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HomeMy WebLinkAboutContract 2012 2426 2012 \2426.. - MASTER GROUP CONTRACT BETWEEN CITY-OF COLUMBIA HEIGHTS AND MEDICA INSURANCE COMPANY MEDICA INSURANCE COMPANY ( "MEDICA ") MASTER GROUP CONTRACT ARTICLE 1 INTRODUCTION This Master Group Contract ( "Contract ") is entered into by and between Medica Insurance Company ( "Medica ") and the employer group identified in Exhibit 1 ( "Employer "). This Contract includes Exhibit 1, Exhibit 2, the Certificate of Coverage ( "Certificate "), and any Amendments. This Contract includes the coverage option(s) set forth in Exhibit 2, offered by the Employer under a single group health plan. This Contract is delivered in the state of Minnesota. The capitalized terms used in this Contract have the same meanings given to those terms defined in the Certificate, unless otherwise specifically defined in this Contract. 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. If this Contract is governed by ERISA, any legal action arising out of or relating to this Contract shall be brought in the federal district court for the district of Minnesota. If this Contract is not governed by ERISA, any legal action arising out of or relating to this Contract shall be brought in state court in Hennepin County, Minnesota. In consideration of payment of the Premiums by the Employer and payment of applicable Deductibles, 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. ARTICLE 2 TERM OF CONTRACT Section 2.1 Term and Renewal. The initial Term of this Contract is set forth in Exhibit 1. At least 30 days before each Expiration Date, as set forth in Exhibit 1, 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 following reasons and will be effective as stated below. Except as specified otherwise, 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 that Employer failed to pay the required Premium when due, provided, however, that this Contract can be reinstated Medica Large Group MGC 1 City of Columbia Heights 01/01/2012 pursuant to Section 5.2. If Employer fails to pay the required Premium within the grace period described in Section 5.2, the Contract will be terminated, subject to a 30 -day advance written notice of termination by Medica to Employer. The date of the termination shall be retroactive to not more than 30 days prior to the effective date of the notice of termination; (b) On the date specified by Medica because Employer committed fraud (through act, practice, or omission) or intentionally 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 original effective date; (c) On the date specified by Medica due to Employer'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) Automatically on the date Employer ceases to do business for any reason; (f) On the date specified by Medica, after at least 90 days prior written notice to Employer, that this is Medics will no longer issue this particular type of group health benefit plan within the applicable employer*market; (g) 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; (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; (i) Automatically on the date that Employer fails to maintain any active employees who are Subscribers; (j) 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 renewable basis. Section 2.3 Notice of Termination. Medica will notify Employer in writing if Medica terminates this Contract for any reason. In accordance with applicable law, Medica will notify Subscribers in writing if Medica terminates this Contract pursuant to Section 2.2(a), (b), (d), (f), br (g). 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. Medica Large Group MGC 2 City of Columbia Heights 01/01/2012 ARTICLE 3 ENROLLMENT AND ELIGIBILITY Section 3.1 Eligibility. The Eligibility conditions stated in Exhibit 1 of this Contract govern who is eligible to enroll under this Contract. The eligibility conditions stated in Exhibit 1 are in addition to those specified in the Certificate. Section 3.2 Enrollment. The Certificate governs when eligible employees and eligible dependents may enroll for coverage 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 to ensure appropriate enrollment of Members under the Contract. 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 - 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 discretion to determine whether employees and their dependents are eligible to enroll for coverage under this Contract. Medica shall be entitled to rely upon Employer's determination regarding an employee's and /or dependent's eligibility to enroll for coverage under this Contract. 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. Section 3.5 Notification. The Employer must notify Medica within 30 days of an individual's initial enrollment application, changes to a Member's name or address, changes to a Member's eligibility for coverage (including a loss of eligibility), or other changes to enrollment. Section 3.6 Multiple Benefit Package Options. Subscribers and enrolled Dependents may only switch between Employer's health coverage options offered under the Contract during a Special Enrollment Period, or the Open Enrollment Period, if applicable, as described in the Certificate. ARTICLE 4 ELECTRONIC DELIVERY OF INSURANCE DOCUMENTS The Employer agrees to deliver, as Medica's agent, insurance documents required by law to be furnished to Subscribers. These documents shall be furnished by Medica to the Employer for delivery to Subscribers. The Employer shall not modify these documents in any way. The Employer agrees to deliver such documents electronically to the extent permissible under Title I Medica Large Group MGC 3 City of Columbia Heights 01/01/2012 of the Employee Retirement Income Security Act of 1974, Department of Labor Regulation § 2520.104b -1(c), if applicable, and Minn. Stat. § 72A.20, subd. 37. Such documents shall be delivered electronically only to Subscribers who meet the following requirements: (a) has the ability to access an electronic document effectively at any location where the Subscriber is reasonably expected to perform his or her duties as an employee, and (b) with respect to whom access to the plan sponsor's electronic information system is an integral part of those duties. The Employer shall implement procedures that ensure actual receipt of these documents and notify Subscribers of the significance of the materials at the time of delivery. In addition, the Employer shall inform the recipient of his or her right to request a paper version of these documents, and an expedient process for doing so. Upon such a request, Employer shall furnish the recipient with paper copies supplied by Medica. Employer shall inform Medica of individuals who do not qualify for electronic delivery because they do not meet the requirements regarding access to a computer, or they are not in the workplace, including but not limited to those on continuation coverage, on retiree coverage, or covered pursuant to a qualified medical child support order. Employer shall provide the individual's mailing information to Medica so that Medics can provide the documents. ARTICLE 5 PREMIUMS Section 5.1 Monthly Premiums. The monthly Premiums for this Contract are: set forth in Exhibit 2. The Premiums are due on the first day of each calendar month. Employer shall pay the Premiums to Medica in accordance with the method set forth in the invoice. 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 5.2 Grace Period and Reinstatement. Employer has a grace period of 10 days after the due date stated in Section 5.1 to pay the monthly Premiums. If Employer fails to pay the 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 the event this Contract is not reinstated pursuant to this Section, Medica shall not be responsible for any Claims for health services received by Members after the effective date of the termination. Section 5.3 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. Subject to Section 5.4, 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 whose effective date falls after the 15th day of that calendar month. With the exception of termination of coverage due to a Member's death, a Member's coverage 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 coverage will be terminated on the date of death. Section 5.4 Retroactive Adjustments. In accordance with applicable law and this Agreement, retroactive adjustments may be made for addition of Members, changes in Medica Large Group MGC 4 City of Columbia Heights 01/01/2012 4 Members' coverage classifications, and certain terminations of Members not reflected in Medica's records at the time the monthly Premiums were calculated by Medica. Employer understands and acknowledges that federal law prohibits the retroactive termination of a Member's coverage except in instances of fraud, intentional misrepresentation of material fact, or failure to timely pay premiums or premium contributions. Employer agrees that it will not request retroactive termination of any Member's coverage if such termination is prohibited by law. Notwithstanding the foregoing, 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. Notwithstanding the foregoing, Employer shall pay a Premium for any month during which a Member received Benefits (except as described in Section 5.3). Section 5.5 Premium Changes. Medica may change the Premiums after 30 days prior written notice to Employer. Section 5 :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. (c) an administrative service fee of $250.00 at time of request for reinstatement. Section 5.7 Premium Rebate Administration (When Applicable). (a) General Obligation. In accordance with the Patient Protection and Affordable Care Act ( "PPACA "), Medica is obligated to provide a rebate to each Subscriber and group policy holder (such as Employer) obtaining coverage in the large group market if the ratio of Medica's premium revenue spent on claims expenses and health care quality improvement activities for the large group market is less than eighty -five percent (85 %) of Medica's total premium revenue (minus certain taxes and fees) for that group market. PPACA requires Medica to make such determinations on a calendar year basis, regardless of the Effective Date and Expiration Date of this Contract. (b) Rebate Determinations and Remittances. Medica agrees to determine whether such rebates are owed under this Contract and, if applicable, remit to Employer either: (i) the full amount of such rebates (that is, the rebate amount owed based on the full Premium payment — including both Employer -paid and Subscriber -paid portions of said payment); or, at Medica's sole option, (ii) the Employer -paid portion of such rebates, only (in which case, Medica would remit the Subscriber -paid portion of such rebates directly to Subscribers). If Medica remits the full amount of such rebates to Employer (as described in (b)(i) above), Medica shall remit such payment no later than July 1 of the calendar year following any calendar year during which this Contract was in effect (for all or part of the year), and for which a rebate is owed (for all or part of the year). In the event Medica elects to remit the Subscriber -paid portion of such rebates directly to the applicable Subscribers (as described in (b)(ii) above), Medica shall remit rebate payments no later than August 1 of the calendar year following any calendar year during which this Contract was in effect (for all or part of the year), and for which a rebate is owed (for all or part of the year). (c) Form of Rebates. Medica may, in its sole discretion, elect to provide any such rebates owed in the form of a premium credit, a lump -sum check, or a lump -sum credit to the account used to pay the premium. (d) Rebate Distributions. Upon written request by Medica, Employer agrees to distribute to Subscribers (including former Subscribers) that portion of any such rebate attributable to the Medica Large Group MGC 5 City of Columbia Heights 01/01/2012 Subscriber -paid portion of the applicable Premium payment. Employer agrees to disburse any unclaimed rebates attributable to the Subscriber -paid portion of such rebates in accordance with applicable state law governing unclaimed property. (e) Information Required to Support Rebate Distributions. Under PPACA, Medica is required to collect and retain (for audit by the federal Department of Health and Human Services) the following information —which information Employer agrees to supply to Medica upon Medica's written request: (i) the amount of Premium paid by each Subscriber; (ii) the amount of Premium paid by Employer; (iii) the amount of rebate distributed to each Subscriber; (iv) the amount of rebate retained by Employer; and (v) the amount of unclaimed rebates and how and when they were distributed. ARTICLE 6 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 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' 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 6. ARTICLE 7 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 8 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 9 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 of the employee welfare benefit plan, as that term is used in ERISA. Medica shall only be considered a named fiduciary for purposes of claims adjudication. Medica Large Group MGC 6 City of Columbia Heights 01/01/2012 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 10 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. ARTICLE 11 CONTINUATION OF COVERAGE Medica shall provide coverage 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 12 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 or upon request by Members. 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 13 NONDISCRIMINATION In accordance with the Patient Protection and Affordable Care Act ( "PPACA "), fully- insured group health plans other than grandfathered plans are generally subject to nondiscrimination rules similar to those applicable to self- insured health plans under Section 105(h) of the Internal Revenue Code. Medica assumes no responsibility for compliance with such rules. Employer, as the sponsor of the insured employee benefit plan, shall be responsible for ensuring Medica Large Group MGC 7 City of Columbia Heights 01/01/2012 compliance with all PPACA nondiscrimination requirements applicable to the insurance coverage, including but not limited to payment 'of any and all governmental or regulatory taxes, penalties, interest, or other charges resulting from noncompliance with applicable nondiscrimination requirements. Employer, as the sponsor of the insured employee benefit plan, is solely responsible (1) for determining whether, with respect to its employee workforce, the aspects of a particular insurance contract are discriminatory under PPACA, and (2) for appropriately addressing the situation if it is discriminatory under PPACA (including but not limited to correcting, self - reporting, and payment of any penalties and interest related to the discrimination). ARTICLE 14 AMENDMENTS AND ALTERATIONS Section 14.1 Standard Amendments. Except as provided in Section 14.2, 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 �r broker has authority to this Contract or to waive any of its provisions: -- Section 14.2 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 15 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 and inure to the benefit of each party's successors and assigns. ARTICLE 16 DISPUTE RESOLUTION In the event that any dispute, claim, or controversy of any kind or nature relating to this Contract arises between the parties, the parties agree to meet and make a good faith effort to resolve the dispute. The party requesting the meeting shall provide the other, in advance of the meeting, with written notice of the claimed dispute. Upon receipt of the written notice, representatives for each party shall meet promptly to attempt to resolve the dispute. If a mutually agreeable resolution is not reached within thirty (30) days following receipt of the written notice, either party may pursue legal action in accordance with the terms of this Contract. The parties may mutually agree to waive the informal dispute resolution process set forth herein. Any such waiver must be in writing and executed by both parties. ARTICLE 17 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. Medica Large Group MGC 8 City of Columbia Heights 01/01/2012 ARTICLE 18 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 relationships 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 the Network Provider is solely responsible for the services provided to any Member. ARTICLE 19 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. 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. Unless Employer provides the appropriate written assurances required by 45 CFR 164.504, Medica will only provide Employer with summary health information (for the purposes of obtaining premium bids or for modifying, amending, or terminating the group health plan only) and information on whether individuals are participating in the group health plan, or is enrolled in or has disenrolled from the health plan as provided in 45 CFR 164.504 (f)(1) and the minimum necessary information for purposes of auditing Medica's operations or services. ARTICLE 20 NOTICE Except as provided in Article 2, notice given by Medi'ca 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 the Group 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 (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 21 COMMON LAW No language contained in the Contract constitutes a waiver of Medica's rights under common law. Medica Large Group MGC 9 City of Columbia Heights 01/01/2012 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. IN WITNESS WHEREOF, Medica has caused this Contract to be executed on this January 16, 2012, to take effect on the Effective Date stated in Exhibit 1 to this Contract. MEDICA INSURANCE COMPANY EMPLOYER 401 Carlson Parkway Minnetonka, MN 55305 City of Columbia Heights (952) 992 -2200 Address: 590 40th Avenue Northeast Columbia Heights MN 554_ Billing Address: 41,NW 7958 By: PO Box 1450 � & - /7 Minneapolis, MN 55485 -7958 Title: LA �/ q Employer Representative: Mailing Address: Linda Magee PO Box 9310 Minneapolis, MN 55440 Date: ,{ —� a1 By: John Naylor Vice President and General Manager Commercial Sales By: James P. Jacobson Senior Vice President and Assistant Secretary Medica Large Group MGC 10 City of Columbia Heights 01/01/2012 EXHIBIT 1 1. Parties. The parties to this Master Group Contract ( "Contract ") are Medica Insurance Company ( "Medica ") and the employer group City of Columbia Heights ( "Employer "), an employer under Minnesota law and other applicable law. 2. Effective Date and Expiration Date of this Contract. This Contract is effective from 01/01/2012 ( "Effective Date ") to 12/31/2012 ( "Expiration Date "). All coverage under this Contract begins at 12:01 a.m. Central Time. 3. Amendment(s) Number: Amendments attached as applicable for benefit package log (BPL) as listed in Exhibit 2. 4. Eligibility. The following conditions are in addition to those specified in the Certificate: 4.1 Eligibility to Enroll. A Subscriber and his or her Dependents who satisfy 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. 4.2 Subscriber Definition. An employee eligible to enroll under the Contract as a Subscriber must be an individual who satisfies the Employer participation and eligibility requirements as defined below. The term "Subscriber" as used in the Contract will include the types of employees and conditions identified below: Classifications Applicable Waiting Period or Effective Date 1. Employees: Employees working New Hires: Date of hire a minimum of 40 hours /week Status Change: Date of change Return: Date of return Rehire: Date of rehire Medica Large Group MGC Exhibit 1 City of Columbia Heights Page 1 01/01/2012 EXHIBIT 2 Premiums The monthly Premiums for MIC PPMN HSA 1500 -100 %, group number(s) 80515, BPL #67276 are: Single $507.47 The monthly Premiums for MIC PPMN HSA 1500 -100 %, group number(s) 80695, BPL #67277 are: Family $1,167.16 -The monthly Premiums for MIC- PPMN HSA 2500 -100 %, group number(s) 80517, BPL #67284 - - are: Single $451.14 Family - $1,037.61 The monthly Premiums for MIC FOCUSMN HSA 1500 -100 %, group number(s) 80516, BPL #67318 are: Single $405.97 The monthly Premiums for MIC FOCUSMN HSA 1500 -100 %, group number(s) 80694, BPL #67319 are: Family $933.73 The monthly Premiums for MIC PPMN 100 % -15, group number(s) 80513, BPL #84241 are: Single $665.80 Family $1,531.32 Medica Large Group MGC Exhibit 2 City of Columbia Heights Page 1 01/01/2012 o s73 I I Medica Choice Passport Certificate of Coverage MEDICA® MIC PPMN (3/11) 100 % -15 BPL 84241 DOC 21290 Table Of Contents Table Of Contents Introduction x To be eligible for benefits x Language interpretation xi I Acceptance of coverage xi Nondiscrimination policy xi A . Member Rights And Responsibilities 1 Member bill of rights 1 . Member responsibilities 1 B. How To Access Your Benefits 3 I Important member information about in- network benefits 3 Important member information about out -of- network benefits 5 Continuity of care 7 Prior authorization 8 Certification of qualifying coverage 9 C. How Providers Are Paid By Medica 10 Network providers 10 Non - network providers 10 D. Your Out -Of- Pocket Expenses 11 Copayments, coinsurance, and deductibles 11 More information concerning deductibles 12 Out -of- pocket maximum 12 Lifetime maximum amount 13 Out -of- Pocket Expenses 14 E. Professional Services 15 Covered 15 Not covered 16 Office visits 16 E- visits 16 Convenience care /retail health clinic visits 16 Urgent care center visits 17 Prenatal care services 17 Preventive health care 18 Allergy shots 18 MIC PPMN (3/11) iii 100 % -15 BPL 84241 DOC 21290 Table Of Contents Routine annual eye exams 18 Chiropractic services 18 Surgical services 19 Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 19 Services received from a physician during an emergency room visit 19 Services received from a physician during an inpatient stay 19 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 19 Services received from a physician during an inpatient stay for prenatal care and labor and delivery 19 Outpatient lab and pathology 19 Outpatient x -rays and other imaging services 19 Other outpatient hospital or ambulatory surgical center services 19 Treatment to lighten or remove the coloration of a port wine stain 19 Diabetes self- management training and education 20 Neuropsychological evaluations /cognitive testing 20 Services related to lead testing 20 Vision therapy and orthoptic and /or pleoptic training 20 Genetic counseling 20 Genetic testing 21 F. Prescription Drug Program 22 Preferred drug list 22 Exceptions to the preferred drug list 22 Prior authorization 23 Step therapy 23 Quantity limits 23 Covered 23 Prescription unit 24 Not covered 25 Outpatient covered drugs 26 Emergency covered drugs 26 Diabetic equipment and supplies, including blood glucose meters 26 Tobacco cessation products 26 Drugs considered preventive health services 27 G. Specialty Prescription Drug Program 28 Designated specialty pharmacies 28 MIC PPMN (3/11) iv 100 % -15 BPL 84241 DOC 21290 Table Of Contents Specialty preferred drug list 28 Exceptions to the specialty preferred drug list 28 Prior authorization 29 Step therapy 29 Quantity limits 29 Covered 29 Prescription unit 29 Not covered 30 Specialty prescription drugs received from a designated specialty pharmacy 30 Specialty growth hormone received from a designated specialty pharmacy 30 - H. 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 33 Inpatient services 33 Services received from a physician during an inpatient stay 33 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 33 I. Ambulance Services 34 Covered 34 Not covered 34 Ambulance services or ambulance transportation 35 Non - emergency licensed ambulance service 35 J. Home Health Care 36 Covered 36 Not covered 37 Intermittent skilled care 37 Skilled physical, speech, or occupational therapy 38 Home infusion 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 MIC PPMN (3/11) v 100 % -15 BPL 84241 DOC 21290 Table Of Contents Speech therapy received outside of your home 40 Occupational therapy received outside of your home 40 L. Mental Health 41 Covered 42 Not covered 43 Office visits, including evaluations, diagnostic, and treatment services 43 Intensive outpatient programs 44 Inpatient services (including residential treatment services) 44 M. Substance Abuse 45 Covered 46 Not covered 47 Office visits, including evaluations, diagnostic, and treatment services 47 Intensive outpatient programs 47 Opiate replacement therapy 47 Inpatient services (including residential treatment services) 48 N. Durable Medical Equipment And Prosthetics 49 Covered 49 Not covered 50 Durable medical equipment and certain related supplies 50 Repair, replacement, or revision of durable medical equipment 50 Prosthetics 50 Hearing aids 51 O. Miscellaneous Medical Services And Supplies 52 Covered 52 Not covered 52 Blood clotting factors 53 Dietary medical treatment of PKU 53 Amino acid -based elemental formulas 53 Total parenteral nutrition 53 Eligible ostomy supplies 53 Insulin pumps and other eligible diabetic equipment and supplies 53 P. Organ And Bone Marrow Transplant Services 54 Covered 54 Not covered 55 Office visits 55 E- visits 55 MIC PPMN (3/11) vi 100 % -15 BPL 84241 DOC 21290 Table Of Contents Outpatient services 56 Inpatient services 57 Services received from a physician during an inpatient stay 57 Anesthesia services received from a provider during an inpatient stay 57 Transportation and lodging 57 Q. Infertility Diagnosis 59 Covered 59 Not covered 59 Office visits, including any services provided during such visits 60 E- visits 60 Outpatient services received at a hospital 60 Inpatient services 60 R. Reconstructive And Restorative Surgery 61 Covered 61 Not covered 61 Office visits 62 E- visits 62 Outpatient services 62 Inpatient services 63 Services received from a physician during an inpatient stay 63 Anesthesia services received from a provider during an inpatient stay 63 S. Skilled Nursing Facility Services 64 Covered 64 Not covered 64 Daily skilled care or daily skilled rehabilitation services 65 Skilled physical, speech, or occupational therapy 65 Services received from a physician during an inpatient stay in a skilled nursing facility 65 T. Hospice Services 66 Covered 66 Not covered 67 Hospice services 67 U. Temporomandibular Joint (TMJ) Disorder 68 Covered 68 Not covered 68 Office visits 69 E- visits 69 MIC PPMN (3/11) vii 100 % -15 BPL 84241 DOC 21290 Table Of Contents Outpatient services 69 Physical therapy received outside of your home 70 Inpatient services 70 Services received from a physician or dentist during an inpatient stay 70 Anesthesia services received from a provider during an inpatient stay 70 TMJ splints and adjustments 70 V. Medical - Related Dental Services 71 Covered 71 Not covered 71 Charges for medical facilities and general anesthesia services 72 Orthodontia related to cleft lip and palate 72 Accident - related dental services 73 Oral surgery 73 W. Referrals To Non - Network Providers 74 What you must do 74 What Medica will do 74 X. Harmful Use Of Medical Services 76 When this section applies 76 Y. Exclusions 77 Z. How To Submit A Claim 80 Claims for benefits from network providers 80 Claims for benefits from non - network providers 80 Claims for services provided outside the United States 81 Time limits 81 AA. Coordination Of Benefits 82 Applicability 82 Definitions that apply to this section 82 Order of benefit determination rules 83 Effect on the benefits of this plan 84 Right to receive and release needed information 85 Facility of payment 85 Right of recovery 85 BB. Right Of Recovery 86 CC. Eligibility And Enrollment 87 Who can enroll 87 How to enroll 87 MIC PPMN (3/11) viii 100 % -15 BPL 84241 DOC 21290 Table Of Contents Notification 87 Initial enrollment 87 Open enrollment 88 Special enrollment 88 Late enrollment 91 Qualified Medical Child Support Order (QMCSO) 91 The date your coverage begins 92 DD. Ending Coverage 93 When coverage ends 93 EE. Continuation 95 Your right to continue coverage under state law 95 Your right to continue coverage under federal law 98 FF. Conversion 104 Minnesota residents 104 Residents of a state other than Minnesota 105 GG. Complaints 106 First level of review 106 Second level of review 107 External review 107 Civil action 108 HH. General Provisions 109 Definitions 111 MIC PPMN (3/11) ix 100 % -15 BPL 84241 DOC 21290 Introduction Introduction THIS POLICY IS REGULATED BY MINNESOTA LAW. The benefits of the policy providing your coverage are governed primarily by the law of a state other than Florida. Many words m this.certificate have specific t meanings. These words are identified m each section and defined m Defin See Definitions. These words have spec fic meanings benefits, clarm, dependent, member, network, premium, pro - Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota number one qualified plan. This Certificate of Coverage (this certificate) describes health services that are eligible for coverage and the procedures you must follow to obtain benefits. The Contract refers to the Contract between Medica and the employer. You should contact the employer to see the Contract. 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 may arrange for various persons or entities to provide administrative services on its 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. Additional network administrative support is provided by one or more organizations under contract with Medica. The employer is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by applicable law. In this certificate, the words you, your, and yourself refer to the member. The word employer refers to the organization through which you are eligible for coverage. To be eligible for benefits Each time you receive health services, you must: 1. Confirm with Customer Service that your provider is a network provider to be eligible for in- network benefits; and 2. Identify yourself as a Medica member; and 3. Present your Medica identification card. (If you do not show your Medica identification card, providers have no way of knowing that you are a Medica member and you may receive a bill MIC PPMN (3/11) x 100 % -15 BPL 84241 DOC 21290 Introduction for health services or be required to pay at the time you receive health services.) However, possession and use of a Medica identification card does not necessarily guarantee coverage. Network providers are required to submit claims within 180 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 180 days of the date of service, you may be responsible for paying the cost of the service you received. 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. If you have an impairment that requires alternative communication formats such as Braille, large print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials. 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 that has been issued in Minnesota between Medica and the employer. This certificate is being delivered to you by, or on behalf of, your 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 unless otherwise prohibited by state law; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and complete. You understand and agree that any omission or incorrect statement concerning a material fact intentionally made by you in connection with your enrollment under the Contract may invalidate your coverage. Nondiscrimination policy Medica's policy is 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, genetic information, 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. MIC PPMN (3/11) xi 100 % -15 BPL 84241 DOC 21290 I Member Rights And Responsibilities A. Member Rights And Responsibilities See Definitions: These words have specific meanings b emergency,` member, network rovider Member bill of rights As a member of Medica, 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; and 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; and 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; and 4. Be treated with respect and recognition of your dignity and privacy, including privacy of your medical and financial records maintained by Medica or any network provider in accordance with existing law; and 5. Contact Customer Service and Minnesota's Commissioner of Commerce to file a complaint about issues related to benefits (see Complaints). To file a complaint with the Minnesota Department of Commerce, call (651) 296 -2488 and request insurance information. You may begin a legal proceeding if you have a problem with Medica or any provider; and 6. Receive information about Medica, its services, its practitioners and providers, and member rights and responsibilities; and 7. Appeal a decision regarding your health care coverage by calling Customer Service at one of the telephone numbers listed inside the front cover. See Complaints for information on your appeal rights; and 8. Make recommendations regarding Medica's member rights and responsibilities statement. 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; and 2. Providing the necessary information to health care professionals or Medica needed to determine the appropriate care. This objective is best obtained when you share: a. Information about lifestyle practices; and b. Personal health history; and MIC PPMN (3/11) 1 100 % -15 BPL 84241 DOC 21290 Member Rights And Responsibilities 3. Understanding your health problems and agreeing to, and following, the plans and instructions for care given by those providing health care; and 4. Practicing self -care by knowing: a. How to recognize common health problems and what to do when they occur; and b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and 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 find additional information on member responsibilities in this certificate. MIC PPMN (3/11) 2 100 % -15 BPL 84241 DOC 21290 How To Access Your Benefits B. How To Access Your Benefits See Definitions The words have specific meanings benefits, claim, coinsurance,' iicopayment, deductible, dependent, emergency,„ enrollment d hospital, inpatient, late entran member, _network, non network„Jnon network provider reimbursement amount, physician placed for.adoption, premium, prescription drug, provider qualifying cove reconstructive, restorat skilled nursing fa ty, }subs criber, y r aiting pe riod Provider network In- network benefits are available through the Medica Choice Passport provider network. For a list of the in- network providers, please consult your Medica Choice Passport provider directory _ by signing in at www.mymedica.com or contacting Customer Service. Out -of- network benefits will apply when you choose to receive eligible health services from providers that are not contracted with Medica. 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. To be eligible for in- network benefits, follow -up care or scheduled care after an emergency must be received from a network provider. 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. Providers Enrolling in Medica does not guarantee that a particular provider will remain a network provider or provide you with health services. When a provider no longer participates in the network, you must choose to receive health services from network providers to continue to MIC PPMN (3/11) 3 100 % -15 BPL 84241 DOC 21290 How To Access Your Benefits be eligible for in- network benefits. You must verify that your provider is a network provider each time you receive health services. 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's hospital network is different from Medica's hospital network. Certain mental health and substance abuse services require prior authorization by Medica's designated mental health and substance abuse provider. Emergency services do not require prior authorization. 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. Medica does not automatically know of a birth or whether you would like coverage for the newborn dependent. Call Customer Service at one of the telephone numbers listed inside the front cover for more information. To be eligible for in- network benefits, health services must be 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 reduce payment by the amount of premium that is past due 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. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. MIC PPMN (3/11) 4 100 % -15 BPL 84241 DOC 21290 How To Access Your Benefits 2. Important member information about out -of- network benefits The information below describes your covered health services and provides important information concerning your out -of- network benefits. Read this certificate for a detailed explanation of both in- network and out -of- network benefits. Please carefully review the general sections of this certificate as well as the section(s) that specifically describe the services you are considering, so you are best able to determine the benefits that will apply to you. Benefits Medica pays out -of- network benefits for eligible health services received from non - network providers. Prior authorization may be required from Medica before you receive certain services, in order to determine whether those services are eligible for coverage under your out -of- network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out -of- network benefits. 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. Emergency services received from non - network providers are covered as in- network benefits and are not considered out -of- network benefits. Additionally, under certain circumstances Medica will authorize your obtaining services from a non - network provider at the in- network benefit level. Such authorizations are generally provided only in situations where the requested services are not available from network providers. Be aware that if you choose to go to a non - network provider and use out -of- network benefits, you will likely have to pay much 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. This additional amount you must pay to the provider will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses and you will owe this amount regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. Please see the example calculation below. Because obtaining care from non - network providers may result in significant out -of- pocket expenses, it is important that you do the following before receiving services from a non - network provider: • Discuss the expected billed charges with your non - network provider; and • Contact Customer Service to verify the estimated non - network provider reimbursement amount for those services, so you are better able to calculate your likely out -of- pocket expenses; and • If you wish to request that Medica authorize the non - network provider's services be covered at the in- network benefit level, follow the procedure described under Prior authorization in How To Access Your Benefits. MIC PPMN (3/11) 5 100 % -15 BPL 84241 DOC 21290 How To Access Your Benefits An example of how to calculate your out -of- pocket costs* You choose to receive non - emergency inpatient care at a non - network hospital provider without an authorization from Medica providing for in- network benefits. The out -of- network benefits described in this certificate apply to the services you receive. For purposes of this example, you have previously satisfied your deductible. The non - network hospital provider bills $30,000 for your hospital stay. Medica's non - network provider reimbursement amount for those hospital services is $15,000. You must pay a portion of the non - network provider reimbursement amount, generally as a percentage coinsurance. In addition, the non - network provider will likely bill you for the amount by which the provider's charge exceeds the non - network provider reimbursement amount. If your coinsurance is 40 %, you will be required to pay: • 40% coinsurance (40% of $15,000 = $6,000) and • The billed- charges that exceed the non - network provider reimbursement amount - - - -- - ($30,000 - $15,000 = $15,000) • The total amount you will owe is $6,000 + $15,000 = $21,000. • The $6,000 you pay as coinsurance will be applied to the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. However, the $15,000 amount you pay for billed charges in excess of the non - network provider reimbursement amount will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. You will owe the provider this $15,000 amount regardless of whether you have previously reached your out -of- pocket maximum with amounts paid for other services. *Note: The numbers in this example are used only for purposes of illustrating how out -of- network benefits are calculated. The actual numbers will depend on the services received. Lifetime maximum amount Out -of- network benefits are subject to a lifetime maximum amount payable per member. See Your Out -Of- Pocket Expenses for a detailed explanation of the lifetime maximum amount. Exclusions Some health 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. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including Iymphedemas, at all stages of mastectomy. MIC PPMN (3/11) 6 100 % -15 BPL 84241 DOC 21290 How To Access Your Benefits 3. Continuity of care To request continuity of care or if you have questions about how this may apply to you, call Customer Service at one of the telephone numbers listed inside the front cover. In certain situations, you have a right to continuity of care. a. If your current provider is terminated 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 provider 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 all necessary medical information related to your care, and accept as payment in full the lesser of the network provider reimbursement or the provider's customary charge for the service. This does not apply when a provider's contract is terminated for cause. i. 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; • 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 provider may 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 a network provider who has special expertise in the delivery of those culturally appropriate services is not available; or • if you do not speak English and a network provider who can communicate with you, either directly or through an interpreter, is not available. 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. You may appeal this decision. Coverage will not be provided for services or treatment that are not otherwise covered under this certificate. MIC PPMN (3/11) 7 100 % -15 BPL 84241 DOC 21290 How To Access Your Benefits 4. 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. To determine whether a certain service or supply requires prior authorization, please call Customer Service at one of the telephone numbers listed inside the front cover. Emergency services do not require prior authorization. Your attending provider, you, or someone on your behalf may contact Customer Service to request prior authorization. Your network provider will contact Customer Service to request prior authorization for a service or supply. You must contact Customer Service to request prior authorization for services or supplies received from a non - network provider. If a network provider fails to obtain prior authorization after you have consulted with them about services requiring prior authorization, you are not subject to a penalty for failure to obtain prior authorization. Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; • Treatment of a diagnosed temporomandibular joint disorder or craniomandibular disorder; • Organ and bone marrow transplant; • Home health care; • Medical supplies and durable medical equipment; • Outpatient surgical procedures; • Certain genetic tests; • Skilled nursing facility services; and • In- network benefits for services from non - network providers, with the exception of emergency services. This is not an all- inclusive list of all services and supplies that may require prior authorization. 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). Your request will be reviewed and a response will be provided to you and your attending provider within 10 business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available. MIC PPMN (3/11) 8 100 % -15 BPL 84241 DOC 21290 • How To Access Your Benefits Both you and your provider will be informed of the decision within 24 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or it is concluded that a delay could seriously jeopardize your life, health, or ability to regain maximum function. You have the right to appeal the decision as described in Complaints, if the request for prior authorization has not been approved. 5. Certification of qualifying coverage You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. MIC PPMN (3/11) 9 100 % -15 BPL 84241 DOC 21290 How Providers Are Paid By Medica C. How Providers Are Paid By Medica This section describes how providers are generally paid for health services. See Definitions. These words have specific meanings. coinsurance; copayment, deductible, hospital, member, network, non- network; physician,' provider. , 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 2. 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 is fee - for- service. Fee - for - service payment means that the network provider is paid 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, Tess any applicable copayment, coinsurance, or deductible, is considered to be payment in full. Risk - sharing payment means that the network provider is paid 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. Some network providers are authorized to arrange for a member to receive certain health services from other providers. This decision may result in a network provider keeping more or less of the risk - sharing payment. 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. MIC PPMN (3/11) 10 100 % -15 BPL 84241 DOC 21290 Your Out -Of- Pocket Expenses II I D. Your Out -Of- Pocket Expenses This section describes the expenses that are your responsibility to pay. These expenses are commonly called out -of- pocket expenses. See Definitions.; These words have specific,meanings benefits,, claim, coinsurance;. copayment, deductible, dependent, member, network, non - network, non- network provider reimbursement amount, prescription dru ro■ider, subscriber. ` 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.) If you miss or cancel an office visit Tess than 24 hours before your appointment, your provider may bill you for the service. Please see the applicable benefit section(s) of this certificate for specific information about your in- network and out -of- network benefits and coverage levels. To verify coverage before receiving a particular service or supply, call Customer Service at one of the telephone numbers listed inside the front cover. Copayments, coinsurance, and deductibles For in- network benefits, you must pay the following: 1. Any applicable copayment or coinsurance each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). 2. Any charge that is not covered under the Contract. For out -of- network benefits, you must pay the following: 1. Any applicable copayment, coinsurance, and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). When members in a family unit (a subscriber and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section), then all members of the family unit are considered to have satisfied the applicable per member and per family deductible for that calendar year. Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. MIC PPMN (3/11) 11 100 % -15 BPL 84241 DOC 21290 Your Out -Of- Pocket Expenses 2. Any charge that exceeds the non - network provider reimbursement amount. This means you are required to pay the difference between the payment to the provider and what the provider bills. If you use out -of- network benefits, you may incur costs in addition to your copayment, coinsurance, and deductible amounts. If the amount that your non - network provider bills you is more than the non - network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out -of- pocket maximum (described in this section). 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 deductibles. 3. Any charge that is not covered under the Contract. More information concerning deductibles The time period used to apply the deductible (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. Out - of - pocket maximum The out -of- pocket maximum is an accumulation of copayments, coinsurance, and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per member out -of- pocket maximum for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non - network provider reimbursement amount are not applicable toward the out -of- pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. The time period used to calculate whether you have met the out -of- pocket maximum (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. MIC PPMN (3/11) 12 100 % -15 BPL 84241 DOC 21290 Your Out -Of- Pocket Expenses When members in a family unit (the subscriber and his or her dependents) have together met the applicable per family out -of- pocket maximum for benefits received during the calendar year, then all members of the family unit are considered to have met the applicable per member and per family out -of- pocket maximum for that calendar year (see the Out -of- Pocket Expenses table in this section). After an applicable out -of- pocket maximum has been met for a particular type of benefit (as described in the Out -of- Pocket Expenses table in this section), all other covered benefits of the same type received during the rest of the calendar year will be covered at 100 percent, except for any charge not covered by Medica or charge in excess of the non - network provider reimbursement amount. However, you will still be required to pay any applicable copayments, coinsurance, and deductibles for other types of benefits received. Note that out -of- pocket maximum amounts are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new out -of- pocket maximum will apply for the rest of the current calendar year, whether or not you had met the previously applicable out -of- pocket maximum. This means that it is possible that your out -of- pocket maximum will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. Medica refunds the amount over the out -of- pocket maximum during any calendar year when proof of excess copayments, coinsurance, and deductibles is received and verified by Medica. 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, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Out -of- Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced pertains only to those health care services and supplies that are not essential benefits as defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules or other guidance issued with respect to the "Act." MIC PPMN (3/11) 13 100 % -15 BPL 84241 DOC 21290 Your Out -Of- Pocket Expenses Out -of- Pocket Expenses In- network x * Out -of network benefits benefits * out-of network benefits, in addition to the deductible, copayment, and coinsurance, you are respon for a ny charges in excess of theinon- network; provider "reimbursements amount Additionally, these charges will not be applied toward satisfaction of the deductrble"or the out of pocket maximum. 4 Copayment or coinsurance See specific benefit for applicable copayment or coinsurance. Deductible A deductible does not apply to in- network benefits. Per member $3,000 Per family $9,000 Out -of- pocket maximum Per member $2,000 $9,000 Per family $5,000 Out -of- pocket maximum does not apply. Refer to the per member out -of- pocket maximum above. Lifetime maximum amount Unlimited $1,000,000. Applies to payable per member all benefits you receive under this or any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. MIC PPMN (3/11) 14 100 % - BPL 84241 DOC 21290 Professional Services E. Professional Services This section describes coverage for professional services received from or directed by a physician. See Definitions.' These words have specific'meanings benefits, coinsurance, convenience care /retail health clinic, copayment, deductible, emergency, e- visits, hospital, inpatient, member, network, non network, non network }provider reimbursement amount, physician, .prenatal care, preventive health service, provider, urgent care center. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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; 2. 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. Family planning services do not include infertility treatment services. • 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 out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. 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 transplant services are described in Organ And Bone Marrow Transplant Services. For some services, there may be a facility charge resulting in copayment or coinsurance (see Hospital Services) in addition to the professional services copayment or coinsurance. Also, more than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. MIC PPMN (3/11) 15 100 % -15 BPL 84241 DOC 21290 1 Professional Services Not covered Drugs provided or administered by a physician or other provider, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Y Pa _our Benefits and fine "Amounts You , y Benefits "'` In- network benefits $ f *"Out- of-network benefits ' after deductible * For out- of- network`benefits, in addition°to the deductible, copayment, and coinsurance, you are responsible: for °any :charges in excess of.the _non -network provider reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out -of- pocket maximum. = 1. Office visits $15 /visit 50% coinsurance Please note: Some services received during an office visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an office visit. For example, certain services received during an office visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an office visit copayment or coinsurance and outpatient surgical or imaging services copayment or coinsurance apply. CaII Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 2. E- visits $15 /visit No coverage 3. Convenience care /retail health $5 /visit 50% coinsurance clinic visits MIC PPMN (3/11) 16 100 % -15 BPL 84241 DOC 21290 Professional Services Your Benefits and the Amounts You Pay Benefits In- network benefits' * Ou of network benefits "` after deductible * For out of: network benefits, in addition to;the dedu copayment, and coinsurance; you are 3 T . responsible for any charges in.excess of the non network providerrreimbursement amount - Additionally,lthese'charges will not be applied toward satisfactiion of the deductible or the out =of pocket maximum:' 4. Urgent care center visits $15 /visit Covered as an in- network Please note: Some services benefit. received during an urgent care visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an urgent care visit. For example, certain services received during an urgent care visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care visit copayment or coinsurance and outpatient surgical or imaging services copayment or coinsurance apply. CaII Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage , level for each service that you receive. 5. Prenatal care services received Nothing Covered as an in- network from a physician during an office benefit. visit or an outpatient hospital visit MIC PPMN (3/11) 17 100 % -15 BPL 84241 DOC 21290 I Professional Services Your Bene and: the Amoun You`Pay Benefits - In-network benefits - ._: * O of network benefit a after deductible * For out-of b m addition.to the deductible, copayment, and coinsurance, you a re responsible - for any charges-in excess of,the non - network provider reimbu amount Additionally „th will not be applied: t satis fa c tion of the deductible or the out of pocket maximum 6. Preventive health care Please note: I f y receive preventive and non preventive I health services during the same visit, the non - preventive health services may be subject to a copayment, coinsurance, or deductible, as described elsewhere in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during a visit. a. Child health supervision Nothing Covered as an in-network services, including well -baby benefit. over care b. Immunizations Nothing 50% coinsurance c. Early Nothing 50% coinsurance services disease including detection icals phys d. Routine Nothing 50% coinsurance procedures screening ncer for ca e. Other preventive health Nothing 50% coinsurance services 7. Allergy shots Nothing 50% coinsurance 8. Routine annual Nothing 50% coinsurance Coverage is limited eye to one exams. visit per calendar year for in- network and out -of- network benefits combined. 9. Chiropractic services to $15 /visit 50% coinsurance. diagnose and to treat (by manual Coverage is limited to a manipulation or certain maximum o f 15 vi r ts per therapies) conditions related to calendar that you pay ye the muscles, skeleton, and Please note: T visit limit nerves of the body includes chiropractic visits in order to satisfy any part of your deductible. MIC PPMN (3/11) 18 100 % -15 BPL 84241 DOC 21290 Professional Services You Benefits and the Amounts Yo u` "Pay Benefits In, networ -k benefits *Out of network benefits after d eductible * For out of network benefits, in addition to the deductible, copayment, and coinsurance, you are responsible for any charges in ;excess of #the non network prov ider reimbursement amount Additionally,wthese charges.will not be, app tow ard satisfaction of:the de=ductible or tf a out -of pocket maximum: 10. Surgical services (as defined in $15 /visit 50% coinsurance the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit 11. Anesthesia services received $15 /visit 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 12. Services received from a Nothing Covered as an in - network physician during an emergency benefit. • room visit 13. Services received from a Nothing 50% coinsurance - physician during an inpatient stay 14. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery 15. Services received from a Nothing 50% coinsurance physician during an inpatient Please note: Out -of- stay for prenatal care and labor network services for and delivery prenatal care are covered as an in- network benefit. 16. Outpatient lab and pathology Nothing 50% coinsurance 17. Outpatient x -rays and other Nothing 50% coinsurance imaging services 18. Other outpatient hospital or $15 /visit 50% coinsurance ambulatory surgical center services received from a physician 19. Treatment to lighten or remove $15 /visit 50% coinsurance the coloration of a port wine stain MIC PPMN (3/11) 19 100 % -15 • BPL 84241 DOC 21290 Professional Services Your" Benefits and the "Amounts You Pay Benefits °, I�nnetwork_ be nefits " ' *'Out of network benefits after deductible * for out' of network benefits, rn addrti the:deduc`tible, copayment, and coinsurance, you are `responsible for any charges -rn exce the non network provider reimbursement amount Additionally, these charges will not be applied toward satisfaction' of the or�the out-of p ocket" "maximum °� 20. Diabetes self- management $15 /visit 50% coinsurance 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) 21. Neuropsychological $15 /visit 50% coinsurance evaluations /cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury 22. Services related to lead testing $15 /visit 50% coinsurance 23. Vision therapy and orthoptic $15 /visit 50% coinsurance and /or pleoptic training, to establish a home program, for the treatment of strabismus and other disorders of binocular eye movements. Coverage is limited to a combined in- network and out -of- network total of 5 training visits and 2 follow -up eye exams per calendar year. Please note: These visit and exam limits include visits and exams that you pay for in order to satisfy any part of your deductible. • 24. Genetic counseling, whether pre- $15 /visit 50% coinsurance or post -test, and whether occurring in an office, clinic, or telephonically MIC PPMN (3/11) 20 100 % =15 BPL 84241 DOC 21290 :jos ProfessionaB Services Y Benefits and'the A unt_ You s Pay Benefits _ In network benef *Out of- netw benefits a deductible * For o -of network benefi - in a ddition to the deductibl copaymen and comsurance� you are • re sponsible- for any c harges in;:exce of t he n on - ne twork p "rovider ent amount Additionally, t h es e T charges wi ;not be applied 'toward satis of the deductible o r t h e out of- pocke ataxia, umz; 25. Genetic testing when test results Nothing 50% coinsurance • will directly affect treatment decisions or frequency of • ng a disease, or when • results screeni for of the te will affect reproductive choices • 100 % -15 MIC PPMN (3/11) 21 BPL 84 DOC 21290 • Professional Services Your Benefits and the Amounts You Pay. Benefits;. in- network benefits * Out -of- network benefits !. after deductible * For out of- networkkbenefits, in addition, to the deductible, copayment, and coinsurance,' you are responsible for any charges in excess of. the nori- network provider - reimbursement amount Additionally, these charges will not be 4pOlied satisfaction of the deductible or the 'out -of- pocket maximum.' 25. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment • decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices MIC PPMN (3/11) 21 100 % -15 BPL 84241 DOC 21290 Prescription Drug Program F. Prescription Drug Program This section describes coverage for prescription drugs and supplies received from a pharmacy or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" is meant to include those ,prescription drugs and supplies found on the Preferred Drug List (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such prescription drugs and supplies are identified in this certificate as not covered. The phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase "self- administered drugs" means all other drugs. For the definition and coverage of specialty prescription drugs, see Specialty Prescription Drug Program. See Definitions These words have specific meanings: benefits, -claim ,coinsurance, . copayment, deductible, durable medical equipment, emergency, hospital, member, network, non- network, non-network ,provider reimbursement amount, physician, prescription preventivehealth service,; provider, urgent care center. Preferred drug list Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: Tier 1 is your lowest copayment or coinsurance option. For the lowest out -of- pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Tier 2 is your higher copayment or coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate. Tier 3 is your highest copayment or coinsurance option. The covered drugs in Tier 3 are usually more costly. If you have questions about Medica's PDL or whether a specific drug is covered (and /or the PDL tier in which the drug may be covered), or if you would like to request a copy of the PDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The PDL is also available when you sign in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a drug should be considered a covered drug. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the PDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each drug based on a review of the drug's cost and effectiveness. Exceptions to the preferred drug list Exceptions to the PDL 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 PDL or you change health plans. If you would like to request a copy of MIC PP (3/11) 22 100 % -15 • BPL 84241 DOC 21290 1 ' Prescription Drug Program Medica's PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. • Prior'authorization ` Certain covered drugs require prior authorization as indicated on the PDL. The provider who prescribes the drug initiates prior authorization. The PDL is made available to providers, including pharmacies and the designated mail order pharmacies. You are responsible for paying the cost of drugs received if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step therapy involves trying an alternative covered drug first (typically a Tier 1 drug) before moving on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. Quantity limits Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. . Covered The following table provides important general information concerning in- network, out -of- network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that the Prescription Drug Program section describes your copayment or coinsurance for prescription drugs themselves. An additional copayment or coinsurance applies for the provider's services if you require that a provider administer self- administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. min network benefits Out-of-network benefits* - Mail order benefits Covered drugs received at a Covered drugs received at a Covered drugs received from network pharmacy; and non - network pharmacy; and a designated mail order pharmacy; and MIC PPMN (3/11) 23 100 % -15 BPL 84241 DOC 21290 Prescription Drug Program In- network benefits Out-of-network benefits* Mail order benefits Covered drugs for family See In- network benefits Covered drugs for family planning services or the column. planning services or the treatment of sexually treatment of sexually transmitted diseases when transmitted diseases when prescribed by or received from prescribed by either a either a network or a non- network or a non - network network provider. Family provider and received from a planning services do not designated mail order include infertility treatment pharmacy. Family planning II services; and services do not include infertility treatment services; and Diabetic equipment and Diabetic equipment and Diabetic equipment and supplies, including blood supplies, including blood supplies (excluding blood glucose meters when received glucose meters when received glucose meters) received from a network pharmacy; and from a non - network pharmacy; from a designated mail order and pharmacy. Tobacco cessation products Tobacco cessation products Not available. when prescribed by a provider when prescribed by a provider authorized to prescribe the authorized to prescribe the product and received at a product and received at a non- 11 network pharmacy. network pharmacy. * When out -of- network benefits are received from non - network providers, 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 out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Specialty Prescription Drug Program for coverage of growth hormone and other specialty prescription drugs. Prescription unit Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31- consecutive -day supply of a covered drug from your pharmacy (or, in the case of oral contraceptives, up to a one -cycle supply) or a 93- consecutive -day supply of a covered drug from your designated mail order pharmacy (or, in the case of oral contraceptives, up to a three -cycle supply), unless limited by drug manufacturers' packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits as indicated on the PDL. Copayment or coinsurance amounts will apply to each prescription unit dispensed. MIC PPMN (3/11) 24 100 % -15 BPL 84241 DOC 21290 Prescription Drug Program Three prescription units may be dispensed for covered drugs prescribed to treat chronic conditions that are received at a network pharmacy that Medica has specifically designated to dispense multiple prescription units. For the current list of such designated pharmacies, sign in at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside the front cover. Not covered The following 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.) 2. OTC drugs not listed on the PDL. 3. Replacement of a drug due to loss, damage, or theft. 4. Appetite suppressants. 5. Erectile dysfunction medications. 6. Non - sedating antihistamines and non - sedating antihistamine /decongestant combinations. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and those members who have a feeding tube. 8. Tobacco cessation products or services dispensed through a mail order pharmacy. 9. Drugs prescribed by a provider who is not acting within his /her scope of Iicensure. 10. Homeopathic medicine. 11. Infertility drugs. 12. Specialty prescription drugs, except as described in Specialty Prescription Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. MIC PPMN (3/11) 25 100 % -15 BPL 84241 DOC 21290 7 Prescription Drug Program Your Benefits and the Amounts You P ay "F out -of network_. bene in addition to the deductible, copayment, -and ` coinsurance, you are responsible for any charges in excess of the non network provider reimbursement3amount Additionally, these charges will notibe applied toward satisfaction of the d or the o pocket pocket maximu In- networ bene fi ts * Out -o #network benefits : Mail order. benefits after--deductible 1. Outpatient covered drugs other than those described below or in Specialty Prescription Drug Program Tier 1: $12 per prescription $90 or 40% coinsurance Tier 1: $24 per prescription unit; or (whichever is greater) per unit; or Tier 2: $50 per prescription prescription u Tier 2: $100 per prescription unit; or unit; or Tier 3: $90 per prescription Tier 3: $180 per prescription unit unit 2. Up to a 24 - hour supply of emergency covered drugs received from a hospital or urgent care center Nothing Covered as an in- network Not available through a mail benefit. order pharmacy. 3. Diabetic equipment and supplies, including blood glucose meters Tier 1: 20% coinsurance per 40% coinsurance per Tier 1: 20% coinsurance per prescription unit; or prescription unit prescription unit; or Tier 2: 20% coinsurance per Tier 2: 20% coinsurance per prescription unit; or prescription unit; or Tier 3: 40% coinsurance per Tier 3: 40% coinsurance per prescription unit prescription unit 4. Tobacco cessation products Tier 1: Nothing per $90 or 40% coinsurance Not available through a mail prescription unit; or (whichever is greater) per order pharmacy. Tier 2: Nothing per prescription unit prescription unit; or Tier 3: Nothing per prescription unit MIC PPMN (3/11) 26 100 % -15 BPL 84241 DOC 21290 --, Prescription Drug Program I r _ You Benefits and the Amounts You Pay ;y * For of,.- network benefits, in addition to the deductible, copayment an'd coinsuran you ; a re responsible for any charges, ini excess of the non - network provider reimbursement amo Additionally, these charg . will not be applied ,toward satisfaction of 'the deductible or the o of pocket m f In- networ benefits, * Out = o f- network benefits Mail :order after de ductible 5. Drugs (other than tobacco cessation products) considered prevent as specifically defined in Definitions, when prescribed by a provider authorized ve health to services prescribe such drugs. This group of d . For , please refer to the Preven drugs ive is Drug List specific within an th e limited PDL or call the Customer current list Service of such at one drugs of the telephone numbers listed inside the front cover. Tier 1: Nothing per $90 or 40% coinsurance Not available through a mail prescription unit; or (whichever is greater) per order pharmacy. Tier 2: Nothing per prescription unit prescription unit; or Tier 3: Nothing per prescription unit I MIC PPMN (3/11) 27 100 % -15 BPL 84241 DOC 21290 Specialty Prescription Drug Program G. Specialty Prescription Drug Program This section describes coverage for specialty prescription drugs received from a designated specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology prescription drug products for individuals with diseases that require complex therapies. Such specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as described below. For purposes of this section, the phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; and the phrase "self- administered drugs" means all other drugs. See Definitions. These words have specific meanings benefits' claim, coinsurance, copayment, member, network ,,physician prescription drug Designated specialty pharmacies A designated specialty pharmacy means a specialty pharmacy that has entered into a separate contract with Medica to provide specialty prescription drug services to members. For the current list of designated specialty pharmacies, call Customer Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com. Specialty preferred drug list Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty prescription drugs on Medica's SPDL are eligible for benefits under this certificate. The applicable copayment and coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is covered (and /or the SPDL tier in which the drug may be covered), or if you would like to request a copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The SPDL is also available by signing in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a specialty prescription drug should be covered. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the SPDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. Exceptions to the specialty preferred drug list Exceptions to the SPDL 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 SPDL or you change health plans. If you would like to request MIC PPMN (3/11) 28 100 % -15 BPL 84241 DOC 21290 Specialty Prescription Drug Program a copy of Medica's SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain specialty prescription drugs require prior authorization. The provider who prescribes the specialty drug initiates prior authorization. The SPDL is made available to providers, including designated specialty pharmacies. You are responsible for paying the cost of specialty prescription drugs you receive if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying a Tier 1 specialty prescription drug before moving on to a Tier 2 specialty prescription drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 specialty prescription drugs. Quantity limits Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy. This section describes your copayment or coinsurance for specialty prescription drugs. An additional copayment or coinsurance applies for the provider's services if you require that a provider administer self- administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. Prescription unit Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. One prescription unit is equal to a 31- consecutive -day supply of a specialty prescription drug, unless limited by the manufacturers' packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. MIC PPMN (3/11) 29 100 % -15 BPL 84241 DOC 21290 Specialty Prescription Drug Program Not covered The following are not covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the designated specialty pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Replacement of a specialty drug due to loss, damage, or theft. 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of licensure. 4. Prescription drugs and OTC drugs, except as described in Prescription Drug Program. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 6. Infertility drugs. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Your Benefits and: the, Amounts You Pay Benefits = You pa 1. Specialty prescription drugs, Tier 1 specialty prescription drugs: 20% other than those described coinsurance up to a maximum of $200 per prescription below, received from a unit; or designated specialty pharmacy Tier 2 specialty prescription drugs: 40% coinsurance per prescription unit 2. Specialty growth hormone when Tier 1 specialty prescription drugs: 20% prescribed by a physician for the coinsurance up to a maximum of $200 per prescription treatment of a demonstrated unit; or growth hormone deficiency and Tier 2 specialty prescription drugs: 40% received from a designated coinsurance per prescription unit specialty pharmacy • MIC PPMN (3/11) 30 100 % -15 BPL 84241 DOC 21290 Hospital Services H. Hospital Services This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. See ,Def►nitrons ` These words have specific meanings benefits, coinsurance, co a ment deductible, emergency,`.hospital, inpatient, member, network, ,non network, :non netwo k"provider reimbursement'amoun# physician, prenatal care, provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 Tess (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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency.services from non - network providers will be covered as in- network benefits. If you are confined in a non - network facility as a result of an emergency you will be eligible for in- network benefits until your attending physician agrees it is safe to transfer you to a network facility. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. Each member's admission is separate from the admission of any other member. A separate deductible and copayment or coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. MIC PPMN (3/11) 31 100 % -15 BPL 84241 DOC 21290 Hospital Services Not covered 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. 2. Transfers and admissions to network hospitals solely at the convenience of the member. 3. Admission to another hospital is not covered when care for your condition is available at the network hospital where you were first admitted. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefitsiand the Amounts You` x Benefits In network benefits * Out of network benefits - , € � � � after deductible * For out of network benefits, in addition'to the deductible, copayment, and coinsurance, you are responsible for any charges in excess.ofthe non network provider <reimburser"rent'amount;,' Additional) these char es will n to ot be applied ward [satisfaction of the deductible or the out of Y� � � pocket maximumx _ ;' 1. Outpatient services a. Services provided in a $95 /visit Covered as an in- network hospital or facility -based benefit. emergency room b. Outpatient lab and pathology Nothing 50% coinsurance c. Outpatient x -rays and other Nothing 50% coinsurance imaging services d. Prenatal care services Nothing Covered as an in- network benefit. e. Genetic testing when test Nothing 50% coinsurance results will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices f. Other outpatient services $15 /visit 50% coinsurance g. Other outpatient hospital and $15 /visit 50% coinsurance ambulatory surgical center services received from a physician MIC PPMN (3/11) 32 100 % -15 BPL 84241 DOC 21290 • Hospital Services Your Benefits and the Amounts You Pay Benefits - in network benefits * Out of- network benefits after deductible For,out of= netwo benefits, in addition tofthe deductible, cop and coinsurance, you are responsible for any charges in excess of the non network provider reimbursement_ amount Additionally, these charges will not be applied toward s atisfaction of the dedu or the out of pocket maximum h. Anesthesia services received $15 /visit 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 2. Services provided in a hospital $15 /visit 50% coinsurance observation room • 3. Inpatient services, including Nothing 50% coinsurance, except inpatient maternity labor and you pay nothing for delivery services inpatient services related Please note: Maternity labor and to prenatal care services delivery services are considered that do not result in a inpatient services regardless of the delivery length of hospital stay. • 4. Services received from a Nothing 50% coinsurance physician during an inpatient stay 5. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery • MIC PPMN (3/11) 33 100 % -15 BPL 84241 DOC 21290 Ambulance Services L 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). See, Definitions These words have specific meanings benefits, coinsurance copayment, deductible, emergency, hospital, network, non - network, non - network provider reimbursement amount, "phy provider",' skilled nursing facility. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For non - emergency licensed ambulance services described 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 non - emergency ambulance services described in this section that are arranged through 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 will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN (3/11) 34 100 % -15 BPL 84241 DOC 21290 Ambulance Services ...__.._..........._. Your Benefits and the Amounts You Pay Beneft #s" In- network benefits * iOut network b enefits after deductible *. "Fo out of ne twork benefits, rn addition to the deductible copayment, and coinsurance, you responsible for any charges" in excess" of the non - network provider reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out -of : pocket maximum " ' 1. Ambulance services or Nothing Covered as an in- network ambulance transportation to the benefit. nearest hospital for an emergency 2. Non - emergency licensed ambulance service that is arranged through an attending physician, as follows: 0 a. Transportation from hospital Nothing 50% coinsurance to hospital when: 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 Nothing 50% coinsurance to skilled nursing facility MIC PPMN (3/11) 35 100 % -15 BPL 84241 DOC 21290 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. See De finitions These words have specific rneanings benefits, - ;coinsurance, copayment,' custodial care, deductible, dependent, hospital, network, non-network, :non network provider reimbursement amount, physician, prenatal ; care,: provider, skilled care, skilled nursing' facility., Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare guidelines) 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 1. and 2. in the table in this section are limited to a combined maximum of 120 visits per calendar year for in- network and 60 visits per calendar year for out -of- network benefits. Please note: These visit limits include any visits that you pay for in order to satisfy any part of your deductible. You may be eligible for additional intermittent skilled care if you have Medica coverage and are also enrolled in the Medical Assistance Program. • 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. 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. MIC PPMN (3/11) 36 100 % -15 BPL 84241 DOC 21290 1 • 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 non- skilled services. 4. Physical, speech, or occupational therapy provided in your home for convenience. 5. Services provided in your home when you are not homebound. 6. Services primarily educational in nature. 7. Vocational and job rehabilitation. 8. Recreational therapy. • 9. Self -care and self -help training (non - medical). 10. Health clubs. 11. Disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. 12. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 13. Voice training. 14. Outpatient rehabilitation services when no medical diagnosis is present. 15. Home health aide services, except when rendered in conjunction with intermittent skilled care and related to the medical condition under treatment. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Youtt Benefits and the Amounts - You Pay Benefits In-network benefits - . - Out ofnetwork. benefits after educttble For out -of - - network ben r efets �n addition to the deciucttble copayment, and coinsurance you are responsible for any charges in excess of the non - network provider reimbursement amount Additi these charg wi not be applied toward satisf of the deductibl or o the ut ,of pocket maximum := , 1. Intermittent skilled care when 20% coinsurance, except 50% coinsurance, except you are homebound, provided by you pay nothing for high- you pay nothing for high - or supervised by a registered risk prenatal care risk prenatal care nurse services services MIC PPMN (3/11) 37 100 % -15 BPL 84241 DOC 21290 Home Health Care You Benefits and the Amounts You Pay Benefits In benefits * Out of n etwork.benef i ts after deductible *fo out-of-network 'benefits, m addition,to the deductible, copayinent; and coinsurance, you are responsible "for any charges ;in of the non network provider reimbursement, amount - Additionally, these charges will not be applied toward satisfaction of the. deductible or;th out o f .'" pocket maximum N 9 2. Skilled physical, speech, or 20% coinsurance 50% coinsurance occupational therapy when you are homebound 3. Home infusion therapy 20% coinsurance, except 50% coinsurance, except pY P p you pay nothing for high- you pay nothing for high - risk prenatal care risk prenatal care services services 4. Services received in your home 20% coinsurance 50% coinsurance from a physician MIC PPMN (3/11) 38 100 % -15 BPL 84241 DOC 21290 Outpatient Rehabilitation K. Outpatient Rehabilitation This section describes coverage for both professional and outpatient health care facility services. A physician must direct your care. See Definitions -These words have specific meanings -. benefits coinsurance :copayment, 'deductible, network, ion network, ncin network provider reirnbursement amount,: physician Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to outpatient rehabilitation services arranged through a 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 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. 6. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 7. Voice training. 8. Outpatient rehabilitation services when no medical diagnosis is present. MIC PPMN (3/11) 39 100 % -15 BPL 84241 DOC 21290 Outpatient Rehabilitation 9. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your B an d t he A mounts Y O , � _ ma r 5 x ��§ � # u a 3 B !n ne t w ork benefit * :Out of netw benefits , a deductible * For out -of networ b i n additio to the °ded u ctible , co a coinsuran y o u are • responsible f or :a c harge s in excess of t no - n provider reimburs a , Additionally, these c not be applied toward s atisfacti o n o the.deductible or the out of poc m :: $15 /visit 1. Physical therapy received 50% coinsurance. outside of your home Coverage for physical and occupational therapy is limite pay to a or c omb ined l imit of 20 visits per calendar year. P lease o ccupa note: Th v l includes tional physical therapy and visits t hat you f i der to s atisfy any part o your deductible. 2. Speech therapy received outside $15 /visit 50% coinsurance. of your home when speech is Coverage for speech impaired due to a medical illness therapy is limited to 20 or injury, or congenital or visits per calend year. developmental conditions that Please note: Thi visit limit have delayed speech includes s peech therapy development visits that you p for in order to satisfy any part of 3. Occupational therapy received $15 /visit your coinsurance vts outside of your hom when Cover deductible. for physical physical function is impaired due and 50% occupational of 20 p therapy to a medical illness or injury or is to a combid limi i conditions that have delayed motor development calendar limited year. Please note: Th v isit ne limit includes physical and congenital or developmental v it that you pay for in orde to satisfy occupational any part of your therapy deductible. MIC PPMN (3/11) 40 100 % -15 BPL 84241 DOC 21290 • 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. See Definitions These wards have specific meanings`. benefits, claim,coinsurance, eopayment custodial care, deductible, emergency, hospital, ;inpatient, medically necessary, member, mental disorder, network, non-network, non °network provider reimbursement amount, provider. Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations and psychological testing. b. Psychotherapy and psychiatric services. c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week). d. Treatment for a minor, including family therapy. e. Treatment of serious or persistent disorders. f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD). g. 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. h. Treatment of pathological gambling. 2. Inpatient services include: a. Room and board. b. Attending psychiatric services. c. Hospital or facility -based professional services. d. 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 means a treatment program of 20 hours or more per week and may include lodging. ,e. Services, care, or treatment described as benefits in this certificate and 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. MIC PPMN (3/11) 41 100 % -15 BPL 84241 DOC 21290 Mental Health f. Residential treatment services. These services include either: i. A residential treatment program serving children and adolescents with severe emotional disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic services. In addition to room and board, at least 30 hours a week per individual of mental health services must be provided, including group and individual counseling, client education, and other services specific to mental health treatment. Also, the program must provide an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. Covered For benefits and the amounts you pay, see the table in this section. • For in- network benefits: I Medica's designated mental health and substance abuse provider arranges in- network mental health benefits. 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). For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1-866-214-6829. • For out -of- network benefits: 1. Mental health services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the mental health services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Mental health clinic e. Mental health residential treatment center f. Independent clinical social worker g. Marriage and family therapist h. Hospital that provides mental health services 2. Emergency mental health services are eligible for coverage under in- network benefits. 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN (3/11) 42 100 % -15 BPL 84241 DOC 21290 • � _ J 1 Mental Health 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 fora condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. 4. Relationship counseling. 5. Family counseling services, except as specifically described in this certificate as treatment for a minor. • 6. Services for telephone psychotherapy. 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, as those conditions are defined in the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual. of Mental Disorders. 8. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide mental health services. This includes, but is not limited to, services provided by mental health providers who are not authorized under state law to practice independently, and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch. 9. 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. 10. Room and board charges associated with mental health residential treatment services providing Tess than 30 hours a week per individual of mental health services, or lacking an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts you. Paygq • Benefits; In :network benefits *Out o #network benefits, after deductible * For out -of network benefits in addition to the deductible copayment, and coinsurance you are responsiblefor any charges in:excess�of the nonretwo�k provider reimbursement- amount Additionally, these charges will not be applied toward satisfaction of the deductible or the out-of }pocket m - 1. Office visits, including $10 /visit - group; $15 /visit 50% coinsurance evaluations, diagnostic, and individual treatment services ;MIC PPMN (3/11) 43 • 100 % - U:' BPL 84241 DOC 21290 Mental Health Your Benefits and the Amounts You Pay Benefits En network benefits * Out of network benefits aft er d uctible * For out-of-network benefits, in addition to the deductible,-copayment,.and coins you are responsible for any charges in excess of the non - network provider reimbursement amount - Additionally, these; charges- will notbe applied toward satisfaction. of the,deductible or the out # of - pocket maximum a 2. Intensive outpatient programs $15 /day 50% coinsurance 3. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending psychiatrist Nothing 50% coinsurance services d. Partial program Nothing 50% coinsurance MIC PPMN (3/11) 44 100 % -15 BPL 84241 DOC 21290 II 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 the Diagnostic and Statistical Manual of Mental Disorders. See ` Definitions. These words have`specific meanings benefits, claim coinsurance, copayment, custodial care, deductible, emergency, hospital, inpatient, medically necessary member, mental disorder, network, non- network, .non- network provider reimbursement amount, physician, provider. Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations. b. Outpatient treatment. c. Intensive outpatient programs, including day treatment and partial programs, which may include multiple services and modalities, delivered in an outpatient setting. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. 2. Inpatient services include: a. Room and board. b. Attending physician services. c. Hospital or facility -based professional services. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. e. Residential treatment services. These are services from a licensed chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours per week per individual of chemical dependency services must be provided, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. MIC PPMN (3/11) 45 100 % -15 BPL 84241 DOC 21290 Substance Abuse Covered For benefits and the amounts you pay, see the table in this section. • For in- network benefits: 1. Medica's designated mental health and substance abuse provider arranges in- network substance abuse benefits. 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). 2. In- network benefits will apply to services, care or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Substance abuse services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Chemical dependency clinic e. Chemical dependency residential treatment center f. Hospital that provides substance abuse services g. Independent clinical social worker h. Marriage and family therapist 2. Emergency substance abuse services are eligible for coverage under in- network benefits. 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN (3/11) 46 100 % - BPL 84241 DOC 21290 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary. 4. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received. 5. Telephonic substance abuse treatment services. 6. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide substance abuse services. This includes, but is not limited to, services provided by mental health or substance abuse providers who are not authorized under state law to practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch. 7. Room and board charges associated with substance abuse treatment services providing less than 30 hours a week per individual of chemical dependency services, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. 8. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. m 1 R F AIL % �xfi Your Benefits3an4 the Amounts •YouPay Benefits t in- network benefits; " Out-of-network benefits de � after ductitile * For out of= network benefts in addition to the deductible copayment, and coinsurance, yob are responsible_ for any charges in excess of the non network provider reimbursement amount° Additionally, these charges will not be applied toward sat,sfact on of the deductible or the out-of pocket maximum ki ; 1. Office visits, including $10 /visit - group; $15 /visit- 50% coinsurance evaluations, diagnostic, and individual treatment services 2. Intensive outpatient programs $15 /day 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance MIC PPMN (3/11) 47 100 % -15 BPL 84241 DOC 21290 Substance Abuse Your Benefits and the Amounts You Pay Benefits , tn- network benefits * Out of - network benefits. _ ; ' _ after deductible *:For out of ne twork benefits, in to the deductible, copayment, and coinsurance, yo are responsible for any charges in excess of. the nor► network : - reimbursement amount Additionally, these charges will not be applied toward satisfaction of the deductible orthe aut f_ po cket Maximum. 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending physician services Nothing 50% coinsurance MIC PPMN (3/11) 48 100 % - BPL 84241 DOC 21290 • 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. See Definitions These words have specific meanings benefits, coinsurance m y co a eet, t' deductible, durable medical equipment, network, network, non - network: provider ?eirnbursement amount, physician, = provider. = Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. Medica covers only a limited selection of durable medical equipment, certain related supplies, and hearing aids that meet the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. The list of eligible durable medical equipment and certain related supplies is periodically reviewed and modified by Medica. 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 purchased 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. If the durable medical equipment, prosthetic device, or hearing aid is covered by Medica, but the model you select is not Medica's standard model, you will be responsible for the cost difference. • In- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a network durable medical equipment provider, and hearing aids as described in 4. in the table in this section when prescribed by a network provider. To request a list of the durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. • Out -of- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a non - network provider. Out -of- network benefits also apply to hearing aids as described in 4. in the table in this section. 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN (3/11) 49 100 % -15 BPL 84241 DOC 21290 Durable .Medical Equipment And Prosthetics Not covered These services, supplies, and associated expenses are not covered: 1. Durable medical equipment and supplies, prosthetics, appliances, and hearing aids not on the Medica eligible list. 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, or hearing aids. 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, replacement, or revision of duplicate items. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay f Benefits In n O etwork benefits * u -o -network benefits: - Ie P a fter deductili *:Far out-of network benefits, m addition to the deductible, copayment, and coinsurance, you are responsible£for = any charges excess of.the non network provider reimbursem amount Additionally, these charges will notbe applied toward satisfaction of the deductible or the pocket maximu m 1. Durable medical equipment and 20% coinsurance 50% coinsurance certain related supplies 2. Repair, replacement, or revision 20% coinsurance 50% coinsurance of durable medical equipment made necessary by normal wear and use 3. Prosthetics a. Initial purchase of external 20% coinsurance 50% coinsurance prosthetic devices that replace a limb or an external body part, limited to: i. Artificial arms, legs, feet, and hands; ii. Artificial eyes, ears, and noses; iii. Breast prostheses b. Scalp hair prostheses due to 20% coinsurance. 50% coinsurance. alopecia areata Medica pays up to $350. Medica pays up to $350. This is calculated each This is calculated each calendar year. calendar year. MIC PPMN (3/11) 50 100 % -15 BPL 84241 DOC 21290 Durable Medical Equipment And Prosthetics Your Benefits and the Amounts Yo u Pay Benefits 'In benefits *.Out of network benefits x a' �' �.: - � ,... � � m after edu d ctrble *,For - out -of network benefits, in additiorrto the deductible, copayrnent, and coinsurance; you a re responsible for any charges in excess of the non-network provider reimbursement amount Additionally, these charges will not be applied` toward =satisfaction of the deductible or -the out-of pocket maximum c. Repair, replacement, or 20% coinsurance 50% coinsurance revision of artificial arms, legs, feet, hands, eyes, ears, noses, and breast prostheses made necessary by normal wear and use 4. Hearing aids for members 18 20% coinsurance. 50% coinsurance. years of age and younger for Coverage is limited to Coverage is limited to hearing loss that is not one hearing aid per ear one hearing aid per ear correctable by other covered every three years. every three years. procedures Related services must be prescribed by a network provider. • - :MIC.PPMN (3/11) 51 100 % -15 BPL 84241 DOC 21290 Miscellaneous Medical Services And Supplies 0. Miscellaneous Medical Services And Supplies This section describes coverage for miscellaneous medical services and supplies prescribed by a physician. Medica covers only a limited selection of miscellaneous medical services and supplies that meet the criteria established by Medica. Some items ordered by a physician, even if medically necessary, may not be covered. See Definitions. These words have specific meanings. benefits, coinsurance, copayment, deductible, network, non network, non- network provider reimbursement amount;-physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to miscellaneous medical services and supplies received from a network provider. • Out -of- network benefits apply to miscellaneous medical services and 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered Other disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN (3/11) 52 100 % -15 BPL 84241 DOC 21290 Miscellaneous Medical Services And Supplies Your Benefits and the Amounts You Pa Bene fits T In-network benefits * Out -of- network benefit after deductible * For. out-of network, benefits iin ad dition to the deductible, copayment, and coinsurn a . you are responsible: for any.charges in+excess.of the non - network provider reimbursement amount: Additionally, these charges will not- be applied toward satisfaction of`the deductible or the` -of pocket mazunum 1. Blood clotting factors 20% coinsurance 50% coinsurance 2. Dietary medical treatment of 20% coinsurance 50% coinsurance phenylketonuria (PKU) 3. Amino acid -based elemental 20% coinsurance 50% coinsurance formulas for the following diagnoses: a. cystic fibrosis; b. amino acid, organic acid, and fatty acid metabolic and malabsorption disorders; c. IgE mediated allergies to food proteins; d. food protein - induced enterocolitis syndrome; e. eosinophilic esophagitis; f. eosinophilic gastroenteritis; and g. eosinophilic colitis. Coverage for the diagnoses in 3.c. -g. above is limited to members five years of age and younger. 4. Total parenteral nutrition 20% coinsurance 50% coinsurance 5. Eligible ostomy supplies 20% coinsurance 40% coinsurance Please note: Eligible ostomy supplies may be received from a pharmacy or a durable medical equipment provider. 6. - Insulin pumps and other eligible 20% coinsurance 40% coinsurance ' diabetic equipment and supplies : AIC,PPMN (3/11) 53 100 % - BPL 84241 DOC 21290 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 network physician and received at a designated 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 appropriate for the diagnosis, without contraindications and non- investigative. See Definitions These words have specific meanings -Abenefits,.rcoinsurance copayment deductible, a visits, hospital, inpatient, investigative, "medically necessary, member, network non-network, .non- network: ":provider reimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica is required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood. The preceding is not a comprehensive list of eligible organ and bone marrow transplant services. • 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. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 network transplant facilities). Based on the type of transplant you receive, Medica will determine the specific time period medically necessary for these services. MIC PPMN (3/11) 54 100 % -15 BPL 84241 DOC 21290 L Organ And Bone .Marrow Transplant Services Not covered These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow transplant services except as described in this section. 2. 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. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. - 5. Islet cell transplants except for autologous islet cell transplants associated with pancreatectomy. 6. 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 suppressants, and supplies of a similar nature not otherwise covered under this certificate. • 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. 10. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as'described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You a Benefits In` network.benefits1 *Out of :network benefit after deductible * For ='out of- network benefits in addition to.the deductible, cop an d coinsurance, you are responsible for any cha ges in excess of the non - network provider reimbursement amount Additionally, these charges will not be applied toward satisfaction of the deductible or the out of pocket maximum _ t 1. Office visits $15 /visit No coverage 2. E- visits $15 /visit No coverage MIC PPMN (3/11) 55 100 % -15 BPL 84241 DOC 21290 Organ And Bone Marrow Transplant Services Your Benefits and the Amounts You Pay Benefits in network benefits * Out-�f-network benefits e deductible educti e For benefit addition t the.deductible, copayment;:and coinsurance, you are r for any charges,in excess of the non network provaderreambur amount '. Additionally, these charges wail not be applied towardsatrsfaction of the p deductible or the out -of pocket maximum 3. Outpatient services a. Professional services i. Surgical services (as $15 /visit No coverage defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit ii. Anesthesia services $15 /visit No coverage received from a provider during an office visit or an outpatient hospital or • ambulatory surgical center visit iii. Outpatient lab and Nothing No coverage pathology iv. Outpatient x -rays and Nothing No coverage other imaging services v. Other outpatient hospital $15 /visit No coverage services received from a physician vi. Services related to $15 /visit No coverage human leukocyte antigen testing for bone marrow transplants b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x -rays and Nothing No coverage other imaging services iii. Other outpatient hospital $15 /visit No coverage services MIC PPMN (3/11) 56 100 % -15 BPL 84241 DOC 21290 r; Organ And Bone Marrow Transplant Services Your Benefits `and the Amounts You Pay Benefits _ :: In network benefits *Out o #- network benefits after deductible *For out of ne two r k benefits, in addition to- -the deduct co and'coinsurance you are responsible forany charges in;excess' of the non- network provider'reirnbursemenf-amount Additionally, _ these charges willknot be apptietl.;toward satisfaction of -the deductible or the out of= pocket rriaximum, 4. Inpatient services Nothing No coverage 5. Services received from a Nothing No coverage physician during an inpatient stay 6. Anesthesia services received Nothing No coverage from a provider during an inpatient stay 7. Transportation and lodging The deductible does not No coverage a. As described below, apply to this reimbursement of reasonable reimbursement benefit. and necessary expenses for You are responsible for travel and lodging for you paying all amounts riot and a companion when you reimbursed under this receive approved services at benefit. Such amounts a designated facility for do not count toward your transplant services and you out -of- pocket maximum live more than 50 miles from or toward satisfaction of that designated facility your deductible. i. Transportation of you and one companion (traveling on the same day(s)) to and /or from a designated facility for transplant services for pre - transplant, transplant, and post - transplant services. If you are a minor child, transportation expenses for two companions will be reimbursed. MIC PPMN (3/11) 57 100 % -15 BPL 84241 DOC 21290 Organ And Bone Marrow Transplant Services -'" Yo:ur Benefiits and 3theAmounts You Pay �_ Benefits' • to network bene #its *Out of network benefits d b =afte educ * For out H of network benefits; m addition to the deductible, copayment, and coinsurance, youare responsible for any,charges a_n excess;of -the non network provider' "reimbursement amount^` Additional these charges will not be applaed toward satisfactron:of the deductible or;the out of pocket maximum ii. Lodging for you (while not confined) and one companion. Reimbursement is available for a per diem amount of up to $50 for one person or up to $100 • for two people. If you are a minor child, reimbursement for lodging expenses for two companions is available, up to a per diem amount of $100. • iii. There is a lifetime maximum of $10,000 per member for all transportation and lodging expenses incurred by you and your companion(s) and reimbursed under the Contract or under any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. b. Meals are not reimbursable under this benefit. MIC PPMN (3/11) 58 100 % -15 BPL 84241 DOC 21290 Infertility Diagnosis Q. Infertility Diagnosis This section describes coverage for the diagnosis of infertility. Coverage includes benefits for professional, hospital, and ambulatory surgical center services. Services for the diagnosis of infertility must be received from or under the direction of a physician. All services, supplies, and associated expenses for the treatment of infertility are not covered. See Definitions. These words have; sp meanings: benefits, coinsurance „ "copayment, deductible, .e visits, ^ hospital, inpatient, , member, network, non - network, non networ reimbursement amount, physician, provider--. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered Benefits apply to services for the diagnosis of infertility received from a network or non - network provider. Coverage for infertility services is limited to a maximum of $5,000 per member per calendar year for in- network and out -of- network benefits combined. More than one copayment or coinsurance may required if you receive more than one service or see more than one provider per visit. Not covered All services, supplies, and associated expenses for the treatment of infertility are not covered including the following: 1. Professional, hospital, and ambulatory surgical center services for the treatment of infertility. 2. Infertility drugs. 3. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 4. Services for a condition that a physician determines cannot be successfully treated. 5. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 6. Sperm banking. 7. Adoption. 8. Donor sperm. 9. Embryo and egg storage. See Exclusions for additional services, supplies, and associated expenses that are not covered. -MI,C PPMN (3/11) 59 100 % -15 BPL 84241 DOC 21290 Infertility Diagnosis Your Benefits and the Amounts You Pay Benefits In- network benefits *.Out of= network benefits after deductible s For out -of network benefits, in addition to the deductible,:copayment, and coinsurance, you are responsible for any charges in excess of the'non network provider: reimbursement amount Additionally, these charges will not. be applied towa,d satisfaction the deductible or he out -of pocket maximum 1. Office visits, including any 20% coinsurance 50% coinsurance services provided during such visits 2. E- visits $15 /visit No coverage 3. Outpatient services received at a 20% coinsurance 50% coinsurance hospital 4. Inpatient services 20% coinsurance 50% coinsurance MIC PPMN (3/11) 60 100 % -15 BPL 84241 DOC 21290 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. See ' Definitions ', T words have specific meanings benefits, coinsurance, copayment, cosmetic, deductible-;e visits hospital, inpatient, medically necessary, member, network, Inon network, non provider reimbursement amount physici "provider, reconstructive, -restorative. . Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Yo Benefits for more information about the prior authorization process. • 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 no n - network provider reimbursement amount. The out -of- pocket maximum does not ap p ly to these charges. Please see Important member information about out -of- network ben efits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Revision of blemishes on skin surfaces and scars (including scar excisions) primarily for cosmetic purposes, unless otherwise covered in Professional Services. j 2. Repair of a pierced body part 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. 5 . Surgical correction of male breast enlargement primarily for cosmetic purposes. 6 . Hair transplants. •MICT,P,MN (3/11) 61 100 % -15 BPL 84241 DOC 21290 Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. R S Your Benefita'-and the Amounts You Pay Benefits " in network benefits * Out-of-network benefits 1 after deduc tible * For out,of network benefits,Tin addition to the deductible,,copayment, and coinsurance, you are responsible for any charges in excess.of -the non- network provider reimbursement amount Additionally these charges will not be applied toward satisfaction of the deductible or the out-of pocket maximum 1. Office visits $15 /visit 50% coinsurance 2. E - visits $15 /visit No coverage 3. Outpatient services a. Professional services i. Surgical services (as 20% coinsurance 50% coinsurance 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. Anesthesia services 20% coinsurance 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services MIC PPMN (3/11) 62 100 % -15 BPL 84241 DOC 21290 1 Reconstructive And Restorative Surgery Your Benefits and the Amounts You Pay Benefits In- network benefits *:Out of- network benefits after deductible * For out-of-network b enefits ,in addition to the 'deductible, copaymen-t, and coinsurance; you are onsible for any charges n excess of the non network provider =reimbursement amount. Additionally, these charges will net be applied toward satisfaction of the deductiblefor the out -of pocket maximum: v. Other outpatient hospital 20% coinsurance 50% coinsurance or ambulatory surgical center services received from a physician b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services iii. Other outpatient hospital 20% coinsurance 50% coinsurance and ambulatory surgical center services 4. Inpatient services 20% coinsurance 50% coinsurance 5. Services received from a 20% coinsurance 50% coinsurance physician during an inpatient stay 6. Anesthesia services received 20% coinsurance 50% coinsurance from a provider during an inpatient stay 2MIC PPMN (3/11) 63 100 % -15 , P . , BPL 84241 DOC 21290 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 qualify as reimbursable under Medicare. See Definitions These .words have specific meanings benefits, coinsurance, copayment, custodial care, ;deductible, emergency; hospital, inpatient, network, non - network, non_ network, provider reimbursement amount ;physician, skilled dare, skilled nursing- facility_ Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For purposes of this section, room and board includes coverage of health services and supplies. • 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. I. Not covered These services, supplies, and associated expenses are not covered: 1. Custodial care and other non - skilled services. 2. Self -care or self -help training (non - medical). 3. Services primarily educational in nature. 4. Vocational and job rehabilitation. 5. Recreational therapy. 6. Health clubs. 7. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 8. Voice training. MIC PPMN (3/11) 64 100 % -15 BPL 84241 DOC 21290 Skilled Nursing Facility Services 9. Outpatient rehabilitation services when no medical diagnosis is present. 10. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay; Benefits = In network benefits' * Out of- network benefits after - deductible For .; out -of- network benefits, in addition to the deductible, copayment, and coinsurance, are responsible for any charges axcess of the non-network provider reimbursement amount Additionally, these charges will not be applied toward satisfaction of the deductible . 6 - r•-the out-of- pocket maximum.' 1. Daily skilled care or daily. skilled 20% coinsurance 50% coinsurance rehabilitation services, including room and board Please note: Such services are eligible for coverage only if they would qualify as reimbursable under Medicare. 2. Skilled physical, speech, or 20% coinsurance 50% coinsurance occupational therapy when room and board is not eligible to be covered 3. Services received from a 20% coinsurance 50% coinsurance physician during an inpatient stay in a skilled nursing facility MIC PPMN (3/11) 65 100 % - BPL 84241 DOC 21290 Hospice Services T. Hospice Services This section describes coverage for hospice services including respite care. Care must be 9 p g p ordered, provided, or arranged under the direction of a physician and received from a hospice program. See © efinitrons These words have specific meanings benefits, coinsurance, deductible,, member, network; non network, non network provider reim bursement amount, physician skilled �_. nursm0.aef14:, 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. 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 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 network hospice program. • Out -of- network benefits apply to hospice services arranged through a physician and received from a non - network hospice program. 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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). 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. Members who elect to receive hospice services do so in place of curative treatment for their terminal illness for the period they are enrolled in the hospice program. You may withdraw from the hospice program at any time upon written notice to the hospice program. You must follow the hospice program's requirements to withdraw from the hospice program. MIC PPMN (3/11) 66 100 % -15 BPL 84241 DOC 21290 Hospice Services Not covered These services, supplies, and associated expenses are not covered: 1. Respite care for more than five consecutive days at a time. 2. 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 hospice program's plan of care. 4. Services not provided by the hospice program.. • 5. Hospice daycare, except when recommended and provided by the hospice program. 6. Any services provided by a family member or friend, or individuals who are residents' in your home. - 7. Financial or legal counseling services, except when recommended and provided by the hospice program. • 8. Housekeeping or meal services in your home, except when recommended and provided by the hospice program. 9. Bereavement counseling, except when recommended and provided by the hospice program. See Exclusions for additional services, supplies, and associated expenses that are not covered. • You Benefits • and the Am YouiPay, B € n :. s " � � In network benefits * Out-of network benefits m a rde ble' * For out- of-networklb nefi rig addition to.the °deductible, copayment, and coinsuranc you are responsible for any charges 1 in excess of the non network provider reimbursement amount Addytzonally, these charges wi11 not be applied toward of the deductible or the out pock maxim 1. Hospice services Nothing 50% coinsurance • • MIC PPMN (3/11) 67 100 % -15 BPL 84241 DOC 21290 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. TMJ disorder is covered the same as any other joint disorder under this certificate. See Definitions These words have specific meanings benefits, coinsurance, copayment, deductible, e- visits, hospital, inpatient, }member, network, non - network, non network provider reimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN (3/11) 68 100 % -15 BPL 84241 DOC 21290 • • Temporomandibular Joint (TIM) Disorder Your Benefits and the Amounts You Pay r Benefits .In network benefits * Out of network benefits after deductib *,Fo r , out of network benefits,in addition to : =the deductible, .copayment, and- coinsurance, "you,are responsible for any charges to excess of thenon network provider, reimbursement amount Additionatty, these charges will not be applied toward satisfaction ofthe deducttble or: the out -of pocket maximum:, 1. Office visits $15 /visit 50% coinsurance 2. E - visits $15 /visit No coverage 3. Outpatient services a. Professional services i. Surgical services (as $15 /visit 50% coinsurance 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. Anesthesia services $15 /visit 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital $15 /visit 50% coinsurance and ambulatory surgical center services received from a physician or dentist b. Hospital and ambulatory surgical center services • i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services MIC PPMN (3/11) 69 100 % -15 BPL 84241 DOC 21290 TemporomandibuDar Joint (TMJ) Disorder Your Bene frts and the Amounts You Pay Bene #its ;, ,_ In network bene * Out -of network benefit y c u t after ded ibie " For out of network benefits; in addition fo ▪ the deductible, copayment, and coinsurance, you are responsibie for�any charges =rn excess of the non network provider re�mborserr�ent amount Additionally, these chargeswill not -be appli ed towar satisfaction of the deductible or the out f pocket maximum 1 5 iii. Other outpatient hospital $15 /visit 50% coinsurance and ambulatory surgical center services 4. Physical therapy received $15 /visit 50% coinsurance outside of your home 5. Inpatient services Nothing 50% coinsurance 6. Services received from a Nothing 50% coinsurance physician or dentist during an inpatient stay 7. