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Contract No. 2013 2479
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 01/01/2013 pU[SU8rt to 8eCU0O 5.2. K EO1nkx* r fails to pay the required P[8DliUDl within the grace period described iD Section 5.2. the Contract will b9 terminated, subject t0G3O'd8yadvance written DOtiC8 Of termination by K4ediCG to Employer. The date Of the termination Sh8|| be retroactive t0 not more than 30 d@VS prior to the effective date of the DOtiC8 of termination; /b\ On the date specified by K4ediC8 because Employer committed fraud (through act, practice, or omission) or intentionally provided K88diCa with false iDf0[[n8UOD nl@t8[iG| to the eX8CUtiUO of this C0DL[8Ct 0[ t0 the pnOViSiOD of Benefits under this Contract. K88diC8 has the right to rescind this Contract back to the original effective date; (o) On the date specified by MediC8 due to Employer's violation Of the participation or COOt[ibUtiOD rules @Sdetermined by K4BdiC@; (d) Automatically on the date Employer ceases to do business pursuant to 11 U.@.C. Chapter 7; (e) Automatically Vn the date Employer ceases 10dO business for any reason; (f) (]O the date specified by M8diC@, after Gt least 9O days prior written notice tO Employer, that this Contract is terminated because K48diCG will DO |ODg8r issue this particular type of group health benefit plan within the applicable employer market; /g\ On the date specified by M8diC@. after at least 180 days prior written notice to the applicable state authority and Employer, that this COOt[@{t will be terminated because K88diC8 will DO |0Dg8r FeORVV or iSSU8 any HOOp|0y8r health benefit p|@O within the Gpp|iC8b|8 8nlp|Oy8[ D08rkft' . (h) If this Contract i9 made available to Employer only through one or more bOO2 fide oSSuoiatjonS, on the date specified by MediC8 after Employer's nlernb8[Ship in the association ceases; /i\ AUtO08tiCG||V OD the date that Employer fails to O0@iOt@iO any GCtiV8 80p|Oy8eS who are Subscribers; U\ Any other reasons or grounds permitted by the |iC8OSinQ |avvm and regulations governing M0diC8. Notwithstanding the GbOV8. MediCG may modify the P[e[DiUD1 rate and/or the 00V8r8ge at renewal. NODr8naw@| Of CVv8r8Aa as a result of failure of K8edima and the Employer to reach Ggre8rnuDt with respect to nlodifiC@UOOS in the Premium rate Or coverage shall not be considered 8f8i|u[e of W1ediCG to provide coverage On G guaranteed r8OHvv8b|e basis. Section 2'3 Notice of Termination. K48diC@ will notify EDlp|Oy8[ in VV[|tiDg if K48diCG t9[OOiOGt83 this Contract for any [H@S0D. In accordance with applicable l8Vv' Medica will notify 0UbSCFiben8 in writing ifK88diC8terminates this CODt[8Ct pursuant to Section 2.2(@). /b\' (d), ( ). or (g). Employer will provide U[Oe|y written OU[ifiC@UOO t0 Subscribers in all circumstances for which Medic8 does not provide written notification tOSubscribers. 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) MediC@ will not be responsible for any Claims for health G8rviCHG received by Members after the effective date of the 1e[noiD@tiOD; and (c) Employer Sh8|| be and Sh8|| remain liable to yNHdiC@ for the poyO08D[ Of any and all Pn9rDiunnS that are unpaid at the time of termination. Medica Large Group MGC 2 City of Columbia Heights ARTICLE 3 ENROLLMENT AND ELIGIBILITY Section 3'1 Eligibility. The Eligibility conditions Stated in Exhibit 1 of this Contract govern who is eligible to 8DrUU under this Contract. The eligibility conditions stated in Exhibit 1 are in addition tV those specified iO the Certificate. Section 3'2 Enrollment. The Certificate governs when eligible employees and eligible dependents may eOnnU for C0VecGge under this Contract, including the |Did@| EOnDUrD8Ot Peh0d, C>p8O Enrollment P8[iOd, and any @pp|iCGb|B Special EOnO||rDeDt P6hOdS, Employer Sh8|| conduct the Initial EDrO||D7eDt Period and [}p8D EDrO||[OeDt Period. Employer Sh8|| C0Op8nGt8 with K8ediCG to 8OSupe appropriate eDPU||08nt of K48mb8r3 under the Contract. Section 3'3 Qualified Medical Child Support Orders. Employer will establish, maintain, and enforce all written pnDCedU[e8 for dStRr[OiDiDQ Vvh9Lh8[ 8 child support order is @ qualified Ol8diCa| child support order 88 defined by ER|8A. Employer will provide K48diC8 with notice Of Such determination and @ copy of the OFd8[, 8|OD0 with an Gpp|iC8UoO for coverage, within the greater Of 30 days after iSSU@DD8 of the order or the time in which Employer provides O0tiD8 of its determination tU the persons specified iO the order. When and if Employer [8C8iVe8 notice that the child has designated a representative or of the existence Of @ |8O8| QU@[di8D or custodial p8[8Dt Of the child, E0p|0y8[ Sh@|| pn}0ot\y DOdfv K88diC2Of such penS0O/S\. WYediCG shall have OO responsibility for: /i\ establishing, maintaining, O[enforcing the pn]D8dUFeS described above; (ii) determining whether 8 support order i8 qualified; Or (iii) providing F8qViF8d O[tiC8S to the child 0[the designated rBp[8S8Ot@tim3. Section 3'4 Eligibility and Enrollment Decisions. Subject to applicable law and the terms of this CODt[8Ct. Employer has discretion to determine whether employees and their dependents are eligible to enroll for coverage under this Contract. M8diC@ shall be entitled to [8|y VpOO Employer's determination regarding an employee's and/or dependent's eligibility to enroll for C0me[8ge UOd8[ this Contract. The Employer will be n3SpUDSib|e for Dl@iDtGiOiDg iDf0[rD@bOO verifying its c0OUDUiDg eligibility and the continuing eligibility Of its eligible Subscribers and eligible Dependents. This information shall be provided to W1edicoaa reasonably requested by K48diC8. The Employer ShG|| also Dl8iDt3iO VV[itt8O dOCUOOeDtGtiOn Of@ waiver nfcoverage by an eligible Subscriber or eligible Dependent and provide this documentation to M8dic8 UpOO reasonable request. Section 3.5 Notification. The Employer must notify Medica within 30 days of on individual's initial enrollment application, changes to 8 W1ennbar`G name or address, changes to a Member's eligibility for coverage (including a |OsS of eligibility), or other changes to 8DnJ||nO8Dt. 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 W1edice'o ageDt, 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 tU deliver such dOCU0eDtS electronically tOthe extent permissible under Title | Medica Large Group MGC 3 City of Columbia Heights 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 Medica 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 01/01/2013 K4eD1berS` C0Vec@ge classifications, and certain tgrDiD@tiODS of Members not reflected in M8diCg's records at the time the [nnOth|y PnerDiuDlS were calculated by K48diC8. EDlpk]y8[ understands and GCkDUw|8dgeS that federal |8VV prohibits the retroactive termination of G K48OOber'S COve[8g8 except in instances of fraud, intentional misrepresentation Of D1@h}[ia| fact, Or t@i|UR9 t0 timely pay pr8DliU[nS or pP8rniuQD contributions. Employer agnB8S that it will not request retroactive termination of any K4eOlb8r`S coverage if such termination is prohibited by {8vV. Notwithstanding the foregoing, DO retroactive credit will be granted for any OlQDth in which 8 yW80be[ received Benefits. NO retroactive adjustments 10 enrollment or Premium refund ShG|| be granted for any Ch8DgH 0CCU[hDg more than 00 days prior to the date MediCG received notification Of the change from Employer. Notwithstanding the foregoing, Employer shall pay Premium for any month during which 8 Member received Benefits (except @S described in Section 5.3). Section 5'5 Premium Changes. MQdiCG may change the Premiums after 30 days prior written notice tOEmployer. Section 5.6 Employer Fees. K4edica may charge Employer: (@) @ late p8y[DSVt charge in the form Of@finance charge of 12% per annum for any Pren0iUDlS not received by the due date; and (b) G service charge for any OOD-SUfhCieOt-hJDd check n3CeiV8d 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 [)b|iQGtiOD. In 8CCOFdaOC8 with the Patient P[Ot8Cti0D and Affordable Care Act /^'PPACA"\' W18diC@ is obligated t0 provide @ premium rebate to Employer if K8ediC8'S OlediC@| |VGs r8hO ("yWLR") for the group market applicable to Employer's coverage does not meet or exceed the minimum percentage required by PPACA for such group market. PPACA requires K4edica to make such determinations on a calendar year basis, naganj|8SS of the Effective Dote and Expiration Date of this Contract. For purposes of this Section 5.7, ' "rD8diC8| loss ratio" shall be defined in accordance with PPACA@Dd the group market size applicable t0 Employer's unv9n9ge shall be determined in accordance with PPACA's MLR provisions and applicable state law and requirements. (b) Rebate Determinations and Remittances. yWedice ogr888 to determine whether such rebates are 0vv8d under this Contract ond, if applicable, remit such rebates 10 Employer no later than August 1 of the calendar year following any C8|8Dd@r year during which this Contract was in effect (for all or part of the year), and for which @ rebate is owed (for all or pG[1 of the year). Notwithstanding the fOF8gOiOQ, in the event that Employer's group health plan has been terminated at the time rebate payment is due and, despite reasonable efforts, Medica is unable to locate Employer, MediCa will distribute the entire rebate to Subscribers, in accordance with applicable |8w. (C) Form Of Rebates. yWediCG may, in its SO|8 diSCretiOD, elect to provide any such rebates owed in the form of p[8n0iUDl credit, @ |U[np-Sunl check, o[3 |UDlp-SUDl credit tOthe 8CC0VOt used to pay the p[eDliU[n. (d) Employer's Responsibility Concerning Rebates. Employer ogr8B3 that it is Employer's responsibility to determine how tO treat any rebate funds remitted to Employer by Medico in accordance with applicable |8vv, including but not limited to 45 C.F.R. §158.242 and ER|SA [8qVineDl8OtS. Additionally, in no way limiting the foregoing, if Employer's group health p|8O is not @ governmental plan and is not subject to EF{|GA. Employer agrees that Employer shall use the amount of any rebate that is proportionate to the total amount of premium paid Medica Large Group MGC 5 City of Columbia Heights by all Subscribers for the coverage in a manner that benefits Subscribers and is specifically provided iD45C.F.F|. §158.242(b)/1\ and (2). ARTICLE INDEMNIFICATION M8diC3 will hold h@rOkeSS and indemnify Employer against any and all C|GiDlG. liabilities, d@[Dag89. or jVdgOOOOtS asserted against, iDlpV88d UpOD or iDCU[[8d by EDlp|Oy8r, including reasonable attorney fees and costs, that arise out of Medica's negligent acts or omissions in the discharge Of its responsibilities toGMember. Employer will hold harmless and iOd8OODifv K4ediC8 against any and all C|8iDlS. liabilities, d@Ol8g8S' Or judgments asserted against, i[DpOS8d upon, or iOCU[F8d by K8ediCG, including reasonable attorney fees and coato, that arise out of Employer's or Employer's 8nnp|oyeea', oQenie', and representatives' negligent oote Or omissions in the discharge of its or their responsibilities under this Contract. Employer and K8edic8 Sh@|| promptly notify the other of any potential or @CtU8| C|GiDl for which the other party may be responsible under this Article 8. ARTICLE 7 ADMINISTRATIVE SERVICES The services DeC8SS@ry t0 administer this Contract and the Benefits provided under it will be provided in accordance with Medioa'aor its designee's standard administrative procedures. If E[Dp|0ye. requests such administrative services be provided in @ manner other than in accordance with these standard procedures, including requests for non-standard repurta, and if Medico o0r8eS to provide Such non-standard GdrniDiSt[@hve S8rviC8S. Employer aho|| 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 UOd8[ the [|OOt[a{t because of clerical e[R}[ Furthermore, o Member will not be eligible for coverage beyond the scheduled termination date because of a failure to record the termination. ARTICLE 9 ERUSA When this Contract is entered into by Employer to provide benefits under on gnlp|Oy88 vve|fm[e benefit plan governed by ER|SA. K8ediC@ Sh@|| not be named as and ah8|| not be the plan administrator of the employee welfare benefit plan, as that term is used in ERISA. M9diC8Gh@|} only be considered @ named fiduciary for purposes of claims adjudication. The parties agree that PWedic8 has sole, final, and exclusive discretion to: (@) interpret and construe the Benefits under the Contract; /b\ interpret and construe the other terms, conditions, limitations, and exclusions set out in the CODtF8Ci' ' /C\ change, interpret, rDOdif». Yithd[GVV` or add Benefits without approval by Members; and (d) make factual determinations related tOthe Contract and the Benefits. Medica Large Group MGC 6 City of Columbia Heights 01/O1/2O13 For purposes of overall cost savings or efficiency, Medica may, in its sole discretion, provide services that would otherwise not b8Benefits. The fact that M8diC@ does sDiD any particular case shall not iD any way b8deemed tO require it03d0SoiO other similar cases. K49diC8 may, from time t0 ti08, delegate discretionary authority to other pe[SOOS or entities providing services under this Contract. ARTICLE 10 DATA OWNERSHIP AND USE |nfO[QOG1iOD and data @CqUi[8d. developed, generated, or maintained by K48diCa in the CDUrS8 Of p8rfO[OOiDQ Under this Contract Sh8|| be YN8diCa'S SO|R property. Except as this Contract or 8pp|iCGb|8 |@vv requires OtheRNiS8' K48diC8 Sh@|| have DO Ob|iQ@tiOO to F8|gGS8 such information or data to Employer. Medico Dl8y' in its sole discretion, PB|e3S8 such iOh]r08tiOO Or data to Employer, but only to the extent permitted by |mvv and subject to any restrictions determined by K48diC@. ARTICLE 11 CONTINUATION OF COVERAGE M9diCm ShG{| provide COVRo3g8 under this Contract to those Members who are eligible to continue coverage under federal Or state |GVV. K48diCG will not provide any administrative dUd8S with n9Sp8{t to ErDp|0y8[`s CODlp|i8Dce with federal or state cOOtiDVodOD of coverage |GvvS. All duties Of the Employer, including, but not limited to, notifying MeDOb8[S regarding federal and state |GVV continuation rights and P[eDliUnO billing and CO||eCtiOD, r8no@iO Employer's SO|e responsibility. ARTICLE 12 CERTIFICATION OF QUALIFYING COVERAGE FORMS/SUMMARY OF BENEFITS AND COVERAGE As required by the Health |RSUr8O0e Portability and Accountability /\Ct Of 1996 (H|PAA). K88dio@ will produce Certification of Qualifying Coverage forms for Members VVhOSH coverage under this Contract terminates Or upon request by PWO[ObHrS. The Certification Of {}UG|ifviDg Coverage fOrnDS will be b8GgU on the eligibility and i8[rDiDedi0O data Employer provides to K48diC@. Employer Sh@|| provide all DeC8S8@ry eligibility and t8rO0iD@UVD data to K8ediC@ in aCcOrd8DC8 with M8diQ@`G data specifications. The [|ertif(C8{iOD of {jU8|if«iDg C0w8[8ge hJrrOS will only include periods of coverage K8adiC@ administers under this Contract. W1edica will prepare a Summary of Benefits and Coverage ('^GBC''). as described under the Patient Protection and Affordable CuR9 Act (^PPACA") and related nGgu|@tiVna, for each coverage option set forth in Exhibit 2 and offered by Employer. MediCe will provide applicable GBCa to Employer. Employer will distribute such 8BCS to individuals eligible for and covered under E[Op|Oy8r`S group health p|@O in accordance with applicable federal regulations. ARTICLE 13 NONDISCRIMINATION In accordance with the Patient Protection and Affordable Care Act (''PP/\C/Y')` fully-insured group health plans other than QruDdfatherod plans are generally subject to nondiscrimination rU|8S similar tO those applicable tO S8|AnSu[Sd health plans under Section 105(h) of the Internal Revenue Code. K48diC8 8sOU[neG OO responsibility for CO[np|i8OC8 with such [U|8S. EnDp|Oy8r' as the sponsor of the insured employee benefit plan, ah8|| be responsible for ensuring Co[Op}i8DCO with all PPACA DOOdiSC[i[niO8tiOO requirements applicable to the iDSurGOQ3 coverage, including but not limited to payment of any and all gOv8[DO08Ota| Or U5gUi@tVry t@XR8. Medica Large Group MGC 7 City of Columbia Heights p8O8bkeS. interest, or other charges reSUUjDg from DODDODlD|iaDC8 with @ppUC@bk} DODdiSCrDliO8tiVD [eqUir8Dl8OtS. Employer, as the Sp0OS0[ of the insured employee benefit plan, is SO|8|y responsible (1) for determining whether, with respect to its employee workforce, the aspects Of @ p@rtiCU|8[ iDSU[8OCR c0Dt[8Ct are discriminatory under PPA[|A' and /2\ for appropriately addressing the Si1U@tiOO if it is discriminatory UDd8[ PPACA /iDC|UdiDg but not limited to correcting, self-reporting, and payment of any penalties and interest related to the diSC[irDiDGtiOD\. 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 afterK88diC8 sends Employer written amendment. Unless [8gU|GtO[y authorities direct otherwise, EDlp|Oy8['S SiQD@tUr8 will not be required. NO M8dica agent or broker has authority to change this Contract or to waive any of its provisions. Smct|x»m 14'2 Regulatory Amendment. Medic@ may 808Dd this Contract to comply with requirements of state and federal |avv ("Regulatory Amendment") and shall issue to Employer such Regulatory Amendment and give Employer notice Of its effective date. The Regulatory Amendment will not n3qUi[g Employer's C0OS8Dt and, UO|eGS [9gU|@tOn/ authorities direct 0thgmviS8, Employer's signature will not be required. Any provision of this Contract that conflicts with the terms Of applicable federal or state |@wG is deemed GDl8Od8d t0 CoDfOrn0 to the minimum requirements Vfsuch |@VVS. ARTICLE 15 ASSIGNMENT Neither party Sh8|| 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, hOvv8v8[, that MediC8 Ol8y' without the prior written COO88Ot of the E0p|OVe[. @GGigD the Contract to any entity that COntrO|S K8ed|CG, is controlled by MediCG' or is under common control with K48diC@. In the event Of assignment, the Contract shall be binding upon and inure tO the benefit 0f each party's successors and assigns. ARTICLE 16 DISPUTE RESOLUTION In the event that any dispute, c|8i[O. O[ controversy ofany kind or nature relating i0 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 8h@|| provide the other, in advance of the meeting, with VY[i1t8n notice of the claimed dispute. Upon receipt of the written OntiC8' F8preG8Dt@tiV8S for each party Sh8|| meet promptly to attempt t0 resolve the dispute. If o mutually agreeable o9So|U1iOO i8 not reached within thirty (30) d@YS fD||VVViOg receipt Of the VvFiti8D notice, either party may pursue |8gG| action in auoOmd8nue with the terms of this Contract. The parties may OOUtU@||V agree to VV@iVe the informal dispute neSO|UtiOO process 8Oi forth herein. Any such waiver must b8iD writing and executed by both parties. ARTICLE 17 TIME LIMIT ON CERTAIN DEFENSES NO statement nl8d8 by Ennp|oy8[. euoHct @ fraudulent otot8nl8nt, oh8|| be used t0 void this Contract after it has been in force for @ period Vf2years. Medica Large Group MGC 8 City of Columbia Heights ARTICLE 10 RELATIONSHIP BETWEEN PARTIES The n8|3UDO3hip between Employer and any Member is that Of Employer and Subscriber, Dependent, Or other coverage classification @S defined iD this Contract. The relationships between MediC8 and Network Providers and the relationship between K1ediC@ and Employer are solely contractual relationships between independent contractors. Network P[0Vid8[S and Employer are not agents 0r employees VfM8diC8. MediC8 and its eODp|0y8e8 are not agents 0[employees 0fNetwork Providers or EOOp|Oy0[. The n*|GtiOOShip between @ Network Provider and any Member iSthat of provider and p@b8Ot and the Network Provider iS solely responsible for the services provided tO any Member. ARTICLE 19 EMPLOYER RECORDS Employer ShGU furnish MediC@ with all }nf0[Ol@bOO and pnDOtS that K8ediCG may [88SOO@b|y require with [Bg@Pd to any O1Gtt8rS pertaining to this Contract. M8diC8 may at any reasonable time inspect all d0CUD19DtS furnished to EO0p|Oy8F by GD individual in :UDneCtiVO with the Benefits, Employer's p8yn}i| [eCOPds' and any other PeCO[dS pertinent to the Benefits under this Contract. []n|BSS EnOp|OyD[ pPUVidSS the appropriate written GS8UrGDceS required by 45 CFR 184.504' K48diC8 will only provide Employer with SUDlDl8ry health iOfO[[D8UOD 0o[ the purposes Of obtaining premium bids or for modifying, amending, Or terminating the group health p|GD 0O|y\ and iOfOrDN@UOD On whether individuals are participating in the group health p|an, or is 8OrO||Hd in Or has diSeOrOl|8d from the health p|GD as provided in 45 CFR 104.504 /M(1) and the DliOiDlUDl O8C8sS@ry information for purposes of auditing K4edic@`s operations or services. ARTICLE 20 NOTICE Except GS provided in Article 2, notice given by K88dica t0 an authorized representative of Employer will be deemed notice to all Members. All notices t0 W1ediC@ Sh8i| be sent to the address stated in the ACQeDtaDQ8 of Contract. All notices to Employer ohe|| be sent to the persons and addresses Stated in the Group Application. All O0bCeS to K4SdiC@ and ED7p|Oy8[ Sh8|| be deemed delivered: /G\ if delivered in person, on the date delivered in person; /b\ if delivered by 8 courier, OD the date stated by the COU[i8r; /c\ if delivered by an express mail s8rvice. On the date stated by the mail service vendor; or /d\ if delivered by United Gt8iea 08i|. 3 buaiO8S8 days after date Of mailing. A party can change its address for receiving D0tiC8S by providing the other party G VVFitt8D OOtiD8 of the change. ARTICLE 21 COMMON LAW No |3DgU@ge COD{@iD8d in the Contract constitutes @ VvGiV8r of K8ediC@'8 rights under CODlDlOO Medica Large Group MGC 9 City of Columbia Heights 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 November 20, 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 Hei hts N 5,5421 Billing Address: - , NW 7958 By: � PO Box 1450 Title: Minneapolis, MN 55485-7958 Date: Mailing Address: PO Box 9310 Minneapolis, MN 55440 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 01/01/2013 EXHIBIT 1 1 Parties' The parties to this Master Group Contract are K80dkca Insurance Company /"K8ediCa"\ and the employer group City [fColumbia 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 01/01/2813 ("Effective Date") t0 12/31/2013 ("Expiration Date"). All COv8r@g8 under this Contract begins at 12:01 8.[D. Central Time. 3' Amendment(s) Number: Amendments attached as applicable for benefit package |o0 (BPL) 8Slisted 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 CVOdiUOOS stated in this Contract are eligible to eDnD|| for coverage under this Contract. Any p8nGOn who does not satisfy the definition Of Subscriber Or Dependent is not eligible for COVo[Gge 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 eOrV|| under the Contract 8S 8 Subscriber must be an individual who S8dSfieS the Employer participation and eligibility requirements as defined b8|OVV. The term "Subscriber" GS used in the Contract will include the types of employees and conditions identified below: Classifications Applicable Waiting Period or Effective Date 1. Employees: Actively scheduled New Hires: [)Gt8 Of hire tO work 4Ohours/week Status Change: Date ofchange Return: Date Ofreturn Rehire: Date of rehire Medica Large Group MGC Exhibit 1 City of Columbia Heights Page 1 01/01/2013 EXHIBIT 2 Premiums The monthly Premiums for MIC PP MN HSA 1500-100%, group number(s) 80515, BPL#21277 are: I Single $563.29 The monthly Premiums for MIC PP MN HSA 1500-100%, group number(s) 80695, BPL#21278 are: I Family $1,295.55 The monthly Premiums for MIC PP MN HSA 2500-100%, group number(s) 80517, BPL#21285 are: Single $500.77 Family $1,151.75 The monthly Premiums for MIC FOCUSMN HSA 1500-100%, group number(s) 80516, BPL#21316 are: I Single $450.63 The monthly Premiums for MIC FOCUSMN HSA 1500-100%, group number(s) 80694, BPL#21317 are: I Family $1,036.44 The monthly Premiums for MIC PP MN 100%-15, group number(s) 80513, BPL #85259 are: Single $739.04 Family $1,699.77 Medica Large Group MGC Exhibit 2 City of Columbia Heights Page 1 01/01/2013 I�{ 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 • 01/01/2013 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 Contract is terminated because Medica 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 olr 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), or (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 Mi C 2 City of Columbia Heights 01/01/2013 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 the time in which Employer provides notice of its determination to the persons specified in the order. When and if Employer receives notice that the child has designated a representative or of the existence of a legal guardian or custodial parent of the child, Employer shall promptly notify Medica of such person(s). Medica shall have no responsibility for: (i) establishing, maintaining, or enforcing the procedures described above; (ii) determining whether a support order is qualified; or (iii) providing required notices to the child or the designated representative. Section 3.4 Eligibility and Enrollment Decisions. Subject to applicable law and the terms of this Contract, Employer has 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 01/01/2013 • • 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 Medica 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 anyl 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 days 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 01/01/2013 I • 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 premium rebate to Employer if Medica's medical loss ratio ("MLR") for the group market applicable to Employer's coverage does not meet or exceed the minimum percentage required by PPACA for such 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. For purposes of this Section 5.7, "medical loss ratio" shall be defined in accordance with PPACA and the group market size applicable to Employer's coverage shall be determined in accordance with PPACA's MLR provisions and applicable state law and requirements. (b) Rebate Determinations and Remittances. Medica agrees to determine whether such rebates are owed under this Contract and, if applicable, remit such rebates to Employer 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). Notwithstanding the foregoing, in the event that Employer's group health plan has been terminated at the time rebate payment is due and, despite reasonable efforts, Medica is unable to locate Employer, Medica will distribute the entire rebate to Subscribers, in accordance with applicable law. (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) Employer's Responsibility Concerning Rebates. Employer agrees that it is Employer's responsibility to determine how to treat any rebate funds remitted to Employer by Medica in accordance with applicable law, including but not limited to 45 C.F.R. §158.242 and ERISA requirements. Additionally, in no way limiting the foregoing, if Employer's group health plan is not a governmental plan and is not subject to ERISA, Employer agrees that Employer shall use the amount of any rebate that is proportionate to the total amount of premium paid Medica Large Group MGC 5 City of Columbia Heights 01/01/2013 • by all Subscribers for the coverage in a manner that benefits Subscribers and is specifically provided in 45 C.F.R. §158.242(b)(1) and (2). 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 request 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. The parties agree that Medica has sole, final, and exclusive discretion to: (a) interpret and cdnstrue the Benefits under the Contract; (b) interpret and cdnstrue 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 dei terminations related to the Contract and the Benefits. Medica Large Group MGC 6 City of Columbia Heights 01/01/2013 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/SUMMARY OF B_ ENEFITS AND COVERAGE 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 Medics. 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. Medica will prepare a Summary of Benefits and Coverage ("SBC"), as described under the Patient Protection and Affordable Care Act ("PPACA") and related regulations, for each coverage option set forth in Exhibit 2 and offered by Employer. Medica will provide applicable SBCs to Employer. Employer will distribute such SBCs to individuals eligible for and covered under Employer's group health plan in accordance with applicable federal regulations. 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 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, Medica Large Group MGC 7 City of Columbia Heights 01/01/2013 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 or broker has authority to change 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 01/01/2013 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 Medica to an authorized representative of Employer will be deemed notice to all Members. All notices to Medica shall be sent to the address stated in the Acceptance of Contract. All notices to Employer shall be sent to the persons and addresses stated in 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 01/01/2013 • I 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 November 20, 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 55421 Billing Address: NW 7958 By: / is' !; PO Box 1450 Title: - / , Minneapolis, MN 55485-7958 Date: Mailing Address: PO Box 9310 Minneapolis, MN 55440 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 01/01/2013 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 01/01/2013 ("Effective Date") to 12/31/2013 ("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: Actively scheduled New Hires: Date of hire to work 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 01/01/2013 EXHIBIT 2 Premiums The monthly Premiums for MIC PP MN HSA 1500-100%, group number(s) 80515, BPL#21277 are: Single $563.29 The monthly Premiums for MIC PP MN HSA 1500-100%, group number(s) 80695, BPL#21278 are: Family $1,295.55 The monthly Premiums for MIC PP MN HSA 2500-100%, group number(s) 80517, BPL#21285 are: Single $500.77 Family $1,151.75 The monthly Premiums for MIC FOCUSMN HSA 1500-100%, group number(s) 80516, BPL#21316 are: Single $450.63 The monthly Premiums for MIC FOCUSMN HSA 1500-100%, group number(s) 80694, BPL#21317 are: Family $1,036.44 The monthly Premiums for MIC PP MN 100%-15, group number(s) 80513, BPL #85259 are: Single I $739.04 Family $1,699.77 Medica Large Group MGC Exhibit 2 City of Columbia Heights Page 1 01/01/2013 Medica Choice Passport Certificate of Coverage MEDICA� MIC PP MN HSA (3/12) 1500-100% BPL 21277 DOC 23742 MEDICA CUSTOMER SERVICE Table Of Contents Table Of Contents Minneapolis/St. Paul Hearing Impaired: . Metro Area: National Relay Center Introduction x Medical Loss Ratio (MLR) standards under the federal Public Health Service Act x (952) 945-8000 1 -800-855-2880, then To be eligible for benefits xi Outside the Metro Area: ask them to dial Medica Language interpretation xi at 1 -800-952-3455 Acceptance of coverage xi 1 -800-952-3455 Nondiscrimination policy • xii More information about the plan can also be obtained by Health savings accounts xii signing in at wwwemymeducaocomo A. Member Rights And Responsibilities 1 Member bill of rights 1 Member responsibilities 1 1 B. How To Access Your Benefits 3 41L121.3-.)111'Ala ayy411 AA c1�4 uL4..,k431 owe EC7N BaM rryxcrra nomoutry B nepaaoAe aTOir Important member information about in-network benefits 3 ,:_•at."1. fi ogle %t.�y,j9 A�iLs..i�L,.w fit`~',",iS 131 mupopmannit, rto3BOriGrTe no froMePy, • yxa3anlroMy rra ofiparnoi-i czoporre sanle1 Important member information about out-of-network benefits 5 Medica sli A..�1i11 ;i.;4.1=31 �a,yul) MC,acLunicxoil KapToLIKH turaxa Medica. Continuity of care 7 Haddii aad doonayso in Af Soomaali laguugu Itichtf,iilitiniirofir 1tCPiltiniftitinitiCatai tltl6tilG;6f1s tarjatnadda rnacluurnaadkani,oo laca Prior authorization 8 g Fiiti,i,toi'gttiltui3f�dnifcl a121i13tfiililiittl�m Medica W la'aan ah, Fadlan wac Lambarka ku (loran Certification of qualifying coverage 9 Kaarka Caafimaadka ee:Medica dhabarkiisa. Si usted desea ayuda gratuita pars iraducir esta informacion, 'lame al nninero de C. How Providers Are Paid By Medica 10 Ako zelite besplatano turnacenje ovih telefono situado al reverso de su tarjeta Network providers 10 informacija posovite broj na pozadini,vase de identificacian de Medica. Medica kartice. Neu a vi tnuon au rc Non-network providers q ,, 4 'giup der dick tai lieu nay Iran p 10 phi,xin ggi si.i ghi 0 mat sau the Medica cua quy vi. D. Your Out-Of-Pocket Expenses 11 Yog koj xav tau key pab txhais cov ntaub ntawv no dawb,hu rau tus xov tooj nyob Dine k'ehji shich'i' hadoodzih ninizingo, beesh Coinsurance and deductibles 11 nram gab koj daim Medica Khaj (card), bee bane'e binui ber naaltsoos bikaahigii bich'i` hodiilnih ei doodaii bee neehozin biniiye More information concerning deductibles 12 nanitinigii bine'dee bikaa doo aldo'. Out-of-pocket maximum 12 tii-m;-0.J w i5iQ i c.t �:?;.0 -,ii a, Yrzr�,ca ni9n z; u'iVnt:�rla ,1n:a cx,4atriG�ri.gnopr,,z 7�jr,;■ , Medica Para sa tulong sa Tagalog, tawagan ang Lifetime maximum amount 13 numerong kabilang sa dokumentong ito o sa Yoo odeeyssi kun bilashitti afaan keetitti akka likod ng iyong ID card. Out-of-Pocket Expenses 14 sii hiikamu feete lakkoofsa caaardiii meedikaa % R-14/.lj.litj ill#A#T X'f ( -OC *. E. Ambulance Services 15 (Medica)gama dubaarra jiru kana bilbili. -P. wit-1-1-3o Covered 15 UNV1D11 — If you want free help translating this information, call the number Not covered 15 on the back of your Medica identification card. Ambulance services or ambulance transportation 16 J Non-emergency licensed ambulance service 16 F. Durable Medical Equipment And Prosthetics 17 Covered 17 ©2012 Medica. Medica®is a registered service mark of Medica Health Plans. "Medica"refers to the family of health plan businesses at includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, MIC PP MN HSA (3/12) III 1500-100 that Medica Self-Insured, and Medica Health Management, LLC. BPL 21277 DOC 23742 Table Table Of Contents able ®f Contents Not covered 18 K. Maternity Services 30 Durable medical equipment and certain related supplies 18 Newborns' and Mothers' Health Protection Act of 1996 30 Repair, replacement, or revision of durable medical equipment 18 Covered 30 Prosthetics 18 Additional information about coverage of maternity services 31 Hearing aids 19 Not covered 31 G. Home Health Care 20 I Prenatal services 31 Covered 20 Inpatient hospital stay for labor and delivery services 32 Not covered 21 Professional services received during an inpatient stay for labor and delivery 32 Intermittent skilled care 21 Anesthesia services received during an inpatient stay for labor and delivery 32 Skilled physical, speech, or occupational therapy 21 Labor and delivery services at a freestanding birth center 32 Home infusion therapy 22 Home health care visit following delivery 32 Services received in your home from a physician 22 L. Medical-Related Dental Services 33 H. Hospice Services 23 Covered 33 Covered 23 Not covered 33 Not covered 24 Charges for medical facilities and general anesthesia services 34 Hospice services 24 Orthodontia, dental implants, and oral surgery related to cleft lip and palate 34 I. Hospital Services 25 Accident-related dental services 35 Covered 25 Oral surgery 35 Not covered 25 M. Mental Health Outpatient services 26 Covered 37 Services provided in a hospital observation room 26 Not covered 38 Inpatient services 26 Office visits, including evaluations, diagnostic, and treatment services 39 1 Services received from a physician during an inpatient stay 26 Intensive outpatient programs 39 �I Anesthesia services received from a provider during an inpatient stay 26 Inpatient services (including residential treatment services) 39 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 27 N. Miscellaneous Medical Services And Supplies 40 J. Infertility Diagnosis 28 Covered 40 Covered 28 Not covered 40 Not covered 28 Blood clotting factors 41 Office visits, including any services provided during such visits 29 Dietary medical treatment of PKU 41 Virtual care 29 Amino acid-based elemental formulas 41 Outpatient services received at a hospital 29 Total parenteral nutrition 41 Inpatient services 29 Eligible ostomy supplies 41 Services received from a physician during an inpatient stay 29 Insulin pumps and other eligible diabetic equipment and supplies 41 Anesthesia services received from a provider during an inpatient stay 29 O. Organ And Bone Marrow Transplant Services 42 Covered 42 MIC PP MN HSA(3/12) iv 1500-100% MIC PP MN HSA (3/12) V BPL 21277 150 2370% BPL 21277 DOC 23742 I • TabBe Of Contents i TabDe Of Contents Not covered 43 Prescription unit 57■ Office visits 43 Not covered 58 Virtual care 43 Specialty prescription drugs received from a designated specialty pharmacy 58 Outpatient services 44 , Specialty growth hormone received from a designated specialty pharmacy 58 Inpatient services 44 S. Professional Services 59 Services received from a physician during an inpatient stay 45 Covered 59 Anesthesia services received from a provider during an inpatient stay 45 Not covered 60 Transportation and lodging 45 Office visits 60 P. Physical, Speech, And Occupational Therapies 47 i Virtual care 60 Covered 47 i Convenience care/retail health clinic visits 60 Not covered 47 Urgent care center visits 61 Physical therapy received outside of your home 48 Preventive health care 61 Speech therapy received outside of your home 48 Allergy shots 62 Occupational therapy received outside of your home 49 Routine annual eye exams 62 Q. Prescription Drug Program 50 Chiropractic services 62 Preferred drug list 50 Surgical services 62 Exceptions to the preferred drug list 50 Anesthesia services received from a provider during an office visit or an outpatient hospital Prior authorization 51 or ambulatory surgical center visit 62 Step therapy 51 Services received from a physician during an emergency room visit 62 Quantity limits 51 Services received from a physician during an inpatient stay 62 Covered 51 Anesthesia services received from a provider during an inpatient stay 63 Prescription unit 52 Outpatient lab and pathology 63 Not covered 53 Outpatient x-rays and other imaging services 63 Outpatient covered drugs 54 Other outpatient hospital or ambulatory surgical center services 63 Diabetic equipment and supplies, including blood glucose meters 54 Treatment to lighten or remove the coloration of a port wine stain 63 Tobacco cessation products 54 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 63 Drugs and other supplies considered preventive health services 55 Diabetes self-management training and education 64 R. Prescription Specialty Drug Program 56 Neuropsychological evaluations/cognitive testing 64 Designated specialty pharmacies 56 Services related to lead testing 64 Specialty preferred drug list 56 Vision therapy and orthoptic and/or pleoptic training 64 Exceptions to the specialty preferred drug list 56 Genetic counseling 64 Prior authorization 57 Genetic testing 65 Step therapy 57 T. Reconstructive And Restorative Surgery 66 Quantity limits 57 Covered 66 Covered 57 Not covered 66 MIC PP MN HSA(3/12) vi 1500-100% MIC PP MN HSA(3/12) vii 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 TabDe Of Contents liab @e Of Contents Office visits 67 Right to receive and release needed information 86 Virtual care 67 Facility of payment 86 Outpatient services 67 Right of recovery 86 Inpatient services 68 BB. Right Of Recovery 87 Services received from a physician during an inpatient stay 68 CC. Eligibility And Enrollment 88 Anesthesia services received from a provider during an inpatient stay 68 Who can enroll 88 U. Skilled Nursing Facility Services 69 How to enroll 88 I Covered 69 1 Notification 88 Not covered 69 Initial enrollment 88 Daily skilled care or daily skilled rehabilitation services 70 Open enrollment 89 Skilled physical, speech, or occupational therapy 70 Special enrollment 89 Services received from a physician during an inpatient stay in a skilled nursing facility....70 Late enrollment 92 V. Substance Abuse 71 Qualified Medical Child Support Order (QMCSO) 92 Covered 72 The date your coverage begins 92 Not covered 73 DD. Ending Coverage 94 Office visits, including evaluations, diagnostic, and treatment services 73 When coverage ends 94 Intensive outpatient programs 73 EE. Continuation 96 Opiate replacement therapy 73 Your right to continue coverage under state law 96 Inpatient services (including residential treatment services) 73 Your right to continue coverage under federal law 99 W. Referrals To Non-Network Providers 75 FF. Conversion 105 What you must do 75 Minnesota residents 105 What Medica will do 75 Residents of a state other than Minnesota 106 X. Harmful Use Of Medical Services 77 GG. Complaints 107 When this section applies 77 First level of review 107 Y. Exclusions 78 Second level of review 108 Z. How To Submit A Claim 81 External review 108 Claims for benefits from network providers 81 Civil action 109 Claims for benefits from non-network providers 81 HH. General Provisions 110 Claims for services provided outside the United States 82 Definitions 112 Time limits 82 AA. Coordination Of Benefits 83 Applicability 83 Definitions that apply to this section 83 Order of benefit determination rules 84 Effect on the benefits of this plan 85 MIC PP MN HSA (3/12) viii 1500-100% MIC PP MN HSA (3/12) ix o BPL 21277 DOC 23742 1500-100 BPL 21277 DOC 23742 2 introduction 'Introduction To be eligible for benefits Introduction 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- THIS POLICY IS REGULATED BY MINNESOTA LAW. network benefits; and 2. Identify yourself as a Medica member; and The benefits of the policy providing your coverage are governed primarily by the law of a state 3. Present your Medica identification card. (If you do not show your Medica identification card, other than Florida. providers have no way of knowing that you are a Medica member and you may receive a bill Ma inio�tls in this certificate haves ecific rneamri s� These words are identi#ied�in each = = for health services or be required to ry ( 3aV sip t r _ p 9 _5 q pay at the time you receive health services.) However, 4secteon and..defined rn Definitions: w � possession and use of a Medica identification card does not necessarily guarantee A � k coverage. See Defrnit� s hese words haye$specifrc meanings benefits, claim; dependent, rrrnember, r rouider Network providers are required to submit claims within 180 days from when you receive a network �prerr�rum - a ;. -- ,� 2 � �i'.€ � Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota non- service. If your provider asks for your health care identification card and you do not identify qualified plan. This Certificate of Coverage (this certificate) describes health services that are yourself as a Medica member within 180 days of the date of service, you may be responsible for eligible for coverage and the procedures you must follow to obtain benefits. paying the cost of the service you received. The Contract refers to the Contract between Medica and the employer. You should contact the Language interpretation employer to see the Contract. Because many provisions are interrelated, you should read this certificate in its entirety. Language interpretation services will be provided upon request, as needed in connection with Reviewing just one or two sections may not give you a complete understanding of the coverage the interpretation of this certificate. If you would like to request language interpretation services, described. The most specific and appropriate section will apply for those benefits related to the please call Customer Service at one of the telephone numbers listed inside the front cover. treatment of a specific condition. If you have an impairment that requires alternative communication formats such as Braille, large Members are subject to all terms and conditions of the Contract and health services must be print, or audiocassettes, please call Customer Service at one of the telephone numbers listed medically necessary. inside the front cover to request these materials. Medica may arrange for various persons or entities to provide administrative services on its If this certificate is translated into another language or an alternative communication format is behalf, including claims processing, and utilization management services. To ensure efficient used, this written English version governs all coverage decisions. administration of your benefits, you must cooperate with them in the performance of their responsibilities. Acceptance of coverage Additional network administrative support is provided by one or more organizations under contract with Medica. 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 is responsible for remitting the premium to Medica and notifying you of any i the employer. This certificate is being delivered to you by, or on behalf of, your employer. changes to this certificate as required by applicable law. By accepting the health care coverage described in this certificate, you, on behalf of yourself 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. 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 Medical Loss Ratio (MLR) standards under the federal Public Health Service Act by state law; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and Federal law establishes standards concerning the percentage of premium revenue that insurers complete. pay out for claims expenses and health care quality improvement activities. If the amount an You understand and agree that any omission or incorrect statement concerning a material fact insurer pays out for such expenses and activities is less than the applicable MLR standard, the intentionally made by you in connection with your enrollment under the Contract may invalidate insurer is required to provide a premium rebate. MLR calculations are based on aggregate market data rather than on a group by group basis. In the event Medica is required to pay your coverage. rebates pursuant to federal law, Medica will pay such rebates to your employer unless prohibited by federal law. MIC PP MN HSA(3/12) x 1500-100% MIC PP MN HSA (3/12) xi 1500-100% BPL 21277 DOC 23742 I BPL 21277 DOC 23742 introduction Member Rights And Responsibilities Nondiscrimination policy Medica's policy is to treat all persons alike, without distinctions based on race, color, creed, A. Member Rights And Responsibilities 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. ; a See Definitions These words have specifrclmeanings benefits, emergency member? If you have questions, call Customer Service at one of the telephone numbers listed inside the ' Y q p netw,ork, provider _ . .� . . � _ � .._ � T. front cover. Member bill of rights Health savings accounts As a member of Medica, you have the right to: This coverage is intended to comply with the requirements of the Internal Revenue Code section 223 for a federally qualified high deductible health plan. This coverage may qualify you 1. Available and accessible services, including emergency services (defined in this certificate) to make a pre-tax contribution to a health savings account. You are responsible for the cost of 24 hours a day, seven days a week; and all health services, other than preventive care, up to the deductible amount. 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 PP MN HSA (3/12) xii 1500-100% MIC PP MN HSA (3/12) 1 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Member Rights And Responsibilities How To Access Your Benefits 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 B. How To Access Your Benefits c. How to prevent health problems from recurring; and 5. Practicing preventive health care b y See'Definitions. These words have specific meanings: 'benefits, claim, coinsurance, a. Having the appropriate tests, exams and immunizations eductible, dependent, emergency, enrollment:date, hospital, inpatient, late entrant, member, and age as described in this certificate; and munizations recommended for your gender network, non-network;;non-network provider reimbursement amount, physician, placed for adoption, premiurn, prescription drug, provider, qualifying coverage, reconstructive restorative, b. Engaging in healthy lifestyle choices (such as exercise, proper diet, and rest). skr lied nursing facility subseriber,.virtual care,,waitingf period.:' --;; 4 _ You will find additional information on member responsibilities in this certificate. 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 PP MN HSA (3/12) 2 1500-100% MIC PP MN HSA (3/12) 3 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 How To Access Your Benefits How To Access Your Benefits be eligible for in-network benefits. You must verify that your provider is a network provider 2. Important member information about out-of-network benefits l' each time you receive health services. The information below describes your covered health services and provides important Exclusions 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 Certain health services are not covered. Read this certificate for a detailed explanation of all general sections of this certificate as well as the section(s) that specifically describe the exclusions. f services you are considering, so you are best able to determine the benefits that will apply Mental health and substance abuse to you. Medica's designated mental health and substance abuse provider will arrange your mental Benefits 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 Medica pays out-of-network benefits for eligible health services received from non-network mental health and substance abuse services require prior authorization by Medica's 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 designated mental health and substance abuse provider. Emergency services do not require prior authorization. out-of-network benefits. This certificate defines your benefits and describes procedures you must follow to obtain out-of-network benefits. Continuation/conversion Decisions about coverage are made based on appropriateness of care and service to the You may continue coverage or convert to an individual conversion plan under certain member. Medica does not reward providers for denying care, nor does Medica encourage circumstances. See Continuation and Conversion for additional information. inappropriate utilization of services. Cancellation Emergency services received from non-network providers are covered as in-network benefits and are not considered out-of-network benefits. Your coverage may be canceled only under certain conditions. This certificate describes all Additionally, under certain circumstances Medica will authorize your obtaining services from reasons for cancellation of coverage. See Ending Coverage for additional information. a non-network provider at the in-network benefit level. Such authorizations are generally Newborn coverage provided in situations where the requested services are not available from network Your dependent newborn is covered from birth. Medica does not automatically know of a Be aware that if you choose to go to a non-network provider and use out-of-network birth or whether you would like coverage for the newborn dependent. Call Customer benefits, you will likely have to pay much more than if you use in-network benefits. Service at one of the telephone numbers listed inside the front cover for more information. To The charges billed by your non-network provider may exceed the non-network provider be eligible for in-network benefits, health services must be provided by a network provider or reimbursement amount, leaving a balance for you to pay in addition to any applicable i authorized by Medica. Certain services are covered only upon referral. If additional coinsurance and deductible amount. This additional amount you must pay to the provider premium is required, Medica is entitled to all premiums due from the time of the infant's birth will not be applied toward the out-of-pocket maximum amount described in Your Out-Of- , until the time you notify Medica of the birth. Medica may reduce payment by the amount of Pocket Expenses and you will owe this amount regardless of whether you previously premium that is past due for any health benefits for the newborn infant until any premium reached your out-of-pocket maximum with amounts paid for other services. Please see the you owe is paid. For more information, see Eligibility And Enrollment. example calculation below. Prescription drugs and medical equipment Because obtaining care from non-network providers may result in significant out-of-pocket important that you do the following before receiving services from a non- , expenses, it is impo y g g Enrolling in Medica does not guarantee that a particular prescription drug or piece of medical network provider: i equipment will continue to be covered, even if the drug or equipment is covered at the start of the calendar year. • Discuss the expected billed charges with your non-network provider; and 1 Post-mastectomy coverage • 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 Medica will cover all stages of reconstruction of the breast on which the mastectomy was expenses; and performed and surgery and reconstruction of the other breast to produce a symmetrical • If you wish to request that Medica authorize the non-network provider's services be appearance. Medica will also cover prostheses and physical complications, including covered at the in-network benefit level, follow the procedure described under Prior lymphedemas, at all stages of mastectomy. authorization in How To Access Your Benefits. MIC PP MN HSA (3/12) 4 1500-100% MIC PP MN HSA (3/12) 5 1500-100% 21277 DOC 23742 BPL 21277 DOC 23742 j How To Access Your Benefits How To Access Your Benefits i An example of how to calculate your out-of-pocket costs* 3. Continuity of care You choose to receive non-emergency inpatient care at a non-network hospital provider To request continuity of care or if you have questions about how this may apply to you, call without an authorization from Medica providing for in-network benefits. The out-of-network Customer Service at one of the telephone numbers listed inside the front cover. 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 In certain situations, you have a right to continuity of care. bills $30,000 for your hospital stay. Medica's non-network provider reimbursement amount a. If your current provider is terminated without cause, you may be eligible to continue care for those hospital services is $15,000. You must pay a portion of the non-network provider with that provider at the in-network benefit level. 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 b. If you are a new Medica member as a result of your employer changing health plans and the non-network provider reimbursement amount. If your coinsurance is 40%, you will be your current provider is not a network provider, you may be eligible to continue care with required to pay: that provider at the in-network benefit level. • 40% coinsurance (40% of$15,000 = $6,000) and 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 • The billed charges that exceed the non-network provider reimbursement amount as payment in full the lesser of the network provider reimbursement or the provider's ($30,000 - $15,000 = $15,000) I customary charge for the service. This does not apply when a provider's contract.is • The total amount you will owe is $6,000 + $15,000 = $21,000. terminated for cause. • The $6,000 you pay as coinsurance will be applied to the out-of-pocket maximum i. Upon request, Medica will authorize continuity of care for up to 120 days as amount described in Your Out-Of-Pocket Expenses. However, the $15,000 amount you described in a. and b. above for the following conditions: pay for billed charges in excess of the non-network provider reimbursement amount will • an acute condition; 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 • a life-threatening mental or physical illness; you have previously reached your out-of-pocket maximum with amounts paid for other • pregnancy beyond the first trimester of pregnancy;• services. • a physical or mental disability defined as an inability to engage in one or more *Note: The numbers in this example are used only for purposes of illustrating how out-of- major life activities, provided that the disability has lasted or can be expected to network benefits are calculated. The actual numbers will depend on the services received. last for at least one year, or can be expected to result in death; or Lifetime maximum amount • a disabling or chronic condition that is in an acute phase. Out-of-network benefits are subject to a lifetime maximum amount payable per member. Authorization to continue to receive services from your current provider may extend See Your Out-Of-Pocket Expenses for a detailed explanation of the lifetime maximum to the remainder of your life if a physician certifies that your life expectancy is 180 amount. days or less: ii. Upon request, Medica will authorize continuity of care for up to 120 days as Exclusions described in a. and b. above in the following situations: Some health services are not covered when received from or under the direction of non- o if you are receiving culturally appropriate services and a network provider who network providers. Read this certificate for a detailed explanation of exclusions. has special expertise in the delivery of those culturally appropriate services is not Claims available; or • When you use non-network providers, you will be responsible for filing claims in order to be if you do not speak English and a network provider who can communicate with reimbursed for the non-network provider reimbursement amount. See How To Submit A you either directly or through an interpreter, is not available. Claim for details. 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 Post-mastectomy coverage authorizes your request to continue care with your current provider, Medica will explain how Medica will cover all stages of reconstruction of the breast on which the mastectomy was 1 continuity of care will be provided. After that time, your services or treatment will need to be performed and surgery and reconstruction of the other breast to produce a symmetrical 1 transitioned to a network provider to continue to be eligible for in-network benefits. If your appearance. Medica will also cover prostheses and physical complications, including request is denied, Medica will explain the criteria used to make its decision. You may lymphedemas, at all stages of mastectomy. appeal this decision. Coverage will not be provided for services or treatments that are not otherwise covered . under this certificate. MIC PP MN HSA (3/12) 6 1500-100% MIC PP MN HSA (3/12) 7 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 i . How To Access Your Benefits How To Access Your Benefits 4. Prior authorization 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 Prior authorization from Medica may be required before you receive certain services or reasonably necessary to make a decision has been made available to Medica. supplies in order to determine whether a particular service or supply is medically necessary Both you and your provider will be informed of the decision within 72 hours from the time of and a benefit. Medica uses written procedures and criteria when reviewing your request for the initial request if your attending provider believes that an expedited review is warranted, prior authorization. To determine whether a certain service or supply requires prior or if it is concluded that a delay could seriously jeopardize your life, health, or ability to authorization, please call Customer Service at one of the telephone numbers listed inside regain maximum function, or subject you to severe pain that cannot be adequately managed the front cover or sign in at www.mymedica.com. Emergency services do not require prior without the care or treatment you are requesting. authorization. Your attending provider, you, or someone on your behalf may contact Customer Service to If Medica does not approve your request for prior authorization, you have the right to appeal request prior authorization. Your network provider will contact Customer Service to request Medica's decision as described in Complaints. prior authorization for a service or supply. You must contact Customer Service to request Under certain circumstances, Medica may perform concurrent review to determine whether prior authorization for services or supplies received from a non-network provider. If a services continue to be medically necessary. If Medica determines that services are no network provider fails to obtain prior authorization after you have consulted with them about longer medically necessary, Medica will inform both you and your attending provider in services requiring prior authorization, you are not subject to a penalty for failure to obtain writing of its decision. If Medica does not approve continued coverage, you or your prior authorization. attending provider may appeal Medica's initial decision (see Complaints). Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; 5. Certification of qualifying coverage • Certain drugs; You have the right to a certification of qualifying coverage when coverage ends. You will Home health care; 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 • Medical supplies and durable medical equipment; 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 • Outpatient surgical procedures; front cover. Upon receipt of your request, the certification of qualifying coverage will be • Certain genetic tests; and issued as soon as reasonably possible. • Skilled nursing facility services. Prior authorization is always required for: • Organ and bone marrow transplant 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 PP MN HSA (3/12) 8 1500-100% MIC PP MN HSA(3/12) 9 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 How Providers Are Paid By Medica Your Out-Of-Pocket Expenses D. Your Out-Of-Pocket Expenses C. How Providers Are Paid By Medica 1� This section describes how providers are generally paid for health services. This section describes the expenses that are your responsibility to pay. These expenses are commonly called out-of-pocket expenses. See Defintton s These words,hare s specific meanings: co in su_a a n-_ce deducille.hos g itel' _- �.... See�Defrn�trons. These words.haves spec' rneamn s. �benefits claim C616`surance ..member,,network no ,..network_ h sicaan rov�der. �_ - _ �. ,, _,. � -. .,,. z, � � � .. . �,.L .P. _,:, - ,,- .- ,:9..T. �__> .� . ded ible;,deperdent ember network, non network non tworkgpro�vtder reimbursernent Var,amountres criPtion,drug,IProvrder,Rsot�scriber _ _ M n-4 Network providers You are responsible for paying the cost of a service that is not medically necessary or a benefit Network providers are paid using various types of contractual arrangements, which are intended even if the following occurs: to promote the delivery of health care in a cost efficient and effective manner. These 1. A provider performs, prescribes, or recommends the service; or arrangements are not intended to affect your access to health care. These payment methods I. may include: 2. The service is the only treatment available; or 1. A fee-for-service method, such as per service or percentage of charges; 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 2. A risk-sharing arrangement, such as an amount per day, per stay, per episode, per case, you to sign.) per period of illness, per member, or per service with targeted outcome. If you miss or cancel an office visit less than 24 hours before your appointment, your provider The methods by which specific network providers are paid may change from time to time. may bill you for the service. Methods also vary by network provider. The primary method of payment under Medica is fee- for-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. 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 verify coverage before receiving a particular service or supply, call Customer Service at one to a set fee schedule. The amount the network provider receives is the lesser of the fee of the telephone numbers listed inside the front cover. 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 Coinsurance and deductibles ii charge. The amount paid to the network provider, less any applicable coinsurance or deductible, is considered to be payment in full. For in-network benefits, you must pay the following: Risk-sharing payment means that the network provider is paid a specific amount for particular 9 p Y P P p p 1. Any applicable coinsurance and per member deductible each calendar year as described in unit of service, such as an amount per day, an amount per stay, an amount per episode, an this certificate (see the Out-of-Pocket Expenses table in this section). 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 Note that applicable deductibles are determined by the Contract between Medica and the for a member's health services, the network provider may bear some of the shortfall. If the employer and may increase when Medica and the employer renew the Contract. If this amount paid to the network provider is more than the cost of providing or arranging a member's occurs, the new deductible will apply for the rest of the current calendar year, whether or not health services, the network provider may keep some of the excess. 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 Some network providers are authorized to arrange for a member to receive certain health and that you may have additional out-of-pocket expenses as a result. services from other providers. This decision may result in a network provider keeping more or less of the risk-sharing payment. 2. Any charge that is not covered under the Contract. For out-of-network benefits, you must pay the following: Non-network providers 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 a service from a non-network provider is covered, the non-network provider is paid a fee Note that applicable deductibles are determined by the Contract between Medica and the 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. 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 PP MN HSA(3/12) 10 1500-100% MIC PP MN HSA (3/12) 11 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 • Your Out-Of-Pocket Expenses Your Out-Of-Pocket Expenses deductible will increase mid-year when your employer's Contract with Medica is renewed After an applicable out-of-pocket maximum has been met for a particular type of benefit (as and that you may have additional out-of-pocket expenses as a result. 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 2. Any charge that exceeds the non-network provider reimbursement amount. This means you for any charge not covered by Medica or charge in excess of the non-network provider are required to pay the difference between the payment to the provider and what the reimbursement amount. However, you will still be required to pay any applicable coinsurance provider bills. and deductibles for other types of benefits received. If you use out-of-network benefits, you may incur costs in addition to your coinsurance and Note that out-of-pocket maximum amounts are determined by the Contract between Medica and 1 deductible amounts. If the amount that your non-network provider bills you is more than the the employer and may increase when Medica and the employer renew the Contract. If this non-network provider reimbursement amount, you are responsible for paying the difference, occurs, the new out-of-pocket maximum will apply for the rest of the current calendar year, In addition, the difference will not be applied toward satisfaction of the deductible or the out- whether or not you had met the previously applicable out-of-pocket maximum. This means that of-pocket maximum (described in this section). it is possible that your out-of-pocket maximum will increase mid-year when your employer's To inquire about the non-network provider reimbursement amount for a particular procedure, Contract with Medica is renewed and that you may have additional out-of-pocket expenses as a call Customer Service at one of the telephone numbers listed inside the front cover. When result. you call, you will need to provide the following: Medica refunds the amount over the out-of-pocket maximum during any calendar year when • The CPT (Current Procedural Terminology) code for the procedure (ask your non- proof of excess coinsurance and deductibles is received and verified by Medica. network provider for this); and • The name and location of the non-network provider. Lifetime maximum amount Customer Service will provide you with an estimate of the non-network provider The lifetime maximum amount payable per member for out-of-network benefits under the reimbursement amount based on the information provided at the time of your inquiry. The Contract and for out-of-network benefits under any other Medica, Medica Health Plans, or actual amount paid will be based on the information received at the time the claim is Medica Health Plans of Wisconsin coverage offered through the same employer is described in submitted and subject to all applicable benefit provisions, exclusions and limitations, the Out-of-Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced including but not limited to coinsurance and deductibles. , pertains only to those health care services and supplies that are not essential benefits as 3. Any charge that is not covered under the Contract. defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules, or other guidance issued with respect to the Act. 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 PP MN HSA (3/12) 12 1500-100% MIC PP MN HSA (3/12) 13 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Your Out-Of-Pocket Expenses Ambulance Services Out-of-Pocket Expenses E. Ambulance Services �� 41n network , Out-of net work :0'4t44: � _ mm benefrts {� � , , ben n' eiivied for.3 coverage for ambulance transportation and related services rec is section escri es� covered medical and medical-related dental services (as described in this certificate).out-of-network;benefits, rn addition to�the deductible=and coinsurance,you are responsible-y -_ _ .. . ,.',?t .> ._ ..->.- : SW,e.,..� ,">�... -. '.x �`, .�+.+u.k�. .. r e .. .. ..... _» -__ <,-.?� .» ..4�. 1 i 3.. _•`Y far an .::char es in.excessof the.non. ne rk r . � . . a,. , < , ._...two o .der a mbursement.amount..-_Add�tionail . . � . . _ _..-. nY k 9 __. .... .� �, _____ .-,< . . See t?e�nit�ons. These words haves ecific me n� en is., or: u ante deductible 4" ---- -- ..-. ._.._-....K �._m..-.. .� p .,.. .. ._. ,.....�._.._..-. -.. __._ .� .... .... a h S b._..@fl _�C. thesecharges_will.not be,a 11 d_. � :. . . e_ toward.sa#�sfaction of_#h :-deductible or_thexou f _ .... �, , . , _. , ,. _ > . , .-. _ .. . . - _ a x � __ p mer c hos ital twork n � <, __.. _.. __- � ., �_ _ e� � ne � on network non network tovrder.cermbursement amount ...- - .. »_.. ,. >:__ .: • _.. ..�. ....-.N �.,.,-_.__ .,.. .., . ...,:,,.gig, gt ..... 3.. ., ..s,.,. _•_a..�_. __ _.xv ,__- .. .6.. _,.,_... ..._ _ .. .':.�-. _. .,,_._. � .. � -_, 9r 'sew-.a#`„�,.,d,. �..'�v_e s s.-'s m tm _z__ g S _.. � h,.s�c�an rovrder skilled.nursing facile Coinsurance See specific benefit for applicable coinsurance. Prior authorization. Prior authorization from Medica may be required before you receive Deductible 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 Per member $1,500 $4,000 process. Out-of-pocket maximum • Per member $1,500 $9,000 Covered Lifetime maximum amount Unlimited $1,000,000. Applies to For benefits and the amounts you pay, see the table in this section. More than one coinsurance payable per member all benefits you receive may be required if you receive more than one service or see more than one provider per visit. under this or any other Medica, Medica Health For non-emergency licensed ambulance services described in the table in this section: Plans, or Medica Health • In-network benefits apply to ambulance services arranged through a physician and received Plans of Wisconsin from a network provider. coverage offered through the same employer. • 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 PP MN HSA (3/12) 14 1500-100% MIC PP MN HSA (3/12) 15 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Ambulance Services Durable Medical Equipment And Prosthetics Your Benefits and the€AmountsYou Pay � F. Durable Medical Equipment And Prosthetics Benefits In network benefits *Out-of network benefits ' ° ' ._ after deductible ; after deductible This section describes coverage for durable medical equipment, certain related supplies, and *For=outer-of network benefits, irn+addition to the deductible and coinsurance,you.are responsible for = prosthetics. an. char es.in excessof the.non network. rovrderwrermb rs a t- o n -�. � _ . . �, :� .._. Y. 9 ....°. � . ._ u em n .am u t. �►dd�tiornall ..,these. ,_ � ., __ _ � - � 9 - -.. _ . -. . . .-� __�, . ..� _-_ ,. ,. eci eanrn s. benefits..- Dins r�ance deductible.-...- .. -.. . ._..� ., .-_. .__ .w, 5. _. ,. -___ . � _,. _ D nitEOns._ These words haves fic rn � c u- ar< es wrli notbex.a ii � E � � ...._ .._ _. . . _... ...-_.. .. _.°. .. ..�. ch _ _ . ed_towartl satisfaction,of the deductible,or he.out-of oak -.� .� _,.. � ,. PPn . .� et.,ma _ - �.- �- -� ._ .,, �_ . ,. __-.. _..- .�,._ �.. ___- - ..- � 3 ;:.._: . -. � _ , . _ non network. covtder._�reimbursement amount _-_�__- � . . , .....,. �. .._ _. __ . _ � _. - . . . _. _ � le._medreal e w ment,rr�etr�uork non network . --_ �, �. __ •� ,,.,.. r�, - __ __� dumb � , �#?T -5,.�, r� ,.proytder �� �.�. � � �,� � ���� ���z�nE 1. Ambulance services or Nothing Covered as an in-network ysan �, � _- = ambulance transportation to the benefit. Prior authorization. Prior authorization from Medica may be required before you receive nearest hospital for an services or supplies. Call Customer Service at one of the telephone numbers listed inside the emergency front cover. See How To Access Your Benefits for more information about the prior authorization 2. Non-emergency licensed process. ambulance service that is arranged through an attending Covered physician, as follows: a. Transportation from hospital Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance to hospital when: may be required if you receive more than one service or see more than one provider per visit. i. Care for your condition is Medica covers only a limited selection of durable medical equipment, certain related supplies, and not available at the hearing aids that meet the criteria established by Medica. Some items ordered by your physician, . hospital where you were even if medically necessary, may not be covered. The list of eligible durable medical equipment first admitted; or 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 ii. Required by Medica at one of the telephone numbers listed inside the front cover. b. Transportation from hospital Nothing 50% coinsurance Medica determines if durable medical equipment will be purchased or rented. Medica's approval to skilled nursing facility 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 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 PP MN HSA (3/12) 16 1500-100% MIC PP MN HSA (3/12) 17 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 I1 Durable Medical Equipment And Prosthetics Durable Medical Equipment And Prosthetics Not covered Your Benefits and-the Amounts You Pay These services, supplies, expenses ' * � , su lies, and associated ex enses are not covered: • � '� aenefits In k networ benefits a Out-of-network benefits 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the : . � ` � ,a A � g � � after eductile after deductible Medica eligible list. �._ ��"� £&; 2. Charges in excess of the Medica For.c'ut-of-network benefits rinaddition toxthe deduct�ble'and'coinsurance,.you are'responsible;for g edica standard model of durable medical equipment, prosthetics, € � Y �fa,. or hearing aids. army charrg in excess3of the non-network"provider�reimbursement amount. ,Additionally,these.y: i charges will mot be applied toward satisfaction of the deductible.or the.out-of:pocket maximum 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. c. Repair, replacement, or Nothing 50% coinsurance • revision of artificial arms, 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, legs, feet, hands, eyes, ears, replacement, or revision of duplicate items. noses, and breast See Exclusions for additional services, supplies, and associated expenses that are not prostheses made necessary covered. 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 `,s Your Benefits arid the Amounts You Pay hearing loss that is not per ear every three years. one hearing aid per ear h �' � correctable by other covered Related services must be every three years. .Benefits to network benefits *-Out of°net work"benefits = procedures prescribed by a network after deductible after deductible.., provider. *For out-of network benefits, imaddition to the deductible and coinsurance,you are responsible for any charges excess.of the non-network;provider reimbursement amount Additionally, hese charges will not be applied toward satisfaction;of the deductible pr the out-of-pocket maximum r3 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 PP MN HSA (3/12) 18 1500-100% MIC PP MN HSA (3/12) 19 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 l • Home Health Care Home Health Care Not covered G. Home Health Care These services, supplies, and associated expenses are not covered: 1. Companion, homemaker, and personal care services. +, I� 2. Services provided by a member of your family. This section describes coverage for home health care. Home health care must be directed by a 3. Custodial care and other non-skilled services. physician and received from a home health care agency authorized by the laws of the state in which treatment is received. 4. Physical, speech, or occupational therapy provided in your home for convenience. ' -i - mm 5. Services provided in your home when you are not homebound. See Definitions(These words have�specific meanings: benefits, coinsurance ,custoc ial care, p y y ductible,_dependent, hospital network, r network, non-network provider reimbursement 6. Services primarily educational in nature. amount, physician, provider, skilled cae, skillednur-sing3facility 7. Vocational and job rehabilitation. Prior authorization. Prior authorization from Medica may be required before you receive 8. Recreational therapy. 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 9. Self-care and self-help training (non-medical). authorization process. 10. Health clubs. Covered 11. Disposable supplies and appliances, except as described in Durable Medical Equipment And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug For benefits and the amounts you pay, see the table in this section. More than one coinsurance Program. may be required if you receive more than one service or see more than one provider per visit. 12. Physical, speech, or occupational therapy services when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare generally accepted standards in the medical community. 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 13. Voice training. dependent child may still be considered "confined to home"when attending school where life 14. Home health aide services, except when rendered in conjunction with intermittent skilled support specialized equipment and help are available. care and related to the medical condition under treatment. Benefits covered under 1. and 2. in the table in this section are limited to a combined maximum of See Exclusions for additional services, supplies, and associated expenses that are not 120 visits per calendar year for in-network and 60 visits per calendar year for out-of-network covered. 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. Your Benefits and the Amounts Pa In-network benefits apply to home health care services ordered or prescribed by a physician : Y • ;3 t �5 x _ s' and received from a network home health care agency: Benefits - � ln1network benefits °; *Out of network benefits • Out-of-network benefits apply to home health care services that are ordered or prescribed by a after deductible after deductible= physician and received from a non-network home health care agency. In addition to the u *For out-of- etwark benefits, in addition to ilia eductiOle e`nd:coinsurance you are res: of Bible for, deductible and coinsurance described for out-of-network benefits, you will be responsible for r -- �y P y p any char es in excess of the non-network provider reimbursement amount. Additionally these any charges in excess of the non-network provider reimbursement amount. The out-of- = -_ e,,. p. -. o _ d the the poc�- axi um. �,�charges will not be?applFed,toward satisfaction of the deductible or'the out;;-of pocket maximum 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 1. Intermittent skilled care when Nothing 50% coinsurance information and an example calculation of out-of-pocket costs associated with out-of- you are homebound, provided by network benefits. or supervised by a registered Please note: Your place of residence is where you make your home. This may be your own nurse dwelling, a relative's home, an apartment complex that provides assisted living services, or 2. Skilled physical, speech, or Nothing 50% coinsurance some other type of institution. However, an institution will not be considered your home if it is a occupational therapy when you hospital or skilled nursing facility. are homebound • MIC PP MN HSA (3/12) 20 1500-100% MIC PP MN HSA(3/12) 21 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Home Health Care Hospice Services YOur Benefits and the Amounts YouPay H. Hospice Services Benefits In network benefits ..*O t,pf network benefits after deductible after deductibles ,, ,: 3 This section describes coverage for hospice services including respite care. Care must be * _- u;- ' -- ; .E: ordered provided, or arranged under the direction of a physician and received from a hospice I ` For-out of network benefits, in addition to the deductible and coinsurance,.You ars responsible for P 9 P Y P , t excess s of the non-network provider reimbursement aamount °Additionally these ' program. cha�r 9 e�,s will n t._- a p fe_:. to..,w, a_rd.sa._t f fa,,�.c_tin- f_t �de d_.u ctf_bf e o _t e__. o.��ut-.�..o_-_._,f:,- .o_c__c et:ma_,xi mum_._. ,.., See D of r .rt�o ns T e ses wards.have_s ecifi benef t s GOrrs an te�deductible 3. Home infusion therapy Nothing 50% coinsurance member, netWork, non network, non-network mprovider re._m ursement amoun , physician, .ia...•.a: s _._:,_mm____ skilled _ nursing far ility 4. Services received in your home Nothing 50% coinsurance from a physician Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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. Ij • 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. jl 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. MIC PP MN HSA (3/12) 22 1500-100% MIC PP MN HSA (3/12) 23 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Hospice Services Hospital Services 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 I. Hospital Services program. Not covered This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. These services, supplies, and associated expenses are not covered: �n See=_Definitrans these words haves crfic mess ,benefits, cornsurance, deductible, ; 1. Respite care for more than five consecutive days at a time. emergency,genetic testing, hospital inp tient,member,.network, non network, non network L 2. Home health care and skilled nursing facility services when services are not consistent with :provider reimbursement amount, physician, provider. � ; the hospice program's plan of care. Prior authorization. Prior authorization from Medica may be required before you receive • 3. Services not included in the hospice program's plan of care. 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 4. Services not provided by the hospice program. process. 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 Covered home. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 7. Financial or legal counseling services, except when recommended and provided by the may be required if you receive more than one service or see more than one provider per visit. hospice program. • In-network benefits apply to hospital services received from a network hospital or ambulatory 8. Housekeeping or meal services in your home, except when recommended and provided by surgical center. the hospice program. • Out-of-network benefits apply to hospital services received from a non-network hospital or 9. Bereavement counseling, except when recommended and provided by the hospice ambulatory surgical center. In addition to the deductible and coinsurance described for out- program. of-network benefits, you will be responsible for any charges in excess of the non-network See Exclusions for additional services, supplies, and associated expenses that are not provider reimbursement amount. The out-of-pocket maximum does not apply to these covered. 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 mo _. ay � providers will be covered as in-network benefits. If you are confined in a non-network facility Y Benefits enefits and'the Aunts You P asa 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. Benefits : Ian network:benefits Out-of network benefits .� after�deductible after deductible Not covered *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 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous char es willnotbea liedtoward:satisfaction;ofthe deductible orthe out-ofapocket;maximum g pp 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 1. Hospice services Nothing 50% coinsurance Prescription Drug Program and Prescription Specialty 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. II � o MIC PP MN HSA (3/12) 24 1500-100% MIC PP MN HSA (3/12) 25 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Hospital Services Hospital Services +i e. _.. E . F.>..... <. _ >a , _- ,,._ .� ,,: ._,,_ _., _. :E _ x � . �...� ._ .__._..,, �_..-. �, . _. <_'....':-,,q1-� _."._.. Your Benefits antl the Amounts You Pa. _._ mm ._...�_ ..-. < �v.. --. _ � � _... _ � the.A _ .. _. � R � ..,..._ _ _, _ Your Benefit's and r mounts You. Pa. _ >7 Y ,.... .. _- _,. .3 .. 4.. ....... ."- -.",,. '}i ., xffi•-a .,.. ... `5 .,., .. :_».. a...»„c c.....s......... . a. ... ... ...-......,s...,. ,x... ...,.... _, ...-. .'Z -_........." 9-. .. _._,... ...E <,.,t., > y� �, _ a� . . _. _ _ .. , Benefits �.- _ .. � ., . . ..in network bane#its:. 04t -network benefits;�� r E, - �. rk� n _" . f network bane#its., . < R.._._ ,� ._-�In netwo, be a#rts Outo _ . , x . . .,..- _ ,, >. ..... en fits � _ .__... _ __. �. _-. _ . .. .. . _ _- _ � �i�.�' y .. .....z ,, ,a- . .....n., .... .- ,....,, -....._ ..t:<. _,... -��p s,.y,. ,:-a-.. �� ».....Sk� ....x. ,:E -'_' ?rxpt ___� < .. _... . _ _. _._. _ .. _"... ___ <_ ._�.a#ter deductible _..._. after�deduct<bte , r ..� fterdeductrbie__.... ___r. after de ___.. �. �.- ..:_. ..-.....,t. ..... - . a._. �... .mi=x.. ....- a'_.. ..... m.._ .. ....... � ...�` .;Pr . .:rz. ..�' L. � _�.. .. <...-.._, :.. .,.,e.... ,..,- � ,.., ... ..... _..., ,._....fix. � ...?-.. m < Fo (5.h: t�f ntwork_be a .rn" d ionTto the deductible nd c suran e < ce.res on b # =t§n, nsr ie for r u . n fits ad ka d C oar a si !e or i -,: _ > � t ou.tar _ es -o b I.._ . _ rt on._ o the.deductrble and cornsura e , e_ .,,. .« . _ _ ... , - ,. . ,f network.benefits n_add t _t _ . __ a nc. _ ._ , .. . . - ,. <- Y P"F rout-o , _r P x . _. ,. . _ u _ �, - � _ - �_<..� .., <m3,. �,r�._ ? a�._ s�.�s �; h*< - - . ��-_. .z__" _xom_ �., _ . ,. __� an car esexceo#thenonnetwork ro�rder reimbursementr.':amount. Adf,rtronatl: ,,these _--:_ ,:: _ i ionaii , these........._.a ro ,i eimbursemerit amount.<-.Add t � _ Y 9 _ ,. _. �.. , . _<,.char. es ex ass of the..non network v der.r .., ,. , _____.�. F Y,.an tin c _ Y ---. . . . ,.L ' .. . _c_ r ,. a ![ -. ,< . '€, ers ..: S ,.d i✓< , Fc. ,. � �«h * .,,..._. _........ .x = ...,? ,t: _:,. , .,..t,,.,T>': ig ._ iu. , x'86`...,..�F.�S _.. �.., , �t : _.<,T..__..E char esswrii not be li d_tow rd_satrsfaction of the.deductible or the°,1!t-°f:713,: ocket maxima .. � < .maxima ,r a e a � � u� m . _.. E the._deduc ibie r_the,o f ocket m. - .., 9... ,... ._, . .. _ ___._.. r. ,. . ._.- � >,. _.. ._..� .. _� ___ _ w n t, e a had t ward satisfactien of _ t a -.tat-o. � _ .. __. t . .w. �. tspR "-- _x ." e .-e mm.. h e iii o_b .; � , o e . .. . t,. ... < # _.- .o_.__ ." .. . . �: , � ...._ .:- 2, <� ,.;.v4 ...... dt ._..,_.,. t} ,� ;.Y."1._ _...i„_ ,q� .t,. ,IDs ... .... __.............. ____...._yr.x�<"aat•�.+z'�Ttt�°'�__kx ..,.::..:3�,...,,.,_:_....:_ ._.___..__,. _,._.._._.. _.,..: ..< .n..,._. ,,.,- '........... ......... .<. .a. -..�.r.�-�...-.a.,.....__,...c.=S.._�.;;_. i ..,�# .._- Ii<,: ,c- :_:.wit->3� f Px : �V.f:W � � .' :.::_v."...:—�'_._.� :'ar, � � .�.`-: _: , c: 1. Outpatient services 6. Treatment of temporomandibular Covered at the Covered at the joint (TMJ) disorder and corresponding in-network corresponding out-of- a. Services provided in a Nothing Covered as an in-network craniomandibular disorder benefit level, depending network benefit level, hospital or facility-based benefit. on type of services depending on type of emergency room provided. services provided. b. Outpatient lab and pathology Nothing 50% coinsurance For example, office visits For example, office visits c. Outpatient x-rays and other Nothing 50% coinsurance are covered at the office are covered at the office imaging services visit in-network benefit visit out-of-network d. Genetic testing when test Nothing 50% coinsurance level and surgical benefit level and surgical services are covered at services are covered at results will directly affect the surgical services in- the surgical services out- treatment decisions or network benefit level. of-network benefit level. frequency of screening for a Please note: Dental Please note: Dental disease, or when results of coverage is not provided coverage is not provided the test will affect under this benefit. under this benefit. reproductive choices . e. Other outpatient services Nothing 50% coinsurance f. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician g. 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 Nothing 50% coinsurance 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 MIC PP MN HSA (3/12) 26 1500-100% MIC PP MN HSA(3/12) 27 1500-100% j 1 BPL 21277 DOC 23742 BPL 21277 DOC 23742 I 1 Infertility Diagnosis Infertility Diagnosis J. Infertilit Dia nosis lour B m enefits and the You Pay Y 9► > Benefits ; � ` In-network tri=networiCilSeinefiti * Out-of-network:benefits , �-' ' � after�deductible after deductible ;� 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 For_out-of-network benefits,,in addition to the'dedctible and coinsurance, oukare res onsible.for.��- infertility must be received from or under the direction of a physician. All services, supplies, and '>` Y p y pp �,�,�any charges m�excess�of�thnon�n�etwa ,provktler re ursement amount Ady�ditionaiiy, associated expenses for the treatment of infertility are not covered. charges�will�not be applied toward satisfaction of the deductible or the out-of;pocket maxim um 3 I See Definitions', These words have specific meanings benefits, coinsurance, deductible, 1. Office visits, including any Nothing Covered as an in network !hospital, inpatient,member network, non network, non net n ork provider reimbursement � ,,� �- , , ? €E services provided during such benefit. amount,physician, Provider, virtual care .._i `', virtue' � visits Prior authorization. Prior authorization from Medica may be required before you receive 2. Virtual care Nothing No coverage 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 3. Outpatient services received at a Nothing Covered as an in-network hospital benefit. authorization process. 4. Inpatient services Nothing Covered as an in-network Covered benefit. 5. Services received from a Nothing Covered as an in-network Benefits apply to services for the diagnosis of infertility received from a network or non-network physician during an inpatient benefit. provider. More than one coinsurance may be required if you receive more than one service or stay see more than one provider per visit. 6. Anesthesia services received Nothing Covered as an in-network Coverage for infertility services is limited to a maximum of$5,000 per member per calendar year from a provider during an benefit. for in-network and out-of-network benefits combined. inpatient stay 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. 10. Services for intrauterine insemination (IUD. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PP MN HSA (3/12) 28 1500-100% MIC PP MN HSA (3/12) 29 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Maternity Services Maternity Services Additional information about coverage of maternity services K. Maternity Services Not all services that are received during your pregnancy are considered prenatal care. Some of the services that are not considered prenatal care include (but are not limited to) treatment of the following: This section describes coverage for maternity services. Benefits for maternity services include all medical services for prenatal care, labor and delivery, postpartum care, and related complications. 1. Conditions that existed prior to (and independently of) the pregnancy, such as diabetes or , sx � , �� lupus, even if the pregnancy has caused those conditions to require more frequent care or See Definitions These words have specifc meanings benefits, coinsurance, deductible, monitoring. dependent; hospital, inpatient member, network, non network, non-network..provider n al , ,F 2. Conditions that have arisen concurrently with the pregnancy but are not directly related to care = � Y P 9 Y Y reimbursement amount, physician;,.prenatalcare, pr ovidersktlled care_ _ „. of the pregnancy, such as back and neck pain or skin rash. Prior authorization. Prior authorization from Medics may be required before you receive 3. Miscarriage and ectopic pregnancy. 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 Services that are not considered prenatal care may be eligible for coverage under the most process. specific and appropriate section of this certificate. Please refer to those sections for coverage information. Newborns'and Mothers'Health Protection Act of 1996 Not covered 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 These services, supplies, and associated expenses are not covered: than 96 hours following a cesarean section). However, federal law generally does not prohibit the 1. Health care professional services for maternity labor and delivery in the home. 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 2. Services from a doula. case, Medica may not require a provider to obtain prior authorization from Medica for a length of 3. Childbirth and other educational classes. stay of 48 hours or less (or 96 hours, as applicable). See Exclusions for additional services, supplies, and associated expenses that are not Covered covered. � fi 3x'i E Y �... vi.. .�'• 11'; � For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Your#Benefits andthe Amounts You'Pay 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 ' Benefits �' - �, In;network benefits *Out-of network benefits services related to maternity labor and delivery. Please note: We encourage you to enroll your _ P after deductible ,-v after deductible newborn dependent under the Contract within 30 days from the date of birth, date of placement .. ..,;, n for additional =.•*For out-of-network benefits,.inaddition�tothe deductible and coinsurance,your are responsible for for adoption, or date of adoption. Please refer to Eligibility And Enrollment � � , _ 7 , _ .., ,•� , ' any�charges in excess of,the non network`provider�rye mbursement amount Additionally,these information. charges will not be applied toward satisfaction of they deductible or the out-of-pocket maximum � ! • In-network benefits apply to maternity services received from a network provider. Out-of-network benefits apply to maternity services received from a non-network provider. In 1. Prenatal services • addition to the deductible and coinsurance described for out-of-network benefits, you will be a. Office visits for prenatal care, Nothing. The deductible 50% coinsurance responsible for any charges in excess of the non-network provider reimbursement amount. including professional does not apply. The out-of-pocket maximum does not apply to these charges. Please see Important services, lab, pathology, member information about out-of-network benefits in How To Access Your Benefits for more x-rays, and imaging information and an example calculation of out-of-pocket costs associated with out-of- b. Hospital and ambulatory Nothing. The deductible 50% coinsurance network benefits. surgical center services for does not apply. prenatal care, including professional services received during an inpatient stay for prenatal care MIC PP MN HSA (3/12) 30 1500-100% MIC PP MN HSA(3/12) 31 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Maternity Services Medical-Related Dental Services � a mm Your Benefits and the,Amounts You Pay � . � L. Medical-Related Dental Services Benefits ;, n-network benefits - Out of-network benefits d after deductible �� �__ after deductible � �°. � This section describes coverage for medical-related dental services. Services must be received from a physician or dentist. For out-of network benefits in addition to the deduct ble and cc surence,you are responsible o c : . - ° v der:reimbursement;amount Adti ttonally,these This section does not describe coverage for comprehensive dental procedures. Comprehensive any charges in excess.of:the non�n�ork pro,. �� �,. .- �� �",,,� �.���.K -_ ar s will not e a tied oi4rd at�sfaction of the deductible pi the out'of pocket�rheximum �� dental procedures are services rendered by a dentist to treat teeth, their supporting soft t" pP pe 9 ft issue and bony structure, or the alignment or occlusion of the teeth. These services are not covered under c. Intermittent skilled care or Nothing. The deductible 50% coinsurance any section of this certificate. home infusion therapy when does not apply. See=Deifinitioris These'words haves cific meanies benefits *coins man ° `' ' you are homebound due to a .-: �� ,T � ur ce, deductible, high risk pregnancy dependent,hospitals member, network, on-netwoork-..noe network rovide reimbursement'•amountspiysic�an. provider 2. Inpatient hospital stay for labor Nothing 50% coinsurance Prior authorization. Prior authorization from Medica may be required before you receive and delivery services services or supplies. Call Customer Service at one of the telephone numbers listed inside the Please note: Maternity labor and front cover. See How To Access Your Benefits for more information about the prior authorization delivery services are considered inpatient services regardless of the process. length of hospital stay. 3. Professional services received Nothing 50% coinsurance Covered during an inpatient stay for labor and delivery For benefits and the amounts you pay, see the table in this section. More than one coinsurance 4. Anesthesia services received Nothing 50% coinsurance may be required if you receive more than one service or see more than one provider per visit. during an inpatient stay for labor • In-network benefits apply to medical-related dental services received from a network and delivery provider. 5. Labor and delivery services at a • Out-of-network benefits apply to medical-related dental services received from a non- freestanding birth center network provider. In addition to the deductible and coinsurance described for out-of-network o 50/o coinsurance benefits, you will be responsible for any charges in excess of the non-network provider a. Facility services for labor and Nothing reimbursement amount. The out-of-pocket maximum does not apply to these charges. delivery Please see Important member information about out-of-network benefits in How To Access b. Professional services Nothing 50% coinsurance Your Benefits for more information and an example calculation of out-of-pocket costs received for labor and associated with out-of-network benefits. delivery 6. Home health care visit following Nothing. The deductible 50% coinsurance Not covered delivery does not apply. Please note: One home health visit These services, supplies, and associated expenses are not covered: is covered if it occurs within 4 days 1. Dental services to treat an injury from biting or chewing. of discharge. If services are received after 4 days, please refer 2. Osteotomies and other procedures associated with the fitting of dentures or dental implants. to Home Health Care for benefits. 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. MIC PP MN HSA (3/12) 32 1500-100% MIC PP MN HSA (3/12) 33 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Medical-Related Dental Services Medical-Related Dental Services 7. Any dental procedures or treatment related to periodontal disease. ,,- ' Your Benefits and the Amou to s You Pa 8. Endodontic procedures and treatment, including root canal procedures and treatment, unless provided as accident-related de ntal services as described in this section. � Benefits a =�� , " In-network benefits k Outlof netv+rork benefits . � � 9. Routine diagnostic and preventive dental services. ' 3 � after deductibles after deductible , . and associated expenses that are not See Exclusions for additional services, supplies, an as p For out-of-network benefits, . in�aticlton.tothe deduitible and coinsurance you are respariE s rblefor covered. _any charges in excessHof the nan netwok provider reimbursement amount. Additionally;these charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum r; 3. Accident-related dental services Nothing 50% coinsurance 1 .3 Your Benefits and the:Amounts You Pay - i3 to treat an injury to sound, 9 f i -- ```Outs--oof network benefits natural teeth and to repair (not Benefats, , . ` in-netniot�k benefits _ replace) sound, natural teeth. after deductible e fter d edu ct�b le � 1 T h e following conditions apply: * For out-of-network benefits, in addition to the deductible and coinsurance,y�ouare responsiblefor �' ' a. Coverage is limited to any charges excess of:tthhe non-network provider reimbursement amount Additionally',these services received within 24 charges will not be applied toward satisfaction of the deductible or;the out-of-pocket maximum ; I months from the later of: 1. Charges for medical facilities Nothing 50% coinsurance i. the date you are first and general anesthesia services covered under the that are: Contract; or a. Recommended by a ii. the date of the injury physician; and . b. A sound, natural tooth means • b. Received during a dental a tooth (including supporting structures) that is free from procedure; and disease that would prevent c. Provided to a member who: continual function of the tooth i. Is a child under age five for at least one year. (prior authorization is not In the case of primary (baby) required); or teeth, the tooth must have a ii. Is severely disabled; or life expectancy of one year. iii. Has a medical condition 4. Oral surgery for: Nothing 50% coinsurance and requires a. Partially or completely hospitalization or general unerupted impacted teeth; or anesthesia for dental care treatment b. A tooth root without the Please note: Age, anxiety, extraction of the entire tooth and behavioral conditions (this does not include root I are not considered medical canal therapy); or conditions. c. The gums and tissues of the 2. For a dependent child, Nothing 50% coinsurance mouth when not performed in orthodontia, dental implants, and connection with the oral surgery treatment related to extraction or repair of teeth cleft lip and palate i o MIC PP MN HSA(3/12) 34 1500-100% MIC PP MN HSA (3/12) 35 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Mental Health Mental Health f. Residential treatment services. These services include either: i. A residential treatment program serving children and adolescents with severe emotional M. Mental Health disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic This section describes coverage for services to diagnose and treat mental disorders listed in the services. In addition to room and board, at least 30 hours a week per individual of current edition of the Diagnostic and Statistical Manual of Mental Disorders. For a description of mental health services must be provided, including group and individual counseling, coverage for the diagnosis and primary treatment of substance abuse disorders, see Substance client education, and other services specific to mental health treatment. Also, the Abuse. program must provide an on-site medical/psychiatric assessment within 48 hours of "' 5 :` benefiits claim corisiararcecustodial admission, psychiatric follow-up visits at least once per week, and 24-hour nursing Seed©efin�tloRS These wards have specific meaEngs :, , gi ew , � �f � coverage. care, deductible, emergency, hospital, mpatientrnedrealty necessary memlrmental dlsarder net work, non-network, Wort networ provider reimilc.rsement amount, pravideii Prior authorization. For prior authorization requirements of in-network and out-of-network Covered benefits, call Medica's designated mental health and substance abuse provider at For benefits and the amounts you pay, see the table in this section. More than one coinsurance 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center may be required if you receive more than one service or see more than one provider per visit. 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. • For in-network benefits: For purposes of this section: Medica's designated mental health and substance abuse provider arranges in-network mental 1. Outpatient services include: health benefits. If you require hospitalization, Medica's designated mental health and a. Diagnostic evaluations and psychological testing. substance abuse provider will refer you to one of its hospital providers (Medica and Medica's b. Psychotherapy and psychiatric services. designated mental health and substance abuse provider hospital networks are different). c. Intensive outpatient programs, including day treatment, meaning time limited For claims questions regarding in-network benefits, call Medica's designated mental health comprehensive treatment plans, which may include multiple services and modalities, and substance abuse provider Customer Service at 1-866-214-6829. delivered in an outpatient setting (up to 19 hours per week). For out-of-network benefits: d. Treatment for a minor, including family therapy. 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 e. Treatment of serious or persistent disorders. licensed, certified, or otherwise qualified under state law to provide the mental health f. Diagnostic evaluation for attention deficit hyperactivity disorder(ADHD) or pervasive services and practice independently: development disorders (PDD). a. Psychiatrist 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 b. Psychologist psychologist and that includes an individual treatment plan. c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric h. Treatment of pathological gambling. and mental health nursing 2. Inpatient services include: d. Mental health clinic a. Room and board. e. Mental health residential treatment center b. Attending psychiatric services. f. Independent clinical social worker c. Hospital or facility-based professional services. g. Marriage and family therapist d. Partial program. This may be in a freestanding facility or hospital based. Active treatment j h. Hospital that provides mental health services is provided through specialized programming with medical/psychological intervention and 2. Emergency mental health services are eligible for coverage under in-network benefits. supervision during program hours. Partial program means a treatment program of 20 hours In addition to the deductible and coinsurance described for out-of-network benefits, you will or more per week and may include lodging. be responsible for any charges in excess of the non-network provider reimbursement e. Services, care, or treatment described as benefits in this certificate and ordered by a court amount. The out-of-pocket maximum does not apply to these charges. Please see on the basis of a behavioral health care evaluation performed by a physician or licensed Important member information about out-of-network benefits in How To Access Your psychologist and that includes an individual treatment plan. MIC PP MN HSA (3/12) 36 1500-100% MIC PP MN HSA (3/12) 37 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Mental Health Mental Health Benefits for more information and an example calculation of out-of-pocket costs associated ¢` g•with out-of-network benefits. :Your Benefits and the Amounts ou Pay�q� °.-Benefits � � ; in network benefits * Out-of-network-benefits Not covered - �, i,after deductible �aftef�deductrbleA � These services, supplies, and associated expenses are not covered: m - -. #,, , _ _ z �s; For out-of network benefits, in addition to.thedeductible and co�nsurance,,you.are responsible for 1. Services for mental disorders not listed any char es in excessof=the non-network provider reimbursement a iiount ddit onall hese ted in the current edition of the Diagnostic and Statistical Y c, r,1"g. T p Manual of Mental Disorders. charges will not be applied toward satisfaction of the deductible.or the out-o#-pocket maximum � `, � . gym 0� ,rmti�,�� , r.._ 2. Services for a condition when there is no reasonable expectation that the condition will 1. •Office visits, including Nothing 50% coinsurance improve. evaluations, diagnostic, and 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as treatment services specifically described in this section. 2. Intensive outpatient programs Nothing 50% coinsurance 4. Relationship counseling. 3. Inpatient services (including 5. Family counseling services, except as specifically described in this certificate as treatment residential treatment services) for a minor. a. Room and board Nothing 50% coinsurance 6. Services for telephone psychotherapy. b. Hospital or facility-based Nothing 50% coinsurance 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, professional services as those conditions are defined in the current edition of the American Psychiatric c. Attending psychiatrist Nothing 50% coinsurance Association's Diagnostic and Statistical Manual of Mental Disorders. services 8. Services, including room and board charges, provided by health care professionals or d. Partial program Nothing 50% coinsurance 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 PP MN HSA(3/12) 38 1500-100% MIC PP MN HSA (3/12) 39 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Miscellaneous Medical Services And Supplies Miscellaneous Medical Services And Supplies e ter Your Benefits and the Amounts You Pay s N. Miscellaneous Medical Services And Supplies Benefits - - • to network benefits *Out-of network benefits afterdeductible aftedeductible 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 *For out of-networiebenefits,in° addition to the deductible and-coinsurance, ou!are res onsibie,for. supplies that meet the criteria established by Medica. Some items ordered by a physician, even any charges in.excess of':the non-network provider reimbursement amount. Additio ll these if medically necessary, may not be covered. charges will not be applied toward satisfaction-471.111e deductible-or the out-of-pocket maximum FE[,� �� ice, .___.� �h _._.__...._._ �~ 'See Definitions These words have specific meanings benefits,,coinsurance, deductible; 1. Blood clotting factors Nothing 50% coinsurance � . g g /° comsurance iedicaiiynEcessary, ne work, non network, non-network provider reimbursementamount, physician, provider 2. Dietary medical treatment of Nothing 50% coinsurance phenylketonuria (PKU) Prior authorization. Prior authorization from Medica may be required before you receive 3. Amino acid-based elemental Nothing 50% coinsurance services or supplies. Call Customer Service at one of the telephone numbers listed inside the formulas for the following front cover. See How To Access Your Benefits for more information about the prior • authorization process. diagnoses: a. cystic fibrosis; Covered b. amino acid, organic acid, and fatty acid metabolic and For benefits and the amounts you pay, see the table in this section. More than one coinsurance malabsorption disorders; may be required if you receive more than one service or see more than one provider per visit. c. IgE mediated allergies to • In-network benefits apply to miscellaneous medical services and supplies received from a food proteins; network provider. d. food protein-induced • Out-of-network benefits apply to miscellaneous medical services and supplies received from enterocolitis syndrome; a non-network provider. In addition to the deductible and coinsurance described for out-of- e. eosinophilic esophagitis; 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. f. eosinophilic gastroenteritis; Please see Important member information about out-of-network benefits in How To Access and Your Benefits for more information and an example calculation of out-of-pocket costs g. eosinophilic colitis. associated with out-of-network benefits. Coverage for the diagnoses in 3.c.-g. above is limited to Not covered members five years of age and Other disposable supplies and appliances, except as described in Durable Medical Equipment younger. And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program. 4. Total parenteral nutrition Nothing 50% coinsurance See Exclusions for additional services, supplies, and associated expenses that are not 5. Eligible ostomy supplies Nothing 50% coinsurance covered. 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 PP MN HSA (3/12) 40 1500-100% MIC PP MN HSA (3/12) 41 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services Not covered O. Organ And Bone Marrow Transplant Services These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow,transplant services except as described in this section. This section describes coverage for certain organ and bone marrow transplant services. 2. Supplies and services related to transplants that would not be authorized by Medica under Services must be provided under the direction of a network physician and received at a the medical criteria referenced in this section. designated transplant facility. This section also describes benefits for professional, hospital, 3. Chemotherapy, radiation therapy, drugs, or any therapy used to damage the bone marrow and ambulatory surgical center services. Coverage is provided for certain types of organ transplants and related services (including and related to transplants that would not be authorized by Medica under the medical criteria g P yp g p ( g referenced in this section. organ acquisition and procurement) and for certain bone marrow transplant services that are appropriate for the diagnosis, without contraindications, and non-investigative. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. See Definitions Thesewords have specific meanings: benefits,,coinsurance,deductible, E � 5. Islet cell transplants except for autologous islet cell transplants associated with hospital, inpatient, investigativ medically necessary member network, non network, non- network pr000vvider3reimbursementamount, physician,pprovider,virtual re pancreatectomy. � } � 6. Services required to meet the patient selection criteria for the authorized transplant Prior authorization. Prior authorization from Medica is required before you receive services or 1 procedure. This includes treatment of nicotine or caffeine addiction, services and related supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. I expenses for weight loss programs, nutritional supplements, appetite suppressants, and See How To Access Your Benefits for more information about the prior authorization process. supplies of a similar nature not otherwise covered under this certificate. Covered 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. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 8. Transplants and related services that are investigative. may be required if you receive more than one service or see more than one provider per visit. 9. Private collection and storage of umbilical cord blood for directed use. Medica uses specific medical criteria to determine benefits for organ and bone marrow I 10. Drugs provided or administered by a physician or other provider on an outpatient basis, transplant services. Because medical technology is constantly changing, Medica reserves the except those requiring intravenous infusion or injection, intramuscular injection, or right to review and update these medical criteria. Benefits for each individual member will be - intraocular injection. Coverage for drugs is as described in Prescription Drug Program and determined based on the clinical circumstances of the member according to Medica's medical ! Prescription Specialty Drug Program or otherwise described as a specific benefit in this criteria. certificate. ■ Coverage is provided for the following human organ transplants, if appropriate, under Medica's See Exclusions for additional services, supplies, and associated expenses that are not medical criteria and not otherwise excluded from coverage (see Not covered below): cornea, I covered. 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. Your Benefits and the Amounts You,Pay . The preceding is not a comprehensive list of eligible organ and bone marrow transplant r � . � � � � � _ , , services. Benefits �° e ,„' In-network benefits *.Out of-network:benefits , � _' >° after deductible • In-network benefits apply to transplant services provided by a network provider and received after deductible at a designated transplant facility. A designated transplant facility means a hospital that has 1 � . - ;r __ . >.� ,. entered into a separate *For_out-of network benefits, in addition to the deductibleiand coinsurance,you are,responsible:for parate contract with Medica to provide certain transplant-related health �• �-� any charges-in excess of the non network provider reimbursement amount. Additionally,these ;`. services to members receiving transplants. You may be evaluated and listed as a potential g Will - � . the - ° � xi _ • . . . P , charges�will not be applied toward satisfaction of the deductible or theout-of-pc�ket maximum.. recipient at multiple designated facilities for transplant services. Medica requires that all pre-transplant, transplant, and post-transplant services, from the 1. Office visits Nothing No coverage time of the initial evaluation through no more than one year after the date of the transplant, 2. Virtual care Nothing No coverage 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 PP MN HSA (3/12) 42 1500-100% MIC PP MN HSA(3/12) 43 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services ., ...,.,. ♦., ....mss._.. ..._._ ,,. ._._ .L._.z._....., v:. ..«.:.H. ^^_.,, � _. .... _._.. ...._. -..ti .� ..x....i.._ ___ ...fir•__^ ^ .: ., ,__..._._�.. � < s,,.. t.. . . r ; .i .Sk .d..._ ,_. ac,.>...... • .`.._... _...... ._.....-.�.-:..2...v...,_ You r Ben: e fits_x. ajn dt �the As..n,._...,.<-a us-.s>n..,:. tsl3Y+o..u._....P a, 7t .mo .. � ..-- � . , 1(our Benef�ts and the.�Amounts,�.Y o' Pa �-� = r ,^E ` `3 . _ < _ _ _ r 5,!7 .- ...:.;=,:' a7 x . ' ; ^ , _ ix te £ R...... . ... _.„,.^,..._.....s-...,..,..,_.f . a+ yy. .. f ...,. -.L.' Benefits ...s a-.._;<�3 r -< . d�k .e,. a3:+. .t. , .« - .� ..,.,1 . .E. o ne..}twork benef.ts .x. . �.' . Outof netwo<rk benefW i#s e e is >. F< _ .�n 1 � 1 In-n etwor benef�ts . �� � Ou# f_networ k bane #s i aa' . ?_< .' ^. . s-$,F,."="'.,,- ._..4 � A. ?x ^., v . a x l � ..r . F a _ ^ . ?�,. Yh,gy � F ba =1::14''' ''' ibl ill--#1: .7_ _ _. after d eductible after d , �3 - a. > _ �3 � ,after deductile _ . after deductible ••„1:004.--z,..,_,.zti'. .r aa x c .. L _...... �'....___......,-<... _ ,..,.-n_ t__ _. .2xE�. E s„ __..:_;:: « .il't )'.' »,:.:. r ,. ...<_. "� _x ,...__. .._ _...._ .,..,..». •..1.... .,:s = _._ ,:'«�. », __.<. .._. .... . ...._ ._. .. _,< . ..._.. ...£......_._._._« _ :::-.., .. _ _...:... deductible,_. . . - ._.3 __ .,.�_ :..: For.outer#ne or ..b � ^_._. 7� _,o # #- e#vjc r benefi in addition to:. .an msur ce. ou_ mre ns le:_f . . tw k eneflts in addition to ;deductible^.and. rn ranee 3 ., _ .._ <.., or.._ u -c n o k, is .r a the d<ca an ace s o ib or _.,. _.. _.. _ca su you:are nsbiefor , ^>- .. ._.. ..... ....... .._. _-.-. __.^.. _., char esrrn exces _of._th on e a hac . .. excess . provider......^3... „_..__.,..•..... �?_.....•......_,.u ... ...x x..,. ._._...x..�....�r'.•� ...^......._ _.......: x.....;1 x, _..t 1:... s .._a�... __- ,�+( �. - 4 < ... ._:_.. �'<'.F..,..•^..- , _.34th �y.+... > ., ;E1� ., .....f.. ... .:... x.atxf.;, : .._. ,> � +^... char - m .; < „_ es-wilt not be_a tied ' _ �. : _:, _ .,char es_wrii�not bea. Ired t-war-d satisfaction-of;- he�deductrb#e,>or he�out-of= ocket' axrmum: toward atisfactron of deductrbie.or_ he, ut-of ck �, o t t ,•m o et maxrmu _._. . m. . ...xx '” _ �...x<.�.. �<���F&°S� �,.< 4.d,?dl�l 3rs7.�s�ff a � ..,.z '"._ �.: .. ,..., t F .. .^ ^. _ at...�£�i,. .. _. ; -.1.,:3 ... .,rgh, t.E ..< 3. Outpatient services 5. Services received from a Nothing No coverage a. Professional services physician during an inpatient stay i. Surgical services (as Nothing No coverage I 6. Anesthesia services received Nothing No coverage defined in the Physicians' from a provider during an Current Procedural Terminology code book) inpatient stay received from a physician I 7. Transportation and lodging The deductible does not No coverage during an office visit or an apply to this a. As described below, outpatient hospital visit reimbursement benefit. reimbursement of reasonable You are responsible for ii. Anesthesia services Nothing No coverage and necessary expenses for paying all amounts not received from a provider travel and lodging for you during an office visit or an 1 and a companion when you reimbursed under this outpatient hospital or receive approved services at benefit. Such amounts ambulatory surgical a designated facility for do not count toward your center visit transplant services and you out-of-pocket maximum live more than 50 miles from or toward satisfaction of iii. Outpatient lab and Nothing No coverage that designated facility your deductible. pathology i. Transportation of you and iv. Outpatient x-rays and Nothing No coverage one companion (traveling other imaging services on the same day(s)) to v. Other outpatient hospital Nothing No coverage 1 and/or from a designated services received from a facility for transplant physician I services for pre- vi. Services related to Nothing No coverage transplant, transplant, human leukocyte antigen and post-transplant testing for bone marrow I services. If you are a transplants minor child, transportation expenses b. Hospital and ambulatory for two companions will surgical center services be reimbursed. • i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x-rays and Nothing No coverage I other imaging services iii. Other outpatient hospital Nothing No coverage services 4. Inpatient services Nothing No coverage MIC PP MN HSA (3/12) 44 1500-100% MIC PP MN HSA (3/12) 45 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 I Organ And Bone Marrow Transplant Services Physical, Speech, And Occupational Therapies moo. <q 4x -:"A?-1°%i" s `' _ _� : Your Benefits and the-ArxlountsYou Payt ::1 P. Physical, Speech, And Occupational Therapies i a Benefits - ' ti In network benefits `` *Ou# of•netwo_rk=benefits afterdeductible� after deductible r This section describes coverage for physical therapy, speech therapy, and occupational therapy x For out-of-networlcben of ' � _.e. d of y_ EE, ea n - services provided on an outpatient basis. A physician must direct your care in order for it to be ... neits, inadd�tionpto the deductil�leand�cornsurar►ce,youareresponsblefot p P p Y Y any.charges:rn excess of the non netwo rk ro id . r -n �:.t di l charges r p y der rembursement.arnount,�Addrtionall ,these � �j eligible for coverage. Coverage for services provided on an inpatient basis is as described charges will not be applied�toward satisfaction offtthe deductible orthelout-o#pocket maximum - elsewhere in this certificate. F ■ • ii. Lodging for you (while not See Defirt/flOnS These words;have specific' pecific,meartings _benefits,=col.nsurarrce, deductible, confined) and one in-patient, network, n nor-network, non_,network=provider:reimbursement amount,..physician, companion. Reimbursement is Prior authorization. Prior authorization from Medica may be required before you receive available for a per diem services or supplies. Call Customer Service at one of the telephone numbers listed inside the amount of up to $50 for front cover. See How To Access Your Benefits for more information about the prior authorization process. one person or up to $100 for two people. If you are a minor child, Covered reimbursement for lodging expenses for two For benefits and the amounts you pay, see the table in this section. More than one coinsurance companions is available, may be required if you receive more than one service or see more than one provider per visit. up to a per diem amount • In-network benefits apply to outpatient physical therapy, speech therapy, and occupational of$100. therapy services arranged through a physician and received from the following types of iii. There is a lifetime • network providers: physical therapist, speech therapist, occupational therapist, or physician. maximum of$10,000 per • Out-of-network benefits apply to outpatient physical therapy, speech therapy, and member for all occupational therapy services arranged through a physician and received from the following transportation and types of non-network providers: physical therapist, speech therapist, occupational therapist, lodging expenses or physician. In addition to the deductible and coinsurance described for out-of-network incurred by you and your benefits, you are responsible for any charges in excess of the non-network provider companion(s) and reimbursement amount. The out-of-pocket maximum does not apply to these charges. reimbursed under the I Please see Important member information about out-of-network benefits in How To Access Contract or under any I Your Benefits for more information and an example calculation of out-of-pocket costs other Medica, Medica associated with out-of-network benefits. Health Plans, or Medica Health Plans of Not covered Wisconsin coverage offered through the same employer. These services, supplies, and associated expenses are not covered: b. Meals are not reimbursable 1. Services primarily educational in nature. under this benefit. 2. Vocational and job rehabilitation. 3. Recreational therapy. 4. Self-care and self-help training (non-medical). 5. Health clubs. 6. Voice training. 7. Group physical, speech, and occupational therapy. MIC PP MN HSA(3/12) 46 1500-100% MIC PP MN HSA(3/12) 47 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Physical, Speech, And Occupational Therapies , Physical, Speech, And Occupational Therapies 1 8. Physical, speech, or occupational therapy services (including but not limited to services for ; 4 � �` � - �€ f3 = the correction of speech impediments or assistance in the development of verbal clarity) '+ — �'' =Your1Benefits andgthe�Amoun s You Pays i ° wpb_ ,_ ._. when there is no reasonable expectation that the member's condition will improve over a � _ P r. ,.. �, I, predictable period of time according to generally accepted standards in the medical Benefits� a In network benefits *Out-ofnetworkbenefits p P g g Y p �� f� � � � �� � - F �� ��� community. = y. � � � � ���� `a� �g��� �4 �h � after deduct�bl'e��` E�� � �after�deductible� 9. Massage therapy, provided in any setting, even when it is part of a comprehensive * � "R �' _ For°out-of network'b`enefi#s, irraddition to the4deductibleaand comsurance,�you 117-,!.: ,,, P,°-`1--::::----,::...:...,ssible for•treatment plan. any charges in exc ss of the€non network provider reimbursem nt amount Additio lly,th . �' ..,a«m �axe �,_ a � R4^.' n "`� a ro ;� See Exclusions for additional services, :charges will-not be aj plied toward=satisfaction of the deductible°or the out-of-pocket maximum. se ices, supplies, and associated expenses that are not covered. 