care or daily skilled 20% coinsurance rehabilitation services, including room and board Skilled physical, speech or occupational therapy when room and board is not eligible to be covered 20% coinsurance 20% coinsurance. Services are covered only after transfer to a skilled nursing facility within 30 days of discharge from a hospital in which you were confined for not less than three consecutive calendar days. Coverage is limited to a combined total of 120 days per calendar year for all out- of-network inpatient benefits described in this certificate. This day limitation applies whether or not the deductible has been met. 20% coinsurance MCS7 (1/02) BPL 56741 68 Skilled Nursing Facility Services Services received from a physician during an inpatient stay in a skilled nursing facility Nothing 20% coinsurance 69 MOS7 (1/02) BPL 56741 Hospice Services T. Hospice Services This section describes coverage for hospice services including respite care. Care must be ordered, provided or arranged under the direction of a physician and received from a designated hospice program. Covered For benefits and the amounts you pay, see the table in this section. Hospice services are comprehensive palliative medical care and supportive social, emotional and spiritual services. These services are provided to terminally ill persons and their families, primarily in the patients' homes. A hospice interdisciplinary team, composed of professionals and volunteers, coordinates an individualized plan of care for each patient and family. Respite care is a form of hospice services that gives uncompensated primary caregivers (i.e., family members or friends) rest or relief when necessary to maintain a terminally ill member at home. Respite care is limited to not more than five consecutive days at a time. In-network benefits apply to hospice services arranged through a physician and received from a designated hospice program. There is no coverage under out-of-network benefits for hospice services received from a non-network hospice program. A plan of care must be established and communicated by the designated hospice program staff to Medica. To be eligible for coverage, hospice services must be consistent with the designated hospice program's plan of care. To be eligible for the hospice benefits described in this section, you must: 1. Be a terminally ill patient; and 2. Have chosen a palliative treatment focus (i.e., one that emphasizes comfort and supportive services MCS7 (1/02) -' 70 BPL 56741 Hospice Services rather than treatment attempting to cure the disease or condition). You will be considered terminally ill if there is a written medical prognosis by your physician that your life expectanCy is six months or less if the terminal illness runs its normal course. This certification must be made not later than two days after the hospice care is initiated. You may withdraw from the hospice program at any time upon written notice to the designated hospice program. You must follow the designated hospice program's requirements to withdraw from the designated hospice program. Not covered These services, supplies and associated expenses are not covered: 1. Respite care for more than five consecutive days at a time. Home health care and skilled nursing facility services when services are not consistent with the hospice program's plan of care. 3. Services not included in the designated hospice program's plan of care. 4. Services not provided by the designated hospice program. 5. Hospice daycare, except when recommended and provided by the designated hospice program. Any services provided by a family member or friend, or individuals who are residents in your home. Financial or legal counseling services, except when recommended and provided by the designated hospice program. Housekeeping or meal services in your home, except when recommended and provided by the designated hospice program. 71 MCS7 (1/02) BPL 56741 Hospice Services Bereavement counseling, except when recommended and provided by the designated hospice program. 1. Hospice services Nothing No coverage MCS7 (1/02) 72 BPL 56741 Temporomandibular Joint (TMJ) Disorder U. Temporomandibular Joint (TMJ) Disorder This section describes coverage for the evaluation(s) to determine whether you have TMJ disorder and the surgical and non-surgical treatment of a diagnosed TMJ disorder. Services must be received from (or under the direction of) physicians or dentists. Coverage for treatment of TMJ disorder includes coverage for the treatment of craniomandibular disorder. This section also describes benefits for professional, hospital and ambulatory surgical center services. Covered For benefits and the amounts you pay, see the table in this section. In-network benefits apply to TMJ services received from a network provider. Out-of-network benefits apply to TMJ services received from a non-network provider. In addition to the deductible and copayment or coinsurance described for out-of-network benefits, you will be responsible for any charges in excess of the non- network provider reimbursement amount. Not covered These services, supplies and associated expenses are not covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. 73 MCS7 (1/02) BPL 56741 Temporomandibular Joint (TMJ) Disorder 1. Initial office visit for evaluation $15/visit 2. Office visits (including further $15/visit evaluations) 3. Outpatient services a. Professional services i. Surgical services (as $15/visit defined in the Physicians' Current Procedural Terminology code book) received from a physician or dentist during an office visit or an outpatient hospital or ambulatory surgical center visit ii. Outpatient lab, pathology Nothing and x-rays iii. Other outpatient hospital Nothing and ambulatory surgical center services received from a physician or dentist b. Hospital and ambulatory surgical center services i. Outpatient lab, pathology Nothing and x-rays ii. Other outpatient hospital $15/visit and ambulatory surgical center services Physical therapy received outside of your home $15/visit 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20%coinsurance 20% coinsurance 20% coinsurance MCS7 (1/02) BPL 56741 74 Temporomandibular Joint (TMJ) Disorder 5. Inpatient services Services received from a physician or dentist during an inpatient stay TMJ splints and adjustments if your primary diagnosis is joint disorder Nothing Nothing 20% coinsurance 20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all out-of-network inpatient benefits described in this certificate. This day limitation applies whether or not the deductible has been met. 20% coinsurance 20% coinsurance 75 MCS7 (1/02) BPL 56741 Medical-Related Dental Services V. Medical-Related Dental Services This section describes coverage for medical-related dental services. Services must be received from a physician or dentist. Covered For benefits and the amounts you pay, see the table in this section. · In-network benefits apply to medical-related dental services received from a network provider. Out-of-network benefits apply to medical-related dental services received from a non-network provider. In addition to the deductible and copayment or coinsurance described for out-of- network benefits, you will be responsible for any charges in excess of the non-network provider reimbursement amount. MCS7 (1/02) 76 BPL 56741 Medical-Related Dental Services Not covered These services, supplies and associated expenses are not covered: 1. Accident-related dental services to treat an injury from biting or chewing. 2. Osteotomies and other procedures associated with the fitting of dentures or dental implants. 3. Dental implants (tooth replacement). Any other dental procedures or treatment, whether the dental treatment is needed because of a primary dental problem or as a manifestation of a medical treatment or condition. Any orthodontia including that associated with orthognathic procedures or accident-related dental injuries, except as described in number 2. in the table in this section. 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. Endodontic procedures and treatment, including root canal procedures and treatment, except as described in number 3. in the table in this section. 9. Routine diagnostic and preventive dental services. 77 MCS7 (1/02) BPL 56741 Medical-Related Dental Services Charges for medical facilities and general anesthesia services that are: a. Recommended by a network physician; and b. Received during a dental procedure; and c. Provided to a member who: Is a child under age five (prior authorization is not required); or ii. Is severely disabled; or iii. Has a medical condition and requires hospitalization or general anesthesia for dental care treatment. Please note. Age, anxiety and behavioral conditions are not considered medical conditions. For a dependent child, orthodontia related to cleft lip and palate Please note. For a dependent child, benefits for oral surgery treatment for cleft lip and palate are covered in Professional Services and Hospital Services. Nothing 20% coinsurance No coverage 20% coinsurance MCS7 (1/02) BPL 56741 78 Medical-Related Dental Services Accident-related dental services to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth, The following conditions apply: Coverage is limited to services received within six months of the injury. A sound, natural tooth means a tooth (including supporting structures) that is free from disease that would prevent continual function of the tooth for at least one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year. 4. Oral surgery for: a= Partially or completely unerupted impacted teeth; A tooth root without the extraction of the entire tooth (this does not include root canal therapy); or The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth. 20% coinsurance Coverage available under Out-of-network benefits No coverage 20% coinsurance 79 MOS7 (1/02) BPL 56741 Emergency Services From Non-Network Providers W. Emergency Services From Non-Network Providers This section describes coverage for emergency services from non-network providers. In- network benefits will apply to emergency services as described in this section. Covered For benefits and the amounts you pay, see the table in this section. To be eligible for coverage, services must be due to an emergency. You must notify Medica of emergency inpatient services as soon as reasonably possible after receiving inpatient services: Call Customer Service at one of the telephone numbers listed inside the front cover. For emergency mental health or substance abuse inpatient services, you must notify Medica's designated mental health and substance abuse provider as soon as reasonably possible. Medica's designated mental health and substance abuse provider can be reached at: · 1-800-848-8327 · TTY: 1-800-543-7162 If the health services that you require do not meet the definition of emergency, you should refer to the remainder of this certificate for a description of your out-of-network benefits. For information on submitting claims for emergency services received in a foreign country, refer to How To Submit A Claim. Not covered These services, supplies and associated expenses are not covered: 1. Non-emergency care from non-network providers except as described in this certificate. MCS7 (1/02) 80 BPL 56741 Emergency Services From Non-Network Providers Unauthorized continued inpatient services in a non- network facility once the attending physician agrees it is safe to transfer you to a network facility. Follow-up care or scheduled care from a non- network provider except as described in this certificate. Transfers and admissions to network hospitals solely at the convenience of the member. 1. Emergency services that are: Administered under the direction of a physician; and Received from a non-network provider; and Otherwise eligible for coverage in this certificate. Ambulance service or ambulance transportation to the nearest hospital for an emergency 20% coinsurance up to a maximum of $500 per calendar year for numbers 1. and 2, combined 20% coinsurance up to a maximum of $500 per calendar year for numbers 1. and 2. combined 81 MCS7 (1/02) BPL 56741 Referrals To Non-Network Providers X. Referrals To Non-Network Providers This section describes coverage for referrals from network providers to non-network providers. In-network benefits will apply to referrals from network providers to non-network providers when services are not available from network providers and prior authorization is obtained as described in this section. It is to your advantage to seek Medica's authorization for referrals to non-network providers before you receive services. Medica can then tell you what your benefits will be for the services you may receive. What you must do Request a referral or standing referral from a network provider to receive medically necessary services from a non-network provider. The referral will be in writing and will: a. Indicate the time period during which services must be received; and b. Specify the service(s) to be provided; and c. Direct you to the non-network provider selected by your network provider. Seek prior authorization from Medica by calling one of the telephone numbers listed inside the front cover. Medica does not guarantee coverage of services that are received before you obtain prior authorization from Medica. If prior authorization has been obtained from Medica, pay the same amount you would have paid if the services had been received from a network provider. Pay any charges not authorized for coverage by Medica. MCS7 (1/02) ,' 82 BPL 56741 Referrals To Non-Network Providers What Medica will do May require that you see another network provider selected by Medica before a determination by Medica that a referral or standing referral to a non- network provider is medically necessary. May require that you obtain a referral or standing referral (as described in this section) from a network provider to a non-network provider practicing in the same or similar specialty. 3. Provides coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Determined by Medica not to be available from network providers; and c. Recommended by a network physician. Notifies you of authorization or denial of coverage within ten days of receipt of your request. Medica will inform both you and your provider of Medica's decision within 72 hours from the time of the initial request if your attending provider believes that an expedited appeal is warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function. 83 MCS7 (1/02) BPL 56741 Harmful Use Of Medical Services Y. Harmful Use Of Medical Services This section describes what Medica will do if it is determined you are receiving health services or prescription drugs in a quantity or manner that may harm your health. When this section applies After Medica notifies you that this section applies, you have 30 days to choose one network physician, hospital and pharmacy to be your coordinating health care providers. If you do not choose your coordinating health care providers within 30 days, Medica will choose for you. Your in-network benefits are then restricted to services provided by or arranged through your coordinating health care providers. Failure to receive services from or through your coordinating health care providers will result in a denial of coverage. Medica will send you specific information about: 1. How to obtain approval for benefits not available from your coordinating health care providers; 2. How to obtain emergency care; and 3. When these restrictions end. MCS7 (1/02) 84 BPL 56741 Exclusions Z. Exclusions This section describes additional exclusions to the services, supplies and associated expenses already listed as Not covered in this certificate. These include: Services that are not medically necessary. This includes but is not limited to services inconsistent with the medical standards and accepted practice parameters of the community and services inappropriate--in terms of type, frequency, level, setting and duration--to the diagnosis or condition. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive. 3. Refractive eye surgery. The purchase, replacement or repair of eyeglasses, eyeglass frames, or contact lenses when prescribed solely for vision correction, and their related fittings. Services provided by an audiologist when not under the direction of a physician, hearing aids and other devices to improve hearing, and their related fittings, except cochlear implants and related fittings and except as stated in Durable Medical Equipment And Prosthetics. 6. A drug, device or medical treatment or procedure that is investigative. 7. Services for genetic screening and testing except when: Recommended by a genetic counselor as predictive of a disease process, and treatment standards of care exist for the disease process; or b. Reproductive choices would be made based on the test findings. 8. Autopsies. 85 MCS7 (1/02) BPL 56741 Exclusions Enteral feedings (unless they are the sole soume of nutrition) except for the dietary medical treatment of PKU. 10. Nutritional and electrolyte substances. 11. Physical, occupational or speech therapy when there is no reasonable expectation that the condition will improve over a predictable period of time. 12. Reversal of voluntary sterilization. 13. Neuropsychological evaluations/cognitive testing, except as stated in Professional Services. 14. Personal comfort or convenience items or services. 15. Custodial care, unskilled nursing or unskilled rehabilitation services. 16. Respite or rest care except as otherwise covered in Hospice Services. 17. Travel, transportation or living expenses. 18. Household equipment, fixtures, home modifications and vehicle modifications. 19. Services to treat nicotine addiction except as stated in Prescription Drugs And Pharmacy Services. 20. Charges billed by a non-network provider that are not in compliance with generally accepted coding and reimbursement guidelines including those of the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS) and the community. 21. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. 22. Routine foot care, except for members with diabetes, peripheral vascular disease, peripheral neuropathies or blindness. 23. Services by persons who are family members or who share your legal residence. MCS7 (1/02) 86 BPL 56741 Exclusions 24. Services for which coverage is available under workers' compensation, employer liability or any similar law. 25. Services received before coverage under the Contract becomes effective. 26. Services received after coverage under the Contract ends. 27. Unless requested by Medica, charges for duplicating and obtaining medical records from non-network providers and non-network dentists. 28. Photographs, except for the condition of multiple dysplastic syndrome. 29. Occlusal adjustment or occlusal equilibration. 30. Dental implants (tooth replacement). 31. Dental prostheses. 32. Any orthodontia including that associated with orthognathic procedures, accident-related dental injuries, or temporomandibular joint (TM J) disorder. However, this exclusion does not apply when orthodontia is used as secondary treatment for TMJ disorder in cases where primary treatment has been completed and lack of orthopedic (tooth) support has caused additional episodes of TMJ disorder, or as stated in Medical-Related Dental Services (for cleft lip and palate). 33. Treatment for bruxism. 34. Services prohibited by law or regulation, or illegal under Minnesota law. 35. Services to treat injuries that occur while on military duty to the extent that such care is otherwise covered or available in another program of coverage. 36. Exams, other evaluations or other services for employment, insurance or licensure, unless otherwise covered under this certificate. 37. Exams, other evaluations or other services for judicial or administrative proceedings or research (except emergency examination of a child ordered 87 MCS7 (1/02) BPL 56741 Exclusions by judicial authorities) unless otherwise covered under this certificate. 38. Non-medical self-care or self-help training. 39. Educational classes, programs or seminars. 40. Coverage for costs associated with translation of medical records and claims to English. 41. Treatment for spider veins. 42. Services not received from or under the direction of a physician, except as described in this certificate. 43. Services billed by an acupuncturist. MCS7 (1/02) 88 BPL 56741 How To Submit A Claim AA. How To Submit A Claim This section describes the process for submitting a claim. Claims for benefits from network providers If you receive a bill for any benefit from a network provider, you may submit the claim following the procedures described below, under Claims for benefits from non-network providers, or call Customer Service at one of the telephone numbers listed inside the front cover. Claims for benefits from non-network providers Claim forms are provided in your enrollment materials. You may request additional claim forms by calling Customer Service at one of the telephone numbers listed inside the front cover. If the claim forms are not sent to you within 15 days, you may submit an itemized statement without the claim form to Medica. You should retain copies of all claim forms and correspondence for your records. You must submit the claim in English along with a Medica claim form to Medica no later than 365 days after receiving benefits. Your Medica member number must be on the claim. Mail to: Medica Claims Route 2901 PO Box 659752 San Antonio, TX 78265-9752 Upon receipt of your claim for benefits from non- network providers, Medica will pay to you directly the non-network provider reimbursement amount. Medica will not accept your direction or authorization to pay the non-network provider. Medica will notify you of authorization or denial of the claim within 30 days of receipt of the claim. If your claim does not contain all the information Medica needs to make a determination, Medica may request additional information. Medica will notify you of its decision with 15 days of receipt of the additional information. If you do not respond to 89 MCS7 (1/02) BPL 56741 How To Submit A Claim Medica's request within 45 days, your claim may be denied. Claims for services provided outside the United States Claims for services rendered in a foreign country will require the following additional documentation: · Claims submitted in English with the currency exchange rate for the date health services were received. · Itemization of the bill or claim. · The related medical records (submitted in English). · Proof of your payment of the claim. · A complete copy of your passport and airline ticket. · Such other documentation as Medica may request. Time limits If you have a complaint or disagree with a decision by Medica, you may follow the complaint procedure outlined in Complaints or you may initiate legal action at any point. However, you may not bring legal action more than six years after Medica has made a coverage determination regarding your claim. MOS7 (1/02) 90 BPL 56741 Coordination Of Benefits BB. Coordination Of Benefits This section describes how benefits are coordinated when you are covered under more than one plan. 1. Applicability This coordination of benefits (COB) provision applies to this plan when an employee or the employee's covered dependent has health care coverage under more than one plan. Plan and this plan are defined below. If this coordination of benefits 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. Under the Order of benefit determination rules, the benefits of this plan: Shall not be reduced when this plan determines its benefits before another plan; but ii. May be reduced when another plan determines its benefits first. The above reduction is described in Effect on the benefits of this plan. 2. Definitions that apply to this section Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment: 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. ii. Coverage under a governmental plan, or coverage required or provided by law. This does not include a state plan under Medicaid (Title XIX, Grants to States for 91 MCS7 (1/02) BPL 56741 Coordination Of Benefits Medical Assistance Programs, of the United States Social Security Act, as amended from time to time). Each Contract or other arrangement for coverage under i. or ii. 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 Contract 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 as to another 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 two or more 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 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 person for whom the claim is made. The difference between the cost of a private hospital room and the cost of a semiprivate hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private hospital room is medically necessary, either in terms of generally accepted medical practice or as specifically defined in the plan. The difference between the charges billed by a provider and the non-network provider MCS7 (1/02) BPL 56741 92 Coordination Of Benefits reimbursement amount is not considered an allowable expense under the above definition. 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 a covered 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, and preferred provider arrangements. Claim determination period means a calendar year. However, it does not include any part of a year during which a person has no coverage under this plan, or any part of a year before the date this COB provision or a similar provision takes effect. 3. 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: i. The other plan has rules coordinating its benefits with the rules of this plan; and ii. Both the other plan's rules and this plan's rules, in number 3.b. below, 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: Nondependent/dependent. The benefits of the plan that covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the plan, which covers the person as a dependent. 93 MCS7 (1/02) BPL 56741 Coordination Of Benefits ii. III. Dependent child/parents not separated or divorced. Except as stated in 3.b.iii. 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 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 the 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, Dependent child/separated or divorced parents. If two or more plans cover a person 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; b) Then, the plan of the spouse of the parent with the custody of the child; 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 shall be the secondary plan. This paragraph does not apply with respect to any claim MCS7 (1/02) BPL 56741 · ' 94 iv. vi. vii. VIII. determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. 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 follow the Order of benefit determination rules outlined in number b.ii. Active/inactive employee. The benefits of a plan which covers a person as an employee who is neither laid off nor retired (or as that employee's dependent) are determined before those of a plan which covers that person as a laid off or retired employee (or as that employee's dependent). 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 is ignored. Workers' compensation. Coverage under any workers' compensation act or similar law applies first. You should submit claims for expenses incurred as a result of an on- duty injury to the employer, before submitting them to Medica. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance Act or similar law applies first. Longer/shorter length of coverage. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, member, or subscriber longer are determined before those of the plan which covered that person for the shorter term. 4. Effect on the benefits of this plan When this section applies. This number 4. applies when, in accordance with number 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that event, the benefits of this plan may be 95 Coordination Of Benefits MCS7 (1/02) BPL 56741 Coordination Of Benefits reduced under this section. Such other plan or plans are referred to as the otherplans in b. immediately below. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of: The benefits that would be payable for the allowable expense under this plan in the absence of this COB provision; and ii. The benefits that would be payable for the allowable expenses 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. For non-emergency services received from a non-network provider, and determined to be out-of-network benefits, the following reduction of benefits will apply: When this plan is a secondary plan, this plan will pay the balance of any remaining expenses determined to be eligible under the Contract, according to the out-of-network benefits described in this certificate. Most out-of- network benefits are covered at 80 percent of the non-network provider reimbursement amount, after you pay the applicable deductible amount. In no event will this plan provide duplicate coverage. 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. 5. Right to receive and release needed information Certain facts are needed to apply these COB rules. Medica has the right to decide which facts it needs. It may get needed facts from or give them to any other organization or person. Medica need not tell, MCS7 (1/02) 96 BPL 56741 Coordination Of Benefits or get the consent of, any person to do this. Unless applicable federal or state law prevents disclosure of the information without the consent of the patient or the patient's representative, each person claiming benefits under this plan must give Medica any facts it needs to pay the claim. 6. Facility of payment A payment made Under another plan may include an amount, which should have been paid under this plan. If it does, Medica may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under this plan. Medica 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. 7. Right of recovery If the amount of the payments made by Medica is more than it should have paid under this COB provision, it may recover the excess from one or more of the following: a. The persons it has paid or for whom it has paid; b. Insurance companies; or c. Other organizations. The amount of the payments made includes the reasonable cash value of any benefits provided in the form of services. 97 MCS7 (1/02) BPL 56741 Right Of Recovery CC. Right Of Recovery This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and federal law. Medica has a right of subrogation against any third party, individual, corporation, insurer, or other entity or person who may be legally responsible for payment of medical expenses related to your illness or injury. Medica's right of subrogation shall be governed according to this section. Medica's right to recover its subrogation interest applies only after you have received a full recovery for your illness or injury from another source of compensation for your illness or injury. Medica's subrogation interest is the reasonable cash value of any benefits received by you. Medica's right to recover its subrogation interest may be subject to an obligation by Medica to pay a pro rata share of your disbursements, attorney fees and costs, and other expenses incurred in obtaining a recovery from another source unless Medica is separately represented by an attorney. If Medica is represented by an attorney, an agreement regarding allocation may be reached. If an agreement cannot be reached, the matter must be submitted to binding arbitration. By accepting coverage under the Contract, you agree: a= To cooperate with Medica or its designee to help protect Medica's legal rights under this subrogation provision and to provide all information Medica may reasonably request to determine its rights under this provision. To provide prompt written notice to Medica when you make a claim against a party for injuries. To provide prompt written notice of Medica's subrogation rights to any party against whom you assert a claim for injuries. MCS7 (1/02) BPL 56741 98 Right Of Recovery To do nothing to decrease Medica's rights under this provision, either before or after receiving benefits, or under the Contract. Medica may take action to preserve its legal rights. This includes bringing suit in your name. Medica may collect its subrogation interest from the proceeds of any settlement or judgment recovered by you, your legal representative or the legal representative(s) of your estate or next-of-kin. To hold in trust the proceeds of any settlement or judgment for Medica's benefit under this provision. 99 MCS7 (1/02) BPL 56741 Eligibility And Enrollment DD. Eligibility And Enrollment This section describes who can enroll and how to enroll. Who can enroll To be eligible to enroll for coverage you must reside or work in the service area, meet the eligibility requirements of the Contract and be a subscriber or dependent as defined in the Contract. (A child who is the subject of a qualified medical child support order (QMCSO) and is otherwise eligible for coverage does not have to reside in the service area.) Extending a child's eligibility A dependent child is no longer eligible for Medica coverage when he or she reaches the dependent limiting age of 19 or as otherwise stated in the Contract. However, the child's eligibility continues in either of the following situations: · Handicapped dependent. The child is incapable of self-sustaining employment by reason of mental retardation, mental illness, mental disorder or physical handicap and is chiefly dependent upon the subscriber for support and maintenance. To continue coverage for a handicapped dependent, you must provide Medica with proof of such handicap and dependency within 31 days of the child reaching the dependent limiting age. Beginning two years after the child reaches the dependent limiting age, Medica will require annual proof of handicap and dependency. Your handicapped dependent is covered under the Contract regardless of age and without application of health screening or waiting periods. · Full-time student. The child is eligible up to the student limiting age of 25 or above age 25 if stated in the Contract if he or she is enrolled full-time in a recognized high school, college, university, trade or vocational school. To continue coverage for a full- time student dependent, you must provide Medica with proof of full-time student status within 31 days of the child reaching the dependent limiting age. If MCS7 (1/02) lOO BPL 56741 Eligibility And Enrollment the student is unable to carry a full-time course load due to illness, injury, or a physical or mental disability (as documented by a physician), full-time student status will be granted if the student carries at least 60 percent of a full-time course load, as determined by the educational institution that they are enrolled in. At a minimum, Medica will require annual proof of full-time student status, and may require such proof on a quarterly basis. Qualified Medical Child Support Order (QMCSO) Medica will provide coverage in accordance with a QMCSO pursuant to the applicable requirements under Section 609 of the Employee Retirement Income Security Act (ERISA) and Section 1908 of the Social Security Act. It is the employer's responsibility to determine whether a medical child support order is qualified. Upon receipt of a medical child support order issued by an appropriate court or governmental agency, the employer will follow its established procedures in determining whether the medical child support order is qualified. The employer will provide Medica with notice of a QMCSO and a copy of the order, along with an application for coverage, within the greater of 30 days after issuance of the order or the time in which the employer provides notice of its determination to the persons specified in the order. · Where a QMCSO requires coverage be provided under the Contract for an eligible employee's dependent child who is not already a member, such child will be provided a special enrollment period. · Where a QMCSO requires coverage be provided under the Contract for an eligible employee's dependent child who is already a member, such child will continue to be provided coverage under the Contract pursuant to the terms of the QMCSO. How to enroll You must submit an application for coverage for yourself and any dependents to the employer: 1. During the initial enrollment period as described in this section under Initial enrollment;, or 101 MCS7 (1/02) BPL 56741 Eligibility And Enrollment 2. During the open enrollment period as described in this section under Open enrollment, or 3. During a special enrollment period as described in this section under Special enrollment, or 4. At any time as a late entrant as described in this section under Late enrollment. Notification You must notify the employer in writing within 30 days of the effective date of any changes to address or name, addition or deletion of dependents, change in full-time student status for dependents beyond the dependent limiting age, or other facts identifying you or your dependents. (The notification period is not limited to 30 days for newborn dependents; however, we encourage you to enroll your newborn dependent under the Contract within 30 days from the date of birth.) The employer must notify Medica within 30 days of the effective date of your initial enrollment application, changes to your name or address, or changes to enrollment, including if you or your dependents are no longer eligible for coverage. Initial enrollment The period occurring within 30 days of first becoming eligible (or as otherwise stated under the Contract) during which an application for an eligible employee and any dependents must be submitted to the employer. Open enrollment The annual period during which eligible employees and dependents who are not covered under the Contract may elect coverage for the upcoming Contract year without application of health screening or waiting periods. An application must be submitted to the employer for yourself and any dependents. MOS7 (1/02) 102 BPL 56741 Eligibility And Enrollment Special enrollment Medica is required to allow special enrollment periods under certain circumstances. A special enrollment period will apply to an eligible employee and dependent if: The eligible employee or dependent was covered under qualifying coverage at the time the eligible employee or dependent was first eligible to enroll under the Contract and: a. Declined coverage in writing for that reason; and b. Presents to Medica either (i) evidence of the loss of prior coverage due to loss of eligibility for that coverage, or (ii) evidence that employer contributions toward the prior coverage have terminated; and c. Maintains continuous coverage; and d. Requests enrollment in writing within 30 days of the date of the loss of coverage or the date the employer's contribution toward that coverage terminates. For purposes of number 1 .: i. Prior coverage does not include continuation coverage required under federal law; ii. Loss of eligibility includes loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment; iii. Loss of eligibility does not include a loss due to failure of the eligible employee or dependent to pay premiums on a timely basis or termination of coverage for cause. The eligible employee or dependent was covered under benefits available under (i) the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or (ii) any state continuation laws applicable to the employer or Medica and: a. Declined coverage in writing for that reason; and 103 MCS7 (1/02) BPL 56741 Eligibility And Enrollment b. Presents to Medica evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to either failure of the eligible employee or dependent to pay premiums on a timely basis or for cause; and c. Maintains continuous coverage; and d. Requests enrollment in writing within 30 days of the loss of coverage. 3. The dependent is a new spouse of the subscriber or eligible employee, provided that the marriage is legal and enrollment is requested in writing within 30 days of the date of marriage. 4. The dependent is a new dependent child of the subscriber or eligible employee, provided that enrollment is requested in writing within 30 days of the subscriber or eligible employee acquiring the dependent (the notification period is not limited to 30 days for newborn dependents); 5. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in number 4. above claims dependent status and: a. That spouse is eligible for coverage; and b. Is not already enrolled under the Contract; and c. Enrollment is requested in writing within 30 days of the dependent child becoming a dependent. 6. The dependents are eligible dependent children of the subscriber or eligible employee and enrollment is requested in writing within 30 days of a dependent, as described in numbers 3. or 4. above, becoming eligible to enroll under the coverage. Additionally, when the employer provides Medica with notice of QMCSO and a copy of the order, as described in this section, Medica will provide the eligible dependent child with a special enrollment period. Late enrollment Medica may allow enrollment at other times agreed upon between Medica and the employer. Certain restrictions stated in the Contract may apply. MCS7 (1/02) 104 BPL 56741 Eligibility And Enrollment The date your coverage begins 1. For eligible employees and dependents who enroll during the initial enrollment period, coverage begins on the effective date specified in the Contract. 2. For eligible employees and dependents who enroll during the open enrollment period, coverage begins on the first day of the Contract year for which the open enrollment period was held. 3. For eligible employees and/or dependents who enroll during a special enrollment period, coverage begins on the date indicated below for the particular special enrollment. In the case of: Numbers 1., 2. or 3. under Special enrollment, coverage begins on the date specified in the Contract; Number 4. under Special enrollmenh in the case of birth, the date of birth; in the case of adoption or placement for adoption, date of adoption placement. In all other cases, the date the subscriber acquires the dependent child; Number 5. under Special enrollment, the date coverage for the dependent child is effective, as set forth in number 3.c. above; dm Number 6. under Special enrollment, the date coverage for the dependent identified in numbers 3. or 4. under Special enrollment becomes effective; e. A QMCSO, the first day of the first calendar month following the date the completed request for enrollment is received by Medica. For eligible employees and/or dependents who enroll during Late enrollment, coverage begins on the date specified in the Contract. 105 MCS7 (1/02) BPL 56741 Ending Coverage EE. Ending Coverage This section describes when coverage ends under the Contract. When this happens you may exercise your right to continue or convert your coverage as described in Continuation or Conversion. When coverage ends Unless otherwise specified in the Contract, coverage ends the earliest of the following: = = = The end of the month in which the Contract is terminated by the employer or Medica in accordance with the terms of the Contract. The end of the month for which the subscriber last paid his or her contribution toward the premium. The end of the month in which the subscriber retires or is pensioned, unless Medica and the employer have agreed to provide coverage for retirees under the Contract or a separate Medicare contract. The end of the month in which the subscriber is no longer eligible as determined by the employer. (See Eligibility And Enrollment for information on eligibility.) The end of the month in which the subscriber requests that coverage end. You must notify the employer to terminate coverage. The date specified by Medica in written notice to you that coverage ended due to fraud. Fraud includes but is not limited to: a. Knowingly providing Medica with false material information such as: i. Information related to your eligibility or another person's eligibility for coverage or status as a dependent; or ii. Information related to your health status or that of any dependent; or MOS7 (1/02) 106 BPL 56741 Ending Coverage b. Misrepresentation of the employer-employee relationship; or c. Permitting the use of your member identification card by any unauthorized person; or d. Using another person's member identification card; or e. Submitting fraudulent claims. 