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay 8. TMJ splints and adjustments if 20% coinsurance 50% coinsurance your primary diagnosis is joint disorder • MIC PPMN (3/11) 70 100% - BPL 84241 DOC 21290 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. 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 alignment or occlusion of the teeth. These services are not covered under any section of this certificate. See Definitions. These words have specific meanings: benefits, coinsurance, copayment, deductible,; dependent, hospital, member, .network, non network, non network provider reimbursement amount, physician, provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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), except as described in this section for the treatment of cleft lip and palate. 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, except as described in this section for the treatment of cleft lip and palate. 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. Mlq PFMN (3/11) 71 100 % -15 • BPL 84241 DOC 21290 Medical- Related Dental Services 8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident - related dental services as described in this section. 9. Routine diagnostic and preventive dental services. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits �' In network ben * Out of network benefits � after de uctible ff * For out of network benefits, in addition to the deductible, copayment, and coinsurance ou re "sponsible for any charges in ex of <the non' - network provider reimbuisement amount Additionally, these charges ..will not be applied toward satisfaction the ded uctible or - the out�of pocket m 1. Charges for medical facilities $15 /visit 50% coinsurance and general anesthesia services that are: a. Recommended by a physician; and b. Received during a dental procedure; and c. Provided to a member who: i. 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. 2. For a dependent child, 20% coinsurance 50% coinsurance orthodontia, dental implants, and oral surgery treatment related to • cleft lip and palate • MIC PPMN (3/11) 72 100 % -15 BPL 84241 DOC 21290 Medical- Related Dental Services .......... ..... _.....- _..- ._..... Your Benefits and the Amounts You Pay Benefits In network benefits "" Out -of- network benefits af deductible * For out-of - network benefits, in addition to deductible, copayment, and coinsurance, you are responsible for any2charges•in of the non network provider reimbursemen't,amount Additionally, these charges will not=be toward satisfaction of the deductible or the out =of pocket'maximum.' 3. Accident - related dental services 20% coinsurance 50% coinsurance to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply: a. Coverage is limited to services received within 24 months from the later of: i. the date you are first covered under the Contract; or ii. the date of the injury 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 one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year. 4. Oral surgery for: 20% coinsurance 50% coinsurance a. Partially or completely unerupted impacted teeth; or b. A tooth root without the extraction of the entire tooth (this does not include root canal therapy); or c. The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth MIC PPMN (3/11) 73 100 % -15 BPL 84241 DOC 21290 Referrals To Non - Network Providers W. 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 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. See Definitions These words have specific meanings benefits; medically necessary, network, non- network, physician, provider If you want to apply for a standing referral to a non - network provider, contact Medica for more information. If determined by Medica to be clinically appropriate, a standing referral may be granted by Medica. A standing referral is a referral issued by a network provider and authorized by Medica for conditions that require ongoing services from a specialist provider. Standing referrals will only be covered for the period of time appropriate to your medical condition. Referrals and standing referrals will not be covered to accommodate personal preferences, family convenience, or other non - medical reasons. Referrals will also not be covered for care that has already been provided. If your request for a standing referral is denied, you have the right to appeal this decision as described in Complaints. What you must do 1. 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. 2. 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. 3. 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. 4. Pay any charges not authorized for coverage by Medica. What Medica will do 1. May require that you see another network provider selected by Medica before a determination by Medica that a referral to a non - network provider is medically necessary. 2. 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. MIC PPMN (3/11) 74 100 % -15 BPL 84241 DOC 21290 � J Referrals To Non - Network Providers 3. Provides coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. 4. 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 24 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. MIC PPMN (3/11) 75 100 % -15 BPL 84241 DOC 21290 Harmful Use Of Medical Services X. 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. See Definitions ;These words have specific meanrrigs benefits emergency, hospital network physician, prescription drug, provider :A : 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. You must obtain a referral from your coordinating health care provider if your condition requires care or treatment from a provider other than your coordinating health care provider. Medica will send you specific information about: 1. How to obtain approval for benefits not available from your coordinating health care providers; and 2. How to obtain emergency care; and 3. When these restrictions end. MIC PPMN (3/11) 76 100 % -15 BPL 84241 DOC 21290 • Exclusions V. Exclusions See Definitions. These words have specific meanings: claim,-cosmetic, custodial care, durable medical equipment, emergency, investigatrve,,_medically necessary, member, non network, physician, provider, reconstructive, ;routine foot care. Medica will not provide coverage for any of the services, treatments, supplies, or items described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition. This section describes additional exclusions to the services, supplies, and associated expenses already listed as Not covered in this certificate. These include: 1. 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. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive. 3. Refractive eye surgery, including but not limited to LASIK 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 a physician, air and bone conduction hearing aids (including internal, external, or implantable hearing aids or devices) 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. Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct -to- consumer marketing and not under the direction of your physician. 8. Services or supplies not directly related to care. 9. Autopsies. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition. 11. Nutritional and electrolyte substances except as specifically described in Miscellaneous Medical Services And Supplies. 12. Physical, occupational, or speech therapy or chiropractic services when there is no reasonable expectation that the condition will improve over a predictable period of time. 13. Reversal of voluntary sterilization. MIC PPMN (3/11) 77 100 % -15 BPL 84241 DOC 21290 � i� Exclusions 14. Personal comfort or convenience items or services, including but not limited to breast pumps, except when the pump is medically necessary. 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, except as described in Organ And Bone Marrow Transplant Services. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 19. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular disease, peripheral neuropathies, and significant neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. 21. Services by persons who are family members or who share your legal residence. 22. Services for which coverage is available under workers' compensation, employer liability, or any similar law. 23. Services received before coverage under the Contract becomes effective. 24. Services received after coverage under the Contract ends. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non - network providers and non - network dentists. 26. Photographs, except for the condition of multiple dysplastic syndrome. 27. Occlusal adjustment or occlusal equilibration. 28. Dental implants (tooth replacement), except as described in Medical - Related Dental Services. 29. Dental prostheses. 30. Orthodontic treatment, except as described in Medical - Related Dental Services. 31. Treatment for bruxism. 32. Services prohibited by applicable law or regulation. 33. Services to treat injuries that occur while on military duty, and any services received as a result of war or any act of war (whether declared or undeclared). 34. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or licensure. 35. Exams, other evaluations, or other services received solely for the purpose of judicial or administrative proceedings or research except emergency examination of a child ordered by judicial authorities. 36. Non - medical self -care or self -help training. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services. 38. Coverage for costs associated with translation of medical records and claims to English. MIC PPMN (3/11) 78 100 % -15 BPL 84241 DOC 21290 How To Submit A Claim Z. How To Submit A Claim This section describes the process for submitting a claim. See Definitions These words have specific meanings benefits, claim, dependent, member, o network;'non- network, non networkOrovider reimbursement amount, provider 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. Claim forms may also be obtained by signing in at www.mymedica.com. Network providers are required to submit claims within 180 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 180 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 one of the telephone numbers listed inside the front cover. Claim forms may also be obtained by signing in at www.mymedica.com. 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 the address identified on the back of your identification card. Upon receipt of your claim for benefits from non - network providers, Medica will generally pay to you directly the non - network provider reimbursement amount. Medica will only pay the provider of services if: 1. The non - network provider is one that Medica has determined can be paid directly; and 2. The non - network provider 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 claims 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 receiving the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. Call Customer Service at one of the telephone numbers listed inside the front cover for a list of non - network providers that Medica will not pay directly. MIC PPMN (3/11) 80 100 % -15 BPL 84241 DOC 21290 How To Submit A Claim 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 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. MIC PPMN (3/11) 81 100 % -15 BPL 84241 DOC 21290 Coordination Of Benefits AA. Coordination Of Benefits This section describes how benefits are coordinated when you are covered under more than one plan. See Definitions These words ;have specific meanings benefits, claim, deductible, dependent, emergency, hospital, member, non- network, non network provider reimbursement 'amount, provider, subscriber: 1. Applicability a. 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. b. If this coordination of benefits provision applies, 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 Order of benefit determination rules, the benefits of this plan: i. 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 a. Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment: i. Group insurance or group -type coverage, whether insured or uninsured, or individual coverage. 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 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. b. This plan is the part of the Contract that provides benefits for health care expenses. c. 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. MIC PPMN (3/11) 82 100 % -15 BPL 84241 DOC 21290 Coordination Of 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. d. 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. Allowable expense does not include the deductible for members with a primary high deductible plan and who notify Medica of an intention to contribute to a health savings account. The difference between the cost of a private hospital room and the cost of a semi - private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private 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 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 member 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. e. 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 a. 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 3.b. below, require that this plan's benefits be determined before those of the other plan. b. Rules. This plan determines its order of benefits using the first of the following rules which applies: i. 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. ii. 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 MIC PPMN (3/11) 83 100 % - 15 BPL 84241 DOC 21290 Coordination Of Benefits 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. iii. 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 determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. iv. 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 3.b.ii. v. 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. vi. 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. vii. No -fault automobile insurance. Coverage under the No -Fault Automobile Insurance Act or similar law applies first. viii. 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 a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that MIC PPMN (3/11) 84 100 % -15 BPL 84241 DOC 21290 Coordination Of Benefits event, the benefits of this plan may be reduced under this section. Such other plan or plans are referred to as the other plans in b. immediately below. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of: i. 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. 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, 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; or 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. Please note: See Right Of Recovery for additional information. MIC PPMN (3/11) 85 100 % -15 BPL 84241 DOC 21290 Right Of Recovery BB. Right Of Recovery This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and federal law. For information about the effect of applicable state and federal law on Medica's subrogation rights, contact an attorney. See Definitions _,This word has a specific meaning benefits 1. 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. 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 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. 4. By accepting coverage under the Contract, you agree: a. That if Medica pays benefits for medical expenses you incur as a result of any act by a third party for which the third party is or may be liable, and you later obtain full recovery, you are obligated to reimburse Medica for the benefits paid in accordance to Minnesota law. b. 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. c. To provide prompt written notice to Medica when you make a claim against a party 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. f. 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. MIC PPMN (3/11) 86 100 % -15 BPL 84241 DOC 21290 Eligibility And Enrollment CC. Eligibility And Enrollment This section describes who can enroll and how to enroll. = °See Definitions. These words have specific-meanings: continuous coverage, dependent, late entrant, member, mental disorder, physician,. placed for adoption, premium, qualifying coverage, :subscriber, waiting period.. Who can enroll To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract and be a subscriber or dependent as defined in this certificate. See Definitions. 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 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 other time for consideration as a late entrant as described in this section under Late enrollment. Dependents will not be enrolled without the eligible employee also being enrolled. A child who is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical Child Support Order (QMCSO) and 6. under Special 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, a dependent child reaching the dependent limiting age, or other facts identifying you or your dependents. (For dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption; however, we encourage you to enroll your newborn dependent under the Contract within 30 days from the date of birth, date of placement for adoption, or date of adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with the subscriber, and any child who is a member pursuant to a QMCSO will be covered without application of health screening or waiting periods. The employer must notify Medica, as set forth in the Contract, 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 A 30 -day time period starting with the date an eligible employee and dependents are first eligible to enroll for coverage under the Contract. An eligible employee must enroll within this MIC PPMN (3/11) 87 100 % -15 BPL 84241 DOC 21290 Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30 -day time period does not apply to newborns or children newly adopted or placed for adoption; see Special enrollment.) An eligible employee and dependents that enroll during the initial enrollment period are accepted without application of health screening or affiliation periods. An eligible employee and dependents who do not enroll during the initial enrollment period may enroll for coverage during the next open enrollment, any applicable special enrollment periods, or as a late entrant (if applicable, as described below). A member who is a child entitled to receive coverage through a QMCSO is not subject to any initial enrollment period restrictions, except as noted in this section. Open enrollment A minimum 14 -day period set by the employer and Medica each year during which eligible employees and dependents who are not covered under the Contract may elect coverage for the upcoming Contract year. An application must be submitted to the employer for yourself and any dependents. Special enrollment Special enrollment periods are provided to eligible employees and dependents under certain circumstances. 1. Loss of other coverage a. A special enrollment period will apply to an eligible employee and dependent if the individual was covered under Medicaid or a State Children's Health Insurance Plan and lost that coverage as a result of loss of eligibility. The eligible employee or dependent must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. In the case of the eligible employee's loss of coverage, this special enrollment period applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of coverage, this special enrollment period applies to both the dependent who has lost coverage and the eligible employee. b. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under qualifying coverage other than Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment, and declined coverage for that reason. The eligible employee or dependent must present either evidence of the loss of prior coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated; and request 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, or the date on which a claim is denied due to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; MIC PPMN (3/11) 88 100 % -15 BPL 84241 DOC 21290 r Eligibility And Enrollment ii. Loss of eligibility includes: • *loss of eligibility as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment; • cessation of dependent status; • incurring a claim that causes the eligible employee or dependent to meet or exceed the lifetime maximum limit on all benefits; • if the prior coverage was offered through an individual health maintenance organization (HMO), a Toss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area; • if the prior coverage was offered through a group HMO, a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other coverage option is available; and • the prior coverage no longer offers any benefits to the class of similarly situated individuals that includes the eligible employee or dependent. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is eligible for or elects applicable federal or state continuation coverage; iv. 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; In the case of the eligible employee's loss of other coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of other coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. c. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under benefits available under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or any applicable state continuation laws at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. The eligible employee or dependent must present evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to failure of the eligible employee or dependent to pay premiums on a timely basis or for cause, and request enrollment in writing within 30 days of the date of the exhaustion of coverage. For purposes of 1.c.: i. Exhaustion of COBRA or state continuation coverage includes: • losing COBRA or state continuation coverage for any reason other than those set forth in ii. below; • losing coverage as a result of the employer's failure to remit premiums on a timely basis; MIC PPMN (3/11) 89 100 % -15 BPL 84241 DOC 21290 Eligibility And Enrollment • losing coverage as a result of the eligible employee or dependent incurring a claim that meets or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or • if the prior coverage was offered through a health maintenance organization (HMO), losing coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other COBRA or state continuation coverage is available. ii. Exhaustion of COBRA or state continuation coverage 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. iii. In the case of the eligible employee's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. 2. 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 and provided that the eligible employee also enrolls during this special enrollment period; 3. 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 (for dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption) and provided that the eligible employee also enrolls during this special enrollment period; 4. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in 3. 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; and d. The eligible employee also enrolls during this special enrollment period; or 5. 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 2. or 3. above, becoming eligible to enroll under the coverage provided the eligible employee also enrolls during this special enrollment period. 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as described in this section, Medica will provide the eligible dependent child with a special enrollment period provided the eligible employee also enrolls during this special enrollment period. 7. When the eligible employee or dependent becomes eligible for group health plan premium assistance provided by Medicaid or a State Children's Health Insurance Plan, the eligible employee must request enrollment within 60 days after the date the employee or dependent is determined to be eligible for premium assistance. MIC PPMN (3/11) 90 100 % - BPL 84241 DOC 21290 Eligibility And Enrollment In the case of the eligible employee becoming eligible for premium assistance, this special enrollment period applies to the eligible employee and all of his or her dependents. In the case of a dependent becoming eligible for premium assistance, this special enrollment period applies to both that dependent and the eligible employee. Late enrollment An eligible employee or an eligible employee and dependents who do not enroll for coverage offered through the employer during the initial or open enrollment period or any applicable special enrollment period will be considered late entrants. Late entrants who have maintained continuous coverage may enroll and coverage will be effective the first day of the month following date of Medica's approval of the request for enrollment. Continuous coverage will be determined to have been maintained if the late entrant requests enrollment within 63 days after prior qualifying coverage ends. Individuals who have not maintained continuous coverage may not enroll as late entrants. An eligible employee or dependent who: 1. does not enroll during an initial or open enrollment period or any applicable special enrollment period; and 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the 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. 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. If the eligible employee whose dependent child is the subject of the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, the eligible employee must also enroll for coverage under the Contract during the 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. MIC PPMN (3/11) 91 100 % - BPL 84241 DOC 21290 Eligibility And Enrollment The date your coverage begins Your coverage begins at 12:01 a.m. on the effective date of your enrollment. 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: a. Number 1., 2., or 7. under Special enrollment, coverage begins on the first day of the first calendar month following the date on which the request for enrollment is received by Medica; b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of adoption or placement for adoption, date of adoption or placement. In all other cases, the date the subscriber acquires the dependent child; c. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.b. above; d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. or 3. under Special enrollment becomes effective; e. Number 6. under Special enrollment, the first day of the first calendar month following the date the completed request for enrollment is received by Medica. 4. For eligible employees and /or dependents who enroll during late enrollment, coverage begins on the first day of the month following date of Medica's approval of the request for enrollment. MIC PPMN (3/11) 92 100 % -15 BPL 84241 DOC 21290 Ending Coverage DD. 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. See Definitions. These words have specific meanings certification of qualifying coverage, claim, dependent, member-; p;remiurn subscriber.. You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. When coverage ends Unless otherwise specified in the Contract, 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 Eligibility And 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. If coverage ends due to fraud, 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. Fraud includes but is not limited to: a. Intentionally 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 b. Intentional 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 MIC PPMN (3/11) 93 100 % -15 L_ BPL 84241 DOC 21290 Ending Coverage e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional misrepresentation with regard to any aspect of coverage under the Contract. 7. 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; 8. 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; 9. For a spouse, the end of the month following the date of divorce; 10. For a dependent child, the end of the month in which the child is no longer eligible as a dependent; or 11. 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. MIC PPMN (3/11) 94 100 % -15 BPL 84241 DOC 21290 Continuation EE. Continuation This section describes continuation coverage provisions. When coverage ends, members may be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer: See Definitions These words have specific meanings: benefits, dependent, member, placed, for adoption, premium, subscriber, total >disability ; The paragraph below describes the continuation coverage provisions. State continuation is described in 1. and federal continuation is described in 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. When your continuation coverage under this section ends, you have the option to enroll in an individual conversion health plan as described in Conversion. 1. Your right to continue coverage under state law Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: a. 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. b. 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. It is intended that no greater rights be provided than those required by Minnesota law. Take time to read this section carefully. Subscriber's Toss 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. In 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. MIC PPMN (3/11) 95 100 % -15 BPL 84241 DOC 21290 Continuation 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; 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. Subscriber's child's Toss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following 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. 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. Consistent with Minnesota law, the subscriber and dependents have 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. If continuation coverage is not elected, your coverage under the Contract will end. MIC PPMN (3/11) 96 100 % -15 BPL 84241 DOC 21290 i Continuation 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 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. Surviving dependents of a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. 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: a. 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. b. 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 iii. The date coverage would otherwise terminate under the Contract. c. For instances where dependent children lose coverage as a result of loss of dependent 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 iii. The date coverage would otherwise terminate under the Contract. d. 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: i. The date the former spouse becomes covered under another group health plan; 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: i. The date the former spouse becomes covered under another group health plan; or ii MIC PPMN (3/11) 9 100 % -15 BPL 84241 DOC 21290 • Continuation ii. The date coverage would otherwise terminate under the Contract. e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of: i. The date the surviving spouse and dependent children become covered under another group health plan; 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 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. 2. 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 General COBRA information in this section. USERRA continuation coverage Continued coverage shall be provided as required under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The employer shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General USERRA information in this section. General COBRA information 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 coverage is a group health plan for purposes of COBRA. This section 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 section carefully. MIC PPMN (3/11) 98 100 % -15 BPL 84241 DOC 21290 Continuation Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as: 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 c. A dependent child of a covered employee. (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; 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. Subscriber's child's Toss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following 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 the subscriber 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. MIC PPMN (3/11) 99 100 % -15 BPL 84241 DOC 21290 Continuation 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. 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. Consistent with federal law, the subscriber and dependents have 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 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. 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 amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 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 of COBRA coverage 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. MIC PPMN (3/11) 100 100 % -15 BPL 84241 DOC 21290 Continuation 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. 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. 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 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 pre- existing condition; or d. The subscriber becomes entitled to (actually covered under) Medicare. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. General USERRA information USERRA requires employers to offer employees 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 coverage is a group health plan for the purposes of USERRA. This section 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 section carefully. Employee's Toss The employee has the right to elect continuation of coverage if there is a Toss of coverage under the Contract because of absence from employment due to service in the uniformed services, and the employee was covered under the Contract at the time the absence began, and the employee, or an appropriate officer of the uniformed services, provided the employer with advance notice of the employee's absence from employment (if it was possible to do so). Service in the uniformed services means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active duty for training, initial active duty for training, inactive duty training, full -time National MIC PPMN (3/11) 101 100 % -15 • BPL 84241 DOC 21290 Continuation Guard duty, and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of these duties. Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army National Guard, and the Air National Guard, when engaged in active duty for training, inactive duty training, or full -time National Guard duty, and the commissioned corps of the Public Health Service. Election rights The employee or the employee's authorized representative may elect to continue the employee's coverage under the Contract by making an election on a form provided by the employer. The employee has 60 days to elect continuation coverage measured from the date coverage would be lost because of the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The employee may elect continuation coverage on behalf of other covered dependents, however, there is no independent right of each covered dependent to elect. If the employee does not elect, there is no USERRA continuation available for the spouse or dependent children. In addition, even if the employee does not elect USERRA continuation, the employee has the right to be reinstated under the Contract upon reemployment, subject to the terms and conditions of the Contract. p subject of coverage and cost If the employee elects 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. The amount charged cannot exceed 102 percent of the cost of the coverage unless the employee's leave of absence is less than 31 days, in which case the employee is not required to pay more than the amount that they would have to pay as an active employee for that coverage. There is a grace period of at least 30 days for the regularly scheduled premium. Duration of USERRA coverage When an employee takes a leave for service in the uniformed services, coverage for the employee and dependents for whom coverage is elected begins the day after the employee would lose coverage under the Contract. Coverage continues for up to 24 months. Federal law provides that continuation coverage may end earlier for any of the following reasons: a. The employer no longer provides group health coverage to any of its employees; b. The premium for continuation coverage is not paid on time; c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct; d. The employee fails to return to work following the completion of his or her service in the uniformed services; or e. The employee returns to work and is reinstated under the Contract as an active employee. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. MIC PPMN (3/11) 102 . 100 % -15 BPL 84241 DOC 21290 Continuation COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation coverage in addition to USERRA continuation coverage, these coverages run concurrently. MIC PPMN (3/11) 103 ' 100 % =1'5 BPL 84241 DOC 21290 Conversion FF. Conversion See Definitions. These words have specific meanings: continuous coverage, dependent, premium, waiting period: Your conversion plan coverage may not provide the same coverage as your previous group health plan. Benefits and provider networks may be different. Minnesota residents This section describes your right to convert to an individual conversion plan if you are a resident of Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. If you are a Minnesota resident, you may be eligible to obtain coverage from 1) other private sources of health coverage, or 2) the Minnesota Comprehensive Health Association, without a pre- existing condition limitation. Contact the Minnesota Comprehensive Health Association for further information: • For deductible plan options call 1- 866 - 894 -8053 or TTY: 1- 800 - 841 -6753. • For Medicare Supplement plan options call 1- 800 - 325 -3540 or TTY: 1- 800 - 234 -8819. Overview 1. You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in Continuation, is exhausted. b. Your coverage or continuation coverage ends because the Contract is terminated and the Contract is not replaced with other continuous group coverage. c. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. 2. Your conversion plan goes into effect the day following 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. 3. Conversion coverage is not available: a. When continuous coverage is not maintained; or b. If your coverage is terminated due to nonpayment of premium; or c. If you have not exhausted your right to continue coverage as described in Continuation; or d. If your coverage or continuation coverage ends because the Contract is terminated and the Contract is replaced with other continuous group coverage; or e. The commission of fraud. MIC PPMN (3/11) 104 100 % -15 BPL 84241 DOC 21290 ■ l Conversion • For purposes of 2. and 3.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 coverage, whichever is later. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor 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. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor 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. Residents of a state other than Minnesota This section describes your right to convert to an individual conversion plan if you are a resident of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. Overview You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods, in accordance with the laws of the state in which you reside on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You will be required to include your first month premium payment with your enrollment form for conversion coverage. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. MIC PPMN (3/11) 105 100 % -15 BPL 84241 DOC 21290 Complaints GG. Complaints This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. See Definitions. These words have specific meanings inpatient provider., 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, 2. You also may contact the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296 -2488 or 1- 800 - 657 -3602. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. You may appoint an authorized representative to make a complaint on your behalf. You may be required to sign an authorization which will allow Medica to release confidential information to your authorized representative and allow them to act on your behalf during the complaint process. 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. In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Commerce at the telephone number listed at the beginning of this section. 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. 1. If your complaint is regarding an initial decision made by Medica, your complaint must be made within one year following Medica's initial decision. 2. For an oral complaint that does not require a medical determination in its outcome, 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 3. 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 or request. 4. When an initial decision by Medica not to grant a prior authorization request is made before 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 MIC PPMN (3/11) 106 100 % -15 BPL 84241 DOC 21290 Complaints 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. 5. 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. Second level of review If you are not satisfied with Medica's first level of review decision, you may request a second level of review through either a written reconsideration or a hearing. 1. 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 the address listed above in First level of review, 2. 2. 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. 3. Medica will provide written notice of its second level of review decision to you within: a. 30 calendar days from receipt of written notice of your appeal for required second level reviews; or b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews. For some complaints, the second level of review must be exhausted before you have the right to submit a request for external review. For other complaints, this second level of review is optional before you may submit a request for external review. Medica will inform you in writing whether the second level of review is optional or required. External review If you consider Medica's decision to be partially or wholly adverse to you, you may submit a written request for external review of Medica's decision to the Commissioner of Commerce at: Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101 -2198 A filing fee of $25 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 will not be binding on you but will be binding on Medica. Contact 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. MIC PPMN (3/11) 107 100 % -15 BPL 84241 DOC 21290 Complaints Civil action If you are dissatisfied with Medica's first or second level review decision or the external review decision, you have the right to file a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA). MIC PPMN (3/11) 108 100 % -15 BPL 84241 DOC 21290 • iJ r General Provisions HH. General Provisions This section describes the general provisions of the Contract. See pefiniticins. These words have specific meanings, benefits, claim, dependent, member; network,: premium; xprovider, subscriber., 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. 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. 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. MIC PPMN (3/11) 109 100 % -15 BPL 84241 DOC 21290 General Provisions 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. MIC PPMN (3/11) 110 % -15 100 / BPL 84241 DOC 21290 Definitions Definitions In this certificate (and in any amendments), some words have specific meanings. Benefits.' The health services or supplies (described in this certificate and any subsequent amendments) approved by Medica as eligible for coverage. Certification of qualifying 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. 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. 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 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. 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 Drug Program and Specialty 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. Continuous coverage. 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. Convenience care /retail health clinic. A health care clinic located in a setting such as a retail store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. MIC PPMN (3/11) 111 100%-15 BPL 84241 DOC 21290 Definitions copayment. 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. Any remaining amount is paid according to the written agreement with 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. Cosmetic. Services and rocedures that improve physical appearance but do not correct or p p p Y pp improve a physiological function, and that are not medically necessary, unless the service or procedure meets the definition of reconstructive. Custodial care. 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. Deductible. The fixed dollar amount you must pay for eligible services or supplies 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 following are considered dependents: I ' 1. The subscriber's spouse. 2. The following dependent children up to the dependent limiting age of 26: a. The subscriber's or subscriber's spouse's natural or adopted child; b. A child placed for adoption with the subscriber or subscriber's spouse; 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 legal guardianship; d. The subscriber's stepchild; and e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent incapable of self- sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber for support and maintenance.., An illness that does not cause a child to be incapable of self - sustaining employment will not be considered a physical disability. This dependent may remain covered under the Contract regardless of age and without application of health screening or waiting periods. To continue coverage for a disabled dependent, you must I provide Medica with proof of such disability and dependency within 31 days of the child reaching the dependent limiting age set forth in 2. above. Beginning two years after the MIC PPMN (3/11) 112 100 % -15 BPL 84241 DOC 21290 Definitions child reaches the dependent limiting age, Medica may require annual proof of disability and dependency. For residents of a state other than Minnesota, the dependent limiting age may be higher if required by applicable state law. 4. The subscriber's or subscriber's spouse's disabled dependent who is incapable of self - sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber or subscriber's spouse for support and maintenance. For coverage of a disabled dependent, you must provide Medica with proof of such disability and dependency at the time of the dependent's enrollment. Emergency. A condition or symptom (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, 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 (or, if you are pregnant, the health of your unborn child) 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. E- visits. A member - initiated online evaluation and management service provided to patients via the Internet. E- visits are used to address non- urgent medical symptoms for established patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. Hospital. 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. Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing facility, or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally disabled children will be covered as any other health condition. Investigative. 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: 1. 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 MIC PPMN (3/11) 113 100 % -15 BPL 84241 DOC 21290 I ' Definitions 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;. 2. 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 3. 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 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 any authoritative compendia as identified by the Medicare program for use in the determination of a medically accepted indication of drugs and biologicals used off - label. 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 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 member who is a child entitled to receive coverage through a QMCSO 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: 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. Member. A person who is enrolled under the Contract. Mental disorder. 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). MIC PPMN (3/11) 114 100 % -15 BPL 84241 DOC 21290 Definitions Nett. 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 to provide benefits to you. The participation status of providers will change from time to time. The network provider directory will be furnished automatically, without charge. Non - network. A term used to describe a provider not under contract as a network provider. Non- network provider reimbursement amount. The amount that Medica will pay to a non - network provider for each benefit is based on one of the following, as determined by Medica: 1. A percentage of the amount Medicare would pay for the service in the location where the service is provided. Medica generally updates its data on the amount Medicare pays within 30 -60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or 2. A percentage of the provider's billed charge; or • 3. A nationwide provider reimbursement database that considers prevailing reimbursement rates and /or marketplace charges for similar services in the geographic area in which the service is provided; or 4. An amount agreed upon between Medica and the non - network provider. Contact Customer Service for more information concerning which method above pertains to your services, including the applicable percentage if a Medicare -based approach is used. For certain benefits, you must pay a portion of the non - network provider reimbursement amount as a copayment or coinsurance. In addition, if the amount billed by the non - network provider is greater than the non - network provider reimbursement amount, the non - network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any copayment, coinsurance, or deductible amount you may be responsible for according to the terms .. described in this certificate. Furthermore, such difference will not be applied toward the out -of- pocket maximum described in Your Out -Of- Pocket Expenses. Additionally, -you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non - network provider will likely be much higher than if you had received services from a network provider. Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (0.0.), Doctor of Podiatry, (D.P.M.), Doctor of Optometry (0.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. 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. (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.) 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 defined by Standards for Obstetric - Gynecologic Services issued by the American College of Obstetricians and Gynecologists. MIC PPMN (3/11) 115 100 % -15 BPL 84241 DOC 21290 Definitions Prescription drug. A drug approved by the FDA for the prescribed use and route of administration. Preventive health service. The following are considered preventive health services: 1. Evidence -based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; 2. Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the member involved; 3. With respect to members who are infants, children, and adolescents, evidence - informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; 4. With respect to members who are women, such additional preventive care and screenings not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Contact Customer Service for information regarding specific preventive health services and services that are rated "A" or "B." 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 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; 15. State Children's Health Insurance Program; or MIC PPMN (3/11) 116 100 % -15 BPL 84241 DOC 21290 cL 1/1 Definitions 16. A public health plan similar to any of the above plans established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. • 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; 4. 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. 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. Restorative. 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. Routine foot care. Services that are routine foot care may require treatment by a professional and include but are not limited to any of the following: 1. Cutting, paring, or removal of corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removal of toenails, dead skin, or underlying tissue). Routine foot care may also include hygiene and preventive maintenance such as: 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. MIC PPMN (3/11) 117 100 % -15 BPL 84241 DOC 21290 Definitions 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 by themselves define 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 nursing care, skilled transitional care, or other related health services including rehabilitative services. 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. Total disability. 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. Urgent care center. 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. Waiting period. 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. Periods of employment in an employment classification that is not eligible for coverage under the Contract do not constitute a waiting period. MIC PPMN (3/11) 118 100 % -15 BPL 84241 DOC 21290 Medica Choice Passport Certificate of Coverage MEDICA. MIC PPMN HSA (3/11) 1500 -100% BPL 67276 DOC 21410 PO Box 9310 Minneapolis, MN 55440 -9310 952- 992 -2900 MEDICA® 1. CP280 80515 - coon CITY OF COLUMBIA HEIGHT LINDA MAGEE 590 40TH AVENUE NE COLUMBIA HEIGHT, MN 55421 -0 Dear Group Administrator: Enclosed is an amendment which modifies your current Certificate of Coverage. We apologize for the delay in mailing this amendment and for any inconvenience this may have caused. If you have any questions about your benefits, please feel free to contact Medica Customer Service by calling the number on the back of your ID card. Once again, thank you for your membership. Medica° is a registered service mark of Medica•Health Plans. "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 Medica Health Management, LLC. 'Accredited by the National Committee for Quality Assurance in the states of MN, ND, SD and WI. Medica Commercial HMOIPOS C0R1709 -50311 An Equal Opportunity Employer and Medicaid Plans 1.• AMENDMENT TO THE CERTIFICATE OF COVERAGE This amendment modifies your Medica Health Plans ( "Medica ") Certificate of Coverage ( "Certificate "). The terms of the Master Group Contract will determine the effective and termination dates of this amendment. I. The out -of- network benefit for item 5. Prenatal care services received from a physician during an office visit or an outpatient hospital visit in the benefit table of Professional Services has been deleted and replaced with the following: Covered as an in- network benefit. II. The out -of- network benefit for item 6.a. Child health supervision services, including well - baby care in the benefit table of Professional Services has been deleted and replaced with the following: Covered as an in- network benefit. - -- III: -The- following - language has been added after the out-of-network benefit for item 15. Services received from a physician during an inpatient stay for prenatal care in the benefit table of Professional Services: Please note: Out -of- network services for prenatal care are covered as an in- network benefit. IV. The out -of- network benefit for item 1.d. Prenatal care services in the benefit table of Hospital Services has been deleted and replaced with the following: Covered as an in- network benefit. V. The following language has been added after the out -of- network benefit for item 3. Inpatient services, including inpatient maternity labor and delivery services in the benefit table of Hospital Services: except you pay nothing for inpatient services related to prenatal care services that do not result in a delivery VI. The following language has been added after the out -of- network benefit for item 1. Intermittent skilled care when you are homebound, provided by or supervised by a registered nurse in the benefit table of Home Health Care: except you pay nothing for high -risk prenatal care services VII.The following language has been added after the out -of- network benefit for item 3. Home infusion therapy in the benefit table of Home Health Care: except you pay nothing for high -risk prenatal care services 11 Prenatal and Child Health Supervision HSA 1 Table Of Contents Table Of Contents Introduction xi To be eligible for benefits xi Language interpretation xii Acceptance of coverage xii Nondiscrimination policy xii A. Member Rights And Responsibilities 1 Member bill of rights 1 Member 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 7 Prior authorization 8 Certification of qualifying coverage 9 C. How Providers Are Paid By Medica 10 Network providers 10 Non- network providers 10 D. Your Out -Of- Pocket Expenses 11 Coinsurance and deductibles 11. More information concerning deductibles 12 Out -of- pocket maximum 12 Lifetime maximum amount 13 Out -of- Pocket Expenses 14 E. Professional Services 15 Covered 15 Not covered 16 Office visits 16 E- visits 16 Convenience care /retail health clinic visits 16 Urgent care center visits 17 Prenatal care services 17 MIC PPMN HSA (3/11) III 1500 -100% BPL 67276 DOC 21410 Table Of Contents Preventive health care 18 Allergy shots 18 Routine annual eye exams 18 Chiropractic services 18 Surgical services 19 Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 19 Services received from a physician during an emergency room visit 19 Services received from a physician during an inpatient stay, including maternity labor and delivery 19 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 19 Services received from a physician during an inpatient stay for prenatal care 19 Outpatient lab and pathology 19 Outpatient x -rays and other imaging services 19 Other outpatient hospital or ambulatory surgical center services received from a physician 19 Treatment to lighten or remove the coloration of a port wine stain 19 Diabetes self- management training and education 20 Neuropsychological evaluations /cognitive testing 20 Services related to lead testing 20 Vision therapy and orthoptic and /or pleoptic training 20 Genetic counseling 20 Genetic testing 21 F. Prescription Drug Program 22 Preferred drug list 22 Exceptions to the preferred drug list 22 Prior authorization 23 Step therapy 23 Quantity limits 23 Covered 23 Prescription unit 24 Not covered 25 Outpatient covered drugs 25 Emergency covered drugs 26 Diabetic equipment and supplies, including blood glucose meters 26 • MIC PPMN HSA (3/11) iv 1500 -100% BPL 67276 DOC 21410 I ` Table Of Contents Tobacco cessation products 26 Drugs considered preventive health services 26 G. Specialty Prescription Drug Program 27 Designated specialty pharmacies 27 Specialty preferred drug list 27 Exceptions to the specialty preferred drug list 27 Prior authorization 28 Step therapy 28 . Quantity limits 28 Covered 28 Prescription unit 28 Not covered 29 Specialty prescription drugs received from a designated specialty pharmacy 29 Specialty growth hormone received from a designated specialty pharmacy 29 H. Hospital Services 30 Newborns' and Mothers' Health Protection Act of 1996 30 Covered 30 Not covered 31 Outpatient services 31 Services provided in a hospital observation room 32 Inpatient services 32 Services received from a physician during an inpatient stay, including maternity labor and delivery 32 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 32 I. Ambulance Services 33 Covered 33 Not covered 33 Ambulance services or ambulance transportation 34 Non - emergency licensed ambulance service 34 J. Home Health Care 35 Covered 35 Not covered 36 Intermittent skilled care 36 Skilled physical, speech, or occupational therapy 37 MIC PPMN HSA (3/11) v 1500 -100% BPL 67276 DOC 21410 i Table Of Contents Services received from a physician during an inpatient stay in a skilled nursing facility 63 T. Hospice Services 64 Covered 64 Not covered 65 Hospice services 65 U. Temporomandibular Joint (TMJ) Disorder 66 Covered 66 Not covered 66 Office visits 67 E- visits 67 Outpatient services 67 Physical therapy received outside of your home 68 Inpatient services 68 Services received from a physician or dentist during an inpatient stay 68 Anesthesia services received from a provider during an inpatient stay 68 TMJ splints and adjustments 68 V. Medical - Related Dental Services 69 Covered 69 Not covered 69 Charges for medical facilities and general anesthesia services 70 Orthodontia related to cleft lip and palate 70 Accident - related dental services 71 Oral surgery 71 W. Referrals To Non- Network Providers 72 What you must do 72 What Medica will do 72 X. Harmful Use Of Medical Services 74 When this section applies 74 Y. Exclusions 75 Z. How To Submit A Claim 78 Claims for benefits from network providers 78 Claims for benefits from non - network providers 78 Claims for services provided outside the United States 79 Time limits 79 MIC PPMN HSA (3/11) viii 1500 -100% BPL 67276 DOC 21410 . i Table Of Contents AA. Coordination Of Benefits 80 Applicability 80 Definitions that apply to this section 80 Order of benefit determination rules 81 Effect on the benefits of this plan 82 Right to receive and release needed information 83 Facility of payment 83 Right of recovery 83 BB., Right Of Recovery 84 CC. Eligibility And Enrollment 85 Who can enroll 85 How to enroll 85 Notification 85 Initial enrollment 85 Open enrollment 86 Special enrollment 86 Late enrollment 89 Qualified Medical Child Support Order (QMCSO) 89 The date your coverage begins 89 DD. Ending Coverage 91 When coverage ends 91 EE. Continuation 93 Your right to continue coverage under state law 93 Your right to continue coverage under federal law 96 FF. Conversion 102 Minnesota residents 102 Residents of a state other than Minnesota 103 GG. Complaints 104 First level of review 104 Second level of review 105 External review 105 Civil action 106 MIC PPMN HSA (3/11) ix 1500 -100% BPL 67276 DOC 21410 Table Of Contents HH. General Provisions 107 Definitions 109 MIC PPMN HSA (3/11) x 1500 -100% BPL 67276 DOC 21410 Introduction Introduction THIS POLICY IS REGULATED BY MINNESOTA LAW. The benefits of the policy providing your coverage are governed primarily by the laws of a state other than Florida. Many words in this „certificate have specific meanings. ,These words are identified each section defined in..Definitions See pefinitions These words have specific meanings: benefits, claim dependent, member, network, = premium, provider., - Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota non - qualified plan. This Certificate of Coverage (this certificate) describes health services that are eligible for coverage and the procedures you must follow to obtain benefits. The Contract refers to the Contract between Medica and the employer. You should contact the employer to see the Contract. 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 may arrange for various persons or entities to provide administrative services on its 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. Additional network administrative support is provided by one or more organizations under contract with Medica. The employer is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by'applicable law. In this certificate, the words you, your, and yourself refer to the member. The word employer refers to the organization through which you are eligible for coverage. To be eligible for benefits Each time you receive health services, you must: 1. Confirm with Customer Service that your provider is a network provider to be eligible for in- network benefits; and 2. Identify yourself as a Medica member; and 3. Present your Medica identification card. (If you do not show your Medica identification card, providers have no way of knowing that you are a Medica member and you may receive a bill for health services or be required to pay at the time you receive health services.) However, MIC PPMN HSA (3/11) xi 1500 -100% BPL 67276 DOC 21410 cl, Introduction possession and use of a Medica identification card does not necessarily guarantee coverage. Network providers are required to submit claims within 180 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 180 days of the date of service, you may be responsible for paying the cost of the service you received. 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. If you have an impairment that requires alternative communication formats such as Braille, large print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials. 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 that has been issued in Minnesota between Medica and the employer. This certificate is being delivered to you by, or on behalf of, your 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 unless otherwise prohibited by state law; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and complete. You understand and agree that any omission or incorrect statement concerning a material fact intentionally made by you in connection with your enrollment under the Contract may invalidate your coverage. Nondiscrimination policy Medica's policy is 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, genetic information, 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. MIC PPMN HSA (3/11) xii 1500 -100% BPL 67276 DOC 21410 Member Rights And Responsibilities A. Member Rights And Responsibilities �Seevfiefrn�trons `These - words have' spe mean benefits, emergency; Member, gnetIp4)0 provider: Member bill of rights Asa member of Medica, 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; and 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; and 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; and 4. Be treated with respect and recognition of your dignity and privacy; including privacy of your medical and financial records maintained by Medica or any network provider in accordance with existing law; and 5. Contact Customer Service and Minnesota's Commissioner of Commerce to file a complaint about issues related to benefits (see Complaints). To file a complaint with the Minnesota Department of Commerce, call (651) 296 -2488 and request insurance information. You may begin a legal proceeding if you have a problem with Medica or any provider; and 6. Receive information about Medica, its services, its practitioners and providers, and member rights and responsibilities; and 7. Appeal a decision regarding your health care coverage by calling Customer Service at one of the telephone numbers listed inside the front cover. See Complaints for information on your appeal rights; and 8. Make recommendations regarding Medica's member rights and responsibilities statement. 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; and 2. Providing the necessary information to health care professionals or Medica needed to determine the appropriate care. This objective is best obtained when you share: a. Information about lifestyle practices; and b. Personal health history; and 3. Understanding your health problems and agreeing to, and following, the plans and instructions for care given by those providing health care; and ,MIC PPMN HSA (3/11) 1 1500 -100% BPL 67276 DOC 21410 Member Rights And Responsibilities 4. Practicing self -care by knowing: a. How to recognize common health problems and what to do when they occur; and b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and 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 find additional information on member responsibilities in this certificate. MIC PPMN HSA (3/11) 2 1500 -100% BPL 67276 DOC 21410 How To Access Your Benefits B. How To Access Your Benefits See`Definitions These words have =specific meanings benefits,' claim, coinsurance, deductible, dependent,, emergency, enrollment date, hospital, inpatient, Iate.entrant, member, network, non network, non network "provider reimbursement amount, physician, ,placed for adoption, premium, prescription drug provider, qualifying coverage, reconstructive, restorative," skilled nursing facility, subscriber, waiting period. Provider network In- network benefits are available through the Medica Choice Passport provider network. For a list of the in- network providers, please consult your Medica Choice Passport provider directory by signing in at www.mymedica.com or contacting Customer Service. Out -of- network benefits will apply when you choose to receive eligible health services from providers that are not contracted with Medica. 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. To be eligible for in- network benefits, follow -up care or scheduled care after an emergency must be received from a network provider. 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. Providers Enrolling in Medica does not guarantee that a particular provider will remain a network provider or provide you with health services. When a provider no longer participates in the network, you must choose to receive health services from network providers to continue to MIC PPMN HSA (3/11) 3 1500 -100% BPL 67276 DOC 21410 How To Access Your Benefits be eligible for in- network benefits. You must verify that your provider is a network provider each time you receive health services. 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's hospital network is different from Medica's hospital network. Certain mental health and substance abuse services require prior authorization by Medica's designated mental health and substance abuse provider. Emergency services do not require prior authorization. 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. Medica does not automatically know of a birth or whether you would like coverage for the newborn dependent. Call Customer Service at one of the telephone numbers listed inside the front cover for more information. To be eligible for in- network benefits, health services must be 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 reduce payment by the amount of premium that is past due 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. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. MIC PPMN HSA (3/11) 4 1500 -100% BPL 67276 DOC 21410 How To Access Your Benefits 2. Important member information about out -of- network benefits The information below describes your covered health services and provides important . information concerning your out -of- network benefits. Read this certificate for a detailed explanation of both in- network and out -of- network benefits. Please carefully review the general sections of this certificate as well as the section(s) that specifically describes the services you are considering, so you are best able to determine the benefits that will apply to you. Benefits Medica pays out -of- network benefits for eligible health services received from non - network providers. Prior authorization may be required from Medica before you receive certain • services, in order to determine whether those services are eligible for coverage under your out -of- network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out -of- network benefits. 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. Emergency services received from non - network providers are covered as in- network benefits and are not considered out -of- network benefits. Additionally, under certain circumstances Medica will authorize your obtaining services from a non - network provider at the in- network benefit level. Such authorizations are generally provided only in situations where the requested services are not available from network providers. Be aware that if you choose to go to a non- network provider and use out -of- network benefits, you will likely have to pay much 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 coinsurance and deductible amount. This additional amount you must pay to the provider will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses and you will owe this amount regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. Please see the example calculation below. i Because obtaining care from non - network providers may result in significant out -of- pocket � expenses, it is important that you do the following before receiving services from a non- network provider: • Discuss the expected billed charges with your non - network provider; and • Contact Customer Service to verify the estimated non - network provider reimbursement amount for those services, so you are better able to calculate your likely out -of- pocket expenses; and • If you wish to request that Medica authorize the non - network provider's services, be I covered at the in- network benefit level, follow the procedure described under Prior authorization in How To Access Your Benefits. MIC PPMN HSA (3/11) 5 1500 -100% BPL 67276 DOC 21410 h How To Access Your Benefits An example of how to calculate your out -of- pocket costs* You choose to receive non - emergency inpatient care at a non - network hospital provider without an authorization from Medica providing for in- network benefits. The out -of- network benefits described in this certificate apply to the services you receive. For purposes of this example, you have previously satisfied your deductible. The non - network hospital provider bills $30,000 for your hospital stay. Medica's non - network provider reimbursement amount for those hospital services is $15,000. You must pay a portion of the non - network provider reimbursement amount, generally as a percentage coinsurance. In addition, the non - network provider will likely bill you for the amount by which the provider's charge exceeds the non - network provider reimbursement amount. If your coinsurance is 40 %, you will be required to pay: • 40% coinsurance (40% of $15,000 = $6,000) and • The billed charges that exceed the non - network provider reimbursement amount ($30,000 - $15,000 = $15,000) • The total amount you will owe is $6,000 + $15,000 = $21,000. • The $6,000 you pay as coinsurance will be applied to the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. However, the $15,000 amount you pay forbilled charges in excess of the non - network provider reimbursement amount will not be applied toward the out -of- pocket maximum amount described in Your Out-Of- Pocket Expenses. You will owe the provider this $15,000 amount regardless of whether you have previously reached your out -of- pocket maximum with amounts paid for other services. *Note: The numbers in this example are used only for purposes of illustrating how out-of- network benefits are calculated. The actual numbers will depend on the services received. Lifetime maximum amount Out -of- network benefits are subject to a lifetime maximum amount payable per member. See Your Out -Of- Pocket Expenses for a detailed explanation of the lifetime maximum amount. • Exclusions Some health services are not covered when received from or under the direction of non - 1 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. • Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. • MIC PPMN HSA (3/11) 6 1500 -100% BPL 67276 DOC 21410 How To Access Your Benefits .3. Continuity of care To request continuity of care or if you have questions about how this may apply to you, call Customer Service at one of the telephone numbers listed inside the front cover. In- certain situations, you have a right to continuity of care. a: If your current provider is terminated 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 provider 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 all necessary medical information related to your care, and accept as payment in full the lesser of the network provider reimbursement or the provider's customary charge for the service. This does not apply when a provider's contract is terminated for cause. i. 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; • 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 x •,, 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 provider may 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 a network provider who has special expertise in the delivery of those culturally appropriate services is not available; or • if you do not speak English and a network provider who can communicate with you, either directly or through an interpreter, is not available. 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. You may appeal this decision. NIIC PPMN HSA (3/11) 7 1500 -100% • BPL 67276 DOC 21410 tl How To Access Your Benefits Coverage will not be provided for services or treatment that are not otherwise covered under this certificate. 4. 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. To determine whether a certain service or supply requires prior authorization, please call Customer Service at one of the telephone numbers listed inside the front cover. Emergency services do not require prior authorization. Your attending provider, you or someone on your behalf may contact Customer Service to request prior authorization. Your network provider will contact Customer Service to request prior authorization for a service or supply. You must contact Customer Service to request prior authorization for services or supplies received from a non - network provider. If a network provider fails to obtain prior authorization after you have consulted with them about services requiring prior authorization, you are not subject to a penalty for failure to obtain prior authorization. Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; • Treatment of a diagnosed temporomandibularjoint disorder or craniomandibular disorder; • Organ and bone marrow transplant; • Home health care; • Medical supplies and durable medical equipment; • Outpatient surgical procedures; • Certain genetic tests; • Skilled nursing facility services; and • In- network benefits for services from non - network providers with the exception of emergency services. This is not an all- inclusive list of all services and supplies that may require prior authorization. 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). MIC PPMN HSA (3/11) 8 1500 -100% BPL 67276 DOC 21410 How To Access Your Benefits Your request will be reviewed and a response will be provided to you and your attending provider within 10 business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available. Both you and your provider will be informed of the decision within 24 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or it is concluded that a delay could seriously jeopardize your life, health, or ability to regain maximum function. You have the right to appeal the decision as described in Complaints, if the request for prior authorization has not been approved. 5. Certification of qualifying coverage You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. MIC PPMN HSA (3/11) 9 1500 -100% BPL 67276 DOC 21410 Flow Providers Are Paid By Medica C. How Providers Are Paid By Medica This section describes how providers are generally paid for health services. See Definitions These words have specific meanings: coinsurance, - "deductible, hospital; member network, non network, physician, provider., 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 2. 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 is fee - for- service. Fee - for - service payment means that the network provider is paid 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, Tess any applicable coinsurance or deductible, is considered to be payment in full. Risk - sharing payment means that the network provider is paid 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. Some network providers are authorized to arrange for a member to receive certain health services from other providers. This decision may result in a network provider keeping more or less of the risk - sharing payment. 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 Tess than the charges billed by the non - network provider. If this happens, you are responsible for paying the difference. MIC PPMN HSA (3/11) 10 1500 -100% BPL 67276 'DOC 21410 Your Out -Of- Pocket Expenses D. Your Out -Of- Pocket Expenses This section describes the expenses that are your responsibility to pay. These expenses are commonly called out -of- pocket expenses. See Definitions. These words have specific meanings 'benefits, claim, coinsurance, deductible,:xdependent, member, network, non- network,non network provider reimbursement amount, prescriptionrdrug, provider, subscriber 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.) If you miss or cancel an office visit less than 24 hours before your appointment, your provider may bill you for the service. Please see the applicable benefit section(s) of this certificate for specific information about your in- network and out -of- network benefits and coverage levels. To verify coverage before receiving a particular service or supply, call Customer Service at one of the telephone numbers listed inside the front cover. Coinsurance and deductibles For in- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that is not covered under the Contract. For out -of- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your MIC PPMN HSA (3/11) 11 1500 -100% BPL 67276 DOC 21410 Your Out -Of- Pocket Expenses deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that exceeds the non - network provider reimbursement amount. This means you are required to pay the difference between the payment to the provider and what the provider bills. If you use out -of- network benefits, you may incur costs in addition to your coinsurance and deductible amounts. If the amount that your non - network provider bills you is more than the non - network provider reimbursement amount, you are responsible for paying_ the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out - of- pocket maximum (described in this section). 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 coinsurance and deductibles. 3. Any charge that is not covered under the Contract. More information concerning deductibles The time period used to apply the deductible (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. Out - of - pocket maximum The out -of- pocket maximum is an accumulation of coinsurance and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per member out -of- pocket maximum for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non - network provider reimbursement amount are not applicable toward the out -of- pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. The time period used to calculate whether you have met the out -of- pocket maximum (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. MIC PPMN HSA (3/11) 12 1500 -100% BPL 67276 DOC 21410 i } Your Out -Of- Pocket Expenses After an applicable out -of- pocket maximum has been met for a particular type of benefit (as described in the Out -of- Pocket Expenses table in this section), all other covered benefits of the same type received during the rest of the calendar year will be covered at 100 percent, except for any charge not covered by Medica or charge in excess of the non - network provider reimbursement amount. However, you will still be required to pay any applicable coinsurance and deductibles for other types of benefits received. Note that out -of- pocket maximum amounts are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new out -of- pocket maximum will apply for the rest of the current calendar year, whether or not you had met the previously applicable out -of- pocket maximum. This means that it is possible that your out -of- pocket maximum will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. Medica refunds the amount over the out -of- pocket maximum during any calendar year when proof of excess coinsurance and deductibles is received and verified by Medica. 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, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Out- of- Pocket•Expenses table in this section. Any lifetime maximum dollar limit referenced pertains only to those health care services and supplies that are not essential benefits as defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules, or other guidance issued with respect to the "Act." MIC PPMN HSA (3/11) 13 1500 -100% BPL 67276 DOC 21410 Your Out -Of- Pocket Expenses Out -of- Pocket Expenses to network Ou, t of network * benefits benefits * For out-of network benefits, in addition to th deductible and coinsurance ,,you °are responstble for any charges in excess o the non-network ,provider reimbursement amount: A ddi #tonally, these charges; will not be applied "toward satisfaction of the deductible or the out of pocket Rr 3 M maximum Coinsurance See specific benefit for applicable coinsurance. Deductible Per member $1,500 $4,000 Out -of- pocket maximum Per member $1,500 $9,000 Lifetime maximum amount Unlimited $1,000,000. Applies to payable per member all benefits you receive under this or any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. • MIC PPMN HSA (3/11) 14 1500 -100% BPL 67276 DOC 21410 Professional Services E. Professional Services This section describes coverage for professional services received from or directed by a physician. See Definitions These words have specific meanings benefits, coinsurance, Convenience care /retail health clinic, deductible, ; emer genc ,. g y" e vasits hospital, inpatient, Member, network;.:." non network, non-network provider reimbursement amount p hysician, prenatal care, preventive health - service, provider, urgent care center :.' Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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; 2. 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. Family planning services do not include infertility treatment services. • Out -of- network benefits apply to professional services received from a non - network provider. In addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. 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 transplant services are described in Organ And Bone Marrow Transplant Services. For some services, there may be a facility charge resulting in coinsurance (see Hospital Services) in addition to the professional services coinsurance. Also, more than one coinsurance may be required if you receive more than one service or see more than one provider per visit. MIC PPMN HSA (3/11) 15 1500 -100% BPL 67276 DOC 21410 ' I Professional Services Not covered Drugs provided or administered by a physician or other provider, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. rot - •. -. = -... ` '. J' YourBenefits and the Amount You Pay u Benefits x In network benefit * Outof network benefits - after d eductible. 1 .after deducti k *.For out-of-network benefits, in addition to the - deductibl a nd coinsurance,iyou are respons for: any charges in excess of the, non- network provider: reimbursement amount Additionally -these charges will not be applied toward.satisfaction of the deductible or the out-of-pocket ; maximum 1. Office visits Nothing 50% coinsurance Please note: Some services received during an office visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an office visit. For example, certain services received during an office visit may be considered surgical services; see 10. below for coverage of these surgical services. In such instances, both an office visit coinsurance and outpatient surgical services coinsurance apply. CaII Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 2. E - visits Nothing No coverage 3. Convenience care /retail health Nothing 50% coinsurance clinic visits MIC PPMN HSA (3/11) 16 1500 -100% BPL 67276 DOC 21410 1 L • Professional Services Your Benefits and the Amounts You Pa Y Benefits �� � ;.1n network benefits *Out of network benefits E ' after ded uctible ` after deductibl ri fTf. or out of; network benefits, in addition to the deductible and coinsurance,_ you a re responsible for any �n excess of the non network #provider retmb urseriient amount: iAddit ovally these charges will not b:e applied toward satrsfaction of ._the deductible or:the out -of po cket maximum; 4. Urgent care center visits Nothing Covered as an in- network Please note: Some services benefit. received during an urgent care visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an urgent care visit. For example, certain services received during an urgent care visit may be considered surgical or imaging services; see below for coverage of these surgical or • imaging services. In such • instances, both an urgent care visit coinsurance and outpatient surgical or imaging services coinsurance apply. Call Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 5. Prenatal care services received Nothing. The deductible 50% coinsurance from a physician during an office does not apply. visit or an outpatient hospital visit MIC PPMN HSA (3/11) 17 1500 -100% BPL 67276 DOC 21410 - 7 Professional Services Benefits 'and the Amounts You Pa Benefits : _ m In network benefits *O o f - n e t work ben'efits aft er deductible after deductible r For out of n etwork,benefits, w in a ddition to the,deductible aria coinsurance, you are responsible.. ; f og ider rei an char es m exces of the non networ plied AO—Ward rov mbursement amount Additionall theseft charges will not be ap s -of the deductible or the out =of pocket maximum. $ 6. Preventive health care Please note: If you receive preventive and non - preventive • health services during the same visit, the non - preventive health services may be subject to a coinsurance or deductible, as described elsewhere in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received • during a visit. a. Child health supervision Nothing. The deductible 50% coinsurance ' services, including well -baby does not apply. fq care b. Immunizations Nothing. The deductible 50% coinsurance -:`) does not apply. c. Early disease detection Nothing. The deductible 50% coinsurance services including physicals does not apply. d. Routine screening Nothing. The deductible 50% coinsurance ; procedures for cancer does not apply. e. Other preventive health Nothing. The deductible 50% coinsurance, , services does not apply. 7. Allergy shots Nothing 50% coinsurance • ( ._ 8. Routine annual eye exams. Nothing. The deductible 50% coinsurance' Coverage is limited to one visit does not apply. per calendar year for in- network and out -of- network benefits combined. 9. Chiropractic services to Nothing 50% coinsurance. diagnose and to treat (by manual Coverage is limited to a manipulation or certain maximum of 15 visits per therapies) conditions related to calendar year. the muscles, skeleton, and Please note: This visit limit nerves of the body includes chiropractic visits that you pay for in order to satisfy any part of your deductible. MIC PPMN HSA (3/11) 18 1500 x'0 BPL 67276 DOC.2141'0 Professional Services • Your Benefit ;and the Amounts You, , Pay 1 Benefits fin,- network benefits * Out of network benefits 4. _ after deductible after deductible * For out o ntwor ek bene #its, in addition to the deductible and comsu�ance, you are responsible, #or ; any - charges, mmxcess of�ythe -nnetw on ork•provider reimbursement amu ont Additionally, these charges will not lie applied toward sat of:th "ded uctible or out -of pocket maximum., 10. Surgical services (as defined in Nothing 50% coinsurance the Physicians' Current Procedural Terminology code book) from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit 11. Anesthesia services received Nothing 50% coinsurance from a, provider during an office visit or an outpatient hospital or ambulatory surgical center visit 12. Services received from a Nothing Covered as an in- network physician during an emergency benefit. room "visit • 13. Services , received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 14. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery 15. Services received from a Nothing. The deductible 50% coinsurance physician during an inpatient does not apply. stay for prenatal care 16. Outpatient lab and pathology Nothing 50% coinsurance 17. Outpatient x -rays and other Nothing 50% coinsurance imaging services 18. Other outpatient hospital or Nothing 50% coinsurance ambulatory surgical center services received from a physician 19. Treatment to lighten or remove Nothing 50% coinsurance the coloration of a port wine stain MIC P,PMN HSA (3/11) 19 1500 -100% BPL 67276 DOC 21410 Professional Services Your 13 fits and the Amounts You Pay Benefits: In network benefits * °;Out of networ benefits after.deductible after deductible * For ou -of network benefits, -in addition to the deductible and coi suranc You are responsible for any charges in, excess of the non - network provider reimbursement ;amount:° °Additionally, these charges will not be toward satesfactwn = of the deductible or he out of- pocket m aximum 20. Diabetes self- management Nothing 50% coinsurance 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) 21. Neuropsychological Nothing 50% coinsurance evaluations /cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury 22. Services related to lead testing Nothing 50% coinsurance 23. Vision therapy and orthoptic Nothing 50% coinsurance and /or pleoptic training, to establish a home program, for the treatment of strabismus and other disorders of binocular eye movements. Coverage is limited to a combined in- network and out -of- network total of 5 training visits and 2 follow -up eye exams per calendar year. Please note: The v and exam limits include visits and exams that you pay for in order to satisfy any part of your deductible. 24. Genetic counseling, whether pre- Nothing 50% coinsurance or post -test, and whether occurring in an office, clinic, or telephonically MIC PPMN HSA (3/11) 20 1500 -100% BPL 67276 DOC 21410 Professional Services .. __._.._......... . Your Benefits and, the Amounts You Pay Benefits In network benefits * Out-of-network benefits after deductible after deductible * :For out of network benefits, in addition to the deductible and coinsurance, you are responsible for any charges in of the network provider reimbursement amount :iAdditionaily, these c harges will not be:applied toward ,satisfaction " -of the. deductible or the out -of pocket maximum 25. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices MIC PPMN HSA (3/11) 21 1500 -100% BPL 67276 DOC 21410 Prescription Drug Program F. Prescription Drug Program This section describes coverage for prescription drugs and supplies received from a pharmacy or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" is meant to include those prescription drugs and supplies found on the Preferred Drug List (PDL) and prescribed by a.provider authorized to prescribe such covered drugs, unless such prescription drugs and supplies are identified in this certificate as not covered. The phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase "self- administered drugs" means all other drugs. For the definition and coverage of specialty prescription drugs, see Specialty Prescription Drug Program. See Definitions These words have specif meanings: benefits, claim, coinsurance, deductible, durable medical equipment, emergency, hospital, member, network, non- network, non network provider. reimbursement amount, physician, prescription drug, preventive health service, provider, urgent °care center. Preferred drug list Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: Tier 1 is your lowest coinsurance option. For the lowest out -of- pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate. Tier 3 drugs are not covered unless they meet the requirements under the PDL exception process described in this certificate. If you have questions about Medica's PDL or whether a specific drug is covered (and /or the PDL tier in which the drug may be covered), or if you would like to request a copy of the PDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The PDL is also available when you sign in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a drug should be considered a covered drug. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the PDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each drug based on a review of the drug's cost and effectiveness. Exceptions to the preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants MIC PPMN HSA (3/11) 22 1500 -100% BPL 67276 DOC 21410 Prescription Drug Program will improve the coverage by only one tier. Exceptions to the PDL can also include a ntipsychotic 'drugs.'prescribed to treat emotional disturbance or mental illness, and certain ' I . drugs for diagnosed mental illness or emotional disturbance if removed from the PDL or you change health plans. If you would like to request a copy of Medica's PDL exception process, call CustorraePService at one of the telephone numbers listed inside the front cover. Prior authorization Certaih'covered'drugs require prior authorization as indicated on the PDL. The provider who prescribes the drug initiates prior authorization. The PDL is made available to providers, �rr, p including,phar and the designated mail order pharmacies. You are responsible for paying th'e cost of drugs received if you do not meet Medica's authorization criteria. Step therapy Medica re,quires'step therapy prior to coverage of specific drugs as indicated on the PDL. Step ' •+ P therapy n olves trying an alternative covered drug first (typically a Tier 1 drug) before moving on to a Tier2'or• ier 3'covered drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. Quantity limit • i� Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits indicate.the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered' r '' The following table provides important general information concerning in- network, out -of- network,and mail'order benefits. For specific information concerning benefits and the amounts you pay, :see the benefit table at the end of this section. Please note that the Prescription Drug Program section describes your coinsurance for prescription drugs themselves. An additional 1 coinsurance. applies for the provider's services if you require that a provider administer self- administered as described in other applicable sections of this certificate including, but not limited to, 'Profe Services, Hospital Services, and Infertility Diagnosis. '! In network�benefts , Out- of - network benefits* M ait order benefitsf Covered drugs ° received at a Covered drugs received at a Covered drugs received from network pharrriacy; and • non - network pharmacy; and a designated mail order pharmacy; and, 1' • M ic PPMN • HSA (3/11) 23 1500 - 100% a• BPL 67276 DOC 21410 _Prescription Drug Program Iii- twork benefits ; Out -of- network benefits* Mail order benefits Covered drugs for family See In- network benefits Covered drugs for family planning services or the column. planning services or the treatment of sexually treatment of sexually transmitted diseases when transmitted diseases when prescribed by or received from prescribed by either a either a network or a non- network or a non - network network provider. Family provider and received from a planning services do not designated mail order include infertility treatment pharmacy. Family planning services; and services do not include infertility treatment services; and Diabetic equipment and Diabetic equipment and Diabetic equipment and supplies, including blood supplies, including blood supplies (excluding blood glucose meters when received glucose meters when received glucose meters) received from a network pharmacy; and from a non - network pharmacy; from a designated mail order and pharmacy. Tobacco cessation products Tobacco cessation products Not available. when prescribed by a provider when prescribed by a provider authorized to prescribe the authorized to prescribe the product and received at a product and received at a non - network pharmacy. network pharmacy. * When out -of- network benefits are received from non - network providers, in addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Specialty Prescription Drug Program for coverage of growth hormone and other specialty prescription drugs. Prescription unit Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31- consecutive -day supply of a covered drug from your pharmacy (or, in the case of oral contraceptives, up to a one -cycle supply) or a 93- consecutive -day supply of a covered drug from your designated mail order pharmacy (or, in the case of oral contraceptives, up to a three -cycle supply), unless limited by drug manufacturers' packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed. Three prescription units may be dispensed for covered drugs prescribed to treat chronic conditions that are received at a network pharmacy that Medica has specifically designated to MIC PPMN HSA (3/11) 24 1500 -100% BPL 67276 DOC 21410 Prescription Drug Program dispense multiple prescription units. For the current list of such designated pharmacies, sign in at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside the front cover. Not covered The following 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.) 2. OTC drugs not listed on the PDL. 3. Replacement of a drug due to loss, damage, or theft. 4. Appetite suppressants. 5. Erectile dysfunction medications. 6. Non - sedating antihistamines and non- sedating antihistamine /decongestant combinations. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and those members who have a feeding tube. 8. Tobacco cessation products or services dispensed through a mail order pharmacy. 9. Drugs prescribed by a provider who is not acting within his /her scope of licensure. 10. Homeopathic medicine. 11. Infertility drugs. 12. Specialty prescription drugs, except as described in Specialty Prescription Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Your Benefits and the Amount Y ou Pay * or.ut ' - o-of- network benefits in addition to deductib F e and coinsurance, you are responsible for any Tcharges in'excess�of the non network provider reimbursement amount Addit onally rthese , charges will not be applied toward' satisfaction of'the deductible or the out of pocket maximum In network' benefits * Out of- network benefi Mail orderFbenefits " after deductible after deductible after deductible 1. Outpatient covered drugs other than those described below or in Specialty Prescription Drug Program Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage MIC PPMN HSA (3/11) 25 1500 -100% BPL 67276 DOC 21410 Prescription Drug Program Your Benefits and the Amounts You Pay * For out -of network; benefits, in• addition to the deductible and coinsurance, you:are responsible for any charges in excess, of the non - network, provider. reimbursement amount es n Additronaily charges will ot be applied toward satisfaction of the deductible or the out of ` p x . , 9 �:.. Pp p�ocket,ma ximum In- network: benefits £ Out -of network benefits Mail' order benefits after deductible -after deductible after deductible 2. Up to a 24 -hour supply of emergency covered drugs received from a hospital or urgent care center Nothing Covered as an in- network Not available through a mail benefit. order pharmacy. 3. Diabetic equipment and supplies, including blood glucose meters Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage 4. Tobacco cessation products Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. 5. Drugs (other than tobacco cessation products) considered preventive health services, as specifically defined in Definitions, when prescribed by a provider authorized to prescribe such drugs. This group of drugs is specific and limited. For the current list of such drugs, please refer to the Preventive Drug List within the PDL or call Customer Service at one of the telephone numbers listed inside the front cover. Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. MIC PPMN HSA (3/11) 26 1500 -100% BPL 67276 DOC 21410 JINN Specialty Prescription Drug Program 1 G. Specialty Prescription Drug Program This section describes coverage for specialty prescription drugs received from a designated specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology prescription drug products for individuals with diseases that require complex therapies. Such specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as described below. For purposes of this section, the phrase "professionally administered drugs" j means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; and the phrase "self- administered drugs" means all other drugs. See Definitions These words have specific meanings: benefits, claim, coinsurance, , �. deductible, member network, physician; prescription drug, provider., Designated specialty pharmacies A designated specialty pharmacy means a specialty pharmacy that has entered into a separate contract with Medica to provide specialty prescription drug services to members. For the current list of designated specialty pharmacies, call Customer Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com. . Specialty preferred drug list Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty • prescription drugs on Medica's SPDL are eligible for benefits under this certificate. The ,j applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is covered (and /or the SPDL tier in which the drug may be covered), or if you would like to request a copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The SPDL is also available by signing in at www.mymedica.com. I Medica utilizes medication request guidelines to determine whether a specialty prescription drug should be covered. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the SPDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. i Exceptions to the specialty preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Specialty preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also MIC PPMN NSA (3/11) 27 1500 -100% BPL 67276 DOC 21410 Specialty Prescription Drug Program 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 SPDL or you change health plans. If you would like to request a copy of Medica's SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain specialty prescription drugs require prior authorization. The provider who prescribes the specialty drug initiates prior authorization. The SPDL is made available to providers, including designated specialty pharmacies. You are responsible for paying the cost of specialty prescription drugs you receive if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying a Tier 1 specialty prescription drug before moving on to a Tier 2 specialty prescription drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 specialty prescription drugs. Quantity limits Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy. This section describes your coinsurance for specialty prescription drugs. An additional coinsurance applies for the provider's services if you require that a provider administer self - administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. Prescription unit Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. One prescription unit is equal to a 31- consecutive -day supply of a specialty prescription drug, unless limited by the manufacturers' packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. MIC PPMN HSA (3/11) 28 1500 -100% BPL 67276 DOC 21410 Specialty Prescription Drug Program Not covered The following are not covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the designated specialty pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Replacement of a specialty drug due to loss, damage, or theft. 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of licensure. 4. Prescription drugs and OTC drugs, except as described in Prescription Drug Program. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 6. Infertility drugs. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Your Benefits and thesArriounts You Pay Benefits . � You pay after deductible 1. Specialty prescription drugs, Tier 1 specialty prescription drugs: Nothing per other than those described prescription unit; or below, received from a Tier 2 specialty prescription drugs: No coverage designated specialty pharmacy 2. Specialty growth hormone when Tier 1 specialty prescription drugs: Nothing per prescribed by a physician for the prescription unit; or treatment of a demonstrated Tier 2 specialty prescription drugs: No coverage growth hormone deficiency and received from a designated specialty pharmacy MIC PPMN HSA (3/11) 2g o 1500 -100 /o BPL 67276 DOC 21410 Hospital Services H. Hospital Services This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. See Definitions These words have specific meanings benefits, °coinsurance, deductible emergency, hospital, inpatient,- nor network,provider reimbursement amount, physician, prenatal care, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out - of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. If you are confined in a non - network facility as a result of an emergency you will be eligible for in- network benefits until your attending physician agrees it is safe to transfer you to a network facility. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Each member's admission is separate from the admission of any other member. A separate deductible and coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. MIC PPMN HSA (3/11) 30 1500 BPL 67276 DOC 21410 7 Hospital Services Not covered 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. 2. Transfers and admissions to network hospitals solely at the convenience of the member. 3. Admission to another hospital is not covered when care for your condition is available at the network hospital where you were first admitted. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benef tw rk * Ou ton e o benefits t of network ben after ded after deductible i ' e fit s * For out -of network benefits,,in addition to deductible and coinsurance, you are resp onsible for. any charges in excess of the non network provider reimbursement arnount. Additionally, these charges will not, be applied toward satisfaction of the deductible or the out -of poc maximum; 1. Outpatient services a. Services provided in a Nothing Covered as an in- network hospital or facility -based benefit. emergency room b. Outpatient lab and pathology Nothing 50% coinsurance c. Outpatient x -rays and other Nothing 50% coinsurance imaging services d. Prenatal care services Nothing. The deductible 50% coinsurance does not apply. e. Genetic testing when test Nothing 50% coinsurance results will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices f. Other outpatient services Nothing 50% coinsurance g. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician MIC PPMN HSA (3/11) 31 1500 - 100% BPL 67276 DOC 21410 Hospital Services Your Benefits and the Amounts You Pay Benefits In network benefits * Out of- networkbenefits after deductible after deductible * For out of network benefit in.additaon to the deductible and coin :you are.:responsible for any charges in= excess of the non - network provider reimbursement. amount Additronally, these charges ,will not ; be applied toward satisfaction of the` deductible or the " out o #pocket maximum h. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 2. Services provided in a hospital Nothing 50% coinsurance observation room 3. Inpatient services, including Nothing 50% coinsurance inpatient maternity labor and delivery services Please note: Maternity labor and delivery services are considered inpatient services regardless of the length of hospital stay. 4. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 5. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery MIC PPMN HSA (3/11) 32 1500 -100% BPL 67276 DOC 21410 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). See Definitions. These words have specific meanings: benefits, coinsurance, deductible, emergency, hospital, g'network non network, non- networkprorider reimbursement amount, h si p y 'cian;:provider, skilled nursing.faality. =; � Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For non - emergency licensed ambulance services described 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 non - emergency ambulance services described in this section that are arranged through a physician and received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 33 1500 -100% BPL 67276 DOC 21410 Ambulance Services Your Benefits and the Amounts You Pa ,Benefits In network benefits * Out-of-network benefits after deductible. '''a fter deductible * For out -of- network benefits, in addition to the andreoinsurance, yoware responsible for anycharges in excess of the non network provider reimbursement amount Additionally,. these charges will not be applied toward sa tisfaction of the deductible or_ the out of pocket maximum 1. Ambulance services or Nothing Covered as an in- network ambulance transportation to the benefit. nearest hospital for an emergency 2. Non - emergency licensed ambulance service that is arranged through an attending physician, as follows: a. Transportation from hospital Nothing 50% coinsurance to hospital when: 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 Nothing 50% coinsurance to skilled nursing facility MIC PPMN HSA (3/11) • 34 1500 =100% BPL 67276 DOC 21410 • 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. See 3 Definitions These words have specific meanings benefits, coinsurance, ;custodial care, deductible, dependent, hospital, network, non - network, -non- network: provider reimbursement „- amount, physician, prenatal. care, provider, skilled care,; skilled nursing facility. £ s. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare guidelines) 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 1. and 2. in the table in this section are limited to a combined maximum of 120 visits per calendar year for in- network and 60 visits per calendar year for out -of- network benefits. Please note: These visit limits include any visits that you pay for in order to satisfy any part of your deductible. You may be eligible for additional intermittent skilled care if you have Medica coverage and are also enrolled in the Medical Assistance Program. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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. MIC PPMN HSA (3/11) 35 1500 -100% BPL 67276 DOC 21410 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 non - skilled services. 4. Physical, speech, or occupational therapy provided in your home for convenience. 5. Services provided in your home when you are not homebound. 6. Services primarily educational in nature. 7. Vocational and job rehabilitation. 8. Recreational therapy. 9. Self -care and self -help training (non - medical). 10. Health clubs. 11. Disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. • 12. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 13. Voice training. 14. Outpatient rehabilitation services when no medical diagnosis is present. 15. Home health aide services, except when rendered in conjunction with intermittent skilled care and related to the medical condition under treatment. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and" the Amounts You Pay Bene �� ` 1n network benefi #s Out of network benefits afte tl d ct le de ductible ` r e u �b after tl tibl * =For out -of network benefits, m addition to the'deductible and coinsurance, you are for any charges in excess of the non-network provider reimbursement amount Addi #iortatly, these charges will,:hot be applied toward sati of t he deductibl ar_ out of pocket maximum E 1. Intermittent skilled care when Nothing 50% coinsurance you are homebound, provided by or supervised by a registered nurse MIC PPMN HSA (3/11) 36 1500 -100% BPL 67276 DOC 21410 Horne Health Care Your Benefits and the Amounts You",Pay .Benefits In- network benefits * Out -of- network "benefits after " deductible after deductible For out -of "network benefits in addition to the:deductible and coinsurance, you are responsible for anykcharges in excess of the ; non network reimbursement amount Atlditronally, these charges will not =be applied toward satisfaction of the deductible or the out` -of pocket"max�mum" 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when you are homebound 3. Home infusion therapy Nothing 50% coinsurance 4. Services received in your home Nothing 50% coinsurance from a physician • MIC PPMN HSA (3/11) 37 1500 -100% BPL 67276 DOC 21410 Outpatient Rehabilitation K. Outpatient Rehabilitation This section describes coverage for both professional and outpatient health care facility services. A physician must direct your care. See Definitions These words have specific meanings benefits coinsurance deductible network;` non - network,; non - network' provider reimbursement amount, physician " Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to outpatient rehabilitation services arranged through a 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 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 coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. 6. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 7. Voice training. 8. Outpatient rehabilitation services when no medical diagnosis is present. MIC PPMN HSA (3/11) 38 1500 -100% BPL 67276 DOC 21410 Outpatient Rehabilitation 9. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your, Ben an the Amounts Yous'Pak Benefits In two"' rk benefits *O -of network - benefits alter after , deductible deductible * For out,of- network,benefits, in addition to the deductible and coinsurance, you are responsible for any charges =in excess.o the non network provider reimbursement.amoun# Additionally, these charges not. be applied toward satisfaction of the deductible or the out-of-pocket maximum. 1. Physical therapy received Nothing 50% coinsurance. outside of your home Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible. 2. Speech therapy received outside Nothing 50% coinsurance. of your home when speech is Coverage for speech impaired due to a medical illness therapy is limited to 20 or injury, or congenital or visits per calendar year. developmental conditions that Please note: This visit limit have delayed speech includes speech therapy development visits that you pay for in order to satisfy any part of your deductible. 