3. Occupational therapy received Nothing 50% coinsurance. outside of your home when Coverage for physical physical function is impaired due and occupational therapy �--- , Your BOtefitti'and-thiiiiArrtounts You Pay , : k =- to a medical illness or injury or is limited to a combined . is . :�z congenital or developmental limit of 20 visits per Benefits In network benefits y � �,� � *Out o#-ne#vvorkAbenefits �. conditions that have delayed calendar year. after deductiblexPafte deductible #r motor development Please note: This visit limit z x 3Y 3 , 3 includes physical and *For out of-network benefits in addition to the�c eductible and coinsurance ou are res onsible fog occupational therapy visits � - �� �=" �y p that you pay for in order to any charges in excess oftthe=`non network provider reimbursement amount Additionally,then Y p Y charges willinot be applied toward satisfaction of�,the deductible or-the out-of pocket maximum . _: .'r_ , ._ mm - . i .' ' deductible. rt o y your �� � ;, a.. ��� satisfy any part of o 1. Physical 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 j includes physical and occupational therapy visits that you pay for in order to I satisfy any part of your deductible. 2. Speech therapy received outside Nothing 50% coinsurance. Ii of your home when speech is Coverage for speech . impaired due to a medical illness therapy is limited to 20 I� 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 j your deductible. • MIC PP MN HSA (3/12) 48 1500-100% MIC PP MN HSA(3/12) 49 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 1 Prescription Drug Program rescription Drug Program will improve the coverage by only one tier. Exceptions to the PDL can also include Q. Prescription Drug Program 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, This section describes coverage for prescription drugs and supplies received from a pharmacy call Customer Service at one of the telephone numbers listed inside the front cover. or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" i is meant to include those prescription drugs and supplies found on the Preferred Drug List Prior authorization (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 Certain covered drugs require prior authorization as indicated on the PDL. The provider,who "professionally administered drugs" means drugs requiring intravenous infusion or injection, prescribes the drug initiates prior authorization. The PDL is made available to providers intramuscular injection, or intraocular injection; the phrase "self-administered drugs" means all including pharmacies and the designated mail order pharmacies. You are responsible for other drugs. For the definition and coverage of specialty prescription drugs, see Prescription paying the cost of drugs received if you do not meet Medica's authorization criteria. Specialty Drug Program. Seel/et/nit ons These words have specific meanings benefits, claim coinsurance, , ... Step therapy deductible, d urableme d�ic a le qu ip_men t, emergency,rh`os p ita=l m ember, network non-network;reimbursement amount physician, p rescrip tion d rug, preventive health Medica requires step thera py prior i vte o ccoovveerread g e d rouf g s fpiersct if(itc y pdircuagls y aa s Tiniedr i c1 a dterd u go)n b tehfe o rPe DmLo.vSintg e p thera py i nvolves trying an alternaservice, provider, urgent care center. 1 , _ , on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable Preferred drug list step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 Quantity limits covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits Tier 1 is your lowest coinsurance option. For the lowest out-of-pocket expense, you should indicate the maximum quantity allowed per prescription over a specific time period. Some consider a Tier 1 covered drug if you and your physician decide it is appropriate for your quantity limits are based on packaging, FDA labeling, or clinical guidelines. treatment. Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your Covered 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 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 process described in this certificate. you pay, see the benefit table at the end of this section. Please note that Prescription Drug If you have questions about Medica's PDL or whether a specific drug is covered (and/or the PDL Program describes your coinsurance for prescription drugs themselves. An additional tier in which the drug may be covered), or if you would like to request a copy of the PDL at no coinsurance applies for the provider's services if you require that a provider administer self- charge, call Customer Service at one of the telephone numbers listed inside the front cover. administered drugs, as described in other applicable sections of this certificate including, but not The PDL is also available when you sign in at www.mymedica.com. limited to, Hospital Services, Infertility Diagnosis, and Professional Services. 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) a pproval, manufacturers' packaging guidelines, and In-net w oF�r r- k ben efi'ts Out-of-network ben e f its' M__ail:order benefits** clinical publications. These medication request guidelines, as well as the PDL, are periodically Covered drugs received at a ed d reviewed and modified by Medica. In addition to the medication request guidelines, Medica network pharmacy; and non-nCoveretwork rugs pharmacy;received and at a a Covered designated drugs mail re order from assigns a tier to each drug based on a review of the drug's cost and effectiveness. pharmacy; and Exceptions p ns 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 PP MN HSA (3/12) 50 1500-100% MIC PP MN HSA (3/12) 51 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 i Prescription Drug Program Prescription Drug Program Three prescription units may be dispensed for covered drugs prescribed to treat chronic to network benefits: — Out-of-network benefit's* Mail order benefits* , 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 Covered drugs for family See In-network benefits Covered drugs for family at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside planning services or the column. planning services or the the front cover. treatment of sexually treatment of sexually transmitted diseases when transmitted diseases when Not covered prescribed by or received from prescribed by either a either a network or a non- network or a non-network The following are not covered: network provider. Family provider and received from a planning services do not designated mail order 1. Any amount above what Medica would have paid when you fail to identify yourself to the include infertility treatment pharmacy. Family planning pharmacy as a member. (Medica will notify you before enforcement of this provision.) services; and services do not include 2. OTC drugs not listed on the PDL. infertility treatment services; and 3. Replacement of a drug due to loss, damage, or theft. Diabetic equipment and Diabetic equipment and Diabetic equipment and 4. Appetite suppressants. supplies, including blood supplies, including blood supplies (excluding blood 5. Erectile dysfunction medications. 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 6. Non-sedating antihistamines and non-sedating antihistamine/decongestant combinations. and pharmacy. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and Tobacco cessation products Tobacco cessation products Not available. those members who have a feeding tube. when prescribed by a provider when prescribed by a provider 8. Tobacco cessation products or services dispensed through a mail order pharmacy. authorized to prescribe the authorized to prescribe the product and received at a product and received at a non- 9. Drugs prescribed by a provider who is not acting within his/her scope of licensure. network pharmacy. network pharmacy. 10. Homeopathic medicine. 11. Infertility drugs. * 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- 12. Specialty prescription drugs, except as described in Prescription Specialty Drug Program. network provider reimbursement amount. The out-of-pocket maximum does not apply to See Exclusions for additional drugs, supplies, and associated expenses that are not these charges. Please see Important member information about out-of-network benefits in covered. 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: Some drugs and supplies are not available through the designated mail order pharmacy. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Prescription Specialty 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 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 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. MIC PP MN HSA(3/12) 52 1500-100% MIC PP MN HSA(3/12) 53 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Prescription Drug 9 Program r am Prescription Drug Program } r ..:,: , You � . _. .� . � � � Your. a,,.'. .. Amounts You Pay �, r. � _ Your Beneftts,-and°,the„;•Amounts YOU Ply./ SOU _ .:.,. tworkabe addition ;” refits,>_m �t • : :, ,s �. � . o the deductible . ,. uctrble.and corn ., 'any Charges � f.. -.,. � coinsurance, :.:, � * ;. r e z e you are �� : . _ . g s m„ex A lly,these-rble,for r F r> u# o -network.,benefi s n adds e, c r c i an ,w-. �. ..: cess_o#th - _: ,. x . o o f t ,-i ton:to th dedu t ble and o nsur ce,. ou are res onsrble for enon network rovsder reimbursement xch e ; p ar „ , „ amo - I` , , ges�ws!� T_ amount Additionally, .,-:�._.” ' � _ - : � ... l not - . deductible.. ,�these���. _ i x ' h _n n n r: v . r r m n ' m n be applied ,. x Y -., F�_ , an. char es en cess oft a o etwo k ro rde ei burseme t a au t,,,Addrtronall ; .,Y g p Y►these pp,, ed toward satisfaction of .�. - >. . the , duct}ble ,�-�"=�. ,.- . .r. � _. . _ . . ,.. _ or the out f- ,fr, �� ,. � ^ p maximum. ., x�..�, :.. .:, chase s-w�l! not be:a Iced toward-satrs#actson o#.the deductsble orthe,ouf-of ocket . , �,. maximum. il£tW0 � � [ be „x. Out,.... _, v of networ of - >.m a .,�... �� t" :. � . k benefits a„ .� �,., s. . R_.. „. after*.d Malt order benefits .a;., *. a ' educ '� �" .. �. =:: : _ ne#its . > n:F�����, ,, _ ,�,�..�.. trbf �.,.. �.:., _,_,.., . . ,_ , ,� F: In network.benefrts - „_�_ e _ �Outof network_.benefits._ ,Marl order benefr s - � .- ,.. . . after � .. ,_�. ' ,, a�- ��,. x �"= deductible : ,F after deductible after ,. after. deductf 1. Outpatient covered drugs other than those described below or in Prescription Specialty Drug 4. D v Program g rugs and other supplies (other than tobacco cessation products) considered preventive Tier 1: Nothing health services, as specifically defined in Definitions, when prescribed by a provider g per 50% coinsurance per Tier 1: Nothing per z to pie uh u prescription unit; or prescription unit authorilimited. For ed the rescr current bs list c of such drugs. drugs This group and supplieof drs,gs please and refer supplies is specific and to the Preventive Drug prescription unit; or Tier 2: Nothing per and Supply List within the PDL or call Customer Service at one of the telephone numbers listed prescription unit; or Tier 2: Nothing per inside the front cover. Tier 3: prescription unit; or No coverage Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per 2• Diabetic equipment and supplies, including blood glucose meters Tier 3: No coverage prescription unit; or prescription unit prescription unit; or Tier 2: Nothing per Tier 2: Nothing per Tier 1: Nothing per 50% coinsurance per Tier 1: Nothin prescription unit; or prescription unit; or prescription unit; or prescription unit 9 per prescription unit; or Tier 3: No coverage Tier 3: No coverage Tier 2: Nothing per prescription unit; or Tier 2: Nothing per The deductible does not The deductible does not prescription unit; or apply. apply. Tier 3: No coverage Tier 3: No coverage 3• 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 PP MN HSA (3/12) 54 1500-100% MIC PP MN HSA(3/12) 55 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Prescription Specialty Drug Program Prescription Specialty Drug Program Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also include antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and R. Prescription Specialty Drug Program 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 This section describes coverage for specialty prescription drugs received from a designated process, call Customer Service at one of the telephone numbers listed inside the front cover. 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 Prior authorization specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as Certain s pecialt y prescription drugs require prior authorization. The provider who prescribes the described below. For purposes of this section, the phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular specialty drug initiates prior authorization. The SPDL is made available to providers, including injection; the phrase "self-administered drugs" means all other drugs. designated specialty pharmacies. You are responsible for paying the cost of specialty See Definitions These words haves specific megrims prescription drugs you receive if you do not meet Medica's authorization criteria. ' e s pe 9 benefits, claim coinsurance, = .deductible, network, physician; prescription drug,sprovider k f I Step therapy Designated specialty pharmacies Medica requires step therapy prior to coverage of specific specialty prescription drugs as A designated specialty pharmacy means a specialty pharmacy that has entered into a separate indicated on the SPDL. Step therapy involves trying an alternative covered specialty contract with Medica to provide specialty prescription drug services to members. For the prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other current list of designated specialty pharmacies, call Customer Service at one of the telephone Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. numbers listed inside the front cover or sign in at www.mymedica.com. p Applicable step therapy requirements must be met before Medica will cover certain Tier 1 or Tier 2 specialty prescription drugs. Specialty preferred drug list Quantity limits 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 Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. classified by Medica as a Tier 1 or Tier 2 specialty g These limits indicate the maximum quantity allowed per prescription over a specific time period. prescription drugs on Medica's SPDL are eligible for benefits under this certificate.only specialty Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. Covered If you have questions about Medica's SPDL or whether a specific specialty prescription drug is For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to covered (and/or the SPDL tier in which the drug may be covered), or if you would like to request a specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed received from a designated specialty pharmacy. inside the front cover. The SPDL is also available by signing in at www.mymedica.com. This section describes your coinsurance for specialty prescription drugs. An additional Medica utilizes medication request guidelines to determine whether a specialty prescription drug coinsurance applies for the provider's services if you require that a provider administer self- should be covered. Medica's medication request guidelines are based on United States Food administered drugs, as described in other applicable sections of this certificate including, but not and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical limited to Hospital Services, Infertility Diagnosis, and Professional Services. 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 Prescription unit effectiveness. Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. Exceptions to the s ecia/t One prescription unit is equal to a 31-consecutive-day supply of a specialty prescription drug, p y preferred drug list unless limited by the manufacturer's packaging or Med ica's medication request guidelines, including quantity limits as indicated on the SPDL. 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 MIC PP MN HSA (3/12) 56 1500-100% MIC PP MN HSA(3/12) 57 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Prescription Specialty Drug Program Professional Services Not covered The following are not covered: S. Professional Services 1. Any amount above what Medica would have paid when you fail to identif our designated specialty pharmacy as a member. (Medica will notif y y self to the this provision.) y you before enforcement of This section describes coverage for professional services received from or directed by a 2. Replacement of a specialty drug due to loss, damage, or theft. physician. 3. Specialty prescription drugs prescribed by a provider See Definitions. These words have specific meanings: benefits, Coinsurance, convenience licensure. p who is not acting within their scope of deductible, hospital,deductible, emergency, genetic testing, hospital, inpatient, member, 4. Prescription drugs, except as network, non network, non network provider.reimbursement amount, physician, preventive p described in Prescription Drug Program. health service, provider, urgent care center, virtual care� _ � =- 5. Specialty � - , p y prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 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 6. Infertility drugs. front cover. See How To Access Your Benefits for more information about the prior authorization See Exclusions for additional drugs, supplies, and associated expenses that are not process. covered. Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance °� �: g� °��� � Your Benefits.and�the�Amount : ��� � �_ _a f Your e Amounts Pay - = may be required if you receive more than one service or see more than one provider per visit. Benefits $_ i€' t $ *� - a- � You pay after ����� � � ���._��` , �� • In-network benefits apply to: 1. Specialty prescription drugs �� _ . _ � 1. Professional services received from a network provider; other than those described Tier 1 specialty prescription drugs: Nothing unit; or g per 2. Professional services for testing and treatment of a sexually transmitted disease and below, received from a testing for AIDS and other HIV-related conditions received from a network provider or a designated specialty pharmacy Tier 2 specialty prescription drugs: No coverage non-network provider; 2. Specialty growth hormone when Tier 1 specialty 3. Family planning services, for the voluntary planning of the conception and bearing of prescribed by a physician for the prescription unit; orescription drugs: Nothing per children, received from a network provider or a non-network provider. Family planning treatment of a demonstrated services do not include infertility treatment services. growth hormone deficiency and Tier 2 specialty prescription drugs: No covers e received from a designated g Out-of-network benefits apply to professional services received from a non-network provider. specialty pharmacy 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. MIC PP MN HSA (3/12) 58 1500-100% MIC PP MN HSA (3/12) 59 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Professional Services Not covered Professional Services These services, supplies, and associated expenses are not covered: .. Your'Benefits and the Amounts.You Pay 1. Drugs provided or administered by a physician or ��� � � +� - � � M• - intravenous infusion or injection in y other provider, except those requiring Benefits ' ° in-network benefits * Out of networkk;benefits : J intramuscular injection, or intraocular injection. Coverage after deductible ' after'deductible for drugs is in described in Prescription Drug Program and Prescription Specialty D Program or otherwise described as a specific benefit in this certificate. y ru �: ,,,For out of network benefits, in the deductible_and coinsurance,youThre°responsible for `. 2. Diagnostic casts, diagnostic study models and bite o'any charges,,in-excess of_the non-network provider'reimbursement amount. Additionally,these temporomandibularjolnt (TMJ) disorder and cr adjustments related to the treatment of charges will of be applied toward,satisfaction of the deductrtile or the'out-of-pocket maximum aniomandibular disorder. �. .r. tw��_�...�...__-__ � � See Exclusions for additional services, supplies, and associated expenses that are not 4. Urgent care center visits Nothing Covered as an in-network covered. Please note: Some services benefit. received during an urgent care center visit may be covered under t ' g another benefit in this certificate. Your Benefits and the 3 f €y§ -s,' _ Amounts You Pay -� '- -' £ - The most specific and appropriate Benefits g z pp y ,� £ ,a�� � �� k_,� �� benefit in this certificate will a I• -- �� k-' r _ ' t _; In-network benefits. g�*Ou Of-n for each service received during an •. - t of-network3benefits £ after deductible urgent care center visit. afterdeductibie For out of network benefits in addition to$th s For example, certain services a. s received during an urgent care the deductible and_comsurance you are responst[e for any charges in excess_of the non network provider=reirr bursement amount. Additionally, charges will fnot be applied toward satisfaction'of°the • ock these center visit may be considered e deductible or the out-gf packet maximum g , surgical or imaging services; see 1• Office visits below for coverage of these surgical Nothing Please note: Some services 50% coinsurance or imaging services. In such received during an office visit may instances, both an urgent care be covered under another benefit in center visit coinsurance and 'I this certificate. The most specific outpatient surgical or imaging services coinsurance apply. { and appropriate benefit in this pp y' certificate will apply for each service Call Customer Service at one of the received during an office visit. telephone numbers listed inside the For example, certain services front cover to determine in advance received during an office visit may whether a specific procedure is a be considered surgical or imaging benefit and the applicable coverage services; see below for coverage of level for each service that you these surgical or imaging services. ive. In such instances, both an office 5. Preventive health care visit coinsurance and outpatient Please note: If you receive surgical or imaging services preventive and non-preventive coinsurance apply. health services during the same Call Customer Service at one of the visit, the non-preventive health telephone numbers listed inside the services may be subject to a front cover to determine in advance coinsurance or deductible, as whether a specific procedure is a described elsewhere in this certificate. The most s ecific and i benefit and the applicable coverage p �, level for each service that you appropriate benefit in this certificate receive. will apply for each service received 2. Virtual care during a visit. I Nothing No coverage a. Child health supervision Nothing. The deductible as an in-network clinic visits 3. Convenience care/retail health Nothing services, including well-baby does not apply. benefiCovered t.50% coinsurance care MIC PP MN HSA (3/12) 60 1500-100% MIC PP MN HSA (3/12) 61 BPL 21277 DOC 23742 1500-100% BPL 21277 DOC 23742 I Professional Services Professional Services } } .rte -Be ,_ �: _ .. . _. Its. _ ._- :� ou �_ , A _ . , .� _. .A. _� �..� ,.e ._ _ � �_,. � � � � � - �� _<�� � Your B . _ , ,_ .. ,_ _._ ._ . - .- - .� ,_ � . , ate_. , _ � __ < - e_ �.. < ,__ ., ".� _.., y_ � Benefits Pa- Benefits-_ � ,, � £_ > . .. _� � __.__ fu� t. � Y. new . t x ,.�._ r $ra ,:_ ,� - .� .. . ene �_. � ., n � �_, fi after. - benefits ,. �_ _ _ tled Benefits in,n k n f ucti a _ , - . .: etwor be e its , ,-___:ftOeurt-cloefd-nuectwtibolerk benefits fter r _� _ �.,;? after d � �For o _ . . educt�ble " ede any charges : _ .._ductib _ gesin.exc _� y and coinsurance, . . ;; : ,_ �y= � ,.-: excess are :--: . . s non-network rovi reimbursement responsible f _ r<chac . , !? der. _ or�� For out of network n < es. , . , , _ , . . � .-. be efits in addEtionao thedeductible and coinsurance ou ar res onsi ! d a.- u <� , ,Y e .. p - b e.for.._ 9 will amount _., .� � _ � - _ , . _.-.. nt. Ad B applied .: _ , . . di < r__,. .� :,. , and ton satisfaction� these an -ch charges in excess f of thededu . � -__:.,. a s, o .the,non network ravider. reimbursement amount. AddEtionall ctible.or the _ Y 9 E p Y.<,these.:. � ,out. :_ > , z -- .. < :, , �... p ,r.. maximum�� , . . ..- . - . b. .>F: char es willanot,be.a _ lied,toward satisfaction of the:deductible°or--the out-of- ocket maximum. Immunizations g_ . �p_ Nothing. The deductible 50% coinsurance 13. Anesthesia services received Nothing 50% coinsurance does not apply. c. Early disease detection from a provider during an I services including physicals Nothing. The deductible 50% coinsurance inpatient stay g p Y does not apply. d. Routine screening 14. Outpatient lab and pathology Nothing 50% coinsurance g Nothing. The deductible 50% coinsurance procedures for cancer 15. Outpatient x-rays and other Nothing 50% coinsurance does not apply. e. Other preventive health imaging services surgical services Nothing. The deductible 50% coinsurance Nothing 50% coinsurance does not apply. 16. Other outpatient hospcenter ital or 6. Allergy shots ambulatory Nothing 50% coinsurance services received from a 7. Routine annual eye exams physician Nothing. The deductible 50% coinsurance does not apply. 17. Treatment to lighten or remove Covered at the Covered at the 8.. Chiropractic services to diagnose and services treat to manual Nothing 50% coinsurance. the coloration of a port wine stain corresponding in-network manipulation or certain benefit level, depending network benefit level, Coverage is limited to a on type of services depending on corresponding type out-of- of therapies) conditions related to maximum of 15 visits per provided. services provided. the muscles, skeleton, and calendar year. nerves of the body Please note: This visit limit , fe sor l , ffcs includes chiropractic visits are For covered example at of the ic office vi its are F covered at o the i office its that you pay for in order to visit in-network benefit visit out-of-network exampe e satisfy any part of your level and surgical benefit level and surgical 9. Surgical services (as defined in deductible. services are covered at services are covered at the Physicians'Current Nothing 50% coinsurance se the surgical services out- 9. Terminology code book) received from a physician network the surgical benefit rvices level.in- of-network benefit level. 18. am Covered at the during an office visit or an joint t(TMJ)ent of disorder and temporomandibular corresponding in-network services provided. corresponding out-of- outpatient hospital or craniomandibular disorder benefit level, depending network benefit level, ambulatory surgical center visit on type of services depending on type of 10. Anesthesia services received provided. from a provider during an office Nothing 50% coinsurance visit or an outpatient hospital or For example, office visits For example, office visits ambulatory surgical center visit are covered at the office are covered at the office visit in-network benefit visit out-of-network 11. Services received from a level and surgical benefit level and surgical physician during an emergency Nothing Covered as an in-network services are covered at services are covered at room visit benefit. the surgical services in- the surgical services out- 12. Services received from a network benefit level. of-network benefit level. Nothing Please note: Dental Please note: Dental physician during an inpatient 50% coinsurance coverage is not provided coverage is not provided stay under this benefit. under this benefit. MIC PP MN HSA (3/12) 62 1500-100% MIC PP MN HSA (3/12) 63 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 1 P Professional Services Professional Services - .- 1 is w_ ,_ .< _ _ Amounts ,. ..-A. __ t ,. c _ . s �_ _-, You pay � < r ,b. . � is �i _ . �: . .. : Your. , Bene � �.. _ _ . ... Benefrts and the Am fi � . � < , ousts.You.Pa �_ � � In-network. . _. __. _� . : aft benefits-, . er - _ tled � .. Benefits_ .< , � _-,�,,_Out-of-network w x.^. uct� � �. _. . � tn.netw network benefits b1e._ � � ,N� ,, o benef ts_ ,� . , - . .,.., . ,_ � � ..b nefits: .�. . _ a _,, _. o# benefits, .._ -:. ., , .. . a#tec deduct�bie ��: ,. o.. ._._ rre .: . . . . ._ ... _ _ < ^ after deductiti taro . � �-r� .m le ,.. .. ,_ � - ti Y es in- ,.,. e an . � ,x y �,.. �aY� .� , g nex ess f . nsur .. w. o .th C ance responsible r ' t , fid the non-: . .... ,: > . non-network Y._. charges p rider. these '' s W.. _ � ._ , � , ., . _. ..<_ , . ..-.. or_..,. F.orout ofnetwoc ,. will applied .. ,. x.._. ._ � _ . . . :..r.., _^,.. k<bene#its in addition*43 a uctibl rh: . -..., _.<not be ... ._ .. , :,- ,w ^..._ � d d e and coinsurance :you are res onsibrefor to unt..., .. <..a. ,.. .< war.�.jj, p Additionally, ,.,., _. ..,.toward ,.. . 4 l�iti .: CT4,... t, .. .:.:.. .. -...... ,-x.-.:. ,,.. _ '. ..... tisfac e m twn tt � � , of Y se _ ,_ F �.�....�, .,. .deducts � �._ , ,._. _ _an .char. es=in excess-o#the,non-network:.. rovider reimbursement � ,,.< ble^orahe< ,_ .,. :.. Y g _.- p ,.. serpent amount.-:Additronall ,,ahese, ., >. -_: d ti or t out-of _ocket s .,. • pA maximum. ,-x,��, ..- . 19. Diabetes self-management .. ; a charges w'II not be applied toward satisfaction of the deductible.or-the out-of-Pocket maximum. .. _. .. P. Nothing ..,.._. � ..k�.,_. training and education, including 50% coinsurance 24. Genetic testing when test results Nothing 50% coinsurance medical nutrition therapy, will directly affect treatment received from a provider in a decisions or frequency of program consistent with national screening f diseaseaff, when educational standards (as results of thor e test a will affect established by the American reproductive choices Diabetes Association) 20. Neuropsychological evaluations/cognitive testing Nothing 50% coinsurance limited to services necessary for the diagnosis or treatment of a medical illness or injury 21. Services related to lead testing Nothing 22. Vision therapy 50% coinsurance py and orthoptic Nothin 1 and/or pleoptic training, to g 50% coinsurance 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. 23. Genetic counseling, whether pre- Nothing or post-test, and whether 50% coinsurance occurring in an office, clinic, or telephonically MIC PP MN HSA (3/12) 64 1500-100% MIC PP MN HSA(3/12) 65 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 R Reconstructive And Restorative Surgery Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, T. Reconstructive And Restorative Surgery except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program this and This section describes coverage for professional, hospital, and ambulatory surgical center cePrretificate.scriptio n Specialty Drug Program or otherwise described as a specific benefit in services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative surgery services must be medically necessary and not cosmetic. See Exclusions for additional services, supplies, and associated expenses that are not See Definitions. These words have specific meanings benefits„.coinsurane,:cosmeti covered deductible, hose..t inpatient,meth c o a, medically ne ..g R necessary member , rove reimbursement _ . _ - _, twork s .__r or :: ... .� k tiv .�....t? .Y�., n rod/ �_reconstructive, g ;¢ ; as h;.. 'Y.._. r. x-..._ Y�. . @.. ..::. • sd ._. z, , ..- 3t'xfl: `x care. _ der . p F � .R r�Your::Benefits ,:;__- �- °= ,�_ .. ., _ x:, = rector and.the Amounts You 'uirtual._F Y Priorauthorizx� .:.. �._ anon. Prior authorization from Medics ma Benefits In network benefits *Out=of-network”benefits services or supplies. Call Customer Service at one y be required before you receive ' X ,-, front cover. See How Call Access Your Benefits for more telephone numbers listed inside the ` r after deductible� � after deductible authorization process. information about the prior *,Focharg charges in on- dition-tothvdeductibl urse cot amount. A u are ally,t sitile'fur any charges in excess of,the non network provider-reimbursement amount Additionally,these Covered charges will not be applied toward satisfaction of the deductible or the eet-ef pocket maximum 1. Office visits Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance may b e required if you receive more than one service or see more than one provider per visit. 2. Virtual care Nothing No coverage • In-network benefits apply to reconstructive and restorative surgery services received from a 3. a.Outpatient services network provider. services • Out-of-network benefits apply to reconstructive and restorative surgery services received i. Surgical services (as Nothing 50% coinsurance from a non-network provider. In addition to the deductible and coinsurance described for defined in the out-of-network benefits, you will be responsible for any charges in excess of the non- Physicians'Current network provider reimbursement amount. The out-of-pocket maximum does not apply to Procedural Terminology these charges. Please see Important member information about out-of-network benefits in code book) received How To Access Your Benefits for more information and an example calculation of out-of- from a physician during pocket costs associated with out-of-network benefits. an office visit or an outpatient hospital or Not covered ambulatory surgical center visit i These services, supplies, and associated expenses are not covered: ii. Anesthesia services Nothing 50% coinsurance received from a provider 1. Revision of blemishes on skin surfaces and scars (including scar excisions) cosmetic purposes, unless otherwise covered in Professional Services. primarily for during an office visit or an outpatient hospital or 2. Repair of a pierced body part and surgical repair of bald spots or loss of hair. ambulatory surgical 3. Repairs to teeth, including any other dental procedures or treatment, whether the dental center visit treatment is needed because of a primary dental problem iii. Outpatient lab and Nothing 50% coinsurance m or as a manifestation of a medical treatment or condition. pathology 4. Services and procedures primarily for cosmetic purposes. iv. Outpatient x-rays and Nothing 50% coinsurance other imaging services 5. Surgical correction of male breast enlargement primarily for cosmetic purposes.6. Hair transplants. v. Other outpatient hospital Nothing 50% coinsurance ses. or ambulatory surgical center services received from a physician j MIC PP MN HSA (3/12) 66 1500-100% MIC PP MN HSA (3/12) 67 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Reconstructive And Restorative Surgery Skilled Nursing Facility Services �_ '.-� }Benefits and.-the Amounts�You Pa* � Benefits , st :7 - f network benefit' o x z * ; try a U. Skilled Nursing Facility Services Out o g . after deductible ; * f network bene#its E after deductible out of ne twork�benefts�i t . ,<in addition§ -€' '. .. `$ ss { rE Stz ariycharges'network b of the "to theAdeductitai and.°coins This section describes coverage for use of skilled nursing facility services. Care must be e non-network,provider"rei urance charges will not be to ;"You are#responsible for i>' provided under the direction of a physician. Coverage of the services described in this section reimbursement amount Addition'ally,-these$ „' _ is limited to a maximum benefit of 120 days per person per calendar year. Skilled nursing ward satisfaction of the:deductible,or the out-of pocketmaxi b. Hospital and ambulatory � � ° �- ����_ r.._�:��$ ���rF� * �- mur►� � ��r,� facility services are eligible for coverage only if you are admitted to a skilled nursing facility surgical center services � � � within 30 days after a hospital admission of at least three consecutive days for the same illness i. Outpatient lab and or condition. pathology or 50% coinsurance See Definitions These words havespecific meanings benefits, coinsurance,£custodial:care,, ii. Outpatient x-rays and deductible, hospital; inpatient, network, non network, non-netw°rkprovider reimbursements Y, y Nothing amount, physician, skilled Care, skilled nurs�n -facil other imaging services 50% coinsurance 9 Prior authorization. Prior authorization from Medica may be required before you receive iii. Other outpatient hospital Nothing ambulatory surgical g services or supplies. Call Customer Service at one of the telephone numbers listed inside the 50% coinsurance front cover. See How To Access Your Benefits for more information about the prior authorization center services process. 4. Inpatient services Nothing coinsurance 5. Services received from a 50% co Covered physician during an inpatient Nothing ° coinsurance 50/o For benefits and the amounts you pay, see the table in this section. More than one coinsurance 6. Anesthesia services received may be required if you receive more than one service or see more than one provider per visit. from a provider during an Nothing For purposes of this section, room and board includes coverage of health services and supplies. 50% coinsurance • inpatient stay 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. MIC PP MN NSA (3/12) 68 1500-100% MIC PP MN NSA (3/12) 69 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Skilled Nursing Facility Services Substance Abuse I 7. Physical, speech, or occupational thera 1 py services when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to generally accepted standards in the medical community. V. Substance Abuse 8. Voice training. 9. Group physical, speech, and occupational therapy. This section describes coverage for the diagnosis and primary treatment of substance abuse 10. Long-term care. disorders listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. See Exclusions for additional services, supplies, and associated expenses see Definitions: These words have specific meanings: benefits, claim, coinsurance, custodial covered. p es that are not � � �°� �° ��-- 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 Your Benefits and the AmountsYou;Pa benefits, call Medica's designated mental health and substance abuse provider at , .; -a .4 ;- _ 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center Benefits - A --ln-network -* 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. ,4 '.. ,K benefits Out of network benefits after deductible after deductible . For purposes of this section: =s� *For out of=network benefits; in addition to the �� deductib a and coinsurance ou'the 1. Outpatient services include: 3Y-,� ponsible far any charges in excess of the xnon-network provider reimbursement amount 'Additionally,these a. Dia nostic evaluations. charges will not beapplied toward satiSfactidn of the deductible or the out-of packet maximum ` g b. Outpatient treatment. 1. Daily skilled care or daily skilled Nothing 500/0 coinsurance rehabilitation services, including c. Intensive outpatient programs, including day treatment and partial programs, which may Ir room and board, up to 120 days include multiple services and modalities, delivered in an outpatient setting. per person per calendar year d. Services, care, or treatment for a member that has been placed in any applicable Please note: Such services are Department of Corrections' custody following a conviction for afirst-degree driving while eligible for coverage only if you are admitted to a skilled nursing facility impaired offense; to be eligible, such services, care, or treatment must be required and within 30 days after a hospital provided by any applicable Department of Corrections. admission of at least three 2. Inpatient services include: consecutive days for the same illness or condition. This day limit a. Room and board. includes days that you pay for in b. Attending physician services. order to satisfy any part of your deductible. c. Hospital or facility-based professional services. 2. Skilled physical, speech, or Nothing 50% coinsurance d. Services, care, or treatment for a member that has been placed in any applicable occupational therapy when room Department of Corrections' custody following a conviction for afirst-degree driving while and board is not eligible to be impaired offense; to be eligible, such services, care, or treatment must be required and covered provided by any applicable Department of Corrections. 3. Services received from a Nothing 50% coinsurance e. Residential treatment services. These are services from a licensed chemical dependency physician during an inpatient rehabilitation program that provides intensive therapeutic services following detoxification. stay in a skilled nursing facility 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. I MIC PP MN HSA (3/12) 70 71 1500-100% 1500-100% MIC PP MN HSA(3/12) BPL 21277 DOC 23742 BPL 21277 DOC 23742 Substance Abuse Substance Abuse Covered Not covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance These services, supplies, and associated expenses are not covered: may be required if you receive more than one service or see more than one provider per visit. 1. Services for substance abuse disorders not listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. • For in-network benefits: 2. Services for a condition when there is no reasonable expectation that the condition will 1. Medica's designated mental health and substance abuse provider arranges in-network improve. 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 ; 3. Services, care, or treatment that is not medically necessary. and Medica's designated mental health and substance abuse provider hospital networks 4. Services to hold or confine a person under chemical influence when no medical services are are different). required, regardless of where the services are received. 2. In-network benefits will apply to services, care or treatment for a member that has been 5. Telephonic substance abuse treatment services. 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 6. Services, including room and board charges, provided by health care professionals or treatment must be required and provided by any applicable Department of Corrections. 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 For claims questions regarding in-network benefits, call Medica's designated mental health by mental health or substance abuse providers who are not authorized under state law to ! and substance abuse provider Customer Service at 1-866-214-6829. practice independently, and services received from a halfway house, therapeutic group • For out-of-network benefits: home, boarding school, or ranch. 1. Substance abuse services from a non-network provider listed below will be eligible for 7. Room and board charges associated with substance abuse treatment services providing coverage under out-of-network benefits provided that the health care professional or less than 30 hours a week per individual of chemical dependency services, including group facility is licensed, certified, or otherwise qualified under state law to provide the substance and individual counseling, client education, and other services specific to chemical abuse services and practice independently: . dependency rehabilitation. 8. Services to assist in activities of daily living that do not seek to cure and are performed a. Psychiatrist regularly as a part of a routine or schedule. b. Psychologist See Exclusions for additional services, supplies, and associated expenses that are not I' c. Registered nurse certified as a clinical specialist or as a nurse practitioner in covered. I' psychiatric and mental health nursing d. Chemical dependency clinic e. Chemical dependency residential treatment center . Your Benefits and the Amounts You Pay f. Hospital that provides substance abuse services Benefits �� � � !n network benefits *Out-of-network benefits g. Independent clinical social worker after deductible after deductible h. Marriage and family therapist *for out of networkbenefits, in addition to the deductible and coinsurance,you are responsible for 2. Emergency substance abuse services are eligible for coverage under in-network any charges in excess of the non network provider reimbursement amount. Additionally,these _r benefits. chargestwillxnot be applied toward satisfaction of the deductible or the out-of-pocket maximum. In addition to the deductible and coinsurance described for out-of-network benefits, you will 1. Office visits, including Nothing 50% coinsurance be responsible for any charges in excess of the non-network provider reimbursement evaluations, diagnostic, and amount. The out-of-pocket maximum does not apply to these charges. Please see treatment services 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 2. Intensive outpatient programs Nothing 50% coinsurance with out-of-network benefits. 3. Opiate replacement therapy Nothing 50% coinsurance 4. Inpatient services (including residential treatment services) i' a. Room and board Nothing 50% coinsurance MIC PP MN HSA (3/12) 72 1500-100% MIC PP MN HSA (3/12) 73 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Substance Abuse Referrals To Non-Network Providers Your Benefits and the Amounts You Pay = A z� �- � � � � �� � $ � _ a � � Benefits W.Referrals To Non-Network Providers , � In-network benefits� Out of-network benefits after deductible after deductible *For out-of-network � " �y: � � This section describes coverage for referrals from network providers to non-network providers. benefits, m addition-to the deductible and cotnsurartce,�youaeres responsible for In-network benefits will apply to referrals from network providers to non-network providers as any charges in excess ofx the,non-network-provider-reimbursement amount. Additionally,-these p _° authorization f r referrals to charges not be applied=toward satisfaction � � described in this section. It is to your advantage to seek Medica's o e of the deductible or the out-of-pocket maximum non-network providers before you receive services. Medica can then tell you what your benefits will be for the services you may receive. b. Hospital or facility-based Nothing 50% coinsurance professional services See Definitions..-:These words have specific meanings: benefits, medically necessary, network,:non-network, physician, provider: c. Attending physician services Nothing 9 50% coinsurance 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 PP MN HSA(3/12) 74 1500-100% MIC PP MN HSA(3/12) 75 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Referrals To Non-Network Providers Harmful Use Of Medical Services 3. Provide coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and X. Harmful Use Of Medical Services b. Recommended by a network physician. 4. Notify you of authorization or denial of coverage within ten days of receipt of your request. This section describes what Medica will do if it is determined you are receiving health services Medica will inform both you and your provider of Medica's decision within 72 hours from the or prescription drugs in a quantity or manner that may harm your health. 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 See Definitions These,words have specific meanings *benefits, emergency, hospital, network, physician prescription,drug, provider. s " d ability to regain maximum function, or could subject you to severe pain that cannot be -. - -- adequately managed without the care or treatment you are seeking. 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 PP MN HSA(3/12) 76 1500-100% MIC PP MN HSA (3/12) 77 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Exclusions . ! Exclusions 14. Personal comfort or convenience items or services. Y. Exclusions 15. Custodial care, unskilled nursing, or unskilled rehabilitation services. 16. Respite or rest care, except as otherwise covered in Hospice Services. See Definitions These words have specific meanings claim, cosmetic, custodial care, , 17. Travel, transportation, or living expenses, except as described in Organ And Bone Marrow durable medical'equipment, emergency, Transplant Services. y,:investigative,medically necessary, member, non network, physician, provider, reconstructive, routine foot care 18. Household equipment, fixtures, home modifications, and vehicle modifications. Medica will not provide coverage for any of the services, treatments, supplies, or items 19. Massage therapy, provided in any setting, even when it is part of a comprehensive described in this section even if it is recommended or prescribed by a physician or it is the only treatment plan. available treatment for your condition. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular This section describes additional exclusions to the services, supplies, and associated expenses disease, peripheral neuropathies, and significant neurological conditions such as already listed as Not covered in this certificate. These include: Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral 1. Services that are not medically necessary. This includes but is not limited to services sclerosis. inconsistent with the medical standards and accepted practice parameters of the community 21. Services by persons who are family members or who share your legal residence. and services inappropriate-in terms of type, frequency, level, setting, and duration-to the 22. Services for which coverage is available under workers' compensation, employer liability, or diagnosis or condition. any similar law. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise 23. Services received before coverage under the Contract becomes effective. determined to be reconstructive. 24. Services received after coverage under the Contract ends. 3. Refractive eye surgery, including but not limited to LASIK surgery. ;, 4. The purchase, replacement, or repair of eyeglasses, eyeglass frames, or contact lenses 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non-network providers and non-network dentists. 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 26. Photographs, except for the condition of multiple dysplastic syndrome. bone conduction hearing aids (including internal, external, or implantable hearing aids or 27. Occlusal adjustment or occlusal equilibration. devices) and other devices to improve hearing, and their related fittings, except cochlear 28. Dental implants (tooth replacement), except as described in Medical-Related Dental implants and related fittings and except as described in Durable Medical Equipment And Services. Prosthetics. 6. A drug, device, or medical treatment or procedure that is investigative. 29. Dental prostheses. 7. Genetic testing when performed in the absence of symptoms or high risk factors for a 30. Orthodontic treatment, except as described in Medical-Related Dental Services. genetic disease; genetic testing when knowledge of genetic status will not affect treatment 31. Treatment for bruxism. decisions, frequency of screening for the disease, or reproductive choices; genetic testing 32. Services prohibited by applicable law or regulation. that has been performed in response to direct-to-consumer marketing and not under the direction of your physician. 33. Services to treat injuries that occur while on military duty, and any services received as a 8. Services or supplies not directly related to care. 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, 9. Autopsies. es. insurance, or licensure. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of 35. Exams, other evaluations, or other services received solely for the purpose of judicial or standard infant formulas, standard baby food, and regular grocery products used in administrative proceedings or research except emergency examination of a child ordered by blenderized formulas are excluded regardless of whether they are the sole source of judicial authorities. nutrition. 11. Nutritional and electrolyte substances except as specifically described in Miscellaneous 36. Non-medical self-care or self-help training. Medical Services And Supplies. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, except as described in Professional Services. 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. 38. Coverage for costs associated with translation of medical records and claims to English. 13. Reversal of voluntary sterilization. 39. Treatment for superficial veins, also referred to as spider veins or telangiectasia. MIC PP MN HSA(3/12) 78 1500-100% MIC PP MN HSA (3/12) 79 1500-100 BPL 21277 DOC 23742 BPL 21277 DOC 23742 Exclusions How To Submit A Claim 40. Services not received from or under the direction of a physician, except as described in this certificate. 41. Orthognathic surgery. Z. How To Submit A Claim 42. Sensory integration, including auditory integration training. This section describes the process for submitting a claim. 43. Services for or related to vision therapy and orthoptic and/or pleoptic training, except as described in Professional Services. See Definitions. These words have specific meanings: benefits, claim, dependent, member, 44. Services for or related to intensive behavior therapy treatment programs for the treatment of network, non-network, nQn-n'etworJc=provident reirnbursementatnont; provider autism spectrum disorders. Examples of such services include, but are not limited to Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral Claims for benefits from network providers Intervention (IBI), and Lovaas therapy. 45. Health care professional services for maternity labor and delivery in the home. 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 46. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and Customer Service at one of the telephone numbers listed inside the front cover. Claim forms subsequent procedures. may also be obtained by signing in at www.mymedica.com. 47. Services for the treatment of infertility. Network providers are required to submit claims within 180 days from when you receive a 48. Infertility drugs. service. If your provider asks for your health care identification card and you do not identify 49. Acupuncture. 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. 50. Services solely for or related to the treatment of snoring. 51. Interpreter services. Claims for benefits from non-network providers 52. Services provided to treat injuries or illness that are the result of committing a crime or Claim forms are provided in your enrollment materials. You may request additional claim forms attempting to commit a crime. by calling Customer Service at one of the telephone numbers listed inside the front cover. 53. Services for private duty nursing, except as described in Home Health Care. Examples of Claim forms may also be obtained by signing in at www.mymedica.com. If the claim forms are private duty nursing services include, but are not limited to, skilled or unskilled services not sent to you within 15 days, you may submit an itemized statement without the claim form to provided by an independent nurse who is ordered by the member or the member's Medica: You should retain copies of all claim forms and correspondence for your records. representative, and not under the direction of a physician. You must submit the claim in English along with a Medica claim form to Medica no later than 54. Laboratory testing that has been performed in response to direct-to-consumer marketing 365 days after receiving benefits. Your Medica member number must be on the claim. and not under the direction of a physician. Mail to the address identified on the back of your identification card. 55. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), Upon receipt of your claim for benefits from non-network providers, Medica will generally pay to other than those granted a humanitarian device exemption. you directly the non-network provider reimbursement amount. Medica will only pay the provider 56. Health clubs. of services if: 57. Long-term care. 1. The non-network provider is one that Medica has determined can be paid directly; and 58. Expenses associated with participation in weight loss programs, including but not limited to 2. The non-network provider notifies Medica of your signature on file authorizing that payment membership fees and the purchase of food, dietary supplements, or publications. 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 PP MN HSA(3/12) 80 1500-100% MIC PP MN HSA(3/12) 81 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 How To Submit A Claim Coordination Of Benefits Claims for services provided outside the United States Claims for services rendered in a foreign country will require the following additional AA. Coordination Of Benefits documentation: • Claims submitted in English with the currency exchange rate for the date health services This section describes how benefits are coordinated when you are covered under more than were received. one plan. • Itemization of the bill or claim. See Definitions These words have 4specific gmeanings:,.benefits, claim,.deductible, dependent,{ • The related medical records (submitted in English). emergency, hospital, member, non network, non network provider reimbursement amount, provider, subscriber. • Proof of your payment of the claim. • A complete copy of your passport and airline ticket. 1. Applicability • Such other documentation as Medica may request. of benefits a. This coordinatio n o be a is (COB) provision applies to this plan when an employee or i For services rendered in a foreign country, Medica will pay you directly. the employee's covered dependent has health care coverage under more than one plan. Medica will not reimburse you for costs associated with translation of medical records or claims. Plan and this plan are defined below. b. If this coordination of benefits provision applies, Order of benefit determination rules Time limits 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 If you have a complaint or disagree with a decision by Medica, you may follow the complaint rules, the benefits of this plan: procedure outlined in Complaints or you may initiate legal action at any point. i. Shall not be reduced when this plan determines its benefits before another plan; but However, you may not bring legal action more than six years after Medica has made a coverage ii. May be reduced when another plan determines its benefits first. The above determination regarding your claim. 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 PP MN HSA (3/12) 82 1500-100% MIC PP MN HSA (3/12) 83 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Coordination Of Benefits Coordination Of Benefits When there are two or more plans covering the person, this plan may be a primary plan b) If both parents have the same birthday, the benefits of the plan which covered as to one or more other plans, and may be a secondary plan as to a different plan or one parent longer are determined before those of the plan which covered the plans. other parent for a shorter period of time. d. Allowable expense means a necessary, reasonable, and customary item of expense for However, if the other plan does not have the rule described in (a) immediately above, health care, when the item of expense is covered at least in part by one or more plans but instead has a rule based on the gender of the parent, and if, as a result, the covering the person for whom the claim is made. Allowable expense does not include plans do not agree on the order of benefits, the rule in the other plan will determine the deductible for members with a primary high deductible plan and who notify Medica of the order of benefits. an intention to contribute to a health savings account. iii. Dependent child/separated or divorced parents. If two or more plans cover a person The difference between the cost of a private hospital room and the cost of a semi-private as a dependent child of divorced or separated parents, benefits for the child are hospital room is not considered an allowable expense under the above definition unless determined in this order: the patient's stay in a private hospital room is medically necessary, either in terms of a) First, the plan of the parent with custody of the child; 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 b) Then, the plan of the spouse of the parent with the custody of the child; and reimbursement amount is not considered an allowable expense under the above c) Finally, the plan of the parent not having custody of the child. definition. However, if the specific terms of a court decree state that one of the parents is When a plan provides benefits in the form of services, the reasonable cash value of responsible for the health care expense of the child, and the entity obligated to pay each service rendered will be considered both an allowable expense and a benefit paid. or provide the benefits of the plan of that parent has actual knowledge of those When benefits are reduced under a primary plan because a member does not comply terms, the benefits of that plan are determined first. The plan of the other parent with the plan provisions, the amount of such reduction will not be considered an 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 allowable expense. Examples of such provisions are those related to second surgical provided before the entity has that actual knowledge. opinions, and preferred provider arrangements. iv. Joint custody. If the specific terms of a court decree state that the parents shall e. Claim determination period means a calendar year. However, it does not include any share joint custody, without stating that one of the parents is responsible for the part of a year during which a person has no coverage under this plan, or any part of a health care expenses of the child, the plans covering follow the Order of benefit year before the date this COB provision or a similar provision takes effect. determination rules outlined in 3.b.ii. v. Active/inactive employee. The benefits of a plan which covers a person as an 3. Order of benefit determination rules 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 a. General. When there is a basis for a claim under this plan and another plan, this plan is employee (or as that employee's dependent). If the other plan does not have this a secondary plan which has its benefits determined after those of the other plan, unless: rule, and if, as a result, the plans do not agree on the order of benefits, this rule is i. The other plan has rules coordinating its benefits with the rules of this plan; and ignored. ii. Both the other plan's rules and this plan's rules, in 3.b. below, require that this plan's vi. Workers'compensation. Coverage under any workers' compensation act or similar benefits be determined before those of the other plan. law applies first. You should submit claims for expenses incurred as a result of an b. Rules. This plan determines its order of benefits using the first of the following rules on-duty injury to the employer, before submitting them to Medica. which applies: vii. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance i. Nondependent/dependent. The benefits of the plan that covers the person as an Act or similar law applies first. employee, member or subscriber (that is, other than as a dependent) are determined viii. Longer/shorter length of coverage. If none of the above rules determines the order before those of the plan, which covers the person as a dependent. 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 ii. Dependent child/parents not separated or divorced. Except as stated in 3.b.iii. for the shorter term. 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 4. Effect on the benefits of this plan determined before those of the plan of the parent whose birthday falls later in that year; but 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 PP MN HSA (3/12) 84 1500-100% MIC PP MN HSA (3/12) 85 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Coordination Of Benefits Right Of Recovery 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. BB. Right Of Recovery 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 This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and absence of this COB provision; and federal law. For information about the effect of applicable state and federal law on Medica's subrogation rights, contact an attorney. 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 See Definitions This"word has a;specific.meaning:;,benefits.= q or not claim is made, exceeds those allowable expenses in a claim determination 1. Medica has a right of subrogation against any third party, individual, corporation, insurer, or period. In that case, the benefits of this plan will be reduced so that they and the other entity or person who may be legally responsible for payment of medical expenses benefits payable under the other plans do not total more than those allowable related to your illness or injury. Medica's right of subrogation shall be governed according to expenses. this section. Medica's right to recover its subrogation interest applies only after you have When the benefits of this plan are reduced as described above, each benefit is reduced received a full recovery for your illness or injury from another source of compensation for in proportion. It is then charged against any applicable benefit limit of this plan. your illness or injury. 2. Medica's subrogation interest is the reasonable cash value of any benefits received by you. 5. Right to receive and release needed information 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 Certain facts are needed to apply these COB rules. Medica has the right to decide which incurred in obtaining a recovery from another source unless Medica is separately facts it needs. It may get needed facts from or give them to any other organization or represented by an attorney. If Medica is represented by an attorney, an agreement person. Medica need not tell, or get the consent of, any person to do this. Unless regarding allocation may be reached. If an agreement cannot be reached, the matter must applicable federal or state law prevents disclosure of the information without the consent of be submitted to binding arbitration. 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. 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 6. Facility of payment 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 A payment made under another plan may include an amount, which should have been paid law. under this plan. If it does, Medica may pay that amount to the organization which made that b. To cooperate with Medica or its designee to help protect Medica's legal rights under this payment. That amount will then be treated as though it were a benefit paid under this plan. subrogation provision and to provide all information Medica may reasonably request to Medica will not have to pay that amount again. The term payment made includes providing determine its rights under this provision. benefits in the form of services, in which case payment made means reasonable cash value of the benefits provided in the form of services. c. To provide prompt written notice to Medica when you make a claim against a party for injuries. 7. Right of recovery d. To do nothing to decrease Medica's rights under this provision, either before or after receiving benefits, or under the Contract. If the amount of the payments made by Medica is more than it should have paid under this e. Medica may take action to preserve its legal rights. This includes bringing suit in your COB provision, it may recover the excess from one or more of the following: name. a. The persons it has paid or for whom it has paid; or f. Medica may collect its subrogation interest from the proceeds of any settlement or b. Insurance companies; or judgment recovered by you, your legal representative, or the legal representative(s) of c. Other organizations. your estate or next-of-kin. 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 PP MN HSA(3/12) 86 1500-100% MIC PP MN HSA(3/12) 87 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Eligibility And Enrollment Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30-day time CC. Eligibility And Enrollment 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 This section describes who can enroll and how to enroll. 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, See Definitions. These words have specific meanings benefits, continuous coverage, or as a late entrant (if applicable, as described below). dependent, late entrant, member, mental disorder, physician, placed for adoption, prerniurn, qualifying coverage, subscriber, waiting'period. __ �, : - � � k_ ���_ � �:_ r ��-- 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. Who can enroll Open enrollment To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract A minimum 14-day period set by the employer and Medica each year during which eligible and be a subscriber or dependent as defined in this certificate. See Definitions. 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 How to enroll dependents. You must submit an application for coverage for yourself and any dependents to the employer: Special enrollment 1. During the initial enrollment period as described in this section under Initial enrollment; or Special enrollment periods are provided to eligible employees and dependents under certain 2. During the open enrollment period as described in this section under Open enrollment; or circumstances. 3. During a special enrollment period as described in this section under Special enrollment; or 1. Loss of other coverage 4. At any other time for consideration as a late entrant as described in this section under Late I a. A special enrollment period will apply to an eligible employee and dependent if the enrollment. individual was covered under Medicaid or a State Children's Health Insurance Plan and Dependents will not be enrolled without the eligible employee also being enrolled. A child who lost that coverage as a result of loss of eligibility. The eligible employee or dependent is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical must present evidence of the loss of coverage and request enrollment within 60 days Child Support Order(QMCSO) and 6. under Special enrollment. after the date such coverage terminates. In the case of the eligible employee's loss of coverage, this special enrollment period Notification 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 You must notify the employer in writing within 30 days of the effective date of any changes to dependent who has lost coverage and the eligible employee. address or name, addition or deletion of dependents, a dependent child reaching the dependent b. A special enrollment period will apply to an eligible employee and dependent if the limiting age, or other facts identifying you or your dependents. (For dependent children, the eligible employee or dependent was covered under qualifying coverage other than notification period is not limited to 30 days for newborns or children newly adopted or newly Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or placed for adoption; however, we encourage you to enroll your newborn dependent under the dependent was eligible to enroll under the Contract, whether during initial enrollment, Contract within 30 days from the date of birth, date of placement for adoption, or date of open enrollment, or special enrollment, and declined coverage for that reason. 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 The eligible employee or dependent must present either evidence of the loss of prior application of health screening or waiting periods. coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated, and request enrollment in The employer must notify Medica, as set forth in the Contract, of your initial enrollment writing within 30 days of the date of the loss of coverage or the date the employer's application, changes to your name or address, or changes to enrollment, including if you or your contribution toward that coverage terminates, or the date on which a claim is denied due dependents are no longer eligible for coverage. to the operation of a lifetime maximum limit on all benefits. Initial enrollment For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; 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 PP MN HSA(3/12) 88 1500-100% MIC PP MN HSA(3/12) 89 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Eligibility And Enrollment Eligibility And Enrollment ii. Loss of eligibility includes: • losing coverage as a result of the eligible employee or dependent incurring a • loss of eligibility as a result of legal separation, divorce, death, termination of claim that meets or exceeds the lifetime maximum limit on all benefits and no employment, COBRA or state continuation coverage is available; or mployment, reduction in the number of hours of employment; • if the prior coverage was offered through a health maintenance organization i • cessation of dependent status; (HMO), losing coverage because the eligible employee or dependent no longer • incurring a claim that causes the eligible employee or dependent to meet or resides or works in the HMO's service area and no other COBRA or state exceed the lifetime maximum limit on all benefits; ` continuation coverage is available. • if the prior coverage was offered through an individual health maintenance ii. Exhaustion of COBRA or state continuation coverage does not include a loss due to organization (HMO), a loss of coverage because the eligible employee or failure of the eligible employee or dependent to pay premiums on a timely basis or dependent no longer resides or works in the HMO's service area; termination of coverage for cause. • if the prior coverage was offered through a group HMO, a loss of coverage iii. In the case of the eligible employee's exhaustion of COBRA or state continuation because the eligible employee or dependent no longer resides or works in the coverage, the special enrollment period described above applies to the eligible HMO's service area and no other coverage option is available; and 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 • the prior coverage no longer offers any benefits to the class of similarly situated above applies only to the dependent who has lost coverage and the eligible individuals that includes the eligible employee or dependent. employee. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is 2. The dependent is a new spouse of the subscriber or eligible employee, provided that the eligible for or elects applicable federal or state continuation coverage; marriage is legal and enrollment is requested in writing within 30 days of the date of iv. Loss of eligibility does not include a loss due to failure of the eligible employee or marriage and provided that the eligible employee also enrolls during this special enrollment dependent to pay premiums on a timely basis or termination of coverage for cause; period; In the case of the eligible employee's loss of other coverage, the special enrollment 3. The dependent is a new dependent child of the subscriber or eligible employee, provided period described above applies to the eligible employee and all of his or her dependents. that enrollment is requested in writing within 30 days of the subscriber or eligible employee In the case of a dependent's loss of other coverage, the special enrollment period acquiring the dependent (for dependent children, the notification period is not limited to 30 described above applies only to the dependent who has lost coverage and the eligible days for newborns or children newly adopted or newly placed for adoption) and provided employee. that the eligible employee also enrolls during this special enrollment period; c. A special enrollment period will apply to an eligible employee and dependent if the 4. The dependent is the spouse of the subscriber or eligible employee through whom the eligible employee or dependent was covered under benefits available under the dependent child described in 3. above claims dependent status and: Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or a. That spouse is eligible for coverage; and 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 b. Is not already enrolled under the Contract; and enrollment, or special enrollment and declined coverage for that reason. c. Enrollment is requested in writing within 30 days of the dependent child becoming a The eligible employee or dependent must present evidence that the eligible employee or dependent; and dependent has exhausted such COBRA or state continuation coverage and has not lost d. The eligible employee also enrolls during this special enrollment period; or 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 5. The dependents are eligible dependent children of the subscriber or eligible employee and of the exhaustion of coverage. 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 For purposes of 1.c.: enrolls during this special enrollment period. i. Exhaustion of COBRA or state continuation coverage includes: 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as • losing COBRA or state continuation coverage for any reason other than those set described in this section, Medica will provide the eligible dependent child with a special forth in ii. below; enrollment period provided the eligible employee also enrolls during this special enrollment period. • losing coverage as a result of the employer's failure to remit premiums on a timely basis; MIC PP MN HSA (3/12) 90 1500-100% MIC PP MN HSA (3/12) 91 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Eligibility And Enrollment j Eligibility And Enrollment Late enrollment 2. cFoovr eligible employees and dependents who enroll during the open enrollment period, An eligible employee or an eligible employee and dependents who do not enroll for coverage was held begins on the first day of the Contract year for which the open enrollment period offered through the employer during the initial or open enrollment period or any applicable special enrollment period will be considered late entrants. 3. For eligible employees and/or dependents who enroll during a special enrollment period, Late entrants who have maintained continuous coverage may enroll and coverage will be coverage begins on the date indicated below for the particular special enrollment. In the effective the first day of the month following date of Medica's a case of: enrollment. Continuous coverage will be determined to have been maintained iiff the late entrant requests requests enrollment within 63 days after prior qualifying coverage ends. a. Number calendar 1. or 2. under Special enrollment,month following the date on which the covers request g e be g for ins enrollment on first is day y ceived of the by first Medica; Individuals who have not maintained continuous coverage may not enroll as late entrants. An eligible employee or dependent who: b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of 1. does not enroll during an initial or open enrollment period or any applicable special adoption or placement for adoption, date of adoption or placement. In all other cases, enrollment period; and the date the subscriber acquires the dependent child; 2. is an enrollee of MCHA at the time c. Number 4. under Special enrollment, the date coverage for the dependent child is provided the eligible subscriber or ependentfmaintains e continuous g coverage, employer, effective, as set forth in 3.b. above; will not be considered a late entrant and will be allowed to enroll. Coverage will be effective as d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. determined by Medica. or 3. under Special enrollment becomes effective; e. Number 6. under Special enrollment, the first day of the first calendar month following Qualified Medical Child Support the date the completed request for enrollment is received by Medica. pport Order(QMCSO) 4. For eligible employees and/or dependents who enroll during late enrollment, coverage Medica will provide coverage in accordance with a QMCSO pursuant to the applicable begins on the first day of the month following date of Medica's approval of the request for requirements under Section 609 of the Employee Retirement Income Security Act (ERISA) and enrollment. it 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 PP MN HSA (3/12) 92 1500-100% MIC PP MN HSA(3/12) 93 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Ending Coverage Ending Coverage e. Submitting fraudulent claims; DD. Ending Coverage 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. This section describes when coverage ends under the Contract. When this happens you may Upon completion of active military duty, contact the employer for reinstatement of coverage; exercise your right to continue or convert your coverage as described in Continuation or Conversion. 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 See Definitions These words have specific meanings certification of qualifying coverage, death occurred; claim, dependent, member, premium, subscriber.-. r _ 9. For a spouse, the end of the month following the date of divorce; 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 10. For a dependent child, the end of the month in which the child is no longer eligible as a certification of qualifying coverage at any time while you are covered under the Contract or dependent; or within the 24 months following the date your coverage ends. To request a certification of 11. For a child who is entitled to coverage through a QMCSO, the end of the month in which the qualifying coverage, call Customer Service at one of the telephone numbers listed inside the earliest of the following occurs: front cover. Upon receipt of your request, the certification of qualifying coverage will be issued a. The QMCSO ceases to be effective; or as soon as reasonably possible. b. The child is no longer a child as that term is used in ERISA; or When coverage ends c. The child has immediate and comparable coverage under another plan; or Unless otherwise specified in the Contract, coverage ends the earliest of the following: d. The employee who is ordered by the QMCSO to provide coverage is no longer eligible as determined by the employer; or 1. The end of the month in which the Contract is terminated by the employer or Medica in e. The employer terminates family or dependent coverage; or 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; f. The Contract is terminated by the employer or Medica; or 2. The end of the month for which the subscriber last paid his or her contribution toward the g. The relevant premium or contribution toward the premium is last paid. 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 PP MN HSA (3/12) 94 1500-100% MIC PP MN HSA (3/12) 95 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Continuation Continuation Subscriber's spouse's loss EE. Continuation 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; 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 b. A termination of the subscriber's employment (for any reason other than gross coverage administration are the responsibility of the employer. misconduct) or layoff from employment; These Dissolution of marriage from the subscriber; See Definitions These words have specific meanings: benefits, dependent;Tmember, placed for adoption, premium, subscriber,total disability. . _ ._ . _ ,_.,. .m� , ,�� d. The subscriber's enrollment for benefits under Medicare. The paragraph below describes the continuation coverage provisions. State continuation is Subscriber's child's loss described in 1. and federal continuation is described in 2. The subscriber's dependent child has the right to continuation coverage if coverage under If your coverage ends, you should review your rights under both state law and federal law with the Contract is lost for any of the following reasons: 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. a. Death of the subscriber if the subscriber is the parent through whom the child receives When your continuation coverage under this section ends, you have the option to enroll in an coverage; individual conversion health plan as described in Conversion. b. Termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; 1. Your right to continue coverage under state law 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 Notwithstanding the provisions regarding termination of coverage described in Ending through whom the child receives coverage; Coverage, you may be entitled to extended or continued coverage as follows: a. Minnesota state continuation coverage. e. The subscriber's child ceases to be a dependent child under the terms of the Contract. Continued coverage shall be provided as required under Minnesota law. Minnesota Responsibility to inform 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, Under Minnesota law, the subscriber and dependents have the responsibility to inform the within the parameters of Minnesota law, establish uniform policies pursuant to which employer of a dissolution of marriage or a child losing dependent status under the Contract such continuation coverage will be provided. within 60 days of the date of the event or the date on which coverage would be lost because b. Notice of rights. of the event. Minnesota law requires that covered employees and their dependents (spouse and/or Election rights 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 When the employer is notified that one of these events has happened, the subscriber and coverage under an employer sponsored group health plan(s) would otherwise end. the subscriber's dependents will be notified of the right to continuation coverage. This notice is intended to inform you, in summary fashion, of your rights and obligations Consistent with Minnesota law, the subscriber and dependents have 60 days to elect under the continuation coverage provision of Minnesota law. It is intended that no greater continuation coverage for reasons of termination of the subscriber's employment or the rights be provided than those required by Minnesota law. Take time to read this section subscriber's enrollment for benefits under Medicare measured from the later of: carefully. a. The date coverage would be lost because of one of the events described above; or Subscriber's loss b. The date notice of election rights is received. The subscriber has the right to continuation of coverage for him or herself and his or her If continuation coverage is elected within this period, the coverage will be retroactive to the dependents if there is a loss of coverage under the Contract because of the subscriber's date coverage would otherwise have been lost. voluntary or involuntary termination of employment (for any reason other than gross The subscriber and the subscriber's covered spouse may elect continuation coverage on misconduct) or layoff from employment. In this section, layoff from employment means a behalf of other dependents entitled to continuation coverage. Under certain circumstances, reduction in hours to the point where the subscriber is no longer eligible for coverage under the subscriber's covered spouse or dependent child may elect continuation coverage even if the Contract. the subscriber does not elect continuation coverage. If continuation coverage is not elected, your coverage under the Contract will end. MIC PP MN HSA(3/12) 96 1500-100% MIC PP MN HSA(3/12) 97 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Continuation Continuation Type of coverage and cost ii. The date coverage would otherwise terminate under the Contract. If continuation coverage is elected, the subscriber's employer is required to provide e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent coverage that, as of the time coverage is being provided, is identical to the coverage children may be continued until the earlier of: provided under the Contract to similarly situated employees or employees' dependents. i. The date the surviving spouse and dependent children become covered under Under Minnesota law, a person continuing coverage may have to make a monthly payment another group health plan; or to the employer of all or part of the premium for continuation coverage. The amount ii. The date coverage would have terminated under the Contract had the subscriber charged cannot exceed 102 percent of the cost of the coverage. lived. Surviving dependents of a deceased subscriber have 90 days after notice of the When your continuation coverage under this section ends, you have the option to enroll in an requirement to pay continuation premiums to make the first payment. individual conversion health plan (as described in Conversion). Duration Extension of benefits for total disability of the subscriber Under the circumstances described above and for a certain period of time, Minnesota law Coverage may be extended for a subscriber and his or her dependents in instances where requires that the subscriber and his or her dependents be allowed to maintain continuation the subscriber is absent from work due to total disability, as defined in Definitions. If the coverage as follows: subscriber is required to pay all or part of the premium for the extension of coverage, a. For instances where coverage is lost due to the subscriber's termination of or layoff from payment shall be made to the employer. The amount charged cannot exceed 100 percent employment, coverage may be continued until the earliest of: of the cost of the coverage. 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 2. Your right to continue coverage under federal law employee or otherwise) that does not contain any exclusion or limitation with respect Notwithstanding the provisions regarding termination of coverage described in Ending to any applicable pre-existing condition; or Coverage, you may be entitled to extended or continued coverage as follows: iii. The date coverage would otherwise terminate under the Contract. b. For instances where the subscriber's spouse or dependent children lose coverage COBRA continuation coverage because of the subscriber's enrollment under Medicare, coverage may be continued Continued coverage shall be provided as required under the Consolidated Omnibus Budget until the earliest of: 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 i. 36 months after continuation was elected; uniform policies pursuant to which such continuation coverage will be provided. See ii. . The date coverage is obtained under another group health plan; or General COBRA information in this section. iii. The date coverage would otherwise terminate under the Contract. USERRA continuation coverage c. For instances where dependent children lose coverage as a result of loss of dependent Continued coverage shall be provided as required under the Uniformed Services eligibility, coverage may be continued until the earliest of: Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The i. 36 months after continuation was elected; 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 ii. The date coverage is obtained under another group health plan; or this section. iii. The date coverage would otherwise terminate under the Contract. d. For instances of dissolution of marriage from the subscriber, coverage of the General COBRA information subscriber's spouse and dependent children may be continued until the earliest of: COBRA requires employers with 20 or more employees to offer subscribers and their i. The date the former spouse becomes covered under another group health plan; or 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 ii. The date coverage would otherwise terminate under the Contract. instances where health coverage under employer sponsored group health plan(s) would If a dissolution of marriage occurs during the period of time when the subscriber's otherwise end. This coverage is a group health plan for purposes of COBRA. spouse is continuing coverage due to the subscriber's termination of or layoff from This section is intended to inform you, in summary fashion, of your rights and obligations employment, coverage of the subscriber's spouse may be continued until the earlier of: 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. I. The date the former spouse becomes covered under another group health plan; or MIC PP MN HSA (3/12) 98 1500-100% MIC PP MN HSA(3/12) 99 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 • Continuation Continuation Qualified beneficiary 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 For purposes of this section, a qualified beneficiary is defined as: of hours or within 60 days of the start of the continuation period must notify the employer of a. A covered employee (a current or former employee who is actually covered under a that determination within 60 days of the determination. If determined under the Social group health plan and not just eligible for coverage); Security Act to no longer be disabled, he or she must notify the employer within 30 days of b. A covered spouse of a covered employee; or the determination. c. A dependent child of a covered employee. (A child placed for adoption with or born to Bankruptcy an employee or former employee receiving COBRA continuation coverage is also a Rights similar to those described above may apply to retirees (and the spouses and qualified beneficiary.) dependents of those retirees), if the subscriber's employer commences a bankruptcy Subscriber's loss proceeding and these individuals lose coverage. The subscriber has the right to elect continuation of coverage if there is a loss of coverage Election rights . under the Contract because of termination of the subscriber's employment (for any reason When notified that one of these events has happened, the employer will notify the other than gross misconduct), or the subscriber becomes ineligible to participate under the subscriber and dependents of the right to choose continuation coverage. terms of the Contract due to a reduction in his or her hours of employment. Consistent with federal law, the subscriber and dependents have 60 days to elect Subscriber's spouse's loss continuation coverage, measured from the later of: The subscriber's covered spouse has the right to choose continuation coverage if he or she a. The date coverage would be lost because of one of the events described above; or loses coverage under the Contract for any of the following reasons: b. The date notice of election rights is received. a. Death of the subscriber; If continuation coverage is elected within this period, the coverage will be retroactive to the b. A termination of the subscriber's employment (for any reason other than gross date coverage would otherwise have been lost. • misconduct) or reduction in the subscriber's hours of employment with the employer; The subscriber and the subscriber's covered spouse may elect continuation coverage on c. Divorce or legal separation from the subscriber; or behalf of other dependents entitled to continuation coverage. However, each person entitled to continuation coverage has an independent right to elect continuation coverage. d. The subscriber's entitlement to (actual coverage under) Medicare. The subscriber's covered spouse or dependent child may elect continuation coverage even Subscriber's child's loss if the subscriber does not elect continuation coverage. The subscriber's dependent child has the right to continuation coverage if coverage under If continuation coverage is not elected, your coverage under the Contract will end. the Contract is lost for any of the following reasons: Type of coverage and cost a. Death of the subscriber if the subscriber is the parent through whom the child receives If the subscriber and the subscriber's dependents elect continuation coverage, the employer coverage; is required to provide coverage that, as of the time coverage is being provided, is identical to b. The subscriber's termination of employment (for any reason other than gross the coverage provided under the Contract to similarly situated employees or employees' misconduct) or reduction in the subscriber's hours of employment with the employer; dependents. c. The subscriber's divorce or legal separation from the child's other parent; 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 d. The subscriber's entitlement to (actual coverage under) Medicare if the subscriber is the the cost of the coverage. The amount may be increased to 150 percent of the applicable parent through whom the child receives coverage; or premium for months after the 18th month of continuation coverage when the additional e. The subscriber's child ceases to be a dependent child under the terms of the Contract. months are due to a disability under the Social Security Act. Responsibility to inform There is a grace period of at least 30 days for the regularly scheduled premium. Under federal law, the subscriber and dependent have the responsibility to inform the Duration of COBRA coverage employer of a divorce, legal separation, or a child losing dependent status under the Federal law requires that you be allowed to maintain continuation coverage for 36 months Contract within 60 days of the date of the event, or the date on which coverage would be unless you lost coverage under the Contract because of termination of employment or lost because of the event. reduction in hours. In that case, the required continuation coverage period is 18 months. MIC PP MN HSA(3/12) 100 1500-100% MIC PP MN HSA(3/12) 101 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 , Continuation 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 Guard duty, and the time necessary for a person to be absent from employment for an of an employee or employee's dependent who is determined to be disabled under the Social examination to determine the fitness of the person to perform any of these duties. Security Act at the time of the employee's termination of employment disabled reduction the of hours, ed services eans the U.S. Armed Services, including the Coast Guardtraining, the A, rmy or within 60 days of the start of the 18-month continuation period. NationUniformal Guard, and mthe Air National U Guard, when engaged in active duty for If an employee or the employee's dependent is entitled to 29 months of continuation inactive duty training, or full-time National Guard duty, and the commissioned corps of the coverage due to his or her disability, the other family members' continuation period is also Public Health Service. 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 Election rights from the date of the subscriber's Medicare entitlement even if that entitlement does not cause the subscriber to lose coverage. 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 Under no circumstances is the total continuation period greater than 36 months from the date datelcovera e wou dl be el ohs be aduse of elect continuation coverage measured from the of the original event that triggered the continuation coverage. 9 the event described above. If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage Federal law provides that continuation coverage may end earlier for any of the following would otherwise have been lost. The employee may elect continuation coverage on behalf reasons: of other covered dependents, however, there is no independent right of each covered a. The subscriber's employer no longer provides group health coverage to any of its dependent to elect. If the employee does not elect, there is no USERRA continuation employees; available for the spouse or dependent children. In addition, even if the employee does not b. elect USERRA continuation, the employee has the right to be reinstated under the Contract The premium for continuation coverage is not paid on time; upon reemployment, subject to the terms and conditions of the Contract. 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- Type of coverage and cost existing condition; or If the employee elects continuation coverage, employer required provide g the em to er is re uired to rovide covers e d. The subscriber becomes entitled to (actually covered under) Medicare. that, as of the time coverage is being provided, is identical to the coverage provided under d. The the e Contract to similarly coverage imilarl situated employees. T e ma als Y The amount charged cannot 9 may also end earlier for reasons which would allow regular coverage to 9 of exceed 102 be terminated, such as fraud. 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 General USERRA information 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. 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 Duration of USERRA coverage (called continuation coverage) at group rates in certain instances where health coverage When an employee takes a leave for service in the uniformed services, coverage for the under employer sponsored group health plan(s)would otherwise end. This coverage is a employee and dependents for who coverage is elected begins the day after the employee group health plan for the purposes of USERRA. would lose coverage under the Contract.m Coverage continues for up to 24 months. 1 This section is intended to inform you, in summary fashion, of your rights and obligations 1I under the continuation coverage provision of federal law. It is intended that no greater rights Federal law provides that continuation coverage may end earlier for any of the following be provided than those required by federal law. Take time to read this section carefully. reasons: Employee's loss 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; The employee has the right to elect continuation of coverage if there is a loss of coverage c. The employee loses their rights under USERRA as a result of a dishonorable discharge II under the Contract because of absence from employment due to service in the uniformed g services, and the employee was covered under the Contract at the time the absence began, or other undesirable conduct; 1 and the employee, or an appropriate officer of the uniformed services, d. The employee fails to return to work following the completion of his or her service in the employer with advance notice of the employee's absence from employment (if it was the uniformed services; or possible to do so). e. The employee returns to work and is reinstated under the Contract as an active Service in the uniformed services means the performance of duty on a voluntary or employee. involuntary basis in the uniformed services under competent authority, including active duty, Continuation coverage may also end earlier for reasons which would allow regular coverage active duty for training, initial active duty for training, inactive duty training, full-time National to be terminated, such as fraud. MIC PP MN HSA (3/12) 102 1500-100% MIC PP MN HSA (3/12) 103 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 I T Continuation Conversion COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation FF. Conversion coverage in addition to USERRA continuation coverage, these coverages run concurrently. See Definitions. These words have specific meanings benefits, continuous coverage, dependent, network, premium%:provider,-waiting.period, x 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. If you commit fraud or material misrepresentation in applying for continuation or conversion of coverage. MIC PP MN HSA (3/12) 104 1500-100% MIC PP MN HSA (3/12) 105 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Conversion Complaints 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. GG. Complaints What you must do 1. For conversion coverage information, call Customer Service at one of the telephone This section describes what to do if you have a complaint or would like to appeal a decision numbers listed inside the front cover. made by Medica. 2. Pay premiums to Medica or Medica's designated conversion vendor within 63 days after fter See.Definifons: These words have specific meanings: claim; mpatent, network; provider - i 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 b You writing y t call Customer e below in one level of telephone 2n You also ma 'codntact the nt cover or payment with your enrollment form for conversion coverage. p y y 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 63 Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296-2488 or days after your coverage ends or within 31 days of the date you were notified of your right to 1-800-657-3602. convert, whichever is later. You may include only those dependents who were enrolled Filing a complaint may require that Medica review your medical records as needed to resolve under the Contract at the time of conversion. your complaint. What the employer must do You quir may appoint an authorized representative to make a complaint on your behalf. You may be The employer is required to notify eed sign an authorization which will allow Medica to release confidential information to y you of your right to convert coverage. your mar representative and allow them to act on your behalf during the complaint process. Residents of a state other than Minnesota 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 This section describes your right to convert to an individual conversion plan if you are a resident upon request. of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. 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 Overview at the beginning of this section. You may convert to an individual conversion plan through Medica or Medica's designated conversion vendor without proof of good health or waiting 9 ted First level of review of the state in which you reside on the day that you submit anlednrollment fodrm to Medica or Medica's designated conversion vendor. You may direct any question or complaint t Customer Service by calling one of the telephone numbers listed inside the front cover or by writing to the address listed below. What you must do 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. 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. 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 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after complaint, or if you determine that Medica's decision is partially or wholly adverse to you, your coverage ends or such other period of time as provided under applicable state law. Medica will provide you with a complaint form to submit your complaint in writing. Mail the You will be required to include your first month premium payment with your enrollment form for conversion coverage. completed form to: 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 Customer Service days after your coverage ends or such other period of time as provided under applicable Route 0501 state law. You may include only those dependents who were enrolled under the Contract at PO Box 9310 the time of conversion. 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 PP MN HSA (3/12) 106 1500-100% MIC PP MN HSA(3/12) 107 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 1 C Complaints Complaints provider will have the opportunity to request an expedited review by telephone. Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be Alternatively, if Medica concludes that a delay could seriously jeopardize your life, health, or submitted for external review. ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without care or treatment you are requesting, Medica will process your claim as an expedited review. In such cases, Medica will notify you and your attending provider by Civil action telephone of its decision no later than 72 hours after receiving the request. If you are dissatisfied with Medica's first or second level review decision or the external review 5. If Medica's first level review decision upholds the initial decision made by Medica, you may decision, you have the right to file a civil action under section 502(a) of the Employee have a right to request a second level review or submit a written request for external review Retirement Income Security Act (FRIBA). 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. Generally, a second level review is optional if the complaint requires a medical determination. 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 You must include a filing fee of$25 with 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. Medica may seek judicial review on grounds that the decision was arbitrary and capricious or involved an abuse of discretion. Contact the Commissioner of Commerce for more information about the external review process. MIC PP MN HSA (3/12) 108 MIC PP MN HSA(3/12) 109 1500-100% 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 General Provisions General Provisions Discretionary authority HH. General Provisions 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; provided, however, that this provision shall not be construed to specify a standard of review upon which a This section describes the general provisions of the Contract. court may review a claim denial or any other decision made by Medica with respect to a member. 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 PP MN HSA(3/12) 110 1500-100% MIC PP MN HSA (3/12) 111 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Definitions Definitions 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 Definitions preventive health care services. Cosmetic. Services and procedures that improve physical appearance but do not correct or In this certificate (and in any amendments), some words have specific meanings. Within each improve a physiological function, and that are not medically necessary, unless the service or definition, you may note bold words. These words also are defined in this section. procedure meets the definition of reconstructive. Benefits. The health services or supplies (described in this certificate and any subsequent Custodial care. Services to assist in activities of daily living that do not seek to cure, are amendments) approved by Medica as eligible for coverage. 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 Certification of qualifying coverage. A written certification that group health plans and health services include help in walking, getting in or out of bed, bathing, dressing, feeding, using the insurance issuers must provide to an individual to confirm the qualifying coverage provided to toilet, preparation of special diets, and supervision of medication that can usually be self- the individual under the group health plan or health insurance. administered. Claim. An invoice, bill, or itemized statement for benefits provided to you. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims Coinsurance. The percentage amount you must pay to the provider for benefits received. for health services or supplies received from network or non-network providers are Full coinsurance payments may apply to scheduled appointments canceled less than 24 hours reimbursable as in-network or out-of-network benefits under this certificate. before the appointment time or to missed appointments. Dependent. Unless otherwise specified in the Contract, the following are considered For in-network benefits, the coinsurance amount is based on the lesser of the: dependents: 1. Charge billed by the provider (i.e., retail); or 1. The subscriber's spouse. 2. Negotiated amount that the provider has agreed to accept as full payment for the benefit 2. The following dependent children up to the dependent limiting age of 26: (i.e., wholesale). a. The subscriber's or subscriber's spouse's natural or adopted child; When the wholesale amount is not known nor readily calculated at the time the benefit is b. A child placed for adoption with the subscriber or subscriber's spouse; 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. c. A child for whom the subscriber or the subscriber's spouse has been appointed legal The provider's retail charge is the amount that the provider would charge to any patient, guardian; however, upon request by Medica, the subscriber must provide satisfactory whether or not that patient is a Medica member. proof of legal guardianship; For out-of-network benefits, the coinsurance will be based on the lesser of the: d. The subscriber's stepchild; and 1. Charge billed by the provider (i.e., retail); or 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. 2. Non-network provider reimbursement amount. 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent For out-of-network benefits, in addition to any coinsurance and deductible amounts, you are incapable of self-sustaining employment by reason of developmental disability, mental responsible for any charges billed by the provider in excess of the non-network provider illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber reimbursement amount. for support and maintenance. An illness that does not cause a child to be incapable of self- In addition, for the network pharmacies described in Prescription Drug Program and sustaining employment will not be considered a physical disability. This dependent may Prescription Specialty Drug Program, the calculation of coinsurance amounts as described remain covered under the Contract regardless of age and without application of health above do not include possible reductions for any volume purchase discounts or price screening or waiting periods. To continue coverage for a disabled dependent, you must adjustments that Medica may later receive related to certain prescription drugs and pharmacy provide Medica with proof of such disability and dependency within 31 days of the child services. 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 The coinsurance may not exceed the charge billed by the provider for the benefit. dependency. Continuous coverage. The maintenance of continuous and uninterrupted qualifying For residents of a state other than Minnesota, the dependent limiting age may be higher if coverage by an eligible employee or dependent. An eligible employee or dependent is required by applicable state law. considered to have maintained continuous coverage if enrollment is requested under the Contract within 63 days of termination of the previous qualifying coverage. j 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, MIC PP MN HSA (3/12) 112 1500-100% MIC PP MN HSA (3/12) 113 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Definitions Definitions you must provide Medica with proof of such disability and dependency at the time of the parameters approved by national health professional boards or associations, and entries in any dependent's enrollment. authoritative compendia as identified by the Medicare program for use in the determination of a Emergency. A condition or symptom (including severe pain) that a prudent layperson, who medically accepted indication of drugs and biologicals used off-label. possesses an average knowledge of health and medicine, would believe requires immediate Late entrant. An eligible employee or dependent who requests enrollment under the Contract treatment to: other than during: 1. Preserve your life; or 1. The initial enrollment period set by the employer; or 2. Prevent serious impairment to your bodily functions, organs, or parts; or 2. The open enrollment period set by the employer; or 3. Prevent placing your physical or mental health (or, if you are pregnant, the health of your 3. A special enrollment period as described in Eligibility And Enrollment. unborn child) in serious jeopardy. However, an eligible employee or dependent who is an enrollee of the Minnesota Enrollment date. The date of the eligible employee's or dependent's first day of coverage Comprehensive Health Association (MCHA) at the time Medica offers or renews coverage with under the Contract or, if earlier, the first day of the waiting period for the eligible employee's or the employer will not be considered a late entrant, provided the eligible employee or dependent's enrollment. dependent maintains continuous coverage as defined in this certificate. h a QMCSO is not through e Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if In addition, a member who is a child entitled to receive coverage 9. the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing includes subject to any initial or open enrollment period restrictions. pharmacogenetic testing. Genetic testing does not include an analysis of proteins or Medically necessary. Diagnostic testing and medical treatment, consistent with the diagnosis metabolites that is directly related to a manifested disease, disorder, or pathological condition. of and prescribed course of treatment for your condition, and preventive services. Medically For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. necessary care must meet the following criteria: Hospital. A licensed facility that provides diagnostic, medical, therapeutic, rehabilitative, and 1. Be consistent with the medical standards and accepted practice parameters of the surgical services by, or under the direction of, a physician and with 24-hour R.N. nursing community as determined by health care providers in the same or similar general specialty services. The hospital is not mainly a place for rest or custodial care, and is not a nursing as typically manages the condition, procedure or treatment at issue; and home or similar facility. 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing diagnosis or condition; and 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 3. Help to restore or maintain your health; or condition. 4. Prevent deterioration of your condition; or Investigative. As determined by Medica, a drug, device, diagnostic or screening procedure, or 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. 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 , Member. A person who is enrolled under the Contract. determination based upon an examination of the following reliable evidence, none of which shall ! Mental disorder. A physical or mental condition having an emotional or psychological origin, be determinative in and of itself: 1 as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders 1. Whether there is final approval from the appropriate government regulatory agency, if (DSM). required, including whether the drug or device has received final approval to be marketed for Network. A term used to describe a provider (such as a hospital, physician, home health its proposed use by the United States Food and Drug Administration (FDA), or whether the agency, skilled nursing facility, or pharmacy)that has entered into a written agreement to treatment is the subject of ongoing Phase I, II, or III trials; provide benefits to you. The participation status of providers will change from time to time. 2. Whether there are consensus opinions and recommendations reported in relevant scientific The network provider directory will be furnished automatically, without charge. and medical literature, peer-reviewed journals, or the reports of clinical trial committees and other technology assessment bodies; and Non-network. A term used to describe a provider not under contract as a network provider. 3. Whether there are consensus opinions of national and local health care providers in the Non-network provider reimbursement amount. The amount that Medica will pay to a non- applicable specialty or subspecialty that typically manages the condition as determined by a network provider for each benefit is based on one of the following, as determined by Medica: survey or poll of a representative sampling of these providers. 1. A percentage of the amount Medicare would pay for the service in the location where the Notwithstanding the above, a drug being used for an indication or at a dosage that is an service is provided. Medica generally updates its data on the amount Medicare pays within accepted off-label use for the treatment of cancer will not be considered by Medica to be 30-60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or investigative. Medica will determine if a use is an accepted off-label use based on published 2. A percentage of the provider's billed charge; or reports in authoritative peer-reviewed medical literature, clinical practice guidelines, or • MIC PP MN HSA (3/12) 114 1500-100% MIC PP MN HSA(3/12) 115 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Definitions Definitions 3. A nationwide provider reimbursement database that considers prevailing reimbursement 3. With respect to members who are infants, children, and adolescents, evidence-informed rates and/or marketplace charges for similar services in the geographic area in which the preventive care and screenings provided for in the comprehensive guidelines su PPorted by service is provided; or the Health Resources and Services Administration; 4. An amount agreed upon between Medica and the non-network provider. 4. With respect to members who are women, such additional preventive care and screenings Contact Customer Service for more information concerning which method above pertains to not described in 1. as provided for in comprehensive guidelines supported by the Health your services, including the applicable percentage if a Medicare-based approach is used. Resources and Services Administration. For certain benefits, you must pay a portion of the non-network provider reimbursement Contact Customer Service for information regarding specific preventive health services, services that are rated A or B, and services that are included in guidelines supported by the amount as a coinsurance. Health Resources and Services Administration. In addition, if the amount billed by the non-network provider is greater than the non-network Provider. A health care professional or facility licensed, certified, or otherwise qualified under provider reimbursement amount, the non-network provider will likely bill you for the state law to provide health services. 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 Qualifying coverage. Health coverage provided under one of the following plans: I certificate. Furthermore, such difference will not be applied toward the out-of-pocket maximum p Additionally, you will owe these amounts 1. A health plan in which a health carrier has issued a policy, contract, or certificate for the described in Your Out-Of-Pocket Expenses. Additional) coverage of medical and hospital benefits, including blanket accident and sickness regardless of whether you previously reached your out-of-pocket maximum with amounts paid I insurance other than accident only coverage; g 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 2. Part A or Part B of Medicare; network provider. 3. A medical assistance medical care plan as defined under Minnesota law; Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene- based information to determine the proper drug and dosage for an individual. 4. A general assistance medical care plan as defined under Minnesota law; Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared 5. Minnesota Comprehensive Health Association (MCHA); from the.body of an individual based on their genetic makeup. 6. A self-insured health plan; Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry 7. The MinnesotaCare program as defined under Minnesota law; (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. i 8. The public employee insurance plan as defined under Minnesota law; Placed for adoption. The assumption and retention of the legal obligation for total or partial I 9. The Minnesota employees insurance plan as defined under Minnesota law; support of the child in anticipation of adopting such child. 10. TRICARE or other similar coverage provided under federal law applicable to the armed (Eligibility for a child placed for adoption with the subscriber ends if the placement is forces; ■ interrupted before legal adoption is finalized and the child is removed from placement.) 11. Coverage provided by a health care network cooperative or by a health provider Premium. The monthly payment required to be paid by the employer on behalf of or for you. cooperative; Prenatal care. The comprehensive package of medical and psychosocial support provided 12. The Federal Employees Health Benefits Plan or other similar coverage provided under throughout a pregnancy and related directly to the care of the pregnancy, including risk federal law applicable to government organizations and employees; assessment, serial surveillance, prenatal education, and use of specialized skills and 13. A medical care program of the Indian Health Service or of a tribal organization; technology, when needed, as defined by Standards for Obstetric-Gynecologic Services issued by the American College of Obstetricians and Gynecologists. 14. A health benefit plan under the Peace Corps Act; Prescription drug. A drug approved by the FDA for the prescribed use and route of 15. State Children's Health Insurance Program; or administration. 16. A public health plan similar to any of the above plans established or maintained by a state, Preventive health service. The following are considered preventive health services: the U.S. government, a foreign country, or an 9 p y any political subdivision of a state, the U.S. government, or a foreign country. 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; Coverage of the following types, including any combination of the following types, are not qualifying coverage: 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 1. Coverage only for disability or income protection insurance; with respect to the member involved; 2. Automobile medical payment coverage; • MIC PP MN HSA(3/12) 116 1500-100% MIC PP MN HSA(3/12) 117 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Definitions Definitions 3. Liability insurance or coverage issued as a supplement to liability insurance; Subscriber. The person: 4. Coverage for a specified disease or illness or to provide payments on a per diem, fixed 1. On whose behalf premium is paid; and indemnity, or non-expense-incurred basis, if offered as independent, non-coordinated 2. Whose employment is the basis for membership, according to the Contract; and coverage; 5. Credit accident and health insurance as defined under Minnesota law; 3. Who is enrolled under the Contract. Total disability. Disability due to injury, sickness, or pregnancy that requires regular care and 6. Coverage designed solely to provide dental or vision care; attendance of a physician, and in the opinion of the physician renders the employee unable to 7. Accident only coverage; perform the duties of his or her regular business or occupation during the first two years of the 8. Long-term care coverage as defined under Minnesota law; 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. 9. Medicare supplemental health insurance as defined under Minnesota law; Urgent care center. A health care facility distinguishable from an affiliated clinic or hospital 10. Workers' compensation insurance; or whose primary purpose is to offer and provide immediate, short-term medical care for minor, 11. Coverage for on-site medical clinics operated by an employer for the benefit of the immediate medical conditions on a regular or routine basis. employer's employees and their dependents, in connection with which the employer does Virtual care. Professional evaluation and medical management services provided to patients not transfer risk. through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth services. Virtual care is used to address non-urgent medical symptoms for patients describing Reconstructive. Surgery to rebuild or correct a: new or ongoing symptoms to which providers respond with substantive medical advice. 1. Body part when such surgery is incidental to or following surgery resulting from injury, Virtual care does not include telephone calls for reporting normal lab or test results, or solely sickness, or disease of the involved body part; or calling in a prescription to a pharmacy. 2. Congenital disease or anomaly which has resulted in a functional defect as determined by Waiting period. In accordance with applicable state and federal laws, the period of time that your physician. must pass before an otherwise eligible employee and/or dependent is eligible to become In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was covered under the Contract (as determined by the employer's eligibility requirements). performed and surgery and reconstruction of the other breast to produce a symmetrical However, if an eligible employee or dependent enrolls as a late entrant or through a special appearance shall be considered reconstructive. 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 Restorative. Surgery to rebuild or correct a physical defect that has a direct adverse effect on employment classification that is not eligible for coverage under the Contract do not constitute a the physical health of a body part, and for which the restoration or correction is medically waiting period. 