7. The end of the month following the date 31 days after we notify you that coverage will end because you did not pay a copayment or coinsurance for in- network benefits. 8. The end of the month following the date 31 days after we notify you that coverage will end because you do not live in the service area, provided the notification is made within one year following the date Medica was provided written notification of your address change. However, Medica may approve other arrangements. 9. The end of the month following the date you enter active military duty for more than 31 days. Upon completion of active military duty, contact the employer for reinstatement of coverage. 10. The end of the month following the date the subscriber's coverage ends. 11. The date of the death of the member. In the event of the subscriber's death, coverage for the subscriber's dependents will terminate the end of the month in which the subscriber's death occurred. 12. For a spouse, the end of the month following the date of divorce. 13. For a dependent child, the end of the month in which the child is no longer eligible as a dependent as specified in the Contract. 14. For a student, the end of the month in which the earliest of the following occurs: a. Graduation or completion of the term; Termination of full-time registration at the school for reasons other than graduation, except as specified in Eligibility And Enrollment or c. Reaching the student limiting age specified in the Contract. 107 MCS7 (1/02) BPL 56741 Ending Coverage 15. For a child who is entitled to coverage through a QMCSO, the end of the month in which the earliest of the following occurs: a. The QMCSO ceases to be effective; or b. The child is no longer a child as that term is used in ERISA; or c. The child has immediate and comparable coverage under another plan; or d, The employee who is ordered by the QMCSO to provide coverage is no longer eligible as determined by the employer; or e. The employer terminates family or dependent coverage; or f. The Contract is terminated by the employer or Medica; or g, The relevant premium or contribution toward the premium is last paid, MOS7 (1/02) .' 108 BPL 56741 Continuation FR Continuation This section describes continuation coverage provisions. When coverage ends, members may be able to continue coverage under state law, federal law, or both. The paragraph below describes the continuation coverage provisions. State continuation is described in number 1. and federal continuation is described in number 2. If your coverage ends, you should review your rights under both state law and federal law with the employer. If you are entitled to continuation rights under both, the continuation provisions run concurrently and the more favorable continuation provision will apply to your coverage. 1. Your right to continue coverage under state law Notwithstanding the provisions regarding termination of coverage described in Ending Your Coverage, you may be entitled to extended or continued coverage as follows: Minnesota state continuation coverage. Continued coverage shall be provided as required under Minnesota law. Minnesota state continuation requirements apply to all group health plans that are subject to state regulation, regardless of the number of employees in the group. The employer shall, within the parameters of Minnesota law, establish uniform policies pursuant to which such continuation coverage will be provided. Notice of rights. Minnesota law requires that covered employees and their dependents (spouse and/or dependent children) be offered the opportunity to pay for a temporary extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under an employer sponsored group health plan(s) would otherwise end. This notice is intended to inform you, in summary fashion, of your rights and obligations under the continuation coverage provision of Minnesota law. 109 MCS7 (1/02) BPL 56741 Continuation It is intended that no greater rights be provided than those required by Minnesota law. Take time to read this section carefully. Subscriber's loss The subscriber has the right to continuation of coverage for him or herself and his or her dependents if there is a loss of coverage under the Contract because of the subscriber's voluntary or involuntary termination of employment (for any reason other than gross misconduct) or layoff from employment. Subscriber's spouse's loss The subscriber's covered spouse has the right to continuation coverage if he or she loses coverage under the Contract for any of the following reasons: a. Death of the subscriber; A termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; c. Dissolution of marriage from the subscriber; d. The subscriber's enrollment for benefits under Medicare. Subscriber's child's loss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following reasons: aR Death of the subscriber if the subscriber is the parent through whom the child receives coverage; Termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; c. The subscriber's dissolution of marriage from the child's other parent; dm The subscriber's enrollment for benefits under Medicare if the subscriber is the parent through whom the child receives coverage; MCS7 (1/02) BPL 56741 110 Continuation The subscriber's child ceases to be a dependent child under the terms of the Contract. Responsibility to inform Under Minnesota law, the subscriber and dependents have the responsibility to inform the employer of a dissolution of marriage or a child losing dependent status under the Contract within 60 days of the date of the event or the date on which coverage would be lost because of the event. Election rights When the employer is notified that one of these events has happened, the subscriber and the subscriber's dependents will be notified of the right to continuation coverage. Under Minnesota law, the subscriber and dependents have at least 60 days to elect continuation coverage for reasons of termination of the subscriber's employment or the subscriber's enrollment for benefits under Medicare measured from the later of: a. The date coverage would be lost because of one of the events described above; or b. The date notice of election rights is received. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The subscriber and the subscriber's covered spouse may elect continuation coverage on behalf of other dependents entitled to continuation coverage. Under certain circumstances, the subscriber's covered spouse or dependent child may elect continuation coverage even if the subscriber does not elect continuation coverage. Type of coverage and cost If continuation coverage is elected, the subscriber's employer is required to provide coverage that, as of the time coverage is being provided, is identical to the coverage provided under the Contract to 111 MCS7 (1/02) BPL 56741 Continuation similarly situated employees or employees' dependents. Under Minnesota law, a person continuing coverage may have to make a monthly payment to the employer of all or part of the premium for continuation coverage. The amount charged cannot exceed 102 percent of the cost of the coverage. Duration Under the circumstances described above and for a certain period of time, Minnesota law requires that the subscriber and his or her dependents be allowed to maintain continuation coverage as follows: C= For instances where coverage is lost due to the subscriber's termination of or layoff from employment, coverage may be continued until the earliest of: i. 18 months after the date of the termination of or layoff from employment; ii. The date the subscriber becomes covered under another group health plan (as an employee or otherwise) that does not contain any exclusion or limitation with respect to any applicable pre-existing condition; or iii. The date coverage would otherwise terminate under the Contract. For instances where the subscriber's spouse or dependent children lose coverage because of the subscriber's enrollment under Medicare, coverage may be continued until the earliest of: i. 36 months after continuation was elected; ii. The date coverage is obtained under another group health plan or Medicare; or iii. The date coverage would otherwise terminate under the Contract. For instances where dependent children lose coverage as a result of loss of dependent MOS7 (1/02) BPL 56741 112 Continuation eligibility, coverage may be continued until the earliest of: i. 36 months after continuation was elected; ii. The date coverage is obtained under another group health plan or Medicare; or iii. The date coverage would otherwise terminate under the Contract. For instances of dissolution of marriage from the subscriber, coverage of the subscriber's spouse and dependent children may be continued until the earliest of: The date the former spouse becomes covered under another group health plan or Medicare; or ii. The date coverage would otherwise terminate under the Contract. If a dissolution of marriage occurs during the period of time when the subscriber's spouse is continuing coverage due to the subscriber's termination of or layoff from employment, coverage of the subscriber's spouse may be continued until the earlier of: The date the former spouse becomes covered under another group health plan or Medicare; or ii. The date coverage would otherwise terminate under the Contract. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of: The date the surviving spouse and dependent children become covered under another group health plan or Medicare, or ii. The date coverage would have terminated under the Contract had the subscriber lived. When your continuation coverage under this section ends, you have the option to enroll in an 113 MCS7 (1/02) BPL 56741 Continuation = individual conversion health plan (as described in Conversion). Extension of benefits for total disability of the subscriber Coverage may be extended for a subscriber and his or her dependents in instances where the subscriber is absent from work due to total disability, as defined in Definitions. If the subscriber is required to pay all or part of the premium for the extension of coverage, payment shall be made to the employer. The amount charged cannot exceed 100 percent of the cost of the coverage. Your right to continue coverage under federal law Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: COBRA continuation coverage. Continued coverage shall be provided as required under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended (as well as the Public Health Service Act (PHSA), as amended). The employer shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See COBRA Initial Notice of Rights below. COBRA Initial Notice of Rights. COBRA requires employers with 20 or more employees to offer subscribers and their families (spouse and/or dependent children) the opportunity to pay for a temporary extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under employer sponsored group health plan(s) would otherwise end. This notice is intended to inform you, in summary fashion, of your rights and obligations under the continuation coverage provision of federal law. It is intended that no greater rights be provided than those required by federal law. Take time to read this notice carefully. MCS7 (1/02) BPL 56741 114 Continuation Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as: A covered employee (a current or former employee who is actually covered under a group health plan and not just eligible for coverage); b. A covered spouse of a covered employee; or A dependent child of a covered employee. (As of January 1, 1997, a child placed for adoption with or born to an employee or former employee receiving COBRA continuation coverage is also a qualified beneficiary.) Subscriber's loss The subscriber has the right to elect continuation of coverage if there is a loss of coverage under the Contract because of termination of the subscriber's employment (for any reason other than gross misconduct), or the subscriber becomes ineligible to participate under the terms of the Contract due to a reduction in his or her hours of employment. Subscriber's spouse's loss The subscriber's covered spouse has the right to choose continuation coverage if he or she loses coverage under the Contract for any of the following reasons: a. Death of the subscriber; A termination of the subscriber's em ployment (for any reason other than gross misconduct) or reduction in the subscriber's hours of employment with the employer; c. Divorce or legal separation from the subscriber; or d. The subscriber's entitlement to (actual coverage under) Medicare. 115 MCS7 (1/02) BPL 56741 Continuation Subscriber's child's loss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following reasons: C= Death of the subscriber if the subscriber is the parent through whom the child receives coverage; The subscriber's termination of employment (for any reason other than gross misconduct) or reduction in the subscriber's hours of employment with the employer; The subscriber's divorce or legal separation from the child's other parent; The subscriber's entitlement to (actual coverage under) Medicare if the subscriber is the parent through whom the child receives coverage; or The subscriber's child ceases to be a dependent child under the terms of the Contract. Responsibility to inform Under federal law, the subscriber and dependent have the responsibility to inform the employer of a divorce, legal separation, or a child losing dependent status under the Contract within 60 days of the date of the event, or the date on which coverage would be lost because of the event. Also, a subscriber and dependent who have been determined to be disabled under the Social Security Act as of the time of the subscriber's termination of employment or reduction of hours or within 60 days of the start of the continuation period must notify the employer of that determination within 60 days of the determination. If determined under the Social Security Act to no longer be disabled, he or she must notify the employer within 30 days of the determination. MCS7 (1/02) 116 BPL 56741 Continuation Bankruptcy Rights similar to those described above may apply to retirees (and the spouses and dependents of those retirees), if the subscriber's employer commences a bankruptcy proceeding and these individuals lose coverage. Election rights When notified that one of these events has happened, the employer will notify the subscriber and dependents of the right to choose continuation coverage. Under federal law, the subscriber and dependents have at least 60 days to elect continuation coverage, measured from the later of: a. The date coverage would be lost because of one of the events described above, or The date notice of election rights is received. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The subscriber and the subscriber's covered spouse may elect continuation coverage on behalf of other dependents entitled to continuation coverage. However, each person entitled to continuation coverage has an independent right to elect continuation coverage. The subscriber's covered spouse or dependent child may elect continuation coverage even if the subscriber does not elect continuation coverage. Type of coverage and cost If the subscriber and the subscriber's dependents elect continuation coverage, the employer is required to provide coverage that, as of the time coverage is being provided, is identical to the coverage provided under the Contract to similarly situated employees or employees' dependents. Under federal law, a person electing continuation coverage may have to pay all or part of the premium for continuation coverage. The amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 117 MCS7 (1/02) BPL 56741 Continuation 150 percent of the applicable premium for months after the 18th month of continuation coverage when the additional months are due to a disability under the Social Security Act. There is a grace period of at least 30 days for the regularly scheduled premium. Duration Federal law requires that you be allowed to maintain continuation coverage for 36 months unless you lost coverage under the Contract because of termination of employment or reduction in hours. In that case, the required continuation coverage period is 18 months. The 18 months may be extended if a second event (e.g., divorce, legal separation or death) occurs during the initial 18-month period. It also may be extended to 29 months in the case of an employee or employee's dependent who is determined to be disabled under the Social Security Act at the time of the employee's termination of employment or reduction of hours, or within 60 days of the start of the 18-month continuation period. As of January 1, 1997, if an employee or the employee's dependent is entitled to 29 months of continuation coverage due to his or her disability, the other family members' continuation period is also extended to 29 months. If the subscriber becomes entitled to (actually covered under) Medicare, the continuation period for the subscriber's dependents is 36 months measured from the date of the subscriber's Medicare entitlement even if that entitlement does not cause the subscriber to lose coverage. Federal law provides that continuation coverage may end earlier for any of the following reasons: a. The subscriber's employer no longer provides group health coverage to any of its employees; b. The premium for continuation coverage is not paid on time; Coverage is obtained under another group health plan (as an employee or otherwise) that does not contain any exclusion or limitation with MCS7 (1/02) BPL 56741 118 Continuation d= respect to any applicable pre-existing condition; or The subscriber becomes entitled to (actually covered under) Medicare. 119 MCS7 (1/02) BPL 56741 Conversion GG. Conversion This section describes your right to convert to a Medica individual conversion plan if other group coverage is unavailable. Overview If other group coverage is not available, you are eligible to convert to an HMO individual conversion plan without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in Continuation, is exhausted. Your coverage or continuation coverage ends under the Contract because the Contract is terminated. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. If you move from the service area but still reside in Minnesota, you are eligible to convert to an insurance conversion plan without proof of good health or waiting periods. Your conversion plan goes into effect the date your other coverage ends. You may select a qualified 1,2 or 3 conversion plan. You must maintain continuous coverage when applying for conversion coverage. 4. Conversion coverage is not available if: a. Continuous coverage is not maintained; or b. You have not exhausted your right to continue coverage as described in Continuation; or c. You are eligible for other group coverage. For purposes of numbers 3. and 4.a. above, continuous coverage will be determined to have been maintained if you request enrollment for conversion within 63 days after your coverage ends or within 31 MCS7 (1/02) -' 120 BPL 56741 Conversion days of the date you were notified of the right to convert coverage, whichever is later. What you must do For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. = Pay premiums to Medica within 63 days after your coverage ends or within 31 days of the date you were notified of your right to convert coverage, whichever is later. You will be required to include your first month premium payment with your enrollment form for conversion coverage. = Submit an enrollment form to Medica within 63 days after your coverage ends or within 31 days of the date you were notified of your right to convert, whichever is later. You may include only those dependents who were enrolled under the Contract at the time of conversion. What the employer must do The employer is required to notify you of your right to convert coverage. 121 MCS7 (1/02) BPL 56741 Complaints HH. Complaints This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. You may call Customer Service at one of the telephone numbers listed inside the front cover or by writing to the address below in First level of review. You also may contact the Commissioner of Health, Minnesota Department of Health, at (651) 282-5600 or 1-800-657-3916, regarding complaints about in-network benefits, or the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296-2488 or 1-800-657-3602, regarding complaints about out-of- network benefits. Complaint: Means any grievance against Medica, submitted by you or another person on your behalf, that is not the subject of litigation. Complaints may involve, but are not limited to, the scope of coverage for health care services; retrospective denials or limitations of payment for services; eligibility issues; denials, cancellations, or non- renewals of coverage; administrative operations; and the quality, timeliness, and appropriateness of health care services rendered. If the complaint is from an applicant, the complaint must relate to the application. If the complaint is from a former member, the complaint must relate to services received during the time the individual was a member. Medical Necessity Review: Means Medica's evaluation of the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, for the purpose of determining the medical necessity of the service or admission. First level of review You may direct any question or complaint to Customer Service by calling one of the telephone numbers listed inside the front cover or by writing to the address listed below. MCS7 (1/02) 122 BPL 56741 Complaints Complaints that do not involve a medical necessity review by Medica: a= For an oral complaint, if Medica does not communicate a decision within 10 business days from Medica's receipt of the complaint, or if you determine that Medica's decision is partially or wholly adverse to you, Medica will provide you with a complaint form to submit your complaint in writing. Mail the completed form to: Customer Service Route 0501 PO Box 9310 Minneapolis, MN 55440-9310 Medica will provide written notice of its first level review decision to you within 30 calendar days from the initial receipt of your complaint or request. For a written complaint, Medica will provide written notice of its first level review decision to you within 30 calendar days from initial receipt of your complaint. If Medica's first level review decision upholds the initial decision made by Medica, you have a right to request a second level review. The second level of review, as described in number 2. below, must be exhausted before you have the right to submit a request for external review. Complaints that involve a medical necessity review by Medica: am Your complaint must be made within one year following Medica's initial decision and may be made orally or in writing. b= Medica will provide written notice of its first level review decision to you and your attending provider, when applicable, within 30 calendar days from receipt of your complaint. Gm When an initial decision by Medica does not grant a prior authorization request made before or during an ongoing service, and 123 MCS7 (1/02) BPL 56741 Complaints your attending provider believes that Medica's decision warrants an expedited review, you or your attending provider will have the opportunity to request an expedited review by telephone. Alternatively, if Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function, Medica will process your claim as an expedited review. In such cases, Medica will notify you and your attending provider by telephone of its decision no later than 72 hours after receiving the request. If Medica's first level review decision upholds the initial decision made by Medica, you may have a right to request a second level review or submit a written request for external review as described in this section. The second level of review is optional and you may submit a request for external review without exhausting the second level of review. Second level of review If you are not satisfied with Medica's first level review decision, you may request a second level of review through either a written reconsideration or a hearing. Your request can be oral or in writing. It must be provided to Medica within one year following the date of Medica's first level review decision. If your request is in writing, it must be sent to: Customer Service Route 0501 PO Box 9310 Minneapolis, MN 55440-9310 Regardless of the method chosen for review (hearing or a written reconsideration), testimony, explanation or other information provided by you, Medica staff, providers and others is reviewed. Medica will provide written notice of its second level review decision to you within: MCS7 (1/02) 124 BPL 56741 ComPlaints 30 calendar days from receipt of your request for second level review for required second level reviews; or 45 calendar days from receipt of your request for second level review for optional second level reviews. External review If you consider Medica's decision to be partially or wholly adverse to you, you have a right to submit a written request for external review to the Commissioner of Health for issues related to in- network benefits or the Commissioner of Commerce for issues related to out-of-network benefits. Please contact the Commissioner at: Minnesota Department of Health PO Box 64975 St. Paul, MN 55164-0975 (651) 282-5600 or 1-800-657-3916 Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101-2198 (651) 296-6789 or 1-800-657-3602 An independent entity contracted with the State Commissioner of Administration will review your request. The external review decision will not be binding on you but will be binding on Medica. Contact the Commissioner of Health or the Commissioner of Commerce for more information about the external review process. Civil action If you remain dissatisfied with Medica's determination after completing the required appeals process, you have the right to file a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA). 125 MOS7 (1/02) BPL 56741 General Provisions II. General Provisions This section describes the general provisions of the Contract. Examination of a member To settle a dispute concerning provision or payment of out-of-network benefits under the Contract, Medica may require that you be examined or an autopsy of the member's body be performed, unless prohibited by law. The examination or autopsy will be at Medica's expense. Clerical error You will not be deprived of coverage under the Contract because of a clerical error. However, you will not be eligible for coverage beyond the scheduled termination of your coverage because of a failure to record the termination. Relationship between parties The relationships between Medica, the employer and network providers are contractual relationships between independent contractors. Network providers are not agents or employees of Medica. The relationship between a provider and any member is that of health care provider and patient. The provider is solely responsible for health care provided to any member. Assignment Medica will have the right to assign any and all of its rights and responsibilities under the Contract to any subsidiary or affiliate of Medica or to any other appropriate organization or entity. MCS7 (1/02) 126 BPL 56741 General Provisions Notice Except as otherwise provided in this certificate, written notice given by Medica to an authorized representative of the employer will be deemed notice to all affected in the administration of the Contract in the event of termination or nonrenewal of the Contract. However, notice of termination for nonpayment of premium shall be given by Medica to an authorized representative of the employer and to each subscriber. Entire agreement This certificate, the master group contract and its appendices, and any amendments are the entire Contract between the employer and Medica, and replace all other agreements as of the effective date of the Contract. Amendment This certificate may be amended in accordance with the Contract. When this happens, you will receive a new certificate or amendment. No other person or entity has authority to make any changes or amendments to this certificate. All amendments must be in writing. Discretionary authority Medica has discretion to interpret and construe all of the terms and conditions of the Contract and make determinations regarding benefits and coverage under the Contract. 127 MCS7 (1/02) BPL 56741 Definitions Definitions In this certificate (and in any amendments), some words have specific meanings. Benefits Certification of qualifying coverage Claim Coinsurance The health services or supplies (described in this certificate and any subsequent amendments) approved by Medica as eligible for coverage. A written certification that group health plans and health insurance issuers must provide to an individual to confirm the qualifying coverage provided to the individual under the group health plan or health insurance. An invoice, bill or itemized statement for benefits provided to you. The pementage amount you must pay to the provider for benefits received. Full coinsurance payments may apply to scheduled appointments canceled less than 24 hours before the appointment time or to missed appointments. For in-network benefits, the coinsurance amount typically is based on the lesser of the: 1. Charge billed by the provider (i.e., retail), or 2. Negotiated amount that the provider has agreed to accept as full payment for the benefit (i.e., wholesale). When the wholesale amount is not known nor readily calculated at the time the benefit is provided, Medica uses an amount to approximate the wholesale amount. For services from some network providers, however, the coinsurance is based on the provider's retail charge. The provider's retail charge is the amount that the provider would charge to any patient, whether or not that patient is a Medica member. For out-of-network benefits, the coinsurance will be based on the lesser of the: 1. Charge billed by the provider (i.e., retail) or 2. Non-network provider reimbursement amount. MCS7 (1/02) BPL 56741 128 Definitions Continuous coverage Convenient/urgent care center Copayment For out-of-network benefits, in addition to any copayment, coinsurance and deductible amounts, you are responsible for any charges billed by the provider in excess of the non- network provider reimbursement amount. In addition, for the network pharmacies described in Prescription Drugs And Pharmacy Services and Mail Service Prescription Drug Program, the calculation of coinsurance amounts as described above do not include possible reductions for any volume purchase discounts or price adjustments that Medica may later receive related to certain prescription drugs and pharmacy services. The coinsurance may not exceed the charge billed by the provider for the benefit. The maintenance of continuous and uninterrupted qualifying coverage by an eligible employee or dependent. An eligible employee or dependent is considered to have maintained continuous coverage if enrollment is requested under the Contract within 63 days of termination of the previous qualifying coverage. A health care facility distinguishable from an affiliated clinic or hospital whose primary purpose is to offer and provide immediate, short-term medical care for minor, immediate medical conditions on a regular or routine basis. The fixed dollar amount you must pay to the provider for benefits received. Full copayments may apply to scheduled appointments canceled less than 24 hours before the appointment time or to missed appointments. When you receive eligible health services from a network provider and a copayment applies, you pay the lesser of the charge billed by the provider for the benefit (i.e., retail) or your copayment. Medica pays any remaining amount according to the written agreement between Medica and the provider. The copayment may not exceed the retail charge billed by the provider for the benefit. For out-of-network benefits, in addition to any copayment, coinsurance and deductible amounts, you are responsible for any charges in excess of the non-network provider reimbursement amount, · ' 129 MCS7 (1/02) BPL 56741 Definitions Cosmetic Custodial care Deductible Dependent Services and procedures that improve physical appearance but do not correct or improve a physiological function, and that are not medically necessary, unless the service or procedure meets the definition of reconstructive. Services to assist in activities of daily living that do not seek to cure, are performed regularly as a part of a routine or schedule, and, due to the physical stability of the condition, do not need to be provided or directed by a skilled medical professional. These services include help in walking, getting in or out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that can usually be self-administered. The fixed dollar amount you must pay before claims for health services or supplies received from non-network providers are reimbursable as out-of-network benefits under this certificate. Unless otherwise specified in the Contract, the subscriber's 1. Spouse 2. Unmarried child who is a: a. Natural or adopted child b. Child placed for adoption with the subscriber c. Stepchild Unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. In addition, a child under legal guardianship of the subscriber will be considered a dependent. However, the subscriber must provide satisfactory proof of dependency upon request by Medica. See Extending a child's eligibility in Eligibility And Enrollment for details regarding dependent limiting ages. A child who is the subject of a qualified medical child support order (QMCSO) is not considered a dependent for purposes of coverage under the Contract and may not enroll dependents for coverage, See the definition of subscriber. MCS7 (1/02) BPL 56741 130 Definitions Emergency Enrollment date Hospital Inpatient Investigative A condition or symptom that a prudent layperson would believe requires immediate treatment to: 1. Preserve your life; or 2. Prevent serious impairment to your bodily functions, organs, or parts; or 3. Prevent placing your physical or mental health in serious jeopardy. The date of the eligible employee's or dependent's first day of coverage under the Contract or, if earlier, the first day of the waiting period for the eligible employee's or dependent's enrollment. A licensed facility that provides diagnostic, medical, therapeutic, rehabilitative and surgical services by, or under the direction of, a physician and with 24-hour R.N. nursing services. The hospital is not mainly a place for rest or custodial care, and is not a nursing home or similar facility. An uninterrupted stay of 24 hours or more in a hospital, skilled nursing facility or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally handicapped children will be covered as any other health condition. As determined by Medica, a drug, device, diagnostic or screening procedure, or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness or effect on health outcomes. Medica will make its determination based upon an examination of the following reliable evidence, none of which shall be determinative in and of itself: Whether there is final approval from the appropriate government regulatory agency, if required, including whether the drug or device has received final approval to be marketed for its proposed use by the United States Food and Drug Administration (FDA), or whether the treatment is the subject of ongoing Phase I, II or III trials; 131 MCS7 (1/02) BPL 56741 Definitions Late entrant Whether there are consensus opinions and recommendations reported in relevant scientific and medical literature, peer-reviewed journals or the reports of clinical trial committees and other technology assessment bodies; and Whether there are consensus opinions of national and local health care providers in the applicable specialty or subspecialty that typically manages the condition as determined by a survey or poll of a representative sampling of these providers. Not withstanding the above, a drug being used for an indication or at a dosage that is an accepted off-label use for the treatment of cancer will not be considered by Medica to be investigative. Medica will determine if a use is an accepted off-label use based on published reports in authoritative peer-reviewed medical literature, clinical practice guidelines or parameters approved by national health professional boards or associations and entries in the following drug compendia: The American Hospital Formulary Service Drug Information and the United States Pharmacopeia Dispensing Information. An eligible employee or dependent who requests enrollment under the Contract other than during: 1. The initial enrollment period set by the employer; or 2. The open enrollment period set by the employer; or 3. A special enrollment period as described in Eligibility and Enrollment. However, an eligible employee or dependent who is an enrollee of the Minnesota Comprehensive Health Association (MCHA) at the time Medica offers or renews coverage with the employer will not be considered a late entrant, provided the eligible employee or dependent maintains continuous coverage as defined in this certificate. In addition, a subscriber who is a child entitled to receive coverage through a QMCSO is not subject to any initial or open enrollment period restrictions. MCS7 (1/02) BPL 56741 132 Definitions Medically necessary Member Mental disorder Network Non-network Non=network provider reimbursement amount Diagnostic testing and medical treatment, consistent with the diagnosis of and prescribed course of treatment for your condition, and preventive services. Medically necessary care must meet the following criteria: 1. Be consistent with the medical standards and accepted practice parameters of the community as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure or treatment at issue; and 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your diagnosis or condition; and 3. Help to restore or maintain your health; or 4. Prevent deterioration of your condition; or 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. A person who is enrolled under the Contract. A physical or mental condition having an emotional or psychological origin, as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). A term used to describe a provider (such as a hospital, physician, home health agency, skilled nursing facility or pharmacy) that has entered into a written agreement with Medica or has made other arrangements with Medica to provide benefits to you. The participation status of providers will change from time to time. The Medica network provider directory will be furnished automatically, without charge. A term used to describe a provider not under contract as a network provider. The amount that MIC will pay to a non-network provider for each benefit is equal to the lesser of the: 1. Provider's charge; or 133 MCS7 (1/02) BPL 56741 Definitions Physician Placed for adoption Premium Prenatal care Prescription drug Amount MIC determines, based on prevailing reimbursement rates or marketplace charges, for similar services and supplies, in the geographic area in which the benefit is provided. For hospital benefits, the non-network provider reimbursement amount may also be equal to the lesser of 1. or 2. above or the amount the hospital and MIC have agreed upon. If the amount billed by the non-network provider is greater than the non-network provider reimbursement amount, you must pay the difference. Such difference is in addition to any copayment, coinsurance or deductible amount you may be responsible for according to the terms described in this certificate. In addition, such difference will not be applied to the out-of-pocket maximum described in Your Out-Of-Pocket Expenses. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.) or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. The assumption and retention of the legal obligation for total or partial support of the child in anticipation of adopting such child. (Eligibility for a child placed for adoption with the subscriber ends if the placement is interrupted before legal adoption is finalized and the child is removed from placement.) The monthly payment required to be paid by the employer on behalf of or for you. The comprehensive package of medical and psychosocial support provided throughout a pregnancy and related directly to the care of the pregnancy, including risk assessment, serial surveillance, prenatal education and use of specialized skills and technology, when needed, as defined by Standards for Obstetric-Gynecologic Services issued by the American College of Obstetricians and Gynecologists. A drug approved by the FDA for the prescribed use and route of administration. MCS7 (1/02) BPL 56741 134 Definitions Provider Qualifying coverage A health care professional or facility licensed, certified or otherwise qualified under state law to provide health services. Health coverage provided under one of the following plans: 1. A health plan in which a health carrier has issued a policy, contract or certificate for the coverage of medical and hospital benefits, including blanket accident and sickness insurance other than accident only coverage; 2. Part A or Part B of Medicare; 3. A medical assistance medical care plan as defined under Minnesota law; 4. A general assistance medical care plan as defined under Minnesota law; 5. Minnesota Comprehensive Health Association (MCHA); 6. A self-insured health plan; 7. The MinnesotaCare program as defined under Minnesota law; 8. The public employee insurance plan as defined under Minnesota law; 9. The Minnesota employees insurance plan as defined under Minnesota law; 10. TRICARE or other similar coverage provided under federal law applicable to the armed forces; 11. Coverage provided by a health care network cooperative or by a health provider cooperative; 12. The Federal Employees Health Benefits Plan or other similar coverage provided under federal law applicable to government organizations and employees; 13. A medical care program of the Indian Health Service or of a tribal organization; 14. A health benefit plan under the Peace Corps Act; 135 MCS7 (1/02) BPL 56741 Definitions Reconstructive 15. A plan similar to any of the above plans provided in the State of Minnesota or in another state, as determined by the Commissioner of Health or the Commissioner of Commerce. Coverage of the following types, including any combination of the following types, are not qualifying coverage: 1. Coverage only for disability or income protection insurance; 2. Automobile medical payment coverage; 3. Liability insurance or coverage issued as a supplement to liability insurance; Coverage for a specified disease or illness or to provide payments on a per diem, fixed indemnity, or non-expense- incurred basis, if offered as independent, non-coordinated coverage; 5. Credit accident and health insurance as defined under Minnesota law; 6. Coverage designed solely to provide dental or vision care; 7. Accident only coverage; 8. Long-term care coverage as defined under Minnesota law; 9. Medicare supplemental health insurance as defined under Minnesota law; 10. Workers' compensation insurance; or 11. Coverage for on-site medical clinics operated by an employer for the benefit of the employer's employees and their dependents, in connection with which the employer does not transfer risk. Surgery to rebuild or correct a: Body part when such surgery is incidental to or following surgery resulting from injury, sickness or disease of the involved body part; or 2. Congenital disease or anomaly which has resulted in a functional defect as determined by your physician. MCS7 (1/02) BPL 56741 136 Definitions Restorative Service area Skilled care Skilled nursing facility Subscriber In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance shall be considered reconstructive. Surgery that is cosmetic is not reconstructive. Surgery to rebuild or correct a physical defect that has a direct adverse effect on the physical health of a body part, and for which the restoration or correction is medically necessary. The geographic area in which Medica is approved to provide coverage for in-network benefits. You may contact Customer Service for a current description of the service area. Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to develop provide and evaluate your care and assess your changing condition. Long- term dependence on respiratory support equipment and/or the fact that services are received from technical or professional medical personnel do not by themselves define the need for skilled care. A licensed bed or facility (including an extended care facility, hospital swing-bed and transitional care unit) that provides skilled nursing care, skilled transitional care, or other related health services including rehabilitative services. The person: 1. On whose behalf premium is paid; and 2. Whose employment is the basis for membership, according to the Contract; and 3. Who is enrolled under the Contract. The definition of subscriber may also include a child for whom an employee is required to provide health coverage through a QMCSO. The child is considered a subscriber only if the: Employer has determined and notified Medica that the support order is effective and meets all criteria of a QMCSO, as that term is used in the Employee Retirement Income Security Act (ERISA); and 137 MCS7 (1/02) BPL 56741 Definitions Total disability Waiting period 2. Relevant employee is eligible to enroll for coverage according to the terms of the Contract. When the subscriber is a child who is eligible for coverage as a result of a QMCSO, the child's certain rights and obligations pertaining to other subscribers are modified according to the terms of the Contract. Disability due to injury, sickness or pregnancy that requires regular care and attendance of a physician, and in the opinion of the physician renders the employee unable to perform the duties of his or her regular business or occupation during the first two years of the disability and, after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she is reasonably fitted. In accordance with applicable state and federal laws, the period of time that must pass before an otherwise eligible employee and/or dependent is eligible to become covered under the Contract (as determined by the employer's eligibility requirements). However, if an eligible employee or dependent enrolls as a late entrant or through a special enrollment period as set forth in Special enrollment in Eligibility And Enrollment, any period before such late or special enrollment is not a waiting period. MCS7 (1/02) BPL 56741 138 Ogow. Haddii aad dooneyso in lagaa kaalmeeyo tarjamad~d~ maclmmmadkani, wac Medica: 1-800-952-3455. 1-800-952-3455: Medica eib. ~ Bmmasme: F. aa~ Ba~s ayama 6ecnaam~ IIOMOII~ B nepeBo~e 3xofi lll-Ill~opMallllg, noaBomrre no caelxy~omemy Teae~bomy: Medica: 1-800-952-3455. PqS~tna'm'~ Medica: 1-800-952-3455. AtenciSn. Si desea recibir asistencia gramita para traducir esta informncibn, Hsme a Medica: 1-800-952-3455. ~e~,~ Medica: 1-800-952-3455. Chii'. cia dich thOng-tin aly mien phi, xin ggi Medica: 1-800-952-3455. Ceeb teem. Yog koj xav tau kev pab txhai.q cov xov no mu koj dawb, hu Medica: 1-800-952-3455. Pa~nja. Ako yam je potrebna besplatna pomo~ za preyed eve informacije, nazovite Medica: 1-800-952-3455. Hubaddhu. Ye akka odeeffnnnoon lam sii hiikamu gargaarsa tolaa feeta ta'e, bilbila kana bilbili Medica: 1-800-952-3455. Attention. ff you want free help translating this information, call 1-800-952-3455. © 2003 Medica. Medica ® is a registered trademark of Me&ca. 'Wledica" refers to the family of health plan bn.qlnesses that includes Medica Holding Company, Medica Health Plans, Medica Health Plans of Wisconsin; Me&ca Insurance Company, Medica Self-Insured, Me&ca Foundation, and Me. dim Affiliated Services. ME7 BPL #97425 AMENDMENT TO THE CERTIFICATE OF COVERAGE This amendment modifies your Medica Certificate of Coverage effective January 1, 2002 except as otherwise noted below. I. The following is added to the definition of "Network" as found in the Section rifled Definitions: The Medica network provider directory will be furnished automatically, without charge. II. The definition of "Reconstructive" as found in the Section rifled Definitions is deleted and replaced with the following: Reconstructive Surgery to rebuild or correct a: 1. Body part when such surgery is incidental to or following surgery resulting from injury, sickness or disease of the involved body part; or 2. Congenital disease or anomaly which has resulted in a functional defect as determined by your physician. In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance shall be considered reconstructive. Surgery that is cosmetic is not reconstructive. III. The definition of "Standing referral" as found in the Section rifled Definitions is deleted and replaced with the following: A referral issued by your primary care clinic for conditions that require ongoing services from a specialist provider. You may apply for, and if appropriate, receive a standing referral for: 1) a chronic health condition; 2) a life-threatening mental or physical illness; 3) pregnancy beyond the first trimester of pregnancy; 4) a degenerative disease or disability; or 5) any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist provider. You may request an extension of a standing referral by contacting your primary care clinic. Standing referrals will only be authorized for the period of time appropriate to your medical condition. Standing referrals will not be issued to accommodate personal preferences, family convenience, or other non- medical reasons. Standing referrals will also not be issued for care that has already been provided. I¥. The following is added to the Section titled Introduction: Continuity of Care In certain situations, you have a right to continuity of care. a. IfMedica terminates its contract with your current primary care provider, SPecialist or hospital without cause, you may be eligible to continue care with that provider at the in-network benefit level. b. If you are a new Medica member as a result of your Employer changing health plans and your current primary care provider, specialist or hospital is not a network provider, you may be eligible to continue care with that provider at the in-network benefit level. This applies only if your provider agrees to comply with Medica's prior approval requirements, provide Medica with all necessary medical information related to your care, and accept as payment in full the lesser of Medica's network provider reimbursement or the provider's customary charge for the service. This does not apply when Medica terminates aprovider's con~ract for cause. 02 KEG-ME (10/02) Upon request, Medica will authorize continuity of Care for up to 120 days as described in a. and b. above for the following conditions: an acute condition; a life-threatening mental or physical illness; 1 02 KEG-2 AMENDMENT TO THE CERTIFICATE OF COVERAGE pregnancy beyond the first trimester of pregnancy; a physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year, or can be expected to result in death; or e a disabling or chronic condition that is in an acute phase. Authorization to continue to receive services from your current primary care provider, specialist or hospitalmay extend to the remainder of your life if a physician certifies that your life expectancy is 180 days or less. ii. Upon request, Medica will authorize continuity of care for up to 120 days as described in a. and b. above in the following situations: . if you are receiving culturally appropriate services and Medica does not have a network provider who has special expertise in the delivery of those culturally appropriate services within the time and distance requirements defined in Minnesota law; or if you do not speak English and Medica does not have a network provider who can communicate with you, either directly or through an interpreter, within the time and distance requirements defined in Minnesota law. Medica may require medical records or other supporting documentation from your provider to review your request, and will consider each request on a case-by-case basis. IfMedica authorizes your request to continue care with your current provider, Medica will explain how continuity of care will be provided. After that time, your services or treatment will need to be transitioned to a network provider to continue to be eligible for in- network benefits. If your request is denied, Medica will explain the criteria used to make its decision. Coverage will not be provided for services or treatment that are not otherwise covered under this Certificate. If Medica terminates your current provider's contract for cause, Medica will inform you of the change and how your care wffi be transferred to another network provider. To request continuity of care or if you have questions about how this may apply to you, call Customer Service at the telephone numbers listed throughout this Certificate. The following is added to the Section rifled Prescription Drugs and Pharmacy Services: If you have questions about the formulary, whether a specific prescription drug or supply is covered, or would like to request a copy of the formulary at no charge, call Customer Service at the telephone numbers listed throughout this Certificate. ¥1. The following is added to the Section titled Prescription Drugs and Pharmacy Services: Your physician may request that Medica make an exception to allow the formulary copayment or coinsurance for a non-formulary prescription drug. Medica will work with your physician to determine if an exception is appropriate for your medical condition. Exceptions to the formulary can include antipsychotic drugs prescribed to treat emotional disturbance of mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the formulary or you change health plans. If you would like to request a copy of Medica's formulary exception process, call Customer Service at the telephone numbers listed throughout this Certificate. ¥11. The following is added to the Section rifled Mail Service Prescription Drug Program: If you have questions about the formulary, whether a specific prescription drug or supply is covered, or would like to request a copy of the formulary at no charge, call Customer Service at the telephone numbers listed throughout this Certificate. 02 REG-ME (10/02) 2 02 REG-2 AMENDMENT TO TI:IE CERTIFICATE OF COVERAGE VIII. IX. X= XI. XlI. The following is added to Item 1. "Outpatient services include:" in the Section titled Mental Health effective July 1, 2001: Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. The following is added to Item 2. "Inpatient services." in the Section titled Mental Health effective July 1, 2001: Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. See items a, b, and c above to determine your benefits. See items a, b, and c above to determine your benefits. Item 5 as found in the Section titled Mental Health, under the subsection 'Services, supplies and associated expenses NOT covered:' is deleted and replaced with the following effective July 1, 2001: 5. Services, care or treatment that is not medically necessary, unless ordered by a court as specifically described in this Section. The following item is added to the Section titled Mental Health, under the subsection 'Services, supplies and associated expenses NOT covered:' effective July 1, 2001: 9. Services, including room and board charges, provided by mental health providers who are not licensed to practice independently or substance abuse providers who are not certified, such as services received at a halfway house or therapeutic group home, except for outpatient mental health services that are specifically described in this Section. The following is added to Item 1. "Outpatient services include:" in the Section tifled Substance Abuse effective August 1, 2002: Services, care or treatment for a member that has been placed in the Minnesota Department of Corrections' custody following a conviction for a first-degree driving while impaired offense; to be eligible, such services, care or treatment must be required and provided by the Minnesota Department of Corrections. .02 REG-ME (10/02) 02 REG-2 AMENDMENT TO THE CERTIFICATE OF COVERAGE XlII. XIV. Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician, licensed psychologist, licensed alcohol and dmg dependency counselor or a certified chemical dependency assessor and that includes an individual treatment plan- The following is added to Item 2. "Inpatient services." in the Section titled Substance Abuse effective August 1, 2002: d. Services, care or treatment for a member that has been placed in the Minnesota Department of Corrections' custody following a conviction for a first-degree driving while impaired offense; to be eligible, such services, care or treatment must be required and provided by the Minnesota Department of Corrections. e. Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician, licensed psychologist, licensed alcohol and drug dependency counselor or a certified chemical dependency assessor and that includes an individual treatment plan. See items a, b, and c above to determine your benefits. See items a, b, and c above to determine your benefits. See items a, b, and c above to determine your benefits. See items a, b, and c above to determine your benefits. Item 5 as found in the Section titled Substance Abuse, under the subsection 'Services, supplies and associated expenses NOT covered:' is deleted and replaced with the following: 5. Services, care or treatment that is not medically necessary, unless ordered by a court as specifically described in this Section. The following item is added to the Section titled Substance Abuse, under the subsection 'Services, supplies and associated expenses NOT covered:' effective August 1, 2002: 8. Services, including room and board charges, provided by mental health providers who are not licensed to practice independently or substance abuse providers who axe not certified, such as services received at a halfway house or therapeutic group home, except for outpatient substance abuse services that are specifically described in this Section. 02 REG-ME 4 02 KEG-2 00/02) AMENDMENT TO THE CERTIFICATE OF COVERAGE XVI. Items 39 and 40 as found in the Section titled Exclusions are deleted and replaced with the following: 39. Exams, other evaluations or other services for employment, insurance or licensure, unless otherwise covered under this Certificate. 40. Exams, other evaluations or other services for judicial or administrative proceedings or research (except emergency examination of a child ordered by judicial authorities) unless otherwise covered under this Certificate. X3/II. Item 1 as found in the section tifled Your Right to Convert Coverage is deleted and replaced with the following: 1. If other group coverage is not available, you are eligible to convert to an I-IMO in~vidual conversion plan without proof of good health or waiting periods at the following times: XVIll. Item 4.c. as found in the section rifled Your Right to Convert Coverage is deleted and replaced with the following: c. You are eligible for other group coverage. All other terms and conditions of the Certificate rema/n in full force and effect. Medica Health Plans 02 PEG-ME 5 02 REG-2 (10/02) AMENDMENT TO TIlE CERTIFICATE OF COVERAGE :This amendment modifies your Medica Health Plans ("Medica") Certificate of Coverage ("Certificate") effective August 1, 2003. II, The following language is added in the subsection In-network benefits in the Section titled Durable Medical Equipment And Prosthetics: In-network benefits also apply to hearing aids prescribed by apreferred network physician and received from a preferred network hearing aid vendor. The following item is added to the benefits table in the Section titled Durable Medical Equipment And Prosthetics: Benefits: Hearing aids for members 18 years of age and younger for hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures. For In-Network Benefits, You Pay: 20% coinsurance. Limited to one hearing aid per ear every three years. Related services must be prescribed by a physician and hearing aids must be received from a network hearing aid vendor. For Out-of,Network Benefits After Deductible, You Pay: No coverage. Item 5. in the Section titled Exclusions is deleted and replaced with the following: 5. Services provided by an audiologist when not under the direction of a t)hysician, hearing aids and other devices to improve hearing, and their related fittings, except as stated in the Section titled Durable Medical Equipment And Prosthetics. All other terms and conditions of the Certificate shall remain in full force and effect. Medica Health Plans 03HearingME803 7/03 AMENDMENT TO THE CERTIFICATE OF COVERAGE This amendment modifies your Medica Health Plans ("Medica") Certificate of Coverage effective July 1, 2002. The second paragraph under the subsection titled "Medica's Prior Authorization Process", in the Section rifled Procedures for Obtaining Health Services is deleted and replaced with the following: Medica will review your request and provide a response to you and your attending provider within ten business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available to Medica. Medica will inform both you and your provider of Medica's decision within 72 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function. If Medica does not approve your request for prior authorization, you have the right to appeal Medica's decision as described in the Section tiffed If You Have a Complaint. III The Section rifled How To Submit A Claim is deleted in its entirety and replaced with the following: This section describes the process for submitting a claim. Claims for benefits from network providers. If you receive a bill for any benefit from a network provider, you may submit the claim following the procedures described below, under Claim.q for benefits from non-network providers or call Customer Service at 1-800-952-3455 or (952) 945-8000 (Mpls./St. Paul metro area). The telephone numbers for hearing-impaired members with a TTY phone are 1-800-841-6753 or (952) 992-3190 (Mpls./St. Paul metro area). Network providers are required to submit claims within 120 days from when you receive a service. If your provider asks for your health care identification card and you do not identify yourself as a Medica member within 120 days of the date of service, you may be responsible for paying the cost of the service you received. Claims for benefits from non-network providers. Claim forms are provided in your enrollment materials. You may request additional claim forms by calling Customer Service at 1-800-952-3455 or (952) 945-8000 (Mpls./St. Paul metro area). The telephone numbers for hearing impaired members with a TrY phone axe 1-800-841-6753 or (952) 992-3190 (Mpls./St. Paul metro area). If the claim forms are not sent to you within 15 days, you may submit an itemized statement without the claim form to Medica. You should retain copies of all claim forms and correspondence for your records. You must submit the claim in English along with a Medica claim form to Medica no later than 365 days after receiving benefits. Your Medica member number must be on the claim. Mail to: Medica Claim.q Route 2901 PO Box 659752 San Antonio, TX 78265-9752 DOL REGS 2002 ME 1 7/2002 AMENDMENT TO CERTIFICATE OF COVERAGE Upon receipt of your claim for benefits from non-networkproviders, Medica will pay to you directly the non-networkprovider reimbursement amount. Medica will pay the provider of services if: You or, in the case of a dependent or a child who is the subject of a qualified medical child support order (QMCSO), the custodial parent, ask Medica in writing to pay the provider directly; or The non-networkprovider notifies Medica of your signature on file authorizing that payment be made directly to the provider. Medica will notify you of authorization or denial of the claim within 30 days of receipt of the claim. If your claim does not contain all the information Medica needs to make a determination, Medica may request additional information. Medica will notify you of its decision within 15 days of receipt of the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. Claims for services provided outside the United States Claims for services rendered in a foreign country will require the following additional documentation: Claims submitted in English with the currency exchange rate for the date health services were received. Itemization of the bill or claim. The related medical records (submitted in English). · Proof of your payment of the claim. · A complete copy of your passport and airline ticket. · Such other documentation as Medica may request. For services rendered in a foreign country, Medica will pay you directly. Medica will not reimburse you for costs associated with translation of medical records or claims. Time limits If you have a complaint or disagree with a decision by Medica, you may follow the complaint procedure outlined in the Section titled If You Have A Complaint or you may initiate legal action at any point. However, you may not bring legal action more than six years after Medica has made a coverage determination regarding your claim. The Section titled If You Have A Complaint is deleted in its entirety and replaced with the following: -. This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. You may call Customer Service at 1-800-952-3455 or (952) 945-8000 (Mpls./St. Paul metro area). The telephone numbers for hearing impaired members with a TrY phone are 1-800-841-6753 or (952) 992-3190 (Mpls./St. Paul metro area) or by writing to the address below in First level of revqew. You also may contact the Commissioner of Health, Minnesota Department of Health, at DOL REGS 2002 ME 2 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE (651) 282-5600 or 1-800-657-3916, regarding complaints about in-network benefits, or the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296-6789 or 1-800-657-3602, regarding complaints about out-of-network benefits. Complaint: Means any grievance against Medica, submitted by you or another person on your behalf, that is not the subject of litigation. Complaints may involve, but are not limited to, the scope of coverage for health care services; retrospective denials or limitations of payment for services; eligibility issues; denials, cancellations, or non-renewals of coverage; administrative operations; and the quality, timeliness, and appropriateness of health care services rendered. If the complaint is from an applicant, the complaint must relate to the application. If the complaint is from a former enrollee, the complaint must relate to services receiv_ed during the time the individual was an enrollee. Medical Necessity Review: Means Medica's evaluation of the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, for the purpose of determining the medical necessity of the service or admission. 1. First level of review You may direct any question or complaint to Customer Service by calling at 1-800-952-3455 or (952) 945-8000 0Vlpls./St. Paul metro area). The telephone numbers for hearing impaired members with a TIT phone are 1-800-841-6753 or (952) 992-3190 (Mpls./St. Paul metro area) or by writing to the address listed below. You may have another person make a complaint on your behalf by telephone or in writing. Before releasing confdenfial information to a person filing a complaint on your behalf, Medica will require you to sign an authorization form. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. Upon request, Medica will assist you with completion and submission of your written complaint. Medica will also complete a complaint form on your behalf and mail it to you for your signature upon request. Complaints that do not involve a medical necessity review by Medica: a. For an oral complaint, ifMedica does not communicate a decision within 10 business days from Medica's receipt of the complaint, or if you determine that Medica's decision is partially or wholly adverse to you, Medica will provide you with a complaint form to submit your complaint in writing. Mail the completed form to: Customer Service Route 0501 P.O. Box 9310 Minneapolis, IvIN 55440-9310 Medica will provide written notice of its first level review decision to you within 30 days from the initial receipt of your complaint. b. For a written complaint, Medica will provide written notice of its first level review decision to you within 30 calendar days from initial receipt of your complaint. c. IfMedica's first level review decision upholds the initial decision made by Medica, you have a fight to request a second level review. The second level of review, as described in item 2 below, must be exhausted before you have the fight to submit a request for external review. DOL REGS 2002 ME 3 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE Complaints that involve a medical necessity review by Medica: a. Your complaint must be made within one year following Medica's initial decision and may be made orally or in writing. Medica will provide written notice of its first level review decision to you and your attending provider, when applicable, within 30 calendar days from receipt of your complaint. When an initial decision by Medica, does not grant a prior authorization request made before or during an ongoing service, and your attending provider believes that Medica's decision warrants an expedited review, you or your attending provider will have the opportunity to request an expedited review by telephone. Alternatively, ifMedica concludes that a delay could seriously jeopardize your life, health, or ability to regain maxim~lm furlction, Medica will process your claim as an expedited review. In such cases, Medica wffi notify you and your attending provider by telephone of its decision no later than 72 hours after receiving the request. If Medica's first level review decision upholds the initial decision made by Medica, you have a fight to request a second level review or submit a written request for external review, as described in items 2 and 3 below. The second level of review is optional and you may submit a request for external review without exhausting the second level of review. 2. Second level of review If you are not satisfied with Medica's first level review decision, you may request a second level of review through either a written reconsideration or a hearing. a. Your request may be oral or in writing. It must be provided to Medica within one year following the date of Medica's first level review decision. If your request is in writing, it mn.qt be sent to: Customer Service Route 0501 PO Box 9310 Minneapolis, MN 55440-9310 Regardless of the method chosen for review (hearing or a written reconsideration), testimony, explanation or other information provided by you, Medica staff, providers and others is reviewed. Medica will provide written notice of its second level review decision to you within: i. 30 calendar days from receipt of your request for second level review for required second level reviews; or 45 calendar days from receipt of your request for second level review for optional second level reviews. 3. External review If you consider Medica's decision to be partially or wholly adverse to you, you have a right to submit a written request for external review to the Commissioner of Health for issues related to in-network benefits or the Commi.qsioner of Commerce for issues related to out-of-network benefits. Please contact the Commissioner at: DOL REGS 2002 ME 4 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE }Minnesota DepaFtment of Health P.O. Box 64975 St. Paul, MN 55164-0975 (651) 282-5600 or 1-800-657-3916 Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101-2198 (651) 296-6789 or 1-800-657-3602. An independent entity contracted with the State Commissioner of Administration will review your request. The external review decision will not be binding on you but will be binding on Medica. Contact the Commissioner of Health or the Commissioner of Commerce for more information about the external review process. Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be submitted for external review. Civil Action If you remain dissatisfied with Medica's determination after completing the required appeals process, you have the right to file a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA). In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Health or the Commissioner of Commerce at the telephone numbers listed at the beginning of this section. All other terms and conditions of the Certificate remain in full force and effect. Medica Health Plans DOL REGS 2002 ME 5 7/2002 Welcome to Mediea! As part of Medica, Mediea Health Plans, a health maintenance organization, is dedicated to offering you health care choices that support your and your family's health care needs. At Medica Health Plans, we want your health care experience to be marked with excellence. To do this, we are committed to helping you become familiar with and understand the benefits and services available to you in the health plan in which you enrolled. Medica Health Plans provides your in-network benefits. Medica Insurance Company, a licensed insurance company and another part of Medica, provides your out-of-network benefits. This book is called your Certificate of Coverage. It is an important guide that outlines the benefits and privileges of being enrolled in Medica Health Plans. It: describes available medical services from which you can choose · explain~ how to access the services you choose · guides you when you have a question or need more information Important Information For You This Certificate of Coverage is your benefit and service information resource. Please consider it as your health care experience guide and your first resource to mm to for additional information when you need it. Easy to Read, Easy to Use This Certificate of Coverage is organized in easy-to-read Sections. In the front of this Certificate of Coverage, you will fred a table of contents, consumer information, rights and responsibilities, and key terms and definitions. The Sections that describe medical services and benefits are clearly labeled with title bars on the top of each page, and an index in the back provides easy reference to information you need. At Your Service If you fred that you still have questions about your Certificate of Coverage, medical benefits, or any other health care concern, help is a phone call away. By calling (952) 945-8000 or toll free (800) 952-3455, you can reach a team of highly trained customer service specialists. To ensure you can reach us, these telephone numbers are also listed on the back of your health care identification card. We understand that life is about making choices. At Medica Health Plans, our goal is to provide you with the knowledge you need to help you make the right choices for you and your health. Thank you...for choosing Mediea! Table Of Contents Important Consumer Information .................................................................................................................... 2 In-Network Benefits ........................................................................................................................................... 2 Out-of-Network Benefits ................................................................................................................................... 4 Member Bill Of Rights ....................................................................................................................................... 6 Member Responsibilities .................................................................................................................................. 7 Acceptance Of Coverage .................................................................................................................................. 8 Non-Discrimination Policy ................................................................................................................................ 8 General Disclosure Of Provider Payment Methods ....................................................................................... 9 A. Definitions ................................................................................................................................................... 11 B. Introduction ................................................................................................................................................ 23 What You Must Do ................................................................................................................................ 24 Copayments, Coinsurance, Deductibles and Maximum Amounts Table ............................................. 25 Out-of-Pocket Maximum ....................................................................................................................... 25 For out-of-network benefits, you must pay ........................................................................................... 26 What your Employer must do ............................................................................................................... 27 C. Procedure For Obtaining Health Services ............................................................................................... 29 Selecting a pdmary care clinic .............................................................................................................. 29 What you must do ................................................................................................................................. 29 What Medica does ................................................................................................................................ 29 In-network benefits ............................................................................................................................... 30 Out-of-network benefits ........................................................................................................................ 31 Medica's Prior Authorization Process .................................................................................................... 31 Referral health services to non-network providers ............................................................................... 31 Emergency benefits .............................................................................................................................. 32 D. Professional Services ................................................................................................................................ 33 Office visits ........................................................................................................................................... 34 Convenient/urgent care center visits .................................................................................................... 34 Prenatal care ........................................................................................................................................ 34 ME 7 0/]999) BPL 97425 Page i Table Of Contents Preventive health care .......................................................................................................................... 34 Allergy shots .......................................................................................................................................... 34 Refractive eye exams ............................................................................................................................ 35 Chiropractic services ............................................................................................................................. 35 Professional sign language interpreter services ................................................................................... 35 Surgical services ................................................................................................................................... 35 Services received from a physician during an emergency room visit ................................................... 36 Services received from a physician during an inpatient stay ................................................................ 36 Services received from a physician during an inpatient stay for prenatal care and labor and delivery ............................................................................................................................................. 36 Scheduled outpatient lab, pathology and x-rays ................................................................................... 36 Other scheduled outpatient hospital services received from a physician ............................................. 36 Communication or interpretation services for a ventilator-dependent member .................................... 36 Treatment to lighten or remove the coloration of a port wine stain ....................................................... 36 Diabetes self-management training and education ............................................................................... 37 Not covered ........................................................................................................................................... 37 E. Prescription Drugs And Pharmacy Services ........................................................................................... 39 Outpatient prescription drugs ................................................................................................................ 41 Emergency prescription drugs .............................................................................................................. 41 Infertility prescription drugs ................................................................................................................... 41 Diabetic supplies and equipment .......................................................................................................... 41 Growth hormone .................................................................................................................................... 41 Eligible ostomy supplies ........................................................................................................................ 41 Not covered ........................................................................................................................................... 42 F. Mail Service Prescription Drug Program .................................................................................................. 43 Outpatient prescription drugs ................................................................................................................ 44 Oral contraceptives ............................................................................................................................... 44 Infertility prescription drugs ................................................................................................................... 44 Diabetic supplies ................................................................................................................................... 44 Eligible ostomy supplies ........................................................................................................................ 44 Not covered ........................................................................................................................................... 45 G. Hospital Services ........................................................................................................................................ 47 Outpatient services ............................................................................................................................... 48 Services provided in a hospital observation room ................................................................................ 48 Inpatient services .................................................................................................................................. 49 ME 7 (1/1999) BPL 97425 Page ii Table Of Contents Services received from a physician during an inpatient stay ................................................................ 49 Not covered .......................................................................................................................................... 49 H. Ambulance Services .................................................................................................................................. 51 Ambulance services ............................................................................................................................. 51 Non-emergency licensed ambulance service ....................................................................................... 52 Not covered .......................................................................................................................................... 52 I. Outpatient Rehabilitation ............................................................................................................................ 53 Physical therapy received outside of your home .................................................................................. 53 Speech therapy received outside of your home ................................................................................... 54 Occupational therapy received outside of your home .......................................................................... 54 Neuropsychological evaluations, cognitive testing ............................................................................... 55 Not covered .......................................................................................................................................... 55 J. Mental Health .............................................................................................................................................. 57 Outpatient services ............................................................................................................................... 58 Inpatient services .................................................................................................................................. 59 Partial program ..................................................................................................................................... 59 Not covered .......................................................................................................................................... 60 K. Substance Abuse ....................................................................................................................................... 