3. Occupational therapy received Nothing 50% coinsurance. outside of your home when Coverage for physical and physical function is impaired due occupational therapy is to a medical illness or injury or limited to a combined limit congenital or developmental of 20 visits per calendar conditions that have delayed year. motor development Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible. MIC PPMN HSA (3/11) 39 1500 -100% BPL 67276 DOC 21410 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. See Definitions. These words have specific meanings benefits, 'claim- custodial care, deductible, emergency, hospital, inpatient, medically necessary member, Mental disorder, network, anon- network,: provider Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations and psychological testing. b. Psychotherapy and psychiatric services. c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week). d. Treatment for a minor, including family therapy. e. Treatment of serious or persistent disorders. f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD). g. 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. h. Treatment of pathological gambling. 2. Inpatient services include: a. Room and board. b. Attending psychiatric services. c. Hospital or facility -based professional services. d. 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 means a treatment program of 20 hours or more per week and may include lodging. e. Services, care, or treatment described as benefits in this certificate and 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. MIC PPMN HSA (3/11) 40 1500 -100% BPL 67276 DOC 21410 Mental Health f. Residential treatment services. These services include either: i. A residential treatment program serving children and adolescents with severe emotional disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic services. In addition to room and board, at least 30 hours a week per individual of mental health services must be provided, including group and individual counseling, client education, and other services specific to mental health treatment. Also, the program must provide an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. 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. 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). For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866-214 -6829. • For out -of- network benefits: 1. Mental health services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the mental health services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Mental health clinic e. Mental health residential treatment center f. Independent clinical social worker g. Marriage and family therapist h. Hospital that provides mental health services 2. Emergency mental health services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN HSA (3/11) 41 1500 -100% BPL 67276 DOC 21410 ICI • Mental Health 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. 4. Relationship counseling. 5. Family counseling services, except as specifically described in this certificate as treatment for a minor. 6. Services for telephone psychotherapy. 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, as those conditions are defined in the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. 0 8. Services; including room and board charges, .provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide mental health services. This includes, but is not limited to, services provided by mental health providers who are not authorized under state law to practice independently, and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch. • 9. Services to assist in activitie s. of daily living that do not seek to cure and are performed regularly as a part of a, routine or schedule. 10. Room and board charges associated with mental health residential treatment services providing less than 30 hours a week per individual of mental health services, or lacking an on -site medical /psychiatric assessment within 48 hours of admission,'psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. See Exclusions for additional services, supplies, and associated •expenses that are not covered. You Benefits '� �.�"�� ����4��-� `R $• _�� '� X � i � d and the Amounts YouEPay Benefits to network benefits , ut-of network benef �, �, after � fter deduc bfe " for ou# of network benefits in a tion to �e deductible and c surance, you are respons bie for any charges in excessof�the non netviork pro derr�re�mbursement amount Addition ally ,these charges will not be applied towardsatisfaction of the deductible or the out of- pocket maximum 1. Office visit i Nothing 50% coinsurance evaluations, diagnostic, and treatment services MIC PPMN HSA (3/11.) 42 1500- 100% BPL 67276 DOC 21410 Mental Health • Y o ur Bene and : the Amounts You Pay ;i .2: ,.. , ,,,:s - ., + i ' Benefits ." I network bene * Out -o f - n etwo r k bene after deductible a fter deductible * theFor out-of ' benefits, in additiori d a c you'are responsible �, - fo a ny charges in excess of t he non ne prow der " am oun t. Addit ional l y , se charges will not" be appl t oward fac s a t istion of the deductible or the o ut -of po ck e t maximum ,« 2. Intensive outpatient programs Nothing 50% coinsuran 3. Inpatient services (including residential treatment services) • a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance pr ofessional services c. Attending psychiatrist Nothing 50% coinsurance services d. Partial program Nothing 50% coinsurance MIC PPMN HSA (3/11) 43 1500 - 100% BPL 67276 DOC 21410 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 the Diagnostic and Statistical Manual of Mental Disorders. See Definitions These w ords k have specific meanings benefits, claim, coinsurance, c ustodial "care, deductible' mer eg_ e hospital, inpatient, medically necessary, member, m enta l disorder, network, 'non network, physicianipro■ider. Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations. b. Outpatient treatment. c. Intensive outpatient programs, including day treatment and partial programs, which may include multiple services and modalities, delivered in an outpatient setting. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. 2. Inpatient services include: a. Room and board. b. Attending physician services. c. Hospital or facility -based professional services. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. e. Residential treatment services. These are services from a licensed chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours per week per individual of chemical dependency services must be provided, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. MIC PPMN HSA (3/11) 44 1500 -100% BPL 67276 DOC 21410 Substance Abuse Covered For benefits and the amounts you pay, see the table in this section. • For in- network benefits: 1. Medica's designated mental health and substance abuse provider arranges in- network substance abuse benefits. 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). 2. In- network benefits will apply to services, care or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866- 214 -6829. • For out -of- network benefits: 1. Substance abuse services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Chemical dependency clinic e. Chemical dependency residential treatment center f. Hospital that provides substance abuse services g. Independent clinical social worker h. Marriage and family therapist 2. Emergency substance abuse services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. MIC PPMN HSA (3/11) 45 1500 -100% BPL 67276 DOC 21410 Substance Abuse 2. Services for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary. 4. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received. 5. Telephonic substance abuse treatment services. 6. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide substance abuse services. This includes, but is not limited to, services provided by mental health or substance abuse providers who are not authorized under state law to practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch. 7. Room and board charges associated with substance abuse treatment services providing less than 30 hours a week per individual of chemical dependency services, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. 8. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits ! Innetwork benefits *Out -of- network benefits after- =deductible after deductible For out of n benefits in addition to the deductible and coinsurance, you are'responsible for any charges in excess of the non proyider reimbursement amount Additionally, - these charges will not be applied toward satisfaction of the ded or the out of Rocket maximum .mm 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending physician services Nothing 50% coinsurance MIC PPMN HSA (3/11) 46 1500 -100% BPL 67276 DOC 21410 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. See _Definitions. These words have specific meanings `benefits coinsurance, deductible, durable; medical equipment network, non network, non network provider reimbursement amount, physician,, provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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, and hearing aids that meet the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. The list of eligible durable medical equipment and certain related supplies is periodically reviewed and modified by Medica. 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 purchased 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. If the durable medical equipment, prosthetic device, or hearing aid is covered by Medica, but the model you select is not Medica's standard model, you will be responsible for the cost difference. • In- network benefits apply to durable medical equipment, certain related supplies and prosthetic services prescribed by a physician and received from a network durable medical equipment provider, and hearing aids as described in 4. in the table in this section when prescribed by a network provider. To request a list of the durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. • Out -of- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a non - network provider. Out -of- network benefits also apply to hearing aids as described in 4. in the table in this section. In addition to the deductible or coinsurance described for out -of- network benefits, you are responsible for charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN HSA (3/11) 47 1500 -100% BPL 67276 DOC 21410 Durable Medical Equipment And Prosthetics Not covered These services, supplies, and associated expenses are not covered: l equipment and supplies, eic, appliances, a hearing aids not on Medica eligible list. the i 2. Charges in excess of the Medica standard model prosth t of s durable medical equipmentnd and , prosthetics, or hearing aids. 3. Repair, replacement, or revision of durable medical equipment, prosthetics, hearing aids, except when made necessary by normal wear and use. 4. Duplicate durable ui prosthetics, a ssociated expend hearing aids, including repair, replacement, or revision medical of dup items. , i See Exclusions for additional services, supplies, and anses that are not covered. Your Be n e fits a nd t he A m o un t s You Pay Be n e fit s _ in net b enefits Out-of-network benefits • :: 'after ded = a fter deductible g * Fo out-of bene fit s , in a d dit ion to fi deductible and coinsurance, you are respo for any c h a rges in ex of the non network provi r eim bursement a Additionally, these charges w ill not be applie toward sati sfa c tion o f t he d e du c t i b le ° or the;o m aximu m = �� � � mow 1. Durable medica equipment and Noth 50% coinsurance certain related supplies 2. Repair, replacement, or revision Nothing 50% coinsurance of durable medical equipment made necessary by normal wear. and use 3. Prosthetics I a. Initial purchase of external Nothing 50% coinsurance I prosthetic devices that replace a limb or an external body part, limited to: i. Arti arms, legs, feet, and hands ; ii. Artificial eyes, ears, and noses; iii. Breast prostheses b. Scalp hair prostheses due to Nothing. Medica pays up 50% coinsura nce. to alopecia areata to $350. This is Medica p $350. calculated each calendar This is calculated each year. calendar year. up MIC PPMN HSA (3/11) 48 1500 -100% BPL 67276 DOC 21410 Durable Medical Equipment And Prosthetics ......._... __ .... Your Benefits and the Amounts You Pay • Benefits Ir network benefi * Ou after deductible benefits after aft deductible * Porout of network benefits, in addition to the deductible and coinsurance, you . are responsible for == any charges m excess =of the non network provider reimbursement, amount: Additionally; these charges will not be applied toward satisfaction of the deductible or the out-of pocket maximum: c. Repair, replacement, or Nothing 50% coinsurance revision of artificial arms, legs, feet, hands, eyes, ears, noses, and breast prostheses made necessary by normal wear and use 4. Hearing aids for members 18 Nothing. Coverage is 50% coinsurance. years of age and younger for limited to one hearing aid Coverage is limited to hearing loss that is not per ear every three years. one hearing aid per ear correctable by other covered Related services must be every three years. procedures prescribed by a network provider. MIC PPMN NSA (3/11) 49 1500 -100% BPL 67276 DOC 21410 Miscellaneous Medical Services And Supplies 0. Miscellaneous Medical Services And Supplies This section describes coverage for miscellaneous medical services and supplies prescribed by a physician. Medica covers only a limited selection of miscellaneous medical services and supplies that meet the criteria established by Medica. Some items ordered by a physician, even if medically necessary, may not be covered. See Definitions These words have specific meanings: benefits,. coinsurance, deductible,. network, non- network, non - network provider reimbursement amount,.physician, provider, Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to miscellaneous medical services and supplies received from a network provider. • Out -of- network benefits apply to miscellaneous medical services and supplies received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered Other disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 50 1500 -100% BPL 67276 DOC 21410 ,a� Miscellaneous Medical Services And Supplies Your Benefits and the Amounts You Pay £ . Benefits � ; ' In-network benefits * Out-of-network benefits after deductible after deductible * For out-of network benefits, in addition to the deductible and coinsurance; you are responsible for any charges in excess of the - non network provider reimbursement amount ` Additionally, these charges will not be applied toward satisfaction of deductible or the out- of- pocket 1. Blood clotting factors Nothing 50% coinsurance 2. Dietary medical treatment of Nothing 50% coinsurance phenylketonuria (PKU) 3. Amino acid -based elemental Nothing 50% coinsurance formulas for the following diagnoses: a. cystic fibrosis; b. amino acid, organic acid, and fatty acid metabolic and malabsorption disorders; c. IgE mediated allergies to food proteins; d. food protein- induced enterocolitis syndrome; e. eosinophilic esophagitis; f. eosinophilic gastroenteritis; and g. eosinophilic colitis. Coverage for the diagnoses in 3.c. -g. above is limited to members five years of age and younger. 4. Total parenteral nutrition Nothing 50% coinsurance 5. Eligible ostomy supplies Nothing 50% coinsurance Please note: Eligible ostomy supplies may be received from a pharmacy or a durable medical equipment provider. 6. Insulin pumps and other eligible Nothing 50% coinsurance diabetic equipment and supplies MIC PPMN HSA (3/11) 51 1500 -100% BPL 67276 DOC 21410 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 network physician and received at a designated 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 appropriate for the diagnosis, without contraindications, and non - investigative. See Definitions. These words have specific meanings: benefats,,coinsurance, deductible, e- visits, hospital, "yinpatient, investigative, medically necessary, member, - network, n non etwork non network provider! reimbursem m ent aount p provider# Prior authorization. Prior authorization from Medica is required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood. The preceding is not a comprehensive list of eligible organ and bone marrow transplant. services. • 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. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 network transplant facilities). Based on the type of transplant you receive, Medica will determine the specific time period medically necessary for these services. MIC PPMN HSA (3/11) 52 1500 -1 BPL 67276 DOC 21410 Organ And Bone Marrow Transplant Services Not covered These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow transplant services except as described in this section. 2. 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 toi damage the bone marrow and related to transplants that would not be authorized by Medics under the medical criteria referenced in this section. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. 5. Islet cell transplants except for autologous islet cell transplants associated with pancreatectomy. 6. 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 suppressants, and supplies of a similar nature not otherwise covered under this Certificate. 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. 10. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a s pecific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. g Your Benefits and the Amounts YouPay ' _ ,, Benefits I network ben efits * Out o ne twork benefits after deductible ductible ft er e deductible * For out of-network benefits, in a ddition to the de an coinsurance, you are responsi fo any charges in excess of t he, non network provider reimbursement a Addit pally, these charges wit not be app lied toward satisfaction of.,the deductible or the out -of pocl et maximum. 1. Office visits Nothing No coverage 2. E- visits Nothing No coverage MIC PPMN HSA (3/11) 53 1500 100% BPL 67276 DOC 21410 T • Organ And Bone Marrow transplant Services Yo Ben ef i ts an d t he A mounts You Pay, B enefits t o network b * Out of- ne benefits. ° after deductible a fter d e d uc t i b l e , �e � * F or out of network' benefits, i a ddi tion to =the deductib 'and coinsurance, you a re r espon s ible for- a ny ; charge s in ;exc o f the n on netw p r ovider rei mb ur sement =amount Additionally, these .,• ' ch e s will otb d towa s,atfsfac # ion of t d o the out of pocket "I: aximu 3. Outpatient se a. Professional services • i. Surgical services (as Nothing No coverage defined in the Physicians' Current Procedural Terminology c ode book) received from a physician during an office visit or an outpatient hospital visit ii. Anesthesia services Nothing No coverage received from a provider during an office visit or an outpatient hospital or ambulatory surgical •. center visit iii. Outpatient lab and Nothing No coverage pathology n iv. Outpatient x -rays and Nothing No coverage other imaging services v. Other outpatient hospital ' Nothing No coverage services received from a physician vi. Services related to Nothing No coverage human leukocyte antigen testing for bone marrow transplants b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x -rays and Nothing No coverage other imaging. services ; iii. Other outpatient hospital Nothing No coverage services 4. Inpatient services • Nothing No coverage MIC PPMN HSA (3/11) 54 1500 -100% ______ BPL 67276 DOC 21410 • • Organ And Bone Marrow Transplant Services Your Benefits, and Amounts You ,Pay Benefits In-network benefits * Out -of- network. benefits "" after deductible --after deductible *For out-of network benefits, in addition to the deductible and coinsurance, you are responsible any charges in excess Of the non- network provider reimbursement amount.: Additionally; these charges'will not be applied toward satisfaction of :the deductible or the out -of pocket maximum: 5. Services received from a Nothing No coverage physician during an inpatient stay 6. Anesthesia services received Nothing No coverage from a provider during an inpatient stay 7. Transportation and lodging The deductible does not No coverage a. As described below, apply to this reimbursement of reasonable reimbursement benefit. and necessary expenses for You are responsible for travel and lodging for you paying all amounts riot and a companion when you reimbursed under this receive approved services at benefit. Such amounts a designated facility for do not count toward your transplant services and you out -of- pocket maximum live more than 50 miles from or toward satisfaction of that designated facility your deductible. i. Transportation of you and one companion (traveling on the same day(s)) to and /or from a designated facility for transplant services for pre- ' transplant, transplant, and post - transplant services. If you are a minor child, transportation expenses for two companions will be reimbursed. MIC PPMN HSA (3/11) 55 1500 - 100% BPL 67276 DOC 21410 Organ And Bone Marrow Transplant Serv.i'ces; Your Benefits and .the Amounts `You P y � Benefits �xIn network b e n efits Out o ,network benefits � � after de d uc ti a after ded uc'„t : ! 1 le * For�out of network benefits, in additiorvto the deductible and coinsurance; you are responsible for- .: any charges in excess of the non network provider reimbursement, amount Additionally, these charges wi not be applied toward satisfaction of the d or the out -of poc maximum ii. Lodging for you (while not confined) and one companion. Reimbursement is available for a per diem amount of up to $50 for one person or up to $100 for two people. If you are a minor child, reimbursement for lodging expenses for two companions is available, up to a per diem amount of $100. iii. There is a lifetime maximum of $10,000 per member for all • transportation and lodging expenses incurred by you and. your companion(s) and reimbursed under the Contract or under any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. b. Meals are not reimbursable under this benefit. MIC PPMN HSA (3/11) 56 1500 -100% BPL 67276 DOC 21410 infertility Diagnosis A Q. Infertilit Diagnosis This section describes coverage for the diagnosis of infertility. Coverage includes benefits for professional, hospital and ambulatory surgical center services. Services for the diagnosis of infertility must be received from or under the direction of a physician. All services, supplies, and associated expenses for the treatment of infertility are not covered. See. Definitions. These words have specificmeanings benefits, coinsurance, deductible, e visits, hospital, inpatient, member,network, non network, non - network provider reimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered Benefits apply to services for the diagnosis of infertility received from a network or non - network provider. Coverage for infertility services is limited to a maximum of $5,000 per member per calendar year for in- network and out -of- network benefits combined. More than one coinsurance may be required if you receive more than one service, or see more than one provider per visit. Not covered All services, supplies, and associated expenses for the treatment of infertility are not covered including the following: 1. Professional, hospital, and ambulatory surgical center services for the treatment of infertility. 2. Infertility drugs. 3. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 4. Services for a condition that a physician determines cannot be successfully treated. 5. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 6. Sperm banking. 7. Adoption. 8. Donor sperm. • 9. Embryo and egg storage. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 57 1500 -100% BPL 67276 DOC 21410 Infertility Diagnosis Your Benefits an Amounts You Pay Benefits , . In network benefits * Out-Of-network benefits after deductible after deductible "' out- ofnetwork benefits, in addition to the deductible and coinsurance you are responsible for ar charges in.excess of the non network provider reimbursement amount_ Additionally, these charges will not be applied toward satusfaction of the. deductible =or the out- ofpocket maximum 1. Office visits, including any Nothing 50% coinsurance services provided during such visits 2. E - visits Nothing No coverage 3. Outpatient services received at a Nothing 50% coinsurance • hospital 4. Inpatient services Nothing 50% coinsurance • MIC PPMN HSA (3/11) 58 1500 -100% BPL 67276 DOC 21410 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. See Definitions These words have specific meanings benefits, coinsurance :;cosmetic, deductible, a visits, hospital,; inpatient, medically necessary,: member, network, non network, non- network .provider reimbursement amount,° physicia n, ; provider,: reconstructive, restorative - Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. 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. 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. 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. 6. Hair transplants. MIC PPMN HSA (3/11) 59 1500 -100% BPL 67276 DOC 21410 Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular,injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits . network °benefits * Out- ofnetwork x after deductible after deductible * For out -of- network, benefits, in addition -to the deductible and coinsurance, - you are= responsible for any in excess of the non network provider reimbursement Additionally, these charges will not be applied toward satisfaction of the deductible or theout-of-pocket maximum 1. Office visits Nothing' 50% coinsurance 2. E - visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance or ambulatory surgical center services received from a physician MIC PPMN HSA (3/11) 60 1500 -100% BPL 67276 DOC 21410 Reconstructive And Restorative Surgery Your Benefits and the Amounts You Pay_ Benefits In- network °benefits * Out -of- network benefits after deductible after deductible For out-of-network in addition to the .deductible and coinsurance; you are responsible for any charges in excess of the non - network provider reimbursement amount Additionally; these charges will not.be applied toward satisfaction of the deductible or the out-of-pocket maximum: b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Inpatient services Nothing 50% coinsurance 5. Services received from a Nothing 50% coinsurance physician during an inpatient stay 6. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay MIC PPMN HSA (3/11) 61 1500 -100% BPL 67276 DOC 21410 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 qualify as reimbursable under Medicare. See Definitions These words have specific meanings benefits, coinsurance, custodial "care, deductible, emergency, hospital, inpatient, network, .non network; non network provider reimbursement y arnount, physician, kilied care, skilled nursing facility , Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For purposes of this section, room and board includes coverage of health services and supplies. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. Custodial care and other non - skilled services. 2. Self -care or self -help training (non - medical). 3. Services primarily educational in nature. 4. Vocational and job rehabilitation. 5. Recreational therapy. 6. Health clubs. 7. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 8. Voice training. MIC PPMN HSA (3/11) 62 1500 -100% BPL 67276 DOC 21410 Skilled Nursing Facility Services 9. Outpatient rehabilitation services when no medical diagnosis is present. 10. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits In network benefits * Out of- network benefits after: deductible = after deductible * For out `of- network benefits, in addition to the deductible and coinsurance, you; are responsible for any charges in excess of the non-network reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. 1. Daily skilled care or daily skilled Nothing 50% coinsurance rehabilitation services, including room and board Please note: Such services are eligible for coverage only if they would qualify as reimbursable under Medicare. 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when room and board is not eligible to be covered 3. Services received from a Nothing 50% coinsurance physician during an inpatient stay in a skilled nursing facility , MIC PPMN HSA (3/11) 63 1500 -100% BPL 67276 DOC 21410 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 hospice program. See Definitions These have specif c meanings benefits, coinsurance, deductible, member, network, non network, non network provider reimbursement amount, physician, skilled nursing facility. - 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. 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 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 network hospice program. • Out -of- network benefits apply to hospice services arranged through a physician and received from a non - network hospice program. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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). 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. Members who elect to receive hospice services do so in place of curative treatment for their terminal illness for the period they are enrolled in the hospice program. You may withdraw from the hospice program at any time upon written notice to the hospice program. You must follow the hospice program's requirements to withdraw from the hospice program. MIC PPMN HSA (3/11) 64 1500 -100% BPL 67276 DOC 21410 • Hospice Services Not covered These services, supplies, and associated expenses are not covered: 1. Respite care for more than five consecutive days at a time. 2. 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 hospice program's plan of care. 4. Services not provided by the hospice program. 5. Hospice daycare, except when recommended and provided by the hospice program. 6. Any services provided by a family member or friend, or individuals who are residents in your home. 7. Financial or legal counseling services, except when recommended and provided by the hospice program. 8. Housekeeping or meal services in your home, except when recommended and provided by the hospice program. 9. Bereavement counseling, except when recommended and provided by the hospice program. See Exclusions for additional services, supplies, and associated expenses that are riot covered. B enefits and the Amount You Pay • Benefits < ff In- network benefits '`* • Out of network benefits : •" : ' after deductible after deductible, 'fi t�a E Y F d d 35�?Yy m k For out-of-network benefitsAn addition tothe deductible and c oinsurance , you are responsible for any, charges m excess of the non network provider: reimbursement amount Additionally_, these charges will not be. applied toward satisfaction of the •deductible or the ; ou# of p m m ocket aximu. 1. Hospice services Nothing 50% coinsurance MIC PPMN HSA (3/11) 65 1500 -100% BPL 67276 DOC 21410 I • 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. TMJ disorder is covered the same as any other joint disorder under this certificate. See Definitions These words have specific meanings:- benefits, coinsurance, deductible,3 e visits .hospital, inpatient, :member, network, non network, non- network provider reimbursementamount, physician, provider.; . .. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 66 1500 -100% BPL 67276 DOC 21410 Temporomandibular Joint (TIM) Disorder Your Benefits and the Amounts You Pay Benefits .. x' In- network benefits * Out -of- network benefits after deductible after deductible *For ;out -of- network- benefits,,in addition to the de -and coinsurance,; you: are respons for any charges in excess of the n`on network provider reimbursement amount Additionally, these, :. charges will not beapplied toward satisfaction of the deductible or the out maximum x E � 1. Office visits Nothing 50% coinsurance 2. E - visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology gY iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services . v. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services received from a physician or dentist b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services MIC PPMN HSA (3/11) 67 1500 -100% BPL 67276 DOC 21410 Temporomandibular Joint (TMJ) Disorder Yo ur. Benefits and the •Amounts Pay.... Benefits : m: to network benefits * Out of- network benefits after deductible after deductible * o the deductible and coinsurance, you5are responsible: for for out -of network benefits; �n addition t any charges in excessof thejnon network reimbursement amountAdditionally, theae charges will not be applied toward satisf of the deductible or the out of pocket' maximum iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Physical therapy received Nothing 50% coinsurance outside of your home 5. Inpatient services Nothing 50% coinsurance 6. Services received from a Nothing 50% coinsurance physician or dentist during an inpatient stay 7. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay 8. TMJ splints and adjustments if Nothing 50% coinsurance your primary diagnosis is joint disorder MIC PPMN HSA (3/11) 68 1500 -100% BPL 67276 DOC 21410 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. 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 alignment or occlusion of the teeth. These services are not covered under any section of this certificate. See Definitions These'words ha ve specific meanings. benefits, comsu ance, deductibie, dependent hospital, member, network, non network,..non- network provider, reimbursement arriount physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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), except as described in this section for the treatment of cleft lip and palate. 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, except as described in this section for the treatment of cleft lip and palate. 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. MIC PPMN HSA (3/11) 69 1500 -100% BPL 67276 DOC 21410 Medical- Related Dental Services 8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident - related dental services as described in this section. 9. Routine diagnostic and preventive dental services. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefit the Amounts You Pay Benefits_ 'An-network benefits * Out-of-network benefits after,deductible after deductible * For out-of-network benefits, in addition to the deductible and coinsuranc you a responsible for any charges in excess of,the non - network provider reimbursement - amount. Additi these - ch r es willA t be `li .tow rd satisfaction f he deductible or out= f- ocket °maximum. a g o app ed a o the � e v p 1. Charges for medical facilities Nothing 50% coinsurance and general anesthesia services that are: a. Recommended by a physician; and b. Received during a dental procedure; and c. Provided to a member who: i. 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. 2. For a dependent child, Nothing 50% coinsurance orthodontia, dental implants, and oral surgery treatment related to cleft lip and palate MIC PPMN HSA (3/11) 70 1500 -100% BPL 67276 DOC 21410 • Medical - Related Dental Services Your Benefits and the Amounts You Pay Benefits , In network,benefits * Out of- network benefits after deductible after deductible ` a � a *:- For out of n benefits, : in addition to-the deductible and coinsurance, are re n s posible f or any.charges in excess of the ;non network provider reimbursement amount: y Ad ou tl #tonally; these charges will not be applied toward satisfaction of the deductible or ' the out : of pocket rrfazim 3. Accident - related dental services Nothing 50% coinsurance to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply: a. Coverage is limited to services received within 24 months from the later of: i. the date you are first covered under the Contract; or ii. the date of the injury 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 one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year. 4. Oral surgery for: Nothing 50% coinsurance a. Partially or completely unerupted impacted teeth; or b. A tooth root without the extraction of the entire tooth (this does not include root canal therapy); or c. The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth MIC PPMN HSA (3/11) 71 1500 -100% BPL 67276 DOC 21410 Referrals To Non - Network Providers W.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 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. See Defin�t�ons These words have specific meanings benefits,medically necessary, network; -non- network, physician provider . - If you want to apply for a standing referral to a non - network provider, contact Medica for more information. If determined by Medica to be clinically appropriate, a standing referral may be granted by Medica. A standing referral is a referral issued by a network provider and authorized by Medica for conditions that require ongoing services from a specialist provider. Standing referrals will only be covered for the period of time appropriate to your medical condition. Referrals and standing referrals will not be covered to accommodate personal preferences, family convenience, or other non - medical reasons. Referrals will also not be covered for care that has already been provided. If your request for a standing referral is denied, you have the right to appeal this decision as described in Complaints. What you must do 1. 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. 2. 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. 3. 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. 4. Pay any charges not authorized for coverage by Medica. What Medica will do 1. May require that you see another network provider selected by Medica before a determination by Medica that a referral to a non - network provider is medically necessary. 2. 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. MIC PPMN HSA (3/11) 72 1500 -100% BPL 67276 DOC 21410 Referrals To Non-Network Providers 3. Provides coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. 4. 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 24 hours from the time of the initial request if your attending provider believes that an expedited review warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function. • MIC PPMN NSA (3/11) 73 1500 -100% BPL 67276 DOC 21410 Harmful Use Of Medical Services X. 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. See Definitions These ;words have specific: meanings benefits, emergency; hospital network physician, ;prescription drug, provider. 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. You must obtain a referral from your coordinating health care provider if your condition requires care or treatment from a provider other than your coordinating health care provider. Medica will send you specific information about: 1. How to obtain approval for benefits not available from your coordinating health care providers; and 2. How to obtain emergency care; and 3. When these restrictions end. MIC PPMN HSA (3/11) 74 1500 -100% BPL 67276 DOC 21410 Exclusions Y. Exclusions • See Definitions These words have specific meanings claim, cosmetic, custodial care, durable medical - equipment, emergency, investigative, medically necessary, member, non network, physician, provider, reconstructive, routine foot care. Medica will not provide coverage for any of the services, treatments, supplies, or items described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition. This section describes additional exclusions to the services, supplies, and associated expenses already listed as Not covered in this certificate. These include: 1. 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. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive. 3. Refractive eye surgery, including but not limited to LASIK 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 a physician, air and bone conduction hearing aids (including internal, external, or implantable hearing aids or devices), 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. Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct -to- consumer marketing and not under the direction of your physician. 8. Services or supplies not directly related to care. 9. Autopsies. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition. 11. Nutritional and electrolyte substances, except as specifically described in Miscellaneous Medical Services And Supplies. 12. Physical, occupational, or speech therapy or chiropractic services when there is no reasonable expectation that the condition will improve over a predictable period of time. 13. Reversal of voluntary sterilization. MIC PPMN HSA (3/11) 75 1500 -100% BPL 67276 DOC 21410 Exclusions 14. Personal comfort or convenience items or services, including but not limited to breast pumps, except when the pump is medically necessary. 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, except as described in Organ And Bone Marrow Transplant Services. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 19. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular disease, peripheral neuropathies, and significant neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. 21. Services by persons who are family members or who share your legal residence. 22. Services for which coverage is available under workers' compensation, employer liability, or any similar law. 23. Services received before coverage under the Contract becomes effective. 24. Services received after coverage under the Contract ends. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non - network providers and non - network dentists. 26. Photographs, except for the condition of multiple dysplastic syndrome. 27. Occlusal adjustment or occlusal equilibration. 28. Dental implants (tooth replacement), except as described in Medical - Related Dental Services. 29. Dental prostheses. 30. Orthodontic treatment, except as described in Medical - Related Dental Services. 31. Treatment for bruxism. 32. Services prohibited by applicable law or regulation. 33. Services to treat injuries that occur while on military duty, and any services received as a result of war or any act of war (whether declared or undeclared). 34. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or licensure. 35. Exams, other evaluations, or other services received solely for the purpose of judicial or administrative proceedings or research, except emergency examination of a child ordered by judicial authorities. 36. Non - medical self -care or self -help training. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services. 38. Coverage for costs associated with translation of medical records and claims to English. MIC PPMN HSA (3/11) 76 1500-100% BPL 67276 DOC 21410 Exclusions 39. Treatment for spider veins. 40. Services not received from or under the direction of a physician, except as described in this certificate. 41. Orthognathic surgery. 42. Sensory integration, including auditory integration training. 43. Services for or related to vision therapy and orthoptic and /or pleoptic training, except as described in Professional Services. 44. Services for or related to intensive behavior therapy treatment programs for the treatment of autism spectrum disorders. Examples of such services include, but are not limited to, Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral Intervention (IBI), and Lovaas therapy. • 45. Health care professional services for maternity labor and delivery in the home. 46. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and subsequent procedures. 47. Services for the treatment of infertility. 48. Infertility drugs. 49. Acupuncture. 50. Services solely for or related to the treatment of snoring. 51. Interpreter services. 52. Services provided to treat injuries or illness that are the result of committing a crime or attempting to commit a crime. 53. Services for private duty nursing, except as stated in Home Health Care: Examples of private duty nursing services include, butare not limited to, skilled or unskilled services provided by an independent nurse who is ordered by the member or the member's representative, and not under the direction of a physician. 54. Laboratory testing that has been performed in response to direct -to- consumer marketing and not under the direction of a physician. 55. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), other than those granted a humanitarian device exemption. MIC PPMN HSA (3/11) 77 1500 -100% BPL 67276 DOC 21410 Flow To Submit A Claim Z. How To Submit A Claim This section describes the process for submitting a claim. See Definitions These words have specific meanings benefits, claim, dependent, member, network; non= network, non - network; provider reimbursement amount, provider, 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. Claim forms may also be obtained by signing in at www.mymedica.com. Network providers are required to submit claims within 180 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 180 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 one of the telephone numbers listed inside the front cover. Claim forms may also be obtained by signing in at www.mymedica.com. 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 the address identified on the back of your identification card. Upon receipt of your claim for benefits from non - network providers, Medica will generally pay to you directly the non - network provider reimbursement amount. Medica will only pay the provider of services if: 1. The non - network provider is one that Medica has determined can be paid directly; and 2. The non - network provider 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 claims 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 receiving the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. CaII Customer Service at one of the telephone numbers listed inside the front cover for a list of i non - network providers that Medica will not pay directly. MIC PPMN HSA (3/11) 78 1500 -100% BPL 67276 DOC 21410 How To Submit A Claim 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 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. MIC PPMN HSA 3/11 79 HSA (3/11) 1500 - 100% BPL 67276 DOC 21410 Coordination Of Benefits AA. Coordination Of Benefits This section describes how benefits are coordinated when you are covered under more than one plan. See Definitions. These words have specific meanings: benefits, claim, deductible, dependent, :! emergency, hospital, member, non network, non- network provider reimbursement amount, ' provider, subscriber 1. Applicability a. 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. b. If this coordination of benefits provision applies, 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 Order of benefit determination rules, the benefits of this plan: i. 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 a. Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment: i. Group insurance or group -type coverage, whether insured or uninsured, or individual coverage. 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 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. b. This plan is the part of the Contract that provides benefits for health care expenses. c. 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. MIC PPMN HSA (3/11) 80 1500 -100% BPL 67276 DOC 21410 Coordination Of 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. d. 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. Allowable expense does not include the deductible for members with a primary high deductible plan and who notify Medica of an intention to contribute to a health savings account. The difference between the cost of a private hospital room and the cost of a semi - private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private 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 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 member 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. e. 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 a. 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 3.b. below, require that this plan's benefits be determined before those of the other plan. • b. Rules. This plan determines its order of benefits using the first of the following rules which applies: i. 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. ii. 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 MIC PPMN HSA (3/11) 81 1500 -100% BPL 67276 DOC 21410 Coordination Of Benefits 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. iii. 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 determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. iv. 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 3.b.ii. v. 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. vi. 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. vii. No -fault automobile insurance. Coverage under the No -Fault Automobile Insurance Act or similar law applies first. viii. 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 a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that MIC PPMN HSA (3/11) 82 1500 -100% BPL 67276 DOC 21410 L Coordination Of Benefits event, the benefits of this plan may be reduced under this section. Such other plan or plans are referred to as the other plans in b. immediately below. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of: .' 1. The benefits that would be payable for the allowable expense under this plan in the absence of this COB provision; and 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. 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, 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; or 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. Please note: See Right Of Recovery for additional information. MIC PPMN HSA (3/11) 83 1500 -100% BPL 67276 DOC 21410 Right Of Recovery BB. Right Of Recovery This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and federal law. For information about the effect of applicable state and federal law on Medica's subrogation rights, contact an attorney. See Definitions This has a specific meaning benefits 1. 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. 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 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. 4. By accepting coverage under the Contract, you agree: a. That if Medica pays benefits for medical expenses you incur as a result of any act by a third party for which the third party is or may be liable, and you later obtain full recovery, you are obligated to reimburse us for the benefits paid in accordance to Minnesota law. b. 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. c. To provide prompt written notice to Medica when you make a claim against a party 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. - f. 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. MIC PPMN HSA (3/11) 84 1500 -100% BPL 67276 DOC 21410 Eligibility And Enrollment CC. Eligibility And Enrollment This section describes who can enroll and how to enroll. See Definitions These'words have' Pecific meanings continuous cover dependent, late entrant, member, ,mental- disorder, physician, placed for adoption, premium, qualifying coverage, subscriber, waiting period Who can enroll To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract and be a subscriber or dependent as defined in this certificate. See Definitions. 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 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 other time for consideration as a late entrant as described in this section under Late enrollment. Dependents will not be enrolled without the eligible employee also being enrolled. A child who is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical Child Support Order (QMCSO) and 6. under Special 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, a dependent child reaching the dependent limiting age, or other facts identifying you or your dependents. (For dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption; however, we encourage you to enroll your newborn dependent under the Contract within 30 days from the date of birth, date of placement for adoption, or date of adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with the subscriber, and any child who is a member pursuant to a QMCSO will be covered without application of health screening or waiting periods. The employer must notify Medica, as set forth in the Contract, 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 A 30 -day time period starting with the date an eligible employee and dependents are first eligible to enroll for coverage under the Contract. An eligible employee must enroll within this MIC PPMN HSA (3/11) 85 1500 -100% BPL 67276 DOC 21410 Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30 -day time period does not apply to newborns or children newly adopted or placed for adoption; see Special enrollment.) An eligible employee and dependents that enroll during the initial enrollment period are accepted without application of health screening or affiliation periods. An eligible employee and dependents who do not enroll during the initial enrollment period may enroll for coverage during the next open enrollment, any applicable special enrollment periods or as a late entrant (if applicable, as described below). A member who is a child entitled to receive coverage through a QMCSO is not subject to any initial enrollment period restrictions, except as noted in this section. Open enrollment A minimum 14 -day period set by the employer and Medica each year during which eligible employees and dependents who are not covered under the Contract may elect coverage for the upcoming Contract year. An application must be submitted to the employer for yourself and any dependents. Special enrollment Special enrollment periods are provided to eligible employees and dependents under certain circumstances. 1. Loss of other coverage a. A special enrollment period will apply to an eligible employee and dependent if the individual was covered under Medicaid or a State Children's Health Insurance Plan and lost that coverage as a result of loss of eligibility. The eligible employee or dependent must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. In the case of the eligible employee's loss of coverage, this special enrollment period applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of coverage, this special enrollment period applies to both the dependent who has lost coverage and the eligible employee. b. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under qualifying coverage other than Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment, and declined coverage for that reason. The eligible employee or dependent must present either evidence of the loss of prior coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated; and request 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, or the date on which a claim is denied due to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; MIC PPMN HSA (3/11) 86 1500 -100% BPL 67276 DOC 21410 Eligibility And Enrollment ii. Loss of eligibility includes: • loss of eligibility as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment; • cessation of dependent status; • incurring a claim that causes the eligible employee or dependent to meet or exceed the lifetime maximum limit on all benefits; • if the prior coverage was offered through an individual health maintenance organization (HMO), a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area; • if the prior coverage was offered through a group HMO, a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other coverage option is available; and • the prior coverage no longer offers any benefits to the class of similarly situated individuals that includes the eligible employee or dependent. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is eligible for or elects applicable federal or state continuation coverage; iv. 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; In the case of the eligible employee's loss of other coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of other coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. c. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under benefits available under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or any applicable state continuation laws at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. The eligible employee or dependent must present evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to failure of the eligible employee or dependent to pay premiums on a timely basis or for cause; and request enrollment in writing within 30 days of the date of the exhaustion of coverage. For purposes of 1.c.: i. Exhaustion of COBRA or state continuation coverage includes: • losing COBRA or state continuation coverage for any reason other than those set forth in ii. below; • losing coverage as a result of the employer's failure to remit premiums on a timely basis; MIC PPMN HSA (3/11) 87 1500 -100% BPL 67276 DOC 21410 Eligibility And Enrollment • losing coverage as a result of the eligible employee or dependent incurring a claim that meets or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or • if the prior coverage was offered through a health maintenance organization (HMO), losing coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other COBRA or state continuation coverage is available. ii. Exhaustion of COBRA or state continuation coverage 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. iii. In the case of the eligible employee's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. 2. 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 and provided that the eligible employee also enrolls during this special enrollment period; 3. 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 (for dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption) and provided that the eligible employee also enrolls during this special enrollment period; 4. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in 3. 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; and d. The eligible employee also enrolls during this special enrollment period; or 5. 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 2. or 3. above, becoming eligible to enroll under the coverage provided the eligible employee also enrolls during this special enrollment period. 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as described in this section, Medica will provide the eligible dependent child with a special enrollment period provided the eligible employee also enrolls during this special enrollment period. ■ MIC PPMN HSA (3/11) 88 1500- 100% BPL 67276 DOC 21410 Eligibility And Enrollment Late enrollment An eligible employee or an eligible employee and dependents who do not enroll for coverage offered through the employer during the initial or open enrollment period or any applicable special enrollment period will be considered late entrants. Late entrants who have maintained continuous coverage may enroll and coverage will be effective the first day of the month following date of Medica's approval of the request for enrollment. Continuous coverage will be determined to have been maintained if the Tate entrant requests enrollment within 63 days after prior qualifying coverage ends. Individuals who have not maintained continuous coverage may not enroll as late entrants. An eligible employee or dependent who: 1. does not enroll during an initial or open enrollment period or any applicable special enrollment period; and - 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the 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. 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. If the eligible employee whose dependent child is the subject of the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, the eligible employee must also enroll for coverage under the Contract during the 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. The date your coverage begins Your coverage begins at 12:01 a.m. on the effective date of your enrollment. 1. For eligible employees and dependents who enroll during the initial enrollment period, coverage begins on the effective date specified in the Contract. MIC PPMN HSA (3/11) 89 1500 - 100% BPL 67276 DOC 21410 Eligibility And Enrollment 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: a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first calendar month following the date on which the request for enrollment is received by Medica; b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of adoption or placement for adoption, date of adoption or placement. In all other cases, the date the subscriber acquires the dependent child; c. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.b. above; • d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. or 3. under Special enrollment becomes effective; • e. Number 6. under Special enrollment, the first day of the first calendar month following the date the completed request for enrollment is received by Medica. 4. For eligible employees and /or dependents who enroll during late enrollment, coverage begins on the first day of the month following date of Medica's approval of the request for enrollment. MIC PPMN HSA (3/11) 90 1500 -100% BPL 67276 DOC 21410 Ending Coverage DD. 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. See Definitions. These words have specific meanings certification of qualifying coverage, claim dependent, member, premium, subscriber;" You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. When coverage ends Unless otherwise specified in the Contract, 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 Eligibility And 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. If coverage ends due to fraud, 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. Fraud includes but is not limited to: a. Intentionally 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 b. Intentional 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 MIC PPMN HSA (3/11) 91 1500 -100% BPL 67276 DOC 21410 Ending Coverage e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional misrepresentation with regard to any aspect of coverage under the Contract. 7. 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; 8. 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; 9. For a spouse, the end of the month following the date of divorce; 10. For a dependent child, the end of the month in which the child is no longer eligible as a dependent; or 11. 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. MIC PPMN HSA (3/11) 92 1500 -100% BPL 67276 DOC 21410 i _�, Continuation EE. Continuation This section describes continuation coverage provisions. When coverage ends, members may be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer. See Definitions. These words have specific meanings: benefits, dependent, member, placed for adoption,,, premium, subscriber, total disability. The paragraph below describes the continuation coverage provisions. State continuation is described in 1. and federal continuation is described in 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. When your continuation coverage under this section ends, you have the option to enroll in an individual conversion health plan as described in Conversion. 1. Your right to continue coverage under state law Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: a. 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. b. 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. It is intended that no greater rights be provided than those required by Minnesota law. Take time to read this section carefully. Subscriber's Toss 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. In 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. MIC PPMN HSA (3/11) 93 1500 -100% BPL 67276 DOC 21410 Continuation 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; 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. 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: 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. 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. Consistent with Minnesota law, the subscriber and dependents have 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. If continuation coverage is not elected, your coverage under the Contract will end. MIC PPMN HSA (3/11) 94 1500 -100% BPL 67276 DOC 21410 g Continuation 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 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. Surviving dependents of a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. 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: a. 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. b. 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 iii. The date coverage would otherwise terminate under the Contract. c. For instances where dependent children lose coverage as a result of Toss of dependent 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 iii. The date coverage would otherwise terminate under the Contract. d. 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: i. The date the former spouse becomes covered under another group health plan; 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 maybe continued until the earlier of: 1. i. The date the former spouse becomes covered under another group health plan; or MIC PPMN HSA (3/11) 95 1500 -100 %0 BPL 67276 DOC 21410 Continuation ii. The date coverage would otherwise terminate under the Contract. e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of: i. The date the surviving spouse and dependent children become covered under another group health plan; 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 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. 2. 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 General COBRA information in this section. USERRA continuation coverage Continued coverage shall be provided as required under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The employer shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General USERRA information in this section. General COBRA information 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 coverage is a group health plan for purposes of COBRA. This section 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 section carefully. MIC PPMN HSA (3/11) 96 1500 -100% BPL 67276 DOC 21410 Continuation Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as: 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 c. A dependent child of a covered employee. (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 Toss 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; j j 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. Subscriber's child's Toss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following 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 the subscriber 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 MIC PPMN HSA (3/11) 97 1500 -100% BPL 67276 DOC 21410 Continuation 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. 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. Consistent with federal law, the subscriber and dependents have 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 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. 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 amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 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 of COBRA coverage 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 MIC PPMN HSA (3/11) 98 1500 -100% BPL 67276 DOC 21410 Continuation 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. 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. 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 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 pre- existing condition; or d. The subscriber becomes entitled to (actually covered under) Medicare. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. General USERRA information USERRA requires employers to offer employees 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 coverage is a group health plan for the purposes of USERRA. This section 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 section carefully. Employee's Toss The employee has the right to elect continuation of coverage if there is a loss of coverage under the Contract because of absence from employment due to service in the uniformed services, and the employee was covered under the Contract at the time the absence began, and the employee, or an appropriate officer of the uniformed services, provided the employer with advance notice of the employee's absence from employment (if it was possible to do so). Service in the uniformed services means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active duty for training, initial active duty for training, inactive duty training, full -time National Guard duty, and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of these duties. MIC PPMN HSA (3/11) 99 1500 -100% BPL 67276 DOC 21410 Continuation Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army National Guard, and the Air National Guard, when engaged in active duty for training, inactive duty training, or full -time National Guard duty, and the commissioned corps of the Public Health Service. Election rights The employee or the employee's authorized representative may elect to continue the employee's coverage under the Contract by making an election on a form provided by the employer. The employee has 60 days to elect continuation coverage measured from the date coverage would be lost because of the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The employee may elect continuation coverage on behalf of other covered dependents, however, there is no independent right of each covered dependent to elect. If the employee does not elect, there is no USERRA continuation available for the spouse or dependent children. In addition, even if the employee does not elect USERRA continuation, the employee has the right to be reinstated under the Contract upon reemployment, subject to the terms and conditions of the Contract. Type of coverage and cost If the employee elects 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. The amount charged cannot exceed 102 percent of the cost of the coverage unless the employee's leave of absence is less than 31 days, in which case the employee is not required to pay more than the amount that they would have to pay as an active employee for that coverage. There is a grace period of at least 30 days for the regularly scheduled premium. Duration of USERRA coverage When an employee takes a leave for service in the uniformed services, coverage for the employee and dependents for whom coverage is elected begins the day after the employee would lose coverage under the Contract. Coverage continues for up to 24 months. Federal law provides that continuation coverage may end earlier for any of the following reasons: a. The employer no longer provides group health coverage to any of its employees; b. The premium for continuation coverage is not paid on time; c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct; d. The employee fails to return to work following the completion of his or her service in the uniformed services; or e. The employee returns to work and is reinstated under the Contract as an active employee. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. MIC PPMN HSA (3/11) 100 1500 -100% BPL 67276 DOC 21410 • Continuation COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation coverage in addition to USERRA continuation coverage, these coverages run concurrently. • MIC PPMN HSA (3/11) 101 1500 -100% BPL 67276 DOC 21410 1 Conversion FF. Conversion See Definitions These words have specific meanings: continuous coverage; dependent, premium; waiting period Your conversion plan coverage may not provide the same coverage as your previous group health plan. Benefits and provider networks may be different. Minnesota residents This section describes your right to convert to an individual conversion plan if you are a resident of Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. If you are a Minnesota resident, you may be eligible to obtain coverage from 1) other private sources of health coverage, or 2) the Minnesota Comprehensive Health Association, without a pre- existing condition limitation. Contact the Minnesota Comprehensive Health Association for further information: • For deductible plan options call 1- 866 - 894 -8053 or TTY: 1- 800 - 841 -6753 • For Medicare Supplement plan options call 1- 800 - 325 -3540 or TTY: 1- 800 - 234 -8819 Overview 1. You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in Continuation, is exhausted. b. Your coverage or continuation coverage ends because the Contract is terminated and the Contract is not replaced with other continuous group coverage. c. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. 2. Your conversion plan goes into effect the day following 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. 3. Conversion coverage is not available: a. When continuous coverage is not maintained; or b. If your coverage is terminated due to nonpayment of premium; or c. If you have not exhausted your right to continue coverage as described in Continuation; or d. If your coverage or continuation coverage ends because the Contract is terminated and the Contract is replaced with other continuous group coverage; or e. The commission of fraud. MIC PPMN HSA (3/11) 102 1500 -100% BPL 67276 DOC 21410 Conversion For purposes of 2. and 3.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 coverage, whichever is later. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor 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. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor 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. Residents of a state other than Minnesota This section describes your right to convert to an individual conversion plan if you are a resident of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. Overview You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods, in accordance with the laws of the state in which you reside on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You will be required to include your first month premium payment with your enrollment form for conversion coverage. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. MIC PPMN HSA (3/11) 103 1500 -100% BPL 67276 DOC 21410 Complaints GG. Complaints This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. See Definitions: These words ha re,specific meanings:, ,inpatient, network,,; provider: 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, 2. You also may contact the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296 -2488 or 1- 800 - 657 -3602. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. You may appoint an authorized representative to make a complaint on your behalf. You may be required to sign an authorization which will allow Medica to release confidential information to your authorized representative and allow them to act on your behalf during the complaint process. 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. In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Commerce at the telephone number listed at the beginning of this section. 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. 1. If your complaint is regarding an initial decision made by Medica, your complaint must be made within one year following Medica's initial decision. 2. For an oral complaint that does not require a medical determination in its outcome, 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 3. 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 or request. 4. When an initial decision by Medica not to grant a prior authorization request is made before 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 MIC PPMN HSA (3/11) 104 1500 -100% BPL 67276 DOC 21410 Complaints 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. 5. 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. Second level of review If you are not satisfied with Medica's first level of review decision, you may request a second level of review through either a written reconsideration or a hearing. 1. 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 the address listed above in First level of review, 2. 2. 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. 3. Medica will provide written notice of its second level of review decision to you within: a. 30 calendar days from receipt of written notice of your appeal for required second level reviews; or b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews. For some complaints, the second level of review must be exhausted before you have the right to submit a request for external review. For other complaints, this second level of review is optional before you may submit a request for external review. Medica will inform you in writing whether the second level of review is optional or required. External review If you consider Medica's decision to be partially or wholly adverse to you, you may submit a written request for external review of Medica's decision to the Commissioner of Commerce at: Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101 -2198 A filing fee of $25 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 will not be binding on you but will be binding on Medica. Contact 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. MIC PPMN HSA (3/11) 105 1500 -100% BPL 67276 DOC 21410 Complaints Civil action If you are dissatisfied with Medica's first or second level review decision or the external review decision, you have the right to file a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA). MIC PPMN HSA (3/11) 106 1500 -100% BPL 67276 DOC 21410 __ _ a ' I General Provisions HH. General Provisions This section describes the general provisions of the Contract. See Definitions. These words have specific meanings: benefits, claim, - dependent;: member network, premium, provider, subscriber. . ` 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. 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. 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. MIC PPMN HSA (3/11) 107 1500 - 100% BPL 67276 DOC 21410 General Provisions 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. MIC PPMN HSA (3/11) 108 1500 -100% BPL 67276 DOC 21410 7 Definitions Definitions In this certificate (and in any amendments), some words have specific meanings. Benefits. The health services or supplies (described in this certificate and any subsequent amendments) approved by Medica as eligible for coverage. Certification of qualifying 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. 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. Full coinsurance payments may apply to scheduled appointments canceled Tess than 24 hours before the appointment time or to missed appointments. For in- network benefits, the coinsurance amount 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. For out -of- network benefits, in addition to any 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 Drug Program and Specialty 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. Continuous coverage. 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. Convenience care /retail health clinic. A health care clinic located in a setting such as a retail store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. MIC PPMN HSA (3/11) 109 1500 - 100% BPL 67276 DOC 21410 Definitions Cosmetic. 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. Custodial care. 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. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims for health services or supplies received from network or non - network providers are reimbursable as in- network or out -of- network benefits under this certificate. Dependent. Unless otherwise specified in the Contract, the following are considered dependents: 1. The subscriber's spouse. 2. The following dependent children up to the dependent limiting age of 26: a. The subscriber's or subscriber's spouse's natural or adopted child; b. A child placed for adoption with the subscriber or subscriber's spouse; 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 legal guardianship; d. The subscriber's stepchild; and e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent incapable of self- sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber for support and maintenance. An illness that does not cause a child to be incapable of self - sustaining employment will not be considered a physical disability. This dependent may remain covered under the Contract regardless of age and without application of health screening or waiting periods. To continue coverage for a disabled dependent, you must provide Medica with proof of such disability and dependency within 31 days of the child reaching the dependent limiting age set forth in 2. above. Beginning two years after the child reaches the dependent limiting age, Medica may require annual proof of disability and dependency. For residents of a state other than Minnesota, the dependent limiting age may be higher if required by applicable state law. 4. The subscriber's or subscriber's spouse's disabled dependent who is incapable of self - sustaining employment by reason of developmental disability, mental illness, mental disorder or physical disability and is chiefly dependent upon the subscriber or subscriber's spouse for support and maintenance. For coverage of a disabled dependent, you must provide Medica with proof of such disability and dependency at the time of the dependent's enrollment. MIC PPMN HSA (3/11) 110 1500 -100% BPL 67276 DOC 21410 Definitions Emergency. A condition or symptom (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, 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 (or, if you are pregnant, the health of your unborn child) 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. E- visits. A member initiated online evaluation and management service provided to patients via the Internet. E- visits are used to address non - urgent medical symptoms for established patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. Hospital. 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. Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing facility, or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally disabled children will be covered as any other health condition. • Investigative. 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: 1. 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; 2. 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 3. 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 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 MIC PPMN HSA (3/11) 111 1500 -100% BPL 67276 DOC 21410 Definitions 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 any authoritative compendia as identified by the Medicare program for use in the determination of a medically accepted indication of drugs and biologicals used off - label. 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 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 member who is a child entitled to receive coverage through a QMCSO 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: 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. Member. A person who is enrolled under the Contract. Mental disorder. 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). Network. 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 to provide benefits to you. The participation status of providers will change from time to time. The network provider directory will be furnished automatically, without charge. Non - network. A term used to describe a provider not under contract as a network provider. Non - network provider reimbursement amount. The amount that Medica will pay to a non - network provider for each benefit is based on one of the following, as determined by Medica: 1. A percentage of the amount Medicare would pay for the service in the location where the service is provided. Medica generally updates its data on the amount Medicare pays within 30 -60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or MIC PPMN HSA (3/11) 112 1500 -100% BPL 67276 DOC 21410 Definitions 2. A,percentage of the provider's billed charge; or 3. A nationwide provider reimbursement database that considers prevailing reimbursement rates and /or marketplace charges for similar services in the geographic area in which the service is provided; or • 4. An amount agreed upon between Medica and the non - network provider. Contact Customer Service for more information concerning which method above pertains to your services, including the applicable percentage if a Medicare -based approach is used. For certain benefits, you must pay a portion of the non - network provider reimbursement amount as coinsurance. In addition, if the amount billed by the non - network provider is greater than the non - network provider reimbursement amount, the non - network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any coinsurance or deductible amount you may be responsible for according to the terms described in this certificate. Furthermore, such difference will not be applied toward the out -of- pocket maximum described in Your Out -Of- Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non - network provider will likely be much higher than if you had received services from a network provider. Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.0.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (0.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. Placed for adoption. The assumption and retention of the legal obligation for g g 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.) 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 defined 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. Preventive health service. The following are considered preventive health services: 1. Evidence -based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; 2. Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the member involved; 3. With respect to members who are infants, children, and adolescents, evidence - informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; MIC PPMN HSA (3/11) 113 1500 -100% BPL 67276 DOC 21410 Definitions 4. With respect to members who are women, such additional preventive care and screenings not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Contact Customer Service for information regarding specific preventive health services and services that are rated "A" or "B." 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 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; 15. State Children's Health Insurance Program; or 16. A public health plan similar to any of the above plans established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. 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; 4. 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; MIC PPMN HSA (3/11) 114 1500 -100% BPL 67276 DOC 21410 . r Definitions 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. 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 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. Restorative. 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. Routine foot care. Services that are routine foot care may require treatment by a professional and include but are not limited to any of the following: 1. Cutting, paring, or removal of corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removal of toenails, dead skin, or underlying tissue). Routine foot care may also include hygiene and preventive maintenance such as: 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. 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 by themselves define 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 nursing care, skilled transitional care, or other related health services including rehabilitative services. Subscriber. The person: 1. On whose behalf premium is paid; and 2. Whose employment is the basis for membership, according to the Contract; and MIC PPMN HSA (3/11) 115 '1500- 100% BPL 67276 DOC 2141'0 Definitions 3. Who is enrolled under the Contract. Total disability. 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. Urgent care center. 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. Waiting period. 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. Periods of employment in an employment classification that is not eligible for coverage under the Contract do not constitute a waiting period. MIC PPMN HSA (3/11) 116 1500 -100% BPL 67276 DOC 21410 yos Medica Focus Certificate of Coverage M E RICA® MIC FOCUSMN HSA (3/11) 1500 -100% BPL 67318 DOC 21640 Table Of Contents Table Of Contents Introduction xi To be eligible for benefits xi Language interpretation xii Acceptance of coverage xii Nondiscrimination policy xii A. Member Rights And Responsibilities 1 Member bill of rights 1 Member 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 7 Prior authorization 8 Certification of qualifying coverage 9 C. How Providers Are Paid By Medica 10 Network providers 10 Non - network providers 10 D. Your Out -Of- Pocket Expenses 11 Coinsurance and deductibles 11 More information concerning deductibles 12 Out -of- pocket maximum 12 Lifetime maximum amount 13 Out -of- Pocket Expenses 14 E. Professional Services 15 Covered 15 Not covered 16 Office visits 16 E- visits 16 Convenience care /retail health clinic visits 16 Urgent care center visits 17 Prenatal care services 17 MIC FOCUSMN HSA (3/11) iii 1500 -100% BPL 67318 DOC 21640 Table Of Contents Tobacco cessation products 26 Drugs considered preventive health services 27 G. Specialty Prescription Drug Program 28 Designated specialty pharmacies 28 Specialty preferred drug list 28 Exceptions to the specialty preferred drug list 28 Prior authorization 29 Step therapy 29 Quantity limits 29 Covered 29 Prescription unit 29 Not covered 30 Specialty prescription drugs received from a designated specialty pharmacy 30 H. 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 33 Inpatient services 33 Services received from a physician during an inpatient stay, including maternity labor and delivery 33 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 33 I. Ambulance Services 34 Covered 34 Not covered 34 Ambulance services or ambulance transportation 35 Non - emergency licensed ambulance service 35 J. Home Health Care 36 Covered 36 Not covered 37 Intermittent skilled care 37 Skilled physical, speech, or occupational therapy 38 Home infusion therapy 38 MIC FOCUSMN HSA (3/11) v 1500 -100% BPL 67318 DOC 21640 Table Of Contents 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 of your home 40 Occupational therapy received outside of your home 40 L. Mental Health 41 Covered 42 Not covered 43 Office visits, including evaluations, diagnostic, and treatment services 44 Intensive outpatient programs 44 Inpatient services (including residential treatment services) 44 M. Substance Abuse 45 Covered 46 Not covered 47 J Office visits, including evaluations, diagnostic, and treatment services 47 Intensive outpatient programs 47 Opiate replacement therapy 47 Inpatient services (including residential treatment services) 48 N. Durable Medical Equipment And Prosthetics 49 Covered 49 `Not covered 50 Durable medical equipment and certain related supplies 50 Repair, replacement, or revision of durable medical equipment 50 Prosthetics 50 Hearing aids 51 . O. Miscellaneous Medical Services And Supplies 52 Covered 52 Not covered 52 Blood clotting factors 53 Dietary medical treatment of PKU 53 Amino acid -based elemental formulas 53 , Total�•p� arenteral nutrition 53 Mid F.00USMN HSA (3/11) vi 1500 -100% BPL 67318 DOC 21640 Table Of Contents Eligible ostomy supplies 53 Insulin pumps and other eligible diabetic equipment and supplies 53 P. Organ And Bone Marrow Transplant Services 54 Covered 54 Not covered 55 Office visits 56 E- visits 56 Outpatient services 56 Inpatient services 56 Services received from a physician during an inpatient stay p Y g P 57 Anesthesia services received from a provider during an inpatient stay 57 Transportation and lodging 57 Q. Infertility Diagnosis 59 Covered 59 Not covered 59 Office visits, including any services provided during such visits 60 E- visits 60 Outpatient services received at a hospital 60 Inpatient services 60 R. Reconstructive And Restorative Surgery 61 Covered 61 Not covered 61 Office visits 62 E- visits 62 Outpatient services 62 Inpatient services 63 Services received from a physician during an inpatient stay 63 Anesthesia services received from a provider during an inpatient stay 63 S. Skilled Nursing Facility Services 64 Covered 64 Not covered 64 Daily skilled care or daily skilled rehabilitation services 65 Skilled physical, speech, or occupational therapy 65 Services received from a physician during an inpatient stay in a skilled nursing facility 65 MIC FOCUSMN HSA (3/11) vii 1500 -100% BPL 67318 DOC 21640 Table Of Contents T. Hospice Services 66 Covered 66 Not covered 67 Hospice services 67 U. Temporomandibular Joint (TMJ) Disorder 68 Covered ' 68 Not covered 68 Office visits 69 E- visits 69 Outpatient services 69 Physical therapy received outside of your home 70 Inpatient services 70 Services received from a physician or dentist during an inpatient stay 70 Anesthesia services received from a provider during an inpatient stay 70 TMJ splints and adjustments 70 V. Medical - Related Dental Services 71 Covered 71 Not covered 71 Charges for medical facilities and general anesthesia services 72 Orthodontia related to cleft lip and palate 72 Accident - related dental services 73 Oral surgery 73 W. Referrals To Non - Network Providers 74 What you must do 74 What Medica will do 74 X. Harmful Use Of Medical Services 76 When this section applies 76 Y. Exclusions 77 Z. How To Submit A Claim 80 Claims for benefits from network providers 80 - Claims for benefits from non- network providers 80 .. Claims for services provided outside the United States 81 • . Time, limits • 81 MIC FOC,USMN HSA (3/11) viii 1500 -100% 'l } BPL 67318 DOC 21640 • Table Of Contents AA. Coordination Of Benefits 82 • Applicability 82 Definitions that apply to this section 82 Order of benefit determination rules 83 Effect on the benefits of this plan 84 Right to receive and release needed information 85 Facility of payment 85 Right of recovery 85 BB. Right Of Recovery 87 CC. Eligibility And Enrollment 88 Who can enroll 88 How to enroll 88 Notification 88 Initial enrollment 88 Open enrollment 89 Special enrollment 89 Late enrollment 91 Qualified Medical Child Support Order (QMCSO) 92 The date your coverage begins 92 DD. Ending Coverage 94 When coverage ends 94 EE. Continuation 96 Your right to continue coverage under state law 96 Your right to continue coverage under federal law 99 FF. Conversion 105 Minnesota residents 105 Residents of a state other than Minnesota 106 GG. Complaints 107 First level of review 107 Second level of review 108 External review 108 Civil action 109 MIC FOCUSMN HSA (3/11) ix 1500 -100% BPL 67318 DOC 21640 Table Of Contents HH. General Provisions 110 Definitions 112 MIC FOCUSMN HSA (3/11) x 1500 -100% BPL 67318 DOC 21640 Introduction Introduction Medica' Insurance Company (Medica) offers Medica Focus. This is a Minnesota non - qualified plan. This Certificate of Coverage (this certificate) describes health services that are eligible for coverage and the procedures you must follow to obtain benefits. Many words in this certificate have specific meanings Thesewords are identified in each section and defined in , IDefrnitions P;';":-+ See Definit►ons These words have specific meanings: benefits, claim, dependent, medically .:necessary,;memker, network, premium, provider'; 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. The Contract refers to the Contract between Medica and the employer. You should contact the employer to see the Contract. Members are subject to all terms and conditions of the Contract and health services must be medically necessary. Medica may arrange for various persons or entities to provide administrative services on its ii 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. In this certificate, the words you, your, and yourself refer to the member. The word employer refers to the organization through which you are eligible for coverage.. 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 Focus to be eligible for in- network benefits; and 2. Identify yourself as a Medica Focus member; and 3. Present your Medica Focus identification card. (If you do not show your Medica Focus identification card, providers have no way of knowing that you are a Medica Focus 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 use of a Medica Focus identification card does not necessarily guarantee coverage. Network providers are required to submit claims within 180 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 180 days of the date of service, you may be responsible for paying the cost of the service you received. MIC FOCUSMN HSA (3/11) xi 1500 -100% BPL 67318 DOC 21640 introduction 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 you have an impairment that requires alternative communication formats such as Braille, large print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials. 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 omission or incorrect statement concerning a material fact intentionally made by you in connection with your enrollment under the Contract may invalidate your coverage. Nondiscrimination policy Medica's policy is 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, genetic information, 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. MIC FOCUSMN HSA (3/11) xii 1500 -100% BPL 67318 DOC 21640 Member Rights And Responsibilities A. Member Rights And Responsibilities See Definitions., These words have specific meanings benefits emergency; medically necessary „member, network,rprovider n Member bill of rights As a member of Medica Focus, 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; and 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; and 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; and 4. Be treated with respect and recognition of your dignity and privacy, including privacy of your medical and financial records maintained by Medica or any network provider in accordance with existing law; and 5. Contact Medica and Minnesota's Commissioner of Commerce to file a complaint about issues related to benefits (see Complaints). To file a complaint with the Minnesota Department of Commerce, call (651) 296 -2488 and request insurance information. You may begin a legal proceeding if you have a problem with Medica or any provider; and 6. Receive information about Medica, its services, its practitioners and providers, and member rights and responsibilities; and 7. Appeal a decision regarding your health care coverage by calling Customer Service at one of the telephone numbers listed inside the front cover. See Complaints for more information on your appeal rights; and 8. Make recommendations regarding Medica's member rights and responsibilities statement. 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; and 2. Providing the necessary information to health care professionals or Medica needed to determine the appropriate care. This objective is best obtained when you share: a. Information about lifestyle practices; and b. Personal health history; and 3. Understanding your health problems and agreeing to, and following, the plans and instructions for care given by those providing health care; and MIC FOCUSMN HSA (3/11) 1 1500 - 100% BPL 67318 DOC 21640 Member Rights And Responsibilities 4. Practicing self -care by knowing: a. How to recognize common health problems and what to do when they occur; and b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and 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 find additional information on member responsibilities in this certificate. MIC FOCUSMN HSA (3/11) 2 1500 - 100% BPL 67318 DOC 21640 is How To Access Your Benefits B. How To Access Your Benefits Sep Definitions The words have specific meanings: benefits, claim, coinsurance, `, deductible,. dependent, emergency, enrollment date, e- visits, hospital, inpatient, late entrant, member, network, non network, non network provider reimbursement amount, physician, placed for adoption, premiurn, prescription drug, provider, qualifying coverage, reconstructive, restorative, skilled nursing facility, subscriber,: waiting; period. �' ,' Provider network In- network benefits are available through the Medica Focus provider network. For a list of the in- network providers, please consult your Medica Focus provider directory by signing in at www.mymedica.com or contacting Customer Service. Out -of- network benefits will apply when you choose to receive eligible health services from providers that are not contracted with Medica. 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. To be eligible for in- network benefits, follow -up care or scheduled care after an emergency must be received from a network provider. Benefits Medica will cover health services and supplies as in- network benefits only if they are i l 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. i Medica does not reward providers for denying care, nor does Medica encourage inappropriate utilization of services. I Selecting a home clinic Your home clinic is a primary care clinic that you choose to collaborate with for your healthcare needs. You must select a home clinic from the list of providers designated by Medica as home clinics. You may select the same or a different home clinic for yourself and each of your dependents. If you do not select a home clinic, Medica will designate one for you. You may change your home clinic once in any calendar month. You may change your home clinic by notifying Medica at least 10 calendar days before the first day of the next month, on which date the change will take effect. You will be notified by Medica if your home clinic no longer participates with Medica Focus. At that time, you must then choose a new home clinic from the list of providers designated by Medica as home clinics. I MIC FOCUSMN HSA (3/11) 3 1500 -100% BPL 67318 DOC 21640 How To Access Your Benefits 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. Providers Enrolling in Medica Focus does not guarantee that a particular provider (in the Medica Focus 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 network providers to continue to be eligible for in- network benefits. You must verify that your provider is a network provider each time you receive health services. 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's hospital network is different from Medica's hospital network. Certain mental health and substance abuse services require prior authorization by Medica's designated mental health and substance abuse provider. Emergency services do not require prior authorization. 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. Medica does not automatically know of a birth or whether you would like coverage for the newborn dependent. Call Customer Service at one of the telephone numbers listed inside the front cover for more information. To be eligible for in- network benefits, health services must be received from 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 reduce payment by the amount of premium that is past due for any health benefits for the newborn infant until any premium you owe is paid. For more information, see Eligibility And Enrollment. ,MIC FOCUSMN HSA (3/11) 4 1500- 100% _ BPL 67318 DOC 21640 • How To Access Your benefits 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. Post- mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. 2. Important member information about out - of - network benefits The information below describes your covered health services and provides important information concerning your out -of- network benefits. Read this certificate for a detailed explanation of both in- network and out -of- network benefits. Please carefully review the general sections of this certificate as well as the section(s) that specifically describe the services you are considering, so you are best able to determine the benefits that will apply to you. Benefits Medica pays out -of- network benefits for eligible health services received from non - network providers. Prior authorization may be required from Medica before you receive certain services, in order to determine whether those services are eligible for coverage under your out -of- network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out -of- network benefits. 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. Emergency services received from non - network providers are covered as in- network benefits and are not considered out -of- network benefits. Additionally, under certain circumstances Medica will authorize your obtaining services from a non - network provider at the in- network benefit level. Such authorizations are generally provided only in situations where the requested services are not available from network providers. Be aware that if you choose to go to a non - network provider and use out -of- network benefits, you will likely have to pay much 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 coinsurance and deductible amount. This additional amount you must pay to the provider will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- -� Pocket Expenses and you will owe this amount regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. Please see the example calculation below. MIC FOCUSMN HSA (3/11) 5 1500 - 100% BPL 67318 DOC 21640 How To Access Your Benefits Because obtaining care from non - network providers may result in significant out -of- pocket expenses, it is important that you do the following before receiving services from a non - network provider: • Discuss the expected billed charges with your non - network provider; and • Contact Customer Service to verify the estimated non - network provider reimbursement amount for those services, so you are better able to calculate your likely out -of- pocket expenses; and • If you wish to request that Medica authorize the non - network provider's services be covered at the in- network benefit level, follow the procedure described under Prior authorization in How To Access Your Benefits. An example of how to calculate your out -of- pocket costs* You choose to receive non - emergency inpatient care at a non - network hospital provider without an authorization from Medica providing for in- network benefits. The out -of- network benefits described in this certificate apply to the services you receive. For purposes of this example, you have previously satisfied your deductible. The non - network hospital provider bills $30,000 for your hospital stay. Medica's non - network provider reimbursement amount for those hospital services is $15,000. You must pay a portion of the non - network provider reimbursement amount, generally as a percentage coinsurance. In addition, the non - network provider will likely bill you for the amount by which the provider's charge exceeds the non - network provider reimbursement amount. If your coinsurance is 40 %, you will be required to pay: • 40% coinsurance (40% of $15,000 = $6,000) and • The billed charges that exceed the non - network provider reimbursement amount ($30,000 - $15,000 = $15,000) • The total amount you will owe is $6,000 + $15,000 = $21,000. • The $6,000 you pay as coinsurance will be applied to the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. However, the $15,000 amount you pay for billed charges in excess of the non - network provider reimbursement amount will not be applied toward the out-of-pocket maximum amount described in Your Out -Of- Pocket Expenses. You will owe the provider this $15,000 amount regardless of whether you have previously reached your out -of- pocket maximum with amounts paid for other services. *Note: The numbers in this example are used only for purposes of illustrating how out -of- network benefits are calculated. The actual numbers will depend on the services received. Travel program Medica has made arrangements for you to receive medically necessary services at the in- network benefit level when you are traveling outside the service area and do not have access to a network provider. Travel program coverage is subject to all of the terms and conditions set forth in this certificate. Call Customer Service at one of the telephone numbers listed inside the front cover to confirm that your provider is a travel program provider, and present your identification card at the time of service. This program is not available for all services (i.e., e- visits or chiropractic services) and may not be available in all areas. MIC FOCUSMN HSA (3/11) 6 1500 - 100% BPL 67318 DOC 21640 i I . How To Access Your Benefits Lifetime maximum amount • Out -of- network benefits are subject to a lifetime maximum amount payable per member. See Your Out -Of- Pocket Expenses for a detailed explanation of the lifetime maximum amount. Exclusions Some health services are not covered when received from or under the direction of non - i 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. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. 3. Continuity of care To request continuity of care or if you have questions about how this may apply to you, call Customer Service at one of the telephone numbers listed inside the front cover. In certain situations, you have a right to continuity of care. a. If Medica terminates its contract with your current provider 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 provider 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 pPl� Y I � Y p 9 PY 'rior authorization prior 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. If Medica terminates your current provider's contract for cause, Medica will inform you of the change and how your care will be transferred to another network provider. i. 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; MIC FOCUSMN HSA (3/11) 7 1500 -100% BPL 67318 DOC 21640 How To Access Your Benefits • 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 provider may 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; 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. 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. You may appeal this decision. Coverage will not be provided for services or treatments that are not otherwise covered under this certificate. 4. 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. To determine whether a certain service or supply requires prior authorization, please call Customer Service at one of the telephone numbers listed inside the front cover. Emergency services do not require prior authorization. Your attending provider, you, or someone on your behalf may contact Medica to request prior authorization. Your network provider will contact Medica to request prior authorization for a service or supply. You must contact Medica to request prior authorization for services or supplies received from non - network providers. If a network provider fails to obtain prior authorization after you have consulted with them about services requiring prior authorization, you are not subject to a penalty for failure to obtain prior authorization. Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; • Treatment of a diagnosed temporomandibular joint disorder or craniomandibular disorder; • Organ and bone marrow transplant; • Home health care; MIC FOCUSMN HSA (3/11) 8 1500 -100% BPL 67318 DOC 21640 How To Access Your Benefits • Medical supplies and durable medical equipment; • Outpatient surgical procedures; • Certain genetic tests; • Skilled nursing facility services; and • In- network benefits for services from non - network providers, with the exception of emergency services. This is not an all- inclusive list of all services and supplies that may require prior authorization. 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; ■' I • 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). Medica will review your request and provide a response to you and your attending provider within 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. Medica will inform both you and your provider of Medica's decision within 24 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. 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 attending provider in writing of its decision. If Medica does not approve continued coverage, you or your attending provider may appeal Medica's initial decision (see Complaints). 5. Certification of qualifying coverage You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. MIC FOCUSMN HSA (3/11) 9 1500 -100% BPL 67318 DOC 21640 AV I How Providers Are Paid By Medica C. How Providers Are Paid By Medica This section describes how Medica generally pays providers for health services. b I See Definitions These words have specific' meanings 'coinsurance, deductible, hospital, member, ;network, non- network, physician, provider. 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 2. 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 Focus 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 coinsurance or deductible, is considered to be payment in full. 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. Some network providers are authorized to arrange for a member to receive certain health services from other providers. This decision may result in a network provider keeping more or less of the risk - sharing payment. 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. MIC FOCUSMN HSA (3/11) 10 1500 -100% BPL 67318 DOC 21640 Your Out -Of- Pocket Expenses D. Your Out -Of- Pocket Expenses This section describes the expenses that are your responsibility to pay. These expenses are commonly called out -of- pocket expenses. See Definitions These words have specific meanings benefits, claim, coinsurance, deductible, dependent, medically necessary, member, network, non- network, non network provider, reimbursement amount,p prescription drug, provider, ,subscriber. 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.) If you miss or cancel an office visit less than 24 hours before your appointment, your provider may bill you for the service. Please see the applicable benefit section(s) of this certificate for specific information about your in- network and out -of- network benefits and coverage levels. To verify coverage before receiving a particular service or supply, call Customer Service at one 1 of the telephone numbers listed inside the front cover. Coinsurance and deductibles For in- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge in addition to your coinsurance and deductible, described in Prescription Drug Program and Specialty Prescription Drug Program, that applies when you use a Tier 2 or Tier 3 brand name drug or supply when an equivalent Tier 1 generic drug or supply is on Medica's list of preferred drugs. These additional amounts will not be applied toward the deductible or the out -of- pocket maximum described in this section. 3. Any charge that is not covered under the Contract. For out -of- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). MIC FOCUSMN HSA (3/11) 11 1500 -100% BPL 67318 DOC 21640 Your Out -Of- pocket Expenses Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that exceeds the non - network provider reimbursement amount. This means you are required to pay the difference between what Medica pays to the provider and what the provider bills. If you use out -of- network benefits, you may incur costs in addition to your coinsurance and deductibleamounts. If the amount that your non - network provider bills you is more than the non - network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out - of- pocket maximum (described in this section). 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 coinsurance and deductibles. 3. Any charge that is not covered under the Contract. More information concerning deductibles The time period used to apply the deductible (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes,:. you will receive a new certificate of coverage that will specify the newly applicable time period. You may have 1 additional out -of- pocket expenses associated with this change. Out - of - pocket maximum The out -of- pocket maximum is an accumulation of coinsurance and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per member out -of- pocket maximum for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non - network provider reimbursement amount are not applicable toward the out -of- pocket maximum. Additionally, you will .owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. MIC FOCUSMN HSA (3/11) 12 1500 -100% BPL 67318 DOC 21640 •p Your Out -Of- Pocket Expenses The time period used to calculate whether you have met the out -of- pocket maximum (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. After an applicable out -of- pocket maximum has been met for a particular type of benefit (as described in the Out -of- Pocket Expenses table in this section), all other covered benefits of the same type received during the rest of the calendar year will be covered at 100 percent, except for any charge not covered by Medica, or charge in excess of the non - network provider reimbursement amount, or any charge in addition to your coinsurance and deductible when you use a Tier 2 brand name drug or supply when a chemical equivalent Tier 1 generic drug or supply is on Medica's list of preferred drugs. However, you will still be required to pay any applicable coinsurance and deductibles for other types of benefits received. Note that out -of- pocket maximum amounts are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new out -of- pocket maximum will apply for the rest of the current calendar year, whether or not you had met the previously applicable out -of- pocket maximum. This means that it is possible that your out -of- pocket maximum will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. Medica refunds the amount over the out -of- pocket maximum during any calendar year when proof of excess coinsurance and deductibles is received and verified by Medica. 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, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Out -of- Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced pertains only to those health care services and supplies that are not essential benefits as defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules, or other guidance issued with respect to the "Act." MIC FOCUSMN HSA (3/11) 13 1500 -100% BPL 67318 DOC 21640 Your Out -Of- Pocket Expenses Out -of- Pocket Expenses � : In- network .t * Ou of % n e twork , tie -� t v:. , ._ . � �- Al, . refit s benefits . * For out bene i a ddition,to the. ded and comsur are respon x fo r ' a n y . char g e s w -�n exc of the non - network, provider reimburseme a ,,,-, mount., Additionally, th charges will not_be applied towar � d satesfaction of the d ed uc tible or the out - o f- p ocket - maximum _.. . , ' ' .... _. , . - ' Coinsurance See spec benefit for applicable coinsurance. Deductible Per member $1,500 $4,000 Out - of - pocket maximum Per member $1,500 $9,000 Unlimited Lifetime maximum amount $1,ben000,000fits . payable per member e you Applies receive thr any other to M all edics Me d Health , Me Health h Plans of Wi sconsin under this coverage Plansor offered dici throug the same employer. I I 1500 -100% 14 BPL 67318 DOC 21640 MIC FOCUSMN HSA (3/11) Professional Services E. Professional Services This section describes coverage for professional services received from or directed by a physician. See''Defini #rons. These words have specific meanings benefits coinsurance convenience' care /retail health clinic deductible, emergency, e home clinic, hospital, inpatient, member network, non-network, non network provid reimbursement amount, ,,physician prenatal care', preventive.health service, provider, urgent care_center Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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; 2. 