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 removing corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removing 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. MIC PP MN HSA(3/12) 118 1500-100% MIC PP MN HSA (3/12) 119 1500-100% BPL 21277 DOC 23742 BPL 21277 DOC 23742 Medica Choice Passport Certificate of Coverage MEDICA® MIC PP MN HSA (3/12) 1500-100% BPL 21278 DOC 23744 I MEDICA CUSTOMER SERVICE i. Table OfContents Table Of Contents Minneapolis/St. Paul Hearing Impaired: Introduction x Metro Area: National Relay Center Medical Loss Ratio (MLR) standards under the federal Public Health Service Act x (952) 945-8000 1 -800-855-2880, then To be eligible for benefits xi ask them to dial Medica Language interpretation xi Outside the Metro Area: Acceptance of coverage xi 1 -800-952-3455 at 1 -800-952-3455 Nondiscrimination policy xii More information about the plan can also be obtained by ! Health savings accounts xii signing in at www.mymedica.com. 1 A. Member Rights And Responsibilities 1 Member bill of rights 1 Member responsibilities 1 / 1 B. How To Access Your Benefits 3 L1y Joi-L<.,k. -).ss3,11 AA ! J1-4 Jl oya Ec tH Ba.M ttplota TIOMOUTh B nepeaorte o•roH Important member information about in-network benefits 3 u4o3I.call oye :t....:t...._):,,..,1"apt?...ozat..w cL'u: uiS lit HH o MauHH, 1103BOHHTe HO HoMG py, yxa3aHHOMy Ha o6parnoti cTopone nauieii Important member information about out-of-network benefits 5 Medica a:i...wt a;,L.tl �.4,yat MeleuH-»cxoH Kap-r0LIKH n,aana Medica. Continuity of care 7 Haddii aad doonayso in Af Soomaali laguugu (rrA if;teuir iii ii£;fm trio ntrrit ittttil tatiF attlf tf;< tarjamadda macluumaadkam,00 lacag tijiitji �SEltfrittliniftr9 t 13141ri`lfailtit@3�`�11Medica`t Prior authorization 8 la'aan all, Fadlan wac Lambarka ku goran Certification of qualifying coverage 9 Kaarka C.aafimaadka ee Medica dhabarkiisa. Si usted desea ayuda gratuita para traducir esta informacion, llame al nattiero de C. How Providers Are Paid By Medica 10 A.ko zelite besplatano tumacenje ovih telefono situado al reverses de su tarjeta Network providers 10 informacija posovite broj na pozadini vase de identicac�ion de Medica. Medica kartice. Ncu quy vi main throe gulp do dick tai lieu nay tnicn I Non-network providers 10 phi,xin got so ghi 0 mat sau the Modica cua qu •vi. D. Your Out-Of-Pocket Expenses 11 Yog koj xav tau key pab txhais coy ntaub ntawv no dawb, hu rau tus xov tooj nyob Dine k`ehji shich' ' hadoodzih ninizingo, beesh Coinsurance and deductibles 11 bee hane'e binumber naaltsoos bikaahi ii bich`i' nram gab koj claim Medica Khaj (card). g hodiilnih ei doodah bee neehozin biniiye More information concerning deductibles 12 ,; nanitinigii binedee bikaa doo aldo'. ij�rai-lz c T'a;nt? e.r:ccltril.kir :4-11, r‘,:; 7i-,ltnsr):,c.:.Altf; Out-of-pocket maximum 13 �r Para sa tulong sa Tagalog, tawagan ang Lifetime maximum amount 13 ir,in1t -1�F,;ir° critE°itiJr ncaciPra�t;7e}rtituMcdica numerong kabilang sa dokumentong ito o sa Yoo odeeyssi kun bilashitti afaan keetitti akka likod ng iyong ID card. Out-of-Pocket Expenses 14 sii hiikamu feete lakkoofsa caaardiii meedikaa --5.rya fj j,Eit tJ ,.(t ..N.1z` E. Ambulance Services 15 (Medica) gama dubaarra jiru kana bilbili. 5.- 1-EN Itti 51n�o Covered 15 UNV1011 — If you want free help translating this information, call the number Not covered 15 on the back of your Medica identification card. Ambulance services or ambulance transportation 16 Non-emergency licensed ambulance service 16 F. Durable Medical Equipment And Prosthetics 17 Covered 17 ©2012 Medica. 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, MIC PP MN HSA (3/12) iii 1500-100% Medica Self-Insured, and Medica Health Management, LLC. BPL 21278 DOC 23744 Table Of Contents Table Of Contents Not covered 43 Prescription unit 57 Office visits 43 Not covered 58 Virtual care 43 Specialty prescription drugs received from a designated specialty pharmacy 58 Outpatient services 44 Specialty growth hormone received from a designated specialty pharmacy 58 Inpatient services 44 S. Professional Services 59 Services received from a physician during an inpatient stay 45 Covered 59 Anesthesia services received from a provider during an inpatient stay 45 Not covered 60 Transportation and lodging 45 Office visits 60 P. Physical, Speech, And Occupational Therapies 47 Virtual care 60 Covered 47 Convenience care/retail health clinic visits 60 Not covered 47 Urgent care center visits 61 Physical therapy received outside of your home 48 Preventive health care 61 Speech therapy received outside of your home 48 Allergy shots 62 Occupational therapy received outside of your home 49 Routine annual eye exams 62 Q. Prescription Drug Program 50 Chiropractic services 62 Preferred drug list 50 Surgical services 62 Exceptions to the preferred drug list 50 Anesthesia services received from a provider during an office visit or an outpatient hospital Prior authorization 51 or ambulatory surgical center visit 62 Step therapy 51 Services received from a physician during an emergency room visit 62 Quantity limits 51 Services received from a physician during an inpatient stay 62 Covered 51 Anesthesia services received from a provider during an inpatient stay 63 Prescription unit 52 Outpatient lab and pathology 63 Outpatient x-rays and other imaging services 63 Not covered 53 Outpatient covered drugs 54 Other outpatient hospital or ambulatory surgical center services 63 Diabetic equipment and supplies, including blood glucose meters 54 Treatment to lighten or remove the coloration of a port wine stain 63 Tobacco cessation products 54 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 63 Drugs and other supplies considered preventive health services 55 Diabetes self-management training and education 64 Neuropsychological evaluations/cognitive testing 64 R. Prescription Specialty Drug Program 56 Designated specialty pharmacies 56 Services related to lead testing 64 Specialty preferred drug list 56 Vision therapy and orthoptic and/or pleoptic training 64 Exceptions to the specialty preferred drug list 56 Genetic counseling 64 Prior authorization 57 Genetic testing 65 Step therapy 57 T. Reconstructive And Restorative Surgery 66 Quantity limits 57 Covered 66 Covered 57 Not covered 66 MIC PP MN HSA(3/12) vi 1500-100% MIC PP MN HSA(3/12) vii 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 1 1 T Table Of Contents Table Of Contents Office visits 67 Right to receive and release needed information 86 Virtual care 86 67 Facility of payment Outpatient services 67 Right of recovery 86 Inpatient services 68 BB. Right Of Recovery 87 Services received from a physician during an inpatient stay 68 CC. Eligibility And Enrollment 88 Anesthesia services received from a provider during an inpatient stay 68 Who can enroll 88 U. Skilled Nursing Facility Services 69 How to enroll 88 Covered 69 Notification 88 Not covered 69 Initial enrollment 88 Daily skilled care or daily skilled rehabilitation services 70 Open enrollment 89 Skilled physical, speech, or occupational therapy 70 Special enrollment 89 Services received from a physician during an inpatient stay in a skilled nursing facility....70 Late enrollment 92 V. Substance Abuse 71 Qualified Medical Child Support Order (QMCSO) 92 Covered 92 72 The date your coverage begins Not covered 73 DD. Ending Coverage 94 Office visits, including evaluations, diagnostic, and treatment services 73 When coverage ends 94 Intensive outpatient programs 73 EE. Continuation 96 Opiate replacement therapy 73 Your right to continue coverage under state law 96 Inpatient services (including residential treatment services) 73 Your right to continue coverage under federal law 99 W. Referrals To Non-Network Providers 75 FF. Conversion 105 W Minnesota residents 105 What you must do 75 What Medica will do 75 Residents of a state other than Minnesota 106 X. Harmful Use Of Medical Services 77 GG. Complaints 107 When this section applies 77 First level of review 107 Y. Exclusions 78 Second level of review 108 Z. How To Submit A Claim 81 External review 108 Claims for benefits from network providers 81 Civil action 109 Claims for benefits from non-network providers 81 HH. General Provisions 110 Claims for services provided outside the United States 82 Definitions 112 Time limits 82 AA. Coordination Of Benefits 83 Applicability 83 Definitions that apply to this section 83 Order of benefit determination rules 84 Effect on the benefits of this plan 85 MIC PP MN HSA (3/12) viii MIC PP MN HSA (3/12) ix 1500-100% 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Introduction Introduction To be eligible for benefits Introduction Each time you receive health services, you must: THIS POLICY IS REGULATED BY MINNESOTA LAW. 1 Customer Service that your provider is a network provider to be eligible for in- network benefits; and The benefits of the policy providing your coverage are governed primarily by the law of a state 2. Identify yourself as a Medica member; and other than Florida. 3. Present your Medica identification card. (If you do not show your Medica identification card, 'Many words in this certificate have specific meanings. These words are identified in each 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, 'section'.and defined in Definitions. See Definition These words have specific meanings: benefits, possession and use of a Medica identification card does not necessarily guarantee g ,x claim,dependent, member coverage. network, premium,,provider. Network providers are required to submit claims within 180 days from when you receive a Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota non- service. If your provider asks for your health care identification card and you do not identify qualified plan. This Certificate of Coverage (this certificate) describes health services that are yourself as a Medica member within 180 days of the date of service, you may be responsible for eligible for coverage and the procedures you must follow to obtain benefits. paying the cost of the service you received. The Contract refers to the Contract between Medica and the employer. You should contact the employer to see the Contract. Language interpretation 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 Language interpretation services will be provided upon request, as needed in connection with described. The most specific and appropriate the interpretation of this certificate. If you would like to request language interpretation services, P ppropriate section will apply for those benefits related to the please call Customer Service at one of the telephone numbers listed inside the front cover. treatment of a specific condition. Members are subject to all terms and conditions of the Contract and health services must be If you have an impairment that requires alternative communication formats such as Braille, large medically necessary. print, or audiocassettes, please call Customer Service at one of the telephone numbers listed inside the front cover to request these materials. 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 If this certificate is translated into another language or an alternative communication format is administration of your benefits, you must cooperate with them in the performance of their used, this written English version governs all coverage decisions. responsibilities. Additional network administrative support is provided by one or more organizations under Acceptance of coverage contract with Medica. This certificate is not a legal contract between you and Medica. It is simply an explanation of The employer is responsible for remitting the premium to Medica and notifying you of any the benefits covered under the Contract that has been issued in Minnesota between Medics and changes to this certificate as required by applicable law. the employer. This certificate is being delivered to you by, or on behalf of, your employer. In this certificate, the words you, your, and yourself refer to the member. The word employer By accepting the health care coverage described in this certificate, you, on behalf of yourself refers to the organization through which you are eligible for coverage. 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 Medical Loss Ratio (MLR) standards under the federal Public Health Service Act by state law; and Federal law establishes standards concerning the percentage of premium revenue that insurers 2. That the information supplied by you to Medica for purposes of enrollment is accurate and pay out for claims expenses and health care quality improvement activities. If the amount an complete. insurer pays out for such expenses and activities is less than the applicable MLR standard, the You understand and agree that any omission or incorrect statement concerning a material fact insurer is required to provide a premium rebate. MLR calculations are based on aggregate intentionally made by you in connection with your enrollment under the Contract may invalidate market data rather than on a group by group basis. In the event Medica is required to pay your coverage. rebates pursuant to federal law, Medica will pay such rebates to your employer unless prohibited by federal law. MIC PP MN HSA (3/12) x 1500-100% MIC PP MN HSA (3/12) xi 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Introduction Member Rights And Responsibilities Nondiscrimination policy Medica's policy is to treat all persons alike, without distinctions based on race, color, creed, A. Member Rights And Responsibilities 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. See tDefinitions. :These'words have_specific meanings benefits, emergency,member; If ; 3 you have questions, call Customer Service at one of the telephone numbers listed inside the �network,_provider front cover. Health savings accounts Member bill of rights As a member of Medica, you have the right to: This coverage is intended to comply with the requirements of the Internal Revenue Code section 223 for a federally qualified high deductible health plan. This coverage may qualify you 1. Available and accessible services, including emergency services (defined in this certificate) to make a pre-tax contribution to a health savings account. You are responsible for the cost of 24 hours a day, seven days a week; and all health services, other than preventive care, up to the deductible amount. 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 PP MN HSA (3/12) xii 1500-100% MIC PP MN HSA (3/12) 1 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Member Rights And Responsibilities How To Access Your Benefits 4. Practicing self-care by knowing: a. How to recognize common health problems and what to do when they occur; and B. How To Access Your Benefits b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and See Definitions. These words have specific meanings: benefits, clairn, coinsurance, 5. Practicing preventive health care by: deductible, dependent, emergency, enrollment date, hospital, inpatient, late entrant, member, a. Having the appropriate tests, exams and immunizations recommended for your gender network, non-network, non-network provider reimbursement amount, physician, placed for and age as described in this certificate; and adoption, premium, prescription drug, provider, qualifying coverage, reconstructive, restorative, skilled nursing facility, subscriber, virtual care, waiting period. b. Engaging in healthy lifestyle choices (such as exercise, proper diet, and rest). You will find additional information on member responsibilities in this certificate. 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 PP MN HSA(3/12) 2 1 MIC PP MN HSA(3/12) 3 1500-100% BPL 21278 DOOC C 23744 BPL 21278 DOC 23744 How To Access Your Benefits How To Access Your Benefits be eligible for in-network benefits. You must verify that your provider is a network r ' each time you receive health services. p ovider 2. Important member information about out-of-network benefits Exclusions The information below describes your covered health services and provides important Certain health services are not covered. Read this certificate for a detailed explanation information concerning your out-of-network benefits. Read this certificate for a detailed exclusions. of all 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 Mental health and substance abuse services you are considering, so you are best able to determine the benefits that will apply Medica's designated mental health and substance abuse provider will arrange your to you. health and substance abuse benefits. Medica's designated mental health and subs abuse provider's hospital network is different from Medica's hospital net g y mental Benefits mental health and substance abuse services require prior authorization b substance work. Certain Medics pays out-of-network benefits for eligible health services received from non-network designated mental health and substance abuse provider. Emergency servi esddo n providers. Prior authorization may be required from Medics before you receive certain require prior authorization. services, in order to determine whether those services are eligible for coverage under your 1 of out-of-network benefits. This certificate defines your benefits and describes procedures you Continuation/conversion must follow to obtain out-of-network benefits. You may continue coverage or convert to an individual conversion plan under cert Decisions about coverage are made based on appropriateness of care and service to the circumstances. See Continuation and Conversion for additional information. am member. Medica does not reward providers for denying care, nor does Medics encourage inappropriate utilization of services. Cancellation Emergency services received from non-network providers are covered as in-network Your coverage may be canceled only under certain conditions. This certificate describes benefits and are not considered out-of-network benefits. • reasons for cancellation of coverage. See Ending Coverage for additional information. Additionally, under certain circumstances Medics will authorize your obtaining services from cribes all Newborn coverage anon-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 Your dependent newborn is covered from birth. Medica does not automatically know providers. birth or whether you would like coverage for the newborn dependent. Call Customer Be aware that if you choose to go to anon-network provider and use out-of-network Service at one of the telephone numbers listed inside the front cover form y w of a benefits, you will likely have to pay much more than if you use in-network benefits. be eligible for in-network benefits, health services must be provided by a network The charges billed by your non-network provider may exceed the non-network provider authorized by Medica. Certain services are covered only upon ref ore information. To premium is required, Medica is entitled to all premiums due from the time provider or reimbursement amount, leaving a balance for you to pay in addition to any applicable until the time you notify Medica of the birth. Medica may referral. If additional y of the infant's birth coinsurance and deductible amount. This additional amount you must pay to the provider premium that is past due for any health benefits for the newborn infant until an will not be applied toward the out-of-pocket maximum amount described in Your Out-Of- y reduce payment by the amount of you owe is paid. For more information, see Eligibility And Enrollment. y Premium 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 Prescription drugs and medical equipment example calculation below. Enrolling in Medica does not guarantee that a particular prescription drug or piece Because obtaining care from non-network providers may result in significant out-of-pocket P of medical expenses, it is important that you do the following before receiving services from anon- equipment will continue to be covered, even if the drug or equipment is covered at the start of the calendar year. network provider: ost-mastectomy coverage • Discuss the expected billed charges with your non-network provider; and • Contact Customer Service to verify the estimated non-network provider reimbursement Medica will cover all stages of reconstruction of the breast on which the mastectomy amount for those services, so you are better able to calculate your likely out-of-pocket ns, includin a lymphedemas, at all stages of mastectomy. g performed and surgery and reconstruction of the other breast to produce a symmetric as l expenses; and appearance. Medica will also cover prostheses and physical complications, If you wish to request that Medics 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 PP MN HSA(3/12) 4 BPL 21278 DOC 1500-100% MIC PP MN HSA (3/12) 5 1500-100% BPL 21278 DOC 23744 How To Access Your Benefits How To Access Your Benefits An example of how to calculate your out-of-pocket costs* 3. Continuity of care You choose to receive non-emergency inpatient care at a non-network hospital provider To request continuity of care or if you have questions about how this may apply to you, call without an authorization from Medica providing for in-network benefits. The out-of-network Customer Service at one of the telephone numbers listed inside the front cover. 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 In certain situations, you have a right to continuity of care. bills $30,000 for your hospital stay. Medica's non-network provider reimbursement amount a. If your current provider is terminated without cause, you may be eligible to continue care for those hospital services is $15,000. You must pay a portion of the non-network provider with that provider at the in-network benefit level. 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 b. If you are a new Medica member as a result of your employer changing health plans and the non-network provider reimbursement amount. If your coinsurance is 40%, you will be your current provider is not a network provider, you may be eligible to continue care with required to pay: that provider at the in-network benefit level. • 40% coinsurance (40% of$15,000 = $6,000) and This applies only if your provider agrees to comply with Medica's prior authorization • The billed charges that exceed the non-network provider reimbursement amount requirements, provide all necessary medical information related to your care, and accept ($30,000 - $15,000 = $15,000) 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 • • The total amount you will owe is $6,000 + $15,000 = $21,000. terminated for cause. • The $6,000 you pay as coinsurance will be applied to the out-of-pocket maximum i. Upon request, Medica will authorize continuity of care for up to 120 days as amount described in Your Out-Of-Pocket Expenses. However, the $15,000 amount you described in a. and b. above for the following conditions: pay for billed charges in excess of the non-network provider reimbursement amount will • an acute condition; 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 • a life-threatening mental or physical illness; you have previously reached your out-of-pocket maximum with amounts paid for other • pregnancy beyond the first trimester of pregnancy; services. • a physical or mental disability defined as an inability to engage in one or more *Note: The numbers in this example are used only for purposes of illustrating how out-of- major life activities, provided that the disability has lasted or can be expected to network benefits are calculated. The actual numbers will depend on the services received. last for at least one year, or can be expected to result in death; or Lifetime maximum amount • a disabling or chronic condition that is in an acute phase. Out-of-network benefits are subject to a lifetime maximum amount payable per member. Authorization to continue to receive services from your current provider may extend See Your Out-Of-Pocket Expenses for a detailed explanation of the lifetime maximum to the remainder of your life if a physician certifies that your life expectancy is 180 amount. days or less. Exclusions 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: Some health services are not covered when received from or under the direction of non- if you are receiving culturally appropriate services and a network provider who •network providers. Read this certificate for a detailed explanation of exclusions. has special expertise in the delivery of those culturally appropriate services is not Claims available; or When you use non-network providers, you will be responsible for filing claims in order to be • if you do not speak English and a network provider who can communicate with reimbursed for the non-network provider reimbursement amount. See How To Submit A you, either directly or through an interpreter, is not available. Claim for details. 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 Post-mastectomy coverage authorizes your request to continue care with your current provider, Medica will explain how Medica will cover all stages of reconstruction of the breast on which the mastectomy was continuity of care will be provided. After that time, your services or treatment will need to be performed and surgery and reconstruction of the other breast to produce a symmetrical transitioned to a network provider to continue to be eligible for in-network benefits. If your appearance. Medica will also cover prostheses and physical complications, including request is denied, Medica will explain the criteria used to make its decision. You may lymphedemas, at all stages of mastectomy. appeal this decision. Coverage will not be provided for services or treatments that are not otherwise covered under this certificate. MIC PP MN HSA (3/12) 6 1500-100% MIC PP MN HSA (3/12) 7 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 How To Access Your Benefits How To Access Your Benefits 4. Prior authorization 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 Prior authorization from Medica may be required before you receive certain services or reasonably necessary to make a decision has been made available to Medica. supplies in order to determine whether a particular service or supply is medically necessary Both you and your provider will be informed of the decision within 72 hours from the time of 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 the initial request if your attending provider believes that an expedited review is warranted, or if it is concluded that a delay could seriously jeopardize your life, health, or ability to authorization, please call Customer Service at one of the telephone numbers listed inside regain maximum function, or subject you to severe pain that cannot be adequately managed the front cover or sign in at www.mymedica.com. Emergency services do not require prior without the care or treatment you are requesting. authorization. Your attending provider, you, If Medica does not approve your request for prior authorization, you have the right to appeal g p , y or someone on your behalf may contact Customer Service to Medica's decision as described in Complaints. 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 Under certain circumstances, Medica may perform concurrent review to determine whether prior authorization for services or supplies received from a non-network provider. If a services continue to be medically necessary. If Medica determines that services are no network provider fails to obtain prior authorization after you have consulted with them about longer medically necessary, Medica will inform both you and your attending provider in services requiring prior authorization, you are not subject to a penalty for failure to obtain writing of its decision. If Medica does not approve continued coverage, you or your prior authorization. attending provider may appeal Medica's initial decision (see Complaints). Some of the services that may require prior authorization from Medica include: • Reconstructive or restorative surgery; 5. Certification of qualifying coverage • Certain drugs; You have the right to a certification of qualifying coverage when coverage ends. You will • Home health care; 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 • Medical supplies and durable medical equipment; within the 24 months following the date your coverage ends. To request a certification of • Outpatient surgical procedures; 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 • Certain genetic tests; and issued as soon as reasonably possible. • Skilled nursing facility services. Prior authorization is always required for: • Organ and bone marrow transplant 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 PP MN HSA (3/12) 8 1500-100% MIC PP MN HSA (3/12) 9 1500-100% BPL 21278 DOC 23744 PL 21278 DOC 23744 P• ! ( ) nl How Providers Are Paid By Medica Your Out-Of-Pocket Expenses C. How Providers Are Paid By Medica D. Your Out-Of-Pocket Expenses This section describes how providers are generally p aid for health services. This section describes the expenses that are your responsibility to pay. These expenses are , , , commonly y ca II e d out-of-pocket expenses.These words have specific meanings coinsurance �deductible hospital member, network,..: ,non non-network, physician, provider. z � _ A See Definitions. These�w o rds:hav s pe c�fc meanings: benefits claim, coinsurance, deductible, dependent, member, network, non-network, non network provider reimbursement Network providers amount, prescription drug, provider, subscribes You are responsible for paying the cost of a service that is not medically necessary or a benefit Network providers are paid using various types of contractual arrangements, which are intended even if the following occurs: 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 1. A provider performs, prescribes, or recommends the service; or may include: 2. The service is the only treatment available; or 1. A fee-for-service method, such as per service or percentage of charges; or 3. You request and receive the service even though your provider does not recommend it. 2. A risk-sharing arrangement, such as an amount per day, per stay, per episode, per case, (Your network provider is required to inform you or in some instances provide a waiver for per period of illness, per member, or per service with targeted outcome. you to sign.) The methods by which specific network providers are paid may change from time to time If you miss or cancel an office visit less than 24 hours before your appointment, your provider Methods also vary by network provider. The primary method of payment under Medica is fee- may bill you for the service. for-service. Please see the applicable benefit section(s) of this certificate for specific information about your Fee-for-service payment means that the network provider is paid a fee for each service in-network and out-of-network benefits and coverage levels. provided. If the payment is per service, the network provider's payment is determined according To verify coverage before receiving a particular service or supply, call Customer Service at one to a set fee schedule. The amount the network provider receives is the lesser of the fee of the telephone numbers listed inside the front cover. schedule or what the network provider would have otherwise billed. If the payment is percentage of charges, the network provider's a ment is a set p Y percentage of the provider's der s charge. The amount paid to the network provider, less any applicable coinsurance or Coinsurance and deductibles deductible, is considered to be payment in full. For in-network benefits, you must pay the following: 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 1. Any applicable coinsurance as described in this certificate (see the Out-of-Pocket Expenses amount per case, an amount per period of illness, an amount per member, or an amount per table in this section). service with targeted outcome. If the amount paid is less than the cost of providing or arranging When members in a family unit (a subscriber and his or her dependents) have together paid for a member's health services, the network provider may bear some of the shortfall. If the the applicable per family deductible for benefits received during a calendar year (see the amount paid to the network provider is more than the cost of providing or arranging a member's Out-of-Pocket Expenses table in this section), then all members of the family unit are L' health services, the network provider may keep some of the excess. considered to have satisfied the applicable per member and per family deductible for that calendar year. 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 However, for family coverage, there is no per member deductible for benefits received �! less of the risk-sharing payment. during any calendar year. Non-network providers 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 When a service from a non-network provider is covered, the non-network provider is paid a fee you had met the previously applicable deductible. This means that it is possible that your for each covered service that is provided. This payment may be less than the charges billed by deductible will increase mid-year when your employer's Contract with Medica is renewed the non-network provider. If this happens, you are responsible for paying the difference. and that you may have additional out-of-pocket expenses as a result. 2. Any charge that is not covered under the Contract. MIC PP MN HSA (3/12) 10 1500-100% MIC PP MN HSA (3/12) 11 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 III Expenses E k P f- ocexp Your Out-Of-Pocket Expenses Your Out-Of-Pocket :', For out-of-network benefits, you must pay the following: Out-of-pocket maximum 1. Any applicable coinsurance as described in this certificate (see the Out-of-Pocket Expenses , The out-of-pocket maximum is an accumulation of coinsurance and deductibles paid for benefits table in this section). received during a calendar year. Except as described below or as otherwise specified, you will When members in a family unit (a subscriber and his or her dependents) have together paid not be required to pay more than the applicable per member out-of-pocket maximum for the applicable per family deductible for benefits received during a calendar year (see the benefits received during a calendar year (see the Out-of-Pocket Expenses table in this section). Out-of-Pocket Expenses table in this section), then all members of the family unit are Please note: Charges for services not eligible for coverage and any charge in excess of considered to have satisfied the applicable per member and per family deductible for that the non-network provider reimbursement amount are not applicable toward the out-of- calendar year. pocket maximum. Additionally, you will owe these amounts regardless of whether you However, for family coverage, there is no per member deductible for benefits received previously reached your out-of-pocket maximum with amounts paid for other services. during any calendar year. The time period used to calculate whether you have met the out-of-pocket maximum (calendar Note that applicable deductibles are determined by the Contract between Medica and the year or Contract year) is determined by the Contract between Medica and the employer. This employer and may increase when Medica and the employer renew the Contract. If this time period may change when Medica and the employer renew the Contract. If the time period occurs, the new deductible will apply for the rest of the current calendar year, whether or not changes, you will receive a new certificate of coverage that will specify the newly applicable you had met the previously applicable deductible. This means that it is possible that your time period. You may have additional out-of-pocket expenses associated with this change. deductible will increase mid-year when your employer's Contract with Medica is renewed When members in a family unit (the subscriber and his or her dependents) have together met and that you may have additional out-of-pocket expenses as a result. 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 2. Any charge that exceeds the non-network provider reimbursement amount. This means you per family out-of-pocket maximum for that calendar year (see the Out-of-Pocket Expenses table are required to pay the difference between the payment to the provider and what the provider bills. in this section). ■However, for family coverage, there is no per member out-of-pocket maximum for benefits If you use out-of-network benefits, you may incur costs in addition to your coinsurance and received during any calendar year. 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. After an applicable out-of-pocket maximum has been met for a particular type of benefit (as In addition, the difference will not be applied toward satisfaction of the deductible or the out- described in the Out-of-Pocket Expenses table in this section), all other covered benefits of the of-pocket maximum (described in this section). 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 To inquire about the non-network provider reimbursement amount for a particular procedure, reimbursement amount. However, you will still be required to pay any applicable coinsurance call Customer Service at one of the telephone numbers listed inside the front cover. When you call, you will need to provide the following: and deductibles for other types of benefits received. • The CPT (Current Procedural Terminology) code for the procedure (ask your non- Note that out-of-pocket maximum amounts are determined b the Contract between Medica and network provider for this); 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, • The name and location of the non-network provider. 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 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 Contract with Medica is renewed and that you may have additional out-of-pocket expenses as a actual amount paid will be based on the information received at the time the claim is result. submitted and subject to all applicable benefit provisions, exclusions and limitations, Medica refunds the amount over the out-of-pocket maximum during any calendar year when including but not limited to coinsurance and deductibles. proof of excess coinsurance and deductibles is received and verified by Medica. 3. Any charge that is not covered under the Contract. Lifetime maximum amount More information concerning deductibles 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 The time period used to apply the deductible (calendar year or Contract year) is determined by Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Contract between Medica and the employer. This time period may change when Medica the Out-of-Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced and the employer renew the Contract. If the time period changes, you will receive a new pertains only to those health care services and supplies that are not essential benefits as certificate of coverage that will specify the newly applicable time period. You may have additional out-of-pocket expenses associated with this change. defined in the Patient Protection and Affordable Care Act, including any amendments, regulations, rules, or other guidance issued with respect to the Act. 1500-100% 150 MIC PP MN HSA (3/12) 12 1500-100% MIC PP MN HSA(3/12) 13 BPL 21278 150 23744 BPL 21278 DOC 23744 Your Out-Of-Pocket Expenses Ambulance Services Out-of-Pocket Expenses E. Ambulance Services - '`-'y ., �r 3s r �"In network : c r ..' : .. _ .' . a .benefits,- � " _-.-* Ouf-of ne �.x This section describes coverage for ambulance transportation and related services received for : �� �� � �� . � � � �� � t�►ork g € ' _ "benefits ° covered medical and medical-related dental services (as described in this certificate). Forou# ofnetwortc�be = . � .. fx � ' �.� �� � � � � � �.� ° ' benefits, . � or .,. add�t� . ,-6� � -._. -,,. ;01!� � , : ,r. : ,� ,,: Y are . � ._ _.�� he,. , �� ..fr�< . .s� _t . de _ . _. _. . . �,. . words h es ecific„9 n ex � ._.r. . derc .._ _ � ��._. .._. _ . _ v rneamn s. benefits. comsurancedeductibleces .ti ttbtE _ r__� rte. . �,��. .,.. _. . :rre:rDgeefriicnyit,ii!lonssi;itTahl,enSeqtww°°rk, P 9 _ , ,. � ,_ th do , � � - t e . . non rs ent a :.:�� :. -, F._., se.ch netw anc . _r ges w�1 _ . rove � .are.... ,< ,I no . : P der. : .. A .res ,.� twork :non n 3..... . t be. �re�m n , . ._._. . . on a.., ,etwork.non network. roviderreimbursement.amount, � a 1 burs A...sable p , p ied . em m .. �:: p._ to en �„_, sf t.. �. �3 _� � :<. _ . _. . _ to � _.. . . dd _s�. , z .: .. ____ _ . ,,. _. �._ � � �s _... _._. . . of-the � �. .. a!► �. _ . clan rouider, skilled..nursing facility. _ .._ _,. . � _____ a r ,� _ f � e..0ut Of.pOCiCt s 'i Coinsurance r g� h Prior authorization. Prior authorization from Medica may be required before you receive See specific benefit for applicable coinsurance. services or supplies. Call Customer Service at one of the telephone numbers listed inside the Deductible front cover. See How To Access Your Benefits for more information about the prior authorization Per family process. $3,000 For family coverage, there Covered is no per member For$8, f000 amily coverage, deductible. there is no per member For benefits and the amounts you pay, see the table in this section. More than one coinsurance l Out-of-pocket maximum deductible. may be required if you receive more than one service or see more than one provider per visit. Per family $3,000 For non-emergency licensed ambulance services described in the table in this section: For family coverage, there $18,000 , In-network benefits apply to ambulance services arranged through a physician and received is no per member out-of- For family coverage, from a network provider. Lifetime maximum amount pocket maximum. there is no per member • Out-of-network benefits apply to non-emergency ambulance services described in this I out-of-pocket maximum. payable per member Unlimited section that are arranged through a physician and received from a non-network provider. In $1,000,000. Applies to addition to the deductible and coinsurance described for out-of-network benefits, you will be all benefits you receive responsible for any charges in excess of the non-network provider reimbursement amount. under this or any other The out-of-pocket maximum does not apply to these charges. Please see Important Medica, Medica Health member information about out-of-network benefits in How To Access Your Benefits for more Plans, or Medica Health information and an example calculation of out-of-pocket costs associated with out-of- Plans of Wisconsin network benefits. coverage offered through the same employer. 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 PP MN HSA(3/12) 14 i 1500-100% MIC PP MN HSA (3/12) 15 1500-100% BPL 21278 OC 23744 BPL 21278 DOC 23744 Ambulance Services Durable Medical Equipment And Prosthetics Your Benefits and the Amounts You Pay F. Durable Medical Equipment And Prosthetics Benefits In-network benefits * Out-of-network benefits after deductible after deductible This section describes coverage for durable medical equipment, certain related supplies, and *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for prosthetics. any charges in excess of the non-network provider reimbursement amount. Additionally,these See Definitions. These words have specific meanings: benefits, coinsurance, deductible, charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. S p g _ durable medical equipment, network, non-network, non-network provider reimbursement amount, 1. Ambulance services or Nothing Covered as an in-network physician, provider. ambulance transportation to the benefit. Prior authorization. Prior authorization from Medica may be required before you receive nearest hospital for an services or supplies. Call Customer Service at one of the telephone numbers listed inside the emergency front cover. See How To Access Your Benefits for more information about the prior authorization 2. Non-emergency licensed process. ambulance service that is arranged through an attending Covered physician, as follows: a. Transportation from hospital Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance to hospital when: may be required if you receive more than one service or see more than one provider per visit. i. Care for your condition is Medica covers only a limited selection of durable medical equipment, certain related supplies, and not available at the hearing aids that meet the criteria established by Medica. Some items ordered by your physician, hospital where you were even if medically necessary, may not be covered. The list of eligible durable medical equipment • first admitted; or 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 ii. Required by Medica at one of the telephone numbers listed inside the front cover. b. Transportation from hospital Nothing 50% coinsurance Medica determines if durable medical equipment will be purchased or rented. Medica's approval to skilled nursing facility 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 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 PP MN HSA (3/12) 16 1500-100% MIC PP MN HSA (3/12) 17 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 G�. Durable Medical Equipment And Prosthetics Durable Medical Equipment And Prosthetics Not covered Your Benefits avid the Amounts You Pay These services, supplies, and associated expenses are not covered: x - 'Benefits : K ln-network benefits ° = * out of network benefits 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the of Medica eligible list. n, after deductible after deductible 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for or hearing aids. 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 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. c. Repair, replacement, or Nothing 50% coinsurance 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, revision of artificial arms, legs, feet, hands, eyes, ears, replacement, or revision of duplicate items. noses, and breast See Exclusions for additional services, supplies, and associated expenses that are not prostheses made necessary covered. by normal wear and use 4. Hearin g aids embers 18 Noth i ds for m Nothing. Coverage is 50% coinsurance. years of age and younger for limited to one hearing aid Coverage is limited to } YOU!' Benefits and the Amounts You�Pa hearing loss that is not 4 , � y � � g per ear every three years. one hearing aid per ear „ AS AT correctable by other covered Related services must be every three years. Benefts � In-network � *=outof network�benefts procedures prescribed by a network i7 ! jjIfteide2uctuble xjs after deductible provider. *For out-of network:benefits in addition Ito the deductible and coinsurance,you are�responsible for y2g pie e T any charges in excess o1 the non network provider reimbursement amount Additionally,these <charges will not be applied toward satisfaction ofthe:deductible or thePout-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 PP MN HSA (3/12) 18 1500-100% MIC PP MN HSA(3/12) 19 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 a Home Health Care Home Health Care Not covered G. Home Health Care 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. This section describes coverage for home health care. Home health care must be directed by a 3. Custodial care and other non-skilled services. physician and received from a home health care agency authorized by the laws of the state in which treatment is received. 4. Physical, speech, or occupational therapy provided in your home for convenience. See Definitions. These Words have specific meanings:.benefits, coinsurance,custodial care, :. 5. Services provided in your home when you are not homebound. deductible dependent,dependent, hospital,=network, non-network, non network provider reimbursement 6. Services primarily educational in nature. amount,physician, provider, skilled care; skilled nursing facility. _ = 7. Vocational and job rehabilitation. 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 8. Recreational therapy. front cover. See How To Access Your Benefits for more information about the prior 9. Self-care and self-help training (non-medical). authorization process. 10. Health clubs. 11. Disposable supplies and appliances, except as described in Durable Medical Equipment Covered And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug For benefits and the amounts you pay, see the table in this section. More than one coinsurance Program. may be required if you receive more than one service or see more than one provider per visit. 12. Physical, speech, or occupational therapy services when there is no reasonable expectation As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare that the member's condition will improve over a predictable period of time according to guidelines) considers you homebound when it is medically contraindicated for you to leave your generally accepted standards in the medical community. home (i.e., when leaving your home would directly and negatively affect your physical health). A 13. Voice training. dependent child may still be considered "confined to home"when attending school where life 14. Home health aide services, except when rendered in conjunction with intermittent skilled support specialized equipment and help are available. care and related to the medical condition under treatment. Benefits covered under 1. and 2. in the table in this section are limited to a combined maximum of See Exclusions for additional services, supplies, and associated expenses that are not 120 visits per calendar year for in-network and 60 visits per calendar year for out-of-network covered. 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. '' Your Benefits and the Amounts You Pay • In-network benefits apply to home health care services ordered or prescribed by a physician and received from a network home health care agency. Benefits _ - ., In-network benefits Out-of-network benefits • Out-of-network benefits apply to home health care services that are ordered or prescribed by a a after e pp y p y deductible after deductible f physician and received from a non-network home health care agency. In addition to the x._ deductible and coinsurance described for out-of-network benefits, you will be responsible for For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for any charges in excess of_the`nonnetwork provider reimbursement amount. Additionally,these= any charges in excess of the non-network provider reimbursement amount. The out-of- Y 9 charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. pocket maximum does not apply to these charges. Please see Important member 1. Int 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- you are homeboudnd, provided by Nothing 50% coinsurance network benefits. or supervised by a registered ■ Please note: Your place of residence is where you make your home. This may be your own nurse dwelling, a relative's home, an apartment complex that provides assisted living services, or 2. Skilled physical, speech, or Nothing some other type of institution. However, an institution will not be considered your home if it is a occupational therapy when you 50% coinsurance hospital or skilled nursing facility. are homebound a ai MIC PP MN HSA (3/12) 20 1500-100% MIC PP MN HSA (3/12) 21 1500-100% 1 BPL 21278 DOC 23744 BPL 21278 DOC 23744 Home Health Care Hospice Services d Pay A ne Your Befits and the Amounts You a j � �� H. Hospice Services Ben_efits In network benefits *Out of=network benefits after deductible #after deductible 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 *For out-of-network benefits,to addition to the-deductible and coinsurance,you are responsible for p 9 p Y p charges ,-, . ... ._ ._- , program. am. any.charges in excess of the non network°provider reimbursement amount Additionally,these wai -nat-be a h ed toward at t s faction of the deductible ble or the o ut-of P ock et maximum. See Definitions.nttcons. These�words ha ve,specific meanin s. benefits.,c o s.u�r_an ce deductible, u c tib- le .F a o member, network, 'non network;non-network provider reimbursement amount, physician,*skilled by 3. Home infusion therapy Nothing 50% coinsurance � gym _ nursing facility. 4. Services received in your home Nothing 50% coinsurance from a physician Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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. MIC PP MN HSA (3/12) 22 1500-100% MIC PP MN HSA (3/12) 23 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Hospice Services Hospital Services 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 I. Hospital Services program. Not covered This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. These services, supplies, and associated expenses are not covered: See Definitions, These,words(have specific meanings ,;benefits, coinsurance, deductible, 1. Respite care for more than five consecutive days at a time. emer enc genetic testing, inpatient, member, network, non network non-network 9 Y,�� gig #� - �� � � provider reimbursement amount, physician, provider. 2. Home health care and skilled nursing facility services when services are not consistent with R p-xiysician,=the hospice program's plan of care. Prior authorization. Prior authorization from Medica may be required before you receive 3. Services not included in the hospice program's plan of care. 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 4. Services not provided by the hospice program. process. 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 Covered home. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 7. Financial or legal counseling services, except when recommended and provided by the may be required if you receive more than one service or see more than one provider per visit. hospice program. In-network benefits apply to hospital services received from a network hospital or ambulatory •8. Housekeeping or meal services in your home, except when recommended and provided by surgical center. the hospice program. Out-of-network benefits apply to hospital services received from a non-network hospital or •9. Bereavement counseling, except when recommended and provided by the hospice ambulatory surgical center. In addition to the deductible and coinsurance described for out- program. of-network benefits, you will be responsible for any charges in excess of the non-network See Exclusions for additional services, supplies, and associated expenses that are not provider reimbursement amount. The out-of-pocket maximum does not apply to these covered. 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 Qki costs associated with out-of-network benefits. Emergency services from non-network mm providers will be covered as in-network benefits. If you are confined in a non-network facility Your Benefits and the Amounts You Pay, , � 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. � � ` In network benefits *Out of-network benefits Benefits -� � , x�- ��. a f e after deductible after deductible Not covered 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 amount. these 1. Drugs received at a hospital on an outpatient basis, except� ; � -. ,- ,_ .. , ,.. zi �.. �y. �= 9 p P drugs requiring intravenous charges,will not be applied toward satisfaction of the deductible ortheout-of pocket ma mum infusion or injection, intramuscular 1 injection, or intraocular injection, or drugs received in an emergency room or a hospital observation room. Coverage for drugs is as described in 1. Hospice services Nothing 50% coinsurance Prescription Drug Program and Prescription Specialty 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. MIC PP MN HSA(3/12) 24 1500-100% MIC PP MN HSA (3/12) 25 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 ■ n Hospital Services Hospital Services ...... .-. ,: <9..Y �. .. ..._ �„ � - _ ., , .$. - � i Amount, Pa= ; . , � r and x�Youc.,Benef�ts andthe, . . . .__ .�_. Your Benefits _, . , � __. ; Amounts You.Pa < -x. � ,... #.. _: .... _. . . a .,. _...;;. .. .., :1- a.,.a. : .. ... _ .. ,_..... ... .,. "� _. ;x, . . _ #. . _. _ _-$,.g E. =._ . ...� ,<�, ��� ... .__ _ �. . nefi Ou .of network:berref�ts., Benefits .,, _ .__ . ,< ,:-,In-network r � enefits , , < �.. . ,� ._.. In network...be .. . ts.._. .- t _. �_ �,. <_ 1 netwo k.benefits: � ... _. _ � .. _._. Out of netw rk,be fi B ��. u. � � . .�. _. 9_-._ :. �_:- _ , .. ,, _ ..,.. 'b'enefits, , fter deductible . .. .. _._ _. a#ter deduct�ble_� fter deductible _ . , � ._. A _ after fter�deducti deductible ,�_ .. :_ . .. _ . .. _ .. ..<::. < a.... E. ' _..: :•rim For:out of network, enefi _ fnetwork, in addi't'ion o.,the:deduct�ble.and,:comsurance, ou.are.res ons�ble for _�.. b_<. ts, n addrt�on to the deductible.andcocns ran , For out o , �. .. .. ,,Y p . :. _� : .. ,.. .,._:. _.. u ce,, . u are res onsibie.for . . i -0, an char es.m.excess..of.the provider , x ;- .. < h r. m=.excess of_the,non non-network etwork. rov�der reimburseent�amount.. Addit�anall then ._., .« Y g t exnon non-network network:. rovrder..reimbursement amount. �,, E any c a es< p ..- . .; , Y,..: _... . . . .. n.. .. . P. _.. t.�Additronail ....these_. Y 9 �. charges_wilt_not- � - _ >.: : - owardsat�sfactonrofthedeductcbleor-.the.out-aFf out-of-pock!! .,.E.��.: ,be-a hed toward at►sfactran of he_detlu , _ _ __: .> charges will not be_a applied , P , > : . F?p -: <.. ctibte orthe,out ofx ocket:maximum. .. . >�� 9.:. pp.__:. ,rat 1. Outpatient services 6. Treatment of temporomandibular Covered at the Covered at the a. Services provided in a Nothing Covered as an in-network joint (TMJ) disorder and corresponding in-network corresponding out-of- hospital or facility-based benefit. craniomandibular disorder benefit level, depending network benefit level, on type of services depending on type of emergency room provided. services provided. b. Outpatient lab and pathology Nothing 50% coinsurance For example, office visits For example, office visits c. Outpatient x-rays and other Nothing 50% coinsurance are covered at the office are covered at the office imaging services visit in-network benefit visit out-of-network level and surgical benefit level and surgical d. Genetic testing when test Nothing 50% coinsurance services are covered at services are covered at results will directly affect treatment decisions or the surgical services in- the surgical services out- frequency of screening for a network benefit level. of-network benefit level. disease, or when results of Please note: Dental Please note: Dental the test will affect coverage is not provided coverage is not provided under this benefit. under this benefit. reproductive choices e. Other outpatient services Nothing 50% coinsurance f. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician g. 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 Nothing 50% coinsurance 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 I MIC PP MN HSA(3/12) 26 1500-100% MIC PP MN HSA (3/12) 27 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Infertility Diagnosis Infertility Diagnosis ."" r 3p, x rah n. �, s s J. Infertility Diagnosis Your Benefits and the Amounts.You Pay, �f - . Benefits �:" . �� n �- In-network benefits �fi '` Out-of-network benefits This section describes coverage for the diagnosis of infertility. Coverage includes benefits for x. K after deductible; afterdeductible professional, hospital, and ambulatory surgical center services. Services for the diagnosis of *For'out-of-network,benefits, in`addit an to the deduct bl infertility must be received from or under the direction of a physician. All services supplies, and a and coinsurance,you are responsible for Y P Y pp any in excess of the non network provider_rein►bursement amount 'Additionally,"these associated expenses for the treatment of infertility are not covered. charges,witl notb pplied toward satisfaction of the deductible or the out-of-pocket_maximum . . ,., - .,•=max . .. . See Definitions,%.These_.wards-haves ecifrc meanings:'___benefits coinsurance deductible, ;a, ��. .- e e p , L ctibl , .° 1. Office visits, including any Nothing hospital, inpatient,member, network; non network,snon_network p ovider reimbursement . Covered as an in-network . � services provided during such benefit. amount, physician, roVider, virtual care; ' v � p � visits Prior authorization. Prior authorization from Medica may be required before you receive 2. Virtual care Nothing No coverage 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 3. Outpatient services received at a Nothing Covered as an in-network authorization process. hospital benefit. 4. Inpatient services Nothing Covered as an in-network Covered benefit. 5. Services received from a Nothing Covered as an in-network Benefits apply to services for the diagnosis of infertility received from a network or non-network physician during an inpatient benefit. provider. More than one coinsurance may be required if you receive more than one service or stay see more than one provider per visit. 6. Anesthesia services received Nothing Covered as an in-network Coverage for infertility services is limited to a maximum of$5,000 per member per calendar year from a provider during an benefit. for in-network and out-of-network benefits combined. inpatient stay 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. 1 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. 10. Services for intrauterine insemination (IUI). See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PP MN HSA(3/12) 28 1500-100% MIC PP MN HSA (3/12) 29 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 i Maternity Services Maternity Services K. Maternity Services Additional information about coverage of maternity services Not all services that are received during your pregnancy are considered prenatal care. Some of This section describes coverage for maternity services. Benefits for maternity services include all the services that are not considered prenatal care include (but are not limited to)treatment of the medical services for prenatal care, labor and delivery, ollowing: ry postpartum care, and related complications. 1. Conditions that existed prior to (and independently of)the pregnancy, such as diabetes or See Definitions. These words have specific meanings: benefits, i lu us, even if the re nanc has caused those conditions to re uirec more fr dependent,hospital,,inpatient, member network, non=network, non-network ,deductible, p p g Y q equent care or ° � etwork � monitoring. reimbursement pital,amount; phystcian; prenatal care,provider, skilled care g ° 2. i of d b that han concurrently e Prior authorization. Prior authorization from Medica may be required before you receive of the n pregnancyons , such ve a as sen back and neck pain with the or skin prgnancy rash. but are not directly related to care services or supplies. Call Customer Service at one of the telephone numbers listed inside t he front cover. See How To Access Your Benefits for more information about the prior authorization 3. Miscarriage and ectopic pregnancy. process. t anern craor a u specific Services and hat appropriate re not co section sidred of p this eatal certiaficatee m. y Please be eligible refer f to those cover sections ge nder for the coverage information. Newborns'and Mothers'Health Protection Act of 1996 Generally, Medica may not restrict benefits for any hospital stay in connection with childbirth for Not covered 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 These services, supplies, and associated expenses are not covered: 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 1. Health care professional services for maternity labor and delivery in the home. case, Medica may not require a provider to obtain prior authorization from Medica for a length of 2. Services from a doula. stay of 48 hours or less (or 96 hours, as applicable). 3. Childbirth and other educational classes. Covered See Exclusions for additional services, supplies, and associated expenses that are not covered. For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider �" Each member's admission is separate from the admission of any other me P per visit. 4 , Your Benefits and the AmountsY,ou Pay tuber. A separate ' R mm deductible and coinsurance will be applied to both you and your newborn child for i services related to maternity labor and delivery. Please note: We e inpatient Benefits ', in-network benefits --*. ut of-network benefits newborn dependent under the Contract within 30 days from the ncourage you to enroll your after deductible after deductible for adoption, or date of adoption. Please refer to Eligibility And Enrollment date of placement information. nt for additional Forhar of network s of t e non- etwo to the deductible and ent am unt. you ar;responsible for • In-network benefits apply to ;any chat•ges nm excess_of the non network provider.reimbursement amount'2+Additionally,these PP Y maternity services received from a network provider. � charges�will not beapphed toward satisfaction of the deduct1ble,or the:out of pocket max�rnum. • Out-of-network benefits apply to maternity services received from a non-network provider. InM� addition to the deductible and coinsurance described for out-of-network benefits, you will be 1. Prenatal services responsible for any charges in excess of the non-network provider reimbursement amount. I a. Office visits for prenatal care, Nothing. The deductible 50% coinsurance The out-of-pocket maximum does not apply to these charges. Please see Important including professional does not apply. member information about out-of-network benefits in How To Access Your Benefits for more services, lab, pathology, information and an example calculation of out-of-pocket costs associated with out-of- x-rays, and imaging network benefits. b. Hospital and ambulatory Nothing. The deductible 50% coinsurance surgical center services for does not apply. prenatal care, including professional services received during an inpatient stay for prenatal care MIC PP MN HSA (3/12) 30 1500-100% MIC PP MN HSA (3/12) 31 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 I Maternity Services Medical-Related Dental Services 1 Your Benefits and the Amounts You Pay Benefits =� � .� _� � �� L. Medical-Related Dental Services fit In-network benefits * Out of network benefits ts after deductible ;i-after deductible * �� � :: , _ w� a This section describes coverage for medical-related dental services. Services must be received For out of network benefits, in addition to the deductible and coinsurance, you are responsible for . 1 from a physician or dentist. any charges in excess of the non-network provider reimbursement amountAdditionall charges will not be applied toward satisfaction of:tt the deductible or the out-of-pocket maximum.use.. - This section does not describe coverage for comprehensive dental procedures. Comprehensive ��� h"; dental procedures are services rendered by a dentist to treat teeth, their supporting soft tissue and c. Intermittent skilled care or Nothing. The deductible 50% coinsurance bony structure, or the alignment or occlusion of the teeth. These services are not covered under home infusion therapy when does not apply. any section of this certificate. you are homebound due to a high risk pregnancy See Definitions.. These words have specific meanings bene fits, coinsurance, deductirble; dependent,�lospital, member, network, non-network, non network provider reimbursement 2. Inpatient hospital stay for labor Nothin g 50% coinsurance mount, physician, provider. - and delivery services ,: . - ;� �, �� ��°x Please note: Maternity labor and Prior authorization. Prior authorization from Medica may be required before you receive j delivery services are considered services or supplies. Call Customer Service at one of the telephone numbers listed inside the inpatient services regardless of the front cover. See How To Access Your Benefits for more information about the prior authorization length of hospital stay. process. 3. Professional services received Nothing 50% coinsurance during an inpatient stay for labor Covered and delivery 4. Anesthesia services received Nothing For benefits and the amounts you pay, see the table in this section. More than one coinsurance during an inpatient stay for labor g 50% coinsurance may be required if you receive more than one service or see more than one provider per visit. and delivery • In-network benefits apply to medical-related dental services received from a network 5. Labor and delivery services at a provider. freestanding birth center • Out-of-network benefits apply to medical-related dental services received from a non- a. Facility services for labor and Nothing network provider. In addition to the deductible and coinsurance described for out-of-network delivery g 50% coinsurance 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. b. Professional services Nothing 50% coinsurance Please see Important member information about out-of-network benefits in How To Access received for labor and Your Benefits for more information and an example calculation of out-of-pocket costs delivery associated with out-of-network benefits. 6. Home health care visit following Nothing. The deductible 50% coinsurance delivery does not apply. Not covered Please note: One home health visit pp y is covered if it occurs within 4 days These services, supplies, and associated expenses are not covered: of discharge. If services are received after 4 days, please refer 1. Dental services to treat an injury from biting or chewing. to Home Health Care for benefits. 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. MIC PP MN HSA (3/12) 32 1500-100%o MIC PP MN HSA(3/12) 33 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 1 M Medical-Related Dental Services Medical-Related Dental Services 7. Any dental procedures or treatment related to periodontal disease. 8. Endodontic procedures and treatment, including root canal procedures and treatment �_ Your Benefits and the Amounts You Pay - ` ' , unless provided as accident-related dental services as described in this section. Benefits In network benefits . *Out-Ofnetwork benefits after deductible : after`deducttbie 9. Routine diagnostic and preventive dental services. See Exclusions for additional services, supplies, and associated expenses that are not � covered. *For=out of-network'benefits, in addition to`-the deductible and-coinsurance,you are responsible for ,, any charges in excessiof the,non=network,pr-ovider reirri . ment,amount Additionally;these , lied toward satisfaction of the'�deductible or the out-of-.ocket'maximum � .:, .;. charges will not be applied d s :� � Your Benef�tsand�the�AmountsYouPaV_-. ., - Accident-relateddental services Nothing 50% coinsurance Benefits, to treat an injury to sound, j , In network benefits of-netwo k be -after*Out-of-network is natural teeth and to repair (not r e deductible replace) sound, natural teeth. * The following conditions apply: For out-of-network of network°benefits, in addition to the deductible and coinsurance,you are responsible ny charges.in excess of the non network rovider'reimbursement amount. Addition p for a. Coverage is limited to charges--will not be'applied toward satisfact on of the deductible or the'out-of-pocket maximum.:hu _, services received within 24 u _ :> ... months from the later of: 1. Charges for medical facilities Nothing 50% coinsurance and general anesthesia services i. the date you are first that are: covered under the a. Recommended by a Contract; or physician; and ii. the date of the injury b. Received during a dental b. A sound, natural tooth means procedure; and a tooth (including supporting structures) that is free from c. Provided to a member who: disease that would prevent i. Is a child under age five continual function of the tooth (prior authorization is not for at least one year. required); or In the case of primary (baby) ii. Is severely disabled; or teeth, the tooth must have a life expectancy of one year. iii. Has a medical condition and requires 4. Oral surgery for: Nothing 50% coinsurance hospitalization or general a. Partially or completely anesthesia for dental unerupted impacted teeth; or care treatment Please note: Age, anxiety, b. A tooth root without the and behaviors) conditions extraction of the entire tooth are not considered medical (this does not include root canal therapy); or conditions. 2. For a dependent child, Nothing 50% coinsurance c. The gums and tissues of the orthodontia, dental implants, and mouth when not performed in oral surgery treatment related to connection with the cleft lip and palate extraction or repair of teeth MIC PP MN HSA (3/12) 34 1500-100% MIC PP MN HSA (3/12) 35 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Mental Health Mental Health f. Residential treatment services. These services include either: M. Mental Health 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 This section describes coverage for services to diagnose and treat mental disorders listed in the services. In addition to room and board, at least 30 hours a week per individual of current edition of the Diagnostic and Statistical Manual of Mental Disorders. For a description of mental health services must be provided, including group and individual counseling, coverage for the diagnosis and primary treatment of substance abuse disorders, see Substance client education, and other services specific to mental health treatment. Also, the Abuse. program must provide an on-site medical/psychiatric assessment within 48 hours of See Definitions. These words have specific meanings: benefits, claim, coinsurance, custodial admission, psychiatric follow-up visits at least once per week, and 24-hour nursing care, deductible, emergency, hospital,;inpatient, medically necessary, member, mental disorder, coverage. network, non-network, non-network provider reimbursement amount, provider. Prior authorization. For prior authorization requirements of in-network and out-of-network Covered 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 For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. For purposes of this section: • For in-network benefits: 1. Outpatient services include: Medica's designated mental health and substance abuse provider arranges in-network mental a. Diagnostic evaluations and psychological testing. health benefits. If you require hospitalization, Medica's designated mental health and substance abuse provider will refer you to one of its hospital providers (Medics and Medica's b. Psychotherapy and psychiatric services. designated mental health and substance abuse provider hospital networks are different). c. Intensive outpatient programs, including day treatment, meaning time limited For claims questions regarding in-network benefits, call Medica's designated mental health comprehensive treatment plans, which may include multiple services and modalities, and substance abuse provider Customer Service at 1-866-214-6829. delivered in an outpatient setting (up to 19 hours per week). • For out-of-network benefits: d. Treatment for a minor, including family therapy. 1. Mental health services from a non-network provider listed below will be eligible for coverage e. Treatment of serious or persistent disorders. 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 f. Diagnostic evaluation for attention deficit hyperactivity disorder(ADHD) or pervasive services and practice independently: development disorders (PDD). a. Psychiatrist 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 b. Psychologist psychologist and that includes an individual treatment plan. c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric h. Treatment of pathological gambling. and mental health nursing 2. Inpatient services include: t d. Mental health clinic a. Room and board. e. Mental health residential treatment center b. Attending psychiatric services. f. Independent clinical social worker c. Hospital or facility-based professional services. g. Marriage and family therapist d. Partial program. This may be in a freestanding facility or hospital based. Active treatment h. Hospital that provides mental health services is provided through specialized programming with medical/psychological intervention and 2. Emergency mental health services are eligible for coverage under in-network benefits. supervision during program hours. Partial program means a treatment program of 20 hours or more per week and may include lodging. 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 e. Services, care, or treatment described as benefits in this certificate and ordered by a court amount. The out-of-pocket maximum does not apply to these charges. Please see on the basis of a behavioral health care evaluation performed by a physician or licensed Important member information about out-of-network benefits in How To Access Your psychologist and that includes an individual treatment plan. MIC PP MN HSA (3/12) 36 MIC PP MN HSA (3/12) 37 1500-100% 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 M Mental Health Mental Health Benefits for more information and an example calculation of out-of-pocket costs associated . with out-of-network benefits. Your Benefits and the Amounts�You Pay Not covered � �� �� �' �� ;�� � ;. Benefits E �_ In-network benefits E .� *Out-of network benefits after deductible = aftertdeductible These services, supplies, and associated expenses are not covered: 1. Services for mental disorders not listed in the current -_ *For:out of-network benefits, in�addition to the deductible_and coinsurance'you are responsible ter nt edition of the Diagnostic and Statistical any=charges:in excess of the non-netwo acti ovlder reimbursement amount -Additionally;these F- Manual of Mental Disorders. charges will not be applied toward satisfaction of the deduct�ble_or the out-Of-pocket mazinum 2. Services for a condition when there is no reasonable expectation that the condition will �` _. �._. � _. �_ improve. 1. Office visits, including Nothing 50% coinsurance 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as evaluationstreatment , diagnostic, and specifically described in this section. services 4. Relationship counseling. 2. Intensive outpatient programs Nothing 50% coinsurance 5. Family counseling services, except as specifically described in this certificate as treatment 3. Inpatient services (including for a minor. residential treatment services) 6. Services for telephone psychotherapy. a. Room and board Nothing 50% coinsurance 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, b. Hospital or facility-based Nothing 50% coinsurance as those conditions are defined in the current edition of the American Psychiatric professional services Association's Diagnostic and Statistical Manual of Mental Disorders. c. Attending psychiatrist Nothing 50% coinsurance 8. Services, including room and board charges services provided by health care professionals or d. Partial program Nothing facilities that are not a 50% coinsurance ppropriately 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 PP MN HSA (3/12) 38 1500-100% MIC PP MN HSA (3/12) 39 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Miscellaneous Medical Services And Supplies Miscellaneous Medical Services And Supplies .-ems` °, .,; -� 4 ' N. Miscellaneous Medical Services And Supplies = Your,Benefits and thr9tL1 ou Pa Y �d G ifs h _ L _ Ott �a' 'y 91fi MA £. _ Benefits � In network benefits * Out of network benefits after deductible afterdeductible �� 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 -*For.,p out-of-network benefits, in addition to ttie deductible and coinsurance,you are.responsible for supplies that meet the criteria established by Medica. Some items ordered by a physician, even an. ,cl ay es�m excess ofthe rtor>-network provider reimbursement amount„Additiet ma imam if medically necessary, may not be covered. a wg charges will nat be applied`toward satisfaction of the deduct�blEor the out-o# ocket maxiimurn See Definitions These,wordshave specific meanings:=benefits coinsurance=deductibles a� 50% coinsurance 1. Blood clotting factors Nothing medical) necessa. network, non-network, non network provider reimbursement amount, y� ry, - p physician, provider: � �.: 50%�� 2. Dietary medical treatment of Nothing 50/° coinsurance phenylketonuria (PKU) 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 3. Amino acid-based elemental Nothing 50% coinsurance front cover. See How To Access Your Benefits for more information about the prior formulas for the following authorization process. diagnoses: a. cystic fibrosis; Covered b. amino acid, organic acid, and fatty acid metabolic and For benefits and the amounts you pay, see the table in this section. More than one coinsurance malabsorption disorders; may be required if you receive more than one service or see more than one provider per visit. c. lgE mediated allergies to • In-network benefits apply to miscellaneous medical services and supplies received from a food proteins; network provider. d. food protein-induced • Out-of-network benefits apply to miscellaneous medical services and supplies received from enterocolitis syndrome; 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 e. eosinophilic esophagitis; reimbursement amount. The out-of-pocket maximum does not apply to these charges. f. eosinophilic gastroenteritis; Please see Important member information about out-of-network benefits in How To Access and Your Benefits for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits. g. eosinophilic colitis. Coverage for the diagnoses in Not covered 3.c.-g. above is limited to members five years of age and • Other disposable supplies and appliances, except as described in Durable Medical Equipment younger. And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program. 4. Total parenteral nutrition Nothing 50% coinsurance See Exclusions for additional services, supplies, and associated expenses that are not 5. Eligible ostomy supplies Nothing 50% coinsurance covered. 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 PP MN HSA (3/12) 40 1500-100% MIC PP MN HSA(3/12) 41 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 � ,1 Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services O. Organ And Bone Marrow Transplant Services Not covered These services, supplies, and associated expenses are not covered. This section describes coverage for certain organ and bone marrow transplant 1. Organ and bone marrow transplant services except as described in this section. Services must be provided under the direction of a network physician and received at designated transplant facility. This section also describes benefits ansplant services. a 2. Supplies and services related to transplants that would not be authorized by Medica under and ambulatory surgical center services. fits for professional, hospital, the medical criteria referenced in this section. Coverage is provided for certain types of organ transplants and related services (including 3. Chemotherapy, radiation therapy, drugs, or any therapy used to damage the bone marrow organ acquisition and procurement) and for certain bone marrow transplant services that are and related to transplants that would not be authorized b Medica under the medical criteria referenced in this section. appropriate for the diagnosis, without contraindications, and non-investigative. 4. Living donor transplants that would not be authorized by Medica under the medical criteria See Definitions. These words have specific meanings: benefits, coinsurance, deductible, hospital, inpatient; investigative, medically necessary, member, network, non-network, referenced in this section. network.provider reimbursement amount, physician rovider virtual care, p Y rk, non- 5. Islet cell transplants except for autologous islet cell transplants associated with p pancreatectomy. Prior authorization. Prior authorization from Medics is required before you receive services supplies. Call Cuon. Pr Sery h ri one of the telephone numbers efo listed insi 6. Services required to meet the patient selection criteria for the authorized transplant See How To Access Your Benefits for more information about the prior autho c or procedure. This includes treatment of nicotine or caffeine addiction, services and related inside the front cover. authorization process. expenses for weight loss programs, nutritional supplements, appetite suppressants, and Covered 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 For benefits and the amounts you pay, see the table in this section. More than one coinsurance would not be authorized by Medics under the medical criteria referenced in this section. may be required if you receive more than one service or see more than one provider per visit. Transplants and related services that are investigative. oer visi nce Medica uses specific medical criteria to determine benefits for organ and bone marrow 9. Private collection and storage of umbilical cord blood for directed use. transplant services. Because medical technology is constantly changing, right to review and update these medical criteria. Benefits for each individual w 9 g. Medica reserves the 10. Drugs provided or administered by a physician or other provider on an outpatient basis, determined based on the clinical circumstances of the member according to Medica's member except those requiring intravenous infusion or injection, ibed as cular injection, or dividual member will be criteria. intraocular injection. Coverage for drugs is as described in Prescription Drug Program and medical Prescription Specialty Drug Program or otherwise described as a specific benefit in this Coverage is provided for the following human organ transplants, if appropriate, certificate. medical criteria and not otherwise excluded from coverage (see Not covered below): cornea, under Medica's kidney, lung, heart, heart/lung, See Exclusions for additional services, supplies, and associated expenses that are not marrow. Bone marrow transplants include the trangplanit of stems ells from syngeneic bones covered. peripheral blood, and umbilical cord blood. om bone marrow, The preceding is not a comprehensive list of eligible organ and bone marrow transplant services. Your°Benefits and the Amounts You Pay p t /n-network benefits apply to transplant services provided by a network Benefits In-network benefits *Out-of-network benefits at a designated transplant facility. A designated transplant facility means a after deductible after deductible rk provider and received entered into a separate contract with Medica to provide certain transplant-related health that has services to members receiving transplants. You may be evaluated and h For out-of-network benefite, in addition to the deductible and coinsurance, you are responsible for recipient at multiple designated facilities for transplant services. any charges in t be a s of the non-network provider reimbursement amount: Additionally,these d listed as a potential charges will not be applied toward satisfaction of the deductible or the out-of-pocket:maximum. Medica requires that all pre-transplant, transplant, and post-transplant services, from time of the initial evaluation through no more than one year after the the 1. Office visits Nothing No coverage be received at one designated transplant facility (that you select from among the list network transplant facilities). Based on the type of transplant you receive, Medica will 2. Virtual care Nothing No coverage date of the transplant, determine the specific time period medically necessary for these services. of MIC PP MN HSA (3/12) 42 1500-100% MIC PP MN HSA(3/12) 43 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Organ And Bone Marrow Transplant Services } Organ And Bone Marrow Transplant Services ra s 9 P sr h ax � � Your Benefits. . . m ,. n of r a Amounts rr.. II sx, ., -�. �k, ,- P _.-. � � _ � , � ^ _ ,- - • fi Marrow ._, x _ _ �, Your" Bene �a �, Y fi#s,and the Amounts_You,Pa � ,� d -- .,,x., s"..'.'-., . ..- f..-,,.... « ..-{--. +� Y- . ., - 4_�.-. � a _ D .. ,-. > . of £ r * � after r _. . ne ec, tw _ deductible � - _, _ ^� Or _ .. �_ _ , . . . � 1e_ � �.�- tt- efts,"; � .� �.after , Beets _ _ , .F In k: _ «.. ,; � > w,. � . , ., ^ .. networ _bene#its .-. . ".,Out of network ben. fi n two _ z _ . . . . _,- n a .. ,. ,. ^,�,,. �,F. p- after deductible. _ ._ . ,.. dd _ ^ - � ��-� -� _ . . . . ^. after deductible . _,y charges Ito t « . >.,. .,;�, : non . _ ins ■ .�Fx, «x _ w charges _. . twos coinsurance,, . .:, 3_ .:.:.� 9 will, provider you � P rder, Y are e !not:b rei s . .'- -: ," . . e a �;r, , .;�, reimbursement Pons *. lie ,, rse - - , :.. ble f _ _ _ - PP d tows merit or For o t.of n rds : amo �- u etwork benefits m addition to the deducteble and..co�fisurance , ou_are_res n 7 _.. _.«. atisfact the ... .., ��.. unt.,Ad ;- t ,,Y po sib a for : . r.._ alt , any � • .- �,... : . _ $Y„these or the charges in of..the-non=network' rovider-reimbursem nt,:amo nt.<A 3. Out .w.. ,. out-Of-pocket .-.�. . , ,. , , ,- 9 � P e i Iona y,;t ese;-�� P t maximum . , Outpatient services . .x charges will not be applied toward satisfaction of the deductibleorthe out-of-pocket maximum. a. Professional services 5. Services received from a Nothing No coverage i. Surgical services (as Nothing physician during an inpatient defined in the Physicians' No coverage stay Current Procedural 6. Anesthesia services received Nothing No coverage Terminology code book) from a provider during an g received from a physician inpatient stay during an office visit or an outpatient hospital visit 7. Transportation and lodging The deductible does not No coverage ii. Anesthesia services a. As described below, apply to this received from a provider Nothing reimbursement of reasonable reimbursement benefit. during an office visit or an No coverage and necessary expenses for You are responsible for travel and lodging for you Paying all amounts not outpatient hospital or reimbursed under this ambulatory surgical and a companion when you benefit. Such amounts center visit receive approved services at do not count toward your a designated facility for iii. Outpatient lab and out-of-pocket maximum Nothing tar ransplant services and you pathology No coverage live more than 50 miles from or toward satisfaction of iv. Outpatient x-rays and that designated facility your deductible. other imaging services Nothing No coverage i. Transportation of you and v. Other outpatient hospital Nothing one companion (traveling services received from a No coverage on the same day(s)) to physician and om e vi. Services related to facility for fr transplant dsignated human leukocyte antigen Nothing No coverage services/or for pre- a testing for bone marrow transplant, transplant, transplants and post-transplant services. If you a , surgical center services transportation minor child expenses b. Hospital and ambulatory i• Outpatient lab and for two reimbur companions will pathology Nothing be s No coverage ii. Outpatient x-rays and other imaging services Nothing No coverage iii. Other outpatient hospital Nothing services No coverage 4. Inpatient services Nothing No coverage • 45 1500-100% MIC PP MN HSA (3/12) 44 BPL 21278 DOC 23744 MIC PP MN HSA (3/12) BPL 21278 DOC 23744 Organ And Bone Marrow Transplant Services Fg Physical, Speech, And Occupational Therapies You r B Bene fits fi t s and the Anounts�¢Y o u Pay ;I Benefits ��� � �t m � ;:ys � � ,� �,,. �g � -' y_ � ` ,a � �,I P. Physical, Speech, And Occupational Therapies r s "In network benefits _� ` � `� ���s.=� � after,deductibte� ���� � ' Out-ofnetwork benefits . � .v d after deductible; 'a**¢For oaf of-rietwork:benefits r :A an _ , n addition to.`,the de, n ponsib ., t y charges-in=excessor : ductrble and= f , ; This section describes coverage for physical therapy, speech therapy, occupational therapy py, and occu ational thera consurance;A°clud'arre responsrblefor services provided on an outpatient basis. A physician must direct your care in order for it to be charges the non;network provider reimbursement amount.� P p p Y Y rges;will not be applied toward satisfact►or of the:de r • mo . onamly,these =r g eligible for coverage. Coverage for services provided x= � deductible or�the�out-vf el g g g p i on an inpatient basis is as described pocket'maxrmum� � � � ii. Lodging for you (while not elsewhere in this certificate. confined) and one See Definitions. These words;have specific meanings: benefits, coinsurance, deducti�e;� companion. inpatient, network, non-network,twork non-network provider:reirnbursement amount, physician Reimbursement is available for a per diem Prior authorization. Prior authorization from Medica may be required before you receive amount of up to $50 for services or supplies. Call Customer Service at one of the telephone numbers listed inside the one person or up to $100 front cover. See How To Access Your Benefits for more information about the prior for two people. If you are authorization process. a minor child, reimbursement for Covered lodging expenses for two companions is available, For benefits and the amounts you pay, see the table in this section. More than one coinsurance up to a per diem amount may be required if you receive more than one service or see more than one provider per visit. of$100. • In-network benefits apply to outpatient physical therapy, speech therapy, and occupational iii. There is a lifetime therapy services arranged through a physician and received from the following types of maximum of$10,000 per network providers: physical therapist, speech therapist, occupational therapist, or physician. member for all transportation and • Out-of-network benefits apply to outpatient physical therapy, speech therapy, and lodging expenses occupational therapy services arranged through a physician and received from the following incurred by you and your types of non-network providers: physical therapist, speech therapist, occupational therapist, companion(s) and or physician. In addition to the deductible and coinsurance described for out-of-network reimbursed under the benefits, you are responsible for any charges in excess of the non-network provider Contract or under any reimbursement amount. The out-of-pocket maximum does not apply to these charges. other Medica, Medica Please see Important member information about out-of-network benefits in How To Access Health Plans, or Medica Your Benefits for more information and an example calculation of out-of-pocket costs Health Plans of associated with out-of-network benefits. Wisconsin coverage offered through the same Not covered employer. b. Meals are not reimbursable These services, supplies, and associated expenses are not covered: under this benefit. 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. Voice training. 7. Group physical, speech, and occupational therapy. MIC PP MN NSA (3/12) 46 1500-100% MIC PP MN HSA (3/12) 47 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Physical, Speech And Occupational Therapies 8. Physical, speech, or occupational therapy Physical Speech And Occupational Therapies the correction of speech p pY services (including peec impediments or assistance in the development when there is no reasonable expectation that themember's but not limited to services for predictable of verbal claret �� � � period of time according to generally Y) g � community, condition will i Your'Benefits and the Amounts You Pays 9 general) accepted standards in the improve over a �' � � - � � ���� =� 9. Massage therapy, medical ._ .. = * pY provided in any Out-of-network benefits Benefits � � �: � � .� In network benef�ts� _ treatment plan. Y setting even when it is after deductFbae after deductible part of a comprehensive See Exclusions for additional services covered. supplies, and associated *For out-o#-nefin►ork benefits;in addii`ron to the deductible andca�n"surance,you_are responsi#il for d expenses that are not any charges not be applied of the on networkprov:cr reEmbursement.amount.;Addttrionallc these charges will not be applied toward sates#acti Nothing the deduct ble or'the ouove pocket maximum: �£ 37,..0c.. . Occupational therapy received Nothing 50% coinsurance.Benefits'and the Amounts outside of your home when Coverage for physical Benef�ts � r ntsYpu pays ; physical function is impaired due and occupational therapy �� In-network he benefits � u Pay to a medical illness or injury or is limited to a combined after deductible x° ut of networkbe congenital or developmental limit of 20 visits per I FO�`Q °f n k b after deQj benefit conditions that have delayed calendar year. any char benefits x ucttbt Plea n T En addition tREthe cleductibte and, motor development se oty This visit limit ges�n excess ofthe non networkti , ti s r, s i fo charges will not be Provider reimbursement Amon t ti includes physical and applied toward satisfaction of the deductible:or the'out k a resximumte fir amount ' ?Add�tionali g § , - occupational therapy visits 1. Physical therapy the out-of Y,thesek that you pay for in order to py received Rocket race satisfy any part of your outside of Nothing � your home when physical function is impaired due 50% coinsurance. deductible. to a medical illness or injury Coverage for congenital or developmental or and occupational pmental pational therapy conditions that have delayed is limited to a combined motor development 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 2. Speech therapy satisfy any part of your of your home whreceived outside Nothing deductible. impaired due to a speech is 50% coinsurance. or injury or congenitaldi al illness Coverage for s developmental therapy speech pmental conditions that pY is limited to 20 I have delayed speech visits per calendar development Please note: year. This visit limit includes speech therapy visits that you pay for in order to satisfy any part of your deductible. MIC PP MN HSA (3/12) 48 1500-100% MIC PP MN HSA (3/12) 49 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Prescription Drug Program Prescription Drug Program will improve the coverage by only one tier. Exceptions to the PDL can also include Q. Prescription Drug Program antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain P g g 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. 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" Prior authorization 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 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, "professionally administered drugs" means drugs requiring intravenous infusion or injection, including pharmacies and the designated mail order pharmacies. You are responsible for intramuscular injection, or intraocular injection; the phrase "self-administered drugs" means all paying the cost of drugs received if you do not meet Medica's authorization criteria. other drugs. For the definition and coverage of specialty prescription drugs, see Prescription Specialty Drug Program. Sae-Definitions. These words have specific.meanings benefits, claim, coinsurance, Step therapy deductible, durable medicalequipment, emergency, hospital, member, network nonnetwork; specific drugs as indicated on the PDL. Step Medica requires step therapy prior to coverage of spec g non_network rovider reimbursement amount, ph sician prescription tl preventive health' t icall a Tier 1 drug) before moving p Y p gy''p tnvolves trying an alternative covered drug first service,provider ur ent care center. = a Tier 2 Tier 3 (typically ) on to ier or r 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. Preferred drug list Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 Quantity limits covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: 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 Tier 1 is your lowest coinsurance option. For the lowest out-of-pocket expense, you should quantity limits are based on packaging, FDA labeling, or clinical guidelines. consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Covered 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. The following table provides important general information concerning in-network, out-of- Tier 3 drugs are not covered unless they meet the requirements under the PDL exception network, and mail order benefits. For specific information concerning benefits and the amounts process described in this certificate. you pay, see the benefit table at the end of this section. Please note that Prescription Drug Program describes your coinsurance for prescription drugs themselves. An additional If you have questions about Medica's PDL or whether a specific drug is covered (and/or the PDL coinsurance applies for the provider's services if you require that a provider administer self- tier in which the drug may be covered), or if you would like to request a copy of the PDL at no administered drugs, as described in other applicable sections of this certificate including, but not charge, call Customer Service at one of the telephone numbers listed inside the front cover. limited to, Hospital Services, Infertility Diagnosis, and Professional Services. 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 in-network benefits Out-of-network benefits* = Mail order benefits. Food and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical publications. These medication request guidelines, as well as the PDL, are periodically Covered drugs received at a Covered drugs received at a Covered drugs received from reviewed and modified by Medica. In addition to the medication request guidelines, Medica network pharmacy; and non-network pharmacy; and a designated mail order assigns a tier to each drug based on a review of the drug's cost and effectiveness. pharmacy; and 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 u MIC PP MN HSA (3/12) 50 1500-100% MIC PP MN HSA(3/12) 51 1500-100% 21278 DOC 23744 BPL 21278 DOC 23744 Prescription Drug Program Prescription Drug Program Three prescription units may be dispensed for covered drugs prescribed to treat chronic In-network benefits Out-of-network benefits* Mail order benefits** 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 Covered drugs for family See In-network benefits Covered drugs for family at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside planning services or the column. planning services or the the front cover. I treatment of sexually treatment of sexually i transmitted diseases when transmitted diseases when Not covered prescribed by or received from prescribed by either a either a network or a non- network or a non-network The following are not covered: network provider. Family provider and received from a planning services do not designated mail order 1. Any amount above what Medica would have paid when you fail to identify yourself to the include infertility treatment pharmacy. Family planning pharmacy as a member. (Medica will notify you before enforcement of this provision.) services; and services do not include 2. OTC drugs not listed on the PDL. infertility treatment services; and 3. Replacement of a drug due to loss, damage, or theft. Diabetic equipment and Diabetic equipment and Diabetic equipment and 4. Appetite suppressants. supplies, including blood supplies, including blood supplies (excluding blood 5. Erectile dysfunction medications. 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 6. Non-sedating antihistamines and non-sedating antihistamine/decongestant combinations. and pharmacy. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and Tobacco cessation products Tobacco cessation products Not available. those members who have a feeding tube. when prescribed by a provider when prescribed by a provider 8. Tobacco cessation products or services dispensed through a mail order pharmacy. authorized to prescribe the authorized to prescribe the product and received at a product and received at a non- 9. Drugs prescribed by a provider who is not acting within his/her scope of licensure. network pharmacy. network pharmacy. 10. Homeopathic medicine. *When out-of-network benefits are received from non-network providers, 11. Infertility drugs. p in addition to the deductible and coinsurance, you will be responsible for any charges in excess of the non- 12. Specialty prescription drugs, except as described in Prescription Specialty Drug Program. network provider reimbursement amount. The out-of-pocket maximum does not apply to See Exclusions for additional drugs, supplies, and associated expenses that are not these charges. Please see Important member information about out-of-network benefits in covered. 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: Some drugs and supplies are not available through the designated mail order pharmacy. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Prescription Specialty 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 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 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. 53 1500-100% MIC PP MN HSA(3/12) 52 1500-100% MIC PP MN HSA(3/12) BPL 21278 DOC 23744 BPL 21278 DOC 23744 Prescription Drug Program Prescription Drug Program q,. Y _ ,Your Ben efts,a the.Amounts , , Your.Benefits and the-Amounts You Pay .,.. ,. ,.,r .a,,,# ,.. £. :... _,,.-... ...... . ... ....+,.. _arc h tu.,� 1. ..,..- ✓..,. .... .,, ..x _ additionsto b -l.e a n. d.�-.�_co ms_. u r�F a x.�.__...n..c e,...�,,, _Ao u ,.art ir o e.ti_-.. ,.�nresponsible for tan charges >e cessof:the non-network rk: rovr .amount.. i.., _E fo r-_.out-of-network of ne:t w rk:b e:.'n efats,.,_m-addition, t o a h, e r �a nd coinsurance, s_u_.._ra nce .Y ou x_a re,re, s on.; seible. �fo.r charges, wilt noba ppla tl;toward satisfaction: � deductible the f- . any charges in excess the non-network seine � m oun#. Adda ttY,�thse maximum. charges will not be a I ed. ow r sat i f acti on o f the deductible or the out-of-pocket maximum. I ,benefits w Out-of-network Mail- enefits fter de uctibie s deductible after d In-network benefits Out-ofd-nectwork benefits Mail oreddeurcbteibnlee fts after deductible after deut�ble aer d . _ ,. 1. Outpatient covered drugs other than those described below or in Prescription Specialty Drug 4. Drugs and other supplies (other than tobacco cessation products) considered preventive Program Tier 1: Nothing per health services, as specifically defined in Definitions, when prescribed by a provider 50% coinsurance per Tier 1: Nothing authorized to prescribe such drugs.f such This group and of drugs and supplies is specific and prescription unit; or prescription unit g per prescription unit; or limited. For the current list of drugs supplies, please refer to the Preventive Drug Tier 2: Nothing per and Supply List within the PDL or call Customer Service at one of the telephone numbers listed prescription unit; or Tier 2: Nothing per inside the front cover. Tier 3: No covera a prescription unit; or g Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per Tier 3: No coverage prescription unit; or prescription unit prescription unit; or 2. Diabetic equipment and supplies, including blood glucose meters Tier 2: Nothing per Tier 2: Nothing per Tier 1: Nothing per 50% coinsurance er prescription unit; or prescription unit; or prescription unit; or p Tier 1: Nothing per prescription unit prescription unit; or Tier 3: No coverage Tier 3: No coverage Tier 2: Nothing per . prescription unit; or Tier 2: Nothing per The deductible does not The deductible does not prescription unit; or apply. apply. Tier 3: No coverage Tier 3: No coverage 3. Tobacco cessation products Tier 1: Nothing per 50% coinsurance er p 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. III MIC PP MN HSA(3/12) 54 1500-100% MIC PP MN HSA (3/12) 55 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 P Prescription Specialty Drug Program Prescription Specialty Drug Program Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also R. Prescription Specialty 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 This section describes coverage for specialty prescription drugs received from a designated process, call Customer Service at one of the telephone numbers listed inside the front cover. 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 Prior authorization 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" Certain specialty prescription drugs require prior authorization. The provider who prescribes the means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular specialty drug initiates prior authorization. The SPDL is made available to providers, including injection; the phrase "self-administered drugs" means all other drugs. designated specialty pharmacies. You are responsible for paying the cost of specialty See Definitions. These words have specific meanings: benefits,,claim coinsuranc prescription drugs you receive if you do not meet Medica's authorization criteria. deductible,member, network physician, prescription:drug, provider- _ r Step therapy Designated specialty pharmacies Medica requires step therapy prior to coverage of specific specialty prescription drugs as A designated specialty pharmacy means a specialty pharmacy that has entered into a se crate indicated on the SPDL. Step therapy involves trying an alternative covered specialty contract with Medica to provide specialty prescription drug services to members. For thep prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. current list of designated specialty pharmacies, call Customer Service at one of the telephone Applicable step therapy requirements must be met before Medica will cover certain Tier 1 or numbers listed inside the front cover or sign in at www.mymedica.com. Tier 2 specialty prescription drugs. Specialty preferred drug list Quantity limits Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is These limits indicate the maximum quantity allowed per prescription over a specific time period. classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. 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 Covered benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to covered (and/or the SPDL tier in which the drug may be covered), or if you would like to request a specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed received from a designated specialty pharmacy. inside the front cover. The SPDL is also available by signing in at www.mymedica.com. This section describes your coinsurance for specialty prescription drugs. An additional Medica utilizes medication request guidelines to determine whether a specialty prescription drug coinsurance applies for the provider's services if you require that a provider administer self- should be covered. Medica's medication request guidelines are based on United States Food administered drugs, as described in other applicable sections of this certificate including, but not and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical limited to, Hospital Services, Infertility Diagnosis, and Professional Services. 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 Prescription unit assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. 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, Exceptions to the specialty preferred drug list unless limited by the manufacturer's packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. 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 MIC PP MN HSA (3/12) 56 1500-100% MIC PP MN HSA (3/12) 57 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Prescription Specialty Drug Program Professional Services Not covered The following are not covered: S. Professional Services 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.) This section describes coverage for professional services received from or directed by a physician. 2. Replacement of a specialty drug due to loss, damage, or theft. g See Definitions. These.`words have specific meanings: benefits, coinsurance, convenience 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of care/retail health clinic, deductible, emergency, genetic testing,',hospital, inpatient,'member, licensure. network,.nor network,non network provider reimbursement amount, physician, preventive 4. Prescription drugs, except as described in Prescription Drug Program. health service, provider, urgent care center irtual care z Prior authorization. Prior authorization from Medica may be required before you receive 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. services or supplies. Call Customer Service at one of the telephone numbers listed inside the 6. Infertility drugs. front cover. See How To Access Your Benefits for more information about the prior authorization y g process. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance Your Benefits and the Amounts You Pay may be required if you receive more than one service or see more than one provider per visit. In-network benefits apply to: Benefits Y pay Pp Y ou R a after deductible 1. Professional services received from a network provider; 1. Specialty prescription drugs, Tier 1 specialty prescription drugs: Nothing per 2. Professional services for testing and treatment of a sexually transmitted disease and other than those described prescription unit; or testing for AIDS and other HIV-related conditions received from a network provider or a below, received from a non-network provider; designated specialty pharmacy Tier 2 specialty prescription drugs: No coverage 2. Specialty growth hormone when Tier 1 s ecialt 3. Family planning services, for the voluntary planning of the conception and bearing of p y prescription drugs: Nothing per children, received from a network provider or a non-network provider. Family planning prescribed by a physician for the prescription unit; or services do not include infertility treatment services. treatment of a demonstrated growth hormone deficiency and Tier 2 specialty prescription drugs: No coverage • Out-of-network benefits apply to professional services received from a non-network provider. received from a designated In addition to the deductible and coinsurance, you will be responsible for any charges in specialty pharmacy 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. MIC PP MN HSA (3/12) 58 1500-100% MIC PP MN HSA (3/12) 59 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Professional Services Professional Services Not covered C . Your Benefits and the Amounts You Pay R v,'. These services, supplies, and associated expenses are not covered: x � Benef In network benefits *Out of network=benefits 1. Drugs provided or administered by a physician or other provider, except those requiring `; ; ,_, after deductible ' after deductible= ' k intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage E � �° ` , for drugs is as described in Prescription Drug Program and Prescription Specialty Drug *For:out-of-network benefits,_in addition to the deductible and coinsurance,you are responsitillefor Program or otherwise described as a specific benefit in this certificate. any charges in excess of the non network providerreimbursement amount Additionally,these 2. Diagnostic casts diagnostic study models and bite adjustments related to the treatment charges will not be,applied toward satisfaction of the deductible;or the out-of-pocket maximum-. , 9 9 Y adjustments eatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder. 4. Urgent care center visits Nothing Covered as an in-network See Exclusions for additional services, supplies, and associated expenses that are not Please note: Some services benefit. covered. received during an urgent care center visit may be covered under another benefit in this certificate. s � The most specific and appropriate Your Benefits the Amounts You Pay benefit in this certificate will apply for each service received during an Benefits in network benefits *Out of-network benefits urgent care center visit. = ,; - after deductible after deductible For example, certain services g�... � ' := z received during an urgent care *For Of nehi ork benefits;in addition tovthe.deductible and coinsurance,you are responsible for, � center visit may be considered any chargesin excess.of the non network;providerreimbursement amount. Additionally,these surgical or imaging services; see charges Will not be applied toward satisfaction of the deductible ohhe out-of-pocket maximum , below for coverage of these surgical �� .�; or imaging services. In such 1. Office visits Nothing 50% coinsurance instances, both an urgent care Please note: Some services center visit coinsurance and received during an office visit may outpatient surgical or imaging be covered under another benefit in services coinsurance apply. this certificate. The most specific and appropriate benefit in this Call Customer Service at one of the certificate will apply for each service telephone numbers listed inside the front cover to determine in advance received during an office visit. whether a specific procedure is a For example, certain services benefit and the applicable coverage received during an office visit may level for each service that you be considered surgical or imaging receive. services; see below for coverage of these surgical or imaging services. 5. Preventive health care In such instances, both an office Please note: If you receive visit coinsurance and outpatient preventive and non-preventive surgical or imaging services health services during the same coinsurance apply. visit, the non-preventive health services may be subject to a Call Customer Service at one of the coinsurance or deductible, as telephone numbers listed inside the described elsewhere in this front cover to determine in advance certificate. The most specific and whether a specific procedure is a appropriate benefit in this certificate benefit and the applicable coverage will apply for each service received level for each service that you during a visit. receive. 2. Virtual care Nothing No coverage a. Child health supervision Nothing. The deductible Covered as an in-network g g services, including well-baby does not apply. benefit. 3. Convenience care/retail health Nothing 50% coinsurance care clinic visits MIC PP MN HSA(3/12) 60 1500-100% MIC PP MN HSA (3/12) 61 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Professional Services Professional Services �....:2. ,..,.3.„ Y_o ur Benefits:a-_-_n_.__dt<.h�>n e A._.__m ou fint s,.Y a. u P a. . _. r , F _ , Y_ o-.u.:, ,r Benefits fits and t h__.eKAmount Amounts Yo u P a , .: :•_ : ,• Be �_ ts .. n-netwo k ene#i is k Out of networkx benefit;s� Benefits, � _ _ _ -In net orkbenefits : � t_ f_networ benefits#s � . � after e deductible after deductible F . after deductible � after deductible_ a e _ , , P .. •< .l i • i r...:.b f,.. . ,you .e.., xv. *, .,r-.♦ .. , . . r_,�. coinsurance,you are responsible for _. � , - ,, ::--*Tor_out-of-network, benefits in add�t�on.to the dedctrbleand coi s �Y P ,For � �: _ For ou#ofnetwork bane ts, For out.:of network,benefits �m_addrtron to the and.cornsuran ,k _.-_. � ce ou are re<res onsrb#esfor _: t A, . ._ `._ ,;, <. .-' ;:. >> _ s.., .. wo , id r, e these > b ., ,__ �_� P- ,_ rk covtder.reimbursement amount. Additionally, of �._.__:._ ran. _char es in•excessxofahe non netwo provider . , an ;char es.in excess:of the non network rounder rermbursement�amoun : A -_<f Y 9 ,. _ r,>_ ._ Y_.,_... 9„_. ..,: -_,p t dd�#aonall ,these ..-:.� ., _ . i .,. -deductible or the out-of ocket maximum.,m_,,. - � ,: oward.satisfaction of decl x ; , a'charges will,not.be.a applied toward charges will toward � out-of-pocket � <, ,cha pp -.: >. : #be applied edtoward_satisfaction of the deductible maximum. 4< g the ut _. .<g .,.. pp _.. ocket max um.. .< b. Immunizations Nothing. The deductible 50% coinsurance 13. Anesthesia services received Nothing 50% coinsurance does not apply. from a provider during an inpatient stay c. Early disease detection Nothing. The deductible 50% coinsurance services including physicals does not apply. 14. Outpatient lab and pathology Nothing 50% coinsurance d. Routine screening Nothing. The deductible 50% coinsurance 15. Outpatient x-rays and other Nothing 50% coinsurance procedures for cancer does not apply. imaging services e. Other preventive health Nothing. The deductible 50% coinsurance 16. Other outpatient hospital or Nothing 50% coinsurance services does not apply. ambulatory surgical center 6. Allergy shots Nothing 50% coinsurance services received from a physician 7. Routine annual eye exams Nothing. The deductible 50% coinsurance 17. Treatment to lighten or remove Covered at the Covered at the does not apply. the coloration of a port wine stain corresponding in-network corresponding out-of- 8.8. Chiropractic services to Nothing 50% coinsurance. • benefit level, depending network benefit level, diagnose and to treat (by manual Coverage is limited to a on type of services depending on type of manipulation or certain maximum of 15 visits per provided. services provided. therapies) conditions related to calendar year. For example, office visits For example, office visits the muscles, skeleton, and Please note: This visit limit are covered at the office are covered at the office nerves of the body includes chiropractic visits that you pay for in order to visit in-network benefit visit out-of-network satisfy any part of your level and surgical benefit level and surgical deductible. services are covered at services are covered at the surgical services in- the surgical services out- 9. Surgical services (as defined in Nothing 50% coinsurance network benefit level. of-network benefit level. the Physicians'Current Procedural Terminology code 18. Treatment of temporomandibular Covered at the Covered at the book) received from a physician joint (TMJ) disorder and corresponding in-network corresponding out-of- during an office visit or an craniomandibular disorder benefit level, depending network benefit level, outpatient hospital or on type of services depending on type of ambulatory surgical center visit provided. services provided. 10. Anesthesia services received Nothing 50% coinsurance For example, office visits For example, office visits from a provider during an office are covered at the office are covered at the office visit or an outpatient hospital or visit in-network benefit visit out-of-network ambulatory surgical center visit level and surgical benefit level and surgical services are covered at services are covered at 11. Services received from a Nothing Covered as an in-network the surgical services in- the surgical services out- physician during an emergency benefit. network benefit level. of-network benefit level. room visit Please note: Dental Please note: Dental o coverage is not provided coverage is not provided 12. Services received from a Nothing 50/o coinsurance under this benefit. under this benefit. physician during an inpatient stay MIC PP MN HSA (3/12) 62 1500-100% MIC PP MN HSA (3/12) 63 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Professional Services Professional Services . . s . r _._._,...e ./. :_._-_. ,... _., ...._ YourBenef�ts and the.Amounts_You Pa Youc Benef�ts.and.fhe Amou nts You x a: Jn n etwo r benefits _._-. Out of ne'tw o r k b_e�e.fi,.,t s.:Benefits B__e-n fi t�s., f... ,.> Inn etw or k ben e#rit,s Out of E ne,.3 t wo.rk bane fit afterd eductibte after deducti ble after deductible afte r ...deductible..... Forout-Of-network,ben benefits, ddr i -the: i .�.. _.,�.F ofnetwork benefits m addition to he deductible and:comsurance .,you are're ons�bl for : :.._ a .. .,: a t on�toa ._ deductble andcofnsur ance,you res onsible for � ..- or out _ _. . a ;y sp e any. har es.inexcess of the non-network provider reimbursement amount Additionally,these , an :char es_in excess of the non-network ro v rderreimbu rsem nt amount. =Additionally,these ese r char es will-notbe.applied,toward_satisfaction of e u . . �;��: charges will not be:applied.toward satrsfaction.of the.deductible octhe.out-of ocket maximum. g _ ._. d tl ctible or thesout-of ocket maximum:. < _. < .. . ,-.- ,,,w _ R 19. Diabetes self-management Nothing 50% coinsurance 24. Genetic testing when test results Nothing 50% coinsurance training and education, including will directly affect treatment medical nutrition therapy, decisions or frequency of received from a provider in a screening for a disease, or when program consistent with national results of the test will affect educational standards (as reproductive choices established by the American Diabetes Association) 20. Neuropsychological Nothing 50% coinsurance evaluations/cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury 21. Services related to lead testing Nothing 50% coinsurance 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: The 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 MIC PP MN HSA(3/12) 64 1500-100% MIC PP MN HSA(3/12) 65 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Reconstructive And Restorative Surgery 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 T. Reconstructive And Restorative Surgery intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Prescription Specialty Drug Program or otherwise described as a specific benefit in this certificate. This section describes coverage for professional, hospital, and ambulatory surgical center services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative See Exclusions for additional services, supplies, and associated expenses that are not surgery services must be medically necessary and not cosmetic. covered. ^: -TV Definitions., . 'Coinsurance,.r:x's'n�-•.:X+.n .a,:-'4 ee __These.words haves ecific-meanings: benefits : .cosme -4. r S deductible hos Ita l m Pat►en t,me dical) nece ssa_ry rn ember,n e twork non n etwork .non ._ _.. d�. .., .. . _ Your�Benefits and.the Amounts-You Pa - network rovider.reimbursement arnaunt h sic i n r odder reconstructrve.restoratrve virtual care. - ' _---- _-f - .. Benefits W F In-n et work benefits =*�Qut =of network benefits, �e afterdeducti after deductible ,ble F 4 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 a front cover. See How To Access Your Benefits for more information about the prior For out of-network'benefits, inaddition to the deductible and coinsurance, you are responsible'for authorization process. any charges in excess of,thenon network providerrreimbursement amount=:Additionally,these charges will not be applied toward satisfaction of the deductible orathe out-of-pocket maximum Covered 1. Office visits Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance 2. Virtual care Nothing No coverage may be required if you receive more than one service or see more than one provider per visit. 3. Outpatient services • In-network benefits apply to reconstructive and restorative surgery services received from a a. Professional services network provider. i. Surgical services (as Nothing 50% coinsurance • Out-of-network benefits apply to reconstructive and restorative surgery services received defined in the from a non-network provider. In addition to the deductible and coinsurance described for Physicians'Current out-of-network benefits, you will be responsible for any charges in excess of the non- Procedural Terminology network provider reimbursement amount. The out-of-pocket maximum does not apply to code book) received these charges. Please see Important member information about out-of-network benefits in from a physician during How To Access Your Benefits for more information and an example calculation of out-of- an office visit or an pocket costs associated with out-of-network benefits. outpatient hospital or ambulatory surgical Not covered center visit ii. Anesthesia services Nothing 50% coinsurance These services, supplies, and associated expenses are not covered: received from a provider 1. Revision of blemishes on skin surfaces and scars (including scar excisions) primarily for during an office visit or cosmetic purposes, unless otherwise covered in Professional Services. an outpatient hospital or ambulatory surgical 2. Repair of a pierced body part and surgical repair of bald spots or loss of hair. center visit 3. Repairs to teeth, including any other dental procedures or treatment, whether the dental iii. Outpatient lab and Nothing 50% coinsurance treatment is needed because of a primary dental problem or as a manifestation of a medical pathology treatment or condition. iv. Outpatient x-rays and Nothing 50% coinsurance 4. Services and procedures primarily for cosmetic purposes. other imaging services 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. v. Other outpatient hospital Nothing 50% coinsurance 6. Hair transplants. or ambulatory surgical center services received from a physician MIC PP MN HSA (3/12) 66 1500-100% MIC PP MN HSA (3/12) 67 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Reconstructive And Restorative Surgery Skilled Nursing Facility Services Your Benefits and the Amounts You Pay U. Skilled Nursing Facility Services Benefits " In-network benefits *Out-of-network benefits after deductible after deductible This section describes coverage for use of skilled nursing facility ervicesl described nth this* provided under the direction of a physician. Coverage of For charges out-of-network benefits, in addition to the deductible and coinsurance,moun amount. you are responsible for p y per person per calendar year. Skilled nursing is limited to a maximum benefit of 120 days p P p same illness any charges in excess of the non-network provider:reimbursement amount. Additionally,these facility services are eligible for coverage only if you are admitted to a skilled nursing facility charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum admission of at least three consecutive days for the Y within 30 days after a hospital a i b. Hospital and ambulatory or condition. surgical center services See Definitions. These words have specific eon-network, non network provider reimbursement are; i. Outpatient lab and Nothing 50% coinsurance deductible, hospital, inpatient, network, pathology amount, physician,skilled care, skilled nursing facility. ii. Outpatient x-rays and Nothing 50% coinsurance Prior authorization. Prior authorization from Medica may be required before you receive other imaging services services or supplies. Call Customer Service at one of the telephone numbers listed inside the iii. Other outpatient hospital Nothing 50% coinsurance front cover. See How To Access Your Benefits for more information about the prior authorization and ambulatory surgical process. center services 4. Inpatient services Nothing 50% coinsurance Covered 5. Services received from a Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance h during in physician duri g an inpatient may be required if you receive more than one service or see more than one provider per visit. Stay For purposes of this section, room and board includes coverage of health services and supplies. 