61 Outpatient services ............................................................................................................................... 62 Inpatient services .................................................................................................................................. 63 Not covered .......................................................................................................................................... 63 L. Durable Medical Equipment And Prosthetics .......................................................................................... 65 Durable medical equipment and certain related supplies ..................................................................... 66 Repair, replacement or revision of durable medical equipment ........................................................... 66 Prosthetics ............................................................................................................................................ 66 Not covered .......................................................................................................................................... 67 M. Miscellaneous Medical Supplies .............................................................................................................. 69 Blood clotting factors ............................................................................................................................ 69 Dietary medical treatment of phenylketonuria ...................................................................................... 70 Levonorgestrel ...................................................................................................................................... 70 Total parenteral nutrition ....................................................................................................................... 70 Not covered .......................................................................................................................................... 70 N. Temporomandibular Joint ("TMJ") Disorder ........................................................................................... 71 ME 7 (1/1999) BPL 97425 Page iii Table Of Contents Initial office visit for evaluation .............................................................................................................. 71 Office visits ............................................................................................................................................ 71 Outpatient services ............................................................................................................................... 72 Physical therapy .................................................................................................................................... 72 Inpatient services .................................................................................................................................. 73 Services received from a physician during an inpatient stay ................................................................ 73 TMJ splints and adjustments if your primary diagnosis is TMJ disorder ............................................... 73 Not covered ........................................................................................................................................... 73 O. Organ And Bone Marrow Transplant Services ........................................................................................ 75 Office visits ............................................................................................................................................ 76 Outpatient services ............................................................................................................................... 76 Inpatient services .................................................................................................................................. 77 Services received from a physician during an inpatient stay ................................................................ 77 Not covered ........................................................................................................................................... 78 P. Infertility Services ....................................................................................................................................... 79 Office visits ............................................................................................................................................ 80 Outpatient services ............................................................................................................................... 80 Inpatient services .................................................................................................................................. 80 Not covered ........................................................................................................................................... 80 Q. Reconstructive And Restorative Surgery ................................................................................................ 81 Office visits ............................................................................................................................................ 81 Outpatient services ............................................................................................................................... 82 Inpatient services .................................................................................................................................. 83 Services received from a physician during an inpatient stay ................................................................ 83 Not covered ........................................................................................................................................... 83 R. Home Health Care ....................................................................................................................................... 85 Home health care .................................................................................................................................. 86 Intermittent skilled care ......................................................................................................................... 86 Skilled physical, speech or occupational therapy ................................................................................. 86 Home IV therapy ................................................................................................................................... 86 Services received in your home from a physician ................................................................................. 86 Not covered ........................................................................................................................................... 87 S. Skilled Nursing Facility Services .............................................................................................................. 89 Daily skilled care ................................................................................................................................... 90 ME 7 (1/1999) BPL 97425 Page iv Table Of Contents Skilled physical, speech or occupational therapy ................................................................................. 90 Services received from a physician during an inpatient stay ................................................................ 90 Not covered .......................................................................................................................................... 91 T. Hospice Services ........................................................................................................................................ 93 Hospice Services .................................................................................................................................. 94 Not covered .......................................................................................................................................... 94 U. Medical-Related Dental Services .............................................................................................................. 95 Network medical facilities and general anesthesia services ................................................................ 95 For a dependent child, orthodontia related to cleft lip and palate ......................................................... 96 Accident-related dental services ........................................................................................................... 96 Oral surgery .......................................................................................................................................... 97 Not covered .......................................................................................................................................... 98 V. Emergency Services From Non-Network Providers ............................................................................... 99 Emergency services ............................................................................................................................. 99 Ambulance services ........................................................................................................................... 100 Not covered ........................................................................................................................................ 100 W. Harmful Use Of Medical Services .......................................................................................................... 101 X. Exclusions ................................................................................................................................................ 103 Y. How To Submit A Claim ........................................................................................................................... 105 Claims for benefits from network providers ........................................................................................ 105 Claims for benefits from non-network provider ................................................................................... 105 Claims for services rendered in a foreign country .............................................................................. 105 Time limits ........................................................................................................................................... 105 What Medica does .............................................................................................................................. 106 Z. When You Are Entitled To Benefits From More Than One Plan .......................................................... 107 Introduction: ......................................................................................................................................... 107 Definitions that apply to this Section .................................................................................................... 107 Who pays first ...................................................................................................................................... 107 Order of Rules .................................................................................................................................... 108 Reduction of Benefits .......................................................................................................................... 108 Medica's right to receive and release information .............................................................................. 109 Medica's right to pay another Plan ..................................................................................................... 109 AA. Medica's Right Of Recovery ................................................................................................................. 111 ME 7 BPL 97425 Page v Table Of Contents BB. Enrollment .............................................................................................................................................. 113 Who can enroll .................................................................................................................................... 113 Extending a child's eligibility ............................................................................................................... 113 How to enroll ....................................................................................................................................... 113 What you must do ............................................................................................................................... 113 What your Employer must do .............................................................................................................. 114 Enrolling at other times ....................................................................................................................... 114 The date your coverage begins ............................................................................................................ 115 CC. Ending Your Coverage .......................................................................................................................... 117 When your coverage ends .................................................................................................................. 117 DD, Your Right To Continue Coverage ....................................................................................................... 119 EE. Your Right To Convert Coverage .......................................................................................................... 125 Introduction .......................................................................................................................................... 125 What you must do ............................................................................................................................... 125 What your Employer must do .............................................................................................................. 126 FF, If You Have A Complaint ........................................................................................................................ 127 GG. General Provisions ................................................................................................................................ 131 Index ................................................................................................................................................................ 133 ME 7 (1/1999) BPL 97425 Page vi MEDICA ELECT CERTIFICATE OF COVERAGE ("Certificate") ME 7 (1/1999) BPL 97425 Page 1 Important Consumer Information about In-Network Benefits Benefits: Providers: Referrals: Health services will be covered by Medica Health Hans ('WIedica") as in- network benefits only if such services are: 1. provided by or referred by your primary care clinic and Medica, or 2. provided by apreferred network convenient urgent care center; or 3. provided by the mental health/substance abuse provider desi~ated by your primary care clinic; or provided by apreferred network chiropractor; or provided by apreferred network obstetric/gynecology ("Ob/Gyn") physician whom you have selected from the list of Ob/Gynphysicians designated in your Provider Directory as available to you. The Ob/Gyn physicians available to you are limited, based upon your selection of a primary care clinic and/or your geographic location. This Certificate describes the health services for which you have coverage and the procedures you must follow to obtain in-network benefits. Enrolling in Medica Elect does not guarantee that a parficularprovider on the list of providers will remain participating with Medica Elect or that a particular provider will provide you with health services. When aprovider no longer participates with Medica Elect, you must choose to receive your health services from among the remainingproviders who participate with Medica Elect. You must verify that your provider participates with Medica Elect each time you receive health services. NOTE: Not all Medicaproviders are Medica Elect providers. See your provider directory for a listing of the Mediea Elect providers. Certain health services are covered only upon referral. Read this Certificate for referral requirements. All referrals to non-network providers and certain types of network providers must be prior approved by Medica to be eligible for coverage. ME 7 (1/1999) BPL 97425 Page 2 Emergency Services: Exclusions: Continuation/ Conversion: Cancellation: Mental Health and Substance Abuse: Prescription Drugs and Medical Equipment: Newborn Coverage: Emergency services from non-networkproviders will be covered only if you follow proper procedures. This Certificate explains these procedures and the covered health services associated with emergency care. Certain health services are not covered. Read this Certificate for a detailed explanation of all exclusions. You may convert to an individual conversion plan or continue coverage under certain circumstances. See the Sections titled Your Right To Continue Coverage and Your Right To Convert Coverage for details of these continuation and conversion rights. Your coverage may be canceled only under certain conditions. This Certificate describes all reasons for cancellation of coverage. Medica uses a limited network of hospitals for the provision of mental health and substance abuse benefits. Except for emergencies: 1. all mental health and substance abuse services are arranged by a designated mental health/substance abuse provider; and a treatment plan, including any inpatient services, must be prior approved by your designated mental health/substance abuse provider to be eligible for coverage. Enrolling in Medica does not guarantee that any particularprescription drug will be covered nor that any particular piece of medical equipment will be covered, even if the drug or equipment is covered at the start of the Contract year. Your dependent newborn is covered from birth, but only if health services are provided or referred by his/herprimary care clinic or authorized by Medica. Medica will not automatically know of the infant's birth and that you would like coverage for the newborn dependent. If additional premium is required for each dependent, Medica is entitled to allpremiums due from the time of the infant's birth until the time you notify Medica of the birth. Medica may withhold payment for any health benefits for the newborn infant until any premium you owe is paid. For more information, see the Section titled g, nrollment. ME 7 (1/1999) BPL 97425 Page 3 Important Consumer Information about Out-of-Network Benefits Out-of-Network Benefits: Out-of-network benefits are payable by Medica Insurance Company ("MIC") for health services that are: (1) received from aprovider other than your primary care clinic without having been referred by your primary care clinic or (2) not otherwise authorized by Medica as in-network benefits. Prior approval may be required from Medica for certain out-of-network benefits. This Certificate fully defmes your benefits and describes procedures you must follow to obtain out-of- network benefits. Emergency services received from and prior approved referrals to non-network providers are covered as in-network benefits and are not considered out-of-network benefits, provided you follow proper procedures. Some benefits are provided only as in-network benefits. Read this Certificate for a detailed explanation of in-network and out-of-network benefits. NOTE: It is important to be aware that if you choose to use your out-of-network benefits, you may have to pay more than if you use your in-network benefits. You may choose to use your out-of-network benefits for health services from: a non-networkprovider: If you choose to obtain out-of-network benefits from a non-networkprovider, the charges billed by the non-network provider may exceed the non-network provider reimbursement amount, leaving a balance for you to pay in addition to any applicable copayment, coinsurance and deductible mount. In addition, those excess charges will not be applied to the out-of-pocket maximum amount described in the Section rifled Introduction. Prior to receiving services from a non-network provider, we recommend that you: a. confu'm with the non-networkprovider what the services will be; and bo verify with Customer Service the estimated non-networkprovider reimbursement amount for those services. Please refer to the Section titled Introduction for additional information. a networkprovide~. If you choose to obtain out-of-network benefits ~om a network provider (including apreferred network provider), you will be responsible for any applicable copayment, coinsurance and deductible mount. However, the non-networkprovider reimbursement amount, as described in 1 above, will not apply. Thus, you may have less out-of-pocket expense when you receive out-of-network benefits fxom a network provider. M~ 7 (1/1999) BPL 97425 Page 4 Maximum Amount: Exclusions: Claims: Out-of-network benefits are subject to a maximum mount payable by MIC. Read this Certificate for a detailed explanation of the maximum amount. Some health services, such as preventive care as described in the Section titled Professional Services, are not covered as out-of-network benefits. Read this Certificate for a detailed explanation of exelnsions. When you use non-networkproviders, you will be responsible for filing claims in order to be reimbursed for the non-networkprovider reimbursement amount. See the Section titled How To Submit A Claim for details. ME 7 (1/1999) BPL 97425 Page 5 Member Bill Of Rights The laws of the State of Minnesota grant members of health maintenance organizations certain legal rights including the right to: 1. Available and accessible services, including emergency services (del'reed in this Certificate) 24 hours a day, 7 days a week. 2. Information about your health condition, treatment opti°ns and risks so you can make an informed choice about your health care. 3. Refuse treatment recommended to you by Mediea or anyprovider. 4. Privacy of your medical and financial records maintained by Mediea or any network provider in accordance with existing law. 5. File a complaint with Medica (the complaint process is described in this Certificate) and Minnesota's Commissioner of Health for issues related to in-network benefits or Minnesota's Commissioner of Commerce for issues related to out-of-network benefits. You may begin a legal proceeding if you have a problem with Medica or anyprovider. For information, contact the Minnesota Department of Health ("MDH") at (651) 282-5600 or 1-800-657-3916 and request HMO information or the Minnesota Department of Commerce at (651) 296-2488 and request insurance information. ME 7 (1/1999) .. BPL 97425 Page 6 Member Responsibilities As part of the National Committee for Quality Assurance ("NCQA") accreditation process, NCQA establishes guidelines for member responsibilities. To increase the likelihood of maintaining good health and to ensure that the best quality care is received, it is important that you take an active role in your health care by: 1. Establishing a relationship with aprimary care clinic before becoming ill, as this allows for continuity of care; 2. Providing the necessary information to health care professionals that is needed to determine the appropriate care. This objective is best obtained when you: a. Share information about lifestyle practices; and b. Share personal and family health history; 3. Following the instructions given by those providing health care; 4. Practicing self care by: a. Knowing how to recoLmi~.e common health problems; b. Knowing what to do when they occur; c. Knowing when and where to seek appropriate help; and d. Knowing how to prevent health problems from recurring; 5. Practicing preventive health care by: a. Having the appropriate tests, exams, and immunizations recommended for your gender and age as described in this Certificate; and b. Engaging in healthy lifestyle choices (such as exercise, proper diet and rest). You will fred additional information on Medica member responsibilities in the Section titled Introduction. ME 7 (1/1999) BPL 97425 Page 7 Acceptance Of Coverage This Certificate is not a legal contract between you and Medica~ but simply an explanation of the benefits covered under the contract (the "Contract") between Medica and your Employer. If you wish to see the Contract, contact your group administrator. By accepting the health care coverage described in this Certificate you, on behalf of yourself and any dependents enrolled under the Contract, authorize: 1. the use of a social security number for purposes of identification; and 2. that the information supplied by you to Medica for purposes of enrollment is accurate and complete. Non-Discrimination Policy It is the policy of Medica and MIC to treat all persons alike, without distinctions based on race, color, creed, religion, national origin, gender, marital status, status with regard to public assistance, disability, sexual orientation, age or any other classification protected by law. If you have questions about this policy, contact Customer Service at the telephone numbers listed below. If you have an impairment that requires alternative communication formats such as Braille, large print or audio cassettes, please request these materials from Customer Service at the phone numbers listed below. If one of these alternative communication formats is used, this written English version (not the alternative format) governs all coverage decisions. CUSTOMER SERVICE Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 The telephone numbers for hearing impaired members with a TTY phone are: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 8 General Disclosure Of Provider Payment Methods Mediea and MIC generally pay providers for health services as follows: Network Providers. Network providers are generally paid under either of two payment methods: a fee for service (fee-based) method or a capitated method. The primary method of payment under Mediea Elect is fee for service with annllal target provisions. "Fee for service" payment means that after you receive a health service, Medica pays the provider a fee for each such service. The network provider's fee is determined according to a set fee schedule. This amount is generally less than what the network provider would have billed if there had been no Medica fee schedule. Medica pays some providers a fee for each such service based on the lesser of the provider's standard fee and the fee schedule amount. Some network providers receive a single payment for each episode of illness or injury, regardless of the number of visits or units of service provided. If the cost of providing a member's health services exceeds the provider's per episode payment, the provider generally bears all or some part of the shortfall. If the provider's per episode payment exceeds the provider's costs, the provider generally keeps all or some part of the excess. For primary care clinics paid on a fee for service basis that are atTfliated with other providers as part of a care system, Mediea and the primary care clinic agree upon an annual target amount for providing health services to members who access services through theprimary care clinic. During the calendar year, the primary care clinic will receive a fee for service payment for each service received by members who have chosen to access services through theprimary care clinic, whether the service is provided by or arranged through the primary care clinic. After the year is over, Mediea will compare the annual target amount to the cost of all health services that members access through that primary care clinic during the year. If the annual target amount is more than the cost of providing or arranging for a member's health services, the primary care clinic may receive some part of the excess. If the annual target amount is less than the cost of providing or arran~ng for a member's health services, the primary care clinic may bear some part of the shortfall. "Capitated" payment mean,q the network provider' s annual reimbursement from Mediea is based on a fixed monthly amount for each member who accesses services through the provider. During the calendar year, the provider will receive a fee for each service provided to members who have chosen to access services through the provider. After the year is over, Medica will compare the annual capitation amount to the cost of all health services provided to members through that provider during the year. If the annual capitation amount is less than the cost of providing or arranging for a member's health services, the provider generally bears all or some part of the shortfall. If the annual capitation amount is more than the provider's costs, the provider generally receives all or some part of the excess. Network hospitals might receive, instead of the fee for service payments described above, various other fee for service payments. These include: 1. per diem: this is a payment made to a hospital for each day of an inpatient stay; 2. per stay: this is a payment made to a hospital for each inpatient stay, regardless of the length of the stay (for certain inpatient stays, a hospital might receive both a per stay payment and a per diem payment); ME 7 (1/1999) BPL 97425 Page 9 3. per episode: this is a flat rate payment made to a hospital for each episode, regardless of the m~rnber of visits or units of service provided; and 4. percentage of charges payments: this is a payment made to a hospital based on a percentage of the hospital's charge. For some network providers paid on a fee for service basis, including most network physicians and clinics, Medica holds back some of the fee for service payment mount. The withheld amount generally will not exceed 15% (5% for some network hospitals) of the fee schedule amount. These providers can earn the withheld amount based on certain factors. These factors can include the fmancial circumstances of Medica, and other aggregate and individual measures such as quality, efficiency, cost-effectiveness and member satisfaction. These factors apply in various ways to different types of providers. Medica's Board of Directors may review these factors and decide what amount, if any, of the withheld amount to pay the providers. Based on individual measures, the percentage of the withheld amount paid, if any, can vary among providers. Some network providers can choose whether or not to authorize referrals for certain services from other providers; the decision not to authorize a referral may permit a network provider to keep more of the capitated payment than if the referral were authorized. The member may appeal any denial of authorization for a referral. Some network providers have arrangements with other network providers, such as hospitals, physician specialists and aneillaryproviders. Under these arrangements, the other provider agrees to be paid by the network provider on a eapitated or fee for service basis. Mediea pays the agreed amount to the other provider. Medica then considers that amount when comparing the cost of providing or arranging for a member's health services and the annual fee-for-service target amount or the annual capitation amount. Non-Network Providers. When a service from a non-networkprovider is covered, the provider is paid a fee for service payment for the covered service. The methods by which specific providers are paid may change at the time of the provider's contract renewal. Methods also vary byprovider. For current information regarding a specific provider, contact Customer Service at 1-800-952-3455 or (952) 945-8000 (Mpls./St. Paul metro area). The telephone numbers for hearing impaired members with a TTY phone are 1-800-841-6753 or (952) 992-3190 (Mpls./St. Patti metro area). ME 7 (1/1999) BPL 97425 Page 10 A. Definitions The words listed below have the following meanings when used in this Certificate and its amendments. Benefits The health services or supplies approved by Mediea as eligible for coverage, as described in this Certificate and any amendments. Care System A network of providers, including primary care physicians, that assumes responsibility for managing and ensuring the provision, coordination, referral and delivery of health services for members who have designated aprimary care clinic within a given care system. Each care system establishes its own access procedures for seeing all otherproviders. Some care systems require a referral from your primary care clinic; others allow you to access aprovider affiliated with your designated care system without a referral from your primary care Clinic. Contact your primary care clinic for more information about care system access procedures, or see your Medica Elect Provider Directory for more information. Certification of Qualifying Coverage A written certification that group health plans and health insurance issuers must provide to an individual to confmn the qualifying coverage provided to the individual under the group health plan or health insurance. Claim An invoice, bill or itemized statement for benefits provided to you. Coinsurance The percentage amount you must pay to the provider for benefits received. For in-network benefits, the coinsurance amount will typically be based on the lesser of (i) the charge billed by the provider O.e. retail), or (ii) the negotiated amount that the provider has agreed to accept as full payment for such benefit (i.e. wholesale). When the wholesale amount is not known nor readily calculated at the time the benefit is provided to you, Medica will use an amount designed to approximate such wholesale amount. For services from some network providers, however, the coinsurance will be based on the provider's retail charge. The provider's retail charge is that amount that the provider would charge to any patient, whether or not that patient is a Mediea member. ME 7 (1/1999) BPL 97425 Page 11 Definitions Continuous Coverage Convenient/Urgent Care Center Copayment Cosmetic For om-of-network benefits, the coinsurance will be based on the lesser of (i) the charge billed by the provider (i.e. retail), or (ii) the non-networkprovider reimbursement amount. For out-of-network benefits, you will, in addition to any copayment, coinsurance, and deductible amounts, be responsible for any charges billed by the provider in excess of the non-networkprovider reimbursement amount. In addition, with respect to network pharmacies described in the Section rifled Prescription Drugs And Pharmacy Services, the calculation of coinsurance amounts as described above do not include possible reductions for any volume purchase discounts or price adjustments that Medica may later receive related to certain prescription drugs and pharmacy services. Full coinsurance payments may apply to scheduled appointments canceled less than 24 hours prior to the appointment time or to missed appointments. The coinsurance may not exceed the charge billed by the provider for the benefit. The maintenance of continuous and uninterrupted qualifying coverage by an eligible employee or dependent. An eligible employee or dependent is considered to have maintained continuous coverage if enrollment is requested under the Contract within 63 days of termination of the previous qualifying coverage. A health care facility distinguishable from an affiliated clinic or hospital whose primary purpose is to offer and provide immediate, short-term medical care for minor, immediate medical conditions, on a regular or routine basis. The fixed dollar amount you must pay to the provider for benefits received. Full copayments may apply to scheduled appointments canceled less than 24 hours prior to the appointment time or to missed appointments. When you receive eligible health services from a network provider and a copayment applies, you pay the lesser of the charge billed by the provider for the benefit O.e., retail) or your copayment. Medica pays any amount remaining according to the written agreement between Medica and the provider. The copayment may not exceed the retail charge billed by the provider for the benefit. For out-of-network benefits, you will, in addition to any copayment, coinsurance and deductible amounts, be responsible for any charges in excess of the non- network provider reimbursement amount. Services and procedures that improve physical appearance but do not correct or improve a physiological function, and that are not medically necessary, unless the service and/or procedure meets the def'mifion of reconstructive. ME 7 (1/1999) BPL 97425 Page 12 Definitions Custodial Supportive Services to assist in activities of daily living that do not seek to cure, are Care performed regularly as a part of routine or schedule, and, due to the physical stability of the condition, do not need to be provided or directed by a skilled medical professional. Deducible The fixed dollar mount you must pay before claims for health services or supplies received from non-network providers are reimbursable as out-of-network benefits under this Certificate. Dependent Unless otherwise specified in the Contract, the subscriber's (a) spouse; or (b) unmarried child who is (1) a natural or adopted child, (2) a ehild placed for adoption with the subscriber, or (3) a stepchild; or (c) an unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. In addition, a child under legal guardianship of the subscriber will be considered a dependent. However, the subscriber must provide satisfactory proof of dependency upon request by Medica. A child who is the subject of a qualified medical child support order is not considered a dependent for proposes of coverage under the Contract and may not enroll dependents for coverage. (See def'mition of subscriber.) Designated Mental Health/Substance Abuse Provider An organization, entity or individual selected by Medica and yourprimary care clinic to provide or arrange for the mental health and substance abuse services covered under this Certificate. Emergency A condition that requires immediate treatment to: 1. preserve your life; or 2. prevent serious impairment to your bodily function, organs, or parts; or 3. prevent placing your physical or mental health in serious jeopardy. Enrollment Date The date of the eligible employee's or dependent's first day of coverage under the Contract or, if earlier, the first day of the waiting period for the eligible employee' s or dependent's enrollment. Hospital A facility that provides diagnostic, medical, therapeutic and surgical services by, or under the direction of, aphysician and with 24 hour R.N. nursing services. The hospital is not mainly a place for rest or custodial supportive care, and is not a nursing home or similar facility. ME 7 (1/1999) BPL 97425 Page 13 Definitions Inpatient An uninterrupted stay of 24 hours or more in a hospital, skilled nursing facility or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally handicapped children will be covered as any other health condition. Investigative At the time a determination is made regarding coverage in a particular case, Mediea will determine whether a drug, device, diagnostic or screening procedure, or medical treatment or procedure is investigative: if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. Mediea will make its determination based upon an examination of the following reliable evidence, none of which shall be determinative in and of itself: whether there is f'mal approval from the appropriate government regulatory agency, if required, including whether the drag or device has received final approval to be marketed for its proposed use by the United Stated Food and Drag Administration ("FDA"), or whether the treatment is the subject of ongoing Phase I, II or m t als; whether there are consensus opinions and recommendations reported in relevant scientific and medical literature, peer-reviewed journals, or the reports of clinical trial committees and other technology assessment bodies; and whether there are consensus opinions of national and local health care providers in the applicable specialty or subspecialty that typically manages the condition as determined by a survey or poll of a representative sampling of these providers. Notwithstanding the above, a drag,, device, diagnostic or screening procedure, or medical treatment or procedure will not be considered by Medica to be investigative with respect to a specific diagnosis or condition when it is the subject of ongoing Phase III clinical trials and Medica determines on a case-by- case basis that (a) reliable evidence demonstrates that the drag, device, medical treatment or procedure for the specific diagnosis or condition is safe and efficacious, and Co) network providers practicing in the applicable specialty or subspecialty have concluded that the drag, device, medical treatment or procedure is not investigative, and (c) if applicable, the FDA has indicated that the approval of the drug or device for the proposed use is pending and likely to OCCUr. ME 7 (1/1999) BPL 97425 Page 14 Definitions Notwithstanding the above, a drug, including cancer drags, being used for an indication or at a dosage that is an accepted off-label use will not be considered by Medica to be investigative. Medica will determine if a use is an accepted off- label use based on published reports in authoritative peer-reviewed medical literature, clinical practice guidelines or parameters approved by national health professional boards or associations and entries in the following drag compendia: The American Hospital Formulary Service Drag Information and the United States Pharmacopoeia Dispensing Information. Late Entrant An eligible employee or dependent who requests enrollment under the Contract other than during: 1. the initial enrollment period set by the Employer; or 2. the open enrollment period set by the Employer; or 3. a special enrollment period as described in the Section titled Enrollment. However, an eligible employee or dependent who is an enrollee of the Minnesota Comprehensive Health Association ("MCI-IA") at the time Medica offers or renews coverage with the Employer will not be considered a late entrant, provided the eligible employee or dependent maintains continuous coverage as defmed in this Certificate of Coverage. In addition, a subscriber who is a child entitled to receive coverage through a qualified medical child support order is not subject to any initial or open enrollment period restrictions. Medically Necessary Diagnostic testing and medical treatment, consistent with the diagnosis of and prescribed course of treatment for your condition, and preventive services. Medically necessary care must meet the following criteria: Be consistent with the medical standards and accepted practice parameters of the community as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure or treatment at issue; and 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your diagnosis or condition; and 3. Help to restore or maintain your health; or 4. Prevent deterioration of your condition; or 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. ME 7 (1/1999) BPL 97425 Page 15 Definitions Member A person who is enrolled under the Contract. Mental Disorder A physical or mental condition having an emotional or psychological ori~n~ as defined in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders ("DSM"). Network A term used to described aprovider (such as a hospital, physician, home health agency, skilled nursing facility or pharmacy) that has entered into a written agreement with Medica