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. Family planning services do not include infertility treatment services. • Out -of- network benefits apply to professional services received from a non - network provider. In addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. 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 transplant services are described in Organ And Bone Marrow Transplant Services. For some services, there may be a facility charge resulting in coinsurance (see Hospital Services) in addition to the professional services coinsurance. Also, more than one coinsurance may be required if you receive more than one service or see more than one provider per visit. MIC FOCUSMN HSA (3/11) 15 1500-100% BPL 67318 DOC 21640 Professional Services Not covered Drugs provided or administered by a physician or other provider, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. - Your Benefits and the Amou You Pay3 Benefits In network benefits,._ . * Out -of network benefits after deductible afterdeductible * Forout -of network benefits, infaddition to the deduct and coinsurance, you are respons for any charges in excess of the non- network provider reimbursement amount Additionally, these ' charges will not be applied toward satis faction of the deductible or the out-of-pocket maximum 1. Office visits Nothing 50% coinsurance Please note: Some services received during an office visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an office visit. For example, certain services received during an office visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an office visit coinsurance and outpatient surgical or imaging services coinsurance apply. Call Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 2. E - visits Nothing No coverage 3. Convenience care /retail health Nothing 50% coinsurance clinic visits MIC FOCUSMN HSA (3/11) 16 1500 -100% BPL 67318 DOC 21640 Professional Services Your Benefits and the Amounts You Pay Benefits In-network benefits Out-of-network benefits aft er deductible after deductible * For out of network benefits, in addition to the deductible and coinsurance; you are responsible for -- any, charges in excess of the non network provider reim m bursementFaount t Additionally, h ese charges will not beialipliedAdward satisfaction of,the deductible or : the out -of pocket maximum: • 4. Urgent care center visits Nothing Covered as an in- network Please note: Some services benefit. received during an urgent care visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an urgent care visit. For example, certain services received during an urgent care visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care visit coinsurance and outpatient surgical or imaging services coinsurance apply. CaII Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 5. Prenatal care services received Nothing. The deductible Covered as an in- network from a physician during an office does not apply. benefit. visit or an outpatient hospital visit • MIC FOCUSMN HSA (3/11) 17 1500 -100% BPL 67318 DOC 21640 Professional Services Your Benefits and. the. Amounts You ,Pay Benefits „ -„ In network =benefits *:Out of network benefits after ` deductible after deductible, * For out of network benefits, in addition to the= deductible and coins you are responstble for. an char y, ges in excess o #the non nefiivork provider reiinbursernent amounts �4dditionatly, these charges will not be applied toward satisfaction of the : deductible or the out =o #pocket maximum 6. Preventive health care Please note: If you receive preventive and non - preventive health services during the same visit, the non - preventive health services may be subject to a coinsurance or deductible, as described elsewhere in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during a visit. a. Child health supervision Nothing. The deductible Covered as an in- network services, including well -baby does not apply. benefit. care b. Immunizations Nothing. The deductible 50% coinsurance does not apply. c. Early disease detection Nothing. The deductible 50% coinsurance services including physicals does not apply. d. Routine screening Nothing. The deductible 50% coinsurance procedures for cancer does not apply. e. Other preventive health Nothing. The deductible 50% coinsurance services does not apply. 7. Allergy shots , Nothing 50% coinsurance 8. Routine annual eye exams. Nothing. The deductible 50% coinsurance Coverage is limited to one visit does not apply. per calendar year for in- network and out -of- network benefits combined. MIC FOCUSMN HSA (3/11) 18 1500 -100% BPL 67318 DOC 21640 • Professional Services Your Ben efits and the Amounts You-Pay Benefits In-network benefits * Out-of-network benefits after deductible after deductible x ohs For out-of-network benefits, in addition tolhe deductible and coinsurance, you are respons any:charges in excess of the non network provider reirribursement amount: Additionally, these charges:will` no be applied toward satisfaction of`the deductibl o r: the out of pocket m aximum: 9. Chiropractic services to Nothing 50% coinsurance. diagnose and to treat (by manual Coverage is limited to a manipulation or certain maximum of 15 visits per therapies) conditions related to calendar year. the muscles, skeleton, and Please note: This visit limit nerves of the body. includes chiropractic visits Please note: Providers may be that you pay for in order to network providers for chiropractic satisfy any part of your services only, and not otherwise deductible. part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. 10. Surgical services (as defined in Nothing 50% coinsurance the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit 11. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 12. Services received from a Nothing Covered as an in- network physician during an emergency benefit. room visit 13. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery MIC FOCUSMN HSA (3/11) 19 1500 - 100% BPL 67318 DOC 21640 Professional Services Your1Benefits and the Amounts You Pay Benefits 1n network benefits * Oo t ut f- nework' benefits' after d e d uc t i ble aft deductible * For out -of network benefits, in addition to the deductible and coinsurance, you' are -responsibWfor any charges in ;excess ;of the non network provider reimbursement amount wAdditronally, these charges will not be applied_toward satisfaction of the deductible or the out -of pocket maxim m 14. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery 15. Services received from a Nothing. The deductible 50% coinsurance physician during an inpatient does not apply. Please note: Out - of- . stay for prenatal care network services for prenatal care are covered as an in- network benefit. 16. Outpatient lab and pathology Nothing 50% coinsurance 17. Outpatient x -rays and other Nothing 50% coinsurance imaging services 18. Other outpatient hospital or Nothing 50% coinsurance ambulatory surgical center services received from a physician 19. Treatment to lighten or remove Nothing 50% coinsurance the coloration of a port wine stain 20. Diabetes self- management Nothing 50% coinsurance 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) 21. Neuropsychological Nothing 50% coinsurance evaluations /cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury MIC FOCUSMN HSA (3/11) 20 1500 -100% BPL 67318 DOC 21640 Professional Services Your Benefits and the Amounts You Pay,' Benefits In network benefits * Out of netw ork benefits I after ded uctible after d educt i ble * For out of network benefits, _ in addition to the de tluctibia and�comsurance, you are responsible for anycharges in excess of the non n provid reimbursement amount: Adtltionally, these charges will not be applied toward satisfaction of the.deductit le or the out -of pocket max imum 22. Vision therapy and orthoptic Nothing 50% coinsurance and /or pleoptic training, to establish a home program, for the treatment of strabismus and other disorders of binocular eye movements. Coverage is limited to a combined in- network and out -of- network total of 5 training visits and 2 follow -up eye exams per calendar year. Please note: These visit and exam limits include visits and exams that you pay for in order to satisfy any part of your deductible. 23. Genetic counseling, whether pre- Nothing 50% coinsurance or post -test, and whether occurring in an office, clinic, or telephonically 24. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices MIC FOCUSMN HSA (3/11) 21 1500 -100% BPL 67318 DOC 21640 Prescription Drug Program F. Prescription Drug Program This section describes coverage for prescription drugs and supplies received from a pharmacy or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" is meant to include those prescription drugs and supplies found on the Preferred Drug List (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such prescription drugs and supplies are identified in this certificate as not covered. The phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase "self- administered drugs" means all !! other drugs. For the definition and coverage of specialty prescription drugs, see Specialty Prescription Drug Program. See Definitions These words have specific'meanings benefits, claim, coinsurance; deductible durable medical equipment, emergency,` ho member, network, non network, :sn0:1 reimbursement amount, physician, prescription drug, preven #ive health service,; provider,°urgent care center = _.. Preferred drug list Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: Tier 1 is your lowest coinsurance option. For the lowest out -of- pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate. Tier 3 drugs are not covered unless they meet the requirements under the PDL exception process described in this certificate. If you have questions about Medica's PDL or whether a specific drug is covered (and /or the PDL tier in which the drug may be covered), or if you would like to request a copy of the PDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The PDL is also available when you sign in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a drug should be considered a covered drug. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the PDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each drug based on a review of the drug's cost and effectiveness. Product selection When you receive a Tier 1 prescription drug or supply under your in- network benefit, after you satisfy your deductible, you will pay the Tier 1 coinsurance described in the table in this section. Medica pays any remaining amount according to the written agreement between Medica and .MIC FOCUSMN HSA (3/11) 22 1500 -100% BPL 67318 DOC 21640 Prescription Drug Program the pharmacy. For example, if the agreement states that the Tier 1 prescription drug "A" costs $50, and your Tier 1 copayment is $10, you will pay $10 and Medica will pay $40. When a` chemically equivalent Tier 1 generic drug is on the preferred drug list, and you or your provider still choose (for any reason) to utilize a Tier 2 or Tier 3 brand name prescription drug or supply under your in- network benefit, Medica will pay the amount Medica would have paid had you received the Tier 1 generic drug or supply, as described in the immediately preceding paragraph. You will pay, in addition to the applicable coinsurance described in the table, any remaining charges due to the pharmacy in excess of Medica's payment to the pharmacy. These additional charges will not be applied toward the deductible or the out -of- pocket maximum. Please note that receiving Tier 2 or Tier 3 brand name drugs or supplies when an equivalent Tier 1 generic drug exists may result in significantly more out -of- pocket costs. For example, you receive a Tier 2 or Tier 3 brand name prescription drug "B," although a chemically equivalent Tier 1 generic prescription drug "A" exists. Medica's agreement with the pharmacy states that brand name drug "B" costs $200 and the chemically equivalent Tier 1 generic drug "A" costs $50 (as in the example above). The Tier 1 copayment is $10 and the Tier 2 or Tier 3 copayment is $50. As described in the example above, Medica will pay $40. This is the amount Medica would have paid if you had received the Tier 1 generic drug "A." You will pay $160, an amount that includes the Tier 2 or Tier 3 copayment and the amount remaining due to the pharmacy after you paid your copayment and Medica paid the amount it owed. Exceptions to the preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants will improve the coverage by only one tier. Exceptions to the PDL can also 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 PDL or you change health plans. If you would like to request a copy of Medica's PDL exception process, call' Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain covered drugs require prior authorization as indicated on the PDL. The provider who prescribes the drug initiates prior authorization. The PDL is made available to providers, including pharmacies and the designated mail order pharmacies. You are responsible for paying the cost of drugs received if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step therapy involves trying an alternative covered drug first (typically a Tier 1 drug) before moving on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. i t MIC FOCUSMN HSA (3/11) 23 1500 -100% BPL 67318 DOC 21640 Prescription Drug Program Quantity limits Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered The following table provides important general information concerning in- network, out -of- network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that the Prescription Drug Program section describes your coinsurance for prescription drugs themselves. An additional coinsurance applies for the provider's services if you require that a provider administer self - administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. In-network benefits Out-of-network benefits* Mail order, benefits Covered drugs received at a Covered drugs received at a Covered drugs received from network pharmacy; and non- network pharmacy; and a designated mail order pharmacy; and Covered drugs for family See In- network benefits Covered drugs for family planning services or the column. planning services or the treatment of sexually treatment of sexually transmitted diseases when .transmitted diseases when prescribed by or received from prescribed by either a either a network or a non- network or a non - network network provider. Family provider and received from a planning services do not designated mail order include infertility treatment pharmacy. Family planning services; and services do not include infertility treatment services; and Diabetic equipment and Diabetic equipment and Diabetic equipment and supplies, including blood supplies, including blood supplies (excluding blood glucose meters when received glucose meters when received glucose meters) received from a network pharmacy; and from a non - network pharmacy; from a designated mail order and pharmacy. Tobacco cessation products Tobacco cessation products Not available. when prescribed by a provider when prescribed by a provider authorized to prescribe the authorized to prescribe the product and received at a product and received at a non - network 'pharmacy. network pharmacy. * When out -of- network benefits are received from non - network providers, in addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to MIC FOCUSMN HSA (3/11) 24 1500 -100% BPL 67318 DOC 21640 1 Prescription Drug Program these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. See Miscellaneous Medical Services And Supp lies for coverage of insulin pumps. See Specialty Prescription Drug Program for coverage of specialty prescription drugs. Prescription unit Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31- consecutive -day supply of a covered drug from your pharmacy (or, in the case of oral contraceptives, up to a one -cycle supply) or a 93- consecutive -day supply of a covered drug from your designated mail order pharmacy (or, in the case of oral contraceptives, up to a three -cycle supply), unless limited by drug manufacturers' packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed. Three prescription units may be dispensed for covered drugs prescribed to treat chronic conditions that are received at a network pharmacy that Medica has specifically designated to dispense multiple prescription units. For the current list of such designated pharmacies, sign in at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside the front cover. Not covered The following 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 y y u before enforcement of this rovision. p ) 2. OTC drugs not listed on the PDL. 3. Replacement of a drug due to Toss, damage, or theft. 4. Appetite suppressants. 5. Erectile dysfunction medications. 6. Non - sedating antihistamines and non - sedating antihistamine /decongestant combinations. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and those members who have a feeding tube. 8. Tobacco cessation products or services dispensed through a mail order pharmacy. 9. Drugs prescribed by a provider who is not acting within his /her scope of Iicensure. 10. Homeopathic medicine. 11. Infertility drugs. 12. Specialty prescription drugs, except as described in Specialty Prescription Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 25 1500 - 100% BPL 67318 DOC 21640 Prescription Drug Program _Your: Benefits and the Amounts YOU Pay *,,For out-of-network benefits, in addition to the deductible and coinsurance, you are responsible for any charges irf excess of the non - network provider reimbursement amount: Additionally, these charges _will not be applied toward satisfaction of the deductible or the out -of- pocket maximum In- network benefits * Out -of- network benefits Mail order benefits after deductible _. after deductible deductible . 3 1. Outpatient covered drugs other than those described below or in Specialty Prescription Drug Program Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or '1 Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage 2. Up to a 24 -hour supply of emergency covered drugs received from a hospital or urgent care center Nothing Covered as an in- network Not available through a mail benefit. order pharmacy. 3. Diabetic equipment and supplies, including blood glucose meters Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage 4. Tobacco cessation products Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. MIC FOCUSMN HSA (3/11) 26 1500 -100% BPL 67318 DOC 21640 Prescription Drug Program E Yo ur Benefit Mand the A You Pay al * For out- of,networ benefit i n, addition t the deduc a nd co insurance, y ou are responsibl for TW t. any charges rn e xce s s of the, non netw e provrd e r reim b ur sement a m o unt. A dd i tionally, the char es w ill not bear) plie toward satis of :the deductible or "the out - of pocke m aximum: In-networ ben . * :Out -of ne twork benefits Mail or der; b enef i ts a fte r deducti after d after- dedu 5. Drugs (other than tobacco cessat products) cons preventive health services, specifically defined in De f i ni t ions, when p re s cribed by a provider authorized to prescribe as such drugs. This group o f drugs is specific and l For the current av list of such drugs, please refer to the Preventive Drug List within the PDL or call Customer Service at one o the telephone numbers liste Not d inside the front cover. Tier 1: Nothing per 50% coinsurance per available through a mail prescription unit; or prescription unit order pharmacy. T Nothing prescri ier 2: othi unit; per or Tier 3: No coverage The deductible does not apply. 1 1 1 MIC FOCUSMN HSA (3/11) 27 1500 - 100% BPL 67318 DOC 21640 Specialty Prescription Drug Program G. Specialty Prescription Drug Program This section describes coverage for specialty prescription drugs received from a designated specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology prescription drug products for individuals with diseases that require complex therapies. Such specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as described below. For purposes of this section, the phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; and the phrase "self- administered drugs" means all other drugs. See Definitions These words have "'s pecific meanings benefits claim ,;'coinsurance,' deductible, member, network, physician, prescription; drug,. provider. Designated specialty pharmacies A designated specialty pharmacy means a specialty pharmacy that has entered into a separate contract with Medica to provide specialty prescription drug services to members. For the current list of designated specialty pharmacies, call Customer Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com. Specialty preferred drug list Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty prescription drugs on Medica's SPDL are eligible for benefits under this certificate. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is I ' covered (and /or the SPDL tier in which the drug may be covered), or if you would like to request a copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The SPDL is also available by signing in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a specialty prescription drug should be covered. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the SPDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. Exceptions to the specialty preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Specialty preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also MIC FOCUSMN HSA (3/11) 28 1500 -100% BPL 67318 DOC 21640 Specialty Prescription Drug Program 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 SPDL or you change health plans. If you would like to request a copy of Medica's SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain specialty prescription drugs require prior authorization. The provider who prescribes the specialty drug initiates prior authorization. The SPDL is made available to providers, including designated specialty pharmacies. You are responsible for paying the cost of specialty prescription drugs you receive if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying a Tier 1 specialty prescription drug before moving on to a Tier 2 specialty prescription drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 specialty prescription drugs. Quantity limits Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy. This section describes your coinsurance for specialty prescription drugs. An additional coinsurance applies for the provider's services if you require that a provider administer self- administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. Prescription unit Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. One prescription unit is equal to a 31- consecutive -day supply of a specialty prescription drug, unless limited by the manufacturer's packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. MIC FOCUSMN HSA (3/11) 29 1500 -100% BPL 67318 DOC 21640 Specialty Prescription Drug Program Not covered The following are not covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the designated specialty pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Replacement of a specialty drug due to loss, damage, or theft. 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of licensure. 4. Prescription drugs and OTC drugs, except as described in Prescription Drug Program. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 6. Infertility drugs. 7. Growth hormone. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits You pay after deductible ,. } E t- 1. Specialty prescription drugs Tier 1 specialty prescription drugs: Nothing per received from a designated prescription unit; or specialty pharmacy Tier 2 specialty prescription drugs: No coverage MIC FOCUSMN HSA (3/11) 30 1500 -100% BPL 67318 DOC 21640 Hospital Services H. Hospital Services This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. See Definition These words have specific meanings benefits, coinsurance, deductible, emergency, hos inpatient,: member, network, :non network, non - network provider' ;reimbursement amount, physician, prenatal care, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out - of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Ac cess Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. If you are confined in a non - network facility as a result of an emergency you will be eligible for in- network benefits until your attending physician agrees it is safe to transfer you to a network facility. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Each member's admission is separate from the admission of any other member. A separate deductible and coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. MIC FOCUSMN HSA (3/11) 31 1500 -100% BPL 67318 DOC 21640 Hospital Services Not covered 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. 2. Transfers and admission to network hospitals solely at the convenience of the member. 3. Admission to another hospital is not covered when care for your condition is available at the network hospital where you were first admitted. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You :Pay a �. Benefits ; In network benefits * Out of- network benefits after d eductible after deductible3 * For out of network benefits, in addition to the deductible an coinsurance, you are responsible for: any charges in excessx;of the'non- network provider reimbursement; amount {Additionally, these I charge will not be applied toward satisfaction of the deductible out of pocket maximum 1. Outpatient services a. Services provided in a Nothing Covered as an in- network hospital or facility -based benefit. emergency room b. Outpatient lab and pathology Nothing 50% coinsurance c. Outpatient x -rays and other Nothing 50% coinsurance imaging services d. Prenatal care services Nothing. The deductible Covered as an in- network does not apply. benefit. e. Genetic testing when test Nothing 50% coinsurance results will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices f. Other outpatient services Nothing 50% coinsurance g. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician MIC FOCUSMN HSA (3/11) 32 1500 -100% BPL 67318 DOC 21640 Hospital Services Your Benefits and the Amounts You Pay ' In network,benefits * Out of- network benefits after deductible 3 after deductible E * For out of networ b in addition to the deductible and coinsurance, you are responsi for anycharges an excess oaf the non network'provider reimbursement amount Additionally; these charges will not be applied toward satisfaction of the deductible or the of pocket maximum; h. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 2. Services provided in a hospital Nothing 50% coinsurance observation room 3. Inpatient services, including Nothing 50% coinsurance, except inpatient maternity labor and you pay nothing for delivery services inpatient services related Please note: Maternity labor and to prenatal care services delivery services are considered that do not result in a inpatient services regardless of the delivery. Coverage is length of hospital stay. limited to a combined total of 120 days per calendar year for all inpatient out -of- network benefits described in this certificate. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. 4. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 5. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery MIC FOCUSMN HSA (3/11) 33 1500 - 100% BPL 67318 DOC 21640 f Ambulance Services 1 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). SeekDefimfrons These words have specific meanings benefits coinsurance$ deductible, emergency, hospital,. - network, non - network, non provider reimbursement amount, phy provider, skilled °nursing facility. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts ou pay, see the table in this section. For non-emergency Y p Y 9 Y licensed ambulance services described 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 non - emergency ambulance services described in this section that are arranged through a physician and received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out-of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 34 1500 -100% BPL 67318 DOC 21640 • Ambulance Services Your Benefits and the Amounts You Pay Benefits In network benefits *'Out -of- network benefits after deductible u a erddc ft a tibl e *For out of network benefits in addition to the deductible and coinsurance, you are responsible for any charges ill ` of the non ° network provider reimbursement amount Additionally, these charges will not be applied toward satisfaction of the deductible or the out -of pocket maximum 1. Ambulance services or Nothing Covered as an in- network ambulance transportation to the benefit. nearest hospital for an emergency 2. Non - emergency licensed ambulance service that is arranged through an attending physician, as follows: a. Transportation from hospital Nothing 50% coinsurance to hospital when: 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 Nothing 50% coinsurance to skilled nursing facility MIC FOCUSMN HSA (3/11) 35 1500 -100% BPL 67318 DOC 21640 Horne 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 a home health care agency authorized by the laws of the state in which treatment is received. . efits See DefrnrtioRS These word have s pecifrc mearnng ben com5urance; custodial care, deductible, dependent, hospital, netwo "rk, non-network, non, network provider:reimbursernent amount, ph'ysician, "fal care, provider, skilled care, skille nursing facilit Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts Y ou pay, see the table in this section. As described under 1. and Y P 2. in the table in this section, Medica (in accordance with Medicare guidelines) 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 1. and 2. in the table in this section are limited to a combined maximum of 120 visits per calendar year for in- network and 60 visits per calendar year for out -of- network benefits. Please note: These visit limits include any visits that you pay for in order to satisfy any part of your deductible. You may be eligible for additional intermittent skilled care if you have Medica coverage and are also enrolled in the Medical Assistance Program. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. MIC FOCUSMN HSA (3/11) 36 1500 - 100% BPL 67318 DOC 21640 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 non - skilled services. 4. Physical, speech, or occupational therapy provided in your home for convenience. 5. Services provided in your home when you are not homebound. 6. Services primarily educational in nature. 7. Vocational and job rehabilitation. 8. Recreational therapy. 9. Self -care and self -help training (non - medical). 10. Health clubs. 11. Disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. 12. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 13. Voice training. 14. Outpatient rehabilitation services when no medical diagnosis is present. 15. Home health aide services, except when rendered in conjunction with intermittent skilled care and related to the medical condition under treatment. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay 1Benefits in -network benefits * Out-of-network benefits 0 uct e deductible after tled ib after d cti le * For,out of network benefits, in addition to the deductible and coinsurance, you are responsible for any charges in excess of the non-network provider reimbursement amount Additionally,Ahese, charges will not -be applied toward satisfaction of-the deductible or the out -of pocket maximum._ 1. Intermittent skilled care when you Nothing 50% coinsurance, except are homebound, provided by or you pay nothing for high - supervised by a registered nurse risk prenatal care services MIC FOCUSMN HSA (3/11) 37 1500 -100% BPL 67318 DOC 21640 Home Health Care Your Benefits and the Amounts You Pay Benefits < In- network benefits *;Out -of network benefits after deductible , after deductible * For out-of-network benefits, in addition to the deductible and coinsurance ou are responsible .for. �Y any charges in excess; of the non-network provider reimbursement amount Additionally, these charges will not be applied toward, satisfaction of the - deductible or the out of pocket maximum 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when you are homebound 3. Home infusion therapy Nothing 50% coinsurance, except you pay nothing for high - risk prenatal care services 4. Services received in your home Nothing 50% coinsurance from a physician MIC FOCUSMN HSA (3/11) 38 1500 -100% BPL 67318 DOC 21640 i iL Outpatient Rehabilitation K. Outpatient Rehabilitation This section describes coverage for both professional and outpatient health care facility services. A physician must direct your care. . x See Definitions: These words have specific meanings benefits, coinsurance; deductible, nefwork,.non; network, non networkproVider reimbursement amount, physician.. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to outpatient rehabilitation services arranged through a 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 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 coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. 6. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 7. Voice training. 8. Outpatient rehabilitation services when no medical diagnosis is present. MIC FOCUSMN HSA (3/11) 39 1500 -100% BPL 67318 DOC 21640 Outpatient Rehabilitation 9. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefit and the Amounts You Pay Benefits ,In network:benefits *Out, of network benefi #s :after deductible after deductible *' out-of network benefits, -in additionxto the;deductible and coinsurance, you 'are responsible for; any charges in e of the non-network ; provider reimbur amount. Additionally .charges .will not be applied toward ; satisfaction of -the deductible or the out -of- pocket maximum .- 1. Physical therapy received outside Nothing 50% coinsurance. of your home Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible. 2. Speech therapy received outside Nothing 50% coinsurance. of your home when speech is Coverage for speech impaired due to a medical illness therapy is limited to 20 or injury, or congenital or visits per calendar year. developmental conditions that Please note: This visit limit have delayed speech includes speech therapy development visits that you pay for in order to satisfy any part of your deductible. 3. Occupational therapy received Nothing 50% coinsurance. outside of your home when Coverage for physical physical function is impaired due and occupational therapy to a medical illness or injury or is limited to a combined congenital or developmental limit of 20 visits per conditions that have delayed calendar year. motor development Please note: This visit limit includes physical and • occupational therapy visits that you pay for in order to satisfy any part of your deductible. MIC FOCUSMN HSA (3/11) 40 1500 -100% BPL 67318 DOC 21640 Mental Health L. Mental Health - 1 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. See Definft►on 'These words have specific meanings: benefit claim, coinsurance, custod care m ,emergency, hospit inpatient-, medically necessary member, mental disorder, network,xnon- network, non-network °provider reimbursement amount, physician, provider. Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at: 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations and psychological testing. b. Psychotherapy and psychiatric services. c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week). d. Treatment for a minor, including family therapy. e. Treatment of serious or persistent disorders. f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD). g. Services, care, or treatment described as benefits in this certificate and 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. h. Treatment of pathological gambling. it 2. Inpatient services include: a. Room and board. b. Attending psychiatric services. c. Hospital or facility -based professional services. d. 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 means a treatment program of 20 hours or more per week and may include lodging. e. Services, care, or treatment described as benefits in this certificate and 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. MIC FOCUSMN HSA (3/11) 41 1500 -100% BPL 67318 DOC 21640 1 Mental Health f. Residential treatment services. These services include either: i. A residential treatment program serving children and adolescents with severe emotional disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic services. In addition to room and board, at least 30 hours a week per individual of mental health services must be provided, including group and individual counseling, client education, and other services specific to mental health treatment. Also, the program must provide an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. 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. (Medica and Medica's designated mental health and substance abuse provider networks are different.) 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). Providers may be network providers for mental health services only, and not otherwise part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Mental health services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the mental health services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Mental health clinic e. Mental health residential treatment center f. Independent clinical social worker { MIC FOCUSMN HSA (3/11) 42 1500 -100% BPL 67318 DOC 21640 !� • Mental Health g. Marriage and family therapist h. Hospital that provides mental health services 2. Emergency mental health services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. 4. Relationship counseling. 5. Family counseling services, except as specifically described in this certificate as treatment for -a minor. 6. Services for telephone psychotherapy. 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, as those conditions are defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. 8. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide mental health services. This includes, but is not limited to, services provided by mental health providers who are not authorized under state law to practice independently, and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch. 9. 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. 10. Room and board charges associated with mental health residential treatment services providing Tess than 30 hours a week per individual of mental health services, or lacking an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 43 1500 - 100% BPL 67318 DOC 21640 Mental Health Your Benefits and the Amounts You Pay Benefits in- network benefits * Out -of- network" benefits after deductible after deductible * For out-of-network b = enefits,:in addition to the deductible and cotnsurance,,you_ are responsi for n anycharges in excess of the non network provider reimbursement amount >Addittonally, these , .. charges will not be applied toward "satisfaction of the deductible or the out -o #pocket maximum 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Inpatient services (including residential treatment services) a. Room and board Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending psychiatrist Nothing 50% coinsurance services d. Partial program Nothing 50% coinsurance. Coverage is limited to a combined total of 120 days per calendar P year for all Y inpatient out -of- network benefits described in this certificate. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. MIC FOCUSMN HSA (3/11) 44 1500 -100% BPL 67318 DOC 21640 Tr 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 the Diagnostic and Statistical Manual of Mental Disorders. See' Definition . These words have specific meanings ";benefits, claim, coinsurance, custodial care; -deductible, emergency, hospital, inpatient, medically necessary , °member, mental disorder, network; non xnetwork, non - network provider; reimbursement amount, 'physician, .provider -. Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at: 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations. b. Outpatient treatment. c. Intensive outpatient programs, including day treatment and partial programs, which may include multiple services and modalities, delivered in an outpatient setting. 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. 2. Inpatient services include: a. Room and board. b. Attending physician services. c. Hospital or facility -based professional services. 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. Substance abuse residential treatment services. These are services from a licensed chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours per week per individual of chemical dependency services must be provided, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. MIC FOCUSMN HSA (3/11) 45 1500 -100% BPL 67318 DOC 21640 Substance Abuse Covered For benefits and the amounts you pay, see the table in this section. • For in- network benefits: 1. Medica's designated mental health and substance abuse provider arranges in- network substance abuse benefits. (Medica and Medica's designated mental health and substance abuse provider networks are different.) 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). 2. In- network benefits will apply to 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. Providers may be network providers for substance abuse services only, and not otherwise part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Substance abuse services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Chemical dependency clinic e. Chemical dependency residential treatment center f. Hospital that provides substance abuse services g. Independent clinical social worker h. Marriage and family therapist 2. Emergency substance abuse services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your MIC FOCUSMN HSA (3/11) 46 1500 - 100% BPL 67318 DOC 21640 - Substance Abuse Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary. 4. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received. 5. Telephonic substance abuse treatment services. 6. Services, including room and board charges, provided by health care professionals or facilities that are riot appropriately licensed, certified, or otherwise qualified under state law to provide substance abuse services. This includes, but is not limited to, services provided by mental health or substance abuse providers who are not authorized under state law to practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch. 7. Room and board charges associated with substance abuse treatment services providing less than 30 hours a week per individual of chemical dependency services, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. 8. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your B enefit s and Amounts You Pay Benefits ln- network benefits * Out benefits �� ' after deductible -after, deductible * For out of network benefits, in addit +on to the deductible and coinsurance, you are responsible for W 1 any charge rn excess of.the non networ provider reimbursement amount. --Additionally, these *, charges will not be toward # satisfaction of -the deductible or the out of pocket maximum 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance MIC FOCUSMN HSA (3/11) 47 1500 - 100% BPL 67318 DOC 21640 Substance Abuse Your . Benefits and the Amounts You Pay Benefits ,In-network benefits *-Out of- network benefits after deductible ... after deductible u A j � •Y *For out of network benefits, n „efits,_m addition to the deductible and coinsurance, you _are responsible for any charges in excess of the -non network provider reimbursement amount ,,Additionally, these charges will not be applied toward.satisfact on of the deductrble�or the4out -of pocket maximum 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending physician services Nothing 50% coinsurance MIC FOCUSMN HSA (3/11) 48 1500 -100% BPL 67318 DOC 21640 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. See Definitions. These words have specific meanings benefits, coinsurance, deductible, medically necessary, network,t non network,'.: non network provider reimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. Medica covers only a limited selection of durable medical equipment, certain related supplies, and hearing aids that meet the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. The list of eligible durable medical equipment and certain related supplies is periodically reviewed and modified by Medica. 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 purchased 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. If the durable medical equipment, prosthetic device, or hearing aid is covered by Medica, but the model you select is not Medica's standard model, you will be responsible for the cost difference. • In- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a network durable medical equipment provider who has a durable medical equipment contract with Medica, and hearing aids as described in 4. in the table in this section when prescribed by a network provider. To request a list of network durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. • Out -of- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a non - network provider. Out - of- network benefits also apply to hearing aids as described in 4. in the table in this section. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC FOCUSMN HSA (3/11) 49 1500 -100% BPL 67318 DOC 21640 Durable Medical Equipment And Prosthetics Not covered These services, supplies, and associated expenses are not covered: 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the Medica eligible list. 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, or hearing aids. 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, replacement, or revision of duplicate items. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits: and - the Amounts You Pay Benefits° to network benefits *.Out of- network benefits e+ 4 after deductible afterrdeductible "- xy = " ' B _� , � � o " For ut of network <benefits,;irn addition to the deductible and coinsurance, you are responsible for - anycharges in excess of the non- network provider reimbursement amount Additionally, these charges will not ~be applied toward satisfaction of the deductible or the out-of maximum 1. Durable medical equipment and Nothing 50% coinsurance certain related supplies 2. Repair, replacement, or revision Nothing 50% coinsurance of durable medical equipment made necessary by normal wear and use 3. Prosthetics a. Initial purchase of external Nothing 50% coinsurance prosthetic devices that replace a limb or an external body part, limited to: i. Artificial arms, legs, feet, and hands; ii. Artificial eyes, ears, and noses; iii. Breast prostheses b. Scalp hair prostheses due to Nothing. Medica pays up 50% coinsurance. alopecia areata to $350. This is Medica pays up to $350. calculated each calendar This is calculated each year. calendar year. MIC FOCUSMN HSA (3/11) 50 1500 -100% BPL 67318 DOC 21640 - Durable Medical Equipment And Prosthetics Your Benefits and the Amounts You Pay Benefits In -network benefits * Out-of-network benefits after deductible after deductible * For out-of network benefits, in addition to the deductible and:comsurance you are responsible for any - charges in, excess:ofthe non network provider reimbursement m burseent amount ,Additionally, these charges will not be applied toward satisfaction of the deductible-de-the out -af- pocket maxim�irri °: c. Repair, replacement, or Nothing 50% coinsurance revision of artificial arms, legs, feet, hands, eyes, ears, noses, and breast prostheses made necessary by normal wear and use 4. Hearing aids for members 18 Nothing. Limited to one 50% coinsurance. years of age and younger for hearing aid per ear every Limited to one hearing hearing Toss that is not three years. Related aid per ear every three correctable by other covered services must be years. procedures prescribed by a network provider. MIC FOCUSMN HSA (3/11) 51 1500 -100% BPL 67318 DOC 21640 Miscellaneous Medical Services And Supplies 0. Miscellaneous Medical Services And Supplies This section describes coverage for miscellaneous medical services and supplies prescribed by a physician. Medica covers only a limited selection of miscellaneous medical services and supplies that meet the criteria established by Medica. Some items ordered by a physician, Pp Y Y p Y , even if medically necessary, may not be covered. See Definitions. These swords have specific meanings: benefits, coinsurance, deductible, medically necessary, network,.non- network, non - network provider reimbursement amount, physician, .provider ...... Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to miscellaneous medical services and supplies received from a network provider. • Out -of- network benefits apply to miscellaneous medical services and supplies received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered Other disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 52 1500 -100% BPL 67318 DOC 21640 Miscellaneous Medical Services And Supplies Your Benefits and the Amounts You P ay Benefits In network benefits '* Out of network.benefits after deductible after deductible * For out-of-network i benefits, in addition to'the deductible and coinsurance you are responsrble for any charges m excess:of�the non network provider ' reimbursement; amount. Additionally, th ;charges will not' be applied toward satisfaction of the = deductible or - t he ou -of pocket maximum 1. Blood clotting factors Nothing 50% coinsurance 2. Dietary medical treatment of Nothing 50% coinsurance phenylketonuria (PKU) 3. Amino acid -based elemental Nothing 50% coinsurance formulas for the following diagnoses: a. cystic fibrosis; b. amino acid, organic acid, and fatty acid metabolic and malabsorption disorders; c. IgE mediated allergies to food proteins; d. food protein- induced enterocolitis syndrome; e. eosinophilic esophagitis; f. eosinophilic gastroenteritis; and g. eosinophilic colitis Coverage for the diagnoses in 3.c. -g. above is limited to members five years of age and younger. 4. Total parenteral nutrition Nothing 50% coinsurance 5. Eligible ostomy supplies Nothing 50% coinsurance Please note: Eligible ostomy supplies may be received from a pharmacy or a durable medical equipment provider. 6. Insulin pumps and other eligible Nothing 50% coinsurance diabetic equipment and supplies MIC FOCUSMN HSA (3/11) 53 1500 - 100% BPL 67318 DOC 21640 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 network physician and received at a designated 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. See Definitions ?These words have specific meanings: benefits, coinsurance, deductible, designated facility, e- visits, hospital, inpatient, investigative, :medically necessary, member, network, non- network, non-network provider reimbursement amount physician, provider Prior authorization. Prior authorization from Medica is required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood. The preceding is not a comprehensive list of eligible organ and bone marrow transplant services. • 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. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 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. MIC FOCUSMN HSA (3/11) 54 1500 -100% BPL 67318 DOC 21640 Organ And Bone Marrow Transplant Services Providers may be network providers for transplant services only, and not otherwise part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow transplant services, except as described in this section. 2. 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. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. 5. Islet cell transplants except for autologous islet cell transplants associated with pancreatectomy. 6. 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 suppressants, and supplies of a similar nature not otherwise covered under this certificate. 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. 10. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 55 1500 -100% BPL 67318 DOC 21640 Organ And Bone Marrow Transplant Services Your Benefits and :the - Amounts You Pay Benefits In- network benefits . *O u t -of- network benefits after. deductible after deductible *: For out of network benefits, in addition to the deductible and coinsurance, youxare responsible for an charges in excess; of, the non network provider reimburse a mount Additionally, these charg will not be applied toward s o f the deductible or " the out -of pocket maximum 1. Office visits Nothing No coverage 2. E - visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing No coverage defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit ii. Anesthesia services Nothing No coverage received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing No coverage pathology iv. Outpatient x -rays and Nothing No coverage other imaging services v. Other outpatient hospital Nothing No coverage services received from a physician b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x -rays and Nothing No coverage other imaging services iii. Other outpatient hospital Nothing No coverage services 4. Inpatient services Nothing No coverage MIC FOCUSMN HSA (3/11) 56 1500 -100% BPL 67318 DOC 21640 • Organ And Bone Marrow Transplant Services Your B en efits and t he Amoun You Pa Bene , E _ .. ;In networ be ,- * Out-of-ne be nef i t s a f t er deductible a dedu * Fo ofi network benefits,.inxaddition to -the deductible and "coinsurance, you are re for any. charges in- excess of the non-netwo provider. reimbursement amount .Addu these c _w ill not be applied toward satisfaction of'the deductible or the out-of-p maximum: 5. Services received from a Nothing No coverage physician during an inpatient stay 6. Anesthesia services received Nothing No coverage from a provider during an inpatient stay 7. Transportation and lodging The deductible does not No coverage a. As described below, apply to this reimbursement of reasonable reimbursement benefit. and necessary expenses for You are responsible for travel and lodging for you paying all amounts not and a companion when you reimbursed under this receive approved services at benefit. Such amounts a designated facility for do not count toward your transplant services and you out -of- pocket maximum live more than 50 miles from or toward satisfaction of that designated facility your deductible. i. Transportation of you and one companion (traveling on the same day(s)) to and /or from a designated facility for transplant services for pre - transplant, transplant, and post - transplant ; I services. If you are a minor child, transportation expenses for two companions will be reimbursed. � MIC FOCUSMN HSA (3/11) 57 1500 - 100% BPL 67318 DOC 21640 Organ And Bone Marrow Transplant Services Your Benefits and the ,Amounts You Pay _ Benefits "F In n etwork benefits *Out "of network benefits • ve 3 after deductible after deducti "ble For out of network benefits, in addition'to the deductible and coinsurance, you are responsible for any charges in excess of thenon network provider reimbursement amount ,Additionally, these charges will not be applied toward satisfaction of the deductible or,the'out of pocket maximu ii. Lodging for you (while not confined) and one companion. Reimbursement is available for a per diem amount of up to $50 for one person or up to $100 for two people. If you are a minor child, reimbursement for lodging expenses for two companions is available, up to a per diem amount of $100. iii. There is a lifetime maximum of $10,000 per member for all transportation and lodging expenses incurred by you and your companion(s) and reimbursed under the Contract or under any other Medica, Medica Health Plans or Medica Health Plans of Wisconsin coverage offered through the same employer. b. Meals are not reimbursable under this benefit. MIC FOCUSMN HSA (3/11) 58 1500- 100% BPL 67318 DOC 21640 -- ' — - -� Infertility Diagnosis Q. Infertility Diagnosis This section describes coverage for the diagnosis of infertility. Coverage includes benefits for professional, hospital, and ambulatory surgical center services. Services for the diagnosis of infertility treatment must be received from or under the direction of a physician. All services, supplies, and associated expenses for the treatment of infertility are not covered. See ' Definitions These words have specific meanings benefits, coinsurance, deductible, e vrsrts hospital, inpatient member, network, non network, non network provider rermbursement . amount, physician, provider ..: = Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered Benefits apply to services for the diagnosis of infertility received from a network or non - network provider. Coverage for infertility services is limited to a maximum of $5,000 per member per calendar year for in- network and out -of- network benefits combined. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered All services, supplies, and associated expenses for the treatment of infertility are not covered, including the following: 1. Professional, hospital, and ambulatory surgical center services for the treatment of infertility. 2. Infertility drugs. 3. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 4. Services for a condition that a physician determines cannot be successfully treated. 5. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 6. Sperm banking. 7. Adoption. 8. Donor sperm. MIC FOCUSMN HSA (3/11) 59 1500 -100% BPL 67318 DOC 21640 Infertility Diagnosis 9. Embryo and egg storage. See Exclusions for additional services, supplies, and associated expenses that are not covered. y 44 44 You B a nd the- Amounts Y Pa Benefits In network benefits Out o f network benefi a fter deductib y after deductible i * for out-of network benefits, in add' to thejdeductib and coinsurance, you are respo nsible for any c in excess of the non - network provider reim bursemen t amo Addi these charges ,will not be applied toward satisfaction o th e deductible orthe of- p acket maximu 1. Office visits, including any Nothing 50% coinsurance services provided during such visits 2. E- visits Nothing No coverage 3. Outpatient services received at a Nothing 50% coinsurance hospital 4. Inpatient services Nothing 50% coinsurance. Coverage is limited to a combined total of 120 days per calendar year tf networ all k benefits ient - described inpa in this certificate. e note: limit includ days that This you pay for in o rder to satisfy day any part of your deductible. MIC FOCUSMN HSA (3/11) 60 1500 - 100% BPL 67318 DOC 21640 11 I I 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. See `Definitions ' Thes words have spe cificAmeanings benefits, coin cosmetic, deductible, -e visits hospital, inpatient, medically necessary , member, network, non - network, non-network provider. reimbursement amount phy provider, reconstructi restorative. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. 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. 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. 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. 6. Hair transplants. MIC FOCUSMN HSA (3/11) 61 1500 -100% BPL 67318 DOC 21640 Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and theAmount You Pay Benefits _ _ lin network benefits Out-of-network benefits ` r d u ble c after ed cti � after deductible * For out -of network benefits, in addition (0 the deductible and coinsurance, y ou:are responsible; for any charges in excess :of the ; non network provider reimbursement amount., Additionally, these charges will not-be applied tow satisfaction of the deductible or the out -of- pocket maximum. 1. Office visits Nothing 50% coinsurance 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance or ambulatory surgical center services received from a physician MIC FOCUSMN HSA (3/11) 62 1500 -100% BPL 67318 DOC 21640 • Reconstructive And Restorative Surgery Your Benefits and the Amounts You Pay ^ F Benefits In- network benefits E * Out of- network benefits after deductible after deductible * For out - of network benefits, in addition to the deductible and coinsurance, you 'are; responsible for any charges in excess of the :non networkprovider reimbursement amount Additionally, these charges will not be applied toward titisfiCtiont of the deductible or the out -of pocket maximum b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Inpatient services Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. 5. Services received from a Nothing 50% coinsurance physician during an inpatient stay 6. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay MIC FOCUSMN HSA (3/11) 63 1500 -100% BPL 67318 DOC 21640 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 qualify as reimbursable under Medicare. See Definition These words have spe meanings g benefits,:co in surance, custodial care deductible"; hospital, inpatient, networ non-network, n on - network provider reimbursement • amount, physician, - skilled care, skilled nursing facility. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For purposes of this section, room and board includes coverage of health services and supplies. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The ou t -o f- pocket maximum does not apply to these charges. Please see Important mem information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out-of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. Custodial care and other non - skilled services. 2. Self -care or self -help training (non - medical). 3. Services primarily educational in nature. 4. Vocational and job rehabilitation. 5. Recreational therapy. 6. Health clubs. 7. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 8. Voice training. MIC FOCUSMN HSA (3/11) 64 1500 -100% BPL 67318 DOC 21640 • Skilled Nursing Facility Services 9. Outpatient rehabilitation services when no medical diagnosis is present. 10. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pa Benefits networ benefits *:Out o f network benefits after deduc tible after deductible * For out-of-network ben in addition to the deductible and coinsurance, you are res ponsible for any charges in excess of the non - network provider reimbursement: amount' 'Additionally, charges will not be applied toward satisfa of the deductible or the out -of pocket maximum. 1. Daily skilled care or daily skilled Nothing 50% coinsurance. rehabilitation services, including Coverage is limited to a room and board combined total of 120 Please note: Such services are days per calendar year eligible for coverage only if they for all inpatient out - of- would qualify as reimbursable under network benefits Medicare. described in this certificate. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when room and board is not eligible to be covered 3. Services received from a Nothing 50% coinsurance physician during an inpatient stay in a skilled nursing facility MIC FOCUSMN HSA (3/11) 65 1500 -100% BPL 67318 DOC 21640 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 hospice program. See Definitions These word have spe cific meanings: : benefits, coinsurance, deductible; member, - network, non_ network, non nets► ork-provider reimbursementfarr ount, physician, skilled nursing facility_ 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. 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. A designated hospice program means a hospice program that has entered into a separate contract with Medica to provide hospice services to members. The specific services you receive may vary depending upon which program you select. Members who elect to receive hospice services do so in place of curative treatment for their terminal illness for the period they are enrolled in the hospice program. 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. • Out -of- network benefits apply to hospice services arranged through a physician and received from a non - designated hospice program. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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). MIC FOCUSMN HSA (3/11) 66 1500 -100% BPL 67318 DOC 21640 Hospice Services 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 hospice program. You must follow the hospice program's requirements to withdraw from the 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. 2. 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 hospice program's plan of care. 4. Services not provided by the hospice program. 5. Hospice daycare, except when recommended and provided by the hospice program. 6. Any services 'provided by a family member or friend, or individuals who are residents in your home. 7. Financial or legal counseling services, except when recommended and provided by the hospice program. 8. Housekeeping or meal services in your home, except when recommended and provided by the hospice program. 9. Bereavement counseling, except when recommended and provided by the hospice program. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your: Benefits any! the Amounts_,You Pay �� Benefits In network benefits * Out of network benefits � _ after�deductible after deductible r *'For out of network benefits, in addition to the deductible and coinsurance, you are responsiblefor any charges in excess of the non network provider reimbursement: amount .Additionally,,these ' :charges will: not - applied toward satisfaction of the deductible or the out of- pocket maximum 1. Hospice services Nothing 50% coinsurance MIC FOCUSMN HSA (3/11) 67 1500 -100% BPL 67318 DOC 21640 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. TMJ disorder is covered the same as any other joint disorder under this certificate. See Definitions. These words have specific meanings: benefits, coinsurance, deductible, e visits, hospital, inpatient, member, network, non network, non - network provider reimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 68 1500 -100% BPL 67318 DOC 21640 Temporomandibular Joint (TMJ) Disorder Your Benefits and the Amounts You Pay BenefitsIn network benefi * O,ut of netwiork bene a uctible afte deductible fter ded * For out of network benefits,:in addition to;the =deductible and coinsurance „you are responsible far any charges mexcess of the, non network.provider reimbursement amount °Additionally; these.: charges will notwbe applied toward satisfaction of_ t deductible or the ou pocke maximum. ' x: _ 1. Office visits Nothing 50% coinsurance 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services received from a physician or dentist b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services MIC FOCUSMN HSA (3/11) 69 1500 -100% BPL 67318 DOC 21640 Temporomandibuiar Joint (TMJ) Disorder Your- Benefits and the Amounts, You Pays Benefits r " In network " * Out of ,net be after deductible after deductible m * For out o n b enefit s � in a to t h e deductible and c oinsurance, you . a re responsrtile for any charges in exce oif the non - network provider reimbursement amoun A d di tionally , these c harges wail " not be,appi�ed tow =of the dedu or " the out =of pocket maximum iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Physical therapy received Nothing 50% coinsurance outside of your home 5. Inpatient services Nothing 50% coinsurance. Coverage is limited to a combined total oout -of- f 120 days for all per in P calendar atient year network benefits described in this certificate. Please not This day li mit includes da ys that you pa for in order to satisfy any part of your deductible. 6. Services received from a Nothing 50% coinsurance physician or dentist during an inpatient stay 7. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay 8. TMJ splints and adjustments if Nothing 50% coinsurance your primary diagnosis is joint disorder 1 MIC FOCUSMN HSA (3/11) 70 1500-100% BPL 67318 DOC 21640 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. 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 alignment or occlusion of the teeth. These services are not covered under any section of this certificate. See Definitions ` Th e se words have specific meanings: benefits, coinsurance, deductible, dependent, hospital, member,, network, non network, non network provider reimbursement amount, physician, provide Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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), except as described in this section for the treatment of cleft lip and palate. 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, except as described in this section for the treatment of cleft lip and palate. 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. MIC FOCUSMN HSA 3/11 7 1 1500-100% � � BPL 67318 DOC 21640 Medical- Related Dental Services 8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident - related dental services as described in this section. 9. Routine diagnostic and preventive dental services. See Exclusions for additional services, supplies, and associated expenses that are not covered. ag _� Yo B and the Amounts Y ou Pay Benefits° in benefits *Out of- network benefits a fter deduttibie after deductible * For out of network benefits, m addition to the deductible and coinsurance, you;'are responsi for any in excess of the non - network provider reimbursement amount Additionally, these charges will not be applied toward. satisf n a ctio of the deductible orthe out max 1. Charges for medical facilities Nothing 50% coinsurance 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: i. 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. 2. For a dependent child, Nothin 50% coinsurance orthodontia, dental implants, and oral surgery treatment related to cleft lip and palate MIC FOCUSMN HSA (3/11) 72 1500 -100% BPL 67318 DOC 21640 Medical- Related Dental Services Your Benefits and the Amounts You Pay Benefits In network benefits * Out of network benefits after,deductibie after deductible * For out-of-network benefits in addition to the deductible and coinsurance ,you are responsible for any charges m: excess of the non -network provider reimbursement amount Additionally, these chargeswili not be applied toward satisfaction -of the deductible or the out-of-pocket :;maximum. 3. Accident - related dental services Nothing 50% coinsurance to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply: a. Coverage is limited to services received within 24 months from the later of: i. the date you are first covered under the Contract; or ii. the date of the injury 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 one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year. 4. Oral surgery for: Nothing 50% coinsurance a. Partially or completely unerupted impacted teeth; or b. A tooth root without the extraction of the entire tooth (this does not include root canal therapy); or c. The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth MIC FOCUSMN HSA (3/11) 73 1500 -100% BPL 67318 DOC 21640 Referrals To Non - Network Providers W. 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 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. See Def nitions These words have "specific meanings .:benefits, medically - ,necessary, network, ';non- network; physician, provider. If you want to apply for a standing referral to a non - network provider, contact Medica for more information. If determined by Medica to be clinically appropriate, a standing referral may be granted by Medica. A standing referral is a referral issued by a network provider and authorized by Medica for conditions that require ongoing services from a specialist provider. Standing referrals will only be covered for the period of time appropriate to your medical condition. Referrals and standing referrals will not be covered to accommodate personal preferences, family convenience, or other non - medical reasons. Referrals will also not be covered for care that has already been provided. If your request for a standing referral is denied, you have the right to appeal this decision as described in Complaints. What you must do 1. 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. 2. 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. 3. 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. 4. Pay any charges not authorized for coverage by Medica. What Medica will do 1. May require that you see another network provider selected by Medica before a determination by Medica that a referral to a non - network provider is medically necessary. 2. 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. MIC FOCUSMN HSA (3/11) 74 1500 -100% BPL 67318 DOC 21640 Referrals To Non- Network Providers 3. Provides coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. 4. 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 24 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. MIC FOCUSMN HSA (3/11) 75 1500 -100% BPL 67318 DOC 21640 Harmful Use Of Medical Services X. 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. See Definitions These words have specific meanings benefits, emergency, hospital, network' physician, prescription drug,. provider. - 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. You must obtain a referral from your coordinating health care provider if your condition requires care or treatment from a provider other than your coordinating health care provider. Medica will send you specific information about: 1. How to obtain approval for benefits not available from your coordinating health care providers; and 2. How to obtain emergency care; and 3. When these restrictions end. MIC FOCUSMN HSA (3/11) 76 1500 -100% BPL 67318 DOC 21640 Exclusions Y. Exclusions See Definitions. These words have specific meanings claim, cosmetic, custodial care, emergency, investigative, medically= necessary, member, non - network, physician, provider,,-- reconstructive, routine'foot care . Medica will not provide coverage for any of the services, treatments, supplies, or items described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition. This section describes additional exclusions to the services, supplies and associated expenses already listed as Not covered in this certificate. These include: 1. 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. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive. 3. Refractive eye surgery, including but not limited to LASIK 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 a physician, air and bone conduction hearing aids (including internal, external, or implantable hearing aids or devices), and other devices to improve hearing, and their related fittings, except cochlear implants and related fittings, and except as described in Durable Medical Equipment And Prosthetics. 6. A drug, device, or medical treatment or procedure that is investigative. 7. Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct -to- consumer marketing and not under the direction of your physician. 8. Services or supplies not directly related to care. 9. Autopsies. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition. 11. Nutritional and electrolyte substances, except as specifically described in Miscellaneous Medical Services And Supplies. 12. Physical, occupational, or speech therapy or chiropractic services when there is no reasonable expectation that the condition will improve over a predictable period of time. 13. Reversal of voluntary sterilization. MIC FOCUSMN HSA (3/11) 77 1500 -100% BPL 67318 DOC 21640 Exclusions 14. Personal comfort or convenience items or services, including but not limited to breast pumps, except when the pump is medically necessary. 15. Custodial care, unskilled nursing, or unskilled rehabilitation services. i t 16. Respite or rest care, except as otherwise covered in Hospice Services. 17. Travel, transportation or living expenses, except as described in Organ And Bone Marrow Transplant Services. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 19. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular disease, peripheral neuropathies, and significant neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. 21. Services by persons who are family members or who share your legal residence. 22. Services for which coverage is available under workers' compensation, employer liability, or any similar law. 23. Services received before coverage under the Contract becomes effective. 24. Services received after coverage under the Contract ends. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non - network providers and non - network dentists. 26. Photographs, except for the condition of multiple dysplastic syndrome. 27. Occlusal adjustment or occlusal equilibration. 28. Dental implants (tooth replacement), except as described in Medical - Related Dental Services. 29. Dental prostheses. 30. Orthodontic treatment, except as described in Medical - Related Dental Services. 31. Treatment for bruxism. 32. Services prohibited by law or regulation, or illegal under Minnesota law. 33. Services to treat injuries that occur while on military duty, and any services received as a result of war or any act of war (whether declared or undeclared). 34. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or licensure. 35. Exams, other evaluations, or other services received solely for the purpose of judicial or administrative proceedings or research, except emergency examination of a child ordered by judicial authorities. 36. Non - medical self -care or self -help training. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services. 38. Coverage for costs associated with translation of medical records and claims to English. MIC FOCUSMN HSA (3/11) 78 1500 -100% BPL 67318 DOC 21640 Exclusions 39. Treatment for spider veins. 40. Services not received from or under the direction of a physician, except as described in this certificate. 41. Services for the treatment of infertility. 42. Services for or related to intensive behavior therapy treatment programs for the treatment of autism spectrum disorders. Examples of such services include, but are not limited to, Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral Intervention (IBI), and Lovaas therapy. 43. Sensory integration, including auditory integration training. 44. Services for or related to vision therapy and orthoptic and /or pleoptic training, except as described in Professional Services. 45. Orthognathic surgery. 46. Health care professional services for maternity labor and delivery in the home. 47. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and subsequent procedures. 48. Infertility drugs. 49. Growth hormone. 50. Erectile dysfunction medications. 51. Cosmetic medications. 52. Weight loss medications. 53. Acupuncture. 54. Services solely for or related to the treatment of snoring. 55. Interpreter services. 56. Services provided to treat injuries or illness as a result of committing a crime or attempting to commit a crime. 57. Services for private duty nursing, except as described in Home Health Care. Examples of private duty nursing services include, but are not limited to, skilled or unskilled services provided by an independent nurse who is ordered by the member or the member's representative, and not under the direction of a physician. 58. Laboratory testing that has been performed in response to direct -to- consumer marketing and not under the direction of a physician. 59. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), other than those granted a humanitarian device exemption. MIC FOCUSMN HSA (3/11) 79 1500 -100% BPL 67318 DOC 21640 How To Submit A Claim Z. How To Submit A Claim This section describes the process for submitting a claim. See. Definitions These words have specific meanings: benefits; claim, dependent, member, - network, non- network, non - network provider: reimbursement amount, provider. 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. Network providers are required to submit claims within 180 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 180 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 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 PO Box 30990 Salt Lake City, UT 84130 Upon receipt of your claim for benefits from non - network providers, Medica will generally pay to you directly the non - network provider reimbursement amount. Medica will only pay the provider of services if: 1. The non - network provider is one that Medica has determined can be paid directly; and 2. The non - network provider 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 receiving the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. Call Customer Service at one of the telephone numbers listed inside the front cover for a list of non - network providers that Medica will not pay directly. MIC FOCUSMN HSA (3/11) 80 1500 -100% BPL 67318 DOC 21640 How To Submit A Claim 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 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. MIC FOCUSMN HSA (3/11) 81 1500 -100% BPL 67318 DOC 21640 Coordination Of Benefits AA. Coordination Of Benefits This section describes how benefits are coordinated when you are covered under more than one plan. See Definitions These words have specific ' meanings benefits, claim,£Kdeductible, dependent emergency, hospital, medically necessary, member, non network,:nonnetwork:provider: reimbursement amount, provider, subscriber ; 1. Applicability a. 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. b. If this coordination of benefits provision applies, 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 Order of benefit determination rules, the benefits of this plan: i. 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 a. Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment: i. Group insurance or group -type coverage, whether insured or uninsured, or individual coverage. 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 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. b. This plan is the part of the Contract that provides benefits for health care expenses. c. 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. MIC FOCUSMN HSA (3/11) 82 1500 -100% BPL 67318 DOC 21640 Coordination Of 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. d. 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. Allowable expense does not include the deductible for members with a primary high deductible plan and who notify Medica of an intention to contribute to a health savings account. The difference between the cost of a private hospital room and the cost of a semi - private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private 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 reimbursement amount is not considered an allowable expense under the above definition. I 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. e. 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 a. 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 3.b. below, require that this plan's benefits be determined before those of the other plan. b. Rules. This plan determines its order of benefits using the first of the following rules which applies: i. 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. ii. 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 MIC FOCUSMN HSA (3/11) 83 1500 - 100% BPL 67318 DOC 21640 Coordination Of Benefits 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. iii. 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 determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. iv. 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 3.b.ii. v. 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. vi. 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. vii. No -fault automobile insurance. Coverage under the No -Fault Automobile Insurance Act or similar law applies first. viii. 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 a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that MIC FOCUSMN HSA (3/11) 84 1500 -100% BPL 67318 DOC 21640 `�F Coordination Of Benefits event, the benefits of this plan may be reduced under this section. Such other plan or plans are referred to as the other plans in b. immediately below. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of: i. 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 50 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, 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; or MIC FOCUSMN HSA (3/11) 85 1500 -100% BPL 67318 DOC 21640 Coordination Of Benefits 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. Please note: See Right Of Recovery for additional information. MIC FOCUSMN HSA (3/11) 86 1500 -100% BPL 67318 DOC 21640 Right Of Recovery BB. Right Of Recovery This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and federal law. For information about the effect of Minnesota and federal law on Medica's subrogation rights, contact an attorney. See Definitions: word has a specific meaning: benefit's: 1. 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. 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 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. 4. By accepting coverage under the Contract, you agree: a. That if we pay benefits for medical expenses you incur as a result of any act by a third party for which the third party is or may be liable, and you later obtain full recovery, you are obligated to reimburse us for the benefits paid in accordance to Minnesota law. b. 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. c. To provide prompt written notice to Medica when you make a claim against a party 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. f. 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. MIC FOCUSMN HSA (3/11) 87 1500 - 100% BPL 67318 DOC 21640 Eligibility And Enrollment CC. Eligibility And Enrollment This section describes who can enroll and how to enroll. See Definitions. These words have specific meanings: benefits, continuous coverage, dependent, late entrant, member, mental disorder, physician, placed for adoption, premium, 'covera' e, subscriber,xwaltin qualifying = 9 g period. Who can enroll To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract and be a subscriber or dependent as defined in this certificate. See Definitions. 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 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 other time for consideration as a late entrant as described in this section under Late enrollment. Dependents will not be enrolled without the eligible employee also being enrolled. A child who is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical Child Support Order (QMCSO) and 6. under Special 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, a dependent child reaching the dependent limiting age, or other facts identifying you or your dependents. (For dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption; however, we encourage you to enroll your newborn dependent under the Contract within 30 days from the date of birth, date of placement for adoption, or date of adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with the subscriber, and any child who is a member pursuant to a QMCSO will be covered without application of health screening or waiting periods. The employer must notify Medica, as set forth in the Contract, 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 A 30 -day time period starting with the date an eligible employee and dependents are first eligible to enroll for coverage under the Contract. An eligible employee must enroll within this MIC FOCUSMN HSA (3/11) 88 1500 -100% BPL 67318 DOC 21640 Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30 -day time period does not apply to newborns or children newly adopted or placed for adoption; see Special enrollment.) An eligible employee and dependents that enroll during the initial enrollment period are accepted without application of health screening or affiliation periods. An eligible employee and dependents who do not enroll during the initial enrollment period may enroll for coverage during the next open enrollment, any applicable special enrollment periods, or as a late entrant (if applicable, as described below). A member who is a child entitled to receive coverage through a QMCSO is not subject to any initial enrollment period restrictions, except as noted in this section. Open enrollment A minimum 14 -day period set by the employer and Medica each year during which eligible employees and dependents who are not covered under the Contract may elect coverage for the upcoming Contract year. An application must be submitted to the employer for yourself and any dependents. Special enrollment Special enrollment periods are provided to eligible employees and dependents under certain circumstances. 1. Loss of other coverage a. A special enrollment period will apply to an eligible employee and dependent if the individual was covered under Medicaid or a State Children's Health Insurance Plan and lost that coverage as a result of loss of eligibility. The eligible employee or dependent must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. In the case of the eligible employee's loss of coverage, this special enrollment period applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of coverage, this special enrollment period applies to both the dependent who has.lost coverage and the eligible employee. b. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under qualifying coverage other than Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment, and declined coverage for that reason. The eligible employee or dependent must present either evidence of the loss of prior coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated; and request 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, or the date on which a claim is denied due to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; ii. Loss of eligibility includes: MIC FOCUSMN HSA (3/11) 89 1500 -100% BPL 67318 DOC 21640 Eligibility And Enrollment • loss of eligibility as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment; • cessation of dependent status; • incurring a claim that causes the eligible employee or dependent to meet or exceed the lifetime maximum limit on all benefits; • if the prior coverage was offered through an individual health maintenance organization (HMO), a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area; • if the prior coverage was offered through a group HMO, a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other coverage option is available; and • the prior coverage no longer offers any benefits to the class of similarly situated individuals that includes the eligible employee or dependent. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is eligible for or elects applicable federal or state continuation coverage; iv. 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; In the case of the eligible employee's loss of other coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of other coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. c. A special enrollment period will apply to an eligible employee and dependent if the i t eligible employee or dependent was covered under benefits available under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or any applicable state continuation laws at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. The eligible employee or dependent must present evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to failure of the eligible employee or dependent to pay premiums on a timely basis or for cause; and request enrollment in writing within 30 days of the date of the exhaustion of coverage. For purposes of 1.c.: i. Exhaustion of COBRA or state continuation coverage includes: • losing. COBRA or state continuation coverage for any reason other than those set forth in ii. below; • losing coverage as a result of the employer's failure to remit premiums on a timely basis; • losing coverage as a result of the eligible employee or dependent incurring a claim that meets or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or MIC FOCUSMN HSA (3/11) 90 1500 -100% BPL 67318 DOC 21640 Eligibility And Enrollment • if the prior coverage was offered through a health maintenance organization (HMO), losing coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other COBRA or state continuation coverage is available. ii. Exhaustion of COBRA or state continuation coverage 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. iii. In the case of the eligible employee's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. 2. 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 and provided that the eligible employee also enrolls during this special enrollment period; 3. 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 (for dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption) and provided that the eligible employee also enrolls during this special enrollment period; 4. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in 3. 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; and d. The eligible employee also enrolls during this special enrollment period; or 5. 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 2. or 3. above, becoming eligible to enroll under the coverage provided the eligible employee also enrolls during this special enrollment period. 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as described in this section, Medica will provide the eligible dependent child with a special enrollment period provided the eligible employee also enrolls during this special enrollment period. Late enrollment An eligible employee or an eligible employee and dependents who do not enroll for coverage offered through the employer during the initial or open enrollment period or any applicable special enrollment period will be considered late entrants. MIC FOCUSMN HSA (3/11) 91 1500 -100% BPL 67318 DOC 21640 Eligibility And Enrollment Late entrants who have maintained continuous coverage may enroll and coverage will be effective first day of the month following the date of Medica's approval of the request for enrollment. Continuous coverage will be determined to have been maintained if the late entrant requests enrollment within 63 days after prior qualifying coverage ends. Individuals who have not maintained continuous coverage may not enroll as late entrants. An eligible employee or dependent who: 1. does not enroll during an initial or open enrollment period or any applicable special enrollment period; and 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the 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. 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. If the eligible employee whose dependent child is the subject of the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, the eligible employee must also enroll for coverage under the Contract during the 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. The date your coverage begins Your coverage begins at 12:01 a.m. on the effective date of your enrollment. 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. MIC FOCUSMN HSA (3/11) 92 1500 -100% BPL 67318 DOC 21640 Eligibility And Enrollment I I 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: a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first calendar month following the date on which the request for enrollment is received by Medica; b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of adoption or placement for adoption, date of adoption or placement. In all other cases, the date the subscriber acquires the dependent child; c. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.b. above; d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. or 3. under Special enrollment becomes effective; e. Number 6. under Special enrollment, the first day of the first calendar month following the date the completed request for enrollment is received by Medica. 4. For eligible employees and /or dependents who enroll during late enrollment, coverage begins on the first day of the month following date of Medica's approval of the request for enrollment. MIC FOCUSMN HSA (3/11) 93 1500 -100% BPL 67318 DOC 21640 Ending Coverage DD. 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. SeeDefinitions. These words have specific meanings certification of qualifying coverage,. claim; dependent,_ member,, premium,: ubscriber. You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. When coverage ends Unless otherwise specified in the Contract, 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 Eligibility And 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. If coverage ends due to fraud, 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. Fraud includes but is not limited to: a. Intentionally 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 b. Intentional 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 MIC FOCUSMN HSA (3/11) 94 1500 - 100% BPL 67318 DOC 21640 J is 4 Ending Coverage e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional misrepresentation with regard to any aspect of coverage under the Contract. 7. 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; 8. 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; 9. For a spouse, the end of the month following the date of divorce; 10. For a dependent child, the end of the month in which the child is no longer eligible as a dependent; or 11. 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. MIC FOCUSMN HSA (3/11) 95 1500 - 100% BPL 67318 DOC 21640 Continuation EE. Continuation This section describes continuation coverage provisions. When coverage ends, members may be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer. "See = Definitions These words% have specific= meanin benefits;" dependent, member, placed for adoption; premium, subscriber total:disabil #y tea.. � The paragraph below describes the continuation coverage provisions. State continuation is described in 1. and federal continuation is described in 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. When your continuation coverage under this section ends, you have the option to enroll in an individual conversion health plan as described in Conversion. 1. Your right to continue coverage under state law Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: a. 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. b. 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. It is intended that no greater rights be provided than those required by Minnesota law. Take time to read this section carefully. Subscriber's Toss 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. In 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. MIC FOCUSMN HSA (3/11) 96 1500 -100% BPL 67318 DOC 21640 Continuation 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; 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. 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: 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. 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. Consistent with Minnesota law, the subscriber and dependents have 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. If continuation coverage is not elected, your coverage under the Contract will end. MIC FOCUSMN HSA (3/11) 97 1500 -100% BPL 67318 DOC 21640 Continuation 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 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. Surviving dependents of a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. 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: a. 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. b. 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 iii. The date coverage would otherwise terminate under the Contract. c. For instances where dependent children lose coverage as a result of Toss of dependent 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 iii. The date coverage would otherwise terminate under the Contract. d. 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: i. The date the former spouse becomes covered under another group health plan; 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: i. The date the former spouse becomes covered under another group health plan; or MIC FOCUSMN HSA (3/11) 98 1500 -100% BPL 67318 DOC 21640 Continuation ii. The date coverage would otherwise terminate under the Contract. e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of: i. The date the surviving spouse and dependent children become covered under another group health plan; or ii. The date coverage would have terminated under the Contract had the subscriber lived. 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. 2. 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 General COBRA information in this section. USERRA continuation coverage Continued coverage shall be provided as required under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The employer shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General USERRA information in this section. General COBRA information 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 coverage is a group health plan for purposes of COBRA. This section 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 section carefully. MIC FOCUSMN HSA (3/11) 99 1500 -100% BPL 67318 DOC 21640 Continuation Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as: 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 c. A dependent child of a covered employee. (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 Toss 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 Toss 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; 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. Subscriber's child's Toss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following' 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 the subscriber 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. MIC FOCUSMN HSA (3/11) 100 1500 -100% BPL 67318 DOC 21640 J Continuation 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. 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. Consistent with federal law, the subscriber and dependents have 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 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. 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 amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 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 of COBRA coverage 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. MIC FOCUSMN HSA (3/11) 101 1500 -100% BPL 67318 DOC 21640 Continuation 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. 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. 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 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 pre- existing condition; or d. The subscriber becomes entitled to (actually covered under) Medicare. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. General USERRA information USERRA requires employers to offer employees 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 coverage is a group 1, health plan for the purposes of USERRA. This section 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 section carefully. Employee's loss The employee has the right to elect continuation of coverage if there is a loss of coverage under the Contract because of absence from employment due to service in the uniformed services, and the employee was covered under the Contract at the time the absence began, and the employee, or an appropriate officer of the uniformed services, provided the employer with advance notice of the employee's absence from employment (if it was possible to do so). Service in the uniformed services means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active duty for training, initial active duty for training, inactive duty training, full -time National MIC FOCUSMN HSA (3/11) 102 1500 -100% BPL 67318 DOC 21640 1 � '•r Continuation Guard duty, and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of these duties. Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army National Guard, and the Air National Guard, when engaged in active duty for training, inactive duty training, or full -time National Guard duty, and the commissioned corps of the Public Health Service. Election rights The employee or the employee's authorized representative may elect to continue the employee's coverage under the Contract by making an election on a form provided by the employer. The employee has 60 days to elect continuation coverage measured from the date coverage would be lost because of the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The employee may elect continuation coverage on behalf of other covered dependents, however, there is no independent right of each covered dependent to elect. If the employee does not elect, there is no USERRA continuation available for the spouse or dependent children. In addition, even if the employee does not elect USERRA continuation, the employee has the right to be reinstated under the Contract upon reemployment, subject to the terms and conditions of the Contract. Type of coverage and cost If the employee elects 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. The amount charged cannot exceed 102 percent of the cost of the coverage unless the employee's leave of absence is less than 31 days, in which case the employee is not required to pay more than the amount that they would have to pay as an active employee for that coverage. There is a grace period of at least 30 days for the regularly scheduled premium. Duration of USERRA coverage When an employee takes a leave for service in the uniformed services, coverage for the employee and dependents for whom coverage is elected begins the day after the employee would lose coverage under the Contract. Coverage continues for up to 24 months. Federal law provides that continuation coverage may end earlier for any of the following reasons: a. The employer no longer provides group health coverage to any of its employees; b. The premium for continuation coverage is not paid on time; c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct; d. The employee fails to return to work following the completion of his or her service in the uniformed services; or e. The employee returns to work and is reinstated under the Contract as an active employee. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. MIC FOCUSMN HSA (3/11) 103 1500 - 100% BPL 67318 DOC 21640 Continuation COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation coverage in addition to USERRA continuation coverage, these coverages run concurrently. MIC FOCUSMN HSA 3/11 104 1500-100% ( ) BPL 67318 DOC 21640 . I Conversion FF. Conversion See Definitions These words have specific meanings continuous coverage, dependent, premium; ".waiting period. Your conversion plan coverage may not provide the same coverage as your previous group health plan. Benefits and provider networks may be different. Minnesota residents This section describes your right to convert to a Medica individual conversion plan if you are a resident of Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. If you are a Minnesota resident, you may be eligible to obtain coverage from 1) other private sources of health coverage, or 2) the Minnesota Comprehensive Health Association, without a pre- existing condition limitation. Contact the Minnesota Comprehensive Health Association for further information: • For deductible plan options call 1- 866 - 894 -8053 or TTY: 1- 800 - 841 -6753. • For Medicare Supplement plan options call 1- 800 - 325 -3540 or TTY: 1- 800 - 234 -8819. Overview 1. You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in Continuation, is exhausted. b. Your coverage or continuation coverage ends because the Contract is terminated and the Contract is not replaced with other continuous group coverage. c. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. 2. Your conversion plan goes into effect the day following 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. 3. Conversion coverage is not available: a. When continuous coverage is not maintained; or b. If your coverage is terminated due to nonpayment of premium; or c. If you have not exhausted your right to continue coverage as described in Continuation; or d. If your coverage or continuation coverage ends because the Contract is terminated and the Contract is replaced with other continuous group coverage; or e. If you commit fraud or material misrepresentation in applying for continuation or conversion of coverage. MIC FOCUSMN HSA (3/11) 105 1500 -100% BPL 67318 DOC 21640 Conversion For purposes of 2. and 3.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 coverage, whichever is later. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor 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. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor 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. Residents of a state other than Minnesota This section describes your right to convert to an individual conversion plan if you are a resident of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. Overview You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods, in accordance with the laws of the state in which you reside on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You will be required to include your first month premium payment with your enrollment form for conversion coverage. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. MIC FOCUSMN HSA (3/11) 106 1500 -100% BPL 67318 DOC 21640 • • Complaints GG. Complaints This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. See'Definitrons:; These words have speciftc meanings: claim, inpatient network, provider 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, 2. You also may contact the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296 -2488 or 1- 800 - 657 -3602. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. You may appoint an authorized representative to make a complaint on your behalf. You may be required to sign an authorization which will allow Medica to release confidential information to your authorized representative and allow them to act on your behalf during the complaint process. 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. In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Commerce at the telephone number listed at the beginning of this section. 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. 1. If your complaint is regarding an initial decision made by Medica, your complaint must be made within one year following Medica's initial decision. 2. For an oral complaint that does not require a medical determination in its outcome, 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 3. 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 or request. 4. When an initial decision by Medica not to grant a prior authorization request is made before 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 MIC FOCUSMN HSA (3/11) 107 1500 -100% BPL 67318 DOC 21640 Complaints 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 appeal. 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. 5. 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. 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. 1. 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 i i be sent to the address listed above in First level of review, 2. 2. 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. 3. Medica will provide written notice of its second level review decision to you within: a. 30 calendar days from receipt of written notice of your appeal for required second level reviews; or b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews. For some complaints, the second level of review must be exhausted before you have the right to submit a request for external review. For other complaints, this second level of review is optional before you may submit a request for external review. Medica will inform you in writing whether the second level of review is optional or required. External review If you consider Medica's decision to be partially or wholly adverse to you, you may submit a written request for external review of Medica's decision to the Commissioner of Commerce at: Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101 -2198 A filing fee of $25 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 will not be binding on you but will be binding on Medica. Contact 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. MIC FOCUSMN HSA (3/11) 108 1500 -100% BPL 67318 DOC 21640 Complaints Civil action If you are dissatisfied with Medica's first or second level review decision or the external review decision, you have the right to file a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA). MIC FOCUSMN HSA (3/11) 109 1500 -100% BPL 67318 DOC 21640 General Provisions HH. General Provisions This section describes the general provisions of the Contract. See Definitions These words have specific meanings benefits, claim, dependent, member, network,: premium provider, subscriber. 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. 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 P P Y P 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. 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. MIC FOCUSMN HSA (3/11) 110 1500 -100% BPL 67318 DOC 21640 General Provisions 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. MIC FOCUSMN HSA (3/11) 111 '1500= 100 % BPL 67318 DOC 21.640 Definitions Definitions In this certificate (and in any amendments), some words have specific meanings. Within each definition, you may note bold words. These words also are defined in this section. Benefits. The health services or supplies (described in this certificate and any subsequent amendments) approved by Medica as eligible for coverage. Certification of qualifying 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. 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. 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 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. For out -of- network benefits, in addition to any 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 Drug Program and Specialty 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. Continuous coverage. 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. Convenience care /retail health clinic. A health care clinic located in a setting such as a retail store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. MIC FOCUSMN HSA (3/11) 112 1500 -100% BPL 67318 DOC 21640 Definitions Cosmetic.. 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. Custodial care. 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. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims for health services or supplies received from network or non - network providers are reimbursable as in- network or"out -of- network benefits under this certificate. Dependent. Unless otherwise specified in the Contract, the following are considered dependents: 1. The subscriber's spouse. 2. The following dependent children up to the dependent limiting age of 26: a. The subscriber's or subscriber's spouse's natural or,adopted, child; . b. A child placed for adoption with the subscriber or subscriber's spouse; 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 legal guardianship; d. The subscriber's stepchild; and e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a: dependent incapable of self- sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber for support and maintenance. An illness that does not cause a child to be incapable of self - sustaining employment will not be considered a physical disability. This dependent may remain covered under the Contract regardless of age and without application of health screening or waiting periods. To continue coverage for a disabled dependent, you must provide Medica with proof of such disability and dependency within 31 days of the child reaching the dependent limiting age set forth in 2. above. Beginning two years after the child reaches the dependent limiting age, Medica may require annual proof of disability and dependency. For residents of a state other than Minnesota, the dependent limiting age may be higher if required by applicable state law. 3. The subscriber's or subscriber's spouse's disabled dependent who is incapable of self - sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber or subscriber's spouse for support and maintenance. For coverage of a disabled dependent, you must provide Medica with proof of such disability and dependency at the time of the dependent's enrollment. MIC FOCUSMN HSA (3/11) 113 1500 -100% BPL 67318 DOC 21640 Definitions Designated facility. A network hospital that Medica has authorized to provide certain benefits to members, as described in this certificate. Emergency. A condition or symptom (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, 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 (or, if you are pregnant, the health of your unborn child) 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. E- visits. A member - initiated online evaluation and management service provided to patients via the Internet. E- visits are used to address non - urgent medical symptoms for established patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. Home clinic. The primary care clinic site within the Medica Focus network that you choose to collaborate with for your healthcare needs. Hospital. •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. Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing facility, or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally disabled children will be covered as any other health condition. Investigative. 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: 1. 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; 2. 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 MIC FOCUSMN HSA (3/11) 114 1500 -100% BPL 67318 DOC 21640 Definitions 3. 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 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 any authoritative compendia as identified by the Medicare program for use in the determination of a medically accepted indication of drugs and biologicals used off - Zabel. 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 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 member who is a child entitled to receive coverage through a QMCSO 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: 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. Member. A person who is enrolled under the Contract. Mental disorder. 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). Network. 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 Focus network provider directory will be furnished automatically, without charge. Non- network. A term used to describe a provider not under contract as a network provider. MIC FOCUSMN HSA (3/11) 115 1500 -100% BPL 67318 DOC 21640 Definitions Non- network provider reimbursement amount. The amount that Medica will pay to a non - network provider for each benefit is based on one of the following, as determined by Medica: 1. A percentage of the amount Medicare would pay for the service in the location where the service is provided. Medica generally updates its data on the amount Medicare pays within 30 -60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or 2. A percentage of the provider's billed charge; or 3. A nationwide provider reimbursement database that considers prevailing reimbursement rates and /or marketplace charges for similar services in the geographic area in which the service is provided; or 4. An amount agreed upon between Medica and the non - network provider. Contact Customer Service for more information concerning which method above pertains to your services, including the applicable percentage if a Medicare -based approach is used. For certain benefits, you must pay a portion of the non - network provider reimbursement amount as coinsurance. In addition, if the amount billed by the non - network provider is greater than the non - network provider reimbursement amount, the non - network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any coinsurance or deductible amount you may be responsible for according to the terms described in this certificate. Furthermore, such difference will not be applied toward the out -of- pocket maximum described in Your Out -Of- Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non - network provider will likely be much higher than if you had received services from a network provider. Physician. 