6. Anesthesia services received Nothing 50% coinsurance • In-network benefits apply to skilled nursing facility services arranged through a physician from a provider during an inpatient stay and received from a network skilled nursing facility. • Out-of-network benefits apply to skilled nursing facility services arranged through a to the physician and received from a non-network skilled nursing facility. In dditio responsible for deductible and coinsurance described for out-of-network benefits, you 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. -1 MIC PP MN HSA (3/12) 68 1500-100% MIC PP MN HSA (3/12) 69 BPL 21278 150 150. 00% 23744 BPL 21278 DOC 23744 DOC 1 '1,.' 401 Skilled Nursing Facility Services Substance Abuse 7. Physical, speech, or occupational therapy services when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to V. Substance Abuse generally accepted standards in the medical community. 8. Voice training. 9. Group physical, speech, and occupational therapy. This section describes coverage for the diagnosis and primary treatment of substance abuse 10. Long-term care. 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, custodial See Exclusions for additional services, supplies, and associated expenses that are not covered. care, deductible, emergency, hospital,;inpatient, medically necessary, member, mental disorder, .'network, non-network, non network:provider reimbursement amount, physician, provider. 3. Prior authorization. For prior authorization requirements of in-network and out-of-network benefits, call Medico's designated mental health and substance abuse provider at Your Benefits and the Amounts You Pay . 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center o e 1-800-855-2880, then ask them to dial Medics Behavioral Health at 1-866-567-0550. Benefits In network benefits 1 'after benefits � q� after deductible �� = after dedt ctible, For purposes of this section: t. 3,4 1. Outpatient services include: *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= a. Diagnostic evaluations. charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum b. Outpatient treatment. 1. Daily skilled care or daily skilled Nothing 50% coinsurance c. Intensive outpatient programs, including day treatment and partial programs, which may rehabilitation services, including include multiple services and modalities, delivered in an outpatient setting. room and board, up to 120 days per person per calendar year d. Services, care, or treatment for a member that has been placed in any applicable Please note: Such services are Department of Corrections' custody following a conviction for a first-degree driving while eligible for coverage only if you are impaired offense; to be eligible, such services, care, or treatment must be required and admitted to a skilled nursing facility provided by any applicable Department of Corrections. within 30 days after a hospital 2. Inpatient services include: admission of at least three consecutive days for the same a. Room and board. illness or condition. This day limit includes days that you pay for in b. Attending physician services. order to satisfy any part of your deductible. c. Hospital or facility-based professional services. 2. Skilled physical, speech, or Nothing 50% coinsurance d. Services, care, or treatment for a member that has been placed in any applicable occupational therapy when room Department of Corrections' custody following a conviction for a first-degree driving while and board is not eligible to be impaired offense; to be eligible, such services, care, or treatment must be required and covered provided by any applicable Department of Corrections. 3. Services received from a Nothing 50% coinsurance e. Residential treatment services. These are services from a licensed chemical dependency physician during an inpatient rehabilitation program that provides intensive therapeutic services following detoxification. stay in a skilled nursing facility 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 PP MN HSA (3/12) 70 1500-100% MIC PP MN HSA(3/12) 71 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Substance Abuse Substance Abuse Covered Not covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance These services, supplies, and associated expenses are not covered: may be required if you receive more than one service or see more than one provider per visit. 1. Services for substance abuse disorders not listed in the current edition of the Diagnostic and • For in-network benefits: Statistical Manual of Mental Disorders. 1. Medica's designated mental health and substance abuse provider arranges in-network 2. Services for a condition when there is no reasonable expectation that the condition will improve. 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 3. Services, care, or treatment that is not medically necessary. and Medica's designated mental health and substance abuse provider hospital networks 4. Services to hold or confine a person under chemical influence when no medical services are are different). required, regardless of where the services are received. 2. In-network benefits will apply to services, care or treatment for a member that has been 5. Telephonic substance abuse treatment services. 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 6. Services, including room and board charges, provided by health care professionals or treatment must be required and provided by any applicable Department of Corrections. 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 For claims questions regarding in-network benefits, call Medica's designated mental health by mental health or substance abuse providers who are not authorized under state law to and substance abuse provider Customer Service at 1-866-214-6829. practice independently, and services received from a halfway house, therapeutic group • For out-of-network benefits: home, boarding school, or ranch. 1. Substance abuse services from a non-network provider listed below will be eligible for 7. Room and board charges associated with substance abuse treatment services providing coverage under out-of-network benefits provided that the health care professional or less than 30 hours a week per individual of chemical dependency services, including group facility is licensed, certified, or otherwise qualified under state law to provide the substance and individual counseling, client education, and other services specific to chemical abuse services and practice independently: dependency rehabilitation. a. Psychiatrist 8. Services to assist in activities of daily living that do not seek to cure and are performed b. Psychologist regularly as a part of a routine or schedule. See Exclusions for additional services, supplies, and associated expenses that are not c. Registered nurse certified as a clinical specialist or as a nurse practitioner in covered. psychiatric and mental health nursing d. Chemical dependency clinic w g e. Chemical dependency residential treatment center Your Benefits and the Amounts You Pay ,. f. Hospital that provides substance abuse services Benefits in-network benefits * Out-of-network benefits g. Independent clinical social worker ' after deductible after deductible h. Marriage and family therapist *For out-of-network benefits, in addition to the deductible and coinsurance, you are responsible for 2. Emergency substance abuse services are eligible for coverage under in-network any charges in excess of the.non network provider reimbursement amount. Additionally,these benefits. charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. In addition to the deductible and coinsurance described for out-of-network benefits, you will 1. Office visits, including Nothing 50% coinsurance be responsible for any charges in excess of the non-network provider reimbursement evaluations, diagnostic, and amount. The out-of-pocket maximum does not apply to these charges. Please see treatment services Important member information about out-of-network benefits in How To Access Your 2. Intensive outpatient programs Nothing 50% coinsurance Benefits for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits. 3. Opiate replacement therapy Nothing 50% coinsurance 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance MIC PP MN HSA (3/12) 72 1500-100% MIC PP MN HSA(3/12) 73 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Substance Abuse Referrals To Non-Network Providers W _r Your Benefits and the Amounts You Pay Benefits In-network benefits; � *,Out-of-network benefits W.Referrals To Non-Network Providers after,deductible after deductible This section describes coverage for referrals from network providers to non network non-network providers. as In-network benefits will apply to referrals from network providers these*For charges in in addition to the deductible and ent amount. you are responsible for advantage to seek Medic t authorization for referrals to any charges in excess i the non-network provider reimbursement amount, Additionally,imum. described in this section. It is to your advanta charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. non-network providers before you receive services. Medica can then tell you what your benefits - - - - - -- - - will be for the services you may receive. b. Hospital or facility-based Nothing 50% coinsurance See Definitions.° These words have specific meanings: benefits, medically necessary, professional services network, non-network, physician, provider.- c. Attending physician services Nothing 50% coinsurance 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 to your specialist medp provider.hoer . Standing referrals will only be covered for the period of time appropriate 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 I 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 PP MN HSA 3/12 _ ° MIC PP MN HSA(3/12) 75 1500-100% HSA(3/12) 74 1500 100/o BPL 21278 DOC 23744 PL 21278 DOC 23744 Referrals To Non-Network Providers Harmful Use Of Medical Services 3. Provide coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and X. Harmful Use Of Medical Services b. Recommended by a network physician. 4. Notify you of authorization or denial of coverage within ten days of receipt of your request. This section describes what Medica will do if it is determined you are receiving health services Medica will inform both you and your provider of Medica's decision within 72 hours from the or prescription drugs in a quantity or manner that may harm your health. time of the initial request if your attending provider believes that an expedited review is _ _, warranted, or Medics concludes that a delay could seriously jeopardize your life health or See Definitions These words have specific meanings: benefits, emergency, hospital, Y _prescription:dru rovider. R ability to regain maximum function, or could subject you to severe pain that cannot be , network, physician;� drug, - - adequately managed without the care or treatment you are seeking. 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. 77 1500-100% MIC PP MN HSA(3/12) 76 1500-100% MIC PP MN HSA(3/12) BPL 21278 DOC 23744 BPL 21278 DOC 23744 Exclusions Exclusions 14. Personal comfort or convenience items or services. Y. Exclusions I 15. Custodial care, unskilled nursing, or unskilled rehabilitation services. 16. Respite or rest care, except as otherwise covered in Hospice Services. See Definitions These words have specific meanings claim; cosmetic custodial care 17. Travel, transportation, or living expenses, except as described in Organ And Bone Marrow Transplant Services. durable medical equrprnent, emergency, rnves#igafive, medically necessary, member ndn network„physician, provider,:reconstructive routine foot care w- 18 Household equipment, fixtures, home modifications, and vehicle modifications. Medica will not provide coverage for any of the services, treatments, supplies, or items 19. Massage therapy, provided in any setting, even when it is part of a comprehensive described in this section even if it is recommended or prescribed by a physician or it is the only treatment plan. available treatment for your condition. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular This section describes additional exclusions to the services, supplies, and associated expenses disease, peripheral neuropathies, and significant neurological conditions such as already listed as Not covered in this certificate. These include: Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral 1. Services that are not medically necessary. This includes but is not limited to services sclerosis. inconsistent with the medical standards and accepted practice parameters of the community 21. Services by persons who are family members or who share your legal residence. and services inappropriate-in terms of type, frequency, level, setting, and duration-to the , diagnosis or condition. 22. Services for which coverage is available under workers compensation, employer liability, or any similar law. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive. 23. Services received before coverage under the Contract becomes effective. 3. Refractive eye surgery, including but not limited to LASIK surgery. 24. Services received after coverage under the Contract ends. 4. The purchase, replacement, or repair of eyeglasses, eyeglass frames, or contact lenses 25. Unless requested by Medica, charges for duplicating and obtaining medical records from when prescribed solely for vision correction, and their related fittings. non-network providers and non-network dentists. 5. Services provided by an audiologist when not under the direction of a physician, air and 26. Photographs, except for the condition of multiple dysplastic syndrome. bone conduction hearing aids (including internal, external, or implantable hearing aids or 27. Occlusal adjustment or occlusal equilibration. devices) and other devices to improve hearing, and their related fittings, except cochlear Equipment And 28. Dental implants (tooth replacement), except as described in Medical-Related Dental implants and related fittings and except as described in Durable Medical E Prosthetics. Services. 6. A drug, device, or medical treatment or procedure that is investigative. 29. Dental prostheses. 7. Genetic testing when performed in the absence of symptoms or high risk factors for a 30. Orthodontic treatment, except as described in Medical-Related Dental Services. genetic disease; genetic testing when knowledge of genetic status will not affect treatment 31. Treatment for bruxism. 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 32. Services prohibited by applicable law or regulation. direction of your physician. 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). 8. Services or supplies not directly related to care. 9. Autopsies. 34. Exams, other evaluations, or other services received solely for the purpose of employment, 10. Enteral feedings, unless they are the sole source of nutrition; however, insurance, or licensure. standard infant formulas, standard baby food, and regular grocery enteral feedings of 35. Exams, other evaluations, or other services received solely for the purpose of judicial or Y g g y products used in blenderized formulas are excluded regardless of whether they are the sole administrative proceedings or research except emergency examination of a child ordered by e source of nutrition. judicial authorities. 11. Nutritional and electrolyte substances except as specifically described in Miscellaneous 36. Non-medical self-care or self-help training. Medical Services And Supplies. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, 12. Physical, occupational, or speech therapy or chiropractic services when there is no except as described in Professional Services. reasonable expectation that the condition will improve over a predictable period of time. 38. Coverage for costs associated with translation of medical records and claims to English. 13. Reversal of voluntary sterilization. 39. Treatment for superficial veins, also referred to as spider veins or telangiectasia. MIC PP MN HSA (3/12) 78 1500-100% MIC PP MN HSA (3/12) 79 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Exclusions How To Submit A Claim 40. Services not received from or under the direction of a physician, except as described in this certificate. Z. How To Submit A Claim 41. Orthognathic surgery. 42. Sensory integration, including auditory integration training. This section describes the process for submitting a claim. 43. Services for or related to vision therapy and orthoptic and/or pleoptic training, except as See Definitions. These words have specific meanings: benefits, claim, dependent, member, described in Professional Services. network, non=network, non-network provider reimbursement amount, provider_ 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 Claims for benefits from network providers Intervention (IBI), and Lovaas therapy. If you receive a bill for any benefit from a network provider, you may submit the claim following 45. Health care professional services for maternity labor and delivery in the home. the procedures described below, under Claims for benefits from non-network providers, or call 46. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and Customer Service at one of the telephone numbers listed inside the front cover. Claim forms subsequent procedures. 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 47. Services for the treatment of infertility. service. If your provider asks for your health care identification card and you do not identify 48. Infertility drugs. 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. 49. Acupuncture. 50. Services solely for or related to the treatment of snoring. Claims for benefits from non-network providers 51. Interpreter services. 52. Services provided to treat injuries or illness that are the result of committing a crime or Claim forms are provided in your enrollment materials. You may request additional claim forms attempting to commit a crime. 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 53. Services for private duty nursing, except as described in Home Health Care. Examples of not sent to you within 15 days, you may submit an itemized statement without the claim form to private duty nursing services include, but are not limited to, skilled or unskilled services Medica. You should retain copies of all claim forms and correspondence for your records. provided by an independent nurse who is ordered by the member or the member's You must submit the claim in English along with a Medica claim form to Medica no later than representative, and not under the direction of a physician. g g 365 days after receiving benefits. Your Medica member number must be on the claim. 54. Laboratory testing that has been performed in response to direct-to-consumer marketing and not under the direction of a physician. Mail to the address identified on the back of your identification card. 55. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), Upon receipt of your claim for benefits from non-network providers, Medica will generally pay to other than those granted a humanitarian device exemption. you directly the non-network provider reimbursement amount. Medica will only pay the provider of services if: 56. Health clubs. 1. The non-network provider is one that Medica has determined can be paid directly; and 57. Long-term care. 2. The non-network provider notifies Medica of your signature on file authorizing that payment 58. Expenses associated with participation in weight loss programs, including but not limited to be made directly to the provider. membership fees and the purchase of food, dietary supplements, or publications. 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 PP MN HSA(3/12) 80 1500-100% MIC PP MN HSA(3/12) 81 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 How To Submit A Claim Coordination Of Benefits Claims for services provided outside the United States Claims for services rendered in a foreign country will require the following additional AA. . Coordination Of Benefits documentation: • Claims submitted in English with the currency exchange rate for the date health services This section describes how benefits are coordinated when you are covered under more than were received. one plan. • Itemization of the bill or claim See ee.Defin Definitions. These words have specific meanings: benefits, claim, deductible, dependent, • The related medical records (submitted in English). emergency, hospital, member, non network,non network provider reimbursement;amount, provider, subscriber _H.. • Proof of your payment of the claim. • A complete copy of your passport and airline ticket. 1. Applicability • Such other documentation as Medica may request. a. This coordination of benefits (COB) provision applies to this plan when an employee or For services rendered in a foreign country, Medica will pay you directly. the employee's covered dependent has health care coverage under more than one plan. Medica will not reimburse you for costs associated with translation of medical records or claims. Plan and this plan are defined below. b. If this coordination of benefits provision applies, Order of benefit determination rules Time limits 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 If you have a complaint or disagree with a decision by Medica, you may follow the complaint rules, the benefits of this plan: procedure outlined in Complaints or you may initiate legal action at any point. i. Shall not be reduced when this plan determines its benefits before another plan; but However, you may not bring legal action more than six years after Medica has made a coverage ii. May be reduced when another plan determines its benefits first. The above determination regarding your claim. 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 PP MN HSA (3/12) 82 1500-100% MIC PP MN HSA(3/12) 83 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Coordination Of Benefits Coordination Of Benefits When there are two or more plans covering the person, this plan may be a primary II p g p p Y p ry plan b) If both parents have the same birthday, the benefits of the plan which covered as to one or more other plans, and may be a secondary plan as to a different plan or one parent longer are determined before those of the plan which covered the plans. other parent for a shorter period of time. d. Allowable expense means a necessary, reasonable, and customary item of expense for However, if the other plan does not have the rule described in (a) immediately above, health care, when the item of expense is covered at least in part by one or more plans but instead has a rule based on the gender of the parent, and if, as a result, the covering the person for whom the claim is made. Allowable expense does not include plans do not agree on the order of benefits, the rule in the other plan will determine the deductible for members with a primary high deductible plan and who notify Medica of the order of benefits. an intention to contribute to a health savings account. iii. Dependent child/separated or divorced parents. If two or more plans cover a person The difference between the cost of a private hospital room and the cost of a semi-private as a dependent child of divorced or separated parents, benefits for the child are hospital room is not considered an allowable expense under the above definition unless determined in this order: the patient's stay in a private hospital room is medically necessary, either in terms of First, the plan of the parent with custody of the child; 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 b) Then, the plan of the spouse of the parent with the custody of the child; and reimbursement amount is not considered an allowable expense under the above c) Finally, the plan of the parent not having custody of the child. definition. . However, if the specific terms of a court decree state that one of the parents is When a plan provides benefits in the form of services, the reasonable cash value of responsible for the health care expense of the child, and the entity obligated to pay each service rendered will be considered both an allowable expense and a benefit paid. or provide the benefits of the plan of that parent has actual knowledge of those When benefits are reduced under a primary plan because a member does not comply terms, the benefits of that plan are determined first. The plan of the other parent with the plan provisions, the amount of such reduction will not be considered an shall be the secondary plan. This paragraph does not apply with respect to any allowable expense. Examples of such provisions are those related to second surgical claim determination period or plan year during which any benefits are actually paid or opinions, and preferred provider arrangements. provided before the entity has that actual knowledge. iv. Joint custody. If the specific terms of a court decree state that the parents shall e. Claim determination period means a calendar year. However, it does not include any share joint custody, without stating that one of the parents is responsible for the 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. health care expenses of the child, the plans covering follow the Order of benefit determination rules outlined in 3.b.ii. 3. Order of benefit determination rules 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 a. General. When there is a basis for a claim under this plan and another plan, this plan is employee (or as that employee's dependent). If the other plan does not have this a secondary plan which has its benefits determined after those of the other plan, unless: rule, and if, as a result, the plans do not agree on the order of benefits, this rule is i. The other plan has rules coordinating its benefits with the rules of this plan; and ignored. ii. Both the other plan's rules and this plan's rules, in 3.b. below, require that this plan's vi. Workers'compensation. Coverage under any workers' compensation act or similar benefits be determined before those of the other plan. law applies first. You should submit claims for expenses incurred as a result of an b. Rules. This plan determines its order of benefits using the first of the following rules on-duty injury to the employer, before submitting them to Medica. which applies: vii. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance i. Nondependent/dependent. The benefits of the plan that covers the person as an Act or similar law applies first. employee, member or subscriber (that is, other than as a dependent) are determined viii. Longer/shorter length of coverage. If none of the above rules determines the order before those of the plan, which covers the person as a dependent. of benefits, the benefits of the plan which covered an employee, member, or ii. Dependent child/parents not separated or divorced. Except as stated in 3.b.iii. subscriber longer are determined before those of the plan which covered that person below, when this plan and another plan cover the same child as a dependent of for the shorter term. different persons, called parents: a) The benefits of the plan of the parent whose birthday falls earlier in a year are 4. Effect on the benefits of this plan determined before those of the plan of the parent whose birthday falls later in that year; but 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 NC PP MN HSA (3/12) 84 1500-100% 1500 100% MIC PP MN HSA(3/12) 85 BPL 21278 DOC 23744 BPL 21278 DOC 23744 Coordination Of Benefits Right Of Recovery 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. BB. Right Of Recovery 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 This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and absence of this COB provision; and federal law. For information about the effect of applicable state and federal law on Medica's subrogation rights, contact an attorney. ii. The benefits that would be payable for the allowable expenses under the other plans, EA }. ; benefits. in the absence of provisions with a purpose like that of this COB provision, whether See,Defrnitons. This word Figs a specificrneaning:�7 or not claim is made, exceeds those allowable expenses in a claim determination 1. Medica has a right of subrogation against any third party, individual, corporation, insurer, or period. In that case, the benefits of this plan will be reduced so that they and the other entity or person who may be legally responsible for payment of medical expenses benefits payable under the other plans do not total more than those allowable related to your illness or injury. Medica's right of subrogation shall be governed according to expenses. this section. Medica's right to recover its subrogation interest applies only after you have When the benefits of this plan are reduced as described above, each benefit is reduced received a full recovery for your illness or injury from another source of compensation for in proportion. It is then charged against any applicable benefit limit of this plan. your illness or injury. 2. Medica's subrogation interest is the reasonable cash value of any benefits received by you. 5. Right to receive and release needed information 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 Certain facts are needed to apply these COB rules. Medica has the right to decide which incurred in obtaining a recovery from another source unless Medica is separately facts it needs. It may get needed facts from or give them to any other organization or represented by an attorney. If Medica is represented by an attorney, an agreement person. Medica need not tell, or get the consent of, any person to do this. Unless regarding allocation may be reached. If an agreement cannot be reached, the matter must applicable federal or state law prevents disclosure of the information without the consent of be submitted to binding arbitration. 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. 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 6. Facility of payment 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 A payment made under another plan may include an amount, which should have been paid law. under this plan. If it does, Medica may pay that amount to the organization which made that b. To cooperate with Medica or its designee to help protect Medica's legal rights under this payment. That amount will then be treated as though it were a benefit paid under this plan. subrogation provision and to provide all information Medica may reasonably request to Medica will not have to pay that amount again. The term payment made includes providing determine its rights under this provision. benefits in the form of services, in which case payment made means reasonable cash value of the benefits provided in the form of services. c. To provide prompt written notice to Medica when you make a claim against a party for injuries. 7. Right of recovery d. To do nothing to decrease Medica's rights under this provision, either before or after receiving benefits, or under the Contract. If the amount of the payments made by Medica is more than it should have paid under this e. Medica may take action to preserve its legal rights. This includes bringing suit in your COB provision, it may recover the excess from one or more of the following: name. a. The persons it has paid or for whom it has paid; or f. Medica may collect its subrogation interest from the proceeds of any settlement or b. Insurance companies; or judgment recovered by you your legal representative, or the legal representative(s) of your estate or next-of-kin. 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 PP MN HSA(3/12) 86 1500-100% MIC PP MN HSA(3/12) 87 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Eligibility And Enrollment Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30-day time CC. Eligibility And Enrollment 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 This section describes who can enroll and how to enroll. 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, See Definitions These words have specific,meanings :benefits, continuouscoverage, or as a late entrant (if applicable, as described below). dependent, late entrant,member, mental disorder, physician, placed for adoption, premium qual�fyrngcaverage;�subscnber,„ nraitm � erwd�,r � � �; �� � �� � � � � � � �.:, � A member who is a child entitled to receive coverage through a QMCSO is not subject to any E- _, �' initial enrollment period restrictions, except as noted in this section. y Who can enroll Open enrollment 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. A minimum 14-day period set by the employer and Medica each year during which eligible I 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 How to enroll dependents. You must submit an application for coverage for yourself and any dependents to the employer: Special enrollment 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 Special enrollment periods are provided to eligible employees and dependents under certain circumstances. 3. During a special enrollment period as described in this section under Special enrollment; or 1. Loss of other coverage 4. At any other time for consideration as a late entrant as described in this section under Late enrollment. 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 Dependents will not be enrolled without the eligible employee also being enrolled. A child who lost that coverage as a result of loss of eligibility. The eligible employee or dependent is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical must present evidence of the loss of coverage and request enrollment within 60 days Child Support Order(QMCSO) and 6. under Special enrollment. after the date such coverage terminates. In the case of the eligible employee's loss of coverage, this special enrollment period Notification 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 You must notify the employer in writing within 30 days of the effective date of any changes to dependent who has lost coverage and the eligible employee. address or name, addition or deletion of dependents, a dependent child reaching the dependent limiting age, or other facts identif in b. A special enrollment period will apply to an eligible employee and dependent if the y g you or your dependents. (For dependent children, the eligible employee or dependent was covered under qualifying coverage other than notification period is not limited to 30 days for newborns or children newly adopted or newly Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or 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 dependent was eligible to enroll under the Contract, whether during initial enrollment, adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with open enrollment, or special enrollment, and declined coverage for that reason. the subscriber, and any child who is a member pursuant to a QMCSO will be covered without The eligible employee or dependent must present either evidence of the loss of prior application of health screening or waiting periods. coverage due to loss of eligibility for that coverage or evidence that employer The employer must notify Medica, as set forth in the Contract, of your initial enrollment contributions toward the prior coverage have terminated, and request enrollment in application, changes to your name or address, or changes to enrollment, including if ou or our writing within 30 days of the date of the loss of coverage or the date the employer's dependents are no longer eligible for coverage. g y y 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. Initial enrollment For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; 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 PP MN HSA (3/12) 88 1500-100% MIC PP MN HSA (3/12) 89 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Eligibility And Enrollment Eligibility And Enrollment ii. Loss of eligibility includes: • 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 • loss of eligibility as a result of legal separation, divorce, death, termination of other COBRA or state continuation coverage is available; or employment, reduction in the number of hours of employment; • if the prior coverage was offered through a health maintenance organization • cessation of dependent status; (HMO), losing coverage because the eligible employee or dependent no longer • incurring a claim that causes the eligible employee or dependent to meet or resides or works in the HMO's service area and no other COBRA or state exceed the lifetime maximum limit on all benefits; continuation coverage is available. • if the prior coverage was offered through an individual health maintenance ii. Exhaustion of COBRA or state continuation coverage does not include a loss due to organization (HMO), a loss of coverage because the eligible employee or failure of the eligible employee or dependent to pay premiums on a timely basis or dependent no longer resides or works in the HMO's service area; termination of coverage for cause. • if the prior coverage was offered through a group HMO, a loss of coverage iii. In the case of the eligible employee's exhaustion of COBRA or state continuation because the eligible employee or dependent no longer resides or works in the coverage, the special enrollment period described above applies to the eligible HMO's service area and no other coverage option is available; and 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 • the prior coverage no longer offers any benefits to the class of similarly situated above applies only to the dependent who has lost coverage and the eligible individuals that includes the eligible employee or dependent. employee. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is 2. The dependent is a new spouse of the subscriber or eligible employee, provided that the eligible for or elects applicable federal or state continuation coverage; marriage is legal and enrollment is requested in writing within 30 days of the date of iv. Loss of eligibility does not include a loss due to failure of the eligible employee or marriage and provided that the eligible employee also enrolls during this special enrollment dependent to pay premiums on a timely basis or termination of coverage for cause; period; 3. The dependent is a new dependent child of the subscriber or eligible employee, provided 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. that enrollment is requested in writing within 30 days of the subscriber or eligible employee In the case of a dependent's loss of other coverage, the special enrollment period acquiring the dependent (for dependent children, the notification period is not limited to 30 described above applies only to the dependent who has lost coverage and the eligible days for newborns or children newly adopted or newly placed for adoption) and provided employee. that the eligible employee also enrolls during this special enrollment period; c. A special enrollment period will apply to an eligible employee and dependent if the 4. The dependent is the spouse of the subscriber or eligible employee through whom the eligible employee or dependent was covered under benefits available under the dependent child described in 3. above claims dependent status and: Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or a. That spouse is eligible for coverage; and any applicable state continuation laws at the time the eligible employee or dependent b. Is not already enrolled under the Contract; and was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. c. Enrollment is requested in writing within 30 days of the dependent child becoming a The eligible employee or dependent must present evidence that the eligible employee or dependent; and dependent has exhausted such COBRA or state continuation coverage and has not lost d. The eligible employee also enrolls during this special enrollment period; or 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 5. The dependents are eligible dependent children of the subscriber or eligible employee and of the exhaustion of coverage. 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 For purposes of 1.c.: enrolls during this special enrollment period. i. Exhaustion of COBRA or state continuation coverage includes: 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as • losing COBRA or state continuation coverage for any reason other than those set described in this section, Medica will provide the eligible dependent child with a special forth in ii. below; enrollment period provided the eligible employee also enrolls during this special enrollment period. • losing coverage as a result of the employer's failure to remit premiums on a timely basis; MIC PP MN HSA (3/12) 90 1500-100% MIC PP MN HSA (3/12) 91 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Eligibility And Enrollment Eligibility And Enrollment Late 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 An eligible employee or an eligible employee and dependents who do not enroll for coverage was held. offered through the employer during the initial or open enrollment period or any applicable 3. For eligible employees and/or dependents who enroll during a special enrollment period, special enrollment period will be considered late entrants. coverage begins on the date indicated below for the particular special enrollment. In the Late entrants who have maintained continuous coverage may enroll and coverage will be case of: effective the first day of the month following date of Medica's approval of the request for a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first enrollment. Continuous coverage will be determined to have been maintained if the late entrant calendar month following the date on which the request for enrollment is received by requests enrollment within 63 days after prior qualifying coverage ends. Medica; Individuals who have not maintained continuous coverage may not enroll as late entrants. b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of An eligible employee or dependent who: adoption or placement for adoption, date of adoption or placement. In all other cases, 1. does not enroll during an initial or open enrollment period or any applicable special the date the subscriber acquires the dependent child; enrollment period; and c. Number 4. under Special enrollment, the date coverage for the dependent child is 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the employer, effective, as set forth in 3.b. above; provided the eligible subscriber or dependent maintains continuous coverage, d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. will not be considered a late entrant and will be allowed to enroll. Coverage will be effective as or 3. under Special enrollment becomes effective; determined by Medica. 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. Qualified Medical Child Support Order(QMCSO) 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 Medica will provide coverage in accordance with a QMCSO pursuant to the applicable enrollment. 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 PP MN HSA (3/12) 92 1500-100% MIC PP MN HSA(3/12) 93 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Ending Coverage • Ending Coverage e. Submitting fraudulent claims; DD. Ending Coverage 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. This section describes when coverage ends under the Contract. When this happens you may Upon completion of active military duty, contact the employer for reinstatement of coverage; exercise your right to continue or convert your coverage as described in Continuation or Conversion 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 See Definitions. These words have specific.meanrngs: certification of qualifying coverage, death occurred; claim,dependent, member, premium subscriber.er 4, .. � 9. For a spouse, the end of the month following the date of divorce; 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 10. For a dependent child, the end of the month in which the child is no longer eligible as a certification of qualifying coverage at any time while you are covered under the Contract or dependent; or within the 24 months following the date your coverage ends. To request a certification of 11. For a child who is entitled to coverage through a QMCSO, the end of the month in which the qualifying coverage, call Customer Service at one of the telephone numbers listed inside the earliest of the following occurs: front cover. Upon receipt of your request, the certification of qualifying coverage will be issued a. The QMCSO ceases to be effective; or as soon as reasonably possible. b. The child is no longer a child as that term is used in ERISA; or When coverage ends c. The child has immediate and comparable coverage under another plan; or Unless otherwise specified in the Contract, coverage ends the earliest of the following: d. The employee who is ordered by the QMCSO to provide coverage is no longer eligible as determined by the employer; or 1. The end of the month in which the Contract is terminated by the employer or Medica in e. The employer terminates family or dependent coverage; or 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; f. The Contract is terminated by the employer or Medica; or 2. The end of the month for which the subscriber last paid his or her contribution toward the g. The relevant premium or contribution toward the premium is last paid. 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 PP MN HSA (3/12) 94 1500-100% MIC PP MN HSA (3/12) 95 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Continuation Continuation Subscriber's spouse's loss EE. Continuation 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: This section describes continuation coverage provisions. When coverage ends, members may a. Death of the subscriber; be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer. b. A termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; See Definitions These words have specific meanings benefits, dependent member, for�adoption, premium,�subscriber,$total disability k � � per, placed c. Dissolution of marriage from the subscriber; t = d. The subscriber's enrollment for benefits under Medicare. The paragraph below describes the continuation coverage provisions. State continuation is described in 1. and federal continuation is described in 2. Subscriber's child's loss If your coverage ends, you should review your rights under both state law and federal law with The subscriber's dependent child has the right to continuation coverage if coverage under the employer. If you are entitled to continuation rights under both, the continuation provisions the Contract is lost for any of the following reasons: 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 a. Death of the subscriber if the subscriber is the parent through whom the child receives individual conversion health plan as described in Conversion. coverage; b. Termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; 1. Your right to continue coverage under state law c. The subscriber's dissolution of marriage from the child's other parent; Notwithstanding the provisions regarding termination of coverage described in Ending d. The subscriber's enrollment for benefits under Medicare if the subscriber is the parent Coverage, you may be entitled to extended or continued coverage as follows: through whom the child receives coverage; a. Minnesota state continuation coverage. e. The subscriber's child ceases to be a dependent child under the terms of the Contract. 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 Responsibility to inform 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. employer Under of a Minnesota dissolution law, the of subscriber marriage or and a child dependents losing dependent have the status under responsibility to the inform Contract the b. Notice of rights. within 60 days of the date of the event or the date on which coverage would be lost because of the event. 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 Election rights coverage (called continuation coverage) at group rates in certain instances where health When the employer is notified that one of these events has happened, the subscriber and coverage under an employer sponsored group health plan(s) would otherwise end. the subscriber's dependents will be notified of the right to continuation coverage. 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 Consn M law, usr dependents d rights be provided than those required by Minnesota law. Take time to read this section continuation istet with coverage innesota for reasons the of s termination bcribe of and the ependent subscriber's have employment 60 ays to elect or the carefully. subscriber's enrollment for benefits under Medicare measured from the later of: Subscriber's loss 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. 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 If continuation coverage is elected within this period, the coverage will be retroactive to the voluntary or involuntary termination of employment (for any reason other than gross date coverage would otherwise have been lost. misconduct) or layoff from employment. In this section, The subscriber and the subscriber's covered spouse may elect continuation coverage on reduction in hours to the point where the subscriber is nol longer eliy eligible coverage under behalf of other dependents entitled to continuation coverage. Under certain circumstances, the Contract. 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 PP MN HSA (3/12) 96 1500-100% MIC PP MN HSA (3/12) 97 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Continuation Continuation Type of coverage and cost ii. The date coverage would otherwise terminate under the Contract. If continuation coverage is elected, the subscriber's employer is required to provide e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent coverage that, as of the time coverage is being provided, is identical to the coverage children may be continued until the earlier of: provided under the Contract to similarly situated employees or employees' dependents. Under Minnesota law, a person continuing coverage may have to make a month) i. The date the surviving spouse and dependent children become covered under to the employer of all or part of the premium for continuation coverage. The amount ayment another group health plan; or charged cannot exceed 102 percent of the cost of the coverage. ii. The date coverage would have terminated under the Contract had the subscriber Surviving dependents of a deceased subscriber have 90 days after notice of the lived. requirement to pay continuation premiums to make the first payment. When your continuation coverage under this section ends, you have the option to enroll in an Duration individual conversion health plan (as described in Conversion). Under the circumstances described above and for a certain period of time, Minnesota law Extension of benefits for total disability of the subscriber requires that the subscriber and his or her dependents be allowed to maintain continuation Coverage may be extended for a subscriber and his or her dependents in instances where coverage as follows: the subscriber is absent from work due to total disability, as defined in Definitions. If the a. For instances where coverage is lost due to the subscriber's termination of or la off from subscriber is required to pay all or part of the premium for the extension of coverage, employment, coverage may be continued until the earliest of: y payment shall be made to the employer. The amount charged cannot exceed 100 percent of the cost of the coverage. 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 2. Your right to continue coverage under federal law employee or otherwise)that does not contain any exclusion or limitation with respect to any applicable pre-existing condition; or Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: iii. The date coverage would otherwise terminate under the Contract. b. For instances where the subscriber's spouse or dependent children lose coverage COBRA continuation coverage because of the subscriber's enrollment under Medicare, coverage may be continued Continued coverage shall be provided as required under the Consolidated Omnibus Budget until the earliest of: Reconciliation Act of 1985 (COBRA), as amended (as well as the Public Health Service Act i. 36 months after continuation was elected; (PHSA), as amended). The employer shall, within the parameters of federal law, establish ii. The date coverage is obtained under another group health plan; or uniform policies pursuant to which such continuation coverage will be provided. See General COBRA information in this section. 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 USERRA continuation coverage eligibility, coverage may be continued until the earliest of: Continued coverage shall be provided as required under the Uniformed Services i. 36 months after continuation was elected; Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The employer shall, within the parameters of federal law, establish uniform policies pursuant to ii. The date coverage is obtained under another group health plan; or which such continuation coverage will be provided. See General USERRA information in iii. The date coverage would otherwise terminate under the Contract. this section. d. For instances of dissolution of marriage from the subscriber, coverage of the General COBRA information subscriber's spouse and dependent children may be continued until the earliest of: 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 i. The date the former spouse becomes covered under another group health plan; or ii. The date coverage would otherwise terminate under the Contract. extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under employer sponsored group health plan(s) would If a dissolution of marriage occurs during the period of time when the subscriber's otherwise end. This coverage is a group health plan for purposes of COBRA. spouse is continuing coverage due to the subscriber's termination of or layoff from This section is intended to inform you, in summary fashion, of your rights and obligations employment, coverage of the subscriber's spouse may be continued until the earlier of: under the continuation coverage provision of federal law. It is intended that no greater rights i. The date the former spouse becomes covered under another group health plan; or be provided than those required by federal law. Take time to read this section carefully. • MIC PP MN HSA (3/12) 98 1500-100% MIC PP MN HSA(3/12) 99 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Continuation Continuation Qualified beneficiary Also, a subscriber and dependent who have been determined to be disabled under the For purposes of this section, a qualified beneficiary is defined as: Social Security Act as of the time of the subscriber's termination of employment or reduction a. A covered employee (a current or former employee who is actually covered under a of hours or within 60 days of the start of the continuation period must notify the employer of group health plan and not just eligible for coverage); 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 b. A covered spouse of a covered employee; or the determination. c. A dependent child of a covered employee. (A child placed for adoption with or born to Bankruptcy an employee or former employee receiving COBRA continuation coverage is also a qualified beneficiary.) Rights similar to those described above may apply to retirees (and the spouses and Subscriber's loss dependents of those retirees), if the subscriber's employer commences a bankruptcy proceeding and these individuals lose coverage. The subscriber has the right to elect continuation of coverage if there is a loss of coverage I Election rights 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 When notified that one of these events has happened, the employer will notify the terms of the Contract due to a reduction in his or her hours of employment. subscriber and dependents of the right to choose continuation coverage. Subscriber's spouse's loss Consistent with federal law, the subscriber and dependents have 60 days to elect continuation coverage, measured from the later of: The subscriber's covered spouse has the right to choose continuation coverage if he or she a. The date coverage would be lost because of one of the events described above; or loses coverage under the Contract for any of the following reasons: a. Death of the subscriber; b. The date notice of election rights is received. If continuation coverage is elected within this period, the coverage will be retroactive to the 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; date coverage would otherwise have been lost. The subscriber and the subscriber's covered spouse may elect continuation coverage on c. Divorce or legal separation from the subscriber; or behalf of other dependents entitled to continuation coverage. However, each person d. The subscriber's entitlement to (actual coverage under) Medicare. entitled to continuation coverage has an independent right to elect continuation coverage. Subscriber's child's loss The subscriber's covered spouse or dependent child may elect continuation coverage even if the subscriber does not elect continuation coverage. The subscriber's dependent child has the right to continuation coverage if coverage under If continuation coverage is not elected, your coverage under the Contract will end. 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 Type of coverage and cost coverage; If the subscriber and the subscriber's dependents elect continuation coverage, the employer b. The subscriber's termination of employment (for any reason other than ross is required to provide coverage that, as of the time coverage is being provided, is identical to misconduct) or reduction in the subscriber's hours of employment with th the coverage provided under the Contract to similarly situated employees or employees' e employer; c. The subscriber's divorce or legal separation from the child's other parent; dependents. Under federal law, a person electing continuation coverage may have to pay all or part of d. The subscriber's entitlement to (actual coverage under) Medicare if the subscriber is the the premium for continuation coverage. The amount charged cannot exceed 102 percent of parent through whom the child receives coverage; or the cost of the coverage. The amount may be increased to 150 percent of the applicable e. The subscriber's child ceases to be a dependent child under the terms of the Contract. premium for months after the 18th month of continuation coverage when the additional months are due to a disability under the Social Security Act. Responsibility to inform There is a grace period of at least 30 days for the regularly scheduled premium. 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 Duration of COBRA coverage Contract within 60 days of the date of the event, or the date on which coverage would be Federal law requires that you be allowed to maintain continuation coverage for 36 months lost because of the event. 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 PP MN HSA (3/12) 100 1500-100% MIC PP MN HSA(3/12) 101 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Continuation Continuation The 18 months may be extended if a second event (e.g., divorce, legal separation, or death) Guard duty, and the time necessary for a person to be absent from employment for an occurs during the initial 18-month period. It also may be extended to 29 months in the case examination to determine the fitness of the person to perform any of these duties. of an employee or employee's dependent who is determined to be disabled under the Social Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army Security Act at the time of the employee's termination of employment or reduction of hours, National Guard, and the Air National Guard, when engaged in active duty for training, or within 60 days of the start of the 18-month continuation period. inactive duty training, or full-time National Guard duty, and the commissioned corps of the If an employee or the employee's dependent is entitled to 29 months of continuation Public Health Service. 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) Election rights Medicare, the continuation period for the subscriber's dependents is 36 months measured The employee or the employee's authorized representative may elect to continue the from the date of the subscriber's Medicare entitlement even if that entitlement does not employee's coverage under the Contract by making an election on a form provided by the cause the subscriber to lose coverage. employer. The employee has 60 days to elect continuation coverage measured from the Under no circumstances is the total continuation period greater than 36 months from the date date coverage would be lost because of the event described above. If continuation of the original event that triggered the continuation coverage. 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 Federal law provides that continuation coverage may end earlier for any of the following of other covered dependents, however, there is no independent right of each covered reasons: dependent to elect. If the employee does not elect, there is no USERRA continuation •a. The subscriber's employer no longer provides group health coverage to any of its available for the spouse or dependent children. In addition, even if the employee does not employees; elect USERRA continuation, the employee has the right to be reinstated under the Contract b. The premium for continuation coverage is not paid on time; upon reemployment, subject to the terms and conditions of the Contract. c. Coverage is obtained under another group health plan (as an employee or otherwise) Type of coverage and cost that does not contain any exclusion or limitation with respect to any applicable pre- If the employee elects continuation coverage, the employer is required to provide coverage existing condition; or that, as of the time coverage is being provided, is identical to the coverage provided under d. The subscriber becomes entitled to (actually covered under) Medicare. 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 Continuation coverage may also end earlier for reasons which would allow regular coverage to days, in which case the employee is not required to pay more than the amount that they be terminated, such as fraud. would have to pay as an active employee for that coverage. There is a grace period of at General USERRA information least 30 days for the regularly scheduled premium. USERRA requires employers to offer employees and their families (spouse and/or Duration of USERRA coverage dependent children) the opportunity to pay for a temporary extension of health coverage When an employee takes a leave for service in the uniformed services, coverage for the (called continuation coverage) at group rates in certain instances where health coverage employee and dependents for whom coverage is elected begins the day after the employee under employer sponsored group health plan(s) would otherwise end. This coverage is a would lose coverage under the Contract. Coverage continues for up to 24 months. group health plan for the purposes of USERRA. Federal law provides that continuation coverage may end earlier for any of the following This section is intended to inform you, in summary fashion, of your rights and obligations reasons: 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. a. The employer no longer provides group health coverage to any of its employees; Employee's loss b. The premium for continuation coverage is not paid on time; The employee has the right to elect continuation of coverage if there is a loss of coverage c. The employee loses their rights under USERRA as a result of a dishonorable discharge or other undesirable conduct; 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, d. The employee fails to return to work following the completion of his or her service in the and the employee, or an appropriate officer of the uniformed services, provided the uniformed services; or employer with advance notice of the employee's absence from employment (if it was e. The employee returns to work and is reinstated under the Contract as an active possible to do so). employee. Service in the uniformed services means the performance of duty on a voluntary or Continuation coverage may also end earlier for reasons which would allow regular coverage involuntary basis in the uniformed services under competent authority, including active duty, to be terminated, such as fraud. active duty for training, initial active duty for training, inactive duty training, full-time National MIC PP MN HSA (3/12) 102 1500-100% MIC PP MN HSA(3/12) 103 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Continuation Conversion 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. FF. Conversion See Definitions ;These words have specific meanings benefits, continuous coverage, t „ dependent, network,premium, provider,: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. If you commit fraud or material misrepresentation in applying for continuation or conversion of coverage. MIC PP MN HSA (3/12) 104 1500-100% MIC PP MN HSA (3/12) 105 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Conversion Complaints 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. GG. Complaints What you must do 1. For conversion coverage information, call Customer Service at one of the telephone This section describes what to do if you have a complaint or would like to appeal a decision numbers listed inside the front cover. made by Medics. 2. Pay premiums to Medica or Medica's designated conversion vendor within 63 days after See,Definitions. These words'have specific meanmgsx,..claim, mpafient, network, provider. your coverage ends or within 31 days of the date you were notified of your right to convert You may call Customer Service at one of the telephone numbers listed inside the front cover or coverage, whichever is later. You will be required to include your first month premium payment with your enrollment form for conversion coverage. by writing to the address below in First level of review, 2. You also may contact the 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 63 Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296-2488 or 1-800-657-3602. days after your coverage ends or within 31 days of the date you were notified of your right to ,Filing a complaint may require that Medica review your medical records as needed to resolve convert, whichever is later. You may include only those dependents who were enrolled your complaint. under the Contract at the time of conversion. What the employer must do 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 The employer is required to notify your authorized representative and allow them to act on your behalf during the complaint y you of your right to convert coverage. process. Residents of a state other than Minnesota Upon request, Medica will assist you with completion and submission of your written complaint. y p Medica will also complete a complaint form on your behalf and mail it to you for your signature This section describes your right to convert to an individual conversion plan if you are a resident upon request. of a state other than Minnesota on the day that you submit an enrollment form to Medica or In addition to directing complaints to Customer Service as described in this section, you may Medica's designated conversion vendor. direct complaints at any time to the Commissioner of Commerce at the telephone number listed Overview at the beginning of this section. You may convert to an individual conversion plan through Medica or Medica's designated First level of review conversion vendor without proof of good health or waiting g d of the state in which you reside on the day that you submit panlenrollment form to Medica oraws You may direct any question or complaint to Customer Service by calling one of the telephone Medica's designated conversion vendor. numbers listed inside the front cover or by writing to the address listed below. What you must do 1. If your complaint is regarding an initial decision made by Medica, your complaint must be 1. For conversion coverage information, call Customer Service at one of the telephone 2. For within an oral complaint that not following t does tdrequire laamedcal determination in its outcome, if Medica numbers listed inside the front cover. p does not communicate a decision within 10 business days from Medica's receipt of the 2. Pa y premiums to Medica or Medica's designated conversion vendor within 31 days after complaint, or if you determine that Medica's decision is partially or wholly adverse to you, your coverage ends or such other period of time as provided under applicable state law. Medica will provide you with a complaint form to submit your complaint in writing. Mail the You will be required to include your first month premium payment with your enrollment form completed form to: for conversion coverage. Customer Service 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 Route 0501 days after your coverage ends or such other period of time as provided under applicable PO Box 9310 state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. 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 PP MN HSA (3/12) 106 1500-100% MIC PP MN HSA (3/12) 107 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 C Complaints 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 submitted foreexterinal reviewent marketing practices or agent misrepresentation cannot be ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without care or treatment you are requesting, Medica will process your claim as an expedited review. In such cases, Medica will notify Civil action telephone of its decision no later than 72 hours after receiving thearequestg provider by 5. If Medica's first level review decision upholds the initial decision made by Medica, you If you are dissatisfied with Medica's first or second level review decision or the external review have a right to request a second Y may decision you have the right 1 d level review or submit a written request for external review Retirement Income Security Act ll(ERISA)action under section 502(a) of the Employee as described in this section. Second/eve/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 a our reviews; or Y ppeal for required second level 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. Generally, a second level review is optional if the complaint requires a medical determination. Medica will inform you in writing whether the second level of review is optional or required. 1 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 You must include a filing fee of$25 with 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. Medica may seek judicial review on grounds that the decision was arbitrary and capricious or involved an abuse of discretion. Contact the Commissioner of Commerce for more information about the external review process. MIC PP MN HSA (3/12) 108 1500-100% MIC PP MN HSA(3/12) 109 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 General Provisions General Provisions HH. 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; provided, This section describes the general provisions of the Contract. however, that this provision shall not be construed to specify a standard of review upon which a court may review a claim denial or any other decision made by Medica with respect to a See Definitions These words have specific meanings: benefits, claim, dependent,,-me network, premitiM provider, subscriber. - member. � member, Examination of a member To settle a dispute concerning provision or payment of benefits under the Contract, Medica ma require that you be examined or an autopsy of the member's body be performed. The may 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. you will not be eligible for coverage beyond the scheduled termination of your co eragewever, because of a failure to record the termination. I 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 e of Medica or to any other a under the Contract to any subsidiary or affiliate entity. appropriate organization or 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, entire Contract between the employer and Medica, and replace allll othea agreements as of the effective date of the Contract. Amendment This certificate may be amended in accordance with the Contract. When this happens, you receive a new certificate or amendment. No other person or entity has authority to make anwill changes or amendments to this certificate. All amendments must be in writing. y 110 1500 100% MIC PP MN HSA(3/12) MIC PP MN HSA(3/12) 111 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Definitions Definitions Definitions 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. In this certificate (and in any amendments), some words have specific meanings. Within each Cosmetic. Services and procedures that improve physical appearance but do not correct or definition, you may note bold words. These words also are defined in this section. improve meets the definition n t on of reconstructive. re notmedically necessary, unless the service or procedure Benefits. The health services or supplies (described in this certificate and any subsequent Custodial care. Services to assist in activities of daily living that do not seek to cure, are amendments) approved by Medica as eligible for coverage. Certification of ualifyina coverage. A written certification that group health plans and health performed regularly as a part of a routine or schedule, and, due to the physical stability of the insurance issuers must provide to an individual to confirm the qualifying coverage provided health condition, cl not need to al provided or directed of a skilled medical professional. These insurance ra cd issuers under the group health plan individual health insurance. 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- Claim. An invoice, bill, or itemized statement for benefits provided to you. administered. Coinsurance. The percentage amount you must pay to the provider for benefits received. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims Full coinsurance payments may apply to scheduled appointments for health services or supplies received from network or non-network providers are before the appointment time or to missed appointments. canceled less than 24 hours reimbursable as in-network orout-of-network benefits under this certificate. ppointments. For in-network benefits, the coinsurance amount is based on the lesser of the: Dependent. Unless otherwise specified in the Contract, the following are considered 1. Charge billed by the provider (i.e., retail); or dependents: 1. The subscriber's spouse. 2. Negotiated amount that the provider has agreed to accept as full payment for the benefit (i.e., wholesale). 2. The following dependent children up to the dependent limiting age of 26: When the wholesale amount is not known nor readily calculated at the time the benefit is a. The subscriber's or subscriber's spouse's natural or adopted child; • provided, Medica uses an amount to approximate the wholesale amount. For services from b. A child placed for adoption with the subscriber or subscriber's spouse; some network providers, however, the coinsurance is based on the provider's retail charge. any patient, c. A child for whom the subscriber or the subscriber's spouse has been appointed legal The provider's retail charge is the amount that the provider would charge to an whether or not that patient is a Medica member. guardian; however, upon request by Medica, the subscriber must provide satisfactory proof of legal guardianship; 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 d. The subscriber's stepchild; and e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent 2. Non-network provider reimbursement amount. upon and resides with the subscriber or subscriber's spouse continuously from birth. or out-of-network benefits, in addition to any coinsurance and deductible amounts, you are 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent responsible for any charges billed by the provider in excess of the non-network provider incapable of self-sustaining employment by reason of developmental disability, mental reimbursement amount. 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- In addition, for the network pharmacies described in Prescription Drug Program and Prescription Specialty Drug Program, the calculation of coinsurance amounts as described sustaining employment will not be considered a physical disability. This dependent may above do not include possible reductions for any volume purchase discounts or price remain covered under the Contract regardless of age and without application of health adjustments that Medica may later receive related to certain prescription drugs and pharmacy screening or waiting periods. To continue coverage fora disabled dependent, you must services. provide Medics 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 The coinsurance may not exceed the charge billed by the provider for the benefit. child reaches the dependent limiting age, Medica may require annual proof of disability and. Continuous coverage. The maintenance of continuous and uninterrupted qualifying dependency. coverage by an eligible employee or dependent. An eligible employee or dependent is For residents of a state other than Minnesota, the dependent limiting age may be higher if considered to have maintained continuous coverage if enrollment is requested under the required by applicable state law. Contract within 63 days of termination of the previous qualifying coverage. 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, MIC PP MN HSA (3/12) 112 1500-100% MIC PP MN HSA (3/12) 113 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Definitions Definitions • you must provide Medica with proof of such disability and dependency at the time of the parameters approved by national health professional boards or associations, and entries in any dependent's enrollment. authoritative compendia as identified by the Medicare program for use in the determination of a Emergency. A condition or symptom (including severe pain) that a prudent layperson, who medically accepted indication of drugs and biologicals used off-label. possesses an average knowledge of health and medicine, would believe requires immediate Late entrant. An eligible employee or dependent who requests enrollment under the Contract treatment to: other than during: I 1. Preserve your life; or 1. The initial enrollment period set by the employer; or 2. Prevent serious impairment to your bodily functions, organs, or parts; or 2. The open enrollment period set by the employer; or 3. Prevent placing your physical or mental health (or, if you are pregnant, the health of your 3. A special enrollment period as described in Eligibility And Enrollment. unborn child) in serious jeopardy. However, an eligible employee or dependent who is an enrollee of the Minnesota Enrollment date. The date of the eligible employee's or dependent's first day of coverage Comprehensive Health Association (MCHA) at the time Medica offers or renews coverage with under the Contract or, if earlier, the first day of the waiting period for the eligible employee's or the employer will not be considered a late entrant, provided the eligible employee or dependent's enrollment. dependent maintains continuous coverage as defined in this certificate. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if In addition, a member who is a child entitled to receive coverage through a QMCSO is not the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing includes subject to any initial or open enrollment period restrictions. pharmacogenetic testing. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Medically necessary. Diagnostic testing and medical treatment, consistent with the diagnosis For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. of and prescribed course of treatment for your condition, and preventive services. Medically s ital. A licensed facility that provides diagnostic, medical, therapeutic, rehabilitative, and necessary care must meet the following criteria: Ho surgical services by, or under the direction of, a physician and with 24-hour R.N. nursing 1. Be consistent with the medical standards and accepted practice parameters of the services. The hospital is not mainly a place for rest or custodial care, and is not a nursing community as determined by health care providers in the same or similar general specialty home or similar facility. as typically manages the condition, procedure or treatment at issue; and In atient. An uninterrupted stay, following formal admission to a hospital, skilled nursing 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your facility, or licensed acute care facility. Inpatient services in a licensed residential treatment diagnosis or condition; and facility for treatment of emotionally disabled children will be covered as any other health 3. Help to restore or maintain your health; or condition. 4. Prevent deterioration of your condition; or Investigative. As determined by Medica, a drug, device, diagnostic or screening procedure, or 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. 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 Member. A person who is enrolled under the Contract. determination based upon an examination of the following reliable evidence, none of which shall Mental disorder. A physical or mental condition having an emotional or psychological origin, be determinative in and of itself: 1. Whether there is final approval from the appropriate as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders ppropriate government regulatory agency, if (DSM). required, including whether the drug or device has received final approval to be marketed for Network. A term used to describe a provider (such as a hospital, physician, home health 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; 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. 2. Whether there are consensus opinions and recommendations reported in relevant scientific The network provider directory will be furnished automatically, without charge. and medical literature, peer-reviewed journals, or the reports of clinical trial committees and other technology assessment bodies; and Non-network. A term used to describe a provider not under contract as a network provider. 3. Whether there are consensus opinions of national and local health care providers in the Non-network provider reimbursement amount. The amount that Medica will pay to a non- applicable specialty or subspecialty that typically manages the condition as determined by a network provider for each benefit is based on one of the following, as determined by Medica: survey or poll of a representative sampling of these providers. 1. A percentage of the amount Medicare would pay for the service in the location where the Notwithstanding the above, a drug being used for an indication or at a dosage that is an service is provided. Medica generally updates its data on the amount Medicare pays within accepted off-label use for the treatment of cancer will not be considered by Medica to be 30-60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or investigative. Medica will determine if a use is an accepted off-label use based on published 2. A percentage of the provider's billed charge; or reports in authoritative peer-reviewed medical literature, clinical practice guidelines, or MIC PP MN HSA(3/12) 114 1500-100% MIC PP MN HSA(3/12) 115 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Definitions Definitions 3. A nationwide provider reimbursement database that considers prevailing reimbursement 3. With respect to members who are infants, children, and adolescents, evidence-informed rates and/or marketplace charges for similar services in the geographic area in which the preventive care and screenings provided for in the comprehensive guidelines supported by service is provided; or ! the Health Resources and Services Administration; 4. An amount agreed upon between Medica and the non-network provider. 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 Contact Customer Service for more information concerning which method above pertains to Resources and Services Administration. 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 Contact Customer Service for information regarding specific preventive health services, amount as a coinsurance. services that are rated A or B, and services that are included in guidelines supported by the Health Resources and Services Administration. In addition, if the amount billed by the non-network provider is greater than the non-network Provider. A health care professional or facility licensed, certified, or otherwise qualified under provider reimbursement amount, the non-network provider will likely bill you for the state law to provide health services. 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 Qualifying coverage. Health coverage provided under one of the following plans: certificate. Furthermore, such difference will not be applied toward the out-of-pocket maximum 1. A health plan in which a health carrier has issued a policy, contract, or certificate for the described in Your Out-Of-Pocket Expenses. Additionally, you will owe these amounts coverage of medical and hospital benefits, including blanket accident and sickness regardless of whether you previously reached your out-of-pocket maximum with amounts paid insurance other than accident only coverage; 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 2. Part A or Part B of Medicare; network provider. 3. A medical assistance medical care plan as defined under Minnesota law; Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene- 4. A general assistance medical care plan as defined under Minnesota law; based information to determine the proper drug and dosage for an individual. Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared 5. Minnesota Comprehensive Health Association (MCHA); from the body of an individual based on their genetic makeup. 6. A self-insured health plan; Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry 7. The MinnesotaCare program as defined under Minnesota law; (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. 8. The public employee insurance plan as defined under Minnesota law; Placed for adoption. The assumption and retention of the legal obligation for total or partial 9. The Minnesota employees insurance plan as defined under Minnesota law; support of the child in anticipation of adopting such child. 10. TRICARE or other similar coverage provided under federal law applicable to the armed (Eligibility for a child placed for adoption with the subscriber ends if the placement is forces; interrupted before legal adoption is finalized and the child is removed from placement.) 11. Coverage provided by a health care network cooperative or by a health provider Premium. The monthly payment required to be paid by the employer on behalf of or for you. cooperative; Prenatal care. The comprehensive package of medical and psychosocial support provided 12. The Federal Employees Health Benefits Plan or other similar coverage provided under throughout a pregnancy and related directly to the care of the pregnancy, including risk federal law applicable to government organizations and employees; assessment, serial surveillance, prenatal education, and use of specialized skills and 13. A medical care program of the Indian Health Service or of a tribal organization; technology, when needed, as defined by Standards for Obstetric-Gynecologic Services issued 14. A health benefit plan under the Peace Corps Act; by the American College of Obstetricians and Gynecologists. Prescription drug. A drug approved by the FDA for the prescribed use and route of 15. State Children's Health Insurance Program; or administration. 16. A public health plan similar to any of the above plans established or maintained by a state, Preventive health service. The following are considered preventive health services: the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. 1. Evidence-based items or services that have in effect a rating of A or B in the current Coverage of the following types, including any combination of the following types, are not recommendations of the United States Preventive Services Task Force; qualifying coverage: 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 1. Coverage only for disability or income protection insurance; with respect to the member involved; 2. Automobile medical payment coverage; MIC PP MN HSA(3/12) 116 1500-100% MIC PP MN HSA (3/12) 117 1500-100% BPL 21278 DOC 23744 BPL 21278 DOC 23744 Definitions Definitions 3. Liability insurance or coverage issued as a supplement to liability insurance; Subscriber. The person: 4. Coverage for a specified disease or illness or to provide payments on a per diem, fixed 1. On whose behalf premium is paid; and indemnity, or non-expense-incurred basis, if offered as independent, non-coordinated 2. Whose employment is the basis for membership, according to the Contract; and coverage; 5. Credit accident and health insurance as defined under Minnesota law; 3. Who is enrolled under the Contract. 6. Coverage designed solely to provide dental or vision care; Total disability. Disability due to injury, sickness, or pregnancy that requires regular care and 7. Accident only coverage; 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 8. Long-term care coverage as defined under Minnesota law; the duties of any business or occupation for which he or she is reasonably fitted. 9. Medicare supplemental health insurance as defined under Minnesota law; 10. Workers' compensation insurance; or Urgent care center. A health care facility distinguishable from an affiliated clinic or hospital ensation p whose primary purpose is to offer and provide immediate, short-term medical care for minor, 11. Coverage for on-site medical clinics operated by an employer for the benefit of the immediate medical conditions on a regular or routine basis. employer's employees and their dependents, in connection with which the employer does Virtual care. Professional evaluation and medical management services provided to patients • not transfer risk. through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth Reconstructive. Surgery to rebuild or correct a: services. Virtual care is used to address non-urgent medical symptoms for patients describing new or ongoing symptoms to which providers respond with substantive medical advice. 1. Body part when such surgery is incidental to or following surgery resulting from injury, Virtual care does not include telephone calls for reporting normal lab or test results, or solely sickness, or disease of the involved body part; or calling in a prescription to a pharmacy. 2. Congenital disease or anomaly which has resulted in a functional defect as determined by Waiting period. In accordance with applicable state and federal laws, the period of time that your physician. must pass before an otherwise eligible employee and/or dependent is eligible to become In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was covered under the Contract (as determined by the employer's eligibility requirements). performed and surgery and reconstruction of the other breast to produce a symmetrical However, if an eligible employee or dependent enrolls as a late entrant or through a special appearance shall be considered reconstructive. 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 Restorative. Surgery to rebuild or correct a physical defect that has a direct adverse effect on employment classification that is not eligible for coverage under the Contract do not constitute a the physical health of a body part, and for which the restoration or correction is medically waiting period. 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 removing corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removing 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. MIC PP MN HSA (3/12) 118 1500-100% MIC PP MN HSA(3/12) 119 1500-100% BPL 21278 237 BPL 21278 DOC 23744 Medica Choice Passport Certificate of Coverage MEDICA. MIC PP MN HSA (3/12) 2500-100% BPL 21285 DOC 23751 I MEDICA CUSTOMER SERVICE Table Of Contents Table Of Contents Minneapolis/St. Paul Hearing Impaired: Metro Area: National Relay Center Introduction x Medical Loss Ratio (MLR) standards under the federal Public Health Service Act x (952) 945-8000 1 -800-855-2880, then To be eligible for benefits xi Outside the Metro Area: ask them to dial Medica Language interpretation xi at 1 -800-952-3455 Acceptance of coverage xi 1 -800-952-3455 Nondiscrimination policy xii More information about the plan can also be obtained by Health savings accounts x;; signing in at www.mymedica.com. A. Member Rights And Responsibilities 1 Member bill of rights 1 Member responsibilities 1 C _\ B. How To Access Your Benefits 3 4'u" '..sue y411 (.+�1L, t -La li o:I,a ECM' Ram Hymn-la noMOiub B nepeso,ae 3TOh Important member information about in-network benefits 3 "L,J.1,6411,�a,:taa5.,,ei wt�sAal.ww c t:.; ",;S 1a1 r3HCi)opMatum, IO3BOHHTe HO HoMepy, yxa3aH HoMy na o6paTxo%r cTopone aauieii Important member information about out-of-network benefits 5 Medica a t.,..t.i-h a.p.1,11 ,..;, 1 McLjcWincxo i xapTOLHU4 iraaxa Medica. Continuity of care 7 Haddii aad doonayso in AfSoomaali laguugu fp tifflaiiifitliifil fitilifj tttbnijtrtt;tt.tillaiari itliitlI.;tsr tarjamadda macluumaadkani,oo lacag . : Prior authorization g g ojti(fi ailiffitilLIVA111 tfltrillgiiiltialttitlPitMedica`1 la'aan ah, Fadlan wac Lambarka ku goran Certification of qualifying coverage 9 Kaarka.Caafimaadka ee Medica dhabarkiisa. Si usted desea ayuda gratuita Para traducir esta infornnacion, Name al ntimero de C. How Providers Are Paid By Medica 10 Ako zelite besplatano tumacenje ovih telefono situado al reverso de su tarjeta 10 infonnacija posovite broj na pozadini vase de identificacion de Medica. Network providers Medica kartice. Neu a vi man]dirge Non-network providers 10 q y gegay8adiehtaiWunaytrim phi,xin gut so gilt a mat sau the Medica cua qu}vi. D. Your Out-Of-Pocket Expenses 11 Yog koj xav tau key pab txhais cov ntaub ntawv no dawb, hu rau tus xov tooj nyob Dine k'ehji shich' ' hadoodzh ninizingo, beesh Coinsurance and deductibles 11 nram gab koj claim Medica Khaj (card). bee hanc'e binumber naaltsoos bikaahigii bich'i' hodiihnh et doodaii bee neehozin biniiye More information concerning deductibles 12 nanitinigii bine'dce bikaa doo aldo'. Out-of-pocket maximum 12 t-rnsixsr?s)°j Crria ;Fcer.rrju 1,k1.,1 3G5`117'i° �t»sc-1zl(. =r ai ; c.i ` Para sa tulong sa Tagalog, tawagan ang °k.J.-zi2`'"' .,Lt_ila h li.,�,, 2t.ri?°in�1-F.Medica Lifetime maximum amount 13 numerong kabilang sa dokumentong ito o sa Yoo odeeyssi kun bilashitti afaan keetitti akka likod ng iyong 1D card. Out-of-Pocket Expenses 14 sii hiikamu feete lakkoofsa caaardiii meedikaa -MN ril 3Zttql,b , i.*tl#T2r3tAt- Iv, E. Ambulance Services 15 (Medica)gama dubaarra jiru kana hilbili. 5 GE 1�,1.� o 15 Covered UNV1o11 — Not covered 15 If you want free help translating this information, call the number on the back of your Medica identification card. II Ambulance services or ambulance transportation 16 J Non-emergency licensed ambulance service 16 F. Durable Medical Equipment And Prosthetics 17 Covered 17 ©2012 Medica. Medica®is a registered service mark of Medica Health Plans. "Medica"refers to the family of health ti plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, MIC PP MN HSA(3/12) iii 2500-100% Medica Self-Insured, and Medica Health Management, LLC. BPL 21285 DOC 23751 ;i Table Of Contents Table Of Contents Not covered 18 K. Maternity Services 30 Durable medical equipment and certain related supplies 18 Newborns' and Mothers' Health Protection Act of 1996 30 Repair, replacement, or revision of durable medical equipment Covered 30 18 Prosthetics Hearing aids 18 Additional information about coverage of maternity services 31 G. Home Health Care 19 Not covered 31 Covered 20 Prenatal services 31 Not covered 20 Inpatient hospital stay for labor and delivery services 32 Intermittent skilled care 21 Professional services received during an inpatient stay for labor and delivery 32 21 Anesthesia services received during an inpatient stay for labor and delivery 32 Skilled physical, speech, or occupational therapy 21 Labor and delivery services at a freestanding birth center 32 Home infusion therapy 22 Home health care visit following delivery 32 Services received in your home from a physician 22 L. Medical-Related Dental Services 33 H. Hospice Services Covered 23 Covered 33 Not covered 23 Not covered 33 Hospice services 24 Charges for medical facilities and general anesthesia services 34 Orthodontia, dental implants, and oral surgury related to cleft lip and palate 34 I. Hospital Services 24 Covered 25 Accident-related dental services 35 Not covered 25 Oral surgery 35 25 M. Mental Health 36 Outpatient services 26 Covered 37 Services provided in a hospital observation room 26 Not covered 38 Inpatient services 26 Office visits, including evaluations, diagnostic, and treatment services 39 Services received from a physician during an inpatient stay 26 Intensive outpatient programs 39 Anesthesia services received from a provider during an inpatient stay 26 Inpatient services (including residential treatment services) 39 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 27 N. Miscellaneous Medical Services And Supplies 40 J. Infertility Diagnosis Covered 28 Covered 40 Not covered 28 Not covered 40 28 Blood clotting factors 41 Office visits, including any services provided during such visits 29 Dietary medical treatment of PKU 41 Virtual care 29 Amino acid-based elemental formulas 41 Outpatient services received at a hospital I 41 Inpatient services 29 Total parenteral nutrition 29 Eligible ostomy supplies 41 Services received from a physician during an inpatient stay 29 Insulin pumps and other eligible diabetic equipment and supplies 41 Anesthesia services received from a provider during an inpatient stay 29 , O. Organ And Bone Marrow Transplant Services 42 Covered 42 MIC PP MN HSA (3/12) iv 2500-100% MIC PP MN HSA (3/12) v 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 I Table Of Contents Table Of Contents Not covered 43 Prescription unit 57 Office visits 43 Not covered 58 Virtual care 43 Specialty prescription drugs received from a designated specialty pharmacy 58 Outpatient services 44 Specialty growth hormone received from a designated specialty pharmacy 58 Inpatient services 44 S. Professional Services 59 Services received from a physician during an inpatient stay 45 Covered 59 Anesthesia services received from a provider during an inpatient stay 45 Not covered 60 Transportation and lodging 45 Office visits 60 P. Physical, Speech, And Occupational Therapies 47 Virtual care 60 Covered 47 Convenience care/retail health clinic visits 60 Not covered 47 Urgent care center visits 61 Physical therapy received outside of your home 48 Preventive health care 61 Speech therapy received outside of your home 48 Allergy shots 62 Occupational therapy received outside of your home 49 Routine annual eye exams 62 Q. Prescription Drug Program 50 Chiropractic services 62 Preferred drug list 50 Surgical services 62 Exceptions to the preferred drug list 50 Anesthesia services received from a provider during an office visit or an outpatient hospital Prior authorization 51 or ambulatory surgical center visit 62 Step therapy 51 Services received from a physician during an emergency room visit 62 Quantity limits 51 Services received from a physician during an inpatient stay 62 Covered 51 Anesthesia services received from a provider during an inpatient stay 63 Prescription unit 52 Outpatient lab and pathology 63 Not covered 53 Outpatient x-rays and other imaging services 63 Outpatient covered drugs 54 Other outpatient hospital or ambulatory surgical center services 63 Diabetic equipment and supplies, including blood glucose meters 54 Treatment to lighten or remove the coloration of a port wine stain 63 Tobacco cessation products 54 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 63 Drugs and other supplies considered preventive health services 55 Diabetes self-management training and education 64 R. Prescription Specialty Drug Program 56 Neuropsychological evaluations/cognitive testing 64 Designated specialty pharmacies 56 Services related to lead testing 64 Specialty preferred drug list 56 Vision therapy and orthoptic and/or pleoptic training 64 Exceptions to the specialty preferred drug list 56 Genetic counseling 64 Prior authorization 57 Genetic testing 65 Step therapy 57 T. Reconstructive And Restorative Surgery 66 Quantity limits 57 Covered 66 Covered 57 Not covered 66 MIC PP MN HSA (3/12) vi 2500-100% MIC PP MN HSA (3/12) vii 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 j 1 i Table Of Contents Table Of Contents Office visits 67 Right to receive and release needed information 86 Virtual care 67 Facility of payment 86 Outpatient services 67 Right of recovery 86 Inpatient services 68 BB. Right Of Recovery 87 Services received from a physician during an inpatient stay 68 CC. Eligibility And Enrollment 88 Anesthesia services received from a provider during an inpatient stay 68 Who can enroll 88 U. Skilled Nursing Facility Services 69 How to enroll 88 Covered 69 Notification 88 Not covered 69 Initial enrollment 88 Daily skilled care or daily skilled rehabilitation services 70 Open enrollment 89 Skilled physical, speech, or occupational therapy 70 Special enrollment 89 • Services received from a physician during an inpatient stay in a skilled nursing facility....70 Late enrollment 92 V. Substance Abuse 71 Qualified Medical Child Support Order (QMCSO) 92 Covered 72 The date your coverage begins 92 Not covered 73 DD. Ending Coverage 94 Office visits, including evaluations, diagnostic, and treatment services 73 When coverage ends 94 Intensive outpatient programs 73 EE. Continuation 96 Opiate replacement therapy 73 Your right to continue coverage under state law 96 Inpatient services (including residential treatment services) 73 Your right to continue coverage under federal law 99 W. Referrals To Non-Network Providers 75 FF. Conversion 105 What you must do 75 Minnesota residents 105 What Medica will do 75 Residents of a state other than Minnesota 106 X. Harmful Use Of Medical Services 77 GG. Complaints 107 When this section applies 77 First level of review 107 Y. Exclusions 78 Second level of review 108 Z. How To Submit A Claim 81 External review 108 Claims for benefits from network providers 81 Civil action 109 Claims for benefits from non-network providers 81 HH. General Provisions 110 Claims for services provided outside the United States 82 Definitions 112 Time limits 82 AA. Coordination Of Benefits 83 Applicability 83 Definitions that apply to this section 83 Order of benefit determination rules 84 Effect on the benefits of this plan 85 . MIC PP MN HSA (3/12) viii 2500-100% MIC PP MN HSA (3/12) ix 2500-100% i BPL 21285 DOC 23751 BPL 21285 DOC 23751 1 • Introduction Introduction To be eligible for benefits Introduction 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- THIS POLICY IS REGULATED BY MINNESOTA LAW. network benefits; and The benefits of the policy providing your coverage are governed primarily by the law of a state 2. Identify yourself as a Medica member; and other than Florida. 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 Many words in this certificate have specific meanings These words are identified in each = for health services or be required to pay at the time you receive health services.) However, section and defined in Definitions. . . ' possession and use of a Medica identification card does not necessarily uarantee a See=Definif<ons These words have specs#icit�eanings; benefits, claam, dependent, rriember, coverage. network; premium, provider. _ ' � `M Network providers are required to submit claims within 180 days from when you receive a Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota non- service. If your provider asks for your health care identification card and you do not identify qualified plan. This Certificate of Coverage (this certificate) describes health services that are yourself as a Medica member within 180 days of the date of service, you may be responsible for eligible for coverage and the procedures you must follow to obtain benefits. paying the cost of the service you received. The Contract refers to the Contract between Medica and the employer. You should contact the Language interpretation employer to see the Contract. Because many provisions are interrelated, you should read this certificate in its entirety. Language interpretation services will be provided upon request, as needed in connection with Reviewing just one or two sections may not give you a complete understanding of the coverage the interpretation of this certificate. If you would like to request language interpretation services, described. The most specific and appropriate section will apply for those benefits related to the please call Customer Service at one of the telephone numbers listed inside the front cover. treatment of a specific condition. If you have an impairment that requires alternative communication formats such as Braille, large Members are subject to all terms and conditions of the Contract and health services must be print, or audiocassettes, please call Customer Service at one of the telephone numbers listed medically necessary. inside the front cover to request these materials. Medica may arrange for various persons or entities to provide administrative services on its If this certificate is translated into another language or an alternative communication format is behalf, including claims processing, and utilization management services. To ensure efficient used this written English version governs all coverage decisions. administration of your benefits, you must cooperate with them in the performance of their responsibilities. Acceptance of coverage Additional network administrative support is provided by one or more organizations under contract with Medica. 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 is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by applicable law. the employer. This certificate is being delivered to you by, or on behalf of, your employer. In this certificate, the words you, your, and yourself refer to the member. The word employer By accepting the health care coverage described in this certificate, you, on behalf of yourself refers to the organization through which you are eligible for coverage. 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 Medical Loss Ratio (MLR) standards under the federal Public Health Service Act by state law; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and Federal law establishes standards concerning the percentage of premium revenue that insurers complete. pay out for claims expenses and health care quality improvement activities. If the amount an insurer pays out for such expenses and activities is less than the applicable MLR standard, the You understand and agree that any omission or incorrect statement concerning a material fact insurer is required to provide a premium rebate. MLR calculations are based on aggregate intentionally made by you in connection with your enrollment under the Contract may invalidate market data rather than on a group by group basis. In the event Medica is required to pay your coverage. rebates pursuant to federal law, Medica will pay such rebates to your employer unless prohibited by federal law. MIC PP MN HSA(3/12) x 2500-100% MIC PP MN HSA(3/12) xi 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Introduction Member Rights And Responsibilities Nondiscrimination policy Medica's policy is to treat all persons alike, without distinctions based on race, color, creed, A. Member Rights And Responsibilities 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. See D efinitions These words have specific meanings: benefits, emergency, member, If you have questions, call Customer Service at one of the telephone numbers listed inside the Y q p network, provider. ... = front cover. Health savings accounts Member bill of rights As a member of Medica, you have the right to: This coverage is intended to comply with the requirements of the Internal Revenue Code section 223 for a federally qualified high deductible health plan. This coverage may qualify you 1. Available and accessible services, including emergency services (defined in this certificate) to make a pre-tax contribution to a health savings account. You are responsible for the cost of 24 hours a day, seven days a week; and all health services, other than preventive care, up to the deductible amount. 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 PP MN HSA (3/12) xii 2500-100% MIC PP MN HSA (3/12) 1 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Member Rights And Responsibilities How To Access Your Benefits 4. Practicing self-care by knowing: a. How to recognize common health problems and what to do when they occur; and B. How To Access Your Benefits b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and See Definitions These words have specific meanings:benefits,claim, coinsurance, 5. Practicing preventive health care by: deductible, dependent, emergency, enrollment date, hospital;:inpatient,,late entrant, member, network, non-network, non network provider reimbursement amount, physician, placed for a. Having the appropriate tests, exams and immunizations recommended for your gender adoption;premium prescription drug; provider, qualifying coverage, reconstructive, restorative, and age as described in this certificate; and skilled nursing:facility, subscriber, virtual care waiting period b. Engaging in healthy lifestyle choices (such as exercise, proper diet, and rest). Provider network You will find additional information on member responsibilities in this certificate. 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 2500-100% MIC PP MN HSA(3/12) 2 2500-100% MIC PP MN HSA (3/12) 3 B BPL 21285 DOC 23751 PL 21285 DOC 23751 How To Access Your Benefits How To Access Your Benefits be eligible for in-network benefits. You must verify that your provider is a network provider 2. Important member information about out-of-network benefits each time you receive health services. The information below describes your covered health services and provides important Exclusions information concerning your out-of-network benefits. Read this certificate for a detailed Certain health services are not covered. Read this certificate for a detailed explanation of all explanation of both in-network and out-of-network benefits. Please carefully review the exclusions. 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 Mental health and substance abuse to you. Medica's designated mental health and substance abuse provider will arrange your mental Benefits health and substance abuse benefits. Medica's designated mental health and substance Medica pays out-of-network benefits for eligible health services received from non-network abuse provider's hospital network is different from Medica's hospital network. Certain providers. Prior authorization may be required from Medica before you receive certain mental health and substance abuse services require prior authorization by Medica's services, in order to determine whether those services are eligible for coverage under your designated mental health and substance abuse provider. Emergency services do not out-of-network benefits. This certificate defines your benefits and describes procedures you require prior authorization. must follow to obtain out-of-network benefits. Continuation/conversion Decisions about coverage are made based on appropriateness of care and service to the You may continue coverage or convert to an individual conversion plan under certain member. Medica does not reward providers for denying care, nor does Medica encourage circumstances. See Continuation and Conversion for additional information. inappropriate utilization of services. Emergency services received from non-network providers are covered as in-network Cancellation benefits and are not considered out-of-network benefits. Your coverage may be canceled only under certain conditions. This certificate describes all Additionally, under certain circumstances Medica will authorize your obtaining services from reasons for cancellation of coverage. See Ending Coverage for additional information. 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 Newborn coverage providers. Your dependent newborn is covered from birth. Medica does not automatically know of a Be aware that if you choose to go to a non-network provider and use out-of-network birth or whether you would like coverage for the newborn dependent. Call Customer benefits, you will likely have to pay much more than if you use in-network benefits. Service at one of the telephone numbers listed inside the front cover for more information. To The charges billed by your non-network provider may exceed the non-network provider be eligible for in-network benefits, health services must be provided by a network provider or reimbursement amount, leaving a balance for you to pay in addition to any applicable authorized by Medica. Certain services are covered only upon referral. If additional coinsurance and deductible amount. This additional amount you must pay to the provider premium is required, Medica is entitled to all premiums due from the time of the infant's birth will not be applied toward the out-of-pocket maximum amount described in Your Out-Of- until the time you notify Medica of the birth. Medica may reduce payment by the amount of Pocket Expenses and you will owe this amount regardless of whether you previously premium that is past due for any health benefits for the newborn infant until any premium reached your out-of-pocket maximum with amounts paid for other services. Please see the you owe is paid. For more information, see Eligibility And Enrollment. example calculation below. Prescription drugs and medical equipment 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- Enrolling in Medica does not guarantee that a particular prescription drug or piece of medical network provider: equipment will continue to be covered, even if the drug or equipment is covered at the start of the calendar year. • Discuss the expected billed charges with your non-network provider; and • Contact Customer Service to verify the estimated non-network provider reimbursement Post-mastectomy coverage amount for those services, so you are better able to calculate your likely out-of-pocket Medica will cover all stages of reconstruction of the breast on which the mastectomy was expenses; and performed and surgery and reconstruction of the other breast to produce a symmetrical • If you wish to request that Medica authorize the non-network provider's services be appearance. Medica will also cover prostheses and physical complications, including covered at the in-network benefit level, follow the procedure described under Prior lymphedemas, at all stages of mastectomy. authorization in How To Access Your Benefits. MIC PP MN HSA(3/12) 4 2500-100% MIC PP MN HSA(3/12) 5 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 How To Access Your Benefits How To Access Your Benefits An example of how to calculate your out-of-pocket costs* 3. Continuity of care You choose to receive non-emergency inpatient care at a non-network hospital provider To request continuity of care or if you have questions about how this may apply to you, call without an authorization from Medica providing for in-network benefits. The out-of-network Customer Service at one of the telephone numbers listed inside the front cover. 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 In certain situations, you have a right to continuity of care. bills $30,000 for your hospital stay. Medica's non-network provider reimbursement amount a. If your current provider is terminated without cause, you may be eligible to continue care for those hospital services is $15,000. You must pay a portion of the non-network provider with that provider at the in-network benefit level. 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 b. If you are a new Medica member as a result of your employer changing health plans and the non-network provider reimbursement amount. If your coinsurance is 40%, you will be your current provider is not a network provider, you may be eligible to continue care with required to pay: that provider at the in-network benefit level. • 40% coinsurance (40% of$15,000 = $6,000) and 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 • The billed charges that exceed the non-network provider reimbursement amount as payment in full the lesser of the network provider reimbursement or the provider's ($30,000 - $15,000 = $15,000) customary charge for the service. This does not apply when a provider's contract is • The total amount you will owe is $6,000 + $15,000 = $21,000. • terminated for cause. • The $6,000 you pay as coinsurance will be applied to the out-of-pocket maximum i. Upon request, Medica will authorize continuity of care for up to 120 days as amount described in Your Out-Of-Pocket Expenses. However, the $15,000 amount you described in a. and b. above for the following conditions: pay for billed charges in excess of the non-network provider reimbursement amount will • an acute condition; 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 • a life-threatening mental or physical illness; you have previously reached your out-of-pocket maximum with amounts paid for other • pregnancy beyond the first trimester of pregnancy; services. • a physical or mental disability defined as an inability to engage in one or more *Note: The numbers in this example are used only for purposes of illustrating how out-of- major life activities, provided that the disability has lasted or can be expected to network benefits are calculated. The actual numbers will depend on the services received. last for at least one year, or can be expected to result in death; or Lifetime maximum amount • a disabling or chronic condition that is in an acute phase. Out-of-network benefits are subject to a lifetime maximum amount payable per member. Authorization to continue to receive services from your current provider may extend See Your Out-Of-Pocket Expenses for a detailed explanation of the lifetime maximum to the remainder of your life if a physician certifies that your life expectancy is 180 amount. days or less. Exclusions 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: Some health services are not covered when received from or under the direction of non- if you are receiving culturally appropriate services and a network provider who •network providers. Read this certificate for a detailed explanation of exclusions. has special expertise in the delivery of those culturally appropriate services is not Claims available; or When you use non-network providers, you will be responsible for filing claims in order to be if you do not speak English and a network provider who can communicate with reimbursed for the non-network provider reimbursement amount. See How To Submit A you, either directly or through an interpreter, is not available. Claim for details. 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 Post-mastectomy coverage authorizes your request to continue care with your current provider, Medica will explain how Medica will cover all stages of reconstruction of the breast on which the mastectomy was continuity of care will be provided. After that time, your services or treatment will need to be performed and surgery and reconstruction of the other breast to produce a symmetrical transitioned to a network provider to continue to be eligible for in-network benefits. If your appearance. Medica will also cover prostheses and physical complications, including request is denied, Medica will explain the criteria used to make its decision. You may lymphedemas, at all stages of mastectomy. appeal this decision. Coverage will not be provided for services or treatments that are not otherwise covered under this certificate. MIC PP MN HSA(3/12) 6 2500-100% MIC PP MN HSA (3/12) 7 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 How To Access Your Benefits How To Access Your Benefits 4. Prior authorization 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 Prior authorization from Medica may be required before you receive certain services or reasonably necessary to make a decision has been made available to Medica. supplies in order to determine whether a particular service or supply is medically necessary Both you and your provider will be informed of the decision within 72 hours from the time of and a benefit. Medica uses written procedures and criteria when reviewing your request for the initial request if your attending provider believes that an expedited review is warranted, prior authorization. To determine whether a certain service or supply requires prior or if it is concluded that a delay could seriously jeopardize your life, health, or ability to authorization, please call Customer Service at one of the telephone numbers listed inside regain maximum function, or subject you to severe pain that cannot be adequately managed the front cover or sign in at www.mymedica.com. Emergency services do not require prior without the care or treatment you are requesting. authorization. If Medica does not approve your request for prior authorization, you have the right to appeal Your attending provider, you, or someone on your behalf may contact Customer Service to Medica's decision as described in Complaints. 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 Under certain circumstances, Medica may perform concurrent review to determine whether prior authorization for services or supplies received from a non-network provider. If a services continue to be medically necessary. If Medica determines that services are no network provider fails to obtain prior authorization after you have consulted with them about longer medically necessary, Medica will inform both you and your attending provider in services requiring prior authorization, you are not subject to a penalty for failure to obtain writing of its decision. If Medica does not approve continued coverage, you or your prior authorization. attending provider may appeal Medica's initial decision (see Complaints). Some of the services that may require prior authorization from Medica include: 5. Certification of qualifying coverage • Reconstructive or restorative surgery; • Certain drugs; 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 • Home health care; certification of qualifying coverage at any time while you are covered under the Contract or Medical supplies and durable medical equipment; 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 • • Outpatient surgical procedures; front cover. Upon receipt of your request, the certification of qualifying coverage will be • Certain genetic tests; and issued as soon as reasonably possible. • Skilled nursing facility services. Prior authorization is always required for: • Organ and bone marrow transplant 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 PP MN HSA(3/12) 8 2500-100% MIC PP MN HSA(3/12) 9 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 How Providers Are Paid By Medica Your Out-Of-Pocket Expenses C. How Providers Are Paid By Medica D. Your Out-Of-Pocket Expenses This section describes how providers are generally paid for health services. This section describes the expenses that are your responsibility to pay. These expenses are . __ . -. ., _ _�....-...�.. - . _ " ,.:: . .., - ._. , _ _.,.. .. ._.F.�..-. , . _ .commonly called out-of-pocket expenses. See Definitions. These.words hae sP ecific meanin g coinsurance, deductible, tns ital, member network non-network,tiph sician,,pro provider. _ See Definitions. These words have specific�fe me nm 9s benefits-c laim, coinsurance, a, . :., deductible, dependent, member,_network, non-network,,non-network provider reimbursement = r amount, prescription drug, provider, subscr,"fiber. . , . , . , � ; Network providers You are responsible for paying the cost of a service that is not medically necessary or a benefit i Network providers are paid using various types of contractual arrangements, which are intended even if the following occurs: to promote the delivery of health care in a cost efficient and effective manner. These 1. A provider performs, prescribes, or recommends the service; or arrangements are not intended to affect your access to health care. These payment methods may include: 2. The service is the only treatment available; or • 1. A fee-for-service method, such as per service or percentage of charges; 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 2. A risk-sharing arrangement, such as an amount per day, per stay, per episode, per case, you to sign.) per period of illness, per member, or per service with targeted outcome. If you miss or cancel an office visit less than 24 hours before your appointment, your provider The methods by which specific network providers are paid may change from time to time. may bill you for the service. Methods also vary by network provider. The primary method of payment under Medica is fee- for-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. 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 verify coverage before receiving a particular service or supply, call Customer Service at one to a set fee schedule. The amount the network provider receives is the lesser of the fee of the telephone numbers listed inside the front cover. 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 Coinsurance and deductibles charge. The amount paid to the network provider, less any applicable coinsurance or deductible, is considered to be payment in full. For in-network benefits, you must pay the following: Risk-sharing payment means that the network provider is paid a specific amount for a particular 1. Any applicable coinsurance and per member deductible each calendar year as described in unit of service, such as an amount per day, an amount per stay, an amount per episode, an this certificate (see the Out-of-Pocket Expenses table in this section). 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 When members in a family unit (a subscriber and his or her dependents) have together paid , for a member's health services, the network provider may bear some of the shortfall. If the the applicable per family deductible for benefits received during a calendar year (see the ■ amount paid to the network provider is more than the cost of providing or arranging a member's Out-of-Pocket Expenses table in this section), then all members of the family unit are health services, the network provider may keep some of the excess. considered to have satisfied the applicable per member and per family deductible for that calendar year. 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 Note that applicable deductibles are determined by the Contract between Medica and the less of the risk-sharing payment. 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 I you had met the previously applicable deductible. This means that it is possible that your Non-network providers 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. 