or has made other arrangements with Medica to provide Medica Elect benefits to you. Preferred network providers are network providers; however, not all network providers are preferred network providers. The participation status of providers will change from time to time. Refer to the Section titled Introduction for more information regarding out-of-network benefits for health services received from network providers. Non-network Non-network Provider Reimbursement Amount A term used to describe a provider not under contract as a network provider. The mount that MIC will pay to a non-networkprovider for each benefit as follows: 1. For hospital benefits, the non-networkprovider reimbursement amount is equal to the lesser of: a. the hospital's charge; or b. the amount that the hospital and MIC have agreed upon. 2. For non-hospital benefits, the non-network provider reimbursement amount is equal to the lesser of: a. the non-hospital provider's charge; or bo the amount MIC determines, based on marketplace charges, for similar services and supplies, in the geographic area in which the benefit is provided. If the amount the non-networkprovider bills you for non-hospital benefits is greater than the non-networkprovider reimbursement amount, you must pay the difference. Such difference is in addition to any copayment, coinsurance or deductible amount you may be responsible for according to the terms described in this Certificate. In addition, such difference wffi not be applied to the out-of- pocket maximum described in the Section rifled Introduction. Physician A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.) or Doctor of Optometry (O.D.) or Doctor of Chiropractics (D.C.) practicing within the scope of his or her licensure. ME 7 (1/1999) BPL 97425 Page 16 Definitions Placed for Adoption The assumption and retention of the legal obligation for total or partial support of the child in anticipation of adopting such child. Preferred Network A term used to describe a network provider (such as a network hospital or a network physician) that has an affiliation with a Medica Elect care system or primary care clinic. Preferred network providers are listed in your Provider Directory. Premium The monthly payment required to be paid by the Employer on behalf of or for you. Prenatal Care The comprehensive package Of medical and psychosocial support provided throughout a pregnancy and related directly to the care of the pregnancy, including risk assessment, serial surveillance, prenatal education, and use of specialized skills and technology, when needed, as defmed by Standards for Obstetric-Gynecologic Services issued by the American College of Obstetricians and Gynecologists. Prescription Drug A drug approved by the FDA for the prescribed use and route of administration. Primary Care Clinic An individual or group of network providers practicing in the areas of family practice, general practice, internal medicine or pediatrics, selected by you to coordinate the benefits eligible for coverage under this Certificate. You must select aprimary care clinic from the list of network providers designated by Medica as primary care clinics. The providers to whom you have access under in- network benefits will be determined by your selection of apnmary care clinic. Selection of your primary care clinic determines whether you will be a member of a care system and, if so, which care system. If you are in acare system, your care system establishes the access procedures you must follow to obtain in-network benefits. Contact your primary care clinic for information about these care system access procedures, or see your Medica Elect Provider Directory for more information. Provider A health care professional or facility licensed, certified or otherwise qualified under state law to provide health services. Qualifying Coverage Health coverage provided under one of the following plan.q: a health plan in which a health carder has issued a policy, contract or certificate for the coverage of medical and hospital benefits, including blanket accident and sickness insurance other than accident only coverage; ME 7 (1/1999) BPL 97425 Page 17 Definitions 2. Part A or Part B of Medicare; 3. a medical assistance medical care plan as defmed under Minnesota law; 4. a general assistance medical care plan as defined under Minnesota law; 5. Minnesota Comprehensive Health Association ("MCHA"); 6. a self-insured health plan; 7. the MinnesotaCare program as defined under Minnesota law; 8. the public employee insurance plan as defmed under Minnesota law; 9. the Minnesota employees insurance plan as de£med under Minnesota law; 10. CHAMPUS or other similar coverage provided under federal law applicable to the armed forces; 11. coverage provided by a health care network cooperative or by a health provider cooperative; 12. the Federal Employees Health Benefits Plan or other similar coverage provided under federal law applicable to government organizations and employees; 13. a medical care program of the Indian Health Service or of a tribal organization; 14. a health benefit plan under the Peace Corps Act; 15. a plan similar to any of the above plans provided in the State of Minnesota or in another state, as determined by the Commissioner of Health or the Commissioner of Commerce. Coverages of the following types, including any combination of the following types, are not qualifying coverage: 1. coverage only for disability or income protection insurance; 2. automobile medical payment coverage; 3. liability insurance or coverage issued as a supplement to liability insurance; ME 7 (1/1999) BPL 97425 Page 18 Definitions 4. coverage for a specified disease or illness or to provide payments on a per diem, £~xed indemnity, or non-expense-incurred basis, if offered as independent, non-coordinated coverage; 5. credit accident and health insurance as de£med under Minnesota law; 6. coverage designed solely to provide dental or vision care; 7. accident only coverage; 8. long term care coverage as defined under Minnesota law; 9. Medicare supplement health insurance as defined under Minnesota law; 10. workers' compensation insurance; or 11. coverage for on-site medical clinics operated by an employer for the benefit of the employer's employees and their dependents, in connection with which the employer does not transfer risk. Reconstructive Surgery to rebuild or correct: 1. A body part when such surgery is incidental to or following surgery resulting from injury, sickness or disease of the involved body part; or 2. A functional defect determined by Medica to have been present at birth and that adversely affects your ability to perform routine activities of daily living. Surgery that is cosmetic is not reconstructive. Referral Authorization from a primary care clinic for you to receive medically necessary benefits from another provider when such benefits are not available from the primary care clinic. The authorization will be in writing and will: 1. indicate the time period during which services must be received; and 2. specify the service(s) to be provided; and 3. direct you to the provider selected by your primary care clinic. ME7 (1/1999) BPL 97425 Page 19 Definitions Selection of your primary care clinic determines whether you will be a member of a care system and, if so, which care system. If you are in a care system, your care system establishes the access procedures you must follow to obtain in-network benefits. Some care systems require a referral from yourprimary care clinic; others allow you to access aprovider affiliated with your designated care system without a referral from yourprimary care clinic. Contact yourprimary care clinic for more information about these care system access procedures, or see your Medica Elect Provider Directory for more information. Restorative Surgery to rebuild or correct a physical defect that has a direct adverse effect on the physical health of a body part, and the restoration or correction is determined by Medica to be medically necessary. Service Area The geographic area in which Medics is approved to provide coverage for in- network benefits. You may contact Customer Service for a current description of the service area. Skilled Care Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to develop, provide and evaluate your care and assess your changing condition. Long term dependence on respiratory support equipment and/or the fact that services are received from technical or professional medical personnel do not in and of themselves defme the need for skilled care. Skilled Nursing Facility A licensed bed or facility (including an extended care facility, hospital swing-bed and transitional care unit) that provides skilled transitional care. Standing Referral A referral issued by yourprimary care clinic, for a period no longer than 90 days, generally issued for conditions that require ongoing services from a specialist provider. You may request an extension of a standing referral by contacting your primary care clinic. Standing referrals will not be extended beyond the end of a given calendar year. Subscriber The person: 1. on whose behalf premium is paid; and 2. whose employment is the basis for membership, according to the Contract; and 3. who is enrolled under the Contract. ME 7 (1/1999) BPL 97425 Page 20 Definitions The definition of subscriber ~y ~so ~clude a c~d for whom ~ employee is req~ed to provide hefl~ coverage ~ou~ a q~ed me~cfl c~d suppo~ order. Such c~d is co~idered a subsc~ber o~y fi: the Employer has determined and notified Medica that the support order is effective and meets all criteria of a qualified medical child support order, as that term is used in the Employee Retirement Income Security Act ("EMS^"); and 2. the relevant employee is eligible to enroll for coverage according to the terms of the Contract. When the subscriber is a child who is eligible for coverage as a result of a qualified medical child support order, certain rights and obligations pertaining to other subscribers are modified according to the terms of the Contract. Total Disability Disability due to injury, sickness or pregnancy that requires regular care and attendance of aphysician, and in the opinion of the physician renders the employee unable to perform the duties of his or her regular business or occupation during the first two years of the disability and, after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she is reasonably fitted. Waiting Period The period of time, as determined by the Employer's eligibility requirements, that must pass before an otherwise eligible employee and/or dependent is eligible to become covered under the Contract. However, if an eligible employee and/or dependent enrolls as a late entrant or through a special enrollment period as set forth herein in the Section titled Enrollment, subsection "Enrolling at other times", any period before such late or special enrollment is not a waiting period. ME 7 (1/1999) BPL 97425 Page 21 B. Introduction Medica together with its affiliate Medica Insurance Company ("MIC"), offers Medica Elect. You are entitled to two types of coverage under Medica Elect. Medica provides coverage for your in-networkbenefits and MIC provides coverage for your out-of-network benefits. Coverage is subject to all other terms and conditions of the Contract and health services must be medically necessary. The fact that aprovider has performed, prescribed or recommended a service or that a service is the only available treatment does not mean that the service is medically necessary and/or a covered benefit. Medica and MIC may authorize more efficient methods of providing services that may be in addition to the benefits described in this Certificate. Mediea and MIC may arrange for various persons or entities to provide admini.qtmtive services on their behalf, includingclaims processing and utili?ation management services. You must cooperate with those persons or entities in the performance of their responsibilities in order to ensure efficient administration of your benefits. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Definitions. Use these definitions to best understand this Certificate. By applying these definitions, you will have a clearer understanding of the coverage described under this Certificate. The words "you," "your" and "yourself" in this Certificate refer to the member. The word "Employer" refers to the organi?ation through which you are eligible for coverage. 1. In-network benefits apply to health services: a. received from or referred by yourprimary care clinic or, if your primary care clinic is affiliated with a care system, accessed through the procedures required by your care system; or b. received from a preferred network convenient urgent care center;, or c. received from the mental health/substance abuse provider designated by yourprimary care clinic; or d. received from apreferred network chiropractor; or e. received from apreferred network obstetric/gynecology ("Ob/Gyn")physician whom you have selected from the list of Ob/Gynphysicians designated in your Provider Directory as available to you. The Ob/Gynphysicians available to you are limited, based on your selection ofaprimary care clinic and/or your geographic location. The providers to whom you have access under in-network benefits will be determined by your selection of aprimary care clinic. In addition, if you are in a care system, your care system establishes the access procedures you must follow to obtain in-network benefits. Contact your primary care clinic for information about these care system access procedures, or see your Medica Elect Provider Directory for more information. In-network benefits also apply to coverage for services Medica determines meet emergency criteria and are received from providers other than your primary care clinic, including when you are traveling out of the service area, as described in the Section rifled Emergency Services From Non-Network Providers. Follow-up care or scheduled care following an emergency must be provided or referred by your primary care clinic to be covered as in-network benefits. 2. Out-of-network benefits apply to health services that are received directly from providers other than as described above under "In-network benefits". ME 7 (1/1999) BPL 97425 Page 23 Introduction Generally you will pay more for out-of-network benefits than if benefits are provided or referred by your primary care clinic or care system. Most in-network benefits are covered at 80%. Most out-of-network benefits are covered at 80% after you pay a deductible mount for yourself or your family. In addition, you may pay more for out-of-network benefits received from a non-networkprovider than for out-of-network benefits received from a networkprovider, since only non-networkproviders can bill you for the difference between the charge billed by theprovider for the benefit and what MIC pays the provider. This is often referred to as "balance billing". · When you receive out-of-network benefits from a non-networkprovider, and the mount that your non-network provider bills you is more than the non-network provider reimbursement amount, the provider can bill you for the balance, and you are responsible for paying that difference. Such difference will not be applied toward the out-of-pocket maximum described in this Section of this Certificate. However, when you receive out-of-network benefits from a network provider, Medica does not pay the non-network provider reimbursement amount. The network provider cannot bill you for the difference between the charge billed by the network provider for the benefit and what Medica pays the network provider. You may obtain more information by contacting Customer Service at 1-800-952-3455 or (952) 945-8000 0Vlpls./St. Paul metro area) or TTY phone for the hearing impaired only: 1-800-841-6753 or (952) 992-3190 (Mpls./St. Paul metro area). Language interpretation services will be provided upon request, as needed in connection with the interpretation of this Certificate of Coverage. Please contact Customer Service. If this Certificate is translated into another language, this written English version governs all coverage decisions. NOTE: You are responsible for any charges not covered by Medica or MIC. If you miss or cancel an office visit less than 24 hours before your appointment, your provider may bill you for the service. WltAT YOU MUST DO.' 1. READ TItIS CERTIFICATE CAREFULLY. This Certificate should be read in its entirety. Many provisions of this Certificate are interrelated; therefore, reading just one or two provisions may not give you a complete understanding of the coverage described under this Certificate. The most appropriate Section of this Certificate will apply for those benefits related to the treatment of a speeitie condition. 2. Each time you receive health services you must: a. For in-network benefits, ensure that the health services are: i) provided or referred by yourprimary care clinic or, if yourprimary care clinic is affiliated with a care system, accessed through the procedures required by your care system; or ii) provided by the mental health/substance abuse provider designated by your primary care clinic; or iii) provided by apreferred network convenient urgent care center;, or iv) provided by apreferred network chiropractor; or v) provided by apreferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians desi~tmated in your Provider Directory as available to you. The Ob/Gyn ME 7 (1/1999) BPL 97425 Page 24 Introduction physicians available to you are limited, based upon your selection of aprimary care clinic and/or your geographic location. b. Identify yourself as a Medica Elect member. e. Present your Medica Elect identification card every ~me you request health services. If you do not show your card, providers have no way of knowing that you are a Medica Elect member and you may receive a bill for health services or be required to pay at the time you receive health services. Possession and use of a Mediea Elect identification card will not guarantee coverage. d. Request prior approval from Medica for those benefits marked with an asterisk (*) by calling the phone number listed at the beginning of the Section in which the asterisk appears and by following the prior approval process outlined in the Section titledProcedure For Obtaining Health Services. COPAYMENTS OR COINSURANCE See speei~c benefit for applicable copayment or coinsurance. nNe~O ~: ' DEDUCTIBLE per member Deductible does not apply. $300 per family $900 OUT-OF-POCKET MAXIMUM FOR COPAYMENTS, COINSURANCE AND DEDUCTIBLE per member $1,200 $3,000 per family $2,400 Out-of-pocket maximum does not apply. LI~ETIME MAXIMUM BENEFITS Unlimited $1,000,000 PAYABLE PER MEMBER Out-of-Pocket Maximum. For in-network benefits and out-of-network benefits you must pay any copayment, coinsurance, deductible, charge not covered by Mediea and/or charge in excess of the non- network provider reimbursement amount. The out-of-pocket maximum is an accumulation of copayments, coinsurance and deductibles only. You will not be required to pay more than the out-of-pocket maximum of ME 7 (I/1999) BPL 97425 Page 25 Introduction copayments, coinsurance and/or deductibles, as described in the table above, for benefits received during any calendar year unless otherwise specified. Note that any mount and/or charge not paid by Medica or MIC, including charges for services not eligible for coverage and any charge in excess of the non-networkprovider reimbursement amount, is not applicable toward the out-of-pocket maximum. After you satisfy the out-of- pocket maximum, all other eligible services received during the rest of the calendar year will be covered at 100% except for any charge not paid by Mediea and/or charge in excess of the non-networkprovider reimbursement amount. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. In addition, a family out-of-pocket maximum also applies to your in-network benefits. When any members in a family unit (the subscriber and his or her dependents) have together satisfied the family in-network benefits out-of-pocket maximum of copayments, coinsurance and/or deductibles, as described in the Copayments, Coinsurance, Deductibles and Maximum Amounts Table in this Section, for in-network benefits received during any calendar year, then all members of the family trait are considered to have satisfied the in-network benefits family out-of-pocket maximum for that calendar year. For in-network benefits you must pay: 1. Any applicable copayment or coinsurance as described in tiffs Certificate. 2. Any charge that is not covered under the Contract. IMPORTANT INFORMATION ABOL~ HOW COINSURANCE PAYMENTS ARE CALCULATED WHEN BASED ON RETAIL CHARGES Following is an explanation of how Medica's payments to network providers are determined when the member coinsurance is based on the provider's retail charge, but Medica has negotiated a discount with the network provider. Because Minnesota statutes authorize Mediea to negotiate discounts with medicalproviders, the amount Medica actually pays aprovider may be a discounted amount (i.e. "wholesale"). When a member is asked to pay coinsurance based on the provider's retail charge in these instances, the amount that Mediea pays the provider is as described under either 1 or 2 below. The amount that Medica pays the provider is the difference between the wholesale amount that the provider has agreed to accept and what the member pays as coinsurance (based on the retail charge). For example, if a network provider charges $100 for a particular benefit (i.e. retail), and the member is responsible to pay a 20% coinsurance based on the provider's retail charge, the member must pay $20 (20% of the retail charge). Medica, however, may have negotiated a discount with the provider; for example, a wholesale charge of $60. Less the $20 member coinsurance, Medica would pay the network provider $40, instead of paying 80% of the retail charge ($80). 2. The amount that Medica pays the provider is a "per episode" amount agreed upon by Medica and the provider. This amount might not change based on what the member pays as coinsurance. You may obtain a written Explanation of Benefits (EOB) regarding any claim by calling Customer Service at the phone numbers listed throughout this Certificate to request one. For out-of-network benefits, you must pay: 1. any applicable copayment or coinsurance as described in this Certificate; and ME 7 (1/1999) BPL 97425 Page 26 Introduction 2. an annual per member deductible as described in the Copayments, Coinsurance, Deductibles and Maximum Amounts Table in this Section. However, a family deductible also applies. When members in a family unit (a subscriber and his or her dependents) have together paid the deductibles for benefits received during any calendar year as described in the Copayments, Coinsurance, Deductibles and Maximum Amounts Table in this Section, then all members of the family mt are considered to have satisfied their deductible for that calendar year. 3. for out-of-network benefits received from a network provider (including apreferred network provider), any charge that is not covered under the Contract; and 4. for out-of-network benefits received from a non-networkprovider, any charge that exceeds the non- network provider reimbursement amount and any other charge that is not covered under the Contract. This means you will be required to pay the difference between what is covered under the Contract and what the provider bffied to you. To inquire about the non-networkprovider reimbursement amount for a particular procedure, you may call Customer Service at (952) 945-8000 (Mpls./St. Paul metro area) or 1-800-952-3455 or TTY phone for the hearing impaired only: (952) 992-3190 (Mpls./St. Paul metro area) or 1-800-841-6753. You will need to give them the following information: a. The CPT (Current Procedural Terminology) code for the procedure (ask your non-network provider for the CPT code). b. The name and location of the non-networkprovider. The non-network provider reimbursement amount given to you when you call Customer Service prior to receiving health services will be an estimate based on the information provided at the time of your inquiry. However, the actual non-network provider reimbursement amount paid will be based on the information received at the time the claim is submitted and subject to all applicable benefit provisions, exclusions and limitations, including but not limited to copayments, coinsuranceand deductibles, as described in this Certificate. ANY AMOUNT AND/OR CItARGE NOT COVERED BY MEDICA OR MIC IS NOT APPLICABLE TOWARD TI~E OUT-OF-POCKET MAXIMUM, INCLUDING ANY CItARGE IN EXCESS OF TI~E NON-NETWORK PROVIDER REIMBURSEMENT AMOUNT. NOTE: The maximum amount payable per member for out-of-network benefits under this Contract and for out-of-network benefits under any other Medica contract is described in the Copayments, Coinsurance, Deductibles and Maximum Amounts Table in this Section. You should monitor the amount paid for out-of- network benefits and contact Medica when you are close to reaching your lifetime maximum. What your Employer must do: 1. Remit the premium to Medica. 2. Notify you of any changes to this Certificate as required by applicable law. ME 7 (1/1999) BPL 97425 Page 27 C. Procedure For Obtaining Health Services This Section describes the procedures that you must follow to obtain coverage for the benefits described in this Certificate. As described below, the level of coverage for benefits is determined by whether you choose to receive benefits: (1) through your primary care clinic or care system; or (2) directly from a network provider or a non-networkprovider. To obtain the highest level of coverage, you must seek benefits through your primary care clinic or care system, unless otherwise described in this Certificate under in-network benefits. If you wish to apply for a standing referral to aprovider who is a specialist, contact yourprimary care clinic. Under certain circumstances, your primary care clinic or care system may grant a standing referral. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Definitions. Use these de£mitions to best understand rids Certitieate. 1. Selecting aprimary care clinic: a. What you must do: i) You must, for yourself and your family, select aprimary care clinic from the list ofproviders desi~tmated by Medica as primary care clinics. You may select different primary care clinics for yourself and each of your dependents. Selection of your primary care clinic determines whether you will be a member of a care system and, if so, which care system. If you are in a care system, your care system establishes the access procedures you must follow to obtain in-networkbenefits. ii) You must notify the seleetedprimary care clinic(s) of your decisions, and confirm that each primary care clinic is participating with Mediea Elect and is accepting new Mediea Elect members. Theprimary care clinic that you choose will coordinate all health services. iii) You may change your primary care clinic once in any calendar month. You may change your primary care clinic by notifying Medica at least 10 days before the first day of the next month, on which date the change will take effect. iv) If you change your primary care clinic and are receiving services through a referral from your prior primary care clinic, you must obtain a new referral from your newprimary care clinic. b. What Medica does: i) You will be notified by Mediea if your primary care clinic no longer participates with Mediea Elect. At that time, you must then choose a newprimary care clinic from the list of providers designated by Medica as primary care clinics. There is no assurance that a partieularprimary care clinic will remain aprimary care clinic or continue to be available to accept you as a patient. For any questions regarding the selection of a primary care clinic, contact Customer Service at the phone number listed throughout this Certificate. ME 7 (1/1999) BPL 97425 Page 29 Procedure For Obtaining Health Services In-network benefits: a. Health services provided or referred by your primary care clinic are eligible for coverage as in- network benefits. If you are in a care system, your care system establishes the access procedures you must follow to obtain in-network benefits. Some care systems require a referral from yourprimary care clinic; others allow you to access aprovider affiliated with your desi~cmatedcare system without a referral from your primary care clinic. Contact yourprimary care clinic for information about care system access procedures, or see your Medica Elect Provider Directory for more information. A referral from your primary care clinic is not required for the following health services: i) preferred network convenient/urgent care center visits. ii) health services provided by apreferred network chiropractor. iii) health services provided by apreferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians designated in your Provider Directory as available to you. The Ob/Gynphysicians available to you are limited, based on your selection ofaprimary care clinic and/or your geographic loearion. You are not required to designate apreferred network Ob/Gynphysician nor are you required to obtain a referral from your primary care clinic to receive services from your preferred network Ob/Gynphysician. However, if your preferred network Ob/Gynphysician recommends that you seek specialized services from anotherprovider, you must seek prior approval from Mediea that may include a referral from yourprimary care clinic to determine what your coverage will be. iv) mental health/substance abuse health services provided by your desist, hated mental health/substance abuseprovider. b. What you must do to obtain in-network benefits: i) Before you receive the services, you must obtain a Mediea written referral from yourprimary care clinic indiearing theprovider from whom you will receive the referral health services. (If your provider refers you to a non-networkprovider, you must follow the prior approval process outlined under the item rifled '~Reeommendedreferrals for health services from non-network providers" in this Section.) If yourprimary care clinic is affiliated with a care system, you must follow the access procedures established by your designated care system, which may or may not include a referral from yourprimary care clinic. Contact yourprimary care clinic for information about care system access procedures, or see your Medica Elect Provider Directory for more information. The providers to whom you have access under in-network benefits will be determined by your selection of aprimary care clinic. ii) If a referral from yourprimary care clinic is required, you must obtain a new Medica written referral from yourprimary care clinic prior to receiving additional or other health services if your referralprovider recommends health services not specifically identified in the ori~nal referral. iii) You must request prior approval from Medica for those benefits marked with an asterisk (*) by calling the phone number listed at the beginning of the Section in which the asterisk appears. Prior approval must be obtained before you receive health services, whether or not you have already obtained areferral from yourprimary care clinic or followed your desi~onated care system's access procedures. If you changeprimary care clinics, you must obtain a referral from your newprimary care clinic before obtaining referral health services. ME 7 (]/[999) BPL 97425 Page 30 Procedure For Obtaining Health Services 3. Out-of-network benefits: a. Health services other than those described in this Certificate under in-networkbenefits will be eligible for coverage as out-of-network benefits. You may have less out-of-pocket expense when out-of- network benefits are received from network providers than when out-of-network benefits are received from non-networkproviders, since only non-networkproviders can bffi you for the difference between what MIC pays the provider and the charge bffied by theprovider O.e. "balance billing"). See the Section rifled Introduction for more information. b. What you must do to obtain out-of-network benefits: You must obtain prior approval from Medica for those benefits marked with an asterisk (*) by calling the phone number listed at the be~nning of the Section in which the asterisk appears. Prior approval must be obtained before you receive health services. 4. Mediea's Prior Authorization Process: You, someone on your behalf, or your attending provider must request prior authorization from Medica for those benefits marked with an asterisk (*) by calling the phone number listed at the be~nning of each section in which the asterisks appear. Prior authorization must be obtainedbefore you receive health services. This applies even when services are provided or referred by your primary care clinic. When you call to obtain prior authorization, Medica requires that the following information be provided: a. Name and phone number of theprovider who is making the request; and b. Name, phone number, address and type of specialty of theprovider to whom you are being referred, if applicable; and c. Services being requested and the date those services are to be rendered (if scheduled); and d. Specific information related to your condition (for example, a letter of medical necessity from your provider); and e. Other applicable member info~ation as requested by Medica (i.e., member number). Medica will review your request and provide a response to you and your attendingprovider within ten (10) business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available to Medica. Your attenffmgprovider may request an expedited review from Medica iftheprovider believes that an expedited review is warranted. In the case of an expedited review, Medica will inform both you and your attendingprovider of Medica's decision no later than seventy-two (72) hours from the time of the initial request. If Medica does not approve your request for prior authorization, you have the right to appeal Medica's decision as described in the Section tifledlf You Have A Complaint. Under certain circumstances, Medica may perform concurrent review to determine whether services continue to be medically necessary. If Medica determines that services are no longer medically necessary, Medica will inform both you and your attendingprovider in writing of its decision. If Medica does not approve continued coverage, you or your attendingprovider may appeal Medica's initial decision as described in the Section fitledIf You Have A Complaint. 5. Recommended referrals for health services from non-network providers: a. Referral recommendations from your primary care clinic or care system to a non-network provider will be eligible for coverage as in-network benefits when prior approval is obtained from Medica as described below. It is to your advantage to seek Medica's required approval for ME 7 (1/1999) BPL 97425 Page 31 Procedure For Obtaining Health Services referral recommendations to non-networkproviders before you receive services. Medica can then tell you what your benefits will be. b. }tow to obtain a referral recommendation to a non-networkprovider: What you must do: i) You must obtain a referral recommendation from your primary care clinic or care system. ii) You must also seek prior approval from Mediea by calling Customer Service at the phone number listed throughout this Certificate. Mediea does not guarantee coverage of services that are received before you obtain prior approval from Medica. I/you would like to receive benefits that are identified in this Certificate as requiring prior approval of Medica, you must obtain this prior approval regardless of whether you have akeady obtained a referral recommendation. iii) You must obtain a new written referral recommendation from your primary care clinic or care system prior to receiving additional or other health services if your referralprovider recommends health services not specifically identified in the ori~nal referral recommendation. iv) You must pay any charges not authorized for coverage by Medica. v) You must obtain a referral recommendation from your newprimary care clinic before obtaining referral health services, if you change primary care clinics. What Medica does: i) Medica provides coverage for services that are otherwise eligible for coverage under this Certificate and determined by Medica not to be available from your primary care clinic, care system, or other network providers. Mediea will notify you of approval or denial of coverage. 6. Emergency benefits: a. What you must do: i) You must notify Medlea as soon as reasonably possible after you begin receiving emergency benefits. I/possible, you must also notify your primary care clinic and seek care from the preferred network provider designated by the primary care clinic. ii) You should refer to the Section titled Emergency Services From Non-Network Providers of this Certificate for more detailed instructions on emergency health services from non-network providers. ME 7 (1/1999) BPL 97425 Page 32 D. Professional Services This Section describes your coverage for professional services received from or under the direction of a physician. For some services described in this Section, there may be a facility copayment or coinsurance, as described in the Section rifled Hospital Services, in addition to the professional services copayment or coinsurance. In-network benefits apply to: 1. professional services received from or referred by your primary care clinic or received through the access procedures established by your designated care system; or 2. professional services received from the preferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians available to you, as designated in your Provider Directory. The Ob/Gynphysicians available to you are limited, based on your selection ofaprimary care clinic and/or your geographic location; or 3. professional services received from apreferred network convenient/urgent care center; or 4. professional services received from apreferred network chiropractor; or 5. professional services for the testing and treatment of a sexually transmitted disease, for the testing for AIDS and other HIV related conditions, and for family planning services for the voluntary planning of the conception and bearing of children received from a network provider or a non-networkprovider. Services not received from your primary care clinic or as described in (2), (3), (4) or (5) above require a valid written referral from your primary care clinic. Out-of-network benefits apply to: Out-of-network benefits apply to professional services received other than as described under in-network benefits above. When out-of network benefits are received from non-network providers, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. The most appropriate Section of this Certificate will apply for those professional services related to the treatment of a specific condition. For example, benefits for infertility services are described in the Section titled Infertility Services. Many words used in this Certificate have special meanings. These words appear in italics and are def'med for you in the Section titled Definitions. Use these def'mitions to best understand this Certificate. ME 7 (1/1999) BPL 97425 Page 33 Professional Services 1. Office visits. $15/visit 20% coinsurance 2. Convenient/urgent care center $15/visit visits. 20% coinsurance 3. Prenatal care services received Nothing 20% coinsurance from aphysician during an office visit or an outpatient hospital visit. Preventive health care when there is no existing condition or no complaint about your health: Health education and health supervision services provided during an office visit (including evaluation and follow-up). Nothing No coverage Child health supervision services, including well-baby care. Nothing 20% coinsurance C. Imml]niTations. Nothing 20% coinsurance d. Early disease detection services including physicals. Nothing No coverage Routine screening procedures for cancer including lnammograms and Pap smears. Nothing 20% coinsurance 5. Allergy shots. Nothing 0 20 ~ coinsurance ME 7 (1/1999) BPL 97425 Page 34 Professional Services 6. Refractive eye examq. Chiropractic services to diagnose and to treat, by manual manipulation or certain therapies, neuromusculoskeletal conditions related to the spine or joint. Professional sign language interpreter services in a physician's office. Contact Customer Service to arrange sign language interpreter services. Surgical services (as defined in the Physicians' Ct~ent Procedural Terminology code book) received from aphysician during an office visit or an outpatient hospital visit. Nothing. In-network benefits will apply to 1 visit per calendar year without a referral from your primary care clinic for services received from a preferred network provider. $15/visit Prior Authorization Requirements. Chiropractic services require prior authorization. Prior authorization is initiated by the chiropractic provider. If prior authorization is not obtained for these services, the chiropractic provider must submit a claim with supporting documentation, and Mcdica or its delegate will review the claim for possible coverage. Nothing $15/visit No coverage 20% coinsurance. Coverage is limited to 15 visits per calendar year. This visit limitation applies whether or not your deductible has been met. No coverage 20% coinsurance ME 7 (1/1999) BPL 97425 Page 35 Professional Services 10. Services received from a Nothing physician during an emergency room visit. 11. Services received from aphysician Nothing during an inpatient stay. 12. Services received from aphysician Nothing during an inpatient stay for prenatal care and labor and delivery. 13. Scheduled outpatient lab, Nothing pathology and x-rays. 14. Other scheduled outpatient Nothing hospital services received from a physician. 15. Up to 120 hours of communication Nothing or interpretation services for a ventilator-dependent member. Services must be received from a professional personal care assistant or a private duty nurse during an inpatient stay. 16. Treatment to lighten or remove the $15/visit coloration of a port wine stain. For emergency services from non-network providers, refer to the Section titled Emergency Services From Non-Network Providers. 20% coinsurance for non- emergency services provided in a non-network hospital emergency room. 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance ME 7 (1/1999) BPL 97425 Page 36 Professional Services 17. Diabetes se~management training and education, including medical nutrition therapy, received from a provider in a program consistent with the national standards for such education as established by the American Diabetes Association. $15/visit 20% coinsurance Services, supplies and associated expenses NOT covered: 1. Mental health or substance abuse services, except as stated in the Section rifled Mental Health and the Section rifled Substance Abuse. 