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. 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. (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.) 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 defined 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. Preventive health service. The following are considered preventive health services: 1. Evidence -based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; MIC FOCUSMN HSA (3/11) 116 1500 -100% BPL 67318 DOC 21640 Definitions 2. Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the member involved; 3. With respect to members who are infants, children, and adolescents, evidence - informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; 4. With respect to members who are women, such additional preventive care and screenings not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Contact Customer Service for information regarding specific preventive health services and services that are rated "A" or "B." 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 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; 15. State Children's Health Insurance Program; or 16. A public health plan similar to any of the above plans established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. 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; MIC FOCUSMN HSA (3/11) 117 1500 -100% BPL 67318 DOC 21640 Definitions 2. Automobile medical payment coverage; 3. Liability insurance or coverage issued as a supplement to liability insurance; 4. 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. 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. Restorative. 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. Routine foot care. Services that are routine foot care may require treatment by a professional and include but are not limited to any of the following: 1. Cutting, paring, or removal of corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removal of toenails, dead skin, or underlying tissue). Routine foot care may also include hygiene and preventive maintenance such as: 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. 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 by themselves define the need for skilled care. MIC FOCUSMN HSA (3/11) 118 1500 -100% BPL 67318 DOC 21640 • Definitions Skilled nursing facility. 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. 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. Total disability. 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. Travel program. A national program in which you can receive the in- network benefit level for most services when traveling outside the service area if your provider is a travel program provider. See How To Access Your Benefits for more information about the travel program. Urgent care center. 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. Waiting period. 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. Periods of employment in an employment classification that is not eligible for coverage under the Contract do not constitute a waiting period. MIC FOCUSMN HSA (3/11) 119 1500 -100% BPL 67318 DOC 21640 • Medica Choice Passport Certificate of Coverage MEDICA® MIC PPMN HSA (3/11) 2500 - 100% BPL 67284 DOC 21414 r . Table Of Contents Table Of Contents Introduction xi To be eligible for benefits xi Language interpretation xii Acceptance of coverage xii Nondiscrimination policy xii A. Member Rights And Responsibilities 1 Member bill of rights 1 Member 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 7 Prior authorization 8 Certification of qualifying coverage 9 C. How Providers Are Paid By Medica 10 Network providers 10 Non - network providers 10 D. Your Out -Of- Pocket Expenses 11 Coinsurance and deductibles 11 More information concerning deductibles 12 Out -of- pocket maximum 12 Lifetime maximum amount 13 Out -of- Pocket Expenses 14 E. Professional Services 15 Covered 15 Not covered 16 Office visits 16 E- visits 16 Convenience care /retail health clinic visits 16 Urgent care center visits 17 Prenatal care services 17 MIC PPMN HSA (3/11) iii 2500 -100% BPL 67284 DOC 21414 Table Of Contents Preventive health care 18 Allergy shots 18 Routine annual eye exams 18 Chiropractic services 18 Surgical services 19 Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 19 Services received from a physician during an emergency room visit 19 Services received from a physician during an inpatient stay, including maternity labor and delivery 19 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 19 Services received from a physician during an inpatient stay for prenatal care 19 Outpatient lab and pathology 19 Outpatient x -rays and other imaging services 19 Other outpatient hospital or ambulatory surgical center services received from a physician 19 Treatment to lighten or remove the coloration of a port wine stain 19 Diabetes self- management training and education 20 Neuropsychological evaluations /cognitive testing 20 Services related to lead testing 20 Vision therapy and orthoptic and /or pleoptic training 20 Genetic counseling 20 Genetic testing 21 F. Prescription Drug Program 22 Preferred drug list 22 Exceptions to the preferred drug list 22 Prior authorization 23 Step therapy 23 Quantity limits 23 Covered 23 Prescription unit 24 Not covered 25 Outpatient covered drugs 25 Emergency covered drugs 26 Diabetic equipment and supplies, including blood glucose meters 26 MIC PPMN HSA (3/11) iv 2500 -100% BPL 67284 DOC 21414 • Table Of Contents Tobacco cessation products 26 Drugs considered .preventive health services 1 26 G. Specialty Prescription Drug Program 27 Designated specialty pharmacies 27 Specialty preferred drug list 27 Exceptions to the specialty preferred drug list 27 Prior authorization 28 Step therapy 28 Quantity limits 28 Covered 28 Prescription unit 28 Not covered 29 Specialty prescription drugs received from a designated specialty pharmacy 29 Specialty growth hormone received from a designated specialty pharmacy 29 H. Hospital Services 30 Newborns' and Mothers' Health Protection Act of 1996 30 Covered 30 Not covered - 31 Outpatient services 31 Services provided in a hospital observation room 32 Inpatient services 32 Services received from a physician during an inpatient stay, including maternity labor and delivery 32 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 32 I. Ambulance Services 33 Covered 33 • Not covered 33 Ambulance services or ambulance transportation 34 Non - emergency licensed ambulance service 34 J. Home Health Care 35 Covered 35 Not covered 36 Intermittent skilled care 36 Skilled physical, speech, or occupational therapy 37 MIC PPMN HSA (3/11) v 2500 -100% BPL 67284 DOC 21414 Table Of Contents Home infusion therapy 37 Services received in your home from a physician 37 K. Outpatient Rehabilitation 38 Covered 38 Not covered 38 Physical therapy received outside of your home 39 Speech therapy received outside of your home 39 Occupational therapy received outside of your home 39 L. Mental Health 40 Covered 41 Not covered 42 Office visits, including evaluations, diagnostic, and treatment services 42 Intensive outpatient programs 43 Inpatient services (including residential treatment services) 43 M. Substance Abuse 44 Covered 45 Not covered 45 Office visits, including evaluations, diagnostic, and treatment services 46 Intensive outpatient programs 46 Opiate replacement therapy 46 Inpatient services (including residential treatment services) 46 N. Durable Medical Equipment And Prosthetics 47 Covered 47 Not covered 48 Durable medical equipment and certain related supplies 48 Repair, replacement, or revision of durable medical equipment 48 Prosthetics 48 Hearing aids 49 O. Miscellaneous Medical Services And Supplies 50 Covered 50 Not covered 50 Blood clotting factors 51 Dietary medical treatment of PKU 51 Amino acid -based elemental formulas 51 Mfg PPMN HSA (3/11) vi 2500 -100% BPL 67284 DOC 21414 Table Of Contents Total parenteral nutrition 51 Eligible ostomy supplies 51 Insulin pumps and other eligible diabetic equipment and supplies 51 P. Organ And Bone Marrow Transplant Services 52 Covered 52 Not covered 53 Office visits 53 E- visits 53 Outpatient services 54 Inpatient services 54 Services received from a physician during an inpatient stay 55 Anesthesia services received from a provider during an inpatient stay 55 Transportation and lodging 55 Q. Infertility Diagnosis 57 Covered 57 Not covered 57 Office visits 58 E- visits 58 Outpatient services received at a hospital 58 Inpatient services 58 R. Reconstructive And Restorative Surgery 59 Covered 59 Not covered 59 Office visits 60 E- visits 60 Outpatient services 60 Inpatient services 61 Services received from a physician during an inpatient stay 61 Anesthesia services received from a provider during an inpatient stay 61 S. Skilled Nursing Facility Services 62 Covered 62 Not covered 62 Daily skilled care or daily skilled rehabilitation services 63 Skilled physical, speech, or occupational therapy 63 MIC PPMN HSA (3/11) vii 2500 -100% BPL 67284 DOC 21414 TabDe Of Contents Services received from a physician during an inpatient stay in a skilled nursing facility 63 T. Hospice Services 64 Covered 64 Not covered 65 Hospice services 65 U. Temporomandibular Joint (TMJ) Disorder 66 Covered 66 Not covered 66 Office visits 67 E- visits 67 Outpatient services 67 Physical therapy received outside of your home 68 Inpatient services 68 Services received from a physician or dentist during an inpatient stay 68 Anesthesia services received from a provider during an inpatient stay 68 TMJ splints and adjustments 68 V. Medical - Related Dental Services 69 Covered 69 Not covered 69 Charges for medical facilities and general anesthesia services 70 Orthodontia related to cleft lip and palate 70 Accident - related dental services 71 Oral surgery 71 W. Referrals To Non - Network Providers 72 What you must do 72 What Medica will do 72 X. Harmful Use Of Medical Services 74 When this section applies 74 Y. Exclusions 75 Z. How To Submit A Claim 78 Claims for benefits from network providers 78 Claims for benefits from non - network providers 78 Claims for services provided outside the United States 79 Time limits 79 MIC PPMN HSA (3/11) viii 2500 -100% BPL 67284 DOC 21414 Table Of Contents AA. Coordination Of Benefits 80 Applicability 80 Definitions that apply to this section 80 Order of benefit determination rules 81 Effect on the benefits of this plan 82 Right to receive and release needed information 83 Facility of payment 83 Right of recovery 83 BB. Right Of Recovery 84 CC. Eligibility And Enrollment 85 Who can enroll 85 How to enroll 85 Notification 85 Initial enrollment 85 Open enrollment 86 Special enrollment 86 Late enrollment 89 Qualified Medical Child Support Order (QMCSO) 89 The date your coverage begins 89 DD. Ending Coverage 91 When coverage ends 91 EE. Continuation 93 Your right to continue coverage under state law 93 Your right to continue coverage under federal law 96 FF. Conversion 102 Minnesota residents 102 Residents of a state other than Minnesota 103 GG. Complaints 104 First level of review 104 Second level of review 105 External review 105 Civil action 106 MIC PPMN NSA (3/11) ix 2500 -100% BPL 67284 DOC 21414 Table Of Contents HH. General Provisions 107 Definitions 109 MIC PPMN HSA (3/11) x 2500 -100% BPL 67284 DOC 21414 introduction Introduction THIS POLICY IS REGULATED BY MINNESOTA LAW. The benefits of the policy providing your coverage are governed primarily by the laws of a state other than Florida. Many words in this certificate have specific meanings These words! are, identified in each section and defined in Definitions. , p See Definitions These =words have specific meanings` benefits claim, dependent, member, network, premium, provider. Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota non - qualified plan. This Certificate of Coverage (this certificate) describes health services that are eligible for coverage and the procedures you must follow to obtain benefits. The Contract refers to the Contract between Medica and the employer. You should contact the employer to see the Contract. 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 may arrange for various persons or entities to provide administrative services on its 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. Additional network administrative support is provided by one or more organizations under contract with Medica. The employer is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by applicable law. In this certificate, the words you, your, and yourself refer to the member. The word employer refers to the organization through which you are eligible for coverage. To be eligible for benefits Each time you receive health services, you must: 1. Confirm with Customer Service that your provider is a network provider to be eligible for in- network benefits; and 2. Identify yourself as a Medica member; and 3. Present your Medica identification card. (If you do not show your Medica identification card, providers have no way of knowing that you are a Medica member and you may receive a bill for health services or be required to pay at the time you receive health services.) However, MIC PPMN HSA (3/11) xi 2500 -100% BPL 67284 DOC 21414 Introduction possession and use of a Medica identification card does not necessarily guarantee coverage. Network providers are required to submit claims within 180 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 180 days of the date of service, you may be responsible for paying the cost of the service you received. 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. If you have an impairment that requires alternative communication formats such as Braille, large print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials. 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 that has been issued in Minnesota between Medica and the employer. This certificate is being delivered to you by, or on behalf of, your 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 unless otherwise prohibited by state law; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and complete. You understand and agree that any omission or incorrect statement concerning a material fact intentionally made by you in connection with your enrollment under the Contract may invalidate your coverage. Nondiscrimination policy Medica's policy is 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, genetic information, 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. MI6 PPMN NSA (3/11) xii 2500 -100% BPL 67284 DOC 21414 • Member Rights And Responsibilities A. Member Rights And Responsibilities See Definitions These word's: h ave spec ific rrieanings benefits, emergency, member, rie #work,provider Member bill of rights As a member of Medica, 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; and 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; and 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; and 4. Be treated with respect and recognition of your dignity and privacy; including privacy of your medical and financial records maintained by Medica or any network provider in accordance with existing law; and 5. Contact Customer Service and Minnesota's Commissioner of Commerce to file a complaint about issues related to benefits (see Complaints). To file a complaint with the Minnesota Department of Commerce, call (651) 296 -2488 and request insurance information. You may begin a legal proceeding if you have a problem with Medica or any provider; and 6. Receive information about Medica, its services, its practitioners and providers, and member rights and responsibilities; and 7. Appeal a decision regarding your health care coverage by calling Customer Service at one of the telephone numbers listed inside the front cover. See Complaints for information on your appeal rights; and 8. Make recommendations regarding Medica's member rights and responsibilities statement. 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; and 2. Providing the necessary information to health care professionals or Medica needed to determine the appropriate care. This objective is best obtained when you share: a. Information about lifestyle practices; and b. Personal health history; and 3. Understanding your health problems and agreeing to, and following, the plans and instructions for care given by those providing health care; and MIC PPMN HSA (3/11) 1 2500 -100% BPL 67284 DOC 21414 Member Rights And Responsibilities 4. Practicing self -care by knowing: a. How to recognize common health problems and what to do when they occur; and b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and 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 find additional information on member responsibilities in this certificate. MIC PPMN HSA (3/11) 2 2500 -100% BPL 67284 DOC 21414 How To Access Your Benefits B. How To Access Your Benefits See$,Defint�ons These words specific 'meanungs ben coinsurance," dedu ct ible;: d ependent, �rri eergency, enrollment date- hospital: inpatient; late entrant, rnernber network, non network,'non network= provider reimbursement u amont, physician, placed for adoption; premium,: prescr�ptiQn drop, provider, qualifying coye`rage, reconstructive, restorative skilled_nursmg facilrty, subscriber; witing "per,1od` Provider network In- network benefits are available through the Medica Choice Passport provider network. For a list of the in- network providers, please consult your Medica Choice Passport provider directory by signing in at www.mymedica.com or contacting Customer Service. Out -of- network benefits will apply when you choose to receive eligible health services from providers that are not contracted with Medica. 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. To be eligible for in- network benefits, follow -up care or scheduled care after an emergency must be received from a network provider. 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. { Providers Enrolling in Medica does not guarantee that a particular provider will remain a network provider or provide you with health services. When a provider no longer participates in the network, you must choose to receive health services from network providers to continue to MIC PPMN HSA (3/11) 3 2500 -100% BPL 67284 DOC 21414 How To Access Your Benefits be eligible for in- network benefits. You must verify that your provider is a network provider each time you receive health services. 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's hospital network is different from Medica's hospital network. Certain mental health and substance abuse services require prior authorization by Medica's designated mental health and substance abuse provider. Emergency services do not require prior authorization. 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. Medica does not automatically know of a birth or whether you would like coverage for the newborn dependent. Call Customer Service at one of the telephone numbers listed inside the front cover for more information. To p be eligible for in- network benefits, health services must be 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 reduce payment by the amount of premium that is past due 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 calendar o t e year. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. MIC PPMN HSA (3/11) 4 2500 -100% BPL 67284 DOC 21414 How To Access Your Benefits 2. Important member information about out -of- network benefits The information below describes your covered health services and provides important information concerning your out -of- network benefits. Read this certificate for a detailed explanation of both in- network and out -of- network benefits. Please carefully review the general sections of this certificate as well as the section(s) that specifically describes the services you are considering, so you are best able to determine the benefits that will apply to you. Benefits Medica pays out -of- network benefits for eligible health services received from non - network providers. Prior authorization may be required from Medica before you receive certain services, in order to determine whether those services are eligible for coverage under your out -of- network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out -of- network benefits. 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. Emergency services received from non - network providers are covered as in- network benefits and are not considered out -of- network benefits. Additionally, under certain circumstances Medica will authorize your obtaining services from a non - network provider at the in- network benefit level. Such authorizations are generally provided only in situations where the requested services are not available from network providers. Be aware that if you choose to go to a non - network provider and use out -of- network it benefits, you will likely have to pay much more than if you use in- network benefits. The charges billed by your non - network provider may exceed the non - network provider it reimbursement amount, leaving a balance for you to pay in addition to any applicable coinsurance and deductible amount. This additional amount you must pay to the provider will not be applied toward the out -of- pocket maximum amount described in Your Out-Of- Pocket Expenses and you will owe this amount regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. Please see the example calculation below. Because obtaining care from non - network providers may result in significant out -of- pocket expenses, it is important that you do the following before receiving services from a non - network provider: • Discuss the expected billed charges with your non- network'provider; and • Contact Customer Service to verify the estimated non - network provider reimbursement amount for those services, so you are better able to calculate your likely out -of- pocket expenses; and • If you wish to request that Medica authorize the non - network provider's services be covered at the in- network benefit level, follow the procedure described under, Prior authorization in How To Access Your Benefits. . 1 MIC PPMN HSA (3/11) 5 2500 -100% BPL 67284 DOC 21414 How To Access Your Benefits An example of how to calculate your out -of- pocket costs* - You choose to receive non - emergency inpatient care at a non - network hospital provider without an authorization from Medica providing for in- network benefits. The out -of- network benefits described in this certificate apply to the services you receive. For purposes of this example, you have previously satisfied your deductible. The non - network hospital provider bills $30,000 for your hospital stay. Medica's non - network provider reimbursement amount for those hospital services is $15,000. You must pay a portion of the non - network provider reimbursement amount, generally as a percentage coinsurance. In addition, the non - network provider will likely bill you for the amount by which the provider's charge exceeds the non - network provider reimbursement amount. If your coinsurance is 40 %, you will be required to pay: • 40% coinsurance (40% of $15,000 = $6,000) and • The billed charges that exceed the non - network provider reimbursement amount ($30,000 - $15,000 = $15,000) • The total amount you will owe is $6,000 + $15,000 = $21,000. • The $6,000 you pay as coinsurance will be applied to the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. However, the $15,000 amount you pay for billed charges in excess of the non - network provider reimbursement amount will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. You will owe the provider this $15,000 amount regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. , *Note: The numbers in this example are used only for purposes of illustrating how out -of- network benefits are calculated. The actual numbers will depend on the services received. Lifetime maximum amount Out -of- network benefits are subject to a lifetime maximum amount payable per member. See Your Out -Of- Pocket Expenses fora' detailed explanation of the lifetime maximum amount. Exclusions Some health 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. Post- mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. MIC PPMN HSA (3/11) 6 2500- 100% BPL 67284 DOC 21414 I How To Access Your Benefits 3. Continuity of care To request continuity of care or if you have questions about how this may apply to you, call Customer Service at one of the telephone numbers listed inside the front cover. In certain situations, you have a right to continuity of care. a. If your current provider is terminated 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 provider 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 all necessary medical information related to your care, and accept as payment in full the lesser of the network provider reimbursement or the provider's customary charge for the service. This does not apply when a provider's contract is terminated for cause. i. 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; • 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 provider may 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 a network provider who has special expertise in the delivery of those culturally appropriate services is not available; or • if you do not speak English and a network provider who can communicate with you, either directly or through an interpreter, is not available. 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. You may appeal this decision. ti it MIC PPMN HSA (3/11) 7 2500 -100% BPL 67284 DOC 21414 Flow To Access Your Benefits Coverage will not be provided for services or treatment that are not otherwise covered under this certificate. 4. 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. To determine whether a certain service or supply requires prior authorization, please call Customer Service at one of the telephone numbers listed inside the front cover. Emergency services do not require prior authorization. Your attending provider, you or someone on your behalf may contact Customer Service to request prior authorization. Your network provider will contact Customer Service to request prior authorization for a service or supply. You must contact Customer Service to request prior authorization for services or supplies received from a non - network provider. If a network provider fails to obtain prior authorization after you have consulted with them about services requiring prior authorization, you are not subject to a penalty for failure to obtain prior authorization. Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; • Treatment of a diagnosed temporomandibular joint disorder or craniomandibular disorder; • Organ and bone marrow transplant; • Home health care; • Medical supplies and durable medical equipment; • Outpatient surgical procedures; • Certain genetic tests; • Skilled nursing facility services; and • In- network benefits for services from non - network providers with the exception of emergency services. This is not an all- inclusive list of all services and supplies that may require prior authorization. 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). MIC PPMN HSA (3/11) 8 2500 - 100% BPL 67284 DOC 21414 How To Access Your Benefits Your request will be reviewed and a response will be provided to you and your attending provider within 10 business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available. Both you and your provider will be informed of the decision within 24 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or it is concluded that a delay could seriously jeopardize your life, health, or ability to regain maximum function. You have the right to appeal the decision as described in Complaints, if the request for prior authorization has not been approved. 5. Certification of qualifying coverage You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. MIC PPMN HSA (3/11) 9 2500 -100% BPL 67284 DOC 21414 How Providers Are Paid By Medica C. How Providers Are Paid By Medica This section describes how providers are generally paid for health services. See= Definitions: These words have specific meanings: ; coinsurance, deductible, hospital, member network non - network, physician provider 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 2. 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 is fee - for- service. Fee - for - service payment means that the network provider is paid 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, Tess any applicable coinsurance or deductible, is considered to be payment in full. Risk - sharing payment means that the network provider is paid 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. Some network providers are authorized to arrange for a member to receive certain health services from other providers. This decision may result in a network provider keeping more or less of the risk - sharing payment. 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. MIC PPMN HSA (3/11) 10 2500 -100% BPL 67284 DOC 21414 Your Out -Of- Pocket Expenses D. Your Out -Of- Pocket Expenses This section describes the expenses that are your responsibility to pay. These expenses are commonly called out -of- pocket expenses. See Definitions. These words have specific meanings: benefits, claim coinsurance, deductible, dependent, -member, network, 'non networknon network provider reimbursement amount, .prescription drug, provider; subscriber. > 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.) If you miss or cancel an office visit less than 24 hours before your appointment, your provider may bill you for the service. Please see the applicable benefit section(s) of this certificate for specific information_ about your in- network and out -of- network benefits and coverage levels. To verify coverage before receiving a particular service or supply, call Customer Service at one of the telephone numbers listed inside the front cover. Coinsurance and deductibles For in- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). When members in a family unit (a subscriber and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section), then all members of the family unit are considered to have satisfied the applicable per member and per family deductible for that calendar year. Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when, Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that is not covered under the Contract. For out -of- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). MIC PPMN NSA (3/11) 11 2500 -100% BPL 67284 DOC 21414 Your Out -Of- Pocket Expenses When members in a family unit (a subscriber and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section), then all members of the family unit are considered to have satisfied the applicable per member and per family deductible for that calendar year. Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this . occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that exceeds the non - network provider reimbursement amount. This means you are required to pay the difference between the payment to the provider and what the provider bills. If you use out -of- network benefits, you may incur costs in addition to your coinsurance and deductible amounts. If the amount that your non - network provider bills you is more than the non - network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out- of-pocket maximum (described in this section). 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 coinsurance and deductibles. 3. Any charge that is not covered under the Contract. More information concerning deductibles The time period used to apply the deductible (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. Out - of - pocket maximum The out -of- pocket maximum is an accumulation of coinsurance and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per member out -of- pocket maximum for , MIC PPMN HSA (3/11) 12 2500 -100% BPL 67284 DOC 21414 • Your Out -Of- Pocket Expenses benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non - network provider reimbursement amount are not applicable toward the out -of- pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. The time period used to calculate whether you have met the out -of- pocket maximum (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. When members in a family unit (the subscriber and his or her dependents) have together met the applicable per family out -of- pocket maximum for benefits received during the calendar year, then all members of the family unit are considered to have met the applicable per member and per family out -of- pocket maximum for that calendar year (see the Out -of- Pocket Expenses table in this section). After an applicable out -of- pocket maximum has been met for a particular type of benefit (as described in the Out -of- Pocket Expenses table in this section), all other covered benefits of the same type received during the rest of the calendar year will be covered at 100 percent, except for any charge not covered by Medica or charge in excess of the non - network provider reimbursement amount. However, you will still be required to pay any applicable coinsurance and deductibles for other types of benefits received. Note that out -of- pocket maximum amounts are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new out -of- pocket maximum will apply for the rest of the current calendar year, whether or not you had met the previously applicable out -of- pocket maximum. This means that it is possible that your out -of- pocket maximum will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. Medica refunds the amount over the out -of- pocket maximum during any calendar year when proof of excess coinsurance and deductibles is received and verified by Medica. 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, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Out -of- Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced pertains only to those health care services and supplies that are not essential benefits as defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules, or other guidance issued with respect to the "Act." MIC PPMN HSA (3/11) 13 2500 -100% BPL 67284 DOC 21414 Your Out -Of- Pocket Expenses . Out -of- Pocket Expenses In- network "' *Out of- nefiwork' I. benefits benefits " i * For out-of network_benefits, 'im addition to the :deductible and, coinsurance, _,you are:responsibie for any charges in' excess o f the non network provider reimbursement aount. Addit ovally the c will not be applied toward isatisfaction of the. m deductible or th out of .pocket ? maximum Coinsurance See specific benefit for applicable coinsurance. Deductible Per member $2,500 $6,000 Per family $5,000 $9,900 Out -of- pocket maximum Per member $2,500 $11,000 Per family $5,000 $22,000 Lifetime maximum amount Unlimited $1,000,000. Applies to payable per member all benefits you receive under this or any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. MIC PPMN HSA (3/11) 14 2500 -100% BPL 67284 DOC 21414 Professional Services E. Professional Services This section describes coverage for professional services received from or directed by a physician. See °Def nitcons These words have specific meanings' benefits, coinsurance, convenience carefretail health clinic,.deductible, emergency, e- visits, hospital, inpatient, member, network „ non - network, non- network provider reimbursement amount, physician, prenatal care preventive health service, provider, urgent care: center .._ Y_ .. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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; 2. 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. Family planning services do not include infertility treatment services. • Out -of- network benefits apply to professional services received from a non - network provider. In addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. 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 transplant services are described in Organ And Bone Marrow Transplant Services. For some services, there may be a facility charge resulting in coinsurance (see Hospital Services) in addition to the professional services coinsurance. Also, more than one coinsurance may be required if you receive more than one service or see more than one provider per visit. MIC PPMN HSA (3/11) 15 2500 -100% BPL 67284 DOC 21414 Professional Services Not covered Drugs provided or administered by a physician or other provider, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your behefits and the Amounts You Pay Benefits In network benefit * Out of netw benefits x afterrdeductible " after deductible * For out of- network benefits, in addition to the deductible and coinsurance, you are responsible for . any charges in excess of the non- network provider reimbursement amount. Additionally, ;these charges will not be applied toward satisfaction of the = deductible or the out -of- pocket maximum 1. Office visits Nothing 50% coinsurance Please note: Some services received during an office visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an office visit. For example, certain services received during an office visit may be considered surgical services; see 10. below for coverage of these surgical services. In such instances, both an office visit coinsurance and outpatient surgical services coinsurance apply. CaII Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 2. E- visits Nothing No coverage 3. Convenience care /retail health Nothing 50% coinsurance clinic visits • MIC PPMN HSA (3/11) 16 2500 -100% BPL 67284 DOC 21414 Professional Services Yo B and: =the Amoun YouPay . Benefits x � I n network b ene fit s *Out of n e tw or k ben h after d after deducbble * For o ut o f - n e twork benefits, in a dd i t io n t o the deductible and c : r a nee , =you ar e re for • any c harges in 3 ex c e �ss of themnon networ provider rei a Additionall th charges will no b e applied tovi and s atisfaction: of the deductible or out of pocket ma 4. Urgent care center visits Nothing Cove red as an in- network Please note: Some service benefit. received during an urgent care visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an urgent care visit. For example, certain services received during an urgent care visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care visit coinsurance and outpatient surgical or imaging services coinsurance apply. CaII Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 5. Prenatal care services received Nothing. The deductible 50% coinsurance from a physician during an office does not apply. visit or an outpatient hospital visit MIC PPMN HSA (3/11) 17 2500-100% BPL 67284 DOC 21414 Professional Services Your Benefits and the Amounts You Pay Benefits F In network bene fits =3 * Out of network benefi after deductible ` afte deductible y * For out of network bene #rts; rn addition to the deductible anti coinsurance you are responsible for ,,,` any in excess {o# the non network provider rei amoun Additionally, these charges will not be applied toward ; satisfaction of thedeductible or the t' ° - pocket maxim 6. Preventive health care Please note: If you receive preventive and non - preventive health services during the same visit, the non - preventive health services may be subject to a coinsurance or deductible, as described elsewhere in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during a visit. a. Child health supervision Nothing. The deductible 50% coinsurance services, including well -baby does not apply. care b. Immunizations Nothing. The deductible 50% coinsurance does not apply. c. Early disease detection Nothing. The deductible 50% coinsurance services including physicals does not apply. d. Routine screening Nothing. The deductible 50% coinsurance procedures for cancer does not apply. e. Other preventive health Nothing. The deductible 50% coinsurance services does not apply. 7. Allergy shots Nothing 50% coinsurance 8. Routine annual eye exams. Nothing. The deductible 50% coinsurance Coverage is limited to one visit • does not apply. per calendar year for in- network and out -of- network benefits combined. 9. Chiropractic services to Nothing 50% coinsurance. diagnose and to treat (by manual Coverage is limited to a manipulation or certain maximum of 15 visits per therapies) conditions related to calendar year. the muscles, skeleton, and Pleas note: This visit limit nerves of the body includ chiropractic visits that you pay for in order to satisfy any part of your deductible. MIC PPMN HSA (3/11) 18 2500-100% BPL 67284 DOC 21414 Professional Services Your Benefits and the Arno Onts You; Pay - Benefits In-network benefits * Out of network benefit after deductible after deductible * For out of netvvorklbenefits, in addition to the deductible and'coin surance, you are responsible fore" any: charges in excess°ofthe non network provider reimbur. "sement amount. Additionally, these charges not be appl ed toward satisfaction of =.the deductible or th'e out -of pocket maximum; 10. Surgical services (as defined in Nothing 50% coinsurance the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit 11. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 12. Services received from a Nothing Covered as an in- network physician during an emergency benefit. room visit 13. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 14. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery 15. Services received from a Nothing. The deductible 50% coinsurance physician during an inpatient does not apply. stay for prenatal care 16. Outpatient lab and pathology Nothing 50% coinsurance • 17. Outpatient x -rays and other Nothing 50% coinsurance imaging services 18. Other outpatient hospital or Nothing 50% coinsurance ambulatory surgical center services received from a physician 19. Treatment to lighten or remove Nothing 50% coinsurance the coloration of a port wine stain MIC PPMN NSA (3/11) 19 2500 -100% BPL 67284 DOC 21414 _ ICI Professional Services Your=Benefrts Amounts You Pay Benefit In network benefits * Ou# of- network benefit x after deductible after deductible * Foe. out -of network-be t ` - ra #its, in ad�tition'to the = deductible anii comsurance, you re a resPonsible forf anychar m excess of:the non network provider reimbursement `amount:# Adtlitionaily, these charges will not >be applied toward "satisfaction of the deductible or the out -of- pocke maximum 20. Diabetes self- management Nothing 50% coinsurance 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) 21. Neuropsychological Nothing 50% coinsurance evaluations /cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury 22. Services related to lead testing Nothing 50% coinsurance 23. Vision therapy and orthoptic Nothing 50% coinsurance and /or pleoptic training, to establish a home program, for the treatment of strabismus and other disorders of binocular eye movements. Coverage is limited to a combined in- network and out -of- network total of 5 training visits and 2 follow -up eye exams per calendar year. Please note: The visit and exam limits include visits and exams that you pay for in order to satisfy any part of your deductible. 24. Genetic counseling, whether pre- Nothing 50% coinsurance or post -test, and whether occurring in an office, clinic, or telephonically MIC PPMN HSA (3/11) 20 2500 -100% BPL 67284 DOC 21414 Professional Services Your Benefits and the Amounts You Pay Benefits In network ; benefits' *- Out =of= network benefits . after deductible " after deductible c c * For out o€ network bene #its, °in addition to the deductible, and'coinsurance � you are responsibl_e'for anycharges in °exce of the non network;provider ro`mbursement amount Additional hese charges. will= not,be applied .toward satis #action of "the deductible "or the out -of pocket maximum: 25. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices • MIC PPMN HSA (3/11) 21 2500 -100% BPL 67284 DOC 21414 Prescription Drug Program F. Prescription Drug Program This section describes coverage for prescription drugs and supplies received from a pharmacy or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" is meant to include those prescription drugs and supplies found on the Preferred Drug List (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such prescription drugs and supplies are identified in this certificate as not covered. The phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase "self- administered drugs" means all other drugs. For the definition and coverage of specialty prescription drugs, see Specialty Prescription Drug Program. See 'Definitions. These words have specific meanings benefits, claim, coinsurance, deductible, durable medical equipment, emergency, hospital, member, network, non - network, non'- network provider reimbursement amount, physician, prescription drug preventive health service, provider, urgent care center. ; . Preferred drug list Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: Tier 1 is our lowest coinsurance option. For the lowest out-of-pocket expense, you should Y p Y consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate. Tier 3 drugs are not covered unless they meet the requirements under the PDL exception 9 Y q p process described in this certificate. If you have questions about Medica's PDL or whether a specific drug is covered (and /or the PDL tier in which the drug may be covered), or if you would like to request a copy of the PDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The PDL is also available when you sign in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a drug should be considered a covered drug. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the PDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each drug based on a review of the drug's cost and effectiveness. Exceptions to the preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants MIC PPMN HSA (3/11) 22 2500 -100% BPL 67284 DOC 21414 II Prescription .Drug Program will improve the coverage by only one tier. Exceptions to the PDL can also 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 PDL or you change health plans. If you would like to request a copy of Medica's PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain covered drugs require prior authorization as indicated on the PDL. The provider who prescribes the drug initiates prior authorization. The PDL is made available to providers, including pharmacies and the designated mail order pharmacies. You are responsible for paying the cost of drugs received if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step therapy involves trying an alternative covered drug first (typically a Tier 1 drug) before moving on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. Quantity limits Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered The following table provides important general information concernin g in- network, out -of- network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that the Prescription Drug Program section describes your coinsurance for prescription drugs themselves. An additional coinsurance applies for the provider's services if you require that a provider administer self - administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. ai ,ate � ' `- �tt r a � i'e� - "_ '� -y �a � � '. � 3 a In-network benefits Outo #network benefits*mm Mail order benefits Covered drugs received at a Covered drugs received at a Covered drugs received from network pharmacy; and non - network pharmacy; and a designated mail order pharmacy; and MIC PPMN HSA (3/11) 23 2500 -100% BPL 67284 DOC 21414 Prescription .Drug Program In- network benefits - Out-of-network benefits* Mail ortler benefits Covered drugs for family See In- network benefits Covered drugs for family planning services or the column. planning services or the treatment of sexually treatment of sexually transmitted diseases when transmitted diseases when prescribed by or received from prescribed by either a either a network or a non- network or a non - network network provider. Family provider and received from a planning services do not designated mail order include infertility treatment pharmacy. Family planning services; and services do not include infertility treatment services; and Diabetic equipment and Diabetic equipment and Diabetic equipment and supplies, including blood supplies, including blood supplies (excluding blood glucose meters when received glucose meters when received glucose meters) received from a network pharmacy; and from a non - network pharmacy; from a designated mail order and pharmacy. Tobacco cessation products Tobacco cessation products Not available. when prescribed by a provider when prescribed by a provider authorized to prescribe the authorized to prescribe the product and received at a product and received at a non - network pharmacy. network pharmacy. * When out -of- network benefits are received from non - network providers, in addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Specialty Prescription Drug Program for coverage of growth hormone and other specialty prescription drugs. Prescription unit Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31- consecutive -day supply of a covered drug from your pharmacy (or, in the case of oral contraceptives, up to a one -cycle supply) or a 93- consecutive -day supply of a covered drug from your designated mail order pharmacy (or, in the case of oral contraceptives, up to a three -cycle supply), unless limited by drug manufacturers' packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed. Three prescription units may be dispensed for covered drugs prescribed to treat chronic conditions that are received at a network pharmacy that Medica has specifically designated to MIC PPMN HSA (3/11) 24 2500 - 100% BPL 67284 DOC 21414 r'11111•••- Prescription Drug Program dispense multiple prescription units. For the current list of such designated pharmacies, sign in at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside the front cover. Not covered The following 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.) 2. OTC drugs not listed on the PDL. 3. Replacement of a drug due to loss, damage, or theft. 4. Appetite suppressants. 5. Erectile dysfunction medications. 6. Non - sedating antihistamines and non - sedating antihistamine /decongestant combinations. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and those members who have a feeding tube. 8. Tobacco cessation products or services dispensed through a mail order pharmacy. 9. Drugs prescribed by a provider who is not acting w ithin his /her scope of licensure. 10. Homeopathic medicine. 11. Infertility drugs. 12. Specialty prescription drugs, except as described in Specialty Prescription Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Yo ur Benefits "and the Amounts You Pay For out- of_network benefits, in addition to the {deductible and c oinsu rance, ° are respo nsible for any charges in excess of the non network provider reiiritursementamount ;Additionally, th ese charges will not =be applied toward satisfaction of the deductible or'the out - of pocket- maximurr . In network benefits * Out of networ be ne f its " Mast . order benefits after deducti after deduc ` after deductible 1. Outpatient covered drugs other than those described below or in Specialty Prescript Drug Program Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage MIC PPMN HSA (3/11) 25 2500 -100% BPL 67284 DOC 21414 Prescription Drug Program Your Benefits and. the Pay * For out -of network benefits, in addition the, deductible, and coinsurance, you.are responsible for any charges in- excessYof the non-network provider reimbursement amount Additionally, these charges will not be applied -toward satisfaction of the deductible or the out of- pocket maximum In- network benefits 4 * Out -of- network benefits Mail order, benefits after deductible after deductible =after deductible 2. Up to a 24 -hour supply of emergency covered drugs received from a hospital or urgent care center Nothing Covered as an in- network Not available through a mail benefit. order pharmacy. 3. Diabetic equipment and supplies, including blood glucose meters Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage 4. Tobacco cessation products Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. 5. Drugs (other than tobacco cessation products) considered preventive health services, as specifically defined in Definitions, when prescribed by a provider authorized to prescribe such drugs. This group of drugs is specific and limited. For the current list of such drugs, please refer to the Preventive Drug List within the PDL or call Customer Service at one of the telephone numbers listed inside the front cover. Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. MIC PPMN HSA (3/11) 26 2500 - 100% BPL 67284 DOC 21414 T Specialty Prescription Drug Program G. Specialty Prescription Drug Program This section describes coverage for specialty prescription drugs received from a designated specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology prescription drug products for individuals with diseases that require complex therapies. Such specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as described below. For purposes of this section, the phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; and the phrase "self- administered drugs" means all other drugs. See Definitions:'. These,words have specific meanings benefits, claim, coinsurance, deductible, ;. member, network,; physician, p rescni pfion ; Designated specialty pharmacies A designated specialty pharmacy means a specialty pharmacy that has entered into a separate contract with Medica to provide specialty prescription drug services to members. For the current list of designated specialty pharmacies, call Customer Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com. Specialty preferred drug list Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty prescription drugs on Medica's SPDL are eligible for benefits under this certificate. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is covered (and /or the SPDL tier in which the drug may be covered), or if you would like to request a copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The SPDL is also available by signing in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a specialty prescription drug should be covered. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the SPDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. Exceptions to the specialty preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Specialty preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also I ` MIC PPMN HSA (3/11) 27 2500 -100% 1 BPL 67284 DOC 21414 Specialty Prescription Drug Program 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 SPDL or you change health plans. If you would like to request a copy of Medica's SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain specialty prescription drugs require prior authorization. The provider who prescribes the specialty drug initiates prior authorization. The SPDL is made available to providers, including designated specialty pharmacies. You are responsible for paying the cost of specialty prescription drugs you receive if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying a Tier 1 specialty prescription drug before moving on to a Tier 2 specialty prescription drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 specialty prescription drugs. Quantity limits Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy. This section describes your coinsurance for specialty prescription drugs. An additional coinsurance applies for the provider's services if you require that a provider administer self - administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. Prescription unit Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. One prescription unit is equal to a 31- consecutive -day supply of a specialty prescription drug, unless limited by the manufacturers' packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. MIC PPMN HSA (3/11) 28 2500 -100% BPL 67284 DOC 21414 Specialty Prescription Drug Program Not covered The following are not covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the designated specialty pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Replacement of a specialty drug due to loss, damage, or theft. 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of licensure. 4. Prescription drugs and OTC drugs, except as described in Prescription Drug Program. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 6. Infertility drugs. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Your: Benefits and the Amounts You Pay ' Benefits 4 _ .. .You pa after _� - .r. 1. Specialty prescription drugs, Tier 1 specialty prescription drugs: Nothing per other than those described prescription unit; or below, received from a Tier 2 specialty prescription drugs: No coverage designated specialty pharmacy 2. Specialty growth hormone when Tier 1 specialty prescription drugs: Nothing per prescribed by a physician for the prescription unit; or treatment of a demonstrated Tier 2 specialty prescription drugs: No coverage growth hormone deficiency and received from a designated specialty pharmacy MIC PPMN HSA (3/11) 29 2500 -100% BPL 67284 DOC 21414 Hospital Services H. Hospital Services This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. See, Definitions These words have specific meanings: benefits, coinsurance, deductible, emergency hospital inpatient, members network, non network, -,non- network provider reimbursement amount, physician, prenatal care .provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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). 0 , 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 coinsurance described for out - of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. If you are confined in a non - network facility as a result of an emergency you will be eligible for in- network benefits until your attending physician agrees it is safe to transfer you to a network facility. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Each member's admission is separate from the admission of any other member. A separate deductible and coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. MIC,PPMN HSA (3/11) 30 2500 - 100% BPL 67284 DOC 21414 �1 ' I Hospital Services Not covered 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. 2. Transfers and admissions to network hospitals solely at the convenience of the member. 3. Admission to another hospital is not covered when care for your condition is available at the • network hospital where you were first admitted. See Exclusions for additional services, supplies, and associated expenses that are not covered. ,n Your Benefits and the Amounts You Pay Benefits F .:" In-network benefits * Out-of-network benefits: after deductible after deductible *,For out of- network benefit addition to the deductible and coinsurance, you are or any charges in excess-of the -non network provider reimbursement amount. . Additionally, these charges will not be applied toward "satisfaction of lhe deductible or the out maximum. .......................... . 1. Outpatient services a. Services provided in a Nothing Covered as an in- network hospital or facility -based benefit. emergency room b. Outpatient lab and pathology Nothing 50% coinsurance c. Outpatient x -rays and other Nothing 50% coinsurance imaging services d. Prenatal care services Nothing. The deductible 50% coinsurance does not apply. e. Genetic testing when test Nothing 50% coinsurance results will directly affect treatment decisions or frequency of screening for a • disease, or when results of the test will affect reproductive choices f. Other outpatient services Nothing 50% coinsurance g. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician MIC PPMN HSA (3/11) 31 2500 - 100% BPL 67284 DOC 21414 Hospital Services :Your Benefits and the Amounts You Pay Benefits in network benefits . * Out-of-network benefits. after deductible aftergdeductible * For out -of network benefits,; in addition to the deductible and coinsurance, you_ arelresponsiblefor any charges in excess of the non network provider, reimbursement pli amount Additionally, these` charges will not be aped toward "satisfaction of "the deductible or the out -of pocks# maximum h. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 2. Services provided in a hospital Nothing 50% coinsurance observation room 3. Inpatient services, including Nothing 50% coinsurance inpatient maternity labor and delivery services Please note: Maternity labor and delivery services are considered inpatient services regardless of the length of hospital stay. 4. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 5. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery MIC PPMN HSA (3/11) 32 2500 -100% BPL 67284 DOC 21414 i>_ 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). See Definitions. These words have specific meanings benefits, coinsurance deductible, emergency, hospital,, network, non network, non network provider reimbursement'amount, physician provider ;skilled nursing facility. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For non - emergency licensed ambulance services described 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 non - emergency ambulance services described in this section that are arranged through a physician and received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 33 2500 -100% BPL 67284 DOC 21414 Ambulance Services Your Benefits and -the Amounts You Pay Benefits In network benefits * Out -of- network benefits tt after deductible after deductible * For out -of network benefits, in addition to the deductible and coinsurance you: are responsible for any charges in excess of the non network provider reimbursement amount ,Addibonatly, these char esew�ll not_ be applied toward satisfaction of the deductible or of- pocket maximum 1. Ambulance services or Nothing Covered as an in- network ambulance transportation to the benefit. nearest hospital for an emergency 2. Non - emergency licensed ambulance service that is arranged through an attending physician, as follows: a. Transportation from hospital Nothing 50% coinsurance to hospital when: 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 Nothing 50% coinsurance to skilled nursing facility MIC.PI?MN HSA (3/11) 34 2500 -100% BPL 67284 DOC 21414 Home Health Care j. Home Health Care is • This section describes coverage for home health care. Home health care must be directed by a r physician and received from a home health care agency authorized by the laws of the state in which treatment is received. 1844 {These words have specific meanings benefits, coinsurance„ custodiai care, deductible,':. dependent, hospital,. network, .non network , - network- provider,re_ imbursement amount, , physician, prenatal'.care,: provider, skilled care, skilled nursing, facility. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare guidelines) 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 1. and 2. in the table in this section are limited to a combined maximum of 120 visits per calendar year for in- network and 60 visits per calendar year for out -of- network benefits. Please note: These visit limits include any visits that you pay for in order to satisfy any part of your deductible. You may be eligible for additional intermittent skilled care if you have Medica coverage and are also enrolled in the Medical Assistance Program. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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. MIC PPMN HSA (3/11) 35 2500 -100% BPL 67284 DOC 21414 ',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 non - skilled services. 4. Physical, speech, or occupational therapy provided in your home for convenience. 5. Services provided in your home when you are not homebound. 6. Services primarily educational in nature. 7. Vocational and job rehabilitation. 8. Recreational therapy. 9. Self -care and self -help training (non - medical). 10. Health clubs. 11. Disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. 12. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 13. Voice training. 14. Outpatient rehabilitation services when no medical diagnosis is present. 15. Home health aide services, except when rendered in conjunction with intermittent skilled care 'and related to the medical condition under treatment. See Exclusions for additional services, supplies, and associated expenses that are not covered. _ I 3Your Benefits and theAmounts You Pay Benefits k ' # = a In network b enefits * Out of network benefits • = wafter ded ctible after deductible * For out -of net benefits, in addition tolthe deductible and coinsurance,_ you a re responsible for any charges in excess of the, non - network provider reimbursement - amount. Additionatly, these char es will not bera 4 tied toward satisfaction of the deductible or the out of poc maximum 1. Intermittent skilled care when Nothing 50% coinsurance you are homebound, provided by or supervised by a registered nurse MIC PPMN HSA (3/11) 36 2500 - 100% BPL 67284 DOC 21414 Home Health Care Your Benefits and,the Amounts You Pay y ,2 , . Benefit a s ; In net benefi ts * Out o nework benefits after: deductible ork a fter deductible * For out -of network benefits, rn addition to the deductible and coinsurance, you,are responsible for any charges in excess of the non network provider reimbursement amount Add tionaliy, these charges will not be applied toward satisfa .tion of the deduchb(e or the opt -of pocket maximum ....- __. 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when you are homebound 3. Home infusion therapy Nothing 50% coinsurance 4. Services received in your home Nothing 50% coinsurance from a physician MIC PPMN HSA (3/11) 37 2500 -100% BPL 67284 DOC 21414 Outpatient Rehabilitation K. Outpatient Rehabilitation This section describes coverage for both professional and outpatient health care facility services. A physician must direct your care. See Defin itions . These words have s m b en e f t s, coin dedu g. x network, rion n etwork; - non network provider reir bursement amount physician = Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to outpatient rehabilitation services arranged through a 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 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 coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. 6. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 7. Voice training. 8. Outpatient rehabilitation services when no medical diagnosis is present. MIC PPMN HSA (3/11) 38 2500 - 100% BPL 67284 DOC 21414 • - Outpatient Rehabilitation 9. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. You B and the Amou nts You `Pay Benefi , I n-net w or k =be * Out_ of network�benefit " t ` a ft r d : after, de d uc tible E * For out-of n benefits, in addition t o the deductible -and coin you a re responsible for any charges "in excess of "the non .providerreunbursement amount. Add thes charges;willrnot be applied toward satisfaction " of t d or: t he o ut -of pocket m ax imum: a 1. Physical therapy received Nothing 50% coinsurance. outside of your home Coverage for physical a occupational therapy is limited to a com bined limit per calendar year. of 20 Please note: Th v isit limit include ys s ph ical and therapy that yo u pay for inf ord to satisfy occupa tional any part thera of you visits deduct ible. 2. Speech therapy received outside Nothing 50% coinsurance. of your home when speech is Coverage fo speech impaired due to a medical illness therapy is limited to 20 or injury, or congenital or visits per cal year. developmental conditions that Please note: This vis limit have delayed speech i ncludes speech therapy development visits tha you pay for in o rder to satisfy any part of y our deductible. 3. Occupational therapy received Nothing 50% coinsurance. • outside of your home when Coverage for phys ical and physical function is impaired due occupational thera is to a medical illness or injury or limited to a combine I imit congenital or developmental of 20 visits per cal endar conditions that have delayed year motor development Plea note: This visit lim includes phys ical and occu therapy visits that you pay for in order to satisfy any part of your deductible. MIC PPMN HSA (3/11) 39 2500 - 100% BPL 67284 DOC 21414 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. See De nations. These words have specific meanings benefits, claim, coinsurance, custo dial care, deductible, emergency, hose tal inpatient medically necessary member, mental disorder, network, non network, provider¢ Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations and psychological testing. b. Psychotherapy and psychiatric services. c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week). d. Treatment for a minor, including family therapy. e. Treatment of serious or persistent disorders. f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD). g. 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. h. Treatment of pathological gambling. 2. Inpatient services include: a. Room and board. b. Attending psychiatric services. c. Hospital or facility -based professional services. d. 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 means a treatment program of 20 hours or more per week and may include lodging. e. Services, care, or treatment described as benefits in this certificate and 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. MIC PPMN HSA (3/11) 40 2500 -100% BPL 67284 DOC 21414 ' I Mental Health f. Residential treatment services. These services include either: i. A residential treatment program serving children and adolescents with severe emotional disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic services. In addition to room and board, at least 30 hours a week per individual of mental health services must be provided, including group and individual counseling, client education, and other services specific to mental health treatment. Also, the program must provide an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. 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. 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). For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Mental health services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the mental health services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Mental health clinic e. Mental health residential treatment center f. Independent clinical social worker g. Marriage and family therapist h. Hospital that provides mental health services 2. Emergency mental health services are,eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN HSA (3/11) 41 2500 -100% BPL 67284 DOC 21414 Mental Health 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. " 4. Relationship counseling. 5. Family counseling services, except as specifically described in this certificate as treatment for a minor. 6. Services for telephone psychotherapy. 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, as those conditions are defined in the current edition of the American Psychiatric Association's Diagnostic and Statistical Manu of Mental Disorders. 8. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide mental health services. This includes, but is not limited to, services provided by mental health providers who are not authorized under state law to practice independently, and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch. 9. 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. 10. Room and board charges associated with mental health residential treatment services providing Tess than 30 hours a week per individual of mental health services otr lacking an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. See Exclusions for additional services, supplies, and associated expenses that are not covered. a ' Your Benefits and the Amounts Yo Pa Benefits ��� to network benefits �* Ou t - o f - network benefits ,after deductible �_ after deductible * For out,of network benefits, m addition to the deductible and coinsurance, you are responsible for any charges in excess of th non network provider reimbursement amount Addit onatiy, these charges will not be applie 3toward sa of th deductible or the out , maximum • 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services MIC PPMN HSA (3/11) 42 2500 - 100% BPL 67284 DOC 21414 • Mental Health .Your Benefits and the Amounts You Pay Benefits In-network benefits *:Out -of- network benefits after deductible -,after deductible * F,or out =of network berefits;in addition to the, deductible and you are responsible for any charges in excess of the non:network provider, reimb.ursemert amount ; Additionally, these charges will not be applied toward satisfaction of thedeductible or.the out of pocket maximum; - 2. Intensive outpatient programs Nothing 50% coinsurance 3. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending psychiatrist Nothing 50% coinsurance services d. Partial program Nothing 50% coinsurance MIC PPMN HSA (3/11) 43 2500 -100% BPL 67284 DOC 21414 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 the Diagnostic and Statistical Manual of Mental Disorders. See Definitions Th words have specific meanings: benefits, claim, co nsurance, custodial care, deductible; emergency, hospital, inpatient, medically necessary, member, - network, non- network,-physician, provider. Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1 1. Outpatient services include: a. Diagnostic evaluations. b. Outpatient treatment. c. Intensive outpatient programs, including day treatment and partial programs, which may include multiple services and modalities, delivered in an outpatient setting. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. 2. Inpatient services include: a. Room and board. b. Attending physician services. c. Hospital or facility -based professional services. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. e. Residential treatment services. These are services from a licensed chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours per week per individual of chemical dependency services must be provided, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. MIC PPMN HSA (3/11) 44 2500 - 100% BPL 67284 DOC 21414 Substance Abuse Covered For benefits and the amounts you pay, see the table in this section. • For in- network benefits: 1. Medica's designated mental health and substance abuse provider arranges in- network substance abuse benefits. 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). 2. In- network benefits will apply to services, care or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1 -866- 214 -6829. • For out -of- network benefits: 1. Substance abuse services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Chemical dependency clinic e. Chemical dependency residential treatment center f. Hospital that provides substance abuse services g. Independent clinical social worker h. Marriage and family therapist 2. Emergency substance abuse services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. MIC PPMN HSA (3/11) 45 2500 -100% BPL 67284 DOC 21414 Substance Abuse 2. Services for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary. 4. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received. 5. Telephonic substance abuse treatment services. 6. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide substance abuse services. This includes, but is not limited to, services provided by mental health or substance abuse providers who are not authorized under state law to practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch. 7. Room and board charges associated with substance abuse treatment services providing less than 30 hours a week per individual of chemical dependency services, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. 8. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amount You Pay Benefits s � In network benefits `Out- o #- netw►ork benefits . rafter deductible after deductible F,or ut o- of network benefits, in ad to thdition deductible and cor s * urance, you are re for any charges in excess of the non network provider reimbursemen amount : Addltionaliy, these charges will not be applied toward satisfaction of the deductible or the out of pocket _ �: ��� 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending physician services Nothing 50% coinsurance MIC PPMN HSA (3/11) 46 2500 -100% BPL 67284 DOC 21414 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. See Definitions. These words have specific meanings benefits, coinsurance, deductible durable' medical equipment, network, non network, -non network °provider reimbursement amount, s physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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, and hearing aids that meet the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. The list of eligible durable medical equipment and certain related supplies is periodically reviewed and modified by Medica. 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 purchased 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. If the durable medical equipment, prosthetic device, or hearing aid is covered by Medica, but the model you select is not Medica's standard model, you will be responsible for the cost difference. • In- network benefits apply to durable medical equipment, certain related supplies and prosthetic services prescribed by a physician and received from a network durable medical equipment provider, and hearing aids as described in 4. in the table in this section when prescribed by a network provider. To request a list of the durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. • Out -of- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a non - network provider. Out -of- network benefits also apply to hearing aids as described in 4. in the table in this section. In addition to the deductible or coinsurance described for out -of- network benefits, you are responsible for charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in. How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN HSA (3/11) 47 2500 -100% BPL 67284 DOC 21414 Durable Medical Equipment And Prosthetics Not covered These services, supplies, and associated expenses are not covered: 1. Durable medical equipment and supplies, prosthetics, appliances, and hearing aids not on the Medica eligible list. • 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, or hearing aids. 3. Repair, 'replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, replacement or revision of duplicate items. See Exclusions for additional services, supplies, and associated expenses that are not covered. Yo ur Benefits and the Amounts�You Pay£ fi Benefits In network benefits "` . Out of- network benefits Q fifer de tible after deductible *For out of network benefits, in addition to the deductible and coinsuranc you_ are ; responsible for any charges'rn excess of the non network provides reimbursement amount Additionally, these charges will not be applied satisfaction of the deductible or the out =of pocket maximum ; 1. Durable medical equipment and Nothing 50% coinsurance certain related supplies 2. Repair, replacement, or revision Nothing 50% coinsurance of durable medical equipment made necessary by normal wear and use 3. Prosthetics a. Initial purchase of external Nothing 50% coinsurance prosthetic devices that replace a limb or an external body part, limited to: i. Artificial arms, legs, feet, and hands; ii. Artificial eyes, ears, and noses; iii. Breast prostheses b. Scalp hair prostheses due to Nothing. Me.dica pays up 50% coinsurance. alopecia areata to $350. This is Medica pays up to $350. calculated each calendar This is calculated each year. calendar year. MIC PPMN HSA (3/11) 48 2500 -100% BPL 67284 DOC 21414 Durable Medical Equipment And Prosthetics • Your Benefits a nd the Amounts You Pay E s re Benefits " = In network benefits *,Out - of - network benefi #s after • er deductible aft deductible * For out o #- network benefits, in addition to'_the deductible a id coinsurance, you aie responsi for M " ; any charge in exces of the non network" provider reimbursement amount Additionally; these char " "ges pot c. be applied toward satisfaction of the deductible-or out -of pocket °maximum` c. Repair, replacement, or Nothing 50% coinsurance revision of artificial arms, legs, feet, hands, eyes, ears, noses, and breast prostheses made necessary by normal wear and use 4. Hearing aids for members 18 Nothing. Coverage is 50% coinsurance. years of age and younger for limited to one hearing aid Coverage is limited to hearing loss that is not per ear every three years. one hearing aid per ear correctable by other covered Related services must be every three years. procedures prescribed by a network provider. • I I MIC PPMN HSA (3/11) 49 2500 - 100% BPL 67284 DOC 21414 Miscellaneous Medical Services And Supplies 0. Miscellaneous Medical Services And Supplies This section describes coverage for miscellaneous medical services and supplies prescribed by a physician. Medica covers only a limited selection of miscellaneous medical services and supplies that meet the criteria established by Medica. Some items ordered by a physician, even if medically necessary, may not be covered. See Definitions These_words have specific: meanings benefits, coinsurance,, deductible, network, non - network; non- network provider reimbursement amount, physician, Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to miscellaneous medical services and supplies received from a network provider. • Out -of- network benefits apply to miscellaneous medical services and supplies received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered Other disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 50 2500 -100% BPL 67284 DOC 21414 Miscellaneous Medical Services And Supplies I Your Be an nefits d the Amounts You Pa f Y Benefits F t ne twork bene * Out of " ne twor k „ benefits after deductible a deduct *For out of n etwork be nefits, i n adtlition #o the deductible and co msuranc e y ou a re respons fo any in excess o the non - netw ork provider reimbursement amount: Ad d i tionally, thes charge IN` ial not be applied.toward satisfaction bf ttie : deductible " or.the out-of- pocket maxi um k 1. Blood clotting factors Noth 50% co 2. Dietary medical treatment of Nothing 50% coinsurance phenylketonuria (PKU) 3. Amino acid-based fol elemental wing Nothing 50% coinsurance formulas for the lo diagnoses: a. cystic fibris; b. amino acid organic acid, and fatty acid metabolic and malabs ; c. mediated allergies to foo proteins d. food enterocolitis syndro protein- induced me; e. eosinophilic esophagitis; f. eos i nop hilic gastroenteritis; and g. eosinophilic colitis. Coverage for the diagnoses in 3.c. -g. above is Iimited to members five years of a ge and younger. 4. Total parenteral nutrition Nothing 50% coinsurance 5. Eligible ostomy supplies Nothing 50% coinsurance Please no te: Elig ible ostomy supplies may be received from a pharmacy or a durable medica equipment provider. 6. Insulin pump equ eligible Nothing 50% coinsurance diabetic i pment and supplies MIC PPMN HSA (3/11) 51 2500 - 100% BPL 67284 DOC 21414 Alb— 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 network physician and received at a designated 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 appropriate for the diagnosis, without contraindications, and non - investigative. See Definitions These words have specific+meanings benefits,;coinsurance, deductible, e visits,, hospital, inpatient, investigative, medically necessary, member, network, non - network, non .network provider reimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica is required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood. The preceding is not a comprehensive list of eligible organ and bone marrow transplant services. • 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. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 network transplant facilities). Based on the type of transplant you receive, Medica will determine the specific time period medically necessary for these services. MIC PPMN HSA (3/11) 52 2500 -100% BPL 67284 DOC 21414 Organ And. Bone Marrow Transplant Services Not covered These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow transplant services except as described in this section. 2. 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. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. 5. Islet cell transplants except for autologous islet cell transplants associated with pancreatectomy. 6. 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 suppressants, and supplies of a similar nature not otherwise covered under this Certificate. 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. 10. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your-Benefits and the Anilounts You.Pay iIn ;network benefits * Ouof network benefits d ft d'tb ctibl r de uc � le - after de u e � �' For out of- network benefits, in addition to_-the deductible ipd:coinsuiape,:yoii*eIpAponsi,im any charges in excess of the non-network provided reimbursement amount Additional) theses charges will not be applied toward satisfaction of the deductible or the out of pocket maximum E 1. Office visits Nothing No coverage 2. E- visits Nothing No coverage MIC PPMN HSA (3/11) 53 2500 -100% BPL 67284 DOC 21414 Organ And Bone Marrow Transplant Services Your Benefits and the Amounts You Pay Benefits In- network benefits * Out-of-network benefits `after, deductible after deductible * For out-of-network benefits, in addition tothe deductible and: coinsurance;you are responsible for anyrcharges m excess of the non-network provider reimbursement amount ;Additionally, these` - charges Fwill not be applied toward-satisfaction Of 'f the deductible or'the out of pocket maximum 3. Outpatient services a. Professional services i. Surgical services (as Nothing No coverage defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit ii. Anesthesia services Nothing No coverage received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing No coverage pathology iv. Outpatient x -rays and Nothing No coverage other imaging services v. Other outpatient hospital Nothing No coverage services received from a physician vi. Services related to Nothing No coverage human leukocyte antigen testing for bone marrow transplants b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x -rays and Nothing No coverage other imaging services iii. Other outpatient hospital Nothing No coverage services 4. Inpatient services Nothing No coverage MIC PPMN HSA (3/11) 54 2500 -100% BPL 67284 DOC 21414 Organ And Bone Marrow Transplant Services Your Benefits and the Amounts You Pay Benefits t : In network benefits * Out o #network °benefits after deductible after deductible For out ;of- network benefits, in o the deductible and coinsurance, you are responsible for any charges in excess of the non-network provide' reimbursement amount Additionally; these; charges will not. be applied toward satisfaction, of. the deductible or the out of pocket maximum h 5. Services received from a Nothing No coverage physician during an inpatient stay 6. Anesthesia services received Nothing No coverage from a provider during an inpatient stay 7. Transportation and lodging The deductible does not No coverage a. As described below, apply to this reimbursement of reasonable reimbursement benefit. and necessary expenses for You are responsible for travel and lodging for you paying all amounts not and a companion when you reimbursed under this receive approved services at benefit. Such amounts a designated facility for do not count toward your transplant services and you out -of- pocket maximum live more than 50 miles from or toward satisfaction of that designated facility your deductible. i. Transportation of you and one companion (traveling on the same day(s)) to and /or from a designated facility for transplant services for pre - transplant, transplant, and post - transplant services. If you are a minor child, transportation expenses for two companions will be reimbursed. MIC PPMN HSA (3/11) 55 2500 -100% BPL 67284 DOC 21414 Organ And Bone Marrow Transplant Services jir Your Benefits and the Amounts You Pay' Benefits Jn network benefits *Out of- network benefits after deductible after deductible * For out of network" benefits, in addition to the deductible and coinsurance, you are responsrble,for .' any charges in excess of the non - network provider reimbur amount Additionally, these charges "will not =;be;applied toward:satisfaction of the "deductible or "the out -o p ocket maximum ii. Lodging for you (while not confined) and one companion. Reimbursement is available for a per diem amount of up to $50 for one person or up to $100 for two people. If you are a minor child, reimbursement for lodging expenses for two companions is available, up to a per diem amount of $100. iii. There is a lifetime maximum of $10,000 per member for all • transportation and lodging expenses incurred by you and your companion(s) and reimbursed under the Contract or under any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. b. Meals are not reimbursable under this benefit. MIC PPMN HSA (3/11) 56 2500-100% BPL 67284 DOC 21414 Infertility Diagnosis Q. Infertility Diagnosis This section describes coverage for the diagnosis of infertility. Coverage includes benefits for professional, hospital and ambulatory surgical center services. Services for the diagnosis of infertility must be received from or under the direction of a physician. All services, supplies, and associated expenses for the treatment of infertility are not covered. See Definitions These words have specific meanings benefits, coinsurance, deductible, e visits, hospital, inpatient, member, network, non networ non - network providei reimbursement amount, physician, provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered Benefits apply to services for the diagnosis of infertility received from a network or non - network provider. Coverage for infertility services is limited to a maximum of $5,000 per member per calendar year for in- network and out -of- network benefits combined. More than one coinsurance may be required if you receive more than one service, or see more than one provider per visit. Not covered All services, supplies, and associated expenses for the treatment of infertility are not covered including the following: 1. Professional, hospital, and ambulatory surgical center services for the treatment of infertility. 2. Infertility drugs. 3. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 4. Services for a condition that a physician determines cannot be successfully treated. 5. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 6. Sperm banking. 7. Adoption. 8. Donor sperm. 9. Embryo and egg storage. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 57 2500 - 100% BPL 67284 DOC 21414 Infertility Diagnosis Your Benefits and the Amounts You Pay Benefits In- network benefits * -Out of network benefits . �_ after deductible--- , after deductible * For ou# of network benefits, in additionfto the deductible and coinsurance, you are responsible for any charges in excess of the non network provider reimbursement amount Additionally, these _ charges will not be applieditoward sati of the-deductible 'the otif4of;tiocket maximum 1. Office visits, including any Nothing 50% coinsurance services provided during such visits 2. E- visits Nothing No coverage 3. Outpatient services received at a Nothing 50% coinsurance hospital 4. Inpatient services Nothing 50% coinsurance :MIC;PPMN HSA(3 /11) 58 2500 -100% r ` BPL67284 DOC21414 • 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. See Definitions These words have specific meanings benefits, coinsu rance, cosmetic deductible,: a visits, hospital,;inpatient, med ically necessary , rrember, network, non network, non - network providerreim m burseent amount, ;pysician,7provider, co renstructive, r T Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. 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. 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. 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. 6. Hair transplants. MIC PPMN HSA (3/11) 59 2500 -100% BPL 67284 DOC 21414 Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. le Your Benefit s and -the Amounts You Pay Benefits In network benefit- of-network' benefits after deductible , ,'after-deductible - 4 - *For out -of network benefit's,' in addition; to the deductible and coinsurance, you are responsible for any charges'in excess of the non network provider reimbursement amount. Additionally,these charges will not be applied toward satisfaction of the deductible or the' out -of pocket maximum 1. Office visits Nothing 50% coinsurance 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance or ambulatory surgical center services received from a physician MIC PPMN HSA (3/11) 60 2500 -100% BPL 67284 DOC 21414 it Reconstructive And Restorative Surgery Your Benefits and the Amounts You Pay Benefits .. ° In- network = benefits' * Out-of ;network benefits after deductible after. deductible * For out network benefits, in addition " th e deductible and "coinsurance,` ° you are responsible for any; charges i,n excess of the non- network p reimbur amount: Additionall these charges will not be applied toward satisfaction of the'deductible or the out of pocket maximum b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Inpatient services Nothing 50% coinsurance 5. Services received from a Nothing 50% coinsurance physician during an inpatient stay 6. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay MIC PPMN HSA (3/11) 61 2500 -100% BPL 67284 DOC 21414 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 qualify as reimbursable under Medicare. See Definitions These words have specific meanings benefits, coinsurance,; custodial. care, ° deductible, emergency, hospital, inpatient, network, non-network, non network provider reimbursement amount, physician, skilled care, skilled nursing facility Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For purposes of this section, room and board includes coverage of health services and supplies. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out-of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. Custodial care and other non - skilled services. 2. Self -care or self -help training (non - medical). 3. Services primarily educational in nature. 4. Vocational and job rehabilitation. 5. Recreational therapy. 6. Health clubs. 7. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 8. Voice training. MIC PPMN HSA (3/11) 62 2500 -100% BPL 67284 DOC 21414 Skilled Nursing Facility Services 9. Outpatient rehabilitation services when no medical diagnosis is present. 10. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits _ In network benefits *Out of- network benefi afterideductible after deductible * For out benefits, in addition to the deductible and coinsurance, you are ,responsible for any charges in excess of the non = network provider reimbursement amount. Additionally, these charges will ,not be applied toward satisfaction of the deductible or the out-of-pocket maximum. 1. Daily skilled care or daily skilled Nothing 50% coinsurance rehabilitation services, including room and board Please note: Such services are eligible for coverage only if they would qualify as reimbursable under Medicare. 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when room and board is not eligible to be covered 3. Services received from a Nothing 50% coinsurance physician during an inpatient stay in a skilled nursing facility MIC PPMN HSA (3/11) 63 2500 - 100% BPL 67284 DOC 21414 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 hospice program. See ; Definitions These words have specific meanings benefits „coinsurance deductible, ; member, - network, non- network, non-network provider reimbursement aii ount, physician, skilled nursing facilrtY.., Co vered 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. 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 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 network hospice program. • Out -of- network benefits apply to hospice services arranged through a physician and received from a non - network hospice program. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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). 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. Members who elect to receive hospice services do so in place of curative treatment for their terminal illness for the period they are enrolled in the hospice program. You may withdraw from the hospice program at any time upon written notice to the hospice program. You must follow the hospice program's requirements to withdraw from the hospice program. MIC PPMN HSA (3/11) 64 2500 -100% BPL 67284 DOC 21414 T " 1 Hospice Services Not covered These services, supplies, and associated expenses are not covered: 1. Respite care for more than five consecutive days at a time. 2. 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 hospice program's plan of care. 4. Services not provided by the hospice program. 5. Hospice daycare, except When recommended and provided by the hospice program. 6. Any services provided by a family member or friend, or individuals who are residents in your home. 7. Financial or legal counseling services, except when recommended and provided by the hospice program. 8. Housekeeping or meal services in your home, except when recommended and provided by the hospice program. 9. Bereavement counseling, except when recommended and provided by the hospice program. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits anal the Amounts You Pay` Benefits In, network benefits ut of network enefits after deductible after deductible Fo out -o network benefits, Fri a ddition to dedu an - you are responsible for any En excess of.the non network p rovider reimbursement amount Additionally, cha thesex rges wilt not be applied toward satisfaction of the deductible or the out of pockst maximum 1. Hospice services Nothing 50% coinsurance MIC PPMN HSA (3/11) 65 2500 -100% BPL 67284 DOC 21414 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. TMJ disorder is covered the same as any other joint disorder under this certificate. See Definitions These words have specific meanings benefits, coinsurance,; deductible, e visits, hospitals inpatient, member, network, non network, npn- network °provider reimbursement amount, ,physician,' ,provider , ...,: Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket "maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 66 2500 -100% BPL 67284 DOC 21414 Temporomandibular Joint (TIM) Disorder Your Benefits and the Amounts You °Pay . Benefits ra „In network benefits; _ *Out of network benefits ' %after dedductible aftePr deductible * F orout of network benefits, in addition to ;the deductible and' coinsurance,; you are respon for any.charges �n excess of the non- network provider reimbursement ° amount u; Additionally, these' c harges will not be applied toward satisfaction of the deductible or the outof pocket maximum•:h 1. Office visits Nothing 50% coinsurance 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services received from a physician or dentist b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services MIC PPMN HSA (3/11) 67 2500 -100% BPL 67284 DOC 21414 Temporomandibular Joint (TMJ) Disorder Your Benefits and the Amounts You Pay Benefits -; .In network benefits *.Out of= network benefits rafter deductible 4. , after deductible * For out -of network benefits, in addition;to,the deductible and you °are responsible for any charges in excess of the non network provider reimbursement amount Additionally, these charges will not be applied toward- satisfaction=of the deductible or the out-b#-pocket maximum iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Physical therapy received Nothing 50% coinsurance outside of your home 5. Inpatient services Nothing 50% coinsurance 6. Services received from a Nothing 50% coinsurance physician or dentist during an inpatient stay 7. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay 8. TMJ splints and adjustments if Nothing 50% coinsurance your primary diagnosis is joint disorder MIC PPMN HSA (3/11) 68 2500 -100% BPL 67284 DOC 21414 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. 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 alignment or occlusion of the teeth. These services are not covered under any section of this certificate. SeeDefinitions These words have specific meanings: benefits, coinsurance, deductible, e de ndent h dependent, member, network, non network, non netin�ork provider reimbursement amount, physician, provider: .. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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), except as described in this section for the treatment of cleft lip and palate. 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, except as described in this section for the treatment of cleft lip and palate. 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. MIC PPMN HSA (3/11) 69 2500 - 100% BPL 67284 DOC 21414 Medical- Related Dental Services 8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident - related dental services as described in this section. 9. Routine diagnostic and preventive dental services. See Exclusions for additional services, supplies, and associated expenses that are not covered. s Your Benefits and the Amounts Yo"u Pay; Benefits x , In- network benefits *Out of- network benefits , after . deductble after deductible *.far out of network b enefits, in addition to the deductible and coinsurance, you are responsible for ..any. charges in 'excess!of ttie`non network provider reimbursement amours# Additionally, these charges will not.be applied toward satisfaction of the deductible or the out - of - pocke maximum 1. Charges for medical facilities Nothing 50% coinsurance and general anesthesia services that are: a. Recommended by a physician; and b. Received during a dental procedure; and c. Provided to a member who: i. 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. 2. For a dependent child, Nothing 50% coinsurance orthodontia, dental implants, and oral surgery treatment related to cleft lip and palate MIC PPMN HSA (3/11) 70 2500 - 100% BPL 67284 DOC 21414 Medical- Related Dental Services Your Benefits: and the Amounts You' Pay, Benefits In network benefits * Out -of- network benefits after deductible after deductible * For out of network benefits, in addition to thetdeduc and coinsurance, you are' responsible for any charge "s in excess;of the network provider reimbursement amount:, Additionally, these charges wili not be applied toward satisfaction ofthe x deductible or the "out -of pocket`maximum 3. Accident - related dental services Nothing 50% coinsurance to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply: a. Coverage is limited to services received within 24 months from the later of i. the date you are first covered under the Contract; or ii. the date of the injury 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 one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year. 4. Oral surgery for: Nothing 50% coinsurance a. Partially or completely unerupted impacted teeth; or b. A tooth root without the extraction of the entire tooth (this does not include root canal therapy); or c. The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth MIC PPMN HSA (3/11) 71 2500 -100% BPL 67284 DOC 21414 Referrals To Non- Network Providers W. 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 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. See Definition's These words have specific rieanrngs benefits ;,;; medically #:necessary, network, non network, physician, provide If you want to apply for a standing referral to a non - network provider, contact Medica for more information. If determined by Medica to be clinically appropriate, a standing referral may be granted by Medica. A standing referral is a referral issued by a network provider and authorized by Medica for conditions that require ongoing services from a specialist provider. Standing referrals will only be covered for the period of time appropriate to your medical condition. Referrals and standing referrals will not be covered to accommodate personal preferences, family convenience, or other non - medical reasons. Referrals will also not be covered for care that has already been provided. If your request for a standing referral is denied, you have the right to appeal this decision as described in Complaints. What you must do 1. 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. 2. 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. 3. 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. 4. Pay any charges not authorized for coverage by Medica. What Medica will do 1. May require that you see another network provider selected by Medica before a determination by Medica that a referral to a non - network provider is medically necessary. 2. 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. MIC PPMN HSA (3/11) 72 2500 -100% BPL 67284 DOC 21414 Referrals To Non - Network Providers 3. Provides coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. 4. 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 24 hours from the time of the initial request if your attending provider believes that an expedited review warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function. MIC PPMN HSA (3/11) 73 2500 -100% BPL 67284 DOC 21414 Harmful Use Of Medical Services X. 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. See :Definitions:' These words have specific meanings benefits, emergency, hospital, net physician,, prescription drug,, provider. 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. You must obtain a referral from your coordinating health care provider if your condition requires care or treatment from a provider other than your coordinating health care provider. Medica will send you specific information about: } 1. How to obtain approval for benefits not available from your coordinating health care providers; and 2. How to obtain emergency care; and 3. When these restrictions end. MIS PPMN HSA (3/11) 74 2500 -100% { BPL 67284 DOC 21414 • i Exclusions Y. Exclusions See Defin tions These words have specific meanings claim, cosmetic,, == ',custod care, durable medical equipment emergency, investigative, medically necessary, member non network, physician, provider, reconstructive, routine -foot care: " � Medica will not provide coverage for any of the services, treatments, supplies, or items described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition. This section describes additional exclusions to the services, supplies, and associated expenses already listed as Not covered in this certificate. These include: 1. 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. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive. 3. Refractive eye surgery, including but not limited to LASIK 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 a physician, air and bone conduction hearing aids (including internal, external, or implantable hearing aids or devices), 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. Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct -to- consumer marketing and not under the direction of your physician. 8. Services or supplies not directly related to care. 9. Autopsies. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition. 11. Nutritional and electrolyte substances, except as specifically described in Miscellaneous Medical Services And Supplies. 12. Physical, occupational, or speech therapy or chiropractic services when there is no reasonable expectation that the condition will improve over a predictable period of time. 13. Reversal of voluntary sterilization. MIC PPMN HSA (3/11) 75 2500 -100% BPL 67284 DOC 21414 Exc@usions 14. Personal comfort or convenience items or services, including but not limited to breast pumps, except when the pump is medically necessary. 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, except as described in Organ And Bone Marrow Transplant Services. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 19. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular disease, peripheral neuropathies, and significant neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. 21. Services by persons who are family members or who share your legal residence. 22. Services for which coverage is available under workers' compensation, employer liability, or any similar law. 23. Services received before coverage under the Contract becomes effective. 24. Services received after coverage under the Contract ends. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non- network providers and non - network dentists. 26. Photographs, except for the condition of multiple dysplastic syndrome. 27. Occlusal adjustment or occlusal equilibration. 28. Dental implants (tooth replacement), except as described in Medical - Related Dental Services. 29. Dental prostheses. 30. Orthodontic treatment, except as described in Medical - Related Dental Services. 31. Treatment for bruxism. 32. Services prohibited by applicable law or regulation. 33. Services to treat injuries that occur while on military duty, and any services received as a result of war or any act of war (whether declared or undeclared). 34. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or Iicensure. 35. Exams, other evaluations, or other services received solely for the purpose of judicial or administrative proceedings or research, except emergency examination of a child ordered by judicial authorities. 36. Non - medical self -care or self -help training. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services. 38. Coverage for costs associated with translation of medical records and claims to English. MIC PPMN HSA (3/11) 76 2500 -100% BPL 67284 DOC 21414 r' 14 Exclusion's 39. Treatment for spider veins. 40. Services not received from or under the direction of a physician, except as described in this certificate. 41. Orthognathic surgery. 42. Sensory integration, including auditory integration training. 43. Services for or related to vision therapy and orthoptic and /or pleoptic training, except as described in Professional Services. 44. Services for or related to intensive behavior therapy treatment programs for the treatment of autism spectrum disorders. Examples of such services include, but are not limited to, Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral Intervention (IBI), and Lovaas therapy. 45. Health care professional services for maternity labor and delivery in the home. 46. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and subsequent procedures. 47. Services for the treatment of infertility. 48. Infertility drugs. 49. Acupuncture. 50. Services solely for or related to the treatment of snoring. 51. Interpreter services. • 52. Services provided to treat injuries or illness that are the result of committing a crime or attempting to commit a crime. 53. Services for private duty nursing, except as stated in Home Health Care. Examples of private duty nursing services include, but are not limited to, skilled or unskilled services provided by an independent nurse who is ordered by the member or the member's representative, and not under the direction of a physician. 54. Laboratory testing that has been performed in response to direct -to- consumer marketing and not under the direction of a physician. 55. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), other than those granted a humanitarian device exemption. MIC PPMN HSA (3/11) 77 2500 -100% BPL 67284 DOC 21414 How To Submit A Claim Z. How To Submit A Claim This section describes the process for submitting a claim. See Definitrons These w ords have specific meanings benefits claim, dependent, member, network, non network; non, network piovdei reimbursement amount, provider: 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. Claim forms may also be obtained by signing in at www.mymedica.com. Network providers are required to submit claims within 180 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 180 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 one of the telephone numbers listed inside the front cover. Claim forms may also be obtained by signing in at www.mymedica.com. 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 the address identified on the back of your identification card. Upon receipt of your claim for benefits from non - network providers, Medica will generally pay to you directly the non - network provider reimbursement amount. Medica will only pay the provider of services if: 1. The non - network provider is one that Medica has determined can be paid directly; and 2. The non - network provider 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 claims 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 receiving the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. Call Customer Service at one of the telephone numbers listed inside the front cover for a list of non- network providers that Medica will not pay directly. MIC.PPMN HSA (3/11) 78 2500 -100% BPL 67284 DOC 21414 • Flow To Submit A Claim 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. II • 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 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. ii MIC PPMN HSA (3/11) 79 2500 -100% BPL 67284 DOC 21414 Coordination Of Benefits AA. Coordination Of Benefits This section describes how benefits are coordinated when you are covered under more than one plan. See Definitions. These words have specific meanings benefits, claim deductible, c ependent, emergency, hospital, member, non - network, non-network _provider reimbursement amount, o pr, ve � der, subscriber 1. Applicability a. 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. b. If this coordination of benefits provision applies, 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 Order of benefit determination rules, the benefits of this plan: i. 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 a. Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment: i. Group insurance or group -type coverage, whether insured or uninsured, or individual coverage. 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 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. b. This plan is the part of the Contract that provides benefits for health care expenses. c. 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. MIC PPMN HSA (3/11) 80 2500 -100% BPL 67284 DOC 21414 P Coordination Of 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. d. 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. Allowable expense does not include the deductible for members with a primary high deductible plan and who notify Medica of an intention to contribute to a health savings account. The difference between the cost of a private hospital room and the cost of a semi - private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private 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 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 member 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. e. 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 a. 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 3.b. below, require that this plan's benefits be determined before those of the other plan. b. Rules. This plan determines its order of benefits using the first of the following rules which applies: i. 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. ii. 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 MIC PPMN HSA (3/11) 81 2500 -100% BPL 67284 DOC 21414 Coordination Of Benefits 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. iii. 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 determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. iv. 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 3.b.ii. v. 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. vi. 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. vii. No -fault automobile insurance. Coverage under the No -Fault Automobile Insurance Act or similar law applies first. viii. 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 a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that MIC PPMN HSA (3/11) 82 2500 -100% BPL 67284 DOC 21414 Coordination Of Benefits event, the benefits of this plan may be reduced under this section. Such other plan or plans are referred to as the other plans in b. immediately below. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of: i. 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. 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, 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; or 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. Please note: See Right Of Recovery for additional information. MIC PPMN HSA (3/11) 83 2500 - 100% BPL 67284 DOC 21414 Right Of Recovery BB. Right Of Recovery This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and federal law. For information about the effect of applicable state and federal law on Medica's subrogation rights, contact an attorney. See Definitions This word has a'specific meaning benefits 1. 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. 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 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. 4. By accepting coverage under the Contract, you agree: a. That if Medica pays benefits for medical expenses you incur as a result of any act by a third party for which the third party is or may be liable, and you later obtain full recovery, you are obligated to reimburse us for the benefits paid in accordance to Minnesota law. b. 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. c. To provide prompt written notice to Medica when you make a claim against a party 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. f. 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. MIC PPMN HSA (3/11) 84 2500 -100% BPL 67284 DOC 21414 Eligibility And Enrollment CC. Eligibility And Enrollment This section describes who can enroll and how to enroll. See; Definitions? These words have specific - meanings: contin coverage, dependent, late entrant, member, mental disorder, placed adoption, ',premium, qualifying, coverage, subscnber,:uvaitmg period �- -` Who can enroll To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract and be a subscriber or dependent as defined in this certificate. See Definitions. How to enroll You must submit an application for coverage for yourself and any dependents to the employer: 1. During the initial enrollment period a s described in this section under Initial enrollment; or l m n e t pe 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 other time for consideration as a late entrant as described in this section under Late enrollment. Dependents will not be enrolled without the eligible employee also being enrolled. A child who is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical Child Support Order (QMCSO) and 6. under Special 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, a dependent child reaching the dependent limiting age, or other facts identifying you or your dependents. (For dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption; however, we encourage you to enroll your newborn dependent under the Contract within 30 days from the date of birth, date of placement for adoption, or date of adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with the subscriber, and any child who is a member pursuant to a QMCSO will be covered without application of health screening or waiting periods. The employer must notify Medica, as set forth in the Contract, 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 A 30 -day time period starting with the date an eligible employee and dependents are first eligible to enroll for coverage under the Contract. An eligible employee must enroll within this MIC PPMN HSA (3/11) 85 2500 -100% BPL 67284 DOC 21414 Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30 -day time period does not apply to newborns or children newly adopted or placed for adoption; see Special enrollment.) An eligible employee and dependents that enroll during the initial enrollment period are accepted without application of health screening or affiliation periods. An eligible employee and dependents who do not enroll during the initial enrollment period may enroll for coverage during the next open enrollment, any applicable special enrollment periods or as a late entrant (if applicable, as described below). A member who is a child entitled to receive coverage through a QMCSO is not subject to any initial enrollment period restrictions, except as noted in this section. Open enrollment A minimum 14 -day period set by the employer and Medica each year during which eligible employees and dependents who are not covered under the Contract may elect coverage for the upcoming Contract year. An application must be submitted to the employer for yourself and any dependents. Special enrollment Special enrollment periods are provided to eligible employees and dependents under certain circumstances. 