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 2. Any charge that is not covered under the Contract. the non-network provider. If this happens, you are responsible for paying the difference. 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 PP MN HSA(3/12) 10 2500-100% MIC PP MN HSA (3/12) 11 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 1 I Your Out-Of-Pocket Expenses Your Out-Of-Pocket Expenses When members in a family unit (a subscriber and his or her dependents) have together paid Please note: Charges for services not eligible for coverage and any charge in excess of the applicable per family deductible for benefits received during a calendar year (see the the non-network provider reimbursement amount are not applicable toward the out-of- Out-of-Pocket Expenses table in this section), then all members of the family unit are pocket maximum. Additionally, you will owe these amounts regardless of whether you considered to have satisfied the applicable per member and per family deductible for that previously reached your out-of-pocket maximum with amounts paid for other services. calendar year. The time period used to calculate whether you have met the out-of-pocket maximum (calendar Note that applicable deductibles are determined by the Contract between Medica and the year or Contract year) is determined by the Contract between Medica and the employer. This employer and may increase when Medica and the employer renew the Contract. If this time period may change when Medica and the employer renew the Contract. If the time period occurs, the new deductible will apply for the rest of the current calendar year, whether or not changes, you will receive a new certificate of coverage that will specify the newly applicable you had met the previously applicable deductible. This means that it is possible that your time period. You may have additional out-of-pocket expenses associated with this change. deductible will increase mid-year when your employer's Contract with Medica is renewed When members in a family unit (the subscriber and his or her dependents) have together met and that you may have additional out-of-pocket expenses as a result. the applicable per family out-of-pocket maximum for benefits received during the calendar year, 2. Any charge that exceeds the non-network provider reimbursement amount. This means you then all members of the family unit are considered to have met the applicable per member and are required to pay the difference between the payment to the provider and what the per family out-of-pocket maximum for that calendar year (see the Out-of-Pocket Expenses table provider bills. in this section). If you use out-of-network benefits, you may incur costs in addition to your coinsurance and After an applicable out-of-pocket maximum has been met for a particular type of benefit (as deductible amounts. If the amount that your non-network provider bills you is more than the described in the Out-of-Pocket Expenses table in this section), all other covered benefits of the non-network provider reimbursement amount, you are responsible for paying the difference. same type received during the rest of the calendar year will be covered at 100 percent, except In addition, the difference will not be applied toward satisfaction of the deductible or the out- for any charge not covered by Medica or charge in excess of the non-network provider of-pocket maximum (described in this section). reimbursement amount. However, you will still be required to pay any applicable coinsurance To inquire about the non-network provider reimbursement amount for a particular procedure, and deductibles for other types of benefits received. call Customer Service at one of the telephone numbers listed inside the front cover. When Note that out-of-pocket maximum amounts are determined by the Contract between Medica and you call, you will need to provide the following: 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, • The CPT (Current Procedural Terminology) code for the procedure (ask your non- whether or not you had met the previously applicable out-of-pocket maximum. This means that network provider for this); and it is possible that your out-of-pocket maximum will increase mid-year when your employer's • The name and location of the non-network provider. Contract with Medica is renewed and that you may have additional out-of-pocket expenses as a result. 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 Medica refunds the amount over the out-of-pocket maximum during any calendar year when actual amount paid will be based on the information received at the time the claim is proof of excess coinsurance and deductibles is received and verified by Medica. submitted and subject to all applicable benefit provisions, exclusions and limitations, including but not limited to coinsurance and deductibles. Lifetime maximum amount 3. Any charge that is not covered under the Contract. 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 More information concerning deductibles 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 The time period used to apply the deductible (calendar year or Contract year) is determined by pertains only to those health care services and supplies that are not essential benefits as the Contract between Medica and the employer. This time period may change when Medica defined in the Patient Protection and Affordable Care Act, including any amendments, and the employer renew the Contract. If the time period changes, you will receive a new regulations, rules, or other guidance issued with respect to the Act. 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). MIC PP MN HSA(3/12) 12 2500-100% MIC PP MN HSA (3/12) 13 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 ... — — J Your Out-Of-Pocket Expenses Ambulance Services Out-of-Pocket Expenses E. Ambulance Services y, 3 Std rIn-network * Out of network - benefits benefits This section describes coverage for ambulance transportation and related services received for r � covered medical and medical-related dental services (as described in this certificate). *For out-of-network benefits, in addition to thedeductibie and coinsurance,you are responsible for_:an ,char es Stn excess of�the non.:netw __ coinsurance, _ . _ . ork ro�ider ceimbursement�amoont. See Definitions. words have ave<s a Mfr .Pmeanm s.__benefits ,.._ Y 9. .. ��.. . R _ ....y� c c , , th es...e,_.�, chaxz.r..: e s wi.l l n.�.o..t_b._,e a p?lied to_..__w ard sa r f ac_..tio..9 n,_o._. f h.e«.,deducti b l.e.o�r-,_ahe o_u.�t__.:.of.- . -c ketfacility. emergency,c.;..._hos p�hospital, network,k,.non_,..n e twack.=_.__n_ on_n etw ork rov�der r e� bursement amount maximum. h srcian rovrder skilled nursing �t , . Coinsurance See specific benefit for applicable coinsurance. 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 Deductible front cover. See How To Access Your Benefits for more information about the prior authorization Per member $2,500 $6,000 process. Per family $5,000 $9,900 Covered Out-of-pocket maximum For benefits and the amounts you pay, see the table in this section. More than one coinsurance Per member $2,500 $11,000 may be required if you receive more than one service or see more than one provider per visit. Per family $5,000 $22,000 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. Lifetime maximum amount Unlimited $1,000,000. Applies to Out-of-network benefits apply to non-emergency ambulance services described in this •payable per member all benefits you receive section that are arranged through a physician and received from a non-network provider. In under this or any other addition to the deductible and coinsurance described for out-of-network benefits, you will be Medico, Medica Health responsible for any charges in excess of the non-network provider reimbursement amount. Plans, or Medica Health The out-of-pocket maximum does not apply to these charges. Please see Important Plans of Wisconsin member information about out-of-network benefits in How To Access Your Benefits for more coverage offered through information and an example calculation of out-of-pocket costs associated with out-of- the same employer. 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 PP MN HSA(3/12) 14 2500-100% MIC PP MN HSA (3/12) 15 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Ambulance Sery ices Durable Medical Equipment And Prosthetics Your Benefits and the Amounts You Pay ''' F. Durable Medical Equipment And Prosthetics Benefits In-network benefits - *Out-of-network benefits after deductible after deductible This section describes coverage for durable medical equipment, certain related supplies, and lies *'For out-of-network benefits, in addition.to the deductible and coinsurance,you are responsible for prosthetics. any charges in excess of the non-network provider reimbursement amount. Additionally,these See Definitions. These specific i charges will not be applied toward satisfaction of the deductible or the out-of-pocket�maximum. � hese words have spec�fEC-meanrngs: benefits, coinsurance, deductible, durable medical equipment, network, non-network, non-network provider reimbursement amount, 1. Ambulance services or Nothing Covered as an in-network physician, provider. ambulance transportation to the benefit. Prior authorization. Prior authorization from Medica may be required before you receive nearest hospital for an services or supplies. Call Customer Service at one of the telephone numbers listed inside the emergency front cover. See How To Access Your Benefits for more information about the prior authorization 2. Non-emergency licensed process. ambulance service that is arranged through an attending Covered physician, as follows: For benefits and the amounts you pay, see the table in this section. More than one coinsurance a. Transportation from hospital Nothing 50% coinsurance to hospital when: may be required if you receive more than one service or see more than one provider per visit. i. Care for your condition is Medica covers only a limited selection of durable medical equipment, certain related supplies, and not available at the hearing aids that meet the criteria established by Medica. Some items ordered by your physician, hospital where you were even if medically necessary, may not be covered. The list of eligible durable medical equipment first admitted; or 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 ii. Required by Medica at one of the telephone numbers listed inside the front cover. b. Transportation from hospital Nothing 50% coinsurance Medica determines if durable medical equipment will be purchased or rented. Medica's approval to skilled nursing facility 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 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. I MIC PP MN HSA (3/12) 16 2500-100% MIC PP MN HSA (3/12) 17 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Durable Medical Equipment And Prosthetics Durable Medical Equipment And Prosthetics Not covered Your Benefits and the Amounts You Pay These services, supplies, and associated expenses are not covered: Benefits In-network benefits : *Out of network benefits 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the ; Medics eligible list. after deductible after deductible 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, *For out-of-network,benefits, in'addition to the deductible and coinsurance,you are responsible for or hearing aids. any charges in excess of the in network provider reimbursement amount. Additionally,these charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, . _.__ except when made necessary by normal wear and use. c. Repair, replacement, or Nothing 50% coinsurance 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, revision of artificial arms, replacement, or revision of duplicate items. legs, feet, hands, eyes, ears, noses, and breast See Exclusions for additional services, supplies, and associated expenses that are not prostheses made necessary covered. 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 , Your�Benefits and the Amounts You Pay: •¥a � 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. „Benefits , = In network benefits Out-of-network benefits procedures prescribed by a network after deductible after deductible provider. For out-of-network benefits, m addition to the deductible and coinsurance,you are responsible for any charges inccess of the non network provider reimbursement Additionally,these charges will not,be applied toward satisfaction of the deductibleor 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 PP MN HSA(3/12) 18 2500-100% MIC PP MN HSA(3/12) 19 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 1 Home Health Care Home Health Care Not covered G. Home Health Care 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. This section describes coverage for home health care. Home health care must be directed by a 3. Custodial care and other non-skilled services. physician and received from a home health care agency authorized by the laws of the state in 4. Physical, speech, or occupational therapy provided in your home for convenience. which treatment is received 5. Services provided in your home when you are not homebound. See Definitions. These words have specific meanings: benefits, coinsurance, custodial care, deductible, dependent, hospital,.network,non network, non-network provider re mburssement 6. Services primarily educational in nature. amount, physician, provider, skilled care, skilled nursing facility. = = 7. Vocational and job rehabilitation. Prior authorization. Prior authorization from Medica may be required before you receive 8. Recreational therapy. services or supplies. Call Customer Service at one of the telephone numbers listed inside the 9. Self-care and self-help training (non-medical). front cover. See How To Access Your Benefits for more information about the prior authorization process. 10. Health clubs. 11. Disposable supplies and appliances, except as described in Durable Medical Equipment Covered And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program. For benefits and the amounts you pay, see the table in this section. More than one coinsurance ee,12. Physical, speech, be required if you receive more than one service or see more than one provider per visit. Y p ch, or occupational therapy services when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare generally accepted standards in the medical community. guidelines) considers you homebound when it is medically contraindicated for you to leave your 13. Voice training. 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 14. Home health aide services, except when rendered in conjunction with intermittent skilled support specialized equipment and help are available. care and related to the medical condition under treatment. Benefits covered under 1. and 2. in the table in this section are limited to a combined maximum of See Exclusions for additional services, supplies, and associated expenses that are not 120 visits per calendar year for in-network and 60 visits per calendar year for out-of-network covered. 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. ;_ Your Benefits and the Amounts You Payer • In-network benefits apply to home health care services ordered or prescribed by a physician ; & and received from a network home health care agency. Benefits � � In-network benefits ; * out of network benefits to home health care services that are ordered or prescribed by a f _ after d`eductible ° E • Out-of-network benefits apply h � '`�, � � after deductible - home health care agency. In addition to the * '' ut" _ < physician and received from a non network g ible for For=out-of-network benefits,:.in addition to the deductible and coinsurance,you are responsible fora. deductible and coinsurance described for out-of-network benefits, you will be responsible any-charges in excess or the.non network provider reimbursement amount -:Additionally,these`:` any charges in excess of the non-network provider reimbursement amount. The out-of- charges willnot be applied toward the maximum.charges information about out-of-network benefits in How To Access Your Benefits for more 1. Intermittent skilled care when Nothing 50% coinsurance information and an example calculation of out-of-pocket costs associated with out-of- you are homebound, provided by network benefits. or supervised by a registered Please note: Your place of residence is where you make your home. This may be your own nurse dwelling, a relative's home, an apartment complex that provides assisted living services, or 2. Skilled physical, speech, or Nothing some other type of institution. However, an institution will not be considered your occupational therapy when you our home if it is a 50% coinsurance hospital or skilled nursing facility. ' are homebound M 20 2500-100% IC PP MN HSA(3/12) 21 MIC PP MN HSA (3/12) BPL 21285 DOC 23751 BPL 21285 2500-100% DOC 23751 Home Health Care Hospice Services y Your Benefits and the Amounts You Pay H. Hospice Services Benefits In network benefits " *Out of network benefits after deductible after deductible ^a n, This section describes coverage for hospice services including respite care. Care must be �. wa ordered, provided, or arranged under the direction of a physician and received from a hospice For out of network benefits, in addition to the deductible and coinsurance, you are responsible for m. any charges in excess of the non-network provider reimbursement amount. Additionaliy,these r p ogra m. charges wi l�not;: ,, z. a. :: bea applied.toward satisfaction�of�the.deductible or the e,o out-of-pocket.maximum. - . �.These. .� , ut-of oc t ,._.., �, . See 3efinitons.=. words.haves ecifrcmearnn s. benefits_comsurance deductible ,.„... o member, network,.non network, non-network provider reimbursement amount, physician, skilled 3. Home infusion therapy Nothing 50% coinsurance nursing facility. 4. Services received in your home Nothing 50% coinsurance from a physician Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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. MIC PP MN HSA (3/12) 22 2500-100% MIC PP MN HSA (3/12) 23 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Hospice Services Hospital Services 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 I. Hospital Services program. os 1� Not covered This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. These services, supplies, and associated expenses are not covered: See Definitions. These words have specific meanings: benefits, coinsurance, deductible, 1. Respite care for more than five consecutive days at a time emergency, genetic testing, hospital, inpatient, member, network, non-network, non-network 2. Home health care and skilled nursing facility services when services are not consistent with provider reimbursement amount, physician, provider. the hospice program's plan of care. Prior authorization. Prior authorization from Medica may be required before you receive 3. Services not included in the hospice program's plan of care. services or supplies. Call Customer Service at one of the telephone numbers listed inside the 4. Services not provided by the hospice program. front cover. See How To Access Your Benefits for more information about the prior authorization process. 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 Covered home. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 7. Financial or legal counseling services, except when recommended and provided by the may be required if you receive more than one service or see more than one provider per visit. hospice program. 8. Housekeeping or meal services in your home, except when recommended and provided by • In-network benefits apply to hospital services received from a network hospital or ambulatory the hospice program. surgical center. • 9. Bereavement counseling, except when recommended and provided by the hospice Out-of-network benefits apply to hospital services received from a non-network hospital or program. 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 See Exclusions for additional services, supplies, and associated expenses that are not provider reimbursement amount. The out-of-pocket maximum does not apply to these covered. 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 Your Benefits and the Amounts You Pay 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 Benefits In-network benefits *Out-of-network benefits physician agrees it is safe to transfer you to a network facility. after deductible after deductible Not covered *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 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an 1. Hospice services Nothing 50% coinsurance emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Prescription Specialty 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. MIC PP MN HSA (3/12) 24 2500-100% MIC PP MN HSA(3/12) 25 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Hospital Services Hospital Services ..tom"' _. ,-, . d. ;. ,, -. .__- -,r• _..,..,. :.�:,= ,.: `.: ;..," s: ..,. _ - __. . ... .. - .. - a.�:.-,--_- ._.... .. ,.."S':. _.. ...-_ ,. .. _ ,. _-, _ .,. .,�.,._.,_ - {.;_ -.._-. a- ,,: ..<. .,... o-_x-.«., . r :. ,, ,:. ,. ,,,...._ _.:..:.,, ..%.._,.- is-. __ _ w � _ ,� _.Your Benefits s You-Pay _ Your Be -- - __ t - . _._ efits ands the Amount = --..��� < �--. zax � � x� . . _r . _ _ Benefits and.the�Amounts:Yo -P �__. , __� �___ ._ r. . .. .. > Y Via.' Benefit .:. � � ,. �.,. _ _ _ Ben fi ._ _ F , _ , >_a __ -_. 5,< . . Ann k, fits _r _.�ut�f networkbenefits ._ a ts- . , _._ -In : or n is _ . ..�" etwflr bane v.f < netw kbe of-is ,{,x<.,:- *=Out-of network-benefits � _.. . after deductible . afer,deductib a _ � after deductible . � � after d duc tlble T< :f.. . ..:. •.. Y • , . - 2.;. ..-:. t ,r., gym. _ • te:' * _ *, _.:. • .a -• _... it'..«.__.. - - ,.:out-of-network ; :: ..:. ,. For - -ne x � deductible n .For< out of twork�benefits��n addrt�on_.to the: and c insurance, ou,are_res onsible for...<, benefits in addition to e.ded deductible d;coinsurance, are�. . . � coinsurance,,Y p , uc a an co nsurance,you ar .responsible for S- s : . '( t,'_ .:charges. -. t.p. -. -, an, charges in.excess.of the non network, r vi unt.:A d wnan .= a e $, an : -rn excess of the non ne y .:_ ,. .. a der reimbursement amo ,. __ d i# ,th s X twork, rovider rermbursementxamount. .Add�tronall these - ,,_ .__: charges not be applied toward Satisfaction_ <� � � _�_ , char es-will not.., applied n out-of-Pocket � .,. a tisfact�on-of he deductible_or,the;outof ticket 0! .. _<,._ be a ed toward satisfaction the deductible or%�thea 9 PP 9 PP _maximum. y ex�sx ___ .._ 1. Outpatient services 6. Treatment of temporomandibular Covered at the Covered at the joint (TMJ) disorder and corresponding in-network corresponding out-of- a. Services provided in a Nothing Covered as an in-network craniomandibular disorder benefit level, depending network benefit level, hospital or facility-based benefit. on type of services depending on type of emergency room provided. services provided. b. Outpatient lab and pathology Nothing 50% coinsurance For example, office visits For example, office visits c. Outpatient x-rays and other Nothing 50% coinsurance are covered at the office are covered at the office imaging services visit in-network benefit visit out-of-network d. Genetic testing when test Nothing 50% coinsurance level and surgical benefit level and surgical results will directly affect services are covered at services are covered at the surgical services in- the surgical services out- treatment decisions or network benefit level. of-network benefit level. frequency of screening for a Please note: Dental Please note: Dental disease, or when results of coverage is not provided coverage is not provided the test will affect under this benefit. under this benefit. reproductive choices e. Other outpatient services Nothing 50% coinsurance f. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician g. 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 Nothing 50% coinsurance 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 MIC PP MN HSA(3/12) 26 2500-100% MIC PP MN HSA(3/12) 27 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Infertility Diagnosis Infertility Diagnosis J. Infertility Diagnosis Your Benefits and the Amounts You Pay Benefits In-network_benefits * Out-of-network benefits after deductible after deductible 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 *For out-of-network benefits, in addition to the deductible and coinsurance, you are responsible for infertility must be received from or under the direction of a physician. All services, supplies, and any charges in excess of the non-network provider reimbursement amount. Additionally,these associated expenses for the treatment of infertility are not covered. charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. See Definitions. These words have specific meanings: benefits, coinsurance, deductible, 1. Office visits, including any Nothing Covered as an in-network hospital,_inpatient, member, network, non-network, non-network provider reimbursement services provided during such benefit. amount, physician provider,'virtual care. visits Prior authorization. Prior authorization from Medica may be required before you receive 2. Virtual care Nothing No coverage services or supplies. Call Customer Service at one of the telephone numbers listed inside the Outpatient services received at a Nothing Covered as an in-network front cover. See How To Access Your Benefits for more information about the prior hospital benefit. authorization process. 4. Inpatient services Nothing Covered as an in-network Covered benefit. 5. Services received from a Nothing Covered as an in-network Benefits apply to services for the diagnosis of infertility received from a network or non-network physician during an inpatient benefit. provider. More than one coinsurance may be required if you receive more than one service or stay see more than one provider per visit. 6. Anesthesia services received Nothing Covered as an in-network Coverage for infertility services is limited to a maximum of$5,000 per member per calendar year • from a provider during an benefit. for in-network and out-of-network benefits combined. inpatient stay 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. 10. Services for intrauterine insemination (IUI). See Exclusions for additional services, supplies, and associated expenses that are not covered. 2500-100% MIC PP MN HSA (3/12) 28 2500-100% MIC PP MN HSA (3/12) 29 BPL 21285 DOC 23751 BPL 21285 DOC 23751 Maternity Services Maternity Services Additional information about coverage of maternity services K. Maternity Services Not all services that are received during your pregnancy are considered prenatal care. Some of the services that are not considered prenatal care include (but are not limited to)treatment of the following: This section describes coverage for maternity services. Benefits for maternity services include all 1. Conditions that existed prior to and independently of)the pregnancy, such as diabetes or medical services for prenatal care, labor and delivery, postpartum care, and related complications. p ( p y ) lupus, even if the pregnancy has caused those conditions to require more frequent care or See Defii►►t�ons. These words have specific meanings benefits, coinsurance, deduc#able, monitoring. dependent, hospital,inpatient, member,network, nor►-network, non network provider reimbursement amours#, physician, prenatal care, provider skilled care. '? 2. Conditions that have arisen concurrently with the pregnancy but are not directly related to care � of the pregnancy, such as back and neck pain or skin rash. Prior authorization. Prior authorization from Medica may be required before you receive 3. Miscarriage and ectopic pregnancy. 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 Services that are not considered prenatal care may be eligible for coverage under the most process. specific and appropriate section of this certificate. Please refer to those sections for coverage information. Newborns'and Mothers'Health Protection Act of 1996 Not covered 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 These services, supplies, and associated expenses are not covered: than 96 hours following a cesarean section). However, federal law generally does not prohibit the 1. Health care professional services for maternity labor and delivery in the home. 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 2. Services from a doula. case, Medica may not require a provider to obtain prior authorization from Medica for a length of 3. Childbirth and other educational classes. stay of 48 hours or less (or 96 hours, as applicable). See Exclusions for additional services, supplies, and associated expenses that are not Covered covered. For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Your Benefits and the Amounts You Pay Each member's admission is separate from the admission of any other member. A separate �: a = *x deductible and coinsurance will be applied to both you and your newborn child for inpatient `Benefits - In-network benefits Out of network benefits services related to maternity labor and delivery. Please note: We encourage you to enroll your after deductible after deductible newborn dependent under the Contract within 30 days from the date of birth, date of placement - . � a �- _ °= �- for adoption, or date of adoption. Please refer to Eligibility And Enrollment for additional*For out-of-network benefits,-.in addition to the deductible and coinsurance,you are responsible for Y � _ information. 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 outout-of-pocket maximum. • In-network benefits apply to maternity services received from a network provider. • Out-of-network benefits apply to maternity services received from a non-network provider. In 1. Prenatal services addition to the deductible and coinsurance described for out-of-network benefits, you will be a. Office visits for prenatal care, Nothing. The deductible 50% coinsurance responsible for any charges in excess of the non-network provider reimbursement amount. including professional does not apply. The out-of-pocket maximum does not apply to these charges. Please see Important services, lab, pathology, member information about out-of-network benefits in How To Access Your Benefits for more x-rays, and imaging information and an example calculation of out-of-pocket costs associated with out-of- b. Hospital and ambulatory Nothing. The deductible 50% coinsurance network benefits. surgical center services for does not apply. prenatal care, including professional services received during an inpatient stay for prenatal care MIC PP MN HSA(3/12) 30 2500-100% MIC PP MN HSA (3/12) 31 0BPL 21285 DOG 23751 BPL 21285 DOC 23751 Maternity Services Medical-Related D ental Services Your Benefits and the Amounts You Pay L. Medical-Related Dental Services Benefits In-network benefits * Out-of-network benefits after deductible after deductible This section describes coverage for medical-related dental services. Services must be received *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for from a physician or dentist. any charges in excess of the non-network provider reimbursement amount. Additionally,these This section does not describe coverage for comprehensive dental procedures. Comprehensive charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. dental procedures are services rendered by a dentist to treat teeth, their supporting soft tissue and c. Intermittent skilled care or Nothing. The deductible 50% coinsurance bony structure, or the alignment or occlusion of the teeth. These services are not covered under home infusion therapy when does not apply. any section of this certificate. you are homebound due to a See Definitions. These words have specific meanings: benefits, coinsurance, deductible, high risk pregnancy dependent, hospital, member, network, non-network, non-network provider reimbursement 2. Inpatient hospital stay for labor Nothing 50% coinsurance amount, physician, provider. and delivery services Prior authorization. Prior authorization from Medica may be required before you receive Please note: Maternity labor and services or supplies. Call Customer Service at one of the telephone numbers listed inside the delivery services are considered front cover. See How To Access Your Benefits for more information about the prior authorization inpatient services regardless of the length of hospital stay. process. 3. Professional services received Nothing 50% coinsurance Covered during an inpatient stay for labor and delivery For benefits and the amounts you pay, see the table in this section. More than one coinsurance 4. Anesthesia services received Nothing 50% coinsurance may be required if you receive more than one service or see more than one provider per visit. during an inpatient stay for labor and delivery • In-network benefits apply to medical-related dental services received from a network provider. b. Labor and delivery services at a freestanding birth center • 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 a. Facility services for labor and Nothing 50% coinsurance benefits, you will be responsible for any charges in excess of the non-network provider delivery reimbursement amount. The out-of-pocket maximum does not apply to these charges. b. Professional services Nothing 50% coinsurance Please see Important member information about out-of-network benefits in How To Access received for labor and Your Benefits for more information and an example calculation of out-of-pocket costs delivery associated with out-of-network benefits. 6. Home health care visit following Nothing. The deductible 50% coinsurance Not covered delivery does not apply. Please note: One home health visit is covered if it occurs within 4 days These services, supplies, and associated expenses are not covered: of discharge. If services are received after 4 days, please refer 1. Dental services to treat an injury from biting or chewing. to Home Health Care for benefits. 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. o MIC PP MN HSA(3/12) MIC PP MN HSA (3/12) 32 2500-100% 33 2500-100%B BPL 21285 DOC 23751 BPL 21285 DOC 23751 Medical-Related Dental Services Medical-Related Dental Services 7. Any dental procedures or treatment related to periodontal disease. k r = gyp; ��w '.� Your Benefits and the Amounts You Pa = 8. Endodontic procedures and treatment, including root canal procedures and treatment, y ^ g •unless provided as accident-related dental services as described in this section. i , Benefits � � In-network.=benefits * Out-of-network benefits 9. Routine diagnostic and preventive dental services. W ' after deductible after deductible See Exclusions for additional services, supplies, and associated expenses that are not ' * °" the F For out-of-network beriefits,.in=addition to thdeductible."and-coinsurance,you are'respo nsiblefor covered. any charges in excess of the non network provider reimbursement amount.:=Additionally,;these "x 1 charges will not be applied toward satisfaction of the.deductibleTor the out of-pocket maximum , s 3. Accident related dental services Nothing 50% coinsurance Your Benefits and the Amounts You Pay . to treat an injury to sound, Benefits �� _ In network benef t *:puto# networkbenefits natural teeth and to repair (not -u a � after deductible - after deductible replace) sound, natural teeth. : F = The following conditions apply: For out of network benefits, in addition to the deductible and coinsurance,you are responsible or , a. Coverage is limited to . any charges in excess of the non network-provider reimbursement amount] Additionally,these services received within 24 charges will not be applied toward satisfaction of the deductible or the out-of pocket maximu;m �.:'._ months from the later of: 1. Charges for medical facilities Nothing 50% coinsurance i. the date you are first and general anesthesia services covered under the that are: Contract; or a. Recommended by a ii. the date of the injury physician; and b. A sound, natural tooth means b. Received during a dental a tooth (including supporting procedure; and structures) that is free from c. Provided to a member who: disease that would prevent continual function of the tooth i. Is a child under age five for at least one year. (prior authorization is not In the case of primary (baby) required); or teeth, the tooth must have a ii. Is severely disabled; or life expectancy of one year. iii. Has a medical condition 4. Oral surgery for: Nothing 50% coinsurance and requires a. Partially or completely hospitalization or general unerupted impacted teeth; or anesthesia for dental care treatment b. A tooth root without the Please note: Age, anxiety, extraction of the entire tooth and behavioral conditions (this does not include root are not considered medical canal therapy); or conditions. c. The gums and tissues of the 2. For a dependent child, Nothing 50% coinsurance mouth when not performed in orthodontia, dental implants, and connection with the oral surgery treatment related to extraction or repair of teeth cleft lip and palate i MIC PP MN HSA(3/12) 34 2500-100% MIC PP MN HSA (3/12) 35 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Mental Health Mental Health ' f. Residential treatment services. These services include either: M. Mental Health 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 This section describes coverage for services to diagnose and treat mental disorders listed in the services. In addition to room and board, at least 30 hours a week per individual of current edition of the Diagnostic and Statistical Manual of Mental Disorders. For a description of mental health services must be provided, including group and individual counseling, coverage for the diagnosis and primary treatment of substance abuse disorders, see Substance client education, and other services specific to mental health treatment. Also, the Abuse. program must provide an on-site medical/psychiatric assessment within 48 hours of See Definitions. admission, psychiatric follow-up visits at least once per week, and 24-hour nursing � These words have specific: meanings: claim, coinsurae custodial�benefiits, n% ;� `,� e. care, deductible, emergency, hospital,:inpatient; medicallytnecessary,+member, mental disorder, coverage. ,network,anon-network, nan network;provider-reimbursement amount, provider,. Prior authorization. For prior authorization requirements of in-network and out-of-network Covered benefits, call Medica's designated mental health and substance abuse provider at For benefits and the amounts you pay, see the table in this section. More than one coinsurance 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center 1-800-855-2880, then ask them to dial Medics Behavioral Health at 1-866-567-0550. may be required if you receive more than one service or see more than one provider per visit. '' For purposes of this section: • For in-network benefits: 1. Outpatient services include: 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 a. Diagnostic evaluations and psychological testing. substance abuse provider will refer you to one of its hospital providers (Medica and Medica's b. Psychotherapy and psychiatric services. designated mental health and substance abuse provider hospital networks are different). For claims questions regarding in-network benefits, call Medica's designated mental health i c. Intensive outpatient programs, including day treatment, meaning time limited comprehensive treatment plans, which may include multiple services and modalities, and substance abuse provider Customer Service at 1-866-214-6829. delivered in an outpatient setting (up to 19 hours per week). • For out-of-network benefits: d. Treatment for a minor, including family therapy. 1. Mental health services from a non-network provider listed below will be eligible for coverage e. Treatment of serious or persistent disorders. 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 f. Diagnostic evaluation for attention deficit hyperactivity disorder(ADHD) or pervasive services and practice independently: development disorders (PDD). a. Psychiatrist g. Services, care, or treatment described as benefits in this certificate and ordered by a court b. Psychologist on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric , h. Treatment of pathological gambling. and mental health nursing 2. Inpatient services include: d. Mental health clinic i a. Room and board. e. Mental health residential treatment center 1 b. Attending psychiatric services. f. Independent clinical social worker c. Hospital or facility-based professional services. g. Marriage and family therapist d. Partial program. This may be in a freestanding facility or hospital based. Active treatment h. Hospital that provides mental health services is provided through specialized programming with medical/psychological intervention and 2. Emergency mental health services are eligible for coverage under in-network benefits. supervision during program hours. Partial program means a treatment program of 20 hours or more per week and may include lodging. In addition to the deductible and coinsurance described for out-of-network benefits, you will 1 be responsible for any charges in excess of the non-network provider reimbursement e. Services, care, or treatment described as benefits in this certificate and ordered by a court amount. The out-of-pocket maximum does not apply to these charges. Please see on the basis of a behavioral health care evaluation performed by a physician or licensed Important member information about out-of-network benefits in How To Access Your psychologist and that includes an individual treatment plan. MIC PP MN HSA(3/12) 36 2500-100% MIC PP MN HSA(3/12) 37 250 BPL 21285 2300 BPL 21285 DOC 23751 1 Mental Health Mental Health Benefits for more information and an example calculation of out-of-pocket costs associated 1It1 _, with out-of-network benefits. You� Benefts and the amounts You Pay = _ Not covered Benefits in network benefits . Out Hof network benefits after deductibles = � after,deductible These services, supplies, and associated expenses are not covered: � � 1 *Forout of-of ts, rn addition to the deductible:and coinsurance,you arse responsible for 1. Services for mental disorders not listed in the current edition of the a °any-charges in excess of the non-network provider reimbursement amount Additionally,these Manual of Mental Disorders. e Diagnostic and Statistical charges will not excess ss 0.!t toward satisfaction of the deductible or the out-o#pocket-maximum 2. Services for a condition when there is no reasonable expectation that the condition will 1. Office visits, including Nothing 50% coinsurance improve. evaluations, diagnostic, and 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as treatment services specifically described in this section. 2. Intensive outpatient programs Nothing 50% coinsurance 4. Relationship counseling. 3. Inpatient services (including 5. Family counseling services, except as specifically described in this certificate as treatment residential treatment services) for a minor. a. Room and board Nothing 50% coinsurance 6. Services for telephone psychotherapy. b. Hospital or facility-based Nothing 50% coinsurance 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, professional services as those conditions are defined in the current edition of the American Psychiatric c. Attending psychiatrist Nothing 50% coinsurance Association's Diagnostic and Statistical Manual of Mental Disorders. services 8. Services, including room and board charges, provided by health care professionals or d. Partial program Nothing 50% coinsurance facilities that are not appropriately licensed, certified, or otherwise qualified under state law 1 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. i i 1 MIC PP MN HSA (3/12) 38 2500-100% 39 2500-100%MIC PP MN HSA(3/12) BPL 21285 DOC 23751 BPL 21285 DOC 23751 M Miscellaneous Medical Services And Supplies Miscellaneous Medical Services And Supplies '"-�' a- s' st""�, -' -"" gs . . N. Miscellaneous Medical F Your Benefits and the Amounts You Pay cal Services And Supplies I Benefits In-netwark benefits * Out-of network benefits s� after deductible after deductible `` This section describes coverage for miscellaneous medical services and supplies prescribed by . a physician. Medics covers only a limited selection of miscellaneous medical services and te $ ' -, supplies that meet the criteria established by *For out-of-network'benefits, imaddrtion to tov deductible ble and coinsurance, itionasponsrble for y Medica. Some items ordered by a physician, even any charges in excess oftthe:non network provider redmbursernent amount ofddiket mly,these if medically necessary, may not be covered. See charges will-:not be applied toward satisfaction ofthe deductible<or theout af-pocket°maximum tons These words eve:specrfic meanings ;benefits,coinsurance deduct' , : °g . network:n r 1. Blood clotting factors Nothing 50% coinsurance � , on-network, non network prquider.re�mbursement amount,physicfan, provider Prior authorization. Prior authorization from Medics may be required before you receive 2. Dietary medical treatment of Nothing 50% coinsurance services or supplies. Call Customer Service at one of the telephone numbers listed inside the phenylketonuria (PKU) front cover. See How To Access Your Benefits for more information about the prior 3. Amino acid-based elemental Nothing 50% coinsurance authorization process. formulas for the following diagnoses: Covered a. cystic fibrosis; For benefits and the amounts you pay, see the table in this section. More than one coinsurance b. amino acid organic anid, and m may be required if you receive more than one service or see more than one provider per visit. may acid metabolic and malabsorption disorders; • In-network benefits apply to miscellaneous medical services and supplies received from a network provider. c. IgE mediated allergies to ■ food proteins; • Out-of-network benefits apply to miscellaneous medical services and supplies received from d. food protein-induced a non-network provider. In addition to the deductible and coinsurance described for out-of- enterocolitis syndrome; network benefits, you are responsible for any charges in excess of the non-network provider l tl reimbursement amount. The out-of-pocket maximum does not apply to these charges. e. eosinophilic esophagitis; Please see Important member information about out-of-network benefits in How To Access f. eosinophilic gastroenteritis; Your Benefits for more information and an example calculation of out-of-pocket costs and associated with out-of-network benefits. g. eosinophilic colitis. j Not covered 1 Coverage for the diagnoses in 3.c.-g. above is limited to Other disposable supplies and appliances, except as described in Durable Medical Equipment members five years of age and And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program. younger. See Exclusions for additional services, supplies, and associated expenses that are not 4. Total parenteral nutrition Nothing 50% coinsurance covered. 1 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 PP MN NSA(3/12) 40 2500-100% MIC PP MN NSA(3/12) 41 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 I I Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services Not covered O. Organ And Bone Marrow Transplant Services These services, supplies, and associated expenses are not covered: 1. Organ and bone marrow transplant services except as described in this section. This section describes coverage for certain organ and bone marrow transplant services. 2. Supplies and services related to transplants that would not be authorized by Medica under Services must be provided under the direction of a network physician and received at a the medical criteria referenced in this section. designated transplant facility. This section also describes benefits for professional, hospital, and ambulatory surgical center services. 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 Coverage is provided for certain types of organ transplants and related services (including referenced in this section. organ acquisition and procurement) and for certain bone marrow transplant services that are appropriate for the diagnosis, without contraindications, and non-investigative. 4. Living donor transplants that would not be authorized by Medica under the medical criteria referenced in this section. See Definitions. These words have specific meanings: benefits,coinsurance, deductible, = 5. Islet cell transplants except for autologous islet cell transplants associated with hospital, inpatient; investigative,medically necessary, member, network, non network, non- ■ network-provider reimbursement amount, physician, provider, virtual care. pancreatectomy. . - = 6. Services required to meet the patient selection criteria for the authorized transplant Prior authorization. Prior authorization from Medica is required before you receive services or procedure. This includes treatment of nicotine or caffeine addiction, services and related supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. expenses for weight loss programs, nutritional supplements, appetite suppressants, and See How To Access Your Benefits for more information about the prior authorization process. supplies of a similar nature not otherwise covered under this certificate. Covered 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. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 8. Transplants and related services that are investigative. may be required if you receive more than one service or see more than one provider per visit. 9. Private collection and storage of umbilical cord blood for directed use. Medica uses specific medical criteria to determine benefits for organ and bone marrow p g 10. Drugs provided or administered by a physician or other provider on an outpatient basis, transplant services. Because medical technology is constantly changing, Medica reserves the except those requiring intravenous infusion or injection, intramuscular injection, or right to review and update these medical criteria. Benefits for each individual member will be intraocular injection. Coverage for drugs is as described in Prescription Drug Program and determined based on the clinical circumstances of the member according to Medica's medical Prescription Specialty Drug Program or otherwise described as a specific benefit in this criteria. certificate. Coverage is provided for the following human organ transplants, if appropriate, under Medica's See Exclusions for additional services, supplies, and associated expenses that are not medical criteria and not otherwise excluded from coverage (see Not covered below): cornea, covered. 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, eri heral blood, and umbilical cord blood. p p Your.Benefits and the Amounts You Pay,:: -- The preceding is not a comprehensive list of eligible organ and bone marrow transplant E services. Benefits In network benefits *Outof network?benefits • In-network benefits apply to transplant services provided by a network provider and received ' = after deductible - , u after deductible at a designated transplant facility. A designated transplant facility means a hospital that has E e, entered into a separate contract with Medica to provide certain transplant-related health For out-of-network benefits, in addition to the deductible and coinsurance;you are responsible for, p p p any charges in excess of the non network provider reimbursement amount. :" services to members receiving transplants. You may be evaluated and listed as a potential applied charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. recipient at multiple designated facilities for transplant services. ', Medica requires that all pre-transplant, transplant, and post-transplant services, from the 1. Office visits Nothing No coverage time of the initial evaluation through no more than one year after the date of the transplant, 2. Virtual care Nothing No coverage 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 PP MN HSA(3/12) 42 2500-100% MIC PP MN HSA(3/12) 43 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 EL• . Organ And Bone Marrow Transplant Services i Organ And Bone Marrow Transplant Services enef _ and.the <.. . u_. _ems. r... _. .. .. Your. m_ �,,. u Benefits: Amounts You'P and the a y , ....Benefits ... � n_". n e t. ,-ar_k i s ....� _ e ef its e o f ts,, � ��,. . t to netwo.,r k ben fits ` , *. _Ou t of.�n e, two. r'k be�n e_ fits. deductible ft deductible �, x� , , afer'de du deductible after deductible .-- , _., � . ... ork <:;... bane ..,, fits in .. :. , addition t __. k .. f �_., �,. 3 x.,�-.. _: .• ; .. s addition � -;J� o.the coinsurance, e, deductible and ,,...:x. _,.. an .charges � au.are,re w::� � ,,,. . Y ; n:exc -, ..� Y responsible ; �For_out-of-network .,, ass of the _ � ,. . p e for .. E m to ou-are res onsr le f r non network- r .f<• �.:.:. �.:. :.�..... ,aY p rovider.reim ,.�.e ,., • ,. �,_:. P bur . _ ...: ,. _ _.._. .., sement�amo -.> : �_s .�.:, _ ,.. ...char applied_ . _ .. amount. Additionally, ,, �,;� f,,, es will n _ .. _- _ . _. .. tionall �: -� x._ � non-network J of bet . e these an. :char charges excess f=.the- . tow ., � Y, Y .,, s o rovrder,reimbursernent amount..;�Addrtronall here . �. ^ P ardsatisfac � _, , ., .,.,. ... .'. .._r tion of t Y,. � � .- " _ r- _.. the deductible w .... . . �. ,. will . .- ^<,:: :: the out-of-pocket . -char, es .not be applied toward satisfaction of the deductible or the out-of- � ...k .<.,^ � � poc e#maximum 9 PP out-of-pocket maxrmum; 3. Outpatient services I 5. Services received from a Nothing No coverage a. Professional services physician during an inpatient i. Surgical services (as Nothin stay defined in the Physicians' g No coverage I 6. Anesthesia services received Nothing No coverage Current Procedural from a provider during an Terminology code book) inpatient stay received from a physician during an office visit or an 7. Transportation and lodging The deductible does not No coverage outpatient hospital visit a. As described below, apply to this reimbursement of reasonable reimbursement benefit. ii. A ge'Anesthesia services Nothing No coverage You are responsible for received from a provider and necessary expenses for paying all amounts not during an office visit or an travel and lodging for you reimbursed under this outpatient hospital or and a companion when you benefit. Such amounts receive approved services at ambulatory surgical do not count toward your center visit a designated facility for out-of-pocket maximum transplant services and you iii. Outpatient lab and Nothing live more than 50 miles from or toward satisfaction of pathology g No coverage that designated facility your deductible. iv. Outpatient x-rays and Nothing No coverage i. Transportation of you and other imaging services one companion (traveling v. Other outpatient hospital Nothing No coverage on the same day(s)) to services received from a g and/or from a designated physician facility for transplant services for pre- vi. Services related to Nothing No coverage transplant, transplant, human leukocyte antigen and post-transplant testing for bone marrow services. If you are a transplants minor child, b. Hospital and ambulatory transportation expenses surgical center services for two companions will be reimbursed. i. Outpatient lab and Nothing No coverage pathology ii. Outpatient x-rays and Nothing No covers e other imaging services g iii. Other outpatient hospital Nothing No coverage services g 4. Inpatient services Nothing No coverage MIC PP MN HSA(3/12) 44 2500-100% MIC PP MN HSA (3/12) 45 2500-100 BPL 21285 DOC 23751 BPL 21285 DOC 23751 Organ And Bone Marrow Transplant Services Physical, Speech, And Occupational Therapies Your Benefits and the Amounts You Pay P. Physical, Speech, And Occupational Therapies Benefits� �.� � s% $' . - In-network benefits Out-of network benefits -� deductible._ after deductible .. after � � This section describes coverage for physical therapy, speech therapy, and occupational therapy PY For out-of-network.benefits, in addition tott edeductible:•and,coinsurance` ou'are responsible - services provided on an outpatient basis. A physician must direct your care in order for it to be any chargesAdditionally,_ ,� .,,� ,�' 'for ,._ ;in excess of the provider reimbursement amount �these�-'' eligible for coverage. Coverage for services provided on an inpatient basis is as described charges will not be applied toward satisfaction of the deductible or the 012#-of-pocket maximum elsewhere in this certificate. ii. Lodging for you (while not See Definitions. These words have specific meanings:'; benefits, coinsurance,.deductible", confined) and one inpatient,network,non network, non-network provider reimbursement amount, physician companion. Reimbursement is Prior authorization. Prior authorization from Medica may be required before you receive available for a per diem 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 amount of up to $50 for authorization process. one person or up to $100 for two people. If you are a minor child, Covered reimbursement for lodging expenses for two For benefits and the amounts you pay, see the table in this section. More than one coinsurance companions is available, may be required if you receive more than one service or see more than one provider per visit. up to a per diem amount of$1 00. • In-network benefits apply to outpatient physical therapy, speech therapy, and occupational therapy services arranged through a physician and received from the following types of iii. There is a lifetime network providers: physical therapist, speech therapist, occupational therapist, or physician. maximum of$10,000 per member for all • Out-of-network benefits apply to outpatient physical therapy, speech therapy, and transportation and occupational therapy services arranged through a physician and received from the following lodging expenses types of non-network providers: physical therapist, speech therapist, occupational therapist, incurred by you and your or physician. In addition to the deductible and coinsurance described for out-of-network companion(s) and benefits, you are responsible for any charges in excess of the non-network provider reimbursed under the reimbursement amount. The out-of-pocket maximum does not apply to these charges. Contract or under any Please see Important member information about out-of-network benefits in How To Access other Medica, Medica Your Benefits for more information and an example calculation of out-of-pocket costs Health Plans, or Medica associated with out-of-network benefits. Health Plans of Wisconsin coverage Not covered offered through the same employer. These services, supplies, and associated expenses are not covered: b. Meals are not reimbursable 1. Services primarily educational in nature. under this benefit. 2. Vocational and job rehabilitation. 3. Recreational therapy. 4. Self-care and self-help training (non-medical). 5. Health clubs. 6. Voice training. 7. Group physical, speech, and occupational therapy. MIC 47 2500-100% MIC PP MN HSA(3/12) PP MN HSA(3/12) 46 2500-100% B BPL 21285 DOC 23751 PL 21285 DOC 23751 Physical, Speech, And Occupational Therapies Physical, Speech, And Occupational Therapies 8. Physical, speech, or occupational therapy services (including but not limited to services for the correction of speech impediments or assistance in the development of verbal clarity) ' � '' Your Benefits and the Amounts You ay when there is no reasonable expectation that the member's condition will improve over a ':.- - predictable period of time according to generally accepted standards in the medical community. Benefits In-networkbenef►ts out-of-network benefits ' after deductible after deductible =' 9. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. �� =" *For out of-network berefits, m"addition tothe�deductible andcoinsurance,you are responsible for See Exclusions for additional services supplies, any chargES ir%excess of the non=networkprovicJet•re►inbursement amount.. Additiflnatly;these' covered. and associated expenses that are not charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum aF 3. Occupational therapy received Nothing 50% coinsurance. outside of your home when Coverage for physical Amounts physical function is impaired due and occupational therapy YourBenefits and Amounts You Pay zr f �" - e-�_ - x"34 -s 'a';., c a. to a medical illness or injury or is limited to a combined Benefits _ n In-network k benefi congenital or developmental limit of 20 visits per I is zOut of-network benefits L. - - conditions that have delayed calendar year. . after deductible -, after deductible - motor development y Please note: This visit limit benefits, includes physical and *For out of network in addition fo`the deductible end coins reric ' occupational therapy visits zany charges in excess of ion ditionk provider deductible and ent a noun , you are responsible for charges will not be applied toward satisfaction of the deductible or the t. Additionally,pocket these _ that you pay for in order to 1 ,q", - out of pocket maxirnum satisfy any part of your I 1. Physical therapy deductible. py received Nothing 50% coinsurance. outside of your home when physical function is impaired due Coverage for physical to a medical illness or injury or and occupational therapy congenital or developmental is limited to a combined conditions that have delayed limit of 20 visits per motor development 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 impaired due to a medical illness Coverage for speech or injury, or congenital or therapy is limited to 20 developmental conditions that visits per calendar year. have delayed speech Please note: This visit limit development includes speech therapy visits that you pay for in order to satisfy any part of your deductible. MIC PP MN NSA (3/12) 48 2500-100% MIC PP MN NSA(3/12) 49 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Prescription Drug Program Prescription Drug Program will improve the coverage by only one tier. Exceptions to the PDL can also include Q. Prescription Drug Program 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. 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 Prior authorization (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 Certain covered drugs require prior authorization as indicated on the PDL. The provider who "professionally administered drugs" prescribes the drug initiates prior authorization. The PDL is made available to providers, means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular injection; the phrase "self-administered drugs" means all including pharmacies and the designated mail order pharmacies. You are responsible for other drugs. For the definition and coverage of specialty prescription drugs, see Prescription paying the cost of drugs received if you do not meet Medica's authorization criteria. Specialty Drug Program. See,.Definitions. These words have speak meanin s benefits claim coinsurance Step thera py de. ductible, durablekmedica equipment;:emergency, hospital, member, network, non-network, -' w r = r Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step anon network provider reimbursement amount, physician, prescription drttg; preventive health servtce; provider, urgerit care center :- � � � _ � � � :. 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 Preferred drug list step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 Quantity limits covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this certificate. The PDL includes the following tiers: 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 Tier 1 is your lowest coinsurance option. For the lowest out-of-pocket expense, you should quantity limits are based on packaging, FDA labeling, or clinical guidelines. consider a Tier 1 covered drug if you and your physician decide it is appropriate for your treatment. Covered 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. The following table provides important general information concerning in-network, out-of- Tier 3 drugs are not covered unless they meet the requirements under the PDL exception network, and mail order benefits. For specific information concerning benefits and the amounts process described in this certificate. you pay, see the benefit table at the end of this section. Please note that Prescription Drug Program describes your coinsurance for prescription drugs themselves. An additional If you have questions about Medica's PDL or whether a specific drug is covered (and/or the PDL coinsurance applies for the provider's services if you require that a provider administer self- tier in which the drug may be covered), or if you would like to request a copy of the PDL at no administered drugs, as described in other applicable sections of this certificate including, but not charge, call Customer Service at one of the telephone numbers listed inside the front cover. limited to, Hospital Services, Infertility Diagnosis, and Professional Services. 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 Inp network benefits ra Out-of-network benefi#s* Malt order benefits** Food and Drug Administration (FDA) approval, manufacturers' acka in � ��-• :� ,- e _ r '�: _ �. 1.,. . . a':� _ .. p g• g guidelines, and ' clinical publications. These medication request guidelines, as well as the PDL, are periodically Covered drugs received at a Covered drugs received at a Covered drugs received from reviewed and modified by Medica. In addition to the medication request guidelines, Medica network pharmacy; and non-network pharmacy; and a designated mail order assigns a tier to each drug based on a review of the drug's cost and effectiveness. pharmacy; and 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 PP MN HSA (3/12) 50 2500-100% MIC PP MN HSA(3/12) 51 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Prescription Drug Program Prescription Drug Program Three prescription units may be dispensed for covered drugs prescribed to treat chronic in network benefits Ou# of network benefits*. .. Mail order benefits' ` 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 Covered drugs for family See In-network benefits Covered drugs for family at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside planning services or the column. planning services or the the front cover. treatment of sexually treatment of sexually transmitted diseases when transmitted diseases when Not covered prescribed by or received from prescribed by either a either a network or a non- network or a non-network The following are not covered: network provider. Family provider and received from a planning services do not designated mail order 1. Any amount above what Medica would have paid when you fail to identify yourself to the include infertility treatment pharmacy. Family planning I pharmacy as a member. (Medica will notify you before enforcement of this provision.) services; and services do not include 2. OTC drugs not listed on the PDL. infertility treatment services; and 3. Replacement of a drug due to loss, damage, or theft. Diabetic equipment and Diabetic equipment and Diabetic equipment and 4. Appetite suppressants. supplies, including blood supplies, including blood supplies (excluding blood 5. Erectile dysfunction medications. 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 6. Non-sedating antihistamines and non-sedating antihistamine/decongestant combinations. and pharmacy. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and Tobacco cessation products Tobacco cessation products Not available. those members who have a feeding tube. when prescribed by a provider when prescribed by a provider 8. Tobacco cessation products or services dispensed through a mail order pharmacy. authorized to prescribe the authorized to prescribe the product and received at a product and received at a non- 9. Drugs prescribed by a provider who is not acting within his/her scope of licensure. network pharmacy. network pharmacy. 10. Homeopathic medicine. 11. Infertility drugs. * 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- 12. Specialty prescription drugs, except as described in Prescription Specialty Drug Program. network provider reimbursement amount. The out-of-pocket maximum does not apply to See Exclusions for additional drugs, supplies, and associated expenses that are not these charges. Please see Important member information about out-of-network benefits in covered. 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: Some drugs and supplies are not available through the designated mail order pharmacy. See Miscellaneous Medical Services And Supplies for coverage of insulin pumps. See Prescription Specialty 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 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 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. MIC PP MN HSA (3/12) 52 2500-100% MIC PP MN HSA (3/12) 53 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Prescription Drug Program Prescription Drug Program i. Y and the_Amounts_. ou_.Pa _ � �. -_ your Benefits a Y .� =; �__ Your.Benefit �: __ __ the mounts.You__. . yam 3.. : _.,.... _ - -... ., .. ... :..<-.._ . .> p:.. s- -,..-.,. ,_. - out-of-network.. , , .. ;:: out-of-network aF , > For� .benefits n r ,. or > . m addrt�on-to the and�coi su ance ou are res onsible for ,benefits in addition to the r � k -.- j ..._ , you p ... . , t e deduct ble.and coinsurance -you .f , . � - Y ar_ > . . .:-. a Y,ch-.a�.<r._ s.:.a n:excess o.f,t h e non-network rov r de r;re rm bu r se nt amount., mo n t, A.1.d tl rti� o n ly,.,.:t:_h ese 4t any Charges m e xces >o f the .x non-network ro�rd err im buc se m e nt-am�amount., Additionally,these charges will no t be,a pp ed.tavard satisfaction of ahe deductible or the out,of. ck x char es will not be applied toward satisfaction of the deductible or the out-of-pocket max>mum. I M .c,In-network benefrts Out-of-network g ,benefrt s Mail order b n efit s :-In network benefits . Out-of-network benefits :Mail order benefits -_ , deductible .., : _ - -after.dedu deductible aft er deductible after deductible afteraeductrbl e after after deductible 1. Outpatient covered drugs other than those described below or in Prescription Specialty Drug 4. Drugs and other supplies (other than tobacco cessation products) considered preventive Program health services, as specifically defined in Definitions, when prescribed by a provider o authorized to prescribe such drugs. This group of drugs and supplies is specific and Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per limited. For the current list of such drugs and supplies, please refer to the Preventive Drug prescription unit; or prescription unit prescription unit; or and Supply List within the PDL or call Customer Service at one of the telephone numbers listed Tier 2: Nothing per Tier 2: Nothing per inside the front cover. prescription unit; or prescription unit; or Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per Tier 3: No coverage Tier 3: No coverage prescription unit; or prescription unit prescription unit; or 2. Diabetic equipment and supplies, including blood glucose meters Tier 2: Nothing per Tier 2: Nothing per Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or prescription unit; or prescription unit; or prescription unit prescription unit; or Tier 3: No coverage Tier 3: No coverage Tier 2: Nothing per Tier 2: Nothing per The deductible does not The deductible does not prescription unit; or prescription unit; or . apply. apply. Tier 3: No coverage Tier 3: No coverage 3. 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 PP MN HSA (3/12) 54 2500-100% MIC PP MN HSA(3/12) 55 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Prescription Specialty Drug Program Prescription Specialty Drug Program Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also R. Prescription Specialty 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 This section describes coverage for specialty prescription drugs received from a designated process, call Customer Service at one of the telephone numbers listed inside the front cover. 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 Prior authorization 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" Certain specialty prescription drugs require prior authorization. The provider who prescribes the means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular specialty drug initiates prior authorization. The SPDL is made available to providers, including injection; the phrase "self-administered drugs" means all other drugs. designated specialty pharmacies. You are responsible for paying the cost of specialty See Definitions. These words have sp ec fic meanie s 'benefits,;claim -.coinsurance prescription drugs you receive if you do not meet Medica's authorization criteria. �g � p 4 � g4rE , deductible, member, network, physician, prescriptiengdrug,;provider ' a Step therapy Designated specialty pharmacies Medica requires step therapy prior to coverage of specific specialty prescription drugs as A designated specialty pharmacy means a specialty pharmacy that has entered into a separate indicated on the SPDL. Step therapy involves trying an alternative covered specialty contract with Medica to provide specialty prescription drug prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other p p y prescri tion dru services to members. For the Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. current list of designated specialty pharmacies, call Customer Service at one of the telephone Applicable step therapy requirements must be met before Medica will cover certain Tier 1 or numbers listed inside the front cover or sign in at www.mymedica.com. Tier 2 specialty prescription drugs. Specialty preferred drug list Quantity limits Medica has a tiered SPDL that identifies specialty prescription drugs that are covered, unless Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. otherwise listed as not covered in this certificate. The SPDL also identifies whether a drug is These limits indicate the maximum quantity allowed per prescription over a specific time period. classified by Medica as a Tier 1 or Tier 2 specialty prescription drug. In general, only specialty drugs on Medica's SPDL are eligible for benefits under this certificate. Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the Covered benefit table below. If you have questions about Medica's SPDL or whether a specific specialty prescription drug is For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to covered (and/or the SPDL tier in which the drug may be covered), or if you would like to request a specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed received from a designated specialty pharmacy. inside the front cover. The SPDL is also available by signing in at www.mymedica.com. This section describes your coinsurance for specialty prescription drugs. An additional Medics utilizes medication request guidelines to determine whether a specialty prescription drug coinsurance applies for the provider's services if you require that a provider administer self- should be covered. Medica's medication request guidelines are based on United States Food administered drugs, as described in other applicable sections of this certificate including, but not and Drug Administration (FDA) approval, manufacturers' packaging guidelines, and clinical limited to, Hospital Services, Infertility Diagnosis, and Professional Services. 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 Prescription unit assigns a tier to each specialty prescription drug based on a review of the drug's cost and effectiveness. 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, Exceptions to the specialty preferred drug list unless limited by the manufacturer's packaging or Medica's medication request guidelines, including quantity limits as indicated on the SPDL. 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 MIC PP MN HSA (3/12) 56 /o MIC PP MN HSA(3/12) 57 2500-100 2500-100% ° BPL 21285 DOC 23751 BPL 21285 DOC 23751 Prescription Specialty Drug Program Professional Services Not covered The following are not covered: S. Professional Services 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 section describes coverage for professional services received from or directed by a this provision.) physician. 2. Replacement of a specialty drug due to loss, damage, or theft. =See Definitions. These words have specific meanings: benefits, coinsurance, convenience 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of care/retail,health clinic, deductible, emergency, genetic testing, hospital, inpatient, member, licensure. network, non-network, non network provider reimbursement amount,physician; preventive "R ffii health service, provider,_urgentparecenter, virtual care 4. Prescription drugs, except as described in Prescription Drug Program. Prior authorization. Prior authorization from Medica may be required before you receive 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 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 6. Infertility drugs. process. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Your Benefits and the Amounts You Pay • In-network benefits apply to: Benefits You pay after deductibles 1. Professional services received from a network provider; P Y 1. Specialty prescription drugs, Tier 1 specialty prescription drugs: Nothing per 2. Professional services for testing and treatment of a sexually transmitted disease and other than those described prescription unit; or testing for AIDS and other HIV-related conditions received from a network provider or a below, received from a non-network provider; designated specialty pharmacy Tier 2 specialty prescription drugs: No coverage 3. Family planning services, for the voluntary planning of the conception and bearing of 2. Specialty growth hormone when Tier 1 specialty prescription drugs: Nothing per children, received from a network provider or a non-network provider. Family planning prescribed by a physician for the prescription unit; or services do not include infertility treatment services. treatment of a demonstrated Tier 2 specialty prescription drugs: No coverage • Out-of-network benefits apply to p rofessional services received from a non-network provider.growth hormone deficiency and received from a designated In addition to the deductible and coinsurance, you will be responsible for any charges in specialty pharmacy 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. MIC PP MN HSA (3/12) 58 2500-100% MIC PP MN HSA(3/12) 59 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Professional Services Professional Services Not covered g ` ' r Your-Benefits and the Amounts You Pay These services, supplies, � pp and associated expenses are not covered: 1. Drugs provided or administered by a physician or other provider, except those requiring Benefits ln-er dew k benefits 2 * Out-of network benefits intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage after deductibleafter�deductiblie for drugs is as described in Prescription Drug Program and Prescription Specialty Drug , -- is i d c • Program or otherwise described as a specific For out of-network benefits,m�-addition to`the deaductible:and.comsurance,,youare responsible�for p benefit in this certificate. e r � �anycharges�n excess of�thenon network�p�ov�cler=reimbursement amount ;'Additionally,�theser 2. Diagnostic casts, diagnostic study models and bite adjustments related to the treatment of charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum temporomandibular joint (TMJ) disorder and craniomandibular disorder. 4. Urgent care center visits Nothing Covered as an in-network See Exclusions for additional services, supplies, and associated expenses that are not Please note: Some services benefit. covered. received during an urgent care center visit may be covered under another benefit in this certificate. The most specific and appropriate Your Benefits and the Amounts:You Pay � � benefit in this certificate will apply Benefits 'in-network benefits * e for each service received during an Out of-network'benefits urgent care center visit. after deductible - after deductible g -� For example, certain services received during an urgent care *For out-of-network benefits;in addition to the.deductible and coinsurance,you,are_responsibleAfor g g �-- , � . center visit may be considered any charges in excess of the non network,provider reimbursement amount Additionally, surgical or imaging services; see charges will not be applied toward satisfaction of the deductible or theout of pocket maximum below for coverage of these surgical "� _..:i �.tt _ ¢�- �x=:.... '.- ".�:� .S:r.-� - ice- "..�k,- ,.Via-- :3.,«-.- .xa; .✓t" '�, ��r„._ -- �_=^�. k'_;_.. ._. �-:.:.- 6.. or imaging services. In such 1. Office visits Nothing 50% coinsurance instances, both an urgent care Please note: Some services center visit coinsurance and received during an office visit may outpatient surgical or imaging be covered under another benefit in services coinsurance apply. this certificate. The most specific and appropriate benefit in this Call Customer Service at one of the certificate will apply for each service telephone numbers listed inside the received during an office visit. front cover to determine in advance whether a specific procedure is a For example, certain services benefit and the applicable coverage received during an office visit may level for each service that you be considered surgical or imaging receive. services; see below for coverage of these surgical or imaging services. 5. Preventive health care In such instances, both an office Please note: If you receive visit coinsurance and outpatient preventive and non-preventive surgical or imaging services health services during the same coinsurance apply. visit, the non-preventive health services may be subject to a Call Customer Service at one of the coinsurance or deductible, as telephone numbers listed inside the described elsewhere in this front cover to determine in advance certificate. The most specific and whether a specific procedure is a appropriate benefit in this certificate benefit and the applicable coverage will apply for each service received level for each service that you during a visit. receive. 2. Virtual care Nothing No coverage a. Child health supervision Nothing. The deductible Covered as an in-network services, including well-baby does not apply. benefit. 3. Convenience care/retail health Nothing 50% coinsurance care clinic visits MIC PP MN HSA(3/12) 60 2500-100% MIC PP MN HSA(3/12) 61 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 1 Professional Services Professional Services r..-,,._-_...,,_-.�,,,��-.w_-_-...r__.__._,..,.._-._;...x.,.., ___.�,.r-,_.--,..-,,a_r.,__.,..,,-_. ..^-,_,_.-:,,_.,_..-_.._.__..>.,.....�.-�_•__._-._?__;.�.,......-..^.�._-.x�:...,.^_.,--..._y C_...-._.,-..:_,_....._-._.._,.a_-__,-_,,:_�._-,_..-..,.__:.....�;^__,_�^a ,-9___.__.__."b_z..-__.,,, . You Y,.r �-o�. u-. ._-r,:�._....s B�°`�...e ne_f.ts_;.._a,4 n:i d t.....h,..e:._,A"f"� mo.:,': ut nrr_p Et s Y o_u P..:_.a,.Y � . >:...- Benefits and the Amo ants YoumPa : � t ms �: _ l'';:**.Y a_ . L ntwok bne#its 'Out-of-network, bene f i�- t s>> e t _Benefs E .E � . n,network,be n fs is out_ f_ benefits � Benefits � �._ ' _ > _ _ after:dedu deductible., � after deductible a x r Adada deductible after de ductible� _ � ,*For out-ofnetwork_ben fits in addition o to he:deductible.an dcornsurance, you- responsible any charges in excessaof the non-network ?rortder reimbursement amount. Additionally,these For out_of networkWi.benefits .m addition to the dad t ibie and co t sama uce,Y A dudianr es t ,o#nhs b e,for be any charges m.excess»o f the Wor_network provider ._ .charges will not PPhedloward satisfacti on of.#he_de ductible or the o ut o _ ocke maximum- char es will be towardsatsfact�on of the_ deduct�bl or the;out. f oc ke _ma im um. b. Immunizations Nothing. The deductible 50% coinsurance 13. Anesthesia services received Nothing 50% coinsurance does not apply. from a provider during an c. Early disease detection Nothing. The deductible 50% coinsurance inpatient stay services including physicals does not apply. 14. Outpatient lab and pathology Nothing 50% coinsurance d. Routine screening Nothing. The deductible 50% coinsurance 15. Outpatient x-rays and other Nothing 50% coinsurance procedures for cancer does not apply. imaging services e. Other preventive health Nothing. The deductible 50% coinsurance 16. Other outpatient hospital or Nothing 50% coinsurance services does not apply. ambulatory surgical center services received from a 6. Allergy shots Nothing 50% coinsurance physician 7. Routine annual eye exams Nothing. The deductible 50% coinsurance 17. Treatment to lighten or remove Covered at the Covered at the does not apply. 8. Chiropractic services to Nothing the coloration of a port wine stain corresponding in-network corresponding out-of- diagnose and to treat (by g 50% coinsurance. benefit level, depending network benefit level, ( y manual Coverage is limited to a on type of services depending on type of manipulation or certain maximum of 15 visits per provided. services provided. therapies) conditions related to calendar year. For example office visit For exampleffiiits nerves of the body the muscles, skeleton, and Please note: This visit limit Y includes chiropractic visits are covered at, the office s are covered a, to the ce office visit in-network benefit visit out-of-network that you pay for in order to satisfy any part of your level and surgical benefit level and surgical deductible. services are covered at services are covered at 9. Surgical services (as defined in Nothing 50% coinsurance the surgical services in- the surgical services out- the Physicians'Current network benefit level. of-network benefit level. Procedural Terminology code book) received from a physician 18. Treatment of temporomandibular Covered at the Covered at the during an office visit or an joint (TMJ) disorder and corresponding in-network corresponding out-of- outpatient hospital or craniomandibular disorder benefit level, depending network benefit level, on type of services depending on type of ambulatory surgical center visit provided. services provided. 10. Anesthesia services received Nothing 50% coinsurance from a provider during an office For example, office visits For example covered at, office visits visit a an outpatient hospital or are covered at the office are the ambulatory surgical center visit visit in-network benefit visit out-of-network level and surgical benefit level and surgical 11. Services received from a Nothing Covered as an in-network services are covered at services are covered at physician during an emergency benefit. the surgical services in- the surgical services out- room visit network benefit level. of-network benefit level. Please note: Dental Please note: Dental 12. Services received from a Nothing 50% coinsurance coverage is not provided coverage is not provided physician during an inpatient under this benefit. under this benefit. stay MIC PP MN HSA (3/12) 62 ° MIC PP MN HSA (3/12) 63 2500-100% 2500-100/o BPL 21285 DOC 23751 BPL 21285 DOC 23751 P Professional Services Professional Services �, . ;:and r _. ..., _. �.._ .. > ,� . � _ _ _ , . _ __ y_ ._ - . ., $_ _,:� � _ , ,, : x Amourrts.�Y ouPa ,.�. �r > _. .,..� - . . __.. .,_._,_ _. _ ., . . . , ,., .,, _ �. ., ,_ � _�� .Your�Benefwts.and the, u , .._, . .Your Beneflts:_and You> _.. . .- _ _ _ _ . ,_, ��.,_�::.� . .. 9 x_, Yo . � _..x .. :, . the Amounts Yo _ Benefits , - ..,, _. ., �., , �.. ,, , - _ __ _ . . . ...- > rk.bene�ts }3, _ _ *_ # Out-of nefinfo Benefits � _ _ < . , . .Out-Of-network , „_ ___ �. ,, �- F,.In netvuork bene its ,,- , . ._„. . � _ . � .. n.:network;:be ., = ,��.. e is -���... .,, _ ,, ._'. .. . � . , _ ..benefits ; ,_ - . .Ben � � . . _ • a._ . table after.d :du * :after deductible ,x ,x� ..:fix. ...-after .. d_ � @ _ y �., _. = onsible;for. F r � ,� � ,� > ,_,� � � deductible coinsurance ou are ces ,,.. Fo rout of network.benefits,:in x; - rk,benefits,in addltian to;the tledu Y I? � , . addition toethe_tletluct�bleand�co�ns � 9 .,.: Forout of netwo b s, ,,... :..__ . Y .. _.,a. . .. urance :you'are responsible ,, x�-- , . non-network " ,. unt.: Additionally, here an .,.char. es?t�nexce excess non-network- rovider�reimbursement:amo Y, Y -�_ s of the= ; rovrderre�m : �, ,� _. char es'm excess of p _ ._ _., :� : .. =.. .,� , 9 p.._ bursement amount.,,Atltl� r . . ,> an ,. . ,,.� .m.Will �._ ._... .. . tonal) these Y 9 . �.x x . u. r the out-of-pocket maximum._, char es �not�be. � -.-w � #action-.of.the deductrbie_o, maximum. 9 a Iced toward satisfaction the - _ _ _ .,.. f.-- will not applied toward satisfaction -.* pp... n of the tleductrble.orah � ,..,...char.charges . ,< e out of. _oaket maximum. .,. 9 PP ..__.>_1 19. Diabetes self-management Nothing 50% coinsurance 24. Genetic testing when test results Nothing 50% coinsurance training and education, including will directly affect treatment medical nutrition therapy, decisions or frequency of received from a provider in a screening for a disease, or when program consistent with national results of the test will affect educational standards (as reproductive choices established by the American Diabetes Association) 20. Neuropsychological Nothing 50% coinsurance evaluations/cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury 21. Services related to lead testing Nothing 50% coinsurance 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: The 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 65 2500-100% MIC PP MN HSA (3/12) 64 2500-100% MIC PP MN HSA(3/12) BPL 21285 DOC 23751 BPL 21285 DOC 23751 Reconstructive And Restorative Surgery Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, T. Reconstructive And Restorative Surgery except those requiring intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage for drugs is as described in Prescription Drug Program and I Prescription Specialty Drug Program or otherwise described as a specific benefit in this This section describes coverage for professional, hospital, and ambulatory surgical center certificate. services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative surgery services must be medically necessary and not cosmetic. See Exclusions for additional services, supplies, and associated expenses that are not covered.These �word have specific meanin gs benefits,coinsurance cosmetic, tledttctibie, hospital, iii ati medically-necessary member network, network.; :., non-network,� . oui , .� . . .� non ..�- mbur _ F seine uctrve .. care. _ _ -,; _ _ . ., __. ,�,,. . �, _.,. 9.. �.,_�, . re �. _ �_ e. --� � . �.>.. . _. . _ . _ __ . , . �. ,_ __ .. . restorative, �, .,, r;�Your Benefits and she Amounts You Pay ' .., '- %' ' fir_ °,. .v t �"" na'�'a "'c .1� r.. " Prior authorization. Prior authorization from Medics may be required ti Benefits E- In network benefits *Out-of-network'benefiits services or supplies. Call Customer Service at one y equired before you receive " � a ° � . i e of the telephone numbers listed inside the afterdeduct�bleafter:deductible front cover. See How To Access Your Benefits for more information about the prior - - � you are authorization process. p *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 deductibleor the out-of-pocket maximum Covered :_,. . . : , "��..�. � _ . .,__. 1. Office visits Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 2. Outpatient care Nothing No coverage • In-network benefits apply to reconstructive and restorative surgery services received from a 3. a. Professional s ionaices network provider. a. Professional services • • Out-of-network benefits apply to reconstructive and restorative surgery services received i. Surgical services (as Nothing 50% coinsurance from a non-network provider. In addition to the deductible and coinsurance described for dhfised in the out-of-network benefits, you will be responsible for any charges in excess of the non- Physicians'Current Procedural Terminology network provider reimbursement amount. The out-of-pocket maximum does not apply to code e book) received 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- from an office physice visit or visit or during pocket costs associated with out-of-network benefits. an outpatient hospital or Not covered ambulatory surgical center visit These services, supplies, and associated expenses are not covered: ii. Anesthesia services Nothing 50% coinsurance received from a provider 1. Revision of blemishes on skin surfaces and scars (including scar excisions) primarily for cosmetic purposes, unless otherwise covered in Professional Services. during an office visit or an outpatient hospital or 2. Repair of a pierced boo ambulatory surgical y part and surgical repair of bald spots or loss of hair. center visit 50% coinsurance 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 iii. Outpatient lab and Nothing treatment or condition. pathology 4. Services and procedures primarily for cosmetic purposes. iv. Outpatient x-rays and Nothing 50% coinsurance 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. other imaging services 6. Hair transplants. v. Other outpatient hospital Nothing 50% coinsurance or ambulatory surgical center services received from a physician MIC PP MN HSA (3/12) 66 2500-100% MIC PP MN HSA(3/12) 67 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Reconstructive And Restorative Surgery Skilled Nursing Facility Services E � Your Benefits and the A You Pay Benefits ' U. Skilled Nursing Facility Services Benefits` network benefits *Out-of netw k*benefit or s - after deductible a £ after deductible For,_out'of=ne This section describes coverage for use of skilled nursing facility services. Care must be #work benefits,in addition-to.the-deductible and g g Y d coinsurance you responsible for�� provided under the direction of a physician. Coverage of the services described in this section any charges in excess of the non-network provider reimbursement a coinsurance, y mount Additionally,these is limited to a maximum benefit of 120 days per person per calendar year. Skilled nursing charges will not be applied toward satisfaction af�the�deductible orthe;out- - h` rg l n � e applied out-of-pocket maximum _„ facility services are eligible for coverage only if you are admitted to a skilled nursing facility .._..:: .....:C-.._......N._n.:s_k`...tt.m 1-F �.x�,.d-- ...,Re.�.�:�k. �- �....-�-'L•� ,, f A a '§ - � .,?.c-xe:::G -� b. Hospital and ambulatory within 30 days after a hospital admission of at least three consecutive days for the same illness surgical center services or condition. i. Outpatient lab and See Definitions. These words havers specific meaning s benefits coinsu ance,.custodial care; Nothing o = p - � 9 �- pathology 50/° coinsurance deductible, hospital, inpatient, network, non-network, non network provider reimbursement amount, physician,'skilled care, skilled nurses facility. ii. Outpatient x-rays and Nothing ° skilled 9` other imaging services 50/o coinsurance Prior authorization. Prior authorization from Medica may be required before you receive iii. Other outpatient hospital Nothing ° services or supplies. Call Customer Service at one of the telephone numbers listed inside the and ambulatory surgical g 50/° coinsurance front cover. See How To Access Your Benefits for more information about the prior authorization center services process. 4. Inpatient services Nothin g 50% coinsurance Covered 5. Services received from a physician during an inpatient Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance stay may be required if you receive more than one service or see more than one provider per visit. 6. Anesthesia services received Nothing ° For purposes of this section, room and board includes coverage of health services and supplies. from a provider during an 50/o coinsurance • In-network benefits apply to skilled nursing facility services arranged through a physician inpatient stay 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. MIC PP MN HSA (3/12) 68 2500-100% MIC PP MN HSA(3/12) 69 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Skilled Nursing Facility Services Substance Abuse 7. Physical, speech, or occupational therapy services when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to generally accepted standards in the medical community. V. Substance Abuse 8. Voice training. 9. Group physical, speech, and occupational therapy. This section describes coverage for the diagnosis and primary treatment of substance abuse 10. Long-term care. disorders listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. expenses that are See.Definitions. These:wordshave specific meanings: benefits, claim, coinsurance, custodial See Exclusions for additional services, supplies, and associated ex covered. p e not 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 t.... ye = benefits, call Medica's designated mental health and substance abuse provider at Your Benefits and the'Amounts You Pay- 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center Benefits 1-800-855-2880, then ask them to dial Medici Behavioral Health at 1-866-567-0550. !n network *benefits � Out-of-network benefits after deductible _ after deductible For purposes of this section: - 1. Outpatient services include: *For out oPnetwork benefits;in addition to=the deductible-and?coinsurance you:are responsible for , any charges invexcessof the non network provider reimbursement amount.;Additionally,these a. Diagnostic evaluations. charges will.not be applied toward satisfaction of the deductible or the out-of-pocket maximum b. Outpatient treatment. 1. Daily skilled care or daily skilled Nothing 50% coinsurance c. Intensive outpatient programs, including day treatment and partial programs, which may rehabilitation services, including include multiple services and modalities, delivered in an outpatient setting. room and board, up to 120 days per person per calendar year d. Services, care, or treatment for a member that has been placed in any applicable Please note: Such services are Department of Corrections' custody following a conviction for a first-degree driving while eligible for coverage only if you are impaired offense; to be eligible, such services, care, or treatment must be required and admitted to a skilled nursing facility provided by any applicable Department of Corrections. within 30 days after a hospital admission of at least three 2. Inpatient services include: consecutive days for the same a. Room and board. illness or condition. This day limit includes days that you pay for in b. Attending physician services. order to satisfy any part of your deductible. c. Hospital or facility-based professional services. d. Services, care, or treatment for a member that has been placed in any applicable 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when room Department of Corrections' custody following a conviction for a first-degree driving while and board is not eligible to be impaired offense; to be eligible, such services, care, or treatment must be required and covered provided by any applicable Department of Corrections. e. Residential treatment services. These are services from a licensed chemical dependency 3. Services received from a Nothing 50% coinsurance physician during an inpatient rehabilitation program that provides intensive therapeutic services following detoxification. stay in a skilled nursing facility 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 PP MN HSA (3/12) 70 2500-100% MIC PP MN HSA (3/12) 71 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Substance Abuse Substance Abuse Covered Not covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 1 These Services for substance abuse disorders x not listed in the current edition of the Diagnostic and • For in-network benefits: p p Statistical Manual of Mental Disorders. 1. Medica's designated mental health and substance abuse provider arranges in-network 2. Services for a condition when there is no reasonable expectation that the condition will substance abuse benefits. If you require hospitalization, Medica's designated mental improve. health and substance abuse provider will refer you to one of its hospital providers (Medica 3. Services, care, or treatment that is not medically necessary. and Medica's designated mental health and substance abuse provider hospital networks are different). 4. Services to hold or confine a person under chemical influence when no medical services are 2. In-network benefits will apply to services, care or treatment for a member that has been required, regardless of where the services are received. placed in any applicable Department of Corrections' custody following a conviction for a 5. Telephonic substance abuse treatment services. first-degree driving while impaired offense. To be eligible, such services, care, or 6. Services, including room and board charges, provided by health care professionals or treatment must be required and provided by any applicable Department of Corrections. facilities that are not appropriately licensed, certified, or otherwise qualified under state law For claims questions regarding in-network benefits, call Medica's designated mental health to provide substance abuse services. This includes, but is not limited to, services provided and substance abuse provider Customer Service at 1-866-214-6829. by mental health or substance abuse providers who are not authorized under state law to • For out-of-network benefits: practice independently, and services received from a halfway house, therapeutic group home, boarding school, or ranch. 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 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 facility is licensed, certified, or otherwise qualified under state law to provide the substance abuse services and practice independently: and individual counseling, client education, and other services specific to chemical a. Psychiatrist dependency rehabilitation. b. Psychologist 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. c. Registered nurse certified as a clinical specialist or as a nurse practitioner in See Exclusions for additional services, supplies, and associated expenses that are not psychiatric and mental health nursing covered. d. Chemical dependency clinic e. Chemical dependency residential treatment center Your Benefits and the Amounts You Pay. f. Hospital that provides substance abuse services g. Independent clinical social worker Benefits in network benefits *Out of network benefits after deductible =after deductible h. Marriage and family therapist 2. Emergency substance abuse services are eli � For out-of-network benefits, in addition to the deductible and coinsurance,you are resp�ansblefor benefits. able for coverage under in-network g any charges in excess of the non network provider reimbursement amount. Additionally,these 4 :_ charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum �.r 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 1. Office visits, including Nothing 50% coinsurance amount. The out-of-pocket maximum does not apply to these charges. Please see evaluations, diagnostic, and Important member information about out-of-network benefits in How To Access Your treatment services Benefits for more information and an example calculation of out-of-pocket costs associated 50% coinsurance with out-of-network benefits. 2. Intensive outpatient programs Nothing 3. Opiate replacement therapy Nothing 50% coinsurance 4. Inpatient services (including residential treatment services) a. Room and board Nothing 50% coinsurance MIC PP MN HSA (3/12) 72 2500-100% MIC PP MN HSA(3/12) 73 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Substance Abuse Referrals To Non-Network Providers _ Your Benefits and the Amounts You Pay x r B ' W.Referrals To Non-Network Providers Benefits 4 In network benefits Out-of-network benefits after deductible rafter deductible This section describes coverage for referrals from network providers to non-network providers. *For out-of-network benefits,in addition,to°the deductible and coinsurance, .ou are responsible for. h In-network benefits will apply to referrals from network providers to non-network providers as any charges in excess of the non-network provider reimbursement amount. Additionally these described in this section. It is to your advantage to seek Medica's authorization for referrals to charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum non-network providers before you receive services. Medica can then tell you what your benefits will be for the services you may receive. b. Hospital or facility-based Nothing 50% coinsurance > professional services See.Definitions. These words have specific meanings: benefits, medically necessary � it network non-network, physician, provider. c. Attending physician services Nothing 9 50% coinsurance 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 PP MN HSA (3/12) 74 2500-100% MIC PP MN HSA (3/12) 75 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Referrals To Non-Network Providers Harmful Use Of Medical Services 3. Provide coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. X. Harmful Use Of Medical Services 4. Notify you of authorization or denial of coverage within ten days of receipt of your Medics will inform both you and your provider of Medica's decision within 72 hours This section describes what Medica will do if it is determined you are receiving health services time of the initial request if your attending r request. warranted, or Medica concludes that a delay could seriously jeopardize from the or prescription drugs in a quantity or manner that may harm your health. g provider believes that an expedited review is ability to regain maximum function, or could subject y J opardize your life, health, or adequately managed without J you to severe pain t See Definitions. These words have.specific meanings: benefits, emergency, hospital,` p that cannot be network„physician prescription drug, provider R e� = E' g thout the care or treatment you are seeking. 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 PP MN HSA (3/12) 76 2500-100% MIC PP MN HSA (3/12) 77 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 . i Exclusions Exclusions Y. Exclusions 14. Personal comfort or convenience items or services. 15. Custodial care, unskilled nursing, or unskilled rehabilitation services. 16. Respite or rest care, except as otherwise covered in Hospice Services. i ri 17. Travel, transportation, or livin g expenses, except as described in Organ And Bone Marrow Definitions..;These have specific reanrtgs claret cosme#tc custodial doable medical equipment, emergency, investigative, medically necessary, member,'non Transplant Services. network, physrcaan,,provider,'reconstructive, routine foot care. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 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 19. treatment plan.py' provided in any setting, even when it is part of a comprehensive available treatment for your condition. This section describes additional exclusions to the services supplies, and associated ex enses 20 disease,fperipheral neupropathiesmand s gtnifiiclannt neurological conditions e rsuch as vascular p 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 Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. inconsistent with the medical standards and accepted practice parameters of the communit y 21. Services b and services inappropriate-in terms of type, frequency, level, setting, and duration-to the Y persons who are family members or who share your legal residence. diagnosis or condition. 22. Services for which coverage is available under workers' compensation, employer liability, or 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise any similar law. determined to be reconstructive. 23. Services received before coverage under the Contract becomes effective. 3. Refractive eye surgery, including but not limited to LASIK surgery. 24. Services received after coverage under the Contract ends. 4. The purchase, replacement, or repair of eyeglasses, eyeglass frames, or contact lenses when prescribed solely for vision correction, and their related fittings. non-network providers and non-network dentists. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from • 26. Photographs, except for the condition of multiple dysplastic syndrome. 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 27. Occlusal adjustment or occlusal equilibration. 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 28. Dental implants (tooth replacement), except as described in Medical-Related Dental Prosthetics. Services. 6. A drug, device, or medical treatment or procedure that is investigative. 29. Dental prostheses. 7. Genetic testing when performed in the absence of symptoms or high risk factors for a 30. Orthodontic treatment, except as described in Medical-Related Dental Services. genetic disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing 31. Treatment for bruxism. that has been performed in response to direct-to-consumer marketing and not under the 32. Services prohibited by applicable law or regulation. direction of your physician. 33. Services to treat injuries that occur while on military duty, and any services received as a 8. Services or supplies not directly related to care. result of war or any act of war (whether declared or undeclared). 9. Autopsies. 34. Exams, other evaluations, or other services received solely for the purpose of employment, 10. Enteral feedings, unless they are the sole source of nutrition; however, insurance, or licensure. standard infant formulas, standard baby food, and regular grocery enteral feedings of y p p j y g g ry products used in 35. Exams, other evaluations, or other services received sole) for the ur ose of udicial or blenderized formulas are excluded regardless of whether they are the sole source of administrative proceedings or research except emergency examination of a child ordered by nutrition. judicial authorities. 11. Nutritional and electrolyte substances except as specifically described in Miscellaneous 36. Non-medical self-care or self-help training. Medical Services And Supplies. 12. Physical, occupational, or speech therapy 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, py or chiropractic services when there is no except as described in Professional Services. reasonable expectation that the condition will improve over a predictable period of time. 13. Reversal of voluntary sterilization. 38. Coverage for costs associated with translation of medical records and claims to English. 39. Treatment for superficial veins, also referred to as spider veins or telangiectasia. MIC PP MN HSA (3/12) 78 2500-100% MIC PP MN HSA (3/12) 79 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Exclusions How To Submit A Claim 40. Services not received from or under the direction of a physician, except as described in this certificate. 41. Orthognathic surgery. Z. How To Submit A Claim 42. Sensory integration, including auditory integration training. 43. Services for or related to vision therapy and orthoptic and/or pleoptic training, except as This section describes the process for submitting a claim. described in Professional Services. See Definitions These words have specific meanings: benefits, claim, member, 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, network, rionnetwork, non-network provider reimbursement amount, provider Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Intervention (IBI), and Lovaas therapy. Behavioral Claims for benefits from network providers 45. Health care professional services for maternity labor and delivery in the home. If you receive a bill for any benefit from a network provider, you may submit the claim following 46. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and the procedures described below, under Claims for benefits from non-network providers, or call subsequent procedures. d Customer Service at one of the telephone numbers listed inside the front cover. Claim forms 47. Services for the treatment of infertility. may also be obtained by signing in at www.mymedica.com. 48. Infertility drugs. Network providers are required to submit claims within 180 days from when you receive a 49. Acupuncture. 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 50. Services solely for or related to the treatment of snoring. paying the cost of the service you received. 51. Interpreter services. 52. Services provided to treat injuries or illness that are the result of committing a crime Claims for benefits from non-network providers attempting to commit a crime. 9 e or Claim forms are provided in your enrollment materials. You may request additional claim forms 53. Services for private duty nursing, except as described in Home Health Care. Exam les of by calling Customer Service at one of the telephone numbers listed inside the front cover. private duty nursing services include, but are not limited to, skilled or unskilled services Claim forms may also be obtained by signing in at www.mymedica.com. If the claim forms are provided by an independent nurse who is ordered the member or the member's not sent to you within 15 days, you may submit an itemized statement without the claim form to representative, and not under the direction of a physician. Medica. You should retain copies of all claim forms and correspondence for your records. 54. Laboratory testing that has been performed in response to direct-to-consumer marketing You must submit the claim in English along with a Medica claim form to Medica no later than and not under the direction of a physician. 365 days after receiving benefits. Your Medica member number must be on the claim. g 55. Medical devices that are not approved Mail to the address identified on the back of your identification card. other than those granted a humanitarian device exemption. d Drug Administration (FDA) Upon receipt of your claim for benefits from non-network providers, Medica will generally pay to 56. Health clubs, you directly the non-network provider reimbursement amount. Medica will only pay the provider 57. Long-term care. of services if: 1. The non-network provider is one that Medica has determined can be paid directly; and 58. Expenses associated with participation in weight loss programs, including but not limited membership fees and the purchase of food, dietary supplements, or publications. to 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 PP MN HSA (3/12) 80 2500-100% MIC PP MN HSA(3/12) 81 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 How To Submit A Claim Coordination Of Benefits Claims for services provided outside the United States Claims for services rendered in a foreign country will require the following additional documentation: AA. Coordination Of Benefits • Claims submitted in English with the currency exchange rate for the date health services were received. es This section describes how benefits are coordinated when you are covered under more than • Itemization of the bill or claim. one plan. • The related medical records (submitted in English). See Definitions These words have specific meanings benefits, claim, deductible, dependent,' emergency, hospital, member,,non network,non network provider reimbursement amount, • Proof of your payment of the claim. ¢provider, subscriber. • A complete copy of your passport and airline ticket. • Such other documentation as Medica may request. 1. Applicability For services rendered in a foreign country, will pay a. This coordination of benefits (COB) provision applies to this plan when an employee or ry p y you directly. Medica will not reimburse you for costs associated with translation of medical records or claims. the employee's covered dependent has health care coverage under more than one plan. Plan and this plan are defined below. Time limits 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 If you have a complaint or disagree with a decision by Medica, you may follow the complaint determined before or after those of another plan. Under Order of benefit determination procedure outlined in Complaints or you may initiate legal action at an rules, the benefits of this plan: y y g y point. However, you may not bring legal action more than six years after Medica has made a coverage i. Shall not be reduced when this plan determines its benefits before another plan; but determination regarding your claim. 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. MICPPMNHSA (3/12) 82 2500-100% MIC PP MN HSA (3/12) 83 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Coordination Of Benefits 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 b)plans, and may be a secondary plan as to a different plan or boe se rt , e its f teed plans. on If e parent th par longer nts have are the determined before hday the those of nef the o plan he which plan which covered cov the other parent for a shorter period of time. 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 However, if the other plan does not have the rule described in (a) immediately above, covering the person for whom the claim is made. Allowable expense does not include but instead has a rule based on the gender of the parent, and if, as a result, the the deductible for members with a primary high deductible plan and who notify Medica of plans do not agree on the order of benefits, the rule in the other plan will determine an intention to contribute to a health savings account. the order of benefits. The difference between the cost of a private hospital room and the cost of a semi-private iii. Dependent child/separated or divorced parents. If two or more plans cover a person hospital room is not considered an allowable expense under the above definition unless as a dependent child of divorced or separated parents, benefits for the child are the patient's stay in a private hospital room is medically necessary, either in terms of determined in this order: generally accepted medical practice or as specifically defined in the plan. a) First, the plan of the parent with custody of the child; The difference between the charges billed by a provider and the non-network provider b) Then, the plan of the spouse of the parent with the custody of the child; and reimbursement amount is not considered an allowable expense under the above definition. c) Finally, the plan of the parent not having custody of the child. When a plan provides benefits in the form of services, However, if tfhper specific terms of xapceonuaert decree state that one of the parents is value of each service rendered will be considered both an allowable e expense and cash benefit paid. or provide the benefits of the plan of that parent has actual knowledge of those pay When benefits are reduced under a primary p p g p ry plan because a member does not comply terms, the benefits of that plan are determined first. The plan of the other parent with the plan provisions, the amount of such reduction will not be considered an shall be the secondary plan. This paragraph does not apply with respect to any allowable expense. Examples of such provisions are those related to second surgical claim determination period or plan year during which any benefits are actually paid or opinions, and preferred provider arrangements. provided before the entity has that actual knowledge. e. Claim determination period means a calendar year. However, it does not include any iv. Joint custody. If the specific terms of a court decree state that the parents shall part of a year during which a person has no coverage under this plan, or any part of a share joint custody, without stating that one of the parents is responsible for the year before the date this COB provision or a similar provision takes effect. health care expenses of the child, the plans covering follow the Order of benefit determination rules outlined in 3.b.ii. 3. Order of benefit determination rules v. Active/inactive employee. The benefits of a plan which covers a person as an a. General. When there is a basis for a claim under this plan and another plan, this plan is employee who is neither laid off nor retired (or as that employee's dependent) are a secondary determined before those of a plan which covers that person as a laid off or retired ry plan which has its benefits determined after those of the other plan, unless: employee (or as that employee's dependent). If the other plan does not have this i. The other plan has rules coordinating its benefits with the rules of this plan; and rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ii. Both the other plan's rules and this plan's rules, in 3.b. below, require that this plan's ignored. benefits be determined before those of the other plan. vi. Workers'compensation. Coverage under any workers' compensation act or similar b. Rules. This plan determines its order of benefits using the first of the following rules law applies first. You should submit claims for expenses incurred as a result of an which applies: on-duty injury to the employer, before submitting them to Medica. vii. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance i. Nondependent/dependent. The benefits of the plan that covers the person as an Act or similar law applies first. employee, member or subscriber (that is, other than as a dependent) are determined viii. Longer/shorter length of coverage. If none of the above rules determines the order 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. 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 below, when this plan and another plan cover the same child as a dependent of for the shorter term. different persons, called parents: a) The benefits of the plan of the parent whose birthday falls earlier in a year are 4. Effect on the benefits of this plan determined before those of the plan of the parent whose birthday falls later in that year; but 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 PP MN HSA (3/12) 84 2500-100% MIC PP MN HSA(3/12) 85 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Coordination Of Benefits Right Of Recovery 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 BB. Right Of Recovery of: hen the sum ; i. The benefits that would be payable for the allowable expense under this plan in absence of this COB provision; and p n the 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 ii. The benefits that would be payable for the allowable expenses under the other plans, subrogation rights, contact an attorney. 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 See Definitions This word has a specific meaning benefits.=; period. In that case, the benefits of this plan will be reduced so that they and the 1. Medica has a right of subrogation against any third party, individual, corporation, insurer, or expenses.payable under the other plans do not total more than those allowable other entity or person who may be legally responsible for payment of medical expenses expenses. . related to your illness or injury. Medica's right of subrogation shall be governed according to When the benefits of this plan are reduced as described above, each benefit is reduced 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 in proportion. It is then charged against any applicable benefit limit of this plan. your illness or injury. 2. Medica's subrogation interest is the reasonable cash value of any benefits received by you. 5. Right to receive and release needed information 3. Medica's right to recover its subrogation interest may be subject to an obligation by Medica Certain facts are needed to apply these COB rules. Medica has the right to decide which to pay a pro rata share of your disbursements, attorney fees and costs, and other expenses facts it needs. It may get needed facts from or give them to any other organization or g recovery separately person. Medica need not tell, or get the consent of, any incurred in obtaining a recove from another source unless Medica is se aratel applicable federal or state law prevents disclosure of the pinformation d this. the consent of represented by an attorney. If Medics is represented by an attorney, an agreement regarding allocation may be reached. If an agreement cannot be reached, the matter must the patient or the patient's representative, each person claiming benefits under this plan be submitted to binding arbitration. must give Medica any facts it needs to pay the claim. 4. By accepting coverage under the Contract, you agree: 6. Facility of payment 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, A payment made under another plan may include an amount which should have law. been paid you are obligated to reimburse Medica for the benefits paid in accordance to Minnesota under this plan. If it does, Medica may p payment. That amount will then be treated as though t were a benefit paid under this that b. subrogation To cooperate with Medica to or its designee to help protect a may legal rights under this Medica will the form of pay that amount again. The term payment made includes providin subrogation provision and to provide all information Medica may reasonably request to plan. benefits in the form of services, in which case payment made means reasonable cash vale determine its rights under this provision. of the benefits provided in the form of services. c. To provide prompt written notice to Medica when you make a claim against a party for 7. Right of recovery injuries. d. To do nothing to decrease Medica's rights under this provision, either before or after If the amount of the payments made by Medica is more than it should have paid under this receiving benefits, or under the Contract. COB provision, it may recover the excess from one or more of the following: e. Medica may take action to preserve its legal rights. This includes bringing suit in your a. The persons it has paid or for whom it has paid; or name. b. Insurance companies; or f. Medica may collect its subrogation interest from the proceeds of any settlement or c. Other organizations. judgment recovered by you, your legal representative, or the legal representative(s) of your estate or next-of-kin. 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 PP MN HSA (3/12) 86 2500-100% MIC PP MN HSA(3/12) 87 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 E Eligibility And Enrollment Eligibility And Enrollment CC. Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The tion; s time period does not apply to newborns or children newly adopted or placed for adoption; see j 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 This section describes who can enroll and how to enroll. S eligible employee and dependents the next who do not enro during the initial enro men period may. See'Definrtions These words have°specific meanings: benefits, enroll for coverage during the next open enrollmentll anylapplicable •special) enrollment periods, g efits, cont,nuous coverage, f s; or as a late entrant (if applicable, as described below). dependent, late. entrant, member, mental disorder, physician, placed for ado qualifying coverage, subscriber; waiting period : ; adoption, premium; � 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. Who can enroll To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract Open enrollment and be a subscriber or dependent as defined in this certificate. See Definitions. A minimum 14-day period set by the employer and Medics each year during which eligible employees and dependents who are not covered under the Contract may elect coverage for the How to enroll upcoming Contract year. An application must be submitted to the employer for yourself and any dependents. 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 Special enrollment 2. During the open enrollment period as described in this section under Open enrollment or Special enrollment periods are provided to eligible employees and dependents under certain 3. During a special enrollment period as described in this section under Special enrollment; or circumstances. 