2. Injections for spider veins. See additional exclusions from coverage listed in the Section titled Exclusions. ME 7 (1/1999) BPL 97425 Page 37 E. Prescription Drugs And Pharmacy Services This Section describes your coverage for Medica drug formulary ("formulary") prescription drugs, certain diabetic equipment and supplies, eligible ostomy supplies and smoking cessation products received from a pharmacy. Only prescription drugs, diabetic equipment and supplies, growth hormone, eligible ostomy supplies and smoking cessation products on Medica's formulary are eligible for benefits under this Certificate. The formulary identifies prescription drugs, diabetic equipment and supplies, and eligible ostomy supplies that are preferred by Mediea for dispensing to members. Wherever appropriate, the formulary includes generic equivalents of brand name prescription drugs. This formulary and the appropriate use guidelines are subject to periodic review and modification by Mediea. Network providers and network pharmacies have Medica's drug formulary. You will have your lowest copayment or coinsurance when you use formulary products. Your physician may request that Medica make an exception to allow coverage of a non-formulary prescription drug. Mediea will work with your physician to determine if an exception is appropriate for your medical condition. Exceptions to the formulary can include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the formulary or you change health plans. If you would like to request a copy of Mediea's formulary exception process, call Customer Service at one of the telephone numbers listed throughout this Certificate. Prescription drugs, diabetic supplies, eligible ostomy supplies and smoldng cessation products will not be dispensed in excess of one prescription unit. (However, you may refill your prescription up to 7 days prior to your refill date.) 1. For prescription drugs one prescription unit is equal to: a. up to a 31 consecutive day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines); b. up to a 31 day supply per type of insulin; or c. up to a 1-cycle supply of oral contraceptives. 2. For diabetic supplies one prescription unit is equal to the greater of: a. up to a 31 consecutive day supply (unless limited by the drug manufacturer's packaging or Mediea's appropriate use guidelines); or b. 100 uuits. 3. For eligible ostomy supplies, one prescription unit is equal to up to a 31 consecutive day supply 0mless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines). 4. For smoking cessation products, coverage is limited to nicotine patches, nicotine gum and Zyban. One prescription unit is equal to up to a 30 consecutive day supply of nicotine patches OR nicotine gum OR Zyban (unless limited by drag manufacturer's packaging) as determined by the manufacturer's dosing instructions for appropriate use. lV~ 7 (1/1999) BPL 97425 Page 39 Prescription Drugs And Pharmacy Services Coverage is limited to a maximum benefit of up to 6 prescription units for Zyban, 2 prescription units for nicotine patches, and up to 3 prescription units for nicotine gum per calendar year. Amounts less than a 30 consecutive day supply of any of the products listed above will be counted as 1 prescription unit for the purposes of calculating your annual maximum benefit. Prior Authorization Requirements. Certainprescription drugs and supplies on Medica's formulary require prior authorization at the point of service. Prior authorization is initiated by the provider who has prescribed the prescription drug or supply or by the pharmacist. If prior authorization is not obtained for these products prior to being dispensed, you must submit a paper claim with supporting documentation, and Mediea will review the claim for possible coverage. Medica network providers, including network pharmacies, are given a list of formularyprescription drugs and supplies that require prior authorization. In-network benefits apply to: 1. Prescription drugs received from a network pharmacy and prescribed by your primary care clinic; or the preferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians designated in your Provider Directory as available to you; or any other provider to whom you were referred by your primary care clinic who is authorized to prescribe prescription drugs; and 2. Prescription drugs for family planning services or the treatment of sexually tran.qmitted diseases when prescribed by or received from either a network or a non-networkprovider; and 3. Diabetic equipment and supplies and eligible ostomy supplies described in this Section when received from a networkpharmaey or a network durable medical equipment provider. You must provide the name of your network provider to the network pharmacist or durable medical equipment provider; and 4. Smoking cessation products described in this Section when prescribed by a networkprovider authorized to prescribe prescription drugs and received at a network pharmacy. Out-of-network benefits apply to: 1. Prescription drugs prescribed by a non-networkprovider authorized to prescribe prescription drugs or received at a non-network pharmacy; and 2. Diabetic equipment and supplies and eligible ostomy supplies described in this Section when received from a non-network pharmacy or a non-network durable medical equipmentprovider. 3. There is no coverage under out-of-network benefits for smoking cessation products. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Copayments may not exceed the retail charge billed by the provider for the benefit. Coinsurance amounts will typically be based on the lesser of: 1. The charge billed by the provider O.e. retail), or 2. For network providers, the negotiated amount that the provider has agreed to accept as full payment for such benefit O.e. wholesale), or for non-network providers, the non-network provider reimbursement amount. Please refer to the Section titled Definitions for additional information regarding copayment and coinsurance. ME 7 (1/1999) BPL 97425 Page 40 Prescription Drugs And Pharmacy Services You should refer to the Section titled Miscellaneous Medical Supplies Section of this Certificate for coverage of supplies such as dietary medical treatment of phenylketonuria (PKU). Many words used in this Certificate have special meanings. These words appear in italics and are deemed for you in the Section rifled Defmitions. Use these deEmitious to best understand this Certificate. Outpatient prescription drugs other than those listed in 2, 3, 4, 5, 6 or 7 of this Section. Up to a 24-hour supply of emergency prescription drugs from a hospital or convenient / urgent care center. 3. Infertility prescription drugs. Diabetic supplies and equipment, including blood glucose monitor and test strips, disposable insulin syringes, lancets, lancet devices and alcohol swabs. Growth hormone, if medically necessary and appropriately prescribed by aphysician, for the treatment of a demonstrated growth hormone deficiency. 6. Eligible ostomy supplies. 20% coinsurance with a minimum copayment of $10 and a maximum copayment of $25 per prescription unit or refill. Nothing 20% coinsurance per prescription unit or ref'fll. 20% coinsurance per prescription unit or refill. 20% coinsurance per prescription unit or reEfll. 20% coinsurance per prescription unit or refill. $25 or 40% coinsurance (whichever is greater) per prescription unit or refill. See the Section rifled Emergency Services From Non-Network Providers. 40% coinsurance per prescription unit or reEfll. 40% coinsurance per prescription unit or refill. 40% coinsurance per prescription unit or refill. 40% coinsurance per prescription unit or refill. ME 7 (1/1999) BPL 97425 Page 41 Prescription Drugs And Pharmacy Services 7. Smoking cessation products 20% coinsurance. Coverage No coverage limited to nicotine replacement is limited to an annual therapy (Zyban, nicotine patch, maximum benefit of up to and nicotine gum only). Coverage 6 prescription units for is limited to an annual maximum Zyban, 2 prescription units benefit of up to 6 prescription units for nicotine patches, and up for Zyban, 2 prescription units for to 3 prescription units for nicotine patches, and up to 3 nicotine gum. This annual prescription units for nicotine limit is calculated each gum. This annual limit is calendar year. calculated each calendar year. Services, supplies and associated expenses NOT covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Medications available over-the-counter (OTC) that by federal or state law do not require a prescription order or refill and any medication that is equivalent to an OTC medication except as otherwise covered in this Section. 3. Replacement of aprescription drug due to loss, damage or theft. 4. Appetite suppressants. 5. Smoking cessation products or services, except as otherwise covered in this Section. 6. Medications that are not prescribed by a£rovider acting within the scope of hisgner licensure. 7. Homeopathic medicine. 8. For in-network benefits, prescription drugs, diabetic equipment and supplies, growth hormone, eligible ostomy supplies and smoking cessation products not on Medica's formulary. See additional exclusions from coverage listed in the Section rifled Exclusions. ME 7 (1/1999) BPL 97425 Page 42 F. Mail Service Prescription Drug Program This Section describes your coverage for Medica drug formulary ("formulary") prescription drugs, certain diabetic equipment and supplies, and eligible ostomy supplies received from the desi~tmated mail service prescription drug program when prescribed as described in this Section. Only prescription drugs, diabetic equipment and supplies and eligible ostomy supplies on Medica's formulary are eligible for benefits under this Certificate. The formulary identifies prescription drugs, diabetic equipment and supplies, and eligible ostomy supplies that are preferred by Mediea for dispensing to members. Wherever appropriate, the formulary includes generic equivalents of brand name prescription drugs. This formulary and the appropriate use guidelines are subject to periodic review and modification by Mediea. The designated mail service prescription drug program has Mediea's drug formulary. You will have your lowest copayment or coinsurance when you use formulary products. Prescription drugs, diabetic supplies and eligible ostomy supplies will not be dispensed in excess of one prescription unit. (However, you may refill your prescription up to 7 days prior to your ret'~ date.) 1. For prescription drugs one prescription unit is equal to: a. a 93 day supply (unless limited by the drug manufacturer's paeka~ng or Mediea's appropriate use guidelines); b. a 93 day supply per type of insulin; or e. a 1-cycle supply of oral contraceptives. 2. For diabetic supplies one prescription unit is equal to the greater of: a. a 93 day supply (unless limited by the drug manufacturer's packaging or Mediea's appropriate use guidelines); or b. 100 units. 3. For ostomy supplies, one prescription unit is equal to a 93 day supply (unless limited by the drug manufacturer's packaging or Medica's appropriate use guidelines). Forprescription drugs other than oral contraceptives, if less than one prescription unit as described above is requested, refer to the Section titled Prescription Drugs And Pharmacy Services to determine your benefits. Benefits apply to the following when received from the designated mail service prescription drug program: 1. Prescription drugs prescribed by your primary care clinic; or 2. Prescription drugs prescribed by the preferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians designated in your Provider Directory as available to you; or 3. Prescription drugs prescribed by any other provider, to whom you were referred by your primary care clinic, who is authorized to prescribe the prescription drug; or 4. Prescription drugs for family planning services or the treatment of sexually tran.qmitted diseases when prescribed by either a network or a non-networkprovider; and 5. Diabetic supplies and eligible ostomy supplies described in this Section. You must provide the name of your network physician to the designated mail service prescription drug program. ME 7 (1/1999) BPL 97425 Page 43 Mail Service Prescription Drug Program Coverage for growth hormone is provided under the Section titled Prescription Drags And Pharmacy Services. Copayments may not exceed the retail charge billed by the provider for the benefit. Coinsurance mounts will typically be based on the lesser of: 1. The charge billed by the provider O.e. retail), or 2. For network providers, the negotiated amount that the provider has agreed to accept as full payment for such benefit (i.e. wholesale), or for non-network providers, the non-network provider reimbursement amount. Please refer to the Section titled Defmifions for additional information regarding copayment and coinsurance. Many words used in this Certificate have special meanings. These words appear in italics and are def'med for you in the Section titled De£mifious. Use these definitions to best understand this Certificate. oU:Pay: ~ 1. Outpatient prescription drugs other than those listed in 20% coinsurance with a minimum 2, 3, 4, or 5 of this Section. copayment of $20 and a maximum copayment of $50 per prescription unit or ref'fll. 2. Oral contraceptives. 3. Infertility prescription drugs. Diabetic supplies, including blood glucose monitor and test strips, disposable insulin syringes, lancets, lancet devices and alcohol swabs. 5. Eligible ostomy supplies. 20% coinsurance with a minimum copayment of $10 and a maximum copayment of $25 per prescription unit or refill. If three prescription units are dispensed, two prescription unit copayments will apply. 20% coinsurance per prescription unit or refffi. 20% coinsurance per prescription unit or ref'fll. 20% coinsurance per prescription unit or refill. ME 7 (1/1999) BPL 97425 Page44 Mail Service Prescription Drug Program Services, supplies and associated expenses NOT covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Medications available over-the-counter (OTC) that by federal or state law do not require a prescription order or refill and any medication that is equivalent to an OTC medication, except as covered in the Section rifled Prescription Drugs And Pharmacy Services. 3. Replacement of a prescription drug due to loss, damage or theft. 4. Appetite suppressants. 5. Smoking cessation products or services, except as covered in the Seerion titled Prescription Drugs And Pharmacy Services. 6. Medications that are not prescribed by aprovider acting within the scope of his/her licensure. 7. Homeopathic medicine. 8. For benefits, prescription drugs, diabetic equipment and supplies and eligible ostomy supplies not on Medica's formulary. See additional exclusions from coverage listed in the Section titled Exclnsions. ME 7 (1/1999) BPL 97425 Page 45 G. Hospital Services This Section describes your coverage for use of hospital services when your care is under the direction of a physician. In-network benefits apply to hospital services: 1. arranged through your primary care clinic or care system; or 2. arranged thr~ugh the preferred netw~rk ~b/Gyn physician wh~m y~u have se~e~ted fr~m the ~ist ~f Ob/Gynphysicians designated in your Provider Directory as available to you and received from a network hospital; or 3. that are outpatient services for an emergency provided in a network hospital emergency room. A referral is not required. Out-of-network benefits apply to hospital services received other than as described under in-network benefits above. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-networkprovider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Medica generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child member to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother or newborn member's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, Medica may not require that aprovider obtain prior authorization from Medica for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable). Many words used in this Certificate have special meanings. These words appear in italics and are def'med for you in the Section rifled Def'mifions. Use these def'mitions to best understand this Certificate. For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. ME 7 (1/1999) BPL 97425 Page 47 Hospital Services 1. Outpatient services. a. Services provided in a hospital emergency room. b. Scheduled outpatient lab, pathology and x-rays. c. Maternity labor and delivery services. d. Prenatal care services. e. Other scheduled outpatient services. Other scheduled outpatient hospital services received from a physician. Services provided in a hospital observation room. $60/visit. However, if you are admitted for an inpatient stay to the same hospital within 24 hours for the same condition treated in the emergency room, this copayment will not apply. Nothing 20% coinsurance for non-emergency services provided in a non-network hospital emergency room. For coverage of emergency services from non-network providers refer to the Section rifled Emergency Services From Non-Network Providers. 20% coinsurance Nothing 20% coinsurance Nothing $15/visit 20% coinsurance 20% coinsurance Nothing 20% coinsurance $15/visit. However, if you are admitted for an inpatient stay at the same hospital within 24 hours for the same eondirion treated in the observation room, this copayment will not apply. 20% coinsurance ME 7 (1/1999) BPL 97425 Page 48 Hospital Services 3. Inpatient services, including Nothing inpatient maternity labor and delivery services. Semi-private room and board in a hospital. A private room is covered only for conditions of preeclampsia, radium implants, contagion or immuno-suppression that require isolation, as determined by Medica. *20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. 4. Services received from aphysician during an inpatient stay. Nothing 20% coinsurance Services, supplies and associated expenses NOT covered: 1. Admission to another hospital when care for your condition is available at the network hospital where you were first admitted. See additional exclusions from coverage listed in the Section titled Exclusions. ME 7 (1/1999) BPL 97425 Page 49 H. Ambulance Services This Section describes your coverage for ambulance transportation and ambulance services received in eounection with covered medical and medical-related dental services described in this Certificate. For non-etnergency licensed ambulance services listed under 2 below, in-network benefits apply to ambulance services: 1. arranged through your primary care clinic or care system; or 2. arranged through the preferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians designated in your Provider Directory as available to you and received from a network provider. Out-of-network benefits apply to ambulance services received other than as described under in-network benefits above. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-networkprovider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Definitions. Use these defmifions to best understand this Certificate. 1. Ambulance services and/or 20% coinsurance ambulance transportation to the nearest hospital for an emergency. See the Section tiffed Emergency Services From Non-Network Providers. ME 7 (1/1999) BPL 97425 Page 51 Ambulance Services Non-emergency licensed ambulance service that is scheduled by an attending physictan or nurse, as follows: a. transportation from hospital to hospital when: 20% coinsurance 20% coinsurance i) care for your condition is not available at the hospital where you were first admitted; or ii) required by Medica. b. transportation from hospital to skilled nursingfacility. 20% coinsurance 20% coinsurance Services, supplies and associated expenses NOT covered: 1. Ambulance tran.qportarion to another hospital when care for your condition is available at the network hospital where you were first admitted. 2. Non-emergency ambulance tranapormtion services, except as described in this Section. See additional exclusions from coverage listed in the Section rifled Exclusions. ME 7 (1/1999) BPL 97425 Page 52 I. Outpatient Rehabilitation This Section describes your coverage for benefits for both professional and outpatient health care facility services. In-network benefits apply to outpatient rehabilitation services: 1. received from your primary care clinic; or 2. referred by your primary care clinic; and received from a networkphysical therapist, a network occupational therapist, a network speech therapist or a network, physician, or 3. arranged through the access procedures established by your designated care system. Out-of-network benefits apply to outpatient rehabilitation services arranged other than as described under in-network benefits above and received from a physical therapist, an occupational therapist, a speech therapist, or a physician. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section rifled Def'mirions. Use these definitions to best understand this Certificate. Physical therapy received outside of your home. $15/visit 20% coinsurance ME 7 (1/1999) BPL 97425 For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. Page 53 Outpatient Rehabilitation 2. Speech therapy received outside of your home. a. Initial speech therapy Nothing evaluation to determine if speech is impaired due to a medical illness or injury, or congenital or developmental conditions that have delayed speech development. b. Speech therapy when speech $15/visit is impaired due to a medical illness or injury, or congenital or developmental conditions that have delayed speech development. 3. Occupational therapy received outside of your home. a. Initial occupational therapy Nothing evaluation to determine if physical function is impaired due to a medical illness or injury, or congenital or developmental conditions that have delayed motor development. b. Occupational therapy when $15/visit physical function is impaired due to a medical illness or injury, or congenital or developmental conditions that have delayed motor development. 20% coinsurance *20% coinsurance 20% coinsurance *20% coinsurance ME 7 (1/1999) BPL 97425 Page 54 Outpatient Rehabilitation 4. Neuropsychological $15/visit evaluations/cognitive testing, limited to those services necessary for the diagnosis and/or treatment of a medical illness or injury. Services, supplies and associated expenses NOT covered: 20% coinsurance 1. Services primarily educational in nature. 2. Vocational and job rehabilitation. 3. Recreational therapy. 4. Self-care and self-help training (non-medical). 5. Health clubs. 6. Correction of speech impediments (stuttering or lisps) and assistance in the development of verbal clarity. 7. Voice training and voice therapy. 8. Outpatient rehabilitation services when no medical diagnosis is present. See additional exclusions from coverage listed in the Section titled Exclusions. ME 7 (1/1999) BPL 97425 Page 55 J. Mental Health Mental health benefits include the diagnosis and treatment of mental disorders. In-network benefits: 1. Mental health benefits are covered as in-network benefits only when provided or arranged by your designated mental health/substance abuse provider. Members seeking mental health benefits must contact their primary care clinic or refer to their Medica Elect Provider Directory to determine their designated mental health/substance abuse provider. 2. You must notify your designated mental health/substance abuse provider as soon after as is reasonably possible of any emergency mental health inpatient services. 3. Second opinions fxom a qualified provider are covered under your in-network benefits only if your primary care clinic or designated mental health/substance abuse provider determines that no treatment is necessary. You must receive your second opinion within 30 calendar days of your first evaluation. Your designated mental health/substance abuseproviderwill consider the second opinion but is not required to accept it. Out-of-network benefits: 1. Mental health treatment received directly from aprovider listed below will be covered under your out-of-network benefits. Emergency mental health benefits are eligible for coverage under your in- network benefits. 2. You must receive services directly fxom any of the following providers to obtain your out-of-network benefits: a. licensed psychiatrist; b. licensed consulting psychologist; c. licensed psychologist; d. licensed psychiatric nurse; e. licensed mental healthclinic; f. licensed residential treatment center; g. licensed clinical social worker; h. licensed marriage and family therapists; or i. a hospital that provides mental healthserviees. For in-network benefits: To obtain Substance Abuse Services, call your Designated Mental Health/Substance Abuse Provider. To determine your Designated Mental Health/Substance Abuse Provider, either contact your primary care clinic or refer to your Medica Elect Provider Directory. ** For out-of-network benefits: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 57 Mental Health You will be responsible for any charges in excess of the non-networkprovider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Defmitions. Use these defmitions to best understand this Certificate. 1. Outpatient services include: *$10/visit-group 20% coinsurance $15/visit-individual a. Evaluations and diagnostic services. Therapeutic services including psychiatric services. c. Relationship and family counseling services. d. Treatment for a minor, including family therapy. e. Treatment of serious or persistent disorders. Diagnostic evaluation for attention deficit hyperactivity disorder ("ADHD") or pervasive developmental disorder ("PDD"). For in-network benefits: To obtain Substance Abuse Services, call your Designated Mental Health/Substance Abuse Provider. To determine your Designated Mental Health/Substance Abuse Provider, either contact your primary care clinic or refer to your Medica Elect Provider Directory. ** For out-of-network benefits: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 58 Mental Health go Day treatment program. ("Day treatment program" means less than 4 treatment hours per day.) 2. Inpatient services. a. Semi-private room and board. b. Hospital or facility-based professional services. c. Attending psychiatrist services. Nothing *Nothing *Nothing 3. Partial program. ("Partial Nothing program" means a hospital based program of 4 or more treatment hours per day.) **20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in rids Certificate. This day limitation applies whether or not your deductible has been met. **20% coinsurance **20% coinsurance **20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. For in-network benefits: To obtain Substance Abuse Services, call your Designated Mental Health/Substance Abuse Provider. To determine your Designated Mental Health/Substance Abuse Provider, either contact your primary care clinic or refer to your Medica Elect Provider Directory. ** For out-of-network benefits: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Patti metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 59 Mental Health Services, supplies and associated expenses NOT covered: 1. Services for mental disorders not listed in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders. 2. Services to treat problems of daily living except as stated in 1, 2 and 3 above. 3. Services from a network provider for a condition that Medica determines cannot be improved with treatment. 4. Custodial sup£ortive care. 5. Inpatient services or involuntary care/treatment ordered by aphysician, court or peace officer, that Medica determines is not medically necessary. 6. Relationship counseling beyond initial evaluation and brief intervention services. 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities. 8. Telephone consultations. See additional exclusions from coverage listed in the Section titled Exclusions. For in-network benefits: To obtain Substance Abuse Services, call your Designated Mental Health/Substance Abuse Provider. To determine your Designated Mental Health/Substance Abuse Provider, either contact your primary care clinic or refer to your Medica Elect Provider Directory. ** For out-of-network benefits: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 60 K. Substance Abuse This Section describes your coverage for the diagnosis and primary treatment of substance abuse disorders listed in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders. In-network benefits: 1. Substance abuse benefits are covered as in-network benefits only when provided or arranged by your designated mental health/substance abuse provider. Members seeking substance abuse benefits must contact their primary care clinic or refer to their Medica Elect Provider Directory to determine their designated mental health/substance abuse provider. 2. You must notify your designated mental health/substance abuse provider as soon after as is reasonably possible of any emergency substance abuse inpatient services. 3. Second opinions from a qualifiedprovider are covered only if your designated mental health/substance abuse provider determines that no treatment is necessary. You must receive your second opinion within 30 calendar days of your first evaluation. Your designated mental health/substance abuse provider will consider the second opinion but is not required to accept it. Out-of-network benefits: 1. Substance abuse treatment received directly from aprovider Hsted below will be covered under your out-of-network benefits. Emergency substance abuse benefits are eligible for coverage under your in-network benefits. 2. You must receive services directly from any of the following providers to obtain your out-of-network benefits: a. liceused psychiatrist; b. licensed consulting psychologist; c. licensed psychologist; d. licensed psychiatric nurse; e. licensed chemical dependency clinic; f. licensed residential treatment center; or g. a hospital that provides substance abuse services. You will be responsible for any charges in excess of the non-networkprovider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. For in-network benefits: To obtain Substance Abuse Services, call your Designated Mental Health/Substance Abuse Provider. To determine your Designated Mental Health/Substance Abuse Provider, either contact your primary care clinic or refer to your Medica Elect Provider Directory. ** For out-of-network benefits: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 61 Substance Abuse Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section rifled Def'mifions. Use these def'mitions to best understand this Certificate. 1. Outpatient services include: a. Evaluations and diagnostic services. b. Therapeutic services for primary treatment including: i) outpatient primary treatment program, and intensive outpatient primary treatment program (9 or more treatment hours per week). *$1 O/visit-group $15/visit-individual 20% coinsurance For in-network benefits: To obtain Substance Abuse Services, call your Designated Mental Health/Substance Abuse Provider. To determine your Designated Mental Health/Substance Abuse Provider, either contact your primary care clinic or refer to your Medica Elect Provider Directory. ** For out-of-network benefits: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 62 Substance Abuse 2. Inpatient services: a. Semi-private room and Nothing board. **20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. b. Hospital or facility-based professional services. *Nothing **20% coinsurance c. Attendingphysician *Nothing SCI~CCS. **20% coinsurance Services, supplies and associated expenses NOT covered: 1. Services to hold or confme a person under chemical influence when no medical services are required, regardless of where the services are received. 2. Services beyond the primary treatment of substance abuse. 3. Services from a network provider for a condition that Medica determines cannot be improved with treatment. 4. Custodial supportive care. 5. Inpatient services or involuntary care/treatment, ordered by aphysician, court or peace officer, that Medica determines is not medically necessary. 6. Methadone or Cyclazocine treatment or their equivalents. 7. Telephone consultations. See additional exclusions from coverage listed in the Section titled Exclusions. For in-network benefits: To obtain Substance Abuse Services, call your Designated Mental Health/Substance Abuse Provider. To determine your Desi~cmated Mental Health/Substance Abuse Provider, either contact your primary care clinic or refer to your Mediea Elect Provider Directory. ** For out-of-network benefits: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 ME 7 (1/1999) BPL 97425 Page 63 L. Durable Medical Equipment And Prosthetics This Section describes your coverage for durable medical equipment and certain related supplies and prosthetics. Medica covers only a limited selection of durable medical equipment and certain related supplies that meets the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. Contact Customer Service at the telephone numbers listed below to determine whether the item ordered is included in Medica's list of eligible items or to request a current list of Medica's eligible durable medical equipment and certain related supplies. If the durable medical equipment or prosthetic device is covered by Medica, but the model you select is not Mediea's standard model, you will be responsible for the cost difference. Medica determines if durable medical equipment will be purchased or rented. Medica's approval of rental of durable medical equipment is limited to a specific period of time. Call Customer Service at the telephone numbers listed below to request approval for an extension of the rental period. In-network benefits apply to durable medical equipment and certain related supplies and prosthetic services: 1. prescribed by your primary care clinic; or 2. arranged through the access procedures established by your designated care system; or 3. prescribed by the preferred network Ob/Gynphysician whom you have selected from the list of Ob/Gyn physicians available to you, as designated in your Provider Directory, and received from a network provider who has a durable medical equipment contract with Medica. Out-of-network benefits apply to durable medical equipment and certain related supplies and prosthetic services received other than as described under in-network benefits above. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section rifled Definitions. Use these definitions to best understand this Certificate. For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Patti metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. ME 7 (1/1999) BPL 97425 Page 65 Durable Medical Equipment And Prosthetics ..... . ~ Eo ~: ut.of Netwo~ ~ ~ ~ 1. Durable medical equipment and 20% coinsurance *20% coinsurance certain related supplies. 2. Repair, replacement or revision of 20% coinsurance *20% coinsurance durable medical equipment made necessary by normal wear and use. 3. Prosthetics: a. Iuitial purchase of breast prostheses. b. Initial purchase of artificial limbs and eyes. c. Scalp hair prostheses due to alopecia areata. Repair, replacement or revision of artificial limbs, eyes and breast prostheses made necessary by normal wear and use. 20% coinsurance 20% coinsurance 20% coinsurance of the first $437.50 and 100% of any mount over $437.50. Medica pays up to $350. This is calculated each calendar year. 20% coinsurance 20% coinsurance *20% coinsurance 20% coinsurance of the first $437.50 and 100% of any mount over $437.50. Medica pays up to $350. This is calculated each calendar year. The deductible listed in the Section titled Introduction does not apply to this provision. *20% coinsurance ME 7 (1/1999) BPL 97425 Page 66 Durable Medical Equipment And Prosthetics Services, supplies and associated expenses NOT covered: 1. Any durable medical equipment or supplies and appliances not on the Medica eligible list. 2. Any charges in excess of the Medica standard model of durable medical equipment or prosthetics. 3. Repair, replacement or revision of durable medical equipment and prosthetics, except when made necessary by normal wear and use. 4. Duplicate durable medical eqm'pment and prosthetics. See additional exclusions from coverage listed in the Section ritled Exclusions. ME 7 (1/1999) BPL 97425 Page 67 M. Miscellaneous Medical Supplies This Section describes your coverage for miscellaneous medical supplies prescribed by aphysician. In-network benefits apply to: 1. miscellaneous medical supplies received from or arranged throul,,la your primary care clinic; or 2. arranged through the access procedures established by your designated care system; or 3. miscellaneous medical supplies prescribed by the preferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians available to you, as designated in your Provider Directory, and received from a network provider; or 4. levonorgestrel services received from either a network provider or a non-networkprovider. Out-of-network benefits apply to miscellaneous medical supplies received other than as described under in- network benefits above. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Definitions. Use these de£mitions to best understand this Certificate. 1. Blood clotting factors: 20% coinsurance a. Factor vm. b. Factor IX. 20% coinsurance ME 7 (1/1999) BPL 97425 For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. Page 69 Miscellaneous Medical Supplies 2. Dietary medical treatment of phenylketonuria ("PKU"). 3. Levonorgestrel (i.e. Norplant). Limited to one implant every 3 years. 20% coinsurance 20% coinsurance 20% coinsurance Refer to in-network benefits. 4. Total parenteral nutrition. 20% coinsurance *20% coinsurance Services, supplies and associated expenses NOT covered: 1. Other supplies and appliances that are disposable or non-durable, except as described above. See additional exclusions from coverage listed in the Section titled Exclusions. ME 7 (1/1999) BPL 97425 Page 70 N. Temporornandibular Joint ("TMJ") Disorder This Section describes your coverage for the evaluation(s) to determine whether you have a TMJ disorder and the surgical and non-surgical treatment of a diagnosed TMJ disorder when services are received from or under the direction of physicians or dentists. Coverage for treatment of ~ disorder includes coverage for the treatment of craniomandibular disorder. This Section includes benefits for both professional and hospital services. In-network benefit~ apply to TMJ services received from or referred by your primary care clinic, or arranged through the access procedures established by your designated care gystem. Out-of-network benefit~ apply to TMJ services received other than as described under in-network benefits above. When out-of network benefits are received from non-network providers, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defmed for you in the Section titled Definitions. Use these definitions to best understand this Certificate. 1. Initial office visit for evaluation. $15/visit 2. Office visits (including further $15/visit evaluations). 20% coinsurance *20% coinsurance ME 7 (1/1999) BPL 97425 For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. Page 71 Temporomandibular Joint ("TMJ") Disorder .......... Benefits~! ~ !!!~ aUCti ~ ~ 3. Outpatient services. a. Professional services. i) Surgical services (as $15/visit *20% coinsurance def'med in thc Physicians' Cmxent Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit. ii) Scheduled outpatient Nothing *20% coinsurance lab, pathology and x- rays. iii) Other scheduled Nothing 20% coinsurance outpatient hospital services received from a physician. b. Hospital services. i) Scheduled outpatient Nothing 20% coinsurance lab, pathology and x- rays. * o ii) Other scheduled $15/visit 20 % coinsurance outpatient hospital services. 4. Physical therapy received outside of your home. $15/visit 20% coinsurance ME 7 (1/1999) BPL 97425 Page 72 Temporomandibular Joint ("TMJ") Disorder 5. Inpatient services. Nothing *20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. 6. Services received from aphysician Nothing during an inpatient stay. 7. TMJ splints and adjustments if *20% coinsurance your primary diagnosis is TMJ disorder. 20% coinsurance *20% coinsurance Services, supplies and associated expenses NOT covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. See additional exclusions from coverage listed in the Section rifled Exclusions. ME 7 (1/1999) BPL 97425 Page 73 O. Organ And Bone Marrow Transplant Services This Section describes your coverage for organ and bone marrow transplant services provided under the direction of aphysician and received at a transplant facility. Bone marrow transplants include stem cells from any of the following sources: bone marrow, peripheral blood and umbilical cord blood. This Section includes your benefits for both professional and hospital services. Coverage is provided for certain types of organ transplants and related services (including organ acquisition and procurement), and for bone marrow transplant services that Medica determines to be medically necessary, appropriate for the diagnosis, and without contraindicatious. Coverage is provided for the following human organ transplants: cornea, kidney, single lung, double lung, heart, heart/lung, liver and pediatric partial liver transplants when there is a living related donor. Pancreas transplants are covered if you are a diabetic with end-stage renal disease who previously received a kidney transplant or receives a kidney transplant during the same operative session as the pancreas transplant, or if you are a medically uncontrollable, labile diabetic with one or more secondary complications, but whose kidneys are not seriously damaged. Autologous bone marrow transplants are covered only for diseases originating in the hematologic or lymphatic system, advanced or recurrent neuroblastomas (Stage 3 or 4), testicular/germ cell cancer and breast cancer. Coverage for non-Hodgkin's lymphoma is limited to Stage 3 or 4 disease. Allogeneic and syngeneic bone marrow transplants are covered only for treatment of the following conditions: acute lymphocytic leukemia, acute myelogenous leukemia, acute non-lymphocytic leukemia, chronic myelogenous leukemia, multiple myeloma, aplastic anemia (including Fanconi's anemia), severe combined immunodeficiency disease, Wiskott-Aldrich syndrome, Kostmapn's syndrome, primary granulocyte dysfunction, chronic granulomatous disease, cartilage-hair hypoplasia, infantile osteopetrosis (marble-bone disease), severe mucopolysaccharidoses (including Hurler's syndrome), Burkitt's lymphoma and thalassemia major. Medica, at its discretion, may require all pre-transplant, transplant and post-transplant services you receive from the time of the initial evaluation through no more than one year from the date of the transplant be received at one designated transplant facility that you select from among the list of transplant facilities that Medica provides to you. Based on the type of transplant you have received, Medica will determine the specific time period medically necessary for these services. Coverage for organ and bone marrow transplants is subject to periodic review and modification by Medica. In-network benefits apply to transplant services provided by or referred by your primary care clinic or care system and received at a network designated transplant facility. A desi~tmated transplant facility means a For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Patti metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. ME 7 (1/1999) BPL 97425 Page 75 Organ And Bone Marrow Transplant Services hospital that has entered into a separate contract with Medica to provide certain transplant-related health services to members receiving transplants. Once you have been evaluated and listed as a potential recipient at a designated transplant facility, you will be required to remain with that designated transplant facility, unless it is medically necessary for your transplant to be rendered at another facility. A designated transplant facility may be located outside the Medica service area. Out-of-network benefits apply to organ and bone marrow transplant services arranged other than as described under in-network benefits above and received at a transplant facility. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non- network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Definitions. Use these definitions to best understand this Certificate. Office visits. *$15/visit Outpatient services. a. Professional services. *20% coinsurance i) Surgical services, (as *$15/visit *20% coinsurance defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit. ii) Scheduled outpatient *Nothing *20% coinsurance lab, pathology and x- rays. ME 7 (1/1999) BPL 97425 Page 76 Organ And Bone Marrow Transplant Services iii) Other scheduled *Nothing *20% coinsurance outpatiem hospital services received from a physician. b. Hospital services. i) Scheduled outpatient *Nothing *20% coinsurance lab, pathology and x- rays. ii) Other scheduled *$15/visit *20% coinsurance outpatient hospital services. 3. Inpatient services. *Nothing *20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. 4. Services received from aphysician during an inpatient stay. Nothing 20% coinsurance ME 7 (1/1999) BPL 97425 Page 77 Organ And Bone Marrow Transplant Services Services, supplies and associated expenses NOT covered: 1. Organ and bone marrow transplants or stem cell support procedures not specifically described as covered in this Section. 2. Chemotherapy, radiation therapy or any therapy that damages the bone marrow, drags and related supplies and services, including the after care for, or related to, bone marrow transplants and stem cell support procedures for a condition not specifically described as covered in this Section. 3. Living donor transplants of the liver, lung or any other organ (except kidney and living related donor for pediatric partial liver tran.qplants), including living related segmental and islet cell transplants of the pancreas. 4. Services required to meet the patient selection criteria for the approved transplant procedure, including treatment of nicotine or caffeine addiction, services and related expenses for weight loss programs, nutritional supplements, appetite suppressants and supplies of a similar nature otherwise not covered under this Contract. 5. Computer search for donors at facilities outside of Medica's designated transplant centers. 6. Chemotherapy, drags and other related supplies and services, including the after care for, or related to, mechanical, artificial or non-human organ implants or transplants. 7. Transplants that are investigative. 8. Private collection and storage of umbilical cord blood for directed use. See additional exclusions from coverage listed in the Section rifled Exclusions. ME 7 (]/1999) BPL 97425 Page 78 P. Infertility Services This Section describes your coverage for the diagnosis and treatment of infertility in connection with the voluntary planning of conceiving a child. Infertility treatment must be received from or under the direction of aphysician. This Section includes your benefits for both professional and hospital services. For members with a diagnosis of infertility, up to six artificial inseminations are covered per attempted pregnancy. Benefits renew after a confirmed pregnancy. In-network benefits apply to: 1. infertility treatment services received from or referred by yourprimary care clinic; or 2. infertility treatment services arranged through the access procedures established by your designated care system; or 3. infertility treatment services received from thepreferred network Ob/Gynphysician whom you have selected from the list of Ob/Gynphysicians designated in your Provider Directory as available to you. 4. services received from a network or non-networkprovider for the diagnosis of infertility. Out-of-network benefits apply to infertility treatment services received other than as described under in- network benefits above. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-networkprovider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Definitions. Use these definitions to best understand this Certificate. For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. BPL 97425 Page 79 Infertility Services 1. Office visits, including any 20% coinsurance 20% coinsurance services provided and drugs administered during such visits. 2. Outpatient services received at a hospital. 20% coinsurance 20% coinsurance 3. Inpatient services. 20% coinsurance *20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. Services, supplies and associated expenses NOT covered: 1. Drugs for serf-administration when dispensed by aphysician. 2. In vitro fertilization, gamete and zygote intrafallopian transfer (GI~T and ZIFT) procedures. 3. More than six cycles of artificial insemination per confirmed pregnancy. 4. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 5. Sperm banking. 6. Adoption. 7. Donor sperm. 8. Embryo and egg storage. See additional exclusions from coverage listed in the Section titled Exclusions. ME 7 0/1999) .. BPL 97425 Page 80 Q. Reconstructive And Restorative Surgery This Section describes your benefits for both professional and hospital services for reconstructive and restorative surgery. To be eligible for coverage reconstructive and restorative surgery services must be medically necessary and not cosmetic. In-network benefits apply to reconstructive and restorative surgery services received from or referred by your primary care clinic or care system and received at a network facility. Out-of-network benefits apply to reconstructive and restorative surgery services received other than as described under in-network benefits above. When out-of network benefits are received from non-network providers, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defmed for you in the Section titled Definitions. Use these definitions to best understand this Certificate. 1. Office visits. *20% coinsurance *20% coinsurance ME 7 (1/1999) BPL 97425 For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Patti metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. Page 81 Reconstructive And Restorative Surgery 2. Outpatient services. a. Professional services. i) Surgical services (as *20% coinsurance defmed in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit. *20% coinsurance ii) Scheduled *Nothing outpatient lab, pathology and x- rays. *20% coinsurance iii) Other scheduled *20% coinsurance outpatient hospital services received from a physician. *20% coinsurance b. Hospital services. i) Scheduled outpatient *Nothing lab, pathology and x- rays. *20% coinsurance ii) Other scheduled *20% coinsurance outpatient hospital services. *20% coinsurance ME 7 (1/1999) BPL 97425 Page 82 Reconstructive And Restorative Surgery ~'i' Benefitsii~ D~dUctible *20% coinsurance 3. Inpatient services. *20% coinsurance. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of-network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. 4. Services received from a 20% coinsurance 20% coinsurance physician during an inpatient stay. Services, supplies and associated expenses NOT covered: 1. Blemishes on skin surfaces and scar revision primarily for cosmetic purposes including scar excisions, unless otherwise determined to be reconstructive or otherwise covered in the Section titled Professional Services. 2. Repair ofbifid ear lobes and surgical repair of bald spots or loss of hair. 3. Repairs to teeth, including any other dental procedures or treatment, whether the dental treatment is needed because of a primary dental problem or as a manifestation of a medical treatment or condition. 4. Services and procedures primarily for cosmetic purposes, unless otherwise determined to be reconstructive. 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. 6. Hair transplants. See additional exclusions from coverage listed in the Section rifled Exclusions. ME 7 (1/1999) BPL 97425 Page 83 R. Home Health Care Your home health care must be directed by aphysician and received from a home health care agency that is authorized under the laws of the state in which treatment is received. Services of a home health care agency will be eligible for coverage only if the services are provided through Medica's managed care procedures. In-network benefits apply to home health care services: 1. ordered, provided or arranged under the direction of your primary care clinic or care system; or 2. ordered by the preferred network OB/Gynphysician whom you have selected from the list of Ob/Gyn physicians designated in your Provider D~rectory as available to you and received from a network home health care agency. Out-of-network benefits apply to home health care services received other than as described under in- network benefits above. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-networkprovider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Mediea determines when home health care is an appropriate alternative to inpatient hospital services. As described under 2 and 3 below, Mediea considers you to be "homebound" when it is medically contraindicated for you to leave your home (when leaving your home would directly and negatively affect your physical health). Your place of residence is where you make your home. This may be your own dwelling, a relative's home, an apartment complex that provides assisted living services, or some other type of institution. However, an institution will not be considered your home if it is a hospital or skilled nursing facility. Benefits covered under 2 and 3 below are limited to a combined maximum of 56 hours of care per week, unless otherwise determined by Mediea. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section tiffed Definitions. Use these definitions to best understand this Certificate. For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. ME 7 (1/1999) BPL 97425 Page 85 Home Health Care 1. Home health care provided as an Nothing *20% coinsurance alternative to inpatient hospital services, as determined by Medica. 2. Intermittent skilled care when you *20% coinsurance except *20% coinsurance are homebound, supervised by a you pay nothing for high- registered nurse, risk prenatal care services. 3. Skilled physical, speech or *20% coinsurance *20% coinsurance occupational therapy when you are homebound. 4. Home IV therapy. Nothing *20% coinsurance 5. Services received in your home from a physician. Nothing *20% coinsurance ME 7 (1/1999) BPL 97425 Page 86 Home Health Care Services, supplies and associated expenses NOT covered: 1. Companion, homemaker and personal care services. 2. Services provided by a member of your family. 3. Custodial supportive care and other non-skilled services. 4. Home health care and supplies for ventilator-dependent members unless a skilled nursing facility bed is not available. 5. Physical, speech or occupational therapy provided in your home for convenience. 6. Services provided in your home when you are not homebound. 7. Services primarily educational in nature. 8. Vocational and job rehabilitation. 9. Recreational therapy. 10. Self-care and self-help training (non-medical). 11. Health clubs. 12. Correction of speech impediments (stuttering or lisps) and assistance in the development of verbal clarity. 13. Voice training and voicc therapy. 14. Outpatient rehabilitation services when no medical diagnosis is present. See additional exclusions from coverage listed in the Section titled Exclusions. ME 7 (1/1999) BPL 97425 Page 87 S. Skilled Nursing Facility Services This Section describes your coverage for use of skilled nursing facility services when your care is under the direction of aphysician. Services of a skilled nursing facility will be eligible for coverage only if the services are provided through Medica's managed care procedures. Room and board includes coverage of health services and supplies. Medica determines when a skilled nursing facility is an appropriate alternative to inpatient hospital services. In-network benefits apply to skilled nursing facility services when your care is ordered, provided or arranged under the direction of your primary care clinic or care system. Out-of-network benefits apply to skilled nursing facility services received other than as described under in- network benefits above. When out-of network benefits are received from non-networkproviders, you will be responsible for any charges in excess of the non-networkprovider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are def'med for you in the Section rifled Defmirions. Use these definitions to best understand this Certificate. For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753. See the Section titled Introduction. ME 7 (1/1999) BPL 97425 Page 89 Skilled Nursing Facility Services 1. Daily skilled care or daily skilled *20% coinsurance rehabilitation services, including room and board. 2. Skilled physical, speech or 20% coinsurance occupational therapy when room and board is not eligible to be covered. 3. Services received from aphysician Nothing during an inpatient stay in a skilled nursing facility. *20% coinsurance. Services are covered only after tran,gfer to the skilled nursing facility within 30 calendar days of discharge from a hospital in which you were confmed for not less than 3 consecutive calendar days. Coverage is limited to a combined total of 120 days per calendar year for all inpatient out-of- network benefits described in this Certificate. This day limitation applies whether or not your deductible has been met. *20% coinsurance *20% coinsurance ME 7 (1/1999) BPL 97425 Page 90 Skilled Nursing Facility Services Services, supplies and associated expenses NOT covered: 1. Custodial supportive care and other non-skilled services for ventilator-dependent and non-ventilator- dependent members. 2. Self-care or self-help training (non-medical). 3. Private room, except for conditions of preeelampsia, radium implants, contagion or immunosuppression that require isolation, as determined by Mediea. 4. Services primarily educational in nature. 5. Voearional and job rehabilitation. 6. Recreational therapy. 7. Health clubs. 8. Correction of speech impediments (stuttering or lisps) and assistance in the development of verbal clarity. 9. Voice training and voice therapy. 10. Outpatient rehabilitation services when no medical diagnosis is present. See additional exclusions from coverage listed in the Section rifled Exclnsions. ME 7 (1/1999) BPL 97425 Page 91 T. Hospice Services This Section describes your coverage for hospice services including respite care when your care is ordered, provided, or arranged under the direction of your primary care clinic and received from a designated hospice program. Hospice services are comprehensive palliative medical care, and supportive social, emotional and spiritual services, that are provided to the terminally ill and their families, primarily in the patient's home. A hospice interdisciplinary team~ composed of professionals and volunteers, coordinates an individualized plan of care for each patient and family. The goal of hospice care is to make patients as comfortable as possible to enable them to live their final days to the fullest in the comfort of their own homes and with loved ones. Respite care is a form of hospice services that gives your uncompensated primary caregivers (i.e., family members or friends) rest and/or relief when necessary to maintain a terminally ill member at home. Respite care is limited to not more than 5 consecutive days at a time. Hospice services must be directed by aphysician and received from a designated hospice program. A designated hospice program means a hospice program that has entered into a separate contract with Mediea to provide hospice services to members receiving hospice care under this Certificate. The specific hospice services you receive may vary depending upon which desi~ated hospice program you select. A plan of care must be established and communicated by the designated hospice program staff to Medica. To be eligible for coverage, hospice services must be consistent with the designated hospice program's plan of care. To be eligible for the hospice benefits described in this Section, you must (1) be a terminally ill patient; and (2) have chosen a palliative treatment focus (i.e., one that emphasizes comfort and supportive services rather than treatment attempting to cure the disease or condition). Members who elect to receive hospice services do so in lieu of curative treatment for their terminal illness for the period they are enrolled in the hospice program, You will be considered terminally ill if there is a written medical prognosis by your physician that your life expectancy is 6 months or less if the terminal illness hms its normal course. This certification must be made not later than 2 days after the hospice care is initiated. You may withdraw from the hospice program at any time upon written notice to the designated hospice program~ You must follow the designated hospice program's requirements to withdraw from the designated hospice program. In-network benefits apply to hospice services ordered, provided or arranged under the direction of your primary care clinic or care system and received from a designated hospice program. There is no coverage under out-of-network benefits for hospice services for hospice services received from a non-network hospice program. Many words used in this Certificate have special meanings. These words appear in italics and are defmed for you in the Section titled Definitions. Use these definitions to best understand this Certificate. ME 7 (1/1999) BPL 97425 Page 93 Hospice Services 1. Hospice services. Nothing Services, supplies and associated expenses NOT covered: 1. 2. 4. 5. 6. 7. 8. 10. No coverage Respite care for more than 5 consecutive days at a time. Home health care and skilled nursing facility services when services are not consistent with the designed hospice program's plan of care. Services not included in the desi~ated hospice program's plan of care. Services not provided by the designated hospice program. Hospice daycare, except when recommended and provided by the designated hospice program. Any services provided by a family member or friend, or individuals who are residents in your home. Hospice services directed by aphysician and received from a non-network hospice program. Financial or legal counseling services, except when recommended and provided by the designated hospice program. Housekeeping or meal services in your home, except when recommended and provided by the designated hospice program. Bereavement counseling, except when recommended and provided by the designated hospice program. See additional exclusions from coverage listed in the Section titled Exclnsious. ME 7 (1/1999) BPL 97425 Page 94 U. Medical-Related Dental Services This Section describes your coverage for medical-related dental services received from a physician or a dentist. This Section does not describe coverage for comprehensive dental procedures. Comprehensive dental procedures are services rendered by a dentist to treat teeth, their supporting soft tissue and bony structure, or the ali~tmment or occlusion of the teeth. These services are not covered under any Section of this Certificate. In-network benefits apply to medical-related dental services received from anetworkphysician or a network dentist. Out-of-network benefits apply to medical-related dental services received from a non-network provider. When out-of network benefits are received from non-network providers, you will be responsible for any charges in excess of the non-network provider reimbursement amount, in addition to the deductible and copayment or coinsurance described for out-of-network benefits. When out-of network benefits are received from network providers, the non-network provider reimbursement amount does not apply. Many words used in this Certificate have special meanings. These words appear in italics and are defmed for you in the Section rifled Definitions. Use these definitions to best understand this Certificate. 1. Charges for network medical *Nothing facilities and general anesthesia services that are: a. Recommended by your network physician; b. Received during a dental procedure; and No coverage For benefits in this Section marked with an asterisk (*), you must obtain prior approval from Medica by calling: Customer Service at: Mpls./St. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455. TTY phone for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Patti metro area: 1-800-841-6753. See the Section titled Introduction. IvlE 7 (1/1999) BPL 97425 Page 95 Medical-Related Dental Services c. Provided to a member who: i) is a child under the age of 5 (prior approval is not required); or ii) is severely disabled; or has a medical condition and requires hospitalization or general anesthesia for dental care treatment. NOTE: Age, anxiety and behavioral conditions are not considered medical conditions. 2. For a dependent child, orthodontia related to cleft lip and palate. *20% coinsurance *20% coinsurance NOTE: For a dependent child, benefits for oral surgery treatment for cleft lip and palate are covered in the Sections titled Professional Services and Hospital Services. Accident-related dental services to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply: *20% coinsurance No coverage ao Coverage is limited to services received within 6 months of the injury. ME 7 (1/1999) BPL 97425 Page 96 Medical-Related Dental Services ~ ~Bbnefi ~i¥~ ?i!! ouPa ~ ~ b. A sound, natural tooth means a tooth (including supporting structures) that is free from disease that would prevent continual function of the tooth for at least 1 year. In the ease of primary (baby) teeth, the tooth must have a life expectancy of 1 year. 4. Oral surgery for: Coverage available under 20% coinsurance your out-of-network benefit. a. partially or completely unempted impacted teeth; bo a tooth root without the extraction of the entire tooth (this does not include root canal therapy); or Co the gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth. ME 7 (1/1999) BPL 97425 Page 97 Medical-Related Dental Services Services, supplies and associated expenses NOT covered: 1. Accident-related dental services to treat an injury from biting or chewing. 2. Osteotomies and other procedures associated with the fitting of dentures or dental implants. 3. Dental implants (tooth replacement). 4. Any other dental procedures or treatment, whether the dental treatment is needed because of a primary dental problem or as a manifestation of a medical treatment or condition. 5. Any orthodontia including that associated with orthognathie procedures or accident-related dental injuries, except as otherwise described in this Section. 6. Tooth extractions, except as described in this Section. 7. Any dental procedures or treatment related to periodontal disease. 8. Endodontic procedures and treatment, except as described in Part C of this Seerion. 9. Routine diagnostic and preventive dental services. See additional exclusions from coverage listed in the Section rifled Exclusions. ME 7 (1/1999) BPL 97425 Page 98 V. Emergency Services From Non-Network Providers In-network benefits will apply to emergency services from non-network providers, as described below. Only such emergency services are eligible for coverage under this Section of the Certificate. Emergency services ordered, provided or arranged by your primary care clinic are eligible for coverage as described in the Sections titled Professional Services and Hospital Services of this Certificate. To be eligible for coverage under this Section of the Certificate, services must be due to an emergency, as determined by Medica. The emergency services are eligible for coverage even if you are traveling outside of the service area. You must notify Medica of emergency inpatient services as soon as is reasonably possible after the inpatient services begin by calling Customer Service at: MplsdSt. Paul metro area: (952) 945-8000 Outside Mpls./St. Paul metro area: 1-800-952-3455 TTY for the hearing impaired only: Mpls./St. Paul metro area: (952) 992-3190 Outside Mpls./St. Paul metro area: 1-800-841-6753 For any emergency mental health or substance abuse inpatient services, you must notify your designated mental health/substance abuse provider as soon as is reasonably possible after the emergency services begin. If you are confined in a non-network facility as a result of an emergency, your coverage under this Section of the Certificate continues until your attendingphysician agrees it is safe to transfer you to a network facility. If the health services that you require do not meet the def'mition of emergency, you should refer to the remainder of this Certificate for a description of your out-of-network benefits. Many words used in this Certificate have special meanings. These words appear in italics and are defined for you in the Section titled Def'mitions. Use these definitions to best understand this Certificate. Emergency services that are: a. administered under the direction of a physician; and b. received from a non-networkprovider; and c. otherwise eligible for coverage in this Certificate. 20% coinsurance up to a maximum of $500 for Benefits 1 and 2 combined. ME 7 (1/1999) BPL 97425 Page 99 Emergency Services From Non-Network Providers 2. Ambulance services and/or ambulance 20% coinsurance up to a maximum of $500 for transportation to the nearest hospital for an Benefits 1 and 2 combined. emergency. Services, supplies and associated expenses NOT covered: 1. Non-emergency care from non-networkproviders, except as described in this Certificate. 2. Unauthorized continued inpatient services in a non-network facility once the attendingphysician agrees it is safe to transfer you to a network facility. 3. Follow-up care or scheduled care from a non-networkprovider, except as described in this Certificate. 4. Tranafers and admissions to network hospitals solely at the convenience of the member. See additional exclusions from coverage listed in the Section titled Exclusions. ME 7 (1/1999) BPL 97425 Page 100 W. Harmful Use Of Medical Services This Section applies when Medica determines you are receiving health services or prescription drugs in a quantity or manner that may be harmful to your health. Many words used in this Certificate have special meanings. These words appear in italics and are deemed for you in the Section titled De£mitions. Use these definitions to best understand this Certificate. What happens when this Section applies: 1. After Mediea notifies you that this Section applies, you have 30 days to choose one network physician, hospital, and pharmacy to be your "Coordinating Health Care Providers." 2. If you do not choose your Coordinating Health Care Providers within 30 days, Mediea will choose for you. 3. Your in-network benefits are then restricted to services provided or referred by your Coordinating Health Care Providers. 4. Failure to receive services from or through your Coordinating Health Care Providers will result in a denial of coverage. You must obtain a referral from your Coordinating Health Care Provider if your condition requires care or treatment from aprovider other than your Coordinating Health Care Provider. 5. Medica will send you specific information about: a. how to obtain approval for benefits not available from your Coordinating Health Care Providers; b. how to obtain emergency care; and c. when these restrictions end. M~ 7 (]/]999) BPL 97425 Page 101 X. Exclusions In addition to the items already listed as"Not covered", the following services, supplies and associated expenses are not covered, except as otherwise determined by Mediea. 1. Services that are not medically necessary. Services that are not medically necessary include, but are not limited to, services that are inconsistent with the medical standards and accepted practice parameters of the commllnity and services that are inappropriate, in terms of type, frequency, level, setting and duration, to your diagnosis or condition. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise deemed to be reconstructive. 3. Refractive eye surgery. 4. The purchase, replacement or repair of eyeglasses, eyeglass frames, or contact lenses when prescribed solely for vision correction, and their related fittings. 5. Services provided by an audiologist when not under the direction of aphysician, hearing aids and other devices to improve hearing and their related fittings. 6. A drug, device, or medical treatment or procedure that is investigative. 7. Services for genetic screening and testing except: a. recommended by a genetic counselor as predictive of a disease process, and treatment standards of care exist for the disease process; or b. reproductive choices would be made based on the test findings. 8. Autopsies. 9. Enteral feedings and other nutritional and electrolyte substances, except for the dietary medical treatment of PKU. 10. Physical, occupational or speech therapy when there is no reasonable expectation that your condition will improve over a predictable period of time as determined by Mediea. 11. Reversal of voluntary sterilizatiort 12. Neuropsychologieal evaluarions/eognitive testing except as described in the Section titled Outpatient Rehabilitation. 13. Personal comfort or convenience items or services. 14. Custodial supportive care, unskilled nursing or unskilled rehab'flitationserviees. 15. Respite or rest care except as otherwise covered in the Section rifled Hospice Services. 16. Travel, transportation or living expenses. 17. Air conditioners and hnmidifiers. 18. Services to treat nicotine addiction except as otherwise eoveredin the Section titled Prescription Drugs And Phavamey Services. 19. Massage therapy. ME 7 (1/1999) BPL 97425 Page 103 Exclusions 20. Routine foot care, except for members with diabetes, peripheral vascular disease, peripheral neuropathies or blindness. 21. Charges billed by a non-networkproviderthat are not in compliance with generally accepted coding and reimbursement guidelines including those of the American Medical Association (AMA), the Health Care Financing Administration (HCFA) and the community. 22. Services by persons who are family members or share your legal residence. 23. Services for which coverage is available, if proper claim were made, under worker's compensation. 24. Services received before your coverage under the Contract becomes effective. 25. Services received after your coverage under the Contract ends. 26. Charges for duplicating and obtaining medical records fromnon-networkproviders and non-network dentists when not requested by Medica. 27. Photographs, except for the condition of multiple dysplastic syndrome. 28. Occlusal adjustment or ocelusal equilibration. 29. Dental implants (tooth replacement). 30. Dental prostheses. 31. Orthodontic treatment, except as covered in the Section tifledMedical-Related Dental Services. 32. Treatment for bmxism. 33. Services prohibited by law or regulation, or illegal under the laws of the State of Minnesota. 34. Services to treat injuries that occur while on military duty to the extent that such care is otherwise covered or available in another program of coverage. 35. Exams, other evaluations and/or other services for employment, insurance, or licensure. 36. Exams, other evaluations and/or other services for judicial or administrative proceedings or research, except as an emergency examination of a child ordered by judicial authorities, or which Medica determines is medically necessary, or as otherwise covered under the Contract. 37. Non-medical self-care or self-help training. 38. Educational classes, programs or seminars, including those for stop smoking and weight loss 39. Coverage for costs associated with translation of medical records andclaims to English. 40. Services billed by an aeupuncmrist. ME 7 (1/1999) BPL 97425 Page 104 Y. How To Submit A Claim Claims for benefits from network providers. If you receive a bill for any benefit from your primary care clinic or any other network provider, call Customer Service at (952) 945-8000 0Vlpls./St. Paul metro area) or 1-800-952-3455 (outside Mpls./St. Paul metro area). Hearing impaired members with a TTY phone may contact Customer Service at (952) 992-3190 (Mpls./St. Paul metro area) or 1-800-841-6753 (outside Mpls./St. Paul metro area). Claims for benefits from non-network providers. Claim forms are provided in your enrollment materials. You may request additional claim forms by contacting Customer Service at (952) 945-8000 (Mpls./St. Paul metro area) or 1-800-952-3455 (outside Mpls./St. Paul metro area). Hearing impaired members with a TTY phone may contact Customer Service at (952) 992-3190 (Mpls./St. Paul metro area) or 1-800-841-6753 (outside Mpls./St. Paul metro area). If the claim forms are not sent to you within 15 days, you may submit a itemized statement without the claim form to Medica. You should retain copies of all claim forms and correspondence for your records. You must submit the claim in English along with a Medica claim form to Medica no later than 365 days after receiving benefits. Your Medica membership number must be on the claim. Mail to: Medica Claims Mail Route 2901 PO Box 659752 San Antonio, TX 78265-9752 Claims for services rendered in a foreign country will require the following additional documentation: 1. claims submitted in English with the currency exchange rate for the date health services were received; 2. itemization of the bill or claim; 3. the related medical records (submitted in English); 4. proof of your payment of the claim; 5. a complete copy of your passport and airline ticket; and 6. such other documentation as Medica may request. NOTE: Medica will not reimburse you for costs associated with translation of medical records or claims. Time limits: If you have a complaint or dispute a decision by Medica, you may follow the complaint procedure outlined in the Section titled If You Have A Complaint or you may initiate legal action at any point. However, you may not bring legal action more than 6 years after Medica has made a coverage determination regarding your claim. M~ 7 (1/1999) BPL 97425 Page 105 How To Submit A Claim What Medica does: Provides you with claim forms within 15 days of receiving your request. Medica does not accept assignment of benefits to non-networkproviders. Upon receipt of your claim for benefits from non-networkproviders, Medica will pay to you directly the non-networkprovider reimbursement amount. Medica will not accept your direction or authorization to pay the non-network provider. NOTE: For services rendered in a foreign country, Medica will pay you directly. ME 7 (1/1999) BPL 97425 Page 106 Z. When You Are Entitled To Benefits From More Than One Plan Introduction: This Section: 1. applies when you have health care coverage from more than one Plan, and 2. explain,~ which Plan pays benefits first. Each contract for other health care coverage is a separate Plan. If there are two coverage parts to a Plan, and Order of Benefit Determination Rules ("Rules") apply only to one part, each of the parts is a separate Plan. Definitions that apply to this Section: 1. "Plan" means any contract that provides benefits or services for medical or dental care or treatment, including: a. group or group-type coverage (whether insured or nnin~ured); b. group prepayment or group or individual practice coverage; c. coverage under Medicare or other governmental plans or provided by law, except as deemed below; or d. coverage other than school accident-type coverage. The term "Plan" does not include group or group-type hospitalindemnity benefits of $100 per day or less. 2. "Primary Plan" means the Plan whose benefits are determined first, without considering the benefits of other Plans. 3. "Secondary Plan" means the Plan whose benefits are determined after those of the other Plan and may be reduced because of the other Plan's benefits. When you are covered by more than two Plans, Medica may be both a Primary and a Secondary Plan. 4. "Allowable Expense" means a necessary, reasonable and customary health care expense that is covered at least in part by one or more Plans. When a Plan provides benefits in the form of services, the reasonable cash value of each service received will be considered both an Allowable Expense and abenefitpaid. 5. "Claim Determination Period" means a calendar year. However, it does not include any part of a year during which you have no coverage under Medica, or any part of a year before the date this Section or a similar Section takes effect. Who pays first: 1. Medica follows the order of benefit determination rules as outlined below. 2. Generally, Medica is a Secondary Plan whose benefits are determined after those of the other Plan, unless: a. the other Plan has the same coordination of benefit roles as the Contract; and b. the other Plan and the Contract require that coverage under the Contract applies first. ME 7 (1/1999) BPL 97425 Page 107 When You Are Entitled To Benefits From More Than One Plan Order of Rules: Medica determines its order of benefits using the first of the following n~es that apply: 1. Coverage under a Plan in which a person is covered as an employee or subscriber will be determined before a Plan covering the person as a dependent. 2. For a dependent child whose parents are married: a. Coverage under the Plan of the parent whose birthday (month and day only) falls earlier in the year is determined first. It does not matter which parent is older. b. If both parents have the same birthday (month and day only), coverage under the Plan that has covered a parent longer is determined first. However, if the other Plan does not have this provision, the other Plan's rules will determine the order of payment. 3. For a dependent child whose parents are separated or divorced: a. Coverage under the custodial parent's Plan will be determined first. b. Coverage under the custodial stepparent's Plan will be determined second. e. Coverage under the non-custodial parent's Plan will be determined last. However, if a court decree requires one parent to be responsible for the health care expenses of the child, coverage under that parent's Plan is determined first, as long as that Plan has actual knowledge of those terms. When a court decree requires that the parents shall share joint custody of a dependent child, without stating that one of the parents is responsible for the health care expenses of the child, the order of rules in 2 above will be followed. 4. For an employee or that employee's dependent, coverage under a Plan where an employee is not laid off or retired is determined before coverage under a Plan in which the employee is laid off or retired. If the other Plan does not have this Rule, this Rule is ignored. 5. Coverage under any Workers' Compensation Act or similar law applies first. 6. Coverage under any No-Fault Automobile Insurance Act or similar law applies first. 7. If none of the above Rules apply, the Plan that has covered you the longest will apply first. Reduction of Benefits: For services received from a network provider and determined to be in-network benefits, and for emergency services received from a non-networkprovider, the following reduction of benefits will apply: 1. When Mediea is a Secondary Plan, your Mediea benefits may be reduced: a. up to the total Allowable Expenses from all Plans, but b. not more than the to~ of Allowable Expenses incurred during the Claim Determination period. 2. Your benefits are reduced when the sum of: a. the benefits that would be payable as an Allowable Expense by Mediea in the absence of this Section, and ME 7 (1/1999) BPL 97425 Page 108 When You Are Entitled To Benefits From More Than One Plan b. the benefits that would be payable for an Allowable Expense under another Plan in the absence of a provision such as this Section (whether or not a claim is made) exceeds the Allowable Expenses incurred in a Claim Determination period. When this happens, benefits are reduced in proportion. In such case, the benefits of the Contract will be reduced so that they and the benefits payable under the other plans do not total more than the Allowable Expenses. For non-emergency services received from a non-networkprovider, and determined to be out-of-network benefits, the following reduction of benefits will apply: When Mediea is a Secondary Plan, Mediea will pay the balance of any remaining expenses determined to be eligible under the Contract, according to the out-of-network benefits described in this Certificate. Most out-of-network benefits are covered at 80% of the non-networkprovider reimbursement amount, after you pay the applicable deductible amount. In no event will the Plan provide duplicate coverage. Mediea's right to receive and release information: 1. Certain facts are needed to apply this Section. Medica has the right to decide which facts it needs. 2. Mediea may obtain needed facts from or give them to any other organization or person. Mediea does not need to tell, or get the consent of, any person to do this. 3. Unless applicable federal or state law prevents disclosure of the information without the consent of the patient or the patient's representatives, each person claiming benefits under Mediea must give Medica any facts it needs to pay the claims. Mediea's fight to pay another Plan: 1. If another Plan pays for benefits that Medica should have paid, Medica may pay that amount to that Plan. 2. That amount is then treated as though it were a benefit paid. Mediea is not required to pay that amount again. 3. Payment made includes providing benefits in the form of services and means the reasonable cash value for the benefits provided in the form of services. ME 7 (111999) BPL 97425 Page 109 AA. Medica's Right Of Recovery Medica's rights under this Section are subject to, and may be limited by, the laws of the State of Minnesota and federal law. If you desire information about the effect of Minnesota law and federal law on Medica's subrogation or reimbursement rights, you should contact an attorney. Medica has a right of subrogation again.qt any third party, individual, corporation, insurer, or other entity or person who may be legally responsible for payment of medical expenses related to your illness or injury. Medica's right of subrogation shall be governed according to this Section. Medica's right to recover its subrogation interest applies only after you have received a full recovery for your illness or injury from another source of compensation for your illness or injury. 2. Medica's subrogation interest is the reasonable cash value of any benefits received by you. 3. Medica's right to recover its subrogation interest may be subject to an obligation by Medica to pay a pro rata share of the attorney fees and costs you pay in obtaining your recovery. 4. By accepting coverage under the Contract, you agree: to cooperate with Medica or its designee to help protect Medica's legal rights under this subrogation provision and to provide all information Medica may reasonably request to determine its rights under this provision. b. to provide prompt written notice to Medica when you make a claim against a party for injuries. c. to provide prompt written notice of Medica's subrogation rights to any party against whom you assert a claim for injuries. d. to do nothing to decrease Medica's rights under this provision, either before or after receiving benefits, or under the Contract. e. Medica may take action to preserve its legal rights. This includes bringing suit in your name. Medica may collect its subrogation interest from the proceeds of any settlement or judgment recovered by you, your legal representative or the legal representative(s) of your estate or next- of-kin. g. to hold in trust the proceeds of any settlement or judgment for Medica's benefit under this provision. ME 7 (1/1999) BPL 97425 Page 111 BB. Enrollment This Section describes who can enroll and how to enroll. Who can enroll: Subscriber and dependent eligibility: To be eligible to enroll for coverage you must: 1. reside in the service area (a child who is the subject of a qualified medical child support order and who is otherwise eligible for coverage is not required to reside in the service area); and 2. meet the eligibility requirements of the Contract; and 3. be a subscriber or dependent as defined in the Contract. A child who is the subject of a qualified medical child support order may not enroll dependents for coverage. Extending a child's eligibility: A dependent child is no longer eligible for Medica coverage when he or she reaches the dependent limiting age of 19 or as otherwise stated in the Contract. However, the child's eligibility continues if either of the following occurs: 1. The child is incapable of self-sustaining employment by reason of mental retardation, mental illness, mental disorder or physical handicap and is chiefly dependent upon the subscriber for support and maintenance. To continue coverage for a handicapped dependent, you must provide Medica with proof of such handicap and dependency within 31 days of the child reaching the dependent limiting age. Two years after the child reaches the dependent limiting age, Medica may require proof of handicap and dependency annually. An illness will not be considered a physical handicap. 