1. Loss of other coverage a. A special enrollment period will apply to an eligible employee and dependent if the individual was covered under Medicaid or a State Children's Health Insurance Plan and lost that coverage as a result of loss of eligibility. The eligible employee or dependent must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. it In the case of the eligible employee's loss of coverage, this special enrollment period applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of coverage, this special enrollment period applies to both the dependent who has lost coverage and the eligible employee. b. A special enrollment period will apply to an eligible employee and dependent if the !' eligible employee or dependent was covered under qualifying coverage other than Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment, and declined coverage for that reason. The eligible employee or dependent must present either evidence of the Toss of prior coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated; and request 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, or the date on which a claim is denied due to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; MIC PPMN HSA (3/11) 86 2500 -100% BPL 67284 DOC 21414 Eligibility And Enrollment ii. Loss of eligibility includes: • loss of eligibility as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment; • cessation of dependent status; • incurring a claim that causes the eligible employee or dependent to meet or exceed the lifetime maximum limit on all benefits; • if the prior coverage was offered through an individual health maintenance organization (HMO), a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area; • if the prior coverage was offered through a group HMO, a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other coverage option is available; and • the prior coverage no longer offers any benefits to the class of similarly situated individuals that includes the eligible employee or dependent. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is eligible for or elects applicable federal or state continuation coverage; iv. 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; In the case of the eligible employee's loss of other coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of other coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. c. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under benefits available under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or any applicable state continuation laws at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. The eligible employee or dependent must present evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to failure of the t e eligible employee or dependent to pay premiums on a timely basis or for cause; and request enrollment in writing within 30 days of the date of the exhaustion of coverage. For purposes of 1.c.: i. Exhaustion of COBRA or state continuation coverage includes: • losing COBRA or state continuation coverage for any reason other than those set forth in ii. below; • losing coverage as a result of the employer's failure to remit premiums on a timely basis; MIC PPMN HSA (3/11) 87 2500 - 100% BPL 67284 DOC 21414 Eligibility And Enrollment • losing coverage as a result of the eligible employee or dependent incurring a claim that meets or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or • if the prior coverage was offered through a health maintenance organization (HMO), losing coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other COBRA or state continuation coverage is available. ii. Exhaustion of COBRA or state continuation coverage 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. iii. In the case of the eligible employee's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. 2. 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 and provided that the eligible employee also enrolls during this special enrollment period; 3. 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 (for dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption) and provided that the eligible employee also enrolls during this special enrollment period; 4. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in 3. 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; and d. The eligible employee also enrolls during this special enrollment period; or 5. 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 2. or 3. above, becoming eligible to enroll under the coverage provided the eligible employee also enrolls during this special enrollment period. 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as described in this section, Medica will provide the eligible dependent child with a special enrollment period provided the eligible employee also enrolls during this special enrollment period. MIC PPMN HSA (3/11) 88 2500 - 100% BPL 67284 DOC 21414 Ai Eligibility And Enrollment Late enrollment An eligible employee or an eligible employee and dependents who do not enroll for coverage offered through the employer during the initial or open enrollment period or any applicable special enrollment period will be considered late entrants. Late entrants who have maintained continuous coverage may enroll and coverage will be effective the first day of the month following date of Medica's approval of the request for enrollment. Continuous coverage will be determined to have been maintained if the late entrant requests enrollment within 63 days after prior qualifying coverage ends. Individuals who have not maintained continuous coverage may not enroll as late entrants. An eligible employee or dependent who: 1. does not enroll during an initial or open enrollment period or any applicable special enrollment period; and 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the 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. 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. If the eligible employee whose dependent child is the subject of the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, the eligible employee must also enroll for coverage under the Contract during the 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. The date your coverage begins Your coverage begins at 12:01 a.m. on the effective date of your enrollment. 1. For eligible employees and dependents who enroll during the initial enrollment period, coverage begins on the effective date specified in the Contract. MIC PPMN HSA (3/11) 89 2500- 100% BPL 67284 DOC 21414 1 Eligibility And Enrollment 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: a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first calendar month following the date on which the request for enrollment is received by Medica; b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of adoption or placement for adoption, date of adoption or placement. In all other cases, the date the subscriber acquires the dependent child; c. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.b. above; d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. or 3. under Special enrollment becomes effective; e. Number 6. under Special enrollment, the first day of the first calendar month following the date the completed request for enrollment is received by Medica. 4. For eligible employees and /or dependents who enroll during late enrollment, coverage begins on the first day of the month following date of Medica's approval of the request for enrollment. MIC PPMN HSA (3/11) 90 2500 -100% BPL 67284 DOC 21414 Ending Coverage DD. 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. See Definitions. These words have s eciftc meanie s certification of ualif in covers e, P 9 q Y g g claim,- dependent; member,.pr "emium, subscriber You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. When coverage ends Unless otherwise specified in the Contract, 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 Eligibility And 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. If coverage ends due to fraud, 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. Fraud includes but is not limited to: a. Intentionally 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 b. Intentional 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 MIC PPMN HSA (3/11) 91 2500 -100% BPL 67284 DOC 21414 Ending Coverage e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional misrepresentation with regard to any aspect of coverage under the Contract. 7. 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; 8. 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; 9. For a spouse, the end of the month following the date of divorce; 10. For a dependent child, the end of the month in which the child is no longer eligible as a dependent; or 11. 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. I I MIC PPMN HSA (3/11) 92 2500 -100% BPL 67284 DOC 21414 Continuation EE. Continuation This section describes continuation coverage provisions. When coverage ends, members may be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer. See Definitions. These words have ,specif c r1 6anings: benefits, dependent, member, placed for adoption, premium, subscriber ,_ total x dtsability. x The paragraph below describes the continuation coverage provisions. State continuation is described in 1. and federal continuation is described in 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. When your continuation coverage under this section ends, you have the option to enroll in an individual conversion health plan as described in Conversion. 1. Your right to continue coverage under state law Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: a. 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. b. 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. It is intended that no greater rights be provided than those required by Minnesota law. Take time to read this section carefully. Subscriber's Toss The subscriber has the right to continuation of coverage for him or herself and his or her dependents if there is a Toss 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. In 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. MIC PPMN HSA (3/11) 93 2500 - 100% BPL 67284 DOC 21414 Continuation Subscriber's spouse's Toss 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; 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. Subscriber's child's Toss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following 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. 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. Consistent with Minnesota law, the subscriber and dependents have 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. If continuation coverage is not elected, your coverage under the Contract will end. MIC PPMN HSA (3/11) 94 2500 -100% BPL 67284 DOC 21414 • Continuation 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 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. Surviving dependents of a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. 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: a. 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. b. 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 iii. The date coverage would otherwise terminate under the Contract. �. c. For instances where dependent children lose coverage as a result of loss of dependent 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 iii. The date coverage would otherwise terminate under the Contract. d. 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: i. The date the former spouse becomes covered under another group health plan; or ii. The date coverage would otherwise terminate under the. Contract. • If a dissolution �f 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.. 1 employment, coverage of the subscriber's spouse may be continued until the earlier of: i. The date the former spouse becomes covered under another group health plan; or MIC PPMN HSA (3/11) 95 2500 100 %• BPL 67284 DOC 21414: Continuation ii. The date coverage would otherwise terminate under the Contract. e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of: i. The date the surviving spouse and dependent children become covered under another group health plan; 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 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. 2. 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 General COBRA information in this section. USERRA continuation coverage Continued coverage shall be provided as required under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The employer shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General USERRA information in this section. General COBRA information 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 coverage is a,group health plan for purposes of COBRA. This section 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 section carefully. MIC PPMN HSA (3/11) 96 2500 -100% BPL 67284 DOC 21414 1 Continuation Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as: 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 c. A dependent child of a covered employee. (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; 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. Subscriber's child's Toss The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following 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 the subscriber 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 MIC PPMN HSA (3/11) 97 2500 -100% BPL 67284 DOC 21414 Continuation 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. 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. Consistent with federal law, the subscriber and dependents have 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 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. 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 amount charged cannot exceed 102 percent of the cost of the coverage. The amount may increased to 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 of COBRA coverage 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 MIC PPMN NSA (3/11) 98 2500 -100% BPL 67284 DOC 21414 mow— Continuation 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. 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. 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 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 pre- existing condition; or d. The subscriber becomes entitled to (actually covered under) Medicare. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. General USERRA information USERRA requires employers to offer employees 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 coverage is a group health plan for the purposes of USERRA. This section 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 section carefully. Employee's loss The employee has the right to elect continuation of coverage if there is a loss of coverage under the Contract because of absence from employment due to service in the uniformed services, and the employee was covered under the Contract at the time the absence began, and the employee, or an appropriate officer of the uniformed services, provided the employer with advance notice of the employee's absence from employment (if it was possible to do so). Service in the uniformed services means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active duty for training, initial active duty for training, inactive duty training, full -time National Guard duty, and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of these duties. MIC PPMN HSA (3/11) 99 2500 -100% BPL 67284 DOC 21414 Continuation Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army National Guard, and the Air National Guard, when engaged in active duty for training, inactive duty training, or full -time National Guard duty, and the commissioned corps of the Public Health Service. Election rights The employee or the employee's authorized representative may elect to continue the employee's coverage under the Contract by making an election on a form provided by the employer. The employee has 60 days to elect continuation coverage measured from the date coverage would be lost because of the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The employee may elect continuation coverage on behalf of other covered dependents, however, there is no independent right of each covered dependent to elect. If the employee does not elect, there is no USERRA continuation available for the spouse or dependent children. In addition, even if the employee does not elect USERRA continuation, the employee has the right to be reinstated under the Contract upon reemployment, subject to the terms and conditions of the Contract. Type of coverage and cost If the employee elects 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. The amount charged cannot exceed 102 percent of the cost of the coverage unless the employee's leave of absence is Tess than 31 days, in which case the employee is not required to pay more than the amount that they would have to pay as an active employee for that coverage. There is a grace period of at least 30 days for the regularly scheduled premium. Duration of USERRA coverage When an employee takes a leave for service in the uniformed services, coverage for the employee and dependents for whom coverage is elected begins the day after the employee would lose coverage under the Contract. Coverage continues for up to 24 months. Federal law provides that continuation coverage may end earlier for any of the following reasons: a. The employer no longer provides group health coverage to any of its employees; b. The premium for continuation coverage is not paid on time; c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct; d. The employee fails to return to work following the completion of his or her service in the uniformed services; or e. The employee returns to work and is reinstated under the Contract as an active employee. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. MIC PPMN HSA (3/11) 100 2500 -100% BPL 67284 DOC 21414 • Continuation COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation coverage in addition to USERRA continuation coverage, these coverages run concurrently. MIC PPMN HSA (3/11) 101 2500 -100% BPL 67284 DOC 21414 Conversion FF. Conversion See Definitions These words have specific continuous coverage, dependent, premium, waiting Your conversion plan coverage may not provide the same coverage as your previous group health plan. Benefits and provider networks may be different. Minnesota residents This section describes your right to convert to an individual conversion plan if you are a resident of Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. If you are a Minnesota resident, you may be eligible to obtain coverage from 1) other private sources of health coverage, or 2) the Minnesota Comprehensive Health Association, without a pre- existing condition limitation. Contact the Minnesota Comprehensive Health Association for further information: • For deductible plan options call 1- 866 - 894 -8053 or TTY: 1- 800 - 841 -6753 • For Medicare Supplement plan options call 1- 800 - 325 -3540 or TTY: 1- 800 - 234 -8819 Overview 1. You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in Continuation, is exhausted. b. Your coverage or continuation coverage ends because the Contract is terminated and the Contract is not replaced with other continuous group coverage. c. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. 2. Your conversion plan goes into effect the day following 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. 3. Conversion coverage is not available: a. When continuous coverage is not maintained; or b. If your coverage is terminated due to nonpayment of premium; or c. If you have not exhausted your right to continue coverage as described in Continuation; or d. If your coverage or continuation coverage ends because the Contract is terminated and the Contract is replaced with other continuous group coverage; or e. The commission of fraud. MIC PPMN HSA (3/11) 102 2500 -100% BPL 67284 DOC 21414 L. Conversion For purposes of 2. and 3.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 coverage, whichever is later. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor 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. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor 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. Residents of a state other than Minnesota This section describes your right to convert to an individual conversion plan if you are a resident of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. Overview You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods, in accordance with the laws of the state in which you reside on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You will be required to include your first month premium payment with your enrollment form for conversion coverage. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. MIC PPMN HSA (3/11) 103 2500 -100% BPL 67284 DOC 21414 Complaints GG. Complaints This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. See Definitions. These words have specific meanings inpatient, network, provider. , 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, 2. You also may contact the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296 -2488 or 1- 800 - 657 -3602. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. You may appoint an authorized representative to make a complaint on your behalf. You may be required to sign an authorization which will allow Medica to release confidential information to your authorized representative and allow them to act on your behalf during the complaint process. 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. In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Commerce at the telephone number listed at the beginning of this section. 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. 1. If your complaint is regarding an initial decision made by Medica, your complaint must be made within one year following Medica's initial decision. 2. For an oral complaint that does not require a medical determination in its outcome, 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 3. 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 or request. 4. When an initial decision by Medica not to grant a prior authorization request is made before or during an ongoing service requiring Medica's authorization, and your attending provider 9 9 believes that Medica's decision warrants an expedited appeal, you or your attending MIC PP - ° MN HSA (3/11) 104 2500 100 /o BPL 67284 DOC 21414 Complaints 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. 5. 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. Second level of review If you are not satisfied with Medica's first level of review decision, you may request a second level of review through either a written reconsideration or a hearing. 1. 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 the address listed above in First level of review, 2. 2. 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. 3. Medica will provide written notice of its second level of review decision to you within: a. 30 calendar days from receipt of written notice of your appeal for required second level I' reviews; or b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews. For some complaints, the second level of review must be exhausted before you have the right to submit a request for external review. For other complaints, this second level of review is optional before you may submit a request for external review. Medica will inform you in writing whether the second level of review is optional or required. External review If you consider Medica's decision to be partially or wholly adverse to you, you may submit a written request for external review of Medica's decision to the Commissioner of Commerce at: Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101 -2198 A filing fee of $25 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 will not be binding on you but will be binding on Medica. Contact 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. MIC PPMN HSA (3/11) 105 2500 -100% BPL 67284 DOC 21414 Compoaants Civil action If you are dissatisfied with Medica's first or second level review decision or the external review decision, you have the right to file a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA). MIC PPMN HSA (3/11) 106 2500 -100% BPL 67284 DOC 21414 General Provisions HH. General Provisions This section describes the general provisions of the Contract. See' Definitions. These words have specific meanings: benefits claim, dependent, member, network, premium;, provider, subscriber 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. 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. 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. MIC PPMN HSA (3/11) 107 2500- BPL 67284 DOC 21414: General Provisions 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. MIC PPMN HSA (3/11) 108 2500 -100% BPL 67284 DOC 21414 Definitions Definitions In this certificate (and in any amendments), some words have specific meanings. Benefits. The health services or supplies (described in this certificate and any subsequent amendments) approved by Medica as eligible for coverage. Certification of qualifying 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. 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. 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 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. For out -of- network benefits, in addition to any 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 Drug Program and Specialty 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. Continuous coverage. 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. Convenience care /retail health clinic. A health care clinic located in a setting such as a retail store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. MIC PPMN HSA (3/11) 109 2500 - 100% BPL 67284 DOC 21414 Definitions Cosmetic. 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. Custodial care. 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. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims for health services or supplies received from network or non - network providers are reimbursable as in- network or out -of- network benefits under this certificate. Dependent. Unless otherwise specified in the Contract, the following are considered dependents: 1. The subscriber's spouse. 2. The following dependent children up to the dependent limiting age of 26: a. The subscriber's or subscriber's spouse's natural or adopted child; b. A child placed for adoption with the subscriber or subscriber's spouse; 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 legal guardianship; d. The subscriber's stepchild; and e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent incapable of self- sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber for support and maintenance. An illness that does not cause a child to be incapable of self- sustaining employment will not be considered a physical disability. This dependent may remain covered under the Contract regardless of age and without application of health screening or waiting periods. To continue coverage for a disabled dependent, you must provide Medica with proof of such disability and dependency within 31 days of the child reaching the dependent limiting age set forth in 2. above. Beginning two years after the child reaches the dependent limiting age, Medica may require annual proof of disability and dependency. For residents of a state other than Minnesota, the dependent limiting age may be higher if required by applicable state law. 4. The subscriber's or subscriber's spouse's disabled dependent who is incapable of self - sustaining employment by reason of developmental disability, mental illness, mental disorder or physical disability and is chiefly dependent upon the subscriber or subscriber's spouse for support and maintenance. For coverage of a disabled dependent, you must provide Medica with proof of such disability and dependency at the time of the dependent's enrollment. MIC PPMN HSA (3/11) 110 2500 -100% BPL 67284 DOC 21414 Definitions Emergency. A condition or symptom (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, 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 (or, if you are pregnant, the health of your unborn child) 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. E- visits. A member initiated online evaluation and management service provided to patients via the Internet. E- visits are used to address non - urgent medical symptoms for established patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. Hospital. 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. Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing facility, or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally disabled children will be covered as any other health condition. Investigative. 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: 1. 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 I' 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; 2. 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 3. 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 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 MIC PPMN HSA (3/11) 111 2500 -100% BPL 67284 DOC 21414 Definitions 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 any authoritative compendia as identified by the Medicare program for use in the determination of a medically accepted indication of drugs and biologicals used off - label. 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 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 alate entrant, provided the eligible employee or dependent maintains continuous coverage as defined in this certificate. In addition, a member who is a child entitled to receive coverage through a QMCSO 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: 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. Member. A person who is enrolled under the Contract. Mental disorder. 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). • Network. 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 to provide benefits to you. The participation status of providers will change from time to time. The network provider directory will be furnished automatically, without charge. Non - network. A term used to describe a provider not under contract as a network provider. Non- network provider reimbursement amount. The amount that Medica will pay to a non - network provider for each benefit is based on one of the following, as determined by Medica: 1. A percentage of the amount Medicare would pay for the service in the location where the service is provided. Medica generally updates its data on the amount Medicare pays within 30 -60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or MIC PPMN HSA (3/11) 112 2500 -100% BPL 67284 DOC 21414 Definitions 2. A percentage of the provider's billed charge; or 3. A nationwide provider reimbursement database that considers prevailing reimbursement rates and /or marketplace charges for similar services in the geographic area in which the service is provided; or 4. An amount agreed upon between Medica and the non - network provider. Contact Customer Service for more information concerning which method above pertains to your services, including the applicable percentage if a Medicare -based approach is used. For certain benefits, you must pay a portion of the non- network provider reimbursement amount as coinsurance. In addition, if the amount billed by the non - network provider is greater than the non - network provider reimbursement amount, the non- network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any coinsurance or deductible amount you may be responsible for according to the terms described in this certificate. Furthermore, such difference will not be applied toward the out -of- pocket maximum described in Your Out -Of- Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your, out -of- pocket maximum with amounts paid for other services. As a result, the amount you will be'required to pay for services received from a non - network provider will likely be much higher than if you had received services from a network provider. Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.0.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (0.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. 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. (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.) 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 defined 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. Preventive health service. The following are considered preventive health services: 1. Evidence -based items or services that have in effect a rating of "A" or "B" in the current , recommendations of the United States Preventive Services Task Force; 2. Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the member involved; 3. With respect to members who are infants, children, and adolescents, evidence - informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; MIC PPMN HSA (3/11) 113 2500 -100% BPL 67284 DOC 21414 Definitions 4. With respect to members who are women, such additional preventive care and screenings not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Contact Customer Service for information regarding specific preventive health services and services that are rated "A" or "B." 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 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; 15. State Children's Health Insurance Program; or - 16. A public health plan similar to any of the above plans established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. 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; 4. 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; MIC PPMN HSA (3/11) 114 2500 -100% BPL 67284 DOC 21414 Definitions 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. 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. Restorative. 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. Routine foot care. Services that are routine foot care may require treatment by a professional and include but are not limited to any of the following: 1. Cutting, paring, or removal of corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removal of toenails, dead skin, or underlying tissue). Routine foot care may also include hygiene and preventive maintenance such as: 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. 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 by themselves define 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 nursing care, skilled transitional care, or other related health services including rehabilitative services. Subscriber. The person: 1. On whose behalf premium is paid; and 2. Whose employment is the basis for membership, according to the Contract; and MIC PPMN HSA (3/11) 115 2500 -100% BPL 67284 DOC 21414 Definitions 3. Who is enrolled under the Contract. Total disability. 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. Urgent care center. 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. Waiting period. 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. Periods of employment in an employment classification that is not eligible for coverage under the Contract do not constitute a waiting period. MIC PPMN HSA (3/11) 116 2500 -100% BPL 67284 DOC 21414 0)/ y Medica Focus Certificate of Coverage MEDICA. MIC FOCUSMN HSA (3/11) 1500 -100% BPL 67319 DOC 21641 - ■ Table Of Contents Table Of Contents Introduction xi To be eligible for benefits xi Language interpretation xii Acceptance of coverage xii Nondiscrimination policy xii A. Member Rights And Responsibilities 1 Member bill of rights 1 Member 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 7 Prior authorization 8 Certification of qualifying coverage 9 C. How Providers Are Paid By Medica 10 Network providers 10 Non - network providers 10 D. Your Out -Of- Pocket Expenses 11 Coinsurance and deductibles 11 More information concerning deductibles 13 Out -of- pocket maximum 13 Lifetime maximum amount 14 Out -of- Pocket Expenses 14 E. Professional Services 15 Covered 15 Not covered 16 Office visits 16 E- visits 16 Convenience care /retail health clinic visits 16 1 Urgent care center visits 17 Prenatal care services 17 MIC FOCUSMN HSA (3/11) ill 1500 -100% BPL 67319 DOC 21641 Table:Of Contents Preventive health care 18 Allergy shots 18 Routine annual eye exams 18 Chiropractic services 19 Surgical services 19 Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 19 Services received from a physician during an emergency room visit 19 Services received from a physician during an inpatient stay, including maternity labor and delivery 19 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 20 Services received from a physician during an inpatient stay for prenatal care 20 Outpatient lab and pathology 20 Outpatient x -rays and other imaging services 20 Other outpatient hospital or ambulatory surgical center services received from a physician 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 Vision therapy and orthoptic and /or pleoptic training 21 Genetic counseling 21 Genetic testing 21 F. Prescription Drug Program 22 Preferred drug list 22 Product selection 22 Exceptions to the preferred drug list 23 Prior authorization 23 Step therapy 23 Quantity limits 24 Covered 24 Prescription unit 25 Not covered 25 Outpatient covered drugs 26 Emergency covered drugs 26 Diabetic equipment and supplies, including blood glucose meters 26 MIC FOCUSMN HSA (3/11) iv 1500 -100% BPL 67319 DOC 21641 Table Of Contents Tobacco cessation products 26 Drugs considered preventive health services 27 G. Specialty Prescription Drug Program 28 Designated specialty pharmacies 28 Specialty preferred drug list 28 Exceptions to the specialty preferred drug list 28 Prior authorization 29 Step therapy 29 Quantity limits 29 Covered 29 Prescription unit 29 Not covered 30 Specialty prescription drugs received from a designated specialty pharmacy 30 H. 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 33 Inpatient services 33 Services received from a physician during an inpatient stay, including maternity labor and delivery 33 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 33 I. Ambulance Services 34 Covered 34 Not covered 34 Ambulance services or ambulance transportation 35 Non - emergency licensed ambulance service 35 J. Home Health Care 36 Covered 36 Not covered 37 Intermittent skilled care 37 Skilled physical, speech, or occupational therapy 38 Home infusion therapy 38 MIC FOCUSMN HSA (3/11) v 1500 -100% BPL 67319 DOC 21641 Table Of Contents 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 of your home 40 Occupational therapy received outside of your home 40 L. Mental Health 41 Covered 42 Not covered 43 Office visits, including evaluations, diagnostic, and treatment services 44 Intensive outpatient programs 44 Inpatient services (including residential, treatment services) 44 M. Substance Abuse 45 Covered 46 Not covered 47 Office visits, including evaluations, diagnostic, and treatment services 47 Intensive outpatient programs 47 Opiate replacement therapy 47 Inpatient services (including residential treatment services) 48 N. Durable Medical Equipment And Prosthetics 49 Covered 49 Not covered 50 Durable medical equipment and certain related supplies 50 Repair, replacement, or revision of durable medical equipment 50 Prosthetics 50 Hearing aids 51 O. Miscellaneous Medical Services And Supplies 52 Covered 52 Not covered 52 Blood clotting factors 53 Dietary medical treatment of PKU 53 Amino acid -based elemental formulas 53 Total parenteral nutrition 53 MI6 FOCUSMN HSA (3/11) vi 1500 -100% BPL 67319 DOC 21641 Table Of Contents Eligible ostomy supplies 53 Insulin pumps and other eligible diabetic equipment and supplies 53 P. Organ And Bone Marrow Transplant Services 54 Covered 54 Not covered 55 Office visits 56 E- visits 56 Outpatient services 56 Inpatient services 56 Services received from a physician during an inpatient stay 57 Anesthesia services received from a provider during an inpatient stay 57 Transportation and lodging 57 Q. Infertility Diagnosis 59 Covered 59 Not covered 59 Office visits, including any services provided during such visits 60 E- visits 60 Outpatient services received at a hospital 60 Inpatient services 60 R. Reconstructive And Restorative Surgery 61 Covered 61 Not covered 61 Office visits 62 E- visits 62 Outpatient services 62 Inpatient services 63 Services received from a physician during an inpatient stay 63 Anesthesia services received from a provider during an inpatient stay 63 S. Skilled Nursing Facility Services 64 Covered 64 Not covered 64 Daily skilled care or daily skilled rehabilitation services 65 Skilled physical, speech, or occupational therapy 65 Services received from a physician during an inpatient stay in a skilled nursing facility 65 MIC FOCUSMN HSA (3/11) vii 1500 -100% BPL 67319 DOC 21641 Table Of Contents T. Hospice Services 66 Covered 66 Not covered 67 Hospice services 67 U. Temporomandibular Joint (TMJ) Disorder 68 Covered 68 Not covered 68 Office visits 69 E- visits 69 Outpatient services 69 Physical therapy received outside of your home 70 Inpatient services 70 Services received from a physician or dentist during an inpatient stay 70 Anesthesia services received from a provider during an inpatient stay 70 TMJ splints and adjustments 70 V. Medical - Related Dental Services 71 Covered 71 Not covered 71 Charges for medical facilities and general anesthesia services 72 Orthodontia related to cleft lip and palate 72 Accident- related dental services 73 Oral surgery 73 W. Referrals To Non - Network Providers 74 What you must do 74 What Medica will do 74 X. Harmful Use Of Medical Services 76 When this section applies 76 Y. Exclusions 77 Z. How To Submit A Claim 80 Claims for benefits from network providers 80 Claims for benefits from non - network providers 80 Claims for services provided outside the United States 81 Time limits 81 MIC FOCUSMN HSA (3/11) viii 1500 - 100% BPL 67319 DOC 21641 Table Of Contents AA. Coordination Of Benefits 82 Applicability 82 Definitions that apply to this section 82 Order of benefit determination rules 83 Effect on the benefits of this plan 84 Right to receive and release needed information 85 Facility of payment 85 Right of recovery 85 BB. Right Of Recovery 87 CC. Eligibility And Enrollment 88 Who can enroll 88 How to enroll 88 Notification 88 Initial enrollment 88 Open enrollment 89 Special enrollment 89 Late enrollment 91 Qualified Medical Child Support Order (QMCSO) 92 The date your coverage begins 92 DD. Ending Coverage 94 When coverage ends 94 EE. Continuation 96 Your right to continue coverage under state law 96 Your right to continue coverage under federal law 99 FF. Conversion 105 Minnesota residents 105 Residents of a state other than Minnesota 106 GG. Complaints 107 First level of review 107 Second level of review 108 External review 108 Civil action 109 MIC FOCUSMN HSA (3/11) ix 1500 -100% BPL 67319 DOC 21641 Table Of Contents HH. General Provisions 110 Definitions 112 MIC FOCUSMN HSA (3/11) x 1500 -100% BPL 67319 DOC 21641 introduction Introduction Medica Insurance Company (Medica) offers Medica Focus. This is a Minnesota non - qualified plan. This Certificate of Coverage (this certificate) describes_ health services that are eligible for coverage and the procedures you must follow to obtain benefits. Many words in this certificate have 'specific meanings. These words are identified in. each section -and °defined in Definitions See Definitions " These words have specific meanings: benefits, claim, dependent, medically necessary,: member,:network,:premium, provider. 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. The Contract refers to the Contract between Medica and the employer. You should contact the employer to see the Contract. Members are subject to all terms and conditions of the Contract and health services must be medically necessary. Medica may arrange for various persons or entities to provide administrative services on its 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. In this certificate, the words you, your, and yourself refer to the member. The word employer refers to the organization through which you are eligible for coverage. 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 Focus to be eligible for in- network benefits; and 2. Identify yourself as a Medica Focus member; and 3. Present your Medica Focus identification card. (If you do not show your Medica Focus identification card, providers have no way of knowing that you are a Medica Focus 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 use of a Medica Focus identification card does not necessarily guarantee coverage. Network providers are required to submit claims within 180 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 180 days of the date of service, you may be responsible for paying the cost of the service you received. MIC FOCUSMN HSA (3/11) xi 1500 -100% BPL 67319 DOC 21641 Introduction 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 you have an impairment that requires alternative communication formats such as Braille, large print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials. 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 omission or incorrect statement concerning a material fact intentionally made by you in connection with your enrollment under the Contract may invalidate your coverage. Nondiscrimination policy Medica's policy is 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, genetic information, 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. • MIC FOCUSMN HSA (3/11) xii 1500 - 100% BPL 67319 DOC 21641 • Member Rights And Responsibilities A. Member Rights And Responsibilities . See Definitions: These words have specific meaning "s benefits emergency, medically necessary, member, ,network, provider .. - Member bill of rights As a member of Medica Focus, 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; and 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; and 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; and 4. Be treated with respect and recognition of your dignity and privacy, including privacy of your medical and financial records maintained by Medica or any network provider in accordance with existing law; and 5. Contact Medica and Minnesota's Commissioner of Commerce to file a complaint about issues related to benefits (see Complaints). To file a complaint with the Minnesota Department of Commerce, call (651) 296 -2488 and request insurance information. You may begin a legal proceeding if you have a problem with Medica or any provider; and 6. Receive information about Medica, its services, its practitioners and providers, and member rights and responsibilities; and 7. Appeal a decision regarding your health care coverage by calling Customer Service at one of the telephone numbers listed inside the front cover. See Complaints for more information on your appeal rights; and 8. Make recommendations regarding Medica's member rights and responsibilities statement. 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; and 2. Providing the necessary information to health care professionals or Medica needed to determine the appropriate care. This objective is best obtained when you share: a. Information about lifestyle practices; and b. Personal health history; and 3. Understanding your health problems and agreeing to, and following, the plans and instructions for care given by those providing health care; and MIC FOCUSMN HSA (3/11) 1 1500 -100% BPL 67319 DOC 21641 Member Rights And Responsibilities 4. Practicing self -care by knowing: a. How to recognize common health problems and what to do when they occur; and b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and 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 find additional information on member responsibilities in this certificate. MIC FOCUSMN HSA (3/11) 2 1500 -100% BPL 67319 DOC 21641 How To Access Your Benefits B. How To Access Your Benefits See Definitions. These words have specific'°meanings: benefits, claim, coinsurance, deductible,' dependent, "emergency, enrollment date, e- visits, hospital, inpatient, late entrant, member network, non - network, non network provider; reimbursement amount: physician, placed for adoption, premium, prescription drug, provider qualifying= coverage _reconstructive, =. restorative, skilled =nursing facility, subscriber, waiting period. Provider network In- network benefits are available through the Medica Focus provider network. For a list of the in- network providers, please consult your Medica Focus provider directory by signing in at www.mymedica.com or contacting Customer Service. Out -of- network benefits will apply when you choose to receive eligible health services from providers that are not contracted with Medica. 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. To be eligible for in- network benefits, follow -up care or scheduled care after an emergency must be received from a network provider. 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. Selecting a home clinic Your home clinic is a primary care clinic that you choose to collaborate with for your healthcare needs. You must select a home clinic from the list of providers designated by Medica as home clinics. You may select the same or a different home clinic for yourself and each of your dependents. If you do not select a home clinic, Medica will designate one for you. You may change your home clinic once in any calendar month. You may change your home clinic by notifying Medica at least 10 calendar days before the first day of the next month, on which date the change will take effect. You will be notified by Medica if your home clinic no longer participates with Medica Focus. At that time, you must then choose a new home clinic from the list of providers designated by Medica as home clinics. MIC FOCUSMN HSA (3/11) 3 1500 -100% BPL 67319 DOC 21641 How To Access Your Benefits 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. Providers Enrolling in Medica Focus does not guarantee that a particular provider (in the Medica Focus 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 network providers to continue to be eligible for in- network benefits. You must verify that your provider is a network provider each time you receive health services. 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's hospital network is different from Medica's hospital network. Certain mental health and substance abuse services require prior authorization by Medica's designated mental health and substance abuse provider. Emergency services do not require prior authorization. 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. Medica does not automatically know of a birth or whether you would like coverage for the newborn dependent. CaII Customer Service at one of the telephone numbers listed inside the front cover for more information. To be eligible for in- network benefits, health services must be received from 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 reduce payment by the amount of premium that is past due for any health benefits for the newborn infant until any premium you owe is paid. For more information, see Eligibility And Enrollment. MIC FOCUSMN HSA (3/11) 4 1500 -100% BPL 67319 DOC 21641 11 L Flow To Access ¥our Benefits • 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. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. 2. Important member information about out - of - network benefits The information below describes your covered health services and provides important information concerning your out -of- network benefits. Read this certificate for a detailed explanation of both in- network and out -of- network benefits. Please carefully review the general sections of this certificate as well as the section(s) that specifically describe the '1 services you are considering, so you are best able to determine the benefits that will apply to you. Benefits Medica pays out -of- network benefits for eligible health services received from non - network providers. Prior authorization may be required from Medica before you receive certain services, in order to determine whether those services are eligible for coverage under your out -of- network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out -of- network benefits. 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. Emergency services received from non - network providers are covered as in- network benefits and are not considered out -of- network benefits. Additionally, under certain circumstances Medica will authorize your obtaining services from a non - network provider at the in- network benefit level. Such authorizations are generally provided only in situations where the requested services are not available from network providers. Be aware that if you choose to go to a non - network provider and use out -of- network benefits, you will likely have to pay much 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 1, coinsurance and deductible amount. This additional amount you,must pay to the provider II will not be applied toward the out -of- pocket maximum amount described in Your Out-Of- Pocket Expenses and you will owe this amount regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. Please see the example calculation below. MIC FOCUSMN HSA (3/11) 5 1500 -100% BPL 67319 DOC 21641 Blow To Access Your Benefits Because obtaining care from non - network providers may result in significant out -of- pocket expenses, it is important that you do the following before receiving services from a non - network provider: • Discuss the expected billed charges with your non - network provider; and • Contact Customer Service to verify the estimated non - network provider reimbursement amount for those services, so you are better able to calculate your likely out -of- pocket expenses; and • If you wish to, request that Medica authorize the non - network provider's services be covered at the in- network benefit level, follow the procedure described under Prior authorization in How To Access Your Benefits. An example of how-to calculate your out -of- pocket costs* You choose to receive non - emergency inpatient care at a non - network hospital provider without an authorization from Medica providing for in- network benefits. The out -of- network benefits described in this certificate apply to the services you receive. For purposes of this example, you have previously satisfied your deductible. The non- network hospital provider bills $30,000 for your hospital stay. Medica's non - network provider reimbursement amount for those hospital services is $15,000. You must pay a portion of the non - network provider reimbursement amount, generally as a percentage coinsurance. In addition, the non- network provider will likely bill you for the amount by which the provider's charge exceeds the non - network provider reimbursement amount. If your coinsurance is 40 %, you will be required to pay: • 40% coinsurance (40% of $15,000 = $6,000) and . • The billed charges that exceed the non - network provider reimbursement amount ($30,000 - $15,000 = $15,000) • The total amount you will owe is $6,000 + $15,000 = $21,000. • The $6,000 you pay as coinsurance will be applied to the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. However, the $15,000 amount you pay for billed charges in excess of the non - network provider reimbursement amount will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. You will owe the provider this $15 000 amount regardless of whether p p g you have previously reached your out -of- pocket maximum with amounts paid for other services. *Note: The numbers in this example are used only for purposes of illustrating how out -of- network benefits are calculated. The actual numbers will depend on the services received. Travel program Medica has made arrangements for you to receive medically necessary services at the in- network benefit level when you are traveling outside the service area and do not have access to a network provider. Travel program coverage is subject to all of the terms and conditions set forth in this certificate. Call Customer Service at one of the telephone numbers listed inside the front cover to confirm that your provider is a travel program provider, and present your identification card at the time of service. This program is not available for all services (i.e., e- visits or chiropractic services) and may not be available in all areas. ■ MIC FOCUSMN HSA 3/11 6 1500 -100% BPL 67319 DOC 21641 - How To Access Your Benefits Lifetime maximum amount Out -of- network benefits are subject to a lifetime maximum amount payable per member. See Your Out -Of- Pocket Expenses for a detailed explanation of the lifetime maximum amount. Exclusions Some health 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. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. 3 Continuity of care To request continuity of care or if you have questions about how this may apply to you, call I Customer Service at one of the telephone numbers listed inside the front cover. In certain situations, you have a right to continuity of care. a. If Medica terminates its contract with your current provider 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 provider 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. If Medica terminates your current provider's contract for cause, Medica will inform you of the change and how your care will be transferred to another network provider. i i. 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; MIC FOCUSMN HSA (3/11) 7 1500 -100% BPL 67319 DOC 21641 , How To Access Your Benefits • 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 provider may 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; 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. 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. You may appeal this decision. Coverage will not be provided for services or treatments that are not otherwise covered under this certificate. 4. 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. To determine whether a certain service or supply requires prior authorization, please call Customer Service at one of the telephone numbers listed inside the front cover. Emergency services do not require prior authorization. Your attending provider, you, or someone on your behalf may contact Medica to request prior authorization. Your network provider will contact Medica to request prior authorization for a service or supply. You must contact Medica to request prior authorization for services or supplies received from non - network providers. If a network provider fails to obtain . prior authorization after you have consulted with them about services requiring prior authorization, you are not subject to a penalty for failure to obtain prior authorization. Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; • Treatment of a diagnosed temporomandibular joint disorder or craniomandibular disorder; • Organ and bone marrow transplant; • Home health care; MIC FOCUSMN HSA (3/11) 8 1500 - 100% BPL 67319 DOC 21641 17 How To Access Your Benefits • Medical supplies and durable medical equipment; • Outpatient surgical procedures; • Certain genetic tests; • Skilled nursing facility services; and • In- network benefits for services from non - network providers, with the exception of emergency services. This is not an all- inclusive list of all services and supplies that may require prior authorization. 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). Medica will review your request and provide a response to you and your attending provider within 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. Medica will inform both you and your provider of Medica's decision within 24 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. 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 attending provider in writing of its decision. If Medica does not approve continued coverage, you or your attending provider may appeal Medica's initial decision (see Complaints). 5. Certification of qualifying coverage You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. MIC FOCUSMN HSA (3/11) 9 1500 - 100% BPL 67319 DOC 21641 1 , How Providers Are Paid By Medica C. How Providers Are Paid By Medica This section describes how Medica generally pays providers for health services. See Definitions These` words=have specific meanings coinsurance, deductible, hospital, member, network, .non - network, physician, :provider. 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 2. 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 Focus 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 coinsurance or deductible, is considered to be payment in full. 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. Some network providers are authorized to arrange for a member to receive certain health services from other providers. This decision may result in a network provider keeping more or less of the risk - sharing payment. 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. MIC FOCUSMN HSA (3/11) 10 1500 -100% BPL 67319 DOC 21641 Your Out -Of- Pocket Expenses p. Your Out -Of- Pocket Expenses This section describes the expenses that are your responsibility to pay. These expenses are commonly called out -of- pocket expenses. F` `Definitions. These words have specific meanings benefits, claim, coinsurance, deductible;_dependent, medically, necessary, member, network, non- network, non network %provider reimbursement amount, prescription drug, provider, ;subscriber 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.) If you miss or cancel an office visit less than 24 hours before your appointment, your provider may bill you for the service. Please see the applicable benefit section(s) of this certificate for specific information about your in- network and out -of- network benefits and coverage levels. To verify coverage before receiving a particular service or supply, call Customer Service at one of the telephone numbers listed inside the front cover. Coinsurance and deductibles For in- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). When members in a family unit (a subscriber and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section), then all members of the family unit are considered to have satisfied the applicable per member and per family deductible for that calendar year. However, for family coverage, there is no per member deductible for benefits received during any calendar year. Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge in addition to your coinsurance and deductible, described in Prescription Drug Program and Specialty Prescription Drug Program, that applies when you use a Tier 2 or MIC FOCUSMN HSA (3/11) 11 1500 -100% BPL 67319 DOC 21641 Your Out -Of- Pocket Expenses Tier 3 brand name drug or supply when an equivalent Tier 1 generic drug or supply is on Medica's list of preferred drugs. These additional amounts will not be applied toward the deductible or the out -of- pocket maximum described in this section. 3. Any charge that is not covered under the Contract. For out -of- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). When members in a family unit (a subscriber and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section), then all members of the family unit are considered to have satisfied the applicable per member and per family deductible for that calendar year. However, for family coverage, there is no per member deductible for benefits received during any calendar year. Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that exceeds the non - network provider reimbursement amount. This means you are required to pay the difference between what Medica pays to the provider and what the provider bills. If you use out -of- network benefits, you may incur costs in addition to your coinsurance and deductible amounts. If the amount that your non - network provider bills you is more than the non - network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out - of- pocket maximum (described in this section). 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 coinsurance and deductibles. 3. Any charge that is not covered under the Contract. MIC FOCUSMN HSA (3/11) 12 1500 -100% BPL 67319 DOC 21641 rlow" 1 Your Out -Of- Pocket Expenses More information concerning deductibles The time period used to apply the deductible (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica i and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. i l Out - of - pocket maximum 1 The out -of- pocket maximum is an accumulation of coinsurance and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per member out -of- pocket maximum for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non - network provider reimbursement amount are not applicable toward the out -of- pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. The time period used to calculate whether you have met the out -of- pocket maximum (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. When members in a family unit (the subscriber and his or her dependents) have together met the applicable per family out -of- pocket maximum for benefits received during the calendar year, then all members of the family unit are considered to have met the applicable per member and per family out -of- pocket maximum for that calendar year (see the Out -of- Pocket Expenses table in this section). However, for family coverage, there is no per member deductible for benefits received during any calendar year. After an applicable out -of- pocket maximum has been met for a particular type of benefit (as described in the Out -of- Pocket Expenses table in this section), all other covered benefits of the same type received during the rest of the calendar year will be covered at 100 percent, except for any charge not covered by Medica, or charge in excess of the non - network provider reimbursement amount, or any charge in addition to your coinsurance and deductible when you use a Tier 2 brand name drug or supply when a chemical equivalent Tier 1 generic drug or supply is on Medica's list of preferred drugs. However, you will still be required to pay any applicable coinsurance and deductibles for other types of benefits received. Note that out -of- pocket maximum amounts are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new out -of- pocket maximum will apply for the rest of the current calendar year, whether or not you had met the previously applicable out -of- pocket maximum. This means that it is possible that your out -of- pocket maximum will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. Medica refunds the amount over the out -of- pocket maximum during any calendar year when proof of excess coinsurance and deductibles is received and verified by Medica. MIC FOCUSMN HSA (3/11) 13 1500 -100% BPL 67319 DOC 21641 Your Out -Of- Pocket Expenses 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, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Out -of- Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced pertains only to those health care services and supplies that are not essential benefits as defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules, or other guidance issued with respect to the "Act." Out -of- Pocket Expenses £x In network ':Out of network benefits a benefits % For out -of network benefits, in addition to the * deductible and coinsurance, you ,are responsible for any charges in excess of.the non network provider reimbursement amount Additionally, these charges=will not be * appllied toward satisfaction of the deductible or the out- of`;pocket maximum Coinsurance See specific benefit for applicable coinsurance. Deductible Per family $3,000 $8,000 For family coverage, there For family coverage, is no per member there is no per member deductible. deductible. Out -of- pocket maximum Per family $3,000 $18,000 For family coverage, there For family coverage, is no per member out -of- there is no per member pocket maximum. out -of- pocket maximum. Lifetime maximum amount Unlimited $1,000,000. Applies to payable per member all benefits you receive under this or any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. MIC FOCUSMN HSA (3/11) 14 • 1500 -100% BPL 67319 DOC 21641 Professional Services E. Professional Services This section describes coverage for professional services received from or directed by a physician. See Definitions. Thee s_ words Shave s pecific meanings benefits coinsurance, convenience - care %retail health ClihiC, deductible, ;emergency„ e- visits, home clinic, hospital, inpatient member, network, non - network, non-network provider reimbursement amount, physician, prenatal care, preventive health service, provider, ;urgent care center Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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; 2. 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. Family planning services do not include infertility treatment services. • Out -of- network benefits apply to professional services received from a non - network provider. In addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. 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 transplant services are described in Organ And Bone Marrow Transplant Services. For some services, there may be a facility charge resulting in coinsurance (see Hospital Services) in addition to the professional services coinsurance. Also, more than one coinsurance may be required if you receive more than one service or see more than one provider per visit. MIC FOCUSMN HSA (3/11) 15 1500 -100% BPL 67319 DOC 21641 Professional Services Not covered Drugs provided or administered by a physician or other provider, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits 7,7 x _ = ' In network benefits * Out of network benefits after deductible - after deductible €` * For out -o #network benefits, in addition to the deductible and coinsurance, you are responsible for any charges in excess of the non networkprovider reimbursement am ount Additionally, these charges will not be applied toward satisfaction of the deductible or the y ' , out -of pocket maxim 1. Office visits Nothing 50% coinsurance Please note: Some services received during an office visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an office visit. For example, certain services received during an office visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an office visit coinsurance and outpatient surgical or imaging services coinsurance apply. Call Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 2. E- visits Nothing No coverage 3. Convenience care /retail health Nothing 50% coinsurance clinic visits MIC FOCUSMN HSA (3/11) 16 1500 -100% BPL 67319 DOC 21641 Professional Services 'your Benefits a nd the Amounts You' Pay Benefits In network benefits, _ * Out, of network benefits after deductible er`'d a ft � eductible *F out -of network benefitsi in addition to .the deductible and coinsurance, you are responsible for any charges in excess of the non network',provider reimbursement amount Additionally, these charges will not be,7applied toward satisfaction f ofthe�deductible or the out of pocket-maximum 4. Urgent care center visits Nothing Covered as an in- network Please note: Some services benefit. received during an urgent care visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an urgent care visit. For example, certain services received during an urgent care visit may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care visit coinsurance and outpatient surgical or imaging services coinsurance apply. Call Customer Service at one of the telephone numbers listed inside the front cover to determine in advance whether a specific procedure is a • benefit and the applicable coverage level for each service that you receive. 5. Prenatal care services received Nothing. The deductible Covered as an in- network from a physician during an office does not apply. benefit. visit or an outpatient hospital visit MIC FOCUSMN HSA (3/11) 17 1500 -100% BPL 67319 DOC 21641 Professional Services Your Benefits sand the ==Amounts You Pay Benefits ry In-network benefit's * Out-of-network benefits; after- deductible after deductible * For out -of network benefits, in addition to the deductible and coinsurance you are responsible for zany charges excess of the non network provider reimbursement amount Ad fitionally these charges will not be applied toward; satisfaction4of the= deductible,or the .out ofpocket maximum 6. 'Preventive health care Please note: If you receive preventive and non - preventive health services during the same visit, the non - preventive health services may be subject to a coinsurance or deductible, as described elsewhere in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during a visit. a. Child health supervision Nothing. The deductible Covered as an in- network services, including well -baby does not apply. benefit. care b. Immunizations Nothing. The deductible 50% coinsurance does not apply. c. Early disease detection Nothing. The deductible 50% coinsurance services including physicals does not apply. d. Routine screening Nothing. The deductible 50% coinsurance procedures for cancer does not apply. e. Other preventive health Nothing. The deductible 50% coinsurance services does not apply. 7. Allergy shots Nothing 50% coinsurance 8. Routine annual eye exams. Nothing. The deductible 50% coinsurance Coverage is limited to one visit does not apply. per calendar year for in- network and out -of- network benefits combined. MIC FOCUSMN HSA (3/11) 18 1500 -100% BPL 67319 DOC 21641 Professional Services Your Beneflts.and the Amounts You Pa _ 3� Benefits to network benefit *Out of network benefits after deductible afterdeductible * For out of network benefits in addition to the deductrk le and coinsurance, you are re s pon s i ble far any: charges m excess of the ;;non network, "provrder reimbursement amount: Additionally, these charges will not be applied toward satisfa of`the de iuctible or the out- of"pocket maximum 9. Chiropractic services to Nothing 50% coinsurance. diagnose and to treat (by manual Coverage is limited to a manipulation or certain maximum of 15 visits per therapies) conditions related to calendar year. the muscles, skeleton, and Please note: This visit limit nerves of the body. includes chiropractic visits Please note: Providers may be that you pay for in order to network providers for chiropractic satisfy any part of your services only, and not otherwise deductible. part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. 10. Surgical services (as defined in Nothing 50% coinsurance the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital or ambulatory surgical center visit 11. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 12. Services received from a Nothing Covered as an in- network physician during an emergency benefit. room visit 13. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery MIC FOCUSMN HSA (3/11) 19 1500 - 100% BPL 67319 DOC 21641 Professional Services Your Benefits. and the Amounts You Pay Benefits In network benefits * Out-of-n bene after deductible deductible * For out-of network benefits, in addition tp the deductible and coinsurance, you ar re # or, ' any charges in- excess of the non network provider reimbursement amount Additionally, the ch will not be {applied toward sates f action,of the deductible or tti e out: - #pocket maximum 14. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery 15. Services received from a Nothing. The deductible 50% coinsurance physician during an inpatient does not apply. Please note: Out - stay for prenatal care network services for prenatal care are covered as an in- network benefit. 16. Outpatient lab and pathology Nothing 50% coinsurance 17. Outpatient x -rays and other Nothing 50% coinsurance imaging services 18. Other outpatient hospital or Nothing 50% coinsurance ambulatory surgical center services received from a physician 19. Treatment to lighten or remove Nothing 50% coinsurance the coloration of a port wine stain 20. Diabetes self- management Nothing 50% coinsurance 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) 21. Neuropsychological Nothing 50% coinsurance evaluations /cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury MIC FOCUSMN HSA (3/11) 20 1500 -100% BPL 67319 DOC 21641 4 Professional Services Your Benefits and the Amounts You. Pay Benefits In network benefits * Out of- network benefits after deductible after deductible *_For out-of-network benefits, "in addition to the deductible and coinsurance, you are responsible for any,4charges in= excess °of the ; non - network provider reimbursement amount: Additionally, these charges gs will not,be applied toward satisfaction °of the deductible otthe maximum 22. Vision therapy and orthoptic Nothing 50% coinsurance and /or pleoptic training, to establish a home program, for the treatment of strabismus and other disorders of binocular eye movements. Coverage is limited to a combined in- network and out -of- network total of 5 training visits and 2 follow -up eye exams per calendar year. Please note: These visit and exam limits include visits and exams that you pay for in order to satisfy any part of your deductible. 23. Genetic counseling, whether pre- Nothing 50% coinsurance or post -test, and whether occurring in an office, clinic, or telephonically 24. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices MIC FOCUSMN HSA (3/11) 21 1500 -100% BPL 67319 DOC 21641 Prescription Drug Program F. Prescription Drug Program This section describes coverage for prescription drugs and supplies received from a pharmacy or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" is meant to include those prescription drugs and supplies found on the Preferred Drug List (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such prescription drugs and supplies are identified in this certificate as not covered. The phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase "self- administered drugs" means all other drugs. For the definition and coverage of specialty prescription drugs, see Specialty Prescription Drug Program. See Definitions These specific meanings: benefits, claim, coinsurance, deductible, durable medical equipment hospital, member, network, non network, non network , , provider reimbursement amount, "physician, prescription drug, preventive: health service, provider, urgent care;_center. Preferred drug list Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: Tier 1 is your lowest coinsurance option. For the lowest out -of- pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate. Tier 3 drugs are not covered unless they meet the requirements under the PDL exception process described in this certificate. If you have questions about Medica's PDL or whether a specific drug is covered (and /or the PDL tier in which the drug may be covered), or if you would like to request a copy of the PDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The PDL is also available when you sign in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a drug should be considered a covered drug. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the PDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each drug based on a review of the drug's cost and effectiveness. Product selection When you receive a Tier 1 prescription drug or supply under your in- network benefit, after you satisfy your deductible, you will pay the Tier 1 coinsurance described in the table in this section. Medica pays any remaining amount according to the written agreement between Medica and MIC FOCUSMN HSA (3/11) 22 1500 -100% BPL 67319 DOC 21641 Prescription Drug Program the pharmacy. For example, if the agreement states that the Tier 1 prescription drug "A" costs $50, and your Tier 1 copayment is $10, you will pay $10 and Medica will pay $40. When a chemically equivalent Tier 1 generic drug is on the preferred drug list, and you or your provider still choose (for any reason) to utilize a Tier 2 or Tier 3 brand name prescription drug or supply under your in- network benefit, Medica will pay the amount Medica would have paid had you received the Tier 1 generic drug or supply, as described in the immediately preceding paragraph. You will pay, in addition to the applicable coinsurance described in the table, any remaining charges due to the pharmacy in excess of Medica's payment to the pharmacy. These additional charges will not be applied toward the deductible or the out -of- pocket maximum. Please note that receiving Tier 2 or Tier 3 brand name drugs or supplies when an equivalent Tier 1 generic drug exists may result in significantly more out -of- pocket costs. For example, you receive a Tier 2 or Tier 3 brand name prescription drug "B," although a chemically equivalent Tier 1 generic prescription drug "A" exists. Medica's agreement with the pharmacy states that brand name drug "B" costs $200 and the chemically equivalent Tier 1 generic drug "A" costs $50 (as in the example above). The Tier 1 copayment is $10 and the Tier 2 or Tier 3 copayment is $50. As described in the example above, Medica will pay $40. This is the amount Medica would have paid if you had received the Tier 1 generic drug "A." You will pay $160, an amount that includes the Tier 2 or Tier 3 copayment and the amount remaining due to the pharmacy after you paid your copayment and Medica paid the amount it owed. Exceptions to the preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants will improve the coverage by only one tier. Exceptions to the PDL can also 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 PDL or you change health plans. If you would like to request a copy of Medica's PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain covered drugs require prior authorization as indicated on the PDL. The provider who prescribes the drug initiates prior authorization. The PDL is made available to providers, including pharmacies and the designated mail order pharmacies. You are responsible for paying the cost of drugs received if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step therapy involves trying an alternative covered drug first (typically a Tier 1 drug) before moving on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. MIC FOCUSMN HSA (3/11) 23 1500 -100% BPL 67319 DOC 21641 Prescription Drug Program p 9 9 Quantity limits Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered The following table provides important general information concerning in- network, out -of- network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that the Prescription Drug Program section describes your coinsurance for,prescription drugs themselves. An additional coinsurance applies for the provider's services if you require that a provider administer self - administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. In .network benefits ; Out-of-network benefits* Mail order benefits ,_ Covered drugs received at a Covered drugs received at a Covered drugs received from network pharmacy; and non - network pharmacy; and a designated mail order pharmacy; and Covered drugs for family See In- network benefits Covered drugs for family planning services or the column. planning services or the treatment of sexually treatment of sexually transmitted diseases when transmitted diseases when prescribed by or received from prescribed by either a either a network or a non- network or a non - network network provider. Family provider and received from a planning services do not designated mail order include infertility treatment pharmacy. Family planning services; and services do not include infertility treatment services; and Diabetic equipment and Diabetic equipment and Diabetic equipment and supplies, including blood supplies, including blood supplies (excluding blood glucose meters when received glucose meters when received glucose meters) received from a network pharmacy; and from a non - network pharmacy; from a designated mail order and pharmacy. Tobacco cessation products Tobacco cessation products Not available. when prescribed by a provider when prescribed by a provider authorized to prescribe the authorized to prescribe the product and received at a product and received at a non - network pharmacy. network pharmacy. * When out -of- network benefits are received from non - network providers, in addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to MIC FOCUSMN HSA (3/11) 24 • • • 1500 -100% BPL 67319 DOC 21641 • Prescription Drug Program these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Specialty Prescription Drug Program for coverage of specialty prescription drugs. Prescription unit Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31- consecutive -day supply of a covered drug from your pharmacy (or, in the case of oral contraceptives, up to a one -cycle supply) or a 93- consecutive -day supply of a covered drug from your designated mail order pharmacy (or, in the case of oral contraceptives, up to a three -cycle supply), unless limited by drug manufacturers' packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed. Three prescription units may be dispensed for covered drugs prescribed to treat chronic conditions that are received at a network pharmacy that Medica has specifically designated to dispense multiple prescription units. For the current list of such designated pharmacies, sign in at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside the front cover. Not covered The following 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.) 2. OTC drugs not listed on the PDL. 3. Replacement of a drug due to loss, damage, or theft. 4. Appetite suppressants. 5. Erectile dysfunction medications. 6. Non - sedating antihistamines and non - sedating antihistamine /decongestant combinations. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and those members who have a feeding tube. I 8. Tobacco cessation products or services dispensed through a mail order pharmacy. 9. Drugs prescribed by a provider who is not acting within his /her scope of licensure. 10. Homeopathic medicine. 11. Infertility drugs. 12. Specialty prescription drugs, except as described in Specialty Prescription Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 25 1500 -100% BPL 67319 DOC 21641 Prescription Drug Program Your {Benefits and the Amounts You Pay * For out -of- network benefits, in addition :to the deductible and coinsurance, you are responsible for any charges in excess of the non= network provider reimbursement these charges will not be, applied toward satisfaction of the deductible or out -of- pocket maximum in- network= benefits' * Out -of- network benefits Mail order benefit after deductible after deductible after deductible 1. Outpatient covered drugs other than those described below or in Specialty Prescription Drug Program Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage 2. Up to a 24 -hour supply of emergency covered drugs received from a hospital or urgent care center Nothing Covered as an in- network Not available through a mail benefit. order pharmacy. 3. Diabetic equipment and supplies, including blood glucose meters 0 Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage 4. Tobacco cessation products Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. MIC FOCUSMN HSA (3/11) 26 1500 -100% BPL 67319 DOC 21641 y Prescription Drug Program { Your Benefits and the Amounts You Pay * For out-of-network benefits, in addition to the deductible and coinsurance you are responsible; for any charges in excess of the non-network provider reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum In network benefits , f * Out -of- network benefits Mail-order benefits benefits after deductible; after; deductible aftet- deductible 5. Drugs (other than tobacco cessation products) considered preventive health services, as specifically defined in Definitions, when prescribed by a provider authorized to prescribe such drugs. This group of drugs is specific and limited. For the current list of such drugs, please refer to the Preventive Drug List within the PDL or call Customer Service at one of the telephone numbers listed inside the front cover. Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. MIC FOCUSMN HSA (3/11) 27 1500 -100% BPL 67319 DOC 21641 Specialty Prescription Drug Program G. Specialty Prescription Drug Program This section describes coverage for specialty prescription drugs received from a designated specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology prescription drug products for individuals with diseases that require complex therapies. Such specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as described below. For purposes of this section, the phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; and the phrase "self- administered drugs" means all other drugs. See Defir►itfons These words have specific meanings benefits,, claim, coinsurance, deductible, member,_ network, physician, YPrescription drug, provider Designated specialty pharmacies A designated specialty pharmacy means a specialty pharmacy that has entered into a separate contract with Medica to provide specialty prescription drug services to members. For the current list of designated specialty pharmacies, call Customer Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com. Specialty preferred drug list Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty prescription drugs on Medica's SPDL are eligible for benefits under this certificate. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is covered (and /or the SPDL tier in which the drug may be covered), or if you would like to request a copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The SPDL is also available by signing in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a specialty prescription drug should be covered. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the SPDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. Exceptions to the specialty preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Specialty preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also MIC FOCUSMN HSA (3/11) 28 1500 - 100% BPL 67319 DOC 21641 • 1 Specialty Prescription Drug Program 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 SPDL or you change health plans. If you would like to request a copy of Medica's SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain specialty prescription drugs require prior authorization. The provider who prescribes the specialty drug initiates prior. authorization. The SPDL is made available to providers, including designated specialty pharmacies. You are responsible for paying the cost of specialty prescription drugs you receive if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying a Tier 1 specialty prescription drug before moving on to a Tier 2 specialty prescription drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 specialty prescription drugs. Quantity limits • Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy. This section describes your coinsurance for specialty prescription drugs. An additional coinsurance applies for the provider's services if you require that a provider administer self - administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. Prescription unit Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. One prescription unit is equal to a 31- consecutive -day supply of a specialty prescription drug, unless limited by the manufacturer's packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. I MIC FOCUSMN HSA (3/11) 29 1500 -100% BPL 67319 DOC 21641 Specialty Prescription Drug Program Not covered The following are not covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the designated specialty pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Replacement of a specialty drug due to loss, damage, or theft. 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of licensure. 4. Prescription drugs and OTC drugs, except as described in Prescription Drug Program. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 6. Infertility drugs. 7. Growth hormone. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. ur Benefits and the Amounts You Pay . Yo Benefits g ` . i. You pay after deductible * 1. Specialty prescription drugs Tier 1 specialty prescription drugs: Nothing per received from a designated prescription unit; or specialty pharmacy Tier 2 specialty prescription drugs: No coverage MIC FOCUSMN HSA (3/11) 30 1500 -100% BPL 67319 DOC 21641 Hospital Services H. Hospital Services This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. See Definitions. These words have specific meanings: benefits, coinsurance deductible,'. emergency, hospital, inpatient, member, network, non- network, non- network provider reimbursement amount, physician, prenatalcare, provider. { Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 Tess 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 coinsurance described for out- of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. If you are confined in a non - network facility as a result of an emergency you will be eligible for in- network benefits until your attending physician agrees it is safe to transfer you to a network facility. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Each member's admission is separate from the admission of any other member. A separate deductible and coinsurance will be applied to both you and your newborn child for inpatient 'I services related to maternity labor and delivery. MIC FOCUSMN HSA (3/11) 31 o II 1500 -100 /a BPL 67319 DOC 21641 �' Hospital Services Not covered 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. 2. Transfers and admission to network hospitals solely at the convenience of the member. 3. Admission to another hospital is not covered when care for your condition is available at the network hospital where you were first admitted. See Exclusions for additional services, supplies, and associated expenses that are not covered. _ I Your Benefits and ,the Arnounts You Pay_ Benefits ' In networkbenefits *. Out benefits: after deductible' after deductible * For out of networ in addition to an the deductrblea yo :are responsible for T ch e ar s in, excess o f the non - network- roviee dr rimbursement amout Addiol the :ses K ��� .erg p n tinal charges wall not be applied toward satisfaction of the deductible or:the out-of-pocket anaximum 1. Outpatient services a. Services provided in a Nothing Covered as an in- network hospital or facility -based benefit. emergency room b. Outpatient lab and pathology Nothing 50% coinsurance c. Outpatient x -rays and other Nothing 50% coinsurance imaging services d. Prenatal care services Nothing. The deductible Covered as an in- network does not apply. benefit. e. Genetic testing when test Nothing 50% coinsurance results will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices f. Other outpatient services Nothing 50% coinsurance g. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician MIC FOCUSMN HSA (3/11) 32 1500 -100% BPL 67319 DOC 21641 Hospital Services Your Bene fits and the Amounts You Pa Benefits In- network ben efits * "Out of network benef ;. after deductible after deductible * Fo out -of= network benefits in addition to -the deductible and =coinsurance,you are responsible for any charges in excess of the non network:provider reumbursem ent amount. Additionally the '.., charges will not be applied toward satisfaction of the deductible or th out of pocket maximum h. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 2. Services provided in a hospital Nothing 50% coinsurance observation room 3. Inpatient services, including Nothing 50% coinsurance, except inpatient maternity labor and you pay nothing for delivery services inpatient services related Please note: Maternity labor and to prenatal care services delivery services are considered that do not result in a inpatient services regardless of the delivery. Coverage is length of hospital stay. limited to a combined total of 120 days per calendar year for all inpatient out -of- network benefits described in this certificate. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. 4. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 5. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery MIC FOCUSMN HSA (3/11) 33 1500 -100% BPL 67319 DOC 21641 Ambulance Services L 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). See Definitrons ,These words have specific mean benefits,' coinsurance deductible,. emergency, hospital, network, non- network, non network provider reimbur amount, physician, provider,: skilled rursingfacility Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For non - emergency licensed ambulance services described 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 non - emergency ambulance services described in this section that are arranged through a physician and received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 34 1500 -100% BPL 67319 DOC 21641 i ' i Ambulance Services ,i Y our Benefits and the= A =You Pay x , benefits * Out -of network benefits Benefits . In network, ,- f after deductible after deductible * For out of network benefits, m addition to the deductible and coinsurance, you are responsible for any charges in excess of the non- network provider reimbursement amount Additionally, these' charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum 1. Ambulance services or Nothing Covered as an in- network , 1 ambulance transportation to the benefit. nearest hospital for an emergency 2. Non - emergency licensed ambulance service that is arranged through an attending physician, as follows: a. Transportation from hospital Nothing 50% coinsurance , to hospital when: I i. Care for your condition is not available at the hospital where you were first admitted; or ii. Required by Medica 1 b. Transportation from hospital Nothing 50% coinsurance to skilled nursing facility I i I ii I 1 , MIC FOCUSMN HSA (3/11) 35 1500 -100% BPL 67319 DOC 21641 1 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. • See Defin!tions'` These words have specific meanings }benefits, coinsurance, custodial care;' deductible, dependent, _hospital, network, non network, rion network ;reimbursement: amount, physician, prenatal care, provider, skilled care, skilled nursing facility µ r ' Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare guidelines) 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 1. and 2. in the table in this section are limited to a combined maximum of 120 visits per calendar year for in- network and 60 visits per calendar year for out -of- network benefits. Please note: These visit limits include any visits that you pay for in order to satisfy any part of your deductible. You may be eligible for additional intermittent skilled care if you have Medica coverage and are also enrolled in the Medical Assistance Program. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. MIC FOCUSMN HSA (3/11) • 36 1500 -100% BPL 67319 DOC 21641 Horne 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 non - skilled services. 4. Physical, speech, or occupational therapy provided in your home for convenience. 5. Services provided in your home when you are not homebound. 6. Services primarily educational in nature. 7. Vocational and job rehabilitation. 8. Recreational therapy. 9. Self -care and self -help training (non - medical). 10. Health clubs. 11. Disposable supplies and appliances, except as described in Prescription Drug Program, • Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. • 12. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 13. Voice training. 14. Outpatient rehabilitation services when no medical diagnosis is present. 15. Home health aide services, except when rendered in conjunction with intermittent skilled care and related to the medical condition under treatment. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits °and the Amounts You Pay Benefits ' In network benefits * Out of.- network benefits ;` after deductible after deducti * For o ut of- network benefits, iii addition, to t he deductible and coinsurance; you a responsible for. any _charges jn excess of the network provider reimbursement arhount Additionally,rthese; charges willnot be applied towa rd.satisfaction of the deductible or the out o #pocket maximum. 1. Intermittent skilled care when you Nothing 50% coinsurance, except are homebound, provided by or you pay nothing for high - supervised by a registered nurse risk prenatal care services MIC FOCUSMN HSA (3/11) 37 1500 - 100% BPL 67319 DOC 21641 Horne Health Care Your Benefits and the Amounts You Pay Benefits ! 1n network benefits * Out -of networ be nefits a ft er T deductible after deductible F or o ut-of network benefits; m ad to the; deducti and coinsura are responsible for any, c harges in e of the non- network provider reimbu m rseent amount A these charges will notbe applied towardusati"sfaction of the_deductible or the out -of pocket maximu 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when you are homebound 3. Home infusion therapy Nothing 50% coinsurance, except you pay nothing for high- risk prenatal care services 4. Services received in your home Nothing 50% coinsurance from a physician I I MIC FOCUSMN HSA (3/11) 38 1500 - 100% BPL 67319 DOC 21641 i Outpatient Rehabilitation 1 K. Outpatient Rehabilitation This section describes coverage for both professional and outpatient health care facility I services. A physician must direct your care. See Definitions. These words havespecific meanings benefits coinsurance; deductible, , network non -network, , n= network, non networl4royider sement amount physician . -- . - , ' ' Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to outpatient rehabilitation services arranged through a 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 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 I deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. 6. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 7. Voice training. 8. Outpatient rehabilitation services when no medical diagnosis is present. MIC FOCUSMN HSA (3/11) 39 1500 -100% BPL 67319 DOC 21641 Outpatient Rehabilitation • 9. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits: °;_ in network benefits *Out -of network benef aft deductible ' after d e ductible " For out -of network benefits, m addition tomthe deductible and °co y are responsible for any char in network; provider reimbursement amount. Additionally, these charges. will not be appl toward satisfaction of -the deductil le or the -of pocket ma 1. Physical therapy received outside Nothing 50% coinsurance. of your home Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please,note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible. 2. Speech therapy received outside Nothing 50% coinsurance. of your home when speech is Coverage for speech impaired due to a medical illness therapy is limited to 20 or injury, or congenital or visits per calendar year. developmental conditions that Please note: This visit limit have delayed speech includes speech therapy development visits that you pay fo in order to satisfy any part of your deductible. 3. Occupational therapy received Nothing 50% coinsurance. outside of your home when Coverage for physical physical function is impaired due and occupational therapy to a medical illness or injury or is limited to a combined congenital or developmental limit of 20 visits per conditions that have delayed calendar year. motor development Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible. .MIC FOCUSMN HSA (3/11) 40 1500 - 100% • BPL 67319 DOC 21641 Mental Health L. Mental Health I I 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. See Definitions "::These words have' meanings: benefits, claim coinsurance,:: custodial care, deductible, :emergency, hospital, inpatient, mdically e necess member, mental disorder, network, non network, non-network provider reimbursement amount, physician, provider. Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at: 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations and psychological testing. b. Psychotherapy and psychiatric services. c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week). d. Treatment for a minor, including family therapy. e. Treatment of serious or persistent disorders. f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD). g. Services, care, or treatment described as benefits in this certificate and 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. h. Treatment of pathological gambling. 2. Inpatient services include: a. Room and board. b. Attending psychiatric services. c. Hospital or facility -based professional services. d. 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 means a treatment program of 20 hours or more per week and may include lodging. e. Services, care, or treatment described as benefits in this certificate and 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. MIC FOCUSMN HSA (3/11) 41 1500 -100% BPL 67319 DOC 21641 Mental Health f. Residential treatment services. These services include either: i. A residential treatment program serving children and adolescents with severe emotional disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic services. In addition to room and board, at least 30 hours a week per individual of mental health services must be provided, including group and individual counseling, client education, and other services specific to mental health treatment. Also, the program must provide an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. 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. (Medica and Medica's designated mental health and substance abuse provider networks are different.) 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). Providers may be network providers for mental health services only, and not otherwise part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Mental health services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the mental health services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Mental health clinic e. Mental health residential treatment center f. Independent clinical social, worker MIC .FOCUSMN HSA (3/11) 42 1500 -100% BPL 67319 DOC 21641 3 Mental Health g. Marriage and family therapist h. Hospital that provides mental health services 2. Emergency mental health services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. 4. Relationship counseling. 5. Family counseling services, except as specifically described in this certificate as treatment for a minor. 6. Services for telephone psychotherapy. 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, as those conditions are defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. 8. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide mental health services. This includes, but is not limited to, services provided by mental health providers who are not authorized under state law to practice independently, and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch. 9. 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. 10. Room and board charges associated with mental health residential treatment services providing less than 30 hours a week per individual of mental health services, or lacking an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 43 1500 -100% BPL 67319 DOC 21641 Mental Health Yo Benefits and the Amounts You P , Benefits In network benefits * Out of- network bene 3 after tleductible - after deductible' * For out network benefits, 'in addition to the deductibl and coinsurance, you are responsible for any: charges in exce of the =non networkprovider reimbursement a.mount Add these charges will not be applied toward satisfaction of the deductible or the out -of- po maximum 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Inpatient services (including residential treatment services) a. Room and board Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending psychiatrist Nothing 50% coinsurance services d. Partial program Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. MIC FOCUSMN HSA (3/11) 44 1500 -100% BPL 67319 DOC 21641 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 the Diagnostic and Statistical Manual of Mental Disorders. See Def nitions. These words have specific meanings: benefits, claim, coinsurance, custodial- care, deductible; emergency, hospital, 'inpatient, .medically necessary, member, mental disorder, network, ,non network, non - network provider reimbursement; amount, physician, provider. Prior authorization. For prior authorization requirements of in network and out - network benefits, call Medica's designated mental health and substance abuse provider at: 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations. b. Outpatient treatment. c. Intensive outpatient programs, including day treatment and partial programs, which may include multiple services and modalities, delivered in an outpatient setting. 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. 2. Inpatient services include: a. Room and board. b. Attending physician services. c. Hospital or facility -based professional services. 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. Substance abuse residential treatment services. These are services from a licensed chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours per week per individual of chemical dependency services must be provided, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. MIC FOCUSMN HSA (3/11) 45 1500 -100% BPL 67319 DOC 21641 Substance Abuse Covered For benefits and the amounts you pay, see the table in this section. • For in- network benefits: 1. Medica's designated mental health and substance abuse provider arranges in- network substance abuse benefits. (Medica and Medica's designated mental health and substance abuse provider networks are different.) 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). 2. In- network benefits will apply to 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. Providers may be network providers for substance abuse services only, and not otherwise part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Substance abuse services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Chemical dependency clinic e. Chemical dependency residential treatment center f. Hospital that provides substance abuse services. g. Independent clinical social worker h. Marriage and family therapist 2. Emergency substance abuse services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your MIC FOCUSMN HSA (3/11) 46 1500 -100% BPL 67319 DOC 21641 Substance Abuse Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary. 4. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received. 5. Telephonic substance abuse treatment services. 6. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide substance abuse services. This includes, but is not limited to, services provided by mental health or substance abuse providers who are not authorized under state law to practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch. 7. Room and board charges associated with substance abuse treatment services providing less than 30 hours a week per individual of chemical dependency services, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. 8. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You ,Pay In- network be nefits * Ou #-of network bene fits after deductible after deductible * For out of network benefits, in addition to. the deductible and :coinsurance, you are responsible for any c in excess o # the non networ provider,reimburserrrent amount Addrtionally the charges will not be apptiiecl toward satisfaction of the deductible or the o ut-of-pocket maximum 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance MIC FOCUSMN HSA (3/11) 47 1500 - 100% � BPL 67319 DOC 21641 Substance Abuse Your Benefits and the Amounts You - Pay ,: Benefits In- network benefits * Out of network benefits after deductible after deductible * For out -of network benefits, in'addition;to the deductible,and coinsurance, you' responsible for any charges in excess of the non- network - provider reimbursement, amount Additionally, these charges °will not be°applied toward satisfaction of: the deductible orthe out-of-pocket maximum. 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. b. Hospital or facility -based Nothing 50 % coinsurance professional services c. Attending physician services Nothing 50% coinsurance 1 • MIC FOCUSMN HSA (3/11) 48 1500 - 100% BPL 67319 DOC 21641 s5 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. See ' Definitions. These words have specific meanings: benefits, coinsurance, deductible, medically necessary, network,.non network, non- network provider-reimbursement amount, physician, ,provider. a _ Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, 'see the table in this section. Medica covers only a limited selection of durable medical equipment, certain related supplies, and hearing aids that meet the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. The list of eligible durable medical equipment and certain related supplies is periodically reviewed and modified by Medica. 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 purchased 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. If the durable medical equipment, prosthetic device, or hearing aid is covered by Medica, but the model you select is not Medica's standard model, you will be responsible for the cost difference. • In- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a network durable medical equipment provider who has a durable medical equipment contract with Medica, and hearing aids as described in 4. in the table in this section when prescribed by a network provider. To request a list of network durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. • Out -of- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a non - network provider. Out - of- network benefits also apply to hearing aids as described in 4. in the table in this section. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC FOCUSMN HSA (3/11) 49 1500 -100% BPL 67319 DOC 21641 Durable Medical Equipment And Prosthetics Not covered These services, supplies, and associated expenses are not covered: 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the Medica eligible list. 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, or hearing aids. 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, replacement, or revision of duplicate items. See Exclusions for additional services, supplies, and associated expenses that are not covered. YourBenefits andtheAmounts You Pay Benefits' to network benefits4 * Out of network benefits ft tl r b a er de actable a e c e * For out =of network benefit in addition to the deductible and c oinsurance, you are responsible for any charges in°iexcess of the non network provider reimbursement amount Additionally, these - chargeswiti not be applied toward satisfaction of the deductible or the out of pocket maximum 1. Durable medical equipment and Nothing 50% coinsurance certain related supplies 2. Repair, replacement, or revision Nothing 50% coinsurance of durable medical equipment made necessary by normal wear and use 3. Prosthetics a. Initial purchase of external Nothing 50% coinsurance prosthetic devices that replace a limb or an external body part, limited to: i. Artificial arms, legs, feet, • and hands; ii. Artificial eyes, ears, and noses; iii. Breast prostheses b. Scalp hair prostheses due to Nothing. Medica pays up 50% coinsurance. alopecia areata to $350. This is Medica pays up to $350. calculated each calendar This is calculated each year. calendar year. MIC FOCUSMN HSA (3/11) 50 1500 -100% BPL 67319 DOC 21641 Durable Medical Equipment And Prosthetics Your Benefits andthe Amounts You Pay Benefits - In network benefits * Out of network benefits after deductible after deductible For out of netw * ork'benefits, in addition to * deductiOe and - coi you a re responsible for any charges rn exces the non netw ork,provider ■reimbursemenam t ount . Additionally, thesex charges will not be applied toward satisfaction of the deductible or the out =of pocket ma c. Repair, replacement, or Nothing 50% coinsurance revision of artificial arms, legs, feet, hands, eyes, ears, noses, and breast prostheses made necessary by normal wear and use 4. Hearing aids for members 18 Nothing. Limited to one 50% coinsurance. years of age and younger for hearing aid per ear every Limited to one hearing hearing loss that is not three years. Related aid per ear every three correctable by other covered services must be years. procedures prescribed by a network provider. • MIC FOCUSMN HSA (3/11) 51 1500 -100% BPL 67319 DOC 21641 Miscellaneous Medical Services And Supplies 0. Miscellaneous Medical Services And Supplies This section describes coverage for miscellaneous medical services and supplies prescribed by a physician. Medica covers only a limited selection of miscellaneous medical services and supplies that meet the criteria established by Medica. Some items ordered by a physician, even if medically necessary, may not be covered. -See Definitions These words have specific meanings: benefits, coinsurance, deductible, medically necessary, network, non - network, non network`provider reimbursement amount, h cia pYsi. n; provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to miscellaneous medical services and supplies received from a network provider. • Out -of- network benefits apply to miscellaneous medical services and supplies received from a non - network provider. In addition to the deductible and coinsurance described for out-of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered Other disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 52 1500 -100% BPL67319 DOC21641 — Miscellaneous Medical Services And Supplies Your Benefits and the Amounts Youi Pa ' .,' � .•':.. ter_. 45' '§- .., '- � Benefits to network ben efits * Out -of- network benefits after deductible after deductible For out of network ben efits in addition to the ed uctible14na coinsurance you`are responsible for any: char in. excess of .the n;on network provrderreirnbursement amount % Additionally these c harges will not be applied toward satisfaction of the deductible or ti e- .out -of pocket maximum: 1. Blood clotting factors Nothing 50% coinsurance 2. Dietary medical treatment of Nothing 50% coinsurance phenylketonuria (PKU) 3. Amino acid -based elemental Nothing 50% coinsurance formulas for the following diagnoses: a. cystic fibrosis; b. amino acid, organic acid, and fatty acid metabolic and malabsorption disorders; c. IgE mediated allergies to food proteins; d. food protein- induced enterocolitis syndrome; e. eosinophilic esophagitis; f. eosinophilic gastroenteritis; and g. eosinophilic colitis Coverage for the diagnoses in 3.c. -g. above is limited to members five years of age and younger. 