1. Loss of other coverage 4. any other time for consideration as a late entrant as described in this section under Late enrollment. individual was covered under Medicaid or a State Children's Health Insurance Plan and e is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical lost that coverage as a result of loss of eligibility. The eligible employee or dependent Child Support Order(QMCSO) and 6. under Special enrollment. must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. Notification 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 dependens. In the case of a You must notify the employer in writing within 30 days of the effective date of any changes to dependent's loss of coverage, this special enrollment period applies to both the address or name, addition or deletion of dependents, a dependent child reaching the dependent dependent who has lost coverage and the eligible employee. limiting age, or other facts identifying Y g you or your dependents. (For dependent children,pen b. A special enrollment period will apply to er eligible employee and dependent if the notification period is not limited to 30 days for newborns or children newly adopted or newly eligible employee or dependent was covered under qualifying coverage other than placed for adoption; however, we encourage you to enroll your newborn dependent under the Y Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or 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 dependent was eligible to enroll under the Contract, whether during initial enrollment, the subscriber, and any child who is a member pursuant to a QMCSO will be covered without open enrollment, or special enrollment, and declined coverage for that reason. application of health screening or waiting periods. 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 The employer must notify Medics, as set forth in the Contract, of your initial enrollment contributions toward the prior coverage have terminated, and request enrollment in application, changes to your name or address, or changes to enrollment, including if you or our writing within 30 days of the date of the loss of coverage or the date the employer's dependents are no longer eligible for coverage. Y contribution toward that coverage terminates, or the date on which a claim is denied due Initial enrollment to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.: A 30-day time period starting with the date an eligible employee and dependents are first i. Prior coverage does not include federal or state continuation coverage; eligible to enroll for coverage under the Contract. An eligible employee must enroll within this MIC PP MN HSA (3/12) 88 2500-100% MIC PP MN HSA(3/12) 89 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Eligibility And Enrollment Eligibility And Enrollment ii. Loss of eligibility includes: • losing coverage as a result of the eligible employee or dependent incurring a • loss of eligibility as a result of legal separation, divorce, death, termination of claim that meets or exceeds the lifetime maximum limit on all benefits and no employment, COBRA or state continuation coverage is available; or mployment, reduction in the number of hours of employment; • cessation of dependent status; • if the prior coverage was offered through a health maintenance organization • incurring a claim that causes the eligible employee or dependent to meet or (HMO), losing coverage because the eligible employee or dependent not longer exceed the lifetime maximum limit on all benefits; resides or works in the HMO's service area and no other COBRA or state • if the prior coverage was offered through an individual health maintenance continuation coverage is available. organization (HMO), a loss of coverage because the eligible employee or ii. Exhaustion of COBRA or state continuation coverage does not include a loss due to dependent no longer resides or works in the HMO's service area; failure ti the of coverage employee or dependent to pay premiums on a timely basis or • if the prior coverage was offered through a group HMO, a loss of coverage termination of coverage for cause. because the eligible employee or dependent no longer resides or works in the iii. In the case of the eligible employee's exhaustion of COBRA or state continuation HMO's service area and no other coverage option is available; and coverage, the special enrollment period described above applies to the eligible employee and all of his or her dependents. In the case of al dependent's exhaustion • the prior coverage no longer offers any benefits to the class of similarly situated of COBRA or state continuation coverage, the special enrollment period described individuals that includes the eligible employee or dependent. above applies only to the dependent who has lost coverage and the eligible iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is employee. eligible for or elects applicable federal or state continuation coverage; 2. The dependent is a new spouse of the subscriber or eligible employee, provided that the iv. Loss of eligibility does not include a loss due to failure of the eligible employee or marriage is legal and enrollment is requested in writing within 30 days of the date of dependent to pay marriage and provided that the eligible employee also enrolls during this special enrollment p y premiums on a timely basis or termination of coverage for cause; period; 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. 3. The dependent is a new dependent child of the subscriber or eligible employee, provided In the case of a dependent's loss of other coverage, the special enrollment period . 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 described above applies only to the dependent who has lost coverage and the eligible days for newborns or children newly adopted or newly placed for adoption) and provided employee. g g that the eligible employee also enrolls during this special enrollment period; 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 4. The dependent is the spouse of the subscriber or eligible employee through whom the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or dependent child described in 3. above claims dependent status and: a. That spouse is eligible for coverage; and 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. b. Is not already enrolled under the Contract; and The eligible employee or dependent must present evidence that the eligible employee or c. Enrollment is requested in writing within 30 days of the dependent child becoming a dependent has exhausted such COBRA or state continuation coverage and has not lost dependent; and such coverage due to failure of the eligible employee or dependent to pay premiums on d. The eligible employee also enrolls during this special enrollment period; or a timely basis or for cause, and request enrollment in writing within 30 days of the date of the exhaustion of coverage. 5. The dependents are eligible dependent children of the subscriber or eligible employee and For purposes of 1.c.: 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 i. Exhaustion of COBRA or state continuation coverage includes: enrolls during this special enrollment period. • losing COBRA or state continuation coverage for any reason other than those set 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as forth in ii. below 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 losing coverage as a result of the employer's failure to remit premiums on a period. • timely basis; MIC PP MN HSA (3/12) 90 2500-100% MIC PP MN HSA (3/12) 91 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Eligibility And Enrollment Late enrollment Eligibility And Enrollment 2. For eligible employees and dependents who enroll during the open enrollment period, An eligible employee or an eligible employee and dependents who do not enroll for coverage coverage begins on the first day of the Contract year for which the open enrollment period offered through the employer during the initial or open enrollment period or any applicable erage was held. special enrollment period will during considered late entrants. 3. For eligible employees and/or dependents who enroll during r special enrollment period, Late entrants who have maintained continuous coverage may enroll and coverage will coverage begins on the date indicated below for the particular special enrollment. In the effective the first day of the month following date of Medica's approval g be enrollment. Continuous coverage will be determined to have been maintained request for case of: requests enrollment within 63 days after prior qualifying coverage ends. a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first e late entrant Individuals who have not maintained continuous coverage may not enroll as late en calendar month following the date on which the request for enrollment is received by Medics; An eligible employee or dependent who: entrants. b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of 1. does not enroll during an initial or open enrollment period or any applicable special adoption or placement for adoption, date of adoption or placement. In all other cases, enrollment period; and the date the subscriber acquires the dependent child; 2. is an enrollee of period; at the time Medica offers or renews coverage with the employer, c. Number 4. under Special enrollment, the date coverage for the dependent child is provided the eligible subscriber or dependent maintains continuous coverage effective, as set forth in 3.b. above; will not be considered a late entrant and will be allowed to enroll. Coverage will be effective d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. determined by Medica. or 3. under Special enrollment becomes effective; ctive as e. Number 6. under Special enrollment, the first day of the first calendar month following Qualified Medical Child Support Order(QMCSO) the date the completed request for enrollment is received by Medics. 4. For eligible employees and/or dependents who enroll during late enrollment, coverage Medica will provide coverage in accordance with a QMCSO pursuant to the applicable begins on the first day of the month following date of Medica's approval of the request for requirements under Section 609 of the Employee Retirement Income Security Act (ERISA)1908 of the Social Security Act. It is the employer's responsibility to determine enrollment. a medical child support order is qualified. ) and ne whether Upon receipt of a medical child support order issued by an appropriate agency, the employer will follow its established procedures in determining het her the medical child support order is qualified. The employer will provide Medica with notice of a QMCSO 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 and the persons specified in the order. y s determination to • 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 th enrollment period. the special • p ial 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. 1 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 eri coverage begins on the effective date specified in the Contract. p od, 2500-100 MIC PP MN HSA (3/12) 92 2500-100% MIC PP MN HSA(3/12) 93 BPL 21285 DOC 23751 BPL 21285 DOC 23751 Ending Coverage Ending Coverage DD. 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. This section describes when coverage ends under the Contract. When this happens 7. The end of the month following the date you enter active military duty for more than 31 days. exercise your right to continue or convert your coverage as described in Continuation you may Upon completion of active:mi lit ary duty, contact the employer for reinstatement of coverage; Conversion.Sonversnitions 8. The date of the death of thember. In the event of the subscriber's death, coverage for These words havespecif�c meanings certification of ua1a the subscriber's dependents will terminate the end of the month in which the subscriber's claim, dependent, member, premium, subscriber ;t: q tY+ng`coverage, s£ - death occurred; You have the right to a certification of qualifying coverage ' Y 9 overage when coverage ends. You will 9• For a spouse, the end of the month following the date of divorce; receive a certification of qualifying coverage when coverage ends. You may also request 10. For a dependent child, the end of the month in which the child is no longer eligible as a certification of qualifying coverage at any time while you are covered under the Contract oa within the 24 months following the date your coverage ends. To request a certification of dependent; or qualifying coverage, call Customer Service at one of the telephone numbers listed inside the 11 earliesthof the fol owinitl odccu soverage through a QMCSO, the end of the month in which the front cover. Upon receipt of your request, the certification of qualifying coverage will be issued g as soon as reasonably possible. a. The QMCSO ceases to be effective; or When coverage ends 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 Unless otherwise specified in the Contract, coverage ends the earliest of the following: d. The employee who is ordered by the QMCSO to provide coverage is no longer eligible 1. The end of the month in which the Contract is terminated by the employer or Medica in T determined by the employer; or accordance with the terms of the Contract. If terminated by Medica, Medica will notify each e. The employer terminates family or dependent coverage; or 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 f. The Contract is terminated by the employer or Medica; or premium; oward the g. The relevant premium or contribution toward the premium is last paid. 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 d the employer to terminate coverage; end. You must notify 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. 1 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 NC PP MN HSA (3/12) 94 2500-100% MIC PP MN HSA(3/12) 95 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Continuation Continuation • ;I EE. 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: This section describes continuation coverage provisions. When coverage ends, members may a. Death of the subscriber; be able to continue coverage under state law, federal law, or both. All aspects of continuation coverage administration are the responsibility of the employer. b. A termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; See Definitions. These words have specific meanings: benefits,dependent, member, placed for adoption, Premium, subscriber, total disability. c. Dissolution of marriage from the subscriber; The paragraph below describes the continuation coverage provisions. State contin d. The subscriber's enrollment for benefits under Medicare. described in 1. and federal continuation is described in 2. uation is If your coverage ends, you should review your rights under both state law and federal Subscriber's child's loss the employer. If you are entitled to continuation rights under both, the continuation provisions The the Contract subscriberis's lost dependent for any of child the has following the right reasons:to continuation coverage if coverage under �, . run concurrently and the more favorable continuation provision will apply to your coverage.tion to enroll in an p coverage; When your continuation coverage under this section ends you have the option a. Death of the subscriber if the subscriber is the parent through whom the child receives !` individual conversion health plan as described in Conversion. b. Termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; 1. Your right to continue coverage under state law c. The subscriber's dissolution of marriage from the child's other parent; Notwithstanding the provisions regarding termination of coverage described in End" d. The subscriber's enrollment for benefits under Medicare if the subscriber is the parent Coverage, you may be entitled to extended or continued coverage as follows: mg through whom the child receives coverage; j a. Minnesota state continuation coverage. Continued coverage shall be provided as required under Minnesota law. Minnesota e. The subscriber's child ceases to be a dependent child under the terms of the Contract. Responsibility to inform 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 Under plo er of a disso ut on of marriaee or a hild losin dependents devendent statuslunlder the Contract 1 such continuation coverage will be provided. em y g g p b. Notice of rights. within 60 days of the date of the event or the date on which coverage would be lost because Minnesota law requires that covered employees and their dependents (spouse and/or Election the eneng dependent children) be offered the opportunity to pay for a temporary extension of health Election rights coverage (called continuation coverage) at group rates in certain instances where health When the employer is notified that one of these events has happened, the subscriber and 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 the subscriber's dependents will be notified of the right to continuation coverage. under the continuation coverage provision of Minnesota law. It is intended that no greater Consistent with Minnesota law, the subscriber and dependents have 60 days to elect rights be provided than those required by Minnesota law. Take time to read this section continuation coverage for reasons of termination of the subscriber's employment or the carefully. subscriber's enrollment for benefitso under Medicare measured from the later of: Subscriber's loss a. The date coverage would be lost because of one of the events described above; or The subscriber has the right to continuation of coverage for him or herself and his or her b. The date notice of election rights is received. dependents if there is a loss of coverage under the Contract because of the subscriber's If continuation coverage is elected within this period, the coverage will be retroactive to the voluntary or involuntary termination of employment (for any reason other than gross er's date coverage would otherwise have been lost. misconduct) or layoff from employment. In this section, layoff from employment means a The s sucib 's epeov reduction in hours to the point where the subscriber is no longer eligible for coverage under behalf ubscriber of othe dependents and the bs entitled r er to cover continuation d s ouse coverage.may el ct Under certain continuation cic rcerage umstancon , the Contract. the subscriber'r s do es covered spo lect use or dependent child may elect continuation coverage even es if tb e continuation coverage. If he continuation subscrier coverage not is not elected, your coverage under the Contract will end. MIC PP MN HSA (3/12) 96 2500-100% MIC PP MN HSA (3/12) 97 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Continuation Continuation Type of coverage and cost ii. The date coverage would otherwise terminate under the Contract. If continuation coverage is elected, the subscriber's employer is required to provide e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent coverage that, as of the time coverage is being provided, is identical to the coverage children may be continued until the earlier of: provided under the Contract to similarly situated employees or employees' dependents. i. The date the surviving spouse and dependent children become covered under Under Minnesota law, a person continuing coverage may have to make a monthly payment another group health plan; or 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. ii. The date coverage would have terminated under the Contract had the subscriber lived. Surviving dependents of a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. When your continuation coverage under this section ends, you have the option to enroll in an individual conversion health plan (as described in Conversion). Duration Extension of benefits for total disability of the subscriber 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 may be extended for a subscriber and his or her dependents in instances where coverage as follows: 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, a. For instances where coverage is lost due to the subscriber's termination of or layoff from payment shall be made to the employer. The amount charged cannot exceed 100 percent employment, coverage may be continued until the earliest of: of the cost of the coverage. 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 2. Your right to continue coverage under federal law employee or otherwise) that does not contain any exclusion or limitation with respect to any applicable pre-existing condition; or Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: iii. The date coverage would otherwise terminate under the Contract. b. For instances where the subscriber's spouse or dependent children lose coverage COBRA continuation coverage because of the subscriber's enrollment under Medicare, coverage may be continued Continued coverage shall be provided as required under the Consolidated Omnibus Budget until the earliest of: Reconciliation Act of 1985 (COBRA), as amended (as well as the Public Health Service Act i. 36 months after continuation was elected; (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 ii. The date coverage is obtained under another group health plan; or General COBRA information in this section. iii. The date coverage would otherwise terminate under the Contract. USERRA continuation coverage c. For instances where dependent children lose coverage as a result of loss of dependent eligibility, coverage may be continued until the earliest of: Continued coverage shall be provided as required under the Uniformed Services i. 36 months after continuation was elected; 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 ii. The date coverage is obtained under another group health plan; or iii. The date coverage would otherwise terminate under the Contract. this section. d. For instances of dissolution of marriage from the subscriber, coverage of the General COBRA information subscriber's spouse and dependent children may be continued until the earliest of: 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 i. The date the former spouse becomes covered under another group health plan; or ii. The date coverage would otherwise terminate under the Contract. extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under employer sponsored group health plan(s) would If a dissolution of marriage occurs during the period of time when the subscriber's otherwise end. This coverage is a group health plan for purposes of COBRA. spouse is continuing coverage due to the subscriber's termination of or layoff from This section is intended to inform you, in summary fashion, of your rights and obligations employment, coverage of the subscriber's spouse may be continued until the earlier of: 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. i. The date the former spouse becomes covered under another group health plan; or MIC PP MN HSA (3/12) 98 2500-100% MIC PP MN HSA(3/12) 99 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Continuation . Continuation Qualified beneficiary Also, a subscriber and dependent who have been determined to be disabled under the For purposes of this section, a qualified beneficiary is defined as: Social Security Act as of the time of the subscriber's termination of employment or reduction a. A covered employee (a current or former employee who is actually covered under a of hours or within 60 days of the start of the continuation period must notify the employer of group health plan and not just eligible for coverage); 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 b. A covered spouse of a covered employee; or the determination. c. A dependent child of a covered employee. (A child placed for adoption with or born to Bankruptcy an employee or former employee receiving COBRA continuation coverage is also a qualified beneficiary.) Rights similar to those described above may apply to retirees (and the spouses and Subscriber's loss dependents of those retirees), if the subscriber's employer commences a bankruptcy proceeding and these individuals lose coverage. The subscriber has the right to elect continuation of coverage if there is a loss of coverage under the Contract because of termination g Election rights mmati on of the subscriber's employment (for any reason g other than gross misconduct), or the subscriber becomes ineligible to participate under the When notified that one of these events has happened, the employer will notify the terms of the Contract due to a reduction in his or her hours of employment. subscriber and dependents of the right to choose continuation coverage. Subscriber's spouse's loss Consistent with federal law, the subscriber and dependents have 60 days to elect The subscriber's covered spouse has the right to choose continuation coverage if he or she a continuation The date coverage would beast becauseeof one of the events described loses coverage under the Contract for any of the following reasons: above; or a. Death of the subscriber; b. The date notice of election rights is received. b. A termination of the subscriber's employment (for any reason other than gross If continuation coverage is elected within this period, the coverage will be retroactive to the misconduct) or reduction in the subscriber's hours of employment with the employer; date coverage would otherwise have been lost. 1 c. Divorce or legal separation from the subscriber; or The subscriber and the subscriber's covered spouse may elect continuation coverage on behalf of other dependents entitled to continuation coverage. However, each person d. The subscriber's entitlement to (actual coverage under) Medicare. entitled to continuation coverage has an independent right to elect continuation coverage. Subscriber's child's loss The subscriber's covered spouse or dependent child may elect continuation coverage even if the subscriber does not elect continuation coverage. The subscriber's dependent child has the right to continuation coverage if coverage under If continuation coverage is not elected, your coverage under the Contract will end. 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 Type of coverage and cost coverage; If the subscriber and the subscriber's dependents elect continuation coverage, the employer b. The subscriber's termination of employment (for any reason other than gross is required to provide coverage that, as of the time coverage is being provided, is identical to misconduct) or reduction in the subscriber's hours of employment with-the employer; the coverage provided under the Contract to similarly situated employees or employees'dependents. 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 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 i parent through whom the child receives coverage; or the cost of the coverage. The amount may be increased to 150 percent of the applicable e. The subscriber's child ceases to be a dependent child under the terms of the Contract. premium for months after the 18th month of continuation coverage when the additional months are due to a disability under the Social Security Act. Responsibility to inform There is a grace period of at least 30 days for the regularly scheduled premium. 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 Duration of COBRA coverage Contract within 60 days of the date of the event, or the date on which coverage would be lost because of the event. 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 PP MN HSA(3/12) 100 2500-100% MIC PP MN HSA (3/12) 101 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Continuation Continuation The 18 months may be extended if a second event (e.g., divorce, legal separation, or death) Guard duty, and the time necessary for a person to be absent from employment for an occurs during the initial 18-month period. It also may be extended to 29 months in the case examination to determine the fitness of the person to perform any of these duties. of an employee or employee's dependent who is determined to be disabled under the Social Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army Security Act at the time of the employee's termination of employment or reduction of hours, National Guard, and the Air National Guard, when engaged in active duty for training, or within 60 days of the start of the 18-month continuation period. inactive duty training, or full-time National Guard duty, and the commissioned corps of the If an employee or the employee's dependent is entitled to 29 months of continuation Public Health Service. 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) Election rights Medicare, the continuation period for the subscriber's dependents is 36 months measured The employee or the employee's authorized representative may elect to continue the from the date of the subscriber's Medicare entitlement even if that entitlement does not employee's coverage under the Contract by making an election on a form provided by the cause the subscriber to lose coverage. employer. The employee has 60 days to elect continuation coverage measured from the Under no circumstances is the total continuation period greater than 36 months from the date date coverage would be lost because of the event described above. If continuation of the original event that triggered the continuation coverage. coverage is elected within this period, the coverage will be retroactive to the date coverage Federal law provides that continuation coverage may end earlier for any of the following would otherwise have been lost. The employee may elect continuation coverage on behalf reasons: 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 a. The subscriber's employer no longer provides group health coverage to any of its available for the spouse or dependent children. In addition, even if the employee does not employees; elect USERRA continuation, the employee has the right to be reinstated under the Contract b. The premium for continuation coverage is not paid on time; upon reemployment, subject to the terms and conditions of the Contract. c. Coverage is obtained under another group health plan (as an employee or otherwise) Type of coverage and cost that does not contain any exclusion or limitation with respect to any applicable pre- If the employee elects continuation coverage, the employer is required to provide coverage existing condition; or that, as of the time coverage is being provided, is identical to the coverage provided under d. The subscriber becomes entitled to (actually covered under) Medicare. 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 Continuation coverage may also end earlier for reasons which would allow regular coverage to days, in which case the employee is not required to pay more than the amount that they be terminated, such as fraud. would have to pay as an active employee for that coverage. There is a grace period of at General USERRA information least 30 days for the regularly scheduled premium. USERRA requires employers to offer employees and their families (spouse and/or Duration of USERRA coverage dependent children) the opportunity to pay for a temporary extension of health coverage When an employee takes a leave for service in the uniformed services, coverage for the (called continuation coverage) at group rates in certain instances where health coverage employee and dependents for whom coverage is elected begins the day after the employee under employer sponsored group health plan(s) would otherwise end. This coverage is a would lose coverage under the Contract. Coverage continues for up to 24 months. group health plan for the purposes of USERRA. Federal law provides that continuation coverage may end earlier for any of the following This section is intended to inform you, in summary fashion, of your rights and obligations reasons: 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. a. The employer no longer provides group health coverage to any of its employees; Employee's loss b. The premium for continuation coverage is not paid on time; The employee has the right to elect continuation of coverage if there is a loss of coverage c. The employee loses their rights under USERRA as a result of a dishonorable discharge under the Contract because of absence from employment due to service in the uniformed or other undesirable conduct; services, and the employee was covered under the Contract at the time the absence began, d. The employee fails to return to work following the completion of his or her service in the and the employee, or an appropriate officer of the uniformed services, provided the uniformed services; or employer with advance notice of the employee's absence from employment (if it was possible to do so). e. The employee returns to work and is reinstated under the Contract as an active employee. Service in the uniformed services means the performance of duty on a voluntary or Continuation coverage may also end earlier for reasons which would allow regular coverage involuntary basis in the uniformed services under competent authority, including active duty, to be terminated, such as fraud. active duty for training, initial active duty for training, inactive duty training, full-time National MIC PP MN HSA (3/12) 102 2500-100% MIC PP MN HSA (3/12) 103 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Continuation Conversion COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation FF. Conversion coverage in addition to USERRA continuation coverage, these coverages run concurrently. See Definitions. These words$have specific meanings:'benefits,continuous coverage,. dependent, network, premium, provider, 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. If you commit fraud or material misrepresentation in applying for continuation or conversion of coverage. MIC PP MN HSA (3/12) 104 2500-100% MIC PP MN HSA(3/12) 105 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Conversion Complaints 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. GG. Complaints What you must do I' 1. For conversion coverage information, call Customer Service at one of the telephone This section describes what to do if you have a complaint or would like to appeal a decision numbers listed inside the front cover. made by Medica. 2. Pay premiums to Medics or Medica's designated conversion ve ndor within 63 days after See Definitions. These;words§have spec f c meanings °iclaim, inpatient, network, provider your coverage ends or within 31 days of the date you were notified of your right to convert You may call Customer Service at one of the telephone numbers listed inside the front cover or coverage, whichever is later. You will be required to include your first month premium by writing to the address below in First level of review, 2. You also may contact the payment with your enrollment form for conversion coverage. Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296-2488 or 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 63 1-800-657-3602. days after your coverage ends or within 31 days of the date you were notified of your right to Filing a complaint may require that Medica review your medical records as needed to resolve convert, whichever is later. You may include only those dependents who were enrolled your complaint. under the Contract at the time of conversion. You may appoint an authorized representative to make a complaint on your behalf. You may be What the employer must do required to sign an authorization which will allow Medica to release confidential information to The employer is required to notify your authorized representative and allow them to act on your behalf during the complaint y you of your right to convert coverage. process. Residents of a state other than Minnesota 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 This section describes your right to convert to an individual conversion plan if you are a resident upon request. of a state other than Minnesota on the day that you submit an enrollment form to Medics or In addition to directing complaints to Customer Service as described in this section, you may Medica's designated conversion vendor. direct complaints at any time to the Commissioner of Commerce at the telephone number listed Overview at the beginning of this section. You may convert to an individual conversion plan through Medica or Medica's designated First level of review 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 You may direct any question or complaint to Customer Service by calling one of the telephone Medica's designated conversion vendor. numbers listed inside the front cover or by writing to the address listed below. What you must do 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. 1. For conversion coverage information, call Customer Service at one of the telephone 2. For an oral complaint that does not require a medical determination in its outcome, if Medica numbers listed inside the front cover. does not communicate a decision within 10 business days from Medica's receipt of the 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after complaint, or if you determine that Medica's decision is partially or wholly adverse to you, your coverage ends or such other period of time as provided under applicable state law. Medica will provide you with a complaint form to submit your complaint in writing. Mail the You will be required to include your first month premium payment with your enrollment form completed form to: for conversion coverage. Customer Service 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 Route 0501 days after your coverage ends or such other period of time as provided under applicable PO Box 9310 state law. You may include only those dependents who were enrolled under the Contract at Minneapolis, MN 55440-9310 the time of conversion. 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 PP MN HSA (3/12) 106 2500-100%o MIC PP MN HSA(3/12) 107 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Complaints Complaints provider will have the opportunity to request an expedited review by telephone. Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be Alternatively, if Medica concludes that a delay could seriously jeopardize your life, health, or submitted for external review. ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without care or treatment you are requesting, Medica will process your claim as an Civil action expedited review. In such cases, Medica will notify you and your attending provider by telephone of its decision no later than 72 hours after receiving the request. If you are dissatisfied with Medica's first or second level review decision or the external review 5. If Medica's first level review decision upholds the initial decision made by Medica, you may decision, you have the right to file a civil action under section 502(a) of the Employee have a right to request a second level review or submit a written request for external review Retirement Income Security Act (ERISA). 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. Generally, a second level review is optional if the complaint requires a medical determination. 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 You must include a filing fee of$25 with 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. Medica may seek judicial review on grounds that the decision was arbitrary and capricious or involved an abuse of discretion. Contact the Commissioner of Commerce for more information about the external review process. MIC PP MN HSA (3/12) 108 2500-100% MIC PP MN HSA (3/12) 109 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 General Provisions General Provisions Discretionary authority Medica has discretion to interpret and construe all of the terms and conditions of the Contract HH. General Provisions and make determinations regarding benefits and coverage under the Contract; provided, however, that this provision shall not be construed to specify a standard of review upon which a This section describes the general provisions of the Contract. court may review a claim denial or any other decision made by Medica with respect to a member. See Definitions These words have specific meanings benefits, claim, dependent,,member, network, premium, Provider, subscriber. s= °r :n ... 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 PP MN HSA(3/12) 110 2500-100% MIC PP MN HSA (3/12) 111 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Definitions Definitions Convenience care/retail health clinic. A health care clinic located in a setting such as a retail Definitions store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. Cosmetic. Services and procedures that improve physical appearance but do not correct or In this certificate (and in any amendments), some words have specific meanings. Within each improve a physiological function, and that are not medically necessary, unless the service or i definition, you may note bold words. These words also are defined in this section. procedure meets the definition of reconstructive. Benefits. The health services or supplies (described in this certificate and any subsequent Custodial care. Services to assist in activities of daily living that do not seek to cure, are amendments) approved by Medica as eligible for coverage. 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 Certification of qualifying coverage. A written certification that group health plans and health services include help in walking, getting in or out of bed, bathing, dressing, feeding, using the insurance issuers must provide to an individual to confirm the qualifying coverage provided to toilet, preparation of special diets, and supervision of medication that can usually be self- the individual under the group health plan or health insurance. administered. Claim. An invoice, bill, or itemized statement for benefits provided to you. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims Coinsurance. The percentage amount you must pay to the provider for benefits received. for health services or supplies received from network or non-network providers are Full coinsurance payments may apply to scheduled appointments canceled less than 24 hours reimbursable as in-network or out-of-network benefits under this certificate. before the appointment time or to missed appointments. Dependent. Unless otherwise specified in the Contract, the following are considered For in-network benefits, the coinsurance amount is based on the lesser of the: dependents: 1. Charge billed by the provider (i.e., retail); or 1. The subscriber's spouse. 2. Negotiated amount that the provider has agreed to accept as full payment for the benefit 2. The following dependent children up to the dependent limiting age of 26: (i.e., wholesale). a. The subscriber's or subscriber's spouse's natural or adopted child; When the wholesale amount is not known nor readily calculated at the time the benefit is b. A child placed for adoption with the subscriber or subscriber's spouse; 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. c. A child for whom the subscriber or the subscriber's spouse has been appointed legal The provider's retail charge is the amount that the provider would charge to any patient, guardian; however, upon request by Medica, the subscriber must provide satisfactory whether or not that patient is a Medica member. proof of legal guardianship; For out-of-network benefits, the coinsurance will be based on the lesser of the: d. The subscriber's stepchild; and 1. Charge billed by the provider (i.e., retail); or 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. 2. Non-network provider reimbursement amount. � 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent For out-of-network benefits, in addition to any coinsurance and deductible amounts, you are incapable of self-sustaining employment by reason of developmental disability, mental responsible for any charges billed by the provider in excess of the non-network provider illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber reimbursement amount. for support and maintenance. An illness that does not cause a child to be incapable of self- i In addition, for the network pharmacies described in Prescription Drug Program and sustaining employment will not be considered a physical disability. This dependent may Prescription Specialty Drug Program, the calculation of coinsurance amounts as described remain covered under the Contract regardless of age and without application of health above do not include possible reductions for any volume purchase discounts or price screening or waiting periods. To continue coverage for a disabled dependent, you must adjustments that Medica may later receive related to certain prescription drugs and pharmacy provide Medica with proof of such disability and dependency within 31 days of the child services. reaching the dependent limiting age set forth in 2. above. Beginning two years after the The coinsurance may not exceed the charge billed by the provider for the benefit. child reaches the dependent limiting age, Medica may require annual proof of disability and dependency. Continuous coverage. The maintenance of continuous and uninterrupted qualifying For residents of a state other than Minnesota, the dependent limiting age may be higher if coverage by an eligible employee or dependent. An eligible employee or dependent is required by applicable state law. considered to have maintained continuous coverage if enrollment is requested under the Contract within 63 days of termination of the previous qualifying coverage. 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 1 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, MIC PP MN HSA(3/12) 112 2500-100% MIC PP MN HSA(3/12) 113 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Definitions Definitions you must provide Medica with proof of such disability and dependency at the time of the parameters approved by national health professional boards or associations, and entries in any dependent's enrollment. authoritative compendia as identified by the Medicare program for use in the determination of a Emergency. A condition or symptom (including severe pain) that a prudent layperson, who medically accepted indication of drugs and biologicals used off-label. possesses an average knowledge of health and medicine, would believe requires immediate treatment to: Late entrant. An eligible employee or dependent who requests enrollment under the Contract other than during: 1. Preserve your life; or 1. The initial enrollment period set by the employer; or 2. Prevent serious impairment to your bodily functions, organs, or parts; or 2. The open enrollment period set by the employer; or 3. Prevent placing your physical or mental health (or, if you are pregnant, the health of your 3. A special enrollment period as described in Eligibility And Enrollment. unborn child) in serious jeopardy. Enrollment date. The date of the eligible employee's or dependent's first day of coverage 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 under the Contract or, if earlier, the first day of the waiting period for the eligible employee's or the employer will not be considered a late entrant, provided the eligible employee or dependent's enrollment. g dependent maintains continuous coverage as defined in this certificate. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if In addition, a member who is a child entitled to receive coverage through a QMCSO is not the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing includes subject to any initial or open enrollment period restrictions. pharmacogenetic testing. Genetic testing does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Medically necessary. Diagnostic testing and medical treatment, consistent with the diagnosis For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. of and prescribed course of treatment for your condition, and preventive services. Medically Hos ital. A licensed facility that provides diagnostic, medical, therapeutic, rehabilitative, and necessary care must meet the following criteria: surgical services by, or under the direction of, a physician and with 24-hour R.N. nursing 1. Be consistent with the medical standards and accepted practice parameters of the services. The hospital is not mainly a place for rest or custodial care, and is not a nursing community as determined by health care providers in the same or similar general specialty home or similar facility. as typically manages the condition, procedure or treatment at issue; and In atient. An uninterrupted stay, following formal admission to a hospital, skilled nursing 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your facility, or licensed acute care facility. Inpatient services in a licensed residential treatment diagnosis or condition; and facility for treatment of emotionally disabled children will be covered as any other health 3. Help to restore or maintain your health; or condition. Investigative. As determined by Medica, a drug, device, diagnostic or screening 4. Prevent deterioration of your condition; or medical treatment or procedure is investigative if reliable evidence does not permit d conclusions 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. concerning its safety, effectiveness, or effect on health outcomes. Medica will make its Member. A person who is enrolled under the Contract. determination based upon an examination of the following reliable evidence, none of which shall be determinative in and of itself: Mental disorder. A physical or mental condition having an emotional or psychological origin, 1. Whether there is final approval as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders pproval from the appropriate government regulatory agency, if (DSM). 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 Network. A term used to describe a provider (such as a hospital, physician, home health treatment is the subject of ongoing Phase I, II, or III trials; agency, skilled nursing facility, or pharmacy) that has entered into a written agreement to 2. Whether there are consensus opinions and recommendations reported in relevant scientific provide benefits to you. The participation status of providers will change from time to time. and medical literature, peer-reviewed journals, or the reports of clinical trial committees and The network provider directory will be furnished automatically, without charge. other technology assessment bodies; and r Non-network. A term used to describe a provider not under contract as a network provider. 3. Whether there are consensus opinions of national and local health care providers in the Non-network provider reimbursement amount. The amount that Medica will pay to a non- applicable specialty or subspecialty that typically manages the condition as determined by a network provider for each benefit is based on one of the following, as determined by Medica: 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 1. A percentage provided. Medica Medicare enderally updates its foar on the amount Medi are a rs within accepted off-label use for the treatment of cancer will not be considered by Medica to be service is s after the Centers for Medicare and Medicaid Services updates its Medicare data; or investigative. Medica will determine if a use is an accepted off-label use based on published A percentage days p reports in authoritative peer-reviewed medical literature, clinical practice guidelines, or 2. A percentage of the provider's billed charge; or MIC PP MN HSA(3/12) 114 2500-100% MIC PP MN HSA(3/12) 115 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 D Definitions Definitions 3. A nationwide provider reimbursement database that considers prevailing reimbursement 3. With respect to members who are infants, children, and adole n rates and/or marketplace charges for similar services in the geographic area in which the p siv ts, evidence-informed service is provided; or preventive care and screenings provided for in the comprehensive guidelines supported by 4. An amount agreed upon between Medics and the non-network provider. the Health Resources and Services Administration; 4. With respect to members who are women, such additional preventive care and screenings Contact Customer Service for more information concerning which method above pertains to not described in 1. as provided for in comprehensive guidelines supported by the Health your services, including the applicable percentage if a Medicare-based approach is used. Resources and Services Administration. For certain benefits, you must pay a portion of the non-network provider reimbursement Contact Customer Service for information regarding specific preventive health services, amount as a coinsurance. services that are rated A or B, and services that are included in guidelines supported by the In addition, if the amount billed by the non-network provider is greater than the non-network Health Resources and Services Administration. provider reimbursement amount, the non-network provider will likely bill you for the Provider. A health care professional or facility licensed, certified, or otherwise qualified under difference. This difference may be substantial, and it is in addition to any coinsurance or state law to provide health services. 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 Qualifying coverage. Health coverage provided under one of the following plans: described in Your Out-Of-Pocket Expenses. Additionally, you will owe these amounts 1. A health plan in which a health carrier has issued a policy, contract, or certificate for the regardless of whether you previously reached your out-of-pocket maximum with amounts paid coverage of medical and hospital benefits, including blanket accident and sickness for other services. As a result, the amount you will be required to pay for services received from insurance other than accident only coverage; a non-network provider will likely be much higher than if you had received services from a network provider. 2. Part A or Part B of Medicare; Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene- 3. A medical assistance medical care plan as defined under Minnesota law; based information to determine the proper drug and dosage for an individual. 4. A general assistance medical care plan as defined under Minnesota law; Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared from the body of an individual based on their genetic makeup. 5. Minnesota Comprehensive Health Association (MCHA); Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry 6. A self-insured health plan; (D.P.M.), Doctor of O tomet O.D. or Doctor of Chiro Chiropractic 7. The MinnesotaCare program as defined under Minnesota law; scope of his or her licensurery ( ), D.C.p ( ) practicing within the 8. The public employee insurance plan as defined under Minnesota law; Placed for adoption. The assumption and retention of the legal obligation for total or partial 9. The Minnesota employees insurance plan as defined under Minnesota law; support of the child in anticipation of adopting such child. 10. TRICARE or other similar coverage provided under federal law applicable to the armed (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.) forces; Premium. The monthly 11. Coverage provided by a health care network cooperative or by a health provider ■ y payment required to be paid by the employer on behalf of or for you. cooperative; Prenatal care. The comprehensive package of medical and psychosocial support provided 12. The Federal Employees Health Benefits Plan or other similar coverage provided under throughout a pregnancy and related directly to the care of the pregnancy, including risk assessment, serial surveillance, prenatal education, and use of specialized skills aril federal law applicable to government organizations and employees; technology, when needed, as defined by Standards for Obstetric-Gynecologic Services issued 13. A medical care program of the Indian Health Service or of a tribal organization; by the American College of Obstetricians and Gynecologists. 14. A health benefit plan under the Peace Corps Act; Prescription drug. A drug approved by the FDA for the prescribed use and route of 15. State Children's Health Insurance Program; or administration. 16. A public health plan similar to any of the above plans established or maintained by a state, Preventive health service. The following are considered preventive health services: the U.S. government, a foreign country, or any political subdivision of a state, the U.S. 1. Evidence-based items or services that have in effect a rating of A or B in the current government, or a foreign country. recommendations of the United States Preventive Services Task Force; Coverage of the following types, including any combination of the following types, are not 2. Immunizations for routine use that have in effect a recommendation from the Advisory qualifying coverage: Committee on Immunization Practices of the Centers for Disease Control and P with respect to the member involved; revention 1. Coverage only for disability or income protection insurance; 2. Automobile medical payment coverage; MIC PP MN HSA (3/12) 116 � 2500-100% MIC PP MN HSA (3/12) 117 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Definitions , Definitions 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 Subscriber. The person: indemnity, or non-expense-incurred basis, if offered as independent, non-coordinated 1. On whose behalf premium is paid; and coverage; 2. Whose employment is the basis for membership, according to the Contract; and 5. Credit accident and health insurance as defined under Minnesota law; 6. Coverage designed solely to provide dental or vision care; 3. Who is enrolled under the Contract. Total disability. Disability due to injury, sickness, or pregnancy that requires regular care and 7. Accident only coverage; 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 8. Long-term care coverage as defined under Minnesota law; the duties of any business or occupation for which he or she is reasonably fitted. 9. Medicare supplemental health insurance as defined under Minnesota law; 10. Workers' compensation insurance; or Urgent care center. A health care facility distinguishable from an affiliated clinic or hospital 11. Coverage for on-site medical clinics operated by an employer for the benefit of the with which the em to er does whose primary purpose is to offer and provide immediate, short-term medical care for minor, employer's employees and their dependents, in connection immediate medical conditions on a regular or routine basis. not transfer risk. p Y Virtual care. Professional evaluation and medical management services provided to patients Reconstructive. Surgery to rebuild or correct a: through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth 1. Body services. Virtual care is used to address non-urgent medical symptoms for patients describing y part when such surgery is incidental to or following surgery resulting from injury, new or ongoing symptoms to which providers respond with substantive medical advice. sickness, or disease of the involved body part; or Virtual care does not include telephone calls for reporting normal lab or test results, or solely 2. Congenital disease or anomaly which has resulted in a functional defect as determined by calling in a prescription to a pharmacy. your physician. Waiting period. In accordance with applicable state and federal laws, the period of time that In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was must pass before an otherwise eligible employee and/or dependent is eligible to become performed and surgery and reconstruction of the other breast to produce a symmetrical covered under the Contract (as determined by the employer's eligibility requirements). appearance shall be considered reconstructive. However, if an eligible employee or dependent enrolls as a late entrant or through a special Restorative. Surgery to rebuild or correct a physical defect that has a direct adverse effect on enrollment period as set forth in Special enrollment in Eligibility And Enrollment, any period the physical health of a body before such late or special enrollment is not a waiting period. Periods of employment in an necessary. y part, and for which the restoration or correction is medically employment classification that is not eligible for coverage under the Contract do not constitute a waiting period. 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 removing corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removing 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. MIC PP MN HSA (3/12) 118 2500-100% MIC PP MN HSA (3/12) 119 2500-100% BPL 21285 DOC 23751 BPL 21285 DOC 23751 Medica Focus Certificate of Coverage MEDICA® MIC FOCUSMN HSA(3/12) 1500-100% BPL 21316 DOC 23928 • MEDICA CUSTOMER SERVICE Table Of Contents Table Of Contents Minneapolis/St. Paul Hearing Impaired: Introduction x Metro Area: National Relay Center Medical Loss Ratio (MLR) standards under the federal Public Health Service Act x (952) 945-8000 1 -800-855-2880, then To be eligible for benefits x ask them to dial Medica Language interpretation xi Outside the Metro Area: at 1 -800-952-3455 Acceptance of coverage xi 1 -800-952-3455 Nondiscrimination policy xi More information about the plan can also be obtained by Health savings accounts xii signing in at www.mymedica.com. A. Member Rights And Responsibilities 1 Member bill of rights 1 Member responsibilities 1 1 B. How To Access Your Benefits 3 aju _)d'°u."'4�y411 eS,II4 L 1 "t.4JI.Al1 030, .ECJIN BaM 1iyNCna fOMOIIIb B nepeBorte )Toil xx o MauHH> TI03BOHYITC no xoMe Important member information about in-network benefits 3 c:41.4}1.a.A11 0;�%ait vi A�iL;..1..]i t...4 c liN i-�s5 1:)1 P py> yKa3aHHOMy Ha o6parnoil CTOPone BaluaH Important member information about out-of-network benefits 5 Ithl dica %1114,,o1.i1 :A.,414,11 k.3u 1 MCitCuItIICKOi1 Kap'I`OgiaI IIJIi1Ha Mcdica. Continuity of care 7 Haddii aad do yso in Al Soomaali laguugu (pcil ;ttltirififironacitttitniii titi. tttciAwIriCitrttif3ntt;: Prior authorization 8 tar amadda rnactuumaadkani,oo lacag F�fff£tiFifi1G4f`3U t5 � 1r3li1cE1 �1:Pfl51 Medica 1 la'aan alt, Fadilan wac Lambarka ku (loran Certification of qualifying coverage 9 Kaarka Caafntadka ee Medica dhabarknsa. Si usted desca ayuda gratuita para traducir esta informacion, Marne al numero de C. How Providers Are Paid By Medica 11 Ako zelite beatano tumacenje ovib telefono situado al reverso de su tarjeta informacija p vice broj na pozadini vase de identiticacion de Medica. Network providers 11 Non-network providers 11 Medica kartite. Nevi quy vi main ducsc giup da dch tai lied nay rYliert p phi,xin got so ghi a mat sau the Mcdica cua qty vi. D. Your Out-Of-Pocket Expenses 12 Yog koj xav tau key pab txhais coy ntaub ntawv no daub„hu rau tus xov tooj nyob Dine k'ehji shich'i'hadoodzih ninizingo, beesh Coinsurance and deductibles 12 nram qab koj dim Medica Khaj (card). bee hane'e binumber naaltsoos bikaahigii bich'f hodiilnih ei doodah bee neehozin biniiye More information concerning deductibles 13 nanitinigii bine'dee bikaa doo aldo'. tiinrit ;w 1; _, z.tti; r ,.:LJC ',!`"I sL" 1 4.0 r Out-of-pocket maximum 13 t.ttt1t or1p ,} ,�uer,-I r1 sn al 1 ,v, ,t,a i) ),-,ta:RMedica Para sa tulong sa Tagalog, tawagafa ang numerong kabilang sa dokumentong ito o sa Lifetime maximum amount 14 likod ng iyong ID card. Out-of-Pocket Expenses 15 Yoo odeeyssi bilashitti afaan keetitti akka p sii hiikalnu feette lakkoofsa caaardiii lneedikaa X5PP frs a1 , ICA fj*,,.(tt-it]A;i E. Ambulance Services 16 (Medica)garnadubaarra jiru kana bilbili. + J Eg 95E3o Covered 16 UNV1D11 — III you want free help translating this information, call the number Not covered 16 on the back of your Medica identification card. I Ambulance services or ambulance transportation 17 Non-emergency licensed ambulance service 17 F. Durable Medical Equipment And Prosthetics 18 ©2012 Medica itemdica°is a registered service mark of Medica Health Plans. "Medica"refers to the family of health MIC FOCUSMN HSA (3/12) Ili 1500-100% plan businesses tot includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, BPL 21316 DOC 23928 Medica Self-lnsuist,and Medica Health Management, LLC. Table Of Contents Table Of Contents Covered 18 Anesthesia services received from a provider during an inpatient stay 30 Not covered 19 K. Maternity Services 31 Durable medical equipment and certain related supplies 19 Newborns' and Mothers' Health Protection Act of 1996 31 Repair, replacement, or revision of durable medical equipment 19 Covered 31 Prosthetics 19 Additional information about coverage of maternity services 32 Hearing aids 20 Not covered 32 G. Home Health Care 21 Prenatal services 32 Covered 21 Inpatient hospital stay for labor and delivery services 33 Not covered 22 Labor and delivery services at a freestanding birth center 33 Intermittent skilled care 22 Home health care visit following delivery 33 Skilled physical, speech, or occupational therapy 22 L. Medical-Related Dental Services 34 Home infusion therapy 23 Covered 34 Services received in your home from a physician 23 Not covered 34 H. Hospice Services 24 Charges for medical facilities and general anesthesia services 35 Covered 24 Orthodontia, dental implants, and oral surgery related to cleft lip and palate 35 Not covered 25 Accident-related dental services 36 Hospice services 25 i Oral surgery 36 I. Hospital Services 26 M. Mental Health 37 Covered 26 Covered 38 Not covered 26 Not covered 39 Outpatient services 27 Office visits, including evaluations, diagnostic, and treatment services 40 Services provided in a hospital observation room 27 Intensive outpatient programs 40 Inpatient services 27 Inpatient services (including residential treatment services) 40 Services received from a physician during an inpatient stay 27 N. Miscellaneous Medical Services And Supplies 41 Anesthesia services received from a provider during an inpatient stay 27 Covered 41 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 28 Not covered 41 J. Infertility Diagnosis 29 Blood clotting factors 42 Covered 29 Dietary medical treatment of PKU 42 Not covered 29 Amino acid-based elemental formulas 42 Office visits, including any services provided during such visits 30 Total parenteral nutrition 42 Virtual care 30 Eligible ostomy supplies 42 Outpatient services received at a hospital 30 Insulin pumps and other eligible diabetic equipment and supplies 42 Inpatient services 30 O. Organ And Bone Marrow Transplant Services 43 Services received from a physician during an inpatient stay 30 I Covered 43 MIC FOCUSMN HSA (3/12) iv 1500-100% MIC FOCUSMN HSA(3/12) v 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 1 Table Of Contents Table Of Contents Not covered 44 Quantity limits 58 Office visits 45 Covered 58 Virtual care 45 Prescription unit 58 Outpatient services 45 Not covered 59 Inpatient services 45 Specialty prescription drugs received from a designated specialty pharmacy 59 Services received from a physician during an inpatient stay 46 S. Professional Services 60 Anesthesia services received from a provider during an inpatient stay 46 Covered 60 Transportation and lodging 46 Not covered 61 P. Physical, Speech, And Occupational Therapies 48 Office visits 61 Covered 48 Virtual care 61 Not covered 48 Convenience care/retail health clinic visits 61 Physical therapy received outside of your home 49 Urgent care center visits 62 Speech therapy received outside of your home 49 Preventive health care 62 Occupational therapy received outside of your home 50 Allergy shots 63 Q. Prescription Drug Program 51 Routine annual eye exams 63 Preferred drug list 51 Chiropractic services 63 Product selection 51 Surgical services 63 Exceptions to the preferred drug list 52 Anesthesia services received from a provider during an office visit or an outpatient hospital Prior authorization 52 or ambulatory surgical center visit 64 Step therapy 52 Services received from a physician during an emergency room visit 64 Quantity limits 53 Services received from a physician during an inpatient stay 64 Covered 53 Anesthesia services received from a provider during an inpatient stay 64 Prescription unit 54 Outpatient lab and pathology 64 Not covered 54 Outpatient x-rays and other imaging services 64 Outpatient covered drugs 55 Other outpatient hospital or ambulatory surgical center services received from a physician 64 Diabetic equipment and supplies, including blood glucose meters 55 Treatment to lighten or remove the coloration of a port wine stain 64 Tobacco cessation products 55 Treatment of temporomandibular (TMJ) disorder and craniomandibular disorder 65 Drugs and other supplies considered preventive health services 56 Diabetes self-management training and education 65 R. Prescription Specialty Drug Program 57 Neuropsychological evaluations/cognitive testing 65 Designated specialty pharmacies 57 Vision therapy and orthoptic and/or pleoptic training 66 Specialty preferred drug list 57 Genetic counseling 66 Exceptions to the specialty preferred drug list 57 Genetic testing 66 Prior authorization 58 T. Reconstructive And Restorative Surgery 67 Step therapy 58 Covered 67 MIC FOCUSMN HSA (3/12) vi 1500-100% MIC FOCUSMN HSA(3/12) vii 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Table Of Contents Table Of Contents Not covered 67 Order of benefit determination rules 85 Office visits 68 Effect on the benefits of this plan 86 Virtual care 68 Right to receive and release needed information 87 Outpatient services 68 Facility of payment 87 Inpatient services 69 Right of recovery 87 Services received from a physician during an inpatient stay 69 BB. Right Of Recovery 89 Anesthesia services received from a provider during an inpatient stay 69 CC. Eligibility And Enrollment 90 U. Skilled Nursing Facility Services 70 Who can enroll 90 Covered 70 How to enroll 90 Not covered 70 Notification 90 Daily skilled care or daily skilled rehabilitation services 71 Initial enrollment 90 Skilled physical, speech, or occupational therapy 71 Open enrollment 91 Services received from a physician during an inpatient stay in a skilled nursing facility....71 Special enrollment 91 V. Substance Abuse 72 Late enrollment 94 Covered 73 Qualified Medical Child Support Order (QMCSO) 94 Not covered 74 The date your coverage begins 94 Office visits, including evaluations, diagnostic, and primary treatment services 74 DD. Ending Coverage 96 Intensive outpatient programs 74 When coverage ends 96 Opiate replacement therapy 74 EE. Continuation 98 Inpatient services (including residential treatment services) 75 Your right to continue coverage under state law 98 W. Referrals To Non-Network Providers 76 Your right to continue coverage under federal law 101 What you must do 76 FF. Conversion 107 What Medica will do 76 Minnesota residents 107 X. Harmful Use Of Medical Services 78 Residents of a state other than Minnesota 108 When this section applies 78 GG. Complaints 109 Y. Exclusions 79 First level of review 109 Z. How To Submit A Claim 82 Second level of review 110 Claims for benefits from network providers 82 External review 110 Claims for benefits from non-network providers 82 Civil action 111 Claims for services provided outside the United States 83 HH. General Provisions 112 Time limits 83 Definitions 114 AA. Coordination Of Benefits 84 Applicability 84 Definitions that apply to this section 84 MIC FOCUSMN HSA (3/12) viii 1500-100% MIC FOCUSMN HSA(3/12) ix 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Introduction Introduction 3. Present your Medica Focus identification card. (If you do not show your Medica Focus Introduction 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 Medica Insurance Company (Medica) offers Medica Focus. This is a Minnesota non-qualified not necessarily guarantee coverage. plan. This Certificate of Coverage (this certificate) describes health services that are eligible for Network providers are required to submit claims within 180 days from when you receive a coverage and the procedures you must follow to obtain benefits. service. If your provider asks for your health care identification card and you do not identify Many words in this certificatehavespecr#ie meanings. ;These words are ide '' ` yourself as a Medica member within 180 days of the date of service, you may be responsible for ntrfied m each a in the cost of the service you received. section and defined in Definitions. _ =�- �� � � - paying 9 Y S See Definitions: words have specific`meanings benefits claim, dependent,Medically Language interpretation necessary, member, network, premium, provider Because many provisions are interrelated, you should read this certificate in its entirety. Language interpretation services will be provided upon request, as needed in connection with Reviewing just one or two sections may not give you a complete understanding of the coverage the interpretation of this certificate. If you would like to request language interpretation services, described. The most specific and appropriate section will apply for those benefits related to the please call Customer Service at one of the telephone numbers listed inside the front cover. treatment of a specific condition. If you have an impairment that requires alternative communication formats such as Braille, large The Contract refers to the Contract between Medica and the employer. You should contact the print, or audiocassettes, please call Customer Service at one of the telephone numbers listed employer to see the Contract. inside the front cover to request these materials. Members are subject to all terms and conditions of the Contract and health services must be If this certificate is translated into another language or an alternative communication format is medically necessary. used, this written English version governs all coverage decisions. 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 Acceptance of coverage administration of your benefits, you must cooperate with them in the performance of their responsibilities. 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. The employer is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by applicable law. By accepting the health care coverage described in this certificate, you, on behalf of yourself In this certificate, the words you, your, and yourself refer to the member. The word employer and any dependents enrolled under the Contract, authorize the following: refers to the organization through which you are eligible for coverage. 1. The use of a social security number for purpose of identification; and Medical Loss Ratio (MLR) standards under the federal Public Health Service Act 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 Federal law establishes standards concerning the percentage of premium revenue that insurers intentionally made by you in connection with your enrollment under the Contract may invalidate pay out for claims expenses and health care quality improvement activities. If the amount an your coverage. insurer pays out for such expenses and activities is less than the applicable MLR standard, the insurer is required to provide a premium rebate. MLR calculations are based on aggregate market data rather than on a group by group basis. In the event Medica is required to pay Nondiscrimination policy rebates pursuant to federal law, Medica will pay such rebates to your employer unless prohibited by federal law. 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, To be eligible for benefits 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 Each time you receive health services, you must: front cover. 1. Confirm with Medics 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 MIC FOCUSMN HSA(3/12) x 1500-100% MIC FOCUSMN HSA (3/12) xi 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Introduction Member Rights And Responsibilities Health savings accounts This coverage is intended to comply with the requirements of the Internal Revenue Code A. Member Rights And Responsibilities section 223 for a federally qualified high deductible health plan. This coverage may qualify you to make a pre-tax contribution to a health savings account. You are responsible for the cost of all health services, other than preventive care, up to the deductible amount. See Definitions These fwords have specific meanings: benefits, emergency, medically necessary, member; network, provider. . ;. . 4 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 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 (3/12) xii 1500-100% MIC FOCUSMN HSA(3/12) 1 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Member Rights And Responsibilities How To Access Your Benefits 4. Practicing self-care by knowing: a. How to recognize common health problems and what to do when they occur; and B. How To Access Your Benefits b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and - {`See-Definitions: These words have specific meanings:, claim;coinsurance, 5. Practicing preventive health care by deductible,dependent, emergency, enrollment date, hospital, inpatient,late entrant, member, network, non-network;non-network provider reimbursement amount, physician, placed for a. Having the appropriate tests, exams, and immunizations recommended for your gender adoption, premium, prescription drug, provider, qualifying kcoverage, reconstructive,�=estarative, and age as described in this certificate; and skilled anursing facility, subscriber, virtual care, waiting period: �° � � , ,; b. Engaging in healthy lifestyle choices (such as exercise, proper diet, and rest). You will find additional information on member responsibilities in this certificate. 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(3/12) 2 1500-100% MIC FOCUSMN HSA(3/12) 3 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 How To Access Your Benefits How To Access Your Benefits Referrals Prescription drugs and medical equipment Certain health services are covered only upon referral; read this certificate carefully for Enrolling in Medica does not guarantee that a particular prescription drug or piece of medical referral requirements. All referrals to non-network providers and certain types of network equipment will continue to be covered, even if the drug or equipment is covered at the start providers must be prior authorized by Medica to be eligible for coverage at your highest level of the calendar year. of benefits. Post-mastectomy coverage Emergency services Medica will cover all stages of reconstruction of the breast on which the mastectomy was Emergency services from non-network providers will be covered as in-network benefits. performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Medica will also cover prostheses and physical complications, including Providers lymphedemas, at all stages of mastectomy. 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 2. Important member information about out-of-network benefits 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. The information below describes your covered health services and provides important You must verify that your provider is a network provider each time you receive health information concerning your out-of-network benefits. Read this certificate for a detailed services. 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 Exclusions services you are considering, so you are best able to determine the benefits that will apply Certain health services are not covered. Read this certificate for a detailed explanation of all to you. exclusions. Benefits Mental health and substance abuse Medica pays out-of-network benefits for eligible health services received from non-network Medica's designated mental health and substance abuse provider will arrange your mental 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 health and substance abuse benefits. Medica's designated mental health and substance out-of-network benefits. This certificate defines your benefits and describes procedures you abuse provider's hospital network is different from Medica's hospital network. Certain must follow to obtain out-of-network benefits. mental health and substance abuse services require prior authorization by Medica's designated mental health and substance abuse provider. Emergency services do not Decisions about coverage are made based on appropriateness of care and service to the require prior authorization. member. Medica does not reward providers for denying care, nor does Medica encourage inappropriate utilization of services. Continuation/conversion Emergency services received from non-network providers are covered as in-network You may continue coverage or convert to an individual conversion plan under certain benefits and are not considered out-of-network benefits. circumstances. See Continuation and Conversion for additional information. 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 Cancellation provided only in situations where the requested services are not available from network Your coverage may be canceled only under certain conditions. This certificate describes all providers. reasons for cancellation of coverage. See Ending Coverage for additional information. 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. Newborn coverage The charges billed by your non-network provider may exceed the non-network provider Your dependent newborn is covered from birth. Medica does not automatically know of a reimbursement amount, leaving a balance for you to pay in addition to any applicable birth or whether you would like coverage for the newborn dependent. Call Customer coinsurance and deductible amount. This additional amount you must pay to the provider Service at one of the telephone numbers listed inside the front cover for more information. To will not be applied toward the out-of-pocket maximum amount described in Your Out-Of- be eligible for in-network benefits, health services must be provided by a network provider or Pocket Expenses and you will owe this amount regardless of whether you previously authorized by Medica. Certain services are covered only upon referral. If additional reached your out-of-pocket maximum with amounts paid for other services. Please see the premium is required, Medica is entitled to all premiums due from the time of the infant's birth example calculation below. 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(3/12) 5 1500-100% MIC FOCUSMN HSA(3/12) 4 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 How To Access Your Benefits How To Access Your Benefits Because obtaining care from non-network providers may result in significant out-of-pocket Lifetime maximum amount expenses, it is important that you do the following before receiving services from a non- network provider: 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 • Discuss the expected billed charges with your non-network provider; and amount. • Contact Customer Service to verify the estimated non-network provider reimbursement Exclusions amount for those services, so you are better able to calculate your likely out-of-pocket expenses; and Some health services are not covered when received from or under the direction of non- • If you wish to request that Medica authorize the non-network provider's services be network providers. Read this certificate for a detailed explanation of exclusions. covered at the in-network benefit level, follow the procedure described under Prior Claims authorization in How To Access Your Benefits. 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 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 Claim for details. without an authorization from Medica providing for in-network benefits. The out-of-network Post-mastectomy coverage 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 Medica will cover all stages of reconstruction of the breast on which the mastectomy was bills $30,000 for your hospital stay. Medica's non-network provider reimbursement amount performed and surgery and reconstruction of the other breast to produce a symmetrical for those hospital services is $15,000. You must pay a portion of the non-network provider appearance. Medica will also cover prostheses and physical complications, including reimbursement amount, generally as a percentage coinsurance. In addition, the non- lymphedemas, at all stages of mastectomy. 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 3. Continuity of care required to pay: • 40% coinsurance (40% of$15,000 = $6,000) and To request continuity of care or if you have questions about how this may apply to you, call • The billed charges that exceed the non-network provider reimbursement amount Customer Service at one of the telephone numbers listed inside the front cover. ($30,000- $15,000 = $15,000) In certain situations, you have a right to continuity of care. • The total amount you will owe is $6,000 + $15,000 = $21,000. 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. 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 b. If you are a new Medica member as a result of your employer changing health plans and billed charges in excess of the non-network provider reimbursement amount will not be your current provider is not a network provider, you may be eligible to continue care with applied toward the out-of-pocket maximum amount described in Your Out-Of-Pocket that provider at the in-network benefit level. Expenses. You will owe the provider this $15,000 amount regardless of whether you have This applies only if your provider agrees to comply with Medica's prior authorization previously reached your out-of-pocket maximum with amounts paid for other services. requirements, provide Medica with all necessary medical information related to your care, *Note: The numbers in this example are used only for purposes of illustrating how out-of- and accept as payment in full the lesser of Medica's network provider reimbursement or the network benefits are calculated. The actual numbers will depend on the services received. 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 Travel program cause, Medica will inform you of the change and how your care will be transferred to another network provider. 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 i. Upon request, Medica will authorize continuity of care for up to 120 days as access to a network provider. Travel program coverage is subject to all of the terms and described in a. and b. above for the following conditions: conditions set forth in this certificate. Call Customer Service at one of the telephone • an acute condition; 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 a life-threatening mental or physical illness; available for all services (i.e., virtual care or chiropractic services) and may not be available • pregnancy beyond the first trimester of pregnancy; in all areas. MIC FOCUSMN HSA (3/12) 6 1500-100% MIC FOCUSMN HSA (3/12) 7 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 How To Access Your Benefits How To Access Your Benefits • a physical or mental disability defined as an inability to engage in one or more • Outpatient surgical procedures; major life activities, provided that the disability has lasted or can be expected to • Certain genetic tests; and 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. • Skilled nursing facility services. Authorization to continue to receive services from your current provider may extend Prior authorization is always required for: to the remainder of your life if a physician certifies that your life expectancy is 180 • Organ and bone marrow transplant services; and days or less. In-network benefits for services from non-network providers, with the exception of •ii. Upon request, Medica will authorize continuity of care for up to 120 days as emergency services. described in a. and b. above in the following situations: This is not an all-inclusive list of all services and supplies that may require prior • if you are receiving culturally appropriate services and Medica does not have a authorization. network provider who has special expertise in the delivery of those culturally When you, someone on your behalf, or your attending provider calls, the following appropriate services; or information may be required: • if you do not speak English and Medica does not have a network provider who • Name and telephone number of the provider who is making the request; can communicate with you, either directly or through an interpreter. • Medica may require medical records or other supporting documentation from your provider Name, telephone number, address, and type of specialty of the provider to whom you to review your request, and will consider each request on a case-by-case basis. If Medica are being referred, if applicable; authorizes your request to continue care with your current provider, Medica will explain how • Services being requested and the date those services are to be rendered (if scheduled); 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 Specific information related to your condition (for example, a letter of medical necessity request is denied, Medica will explain the criteria used to make its decision. You may from your provider); appeal this decision. • Other applicable member information (i.e., Medica member number). Coverage will not be provided for services or treatments that are not otherwise covered Medica will review your request and provide a response to you and your attending provider under this certificate. 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. 4. Prior authorization Both you and your provider will be informed of the decision within 72 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, Prior authorization from Medica may be required before you receive certain services or or if it is concluded that a delay could seriously jeopardize your life, health, or ability to supplies in order to determine whether a particular service or supply is medically necessary regain maximum function, or subject you to severe pain that cannot be adequately managed and a benefit. Medica uses written procedures and criteria when reviewing your request for without the care or treatment you are requesting. prior authorization. To determine whether a certain service or supply requires prior If Medica does not approve your request for prior authorization, you have the right to appeal authorization, please call Customer Service at one of the telephone numbers listed inside Medica's decision as described in Complaints. the front cover or sign in at www.mymedica.com. Emergency services do not require prior authorization. Under certain circumstances, Medica may perform concurrent review to determine whether Your attending provider, you, or someone on your behalf may contact Medica to request services continue to be medically necessary. If Medica determines that services are no prior authorization. Your network provider will contact Medica to request prior authorization longer medically necessary, Medica will inform both you and your attending provider in for a service or supply. You must contact Medica to request prior authorization for services writing of its decision. If Medica does not approve continued coverage, you or your or supplies received from non-network providers. If a network provider fails to obtain prior attending provider may appeal Medica's initial decision (see Complaints). 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. 5. Certification of qualifying coverage Some of the services that may require prior authorization from Medica include: You have the right to a certification of qualifying coverage when coverage ends. You will • Reconstructive or restorative surgery; receive a certification of qualifying coverage when coverage ends. You may also request a Certain drugs; 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 • Home health care; qualifying coverage, call Customer Service at one of the telephone numbers listed inside the • Medical supplies and durable medical equipment; MIC FOCUSMN HSA (3/12) 8 1500-100% MIC FOCUSMN HSA (3/12) 9 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 How To Access Your Benefits How Providers Are Paid By Medica front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. 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, 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 (3/12) 10 1500-100% MIC FOCUSMN HSA (3/12) 11 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Your Out-Of-Pocket Expenses 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 D. Your Out-Of-Pocket Expenses provider bills. If you use out-of-network benefits, you may incur costs in addition to your coinsurance and This section describes the expenses that are your responsibility to pay. These expenses are 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. commonly called out-of-pocket expenses. In addition, the difference will not be applied toward satisfaction of the deductible or the out- See Definitions. These words have specific meanings: benefits, claim, coinsurance, of-pocket maximum (described in this section). deductible, dependent, medically necessary, member, network, non-network, non-network To inquire about the non-network provider reimbursement amount for a particular procedure, provider reimbursement amount, prescription drug,;'provider, subscriber. " call Customer Service at one of the telephone numbers listed inside the front cover. When You are responsible for paying the cost of a service that is not medically necessary or a benefit you call, you will need to provide the following: even if the following occurs: • The CPT (Current Procedural Terminology) code for the procedure (ask your non- 1. A provider performs, prescribes, or recommends the service; or network provider for this); and 2. The service is the only treatment available; or • The name and location of the non-network provider. 3. You request and receive the service even though your provider does not recommend it. Customer Service will provide you with an estimate of the non-network provider (Your network provider is required to inform you or in some instances provide a waiver for reimbursement amount based on the information provided at the time of your inquiry. The 1 you to sign.) actual amount paid will be based on the information received at the time the claim is If you miss or cancel an office visit less than 24 hours before your appointment, your provider submitted and subject to all applicable benefit provisions, exclusions and limitations, including but not limited to coinsurance and deductibles. may bill you for the service. Please see the applicable benefit section(s) of this certificate for specific information about your 3. Any charge that is not covered under the Contract. in-network and out-of-network benefits and coverage levels. If you use out-of-network benefits, you may incur costs in addition to your coinsurance and To verify coverage before receiving a particular service or supply, call Customer Service at one 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 of the telephone numbers listed inside the front cover. addition, the difference will not be applied toward satisfaction of the deductible or the out-of- pocket maximum (described in this section). Please see Important member information about Coinsurance and deductibles out-of-network benefits in How To Access Your Benefits for more information. 1 For in-network benefits, you must pay the following: More information concerning deductibles 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). The time period used to apply the deductible (calendar year or Contract year) is determined by the Contract between Medica and the employer. 2. Any charge in addition to your coinsurance and deductible described in Prescription Drug p y er. This time period may change when Medica Program and Prescription Specialty Drug Program that applies when you use a Tier 2 brand and the employer renew the Contract. If the time period changes, you will receive a new name drug or supply when an equivalent Tier 1 generic drug or supply is on Medica's list of certificate of coverage that will specify the newly applicable time period. You may have preferred drugs. These additional amounts will not be applied toward the deductible or the additional out-of-pocket expenses associated with this change. out-of-pocket maximum described in this section. 3. Any charge that is not covered under the Contract. Out-of-pocket maximum The out-of-pocket maximum is an accumulation of coinsurance and deductibles paid for benefits For out-of-network benefits, you must pay the following: 1. Any applicable coinsurance and per member deductible each calendar year as described in received during a calendar year. Except as described below or as otherwise specified, you will this certificate (see the Out-of-Pocket Expenses table in this section). 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). Note that applicable deductibles are determined by the Contract between Medica and the Please note: Charges for services not eligible for coverage and any charge in excess of employer and may increase when Medica and the employer renew the Contract. If this the non-network provider reimbursement amount are not applicable toward the out-of- occurs, the new deductible will apply for the rest of the current calendar year, whether or not pocket maximum. Additionally, you will owe these amounts regardless of whether you you had met the previously applicable deductible. This means that it is possible that your previously reached your out-of-pocket maximum with amounts paid for other services. 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 FOCUSMN HSA (3/12) 13 MIC FOCUSMN HSA(3/12) 12 1500-100% 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 i Your Out-Of-Pocket Expenses Your Out-Of-Pocket Expenses The time period used to calculate whether you have met the out-of-pocket maximum (calendar Out-of-Pocket Expenses 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 In-networks * Out-4.3f network time period. You may have additional out-of-pocket expenses associated with this change. I benefits = benefits °Y After an applicable out-of-pocket maximum has been met for a particular type of benefit (as , . ' ," pp *For out of=network benefits, inaddition to the deductible and coinsurance, you areresponsible, r; described in the Out-of-Pocket Expenses table in this section), all other covered benefits of the _ for any charges in excess of the nonnetwork.prov der reimbursement amount. Additionally, same type received during the rest of the calendar year will be covered at 100 percent, except � theseccharges will not be applied toward satisfaction of the deductible or the out-of-pocket for any charge not covered by Medics, or charge in excess of the non-network provider rymaximum:- 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 Coinsurance See specific benefit for applicable coinsurance. 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. Deductible Note that out-of-pocket maximum amounts are determined by the Contract between Medica and Per member $1,500 $4,000 the employer and may increase when Medica and the employer renew the Contract. If this Out-of-pocket maximum I 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 Per member $1,500 $9,000 it is possible that your out-of-pocket maximum will increase mid-year when your employer's Lifetime maximum amount Unlimited $1,000,000. Applies to Contract with Medica is renewed and that you may have additional out-of-pocket expenses as a payable per member all benefits you receive result. under this or any other Medica refunds the amount over the out-of-pocket maximum during any calendar year when Medica, Medica Health proof of excess coinsurance and deductibles is received and verified by Medica. Plans, or Medica Health . Plans of Wisconsin coverage offered through Lifetime maximum amount the same employer. 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. I I MIC FOCUSMN HSA (3/12) 14 1500-100% MIC FOCUSMN HSA (3/12) 15 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Ambulance Services Ambulance Services E. Ambulance Services f Your Benefits and the Amounts You Pay "` ss Benefits ;° In-network benefits; *Out of-netavi;r=k benefits after deductible after deductible This section describes coverage for ambulance transportation and related services received for covered medical and medical-related dental services (as described in this certificate). >*' � ) For out of network.benefits, addition to deductible and coinsurance,you are responsible �.f o_r.-.a b charges�.._E._..:�.gin._ _.excess_ __.,�� of the t he non-network ._n.,...,."n_._e_.tw..�.__o r k r.. o....Yide r_r._._e_.im_"b._u...,b..r..ser;_-e_n...t ,am oun t. A ddition,.,a .l L ..th e. s..e See Definitions. These words:have rs ecificmmeanin.s� benefits,_co.insurance .deductible "charges will not be applied_toward,sat.sfaction,•o fdthe deducti ble or the out of- ocket maximum. emergency, hoshospital network,.non network, non netwark rovider.reimbursement_amaun t. . .': physician, provider, skilled nursing facility. e 1. Ambulance services or Nothing Covered as an in-network Prior authorization. Prior authorization from Medica may be required before you receive ambulance transportation to the benefit. services or supplies. Call Customer Service at one of the telephone numbers listed inside the nearest hospital for an front cover. See How To Access Your Benefits for more information about the prior authorization emergency process. 2. Non-emergency licensed ambulance service that is Covered arranged through an attending physician, as follows: For benefits and the amounts you pay, see the table in this section. More than one coinsurance a. Transportation from hospital Nothing 50% coinsurance may be required if you receive more than one service or see more than one provider per visit. to hospital when: For non-emergency licensed ambulance services described in the table in this section: i. Care for your condition • In-network benefits apply to ambulance services arranged through a physician and received is not available at the hospital where you were from a network provider. first admitted; or • Out-of-network benefits apply to non-emergency ambulance services described in this ii. Required by Medica 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 b. Transportation from hospital Nothing 50% coinsurance responsible for any charges in excess of the non-network provider reimbursement amount. to skilled nursing facility 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 (3/12) 16 1500-100% MIC FOCUSMN HSA (3/12) 17 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Durable Medical Equipment And Prosthetics Durable Medical Equipment And Prosthetics Not covered F. Durable Medical Equipment And Prosthetics These services, supplies, and associated expenses are not covered: 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the This section describes coverage for durable medical equipment, certain related supplies, and Medica eligible list. prosthetics. 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, See Definitions. These words have specific meanings: benefits, coinsurance, deductible, 'r,, or hearing aids. medically necessary, network,non-network, non-network provider reimbursement amount, . 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, physician, provider. s - � ;�� r except when made necessary by normal wear and use. Prior authorization. Prior authorization from Medica may be required before you receive 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, services or supplies. Call Customer Service at one of the telephone numbers listed inside the replacement, or revision of duplicate items. front cover. See How To Access Your Benefits for more information about the prior authorization See Exclusions for additional services, supplies, and associated expenses that are not process. covered. Covered you pay, , Your,Benefits.and the Amounts You Pay = For benefits and the amounts ou see the table in this section. More than one coinsurance _ .; - Y W. may be required if you receive more than one service or see more than one provider per visit. Benefits �� � � � Y q Y � _ In network benefits *Out-of network benefits ' Medica covers only a limited selection of durable medical equipment, certain related supplies, and _- after deductible after deductible _ �.' 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 For out-of-network benefits, in addition to the deductible and coinsurance, you are responsible for any certain related supplies is periodically reviewed and modified by Medica. To request a list of y char g es in excess'of the non-network provider reimbursement amount. Additionally,these pp charges will pot be applied toward satisfaction of the deductible or the out-of-pocket maximum. Medica's eligible durable medical equipment and certain related supplies, call Customer Service at one of the telephone numbers listed inside the front cover. J 50% coinsurance Medica determines if durable medical equipment will be purchased or rented. Medica's approval certain related supplies of rental of durable medical equipment is limited to a specific period of time. To request approval 2. Repair, replacement, or revision Nothing for an extension of the rental period, call Customer Service at one of the telephone numbers listed of durable medical equipment g 50% coinsurance inside the front cover. made necessary by normal wear If the durable medical equipment, prosthetic device, or hearing aid is covered by Medica, but the and use model you select is not Medica's standard model, you will be responsible for the cost difference. 3. Prosthetics • 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 a. Initial purchase of external Nothing 50% coinsurance equipment provider who has a durable medical equipment contract with Medica, and hearing prosthetic devices that aids as described in 4. in the table in this section when prescribed by a network provider. To replace a limb or an external request a list of network durable medical equipment providers, call Customer Service at one of body part, limited to: the telephone numbers listed inside the front cover. i. Artificial arms, legs, feet, Out-of-network benefits apply to durable medical equipment, certain related supplies, and and hands; • prosthetic services prescribed by a physician and received from a non-network provider. ii. Artificial eyes, ears, and Out-of-network benefits also apply to hearing aids as described in 4. in the table in this noses; section. In addition to the deductible and coinsurance described for out-of-network benefits, iii. Breast prostheses 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 b. Scalp hair prostheses due to Nothing. Medica pays up 50% coinsurance. Important member information about out-of-network benefits in How To Access Your alopecia areata to $350. This is Medica pays up to $350. Benefits for more information and an example calculation of out-of-pocket costs associated calculated each calendar This is calculated each with out-of-network benefits. year. calendar year. MIC FOCUSMN HSA (3/12) 18 1500-100% MIC FOCUSMN HSA (3/12) 19 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Durable Medical Equipment And Prosthetics Home Health Care Your Benefits and the Amounts You Pay '� W� � �- G. Home Health Care Benefits in network benefits ' O ut of ne twor k be nfit es after deductible after deductible This section describes coverage for home health care. Home health care must be directed by a physician and received from a home health care agency authorized by the laws of the state in *For out-of-network benefits:in addition to the deductible and coinsurance,you are responsible or '' any charges in excess;:of the non-network provider reimbursement.amount. Additionally,these - which treatment is received. atmen s rec e charges w illtnot be a lied toward,s t isf a cti on oek f t he d.ed u cti ble o h e-,o ut-of..__o cke t m., ax u m. See Definitions. These words have specific meanings: benefits, co msurance custodial care :_ ,,,. ....a e.....A^.:..:: ...vx.. ..�....._.�._.:.,.5......_.... .::.. <..,$...__.....,..._..... ........... ......u......:..a..�aZ....._-.__3�c..__...,.a .a,`.e -::A"..-.,... .t `.- :..: ,.: _ . . im ,. .wa � -.� ... f o deductible, dependent,,hospital, network, non-network,anonnetworkprovi m provider c. Repair, replacement, or Nothing 50% coinsurance amount, provider,rskilled care,=skilled nursing-facility . revision of artificial arms, legs, feet, hands, eyes, ears, Prior authorization. Prior authorization from Medica may be required before you receive noses, and breast services or supplies. Call Customer Service at one of the telephone numbers listed inside the prostheses made necessary front cover. See How To Access Your Benefits for more information about the prior by normal wear and use authorization process. 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 Covered hearing loss that is not three years. Related aid per ear every three correctable by other covered services must be years. For benefits and the amounts you pay, see the table in this section. More than one coinsurance procedures prescribed by a network may be required if you receive more than one service or see more than one provider per visit. provider. 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. f • 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. I ' MIC FOCUSMN HSA (3/12) 20 1500-100% MIC FOCUSMN HSA(3/12) 21 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 • Home Health Care Home Health Care Not covered Your Benefits and the Amounts You Pay ' These services, supplies, and associated expenses are not covered: Benefits In network benefits *'Out of-network benefits 1. Companion, homemaker, and personal care services. after deductible after deductible 2. Services provided by a member of your family. *For out-of-network benefits, m addition to'the deductible-and coinsurance,you are responsible 3. Custodial care and other non-skilled services. for any charges to excess of the non network provider reimbursement amount.;Additionally,these;,. 4. Physical, speech, or occupational therapy provided in our home for convenience. charges will not=be applied toward satisfaction of the deductible or the out-of-pocket maximum. 5. Services provided in your home when you are not homebound. 3. Home infusion therapy Nothing 50% coinsurance 6. Services primarily educational in nature. 4. Services received in your home Nothing 50% coinsurance 7. Vocational and job rehabilitation. from a physician 8. Recreational therapy. 9. Self-care and self-help training (non-medical). 10. Health clubs. 11. Disposable supplies and appliances, except as described in Durable Medical Equipment And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program. 12. Physical, speech, or occupational therapy services when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to generally accepted standards in the medical community. 13. Voice training. 14. 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 - n � � s 3' Benefits In-network benefits w= * Out-of network benefits 3.°-".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 the-deductible or the out-of pocket maximum 1. Intermittent skilled care when Nothing 50% coinsurance you are homebound, provided by or supervised by a registered nurse 2. Skilled physical, speech, or Nothing 50% coinsurance occupational therapy when you are homebound MIC FOCUSMN HSA (3/12) 22 1500-100% MIC FOCUSMN HSA (3/12) 23 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Hospice Services 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 H. Hospice Services 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 This section describes coverage for hospice services including respite care. Care must be program. You must follow the hospice program's requirements to withdraw from the hospice ordered, provided, or arranged under the direction of a physician and received from a hospice program. program. Not covered See Definitions. These words have specific meanings: benefits, coinsurance,deductible, member, network, non network, non-network provider reimbursement amount physician,.skilled nursing facility.= - _ These services, supplies, and associated expenses are not covered: 1. Respite care for more than five consecutive days at a time. Covered 2. Home health care and skilled nursing facility services when services are not consistent with the hospice,program's plan of care. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 3. Services not included in the hospice program's plan of care. may be required if you receive more than one service or see more than one provider per visit. Hospice services are comprehensive palliative medical care and supportive social, emotional, 4. Services not provided by the hospice program. and spiritual services. These services are provided to terminally ill persons and their families, 5. Hospice daycare, except when recommended and provided by the hospice program. primarily in the patients' homes. A hospice interdisciplinary team, composed of professionals 6. Any services provided by a family member or friend, or individuals who are residents in your and volunteers, coordinates an individualized plan of care for each patient and family. home. The goal of hospice care is to make patients as comfortable as possible to enable them to live 7. Financial or legal counseling services, except when recommended and provided by the their final days to the fullest in the comfort of their own homes and with loved ones. hospice program. A designated hospice program means a hospice program that has entered into a separate 8. Housekeeping or meal services in your home, except when recommended and provided by contract with Medica to provide hospice services to members. The specific services you receive the hospice program. may vary depending upon which program you select. Members who elect to receive hospice services do so in place of curative treatment for their 9. Bereavement counseling, except when recommended and provided by the hospice program. terminal illness for the period they are enrolled in the hospice program. See Exclusions for additional services, supplies, and associated expenses that are not Respite care is a form of hospice services that gives uncompensated primary caregivers (i.e., covered. 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. • Mks In-network benefits apply to hospice services arranged through a physician and received Your Benefits and the Amounts Vol.' Pay from a designated hospice program. • Out-of-network benefits apply to hospice services arranged through a physician and Benefits ° In network benefits *Out of-network benefits received from a non-designated hospice program. In addition to the deductible and "fit after deductible after-deductible coinsurance described for out-of-network benefits, you will be responsible for any charges in *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for excess of the non-network provider reimbursement amount. The out-of-pocket maximum _ . - w .- >. any.charges in excess of the non-network provider reimbursement°amount. Additionally,these does not apply to these charges. Please see Important member information about out-of- R €� : charges will not be applied toward satisfaction of the deductible or the out-of pocket maximum 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. Hospice services Nothing 50% coinsurance 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 (3/12) 24 1500-100% MIC FOCUSMN HSA (3/12) 25 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Hospital Services Hospital Services -Your Benefits and the Amounts You Pay r 7; I. Hospital Services � A Benefits in network benefits ,:_ Out-of-network`benefits - after deductible after deductible This section describes coverage for use of hospital and ambulatory surgical center services. A physician must direct care. For out-of-network benefits, in addition to the deductible and coinsurance, youara responsible"for .. "" non-network,_..,_., .�.,:..<�_.•�-:-, a_...n y charges har es-x in -. ex ce_s s;of the r. o n ne two-m.rk rovi d:_e c,re_"im._._b r s. em e-r t amount._ -Addi t io� na!! , he..s_,.eSee ©efnfttons._These words�h v e specific meanings: benefits, coinsurance, deductible, charges ted toward satisfaction of the deductible a or the out-of-pocket�maximum. emergency, gene#ic-testmg,:hospital, inpatient, memb er n etwork, nonn_etwork � ;... provider reimbursement amount, physiciarn;,provider £` # - �: 1. Outpatient services Prior authorization. Prior authorization from Medica may be required before you receive a. Services provided in a Nothing Covered as an in-network services or supplies. Call Customer Service at one of the telephone numbers listed inside the hospital or facility-based benefit. front cover. See How To Access Your Benefits for more information about the prior authorization emergency room process. b. Outpatient lab and pathology Nothing 50% coinsurance Covered c. Outpatient x-rays and other Nothing 50% coinsurance imaging services For benefits and the amounts you pay, see the table in this section. More than one coinsurance d. Genetic testing when test Nothing 50% coinsurance may be required if you receive more than one service or see more than one provider per visit. results will directly affect • In-network benefits apply to hospital services received from a network hospital or ambulatory treatment decisions or frequency of screening for a surgical center. disease, or when results of • Out-of-network benefits apply to hospital services received from a non-network hospital or the test will affect ambulatory surgical center. In addition to the deductible and coinsurance described for out- reproductive choices of-network benefits, you will be responsible for any charges in excess of the non-network e. Other outpatient services Nothing 50% coinsurance 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 f. Other outpatient hospital and Nothing 50% coinsurance To Access Your Benefits for more information and an example calculation of out-of-pocket ambulatory surgical center costs associated with out-of-network benefits. Emergency services from non-network services received from a I providers will be covered as in-network benefits. If you are confined in a non-network facility physician 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. g. Anesthesia services received Nothing 50% coinsurance from a provider during an office visit or an outpatient I Not covered hospital or ambulatory surgical center visit 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous 2. Services provided in a hospital Nothing 50% coinsurance infusion or injection, intramuscular injection, or intraocular injection; or drugs received in an observation room emergency room or a hospital observation room. Coverage for drugs is as described in Prescription Drug Program and Prescription Specialty Drug Program or otherwise described 3. Inpatient services Nothing 50% coinsurance as a specific benefit in this certificate. 4. Services received from a Nothing 50% coinsurance 2. Transfers and admission to network hospitals solely at the convenience of the member. physician during an inpatient 3. Admission to another hospital is not covered when care for your condition is available at the stay network hospital where you were first admitted. 5. Anesthesia services received Nothing 50% coinsurance See Exclusions for additional services, supplies, and associated expenses that are not from a provider stay during an inpatient covered. • MIC FOCUSMN HSA (3/12) 26 1500-100% MIC FOCUSMN HSA (3/12) 27 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Hospital Services Infertility Diagnosis Your Benefits and the Amounts'You Pay � J. Infertility Diagnosis Benefitsmm = In network benefits Out-of-network benefits • e after deductible I after deductible This section describes coverage for the diagnosis of infertility. Coverage includes benefits for �;. ,� � ." ., _ t professional, hospital, and ambulatory surgical center services. Services for the diagnosis of *For out ofnetwork-benefits, in"addition to the deductible and coinsurance,you are responsible for fi charges'_i "''excess of the non-network provider reimbursement amount. Additionally,these infertility treatment must be received from or under the direction of a physician. All services, any in a .:" P i Y I -charges notbe applied toward satisfaction of the deductible or the out-of supplies, and associated expenses for the treatment of infertility are not covered. pocket maximum.. See Definitions These words havespecific meanings benefits,coinsurance, deductible,�` 6. Treatment of temporomandibular Covered at the Covered at the hospital, inpatient, Member, � a network, non-network, non n etvork.provider reimbursement joint (TMJ) disorder and corresponding in-network corresponding out-of- amount provider; virtual care: . craniomandibular disorder benefit level, depending network benefit level, on type of services depending on type of Prior authorization. Prior authorization from Medica may be required before you receive provided. services provided. 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 For example, office visits For example, office visits authorization process. are covered at the office are covered at the office visit in-network benefit visit out-of-network level and surgical benefit level and surgical Covered services are covered at services are covered at the surgical services in- the surgical services out- Benefits apply to services for the diagnosis of infertility received from a network or non-network network benefit level. of-network benefit level. provider. More than one coinsurance may be required if you receive more than one service or Please note: Dental Please note: Dental see more than one provider per visit. coverage is not provided coverage is not provided Coverage for infertility services is limited to a maximum of$5,000 per member per calendar year under this benefit. under this benefit. 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. Not covered These 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. 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 Prescription Specialty Drug Program or otherwise described as a specific benefit in this certificate. 4. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 5. Services for a condition that a physician determines cannot be successfully treated. 6. Services related to surrogate pregnancy for a person not covered as a member under the Contract. MIC FOCUSMN HSA(3/12) 28 1500-100% MIC FOCUSMN HSA (3/12) 29 1500 100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Infertility Diagnosis Maternity Services 7. Sperm banking. 8. Adoption. 9. Donor sperm. K. Maternity Services 10. Embryo and egg storage. 11. Services for intrauterine insemination (IUI). This section describes coverage for maternity services. Benefits for maternity services include all medical services for prenatal care, labor and delivery, postpartum care, and related complications. See Exclusions for additional services, supplies, and associated expenses that are not covered. See Definitions. These words have specific meanings: benefits, coinsurance, deductible, dependent, hospital, inpatient,member, network, non network, non-network provider reimbursement amount nphysician, prenatal°'care `rovider, skilled care. a Your Benefits the Amounts You Pali Prior authorization. Prior authorization from Medica may be required before you receive � � �, �� ���,� � '` - _ M y services or supplies. Call Customer Service at one of the telephone numbers listed inside the Benefits* tia , : � ; � -� � �� � �_. � In-network=`benefit "�` � � �_� �. . front cover. See How To Access Your Benefits for more information about the prior authorization ' after:deduictible after d dt ctible benefits; process. For out-°f-network benefits, in addition to the dedUctible and . Mothers' any charges in exc.ess of the non network provider reimbursement amount. you P responsible for. Newborns'and Mothers Health Protection Act of 1996 charges will not be applied toward satisfaction of the d ` -d he,out-of-pocket maximum. Generally, Medica may not restrict benefits for any hospital stay in connection with childbirth for � eductible or the Office visits, including any Nothing the mother or newborn child member to less than 48 hours following a vaginal delivery (or less services provided during such Covered as an in-network than 96 hours following a cesarean section). However, federal law generally does not prohibit the visits benefit. 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 2. Virtual care Nothing case, Medica may not require a provider to obtain prior authorization from Medica for a length of g No coverage 3. Outpatient services received at a Nothin stay of 48 hours or less (or 96 hours, as applicable). hospital g Covered as an in-network benefit. Covered 4. Inpatient services Nothing Covered as an in-network benefit. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 5. Services received from a Nothin g may be required if you receive more than one service or see more than one provider per visit. physician during an inpatient Covered as an in-network Each member's admission is separate from the admission of any other member. A separate stay benefit. deductible and coinsurance will be applied to both you and your newborn child for inpatient 6. Anesthesia services received Nothin g services related to maternity labor and delivery. Please note: We encourage you to enroll your from a provider during an Covered as an in-network newborn dependent under the Contract within 30 days from the date of birth, date of placement inpatient stay benefit. for adoption, or date of adoption. Please refer to Eligibility And Enrollment for additional information. • In-network benefits apply to maternity services received from a network provider. • Out-of-network benefits apply to maternity 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. MIC FOCUSMN HSA (3/12) 30 1500-100% MIC FOCUSMN HSA (3/12) 31 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Maternity Services Maternity Services Additional information about coverage of maternity services :, Your.Benefits and the Amounts You Pay °� � . Not all services that are received during your pregnancy are considered prenatal care. Some of - � the services that are not considered prenatal care include (but are not limited to)treatment of the Benefits . :In-network benefits *Out-of-network benefits after deductible after deductible following: � � � �. £; 1. Conditions that existed prior to and independently of)the pregnancy, such as diabetes or * R P ( p Y ) � For out-of-network benefits, in addition to deductibie and coinsurance,you are responsible for lupus, even if the pregnancy has caused those conditions to require more frequent care or any charges in excess of the non network provider reimbursement amount. Additionally,these.•=; monitoring. charges will not be applied toward satisfaction of the deductible or the aut-of pocket maximum. 2. Conditions that have arisen concurrently with the pregnancy but are not directly related to care c. Intermittent skilled care or Nothing. The deductible 50% coinsurance of the pregnancy, such as back and neck pain or skin rash. home infusion therapy when does not apply. 3. Miscarriage and ectopic pregnancy. you are homebound due to a Services that are not considered prenatal care may be eligible for coverage under the most high risk pregnancy specific and appropriate section of this certificate. Please refer to those sections for coverage 2. Inpatient hospital stay for labor Nothing 50% coinsurance information. and delivery services Please note: Maternity labor and Not covered delivery services are considered inpatient services regardless of the length of hospital stay. These services, supplies, and associated expenses are not covered: o 3. Professional services received Nothing 50% coinsurance 1. Health care professional services for maternity labor and delivery in the home. during an inpatient stay for labor 2. Services from a doula. and delivery 3. Childbirth and other educational classes. 4. Anesthesia services received Nothing 50% coinsurance during an inpatient stay for labor See Exclusions for additional services, supplies, and associated expenses that are not and delivery covered. 5. Labor and delivery services at a freestanding birth center Your Benefits andtheAmounts You Pay r x =� :' ; a. Facility services for labor and Nothing 50% coinsurance }> f -' delivery Benefits in-network benefits; *Out of network benefits � ,.,� b. Professional services Nothing 50% coinsurance - after deductible after deductible received for labor and q delive ry ""For out-ofe network benefits, in addition to the:deductible and coinsurance,you areresponsible for any charge skin excess of the non-network provider reimbursement amount Additionally,these' 6. Home health care visit following Nothing. The deductible 50% coinsurance charges-will not be applied toward satisfaction of the deductible or the outer-of pocket maximum. does not apply. Please note: One home health visit 1. Prenatal services is covered if it occurs within 4 days of discharge. If services are a. Office visits for prenatal care, Nothing. The deductible 50% coinsurance received after 4 days, please refer including professional does not apply. to Home Health Care for benefits. services, lab, pathology, x-rays, and imaging b. Hospital and ambulatory Nothing. The deductible 50% coinsurance surgical center services for does not apply. prenatal care, including professional services received during an inpatient stay for prenatal care MIC FOCUSMN HSA(3/12) 32 1500-100% MIC FOCUSMN HSA (3/12) 33 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 M Medical-Related Dental Services 1 Medical-Related Dental Services I 6. Tooth extractions, except as described in this section. 