2. The dependent is eligible up to the student limiting age of 25 or above age 25 if stated in the Contract, if he or she is enrolled full-time in a recogni~.ed high school, college, university, trade or vocational school. If the student is unable to carry a full-time course load due to illness, injury, or a physical or mental disability (as documented by aphysician), full-time student status will be granted if the student carries at least 60% of a full-time course load, as determined by the educational institution. Coverage for a student enrolled in school continues: a. during vacation; or b. between consecutive term periods. You must provide Mediea with proof that the above requirements are met. How to enroll: What you must do: 1. Submit your application for coverage for yourself and any dependents to your Employer: a. within 30 days of first becoming eligible; or b. during the open enrollment period established by your Employer; or ME 7 (1/1999) BPL 97425 Page 113 Enrollment c. during a special enrollment period as described in the subsection of this Section rifled "Enrolling at other times". 2. Notify your Employer within 30 days of the effective date of any changes to address or name, addition or deletion of dependents, or other facts identifying you or your dependents. (The notification period is not limited to 30 days for newborn dependents.) What your Employer must do: 1. Notify Medica of your initial enrollment application. 2. Notify Medica within 30 days of the effective date of your initial enrollment application, changes to your name or address, or changes to enrollment, including if you or your dependents are no longer eligible for coverage. Enrolling at other times: Medica is required to allow special enrollment periods under certain circumstances. A special enrollment period will apply to an eligible employee and dependent if: 1. The eligible employee or dependent: a. was covered under qualifying coverage at the time the eligible employee or dependent was first eligible to enroll under the Contract, and b. declined coverage for that reason, and c. presents to Medica either (i) evidence of the loss of prior coverage due to loss of eligibility for that coverage, or (ii) evidence that employer contributions toward the prior coverage have terminated, and d. maintaina continuous coverage, and e. requests enrollment in writing within 30 days of the date of the loss of coverage or the date the employer's contribution toward that coverage terminates; For purposes of this item: prior coverage does not include continuation coverage required under federal law; loss of eligibility includes loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment; · loss of eligibility does not include a loss due to failure of the eligible employee or dependent to paypremiums on a timely basis or termination of coverage for cause; 2. The eligible employee or dependent: a. was covered under benefits available under (i) the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), Public Law Number 99-272, as amended, or (ii) any state continuation laws applicable to the employer or Medica, and b. declined coverage for that reason, and c. the eligible employee or dependent presents to Medica evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to either failure of the eligible employee or dependent to paypremiums on a timely basis or for cause, and ME 7 (1/1999) BPL 97425 Page 114 Enrollment d. maintains continuous coverage, and e. requests enrollment in writing within 30 days of the loss of coverage; 3. The dependent is a new spouse of the subscriber or eligible employee, provided that the marriage is legal and enrollment is requested in writing within 30 days of the marriage; 4. The dependent is a new dependent child of the subscriber or eligible employee, provided that enrollment is requested in writing within 30 days of the subscriber or eligible employee acquiring the dependent (the notification period is not limited to 30 days for newborn dependents); 5. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in item g4 above claims dependent status and: a. that spouse is eligible for coverage; and b. is not already enrolled under the Contract; and e. enrollment is requested in writing within 30 days of the dependent child becoming a dependent; or 6. The dependents are eligible dependent children of the subscriber or eligible employee and enrollment is requested in writing within 30 days of a dependent, as described in items #3 or g4 above, becoming eligible to enroll under the coverage. Additionally, when Employer provides Medica with notice of a qualified medical child support order and a copy of the order, Mediea will provide such eligible dependent child with a special enrollment period. Employer will provide Medica with such notice, along with an application for coverage, within the greater of 30 days after issuance of the order or the time in which Employer provides notice of its determination to the persons specified in the order. Mediea may allow enrollment at other times agreed upon by Medica and your Employer. Certain restrictions stated in the Contract may apply. The date your coverage begins: 1. Your coverage beans at 12:01 a.m. on the effective date specified in the Contract. 2. If you become eligible after that date, then coverage beans the date you: a. meet the eligibility requirements stated in the Contract; and b. are properly enrolled with Mediea. Your newborn dependent, including a newborn adopted dependent, is covered under the Contract from the date of birth. (Eligibility for a childplacedfor adoption with the subscriber ends if the placement is interrupted before legal adoption and the child is removed from placement.) You must pay the premium required by Mediea for your child's coverage, and you must enroll your child under the Contract. We encourage you to enroll your newborn child under the Contract within 31 days from the date of birth. Your handicapped dependent is covered under the Contract regardless of age. (See Extending a child's eligibility.) Your newborn child, your adopted child, a child placed for adoption with the subscriber, your handicapped dependent, and any child who is a subscriber pursuant to a qualified medical child support order will be covered without application of health screening, or waiting periods. M~ 7 (1/1999) BPL 97425 Page 115 CC. Ending Your Coverage This Section describes when your coverage ends. You may exercise your right to continue your coverage as described in the Section titled Your Right To Continue Coverage. You may exercise your right to convert your coverage as described in the Section rifled Your Right To Convert Coverage. When your coverage ends: Unless otherwise specified in the Contract, your coverage ends the earliest of the following: 1. The end of the month in which the Contract is terminated by the Employer or Medica in accordance with the terms of the Contract. If terminated by Medica, Medica will notify each subscriber at least 30 days in advance of the termination. 2. The end of the month for which the subscriber last paid his or her contribution toward the premium. 3. The end of the month in which the subscriber retires or is pensioned, unless Medica and the Employer have agreed to provide coverage for retirees under the Contract or a separate Medicare contract. 4. The end of the month in which the subscriber is no longer eligible as determined by the Employer. (See the Section titled Enrollment for information on eligibility.) 5. The end of the month in which the subscriber requests that coverage end. You must notify the Employer to terminate coverage. 6. The date specified by Medica in written notice to you that coverage ended due to fraud. Fraud includes, but is not limited to: a. Knowingly providing Medica with false material information such as: i) Information related to your eligibility or another person's eligibility for coverage or status as a dependent; or ii) Information related to your health status or that of any dependent; or iii) Misrepresentation of the employer- employee relationship; or b. Permitting the use of your member identification card by any unauthorized person; or c. Using another person's member identification card; or d. Submitting fraudulent claims. Your coverage will be retroactively terminated at Medica's discretion to the original date of coverage or the date on which the fraudulent act took place. No conversion privilege will be extended. 7. The end of the month following the date 31 days after we notify you that coveragewill end because you did not pay a copayment or coinsurance for in-network benefits. 8. The end of the month following the date 31 days after we notify you that coverage will end because you do not live in the service area, provided the notification is made within one year following the date Medica was provided written notification of your address change. However, Medica may approve other arrangements. 9. The end of the month following the date you enter active military duty for more than 31 days. Upon completion of active military duty, contact your Employer for reinstatement of coverage. ME 7 (1/1999) BPL 97425 Page 117 Ending Your Coverage 10. 11. 12. 13. 14. 15. The end of the month following the date the subscriber's coverage ends. The date of the death of the member. In the event of the subscriber's death, coverage for the subscriber's dependents will terminate the end of the month in which the subscriber 'S death occurred. For a spouse, the end of the month following the date of divorce. For a dependent child, the end of the month in which the child is no longer eligible as a dependent as specified in the Contract. For a student, the end of the month in which the earliest of the following occurs: a. graduation or completion of the term; b. termination of full-time registration at the school for reasons other than graduation, except as specified in the Section titled Enrollment; or c. reaching the student limiting age specified in the Contract. For a child who is entitled to coverage through a qualified medical child support order, the end of the month in which the earliest of the following occurs: a. the qualified medical child support order ceases to be effective; or b. the child is no longer a child as that term is used in ERISA; or e. the child has immediate and comparable coverage under another plan; or d. the employee who is ordered by the qualified medical child support order to provide coverage is no longer eligible as determined by the Employer; or e. the Employer terminates family or dependent coverage; or f. the Contract is terminated by the Employer or Medica; or g. the relevant premium or contribution toward the premium is last paid; h. 31 days after we notify you that coverage will end because you did not pay a copayment or coinsurance. NOTE: You have the right to a certification of qualifying coverage when your coverage ends. You will receive a certification of qualifying coverage when your coverage ends. You may also request a certification of qualifying coverage within the 24 months following the date your coverage ends. Medica reserves its right to pursue other civil remedies in the event of your fraud or misrepresentation with regard to any aspect of coverage under the Contract. IvlE 7 (1/1999) ,. BPL 97425 Page 118 DD. Your Right To Continue Coverage When coverage ends, members may be able to continue coverage under state law, federal law, or both. The provisions below describe the continuation coverage requirements. The state continuation requirements are described first; the federal continuation requirements second. If your coverage ends, you should review your rights under both state law and federal law. If you are entitled to continuation rights under both, the continuation provisions run concurrently and the more favorable continuation provision will apply to your coverage. Please note, the state and federal requirements are separate. Decisions regarding state continuation coverage administrarion are made by Medica in accordance with the state law that requires the continuation coverage. All aspects of the federal continuation coverage administration are the responsibility of your Employer. 1. Your Right to Continue Coverage Under State Law Notwithstanding the provisions regarding termination of coverage described in the Section tiffed Ending Your Coverage, you may be entitled to extended or continued coverage as described below. Minnesota State Continuation Coverage. Continued coverage shall be provided as required under applicable Minnesota law. Minnesota state continuation requirements apply to all group health plans that are subject to state regulation, regardless of the number of employees in the group. The Employer shall, within the parameters of Minnesota law, establish uniform policies pursuant to which such continuation coverage will be provided. Notice of Rights. Minnesota law requires that covered employees and their dependents (spouse and/or dependent children) be offered the oppommity to pay for a temporary extension of health coverage (called "continuation coverage") at group rates in certain instances where health coverage under employer sponsored group health plan(s) would otherwise end. This Section describes your rights and obligations under the continuation coverage provision of Minnesota law. It is intended that no greater rights be provided than those required by Minnesota law. You should take time to read this Section carefully. Subscriber's Loss. The subscriber has the right to continuation of coverage for him/herself anddependents if there is a loss of coverage under the Contract because of the subscriber's voluntary or involuntary termination of employment (for any reason other than gross misconduct) or layoff from employment or the subscriber's absence from work due to total disability, as def'med in the Section rifled Definitions. For purposes of this Section, layoff from employment means a reduction in hours to the point where the subscriber is no longer eligible for coverage under the Contract. Subscriber's Spouse's Loss. The subscriber's covered spouse has the right to continuation coverage if he or she loses coverage under the Contract for any of the following five reasons: a. death of the subscriber;, M~ 7 (1/1999) BPL 97425 Page 119 Your Right To Continue Coverage b. a termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; c. dissolution of marriage from the subscriber; d. the subscriber's enrollment for benefits under Medicare; or e. the subscriber's absence from work due to total disability, as defmed in the Section rifled Definitions. Subscriber's Child's Loss. The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following six reasons: a. death of the subscriber if the subscriber is the parent through whom the child receives coverage; b. termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; c. the subscriber's dissolution of marriage from the child's other parent; d. the subscriber's enrollment for benefits under Medicare if the subscriber is the parent through whom the child receives coverage; e. the subscriber's child ceases to be a dependent child under the terms of the Contract; or f. the subscriber's absence from work due to total disability, as defmed in the Section rifled Definitions. Responsibility to Inform. Under Minnesota law, the subscriber and dependents have the responsibility to inform the Employer of a dissolution of marriage or a enid losing dependent status under the Contract within 60 days of the date of the event or the date on which coverage would be lost because of the event. Election Rights. When the Employer is notified that one of these events has happened, thesubscriber and the subscriber's dependents will be notified of the right to continuation coverage. Under Minnesota law, the subscriber and dependents have at least 60 days to elect continuation coverage for reasons of termination of the subscriber's employment or the subscriber's enrollment for benefits under Medicare measured from the later of (1) the date coverage would be lost because of one of the events described above, or (2) the date notice of election rights is received. If eontinuarion coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The subscriber and the subscriber's covered spouse may elect continuation coverage on behalf of other dependents entitled to eonrinuation coverage. Under certain circumstances, thesubscriber's covered spouse or dependent child may elect continuation coverage even if the subscriber does not elect continuation coverage. If continuation coverage is not elected, your coverage under the Contract will end. Type of Coverage and Cost. If continuation coverage is elected, the subscriber's Employer is required to provide coverage that, as of the time coverage is being provided, is idenrieal to the coverage provided under the Contract to similarly situated employees or employees' dependents. Under Minnesota law, a person eontimfing coverage may have to pay all or part of the premium for continuation coverage. The amount ME 7 (1/1999) BPL 97425 Page 120 Your Right To Continue Coverage charged cannot exceed 102% of the cost of the coverage unless coverage under the Contract has been lost because of the subscriber's absence from work due to total disability, in which case the amount charged cannot exceed 100% of the cost of the coverage. Duration. Under the circumstances described above and for a certain period of time, Minnesota law requires that the subscriber and the subscriber's dependents be allowed to maintain continuation coverage as follows: For instances where coverage is lost due to the subscriber's termination of or layoff from employment, coverage may be continued until the earliest of: (1) 18 months after the date of the termination of or layoff from employment; (2) the date the subscriber becomes covered under another group health plan (as an employee or otherwise) that does not contain any exclusion or limitation with respect to any applicable pre-existing condition; or (3) the date coverage would otherwise terminate under the Contract. For instances where the subscriber's spouse or dependent children lose coverage because of the subscriber's enrollment under Medicare, coverage may be continued until the earliest of: ( 1 ) 36 months after eontin~tion was elected; (2) the date coverage is obtained under another group health plan or Medicare; or (3) the date coverage would otherwise terminate under the Contract. For instances where dependent children lose coverage as a result of loss of dependent eligibility, coverage may be continued until the earliest of: (1) 36 months after continuation was elected; (2) the date coverage is obtained under another group health plan or Medicare; or (3) the date coverage would otherwise terminate under the Contract. For instances of dissolution of marriage from the subscriber, coverage of the subscriber's spouse and dependent children may be continued until the earliest of (1) the date the former spouse becomes covered under another group health plan or Medicare; or (2) the date coverage would otherwise terminate under the Contract. If a dissolution of marriage occurs during the period of time when the subscriber's spouse is continuing coverage due to the subscriber's terrninarion of or layoff from employment, coverage of the subscriber's spouse may be continued until the earlier of ( 1 ) the date the former spouse becomes covered under another group health plan or Medicare; or (2) the date coverage would otherwise terminate under the Contract. If coverage is lost because of the subscriber's absence from work due to total disability, coverage of the subscriber and any dependents may be continued until the date coverage would otherwise terminate under the Contract. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of (1) the date the surviving spouse anddependent children become covered under another group health plan, or (2) the date coverage would have terminated under the Contract had the subscriber lived. When your continuation coverage under this Section ends, you have the option to enroll in an individual conversion health plan as described in the Section rifled Your Right To Convert Coverage. 2. Your Right to Continue Coverage Under Federal Law Notwithstanding the provisions regarding termination of coverage described in the Section rifled Ending Your Coverage, you may be entitled to extended or continued coverage as described below. lvlE 7 (1/1999) BPL 97425 Page 121 Your Right To Continue Coverage COBRA Continuation Coverage. Continued coverage shall be provided as required under the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), as amended (as well as the Public Health Service Act ("PHSA"), as amended). The Employer shall~ within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. A COBRA Initial Notice of Rights appears in this Section. COBRA Initial Notice of Rights. COBRA requires employers with 20 or more employees to offer subscribers and their families (spouse and/or dependent children) the opportunity to pay for a temporary extension of health coverage (called "continuation coverage") at group rates in certain instances where health coverage under employer sponsored group health plan(s) would otherwise end. This plan is a group health plan for purposes of COBRA. This notice is intended to inform you, in summary fashion, of your rights and obligations under the continuation coverage provision of federal law. It is intended that no greater rights be provided than those required by federal law. You should take time to read this notice carefully. Qualified Beneficiary. For purposes of this Section, a qualified beneficiary is defined as one of the following: a. a covered employee (a current or former employee who is actually covered under a group health plan and not just eligible for coverage); b. a covered spouse of a covered employee; or a dependent child of a covered employee. Effective January 1, 1997, a child placed for adoption with or bom to an employee or former employee receiving COBRA continuation coverage is also a qualified beneficiary. Subscriber's Loss. The subscriber has the right to elect continuation of coverage if there is a loss of coverage under the Contract because of termination of the subscriber's employment (for any reason other than gross mi~qeonduet) or beeanse the subscriber become ineligible to participate under the terms of the Contract due to a reduction in their hours of employment. Subscriber's Spouse's Loss. The subscriber's covered spouse has the right to choose continuation coverage if he or she loses coverage under the Contract for any of the following four reasons: a. death of the subscriber;, b. a termination of the subscriber's employment (for any reason other than gross misconduct) or reduction in the subscriber's hours of employment with the Employer; c. divorce or legal separation from the subscriber;, or d. the subscriber's entitlement to (actual coverage under) Medicare. ME 7 (1/1999) BPL 97425 Page 122 Your Right To Continue Coverage Subscriber's Child's Loss. The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following five reasons: a. death of the subscriber if the subscriber is the parent through whom the child receives coverage; b. the subscriber's termination of employment (for any reason other than gross misconduct) or reduction in the subscriber's hours of employment with the Employer; c. the subscriber's divorce or legal separation from the child's other parent; d. the subscriber's entitlement to (actual coverage under) Medicare if thesubscriber is the parent through whom the child receives coverage; or e. the subscriber's child ceases to be a dependent child under the terms of the Contract. Responsibility to Inform. Under federal law, the subscriber and dependent have the responsibility to inform the Employer of a divorce, legal separation, or a child losing dependent status under the Contract within 60 days of the date of the event or the date on which coverage would be lost because of the event. Also, a subscriber and dependent who have been determined to be disabled under the Social Security ACt as of the time of the subscriber's termination of employment or reduction of hours or within 60 days of the start of the continuation period must notify the Employer of that determination within 60 days after the determination. If such person has been determined under the Social Security ACt to no longer be disabled, the person must notify the Employer of that determination within 30 days of the determination. Bankruptcy. Rights similar to those described above may apply to retirees (and the spouses anddependents of those retirees), if the subscriber's Employer commences a bankruptcy proceeding and these individuals lose coverage. Election Rights. When the Employer is notified that one of these events has happened, the Employer will in turn notify the subscriber and dependents of the right to choose continuation coverage. Under federal law, the subscriber and dependents have at least 60 days to elect continuation coverage measured from the later of (1) the date coverage would be lost because of one of the events described above, or (2) the date notice of election rights is received. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The subscriber and the subscriber's covered spouse may elect continuation coverage on behalf of other dependents entitled to continuation coverage. However, each person entitled to continuation coverage has an independent right to elect continuation coverage. The subscriber's covered spouse or dependent child may elect continuation coverage even if the subscriber does not elect continuation coverage. If continuation coverage is not elected, your coverage under the Contract will end. Type of Coverage and Cost. If the subscriber and the subscriber's dependents elect continuation coverage, the Employer is required to provide coverage that, as of the time coverage is being provided, is identical to the coverage provided under the Contract to similarly situated employees or employees' dependents. Under federal law, a person electing continuation coverage may have to pay all or part of the premium for continuation coverage. The mount charged cannot exceed 102% of the cost of the coverage. The amount may be increased to 150% of the applicable premium for months after the 18th month of ME 7 (1/1999) BPL 97425 Page 123 Your Right To Continue Coverage continuation coverage when the additional months are due to a disability under the Social Security Act. There is a grace period of at least 30 days for the regularly scheduled premium. Duration. Federal law requires that you be allowed to maintain continuation coverage for 36 months unless you lost coverage under the Contract because of termination of employment or reduction in hours. In that case, the required continuation coverage period is 18 months. This 18 months may be extended if a second event (for example divorce, legal separation or death) occurs during the initial 18 month period. It may also be extended to 29 months in the case of an employee or employee's dependent who is determined to be disabled under the Social Security Act at the time of the employee's termination of employment or reduction of hours, or within 60 days of the start of the 18 month continuation period. Effective January 1, 1997, if an employee or the employee's dependent is entitled to 29 months of continuation coverage due to his or her disability, the other family members' continuation period is also extended to 29 months. If thesubscriber becomes entitled to (actually covered under) Medicare, the continuation period for thesubscriber's dependents is 36 months measured from the date of the subscriber's Medicare entitlement even if that entitlement does not cause the subscriber to lose coverage. Under no circumstances is the total continuation period greater than 36 months from the date of the original event that triggered the continuation coverage. Federal law provides that continuation coverage may end earlier for any of the following four reasons: a. the subscriber's Employer no longer provides group health coverage to any of its employees; b. the premium for continuation coverage is not paid on time; c. coverage is obtained under another group health plan (as an employee or otherwise) that does not contain any exclusion or limitation with respect to any applicable pr, existing condition; or d. the subscriber becomes entitled to (actually covered under) Medicare. When your continuation coverage under this Section ends, you have the option to enroll in an individual conversion health plan as described in the Section rifled Your Right To Convert Coverage. ME 7 (1/1999) BPL 97425 Page 124 EE. Your Right To Convert Coverage Introduction: 1. Provided you are not covered under another qualified group plan as defmed in Minnesota Statutes 62E.02, subdivision 4, you are eligible to convert to an HMO conversion plan without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in the Section titled Your Right To Continue Coverage, is exhausted; b. Your coverage or continued coverage ends under the Contract because the Contract is terminated; c. Your coverage or continued coverage ends under the Contract because you no longer live within the Medica service area; or d. Your coverage ends under the Contract and you do NOT have the right to continue coverage as described in the Section titled Your Right To Continue Coverage. 2. If you move from the service area, you are eligible to convert to an insurance conversion plan without proof of good health or waiting periods as noted above. 3. Your conversion plan goes into effect the date your other coverage ends. You may select a qualified 1, 2 or 3 conversion plan. You must maintain continuous coverage when applying for conversion coverage. 4. Conversion coverage is not available if: a. continuous coverage is not maintained; b. you have not exhausted your fight to continue coverage as described in the Section titled Your Right To Continue Coverage; or c. you are covered under another qualified group plan as def'med in MN Statutes 62E.02, subdivision 4. For purposes of 3 and 4.a. above, continuous coverage will be determined to have been maintained if you request enrollment for conversion within 63 days after your coverage ends or within 31 days of the date you were notified of the right to convert, whichever is later. What you must do: 1. Call Customer Service at (952) 945-8000 (Mpls./St. Paul metro area) or 1-800-952-3455 (outside Mpls./St. Paul metro area). Hearing impaired members with a TTY phone may contact Customer Service at (952) 992-3190 (Mpls./St. Paul metro area) or 1-800-841-6753 (outside Mpls./St. Paul metro area) for conversion coverage information. 2. Paypremiums to Mediea within 63 days after your coverage ends or within 31 days of the date you were notified of your right to convert coverage, whichever is later. You will be required to include your first month premium payment with your enrollment form for conversion coverage. ME 7 (1/1999) BPL 97425 Page 125 Your Right To Convert Coverage Submit an enrollment form to Medica within 63 days after your coverage ends or within 31 days of the date you were notified of your right to convert coverage, whichever is later. You may include only those dependents who were enrolled under the Contract at the time of conversion. What your Employer must do: 1. Notify you of your right to convert coverage. ME 7 (1/1999) BPL 97425 Page 126 FF. If You Have A Complaint You may direct any question or complaint to Customer Service at (952) 945-8000 (Mpls./St. Paul metro area) or 1-800-952-3455 (outside Mpls./St. Paul metro area). Hearing impaired members with a TTY phone may contact Customer Service at (952) 992-3190 (Mpls./St. Paul metro area) or 1-800-841-6753 (outside Mpls./St. Paul metro area). 1. First level of review. a. You may direct any question or complaint, including requests for re-review of prior authorization determinations, to Customer Service by calling one of the telephone numbers listed above or by writing to the address shown below. You may also have another person make a complaint on your behalf by telephone or in writing. If someone makes a complaint on your behalf, Medica will require you to sign an authorization before Medica will release confidential information to the person who is filing the complaint on your behalf. b. If your complaint is concerning an initial decision made by Medica, and your complaint requires a medical determination in its resolution, your complaint must be made within 1 year following Medica's initial decision. c. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. d. For those oral complaints whose outcomes do not require a medical determination, if Medica does not communicate a decision regarding your complaint within ten (10) business days from Medica's receipt of the complaint, or if you determine that Medica's complaint decision is partially or wholly adverse to you, Medica will promptly provide you with a complaint form to register your complaint in writing. Your completed form should be mailed to: Customer Service Route 0501 P.O. Box 9310 Minneapolis, Minnesota 55440-9310 Upon request, Medica will assist you with completion and submission of your written complaint. Medica will also complete a complaint form on your behalf and mail it to you for your signature upon request. e. Medica will provide written notice of its decision to you and your attending provider, when applicable, within thirty (30) calendar days from receipt of your complaint or request. If Medica cannot make a decision within thirty (30) calendar days due to circnm~qtances outside of its control, Medica may take up to an additional fourteen (14) calendar days to notify you. Medica will inform you in advance of such an extension. f. When an initial decision by Medica not to grant a prior authorization request (or continuation of an inpatient stay) is made prior to or during an ongoing service requiring Medica's authorization, and your attending provider believes that Medica's decision warrants an expedited appeal, you or your attending provider will have the opportunity to request an expedited review by telephone. In such cases, Medica will notify you and your attendingprovider by telephone of its decision no later than seventy-two (72) hours after receiving the request for expedited review. ME 7 (I/1999) BPL 97425 Page 127 If You Have A Complaint g. IfMedica upholds its ori~nal decision regarding your complaint, you may request a second level of review described under 2 below. If Medica's initial decision is not reversed, you will have the right to submit your appeal to the external review process described under 3 below. For some complaints, the second level of review must be exhausted before you will have the right to submit your appeal to the external review process. For other complaints, this second level of review is optional. Medica will inform you in writing whether the second level of review is optional or required. Second level of review. If you are not satisfied with Medica's decision after the first level of review described under 1 above, you may request a written reconsideration or a hearing. a. Your request must be in writing and sent to the address listed under 1 above within 1 year following Medica's initial decision. b. Whether you choose a hearing or a written reconsideration, testimony, explanation or other information from you, Medica staff, providers or other persons will be reviewed. c. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. d. Medica will provide written notice of its decision to you within: i) Thirty (30) calendar days from receipt of written notice of your appeal for written reconsideration; or ii) Forty-five (45) calendar days from receipt of written notice of your appeal for a heating. Your right to external review. If you consider Medica's f'mal decision regarding your complaint or prior authorization request to be partially or wholly adverse to you, you may submit a written request for external review of Medica's appeal decision to the Commissioner of Health for issues related to in-network benefits or the Commissioner of Commerce for issues related to out-of-network benefits at the following addresses: Minnesota Department of Health P.O. Box 64975 St. Paul, Minnesota 55164-0975 (651) 282-5600 or (800) 657-3916 Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, Minnesota 55101-2198 (651) 296-6789 or (800) 657-3602 A filing fee of $25.00 must accompany your written request, unless waived by the Commissioner. An independent entity contracted with the State Commissioner of Administration will review your request. The external review decision shall not be binding on you but shall be binding on Medica. Contact the Commissioner of Health or Commissioner of Commerce for more information about the external review process. NOTE: Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be submitted for external review. ME 7 (1/1999) BPL 97425 Page 128 If You Have A Complaint In addition to directing complaints to Customer Service as described in this Section, you may direct complaints at any time related to in-network benefits to the Commissioner of Health, Minnesota Department of Health at 1-800-657-3916 or complaints related to out-of-network benefits to the Commissioner of Commerce, Minnesota Department of Commerce at 1-800-657-3602. ME 7 (1/1999) BPL 97425 Page 129 GG. General Provisions Records. Clerical Error. Relationship Between Parties. Assignment. Notice. Entire Agreement. Amendment. Examination of a member. To settle a dispute concerning provision or payment of benefits under the Contract, Medica may require that you be examined or an autopsy of the member's body be performed. The examination or autopsy will be at Medica's expense. You will not be deprived of coverage under the Contract because of a clerical error. On the other hand, you will not be eligible for coverage beyond the scheduled termination of your coverage because of a failure to record the termination. The relationships between Mediea, the Employer, and network providers and primary care clinics are contractual relationships between independent contractors. Network providers andprimary care clinics arc not agents or employees ofMedica. The relationship between a provider and any member is that of health care provider and patient. The provider is solely responsible for health care provided to any member. Medica will have the right to assign any and all of its fights and responsibilities under the Contract to any subsidiary or afl'fflate of Medica or to any other appropriate organization or entity. Except as otherwise provided in this Certificate, written notice given by Medica to an authorized representative of the Employer will be deemed notice to all affected in the administration of the Contract in the event of termination or non-renewal of the Contract. However, notice of termination for non-payment of premium shall be given by Medica to an authorized representative of the Employer and to each subscriber. This Certificate and the master group Contract and its appendices, as amended, are the entire Contract between your Employer and Medica, and replace all other agreements as of the effective date of the Contract. Medica may change or amend this Certificate when agreed upon by your Employer and Mediea, or when required by federal or state regulatory agencies. When this happens, you will receive a new Certificate or amendment. No person or entity has authority to make any other changes or amendments to this Certificate. ME 7 (1/1999) BPL 97425 Page 131 Index A Adoption, 13, 115 Ambulance, 51, 52, 100 Anesthesia, 95, 96 Appeal, 10 Artificial insemination, 79, 80 B Breast, 66, 75, 83 C Claims, 26, 27, 40, 104, 105, 109 COBRA, 114 Cognitive testing, 55, 103 Coinsurance, 4, 16, 25, 26, 27, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 47, 48, 49, 51, 52, 53, 54, 55, 58, 59, 61, 62, 63, 65, 66, 69, 70, 71, 72, 73, 76, 77, 79, 80, 81, 82, 83, 85, 86, 89, 90, 94, 95, 96, 97, 99, 100, 117, 118 Complaints, 6, 34, 105, 127 Contact lenses, 103 Continuation, 3, 114, 125 Continuous Coverage, 12, 15, 114, 115, 125 Converting coverage, 3, 117, 125, 126 Copayments, 4, 16, 25, 26, 33, 39, 40, 41, 43, 44, 47, 48, 49, 51, 53, 58, 59, 61, 63, 65, 69, 71, 73, 76, 79, 80, 81, 85, 89, 95, 117, 118 Cosmetic treatments, 19, 81, 83, 103 Custodial care, 13, 108 D Defmifions, 12, 13, 21, 99 Dental care, 19, 51, 83, 95, 96, 98, 107 Dependents, 3, 12, 13, 15, 21, 36, 87, 91, 96, 108, 113, 114, 115, 118 Diabetes, 27, 39, 40, 41, 42, 43, 44, 45, 75 Diagnostic Services, 58, 62 Drugs, 3, 14, 15, 17, 39, 40, 42, 43, 45, 103 Durable medical equipment, 40, 65, 66, 67 E Education, 17, 34, 37 Eligibility, 21, 113, 114, 115, 117 Emergency services, 3, 6, 23, 32, 36, 41, 47, 48, 51, 52, 57, 61, 99, 100, 101, 104, 108, 109 Enrollee, 15 Enrollment, 8, 12, 13, 15, 21, 105, 113, 114, 115, 125, 126 Exercise, 7, 117 Eye care, 19, 35, 103 Eyeglasses, 103 F Family planning, 33, 40, 43 Foot care, 104 Formulary, 39, 40, 41, 42, 43, 44, 45 G Growth hormone, 39, 41, 42, 44 H Home health care, 85, 86, 87 Hospices, 93, 94 Hospital services, 36, 47, 48, 71, 72, 75, 77, 79, 81, 82, 85, 86, 89 I Implants, 49, 78, 91, 98, 104 Infertility, 33, 79 ME 7 (1/1999) BPL 97425 Page 133 Index Inpatient services, 3, 9, 36, 48, 49, 57, 59, 61, 63, 73, 77, 80, 83, 85, 86, 89, 90, 99, 100 Insurance, i, 6, 11, 17, 18, 19, 104, 125 Interpreters, 35 Investigative procedures, 14, 15, 78, 103 L Late entrant, 15, 21 M Maternity care, 49 Maximum, 4, 5, 16, 24, 25, 26, 27, 35, 36, 40, 41, 42, 44, 48, 49, 59, 63, 72, 73, 76, 77, 80, 85, 86, 90, 95, 99, 100 Mental health, 2, 3, 13, 23, 24, 27, 30, 57, 58, 61, 99 N Nutrition, 37, 70 Nutritional supplements, 78 O Outpatient services, 27, 34, 35, 36, 47, 48, 53, 58, 62, 72, 76, 77, 82 P Phenylketonuria, 41, 70 Premiums, 3, 20, 27, 115, 117, 118, 125, 131 Prescriptions, 3, 27, 39, 40, 41, 42, 43, 44, 45, 101 Preventive health care, 5, 7, 15, 98 Prior authorization, 40, 47 Private room, 49, 59, 63 Prostheses, 65 Provider Reimbursement, 16 R Radiation therapy, 78 Reconstructive surgery, 12, 19, 81, 83, 103 Referrals, 2, 10, 11, 20, 29, 30, 32, 33, 35, 47, 101 Rehabilitation, 20, 53, 55, 87, 90, 91, 103 Reimbursement, 4, 5, 9, 16, 24, 25, 27, 33, 40, 44, 47, 51, 53, 58, 61, 65, 69, 71, 76, 79, 81, 85, 89, 95, 104, 109 Respite care, 93 Restorative, 81 S Skilled nursing facility, 14, 16, 52, 85, 87, 89, 90, 94 Splints, 73 Sterilization, 103 Subscriber, 13, 15, 21, 26, 27, 108, 113, 115, 117, 118, 131 Substance abuse, 2, 3, 13, 23, 24, 30, 37, 57, 61, 63, 99 Surgery, 13, 71, 83 T Termination, 12, 114, 117, 118, 131 Therapy, 37, 42, 53, 54, 55, 58, 72, 78, 86, 87, 90, 91, 97, 103 TMJ disorder, 71, 73 Transitional care, 20 Transplants, 75, 76, 78 U Urgent care, 2, 23, 24, 30, 33, 34, 41 W Waiting period, 13, 21, 115, 125 Weight loss, 78, 104 M~ 7 BPL 97425 Page 134