4. Total parenteral nutrition Nothing 50% coinsurance 5. Eligible ostomy supplies Nothing 50% coinsurance Please note: Eligible ostomy supplies may be received from a pharmacy or a durable medical equipment provider. 6. Insulin pumps and other eligible Nothing 50% coinsurance diabetic equipment and supplies MIC FOCUSMN HSA (3/11) 53 1500 - 100% BPL 67319 DOC 21641 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 network physician and received at a designated 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. See Definitions These words have specific meanings ''benefits, coinsurance, deductible, designated facility, e- visits,: hospital, inpatient;Investigative, medicafy'necessary, member, network, non network, non network provider reimbursement amount, physician, provider Prior authorization. Prior authorization from Medica is required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood. The preceding is not a comprehensive list of eligible organ and bone marrow transplant services. • 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. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 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. MIC FOCUSMN HSA (3/11) 54 1500 -100% BPL 67319 DOC 21641 L �J Organ And Bone Marrow Transplant Services Providers may be network providers for transplant services only, and not otherwise part of the Medica Focus network. When you receive other health services you should verify that your provider is a Medica Focus network provider in order to be eligible for in- network benefits. You can do this by reviewing your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow transplant services, except as described in this section. 2. 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. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. 5. Islet cell transplants except for autologous islet cell transplants associated with pancreatectomy. 6. 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 Toss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature not otherwise covered under this certificate. 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. 10. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 55 1500 -100% BPL 67319 DOC 21641 Organ And Bone Marrow Transplant Services Your Benefits and the Amounts Yo Pay 3 Benefits.! - In- network benefits * Out -of- network benefits after deductible after ded * For ou - network benefits, in addition to the deduct ble.and coinsurance, you are responsible for any ,.charges in,excess of the' non - network. provider. reimbursement amount i Additionally,these c harges`wiil no appliedatoward,satisfact■on of. the ;'deductible or. the out-of-pocket maximum 1. Office visits Nothing No coverage 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing No coverage defined in the Physicians' Current Procedural Terminology code book) received from a physician during an office visit or an outpatient hospital visit ii. Anesthesia services Nothing No coverage received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing No coverage pathology iv. Outpatient x -rays and Nothing No coverage other imaging services v. Other outpatient hospital Nothing No coverage services received from a physician b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x -rays and Nothing No coverage other imaging services iii. Other outpatient hospital Nothing No coverage services 4. Inpatient services Nothing No coverage MIC FOCUSMN HSA (3/11) 56 1500 -100% BPL 67319 DOC 21641 Organ And done Marrow transplant Services • Your Benefits;and the A moun ts =Yo Pay: Benefi . In - n e t work benefits * Out of- n etwo rk.ben efi #s after de ductible after deductible * For out-of-netw be n e fits, n addition to the deductible and co y ou a res p o nsible for any c in excess of t he, non p reimburseme a mount: A ddition all y , these ",char w ilt not be applied towardw s a tisfaction o f the deductible.or the out -o pocke ma ximum: 5. Servic rec eived fro a Nothing No covera physician during an inpatient stay 6. A services received Nothing No coverage from a provider during an inpatient stay 7. Transpo rtation and lodging The deductible does not No c o v erage a. As desc below, apply to this reimbursement of re asonable reimbursement benefit. and necessary expenses for You are responsible for travel a nd lodging for you paying all amounts n ot and a companion w you reimbu under this receive approved services at benefit. Such amounts a designated facil fo do not cou towar your tran splant service and you out -o pocket maximu live more than 50 miles from or towar satisfaction o f that designated facil your ded uc tible. i. T rans po rt ation o f you and one c (traveling on the same day(s)) to and /or from a designated facility for transplant services for pre - transplant, transplant, and post - transplant se rvices. If you are a minor child, transportation e xpenses for two companions will be reimbursed. I MIC FOCUSMN HSA (3/11) 57 1500 - 100% BPL 67319 no 21641 Organ And Bone Marrow Transplant Services Your Benefits and the.Amounts You Pa y , Benefits _ In network benefit's *Out of network benefits after d afterdeductible * For out of network benefits,: in addition to the deductible and coinsurance, you .are 'responsible for any=charges in .excess of the non - network; provider reimbursement amount Additionally, these charges will not:be applied toward satisfaction'ofthe deductibl or out -of pocke ii. Lodging for you (while not confined) and one companion. Reimbursement is available for a per diem amount of up to $50 for one person or up to $100 for two people. If you are a minor child, reimbursement for lodging expenses for two companions is available, up to a per diem amount of $100. iii. There is a lifetime maximum of $10,000 per member for all transportation and lodging expenses incurred by you and your companion(s) and reimbursed under the Contract or under any other Medica, Medica Health Plans or Medica Health Plans of Wisconsin coverage offered through the same employer. b. Meals are not reimbursable under this benefit. MIC FOCUSMN HSA (3/11) 58 1500 -100% BPL 67319 DOC 21641 • Infertility Diagnosis Q. Infertility Diagnosis This section describes coverage for the diagnosis of infertility. Coverage includes benefits for professional, hospital, and ambulatory surgical center services. Services for the diagnosis of infertility treatment must be received from or under the direction of a physician. All services, supplies, and associated expenses for the treatment of infertility are not covered. Seei,Definrtion These words have specfic meanings benefits, coinsurance, deductible, e- visits, hospital, inpatient, member, network, non - network, non network provider reimbursemen# amount, . . ysician provider � Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered Benefits apply to services for the diagnosis of infertility received from a network or non - network provider. Coverage for infertility services is limited to a maximum of $5,000 per member per calendar year for in- network and out -of- network benefits combined. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered All services, supplies, and associated expenses for the treatment of infertility are not covered, including the following: 1. Professional, hospital, and ambulatory surgical center services for the treatment of infertility. 2. Infertility drugs. 3. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 4. Services for a condition that a physician determines cannot be successfully treated. 5. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 6. Sperm banking. 7. Adoption. 8. Donor sperm. MIC FOCUSMN HSA (3/11) 59 1500 - 100% BPL 67319 DOC 21641 infertility Diagnosis 9. Embryo and egg storage. See Exclusions for additional services, supplies, and associated expenses that are not covered. Benefits and the Amounts You Pay Benefits s` " In= network benefits * Out of- network bene after deductible s * For o ut-of ne be nefits , in addition " to the deductible and coinsura you are responsible for any charges inexcess- of:the non - network provider reimbursement amount Additionally, these charges wilt not,be applied "toward satisfaction of the or;the out-of-pocket maximum. 1. Office visits, including any Nothing 50% coinsurance services provided during such visits 2. E- visits Nothing No coverage 3. Outpatient services received at a Nothing 50% coinsurance hospital 4. Inpatient services Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. MIC FOCUSMN HSA (3/11) 60 1500 - 100% BPL 67319 DOC 21641 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. See Definitions.= The words ha specific m eaning s : benefit cosmetic, deductible, a visits, hospital, inpatient, medically necessary, member, network, non network, non - network provider reimbursement amount, physician, provider, reconstructive,restorative. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. 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 Toss 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. 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. 6. Hair transplants. MIC FOCUSMN HSA (3/11) 61 1500 - 100% BPL 67319 DOC 21641 Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay ;Benefits 16-network benefits *-Out of network- benefits after deductible after deductible * For out -of network - benefits;' in addition to the deductible a coinsurance, you are; respons for: anyk in`excess the non- network provider reimbursement amount Additionally, these charges will not be applied toward satisfaction of the deductible or the out of pocket maximum 1. Office visits Nothing 50% coinsurance 2. E - visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance or ambulatory surgical center services received from a physician MIC FOCUSMN HSA (3/11) 62 1500 - 100% BPL 67319 DOC 21641 1 Reconstructive And Restorative Surgery ... ....._ ............ Your Benefits and the Amounts You Pay Benefits In- network_ benefits *Out ofnetwork benefits after deductible after deductible * For out network benefits, in addition to the deductible and coinsurance, youare 'any "charges in excess the non networkl"provider reimbursement amount: Additionally, these charges will not be applied toward satisfaction of the deductible or the out -of- pocket maximum b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Inpatient services Nothing 50% 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. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. 5. Services received from a Nothing 50% coinsurance physician during an inpatient stay 6. Anesthesia services received Nothing 50 %coinsurance from a provider during an inpatient stay MIC FOCUSMN HSA (3/11) 63 1500 - 100% BPL 67319 DOC 21641 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 qualify as reimbursable under Medicare. See Definitions These words have,specific meanings benefits, coinsurance, custodial care, ;deductible,:°hospital, inpatient, network,'non- network, non network provider reimbursement . amount, physician, skilled'7care, skilled nursing facility ;. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For purposes of this section, room and board includes coverage of health services and supplies. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. Custodial care and other non - skilled services. 2. Self -care or self -help training (non - medical). 3. Services primarily educational in nature. 4. Vocational and job rehabilitation. 5. Recreational therapy. 6. Health clubs. 7. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 8. Voice training. MIC FOCUSMN HSA (3/11) 64 1500 -100% BPL 67319 DOC 21641 ,L • Skilled Nursing Facility Services 9. Outpatient rehabilitation services when no medical diagnosis is present. 10. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Bene fits and the Amounts Y ou Pay Benefits.' m , * -u ra � . � In netvv 6�nefits Out of - network berie7!i#s after deductible after deductible 3... * For. out -of network benefits, in addition to the deductible and coinsurance, you are responsible for any.charges in excess o f the non network provider reimbursement Additionally, these charges wi ll not be applied toward satisf of the deductible or the out -of pocket maximum, 1. Daily skilled care or daily skilled Nothing 50% coinsurance. rehabilitation services, including Coverage is limited to a room and board combined total of 120 Please note: Such services are days per calendar year eligible for coverage only if they for all inpatient out - of- would qualify as reimbursable under network benefits Medicare. described in this certificate. Please note: This day limit includes days that you pay for in order to satisfy any part of your deductible. 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when room and board is not eligible to be covered 3. Services received from a Nothing 50% coinsurance physician during an inpatient stay in a skilled nursing facility MIC FOCUSMN HSA (3/11) 65 1500 -100% BPL 67319 DOC 21641 L 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 hospice program. See Definitions` The words have specific meanin benefits,= coinsuran deductible;,- mernber, network, non- network, non network provider amount,^: physician, sk nursing ;facility 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. 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. A designated hospice program means a hospice program that has entered into a separate contract with Medica to provide hospice services to members. The specific services you receive may vary depending upon which program you select. Members who elect to receive hospice services do so in place of curative treatment for their terminal illness for the period they are enrolled in the hospice program. 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. • Out -of- network benefits apply to hospice services arranged through a physician and received from a non - designated hospice program. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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). MIC FOCUSMN HSA (3/11) 66 1500 -100% BPL 67319 DOC 21641 Hospice Services • 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 hospice program. You must follow the hospice program's requirements to withdraw from the 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. 2. 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 hospice program's plan of care. 4. Services not provided by the hospice program. 5. Hospice daycare, except when recommended and provided by the hospice program. 6. Any services provided by a family member or friend, or individuals who are residents in your home. 7. Financial or legal counseling services, except when recommended and provided by the hospice program. 8. Housekeeping or meal services in your home, except when recommended and provided by the hospice program. 9. Bereavement counseling, except when recommended and provided by the hospice program. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits ;and the Amounts You Pay x , _ Benefits 54 - ln- network benefits * Out of network benefits Y after deductible a_ fter deductible For' out-of-network b enefits, in addition to deductible and coinsurance, you are responsible for any charges in excess of the non-network provider reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out -o €pocket m maximu 1. Hospice services Nothing 50% coinsurance MIC FOCUSMN HSA (3/11) 67 1500 - 100% BPL 67319 DOC 21641 Temporomandibular Joint (TMJ) Disorder Q.D. 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. TMJ disorder is covered the same as any other joint disorder under this certificate. See Definitions. These words have specific; meanings: ;benefits; coinsurance, deductible; e visits, hospital, inpatient, member, network, non - network, non-network :providerreimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/11) 68 1500 -100% BPL 67319 DOC 21641 Temporomandibular Joint (TMJ) Disorder Your Benefits: and: the Amounts You Pay: Benefits Y In network bene fits * Out of ne twork b enefits _ after dedu ctible a ft er deductible - *Far out o f n etwork network provider reimburse benefits, in addition to thezdeductible and,comsurance `y are responsible for any charges inexcess:of the ' ment- amount Additionally, these charges will not, be applied toward satisfaction ofthe deductible or the :out -of pocket:m 1. Office visits Nothing 50% coinsurance 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services received from a physician or dentist b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services MIC FOCUSMN HSA (3/11) 69 1500 - 100% BPL 67319 DOC 21641 Temporomandibular Joint (TMJ) Disorder Your Benefits and the Amounts You Pay Benefits fn netwo benefits *Out of- netwo benefits after ded uctible af deductible * For'out -of network, benefits in addition to the deductible and coinsuranc you'are re ponsible'fo any c harges in excess of the - non- networkprbvider reimburse amount Addit�onally,these ' charges will not be applied „toward satisfaction-of,the deductible or. the out-of-pocket maximum iii. Other outpatient hospita Nothing 50% coinsurance and ambulatory surgical center services 4. Physical therapy received Nothing 50% coinsurance outside of your home 5. Inpatient services Nothing 50% coinsurance. Coverage is limited to a combined total of 120 days per inpatient c lendar out -of- ye r network benefits described in this certificate. • Plea note This day limit inclu days that you pay f ifn part or n f your order deductible. to satisy a y 6. Services received from a Nothing 50% coinsurance physician or dentist during an inpatient stay 7. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay 8. TMJ splints and adjustments if Nothing 50% coinsurance your primary diagnosis is joint disorder MIC FOCUSMN HSA (3/11) 70 1500-100% BPL 67319 DOC 21641 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. 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 alignment or occlusion of the teeth. These services are not covered under any section of this certificate. _ ................... _............ See Definitions- These words have specific meanings benefits, coinsurance deductible, dependent, hospital, member, network, non network, non network provider reimbursement amount,. physician;. provider:: w.r.., Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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), except as described in this section for the treatment of cleft lip and palate. 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, except as described in this section for the treatment of cleft lip and palate. 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. MIC FOCUSMN HSA (3/11) 71 1500 -100% BPL 67319 DOC 21641 Medical- Related Dental Services 8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident - related dental services as described in this section. 9. Routine diagnostic and preventive dental services. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits'and; the Amounts Y Pay Benefits In network benefits * Out network benefits after deductible after deductible * For out of netw benefits, in addition to the deductible a nd coinsurance, you. are responsible for ay�charges in excess of the non - network provider reirrbursern'ent amount. Additi n onally, these charges will not be applied toward" satisfaction of the deductible or:the out -of pocket maximum 1. Charges for medical facilities Nothing 50% coinsurance 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: i. 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. 2. For a dependent child, Nothing 50% coinsurance orthodontia, dental implants, and oral surgery treatment related to cleft lip and palate MIC FOCUSMN HSA (3/11) 72 1500 -100% BPL 67319 DOC 21641 II Medical- Related Dental Services Your Benefits 'and t he Amou You Pay of n Benefits ; In- network benefits * Out etworkbenefrts a deductible after deductib For out -of network benefits, m addition to the de d u ctible and comsurance, you are responsible for any charge.s excess of the non-network provider. reimbursement amou Ad dit r onally, these charges will not be, applied toward satisfactionof,the deductible or' the ' out- of-pocket ma ximurr 3. Accident - related dental services Nothing 50% coinsurance to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply: a. Coverage is limited to services received within 24 months from the later of: i. the date you are first covered under the Contract; or ii. the date of the injury 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 one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year. 4. Oral surgery for: Nothing 50% coinsurance a. Partially or completely unerupted impacted teeth; or b. A tooth root without the extraction of the entire tooth (this does not include root canal therapy); or c. The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth MIC FOCUSMN HSA (3/11) 73 1500-100% BPL 67319 DOC 21641 Referrals To Non - Network Providers W. 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 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. 'See De`fimt,ons These words have specific meanings benefits rnetlicall necessa etwork non ne n twor physician,proyider = 7 If you want to apply for a standing referral to a non - network provider, contact Medica for more . information. If determined by Medica to be clinically appropriate, a standing referral may be granted by Medica. A standing referral is a referral issued by a network provider and authorized by Medica for conditions that require ongoing services from a specialist provider. Standing referrals will only be covered for the period of time appropriate to your medical condition. Referrals'and standing referrals will not be covered to accommodate personal preferences, family convenience, or other non - medical reasons. Referrals will also not be covered for care that has already been provided. If your request for a standing referral is denied, you have the right to appeal this decision as described in Complaints. What you must do 1. 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. pecify the service(s) to be provided; and c. Direct you to the non- network provider selected by your network provider. 2. 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. 3. 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. 4. Pay any charges not authorized for coverage by Medica. What Medica will do 1. May require that you see another network provider selected by Medica before a determination by Medica that a referral to a non - network provider is medically necessary. 2. 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. MIC FOCUSMN HSA (3/11). 74 1500 -100% BPL 67319 DOC 21641 r Referrals To Non - Network Providers 3. Provides coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. 4. 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 24 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. MIC FOCUSMN HSA (3/11) 75 1500 - 100% BPL 67319 DOC 21641 Harmful Use Of Medical Services X. 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. See Definitions These words have specific "meanings: "benefits, emergency, hospital, network, physician,., prescription drug, provider: 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. You must obtain a referral from your coordinating health care provider if your condition requires care or treatment from a provider other than your coordinating health care provider. Medica will send you specific information about: 1. How to obtain approval for benefits not available from your coordinating health care providers; and 2. How to obtain emergency care; and 3. When these restrictions end. MIC FOCUSMN HSA (3/11) 76 1500 -100% BPL 67319 DOC 21641 Exclusions V. Exclusions See Definitions These words have specific meanings: claim, cosmetic, custodial care, emergency, inve medically necessary m n , meber, no network, physician, provider, reconstructive, routine foot care. r Medica will not provide coverage for any of the services, treatments, supplies, or items described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition. This section describes additional exclusions to the services, supplies and associated expenses already listed as Not covered in this certificate. These include: 1. 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. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be, reconstructive. 3. Refractive eye surgery, including but not limited to LASIK 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 a physician, airand bone conduction hearing aids (including internal, external, or implantable hearing aids or devices), and other devices to improve hearing, and their related fittings, except cochlear implants and related fittings, and except as described in Durable Medical Equipment And Prosthetics. 6. A drug, device, or medical treatment or procedure that is investigative. 7. Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct -to- consumer marketing and not under the !. direction of your physician. 8. Services or supplies not directly related to care. , , 9. Autopsies. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition. 11. Nutritional and electrolyte substances, except as specifically described in Miscellaneous Medical Services And Supplies. 12. Physical, occupational, or speech therapy or chiropractic services when there is no reasonable expectation that the condition will improve over a predictable period of time. 13. Reversal of voluntary sterilization. MIC FOCUSMN HSA (3/11) 77 1500 -100% BPL 67319 DOC 21641 Exclusions 14. Personal comfort or convenience items or services, including but not limited to breast pumps, except when the pump is medically necessary. 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, except as described in Organ And Bone Marrow Transplant Services. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 19. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. 20. Routine foot care, except for members with diabetes, blindness, peripheral'vascular disease, peripheral neuropathies, and significant neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. 21. Services by persons who are family members or who share your legal residence. 22. Services for which coverage is available under workers' compensation, employer liability, g p � Y, or any similar law. 23. Services received before coverage under the Contract becomes effective. 24. Services received after coverage under the Contract ends. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non - network providers and non - network dentists. 26. Photographs, except for the condition of multiple dysplastic syndrome. 27. Occlusal adjustment or occlusal equilibration. 28. Dental implants (tooth replacement), except as described in Medical - Related Dental Services. 29. Dental prostheses. 30. Orthodontic treatment, except as described in Medical - Related Dental Services. 31. Treatment for bruxism. 32. Services prohibited by law or regulation, or illegal under Minnesota law. 33. Services to treat injuries that occur while on military duty, and any services received as a result of war or any act of war (whether declared or undeclared). 34. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or licensure. 35. Exams, other evaluations, or other services received solely for the purpose of judicial or administrative proceedings or research, except emergency examination of a child ordered by judicial authorities. 36. Non- medical self -care or self -help training. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services. 38. Coverage for costs associated with translation of medical records and claims to English. MIC FOCUSMN HSA (3/11) 78 1500 -100% BPL 67319 DOC 21641 Exclusions 39. Treatment for spider veins. 40. Services not received from or under the direction of a physician, except as described in this certificate. 41. Services for the treatment of infertility. 42. Services for or related to intensive behavior therapy treatment programs for the treatment of autism spectrum disorders. Examples of such services include, but are not limited to, Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral Intervention (IBI), and Lovaas therapy. 43. Sensory integration, including auditory integration training. 44. Services for or related to vision therapy and orthoptic and /or pleoptic training, except as described in Professional Services. 45. Orthognathic surgery. 46. Health care professional services for maternity labor and delivery in the home. 47. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and subsequent procedures. 48. Infertility drugs. 49. Growth hormone. 50. Erectile dysfunction medications. 51. Cosmetic medications. 52. Weight loss medications. 53. Acupuncture. 54. Services solely for or related to the treatment of snoring. 55. Interpreter services. 56. Services provided to treat injuries or illness as a result of committing a crime or attempting to commit a crime. 57. Services for private duty nursing, except as described in Home Health Care. Examples of private duty nursing services include, but are not limited to, skilled or unskilled services provided by an independent nurse who is ordered by the member or the member's representative, and not under the direction of a physician. 58. Laboratory testing that has been performed in response to direct -to- consumer marketing and not under the direction of a physician. 59. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), other than those granted a humanitarian device exemption. MIC FOCUSMN HSA (3/11) 79 1500 -100% BPL 67319 DOC 21641 How To Submit A Claim Z. How To Submit A Claim This section describes the process for submitting a claim. See Definitions These words have specific meanings benefits, claim, :dependent, member network, non - network,; non- network provider, reimbursement "amount, prodder 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. Network providers are required to submit claims within 180 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 180 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 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 PO Box 30990 Salt Lake City, UT 84130 Upon receipt of your claim for benefits from non - network providers, Medica will generally pay to you directly the non - network provider reimbursement amount. Medica will only pay the provider of services if: 1. The non - network provider is one that Medica has determined can be paid directly; and 2. The non - network provider 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 receiving the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. CaII Customer Service at one of the telephone numbers listed inside the front cover for a list of non - network providers that Medica will not pay directly. MIC FOCUSMN HSA (3/11) 80 1500 -100% BPL 67319 DOC 21641 How To Submit A Claim 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 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. MIC FOCUSMN HSA (3/11) 81 1500 -100% BPL 67319 DOC 21641 Coordination Of Benefits AA. Coordination Of Benefits This section describes how`benefits are coordinated when you are covered under more than one plan. See, Definitions. :These words have specific °meanings benefits, claim,'deducti tio ble, dependent, emergerncy; hospital, medically necessary; member, non network; non network provider reimbursement amount, provider, subscriber 1. Applicability a. 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. b. If this coordination of benefits provision applies, 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 Order of benefit determination rules, the benefits of this plan: i. 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 a. Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment: i. Group insurance or group -type coverage, whether insured or uninsured, or individual coverage. 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 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. b. This plan is the part of the Contract that provides benefits for health care expenses. c. 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. MIC FOCUSM_ N HSA (3/11) 82 1500 -100% BPL 67319 DOC 21641 • Coordination Of 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. d. 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. Allowable expense does not include the deductible for members with a primary high deductible plan and who notify Medica of an intention to contribute to a health savings account. The difference between the cost of a private hospital room and the cost of a semi - private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private 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 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. e. 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. - i 3. Order of benefit determination rules a. 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 3.b. below, require that this plan's benefits be determined before those of the other plan. b. Rules. This plan determines its order of benefits using the first of the following rules which applies: i. 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. ii. 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 MIC FOCUSMN HSA (3/11) 83 1500 - 100% BPL 67319 DOC 21641 Coordination Of Benefits 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. iii. 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 determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. iv. 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 3.b.ii. v. 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. vi. 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. vii. No -fault automobile insurance. Coverage under the No -Fault Automobile Insurance Act or similar law applies first. viii. 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 a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that MIC FOCUSMN HSA (3/11) 84 1500 -100% BPL 67319 DOC 21641 Coordination Of Benefits event, the benefits of this plan may be reduced under this section. Such other plan or plans are referred to as the other plans in b. immediately below. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of: i. 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 50 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, 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; or MIC FOCUSMN HSA (3/11) 85 1500 - 100% BPL 67319 DOC 21641 Coordination Of Benefits 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. Please note: See Right Of Recovery for additional information. MIC FOCUSMN HSA (3/11) 86 1500 -100% BPL 67319 DOC 21641 1L Right Of Recovery BB. Right Of Recovery This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and federal law. For information about the effect of Minnesota and federal law on Medica's subrogation rights, contact an attorney. See Definitions.: This word has a specific; meaning benefits 4 1. 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. 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 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. 4. By accepting coverage under the Contract, you agree: a. That if we pay benefits for medical expenses you incur as a result of any act by a third party for which the third party is or may be liable, and you later obtain full recovery, you are obligated to reimburse us for the benefits paid in accordance to Minnesota law. b. 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. c. To provide prompt written notice to Medica when you make a claim against a party 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. f. 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. MIC FOCUSMN HSA (3/11) 87 1500 -100% BPL 67319 DOC 21641 Eligibility And Enrollment CC. Eligibility And Enrollment This section describes who can enroll and how to enroll. See Definitions These; words have specific meanings benefits, continuous coverage, dependent, late entrant, member, mental disorder, physician, placed for adoption, premium, qualifying coverage, subscriber, waiting period. Who can enroll To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract and be a subscriber or dependent as defined in this certificate. See Definitions. 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 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 other time for consideration as a late entrant as described in this section under Late enrollment. Dependents will not be enrolled without the eligible employee also being enrolled. A child who is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical Child Support Order (QMCSO) and 6. under Special 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, a dependent child reaching the dependent limiting age, or other facts identifying you or your dependents. (For dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption; however, we encourage you to enroll your newborn dependent under the Contract within 30 days from the date of birth, date of placement for adoption, or date of adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with the subscriber, and any child who is a member pursuant to a QMCSO will be covered without application of health screening or waiting periods. The employer must notify Medica, as set forth in the Contract, 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 A 30 -day time period starting with the date an eligible employee and dependents are first eligible to enroll for coverage under the Contract. An eligible employee must enroll within this MIC FOCUSMN HSA (3/11) 88 1500 -100% BPL 67319 DOC 21641 . . r Eligibility And Enrollment period for coverage to begin :the date he or she was first eligible to enroll. (The 30 -day time period does not apply to newborns or children newly adopted or placed for adoption; see Special enrollment.) An eligible employee and dependents that enroll during the initial enrollment period are accepted without application of health screening or affiliation periods. An eligible employee and dependents who do not enroll during the initial enrollment period may enroll for coverage during the next open enrollment, any applicable special enrollment periods, or as a late entrant (if applicable, as described below). A member who is a child entitled to receive coverage through a QMCSO is. not subject to any initial enrollment period restrictions, except as noted in this section. Open enrollment A minimum 14 -day period set by the employer and Medica each year during which eligible employees and dependents who are not covered under the Contract may elect coverage for the upcoming Contract year. An application must be submitted to the employer for yourself and any dependents. Special enrollment Special enrollment periods are provided to eligible employees and dependents under certain circumstances. • 1. Loss of other coverage a. A special enrollment period will apply to an eligible employee and dependent if the individual was covered under Medicaid or a State Children's Health Insurance Plan and lost that coverage as a result of loss of eligibility. The eligible employee or dependent must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. In the case of the eligible employee's loss of coverage, this special enrollment period applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss' of coverage, this special enrollment period applies to both the dependent who has lost coverage and the eligible employee. b. A special enrollment period will apply taan eligible employee and dependent if the eligible employee or dependent was covered under qualifying coverage other than , Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment, and declined coverage for that reason. The eligible employee or dependent must present either. evidence of the loss of prior coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated; and request 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, or the date on which a claim is denied due to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; ii. Loss of eligibility includes: MIC FOCUSMN HSA (3/11) 89 1500 -100% BPL 67319 DOC 21641 Eligibility And Enrollment • loss of eligibility as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment; • cessation of dependent status; • incurring a claim that causes the eligible employee or dependent to meet or exceed the lifetime maximum limit on all benefits; • if the prior coverage was offered through an individual health maintenance organization (HMO), a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area; • if the prior coverage was offered through a group HMO, a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other coverage option is available; and • the prior coverage no longer offers any benefits to the class of similarly situated individuals that includes the eligible employee or dependent. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is eligible for or elects applicable federal or state continuation coverage; iv. Loss of eligibility does not include a Toss due to failure of the eligible employee or dependent to pay premiums on a timely basis or termination of coverage for cause; In the case of the eligible employee's loss of other coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of other coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. c. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under benefits available under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or any applicable state continuation laws, at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. The eligible employee or dependent must present evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to failure of the eligible employee or dependent to pay premiums on a timely basis or for cause; and request enrollment in writing within 30 days of the date of the exhaustion of coverage. For purposes of 1.c.: i. Exhaustion of COBRA or state continuation coverage includes: • losing COBRA or state continuation coverage for any reason other than those set forth in ii. below; • losing coverage as a result of the employer's failure to remit premiums on a timely basis; • losing coverage as a result of the eligible employee or dependent incurring a claim that meets,or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or MIC FOCUSMN HSA (3/11) 90 1500 -100% BPL 67319 DOC 21641 Eligibility And Enrollment • if the prior coverage was offered through a health maintenance organization (HMO), losing coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other COBRA or state continuation coverage is available. ii. Exhaustion of COBRA or state continuation coverage 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. iii. In the case of the eligible employee's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. 2. 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 and provided that the eligible employee also enrolls during this special enrollment period; 3. 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 (for dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption) and provided that the eligible employee also enrolls during this special enrollment period; 4. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in 3. 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; and d. The eligible employee also enrolls during this special enrollment period; or 5. 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 2. or 3. above, becoming eligible to enroll under the coverage provided the eligible employee also enrolls during this special enrollment period. 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as described in this section, Medica will provide the eligible dependent child with a special enrollment period provided the eligible employee also enrolls during this special enrollment period. Late enrollment An eligible employee or an eligible employee and dependents who do not enroll for coverage offered through the employer during the initial or open enrollment period or any applicable special enrollment period will be considered late entrants. MIC FOCUSMN HSA (3/11) 91 1500 -100% BPL 67319 DOC 21641 Eligibility And Enrollment Late entrants who have maintained continuous coverage may enroll and coverage will be effective first day of the month following the date of Medica's approval of the request for enrollment. Continuous coverage will be determined to have been maintained if the late entrant requests enrollment within 63 days after prior qualifying coverage ends. Individuals who have not maintained continuous coverage may not enroll as late entrants. An eligible employee or dependent who: 1. does not enroll during an initial or open enrollment period or any applicable special enrollment period; and 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the 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. 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 de dependent child who is not already a member, such child will be provided a P already � P special enrollment period. If the eligible employee whose dependent child is the subject of the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, the eligible employee must also enroll for coverage under the Contract during the 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. The date your coverage begins Your coverage begins at 12:01 a.m. on the effective date of your enrollment. 1. For eligible employees and dependents who enroll during the initial enrollment period, coverage begins on the effective date specified in the Contract. 9 9 P 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. MIC FOCUSMN HSA (3/11) 92 1500 -100% BPL 67319 DOC 21641 Eligibility And Enrollment 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: a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first calendar month following the date on which the request for enrollment is received by Medica; b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of adoption or placement for adoption, date of adoption or placement. In all other cases, the date the subscriber acquires the dependent child; c. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.b. above; d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. or 3. under Special enrollment becomes effective; e. Number 6. under Special enrollment, the first day of the first calendar month following the date the completed request for enrollment is received by Medica. 4. For eligible employees and /or dependents who enroll during late enrollment, coverage begins on the first day of the month following date of Medica's approval of the request for enrollment. 1 MIC FOCUSMN HSA (3/11) 93 1500 -100% BPL 67319 DOC 21641 Ending Coverage DD. 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. See Definitions These words have ;specific meanings certification of qualifying coverage= cla n, dependent, rnember,,.premiurn, subscriber. You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. When coverage ends Unless otherwise specified in the Contract, 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 Eligibility And 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. If coverage ends due to fraud, 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. Fraud includes but is not limited to: a. Intentionally 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 b. Intentional 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 MIC FOCUSMN HSA (3/11) 94 1500 -100% BPL 67319 DOC 21641 Ending Coverage e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional misrepresentation with regard to any aspect of coverage under the Contract. 7. 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; 8. 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; 9. For a spouse, the end of the month following the date of divorce; 10. For a dependent child, the end of the month in which the child is no longer eligible as a dependent; or 11. 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. MIC FOCUSMN HSA (3/11) 95 1500 - 100% BPL 67319 DOC 21641 Continuation EE. Continuation This section describes continuation coverage provisions. When coverage ends, members may be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer. See Definitions These words have specific Meanings benefits dependent,:member, placed for adoption, -premium, subscnber,total =.disability„ The paragraph below describes the continuation coverage provisions. State continuation is described in 1. and federal continuation is described in 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. When your continuation coverage under this section ends, you have the option to enroll in an individual conversion health plan as described in Conversion. 1. Your right to continue coverage under state law Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: a. 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. b. 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. 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. In this section, layoff from employment means a reduction in hours to the point where the subscriber is no longer eligible for coverage under l i the Contract. MIC FOCUSMN HSA (3/11) 96 1500 -100% BPL 67319 DOC 21641 Continuation 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; 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. 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: 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. 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. Consistent with Minnesota law, the subscriber and dependents have 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. If continuation coverage is not elected, your coverage under the Contract will end. MIC FOCUSMN HSA (3/11) 97 1500 -100% BPL 67319 DOC 21641 Continuation 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 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. Surviving dependents of•a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. 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: a. 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. b. 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 iii. The date coverage would otherwise terminate under the Contract. c. For instances where dependent children lose coverage as a result of loss of dependent 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 iii. The date coverage would otherwise terminate under the Contract. d. 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: i. The date the former spouse becomes covered under another group health plan; 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: i. The date the former spouse becomes covered under another group health plan; or MIC FOCUSMN HSA (3/11) 98 1500 -100% BPL 67319 DOC 21641 Continuation ii. The date coverage would otherwise terminate under the Contract. e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of: i. The date the surviving spouse and dependent children become covered under another group health plan; or ii. The date coverage would have terminated under the Contract had the subscriber lived. 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. 2. 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 General COBRA information in this section. USERRA continuation coverage Continued coverage shall be provided as required under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The employer shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General USERRA information in this section. General COBRA information 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 coverage is a group health plan for purposes of COBRA. This section 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 section carefully. MIC FOCUSMN HSA (3/11) 99 1500 -100% BPL 67319 DOC 21641 Continuation Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as: 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 c. A dependent child of a covered employee. (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 Toss 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; 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. 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: 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 the subscriber 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. MIC FOCUSMN HSA (3/11) 100 1500 -100% BPL 67319 DOC 21641 Continuation 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. 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. Consistent with federal law, the subscriber and dependents have 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 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. 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 amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 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 of COBRA coverage 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. MIC FOCUSMN HSA (3/11) 101 1500 -100% BPL 67319 DOC 21641 Continuation 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. 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. 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 reasons: a. Thesubscriber'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 pre- , existing condition; or d.. The subscriber becomes entitled to (actually covered under) Medicare. • Continuation.coverage rriayalso end-earlier for reasons which would allow regular coverage to be terminated, such as'fraud.: General USERRA'infor'mation " • • USERRA•requires'employers to offer employees 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 coverage is a group health plan for theApurposes of USERRA This sections •intended.to inform you ; in summary fashion, of your rights and obligations under the continuation coverage provisiontof federal law. It is intended that no greater rights be• provided. thanthose .required1by=fed Take time to read this section carefully. Employee's' Toss; The employee has •niight to• elect continuation of coverage if there is a loss of coverage under the Contract because of absence from employment due to service in the uniformed services, and the= :erployee was coverLed ]under Contract at the time the absence began, and the employee, :or an. appropriate officer' of the uniformed services,, provided the employer with advance: notice.of the: employee's absence from•employment (if it was possible to .do so):, Service in the uniforrned.services,:rr Bans �the'perforrnanc of duty °on a or involuntary;ba'sis in the:uniformed'services under: competent authority, including active duty, active 'dutyifor train initial active dwty for training inactive dutOraining, full -time National • MIC FOCUSMN.HSA•(3 /1 • 102 1500- 100% BPL 67319 DOC 21641 . Continuation Guard duty, and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of these duties. Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army National Guard, and the Air National Guard, when engaged in active duty for training, inactive duty training, or full -time National Guard duty, and the commissioned corps of the Public Health Service. Election rights The employee or the employee's authorized representative may elect to continue the employee's coverage under the Contract by making an election on a form provided by the employer. The employee has 60 days to elect continuation coverage measured from the date coverage would be lost because of the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The employee may elect continuation coverage on behalf of other covered dependents, however, there is no independent right of each covered dependent to elect. If the employee does not elect, there is no USERRA continuation available for the spouse or dependent children. In addition, even if the employee does not elect USERRA continuation, the employee has the right to be reinstated under the Contract upon reemployment, subject to the terms and conditions of the Contract. Type of coverage and cost If the employee elects 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. The amount charged cannot exceed 102 percent of the cost of the coverage unless the employee's leave of absence is Tess than 31 days, in which case the employee is not required to pay more than the amount that they would have to pay as an active employee for that coverage. There is a grace period of at least 30 days for the regularly scheduled premium. Duration of USERRA coverage When an employee takes a leave for service in the uniformed services, coverage for the employee and dependents for whom coverage is elected begins the day after the employee would lose coverage under the Contract. Coverage continues for up to 24 months. Federal law provides that continuation coverage may end earlier for any of the following reasons: a. The employer no longer provides group health coverage to any of its employees; b. The premium for continuation coverage is not paid on time; c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct; d. The employee fails to return to work following the completion of his or her service in the uniformed services; or e. The employee returns to work and is reinstated under the Contract as an active employee. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. MIC FOCUSMN HSA (3/11) 103 1600:1 b0% #' BPL 67319 DOC 21641, Continuation COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation coverage in addition to USERRA continuation coverage, these coverages run concurrently. MIC FOCUSMN HSA (3/11) 104 1500 -100% BPL 67319 DOC 21641 . . J Conversion FF. Conversion See - Definitions. These words have specific me anings: continuous coverage, dependent, premium, waiting period Your conversion plan coverage may not provide the same coverage as your previous group health plan. Benefits and provider networks may be different. Minnesota residents This section describes your right to convert to a Medica individual conversion plan if you are a resident of Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. If you are a Minnesota resident, you may be eligible to obtain coverage from 1) other private sources of health coverage, or 2) the Minnesota Comprehensive Health Association, without a pre- existing condition limitation. Contact the Minnesota Comprehensive Health Association for further information: • For deductible plan options call 1- 866 - 894 -8053 or TTY: 1- 800 - 841 -6753. • For Medicare Supplement plan options call 1- 800 - 325 -3540 or TTY: 1- 800 - 234 -8819. Overview 1. You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in Continuation, is exhausted. b. Your coverage or continuation coverage ends because the Contract is terminated and the Contract is not replaced with other continuous group coverage. c. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. 2. Your conversion plan goes into effect the day following 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. 3. Conversion coverage is not available: a. When continuous coverage is not maintained; or b. If your coverage is terminated due to nonpayment of premium; or c. If you have not exhausted your right to continue coverage as described in Continuation; or d. If your coverage or continuation coverage ends because the Contract is terminated and the Contract is replaced with other continuous group coverage; or e. If you commit fraud or material misrepresentation in applying for continuation or conversion of coverage. MIC FOCUSMN HSA (3/11) 105 1500 -100% BPL 67319 DOC 21641 Conversion For purposes of 2. and 3.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 coverage, whichever is later. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor 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. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor 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. Residents of a state other than Minnesota This section describes your right to convert to an individual conversion plan if you are a resident of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. Overview You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods, in accordance with the laws of the state in which you reside on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You will be required to include your first month premium payment with your enrollment form for conversion coverage. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. MIC FOCUSMN HSA (3/11) 106 1500 -100% BPL 67319 DOC 21641 Complaints GG. Complaints This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. See_Definifions. These words'have specific ;meanings: claim, inpatient,:network provider. 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, 2. You also may contact the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296 -2488 or 1- 800 -657 -3602. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. You may appoint an authorized representative to make a complaint on your behalf. You may be required to sign an authorization which will allow Medica to release confidential information to your authorized representative and allow them to act on your behalf during the complaint process. 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. In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Commerce at the telephone number listed at the beginning of this section. 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. 1. If your complaint is regarding an initial decision made by Medica, your complaint must be made within one year following Medica's initial decision. 2. For an oral complaint that does not require a medical determination in its outcome, 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 3. 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 or request. 4. When an initial decision by Medica not to grant a prior authorization request is made before 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 MIC FOCUSMN HSA (3/11) 107 1500 -100% BPL 67319 DOC 21641 Complaints 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 appeal. 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. 5. 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. 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. 1. 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 the address listed above in First level of review, 2. 2. 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. 3. Medica will provide written notice of its second level review decision to you within: a. 30 calendar days from receipt of written notice of your appeal for required second level reviews; or b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews. For some complaints, the second level of review must be exhausted before you have the right to submit a request for external review. For other complaints, this second level of review is optional before you may submit a request for external review. Medica will inform you in writing whether the second level of review is optional or required. External review If you consider Medica's decision to be partially or wholly adverse to you, you may submit a written request for external review of Medica's decision to the Commissioner of Commerce at: Minnesota Department of Commerce 85 7 h Place East, Suite t ace ast, Su to 500 St. Paul, MN 55101 -2198 A filing fee of $25 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 will not be binding on you but will be binding on Medica. Contact 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. MIC FOCUSMN HSA (3/11) 108 1500 -100% BPL 67319 DOC 21641 Complaints Civil action If you are dissatisfied with Medica's first or second level review decision or the external review decision, you have the right to file a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA). MIC FOCUSMN HSA (3/11) 109 1500 -100% BPL 67319 DOC 21641 General Provisions HH. General Provisions This section describes the general provisions of the Contract. See. Definitions These words have specific meanings: benefits, claim, dependent, member,; network, premium, provider, subscriber 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. 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. 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. MIC FOCUSMN HSA (3/11) 110 1500 - 100% BPL 67319 DOC 21641 General Provisions 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. MIC FOCUSMN HSA (3/11) 111 1500 -100% BPL 67319 DOC 21641 Definitions Definitions I In this certificate (and in any amendments), some words have specific meanings. Within each definition, you may note bold words. These words also are defined in this section. Benefits. The health services or supplies (described in this certificate and any subsequent amendments) approved by Medica as eligible for coverage. Certification of qualifying 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. 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. 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 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. For out -of- network benefits, in addition to any 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 Drug Program and Specialty 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. Continuous coverage. 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. Convenience care /retail health clinic. A health care clinic located in a setting such as a retail store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. MIC FOCUSMN HSA (3/11) 112 1500 -100% BPL 67319 DOC 21641 Definitions Cosmetic. 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. Custodial care. 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. • Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims for health services or supplies received from network or non - network providers are reimbursable as in- network or out -of- network benefits under this certificate. Dependent. Unless otherwise specified in the Contract, the following are considered dependents: 1. The subscriber's spouse. 2. The following dependent children up to the dependent limiting age of 26: a. The subscriber's or subscriber's spouse's natural or adopted child; b. A child placed for adoption with the subscriber or subscriber's spouse; 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 legal guardianship; d. The subscriber's stepchild; and e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent incapable of self- sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber for support and maintenance. An illness that does not cause a child to be incapable of self - sustaining employment will not be considered a physical disability. This depend ent may remain covered under the Contract regardless of age and without application of health screening or waiting periods. To continue coverage for a disabled dependent, you must provide Medica with proof of such disability and dependency within 31 days of the child reaching the dependent limiting age set forth in 2. above. Beginning two years after the child reaches the dependent limiting age, Medica may require annual proof of disability and dependency. For residents of a state other than Minnesota, the dependent limiting age may be higher if required by applicable state law. 3. The subscriber's or subscriber's spouse's disabled dependent,who is incapable of self - sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber or subscriber's spouse for support and maintenance. For coverage of a disabled dependent, you must provide Medica with proof of such disability and dependency at the time of the dependent's enrollment. MIC FOCUSMN HSA (3/11) 113 1500 -100% BPL 67319 DOC 21641 Definitions Designated facility. A network hospital that Medica has authorized to provide certain benefits to members, as described in this certificate. Emergency. A condition or symptom (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, 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 (or, if you are pregnant, the health of your unborn child) 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. E- visits. A member - initiated online evaluation and management service provided to patients via the Internet. E- visits are used to address non- urgent medical symptoms for established patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. II' ' Home clinic. The primary care clinic site within the Medica Focus network that you choose to collaborate with for your healthcare needs. II Hospital. 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. Inpa An uninterrupted stay, following formal admission to a hospital, skilled nursing facility, or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally disabled children will be covered as any other health condition. Investigative. 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: 1. 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; 2. 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 MIC FOCUSMN HSA (3/11) 114 1500 -100% BPL 67319 DOC 21641 Definitions 3. Whether there are consensus opinions of national and_local health care providers in 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 drug being used for an indication or at 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 any authoritative compendia as identified by the Medicare program for use in the determination of a medically accepted indication of drugs and biologicals used off - label. 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 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 member who is a child entitled to receive coverage through a QMCSO 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: 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. Member. A person who is enrolled under the Contract. Mental disorder. 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). Network. 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 Focus network provider directory will be furnished automatically, without charge. Non - network. A term used to describe a provider not under contract as a network provider. MIC FOCUSMN HSA (3/11) 115 1500 -100% BPL 67319 DOC 21641 Definitions Non - network provider reimbursement amount. The amount that Medica will pay to a non- network provider for each benefit is based on one of the following, as determined by Medica: 1. A percentage of the amount Medicare would pay for the service in the location where the service is provided. Medica generally updates its data on the amount Medicare pays within 30 -60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or 2. A percentage of the provider's billed charge; or 3. A nationwide reimbursement provider reimbursement database that considers prevailing e p p g rates and /or marketplace charges for similar services in the geographic area in which the service is provided; or 4. An amount agreed upon between Medica and the non - network provider. Contact Customer Service for more information concerning which method above pertains to your services, including the applicable percentage if a Medicare -based approach is used. For certain benefits, you must pay a portion of the non - network provider reimbursement amount as coinsurance. In addition, if the amount billed by the non - network provider is greater than the non- network provider reimbursement amount, the non - network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any coinsurance or deductible amount you may be responsible for according to the terms described in this certificate. Furthermore, such difference will not be applied toward the out -of- pocket maximum described in Your Out -Of- Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non- network provider will likely be much higher than if you had received services from ,a network provider. Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.0.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (0.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. 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. (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.) 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 defined 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. Preventive health service. The following are considered preventive health services: 1. Evidence -based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; MIC FOCUSMN HSA (3/11) 116 1500 -100% BPL 67319 DOC 21641 Definitions 2. Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the member involved; 3. With respect to members who are infants, children, and adolescents, evidence - informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; 4. With respect to members who are women, such additional preventive care and screenings not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Contact Customer Service for information regarding specific preventive health services and services that are rated "A" or "B." 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 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; 15. State Children's Health Insurance Program; or 16. A public health plan similar to any of the above plans established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. 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; MIC FOCUSMN HSA (3/11) 117 1500 - 100% BPL 67319 DOC 21641 Definitions 2. Automobile medical payment coverage; 3. Liability insurance or coverage issued as a supplement to liability insurance; 4. 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. 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. Restorative. 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. Routine foot care. Services that are routine foot care may require treatment by a professional and include but are not limited to any of the following: 1. Cutting, paring, or removal of corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. _ Debriding (removal of toenails, dead skin, or underlying tissue). Routine foot care may also include hygiene and preventive maintenance such as: 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. 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 by themselves define the need for skilled care. MIC FOCUSMN HSA (3/11) 118 1500 -100% BPL 67319 DOC 21641 Definitions Skilled nursing facility. 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. 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. Total disability. 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. Travel program. A national program in which you can receive the in- network benefit level for most services when traveling outside the service area if your provider is a travel program provider. See How To Access Your Benefits for more information about the travel program. Urgent care center. 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. Waiting period. 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. Periods of employment in an employment classification that is not eligible for coverage under the Contract do not constitute a waiting period. MIC FOCUSMN HSA (3/11) 119 1500 -100% BPL 67319 DOC 21641 9i4,/,.7,*57/F eoG ?_s Medica choice Passport Certificate of Coverage MEDICA, MIC PPMN HSA (3/11) 1500 -100% BPL 67277 DOC 21411 i Table Of Contents Table Of Contents Introduction xi To be eligible for benefits xi Language interpretation xii Acceptance of coverage xii Nondiscrimination policy xii A. Member Rights And Responsibilities 1 Member bill of rights 1 Member 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 7 i Prior authorization 8 Certification of qualifying coverage 9 C. How Providers Are Paid By Medica 10 Network providers 10 Non - network providers 10 D. Your Out -Of- Pocket Expenses 11 Coinsurance and deductibles 11 More information concerning deductibles 12 Out -of- pocket maximum 13 Lifetime maximum amount 13 Out -of- Pocket Expenses 14 E. Professional Services 15 Covered 15 Not covered 16 Office visits 16 E- visits 16 Convenience care /retail health clinic visits 16 Urgent care center visits 17 Prenatal care services 17 MIC PPMN HSA (3/11) iii 1500 -100% BPL 67277 DOC 21411 Table Of Contents Preventive health care 18 Allergy shots 18 Routine annual eye exams 18 Chiropractic services 18 Surgical services 19 Anesthesia services received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 19 Services received from a physician during an emergency room visit 19 Services received from a physician during an inpatient stay, including maternity labor and delivery 19 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 19 Services received from a physician during an inpatient stay for prenatal care 19 Outpatient lab and pathology 19 Outpatient x -rays and other imaging services 19 Other outpatient hospital or ambulatory surgical center services received from a physician 19 Treatment to lighten or remove the coloration of a port wine stain 19 Diabetes self- management training and education 20 Neuropsychological evaluations /cognitive testing 20 Services related to lead testing 20 Vision therapy and orthoptic and /or pleoptic training 20 Genetic counseling 20 Genetic testing 21 F. Prescription Drug Program 22 Preferred drug list 22 Exceptions to the preferred drug list 22 Prior authorization 23 Step therapy 23 Quantity limits 23 Covered 23 Prescription unit 24 Not covered 25 Outpatient covered drugs 25 Emergency covered drugs 26 Diabetic equipment and supplies, including blood glucose meters 26 MIC PPMN HSA (3/11) iv 1500 -100% BPL 67277 DOC 21411 Table Of Contents Tobacco cessation products 26 Drugs considered preventive health services 26 G. Specialty Prescription Drug Program 27 Designated specialty pharmacies 27 Specialty preferred drug list 27 Exceptions to the specialty preferred drug list 27 Prior authorization 28 Step therapy 28 Quantity limits 28 Covered 28 Prescription unit 28 Not covered 29 Specialty prescription drugs received from a designated specialty pharmacy 29 Specialty growth hormone received from a designated specialty pharmacy 29 H. Hospital Services 30 Newborns' and Mothers' Health Protection Act of 1996 30 Covered 30 Not covered 31 Outpatient services 31 Services provided in a hospital observation room 32 Inpatient services 32 Services received from a physician during inpatient stay, including maternity labor and delivery 32 Anesthesia services received from a provider during an inpatient stay, including maternity labor and delivery 32 I. Ambulance Services 33 Covered 33 Not covered 33 Ambulance services or ambulance transportation 34 Non - emergency licensed ambulance service 34 J. Home Health Care 35 Covered 35 Not covered 36 Intermittent skilled care 36 Skilled physical, speech, or occupational therapy 37 MIC PPMN HSA (3/11) v 1500 -100% BPL 67277 DOC 21411 Table Of Contents Home infusion therapy 37 Services received in your home from a physician 37 K. Outpatient Rehabilitation 38 Covered 38 Not covered 38 Physical therapy received outside of your home 39 Speech therapy received outside of your home 39 Occupational therapy received outside of your home 39 L. Mental Health 40 Covered 41 Not covered 42 Office visits, including evaluations, diagnostic, and treatment services 42 Intensive outpatient programs 43 Inpatient services (including residential treatment services) 43 M. Substance Abuse 44 Covered 45 Not covered 45 Office visits, including evaluations, diagnostic, and treatment services 46 Intensive outpatient programs 46 Opiate replacement therapy 46 Inpatient services (including residential treatment services) 46 N. Durable Medical Equipment And Prosthetics 47 Covered 47 Not covered 48 Durable medical equipment and certain related supplies 48 Repair, replacement, or revision of durable medical equipment 48 Prosthetics 48 Hearing aids 49 O. Miscellaneous Medical Services And Supplies 50 o a e s nd Su pp Covered 50 Not covered 50 Blood clotting factors 51 Dietary medical treatment of PKU 51 Amino acid -based elemental formulas 51 MIC PPMN HSA (3/11) vi 1500 - 100% BPL 67277 DOC 21411 Table Of Contents Total parenteral nutrition 51 Eligible g ble ostomy supplies 51 Insulin pumps and other eligible diabetic equipment and supplies 51 P. Organ And Bone Marrow Transplant Services 52 Covered 52 Not covered 53 Office visits 53 E- visits 53 Outpatient services 54 Inpatient services 54 Services received from a physician during an inpatient stay 55 Anesthesia services received from a provider during an inpatient stay 55 Transportation and lodging 55 Q. Infertility Diagnosis 57 Covered 57 Not covered 57 Office visits 58 E- visits 58 Outpatient services received at a hospital 58 Inpatient services 58 R. Reconstructive And Restorative Surgery 59 Covered 59 Not covered 59 Office visits 60 E- visits 60 Outpatient services 60 Inpatient services 61 Services received from a physician during an inpatient stay 61 Anesthesia services received from a provider during an inpatient stay 61 S. Skilled Nursing Facility Services 62 Covered 62 Not covered 62 Daily skilled care or daily skilled rehabilitation services 63 Skilled physical, speech, or occupational therapy 63 MIC PPMN HSA (3/11) vii 1500 -100% BPL 67277 DOC 21411 TabBe Of Contents Services received from a physician during an inpatient stay in a skilled nursing facility 63 T. Hospice Services 64 Covered 64 Not covered 65 Hospice services 65 U. Temporomandibular Joint (TMJ) Disorder 66 Covered 66 Not covered 66 Office visits 67 E- visits 67 Outpatient services 67 Physical therapy received outside of your home 68 Inpatient services 68 Services received from a physician or dentist during an inpatient stay 68 Anesthesia services received from a provider during an inpatient stay 68 TMJ splints and adjustments 68 V. Medical - Related Dental Services 69 Covered 69 Not covered 69 Charges for medical facilities and general anesthesia services 70 Orthodontia related to cleft lip and palate 70 Accident - related dental services 71 Oral surgery 71 W. Referrals To Non - Network Providers 72 What you must do 72 What Medica will do 72 X. Harmful Use Of Medical Services 74 When this section applies 74 Y. Exclusions 75 Z. How To Submit A Claim 78 Claims for benefits from network providers 78 Claims for benefits from non - network providers 78 Claims for services provided outside the United States 79 Time limits 79 MIC PPMN HSA (3/11) viii 1500 -100% BPL 67277 DOC 21411 l i Table Of Contents AA. Coordination Of Benefits 80 Applicability 80 Definitions that apply to this section 80 Order of benefit determination rules 81 Effect on the benefits of this plan 82 Right to receive and release needed information 83 Facility of payment 83 Right of recovery 83 BB. Right Of Recovery 84 CC. Eligibility And Enrollment 85 Who can enroll 85 How to enroll 85 Notification 85 Initial enrollment 85 Open enrollment 86 Special enrollment 86 Late enrollment 89 Qualified Medical Child Support Order (QMCSO) 89 The date your coverage begins 89 DD. Ending Coverage 91 When coverage ends 91 EE. Continuation 93 Your right to continue coverage under state law 93 Your right to continue coverage under federal law 96 FF. Conversion 102 Minnesota residents 102 Residents of a state other than Minnesota 103 GG. Complaints 104 First level of review 104 Second level of review 105 External review 105 Civil action 106 MIC PPMN HSA (3/11) ix 1500 -100% BPL 67277 DOC 21411 Table Of Contents HH. General Provisions 107 Definitions 109 i MIC PPMN HSA (3/11) x 1500 -100% BPL 67277 DOC 21411 [introduction Introduction THIS POLICY IS REGULATED BY MINNESOTA LAW. The benefits of the policy providing your coverage are governed primarily by the laws of a state other than Florida. Many words" in' this certificate have specific meanings. These words are - .identified in each section and defined in Definitions See "Definitfons These words have specific meanings: benefits claim dependent, member, network, ;premium, provider = " Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota non - qualified plan. This Certificate of Coverage (this certificate) describes health services that are eligible for coverage and the procedures you must follow to obtain benefits. The Contract refers to the Contract between Medica and the employer. You should contact the employer to see the Contract. 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 may arrange for various persons or entities to provide administrative services on its 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. Additional network administrative support is provided by one or more organizations under contract with Medica. The employer is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by applicable law. In this certificate, the words you, your, and yourself refer to the member. The word employer refers to the organization through which you are eligible for coverage. To be eligible for benefits Each time you receive health services, you must: 1. Confirm with Customer Service that your provider is a network provider to be eligible for in- network benefits; and 2. Identify yourself as a Medica member; and 3. Present your Medica identification card. (If you do not show your Medica identification card, providers have no way of knowing that you are a Medica member and you may receive a bill for health services or be required to pay at the time you receive health services.) However, MIC PPMN HSA (3/11) xi 1500 -100% BPL 67277 DOC 21411 introduction possession and use of a Medica identification card does not necessarily guarantee coverage. Network providers are required to submit claims within 180 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 180 days of the date of service, you may be responsible for paying the cost of the service you received. 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. If you have an impairment that requires alternative communication formats such as Braille, large print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials. 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 that has been issued in Minnesota between Medica and the employer. This certificate is being delivered to you by, or on behalf of, your 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 unless otherwise prohibited by state law; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and complete. You understand and agree that any omission or incorrect statement concerning a material fact intentionally made by you in connection with your enrollment under the Contract may invalidate your coverage. Nondiscrimination policy Medica's policy is 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, genetic information, 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. MIC PPMN HSA (3/11) xii 1500 - 100% BPL 67277 DOC 21411 • Member Rights And Responsibilities A. Member Rights And Responsibilities See Definitions These words :havespecific meanings: benefits emergency; member network, provider:: Member bill of rights As a member of Medica, 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; and 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; and 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; and 4. Be treated with respect and recognition of your dignity and privacy; including privacy of your medical and financial records maintained by Medica or any network provider in accordance with existing law; and 5. Contact Customer Service and Minnesota's Commissioner of Commerce to file a complaint about issues related to benefits (see Complaints). To file a complaint with the Minnesota Department of Commerce, call (651) 296 -2488 and request insurance information. You may begin a legal proceeding if you have a problem with Medica or any provider; and 6. Receive information about Medica, its services, its practitioners and providers, and member rights and responsibilities; and 7. Appeal a decision regarding your health care coverage by calling Customer Service at one of the telephone numbers listed inside the front cover. See Complaints for information on your appeal rights; and 8. Make recommendations regarding Medica's member rights and responsibilities statement. 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; and 2. Providing the necessary information to health care professionals or Medica needed to determine the appropriate care. This objective is best obtained when you share: a. Information about lifestyle practices; and b. Personal health history; and 3. Understanding your health problems and agreeing to, and following, the plans and instructions for care given by those providing health care; and MIC PPMN HSA (3/11) 1 1500 - 100% BPL 67277 DOC 21411 1_ Member Rights And Responsibilities 4. Practicing self -care by knowing: a. How to recognize common health problems and what to do when they occur; and b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and 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 find additional information on member responsibilities in this certificate. MIC PPMN HSA (3/11) 2 1500 -100% BPL 67277 DOC 21411 • II How To Access Your Benefits B. How To Access Your Benefits - See - Definitions - These words have "specific.meanings benefits, claim, coinsurance, deductible, dependent, emergency„; enrollment date, hospital, inpatient, late entrant, member, network,'non- network, non - network; provider reimbursement amount, physician placed for adoption premium prescription drug, ,provider, - .qualifying coverage, reconstructive, restorative skilled nursing facility, _subscriber, waiting period k Provider network In- network benefits are available through the Medica Choice Passport provider network. For a list of the in- network providers, please consult your Medica Choice Passport provider directory by signing in at www.mymedica.com or contacting Customer Service. Out -of- network benefits will apply when you choose to receive eligible health services from providers that are not contracted with Medica. 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. To be eligible for in- network benefits, follow -up care or scheduled care after an emergency must be received from a network provider. 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. Providers Enrolling in Medica does not guarantee that a particular provider will remain a network provider or provide you with health services. When a provider no longer participates in the network, you must choose to receive health services from network providers to continue to MIC PPMN HSA (3/11) 3 1500 -100% BPL 67277 DOC 21411 How To Access Your Benefits be eligible for in- network benefits. You must verify that your provider is a network provider each time you receive health services. 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's hospital network is different from Medica's hospital network. Certain mental health and substance abuse services require prior authorization by Medica's designated mental health and substance abuse provider. Emergency services do not require prior authorization. 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. Medica does not automatically know of a birth or whether you would like coverage for the newborn dependent. Call Customer Service at one of the telephone numbers listed inside the front cover for more information. To be eligible for in- network benefits, health services must be 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 reduce payment by the amount of premium that is past due 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. Post- mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. MIC PPMN HSA (3/11) 4 1500 -100% BPL 67277 DOC 21411 How To Access Your Benefits 2. Important member information about out -of- network benefits The information below describes your covered health services and provides important information concerning your out -of- network benefits. Read this certificate for a detailed explanation of both in- network and out -of- network benefits. Please carefully review the general sections of this certificate as well as the section(s) that specifically describes the services you are considering, so you are best able to determine the benefits that will apply to you. Benefits Medica pays out -of- network benefits for eligible health services received from non - network providers. Prior authorization may be required from Medica before you receive certain services, in order to determine whether those services are eligible for coverage under your out -of- network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out -of- network benefits. 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. Emergency services received from non - network providers are,covered as in- network benefits and are not considered out -of- network benefits. Additionally, under certain circumstances Medica will authorize your obtaining services from a non - network provider at the in- network benefit level. Such authorizations are generally provided only in situations where the requested services are not available from network providers. Be aware that if you choose to go to a non - network provider and use out -of- network benefits, you will likely have to pay much 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 coinsurance and deductible amount. This additional amount you must pay to the provider will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses and you will owe this amount regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. Please see the example calculation below. Because obtaining care from non - network providers may result in significant out -of- pocket expenses, it is important that you do the following before receiving services from a non - network provider: • Discuss the expected billed charges with your non - network provider; and • Contact Customer Service to verify the estimated non - network provider reimbursement amount for those services, so you are better able to calculate your likely out -of- pocket expenses; and • If you wish to request that Medica authorize the non - network provider's services be covered at the in- network benefit level, follow the procedure described under Prior authorization in How To Access Your Benefits. MIC PPMN HSA (3/11) 5 1500 -100% BPL 67277 DOC 21411 How To Access Your Benefits An example of how to calculate your out -of- pocket costs* You choose to receive non - emergency inpatient care at a non - network hospital provider without an authorization from Medica providing for in- network benefits. The out -of- network benefits described in this certificate apply to the services you receive. For purposes of this example, you have previously satisfied your deductible. The non - network hospital provider bills $30,000 for your hospital stay. Medica's non - network provider reimbursement amount for those hospital services is $15,000. You must pay a portion of the non - network provider reimbursement amount, generally as a percentage coinsurance. In addition, the non - network provider will likely bill you for the amount by which the provider's charge exceeds the non - network provider reimbursement amount. If your coinsurance is 40 %, you will be required to pay: • 40% coinsurance (40% of $15,000 = $6,000) and • The billed charges that exceed the non - network provider reimbursement amount ($30,000 - $15,000 = $15,000) • The total amount you will owe is $6,000 + $15,000 = $21,000. • The $6,000 you pay as coinsurance will be applied to the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. However, the $15,000 amount you pay for billed charges in excess of the non - network provider reimbursement amount will not be applied toward the out -of- pocket maximum amount described in Your Out -Of- Pocket Expenses. You will owe the provider this $15,000 amount regardless of whether you have . previously reached your out -of- pocket maximum with amounts paid for other services. *Note: The numbers in this example are used only for purposes of illustrating how out -of- network benefits are calculated. The actual numbers will depend on the services received. Lifetime maximum amount Out -of- network benefits are subject to a lifetime maximum amount payable per member. See Your Out -Of- Pocket Expenses for a detailed explanation of the lifetime maximum amount. • Exclusions Some health 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. Post - mastectomy coverage Medica will cover all stages of reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. ■IC PPMN HSA (3/11) 6 1500 -100% BPL 67277 DOC 21411 ,y Flow To Access Your Benefits 3. Continuity of care To request continuity of care or if you have questions about how this may apply to you, call Customer Service at one of the telephone numbers listed inside the front cover. In certain situations, you have a right to continuity of care. a. If your current provider is terminated 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 provider 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 all necessary medical information related to your care, and accept as payment in full the lesser of the network provider reimbursement or the provider's customary charge for the service. This does not apply when a provider's contract is terminated for cause. i. 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; • 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 provider may 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 a network provider who has special expertise in the delivery of those culturally appropriate services is not available; or • if you do not speak English and a network provider who can communicate with you, either directly or through an interpreter, is not available. 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. You may appeal this decision. MIC PPMN HSA (3/11) 7 1500 -100% BPL 67277 DOC 21411 How To Access Your Benefits Coverage will not be provided for services or treatment that are not otherwise covered under this certificate. 4. 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. To determine whether a certain service or supply requires prior authorization, please call Customer Service at one of the telephone numbers listed inside the front cover. Emergency services do not require prior authorization. Your attending provider, you or someone on your behalf may contact Customer Service to request prior authorization. Your network provider will contact Customer Service to request prior authorization for a service or supply. You must contact Customer Service to request prior authorization for services or supplies received from a non - network provider. If a network provider fails to obtain prior authorization after you have consulted with them about services requiring prior authorization, you are not subject to a penalty for failure to obtain prior authorization. Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; • Treatment of a diagnosed temporomandibular joint disorder or craniomandibular disorder; • Organ and bone marrow transplant; • Home health care; • Medical supplies and durable medical equipment; • Outpatient surgical procedures; • Certain genetic tests; • Skilled nursing facility services; and • In- network benefits for services from non - network providers with the exception of emergency services. This is not an all- inclusive list of all services and supplies that may require prior authorization. When you, someone on your behalf, or your attending provider calls, the following information may be required: I ' I • 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). MIC PPMN HSA (3/11) 8 1500 -100% BPL 67277 DOC 21411 How To Access Your Benefits Your request will be reviewed and a response will be provided to you and your attending provider within 10 business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available. Both you and your provider will be informed of the decision within 24 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or it is concluded that a delay could seriously jeopardize your life, health, or ability to regain , maximum function. You have the right to appeal the decision as described in Complaints, if the request for prior • authorization has not been approved. 5. Certification of qualifying coverage You have the right to a certification of qualifying coverage when coverage ends. You will 'receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of . qualifying coverage, call Customer Service at one of the telephone numbers listed inside the "front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. MIC PPMN HSA (3/11) 9 1500 -100% • BPL 67277 DOC 21411 How Providers Are Paid By Medica C. How Providers Are Paid By Medica This section describes how providers are generally paid for health services. See Detnit!ons These words have specific: meanings Coinsurance, deductibte, hospital„ member, network, non- network, physician, provider. : 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 2. 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 is fee - for- service. Fee - for - service payment means that the network provider is paid 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, Tess any applicable coinsurance or deductible, is considered to be payment in full. Risk - sharing payment means that the network provider is paid 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. Some network providers are authorized to arrange for a member to receive certain health services from other providers. This decision may result in a network provider keeping more or less of the risk - sharing payment. 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. MIC PPMN HSA (3/11) 10 1500 -100% BPL 67277 DOC 21411 II� Your Out -Of- Pocket Expenses D. Your Out -Of- Pocket Expenses This section describes the expenses that are your responsibility to pay. These expenses are commonly called out -of- pocket expenses. See Definitions These words have spe meanings 3benefits, claim, coinsurance, deductible dependent, member, network, 'non network, non- network provider reimbursement aMOLifit prescription drug, providerisubscriber - i _ , , = , 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.) If you miss or cancel an office visit Tess than 24 hours before your appointment, your provider may bill you for the service. Please see the applicable benefit section(s) of this certificate for specific information about your in- network and out -of- network benefits and coverage levels. To verify coverage before receiving a particular service or supply, call Customer Service at one of the telephone numbers listed inside the front cover. Coinsurance and deductibles For in- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in'this section). When members in a family unit (a subscriber and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section), then all members of the family unit are considered to have satisfied the applicable per member and per family deductible for that calendar year. However, for family coverage, there is no per member deductible for benefits received during any calendar year. Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that is not covered under the Contract. MIC PPMN HSA (3/11) 11 1500 -100% BPL 67277 DOC 21411 Your Out -Of- Pocket Expenses For out -of- network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in this certificate (see the Out -of- Pocket Expenses table in this section). When members in a family unit (a subscriber and his or her dependents) have together paid the applicable per family deductible for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section), then all members of the family unit are considered to have satisfied the applicable per member and per family deductible for that calendar year. However, for family coverage, there is no per member deductible for benefits received during any calendar year. Note that applicable deductibles are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new deductible will apply for the rest of the current calendar year, whether or not you had met the previously applicable deductible. This means that it is possible that your deductible will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. 2. Any charge that exceeds the non - network provider reimbursement amount. This means you are required to pay the difference between the payment to the provider and what the provider bills. If you use out -of- network benefits, you may incur costs in addition to your coinsurance and deductible amounts. If the amount that your non - network provider bills you is more than the non - network provider reimbursement amount, you are responsible for paying the difference. In addition, the difference will not be applied toward satisfaction of the deductible or the out - of- pocket maximum (described in this section). 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 coinsurance and deductibles. 3. Any charge that is not covered under the Contract. More information concerning 'deductibles The time period used to apply the deductible (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. MIC PPMN HSA (3/11) 12 1500 -100% BPL 67277 DOC 21411 Your Out -Of- Pocket Expenses Out -of- pocket maximum The out -of- pocket maximum is an accumulation of coinsurance and deductibles paid for benefits received during a calendar year. Except as described below or as otherwise specified, you will not be required to pay more than the applicable per member out -of- pocket maximum for benefits received during a calendar year (see the Out -of- Pocket Expenses table in this section). Please note: Charges for services not eligible for coverage and any charge in excess of the non - network provider reimbursement amount are not applicable toward the out -of- pocket maximum. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. The time period used to calculate whether you have met the out -of- pocket maximum (calendar year or Contract year) is determined by the Contract between Medica and the employer. This time period may change when Medica and the employer renew the Contract. If the time period changes, you will receive a new certificate of coverage that will specify the newly applicable time period. You may have additional out -of- pocket expenses associated with this change. When members in a family unit (the subscriber and his or her dependents) have together met the applicable per family out -of- pocket maximum for benefits received during the calendar year, then all members of the family unit are considered to have met the applicable per member and per family out -of- pocket maximum for that calendar year (see the Out -of- Pocket Expenses table in this section). However, for family coverage, there is no per member out -of- pocket maximum for benefits received during any calendar year. After an applicable out -of- pocket maximum has been met for a particular type of benefit (as described in the Out -of- Pocket Expenses table in this section), all other covered benefits of the same type received during the rest of the calendar year will be covered at 100 percent, except for any charge not covered by Medica or charge in excess of the non - network provider reimbursement amount. However, you will still be required to pay any applicable coinsurance and deductibles for other types of benefits received. Note that out -of- pocket maximum amounts are determined by the Contract between Medica and the employer and may increase when Medica and the employer renew the Contract. If this occurs, the new out -of- pocket maximum will apply for the rest of the current calendar year, whether or not you had met the previously applicable out -of- pocket maximum. This means that it is possible that your out -of- pocket maximum will increase mid -year when your employer's Contract with Medica is renewed and that you may have additional out -of- pocket expenses as a result. Medica refunds the amount over the out -of- pocket maximum during any calendar year when proof of excess coinsurance and deductibles is received and verified by Medica. 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, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Out -of- Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced pertains only to those health care services and supplies that are not essential benefits as defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules, or other guidance issued with respect to the "Act." MIC PPMN HSA (3/11) 13 1500 - 100% BPL 67277 DOC 21411 Your Out -Of- Pocket Expenses Out-of-Pocket Expenses r., In= ne * Out of- network benefits bene *F out of network bene #its, in addition =to the" deductible -and c oinsurance, you are resp onsible; for`any ° charges in excess of;,the. non- network;provider reimbursement am ount. Additionally, th e se charges will not =be app lied: toward satisfaction of the.deductible or the ouf of- pocket " maxi { Coinsurance See specific benefit for applicable coinsurance. I ; Deductible Per family $3,000 $8,000 For family coverage, there For family coverage, is no per member there is no per member deductible. deductible. Out -of- pocket maximum Per family $3,000 $18,000 For family coverage, there For family coverage, is no per member out -of- there is no per member pocket maximum. out -of- pocket maximum. Lifetime maximum amount Unlimited $1,000,000. Applies to payable per member all benefits you receive uer a Medics nd Medics this or ny Health other Plans, or Medics Health Plans of Wisconsin ffed through the same coverage employer. oer MIC PPMN HSA (3/11) 14 1500 - 100% BPL 67277 DOC 21411 Professional Services E. Professional Services This section describes coverage for professional services received from or directed by a physician. See Definitions. These words have specific meanings benefits, coinsurance, convenience care /retail � health- clinic, deductible' emergency,'e visits; f�ospi #al, inpatient;. member, `n non-network, non network provider n sement amount, physician, prenata care prevetive::' health service,; provider, urgent careLcenter Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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; 2. 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. Family planning services do not include infertility treatment services. • Out -of- network benefits apply to professional services received from a non - network provider. In addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To A ccess Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. The most specific and appropriate section o this certificate will apply for professional services related to the treatment of a specific condition. For example, benefits for transplant services are described in Organ And Bone Marrow Transplant Serv For some services, there may be a facility charge resulting in coinsurance (see Hospital Services) in addition to the professional services coinsurance. Also, more than one coinsurance may be required if you receive more than one service or see more than one provider per visit. MIC PPMN HSA (3/11) 15 1500 -100% BPL 67277 DOC 21411 Professional Services Not covered Drugs provided or administered by a physician or other provider, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Pre scriptio n Drug Pro gram and Specialty Prescription Drug Program or otherwise described as a s pecific benefit in t his certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. m Your Benefits a nd the A Yo Pay Benefits ,. ; 1n networ benefits * 'Out of - n e twork benef a fter ded uc t i bl e `' after deducti i * For ou t -of- network; ben in a dditi o n to the deductible and coins nt nce, y ou a respons "for any in = e x ce ss of th n on - network provider reimburseme amount = Addi hese . . c harges w ill r be applied tow satisfac of th d ed u cti bl e or:fhe ouf -of= po maximum 1. Office visits Nothing 50% coinsurance Please note Some services received during an office visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an office visit. For example certain services received during an office visit may be considered surgical services; see 10. below for coverage of these surgical services. In such instances, both an office visit coinsurance and outpatient surgical services coinsurance apply. Call Customer Service at one of the telephone numbers listed inside the front cover to determine in advance I F whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 2. E- visits Nothing No coverage 3. Convenience care /retail health Nothing 50% coinsurance clinic visits MIC PPMN HSA (3/11) 16 1500-100% BPL 67277 DOC 21411 L Professional Services Your Benefits and the Amounts You Pay Benefits In network benefits * Out of network benefits ,!_ a r ctible after deductible fte d'edu * For out of network benefits, in addition to the deductible and coinsurance, you :are responsible for any ch in excess of the n;on network provider reimbursement: amount. Additionally, thes . ` charges will not be applied toward satisfaction of the deductible orithe out -of pocket maxim um. .xx 4. Urgent care center visits Nothing Covered as an in- network Please note: Some services benefit. received during an urgent care visit may be covered under another benefit in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during an urgent care visit. For example, certain services received during an urgent care visit • may be considered surgical or imaging services; see below for coverage of these surgical or imaging services. In such instances, both an urgent care visit coinsurance and outpatient surgical or imaging services coinsurance apply. Call Customer Service at one of the telephone numbers listed inside the front cover to determine in advance • whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 5. Prenatal care services received Nothing. The deductible 50% coinsurance from a physician during an office does not apply. visit or an outpatient hospital visit I � MIC PPMN HSA (3/11) 17 1500 - 100% BPL 67277 DOC 21411 Professional Services Your Benefits and the Amounts You Pay Benefits, In network benefits * Out of- network benefits • xafter.:dediuctible;° after deductible * For outof network benefits, m addition to the deduct bleand coinsurance, you a re responsible for any c harges in excess of the non- network provider retrrmbursement amount A dditronally, these charges ;will= not;beappliedrtoward_ satisfaction_ of the: deductible or thexout of pocket ma ximum -' 6. Preventive health care Please note: If you receive preventive and non - preventive health services during the same visit, the non - preventive health services may be subject to a coinsurance or deductible, as described elsewhere in this certificate. The most specific and appropriate benefit in this certificate will apply for each service received during a visit. a. Child health supervision Nothing. The deductible 50% coinsurance services, including well -baby does not apply. care b. Immunizations Nothing. The deductible 50% coinsurance does not apply. c. Early disease detection Nothing. The deductible 50% coinsurance services including physicals does not apply. d. Routine screening Nothing. The deductible 50% coinsurance procedures for cancer does not apply. 0 e. Other preventive health Nothing. The deductible 50% coinsurance services does not apply. 7. Allergy shots Nothing 50% coinsurance 8. Routine annual eye exams. Nothing. The deductible 50% coinsurance Coverage is limited to one visit does not apply. per calendar year for in- network and out -of- network benefits combined. 9. Chiropractic services to Nothing 50% coinsurance. diagnose and to treat (by manual Coverage is limited to a manipulation or certain maximum of 15 visits per therapies) conditions related to calendar year. the muscles, skeleton, and Please note: This visit limit nerves of the body includes chiropractic visits that you pay for in order to satisfy any part of your deductible. MIC PPMN HSA (3/11) 18 1500 -100% BPL 67277 DOC 21411 1• I Professional Services ,. r Y our; Benefit and the Amo ou Pay ,/ :,--,,,'::-:--;,:'-,--;- 7::::7f-!:' ' ' '''''';''''' ' -: ( ''''''''' 11';:; Be nefits . ' ",,71 i 1 " 41 0..'( . 1! 7:: rk b *Out-of-network ben -= after : d educti'ble aft de ductible * For out of networ benefits, in a d d ition, to thede l e a coinsuranc yo u'are responsible any char in excess of the non network - provider reimbur amount Add itionally , thes ch w ill not be appli tow s o - deductible or:the out-�f-pocket maximum 10. Surgical services (as defined i n Nothing 50% coinsurance the Physicians' Curren Procedural Terminol book) rece f a physician ogy code during an office visit or an outpatient hospital or ambulatory surgical center visit 11. Anesthesia v Nothing 50% coinsurance from a provider ser during ices an received office visit or an outpatient hospital or ambulatory surgical center visit 12. Services received from a Nothing Covered as an in- network physician during an emergency benefit. room visit 13. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 50% coinsurance 14. Anesthesia services received Nothing from a provider during an inpatient stay, including maternity labor and delivery 15. Services received from a Nothing. The deductible 50% coinsurance physician during an inpatient does not apply. stay for prenatal care 16. Outpatient lab and pathology Nothing 50% coinsurance Nothing 17. Outpatient x -rays and other 50% coinsurance imaging services 18. Other outpatient hospital or Nothing 50% coinsurance ambulatory surgical center services received from a physician 19. Treatment to lighten or remove Nothing 50% coinsurance the coloration of a port wine stain MIC PPMN HSA (3/11) 19 1500 - 100% BPL 67277 DOC 21411 Professional Services , Your Benefits and'the Amounts You,- Pay: Benefits. In ne benefits * Out -of- network benefits after deductible after deductible * -for out of network benefits, :in addition to the deductible and coin 110 asponsible for Y „. - char g es rn ezcesseof the=non networkprovider reimbursement amount Add re re Additionally, these c harges will not be applied toward satisfaction of Ahe deductible or, e out `o# pocket maximum 20. Diabetes self- management Nothing 50% coinsurance 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) 21. Neuropsychological Nothing 50% coinsurance evaluations /cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury 22. Services related to lead testing Nothing 50% coinsurance 23. Vision therapy and orthoptic Nothing 50% coinsurance and /or pleoptic training, to establish a home program, for the treatment of strabismus and other disorders of binocular eye movements. Coverage is limited to a combined in- network and out -of- network total of 5 training visits and 2 follow -up eye exams per calendar year. Please note: The visit and exam limits include visits and exams that you pay for in order to satisfy any part of your deductible. 24. Genetic counseling, whether pre- Nothing 50% coinsurance or post -test, and whether occurring in an office, clinic, or telephonically MIC PPMN HSA (3/11) 20 1500 -100% BPL 67277 DOC 21411 oL Professional Services Your Benefits-and/the Amounts You Pay.: F .- Benefits E" In- network= benefits * Out of- network benefits afterdeductible after deductible For out-of network b in addition to the deductible and:coin'surance, you are responsible for any "charges rn excess of ;the non-network = provide r reimbursement amount := 1Addit onally ( these char es wiqe a lied toward satisfaction of the deductible or the out of pocket maxrmum 9 � ll not bpp 25. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices MIC PPMN HSA (3/11) 21 1500 -100% BPL 67277 DOC 21411 Prescription Drug Program {` F. Prescription Drug Program This section describes coverage for prescription drugs and supplies received from a pharmacy or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" is meant to include those prescription drugs and supplies found on the Preferred Drug List (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such prescription drugs and supplies are identified in this certificate as not covered. The phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase "self- administered drugs" means all other drugs. For the definition and coverage of specialty prescription drugs, see Specialty Prescription Drug Program. See Definitions. These words have specific meanings: benefits, claim, coinsurance, deductible, durable" medical " equipment, emergency, hospital, member, network, non - network, ,"" non netw ork provider reirribursement;amount, physician, prescription drug, preventive health service; provider, urgent care "center. Preferred drug list Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: Tier 1 is your lowest coinsurance option. For the lowest out -of- pocket expense, you should consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your condition if you and your physician decide it is appropriate. Tier 3 drugs are not covered unless they meet the requirements under the PDL exception process described in this certificate. If you have questions about Medica's PDL or whether a specific drug is covered (and /or the PDL tier in which the drug may be covered), or if you would like to request a copy of the PDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The PDL is also available when you sign in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a drug should be considered a covered drug. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the PDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each drug based on a review of the drug's cost and effectiveness. Exceptions to the preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants MIC PPMN NSA (3/11) 22 1500 -100% BPL 67277 DOC 21411 Prescription Drug Program will improve the coverage by only one tier. Exceptions to the PDL can also 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 PDL or you change health plans. If you would like to request a copy of Medica's PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization Certain covered drugs require prior authorization as indicated on the PDL. The provider who prescribes the drug initiates prior authorization. The PDL is made available to providers, including pharmacies and the designated mail order pharmacies. You are responsible for paying the cost of drugs received if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step therapy involves trying an alternative covered drug first (typically a Tier 1 drug) before moving on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. • Quantity limits Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered The following table provides important general information concerning in- network, out-of- network, and mail order benefits. For specific information concerning benefits and the amounts you pay, see the benefit table at the end of this section. Please note that the Prescription Drug Program section describes your coinsurance for prescription drugs themselves. An additional coinsurance applies for the provider's services if you. require that a provider administer self- administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. In networ wor k'benefits Out -of netk benefits* Mail order benefits Covered drugs received at a Covered drugs received at a Covered drugs received from network pharmacy; and non- network pharmacy; and a designated mail order pharmacy; and MIC PPMN HSA (3/11) 23 1500 -100% BPL 67277 DOC 21411 Prescription Drug Program In- network benefits -_ Out-of-network benefits *" Mail - ordepbenefits Covered drugs for family See In- network benefits Covered drugs for family planning services or the column. planning services or the treatment of sexually treatment of sexually transmitted diseases when transmitted diseases when prescribed by or received from prescribed by either a either a network or a non- network or a non - network network provider. Family provider and received from a planning services do not designated mail order include infertility treatment pharmacy. Family planning services; and services do not include infertility treatment services; and Diabetic equipment and Diabetic equipment and Diabetic equipment and supplies, including blood supplies, including blood supplies (excluding blood glucose meters when received glucose meters when received glucose meters) received from a network pharmacy; and from a non - network pharmacy; from a designated mail order and pharmacy. Tobacco cessation products Tobacco cessation products Not available. when prescribed by a provider when prescribed by a provider authorized to prescribe the authorized to prescribe the product and received at a product and received at a non - network pharmacy. network pharmacy. * When out -of- network benefits are received from non - network providers, in addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Specialty Prescription Drug Program for coverage of growth hormone and other specialty prescription drugs. Prescription unit Generally, covered drugs will not be dispensed in excess of one prescription unit except as indicated below. One prescription unit is equal to a 31- consecutive -day supply of a covered drug from your pharmacy (or, in the case of oral contraceptives, up to a one -cycle supply) or a 93- consecutive -day supply of a covered drug from your designated mail order pharmacy (or, in the case of oral contraceptives, up to a three -cycle supply), unless limited by drug manufacturers' packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed. Three prescription units may be dispensed for covered drugs prescribed to treat chronic conditions that are received at a network pharmacy that Medica has specifically designated to MIC PPMN HSA (3/11) 24 1500 -100% BPL 67277 DOC 21411 Prescription Drug Program dispense multiple prescription units. For the current list of such designated pharmacies, sign in at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside the front cover. Not covered The following 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.) 2. OTC drugs not listed on the PDL. 3. Replacement of a drug due to loss, damage, or theft. 4. Appetite suppressants. 5. Erectile dysfunction medications. 6. Non - sedating antihistamines and non - sedating antihistamine /decongestant combinations. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and those members who have a feeding tube. 8. Tobacco cessation products or services dispensed through a mail order pharmacy. 9. Drugs prescribed by a provider who is not acting within his /her scope of licensure. 10. Homeopathic medicine. 11. Infertility drugs. 12. Specialty prescription drugs, except as described in Specialty Prescription Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay * For`out of- network benefits, in addition to the deductible'and `coinsurance, you are responsible for any charges in excess of the non network provider reimbursement- amount. Additionally, these . charges wilt not be applied toward satisfaction of the deductible or the ouof t - pocket maximum. ,& In-network benefits *Out o #- netw`ork bene #its Mail order benefit after deductible after deductible after deductible 1. Outpatient covered drugs other than those described below or in Specialty Prescription Drug Program Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage MIC PPMN HSA (3/11) 25 1500 -100% BPL 67277 DOC 21411 Prescription Drug Program Your Benefits:and the Amounts YouPa * For out -of network benefits, in addition to the deductible and coinsurance, you are responsible for any charges in excess of the non - network provider reimbursement amount Addltionaliy,,these charges not be applied toward; satisfaction of the deductible or the out-of-pocket maximum." In- network benefits *.Out-of-network benefits Mail order benefits after deductible after deductible , ; after deductible 2. Up to a 24 -hour supply of emergency covered drugs received from a hospital or urgent care center Nothing Covered as an in- network Not available through a mail benefit. order pharmacy. 3. Diabetic equipment and supplies, including blood glucose meters Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage 4. Tobacco cessation products Tier 1: Nothing per 50% coinsurance per Not available through a mail unit; or prescription prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. 5. Drugs (other than tobacco cessation products) considered preventive health services, as specifically defined in Definitions, when prescribed by a provider authorized to prescribe such drugs. This group of drugs is specific and limited. For the current list of such drugs, please refer to the Preventive Drug List within the PDL or call Customer Service at one of the telephone numbers listed inside the front cover. Tier 1: Nothing per 50% coinsurance per Not available through a mail prescription unit; or prescription unit order pharmacy. Tier 2: Nothing per prescription unit; or Tier 3: No coverage The deductible does not apply. MIC PPMN HSA (3/11) 26 1500 -100% BPL 67277 DOC 21411 Specialty Prescription Drug Program G. Specialty Prescription Drug Program This section describes coverage for specialty prescription drugs received from a designated specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology prescription drug products for individuals with diseases that require complex therapies. Such specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as described below. For purposes of this section, the phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; and the phrase "self- administered drugs" means all other drugs. See ° Definitions. These words have specific Meanings: claim;: coinsurance, deductible, member, network,: physician, prescri tion_ {� g;" provider. Designated specialty pharmacies A designated specialty pharmacy means a specialty pharmacy that has entered into a separate contract with Medica to provide specialty prescription drug services to members. For the current list of designated specialty pharmacies, call Customer Service at one of the telephone numbers listed inside the front cover or sign in at www.mymedica.com. Specialty preferred drug list Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty prescription drugs on Medica's SPDL are eligible for benefits under this certificate. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is covered (and /or the SPDL tier in which the drug may be covered), or if you would like to request a copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed inside the front cover. The SPDL is also available by signing in at www.mymedica.com. Medica utilizes medication request guidelines to determine whether a specialty prescription drug should be covered. Medica's medication request guidelines are based on United States Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the SPDL, are periodically reviewed and modified by Medica. In addition to the medication request guidelines, Medica assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. Exceptions to the specialty preferred drug list In certain circumstances your physician may request that Medica make an exception to the coverage rules described under Specialty preferred drug list above. Please note that exceptions will only be allowed when specific clinical criteria are satisfied. Any exception Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also MIC PPMN HSA (3/11) 27 1500 -100% BPL 67277 DOC 21411 Specialty Prescription Drug Program 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 SPDL or you change health plans. If you would like to request a copy of Medica's SPDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. Prior authorization I , Certain specialty prescription drugs require prior authorization. The provider who prescribes the specialty drug initiates prior authorization. The SPDL is made available to providers, including designated specialty pharmacies. You are responsible for paying the cost of specialty prescription drugs you receive if you do not meet Medica's authorization criteria. Step therapy Medica requires step therapy prior to coverage of specific specialty prescription drugs as indicated on the SPDL. Step therapy involves trying a Tier 1 specialty prescription drug before moving on to a Tier 2 specialty prescription drug for treatment of the same medical condition. Applicable step therapy requirements must be met before Medica will cover Tier 2 specialty prescription drugs. Quantity limits Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. These limits indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. Covered For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy. This section describes your coinsurance for specialty prescription drugs. An additional coinsurance applies for the provider's services if you require that a provider administer self - administered drugs, as described in other applicable sections of this certificate including, but not limited to, Professional Services, Hospital Services, and Infertility Diagnosis. Prescription unit Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. One prescription unit is equal to a 31- consecutive -day supply of a specialty prescription drug, unless limited by the manufacturers' packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. MIC PPMN HSA (3/11) 28 1500 - 100% BPL 67277 DOC 21411 Specialty Prescription Drug Program Not covered The following are not covered: 1. Any amount above what Medica would have paid when you fail to identify yourself to the designated specialty pharmacy as a member. (Medica will notify you before enforcement of this provision.) 2. Replacement of a specialty drug due to loss, damage, or theft. 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of Iicensure. 4. Prescription drugs and OTC drugs, except as described in Prescription Drug Program. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 6. Infertility drugs. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Y our Benefits and the Amounts You Pay Benefits `. You hpay after deductible mm 1. Specialty prescription drugs, Tier 1: specialty prescription drugs: Nothing per other than those described prescription unit; or below, received from a designated specialty pharmacy Tier 2 specialty prescription drugs: No coverage 2. Specialty growth hormone when Tier 1 specialty prescription drugs: Nothing per prescribed by a physician for the prescription unit; or treatment of a demonstrated I growth hormone deficiency and Tier 2 specialty prescription drugs: No coverage received from a designated specialty pharmacy MIC PPMN HSA (3/11) 29 1500 -100% BPL 67277 DOC 21411 Hospital Services H. Hospital Services This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. See Definitions. These words have specificmeanings benefits coinsurance, °deductible, emergency, hospital, inpatient, member,: network, non- network, non network provider ', reimbursement amount, phys ician, prenatal care, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. CaII Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out - of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Emergency services from non - network providers will be covered as in- network benefits. If you are confined in a non - network facility as a result of an emergency you will be eligible for in- network benefits until your attending physician agrees it is safe to transfer you to a network facility. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Each member's admission is separate from the admission of any other member. A separate deductible and coinsurance will be applied to both you and your newborn child for inpatient services related to maternity labor and delivery. MIC PPMN HSA (3/11) 30 1500 -100% BPL 67277 DOC 21411 i Hospital Services Not covered 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an j emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. 2. Transfers and admissions to network hospitals solely at the convenience of the member. 3. Admission to another hospital is not covered when care for your condition is available at the network hospital where you were first admitted. See Exclusions for additional services, supplies, and associated expenses that are not covered. _...... ___........_.___.... Your Benefits and the Amounts YouFPay Benefits In- network benefits, Out-of-network benefits afte r deductible after le ":4' = For out-of-network benefits, in addition to the deductible and coinsurance, are responsible for any charges in excess `of the `non network provider reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out of poc maximum 1. Outpatient services a. Services provided in a Nothing Covered as an in- network hospital or facility -based benefit. emergency room b: Outpatient lab and pathology Nothing 50% coinsurance c. Outpatient x -rays and other Nothing 50% coinsurance imaging services d. Prenatal care services Nothing. The deductible 50% coinsurance does not apply. e. Genetic testing when test Nothing 50% coinsurance results will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices f. Other outpatient services Nothing 50% coinsurance g. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician ,I li MIC PPMN HSA (3/11) 31 1500 - 100% i BPL 67277 DOC 21411 Hospital Services Your Benefits and the - Amounts You Pay Benefits In network benefits * Out of- network benefits a fter deductible after deductible * For out-of-network benefits, in addition to the deductible and coinsurance, you are responsible for any; charges in excess of the:non network reimbursement amount Additionally, these charges will not be applied ioWarif satisfaction of the deductible or the out: =of pocket maximum h. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit 2. Services provided in a hospital Nothing 50% coinsurance observation room 3. Inpatient services, including Nothing 50% coinsurance inpatient maternity labor and delivery services Please note: Maternity labor and delivery services are considered inpatient services regardless of the length of hospital stay. 4. Services received from a Nothing 50% coinsurance physician during an inpatient stay, including maternity labor and delivery 5. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay, including maternity labor and delivery MIC PPMN HSA (3/11) 32 1500 -100% BPL 67277 DOC 21411 Ambulance Services 1. 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). See'- Defmf�ons These words have specific meanings benefit coinsur deductib , emergency, hospital, network, non - network non - network; provider- reimbursement amount, physician; p skilled nursing facility: Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For non - emergency licensed ambulance services described 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 non - emergency ambulance services described in this section that are arranged through a physician and received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 33 1500 -100% BPL 67277 DOC 21411 Ambulance Services Your Benefits and:: the Amounts You Pay Benefits In network benefits i *.Out of network benefits afterrdeductible after deductible * For out -of network benefits, m addition to the coinsurance, you are responsible for any charges in ofathe non networkEprovider reimbursement amount Additionally, these : charges will not be applied toward satisfaction of the deductible or the out-of pocket maximum 1. Ambulance services or Nothing Covered as an in- network ambulance transportation to the benefit. nearest hospital for an emergency 2. Non - emergency licensed ambulance service that is arranged through an attending physician, as follows: a. Transportation from hospital Nothing 50% coinsurance to hospital when: 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 Nothing 50% coinsurance to skilled nursing facility • • MIC PPMN HSA (3/11) 34 1500 -100% BPL 67277 DOC 21411 • Home Health Care j. Home Health Care j i This section describes coverage for home health care. Home healthcare 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. See Definitions. 'These words have specific meanings: benefits, coinsurance, custodial care, d ductible, dependent, network, non network, non - network provider reimbursement , Kamount, physician, prenatal care, provider, '. skilled care,x;skilled. nursing facility. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare guidelines) 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 1. and 2. in the table in this section are limited to a combined maximum of 1 120 visits per calendar year for in- network and 60 visits per calendar year for out -of- network benefits. Please note: These visit limits include any visits that you pay for in order to satisfy any part of your deductible. You may be eligible for additional intermittent skilled care if you have Medica coverage and are also enrolled in the Medical Assistance Program. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 1 More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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. I MIC PPMN NSA (3/11) 35 1500 -100% BPL 67277 DOC 21411 1 Horne 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 non - skilled services. 4. Physical, speech, or occupational therapy provided in your home for convenience. 5. Services provided in your home when you are not homebound. 6. Services primarily educational in nature. 7. Vocational and job rehabilitation. 8. Recreational therapy. 9. Self -care and self -help training (non - medical). 10. Health clubs. 11. Disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. 12. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 13. Voice training. 14. Outpatient rehabilitation services when no medical diagnosis is present. 15. Home health aide services, except when rendered in conjunction with intermittent skilled care and related to the medical condition under treatment. See Exclusions for additional services, supplies, and associated expenses that are not covered. £Your Benefits and the Amou You Pay Benefits In network benefits Out-of-network bane #its e after M d u t bl le e R e B i ble ed c after duc d '" For out-of network.benefits, in to the'deductible and coin you are responsible or any charges in excess of the non-network provider reimbursement amount Additionally, these charges will not be app toward satisfaction > the out-of pocks# Ma ximum , � � 1. Intermittent skilled care when Nothing 50% coinsurance you are homebound, provided by or supervised by a registered nurse MIC PPMN HSA (3/11) 36 1500 - 100% BPL 67277 DOC 21411 Home Health Care Your Benefits and the Amoun You P ay Benefits In- network benefits * Out of- network benefits after deductible after deductible , E = s * For out-of-network benefits, m adtlition to the deductible and coinsurance, you are re f o r anycharges m exces of the ne twork . 'provider reimbursement amount Additionally, these charges will not be appl towardjsat�sfactiore the `deductible or - the out of pock maximum 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when you are homebound 3. Home infusion therapy Nothing 50% coinsurance 4. Services received in your home Nothing 50% coinsurance from a physician I . MIC PPMN HSA (3/11) 37 1500 - 100% BPL 67277 DOC 21411 Outpatient Rehabilitation K. Outpatient Rehabilitation This section describes coverage for both professional and outpatient health care facility services. A physician must direct your care. See Definrtrons These words have specific meanings' coinsurance, deductible, network non network, non network provider reimbursement amount; physician Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to outpatient rehabilitation services arranged through a 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 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 coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. 6. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 7. Voice training. 8. Outpatient rehabilitation services when no medical diagnosis is present. MIC PPMN HSA (3/11) 38 1500 -100% • BPL 67277 DOC 21411 Outpatient Rehabilitation 9. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. 'Your Benefits'and # the Amounts You Pay Benefits In-network benefits * Out -of network %benefits after deductible after deductible * For out -of network benefits, addition to the.deductible and-coinsurance, you are responsible for any charges in excess of the non-network ; provider reimbursement amount: Additionally, these charges will not be applied toward satisfactionxof deductible or the out-of-pocket maximum 1. Physical therapy received Nothing 50% coinsurance. outside of your home Coverage for physical and occupational therapy is limited to a combined limit of 20 visits per calendar year. Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible. 2. Speech therapy received outside Nothing 50% coinsurance. of your home when speech is Coverage for speech 'impaired due to a medical illness therapy is limited to 20 or injury, or congenital or visits per calendar year. developmental conditions that Please note: This visit limit ! j have delayed speech includes speech therapy 1 development visits that you pay for in order to satisfy any part of your deductible. 3. Occupational therapy received Nothing 50% coinsurance. outside of your home when Coverage for physical and physical function is impaired due occupational therapy is to a medical illness or injury or limited to a combined limit congenital or developmental of 20 visits per calendar conditions that have delayed year. motor development p Please note: This visit limit includes physical and occupational therapy visits that you pay for in order to satisfy any part of your deductible. MIC PPMN HSA (3/11) 39 1500 - 100% BPL 67277 DOC 21411 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. See Defiinrtions These wordshave specific meanings benefits, cla m,'coinsurance custodial :care, deductible, ; emer g enc y , hospital, inpatient, medically, neces member, mental disorder, network, non network, provider: Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations and psychological testing. b. Psychotherapy and psychiatric services. c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, delivered in an outpatient setting (up to 19 hours per week). d. Treatment for a minor, including family therapy. e. Treatment of serious or persistent disorders. f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD) or pervasive development disorders (PDD). g. 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. h. Treatment of pathological gambling. 2. Inpatient services include: a. Room and board. b. Attending psychiatric services. c. Hospital or facility -based professional services. d. 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 means a treatment program of 20 hours or more per week and may include lodging. e. Services, care, or treatment described as benefits in this certificate and 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. MIC PPMN HSA (3/11) 40 1500 -100% BPL 67277 DOC 21411 Mental Health f. Residential treatment services. These services include either: i. A residential treatment program serving children and adolescents with severe emotional disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic services. In addition to room and board, at least 30 hours a week per individual of mental health services must be provided, including group and individual counseling, • client education, and other services specific to mental health treatment. Also, the program must provide an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. 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. 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). For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Mental health services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the mental health services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Mental health clinic e. Mental health residential treatment center f. Independent clinical social worker g. Marriage and family therapist h. Hospital that provides mental health services 2. Emergency mental health services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN NSA (3/11) 41 1500 -100% BPL 67277 DOC 21411 Mental Health 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 for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. 4. Relationship counseling. 5. Family counseling services, except as specifically described in this certificate as treatment for a minor. 6. Services for telephone psychotherapy. 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, as those conditions are defined in the current edition of the'American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. 8. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide mental health services. This includes, but is not limited to, services provided by mental health providers who are not authorized under state law to practice independently, and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch. 9. 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. 10. Room and board charges associated with mental health residential treatment services providing less than 30 hours a week per individual of mental health services, or lacking an on -site medical /psychiatric assessment within 48 hours of admission, psychiatric follow -up visits at least once per week, and 24 -hour nursing coverage. See Exclusions for additional services, supplies, and associated expenses that are not covered. 3r ur Benefits and the Amounts Y Yo u Pa y% , t "� - is � �t^ Benefits �,� � In network 'benefits a Out-of-network benefit after deductible v afterdeductibfe , " � *F or out of network benefits;in additionfto the deductible andcoinsurance, are responsible far any' chargesFin excess of thefnon network4provider reim m burseentTamount .Addition f these charges °wilt not be applied toward satisfaction of the d eductible or the out of ,pocket maximum z 1. Office visits, including 3 Nothing 50% coinsurance evaluations, diagnostic, and treatment services MIC PPMN HSA (3/11) 42 1500 -100% BPL 67277 DOC 21411 • Mental Health } Your Benefits and the Amounts You Pay Benefits in netwo benefits * Out -of network benefits edu after deductible after d ctible For out of= network benefits,in'atlditlon to t1�e dedpctible and'comsurance, you are responsrble' for an ch arges in excess of the non - network prow der reimbursement amount Additionally, thesecharges will not be applied toward satisfaction of'the deductible or the out of- pocket maximum 2. Intensive outpatient programs Nothing 50% coinsurance 3. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance • professional services c. Attending psychiatrist Nothing 50% coinsurance services d. Partial program Nothing 50% coinsurance MIC PPMN HSA (3/11) 43 1500 -100% BPL 67277 DOC 21411 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 the Diagnostic and Statistical Manual of Mental Disorders. See Definitions. These words have specific meanings; benefits, claim, coinsurence,'custodial - care de� " ductibls,- eriaergency, hospital, inpatient, medically necessary; member, rnenta! disorder network; non - network,. physician, provider. ;; ; Prior authorization. For prior authorization requirements of in- network and out -of- network benefits, call Medica's designated mental health and substance abuse provider at 1- 800 - 848 -8327 or for Hearing Impaired members, please contact: National Relay Center 1- 800 - 855 -2880, then ask them to dial Medica Behavioral Health at 1- 866 - 567 -0550. For purposes of this section: 1. Outpatient services include: a. Diagnostic evaluations. b. Outpatient treatment. c. Intensive outpatient programs, including day treatment and partial programs, which may include multiple services and modalities, delivered in an outpatient setting. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. 2. Inpatient services include: a. Room and board. b. Attending physician services. c. Hospital or facility -based professional services. d. Services, care, or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. e. Residential treatment services. These are services from a licensed chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours per week per individual of chemical dependency services must be provided, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. MIC PPMN HSA (3/11) 44 1500 -100% BPL 67277 DOC 21411 y Substance Abuse Covered For benefits and the amounts you pay, see the table in this section. • For in- network benefits: 1. Medica's designated mental health and substance abuse provider arranges in- network substance abuse benefits. 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). 2. In- network benefits will apply to services, care or treatment for a member that has been placed in any applicable 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 any applicable Department of Corrections. For claims questions regarding in- network benefits, call Medica's designated mental health and substance abuse provider Customer Service at 1- 866 - 214 -6829. • For out -of- network benefits: 1. Substance abuse services from a non - network provider listed below will be eligible for coverage under out -of- network benefits provided that the health care professional or facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently: a. Psychiatrist b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing d. Chemical dependency clinic e. Chemical dependency residential treatment center f. Hospital that provides substance abuse services g. Independent clinical social worker • h. Marriage and family therapist 2. Emergency substance abuse services are eligible for coverage under in- network benefits. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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. MIC PPMN HSA (3/11) 45 1500 -100% BPL 67277 DOC 21411 Substance Abuse 2. Services for a condition when there is no reasonable expectation that the condition will improve. 3. Services, care, or treatment that is not medically necessary. 4. Services to hold or confine a person under chemical influence when no medical services are required, regardless of where the services are received. 5. Telephonic substance abuse treatment services. 6. Services, including room and board charges, provided by health care professionals or facilities that are not appropriately licensed, certified, or otherwise qualified under state law to provide substance abuse services. This includes, but is not limited to, services provided by mental health or substance abuse providers who are not authorized under state law to practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch. 7. Room and board charges associated with substance abuse treatment services providing less than 30 hours a week per individual of chemical dependency services, including group and individual counseling, client education, and other services specific to chemical dependency rehabilitation. 8. 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and " the Amounts You Pay Benefits In network benefits * Out of network benefits ft tl a er deductible afters eductible For out of network benefit in addition to the d ." '' eductibte and coinsurance, you dare responsible for any charges inexcess of the non network providerreimbursement amount Additionally, these charges will not" be applied toward satisfaction of the deductible or the out of pocket maximum T 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance b. Hospital or facility -based Nothing 50% coinsurance professional services c. Attending physician services Nothing 50% coinsurance MIC PPMN HSA (3/11) 46 1500 -100% BPL 67277 DOC 21411 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. Se Definitions ; These words have s 13e meanings: benefits, coinsurance, deductible, ura dble medical equipment, network, non-network, non - network provider reimbursement amount, physician, provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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, and hearing aids that meet the criteria established by Medica. Some items ordered by your physician, even if medically necessary, may not be covered. The list of eligible durable medical equipment and certain related supplies is periodically reviewed and modified by Medica. 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 purchased 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. If the durable medical equipment, prosthetic device, or hearing aid is covered by Medica, but the model you select is not Medica's standard model, you will be responsible for the cost difference. • In- network benefits apply to durable medical equipment, certain related supplies and prosthetic services prescribed by a physician and received from a network durable medical equipment provider, and hearing aids as described in 4. in the table in this section when prescribed by a network provider. To request a list of the durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. • Out -of- network benefits apply to durable medical equipment, certain related supplies, and prosthetic services prescribed by a physician and received from a non - network provider. Out -of- network benefits also apply to hearing aids as described in 4. in the table in this section. In addition to the deductible or coinsurance described for out -of- network benefits, you are responsible for charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. MIC PPMN HSA (3/11) 47 1500 -100% BPL 67277 DOC 21411 Durable Medical Equipment And Prosthetics Not covered These services, supplies, and associated expenses are not covered: 1. Durable medical equipment and supplies, prosthetics, appliances, and hearing aids not on the Medica eligible list. 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, or hearing aids. 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, replacement, or revision of duplicate items. See Exclusions for additional services, supplies, and associated expenses that are not covered. ,1!;,:, Yo ur fi tsa .. r he A un Yo and t rno is u Pa Benefits T6- network benefits Out-of-network benefi s after deductible u ' -after deductible forou � r � � 5 _ -t s. .. t-of network benefits, m addition to thededu a coinsurance, you are responsi for a "ny charges in exs the non- network provider reimbursement amount Additionally, these char es will ° not be a lied s _ ces of z � w #f . the deductible he =ou# of p a c ket °maximum .� -m. t ,�: �q� . ..., �, �. action o .m . _� � -. . or t . w.�_�= . ........ ..h.,. 1. Durable gy medical equipment and Nothing 50% coinsurance certain related supplies 2. Repair, replacement, or revision Nothing 50% coinsurance of durable medical equipment • made necessary by normal wear and use 3. Prosthetics a. Initial purchase of external Nothing 50% coinsurance prosthetic devices that replace a limb or an external body part, limited to: i. Artificial arms, legs, feet, and hands; ii. Artificial eyes, ears, and noses; iii. Breast prostheses b. Scalp hair prostheses due to Nothing. Medica pays up 50% coinsurance. alopecia areata to $350. This is Medica pays up to $350. calculated each calendar This is calculated each year. calendar year. MIC PPMN HSA (3/11) 48 1500 -100% BPL 67277 DOC 21411 Durable Medical Equipment And Prosthetics Your Benefits and the Amounts You Pay Benefits In-network benefits * Out of- network benefits after er deductible after deductible * For out of- network benefits, -in addition to the deductible and coinsurance you are responsible for any charges in of the non - network provider reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out-of-pocket-maximum. c. Repair, replacement, or Nothing 50% coinsurance revision of artificial arms, legs, feet, hands, eyes, ears, noses, and breast prostheses made necessary by normal wear and use 4. Hearing aids for members 18 Nothing. Coverage is 50% coinsurance. years of age and younger for limited to one hearing aid Coverage is limited to hearing loss that is not per ear every three years. one hearing aid per ear correctable by other covered Related services must be every three years. procedures prescribed by a network provider. MIC PPMN HSA (3/11) 49 1500 -100% BPL 67277 DOC 21411 Miscellaneous Medical Services And Supplies 0. Miscellaneous Medical Services And Supplies This section describes coverage for miscellaneous medical services and supplies prescribed by a physician. Medica covers only a limited selection of miscellaneous medical services and supplies that meet the criteria established by Medica. Some items ordered by a physician, even if medically necessary, may not be covered. 'See Definitions These words meanings. ,benefits, coinsurance, deductible, network, non network, non-network provider :'.reimbursement amount physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. • In- network benefits apply to miscellaneous medical services and supplies received from a network provider. • Out -of- network benefits apply to miscellaneous medical services and supplies received from a non - network provider. In addition to the deductible and coinsurance described for out -of- network benefits, you are responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered Other disposable supplies and appliances, except as described in Prescription Drug Program, Durable Medical Equipment And Prosthetics, and Miscellaneous Medical Services And Supplies. See Exclusions for additional services, supplies, and associated expenses that are not covered. • I ' MIC PPMN HSA (3/11) 50 1500 -100% BPL 67277 DOC 21411 Miscellaneous Medical Services And Supplies Your Benefits and the Amounts You Pay V.: Benefits In network benefits *:Out of network "benefits after deduc tible -after deductible *"For out of network benefits in addition to the deductible and comsurarice you;are re for °any- charges in; excess of the.non network "provider reimbursement amount.] Additionally, these" charges will be applied toward satisfaction " of the deductible or the out -of- pocket maximum 1. Blood clotting factors Nothing 50% coinsurance 2. Dietary medical treatment of Nothing 50% coinsurance phenylketonuria (PKU) 3. Amino acid -based elemental Nothing 50% coinsurance formulas for the following diagnoses: a. cystic fibrosis; b. amino acid, organic acid, and fatty acid metabolic and malabsorption disorders; c. IgE mediated allergies to food proteins; d. food protein- induced enterocolitis syndrome; e. eosinophilic esophagitis; f. eosinophilic gastroenteritis; and g. eosinophilic colitis. Coverage for the diagnoses in 3.c. -g. above is limited to members five years of age and younger. 4. Total parenteral nutrition Nothing 50% coinsurance 5. Eligible ostomy supplies Nothing 50% coinsurance Please note: Eligible ostomy supplies may be received from a pharmacy or a durable medical equipment provider. 6. Insulin pumps and other eligible Nothing 50% coinsurance diabetic equipment and supplies MIC PPMN HSA (3/11) 51 1500 -100% BPL 67277 DOC 21411 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 network physician and received at a designated 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 appropriate for the diagnosis, without contraindications, and non - investigative. See Definitions These :words have specific - meanings . ° benefits, coinsurance deductible, e- visits,:hospital inpatient, investigative, medically necessary, member, network, non network, non network provider reimbursement arriount, 1physician „provider. x -: Prior authorization. Prior authorization from Medica is required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 and not otherwise excluded from coverage (see Not covered below): cornea, kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood. The preceding is not a comprehensive list of eligible organ and bone marrow transplant services. • 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. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 network transplant facilities). Based on the type of transplant you receive, Medica will determine the specific time period medically necessary for these services. MIC PPMN HSA (3/11) 52 1500 -100% BPL 67277 DOC 21411 Organ And Bone Marrow Transplant Services Not covered These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow transplant services except as described in this section. 2. 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. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. 5. Islet cell transplants except for autologous islet cell transplants associated with pancreatectomy. 6. 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 Toss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature not otherwise covered under this Certificate. 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. 10. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and ,Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. 1,1 Your Benefits and the -Amounts YouP,ay k. Benefits A In network benefits Out-of-network benefits ft r e c a er deductible afte d tlu tab le out-of-network benefits, in addition to .the deductible and coinsurance, yourare responsible for any charges m excess of the.non network provider reimbursement amount Additionally, these: charges will not be applied toward satisfaction of the deductible or the out -of pocket maximum' 1. Office visits Nothing No coverage 2. E- visits Nothing No coverage MIC PPMN HSA (3/11) 53 1500 - 100% BPL 67277 DOC 21411 Organ And Bone Marrow Transplant Services Your Benefits and the Amounts You Pay Benefits . In network benefits * Put-of-network benefits after deductible x` after deductible * For out -of network benefits, in addition to the deductible and coinsurance, you'are responsible for any charges in excess of the non-network provider reimbursement amount. Additionally, these charges will not: be applied toward satisfaction of the'deductil le or the out - of pocket maximum 3. Outpatient services a. Professional services - i. Surgical services (as Nothing No coverage defined in the Physicians' Current Procedural Terminology code book), received from a physician during an office visit or an outpatient hospital visit ii. Anesthesia services Nothing No coverage received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing No coverage pathology iv. Outpatient x -rays and Nothing No coverage other imaging services v., Other outpatient hospital Nothing No coverage services received from a physician vi. Services related to Nothing No coverage human leukocyte antigen testing for bone marrow ' transplants b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x -rays and Nothing No coverage other imaging services iii. Other outpatient hospital Nothing No coverage services 4. Inpatient services Nothing No coverage MIC PPMN HSA (3/11) 54 1500- 100% BPL 67277 DOC 21411 Organ And Bone Marrow Transplant Services Your Beneftts#and the Amounts You Pay Benefits In network benefits * Out of- network benefits after deductible after deductible * Fors out-of network b addition to t he deductible and coinsurance, you °a "re responsible for any charges in. excess of the non network provider reimbursement amount:' Additionally, these • "charges,wilt not be applied toward " "satisfaction of the deductible or the out-of-pocket maxim um 5. Services received from a Nothing No coverage physician during an inpatient stay 6. Anesthesia services received Nothing No coverage from a provider during an inpatient stay 7. Transportation and lodging The deductible does not No coverage a. As described below, apply to this reimbursement of reasonable reimbursement benefit. and necessary expenses for You are responsible for travel and lodging for you paying all amounts not and a companion when you reimbursed under this receive approved services at benefit. Such amounts a designated facility for do not count toward your transplant services and you out -of- pocket maximum live more than 50 miles from or toward satisfaction of that designated facility your deductible. i. Transportation of you and one companion (traveling on the same day(s)) to and /or from a designated facility for transplant services for pre- . transplant, transplant, and post - transplant services. If you are a minor child, transportation expenses for two companions will be reimbursed. MIC PPMN HSA (3/11) 55 1500 -100% BPL 67277 DOC 21411 Organ And Bone Marrow Transplant Services Your Bene and..the Amounts You Pay Benefits I ne twork bene * Ou# of- networ benefits • after deductible :after deductible * F,or out of net�n ork" benefits, in addition`to the deductible and coinsuran y ou are resp far any ch a r ges i n excess of the no network' prow der remnt " :amount ":Additionall hse charges.wili not `be applied toward °satisfac #ionaf the "d out -of- pocket = maxi t mu e m ii. Lodging for you (while not confined) and one companion. Reimbursement is available for a per diem amount of up to $50 for one person or up to $100 for two people. If you are a minor child, reimbursement for lodging expenses for two companions is available, up to a per diem amount of $100. iii. There is a lifetime maximum of $10,000 per member for all transportation and lodging expenses incurred by you and your companion(s) and reimbursed under the Contract or under any other Medica, Medica Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer. b. Meals are not reimbursable under this benefit. MIC PPMN HSA (3/11) 56 1500- 100% BPL 67277 DOC 21411 Infertility Diagnosis Q. Infertility Diagnosis This section describes coverage for the diagnosis of infertility. Coverage includes benefits for professional, hospital and ambulatory surgical center services. Services for the diagnosis of infertility must be received from or under the direction of a physician. All services, supplies, and associated expenses for the treatment of infertility are not covered. See. Definitions These words have specific meanings benefits, coinsurance, deductible, e- visits, hospital, inpatient, member, network, non network, non network_provider. reimbursement amount, physician, provider. Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered Benefits apply to services for the diagnosis of infertility received from a network or non - network provider. Coverage for infertility services is limited to a maximum of $5,000 per member per calendar year for in- network and out -of- network benefits combined. More than one coinsurance may be required if you receive more than one service, or see more than one provider per visit. Not covered All services, supplies, and associated expenses for the treatment of infertility are not covered including the following: 1. Professional, hospital, and ambulatory surgical center services for the treatment of infertility. 2. Infertility drugs. 3. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 4. Services for a condition that a physician determines cannot be successfully treated. 5. Services related to surrogate pregnancy for a person not covered as a member under the Contract. 6. Sperm banking. 7. Adoption. 8. Donor sperm. 9. Embryo and egg storage. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 57 1500 -100% BPL 67277 DOC 21411 Infertility Diagnosis Your Benefits and the Amounts You Pay Benefits in- ne twork, benefits , * Out-of-network benefits - after deductible after deductible * `For out-of ne benefits, in addition to the deductible and coinsurance, you are responsible for any charges excess of the non- network provider re_ imburement; amount Additionally, these charges wi not be applied' toward- satisf of themdeductible or the.out of- pocket maxjmum 1. Office visits, including any Nothing 50% coinsurance services provided during such visits 2. E - visits Nothing No coverage 3. Outpatient services received at a Nothing 50% coinsurance hospital 4. Inpatient services Nothing 50% coinsurance MIC PPMN HSA (3/11) 58 1500 -100% BPL 67277 DOC 21411 ,a, 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. Sep Definitions: These words have specific meanings 'benefits, coinsurance,: cosmetic, deductible,: a visits, hospital, in patie n t , medicall necessary, member, network, non-network, non - network provider reimbursement amount, physician, provider, reconstructive, -restorative;%, Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered • These services, supplies, and associated expenses are not covered: 1. 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. 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. 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. 6. Hair transplants. MIC PPMN HSA (3/11) 59 1500 -100% BPL 67277 DOC 21411 Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Specialty Prescription Drug Program or otherwise described as a specific benefit in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay . . 3 to network benefits e Benefits r , ;� Out-of-network b ' : after;deductible For out -of network benefits, in "addition the deductible and coinsurance,` you are responsible for any:chargesTin exce of the non - network =provider reimbursement amount. Additiona these charges will not toward satisfaction;of the deductible or, the out of- pocket maximum 1. Office visits Nothing 50% coinsurance 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance or ambulatory surgical center services received from a physician MIC PPMN HSA (3/11) 60 1500 -100% BPL 67277 DOC 21411 Reconstructive And Restorative Surgery Your B enefits and the Amounts You Pay Benefits :, In- network - benefits * Out-of-network benefits a ft er deductible after deductible For out-of-network benefits, in addition to°the deductible and coinsurance, you are responsible for any charges in excess of the non- network provider reimbursement amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the Out-of-pocket maximum: b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Inpatient services Nothing 50% coinsurance 5. Services received from a Nothing 50% coinsurance physician during an inpatient stay 6. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay MIC PPMN HSA (3/11) 61 1500 -100% BPL 67277 DOC 21411 it 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 qualify as reimbursable under Medicare. See Definitions. These words have specific meanings benefits, coinsurance, custodial care, deductible, emergency, hospital, inpatient, network, non network, non - network provider reimbursement amount, physician, skilled care, skilled nursing facility. + ` Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. Covered For benefits and the amounts you pay, see the table in this section. For purposes of this section, room and board includes coverage of health services and supplies. • 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. Custodial care and other non - skilled services. 2. Self -care or self -help training (non - medical). 3. Services primarily educational in nature. 4. Vocational and job rehabilitation. 5. Recreational therapy. 6. Health clubs. 7. Correction of speech impediments and assistance in the development of verbal clarity when there is no reasonable expectation that the condition will improve over a predictable period of time according to generally accepted standards in the medical community. 8. Voice training. MIC PPMN HSA (3/11) 62 1500 -100% BPL 67277 DOC 21411 Skilled Nursing Facility Services 9. Outpatient rehabilitation services when no medical diagnosis is present. 10. Group physical, speech, and occupational therapy. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits- and the Amounts You Pay Benefits _ �In network benefits " * Out of net b enefits after deductible after .deductible * For out-of-network benefits, in addition to the deductible and coinsurance,, you are responsibl fo any charges in excess of t he non-network provider reimbursement amount. : these c harges will not be applied toward satisfaction of the deductible or the out-,Of-Pocket maximum. 1. Daily skilled care or daily skilled Nothing 50% coinsurance rehabilitation services, including room and board Please note: Such services are eligible for coverage only if they would qualify as reimbursable under Medicare. 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when room and board is not eligible to be covered 3. Services received from a Nothing 50% coinsurance physician during an inpatient stay in a skilled nursing facility MIC PPMN HSA (3/11) 63 1500 - 100% BPL 67277 DOC 21411 _ I 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 hospice program. See Definitions These words have specific meanings benefits, coinsurance, deductible, member, network non - network, noh network'providern amount, physician, skilled nursing facility. 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. 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 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 network hospice program. • Out -of- network benefits apply to hospice services arranged through a physician and received from a non - network hospice program. In addition to the deductible and coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. 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). 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. Members who elect to receive hospice services do so in place of curative treatment for their terminal illness for the period,they are enrolled in the hospice program. You may withdraw from the hospice program at any time upon written notice to the hospice program. You must follow the hospice program's requirements to withdraw from the hospice program. MIC PPMN HSA (3/11) 64 1500 -100% BPL 67277 DOC 21411 Hospice Services Not covered These services, supplies, and associated expenses are not covered: 1. Respite care for more than five consecutive days at a time. 2. 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 hospice program's plan of care. 4. Services not provided by the hospice program. 5. Hospice daycare, except when recommended and provided by the hospice program. 6. Any services provided by a family member or friend, or individuals who are residents in your home. 7. Financial or legal counseling services, except when recommended and provided by the hospice program. 8. Housekeeping or meal services in your home, except when recommended and provided by the hospice program. 9. Bereavement counseling, except when recommended and provided by the hospice program. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pa nefits f �� . In- n et w ork be * y O ' ut , of netw benefit Be duct�bl a cti =h am *: For out of- network benefits in addition to; the deductible and= coinsurance,', you are responsi for any charges in excess of the �non network provider reimbursement amount ;Additionally, these' charges will not be applied toward satisfaction of the deductible or the out of pocket maximum. 1. Hospice services Nothing 50% coinsurance MIC PPMN HSA (3/11) 65 1500 -100% BPL 67277 DOC 21411 Temporomandibuiar 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. TMJ disorder is covered the same as any other joint disorder under this certificate. See Definitions. Thesemords have specific;meanings . benefits, °coinsurance; deductible, e-visits, hospital, inpatient, member, network, non network, non - network provider reimbursement amount; pfysician,'provider Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover: See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered These services, supplies, and associated expenses are not covered: 1. Diagnostic casts and diagnostic study models. 2. Bite adjustment. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PPMN HSA (3/11) 66 1500 -100% BPL 67277 DOC 21411 Temporomandibular Joint (TMJ) Disorder Your Ben efits -and the Amounts You Pay Benefits - In network benefits *Out. o # network benefits after deductible after deductible Fo "r out o €network be " refits, yin atldition to the detluct�ple and =coinsurance; you are respansitile for any charges in excess of the non network provider reimbursement amount. "Addit�onally, these charges will not• applied toward satisfaction of.the deductible or ;.the out -of pocket maximum 1. Office visits Nothing 50% coinsurance 2. E- visits Nothing No coverage 3. Outpatient services a. Professional services i. Surgical services (as Nothing 50% coinsurance 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. Anesthesia services Nothing 50% coinsurance received from a provider during an office visit or an outpatient hospital or ambulatory surgical center visit iii. Outpatient lab and Nothing 50% coinsurance pathology iv. Outpatient x -rays and Nothing 50% coinsurance other imaging services v. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services received from a physician or dentist b. Hospital and ambulatory surgical center services i. Outpatient lab and Nothing 50% coinsurance pathology ii. Outpatient x -rays and Nothing 50% coinsurance other imaging services MIC PPMN HSA (3/11) 67 1500 -100% BPL 67277 DOC 21411 Temporomandibular Joint (TMJ) Disorder Y Benefits and the Amounts You Pay Benefits m to network bene * fter "deductible a Out -of- work benefits ts For.out * of network benefits; m :addttion'to the deductible and`comsuranc, e ou are respon for any charges in excess of the non-network provrder reimbursement amount. p Ad ditionally, -these charges'wall =not be applied toward satisfactionof the deductible or the out-of maximum iii. Other outpatient hospital Nothing 50% coinsurance and ambulatory surgical center services 4. Physical therapy received Nothing 50% coinsurance outside of your home 5. Inpatient services Nothing 50% coinsurance 6. Services received from a Nothing 50% coinsurance physician or dentist during an inpatient stay 7. Anesthesia services received Nothing 50% coinsurance from a provider during an inpatient stay 8. TMJ splints and adjustments if Nothing 50% coinsurance your primary diagnosis is joint disorder MIC PPMN HSA (3/11) 68 1500 -100% BPL 67277 DOC 21411 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. 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 alignment or occlusion of the teeth. These services are not covered under any section of this certificate. See Definitions` The words have specific rrieanings: benefits, coinsurance, deductible' , dependent, hospital; member, network, non network, non network provider reimbursement amount,, physician, =:provider: Prior authorization. Prior authorization from Medica may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 coinsurance described for out -of- network benefits, you will be responsible for any charges in excess of the non - network provider reimbursement amount. The out -of- pocket maximum does not apply to these charges. Please see Important member information about out -of- network benefits in How To Access Your Benefits for more information and an example calculation of out -of- pocket costs associated with out -of- network benefits. Not covered These services, supplies, and associated expenses are not covered: 1. 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), except as described in this section for the treatment of cleft lip and palate. 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, except as described in this section for the treatment of cleft lip and palate. 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. MIC PPMN HSA (3/11) 69 1500 -100% BPL 67277 DOC 21411 Medical- Related Dental Services 8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident - related dental services as described in this section. 9. Routine diagnostic and preventive dental services. See Exclusions for additional services, supplies, and associated expenses that are not covered. Your Benefits and the Amounts You Pay Benefits Iri network benefits = * Out of- network benefits after deductible after deductible * For out ofi network benefits,;in addition to the deductible, and coin you are responsible for . any charges in_e of the non networkprovider reimbursement amou ;Addiitionally, these charges will not be applied toward satisfaction of�the deductibleror the out- ofpocket maximum 1. Charges for medical facilities Nothing 50% coinsurance and general anesthesia services that are: a. Recommended by a physician; and b. Received during a dental procedure; and c. Provided to a member who: i. 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. 2. For a dependent child, Nothing 50% coinsurance orthodontia, dental implants, and oral surgery treatment related to cleft lip and palate MIC PPMN HSA (3/11) 70 1500 -100% BPL 67277 DOC 21411 Medical- Related Dental Services . -__ ..___.._......... . Your B and the AmountsYou ' Pay You A B -'. In network benefits' * Out of- network b enefits :. after deductible after dedu * For. out -of network benefits, in addition to ; the deductible and comsura you`are responsible for .; any ,charges in excess: of the non-network provtder reimbursement amount Adtlitionallythese charges will not be applied toward satisfaction of the dedu the "out -of pocket maximum. 3. Accident - related dental services Nothing 50% coinsurance to treat an injury to sound, natural teeth and to repair (not replace) sound, natural teeth. The following conditions apply: a. Coverage is limited to services received with 24 months from the later of: i. the date you are first covered under the Contract; or ii. the date of the injury 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 one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year. 4. Oral surgery for: Nothing 50% coinsurance a. Partially or completely unerupted impacted teeth; or b. A tooth root without the extraction of the entire tooth (this does not include root canal therapy); o c. The gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth MIC PPMN HSA (3/11) 71 1500 -100% BPL 67277 DOC 21411 Referrals To Non- Network Providers W.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 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.. See Definrtrons. These words have specific meanings : benefits,,medically necessary network, non - network, ;physician, provider: If you want to apply for a standing referral to a non - network provider, contact Medica for more information. If determined by Medica to be clinically appropriate, a standing referral may be granted by Medica. A standing referral is a referral issued by a network provider and authorized by Medica for conditions that require ongoing services from a specialist provider. Standing referrals will only be covered for the period of time appropriate to your medical condition. Referrals and standing referrals will not be covered to accommodate personal preferences, family convenience, or other non - medical reasons. Referrals will also not be covered for care that has already been provided. If your request for a standing referral is denied, you have the right to appeal this decision as described in Complaints. What you must do 1. 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; p Y (s ) and P , c. Direct ou to the non network provider selected by your network provider. Y P YY P 2. 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. 3. 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. 4. Pay any charges not authorized for coverage by Medica. What Medica will do 1. May require that you see another network provider selected by Medica before a determination by Medica that a referral to a non - network provider is medically necessary. 2. 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. MIC PPMN HSA (3/11) 72 1500 -100% BPL 67277 DOC 21411 Referrals To Non - Network Providers 3. Provides coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. 4. 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 24 hours from the time of the initial request if your attending provider believes that an expedited review warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function. 1 MIC PPMN HSA (3/11) 73 1500 -100% BPL 67277 DOC 21411 Harmful Use Of Medical Services X. 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. See Definitions. These words have specific meanings = benefits, emergency, .hospital, network,: physician, prescription drug, provider. 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. You must obtain a referral from your coordinating health care provider if your condition requires care or treatment from a provider other than your coordinating health care provider. Medica will send you specific information about: 1. How to obtain approval for benefits not available from your coordinating health care providers; and 2. How to obtain emergency care; and 3. When these restrictions end. MIC PPMN HSA (3/11) 74 1500 -100% BPL 67277 DOC 21411 ;4 Exclusions Y. Exclusions See Definitions. These words have specific meanings claim, cosmetic, custodial care, durable medical equipment, emerg ency, investigative, medically necessary, member, non- network, physician, provider, reconstructive, routine foot care. Medica will not provide coverage for any of the services, treatments, supplies, or items described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition. This section describes additional exclusions to the services, supplies, and associated expenses already listed as Not covered in this certificate. These include: 1. 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. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive. 3. Refractive eye surgery, including but not limited to LASIK 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 a physician, air and bone conduction hearing aids (including internal, external, or implantable hearing aids or devices), 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. Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct -to- consumer marketing and not under the direction of your physician. 8. Services or supplies not directly related to care. 9. Autopsies. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition. 11. Nutritional and electrolyte substances, except as specifically described in Miscellaneous Medical Services And Supplies. 12. Physical, occupational, or speech therapy or chiropractic services when there is no reasonable expectation that the condition will improve over a predictable period of time. 13. Reversal of voluntary sterilization. MIC PPMN HSA (3/11) 75 1500 -100% BPL 67277 DOC 21411 Exclusions 14. Personal comfort or convenience items or services, including but not limited to breast pumps, except when the pump is medically necessary. 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, except as described in Organ And Bone Marrow Transplant Services. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 19. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular disease, peripheral neuropathies, and significant neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. 21. Services by persons who are family members or who share your legal residence. 22. Services for which coverage is available under workers' compensation, employer liability, or any similar law. 23. Services received before coverage under the Contract becomes effective. 24. Services received after coverage under the Contract ends. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non - network providers and non - network dentists. 26. Photographs, except for the condition of multiple dysplastic syndrome. 27. Occlusal adjustment or occlusal equilibration. 28. Dental implants (tooth replacement), except as described in Medical - Related Dental Services. 29. Dental prostheses. 30. Orthodontic treatment, except as described in Medical - Related Dental Services. 31. Treatment for bruxism. 32. Services prohibited by applicable law or regulation. 33. Services to treat injuries that occur while on military duty, and any services received as a result of war or any act of war (whether declared or undeclared). 34. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or licensure. 35. Exams, other evaluations, or other services received solely for the purpose of judicial or administrative proceedings or research, except emergency examination of a child ordered by judicial authorities. 36. Non - medical self -care or self -help training. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services. 38. Coverage for costs associated with translation of medical records and claims to English. MIC PPMN HSA (3/11) 76 1500 -100% BPL 67277 DOC 21411 T ' Exclusions 39. Treatment for spider veins. 40. Services not received from or under the direction of a physician, except as described in this certificate. 41. Orthognathic surgery. 42. Sensory integration, including auditory integration training. 43. Services for or related to vision therapy and orthoptic and /or pleoptic training, except as described in Professional Services. 44. Services for or related to intensive behavior therapy treatment programs for the treatment of autism spectrum disorders. Examples of such services include, but are not limited to, Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral Intervention (IBI), and Lovaas therapy. 45. Health care professional services for maternity labor and delivery in the home. 46. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and subsequent procedures. 47. Services for the treatment of infertility. 48. Infertility drugs. 49. Acupuncture. 50. Services solely for or related to the treatment of snoring. 51. Interpreter services. 52. Services provided to treat injuries or illness that are the result of committing a crime or attempting to commit a crime. 53. Services for private duty nursing, except as stated in Home Health Care. Examples of private duty nursing services include, but are not limited to, skilled or unskilled services provided by an independent nurse who is ordered by the member or the member's representative, and not under the direction of a physician. 54. Laboratory testing that has been 'performed in response to direct -to- consumer marketing and not under the direction of a physician. 55. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), other than those granted a humanitarian device exemption. • MIC PPMN HSA (3/11) 77 1500 -100% BPL 67277 DOC 21411 How To Submit A Claim Z. How To Submit A Claim This section describes the process for submitting a claim. See Definitions These words have specific meanings: benefits, claim,; dependent, member network, non-network non-network provider reimbursement amount; provider. 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. Claim forms may also be obtained by signing in at www.mymedica.com. Network providers are required to submit claims within 180 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 180 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 one of the telephone numbers listed inside the front cover. Claim forms may also be obtained by signing in at www.mymedica.com. 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 the address identified on the back of your identification card. Upon receipt of your claim for benefits from non - network providers, Medica will generally pay to you directly the non - network provider reimbursement amount. Medica will only pay the provider of services if: 1. The non - network provider is one that Medica has determined can be paid directly; and 2. The non - network provider 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 claims 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 receiving the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. Call Customer Service at one of the telephone numbers listed inside the front cover for a list of non- network providers that Medica will not pay directly. MIC PPMN HSA (3/11) 78 1500 - 100% BPL 67277 DOC 21411 How To Submit A Claim 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 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. MIC PPMN HSA (3/11) 79 1500 -100% BPL 67277 DOC 21411 Coordination Of Benefits AA. Coordination Of Benefits This section describes how benefits are coordinated when you are covered under more than one plan. See Definitions. These words have specific meanings: :benefits, claim, deductible,cependent emergency, hospital member, non - network, non network provider reimbursement amount, provider, :subscriber, - 1. Applicability a. 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. b. If this coordination of benefits provision applies, 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 Order of benefit determination rules, the benefits of this plan: i. 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 a. Plan is any of these which provides benefits or services for, or because of, medical or dental care or treatment: i. Group insurance or group -type coverage, whether insured or uninsured, or individual coverage. 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 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. b. This plan is the part of the Contract that provides benefits for health care expenses. c. 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 lan is a secondary plan, its benefits are determined after those of the other p rY p plan and may be reduced because of the other plan's benefits. MIC PPMN HSA (3/11) 80 1500 -100% BPL 67277 DOC 21411 I � Coordination Of 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. d. 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. Allowable expense does not include the deductible for members with a primary high deductible plan and who notify Medica of an intention to contribute to a health savings account. The difference between the cost of a private hospital room and the cost of a semi- private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private 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 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 member does not comply i 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. e. 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 a. 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 3:b. below, require that this plan's benefits be determined before those of the other plan. b. Rules. This plan determines its order of benefits using the first of the following rules which applies: i. 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. ii. 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 MIC PPMN HSA (3/11) 81 1500 -100% BPL 67277 DOC 21411 Coordination Of Benefits 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. iii. 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 determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. iv. 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 3.b.ii. v. 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. vi. 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. vii. No -fault automobile insurance. Coverage under the No -Fault Automobile Insurance Act or similar law applies first. viii. 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 a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that MIC PPMN HSA (3/11) 82 1500 -100% BPL 67277 DOC 21411 Coordination Of Benefits event, the benefits of this plan may be reduced under this section. Such other plan or plans are referred to as the other plans in b. immediately below. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum of: i. 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 of this COB provision, whether or not claim is made, exceeds those allowable expenses in a claim determination period. In that case, the benefits of this plan will be reduced so that they and the benefits payable under the other plans do not total more than those allowable expenses. When the benefits of this plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this plan. 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, 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; or 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. Please note: See Right Of Recovery for additional information. MIC PPMN HSA (3/11) 83 1500 -100% BPL 67277 DOC 21411 Right Of Recovery BB. Right Of Recovery This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and federal law. For information about the effect of applicable state and federal law on Medica's subrogation rights, contact an attorney. `See r Definit:ons This word xhas a= specific meaning: benefits 1. 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. 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 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. 4. By accepting coverage under the Contract, you agree: a. That if Medica pays benefits for medical expenses you incur as a result of any act by a third party for which the third party is or may be liable, and you later obtain full recovery, you are obligated to reimburse us for the benefits paid in accordance to Minnesota law. b. 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. c. To provide prompt written notice to Medica when you make a claim against a party 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. f. 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. MIC PPMN HSA (3/11) 84 1500 -100% BPL 67277 DOC 21411 Eligibility And Enrollment CC. Eligibility And Enrollment This section describes who can enroll and how to enroll. See Definitions. These words have specific meanings: continuous coverage, dependent, late entrant, member, mental disorder, physician, placed for adoption,_ premium, qualifying coverage, subscriber, waiting period Who can enroll To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract and be a subscriber or dependent as defined in this certificate. See Definitions. 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 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 other time for consideration as a late entrant as described in this section under Late enrollment. Dependents will not be enrolled without the eligible employee also being enrolled. A child who is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical Child Support Order (QMCSO) and 6. under Special 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, a dependent child reaching the dependent limiting age, or other facts identifying you or your dependents. (For dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption; however, we encourage you to enroll your newborn dependent under the Contract within 30 days from the date of birth, date of placement for adoption, or date of adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with the subscriber, and any child who is a member pursuant to a QMCSO will be covered without application of health screening or waiting periods. The employer must notify Medica, as set forth in the Contract, 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 A 30 -day time period starting with the date an eligible employee and dependents are first eligible to enroll for coverage under the Contract. An eligible employee must enroll within this MIC PPMN HSA (3/11) 85 1500 - 100% BPL 67277 DOC 21411 Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30 -day time period does not apply to newborns or children newly adopted or placed for adoption; see Special enrollment.) An eligible employee and dependents that enroll during the initial enrollment period are accepted without application of health screening or affiliation periods. An eligible employee and dependents who do not enroll during the initial enrollment period may enroll for coverage during the next open enrollment, any applicable special enrollment periods or as a late entrant (if applicable, as described below). A member who is a child entitled to receive coverage through a QMCSO is not subject to any initial enrollment period restrictions, except as noted in this section. Open enrollment A minimum 14 -day period set by the employer and Medica each year during which eligible employees and dependents who are not covered under the Contract may elect coverage for the upcoming Contract year. An application must be submitted to the employer for yourself and any dependents. Special enrollment Special enrollment periods are provided to eligible employees and dependents under certain circumstances. 1. Loss of other coverage a. A special enrollment period will apply to an eligible employee and dependent if the individual was covered under Medicaid or a State Children's Health Insurance Plan and lost that coverage as a result of loss of eligibility. The eligible employee or dependent must present evidence of the Toss of coverage and request enrollment within 60 days after the date such coverage terminates. In the case of the eligible employee's Toss of coverage, this special enrollment period applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of coverage, this special enrollment period applies to both the dependent who has lost coverage and the eligible employee. b. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under qualifying coverage other than Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment, and declined coverage for that reason. The eligible employee or dependent must present either evidence of the loss of prior coverage due to Toss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated; and request 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, or the date on which a claim is denied due to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.:. i. Prior coverage does not include federal or state continuation coverage; MIC PPMN HSA (3/11) 86 1500 -100% BPL 67277 DOC 21411 Eligibility And Enrollment ii. Loss of eligibility includes: • loss of eligibility as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment; • cessation of dependent status; • incurring a claim that causes the eligible employee or dependent to meet or exceed the lifetime maximum limit on all benefits; • if the prior coverage was offered through an individual health maintenance organization (HMO), a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area; • if the prior coverage was offered through a group HMO, a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other coverage option is available; and • the prior coverage no longer offers any benefits to the class of similarly situated individuals that includes the eligible employee or dependent. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is eligible for or elects applicable federal or state continuation coverage; iv. 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; In the case of the eligible employee's loss of other coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's loss of other coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. c. A special enrollment period will apply to an eligible employee and dependent if the eligible employee or dependent was covered under benefits available under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or any applicable state continuation laws at the time the eligible employee or dependent was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. The eligible employee or dependent must present evidence that the eligible employee or dependent has exhausted such COBRA or state continuation coverage and has not lost such coverage due to failure of the eligible employee or dependent to pay premiums on a timely basis or for cause; and request enrollment in writing within 30 days of the date of the exhaustion of coverage. For purposes of 1.c.: i. Exhaustion of COBRA or state continuation coverage includes: • losing COBRA or state continuation coverage for any reason other than those set forth in ii. below; • losing coverage as a result of the employer's failure to remit premiums on a timely basis; MIC PPMN HSA (3/11) 87 1500 -100% BPL 67277 DOC 21411 Eligibility And Enrollment • losing coverage as a result of the eligible employee or dependent incurring a claim that meets or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or • if the prior coverage was offered through a health maintenance organization (HMO), losing coverage because the eligible employee or dependent no longer resides or works in the HMO's service area and no other COBRA or state continuation coverage is available. ii. Exhaustion of COBRA or state continuation coverage 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. iii. In the case of the eligible employee's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of a dependent's exhaustion of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible employee. 2. 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 and provided that the eligible employee also enrolls during this special enrollment period; 3. 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 (for dependent children, the notification period is not limited to 30 days for newborns or children newly adopted or newly placed for adoption) and provided that the eligible employee also enrolls during this special enrollment period; 4. The dependent is the spouse of the subscriber or eligible employee through whom the dependent child described in 3. 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; and d. The eligible employee also enrolls during this special enrollment period; or 5. 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 2. or 3. above, becoming eligible to enroll under the coverage provided the eligible employee also enrolls during this special enrollment period. 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as described in this section, Medica will provide the eligible dependent child with a special enrollment period provided the eligible employee also enrolls during this special enrollment period. MIC PPMN HSA (3/11) 88 1500 -100% BPL 67277 DOC 21411 T _ Eligibility And Enrollment Late enrollment An eligible employee or an eligible employee and dependents who do not enroll for coverage offered through the employer during the initial or open enrollment period or any applicable special enrollment period will be considered late entrants. Late entrants who have maintained continuous coverage may enroll and coverage will be effective the first day of the month following date of Medica's approval of the request for enrollment. Continuous coverage will be determined to have been maintained if the late entrant requests enrollment within 63 days after prior qualifying coverage ends. Individuals who have not maintained continuous coverage may not enroll as late entrants. An eligible employee or dependent who: 1. does not enroll during an initial or open enrollment period or any applicable special enrollment period; and 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the 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. 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. If the eligible employee whose dependent child is the subject of the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, the eligible employee must also enroll for coverage under the Contract during the 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. The date your coverage begins Your coverage begins at 12:01 a.m. on the effective date of your enrollment. 1. For eligible employees and dependents who enroll during the initial enrollment period, coverage begins on the effective date specified in the Contract. MIC PPMN HSA (3/11) 89 1500 -100% BPL 67277 DOC 21411 Eligibility And Enrollment 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: a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first calendar month following the date on which the request for enrollment is received by Medica; b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of adoption or placement for adoption, date of adoption or placement. In all other cases, the date the subscriber acquires the dependent child; c. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.b. above; d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. or 3. under Special enrollment becomes effective; e. Number 6. under Special enrollment, the first day of the first calendar month following the date the completed request for enrollment is received by Medica. 4. For eligible employees and /or dependents who enroll during late enrollment, coverage begins on the first day of the month following date of Medica's approval of the request for enrollment. • • MIC PPMN HSA (3/11) 90 1500 - 100% BPL 67277 DOC 21411 I Ending Coverage 'lII DD. Endin g 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. See'De initions These words have specific meanings certification of-qualifying coverage Claim; dependent, member, premium, subscriber You have the right to a certification of qualifying coverage when coverage ends. You will receive a certification of qualifying coverage when coverage ends. You may also request a certification of qualifying coverage at any time while you are covered under the Contract or within the 24 months following the date your coverage ends. To request a certification of qualifying coverage, call Customer Service at one of the telephone numbers listed inside the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. When coverage ends Unless otherwise specified in the Contract, 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 Eligibility And 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. If coverage ends due to fraud, 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. Fraud includes but is not limited to: a. Intentionally 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 b. Intentional 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 MIC PPMN HSA (3/11) 91 1500 -100% BPL 67277 DOC 21411 Ending Coverage e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional misrepresentation with regard to any aspect of coverage under the Contract. 7. 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; 8. 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; 9. For a spouse, the end of the month following the date of divorce; 10. For a dependent child, the end of the month in which the child is no longer eligible as a dependent; or 11. 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. MIC PPMN HSA (3/11) 92 1500 -100% BPL 67277 DOC 21411 Continuation EE. Continuation • This section describes continuation coverage provisions. When coverage ends, members may be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer. See De €initions. - These words have specific meanings benefit dependent, member; placed forxadoption, Premium; subscriber,= ,total0disabrlity. The paragraph below describes the continuation coverage provisions. State continuation is described in 1. and federal continuation is described in 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. When your continuation coverage under this section ends, you have the option to enroll in an individual conversion health plan as described in Conversion. 1. Your right to continue coverage under state law Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: a. 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. b. 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. It is intended that no greater rights be provided than those required by Minnesota law. Take time to read this section carefully. Subscriber's Toss 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. In 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. MIC PPMN HSA (3/11) 93 1500 -100% BPL 67277 DOC 21411 Continuation 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; 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. 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: 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. 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. Consistent with Minnesota law, the subscriber and dependents have 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. If continuation coverage is not elected, your coverage under the Contract will end. MIC PPMN HSA (3/11) 94 1500 -100% BPL 67277 DOC 21411 Continuation 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 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. Surviving dependents of a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. 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: a. For instances where coverage is 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. b. 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 iii. The date coverage would otherwise terminate under the Contract.. c. For instances where dependent children lose coverage as a result of loss of dependent 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 iii. The date coverage would otherwise terminate under the Contract. d. 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: i. The date the former spouse becomes covered under another group health plan; 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: i. The date the former spouse becomes covered under another group health plan; or MIC PPMN HSA (3/11) 95 1500 - 100% BPL 67277 DOC 21411 Continuation ii. The date coverage would otherwise terminate under the Contract. e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent children may be continued until the earlier of: i. The date the surviving spouse and dependent children become covered under another group health plan; 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 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. • 2. 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 General COBRA information in this section. USERRA continuation coverage Continued coverage shall be provided as required under the Uniformed Services . Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The employer shall, within the parameters of federal law, establish uniform policies pursuant to which such continuation coverage will be provided. See General USERRA information in this section. General COBRA information 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 coverage is a group health plan for purposes of COBRA. . This .section, 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 section carefully. MIC PPMN HSA (3/11) 96 1500 -100% BPL 67277 DOC 21411 Continuation Qualified beneficiary For purposes of this section, a qualified beneficiary is defined as: 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 c. A dependent child of a covered employee. (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 Toss The subscriber has the right to elect continuation of coverage if there is a Toss 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 Toss 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; 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. 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: 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 the subscriber 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 MIC PPMN HSA (3/11) 97 1500 -100% BPL 67277 DOC 21411 Continuation 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. 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. Consistent with federal law, the subscriber and dependents have 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 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. 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 amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 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 of COBRA coverage 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 MIC PPMN HSA (3/11) 98 1500 -100% BPL 67277 DOC 21411 Continuation 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. 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. Consistent with federal law, the subscriber and dependents have 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 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. 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 amount charged cannot exceed 102 percent of the cost of the coverage. The amount may be increased to 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 of COBRA coverage 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 MIC PPMN HSA (3/11) 98 1500 -100% BPL 67277 DOC 21411 it Continuation 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. 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. 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 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 pre- existing condition; or d. The subscriber becomes entitled to (actually covered under) Medicare. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. • General USERRA information USERRA requires employers to offer employees 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 coverage is a group health plan for the purposes of USERRA. This section 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 Take time to read this section carefully. Employee's Toss The employee has the right to elect continuation of coverage if there is a loss of coverage under the Contract because of absence from employment due to service in the uniformed services, and the employee was covered under the Contract at the time the absence began, and the employee, or an appropriate officer of the uniformed services, provided the employer with advance notice of the employee's absence from employment (if it was possible to do so). Service in the uniformed services means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active duty for training, initial active duty for training, inactive duty training, full -time National Guard duty, and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of these duties. MIC PPMN HSA (3/11) 99 1500 -100% BPL 67277 DOC 21411 Continuation Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army National Guard, and the Air National Guard, when engaged in active duty for training, inactive duty training, or full -time National Guard duty, and the commissioned corps of the Public Health Service. Election rights The employee or the employee's authorized representative may elect to continue the employee's coverage under the Contract by making an election on a form provided by the employer. The employee has 60 days to elect continuation coverage measured from the date coverage would be lost because of the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. The employee may elect continuation coverage on behalf of other covered dependents, however, there is no independent right of each covered dependent to elect. If the employee does not elect, there is no USERRA continuation available for the spouse or dependent children. In addition, even if the employee does not elect USERRA continuation, the employee has the right to be reinstated under the Contract upon reemployment, subject to the terms and conditions of the Contract. Type of coverage and cost If the employee elects 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. The amount charged cannot exceed 102 percent of the cost of the coverage unless the employee's leave of absence is Tess than 31 days, in which case the employee is not required to pay more than the amount that they would have to pay as an active employee for that coverage. There is a grace period of at least 30 days for the regularly scheduled premium. Duration of USERRA coverage When an employee takes a leave for service in the uniformed services, coverage for the employee and dependents for whom coverage is elected begins the day after the employee would lose coverage under the Contract. Coverage continues for up to 24 months. Federal law provides that continuation coverage may end earlier for any of the following reasons: a. The employer no longer provides group health coverage to any of its employees; b. The premium for continuation coverage is not paid on time; c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct; d. The employee fails to return to work following the completion of his or her service in the uniformed services; or e. The employee returns to work and is reinstated under the Contract as an active employee. Continuation coverage may also end earlier for reasons which would allow regular coverage to be terminated, such as fraud. MIC PPMN HSA (3/11) 100 1500 -100% BPL 67277 DOC 21411 PP"' . Continuation COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation coverage in addition to USERRA continuation coverage, these coverages run concurrently. • • MIC PPMN HSA (3/11) 101 1500 -100% BPL 67277 DOC 21411 Conversion FF. Conversion See Definitions These'words have specific meanings: continuous coverage dependent, premium, waiting period. Your conversion plan coverage may not provide the same coverage as your previous group health plan. Benefits and provider networks may be different. Minnesota residents This section describes your right to convert to an individual conversion plan if you are a resident of Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. If you are a Minnesota resident, you may be eligible to obtain coverage from 1) other private sources of health coverage, or 2) the Minnesota Comprehensive Health Association, without a pre- existing condition limitation. Contact the Minnesota Comprehensive Health Association for further information: • For deductible plan options call 1- 866 - 894 -8053 or TTY: 1- 800 - 841 -6753 • For Medicare Supplement plan options call 1- 800 - 325 -3540 or TTY: 1- 800 - 234 -8819 Overview 1. You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods at the following times: a. Your continuation coverage with Medica, as described in Continuation, is exhausted. b. Your coverage or continuation coverage ends because the Contract is terminated and the Contract is not replaced with other continuous group coverage. c. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. 2. Your conversion plan goes into effect the day following 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. 3. Conversion coverage is not available: a. When continuous coverage is not maintained; or b. If your coverage is terminated due to nonpayment of premium; or c. If you have not exhausted your right to continue coverage as described in Continuation; or d. If your coverage or continuation coverage ends because the Contract is terminated and the Contract is replaced with other continuous group coverage; or e. The commission of fraud. MIC PPMN HSA (3/11) 102 1500 -100% BPL 67277 DOC 21411 Conversion For purposes of 2. and 3.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 coverage, whichever is later. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor 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. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor 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. Residents of a state other than Minnesota This section describes your right to convert to an individual conversion plan if you are a resident of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. Overview You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting periods, in accordance with the laws of the state in which you reside on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. What you must do 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You will be required to include your first month premium payment with your enrollment form for conversion coverage. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 days after your coverage ends or such other period of time as provided under applicable state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. MIC PPMN HSA (3/11) 103 1500 -100% BPL 67277 DOC 21411 Complaints GG. Complaints This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. See Definitions These words have. specific meaning: network, provider 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, 2. You also may contact the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296 -2488 or 1- 800 - 657 -3602. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. You may appoint an authorized representative to make a complaint on your behalf. You may be required to sign an authorization which will allow Medica to release confidential information to your authorized representative and allow them to act on your behalf during the complaint process. 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. In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Commerce at the telephone number listed at the beginning of this section. 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. 1. If your complaint is regarding an initial decision made by Medica, your complaint must be made within one year following Medica's initial decision. 2. For an oral complaint that does not require a medical determination in its outcome, 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 3. 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 or request. 4. When an initial decision by Medica not to grant a prior authorization request is made before 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 MIC PPMN HSA (3/11) 104 1500 -100% BPL 67277 DOC 21411 Compiailnts 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. 5. 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. Second level of review If you are not satisfied with Medica's first level of review decision, you may request a second level of review through either a written reconsideration or a hearing. 1. 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 the address listed above in First level of review, 2. 2. 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. 3. Medica will provide written notice of its second level of review decision to you within: a. 30 calendar days from receipt of written notice of your appeal for required second level reviews; or b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews. For some complaints, the second level of review must be exhausted before you have the right to submit a request for external review. For other complaints, this second level of review is optional before you may submit a request for external review. Medica will inform you in writing whether the second level of review is optional or required. External review If you consider Medica's decision to be partially or wholly adverse to you, you may submit a written request for external review of Medica's decision to the Commissioner of Commerce at: Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101 -2198 A filing fee of $25 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 will not be binding on you but will be binding on Medica. Contact 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. MIC PPMN HSA (3/11) -105 1500 -100% BPL 67277 DOC 21411 Complaints Civil action If you are dissatisfied with Medica's first or second level review decision or the external review decision, you have the right to file a civil action under section 502(a) of the Employee Retirement Income Security. Act (ERISA). MIC PPMN HSA (3/11) 106 1500 -100% BPL 67277 DOC 21411 General Provisions HH. General Provisions This section describes the general provisions of the Contract. See Definition :. These words have specific Meanings: claim, dependent member; network, premium, provider, subscriber 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. 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, edica, the providers employer, and network roviders are contractual Y 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. 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. MIC PPMN HSA (3/11) 107 1500-100% BPL 67277 DOC 21411 General Provisions 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. MIC PPMN HSA (3/11) 108 1500 -100% BPL 67277 DOC 21411 Definitions Definitions In this certificate (and in any amendments), some words have specific meanings. Benefits. The health services or supplies (described in this certificate and any subsequent amendments) approved by Medica as eligible for coverage. Certification of qualifying 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. 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. 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 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. For out -of- network benefits, in addition to any 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 Drug Program and Specialty 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. Continuous coverage. 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. Convenience care /retail health clinic. A health care clinic located in a setting such as a retail store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. MIC PPMN HSA (3/11) 109 1500 - 100% BPL 67277 DOC 21411 Definitions Cosmetic. 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. Custodial care. 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. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims for health services or supplies received from network or non - network providers are reimbursable as in- network or out -of- network benefits under this certificate. Dependent. Unless otherwise specified in the Contract, the following are considered dependents: 1. The subscriber's spouse. 2. The following dependent children up to the dependent limiting age of 26: a. The subscriber's or subscriber's spouse's natural or adopted child; b. A child placed for adoption with the subscriber or subscriber's spouse; 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 legal guardianship; d. The subscriber's stepchild; and e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent upon and resides with the subscriber or subscriber's spouse continuously from birth. 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent incapable of self- sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber for support and maintenance. An illness that does not cause a child to be incapable of self - sustaining employment will not be considered a physical disability. This dependent may remain covered under the Contract regardless of age and without application of health screening or waiting periods. To continue coverage for a disabled dependent, you must provide Medica with proof of such disability and dependency within 31 days of the child reaching the dependent limiting age set forth in 2. above. Beginning two years after the child reaches the dependent limiting age, Medica may require annual proof of disability and dependency. For residents of a state other than Minnesota, the dependent limiting age may be higher if required by applicable state law. 4. The subscriber's or subscriber's spouse's disabled dependent who is incapable of self - sustaining employment by reason of developmental disability, mental illness, mental disorder or physical disability and is chiefly dependent upon the subscriber or subscriber's spouse for support and maintenance. For coverage of a disabled dependent, you must provide Medica with proof of such disability and dependency at the time of the dependent's enrollment. MIC PPMN HSA (3/11) 110 1500 -100% BPL 67277 DOC 21411 Definitions Emergency. A condition or symptom (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, 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 (or, if you are pregnant, the health of your unborn child) 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. E- visits. A member initiated online evaluation and management-service provided to patients via the Internet. E- visits are used to address non - urgent medical symptoms for established patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. Hospital. 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. Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing facility, or licensed acute care facility. Inpatient services in a licensed residential treatment facility for treatment of emotionally disabled children will be covered as any other health condition. Investigative. 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: 1. 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; 2. 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 3. 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 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 MIC PPMN HSA (3/11) 111 1500 -100% BPL 67277 DOC 21411 Definitions 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 any authoritative compendia as identified by the Medicare program for use in the determination of a medically accepted indication of drugs and biologicals used off - label. 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 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 member who is a child entitled to receive coverage through a QMCSO 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: 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. Member. A person who is enrolled under the Contract. Mental disorder. 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). Network. 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 to provide benefits to you. The participation status of providers will change from time to time. The network provider directory will be furnished automatically, without charge. Non - network. A term used to describe a provider not under contract as a network provider. Non- network provider reimbursement amount. The amount that Medica will pay to a non - network provider for each benefit is based on one of the following, as determined by Medica: 1. A percentage of the amount Medicare would pay for the service in the location where the service is provided. Medica generally updates its data on the amount Medicare pays within 30 -60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or MIC PPMN HSA (3/11) 112 1500 -100% BPL 67277 DOC 21411 Definitions 2. A percentage of the provider's billed charge; or 3. A nationwide provider reimbursement database that considers prevailing reimbursement rates and /or marketplace charges for similar services in the geographic area in which the service is provided; or 4. An amount agreed upon between Medica and the non - network provider. Contact Customer Service for more information concerning which method above pertains to your services, including the applicable percentage if a Medicare -based approach is used. For certain benefits, you must pay a portion of the non- network provider reimbursement amount as coinsurance. In addition, if the amount billed by the non - network provider is greater than the non - network provider reimbursement amount, the non - network provider will likely bill you for the difference. This difference may be substantial, and it is in addition to any coinsurance or deductible amount you may be responsible for according to the terms described in this certificate. Furthermore, such difference will not be applied toward the out -of- pocket maximum described in Your Out -Of- Pocket Expenses. Additionally, you will owe these amounts regardless of whether you previously reached your out -of- pocket maximum with amounts paid for other services. As a result, the amount you will be required to pay for services received from a non - network provider will likely be much higher than if you had received services from a network provider. Physician. 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. 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. (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.) 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 defined 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. Preventive health service. The following are considered preventive health services: 1. Evidence -based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; 2. Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the member involved; 3. With respect to members who are infants, children, and adolescents, evidence - informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; MIC PPMN HSA (3/11) 113 1500 -100% BPL 67277 DOC 21411 Definitions 4. With respect to members who are women, such additional preventive care and screenings not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Contact Customer Service for information regarding specific preventive health services and services that are rated "A" or "B." 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 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; 15. State Children's Health Insurance Program; or 16. A public health plan similar to any of the above plans established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. 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; 4. 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; MIC PPMN HSA (3/11) 114 1500 -100% BPL 67277 DOC 21411 it Definitions 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. 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. Restorative. 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. Routine foot care. Services that are routine foot care may require treatment by a professional and include but are not limited to any of the following: 1. Cutting, paring, or removal of corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removal of toenails, dead skin, or underlying tissue). Routine foot care may also include hygiene and preventive maintenance such as: 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. 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 by themselves define 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 nursing care, skilled transitional care, or other related health services including rehabilitative services. Subscriber. The person: 1. On whose behalf premium is paid; and 2. Whose employment is the basis for membership, according to the Contract; and MIC PPMN HSA (3/11) 115 1500 -100% BPL 67277 DOC 21411 Definitions 3. Who is enrolled under the Contract. Total disability. 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. Urgent care center. 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. Waiting period. 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. Periods of employment in an employment classification that is not eligible for coverage under the Contract do not constitute a waiting period. MIC PPMN HSA (3/11) 116 1500 -100% BPL 67277 DOC 21411