7. Any dental procedures or treatment related to periodontal disease. L. 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. his section describes coverage for medical-related dental services. Services must be received 9 Routine diagnostic and preventive dental services. 1 from a physician or dentist. See Exclusions for additional services, supplies, and associated expenses that are not This section does not describe coverage for comprehensive dental procedures. Comprehensive covered. 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 � � �4 any section of this certificate. fin, .- Your Benefits and the Amounts You Pay t i ..._.__._.. _�... .f, ,_;�•�._,..___.: ,, A.. _ In network be nefr ts •Out of network b e_ .�_n. e_ f_ t_ s See Definitions.�Thene.word s have.'specific� .. _m benefits _ � r ance k deductible, Benefits f : o � �_ , �. � after-deductible e after ,dependent, hos it al member,,< ,.n on ark _ ° .provider reimbursement ur ement_amount_.Physicpan provider. � � _ � � . . , . :- � . _ Prior authorization. Prior authorization from in i "' i m Medics may be required before you receive y charges in excess f the on-ne trorr to tFie deductib#e,,and coinsurance,-you are responsrble for =' services or supplies. Call Customer Service at one of the tel y eive any charges in excess of.the non network provider reimbursement amount Additionally,these,;' front cover.supplies. How To Access Your Benefits telephone numbers listed inside the s for more information about the prior authorization char es w�#1 not be applied toward satisfaction of the�deductrbleor_the out of=pocket maximum.: process. g - . 1. Charges for medical facilities Nothing 50% coinsurance and general anesthesia services Covered that are: For benefits and the amounts you pay, see the table in this section. More than one coinsurance a. Recommended by a network may be required if you receive more than one service or see more than one provider per visit. physician; and and g • In-network benefits apply to medical-related dental services received from a network b. Received d a dental provider. procedure;during and • Out-of-network benefits apply to medical-related dental services received from a non- c. Provided to a member who: network provider. In addition to the deductible and coinsurance described for out-of-network i. is a child under age five benefits, nefi ts, you will be responsible for any charges in excess of the non-network provider (prior authorization is not reimbursement amount. The out-of-pocket maximum does not apply to these charges. required); or 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 ii. is severely disabled; or associated with out-of-network benefits. iii. has a medical condition and requires Not covered hospitalization or general anesthesia for dental care treatment These services, supplies, and associated expenses are not covered: Please note: Age, anxiety, 1. Dental services to treat an injury from biting or chewing. and behavioral conditions are not considered medical 2. Osteotomies and other procedures associated with the fitting of dentures or dental implants. conditions. 3. Dental implants (tooth replacement), except as described in this section for the treatment of 2. For a dependent child, Nothing 50% coinsurance cleft lip and palate. orthodontia, dental implants, and 4. Any other dental procedures or treatment, whether the dental treatment is needed because oral surgery treatment related to of a primary dental problem or as a manifestation of a medical treatment or condition. cleft lip and palate 5. Any orthodontia, except as described in this section for the treatment of cleft lip and palate. MIC FOCUSMN HSA (3/12) 34 MIC FOCUSMN HSA (3/12) 35 1500-100 8 1500-100% ° BPL 21316 DOC 23928 BPL 21316 DOC 23928 i Medical-Related Dental Services Mental Health Your Benefits and the Amounts You Pays' M. Mental Health Benefits in=network benefits *Out of network benefits � Y *r, � _ after deductible after deductible , This section describes coverage for services to diagnose and treat mental disorders listed in the n you g current edition of the Diagnostic and Statistical Manual of Mental Disorders. For a description of *For�out-of-network£bene#its, in addition to the deductible and co�rsurance, b are responsible.#or, 5 P any charges in excess of the no -network provider reimbursement amount. Additionally,these coverage for the diagnosis and primary treatment of substance abuse disorders, see Substance sx" charges will not be applied toward satisfaction of the deductible or the out-of pocket maximum, Abuse. Accident-related dental services Nothing 50% coinsurance See Definitions..,These words have specific meanings: benefits, claim, coinsurance, custodial 3. c g care,deductible;"emergency;'hospital, inpatient, medically necessary, member'mental"disorder,' to treat an injury to sound, natural teeth and to repair (not network, non-network, non network provider reimbursement'amount,,physician,E,provider. replace) sound, natural teeth. Prior authorization. For prior authorization requirements of in-network and out-of-network The following conditions apply: benefits, call Medica's designated mental health and substance abuse provider at a. Coverage is limited to 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center services received within 24 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. months from the later of: For purposes of this section: i. the date you are first 1. Outpatient services include: covered under the Contract; or a. Diagnostic evaluations and psychological testing. ii. the date of the injury b. Psychotherapy and psychiatric services. b. A sound, natural tooth means c. Intensive outpatient programs, including day treatment, meaning time limited a tooth (including supporting comprehensive treatment plans, which may include multiple services and modalities, structures) that is free from delivered in an outpatient setting (up to 19 hours per week). disease that would prevent d. Treatment for a minor, including family therapy. continual function of the tooth e. Treatment of serious or persistent disorders. for at least one year. In the case of primary (baby) f. Diagnostic evaluation for attention deficit hyperactivity disorder(ADHD) or pervasive teeth, the tooth must have a development disorders (PDD). life expectancy of one year. 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 4. Oral surgery for: Nothing 50% coinsurance psychologist and that includes an individual treatment plan. a. Partially or completely h. Treatment of pathological gambling. unerupted impacted teeth; or 2. Inpatient services include: b. A tooth root without the extraction of the entire tooth a. Room and board. (this does not include root b. Attending psychiatric services. canal therapy); or c. Hospital or facility-based professional services. c. The gums and tissues of the mouth when not performed in d. Partial program. This may be in a freestanding facility or hospital based. Active treatment connection with the is provided through specialized programming with medical/psychological intervention and extraction or repair of teeth 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 (3/12) 36 1500-100% MIC FOCUSMN HSA (3/12) 37 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 M Mental Health Mental Health f. Residential treatment services. These services include either: h. Hospital that provides mental health services i. A residential treatment program serving children and adolescents with severe emotional 2. Emergency mental health services are eligible for coverage under in-network benefits. disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or 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 ii. A licensed or certified mental health treatment program providing intensive therapeutic amount. The out-of-pocket maximum does not apply to these charges. Please see services. In addition to room and board, at least 30 hours a week per individual of Important member information about out-of-network benefits in How To Access Your mental health services must be provided, including group and individual counseling, Benefits for more information and an example calculation of out-of-pocket costs associated 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 with out-of-network benefits. admission, psychiatric follow-up visits at least once per week, and 24-hour nursing coverage. Not covered 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 For benefits and the amounts you pay, see the table in this section. More than one coinsurance Manual of Mental Disorders. . may be required if you receive more than one service or see more than one provider per visit. 2. Services for a condition when there is no reasonable expectation that the condition will • For in-network benefits: improve. Medica's designated mental health and substance abuse provider arranges in-network mental 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as health benefits. Medica's designated mental health and substance abuse provider will refer specifically described in this section. you to other mental health providers only if network providers cannot provide the services you 4. Relationship counseling. 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 5. Family counseling services, except as specifically described in this certificate as treatment substance abuse provider will refer you to one of its hospital providers (Medica and Medica's for a minor. designated mental health and substance abuse provider hospital networks are different). 6. Services for telephone psychotherapy. Providers may be network providers for mental health services only, and not otherwise part 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, 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 as those conditions are defined in the current edition of the Diagnostic and Statistical benefits. You can do this by reviewing g Manual of Mental Disorders. y g your provider directory and contacting Customer Service at one of the telephone numbers listed inside the front cover. 8. Services, including room and board charges, provided by health care professionals or For claims questions regarding in-network benefits, call Medica's designated mental health facilities that are not appropriately licensed, certified, or otherwise qualified under state law q 9 9 9 and substance abuse provider Customer Service at 1-866-214-6829. 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, • For out-of-network benefits: and services received from a halfway house, housing with support, therapeutic group home, boarding school, or ranch. 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 9. Services to assist in activities of daily living that do not seek to cure and are performed licensed, certified, or otherwise qualified under state law to provide the mental health regularly as a part of a routine or schedule. services and practice independently: g 10. Room and board charges associated with mental health residential treatment services a. Psychiatrist 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 b. Psychologist visits at least once per week, and 24-hour nursing coverage. c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric See Exclusions for additional services, supplies, and associated expenses that are not and mental health nursing covered. d. Mental health clinic e. Mental health residential treatment center f. Independent clinical social worker • g. Marriage and family therapist 39 1500-100% MIC FOCUSMN HSA (3/12) 38 1500-100% MIC FOCUSMN HSA (3/12) BPL 21316 DOC 23928 BPL 21316 DOC 23928 Mental Health Miscellaneous Medical Services And Supplies ate„_. z - _ �- ;Your-Benefits and the Amounts You Pay �x `� N. Miscellaneous Medical Services And Supplies Benefits An network benefits * Out-of-network benefits = , X after deductible 7. after deductible This section describes coverage for miscellaneous medical services and supplies prescribed by For out-of-network benefits,in addition to the deductible and;coinsurance,you;are responsible for a physician. Medica covers only a limited selection of miscellaneous medical services and any charges Pin-excess of the non network provider reimbursement amount Additionally,these supplies that meet the criteria established by Medica. Some items ordered by a physician, even charges will not be applied toward satisfaction of the deductible or the out-of-pocket inaxirnurn if medically necessary, may not be covered. ° See Definitions These words have specific meanings:= Miscellaneous Medical Services And Supplies Organ And Bone Marrow Transplant Services a � , °You Benefits-and the Amounts You Pa O. Organ And Bone Marrow Transplant Services Benefits M n networkbe efts *out o f ne twork�benefits - n after deductible- after deductible This section describes coverage for certain organ and bone marrow transplant services. *For out-of-network benefits, in addition#o the deductible and coinsurance,you are=res onsible ford= Services must be provided under the direction of a network physician and received at a p P p Y any charges in excess of the non network.provider reimbursement amount.' -,., ,�z _ � n#�Additianallythese designated transplant facility. This section also describes benefits for professional, hospital, charges will not be applied toward-satisfaction of the.deductible or the out-Of-pocket maximum and ambulatory surgical center services. 1. Blood clotting factors Nothing 50% coinsurance Coverage is provided for certain types of organ transplants and related services (including 2. Dietary medical treatment of Nothing organ acquisition and procurement) and for certain bone marrow transplant services that are phenylketonical treatment 50% coinsurance medically necessary, appropriate for the diagnosis, without contraindications, and non- phenylketonuria 3. Amino acid-based elemental Nothing 50% coinsurance formulas for the following See Definitions These wards have specific meanings: benefits, insurance, detluetible �.j diagnoses: designated facility, hospital, inpatient, investigative, medically necessary, member, networks, non-network, non network provider reimbursement amount, physician, provider, virtual care a. cystic fibrosis; Prior authorization. Prior authorization from Medica is required before you receive services or b. amino acid, organic acid, and supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. fatty acid metabolic and See How To Access Your Benefits for more information about the prior authorization process. malabsorption disorders; c. IgE mediated allergies to Covered food proteins; d. food protein-induced For benefits and the amounts you pay, see the table in this section. More than one coinsurance enterocolitis syndrome; may be required if you receive more than one service or see more than one provider per visit. e. eosinophilic esophagitis; Medica uses specific medical criteria to determine benefits for organ and bone marrow transplant services. Because medical technology is constantly changing, Medica reserves the f. eosinophilic gastroenteritis; right to review and update these medical criteria. Benefits for each individual member will be and determined based on the clinical circumstances of the member according to Medica's medical g. eosinophilic colitis criteria. Coverage for the diagnoses in Coverage is provided for the following human organ transplants, if appropriate, under Medica's 3.c.-g. above is limited to medical criteria and not otherwise excluded from coverage (see Not covered below): cornea, members five years of age and kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone younger. marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, peripheral blood, and umbilical cord blood. 4. Total parenteral nutrition Nothing 50% coinsurance The preceding is not a comprehensive list of eligible organ and bone marrow transplant 5. Eligible ostomy supplies Nothing 50% coinsurance services. Please note: Eligible ostomy supplies may be received from a • In-network benefits apply to transplant services provided by a network provider and received pharmacy or a durable medical at a designated transplant facility. A designated transplant facility means a hospital that has equipment provider. entered into a separate contract with Medica to provide certain transplant-related health 6. Insulin pumps and other eligible Nothing services to members receiving transplants. You may be evaluated and listed as a potential g g 50% coinsurance recipient at multiple designated facilities for transplant services. diabetic equipment and supplies 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 (3/12) 42 1500-100% MIC FOCUSMN HSA (3/12) 43 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services Providers may be network providers for transplant services only, and not otherwise part of the ' ,4 Medica Focus network. When you receive other health services, you should verify that your y Your Benefits and the Amounts You Pays., z ,i,. 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 Benefits � In-network:benefits = Out-of-network benefits telephone numbers listed inside the front cover. °� after deductible after deductible_ ,', -- For out of-network benefits, in addition to the deductible and coinsurance, you are responsible for.%. Not covered ' any charges n.excess of the.non-network provider,reimbursement amount AdditionaIIy,.these ; charges wii1 not be applied toward satisfaction of the;deductible or the.cut-of pocket maximum These services, supplies, and associated expenses are not covered: .,.. 1. Organ and bone marrow transplant services, except as described in this section. 1. Office visits Nothing No coverage 2. Supplies and services related to transplants that would not be authorized by Medica under 2. Virtual care Nothing No coverage the medical criteria referenced in this section. 3. Outpatient services 3. Chemotherapy, radiation therapy, drugs, or any therapy used to damage the bone marrow a. Professional services and related to transplants that would not be authorized by Medica under the medical criteria i. Surgical services (as Nothing No coverage referenced in this section. defined in the Physicians' 4. Living donor transplants that would not be authorized by Medica under the medical criteria Current Procedural referenced in this section. Terminology code book) 5. Islet cell transplants, except for autologous islet cell transplants associated with received from a physician during uring an office visit or an outpatient hospital visit 6. Services required to meet the patient selection criteria for the authorized transplant ii. Anesthesia services Nothing No coverage procedure. This includes treatment of nicotine or caffeine addiction, services and related received from a provider expenses for weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature not otherwise covered under this certificate. during an office visit or an outpatient hospital or 7. Mechanical, artificial, or non-human organ implants or transplants and related services that ambulatory surgical would not be authorized by Medica under the medical criteria referenced in this section. center visit 8. Transplants and related services that are investigative. iii. Outpatient lab and Nothing No coverage 9. Private collection and storage of umbilical cord blood for directed use. pathology 10. Drugs provided or administered by a physician or other provider on an outpatient basis, iv. Outpatient x-rays and Nothing No coverage except those requiring intravenous infusion or injection, intramuscular injection, or other imaging services intraocular injection. Coverage for drugs is as described in Prescription Drug Program and v. Other outpatient hospital Nothing No coverage Prescription Specialty Drug Program or otherwise described as a specific benefit in this services received from a certificate. . physician See Exclusions for additional services, supplies, and associated expenses that are not b. Hospital and ambulatory covered. 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(3/12) 44 1500-100% MIC FOCUSMN HSA (3/12) 45 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 • Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services -,_ §,, Your Benefits.and the p. ,. :. �< _._ _... , . - __ . �t Amounts You__Ra ._ � _=m_ �. � :i"._._ F• ..� _ �. _ m-._ Your Benefits and.the Amounts You Pay, - _<__ . -� _.�. .. - _-,,, >._ ar �_.__. . - r .< .._ _ _ _ �_ _._ ,: � Yom. Ben.._.e fits ,< � �r, ; .._ �, .. �<, ,t .netwo benefits,.._..,. . ,O..teu t of_n etw o rk,ben. e f lts,. B e n.,efi tr.-s_ > �,,.x._ -=_. _._. .;:.. _�.. - -n--_r>_ etwock benefits '.. Dut_o f netwock benefits > _ _ after deduc#ib Ie after . , � after deductible after deductible *...... - ..>.. ......,4E _... ._ -_ .,<x. _,... .......v.. - ............... •...... _ } S : - _ A vim. For - < you q, a out-of-network benefit � ,: .-. :, . . _ �, s in coinsurance �: _ For'out-of-network.. . nef�ts �n._add�tion.ta he deductible coinsurance. ou are responsible for <�. .w. <. . : _. ,. ace,_you are responsible for._, , benefits, _. _ �. t �d ,Y R � Y p any charges - ," � ,., on network.provider reimbursement =-- . . ; � , r ement�am unt.�.A d�tronai,t these .,�:_, . Y 9 p ,amoun#..-Additranall these an charges �nexcess_of the-non network rov€derreimbu __. o d , _. :: ,.. Y, _..._ _ - - _. charges will,:not be Iced toward satisfaction � _ maximum:, ..: . , .� ,. 9 --- coon.of deductible the out..-of ocket .... ,. �wilt.notbe,a applied _ � faction;ofrthededuct�ble.or-the au# of ocket maximum. � x;. ..__ applied :.. . ..�-. .... _... ,. charges � toward'satisfaction s ., 9� _._ > . p 5. Services received from a Nothing No coverage ii. Lodging for you (while not physician during an inpatient confined) and one sta companion. y Reimbursement is 6. Anesthesia services received Nothing No coverage available for a per diem from a provider during an amount of up to $50 for inpatient stay one person or up to $100 7. Transportation and lodging The deductible does not No coverage for two people. If you are a. As described below, apply to this a minor child reimbursement of reasonable reimbursement benefit. reimbursement for and necessary expenses for You are responsible for lodging expenses for two paying all amounts not companions is available, travel and lodging for you reimbursed under this up to a per diem amount and a companion when you benefit. Such amounts of$100. receive approved services at a designated facility for do not count toward your iii. There is a lifetime transplant services and you out-of-pocket maximum maximum of$10,000 per live more than 50 miles from or toward satisfaction of member for all that designated facility your deductible. transportation and lodging expenses i. Transportation of you and incurred by you and your one companion (traveling companion(s) and on the same day(s)) to reimbursed under the and/or from a designated Contract or under any facility for transplant other Medica, Medica services for pre- Health Plans, or Medica transplant, transplant, Health Plans of and post-transplant Wisconsin coverage services. If you are a offered through the same minor child, employer. transportation expenses b. Meals are not reimbursable for two companions will be reimbursed. under this benefit. MIC FOCUSMN HSA(3/12) 47 1500-100% MIC FOCUSMN HSA (3/12) 46 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Physical, Speech, And Occupational Therapies Physical, Speech, And Occupational Therapies 8. Physical, speech, or occupational therapy services (including but not limited to services for the correction of speech impediments or assistance in the development of verbal clarity) P. Physical, Speech, And Occupational Therapies when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to generally accepted standards in the medical community. This section describes coverage for physical therapy, speech therapy, and occupational therapy services provided on an outpatient basis. A physician must direct your care in order for it to be 9. Massage therapy, provided in any setting, even when it is part of a comprehensive eligible for coverage. Coverage for services provided on an inpatient basis is as described treatment plan. elsewhere in this certificate. See Exclusions for additional services, supplies, and associated expenses that are not See Definitions These words have specific meanings: benefits, coinsurance, deductible, covered. inpatient, network, non-network,-non-network provider reimbursement amount, physician. authorization. Prior authorization from Medica may be required before you receive `" l Your Benefi ts and the Amounts You Pay q3 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. Benefits k , in-network benefits •Out-of-network benefits after deductible after deductible Covered * For out of-network benefts, in addition to the deductible and coinsurance,you are responsible for any charges,in,excess<of the non-network provider reimbursement amount. Additionally,these For benefits and the amounts you pay, see the table in this section. More than one coinsurance charges will not be applied toward satisfaction of the deductible or the ut-of pocket maximum may be required if you receive more than one service or see more than one provider per visit. 1. Physical therapy received Nothing 50% coinsurance. • In-network benefits apply to outpatient physical therapy, speech therapy, and occupational outside of your home when Coverage for physical therapy services arranged through a physician and received from the following types of physical function is impaired due and occupational therapy network providers: physical therapist, speech therapist, occupational therapist, or physician. to a medical illness or injury, or is limited to a combined • Out-of-network benefits apply to outpatient physical therapy, speech therapy, and congenital or developmental limit of 20 visits per occupational therapy services arranged through a physician and received from the following conditions that have delayed calendar year. motor development Please note: This visit limit types of non-network providers: physical therapist, speech therapist, occupational therapist, includes physical and or physician. In addition to the deductible and coinsurance described for out-of-network occupational therapy visits benefits, you are responsible for any charges in excess of the non-network provider that you pay for in order to reimbursement amount. The out-of-pocket maximum does not apply to these charges. satisfy any part of your Please see Important member information about out-of-network benefits in How To Access deductible. Your Benefits for more information and an example calculation of out-of-pocket costs 2. Speech therapy received outside Nothing 50% coinsurance. associated with out-of-network benefits. of your home when speech is Coverage for speech impaired due to a medical illness therapy is limited to 20 Not covered or injury, or congenital or visits per calendar year. developmental conditions that Please note: This visit limit These services, supplies, and associated expenses are not covered: have delayed speech includes speech therapy development visits that you pay for in 1. Services primarily educational in nature. p order to satisfy any part of 2. Vocational and job rehabilitation. your deductible. 3. Recreational therapy. 4. Self-care and self-help training (non-medical). 5. Health clubs. 6. Voice training. 7. Group physical, speech, and occupational therapy. MIC FOCUSMN HSA (3/12) 48 1500-100% MIC FOCUSMN HSA(3/12) 49 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Physical, Speech, And Occupational Therapies Prescription Drug Program z_ Your Benefits and:the Amounts You Pay Q. Prescription Drug Program Benefits - r t * n nnetwork benefit s .� : � Out-of-network benefits �- after deductible after deductible This section describes coverage for prescription drugs and supplies received from a pharmacy *° i t: the n,' le for or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" For out-of-network benefits, in addition to the deductible and coinsurance,you�are re ponsble for g p y• p p p g is meant to include those prescription drugs and supplies found on the Preferred Drug List any charges in=excessof#he;:non non -network :Add#tonally,these �- P P 9 pp � g charges will not be applied toward satisfaction of`the deductible or the out-of-pocket maximum. (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 3. Occupational therapy received Nothing 50% coinsurance. "professionally administered drugs" means drugs requiring intravenous infusion or injection, outside of your home when Coverage for physical intramuscular injection, or intraocular injection; the phrase "self-administered drugs" means all physical function is impaired due and occupational therapy other drugs. For the definition and coverage of specialty prescription drugs, see Prescription to a medical illness or injury or is limited to a combined Specialty Drug Program. congenital or developmental limit of 20 visits per conditions that have delayed calendar ear. See:DefinrtionsThesewordshave specific meanings: benefits, claim, coinsurance, y deductible,-durable medical-equipment,+emergency, hospital, member, network, non-network, motor development Please note: This visit limit includes physical and non-network provider reimbursement amount, physician,=prescription drug, preventive health occupational therapy visits service, provider, urgent care center.;_ �= that you pay for in order to satisfy any part of your Preferred drug list deductible. 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(3/12) 50 1500-100% MIC FOCUSMN HSA(3/12) 51 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Prescription Drug Program Prescription Drug Program the pharmacy. For example, if the agreement states that the Tier 1 prescription drug "A" costs Quantity limits $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 Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits provider still choose (for any reason) to utilize a Tier 2 or Tier 3 brand name prescription drug or indicate the maximum quantity allowed per prescription over a specific time period. Some quantity limits are based on packagin FDA labeling, or clinical guidelines. � supply under your in-network benefit, Medica will pay the amount Medica would have paid had pgg, g, o gu 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 Covered 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 The following table provides important general information concerning in-network, out-of- maximum. network, and mail order benefits. For specific information concerning benefits and the amounts Please note that receiving Tier 2 or Tier 3 brand name drugs or supplies when an you pay, see the benefit table at the end of this section. Please note that Prescription Drug Program describes your coinsurance for prescription drugs themselves. An additional equivalent Tier 1 generic drug exists may result in significantly more out-of-pocket costs. coinsurance applies for the provider's services if you require that a provider administer self- 1 For example, you receive a Tier 2 or Tier 3 brand name prescription drug "B," although a administered drugs, as described in other applicable sections of this certificate including, but not chemically equivalent Tier 1 generic prescription drug "A" exists. Medica's agreement with the limited to, Hospital Services, Infertility Diagnosis, and Professional Services. 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. .. -. ..; _ In n etrnrork benefits � � � Out-of-network benefits* . Mail order benefi#s 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 Covered drugs received at a Covered drugs received at a Covered drugs received from due to the pharmacy after you paid your copayment and Medica paid the amount it owed. network pharmacy; and non-network pharmacy; and a designated mail order pharmacy; and Exceptions to the preferred drug list Covered drugs for family See In-network benefits Covered drugs for family In certain circumstances your physician may request that Medica make an exception to the planning services sexually 11 the column. planning services f sexually 11 the coverage rules described under Preferred drug list above. Please note that exceptions will treatment of sexually treatment of sexually only be allowed when specific clinical criteria are satisfied. Any exception Medica grants pre transmitted rb diseases when transmitted diseases when will improve the coverage by only one tier. Exceptions to the PDL can also include either bn by neor twork received from prescribed etw rik or by other a antipsychotic drugs prescribed to treat emotional disturbance or mental illness, and certain either k a provider.. a non- network and a non-network drugs for diagnosed mental illness or emotional disturbance if removed from the PDL or you network provider. Family provider and received from a change health plans. If you would like to request a copy of Medica's PDL exception process, planning services do not designated mail order call Customer Service at one of the telephone numbers listed inside the front cover. include infertility treatment searmacd. not planning services; and services do not include infertility treatment services; Prior authorization and ,, Certain covered drugs require prior authorization as indicated on the PDL. The provider who Diabetic equipment and Diabetic equipment and Diabetic equipment and supplies, including blood supplies, including blood supplies (excluding blood prescribes the drug initiates prior authorization. The PDL is made available to providers, glucose meters when received glucose meters when received glucose meters) received including pharmacies and the designated mail order pharmacies. You are responsible for from a network pharmacy; and from a non-network pharmacy; from a designated mail order �' paying the cost of drugs received if you do not meet Medica's authorization criteria. and pharmacy. Tobacco cessation products Tobacco cessation products Not available. • Step therapy when prescribed by a provider when prescribed by a provider Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step product ad to received prescribe the product and to received prescribe the there involves trying an alternative covered drug first (typically a Tier 1 drug) before moving product and received at a product and received at a non- py y g g ( yp y g) g network pharmacy. network pharmacy. 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. * 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 (3/12) 52 1500-100% MIC FOCUSMN HSA (3/12) 53 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 1 1 I Prescription Drug Program 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. Your Benefits and the Amounts You P y ** Please note: Some drugs and supplies are not available through the designated mail order A ' pharmacy. * 1e, ,For-out-of network benefits,,irr,addition to the deductible andacomsurance,,you�are responsible for See Miscellaneous Medical Services And Supplies any charges=m excess ofthe rion network pcovof th ededursernent th aunt f-po ket ma ,these pp ies for coverage of insulin pumps. charges will-snot be applied toward satisfaction of the deductible.or the;out-of pocket maximum . See Prescription Specialty Drug Program for coverage of specialty prescription drugs. In-network benefits '" *°eut-of-network-benefits" Mail order benefits' Prescription unit after deductible afterdeductible� rafter deductible . Generally, covered drugs will not be dispensed in excess of one prescription unit except as 1 Programnt covered drugs other than those described below or in Prescription Specialty Drug indicated below. One prescription unit is equal to a 31-consecutive-day supply of a covered dru from your pharmacy (or, in the case of contraceptives, up to a one-cycle supply) or a 93- 9 Tier ri Nothing per 50% coinsurance per Tier 1: Nothing per consecutive-day supply of a covered drug from your designated mail order pharmacy (or, in the prescription unit; or prescription unit prescription unit; or case of contraceptives, up to a three-cycle supply), unless limited by drug manufacturers' Tier 2: Nothing per Tier 2: Nothing per packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits prescription unit; or prescription unit; or as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed. Tier 3: No coverage Tier 3: No coverage 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 2. Diabetic equipment and supplies, including blood glucose meters dispense multiple prescription units. For the current list of such designated pharmacies, sign in Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside prescription unit; or prescription unit prescription unit; or the front cover. Tier 2: Nothing per Tier 2: Nothing per Not covered prescription unit; or prescription unit; or Tier 3: No coverage Tier 3: No coverage The following are not covered: 3. Tobacco cessation products 1. Any amount above what Medica would have paid when you fail to identify yourself to the Tier 1: Nothing per 50% coinsurance per Not available through a mail pharmacy as a member. (Medica will notify you before enforcement of this provision.) prescription unit; or prescription unit order pharmacy. 2. OTC drugs not listed on the PDL. Tier 2: Nothing per 3. Replacement of a drug due to loss, damage, or theft. prescription unit; or 4. Appetite suppressants. Tier 3: No coverage 5. Erectile dysfunction medications. The deductible does not 6. Non-sedating antihistamines and non-sedating antihistamine/decongestant combinations. apply. 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 Prescription Specialty Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/12) 54 1500-100% MIC FOCUSMN HSA (3/12) 55 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Prescription Drug Program Prescription Specialty Drug Program Your Benefits and the Amounts You Pay R. Prescription Specialty Drug Program *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. 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 In-network benefits - * Out-of-network benefits Mail order benefits prescription drug products for individuals with diseases that require complex therapies. Such after deductible after deductible after deductible specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as - - . pro -- - - --- -` -- described below. For purposes of this section, the phra se "professionally administered dr ugs" 4. Drugs and other supplies (other than tobacco cessation products) considered preventive means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular health services, as specifically defined in Definitions, when prescribed by a provider injection; the phrase "self-administered drugs" means all other drugs. authorized to prescribe such drugs. This group of drugs and supplies is specific and limited. For the current list of such drugs and supplies, please refer to the Preventive Drug See Definitions. These words have specific meanings: benefits, claim, coinsurance, and Supply List within the PDL or call Customer Service at one of the telephone numbers listed deductible, member, network,;physician, prescription drug, provider. m inside the front cover. Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per Designated specialty pharmacies prescription unit; or prescription unit prescription unit; or A designated specialty pharmacy means a specialty pharmacy that has entered into a separate Tier 2: Nothing per Tier 2: Nothing per contract with Medica to provide specialty prescription drug services to members. For the prescription unit; or prescription unit; or current list of designated specialty pharmacies, call Customer Service at one of the telephone Tier 3: No coverage Tier 3: No coverage numbers listed inside the front cover or sign in at www.mymedica.com. The deductible does not The deductible does not apply. apply. 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 • MIC FOCUSMN HSA (3/12) 56 1500-100% MIC FOCUSMN HSA (3/12) 57 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Prescription Specialty Drug Program Prescription Specialty Drug Program Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also Not covered 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 The following are not covered: or you change health plans. If you would like to request a copy of Medica's SPDL exception 1. Any amount above what Medica would have paid when you fail to identify yourself to the process, call Customer Service at one of the telephone numbers listed inside the front cover. designated specialty pharmacy as a member. (Medica will notify you before enforcement of this provision.) Prior authorization 2. Replacement of a specialty drug due to loss, damage, or theft. Certain specialty prescription drugs require prior authorization. The provider who prescribes the 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of specialty drug initiates prior authorization. The SPDL is made available to providers, including licensure. designated specialty pharmacies. You are responsible for paying the cost of specialty 4. Prescription drugs, except as described in Prescription Drug Program. prescription drugs you receive if you do not meet Medica's authorization criteria. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty Step therapy pharmacy. 6. Infertility drugs. Medica requires step therapy prior to coverage of specific specialty prescription drugs as 7. Growth hormone. indicated on the SPDL. Step therapy involves trying an alternative covered specialty prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other See Exclusions for additional drugs, supplies, and associated expenses that are not Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. covered. Applicable step therapy requirements must be met before Medica will cover certain Tier 2 specialty prescription drugs. Your Benefits and the Amounts You Pay Quantity limits j Benefits s ,�. You pay after deductible 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. 1. Specialty prescription drugs Tier 1 specialty prescription drugs: Nothing per Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. received from a designated prescription unit; or specialty pharmacy Tier 2 specialty prescription drugs: No coverage 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, Hospital Services, Infertility Diagnosis, and Professional Services. 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 (3/12) 58 1500-100% MIC FOCUSMN HSA(3/12) 59 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Professional Services Professional Services Not covered S. Professional Services These services, supplies, and associated expenses are not covered: 1. Drugs provided or administered by a physician or other provider, except those requiring This section describes coverage for professional services received from or directed by a intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage physician. for drugs is as described in Prescription Drug Program and Prescription Specialty Drug Program or otherwise described as a specific benefit in this certificate. See Definitions These words have specific meanings benefits, coinsurance, convenience 2. Diagnostic casts, diagnostic study models, and bite adjustments related to the treatment of care/retail healthtclinic,,deductible emergericy, neticgtestin home clinic hos ital ..in anent, g 9 Y adjustments temporomandibular joint (TMJ) disorder and craniomandibular disorder. member, network, non network, non network provider reimbursement amount, physician, preventive health service, provider;urgent care center, virtual care. r See Exclusions for additional services, supplies, and associated expenses that are not Prior authorization. Prior authorization from Medica may be required before you receive covered. 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 rocess. p � � � �� Your Benefits and the Amounts You Pay '� � Covered Benefits.3r P b 1F Out-of-network� a flnnetwork benefits benefits after deductible after deductible For benefits and the amounts you pay, see the table in this section. More than one coinsurance � ` may be required if you receive more than one service or see more than one provider *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for per v - I' p p visit. ; any charges in excess of the,non network provider reimbursement amount. Additionally,_these • In-network benefits apply to: charges will not be applied toward satisfaction.of the deductible or the out-of-pocket maximum. 1. Professional services received from a network provider; o 1. Office visits Nothing 50% coinsurance 2. Professional services for testing and treatment of a sexually transmitted disease and Please note: Some services testing for AIDS and other HIV-related conditions received from a network provider or a received during an office visit may non-network provider; be covered under another benefit in this certificate. The most specific 3. Family planning services, for the voluntary planning of the conception and bearing of and appropriate benefit in this children, received from a network provider or a non-network provider. Family planning certificate will apply for each service services do not include infertility treatment services. received during an office visit. • Out-of-network benefits apply to professional services received from a non-network provider. For example, certain services pp Y p received during an office visit may In addition to the deductible and coinsurance, you will be responsible for any charges in be considered surgical or imaging excess of the non-network provider reimbursement amount. The out-of-pocket maximum services; see below for coverage of does not apply to these charges. Please see Important member information about out-of- these surgical or imaging services. network benefits in How To Access Your Benefits for more information and an example In such instances, both an office calculation of out-of-pocket costs associated with out-of-network benefits. Emergency visit coinsurance and outpatient services from non-network providers will be covered as in-network benefits. surgical or imaging services coinsurance apply. 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 Call Customer Service at one of the described in Organ And Bone Marrow Transplant Services. telephone numbers listed inside the front cover to determine in advance For some services, there may be a facility charge resulting in coinsurance (see Hospital whether a specific procedure is a Services) in addition to the professional services coinsurance. benefit and the applicable coverage level for each service that you receive. 2. Virtual care Nothing No coverage li 3. Convenience care/retail health Nothing 50% coinsurance clinic visits MIC FOCUSMN HSA (3/12) 60 1500-100% MIC FOCUSMN HSA(3/12) 61 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 I Professional Services Professional Services r ,._, _ . _ _ . .., - -- -.,.� ., __._ ,. ,-, _m . ._ _,. �Your,Be' nefits and the Amounts You Pa, . . . . x. _ _ nts You Pay and the Amou ___ x Your Benefits ,_ - �- #, . , r � �. , ._ ., , _ � d ;7 _,..2:-.-:. _ , - "<, - _s , , __r.-, . -.�._ , r #i s _--_ ,.�: ; t-o#-network:,benefits .: ..,. .- _ _ .�� _.: _ _ Benefits- .� �. . � � � ., ., . . .., tn.netwo k bene t" _--- - Ou � . ,. --_ _m_ _._ _ f ork benefits.:.: . _. . ,�, -__� n rk.:benef�ts. � 0ut o ynetw �, __,:Y, � � :x.,_ ,,. ,;. _ . .:..Benefi , _ ,. _ _ � ,; � _ Aw , r deductible- after.de .ar �, , ., _- ---=- _T--_ after'deductible - � _ - after:.deductible_.., ,.. ..... _., -.- .. g�a:, _ tx us.. - . � ,� ° - - .. - f-network benefits :�n.a dtion to he=deduc ible=and�comsurance :you are responsible for,,. *: _ � � For out o , d , t ,y P ,_ _ add; a th <-deductible.and,coinsurance . ou are�res onsible_for�r : _.. . ,. 4 . For of network,benefits m tion t e. , P .._.: _-, � � rr. ,.,. r:. ,� �m :. ,� an. char es in excess of he.non-network provider reimbursement amount.: these.:... .,non-network Additionally,these =�- r,,�. Y, 9 . p Y, in ex ss�ofahe non network, rovider reimbursement amount..,Ad Y, � any charges � ce �. .:, � t charges willnot,be, ;toward satisfaction of the deductible.or the out-of ticket maximum. m .: _ ket:maximum.��� �,,r E, 9 � _:- P ,�. , atisfaction.of the deductible or the outf tic .applied charges will-not.be,applied toward s P _ � .... r_. -- 4. Urgent care center visits Nothing Covered as an in-network b. Immunizations Nothing. The deductible 50% coinsurance Please note: Some services benefit. does not apply. received during an urgent care c. Early disease detection Nothing. The deductible 50% coinsurance center visit may be covered under another benefit in this certificate. services including physicals does not apply. The most specific and appropriate d. Routine screening Nothing. The deductible 50% coinsurance benefit in this certificate will apply procedures for cancer does not apply. for each service received during an urgent care center visit. e. Other preventive health Nothing. The deductible 50% coinsurance For example, certain services services does not apply. received during an urgent care 6. Allergy shots Nothing 50% coinsurance 1 center visit may be considered o surgical or imaging services; see 7. Routine annual eye exams Nothing. The deductible 50% coinsurance below for coverage of these surgical does not apply. or imaging services. In such 8. Chiropractic services to Nothing 50% coinsurance. instances, both an urgent care diagnose and to treat (by manual Coverage is limited to a center visit coinsurance and outpatient surgical or imaging manipulation or certain maximum of 15 visits per services coinsurance apply. therapies) conditions related to calendar year. the muscles, skeleton, and Please note: This visit limit Call Customer Service at one of the nerves of the body P telephone numbers listed inside the includes chiropractic visits p Please note: Providers may be that you pay for in order to front cover to determine in advance whether a specific procedure is a network providers for chiropractic satisfy any part of your p p services only, and not otherwise deductible. benefit and the applicable coverage level for each service that you part of the Medica Focus network. When you receive other health receive. services you should verify that your 5. Preventive health care provider is a Medica Focus network Please note: If you receive provider in order to be eligible for in- preventive and non-preventive network benefits. You can do this health services during the same by reviewing your provider directory visit, the non-preventive health and contacting Customer Service at services may be subject to a one of the telephone numbers listed coinsurance or deductible, as inside the front cover. described elsewhere in this 9. Surgical services (as defined in Nothing 50% coinsurance certificate. The most specific and appropriate benefit in this certificate the Physicians'Current will apply for each service received Procedural Terminology code during a visit. book) received from a physician during an office visit or an a. Child health supervision Nothing. The deductible Covered as an in-network outpatient hospital or services, including well-baby does not apply. benefit. ambulatory surgical center visit care MIC FOCUSMN HSA(3/12) 62 1500-100% MIC FOCUSMN HSA (3/12) 63 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 • Professional Services Professional Services �_..x- •...>_.:. ..- _:. -,:� Your Be n f#s and p t A m o.,g.,n ts Y o u Pa .,.. _. E.. -. _ �,., . __.. ,� , .: Y o ur Benefit's s,a n d,<t he Amounts You Pay _ . �, ,. -� .. - � f'S? r Innetwork:;be _ . _Out-of-network �� _Benefits _ . . , .__. , , .. ,_ �, - ,w >,u-.. . -- - � .:, , nef�ts__ _Ou f rk� n, _ , >i � , ._ .�� . x . .... ._ .._. , � ,_. _..� , t o netwo be efits .�: < _ . � ,. In ne k�benefits _. . _._. ..� - . :. ._ � � � twor be efrts,� � f . ,< w __ �., � __ _. ,.. � Out o network bens r after ... . .. _ �deductible. .., �. _:.. , . . . . .< _ --.: s ,.:-:.: ,,. �. _.. � mm:. . after �_� ,. � ' , _. ,<�_ ..�._ � .j�� _ .efts _ ` - . ____ _._. . . �,r a r.deductible.• *For . . or ou# of.network benefit - < . _. _ � » benefit , addition.to the deductrble.and coinsurance ou� - ,r: Fot.ou# of netw r _ a _ > .. ._ .:. ...... _. are es onsible for o k.benefits yin:addrtion,to th .deductr >.. Y xR ,-_ „ ..: , e- bleand coinsurance ou:.are.res onsr 1 ..�.,. « : . ,... .,� , b e for. « _ :-�-� . ,. , Y p an non-network r: es rn,excess of�the t non-network ro�rder�reimbursement n � =.- . � .<.an. _ ,. . 9-g� F re _ . u e t amount. Additionally,these... char es;m excess of the:P , a. .. Y 9 � provider avrder_.reimbursement< <. . . ,....: ,,r•�. amount. :Atltlition tl. _thes . o, . .. ; . . rte. , - -. ._ Y, k J n. ., :`id's x:_ charges will not applied toward, satisfaction of deductrble_ortbe. _ � __ .,., =::char e � � .:. 9 ,. . pp ,.. . out-of-pocket maximum. .__ .� ,,. s will rlhnot..be'a Iredaowardsafr _ >, . ., ... . w P .=._ ,.. ., g p -_ satisfaction of deductible th . eout-of_ ocket.maximum. 10. Anesthesia services received Nothing 50% coinsurance 18. Treatment of temporomandibular Covered at the Covered at the from a provider during an office joint (TMJ) disorder and corresponding in-network corresponding out-of- visit or an outpatient hospital or craniomandibular disorder benefit level, depending network benefit level, ambulatory surgical center visit on type of services depending on type of 11. Services received from a Nothing Covered as an in-network provided. services provided. physician during an emergency benefit. For example, office visits For example, office visits room visit are covered at the office are covered at the office 12. Services received from a Nothing 50% coinsurance visit in-network benefit visit out-of-network physician during an inpatient level and surgical benefit level and surgical stay services are covered at services are covered at the surgical services in- the surgical services out- 13. Anesthesia services received Nothing 50% coinsurance network benefit level. of-network benefit level. from a provider during an Please note: Dental Please note: Dental inpatient stay coverage is not provided coverage is not provided under this benefit. under this benefit. 14. Outpatient lab and pathology Nothing 50% coinsurance 19. Diabetes self-management Nothing 50% coinsurance 15. Outpatient x-rays and other Nothing 50% coinsurance training and education, including imaging services medical nutrition therapy, 16. Other outpatient hospital or Nothing 50% coinsurance received from a provider in a ambulatory surgical center program consistent with national services received from a educational standards (as physician established by the American Diabetes Association) 17. Treatment to lighten or remove Covered at the Covered at the the coloration of a port wine stain corresponding in-network corresponding out-of- 20. Neuropsychological Nothing 50% coinsurance benefit level, depending network benefit level, evaluations/cognitive testing, on type of services depending on type of limited to services necessary for provided. services provided. the diagnosis or treatment of a medical illness or injury For example, office visits For example, office visits are covered at the office are covered at the office visit in-network benefit visit out-of-network level and surgical benefit level and surgical services are covered at services are covered at the surgical services in- the surgical services out- network benefit level. of-network benefit level. MIC FOCUSMN HSA(3/12) 64 1500-100% MIC FOCUSMN HSA (3/12) 65 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Professional Services Reconstructive And Restorative Surgery Your Benefits and the Amounts:You Pa E y T. Reconstructive And Restorative Surgery Benefits In network benefits * Out of-network benefits 9 �.. after deductible after deductible 3}� �,_ �. _ _. __� _ p£, .p ,m �� � ✓� � ,� -. This section describes coverage for professional, hospital, and ambulatory surgical center *For o coinsurance..-. r res responsible services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative orflout out-of-network additianto the he-deductible and� ,yoii are for an. charges es in excess of the"non-network provider reimbursement amount. Additional these surgery services must be medically necessary and not cosmetic. any ��. 9. ,, . ...'� - ' - � _; . .:, : � Ey°te -' ch are Iln toward ._�_.� s wi ot,be applied o out-of-pocket rv, � �edt ward satisfaction�of the;deductible,or _ o ._..�Q 9 pp the .maxi -_,�,; . . �, 'These �. . . _. ., . _ mum ..£ , , i � e cosmetic _��,:-� See Definrt�ons.,_These words have a ific.meamn s..benef is coinsucanc � 21. Vision therapy and orthoptic Nothing 50% coinsurance deductible, hospital, inpatient, medically,necessary, member, network,,non-network, non- and/or g network provider reimbursement amount, physician, provider, reconstri ctive, restorative, virtual pleoptic training, to p establish a home program, for care. the treatment of strabismus and Prior authorization. Prior authorization from Medica may be required before you receive other disorders of binocular eye services or supplies. Call Customer Service at one of the telephone numbers listed inside the movements. Coverage is limited front cover. See How To Access Your Benefits for more information about the prior to a combined in-network and authorization process. out-of-network total of 5 training visits and 2 follow-up eye exams per calendar year. Covered Please note: These visit and exam limits include visits and exams that For benefits and the amounts you pay, see the table in this section. More than one coinsurance you pay for in order to satisfy any may be required if you receive more than one service or see more than one provider per visit. part of your deductible. • In-network benefits apply to reconstructive and restorative surgery services received from a 22. Genetic counseling, whether pre- Nothing 50% coinsurance network provider. or post-test, and whether occurring in an office, clinic, or • Out-of-network benefits apply to reconstructive and restorative surgery services received telephonically 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- 23. Genetic testing when test results Nothing 50% coinsurance network provider reimbursement amount. The out-of-pocket maximum does not apply to will directly affect treatment these charges. Please see Important member information about out-of-network benefits in decisions or frequency of How To Access Your Benefits for more information and an example calculation of out-of- screening for a disease, or when pocket costs associated with out-of-network benefits. results of the test will affect reproductive choices 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 (3/12) 66 1500-100% MIC FOCUSMN HSA (3/12) 67 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 • Reconstructive And Restorative Surgery 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 Your Benefits and the Amounts You Pay intraocular injection. Coverage for drugs is as described in Prescription Drug Program an d ; � Prescription Specialty Drug Program or otherwise described as a specific benefit in this Benefits In-network benefits - *Out-of network benefits certificate. = after deductible after deductible See Exclusions for additional services, supplies, and associated expenses that are not *For out of network,benefits, in addition to the deductible and coinsurance, you are responsible for covered. any charges in excess of the non network provider reimbursement amount Additionally,these charges will not be applied toward satisfaction of thedeductible+or the out of-pocket maximum. � " bra b. Hospital and ambulatory Benefits Your Bfits and the Amounts You Pay `� . � surgical center services Benefits ", In netwo k benefits *Out-of-network bene its - i. Outpatient lab and Nothing 50% coinsurance �� after deductible after deductible - pathology #' = ii. Outpatient x-rays and Nothing 50% For out of.network benefits, iii addition to the deductible and coinsurance,you are responsible for p Y g 50/o coinsurance any charges in,excess of the non-network provider reimbursement.amount. Additionally,these other imaging services charges will not be applied toward satisfaction of the deductible or the out-Of-Pocket maximum. iii. Other outpatient hospital Nothing 50% coinsurance 1. Office visits Nothing 50% coinsurance ced ambulatory surgical center services 2. Virtual care Nothing No coverage 4. Inpatient services Nothing 50% coinsurance 3. Outpatient services 5. Services received from a Nothing 50% coinsurance a. Professional services physician during an inpatient o stay i. Surgical services (as Nothing 50% coinsurance defined in the 6. Anesthesia services received Nothing 50% coinsurance Physicians'Current from a provider during an Procedural Terminology inpatient stay 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(3/12) 68 1500-100% MIC FOCUSMN HSA (3/12) 69 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Skilled Nursing Facility Services Skilled Nursing Facility Services 7. Physical, speech, or occupational therapy services when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to U. Skilled Nursing Facility Services generally accepted standards in the medical community. 8. Voice training. This section describes coverage for use of skilled nursing facility services. Care must be 9. Group physical, speech, and occupational therapy. provided under the direction of a physician. Coverage of the services described in this section is limited to a maximum benefit of 120 days per person per calendar year. Skilled nursing 10. Long-term care. facility services are eligible for coverage only if you are admitted to a skilled nursing facility See Exclusions for additional services, supplies, and associated expenses that are not within 30 days after a hospital admission of at least three consecutive days for the same illness covered. or condition. See'Definitions. ,.;:: -:..: i a .. ,c" . �i..: k'......,.__ ....: _x�These words have-specific coinsurance .custodial care,.. , , , " � .. �_ __ _- .� _� _ ._-,..,. ". s ecific-rneanrn s.:,�beneflts � ._. ,__. . .,. ,,, x ._. . , - ._ � _ -. . .•.�-. _ m . ._.. _. . ...: rtrons...�T hese wortls_have , . .__- , . . � � � . �_ ., - -. :Your Benefits _ hospital � . . , bursernent _ � �_. =F �: : . _. . enef�ts and the Amounts mounts.:Y _ _ non-network rovrder..rerm _. � ,. . or non ne _.. _ - �� - - :. . _.. .: �... . _. inpatient .:network non netw k� � _e. :: . .. . , . s ,x�--. .. r le_.hos �tal .rn . t e , p .. . �� �m ,� deduct b � network, � ,...� 'd� , . skilled nursing_ . s .. ._ fro x. physician, skilled care,h � , _.._. 9 .._tY pY :_._..._ Benefits _. , ',;.'1. • ,� � : . a In network benefits ;`,:."Out-of network benefits Prior authorization. Prior authorization from Medica may be required before you receive after deductible after deductible services or supplies. Call Customer Service at one of the telephone numbers listed inside the f • front cover. See How To Access Your Benefits for more information about the prior authorization *For--out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for process. anycharges'in excess of the non network provider reimbursement amount Additio ally,these charges will not be applied toward satisfaction of the deductible or the out-of:pocket maximum F Covered 1. Daily skilled care or daily skilled Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance room aind board,services, including may be required if you receive more than one service or see more than one provider per visit. room and bper calendar le d r year days Y q Y � per person per calendar year For purposes of this section, room and board includes coverage of health services and supplies. Please note: Such services are eligible for coverage only if you are • In-network benefits apply to skilled nursing facility services arranged through a physician i admitted to a skilled nursing facility and received from a network skilled nursing facility. within 30 days after a hospital Out-of-network benefits apply to skilled nursing facility services arranged throu h a admission of dat ays sfor three • pp Y 9 Y 9 9 consecutive days for the same physician and received from a non-network skilled nursing facility. In addition to the illness or condition. This day limit deductible and coinsurance described for out-of-network benefits, you will be responsible for includes days that you pay for in any charges in excess of the non-network provider reimbursement amount. The out-of- order to satisfy any part of your pocket maximum does not apply to these charges. Please see Important member deductible. information about out-of-network benefits in How To Access Your Benefits for more 2. Skilled physical, speech, or Nothing 50% coinsurance information and an example calculation of out-of-pocket costs associated with out-of- occupational therapy when room network benefits. and board is not eligible to be covered Not covered 3. Services received from a Nothing 50% coinsurance physician during an inpatient These services, supplies, and associated expenses are not covered: stay in a skilled nursing facility 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. MIC FOCUSMN HSA (3/12) 70 1500-100% MIC FOCUSMN HSA (3/12) 71 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 J Substance Abuse Substance Abuse Covered V. Substance Abuse For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. This section describes coverage for the diagnosis and primary treatment of substance abuse • For in-network benefits: disorders listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. 1. Medica's designated mental health and substance abuse provider arranges in-network See'Definitions These words have specific meanings'. benefits claim, coinsurance custodial ` : substance abuse benefits. (Medics and Medica's designated mental health and `7 substance abuse provider networks are different.) If you require hospitalization, Medica's care,_deductible, emergency, hospital,pinpattent; medtcaliy necessary,-member, Mental disorder, designated mental health and substance abuse provider will refer you to one of its hospital network non network non network provider reimbursement amount, physician, provider. ; I health and substance abuse provider providers (Medica and Medica's designated menta a ance a use Prior authorization. For prior authorization requirements of in-network and out-of-network hospital networks are different). benefits, call Medica's designated mental health and substance abuse provider at: 2. In-network benefits will apply to services, care, or treatment for a member that has been 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center placed in the Minnesota Department of Corrections' custody following a conviction for a 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. For purposes of this section: 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. 1. Outpatient services include: Providers may be network providers for substance abuse services only, and not otherwise a. Diagnostic evaluations. part of the Medica Focus network. When you receive other health services you should verify b. Outpatient treatment. 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 c. Intensive outpatient programs, including day treatment and partial programs, which may Service at one of the telephone numbers listed inside the front cover. include multiple services and modalities, delivered in an outpatient setting. For claims questions regarding in-network benefits, call Medica's designated mental health d. Services, care, or treatment for a member that has been placed in the Minnesota and substance abuse provider Customer Service at 1-866-214-6829. Department of Corrections' custody following a conviction for a first-degree driving while • For out-of-network benefits: impaired offense; to be eligible, such services, care, or treatment must be required and provided by the Minnesota Department of Corrections. 1. Substance abuse services from a non-network provider listed below will be eligible for 2. Inpatient services include: 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 a. Room and board. abuse services and practice independently: b. Attending physician services. a. Psychiatrist c. Hospital or facility-based professional services. b. Psychologist c. Registered nurse certified as a clinical specialist or as a nurse practitioner in 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 psychiatric and mental health nursing impaired offense; to be eligible, such services, care, or treatment must be required and d. Chemical dependency clinic provided by the Minnesota Department of Corrections. e. Chemical dependency residential treatment center e. Substance abuse residential treatment services. These are services from a licensed f. Hospital that provides substance abuse services chemical dependency rehabilitation program that provides intensive therapeutic services following detoxification. In addition to room and board, at least 30 hours per week per g. Independent clinical social worker individual of chemical dependency services must be provided, including group and h. Marriage and family therapist individual counseling, client education, and other services specific to chemical dependency rehabilitation. 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 1500-100% MIC FOCUSMN HSA(3/12) 72 1500-100% MIC FOCUSMN HSA (3/12) 73 BPL 21316 DOC 23928 BPL 21316 DOC 23928 Substance Abuse Substance Abuse Benefits for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits. u � � r Your Benefi#sand theyAmounts You Pay�F' �� � � Not covered Benefits ain-network benefits K -*'Out-of network benefits s4 °after deductible after deductible These services, supplies, and associated expenses are not covered: *For.out-of-network'benefits, �n addition to the deductible and comsurance,`you are respons�ble:for. 1. Services for substance abuse disorders not listed in the current edition of the Diagnostic and any°charges in;excoss of;the non networkzprovider;reimburserr�ent amount is iditior atly,these Statistical Manual of Mental Disorders. 9 har ges will not be applied toward satisfaction of the deductible or the:out-of pocket maximum , 2. Services for a condition when there is no reasonable expectation that the condition will 4. Inpatient services (including improve. residential treatment services) 3. Services, care, or treatment that is not medically necessary. a. Room and board Nothing 50% coinsurance 4. Services to hold or confine a person under chemical influence when no medical services are b. Hospital or facility-based Nothing 50% coinsurance required, regardless of where the services are received. professional services 5. Telephonic substance abuse treatment services. c. Attending physician services Nothing 50% coinsurance 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 after deductible 'after deductible ,� ,.,�"S Fey .-. { �y"^ "' - - '� �t '�� :ro �. �.^ ' _. *;For out-of-network benefits, in addition to the deductible and coinsuraance,you are responsible for �.' err �' nz �= r � any charges in excess of the non-network(provider reimbursement amount Additionally,these charges will not be appliedtoward satisfactionof thexdeductible or the out-of pocket maximum 1. Office visits, including Nothing 50% coinsurance evaluations, diagnostic, and primary treatment services 2. Intensive outpatient programs Nothing 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance MIC FOCUSMN HSA (3/12) 74 1500-100% MIC FOCUSMN HSA (3/12) 75 BPL 21316 DOC 23928 0 BPL 21316 DOC 23928 Referrals To Non-Network Providers Referrals To Non-Network Providers 2. May require that you obtain a referral or standing referral (as described in this section) from W.Referrals To Non-Network Providers a network provider to a non-network provider practicing in the same or similar specialty. 3. Provide coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and This section describes coverage for referrals from network providers to non-network providers. In-network benefits will apply to referrals from network providers to non-network providers when b. Recommended by a network physician. you receive prior authorization from Medica as described in this section. Prior authorization 4. Notify you of authorization or denial of coverage within ten days of receipt of your request. from Medica is required to receive in-network benefits for services from non-network providers. Medica will inform both you and your provider of Medica's decision within 72 hours from the It is to your advantage to seek Medica's prior authorization for referrals to non-network providers time of the initial request if your attending provider believes that an expedited review is before you receive services. Medica can then tell you what your benefits will be for the services warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or you may receive. ability to regain maximum function, or could subject you to severe pain that cannot be =See Definitions.-These words have specific meanings benefits medically necessa adequately managed without the care or treatment you are seeking. network nor-network; physician provider. ry 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. Request 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. MIC FOCUSMN HSA (3/12) 76 1500-100% MIC FOCUSMN HSA (3/12) 77 1500-100 BPL 21316 DOC 23928 BPL 21316 DOC 23928 it Harmful Use Of Medical Services Exclusions X. Harmful Use Of Medical Services Y. Exclusions This section describes what Medica will do if it is determined you are receiving health services See Denit/ons. These words'have specific meanings° claim, cosmetic, custodial care, or prescription drugs in a quantity or manner that may harm your health. emergency, investigative, medically necessary, member, non-network, physician, provider, See Definitions. These words have specific meanings: benefits,emergency, hospital, reconstructive, routine foot care. network, physician, prescription drug, provider. Medica will not provide coverage for any of the services, treatments, supplies, or items When this section applies described in this section even if it is recommended or prescribed by a physician or it is the only available treatment for your condition. After Medica notifies you that this section applies, you have 30 on days to choose This section describes additional exclusions to the services, supplies, and associated expenses Y e network already listed as Not covered in this certificate. These include: physician, hospital, and pharmacy to be your coordinating health care providers. 1. Services that are not medically necessary. This includes but is not limited to services If you do not choose your coordinating health care providers within 30 days, Medica will choose inconsistent with the medical standards and accepted practice parameters of the community for you. Your in-network healths are then restricted to services provided by or arranged and services inappropriate—in terms of type, frequency, level, setting, and duration—to the through your coordinating health care providers. diagnosis or condition. Failure to receive services from or through your coordinating health care providers will result in 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise a denial of covoveragge. determined to be reconstructive. You must obtain a referral from your coordinating health care provider if your condition requires 3. Refractive eye surgery, including but not limited to LASIK surgery. care or treatment from a provider other than your coordinating health care provider. Medica will send you specific information about: 4. The purchase, replacement, or repair of eyeglasses, eyeglass frames, or contact lenses when prescribed solely for vision correction, and their related fittings. 1. How to obtain approval for benefits not available from your coordinating health care 5. Services provided by an audiologist when not under the direction of a physician, air and providers; and 2. How to obtain emergency care; and bone conduction hearing aids (including internal, external, or implantable hearing aids or I devices), and other devices to improve hearing, and their related fittings, except cochlear 3. When these restrictions end. 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 genetic 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 3/12 ( ) 78 1500-100% MIC FOCUSMN HSA(3/12) 79 0-100% BPL 21316 150 150 23928 BPL 21316 DOC 23928 Exclusions Exclusions 14. Personal comfort or convenience items or services. 40. Services not received from or under the direction of a physician, except as described in this 15. Custodial care, unskilled nursing, or unskilled rehabilitation services. certificate. 16. Respite or rest care, except as otherwise covered in Hospice Services. 41. Services for the treatment of infertility. 42. Services for or related to vision therapy and orthoptic and/or pleoptic training, except as 17. Travel, transportation, or living expenses, except as described in Organ And Bone Marrow described in Professional Services. Transplant Services. 18. Household equipment, fixtures, home modifications, and vehicle modifications. 43. Orthognathic surgery. 19. Massage therapy, provided in any setting, even when it is part of a comprehensive 44. Services for or related to intensive behavior therapy treatment programs for the treatment of treatment plan. autism spectrum disorders. Examples of such services include, but are not limited to, Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular Intervention (IBI), and Lovaas therapy. disease, peripheral neuropathies, and significant neurological conditions such as 45. Sensory integration, including auditory integration training. Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral sclerosis. 46. Health care professional services for maternity labor and delivery in the home. 21. Services by persons who are family members or who share your legal residence. 47. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and 22. Services for which coverage is available under workers' compensation, employer liability, or subsequent procedures. any similar law. 48. Infertility drugs. 23. Services received before coverage under the Contract becomes effective. 49. Growth hormone. 24. Services received after coverage under the Contract ends. 50. Erectile dysfunction medications. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from 51. Cosmetic medications. non-network providers and non-network dentists. 52. Weight loss medications. 26. Photographs, except for the condition of multiple dysplastic syndrome. 53. Acupuncture. 27. Occlusal adjustment or occlusal equilibration. 54. Services solely for or related to the treatment of snoring. 28. Dental implants (tooth replacement), except as described in Medical-Related Dental 55. Interpreter services. Services. 29. Dental prostheses. 56. Services provided to treat injuries or illness as a result of committing a crime or attempting to commit a crime. 30. Orthodontic treatment, except as described in Medical-Related Dental Services. 57. Services for private duty nursing, except as described in Home Health Care. Examples of 31. Treatment for bruxism. 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 32. Services prohibited by law or regulation, or illegal under Minnesota law. representative, and not under the direction of a physician. 33. Services to treat injuries that occur while on military duty, and any services received as a 58. Laboratory testing that has been performed in response to direct-to-consumer marketing result of war or any act of war (whether declared or undeclared). and not under the direction of a physician. 34. Exams, other evaluations, or other services received solely for the purpose of employment, 59. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), insurance, or licensure. other than those granted a humanitarian device exemption. 35. Exams, other evaluations, or other services received solely for the purpose of judicial or 60. Health clubs. • administrative proceedings or research, except emergency examination of a child ordered by judicial authorities. 61. Long-term care. 36. Non-medical self-care or self-help training. 62. Expenses associated with participation in weight loss programs, including but not limited to 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, membership fees and the purchase of food, dietary supplements,.or publications. except as described in Professional Services. 38. Coverage for costs associated with translation of medical records and claims to English. 39. Treatment for superficial veins, also referred to as spider veins or telangiectasia. 1500-100% MIC FOCUSMN HSA(3/12) 80 1500-100% MIC FOCUSMN HSA (3/12) 81 BPL 21316 DOC 23928 • BPL 21316 DOC 23928 How To Submit A Claim How To Submit A Claim Claims for services provided outside the United States Z. How To Submit A Claim Claims for services rendered in a foreign country will require the following additional documentation: This section describes the process for submitting a claim. • Claims submitted in English with the currency exchange rate for the date health services were received. See Definitions These words:;have specific meanings: benefits, claim, dependent, member, network, non-network, non network provider reimbursement amount,;provider. Itemization of the bill or claim. It h bill • The related medical records (submitted in English). Claims for benefits from network providers • Proof of your payment of the claim. If you receive a bill for any benefit from a network provider, you may submit the claim following A complete copy of your passport and airline ticket. the procedures described below, under Claims for benefits from non-network providers or call • Such other documentation as Medica may request. Customer Service at one of the telephone numbers listed inside the front cover. For services rendered in a foreign country, Medica will pay you directly. Network providers are required to submit claims within 180 days from when you receive a Medica will not reimburse you for costs associated with translation of medical records or claims. service. If your provider asks for your health care identification card and you do not identify Y 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. Time limits Claims for benefits from non-network providers 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. Claim forms are provided in your enrollment materials. You may request additional claim forms However, you may not bring legal action more than six years after Medica has made a coverage by calling Customer Service at one of the telephone numbers listed inside the front cover. If the determination regarding your claim. 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 (3/12) 82 1500-100% MIC FOCUSMN HSA (3/12) 83 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Coordination Of Benefits Coordination Of Benefits When there are two or more plans covering the person, this plan may be a primary plan AA. Coordination Of Benefits as to one or more other plans, and may be a secondary plan as to a different plan or plans. This section describes how benefits are coordinated when you are covered under more than d. Allowable expense means a necessary, reasonable, and customary item of expense for one plan. health care, when the item of expense is covered at least in part by one or more plans See.Definitions: These"avoi=ds covering the person for whom the claim is made. Allowable expense does not include havesp the deductible for members with a primary high deductible plan and who notify Medics of ecifc meanings benefi#s,�clairn,deductible, dependent, emergency, hospital,medically necessary, mer=nber, non network, non netiork Provider an intention to contribute to a health savings account. reimbursement amount ;provider, subsc�i#er. '��'� � � � �'� � � � � = �P 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 1. Applicability 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. a. This coordination of benefits (COB) provision applies to this plan when an employee or The difference between the charges billed by a provider and the non-network provider plan. reimbursement amount is not considered an allowable expense under the above the employee's covered dependent has health care coverage under more than one an and this plan are defined below. definition. b. If this coordination of benefits provision applies, Order of benefit determination rules When a plan provides benefits in the form of services, the reasonable cash value of should be looked at first. Those rules determine whether the benefits of this plan are each service rendered will be considered both an allowable expense and a benefit paid. determined before or after those of another plan. Under Order of benefit determination rules, the benefits of this plan: 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 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 opinions, and preferred provider arrangements. reduction is described in Effect on the benefits of this plan. 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 2. Definitions that apply to this section year before the date this COB provision or a similar provision takes effect. a. Plan is any of these which provides benefits or services for, or because of, medical or 3. Order of benefit determination rules dental care or treatment: i. Group insurance or group-type coverage, whether insured or uninsured, or individual a. General. When there is a basis for a claim under this plan and another plan, this plan is coverage. This includes prepayment, group practice, or individual practice coverage. a secondary plan which has its benefits determined after those of the other plan, unless: It also includes coverage other than school accident-type coverage. i. The other plan has rules coordinating its benefits with the rules of this plan; and ii. Coverage under a governmental plan, or coverage required or provided by law. This ii. Both the other plan's rules and this plan's rules, in 3.b. below, require that this plan's does not include a state plan under Medicaid (Title XIX, Grants to States for Medical benefits be determined before those of the other plan. Assistance Programs, of the United States Social Security Act,to time). , as amended from b. Rules. This plan determines its order of benefits using the first of the following rules which applies: Each Contract or other arrangement for coverage under i. or ii. is a separate plan. Also, i. Nondependent/dependent. The benefits of the plan that covers the person as an if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate plan. 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. b. This plan is the part of the Contract that provides benefits for health care expenses. c. Primary plan/seconds ii. Dependent child/parents not separated or divorced. Except as stated in 3.b.iii. plan/secondary plan. The Order of benefit determination rules state whether below, when this plan and another plan cover the same child as a dependent of this plan is a primary plan or secondary plan as to another plan covering the person. different persons, called parents: When this plan is a primary plan, its benefits are determined before those of the other a) The benefits of the plan of the parent whose birthday falls earlier in a year are plan and without considering the other plan's benefits. determined before those of the plan of the parent whose birthday falls later in that When this plan is a secondary plan, its benefits are determined after those of the other year; but plan and may be reduced because of the other plan's benefits. MIC FOCUSMN HSA(3/12) 84 1500-100% MIC FOCUSMN HSA (3/12) 85 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Coordination Of Benefits Coordination Of Benefits b) If both parents have the same birthday, the benefits of the plan which covered event, the benefits of this plan may be reduced under this section. Such other lan or one parent longer are determined before those of the plan which covered the other parent for a shorter period of time. plans are referred to as the other plans in b. immediately below. p b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum 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 of: result, the plans do not agree on the order of benefits, the rule in the other plan i. The benefits that would be payable for the allowable expense under this plan in the will determine the order of benefits. absence of this COB provision; and iii. Dependent child/separated or divorced parents. If two or more plans cover a person ii. The benefits that would be payable for the allowable expenses under the other plans, as a dependent child of divorced or separated parents, benefits for the child are in the absence of provisions with a purpose like that of this COB provision, whether determined in this order: 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 a) First, the plan of the parent with custody of the child; benefits payable under the other plans do not total more than those allowable b) Then, the plan of the spouse of the parent with the custody of the child; and expenses. c) Finally the plan of the parent not having custody of the child. For non-emergency services received from a non-network provider, and determined to However, if the specific terms of a court decree state that one of the parents is be out-of-network benefits, the following reduction of benefits will apply: responsible for the health care expense of the child, and the entity obligated to When this plan is a secondary plan, this plan will pay the balance of any remaining pay or provide the benefits of the plan of that parent has actual knowledge of expenses determined to be eligible under the Contract, according to the out-of-network those terms, the benefits of that plan are determined first. The plan of the other benefits described in this certificate. Most out-of-network benefits are covered at 50 parent shall be the secondary plan. This paragraph does not apply with respect percent of the non-network provider reimbursement amount, after you pay the applicable to any claim determination period or plan year during which any benefits are deductible amount. In no event will this plan provide duplicate coverage. actually paid or provided before the entity has that actual knowledge. When the benefits of this plan are reduced as described above, each benefit is reduced . iv. Joint custody. If the specific terms of a court decree state that the parents shall in proportion. It is then charged against any applicable benefit limit of this plan. 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 5. Right to receive and release needed information determination rules outlined in 3.b.ii. v. Active/inactive employee. The benefits of a plan which covers a person as an Certain facts are needed to apply these COB rules. Medica has the right to decide which employee who is neither laid off nor retired (or as that employee's dependent) are facts it needs. It may get needed facts from or give them to any other organization or determined before those of a plan which covers that person as a laid off or retired person. Medica need not tell, or get the consent of, any person to do this. Unless employee (or as that employee's dependent). If the other plan does not have this applicable federal or state law prevents disclosure of the information without the consent of rule, and if, as a result, the plans do not agree on the order of benefits, this rule is the patient or the patient's representative, each person claiming benefits under this plan ignored. must give Medica any facts it needs to pay the claim. 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 6. Facility of payment on-duty injury to the employer, before submitting them to Medica. vii. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance nder thist andef it does nother pl mamay include an amount, which should have been paid Act or similar law applies first. p y 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. viii. Longer/shorter length of coverage. If none of the above rules determines the order Medica will not have to pay that amount again. The term payment made includes providing of benefits, the benefits of the plan which covered an employee, member, or benefits in the form of services, in which case payment made means reasonable cash value subscriber longer are determined before those of the plan which covered that person of the benefits provided in the form of services. for the shorter term. 4. Effect on the benefits of this plan 7. Right of recovery a. When this section applies., This 4. applies when, in accordance with 3. Order of benefit 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: determination rules, this plan is a secondary plan as to one or more other plans. In that a. The persons it has paid or for whom it has paid; or MIC FOCUSMN HSA (3/12) 86 1500-100% MIC FOCUSMN HSA(3/12) 87 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Coordination Of Benefits Right Of Recovery b. Insurance companies; or c. Other organizations. The amount of the payments made includes the reasonable cash value of any benefits BB. Right Of Recovery provided in the form of services. Please note: See Right Of Recovery for additional information. 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 bene#its 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 (3/12) 88 1500-100% MIC FOCUSMN HSA(3/12) 89 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Eligibility And Enrollment Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30-day time CC. Eligibility And Enrollment 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 This section describes who cane enrollment period are accepted without application of health screening or affiliation periods. An enroll and how to enroll. eligible employee and dependents who do not enroll during the initial enrollment period may See Definitions. These words haves specific pplicable p cial enrollmen p no , enroll for coverage during the next open enrollment any a s e ' t e s dependent late entrant, member mental rnearnngs benefits, continuous covers a or as a late entrant (if applicable, as described below). 1, :ctisorder, physician;placed for.adoption, premium qualifying coverage, subscriber, watmg:period # > " .= _ ,. A member who is a child entitled to receive coverage through a QMCSO is not subject to any - - .. .e. .� initial enrollment period restrictions, except as noted in this section. Who can enroll Open enrollment To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract A inmum perd set th ep Medic earg w eligible 1 and be a subscriber or dependent as defined in this certificate. See Definitions. employees and 14-day dependents io newt are e not covered and under the Contract ch year may elect coverage for the How to enroll upcoming Contract year. An application m must loyer be submitted s to the employer duin for hich yourself and any dependents. You must submit an application for coverage for yourself and any dependents to the employer: Special enrollment 1. During the initial enrollment period as described in this section under Initial enrollment; or Special enrollment periods are provided to eligible employees and dependents under certain 2. During the open enrollment period as described in this section under Open enrollment; or circumstances. 3. During a special enrollment period as described in this section under Special enrollment; or 1. Loss of other coverage 4. At any other time for consideration as a late entrant as described in this section under Late a. A special enrollment period will apply to an eligible employee and dependent if the enrollment. Dependents will not be enrolled without the eligible employee also being enr individual was covered under Medicaid or a State Children's Health Insurance Plan and is the subject of a QMCSO can be enrolled as described in this section u enroiied. A child who lost that coverage as a result of loss of eligibility. The eligible employee or dependent Child Support Order(QMCSO) and 6. under Special enrollment. Qualified Medical must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. Notification 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 You must notify the employer in writing within 30 days of the effective date of any dependent's loss of coverage, this special enrollment period applies to both the y changes to dependent who has lost coverage and the eligible employee. address or name, addition or deletion of dependents, a dependent child reaching the dependent b. A special enrollment period will apply tot an eligible employee and dependent if the limiting age, or other facts identifying you or your dependents. (For dependent children the eligible employee or dependent was covered under qualifying coverage other than notification period is not limited to 30 days for newborns or children newly adopted or newly Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or placed for adoption; however, we encourage you to enroll your newborn dependent under the dependent was eligible to enroll under the Contract, whether during initial enrollment, Contract within 30 days from the date of birth, date of placement for adoption, or date of the subscriber,Your newborn child, your newly adopted child, a child newly placed for adoption with open enrollment, or special enrollment, and declined coverage for that reason. the subscriber, and any child who is a member pursuant to a QMCSO will be covered without The eligible employee or dependent must present either evidence of the loss of prior application of health screening or waiting periods. coverage due to loss of eligibility for that coverage or evidence that employer The employer must notify Medics, as set forth in the Contract, of your initial enrollment 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 application, changes to your name or address, or changes to enrollment, including if you or your contribution toward that coverage terminates, or the date on which a claim is denied due dependents are no longer eligible for coverage. to the operation of a lifetime maximum limit on all benefits. Initial enrollment For purposes of 1.b.: i. Prior coverage does not include federal or state continuation coverage; 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 (3/12) 90 91 1500-100% 1500-100% MIC FOCUSMN HSA (3/12) BPL 21316 DOC 23928 BPL 21316 DOC 23928 Eligibility And Enrollment Eligibility And Enrollment ii. Loss of eligibility includes: , • losing coverage as a result of the eligible employee or dependent incurring a • loss of eligibility as a result of legal separation, divorce, death, termination of claim that meets or exceeds the lifetime maximum limit on all benefits and no employment, reduction in the number of hours of employment; other COBRA or state continuation coverage is available; or • cessation of dependent status; • if the prior coverage was offered through a health maintenance organization , losing coverage because the• incurring a claim that causes the eligible employee or dependent to meet or exceed the lifetime maximum limit on all benefits; residOes or works n the HMO's service areal and no other COBRA or state longer continuation coverage is available. • if the prior coverage was offered through an individual health maintenance ii. Exhaustion of COBRA or state continuation coverage does not include a loss due to organization (HMO), a loss of coverage because the eligible employee or failure of the eligible employee or dependent to pay premiums on a timely basis or dependent no longer resides or works in the HMO's service area; termination of coverage for cause. • if the prior coverage was offered through a group HMO, a loss of coverage iii. In the case of the eligible employee's exhaustion of COBRA or state continuation because the eligible employee or dependent no longer resides or works in the coverage, the special enrollment period described above applies to the eligible HMO's service area and no other coverage option is available; and employee and all of his or her dependents. In the case of a dependent's exhaustion • the prior coverage no longer offers any benefits to the class of similarly situated of COBRA or state continuation coverage, the special enrollment period described individuals that includes the eligible employee or dependent. above applies only to the dependent who has lost coverage and the eligible iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is employee. eligible for or elects applicable federal or state continuation coverage; 2. The dependent is a new spouse of the subscriber or eligible employee, provided that the iv. Loss of eligibility does not include a loss due to failure of the eligible employee or marriage is legal and enrollment is requested in writing within 30 days of the date of dependent to pay premiums on a timely basis or termination of coverage for cause; period; ge and provided that the eligible employee also enrolls during this special enrollment In the case of the eligible employee's loss of other coverage, the special enrollment II 3. The dependent is a new dependent child of the subscriber or eligible employee, provided period described above applies to the eligible employee and all of his or her dependents. that enrollment is requested in writing within 30 days of the subscriber or eligible employee In the case of a dependent's loss of other coverage, the special enrollment period acquiring the dependent (for dependent children, the notification period is not limited to 30 described above applies only to the dependent who has lost coverage and the eligible days for newborns or children newly adopted or newly placed for adoption) and provided employee. that the eligible employee also enrolls during this special enrollment period; 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 4. The dependent is the spouse of the subscriber or eligible employee through whom the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or dependent child described in 3. above claims dependent status and: any applicable state continuation laws at the time the eligible employee or dependent a. That spouse is eligible for coverage; and was eligible to enroll under the Contract, whether during initial enrollment, open enrollment, or special enrollment and declined coverage for that reason. b. Is not already enrolled under the Contract; and I The eligible employee or dependent must present evidence that the eligible employee or c. Enrollment is requested in writing within 30 days of the dependent child becoming a dependent has exhausted such COBRA or state continuation coverage and has not lost dependent; and such coverage due to failure of the eligible employee or dependent to pay d. The eligible employee also enrolls during this special enrollment period; or a timely basis or for cause, and request enrollment in writing within 30 days of the date on of the exhaustion of coverage. 5. er gible enrollmentThe dependents is requested are eligible in writing within dependent 30 days children of of a the dependensubscribt, as or deeliscribed in employee 2. or 3.and For purposes of 1.c.: above, becoming eligible to enroll under the coverage provided the eligible employee also i. Exhaustion of COBRA or state continuation coverage includes: enrolls during this special enrollment period. • 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as losing COBRA or state continuation coverage for any reason other than those set described in this section, Medica will provide the eligible dependent child with a special forth in ii. below; enrollment period provided the eligible employee also enrolls during this special enrollment • losing coverage as a result of the employer's failure to remit premiums on a period. timely basis; MIC FOCUSMN HSA (3/12) 92 1500-100% MIC FOCUSMN HSA (3/12) 93 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 . I'I Eligibility And Enrollment Eligibility And Enrollment 11 Late 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 An eligible employee or an eligible employee and dependents who do not enroll for coverage was held. offered through the employer during the initial or open enrollment period or any applicable 3. For eligible employees and/or dependents who enroll during a special enrollment period, special enrollment period will be considered late entrants. coverage begins on the date indicated below for the particular special enrollment. In the Late entrants who have maintained continuous coverage may enroll and coverage will be case of: effective the first day of the month following date of Medica's approval of the request for a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first enrollment. Continuous coverage will be determined to have been maintained if the late entrant calendar month following the date on which the request for enrollment is received by requests enrollment within 63 days after prior qualifying coverage ends. Medica; Individuals who have not maintained continuous coverage may not enroll as late entrants. b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of An eligible employee or dependent who: adoption or placement for adoption, date of adoption or placement. In all other cases, 1. does not enroll during an initial or open enrollment period or any applicable special the date the subscriber acquires the dependent child; enrollment period; and c. Number 4. under Special enrollment, the date coverage for the dependent child is 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the employer, effective, as set forth in 3.b. above; provided the eligible subscriber or dependent maintains continuous coverage, d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. will not be considered a late entrant and will be allowed to enroll. Coverage will be effective as or 3. under Special enrollment becomes effective; determined by Medica. 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. Qualified Medical Child Support Order(QMCSO) 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 Medica will provide coverage in accordance with a QMCSO pursuant to the applicable enrollment. 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 FOCUSMN HSA (3/12) 94 1500-100% MIC FOCUSMN HSA (3/12) 95 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 • - Ending Coverage Ending Coverage e. Submitting fraudulent claims; DD. Ending Coverage 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. This section describes when coverage ends under the Contract. When this happens you may Upon completion of active military duty, contact the employer for reinstatement of coverage; exercise your right to continue or convert your coverage as described in Continuation or Conversion. 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 See Definitions These words have specific meanings certification of qualifying coverage, death occurred; claim dependent, me ber premium subscriber. , , 9. Fora spouse, the end of the month following the date of divorce; You have the right to a certification of qualifying coverage when coverage ends. You will 10. For a dependent child, the end of the month in which the child is no longer eligible as a receive a certification of qualifying coverage when coverage ends. You may also request a dependent; or 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 11. For a child who is entitled to coverage through a QMCSO, the end of the month in which the qualifying coverage, call Customer Service at one of the telephone numbers listed inside the earliest of the following occurs: front cover. Upon receipt of your request, the certification of qualifying coverage will be issued a. The QMCSO ceases to be effective; or as soon as reasonably possible. b. The child is no longer a child as that term is used in ERISA; or When coverage ends 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 Unless otherwise specified in the Contract, coverage ends the earliest of the following: as determined by the employer; or 1. The end of the month in which the Contract is terminated by the employer or Medica in e. The employer terminates family or dependent coverage; or 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; f. The Contract is terminated by the employer or Medica; or 2. The end of the month for which the subscriber last paid his or her contribution toward the g. The relevant premium or contribution toward the premium is last paid. 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 (3/12) 96 1500-100% MIC FOCUSMN HSA (3/12) 97 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Continuation Continuation Subscriber's spouse's loss EE. Continuation 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; 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 b. A termination of the subscriber's employment (for any reason other than gross coverage administration are the responsibility of the employer. misconduct) or layoff from employment; See Definitions. These words have specific meanings benefits, dependent, member, placed c. Dissolution of marriage from the subscriber; for:adoption, premium, subscnber;Aotaldisability x '; k d. The subscribers enrollment for benefits under Medicare. The paragraph below describes the continuation coverage provisions. State continuation is Subscriber's child's loss described in 1. and federal continuation is described in 2. The subscriber's dependent child has the right to continuation coverage if coverage under If your coverage ends, you should review your rights under both state law and federal law with the Contract is lost for any of the following reasons: 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. a. Death of the subscriber if the subscriber is the parent through whom the child receives 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. b. Termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; 1. Your right to continue coverage under state law 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 Notwithstanding the provisions regarding termination of coverage described in Ending through whom the child receives coverage; Coverage, you may be entitled to extended or continued coverage as follows: e. The subscriber's child ceases to be a dependent child under the terms of the Contract. a. Minnesota state continuation coverage. Continued coverage shall be provided as required under Minnesota law. Minnesota Responsibility to inform 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, Under Minnesota law, the subscriber and dependents have the responsibility to inform the within the parameters of Minnesota law, establish uniform policies pursuant to which employer of a dissolution of marriage or a child losing dependent status under the Contract such continuation coverage will be provided. within 60 days of the date of the event or the date on which coverage would be lost because of the event. b. Notice of rights. Minnesota law requires that covered employees and their dependents (spouse and/or Election rights 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 When the employer is notified that one of these events has happened, the subscriber and coverage under an employer sponsored group health plan(s) would otherwise end. the subscriber's dependents will be notified of the right to continuation coverage. This notice is intended to inform you, in summary fashion, of your rights and obligations Consistent with Minnesota law, the subscriber and dependents have 60 days to elect under the continuation coverage provision of Minnesota law. It is intended that no greater continuation coverage for reasons of termination of the subscriber's employment or the rights be provided than those required by Minnesota law. Take time to read this section subscriber's enrollment for benefits under Medicare measured from the later of: carefully. a. The date coverage would be lost because of one of the events described above; or Subscriber's loss b. The date notice of election rights is received. The subscriber has the right to continuation of coverage for him or herself and his or her If continuation coverage is elected within this period, the coverage will be retroactive to the dependents if there is a loss of coverage under the Contract because of the subscriber's date coverage would otherwise have been lost. voluntary or involuntary termination of employment (for any reason other than gross The subscriber and the subscriber's covered spouse may elect continuation coverage on misconduct) or layoff from employment. In this section, layoff from employment means a behalf of other dependents entitled to continuation coverage. Under certain circumstances, reduction in hours to the point where the subscriber is no longer eligible for coverage under the subscriber's covered spouse or dependent child may elect continuation coverage even if the Contract. the subscriber does not elect continuation coverage. If continuation coverage is not elected, your coverage under the Contract will end. MIC FOCUSMN HSA(3/12) 98 1500-100% MIC FOCUSMN HSA(3/12) 99 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Continuation Continuation Type of coverage and cost ii. The date coverage would otherwise terminate under the Contract. If continuation coverage is elected, the subscriber's employer is required to provide e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent coverage that, as of the time coverage is being provided, is identical to the coverage children may be continued until the earlier of: provided under the Contract to similarly situated employees or employees' dependents. i. The date the surviving spouse and dependent children become covered under Under Minnesota law, a person continuing coverage may have to make a monthly payment another group health plan; or to the employer of all or part of the premium for continuation coverage. The amount ii. The date coverage would have terminated under the Contract had the subscriber charged cannot exceed 102 percent of the cost of the coverage. lived. Surviving dependents of a deceased subscriber have 90 days after notice of the requirement to pay continuation premiums to make the first payment. Extension of benefits for total disability of the subscriber Duration 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 Under the circumstances described above and for a certain period of time, Minnesota law subscriber is required to pay all or part of the premium for the extension of coverage, requires that the subscriber and his or her dependents be allowed to maintain continuation payment shall be made to the employer. The amount charged cannot exceed 100 percent coverage as follows: of the cost of the coverage. 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: 2. Your right to continue coverage under federal law i. 18 months after the date of the termination of or layoff from employment; Notwithstanding the provisions regarding termination of coverage described in Ending ii. The date the subscriber becomes covered under another group health plan (as an Coverage, you may be entitled to extended or continued coverage as follows: employee or otherwise) that does not contain any exclusion or limitation with respect to any applicable pre-existing condition; or COBRA continuation coverage iii. The date coverage would otherwise terminate under the Contract. Continued coverage shall be provided as required under the Consolidated Omnibus Budget b. For instances where the subscriber's spouse or dependent children lose coverage Reconciliation Act of 1985 (COBRA), as amended (as well as the Public Health Service Act because of the subscriber's enrollment under Medicare, coverage may be continued (PHSA), as amended). The employer shall, within the parameters of federal law, establish until the earliest of: g y uniform policies pursuant to which such continuation coverage will be provided. See General COBRA information in this section. i. 36 months after continuation was elected; ii. The date coverage is obtained under another group health plan; or USERRA continuation coverage iii. The date coverage would otherwise terminate under the Contract. Continued coverage shall be provided as required under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The c. For instances where dependent children lose coverage as a result of loss of dependent employer shall, within the parameters of federal law, establish uniform policies pursuant to eligibility, coverage may be continued until the earliest of: which such continuation coverage will be provided. See General USERRA information in i. 36 months after continuation was elected; this section. ii. The date coverage is obtained under another group health plan; or General COBRA information iii. The date coverage would otherwise terminate under the Contract. COBRA requires employers with 20 or more employees to offer subscribers and their d. For instances of dissolution of marriage from the subscriber, coverage of the families (spouse and/or dependent children)the opportunity to pay for a temporary subscriber's spouse and dependent children may be continued until the earliest of: extension of health coverage (called continuation coverage) at group rates in certain instances where health coverage under employer sponsored group health plan(s) would i. The date the former spouse becomes covered under another group health plan; or otherwise end. This coverage is a group health plan for purposes of COBRA. ii. The date coverage would otherwise terminate under the Contract. 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 If 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, be provided than those required by federal law. Take time to read this section carefully. 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 (3/12) 100 1500-100% MIC FOCUSMN HSA(3/12) 101 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 i Continuation • Continuation Qualified beneficiary Also, a subscriber and dependent who have been determined to be disabled under the I For purposes of this section, a qualified beneficiary is defined as: Social Security Act as of the time of the subscriber's termination of employment or reduction 1 of hours or within 60 days of the start of the continuation period must notify the employer of a. A covered employee (a current or former employee who is actually covered under a that determination within 60 days of the determination. If determined under the Social group health plan and not just eligible for coverage); y Security Act to no longer be disabled, he or she must notify the employer within 30 days of b. A covered spouse of a covered employee; or the determination. c. A dependent child of a covered employee. (A child placed for adoption with or born to Bankruptcy an employee or former employee receiving COBRA continuation coverage is also a qualified beneficiary.) 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 Subscriber's loss proceeding and these individuals lose coverage. The subscriber has the right to elect continuation of coverage if there is a loss of coverage Election rights under the Contract because of termination of the subscriber's employment (for any reason When notified that one of these events has happened, the employer will notify the other than gross misconduct), or the subscriber becomes ineligible to participate under the subscriber and dependents of the right to choose continuation coverage. terms of the Contract due to a reduction in his or her hours of employment. Subscriber's spouse's loss Consistent with federal law, the subscriber and dependents have 60 days to elect , p continuation coverage, measured from the later of: The subscriber's covered spouse has the right to choose continuation coverage if he or she a. The date coverage would be lost because of one of the events described above; or i loses coverage under the Contract for any of the following reasons: b. The date notice of election rights is received. a. Death of the subscriber; If continuation coverage is elected within this period, the coverage will be retroactive to the b. A termination of the subscriber's employment (for any reason other than gross date coverage would otherwise have been lost. misconduct) or reduction in the subscriber's hours of employment with the employer; The subscriber and the subscriber's covered spouse may elect continuation coverage on I c. Divorce or legal separation from the subscriber; or behalf of other dependents entitled to continuation coverage. However, each person entitled to continuation coverage has an independent right to elect continuation coverage. d. The subscriber's entitlement to (actual coverage under) Medicare. The subscriber's covered spouse or dependent child may elect continuation coverage even Subscriber's child's loss if the subscriber does not elect continuation coverage. The subscriber's dependent child has the right to continuation coverage if coverage under If continuation coverage is not elected, your coverage under the Contract will end. the Contract is lost for any of the following reasons: Type of coverage and cost 1 a. Death of the subscriber if the subscriber is the parent through whom the child receives coverage; 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 b. The subscriber's termination of employment (for any reason other than gross the coverage provided under the Contract to similarly situated employees or employees' misconduct) or reduction in the subscriber's hours of employment with the employer; dependents. c. The subscriber's divorce or legal separation from the child's other parent; 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 d. The subscriber's entitlement to (actual coverage under) Medicare if the subscriber is the , the cost of the coverage. The amount may be increased to 150 percent of the applicable parent through whom the child receives coverage; or premium for months after the 18th month of continuation coverage when the additional e. The subscriber's child ceases to be a dependent child under the terms of the Contract. months are due to a disability under the Social Security Act. Responsibility to inform There is a grace period of at least 30 days for the regularly scheduled premium. Under federal law, the subscriber and dependent have the responsibility to inform the Duration of COBRA coverage 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 Federal law requires that you be allowed to maintain continuation coverage for 36 months lost because of the event. 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(3/12) 102 1500-100% MIC FOCUSMN HSA(3/12) 103 1500-100% 21316 DOC 23928 BPL 21316 DOC 23928 Continuation • Continuation The 18 months may be extended if a second event (e.g., divorce, legal separation, or death) Guard duty, and the time necessary for a person to be absent from employment for an occurs during the initial 18-month period. It also may be extended to 29 months in the case examination to determine the fitness of the person to perform any of these duties. of an employee or employee's dependent who is determined to be disabled under the Social Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army Security Act at the time of the employee's termination of employment or reduction of hours, National Guard, and the Air National Guard, when engaged in active duty for training, or within 60 days of the start of the 18-month continuation period. inactive duty training, or full-time National Guard duty, and the commissioned corps of the If an employee or the employee's dependent is entitled to 29 months of continuation Public Health Service. 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) Election rights Medicare, the continuation period for the subscriber's dependents is 36 months measured The employee or the employee's authorized representative may elect to continue the from the date of the subscriber's Medicare entitlement even if that entitlement does not employee's coverage under the Contract by making an election on a form provided by the cause the subscriber to lose coverage. employer. The employee has 60 days to elect continuation coverage measured from the Under no circumstances is the total continuation period greater than 36 months from the date date coverage would be lost because of the event described above. If continuation of the original event that triggered the continuation coverage. coverage is elected within this period, the coverage will be retroactive to the date coverage Federal law provides that continuation coverage may end earlier for any of the following 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 reasons: dependent to elect. If the employee does not elect, there is no USERRA continuation a. The subscriber's employer no longer provides group health coverage to any of its available for the spouse or dependent children. In addition, even if the employee does not employees; elect USERRA continuation, the employee has the right to be reinstated under the Contract b. The premium for continuation coverage is not paid on time; upon reemployment, subject to the terms and conditions of the Contract. c. Coverage is obtained under another group health plan (as an employee or otherwise) Type of coverage and cost that does not contain any exclusion or limitation with respect to any applicable pre- If the employee elects continuation coverage, the employer is required to provide coverage existing condition; or that, as of the time coverage is being provided, is identical to the coverage provided under d. The subscriber becomes entitled to (actually covered under) Medicare. the Contract to similarly situated employees. The amount charged cannot exceed 102 Continuation coverage may also end earlier for reasons which would allow regular coverage to percent of the cost of the coverage unless the employee's leave of absence is less than 31 be terminated, such as fraud. 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 General USERRA information least 30 days for the regularly scheduled premium. USERRA requires employers to offer employees and their families (spouse and/or dependent Duration of USERRA coverage children) the opportunity to pay for a temporary extension of health coverage (called When an employee takes a leave for service in the uniformed services, coverage for the continuation coverage) at group rates in certain instances where health coverage under employee and dependents for whom coverage is elected begins the day after the employee employer sponsored group health plan(s) would otherwise end. This coverage is a group would lose coverage under the Contract. Coverage continues for up to 24 months. health plan for the purposes of USERRA. This section is intended to inform you, in summary fashion, of your rights and obligations Federal law provides that continuation coverage may end earlier for any of the following under the continuation coverage provision of federal law. It is intended that no greater rights reasons: be provided than those required by federal law. Take time to read this section carefully. a. The employer no longer provides group health coverage to any of its employees; Employee's loss b. The premium for continuation coverage is not paid on time; The employee has the right to elect continuation of coverage if there is a loss of coverage c. The employee loses their rights under USERRA as a result of a dishonorable discharge under the Contract because of absence from employment due to service in the uniformed or other undesirable conduct; services, and the employee was covered under the Contract at the time the absence began, d. The employee fails to return to work following the completion of his or her service in the and the employee, or an appropriate officer of the uniformed services, provided the uniformed services; or employer with advance notice of the employee's absence from employment (if it was e. The employee returns to work and is reinstated under the Contract as an active possible to do so). employee. Service in the uniformed services means the performance of duty on a voluntary or Continuation coverage may also end earlier for reasons which would allow regular coverage involuntary basis in the uniformed services under competent authority, including active duty, to be terminated, such as fraud. active duty for training, initial active duty for training, inactive duty training, full-time National MIC FOCUSMN HSA(3/12) 104 1500-100% MIC FOCUSMN HSA(3/12) 105 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Continuation Conversion COBRA and USERRA coverage are concurrent If the employer is subject to COBRA and USERRA, and you elect COBRA continuation FF. Conversion coverage in addition to USERRA continuation coverage, these coverages run concurrently. 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 (3/12) 106 1500-100% MIC FOCUSMN HSA (3/12) 107 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Conversion Complaints 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 GG. Complaints within 31 days of the date you were notified of the right to convert coverage, whichever is later. What you must do This section describes what to do if you have a complaint or would like to appeal a decision 1. For conversion coverage information, call Customer Service at one of the telephone made by Medica. numbers listed inside the front cover. See Definitions These words have specific meanings: claims inpatient,.network provider, 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 You may call Customer Service at one of the telephone numbers listed inside the front cover or coverage, whichever is later. You will be required to include your first month premium by writing to the address below in First level of review, 2. You also may contact the payment with your enrollment form for conversion coverage. Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296-2488 or 1-800-657-3602. 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 Filing a complaint may require that Medica review your medical records as needed to resolve convert, whichever is later. You may include only those dependents who were enrolled your complaint. under the Contract at the time of conversion. You may appoint an authorized representative to make a complaint on your behalf. You may be What the employer must do 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 The employer is required to notify you of your right to convert coverage. process. Upon request, Medica will assist you with completion and submission of your written complaint. Residents of a state other than Minnesota Medica will also complete a complaint form on your behalf and mail it to you for your signature upon request. This section describes your right to convert to an individual conversion plan if you are a resident In addition to directing complaints to Customer Service as described in this section, you may of a state other than Minnesota on the day that you submit an enrollment form to Medica or direct complaints at any time to the Commissioner of Commerce at the telephone number listed Medica's designated conversion vendor. at the beginning of this section. Overview You may convert to an individual conversion plan through Medica or Medica's designated First level of review conversion vendor without proof of good health or waiting periods, in accordance with the laws You may direct any question or complaint to Customer Service by calling one of the telephone of the state in which you reside on the day that you submit an enrollment form to Medica or numbers listed inside the front cover or by writing to the address listed below. Medica's designated conversion vendor. 1. If your complaint is regarding an initial decision made by Medica, your complaint must be What you must do made within one year following Medica's initial decision. 1. For conversion coverage information, call Customer Service at one of the telephone 2. For an oral complaint that does not require a medical determination in its outcome, if Medica numbers listed inside the front cover. 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, 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. Medica will provide you with a complaint form to submit your complaint in writing. Mail the completed form to: You will be required to include your first month premium payment with your enrollment form for conversion coverage. Customer Service Route 0501 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 PO Box 9310 days after your coverage ends or such other period of time as provided under applicable Minneapolis, MN 55440-9310 state law. You may include only those dependents who were enrolled under the Contract at the time of conversion. 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(3/12) 108 1500-100% MIC FOCUSMN HSA(3/12) 109 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Complaints Complaints provider will have the opportunity to request an expedited review by telephone. Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be Alternatively, if Medica concludes that a delay could seriously jeopardize your life, health, or submitted for external review. ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without care or treatment you are requesting, Medica will process your claim as an Civil action expedited review. In such cases, Medica will notify you and your attending provider by telephone of its decision no later than 72 hours after receiving the request. If you are dissatisfied with Medica's first or second level review decision or the external review 5. If Medica's first level review decision upholds the initial decision made by Medica, you may decision, you have the right to file a civil action under section 502(a) of the Employee have a right to request a second level review or submit a written request for external review Retirement Income Security Act (ERISA). 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 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. Generally, a second level review is optional if the complaint requires a medical determination. 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 You must include a filing fee of$25 with 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. Medica may seek judicial review on the grounds that the decision was arbitrary and capricious or involved an abuse of discretion. Contact the Commissioner of Commerce for more information about the external review process. MIC FOCUSMN HSA (3/12) 110 1500-100% MIC FOCUSMN HSA(3/12) 111 BPL 21316 DOC 23928 BPL 21316 DOC 23928 General Provisions General Provisions Discretionary authority HH. General Provisions 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, provided, however, that this provision shall not be construed to specify a standard of review upon which a This section describes the general provisions of the Contract. court may review a claim denial or any other decision made by Medica with respect to a See Definitions These words have specific meanings benefits, claim,dependent, member, member. network; premium,provider,subscriber. tp 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(3/12) 112 1500-100% MIC FOCUSMN HSA (3/12) 113 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 II Definitions • Definitions Convenience care/retail health clinic. A health care clinic located in a setting such as a retail Definitions store, grocery store, or pharmacy, which provides treatment of common illnesses and certain preventive health care services. Cosmetic. Services and procedures that improve physical appearance but do not correct or In this certificate (and in any amendments), some words have specific meanings. Within each improve a physiological function, and that are not medically necessary, unless the service or definition, you may note bold words. These words also are defined in this section. procedure meets the definition of reconstructive. Benefits. The health services or supplies (described in this certificate and any subsequent Custodial care. Services to assist in activities of daily living that do not seek to cure, are amendments) approved by Medica as eligible for coverage. performed regularly as a part of a routine or schedule, and, due to the physical stability of the Certification of qualifying coverage. A written certification that group health plans and health condition, do not need to be provided or directed by a skilled medical professional. These insurance issuers must provide to an individual to confirm the qualifying coverage provided to 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- the individual under the group health plan or health insurance. Claim. An invoice, bill, or itemized statement for benefits provided to you. administered. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims Coinsurance. The percentage amount you must pay to the provider for benefits received. for health services or supplies received from network or non-network providers are Full coinsurance payments may apply to scheduled appointments canceled less than 24 hours reimbursable as in-network or out-of-network benefits under this certificate. before the appointment time or to missed appointments. Dependent. Unless otherwise specified in the Contract, the following are considered For in-network benefits, the coinsurance amount is based on the lesser of the: dependents: 1. Charge billed by the provider (i.e., retail); or 1. The subscriber's spouse. 2. Negotiated amount that the provider has agreed to accept as full payment for the benefit 2. The following dependent children up to the dependent limiting age of 26: (i.e., wholesale). a. The subscriber's or subscriber's spouse's natural or adopted child; When the wholesale amount is not known nor readily calculated at the time the benefit is b. A child placed for adoption with the subscriber or subscriber's spouse; 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. c. A child for whom the subscriber or the subscriber's spouse has been appointed legal The provider's retail charge is the amount that the provider would charge to any patient, guardian; however, upon request by Medica, the subscriber must provide satisfactory whether or not that patient is a Medica member. proof of legal guardianship; For out-of-network benefits, the coinsurance will be based on the lesser of the: d. The subscriber's stepchild; and 1. Charge billed by the provider (i.e., retail); or 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. 2. Non-network provider reimbursement amount. For out-of-network benefits, in addition to any coinsurance and deductible amounts, you are 1 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent responsible for any charges billed by the provider in excess of the non-network provider incapable of self-sustaining employment by reason of developmental disability, mental illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber reimbursement amount. 1 for support and maintenance. An illness that does not cause a child to be incapable of self- In addition, for the network pharmacies described in Prescription Drug Program and sustaining employment will not be considered a physical disability. This dependent may Prescription Specialty Drug Program, the calculation of coinsurance amounts as described remain covered under the Contract regardless of age and without application of health above do not include possible reductions for any volume purchase discounts or price screening or waiting periods. To continue coverage for a disabled dependent, you must adjustments that Medica may later receive related to certain prescription drugs and pharmacy provide Medica with proof of such disability and dependency within 31 days of the child services. 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 The coinsurance may not exceed the charge billed by the provider for the benefit. Continuous coverage. The maintenance of continuous and uninterrupted qualifying dependency. coverage by an eligible employee or dependent. An eligible employee or dependent is For residents of a state other than Minnesota, the dependent limiting age may be higher if considered to have maintained continuous coverage if enrollment is requested under the required by applicable state law. Contract within 63 days of termination of the previous qualifying coverage. 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, MIC FOCUSMN HSA (3/12) 114 1500-100% MIC FOCUSMN HSA(3/12) 115 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Definitions Definitions you must provide Medica with proof of such disability and dependency at the time of the Notwithstanding the above, a drug being used for an indication or at a dosage that is an dependent's enrollment. accepted off-label use for the treatment of cancer will not be considered by Medica to be Designated facility. A network hospital that Medica has authorized to provide certain investigative. Medica will determine if a use is an accepted off-label use based on published benefits to members, as described in this certificate. reports in authoritative peer-reviewed medical literature, clinical practice guidelines, or parameters approved by national health professional boards or associations, and entries in any Emergency. A condition or symptom (including severe pain) that a prudent layperson, who authoritative compendia as identified by the Medicare program for use in the determination of a possesses an average knowledge of health and medicine, would believe requires immediate medically accepted indication of drugs and biologicals used off-label. treatment to: Late entrant. An eligible employee or dependent who requests enrollment under the Contract 1. Preserve your life; or other than during: 2. Prevent serious impairment to your bodily functions, organs, or parts; or 1. The initial enrollment period set by the employer; or 3. Prevent lacin p g your physical or mental health (or, if you are pregnant, the health of your 2. The open enrollment period set by the employer; or unborn child) in serious jeopardy. 3. A special enrollment period as described in Eligibility And Enrollment. Enrollment date. The date of the eligible employee's or dependent's first day of coverage However, an eligible employee or dependent who is an enrollee of the Minnesota under the Contract or, if earlier, the first day of the waiting period for the eligible employee's or dependent's enrollment. 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 Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if dependent maintains continuous coverage as defined in this certificate. the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing includes In addition, a member who is a child entitled to receive coverage through a QMCSO is not pharmacogenetic testing. Genetic testing does not include an analysis of proteins or subject to any initial or open enrollment period restrictions. 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. Medically necessary. Diagnostic testing and medical treatment, consistent with the diagnosis Home clinic. The primary care clinic site within the Medica Focus network that you choose to of and prescribed course of treatment for your condition, and preventive services. Medically collaborate with for your healthcare needs. necessary care must meet the following criteria: 1. Be consistent with the medical standards and accepted practice parameters of the Hospital. A licensed facility that provides diagnostic, medical, therapeutic, rehabilitative, and community as determined by health care providers in the same or similar general specialty surgical services by, or under the direction of, a physician and with 24-hour R.N. nursing as typically manages the condition, procedure, or treatment at issue; and services. The hospital is not mainly a place for rest or custodial care and is not a nursing home or similar facility. 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing diagnosis or condition; and facility, or licensed acute care facility. Inpatient services in a licensed residential treatment 3. Help to restore or maintain your health; or facility for treatment of emotionally disabled children will be covered as any other health 4. Prevent deterioration of your condition; or condition. Investigative. As determined by Medica, a drug, diagnostic or screening 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. Y g, g g procedure, or medical treatment or procedure is investigative if reliable evidence does not permit conclusions Member. A person who is enrolled under the Contract. concerning its safety, effectiveness, or effect on health outcomes. Medica will make its Mental disorder. A physical or mental condition having an emotional or psychological origin, determination based upon an examination of the following reliable evidence, none of which shall as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders be determinative in and of itself: (DSM). 1. Whether there is final approval from the appropriate government regulatory agency, if Network. A term used to describe a provider (such as a hospital, physician, required, including whether the drug or device has received final approval to be marketed for p ( p home health its proposed use by the United States Food and Drug Administration (FDA), or whether the agency, skilled nursing facility, or pharmacy) that has entered into a written agreement with treatment is the subject of ongoing Phase I, II, or III trials; Medica or has made other arrangements with Medica to provide benefits to you. The participation status of providers will change from time to time. 2. Whether there are consensus opinions and recommendations reported in relevant scientific The Medica Focus network provider directory will be furnished automatically, without charge. and medical literature, peer-reviewed journals, or the reports of clinical trial committees and other technology assessment bodies; and Non-network. A term used to describe a provider not under contract as a network provider. 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. MIC FOCUSMN HSA (3/12) 116 1500-100% MIC FOCUSMN HSA (3/12) 117 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Definitions Definitions Non-network provider reimbursement amount. The amount that Medica will pay to a non- Preventive health service. The following are considered preventive health services: network provider for each benefit is based on one of the following, as determined by Medica: 1. Evidence-based items or services that have in effect a rating of A or B in the current 1. A percentage of the amount Medicare would pay for the service in the location where the recommendations of the United States Preventive Services Task Force; service is provided. Medica generally updates its data on the amount Medicare pays within 2. Immunizations for routine use that have in effect a recommendation from the Advisory 30-60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; Committee on Immunization Practices of the Centers for Disease Control and Prevention or with respect to the member involved; 2. A percentage of the provider's billed charge; or 3. With respect to members who are infants, children, and adolescents, evidence-informed 3. A nationwide provider reimbursement database that considers prevailing reimbursement preventive care and screenings provided for in the comprehensive guidelines supported by rates and/or marketplace charges for similar services in the geographic area in which the the Health Resources and Services Administration; service is provided; or 4. With respect to members who are women, such additional preventive care and screenings 4. An amount agreed upon between Medica and the non-network provider. not described in 1. as provided for in comprehensive guidelines supported by the Health Contact Customer Service for more information concerning which method above pertains to Resources and Services Administration. your services, including the applicable percentage if a Medicare-based approach is used. Contact Customer Service for information regarding specific preventive health services, services that are rated A or B, and services that are included in guidelines supported by the For certain benefits, you must pay a portion of the non-network provider reimbursement Health Resources and Services Administration. amount as a coinsurance. In addition, if the amount billed by the non-network provider is greater than the non-network Provider. A health care professional or facility licensed, certified, or otherwise qualified under provider reimbursement amount, the non-network provider will likely bill you for the state law to provide health services. difference. This difference may be substantial, and it is in addition to any coinsurance or Qualifying coverage. Health coverage provided under one of the following plans: deductible amount you may be responsible for according to the terms described in this 1. A health plan in which a health carrier has issued a policy, contract, or certificate for the certificate. Furthermore, such difference will not be applied toward the out-of-pocket maximum coverage of medical and hospital benefits, including blanket accident and sickness described in Your Out-Of-Pocket Expenses. Additionally, you will owe these amounts insurance other than accident only coverage; 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 2. Part A or Part B of Medicare; a non-network provider will likely be much higher than if you had received services from a 3. A medical assistance medical care plan as defined under Minnesota law; network provider. 4. A general assistance medical care plan as defined under Minnesota law; Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene- based information to determine the proper drug and dosage for an individual. 5. Minnesota Comprehensive Health Association (MCHA); Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared 6. A self-insured health plan; from the body of an individual based on their genetic makeup. 7. The MinnesotaCare program as defined under Minnesota law; Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (110.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.) practicing within the 8. The public employee insurance plan as defined under Minnesota law; scope of his or her licensure. 9. The Minnesota employees insurance plan as defined under Minnesota law; Placed for adoption. The assumption and retention of the legal obligation for total or partial 10. TRICARE or other similar coverage provided under federal law applicable to the armed support of the child in anticipation of adopting such child. forces; (Eligibility for a child placed for adoption with the subscriber ends if the placement is 11. Coverage provided by a health care network cooperative or by a health provider interrupted before legal adoption is finalized and the child is removed from placement.) cooperative; Premium. The monthly payment required to be paid by the employer on behalf of or for you. 12. The Federal Employees Health Benefits Plan or other similar coverage provided under Prenatal care. The comprehensive package of medical and psychosocial support provided federal law applicable to government organizations and employees; throughout a pregnancy and related directly to the care of the pregnancy, including risk 13. A medical care program of the Indian Health Service or of a tribal organization; assessment, serial surveillance, prenatal education, and use of specialized skills and technology, when needed, as defined by Standards for Obstetric-Gynecologic Services issued 14. A health benefit plan under the Peace Corps Act; by the American College of Obstetricians and Gynecologists. 15. State Children's Health Insurance Program; or Prescription drug. A drug approved by the FDA for the prescribed use and route of administration. o MIC FOCUSMN HSA(3/12) 119 1500-100% MIC FOCUSMN HSA (3/12) 118 1500-100/o BPL 21316 DOC 23928 BPL 21316 DOC 23928 I Definitions Definitions 16. A public health plan similar to any of the above plans established or maintained by a state, Skilled care. Nursing or rehabilitation services requiring the skills of technical or professional the U.S. government, a foreign country, or any political subdivision of a state, the U.S. medical personnel to develop, provide, and evaluate your care and assess your changing government, or a foreign country. condition. Long-term dependence on respiratory support equipment and/or the fact that Coverage services are received from technical or professional medical personnel do not by themselves overage of the following types, including any combination of the following types, are not qualifying coverage: define the need for skilled care. 1. Coverage only for disability or income protection insurance; 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, 2. Automobile medical payment coverage; or other related health services including rehabilitative services. 3. Liability insurance or coverage issued as a supplement to liability insurance; Subscriber. The person: 4. Coverage for a specified disease or illness or to provide payments on a per diem, fixed 1. On whose behalf premium is paid; and indemnity, or non-expense-incurred basis, if offered as independent, non-coordinated 2. Whose employment is the basis for membership, according to the Contract; and coverage; 5. Credit accident and health insurance as defined under Minnesota law; 3. Who is enrolled under the Contract. 6. Coverage designed solely to provide dental or vision care; Total disability. Disability due to injury, sickness, or pregnancy that requires regular care and 7. Accident only coverage; 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 8. Long-term care coverage as defined under Minnesota law; 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. 9. Medicare supplemental health insurance as defined under Minnesota law; 10. Workers' compensation insurance; or Travel program. A national program in which you can receive the in-network benefit level for p 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. 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 Urgent care center. A health care facility distinguishable from an affiliated clinic or hospital not transfer risk. whose primary purpose is to offer and provide immediate, short-term medical care for minor, Reconstructive. Surgery to rebuild or correct a: immediate medical conditions on a regular or routine basis. 1. Body part when such surgery is incidental to or following surgery resulting from injury, Virtual care. Professional evaluation and medical management services provided to patients sickness, or disease of the involved body part; or through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth services. Virtual care is used to address non-urgent medical symptoms for patients describing 2. Congenital disease or anomaly which has resulted in a functional defect as determined by new or ongoing symptoms to which providers respond with substantive medical advice. your physician. Virtual care does not include telephone calls for reporting normal lab or test results, or solely In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was calling in a prescription to a pharmacy. performed and surgery and reconstruction of the other breast to produce a symmetrical Waiting period. In accordance with applicable state and federal laws, the period of time that appearance shall be considered reconstructive. 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). Restorative. Surgery to rebuild or correct a physical defect that has a direct adverse effect on However, if an eligible employee or dependent enrolls as a late entrant or through a special the physical health of a body part, and for which the restoration or correction is medically necessary. 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 Routine foot care. Services that are routine foot care may require treatment by a employment classification that is not eligible for coverage under the Contract do not constitute a professional and include but are not limited to any of the following: waiting period. 1. Cutting, paring, or removing corns and calluses; 2. Nail trimming, clipping, or cutting; and 3. Debriding (removing 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 FOCUSMN HSA(3/12) 121 1500-100% MIC FOCUSMN HSA 3/12 120 1500-100% BPL 21316 DOC 23928 BPL 21316 DOC 23928 Medica Focus Certificate of Coverage MEDICA® MIC FOCUSMN HSA (3/12) 1500-100% BPL 21317 DOC 23932 Table Of Contents MEDICA CUSTOMER SERVICE • Table Of Contents Minneapolis/St. Paul Hearing Impaired: Metro Area: National Relay Center Introduction x (952) 945-8000 1 -800-855-2880 then Medical Loss Ratio (MLR) standards under the federal Public Health Service Act X To be eligible for benefits Outside the Metro Area: ask them to dial Medica Language interpretation xi at 1 -800-952-3455 Acceptance of coverage xi 1 -800-952-3455 Nondiscrimination policy xi Health savings accounts xii More information about the plan can also be obtained by 1 signing in at www.mymedica.com. A. Member Rights And Responsibilities • Member bill of rights 1 Member responsibilities 1 B. How To Access Your Benefits 3 Ut14 A.li cry J.. 3i OA e1,44 ,:_A.....3.1.4110:1:. Ec nt Bari apkna rrovtotutr B nepeBORe Troti uta3l....11 o:w ;LA.?. .1 vi%l�tila.a o.�ct..�.a ct�_:.:isS 131 HHCJ)opMaun!, rto3BOxrtTe no xoMepy, Important member information about in-network benefits 3 � ��t � yka3attttomy na o6paTxoi%c cropone Barnett Important member information about out-of-network benefits 5 Medica �I3 4..oti11 •t34.611 ";yai Me,i1Ci]MHCx0ii KapTO=KFI unaxa Medica. 7 Continuity of care Haddii aad doonayso in Af Soomaali laguugu ipei t iiurimiC,l nirjuirt ituitaittriziratarGin tns : 8 tarjatnadda macluumaadkani,oo lacag s,tticylkitstitilif3V,11 tf,1itti 34t8 rn tti 'hmMedica 1 Prior authorization la'aan ah. Fadlan wac Lambarka ku goran Certification of qualifying coverage 9 Kaarka Caafimaadka ce:Medica dhabarkiisa. Si usted desea ayuda gratuita para traducir esta informacion, llame al numero de C. How Providers Are Paid By Medica 11 Ako zelite besplatano tumacenje ovih teleUono situado al reverso de su tarjeta Network providers 11 informacija posovite broj na pozadini vase de identificacion de Medica. Medica kartice. Neu guy vi muon dirge giCcp dei diet,ca11i0 nay mien Non-network providers 11 phi,xin goi so ghi 0 mac sau the Medica eua Try vi. D. Your Out-Of-Pocket Expenses 12 Yog koj xav tau key pab txhais coy ntaub ntawv no dawb, hu mu tus xov tooj nyob Dine k'ehji shich`i' hadoodzih ninizingo, beesh Coinsurance and deductibles 12 nram gab koj claim Medica Khaj (card). bee hane'e binumber naaltsoos bikaahigii bich'i' 14 hodiilnih ei doodaii bee neehozin biniiye More information concerning deductibles t-,t;n�;is� `�in�r.e.,ca.im�• ' nanitinigii bine'dee bikaa doo aldo'. 4:" `' '�`� `°�" '� Out-of-pocket maximum 14 F,'ini'.57F1a )n cz,c.:r, i n or,4 L, It 7•,in:,r,� 8 Medica Para sa tulong sa Tagalog, tawagan ang numerong kabilang sa dokumentong ito o sa Lifetime maximum amount 15 Yoo odeeyssi kun bilashitti afaan keetitti akka likod ng iyong ID card, Out-of-Pocket Expenses 15 sii hiikamu feete lakkoofsa caaardiii meedikaa R pp f j jj,ft i AtT*v fti-45 * E. Ambulance Services 17 (Medica) gama dubaarra jiru kana bilbili. -7,-1Z 'J[sgitifii-io 17 Covered UNV1011 - If you want free help translating this information, call the number Not covered 17 on the back of your Medica identification card. Ambulance services or ambulance transportation 18 Non-emergency licensed ambulance service 18 F. Durable Medical Equipment And Prosthetics 19 ©2012 Medica. Medica®is a registered service mark of Medica Health Plans. "Medica"refers to the family of health 1500-100% plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, MIC FOCUSMN HSA(3/12) III BPL 21317 DOC 23932 Medica Self-Insured, and Medica Health Management, LLC. Table Of Contents Table Of Contents Covered 19 Anesthesia services received from a provider during an inpatient stay 31 Not covered 20 K. Maternity Services 32 Durable medical equipment and certain related supplies 20 Newborns' and Mothers' Health Protection Act of 1996 32 Repair, replacement, or revision of durable medical equipment 20 Covered 32 Prosthetics 20 Additional information about coverage of maternity services 33 Hearing aids 21 Not covered 33 G. Home Health Care 22 Prenatal services 33 Covered 22 Inpatient hospital stay for labor and delivery services Not covered 23 Labor and delivery services at a freestanding birth center 34 Intermittent skilled care 23 Home health care visit following delivery 34 Skilled physical, speech, or occupational therapy 23 L. Medical-Related Dental Services 35 Home infusion therapy 24 Covered 35 Services received in your home from a physician 24 Not covered 35 H. Hospice Services 25 Charges for medical facilities and general anesthesia services 36 Covered 25 Orthodontia, dental implants, and oral surgery related to cleft lip and palate 36 Not covered 26 Accident-related dental services 37 Hospice services 26 Oral surgery 37 I. Hospital Services 27 M. Mental Health 38 Covered 27 Covered 39 Not covered 27 Not covered 40 Outpatient services 28 Office visits, including evaluations, diagnostic, and treatment services 41 Services provided in a hospital observation room 28 Intensive outpatient programs 41 Inpatient services 28 Inpatient services (including residential treatment services) 41 Services received from a physician during an inpatient stay 28 N. Miscellaneous Medical Services And Supplies 42 Anesthesia services received from a provider during an inpatient stay 28 Covered 42 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 29 Not covered 42 J. Infertility Diagnosis 30 Blood clotting factors 43 Covered 30 Dietary medical treatment of PKU 43 Not covered 30 Amino acid-based elemental formulas 43 Office visits, including any services provided during such visits 31 Total parenteral nutrition 43 Virtual care 31 Eligible ostomy supplies 43 Outpatient services received at a hospital 31 Insulin pumps and other eligible diabetic equipment and supplies 43 Inpatient services 31 O. Organ And Bone Marrow Transplant Services 44 Services received from a physician during an inpatient stay 31 Covered 44 MIC FOCUSMN HSA(3/12) iv 1500-100% MIC FOCUSMN HSA(3/12) v 1500-100% ( ) 1500-100/o BPL 21317 DOC 23932 BPL 21317 DOC 23932 Table Of Contents Table Of Contents Not covered 45 59 Quantity limits Office visits 46 Covered 59 Virtual care 46 Prescription unit 59 Outpatient services 46 Not covered 60 Inpatient services 46 Specialty prescription drugs received from a designated specialty pharmacy 60 Services received from a physician during an inpatient stay 47 S. Professional Services 61 Anesthesia services received from a provider during an inpatient stay 47 Covered 61 Transportation and lodging 47 Not covered 62 P. Physical, Speech, And Occupational Therapies 49 Office visits 62 Covered 49 Virtual care 62 Not covered 49 Convenience care/retail health clinic visits 62 Physical therapy received outside of your home 63 Y pY Y 50 Urgent care center visits Speech therapy received outside of your home 63 p PY Y 50 Preventive health care Occupational therapy received outside of your home 51 Allergy shots 64 Q. Prescription Drug Program 52 Routine annual eye exams 64 Preferred drug list 52 Chiropractic services 64 Product selection 64 52 Surgical services Exceptions to the preferred drug list 53 Anesthesia services received from a provider during an office visit or an outpatient hospital Prior authorization 53 or ambulatory surgical center visit 65 Step therapy 53 Services received from a physician during an emergency room visit 65 Quantity limits 54 Services received from a physician during an inpatient stay 65 Covered 54 Anesthesia services received from a provider during an inpatient stay 65 Prescription unit 55 Outpatient lab and pathology 65 Not covered 55 Outpatient x-rays and other imaging services 65 Outpatient covered drugs 56 Other outpatient hospital or ambulatory surgical center services received from a physician 65 Diabetic equipment and supplies, including blood glucose meters 56 Treatment to lighten or remove the coloration of a port wine stain 65 Tobacco cessation products 56 Treatment of temporomandibular (TMJ) disorder and craniomandibular disorder 66 Drugs and other supplies considered preventive health services 57 R. Prescription Specialty Drug Program 58 Diabetes self-management training and education 66 Designated specialty pharmacies 58 Neuropsychological evaluations/cognitive testing 66 Specialty Vision therapy and orthoptic and/or pleoptic training 67 S p y preferred drug list 58 Genetic counseling 67 Exceptions to the specialty preferred drug list 58 Genetic testing 67 Prior authorization 59 T. Reconstructive And Restorative Surgery 68 Step therapy 59 Covered 68 MIC FOCUSMN HSA(3/12) vi 1500-100% MIC FOCUSMN HSA(3/12) vii 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Table Of Contents Table Of Contents Not covered 68 Order of benefit determination rules 86 Office visits 69 Effect on the benefits of this plan 87 Virtual care 69 Right to receive and release needed information 88 Outpatient services 88 p 69 Facility of payment Inpatient services 70 Right of recovery 88 Services received from a physician during an inpatient stay 70 BB. Right Of Recovery 90 Anesthesia services received from a provider during an inpatient stay 70 CC. Eligibility And Enrollment 91 U. Skilled Nursing Facility Services 71 Who can enroll 91 Covered 71 How to enroll 91 Not covered 71 Notification 91 Daily skilled care or daily skilled rehabilitation services 72 Initial enrollment 91 Open enrollment 92 O Skilled physical, speech, or occupational therapy 72 p Services received from a physician during an inpatient stay in a skilled nursing facility....72 Special enrollment 92 V. Substance Abuse 73 Late enrollment 95 Covered 74 Qualified Medical Child Support Order (QMCSO) 95 Not covered 75 The date your coverage begins 95 Office visits, including evaluations, diagnostic, and primary treatment services 75 DD. Ending Coverage 97 p programs 75 When coverage ends 97 Intensive outpatient rams ro Opiate replacement therapy 75 EE. Continuation 99 Inpatient services (including residential treatment services) 76 Your right to continue coverage under state law 99 W. Referrals To Non-Network Providers 77 Your right to continue coverage under federal law 102 What you must do 77 FF. Conversion 108 What Medica will do 77 Minnesota residents 108 X. Harmful Use Of Medical Services 79 Residents of a state other than Minnesota 109 When this section applies 79 GG. Complaints 110 Y. Exclusions 80 First level of review 110 Z. How To Submit A Claim 83 Second level of review 111 Claims for benefits from network providers 83 External review 111 Claims for benefits from non-network providers 83 Civil action 112 Claims for services provided outside the United States 84 HH. General Provisions 113 Time limits 84 Definitions 115 AA. Coordination Of Benefits 85 Applicability 85 • Definitions that apply to this section 85 MIC FOCUSMN HSA(3/12) viii 1500-100% MIC FOCUSMN HSA(3/12) ix 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Introduction Introduction 3. Present your Medica Focus identification card. (If you do not show your Medica Focus Introduction 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 Medica Insurance Company (Medica) offers Medica Focus. This is a Minnesota non-qualified not necessarily guarantee coverage. plan. This Certificate of Coverage (this certificate) describes health services that are eligible for Network providers are required to submit claims within 180 days from when you receive a coverage and the procedures you must follow to obtain benefits. 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 Many words in this certificate have specific meanings These words are identified in each �� � paying the cost of the service you received. section and defined in Definttrans. See Defin►tions These words have specific meanings benefits, claim, dependent medically Language interpretation necessary, menber, network,:premium, provider. Because many provisions are interrelated, you should read this certificate in its entirety. Language interpretation services will be provided upon request, as needed in connection with Reviewing just one or two sections may not give you a complete understanding of the coverage the interpretation of this certificate. If you would like to request language interpretation services, described. The most specific and appropriate section will apply for those benefits related to the please call Customer Service at one of the telephone numbers listed inside the front cover. treatment of a specific condition. If you have an impairment that requires alternative communication formats such as Braille, large The Contract refers to the Contract between Medica and the employer. You should contact the print, or audiocassettes, please call Customer Service at one of the telephone numbers listed employer to see the Contract. inside the front cover to request these materials. If this certificate is translated into another language or an alternative communication format is Members are subject to all terms and conditions of the Contract and health services must be medically necessary. used, this written English version governs all coverage decisions. Medica may arrange for various persons or entities to provide administrative services on its Acceptance of coverage 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. 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. The employer is responsible for remitting the premium to Medica and notifying you of any changes to this certificate as required by applicable law. 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: In this certificate, the words you, your, and yourself refer to the member. The word employer 1. The use of a social security number for purpose of identification; and refers to the organization through which you are eligible for coverage. 2. That the information supplied by you to Medica for purposes of enrollment is accurate and Medical Loss Ratio (MLR) standards under the federal Public Health Service Act complete. You understand and agree that any omission or incorrect statement concerning a material fact Federal law establishes standards concerning the percentage of premium revenue that insurers intentionally made by you in connection with your enrollment under the Contract may invalidate pay out for claims expenses and health care quality improvement activities. If the amount an your coverage. insurer pays out for such expenses and activities is less than the applicable MLR standard, the insurer is required to provide a premium rebate. MLR calculations are based on aggregate Nondiscrimination policy market data rather than on a group by group basis. In the event Medica is required to pay rebates pursuant to federal law, Medica will pay such rebates to your employer unless prohibited by federal law. 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, To be eligible for benefits 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 Each time you receive health services, you must: front cover. 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 MIC FOCUSMN HSA (3/12) x 1500-100% MIC FOCUSMN HSA(3/12) xi BPL 21317 DOC 23932 BPL 21317 DOC 23932 • Introduction Member Rights And Responsibilities Health savings accounts This coverage is intended to comply with the requirements of the Internal Revenue Code A. Member Rights And Responsibilities section 223 for a federally qualified high deductible health plan. This coverage may qualify you to make a pre-tax contribution to a health savings account. You are responsible for the cost of all health services, other than preventive care, up to the deductible amount. See Definitions. These words have specific meanings: 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 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 (3/12) xii 1500-100% MIC FOCUSMN HSA(3/12) 1 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 How To Access Your Benefits 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. How To Access Your Benefits b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and See Definitions These words have specific meanings benefits, claim, coinsurance, 5. Practicing preventive health care by deductible, dependent, emergency, enrollment date, hospital, inpatient,late entrant, member, network, non-network, non-network provider reimbursement amount, physician, placed for a. Having the appropriate tests, exams, and immunizations recommended for your gender adoption, premium, prescri tion drug,;provider, qualifying covera e, reconstructive:r and age as described in this certificate; and p ' = ; 9 , restorative, 9 skilled nursing:facility, subscriber, virtual care, waiting period b. Engaging in healthy lifestyle choices (such as exercise, proper diet, and rest). You will find additional information on member responsibilities in this certificate. 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 3/12) 2 1500-100% MIC FOCUSMN HSA(3/12) 3 1500-100% HSA(3/12) 21317 DOC 23932 BPL 21317 DOC 23932 I,1 How To Access Your Benefits How To Access Your Benefits I; Referrals ' 1 Prescription drugs and medical equipment Certain health services are covered only upon referral; read this certificate carefully for Enrollin in Medica does not uarantee that a particular prescription drug or piece of medical ,I referral requirements. All referrals to non-network providers and certain types of network equipment will continue to be covered, even if the drug or equipment is covered at the start providers must be prior authorized by Medica to be eligible for coverage at your highest level of the calendar year. of benefits. Emergency services Post-mastectomy coverage Emergency services from non-network providers will be covered as in-n Medica will cover all stages of reconstruction of the breast on which the mastectomy was etwork benefits. performed a surgery and ecymmetrical Providers appearance.nd Medica will also cover reconstruction prostheses of the and other physical brast complicatiohas!to produe including lymphedemas, at all stages of mastectomy. 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 2. Important member information about out-of-network benefits 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. The information below describes your covered health services and provides important You must verify that your provider is a network provider each time you receive health information concerning your out-of-network benefits. Read this certificate for a detailed services. explanation of both in-network and out-of-network benefits. Please carefully review t the Exclusions 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 Certain health services are not covered. Read this certificate for a detailed explanation of all to you. exclusions. Benefits Mental health and substance abuse • Medica pays out-of-network benefits for eligible health services received from non-network Medica's designated mental health and substance abuse provider will arrange your mental providers. Prior authorization may be required from Medica before you receive certain health and substance abuse benefits. Medica's designated mental health and substance services, in order to determine whether those services are eligible for coverage under your abuse provider's hospital network is different from Medica's hospital network. Certain out-of-network benefits. This certificate defines your benefits and describes procedures you mental health and substance abuse services require prior authorization by Medica's must follow to obtain out-of-network benefits. designated mental health and substance abuse provider. Emergency services do not Decns out er are made baspess of re sv require prior authorization. member.isio Medica ab cov does age not reward providers ed on for appro denying riaten care, nor does ca Medica and er encouragice to the e Continuation/conversion inappropriate utilization of services. Emergency services received from non-network providers are covered as in-network You may continue coverage or convert to an individual conversion plan under certain benefits and are not considered out-of-network benefits. circumstances. See Continuation and Conversion for additional information. Cancellation 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 Your coverage may be canceled only under certain conditions. This certificate describes all providers. reasons for cancellation of coverage. See Ending Coverage for additional information. Newborn coverage Be aware that if you choose to go to a non-network provider and use out-of-network g 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 Your dependent newborn is covered from birth. Medica does not automatically know of a reimbursement amount, leavin a balance for you to a in addition to any applicable birth or whether you would like coverage for the newborn dependent. Call Customer coinsurance and deductible amount. This additional amount you must pay to the provider Service at one of the telephone numbers listed inside the front cover for more information. To will not be applied toward the out-of-pocket maximum amount described in Your Out-Of- be eligible for in-network benefits, health services must be provided by a network provider or Pocket Expenses and you will owe this amount regardless of whether you previously authorized by Medica. Certain services are covered only upon referral. If additional reached your out-of-pocket maximum premium is required, Medica is entitled to all premiums due from the time of the infant's birth example calculation below. with amounts paid for other services. Please see the 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. 5 1500-100% MIC FOCUSMN HSA(3/12) 4 1500-100% MIC FOCUSMN HSA(3/12) BPL 21317 DOC 23932 BPL 21317 DOC 23932 How To Access Your Benefits How To Access Your Benefits Because obtaining care from non-network providers may result in significant out-of-pocket Lifetime maximum amount expenses, it is important that you do the following before receiving services from a non- network provider: 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 • Discuss the expected billed charges with your non-network provider; and amount. • semen Contact Customer Service to verify the estimated non-network provider reimbursement Exclusions lusions amount for those services, so you are better able to calculate your likely out-of-pocket expenses; and Some health services are not covered when received from or under the direction of non- network• If you wish to request that Medica authorize the non-network provider's services be network providers. Read this certificate for a detailed explanation of exclusions. I I covered at the in-network benefit level, follow the procedure described under Prior Claims it authorization in How To Access Your Benefits. 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 An example of how to calculate your out-of-pocket costs* Claim for details. 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 Post-mastectomy coverage benefits described in this certificate apply to the services you receive. For purposes of this Medica will cover all stages of reconstruction of the breast on which the mastectomy was 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 performed and surgery and reconstruction of the other breast to produce a symmetrical for those hospital services is $15,000. You must pay a portion of the non-network provider appearance. Medica will also cover prostheses and physical complications, including lymphedemas, at all stages of mastectomy. 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 3. Continuity of care required to pay: • 40% coinsurance (40% of$15,000 = $6,000) and 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. • The billed charges that exceed the non-network provider reimbursement amount ($30,000- $15,000 = $15,000) In certain situations, you have a right to continuity of care. • The total amount you will owe is $6,000 + $15,000 = $21,000. 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. The $6,000 you pay as coinsurance will be applied to the out-of-pocket maximum amount b. If you are a new Medica member as a result of your employer changing health plans and described in Your Out-Of-Pocket Expenses. However, the $15,000 amount you pay for your current provider is not a network provider, you may be eligible to continue care with billed charges in excess of the non-network provider reimbursement amount will not be that provider at the in-network benefit level. 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 This applies only if your provider agrees to comply with Medica's prior authorization previously reached your out-of-pocket maximum with amounts paid for other services. 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 *Note: The numbers in this example are used only for purposes of illustrating how out-of- provider's customary charge for the service. This does not apply when Medica terminates a network benefits are calculated. The actual numbers will depend on the services received. provider's contract for cause. If Medica terminates your current provider's contract for Travel program cause, Medica will inform you of the change and how your care will be transferred to another network provider. Medica has made arrangements for you to receive medically necessary services at the in- i. Upon request, Medica will authorize continuity of care for up to 120 days as network benefit level when you are traveling outside the service area and do not have described in a. and b. above for the following conditions: 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 • an acute condition; numbers listed inside the front cover to confirm that your provider is a travel program a life-threatening mental or physical illness; provider, and present your identification card at the time of service. This program is not available for all services (i.e., virtual care or chiropractic services) and may not be available • pregnancy beyond the first trimester of pregnancy; in all areas. MIC FOCUSMN HSA (3/12) 6 1500-100% MIC FOCUSMN HSA (3/12) 7 1500-100%BPL 21317 DOC 23932 BPL 21317 DOC 23932 How To Access Your Benefits How To Access Your Benefits • a physical or mental disability defined as an inability to engage in one or more • Outpatient surgical procedures; major life activities, provided that the disability has lasted or can be expected to • Certain genetic tests; and 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. • Skilled nursing facility services. Authorization to continue to receive services from your current provider may extend Prior authorization is always required for: to the remainder of your life if a physician certifies that your life expectancy is 180 • Organ and bone marrow transplant services; and days or less. • In-network benefits for services from non-network providers, with the exception of ii. Upon request, Medica will authorize continuity of care for up to 120 days as emergency services. described in a. and b. above in the following situations: This is not an all-inclusive list of all services and supplies that may require prior • if you are receiving culturally appropriate services and Medica does not have a authorization. network provider who has special expertise in the delivery of those culturally appropriate services; or When you, someone on your behalf, or your attending provider calls, the following information may be required: • if you do not speak English and Medica does not have a network provider who • Name and telephone number of the provider who is making the request; can communicate with you, either directly or through an interpreter. • Name, telephone number, address, and type of specialty of the provider to whom you Medica may require medical records or other supporting documentation from your provider are being referred, if applicable; 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 • Services being requested and the date those services are to be rendered (if scheduled); continuity of care will be provided. After that time, your services or treatment will need to be Specific information related to your condition (for example, a letter of medical necessity •transitioned to a network provider to continue to be eligible for in-network benefits. If your from your provider); request is denied, Medica will explain the criteria used to make its decision. You may appeal this decision. • Other applicable member information (i.e., Medica member number). Coverage will not be provided for services or treatments that are not otherwise covered Medica will review your request and provide a response to you and your attending provider under this certificate. 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. 4. Prior authorization Both you and your provider will be informed of the decision within 72 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, Prior authorization from Medica may be required before you receive certain services or or if it is concluded that a delay could seriously jeopardize your life, health, or ability to supplies in order to determine whether a particular service or supply is medically necessary regain maximum function, or subject you to severe pain that cannot be adequately managed and a benefit. Medica uses written procedures and criteria when reviewing your request for without the care or treatment you are requesting. prior authorization. To determine whether a certain service or supply requires prior If Medica does not approve your request for prior authorization, you have the right to appeal authorization, please call Customer Service at one of the telephone numbers listed inside Medica's decision as described in Complaints. the front cover or sign in at www.mymedica.com. Emergency services do not require prior authorization. Under certain circumstances, Medica may perform concurrent review to determine whether Your attending provider, you, or someone on your behalf may contact Medica to request 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 prior authorization. Your network provider will contact Medica to request prior authorization writing of its decision. If Medica does not approve continued coverage, you or your for a service or supply. You must contact Medica to request prior authorization for services attending provider may appeal Medica's initial decision (see Complaints). 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. 5. Certification of qualifying coverage Some of the services that may require prior authorization from Medica include: e You have the right to a certification of qualifying coverage when coverage ends. You will • Reconstructive or restorative surgery;rY receive a certification of qualifying coverage when coverage ends. You may also request a • Certain drugs; 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 • Home health care; qualifying coverage, call Customer Service at one of the telephone numbers listed inside the • Medical supplies and durable medical equipment; 1500-100% MIC FOCUSMN HSA (3/12) 8 1500-100% MIC FOCUSMN HSA (3/12) 9 BPL 21317 DOC 23932 BPL 21317 DOC 23932 How To Access Your Benefits How Providers Are Paid By Medica front cover. Upon receipt of your request, the certification of qualifying coverage will be issued as soon as reasonably possible. 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. x . _ R 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 (3/12) 10 1500-100% MIC FOCUSMN HSA (3/12) 11 0-100% BPL 21317 150 150 23932 BPL 21317 DOC 23932 Your Out-Of-Pocket Expenses Your Out-Of-Pocket Expenses ■ I when an equivalent Tier 1 generic drug or supply is on Medica's list of name drug or supply applied toward the deductible list the preferred drugs. These additional amounts will not be app D. Your Out-Of-Pocket Expenses out-of-pocket maximum described in this section. 3. Any charge that is not covered under the Contract. This section describes the expenses that are your responsibility to pay. These expenses are commonly called out-of-pocket expenses. For out-of-network benefits, you must pay the following: i I 1, Any applicable coinsurance as described in this certificate (see the Out-of-Pocket Expenses See Definitions. These words have specific meanings. benefits, claim, coinsurance, � table in this section). deductible, dependent, medically necessary, member,.network, non-network, non-network When members in a family unit (a subscriber and his or d r dependents) a calendar des) h year together er paid provider reimbursement amount, prescription drug, provider, the applicable per family deductible for benefits rece 9 p g p subscriber. Out-of-Pocket Expenses table le i applicable section), per member and per of the deductible for that family unit are You are responsible for paying the cost of a service that is not medically necessary or a benefit family even if the following occurs: considered to have satisfied pp 1. A provider performs, prescribes, or recommends the service; or calendar year. However, for family coverage, there is no per member deductible for benefits received 2. The service is the only treatment available; or during any calendar year. 3. You request and receive the service even though your provider does not recommend it. Note that applicable deductibles are determined by the Contract between Medica and the (Your network provider is required to inform you or in some instances provide a waiver for you to sign.) employer er and ma y 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 If you miss or cancel an office visit less than 24 hours before your appointment, your provider you had met the previously applicable d ducelml . This Contract that it is Moss is renewed hat your may bill you for the service. deductible will increase mid-year when your and that you may have additional out-of-pocket expenses as a result. Please see the applicable benefit section(s) of this certificate for specific information about your char a that exceeds the non-network provider reimbursement amount. This means you in-network and out-of-network benefits and coverage levels. 2. Any 9 To verify coverage before receiving a articular service or are required to pay the difference between the payment to the provider and what the y g g p c o supply, call Customer Service at one provider bills. of the telephone numbers listed inside the front cover. If you use out-of-network benefits, you may incur costs in addition to your coinsurance and - Coinsurance and deductibles the deductible amounts. If the amount that your non-network responsible provider for paying the more t h ante. non-network provider reimbursement amount, you For in-network benefits, you must pay the following: In addition, the difference will not be applied toward satisfaction of the deductible or the out- 1. maximum (described in this section). 1. Any applicable coinsurance as described in this certificate (see the Out-of-Pocket Expenses To inquire about the non-network provider hone numbers ers listed unt for a particular ular procedure table in this section). call Customer Service at one of the p When members in a family unit (a subscriber and his or her dependents) have together paid you call, you will need to provide the following: the applicable per family deductible for benefits received during a calendar year (see the The CPT (Current Procedural Terminology) code for the procedure (ask your non- considered Expenses table in this section), then all members of the family unit are network provider for this); and considered to have satisfied the applicable per member and per family deductible for that calendar year. The name and location of the non-network provider. However, for family coverage, there is no per member deductible for benefits received Customer Service will provide you with an estimate of the non-network provider during any y calendar year. 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 Note that applicable deductibles are determined by the Contract between Medica and the submitted and subject to all applicable benefit provisions, exclusions and limitations, employer and may increase when Medica and the employer renew the Contract. If this including but not limited to coinsurance and deductibles. occurs, the new deductible will apply for the rest of the current calendar year,pp y y whether or not you had met the previously applicable deductible. This means that it is possible that your 3. Any charge that is not covered under the Contract. deductible will increase mid-year when your employer's Contract with Medica is renewed If you use out-of-network that not benefits, you may incur costs in addition to your coinsurance and and that you may have additional out-of-pocket expenses as a result. deductible amounts. If the amount that your non-network provider bills you is more than the 2. Any charge in addition to your coinsurance and deductible described in Prescription Drug non-network provider reimbursement amount, you are responsible for paying the difference. In Program and Prescription Specialty Drug Program that applies when you use a Tier 2 brand addition, the difference will not be applied toward satisfaction of the deductible or the out-of- 1500-100% MIC FOCUSMN HSA (3/12) 12 1500-100% MIC FOCUSMN HSA(3/12) 13 BPL 21317 DOC 23932 BPL 21317 DOC 23932 _ - I Your Out-Of-Pocket Expenses Your Out-Of-Pocket Expenses pocket maximum (described in this section). Please see Important member information about Contract with Medica is renewed and that you may have additional out-of-pocket expenses as a out-of-network benefits in How To Access Your Benefits for more information. result. More information concerning deductibles Medics 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 Medics. The time period used to apply the deductible (calendar year or Contract year) is determined by Lifetime maximum amount 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 The lifetime maximum amount payable per member for out-of-network benefits under the additional out-of-pocket expenses associated with this change. Contract and for out-of-network benefits under any other Medics, Medics Health Plans, or Medica Health Plans of Wisconsin coverage offered through the same employer is described in Out-of-pocket maximum 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, The out-of-pocket maximum is an accumulation of coinsurance and deductibles paid for benefits regulations, rules, or other guidance issued with respect to the Act. 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). Out-of-Pocket Expenses 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 In-network * Out-of-network previously reached your out-of-pocket maximum with amounts paid for other services. benefits, _ The time period used to calculate whether you have met the out-of-pocket maximum (calendar benefits year or Contract year) is determined by the Contract between Medica and the employer. This ""For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible 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 for any charges in excess of the noward sati prov deofthe d rse deductible amount. Additionally, these charges will not be applied toward satisfaction of the deductible or the out-of-pocket Y maximum. 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 Coinsurance See specific benefit for applicable coinsurance. 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 Deductible per family out-of-pocket maximum for that calendar year (see the Out-of-Pocket Expenses table I Per family $3,000 $8,000 in this section). For family coverage, there For family coverage, However, for family coverage, there is no per member out-of-pocket maximum for benefits is no per member there is no per member received during any calendar year. deductible. deductible. After an applicable out-of-pocket maximum has been met for a particular type of benefit (as Out-of-pocket maximum described in the Out-of-Pocket Expenses table in this section), all other covered benefits of the Per family $3,000 $18,000 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 For family coverage, there For family coverage, reimbursement amount, or any charge in addition to your coinsurance and deductible when you is no per member out-of- there is no per member use a Tier 2 brand name drug or supply when a chemical equivalent Tier 1 generic drug or pocket maximum. out-of-pocket maximum. 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 MIC FOCUSMN HSA(3/12) 14 1500-100% MIC FOCUSMN HSA(3/12) 15 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Your Out-Of-Pocket Expenses Ambulance Services • 1n7network. - * Out-of-network E. Ambulance Services benefits benefits For out of-network benefits, in addition to the deductible and coinsurance,you are responsible �._in ° ,a This section describes coverage for ambulance transportation and related services received for for any charges in excess of the.°non=networkprovider�reibursement amount ":Additionally, these charges will not be applied toward satisfaction of the deductible or the out-of-pocket covered medical and medical-related dental services (as described in this certificate). maximum. _. ,. _.. �. -... �have� � benefits, deductible See De�cnrtrons.,.These words have,specific meanings: �. Lifetime maximum amount Unlimited $1,000,000. Applies to emergency,hospital,network, non network, non7network provider rermbursementamount, a able per member physician, provider, skilled:,nursing facility p Y p all benefits you receive under this or any other Prior authorization. Prior authorization from Medica may be required before you receive Medica, Medica Health services or supplies. Call Customer Service at one of the telephone numbers listed inside the Plans, or Medica Health front cover. See How To Access Your Benefits for more information about the prior authorization Plans of Wisconsin process. coverage offered through the same employer. Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 (3/12) 16 1500-100% MIC FOCUSMN HSA (3/12) 17 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Ambulance Services Durable Medical Equipment And Prosthetics ' F. Durable Medical E ment And Prosthetics Your Benefits and the Amounts You Pay quip Benefits. In-network benefits *Out-of-network benefits lies, and after deductible after deductible This section describes coverage for durable medical equipment, certain related supplies,_ F *For out-of-network benefits,in addition to the deductible and coinsurance,you are"responsible prosthetics. in excess of the non-network rovider reimbursement amount. Additional) these Definitions. These words have specific meanings: benefits, coinsurance, deductible, for any charges ace p Y� See Defr benefit reimbursement amount, charges will cet a ices or cowardsatisfactthing -the deducttble"orahe out-of-pocket maximum. medically necessary; network, non-network, non-network provider provider. � - 1. Ambulance services or Nothing Covered as an in-network re you ambulance transportation to the benefit. Prior authorization. Prior authorization ro at one a the telephone ndu efors I ter reside the nearest hospital for an services or supplies. Call Customer ve Service emer ens front cover. See How To Access Your Benefits for more information about the prior authorization g Y 2. Non-emergency licensed process. ambulance service that is arranged through an attending Covered physician, as follows: pay, see the table in this section. More than one coinsurance a. Transportation from hospital Nothing 50% coinsurance For benefits and the amounts you p y, p p may be required if you receive more than one service or see more than one provider per visit. to hospital when: certain related supplies, and Care for your condition Medica covers only a limited selection of durable medical equipment, your physician,, an i. hospital y hearing aids that meet the criteria established e coered MThe f list of eligible d able medical equipment is not i d; at the hospital where you were even if medically necessary, may not admitted; or and certain related supplies is periodically reviewed and modified by Medica.call Customer Service Medica's eligible durable numbers listed inside the front certain coveated supplies, Required by Medica at one of the telephone approval b. Transportation skilled from hospital Nothing 50% coinsurance Medica determines if durable medical equipment will be purchased or rented. Medica's app r i facility of rental of durable medical equipments limited to a specific period of time. To request approval to skilled nu s ng fac y 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, ble for the by cost the difference. model you select is not Medica's standard model, y ou will be respons supplies, and I a • In-network benefits apply to durable medical andreceived from a network durable medical prosthetic services prescribed by physician Medica, ng equipment provider who has a durable medical on when contract . bed by wia th provdide arlTo aids as described in 4. in the table in this section request a list of network durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. • supplies, and Out-of-network benefits apply to durable medical equipment, certain related supp 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 non-network for out-of-network ne benefits, you are responsible for charges in excess of the I to these charges. Please see amount. The out-of-pocket maximum does not app y Important member information about out-of-network lculationfof out-of-pocket costs associated Benefits for more information and an example a with out-of-network benefits. 1500-100% MIC FOCUSMN HSA (3/12) 18 1500-100% MIC FOCUSMN HSA (3/12) 19 BPL 21317 DOC 23932 BPL 21317 DOC 23932 Durable Medical Equipment And Prosthetics i' Durable Medical Equipment And Prosthetics Not covered ' `' ,T _ -, - ,.p. ■ - i Your6enefifs and the Amounts You Payer W These services, supplies, and associated expenses are not covered: m *Out of network benefits - 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing Benefits In-network'benefits Medica eligible list. ng aids not on the after leductible after deductible . 2. Charges in excess of the Medica standard m ' . �� � �� � � � � or h odel of durable medical equipment, prosthetics, "For out-of-network-benefits, in addition:to the deductible and coinsurance,you are responsible for earing aids. 'any charges in excess of the non-network pra elder reimbursement amount Additional#y,=these 3. Repair, replacement, or revision of d charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum durable medical equipment, prosthetics, and hearing aids, except when made necessary by normal wear and use. c. Repair, replacement, or Nothing 50% coinsurance 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, revision of artificial arms, replacement, or revision of duplicate items. legs, feet, hands, eyes, ears, See Exclusions for additional services, supplies, and associated expenses that are not covered. prostheses breastnecessary by normal wear and use ^ k 4. Hearing aids for members 18 Nothing. Limited to one 50% coinsurance. ears of a e and oun er for hearing aid per ear every Limited to one hearing Your Benefits and�theAmounts y g y g g p You P aY hearing loss that is not three years. Related aid per ear every three . =_ � u _ correctable by other covered services must be years. Benefits innetworic benefits y rescribed b a network � � - Out-of-network network benefits procedures p Y after deductible rafter deductible provider. For out of-network benefits, in-addition to the deductible and coinsurance,you are responsible for any charges,ir excess of tt e,non,=networks rovider:reimburseme t amount . Additionally,,tltese charges not be-applied`toward satisfaction of tho 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 (3/12) 20 MIC FOCUSMN HSA(3/12) 21 1500-100% 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Home Health Care Home Health Care II Not covered G. Home Health Care These services, supplies, and associated expenses are not covered: 1. Companion, homemaker, and personal care services. This section describes coverage for home health care. Home health care must be directed by a 2. Services provided by a member of your family. physician and received from a home health care agency authorized by the laws of the state in ,3, Custodial care and other non-skilled services. which treatment is received. 4. Physical, speech, or occupational therapy provided in your home for convenience. See Definitions These words have-specific meanings: benefits, coinsurance, custodial care,. homebound. deductible,mmdependent'tospital, network, non networknon network-provider reimbursement a 5. Services provided in your home when you are not amount, physician, provider, skilled care, skilled nursing facility z - , - Prior authorization. Prior authorization from Medica may be required before you receive 6. Services primarily educational in nature.7. Vocational and job rehabilitation. 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 8. Recreational therapy. authorization process. 9. Self-care and self-help training (non-medical). Covered 10. Health clubs. 11. Disposable supplies and appliances, except as described in Durable Medical Equipment For benefits and the amounts you pay, see the table in this section. More than one coinsurance And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug may be required if you receive more than one service or see more than one provider per visit. Program. As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare 12. , speech, reasonable expectation that the Physical mebers or condition occupational il wl improve therapy over ai services predictable when there period is of no time according to 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). . generally accepted standards in the medical community. p A dependent child may still be considered "confined to home" when attending school where life 13. Voice training. support specialized equipment and help are available. 14. Home health aide services except when rendered in conjunction with intermittent skilled Benefits covered under 1. and 2. in the table in this section are limited to a combined maximum of care and related to the medi, cal condition under treatment. 120 visits per calendar year for in-network and 60 visits per calendar year for out-of-network See Exclusions for additional services, supplies, and associated expenses that are not 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 covered. 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 Your Benefits and the Amounts You Pa and received from a network home health care agency. � ^ � * �; * . In network benefits-_ � Out-of network benefits : • Out-of-network benefits apply to home health care services that are ordered or prescribed by a Benefits � ,� � T � � .- :� - , , �,�_ , - � - t .;_ physician and received from a non-network home health care agency. In addition to the _ after deductible after deductible . 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- For.out of-network benefits,in addition to the deductible and a coinsurance,you are responsible pocket maximum does not apply p ut of- n char"es in excess et the thenon-network provider reimbursement amount Additionally,these p pply to these charges. Please see Important member for a y $ g $� information about out-of-network benefits in How To Access Your Benefits for more charges will not be applied toward satisfaction of the deductible Or the°out-of-pocket maximum information and an example calculation of out-of-pocket costs associated with out-of- 50% coinsurance network benefits. 1. Intermittent skilled care when Nothing you are homebound, provided Please note: Your place of residence is where you make your home. This may be your own by or supervised by a registered dwelling, a relative's home, an apartment complex that provides assisted living services, or nurse some other type of institution. However, an institution will not be considered your home if it is a 2. Skilled physical, speech, or Nothing 50% coinsurance hospital or skilled nursing facility. p Y occupational therapy when you are homebound MIC FOCUSMN HSA (3/12) 22 1500-100% MIC FOCUSMN HSA(3/12) 23 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 H Home Health Care Hospice Services Your Benefits and the Amounts You Rays H. Hospice Services Benefits In-network benefits * Out-of-network benefits care. Care must be after deductible after deductible This section describes coverage for hospice services including respite for For out-of-network rs in ex benefits s o , in addition to k provider deductible and coinsurance,reimbursement omuto. you are responsible . ordered, provided, or arranged under the direction of a physician and received from a hospice for any charges in excess of the non-network amount. Additionally,these program. deductible or he out-of- ocket n aximum. ions. These words have specific meanings: benefits, coinsurance, deductible, skilled charges will not be applied toward satisfaction of the deduct p See Definit � . � non-network, non-nefinrork provider reimbursement amount, member,_network, n 3. Home infusion therapy Nothing 50% coinsurance nursing facility. 4. Services received in your home Nothing 50% coinsurance from a physician Covered For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. i supportive social, emotional, Hospice services are comprehensive palliative medical care and supp their families, and spiritual services. These services are pnterdesdciol nary tea terminally mill composed of profess onals primarily in the patients' homes. A hospice p and volunteers, coordinates an individualized plan of care for each bie patient t enable them to live The goal of hospice care is to make patients as comfortable as possible their final days to the fullest in the comfort of their own homes and with loved ones.red into a separate A designated hospice program means a hospice program that has en 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 idthe hospice of curative treatment for their terminal illness for the period they are enrol Respite care is a form of hospice services that gives maintain da terminally r re9membeeat family members or friends) rest or relief when 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 aln thrto ough a the deductible and received from anon-designated hosp ice program. you will be responsible for any charges in coinsurance described for out-of-network benefits, y excess of the non-network provider reimbursement Please see Important memberunformation maximum does not apply to these charges. PI out-of network benefits in How To Access Your B�e it out-of-network u o information and an example calculation of out-of-pocket costs associated To be eligible for the hospice benefits described in this section, you must: 1. Be a terminally ill patient; and supportive 2. Have chosen a palliative treatment o (i.e., to curethe disease cond�ion)rt and services rather than treatment attempting 25 1500-100% MIC FOCUSMN HSA (3/12) 24 1500-100% MIC FOCUSMN HSA (3/12) BPL 21317 DOC 23932 BPL 21317 DOC 23932 Hospice Services Hospital 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 I. Hospital Services 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 This section describes coverage for use of hospital and ambulatory surgical center services. A program. physician must direct care. Not covered See Definitions. These words have specific meanings: benefits, coinsurance, deductible, emergency, genetic testing, hospital, inpatient, member, network, non network, non-network provider reimbursement amount, physiclan;?provider ` � .. These services, supplies, and associated expenses are not covered: 1. Respite care for more than five consecutive days at a time. 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 2. Home health care and skilled nursing facility services when services are not consistent with front cover. See How To Access Your Benefits for more information about the prior authorization the hospice program's plan of care. process. 3. Services not included in the hospice program's plan of care. 4. Services not provided by the hospice program. Covered 5. Hospice daycare, except when recommended and provided by the hospice program. For benefits and the amounts you pay, see the table in this section. More than one coinsurance 6. Any services provided by a family member or friend, or individuals who are residents in your may be required if you receive more than one service or see more than one provider per visit. home. • In-network benefits apply to hospital services received from a network hospital or ambulatory 7. Financial or legal counseling services, except when recommended and provided by the surgical center. hospice program. • Out-of-network benefits apply to hospital services received from a non-network hospital or 8. Housekeeping or meal services in your home, except when recommended and provided by ambulatory surgical center. In addition to the deductible and coinsurance described for out- the hospice program. 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 9. Bereavement counseling, except when recommended and provided by the hospice charges. Please see Important member information about out-of-network benefits in How program. To Access Your Benefits for more information and an example calculation of out-of-pocket See Exclusions for additional services, supplies, and associated expenses that are not costs associated with out-of-network benefits. Emergency services from non-network covered. 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. Your Benefits and the Amounts You Pay Not covered Benefits - In-network benefits '.* Out-of-network benefits 1. Drugs received at a hospital on an outpatient basis, except drugs requiring intravenous after deductibles .- after deductible g p p p 9 q 9 ;� _: Y i . , ' or injection, intramuscular injection, or intraocular injection; or drugs received in an 3 infusion * a emergency room or a hospital observation room. Coverage for drugs is as described in For out-of-network benefits, in addition to the deductible;andcoinsurance,you-arse;responsible for Prescription Drug Program and Prescription Specialty Drug Program or otherwise described 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 as a specific benefit in this certificate. 1. Hospice services Nothing 50% coinsurance 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. MIC FOCUSMN HSA(3/12) 26 1500-100% MIC FOCUSMN HSA (3/12) 27 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 H Hospital Services Hospital Services �,.- Your ur B, e.te n'.e f i ts an _ d the A mounts You Pr, a_=,Your Benefits_and,the A nts Yo_a a ene is In-network benefits Ou, t_m..:.o f n e#vor k b" e n fi is B n fi In-network benefits .outof_network benefits ,,. after deductible, _u ro_,,. _.aftef deductible. �._ . __after deductible after deductible a}. 'ce .. e�. _:. . , :.._� . . For out-of-network`benefits in addition to,h � r ,,a _.,.. , t e,deduct bke and coinsurance,you areres responsible for *For* . ible and ins r nc ou;arerres onsible_#or_ ., = : ..for outo# network benefits, in addition awthe deduct co' u a e , -,< x ....o.- . - ,, ... , -.> , a ,, . � ...a ,� , . _ _- n charges f m a e excess o the non;-network: coviderreimbursement amount. Additionally,obese l provider imbursem nt,:amo nt.,.Additionally,'.these .� ,. __. -9 a :.char.'es-in excesso#.the non-networkre e amount: .x. • . . .. the :�' '-•7,,. .<...� s.. ,.. r.._r x .:.:....-.. - '• .. .,.__. not '..� . ...: _ ., :, � �.,. .: charges will_:not�be.a applied satisfaction,of ed : 9 Pp t uctibleortheout-of ocketmaximum. the out-of. cket . -. .:.,.._ . ::charges wil not�be applied to ward.satisfaction the or o 1 P. _ a 1. Outpatient services 6. Treatment of temporomandibular Covered at the Covered at the joint (TMJ) disorder and corresponding in-network corresponding out-of- a. Services provided in a Nothing Covered as an in-network craniomandibular disorder benefit level, depending network benefit level, hospital or facility-based benefit. on type of services depending on type of emergency room provided. services provided. b. Outpatient lab and pathology Nothing 50% coinsurance i For example, office visits For example, office visits c. Outpatient x-rays and other Nothing 50% coinsurance are covered at the office are covered at the office imaging services visit in-network benefit visit out-of-network level and surgical benefit level and surgical d. Genetic testing when test Nothing 50% coinsurance services are covered at services are covered at results will directly affect the surgical services in- the surgical services out- treatment decisions or network benefit level. of-network benefit level. frequency of screening for a Please note: Dental Please note: Dental disease, or when results of coverage is not provided coverage is not provided the test will affect under this benefit. under this benefit. reproductive choices e. Other outpatient services Nothing 50% coinsurance f. Other outpatient hospital and Nothing 50% coinsurance ambulatory surgical center services received from a physician g. 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 Nothing 50% coinsurance 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 MIC FOCUSMN HSA(3/12) 28 1500-100% MIC FOCUSMN HSA (3/12) 29 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Infertility Diagnosis Infertility Diagnosis 7. Sperm banking. J. Infertility Diagnosis 8. Adoption. 9. Donor sperm. This section describes coverage for the diagnosis of infertility. Coverage includes benefits for 10. Embryo and egg storage. professional, hospital, and ambulatory surgical center services. Services for the diagnosis of 11. Services for intrauterine insemination (IUI). infertility treatment must be received from or under the direction of a physician. All services, See Exclusions for additional services, supplies, and associated expenses that are not supplies, and associated expenses for the treatment of infertility are not covered. covered. See Definitions. These words have specific meanings benefits, coinsurance, deductible, ` hospital;inpatient, member, network,, non network non-network E r ovlterrembursement r�xm amount physician, provider, v i rtual care. ._y-_... � _-.- ,r x� You- r Benefits an dthe Amounts You Pay 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 Benefits , lnnetwork benefits * Out.. -of-network benefits front cover. See How To Access Your Benefits for more information about the prior = after deductible after deductible = k authorization process. *x For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible or any charges in excess of the non-network provider reimbursement amount. Additionally,these Covered charges will not be appliedfltoward satisfaction of the deductible or the out-of-pocket°maximum Benefits apply to services for the diagnosis of infertility received from a network or non-network 1. Office visits, including any Nothing Covered as an in-network provider. More than one coinsurance may be required if you receive more than one service or services provided during such benefit. see more than one provider per visit. visits Coverage for infertility services is limited to a maximum of$5,000 per member per calendar year 2. Virtual care Nothing No coverage for in-network and out-of-network benefits combined. In addition to the deductible and 3. Outpatient services received at a Nothing Covered as an in-network coinsurance described for out-of-network benefits, you are responsible for any charges in hospital benefit. 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- - 4. Inpatient services Nothing Covered as an in-network network benefits in How To Access Your Benefits for more information and an example benefit. calculation of out-of-pocket costs associated with out-of-network benefits. 5. Services received from a Nothing Covered as an in-network physician during an inpatient benefit. Not covered stay These services, supplies, and associated expenses for the treatment of infertility are not 6. Anesthesia services received Nothing Covered as an in-network covered, including the following: from a provider during an benefit. inpatient stay 1. Professional, hospital, and ambulatory surgical center services for the treatment of infertility. 2. Infertility drugs. 3. 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 Prescription Specialty Drug Program or otherwise described as a specific benefit in this certificate. 4. In vitro fertilization, gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. 5. Services for a condition that a physician determines cannot be successfully treated. 6. Services related to surrogate pregnancy for a person not covered as a member under the Contract. MIC FOCUSMN HSA(3/12) 30 1500-100% MIC FOCUSMN HSA (3/12) 31 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Maternity Services Maternity Services Additional information about coverage of maternity services K. Maternity Services Not all services that are received during your pregnancy are considered prenatal care. Some of the services that are not considered prenatal care include (but are not limited to)treatment of the This section describes coverage for maternity services. Benefits for maternity services include all following: medical services for prenatal care, labor and delivery, postpartum care, and related complications. 1. Conditions that existed prior to (and independently of) the pregnancy, such as diabetes or See'Definrtrons These have c�fcmeanngs benefits, coinsurance deductible lupus, even if the pregnancy has caused those conditions to require more frequent care or dependent, hospital, inpatient, member, network, non network; non-network provider monitoring. reimbursement amount, physician prenatal care, provider skilled care. 2. Conditions that have arisen concurrently with the pregnancy but are not directly related to care Y p 9 Y Y Prior authorization. Prior authorization from Medica may be required before you receive of the pregnancy, such as back and neck pain or skin rash. services or supplies. Call Customer Service at one of the telephone numbers listed inside the 3. Miscarriage and ectopic pregnancy. front cover. See How To Access Your Benefits for more information about the prior authorization Services that are not considered prenatal care may be eligible for coverage under the most process. specific and appropriate section of this certificate. Please refer to those sections for coverage information. Newborns'and Mothers'Health Protection Act of 1996 Generally, Medica may not restrict benefits for any hospital stay in connection with childbirth for Not covered the mother or newborn child member to less than 48 hours following a vaginal delivery (or less These services, supplies, and associated expenses are not covered: 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 1. Health care professional services for maternity labor and delivery in the home. discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any 2. Services from a doula. 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). 3. Childbirth and other educational classes. See Exclusions for additional services, supplies, and associated expenses that are not Covered covered. For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Your Benefits and the Amounts'You P " 'Y Each member's admission is separate from the admission of any other member. A separate ay deductible and coinsurance will be applied to both you and your newborn child for inpatient Benefits _ benefits services related to maternity labor and delivery. Please note: We encourage In-network benefits *_Out of-network benefits g you to enroll your . � � � � � after-deductible after deductible newborn dependent under the Contract within 30 days from the date of birth, date of placement for adoption, or date of adoption. Please refer to Eligibility And Enrollment for additional *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for information. any charges in excess of the non-network Provider reimbursement amount. Additionally,these • In-network benefits apply to maternity services received from a network provider. charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. • Out-of-network benefits apply to maternity services received from a non-network provider. In 1. Prenatal services addition to the deductible and coinsurance described for out-of-network benefits, you will be a. Office visits for prenatal care, Nothing. The deductible 50% coinsurance responsible for any charges in excess of the non-network provider reimbursement amount. including professional does not apply. The out-of-pocket maximum does not apply to these charges. Please see Important services, lab, pathology, member information about out-of-network benefits in How To Access Your Benefits for more x-rays, and imaging information and an example calculation of out-of-pocket costs associated with out-of- network benefits. b. Hospital and ambulatory Nothing. The deductible 50% coinsurance surgical center services for does not apply. , prenatal care, including professional services received during an inpatient stay for prenatal care MIC FOCUSMN HSA (3/12) 32 1500-100% MIC FOCUSMN HSA(3/12) 33 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Maternity Services Medical-Related Dental Services } Your Benefits and the Amounts You Pay �_s � � L. Medical-Related Dental Services Benefits. : a{ In network benefits Out-of network.tenefits. , after deductible after deductible '' For out-of-network benefits, in addition to the deductible:and coinsurance,you are responsible for g ' = _- This section describes coverage for medical-related dental services. Services must be received any charges in excess of the non-network provider reimbursement amount. Additionally,,these from a physician or dentist. charges will not be applied toward satisfaction of the deductible or the'out-of-pocket maximum This section doe's not describe coverage for comprehensive dental procedures. Comprehensive c. Intermittent skilled care or Nothing. The deductible 50% coinsurance dental procedures are services rendered by a dentist to treat teeth, their supporting soft tissue and home infusion therapy when does not apply. bony structure, or the alignment or occlusion of the teeth. These services are not covered under you are homebound due to a any section of this certificate. high risk pregnancy See Definitions These wordsV avespecific meenangs ;benefits' coinsurance,deductible, 2. Inpatient hospital stay for labor Nothing 50% coinsurance dependent,afospita� member, network, non network, non network povider reimbursement ' amount,:physiian,yxprovider �' ' �_ and delivery services � �� � = .: + ' � _. .. .._= . Please note: Maternity labor and delivery services are considered I Prior authorization. Prior authorization from Medica may be required before you receive inpatient services regardless of the services or supplies. Call Customer Service at one of the telephone numbers listed inside the length of hospital stay. front cover. See How To Access Your Benefits for more information about the prior authorization o process. 3. Professional services received Nothing 50% coinsurance � during an inpatient stay for labor and delivery I Covered 4. Anesthesia services received Nothing 50% coinsurance during an inpatient stay for labor For benefits and the amounts you pay, see the table in this section. More than one coinsurance and delivery may be required if you receive more than one service or see more than one provider per visit. 5. Labor and delivery services at a • In-network benefits apply to medical-related dental services received from a network freestanding birth center provider. a. Facility services for labor and Nothing 50% coinsurance • Out-of-network benefits apply to medical-related dental services received from a non- delivery 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 b. Professional services Nothing 50% coinsurance reimbursement amount. The out-of-pocket maximum does not apply to these charges. received for labor and Please see Important member information about out-of-network benefits in How To Access delivery Your Benefits for more information and an example calculation of out-of-pocket costs 6. Home health care visit following Nothing. The deductible 50% coinsurance associated with out-of-network benefits. delivery does not apply. Please note: One home health visit I Not covered is covered if it occurs within 4 days of discharge. If services are received after 4 days, please refer These services, supplies, and associated expenses are not covered: to Home Health Care for benefits. 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. MIC FOCUSMN HSA (3/12) 34 1500-100% MIC FOCUSMN HSA (3/12) 35 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 l Medical-Related Dental Services Medical-Related Dental Services i . 6. Tooth extractions, except as described in this section. - .. -_ `� , _.. , Your!Benefits and the=Amo tints You Pay 7. Any dental procedures or treatment related to p eriodontal disease. l •8. Endodontic procedures and treatment, including root canal procedures and treatment, ' Benefits in network benefits '. f�',A*Out-of network benefits , after deductible =after,deductible unless provided as accident-related dental services as described in this section. ' e 9. Routine diagnostic and preventive dental services. For out4it-network benefits,.in_addition to the deductible:and,coinsurance, you are responsible for .: . See Exclusions for additional services, supplies, and associated expenses th r any'charges, n excess of the nonnetwork�provider�r"eimbursementxamount Additionall thee? pP that are not y' covered. r charges will not be applied toward satisfaction ofthe deductible or the:out of-pocket maxiinurn 3. Accident-related dental services Nothing 50% coinsurance _° . "„..„ to treat an injury to sound, I ;r . -Your Benefits and he Amounts You Pay natural teeth and to repair (not replace) sound, natural teeth. 1. Benefits ¢; 1n network benefits '� - *Out-of-network benefits =, The following conditions apply: - after deductibiet wafter deductibles a. Coverage is limited to *Foro services received within 24 ouf-network benefits, in,addition to the deductible and co nsurance, you are responsible for any,charges4in excess of the non networklprovider reimbursement amount-Additional) these months from the later of: :".::...i-:charges will,not be appliee�d toward satisfaction oft a deductible-or the out-of pocket maximum= �" __.� �"- �_ �_� � i. the date you are first covered under the 1. Charges for medical facilities Nothing 50% coinsurance Contract; or and general anesthesia services that are: ii. the date of the injury a. Recommended by a network b. A sound, natural tooth means physician; and a tooth (including supporting structures) that is free from b. Received during a dental disease that would prevent procedure; and continual function of the tooth c. Provided to a member who: for at least one year. i. is a child under age five In the case of primary (baby) (prior authorization is not teeth, the tooth must have a required); or life expectancy of one year. ii. is severely disabled; or 4. Oral surgery for: Nothing 50% coinsurance iii. has a medical condition •• a. Partially or completely and requires unerupted impacted teeth; or hospitalization or general b. A tooth root without the anesthesia for dental extraction of the entire tooth care treatment (this does not include root Please note: Age, anxiety, canal therapy); or and behavioral conditions pY) are not considered medical • c. The gums and tissues of the conditions. mouth when not performed in 2. For a dependent child, Nothing 50% coinsurance connection with the orthodontia, dental implants, and extraction or repair of teeth oral surgery treatment related to cleft lip and palate MIC FOCUSMN HSA (3/12 BPL 21317 DOC 23932 •MIC FOCUSMN HSA (3/12) 36 1500-100% (3/12) 37 1500-100 BPL 21317 DOC 23932 Mental Health Mental Health f. Residential treatment services. These services include either: M. Mental Health 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 This section describes coverage for services to diagnose and treat mental disorders listed in the services. In addition to room and board, at least 30 hours a week per individual of current edition of the Diagnostic and Statistical Manual of Mental Disorders. For a description of mental health services must be provided, including group and individual counseling, coverage for the diagnosis and primary treatment of substance abuse disorders, see Substance client education, and other services specific to mental health treatment. Also, the Abuse. program must provide an on-site medical/psychiatric assessment within 48 hours of See Definitions. These words have specific meanings: benefits,_claim,.coinsurance,custodial admission, psychiatric follow-up visits at least once per week, and 24-hour nursing care, deductible, emergency, Hospital,'inpatient, medically;necessary, member;mental disorder, coverage. network, non-network, non-network provider reimbursement amount, physician,provider. Prior authorization. For prior authorization requirements of in-network and out-of-network Covered 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 For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. purposes of this section: • For in-network benefits: 1. Outpatient services include: 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 a. Diagnostic evaluations and psychological testing. you to other mental health providers only if network providers cannot provide the services you b. Psychotherapy and psychiatric services. 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 c. Intensive outpatient programs, including day treatment, meaning time limited substance abuse provider will refer you to one of its hospital providers (Medica and Medica's comprehensive treatment plans, which may include multiple services and modalities, designated mental health and substance abuse provider hospital networks are different). delivered in an outpatient setting (up to 19 hours per week). Providers may be network providers for mental health services only, and not otherwise part d. Treatment for a minor, including family therapy. of the Medica Focus network. When you receive other health services you should verify that e. Treatment of serious or persistent disorders. 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 f. Diagnostic evaluation for attention deficit hyperactivity disorder (ADHD)or pervasive Service at one of the telephone numbers listed inside the front cover. development disorders (PDD). For claims questions regarding in-network benefits, call Medica's designated mental health g. Services, care, or treatment described as benefits in this certificate and ordered by a court and substance abuse provider Customer Service at 1-866-214-6829. on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. • For out-of-network benefits: h. Treatment of pathological gambling. 1. Mental health services from a non-network provider listed below will be eligible for coverage 2. Inpatient services include: 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 a. Room and board. services and practice independently: b. Attending psychiatric services. a. Psychiatrist c. Hospital or facility-based professional services. b. Psychologist d. Partial program. This may be in a freestanding facility or hospital based. Active treatment c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric is provided through specialized programming with medical/psychological intervention and and mental health nursing supervision during program hours. Partial program means a treatment program of 20 hours d. Mental health clinic or more per week and may include lodging. e. Mental health residential treatment center 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 f. Independent clinical social worker psychologist and that includes an individual treatment plan. g. Marriage and family therapist MIC FOCUSMN HSA(3/12) 38 1500-100% MIC FOCUSMN HSA (3/12) 39 1500-100% BPL 21317 23932 BPL 21317 DOC 23932 Mental Health Mental Health h. Hospital that provides mental health services b a Your Benefits and the Amounts/You Pay 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 Benefits ; a& In "network benefits Out of net ork benefits be responsible for any charges in excess of the non-network provider reimbursement q" aiterdeductible after°deductible 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 *For"out of-network benefits,asin addition.to the deductible and coinsurance,you are responsible-fors. Benefits for more information and an example calculation of out-of-pocket costs associated any Charges in"excess of the-non-network provider reimbursement amount Additionally,tbese with out-of-network benefits. charges wall riot be applied toward satisfaction of the deductible"or the'iout-of=pocket maximum 1. Office visits, including Nothing 50% coinsurance Not covered evaluations, diagnostic, and treatment services These services, supplies, and associated expenses are not covered: 2. Intensive outpatient programs Nothing 50% coinsurance 1. Services for mental disorders not listed in the current edition of the Diagnostic and Statistical 3. Inpatient services (including Manual of Mental Disorders. residential treatment services) 2. Services for a condition when there is no reasonable expectation that the condition will a. Room and board Nothing 50% coinsurance improve. b. Hospital or facility-based Nothing 50% coinsurance 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as professional services specifically described in this section. 4. Relationship counseling. c. Attending psychiatrist Nothing 50% coinsurance services 5. Family counseling services, except as specifically described in this certificate as treatment d. Partial program Nothing 50% coinsurance 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. i 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(3/12) 40 1500-100% MIC FOCUSMN HSA (3/12) 41 1500-100% ( ) 1500-100/o BPL 21317 DOC 23932 BPL 21317 DOC 23932 Miscellaneous Medical Services And Supplies Miscellaneous Medical Services And Supplies Your Benefits and the Amounts You Pay N. Miscellaneous Medical Services And Supplies Benefits In-network benefits * Out-of-network`'benefits after deductible after deductible 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 *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for supplies that meet the criteria established by Medica. Some items ordered by a physician, even any charges in excess of the non-network provider reimbursement amount. Additionally,these if medically necessary, may not be covered. charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. See Definitions. These words have specific meanings: benefits, coinsurance, deductible, 1. Blood clotting factors Nothing 50% coinsurance medically necessary, network, non-network, non-network provider reimbursementamount, ° physician, provider. 2. Dietary medical treatment of Nothing 50% coinsurance phenylketonuria (PKU) Prior authorization. Prior authorization from Medica may be required before you receive 3. Amino acid-based elemental Nothing 50% coinsurance services or supplies. Call Customer Service at one of the telephone numbers listed inside the formulas for the following front cover. See How To Access Your Benefits for more information about the prior authorization process. diagnoses: a. cystic fibrosis; Covered b. amino acid, organic acid, and fatty acid metabolic and For benefits and the amounts you pay, see the table in this section. More than one coinsurance malabsorption disorders; may be required if you receive more than one service or see more than one provider per visit. c. IgE mediated allergies to • In-network benefits apply to miscellaneous medical services and supplies received from a food proteins; network provider. d. food protein-induced • Out-of-network benefits apply to miscellaneous medical services and supplies received from enterocolitis syndrome; a non-network provider. In addition to the deductible and coinsurance described for out-of- e. eosinophilic esophagitis; 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. f. eosinophilic gastroenteritis; Please see Important member information about out-of-network benefits in How To Access and Your Benefits for more information and an example calculation of out-of-pocket costs g. eosinophilic colitis associated with out-of-network benefits. Coverage for the diagnoses in Not covered 3.c.-g. above is limited to members five years of age and Other disposable supplies and appliances, except as described in Durable Medical Equipment younger. And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program. 4. Total parenteral nutrition Nothing 50% coinsurance See Exclusions for additional services, supplies, and associated expenses that are not 5. Eligible ostomy supplies Nothing 50% coinsurance covered. 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 (3/12) 42 1500-100% MIC FOCUSMN HSA (3/12) 43 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Organ And Bone Marrow Transplant Services 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 O. Organ And Bone Marrow Transplant Services 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. 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 Not covered designated transplant facility. This section also describes benefits for professional, hospital, and ambulatory surgical center services. These services, supplies, and associated expenses are not covered: 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 1. Organ and bone marrow transplant services, except as described in this section. medically necessary, appropriate for the diagnosis, without contraindications, and non- 2. Supplies and services related to transplants that would not be authorized by Medica under investigative. the medical criteria referenced in this section. See Definitions These words have specific meanings: benefits, coinsurance, deductible,- Chemotherapy, radiation therapy, drugs, or any therapy used to damage the bone marrow designated facility, hospital, inpatient, investigative, medically necessary, member, network; by transplants related to trans lants that would not be authorized b Medica under the medical criteria non-network; noh network provider reimbursement amount, physician, provider, virtual care _ referenced in this section. Prior authorization. Prior authorization from Medica is required before you receive services or 4. Living donor transplants that would not be authorized by Medica under the medical criteria supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. referenced in this section. See How To Access Your Benefits for more information about the prior authorization process. 5. Islet cell transplants, except for autologous islet cell transplants associated with pancreatectomy. Covered 6. Services required to meet the patient selection criteria for the authorized transplant For benefits and the amounts you pay, see the table in this section. More than one coinsurance procedure. This includes treatment of nicotine or caffeine addiction, services and related expenses for weight loss programs, nutritional supplements, appetite suppressants, and may be required if you receive more than one service or see more than one provider per visit. supplies of a similar nature not otherwise covered under this certificate. Medica uses specific medical criteria to determine benefits for organ and bone marrow transplant services. Because medical technology is constantly changing, Medica reserves the 7. Mechanical, artificial, or non-human organ implants or transplants and related services that right to review and update these medical criteria. Benefits for each individual member will be would not be authorized by Medica under the medical criteria referenced in this section. determined based on the clinical circumstances of the member according to Medica's medical 8. Transplants and related services that are investigative. criteria. 9. Private collection and storage of umbilical cord blood for directed use. Coverage is provided for the following human organ transplants, if appropriate, under Medica's 10. Drugs provided or administered by a physician or other provider on an outpatient basis, medical criteria and not otherwise excluded from coverage (see Not covered below): cornea, except those requiring intravenous infusion or injection, intramuscular injection, or 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, intraocular injection. Coverage for drugs is as described in Prescription Drug Program and peripheral blood, and umbilical cord blood. Prescription Specialty Drug Program or otherwise described as a specific benefit in this certificate. The preceding is not a comprehensive list of eligible organ and bone marrow transplant See Exclusions for additional services, supplies, and associated expenses that are not services. covered. • In-network benefits apply to transplant services provided by a network provider and received at a designated transplant facility. A designated transplant facility means a hospital that has entered into a separate contract with Medica to provide certain transplant-related health services to members receiving transplants. You may be evaluated and listed as a potential recipient at multiple designated facilities for transplant services. 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 (3/12) 44 1500-100% MIC FOCUSMN HSA(3/12) 45 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services ..4... .�....' -.. r,.,. <. Y o ur_Benefits• mom a. nd the:,.:prx .A m ou-"n_e- ts..._r PYo u .;. n.�.-. ,-� ". _ v 3 .-i S fits x heA Pis Y .� o- � _ , . ln ne twork ben f�ts .�_. out-of-network.. �. ! _b f i is B e.n . ._ . ' _ _ ...__ _benefits' , _ .. .::... benefits . �._ e its Benefi#s � �Fafer:deduc able aftertleductibl after�deductible . � after deductible'_ For out-of-network ,. . . its in . ,, _ addition to ,-N thededuct� = , e d _: any charges 7_ .coinsurance, you are _ . _:: _ t in excess ; , a- . .: ._. .. . : Y ons�ble:for _ _ s 9 . .., s.of the_non P For out of network in addition to the a uc r t network r ,: . _ d d t be and coinsurance doitio res ohes a for ovider rep amount...Additionally, ,Y p . , m e.. .. reimbursement ., , .�. . .� ... . .... , »-ch .will . , . - -,these .. ; ;. , . . ., >. , , � ;-.:.,arges� not<b ._ .... .. _ ,charges _ ,, r_ . .a e a Ired low an. char es4 in excess-of the,non-network pP and satisfaction netk_provider reimbursement amount.,-Addtronalf. ,these.:.,�. .._:- _ ton of the - c any P .,t e a dedu .. u #pocketmaximum. :..m. , P.. .._ a` charges,w�!lnot.be applied#,toward satisfaction of the deductible ortheout, out-of-Pocket maximum:.:. 1. Office visits Nothing No coverage - - -� - - -- - 5. Services received from a Nothing No coverage 2. Virtual care Nothing No coverage physician during an inpatient 3. Outpatient services stay a. Professional services 6. Anesthesia services received Nothing No coverage from a provider during an i. Surgical services (as Nothing No coverage inpatient stay defined in the Physicians' Current Procedural 7. Transportation and lodging The deductible does not No coverage Terminology code book) a. As described below, apply to this received from a physician reimbursement of reasonable reimbursement benefit. during an office visit or an and necessary expenses for You are responsible for outpatient hospital visit travel and lodging for you paying all amounts not and a companion when you reimbursed under this ii. Anesthesia services Nothing No coverage benefit. Such amounts received from a provider receive approved services at do not count toward your during an office visit or an a designated facility for out-of-pocket maximum outpatient hospital or transplant services and you or toward satisfaction of ambulatory surgical live more than 50 miles from your deductible. center visit that designated facility iii. Outpatient lab and Nothing i. Transportation of you and pathology g No coverage one companion (traveling on the same day(s)) to iv. Outpatient x-rays and Nothing No coverage and/or from a designated other imaging services facility for transplant v. Other outpatient hospital Nothing No coverage services for pre- services received from a g transplant, transplant, physician and post-transplant services. If you are a b. Hospital and ambulatory minor child, surgical center services transportation expenses i. Outpatient lab and Nothin for two companions will pathology g No coverage be reimbursed. ii. Outpatient x-rays and Nothing No coverage other imaging services I iii. Other outpatient hospital Nothing No coverage services 9 4. Inpatient services Nothing No coverage MIC FOCUSMN HSA (3/12) 46 1500-100% MIC FOCUSMN HSA (3/12) 47 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Organ And Bone Marrow Transplant Services Physical, Speech, And Occupational Therapies Your Benefits and the Amounts You Pay P. Physical, Speech, And Occupational Therapies Benefits Fn-network benefits *Out-of-network benefits after deductible after deductible This section describes coverage for physical therapy, speech therapy, and occupational therapy *For out-of-network services provided on an outpatient basis. A physician must direct your care in order for it to be -°benefits,.in addition to the and coinsurance, you are for coverage.eligible for Covers e for services provided on an inpatient basis is as described any charges in excess of the non-network provider reimbursement amount. Additionally,these eli 9 g g charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. elsewhere in this certificate. ii. Lodging for you (while not See Definitions. These words have specific meanings: benefits, coinsurance, deductible, confined) and one inpatient, network, non-network, non-network provider reimbursement amount, physician. companion. Prior authorization. Prior authorization from Medica may be required before you receive Reimbursement is services or supplies. Call Customer Service at one of the telephone numbers listed inside the available for a per diem front cover. See How To Access Your Benefits for more information about the prior amount of up to $50 for authorization process. one person or up to $100 for two people. If you are Covered a minor child, reimbursement for lodging expenses for two For benefits and the amounts you pay, see the table in this section. More than one coinsurance companions is available, may be required if you receive more than one service or see more than one provider per visit. up to a per diem amount • benefits apply to outpatient physical therapy, speech therapy, and occupational of$100. therapy services arranged through a physician and received from the following types of iii. There is a lifetime network providers: physical therapist, speech therapist, occupational therapist, or physician. maximum of$10,000 per member for all Out-of-network benefits apply to outpatient physical therapy, speech thera py, and occupational therapy services arranged through a physician and received from the following transportation and types of non-network providers: physical therapist, speech therapist, occupational therapist, lodging expenses or physician. In addition to the deductible and coinsurance described for out-of-network incurred by you and your benefits, you are responsible for any charges in excess of the non-network provider companion(s) and reimbursement amount. The out-of-pocket maximum does not apply to these charges. reimbursed under the Please see Important member information about out-of-network benefits in How To Access Contract or under any Your Benefits for more information and an example calculation of out-of-pocket costs other Medica, Medica associated with out-of-network benefits. Health Plans, or Medica Health Plans of Not covered Wisconsin coverage offered through the same employer. These services, supplies, and associated expenses are not covered: b. Meals are not reimbursable 1. Services primarily educational in nature. under this benefit. 2. Vocational and job rehabilitation. 3. Recreational therapy. 4. Self-care and self-help training (non-medical). 5. Health clubs. 6. Voice training. 7. Group physical, speech, and occupational therapy. MIC FOCUSMN HSA(3/12) 48 1500-100% MIC FOCUSMN HSA (3/12) 49 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Physical, Speech, And Occupational Therapies Physical, Speech, And Occupational Therapies 8. Physical, speech, or occupational therapy services (including but not limited to services for the correction of speech impediments or assistance in the development of verbal clarity) Your Benefits and the Amounts You Pay when there is no reasonable expectation that the member's condition will improve over a predictable period of time according to generally accepted standards in the medical Benefits after work benefits r *Out-of-network benefits community. after deductible after deductible 9. Massage therapy, provided in any setting, even when it is part of a comprehensive treatment plan. For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for 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. See Exclusions for additional services, supplies, and associated expenses that are not covered. - 3. Occupational therapy received Nothing 50% coinsurance. outside of your home when Coverage for physical physical function is impaired due and occupational therapy Your Benefits and the Amounts You Pay to a medical illness or injury or is limited to a combined _ congenital or developmental limit of 20 visits per Benefits k In-network benefits *Out-of-network benefits conditions that have delayed calendar year. after deductible after deductible motor development Please note: This visit limit includes physical and *For out-of-network benefits, in addition to the deductible and coinsurance you are responsible for occupational therapy visits >' that you pay for in order to any charges in excess of the non-network provider reimbursement amount. Additionally,these satisfy any part of your charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. `. deductible. 1. Physical 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. 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. MIC FOCUSMN HSA(3/12) 5Q MIC FOCUSMN HSA (3/12) 51 1500-100% 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 P Prescription Drug Program Prescription Drug Program the pharmacy. For example, if the agreement states that the Tier 1 prescription drug "A" costs Q. Prescription Drug Program $50, and your Tier 1 copayment is $10, you will pay $10 and Medics 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 This section describes coverage for prescription drugs and supplies received from a pharmacy supply under your in-network benefit, Medics will pay the amount Medics would have paid had 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 you received the Tier 1 generic drug or supply, as described in the immediately preceding (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such paragraph. You will pay, in addition to the applicable coinsurance described in the table, any prescription drugs and supplies are identified in this certificate as not covered. The phrase remaining charges due to the pharmacy in excess of Medica's payment to the pharmacy. "professionally administered drugs" means drugs requiring intravenous infusion or injection, These additional charges will not be applied toward the deductible or the out-of-pocket intramuscular injection, or intraocular injection; the phrase "self-administered drugs" means all maximum. other drugs. For the definition and coverage of specialty Please note that receiving Tier 2 or Tier 3 brand name drugs or supplies when an Specialty Drug Program y prescription drugs, see Prescription equivalent Tier 1 generic drug exists may result in significantly more out-of-pocket costs. See p© l Specialty y D ons These words havespectfic meanrn For example, you receive a Tier 2 or Tier 3 brand name exist tion dru "B " I deductible ducal is � § p p g a though a " � rnetlrcal:e"ur me ' gs �beneftts;�claim;coinsufance,,�....� {* ��� „ , ned ct l : a e cal q p y-£nt, emergency, hospital_memb t k, chemically equivalent Tier 1 generic prescription drug A exists. Medics s agreement with the w°rk,pravrtlerrerrnEursement f x , er, network;Han net"viearc 4 harm °° „ . ",_ _ amount, physrcian;:prescrt prescription * - P acy states that brand name drug B costs $200 and the chemically equivalent Tier 1 service,"provider ur9ent care center .. p� ' rug, preventive health x °° „ �,, � � �� � " � f ' �� 13 generic drug A costs $50 (as in the example above). The Tier 1 copayment is $10 and the �•a _� � �� �° � � �������� ��- Tier 2 or Tier 3 copayment is $50. As described in the example above, Medics will pay $40. Preferred drug list This is the amount Medics would have paid if you had received the Tier 1 generic drug em You will pay $160, an amount that includes the Tier 2 or Tier 3 copayment and the amount remaining Medica's PDL identifies whether a drug is classified by Medica as a Tier 1, Tier 2, or Tier 3 due to the pharmacy after you paid your copayment and Medica paid the amount it owed. covered drug. In general, only drugs on Medica's PDL are eligible for benefits under this Exceptions to the preferred dru list certificate. The PDL includes the following tiers: 9► Tier 1 is your lowest coinsurance option. For the lowest out-of-pocket expense, you should In certain circumstances your physician may request that Medics make an exception to the consider a Tier 1 covered drug if you and your physician decide it is appropriate for your coverage rules described under Preferred drug list above. Please note that exceptions will treatment. only be allowed when specific clinical criteria are satisfied. Any exception Medica grants Tier 2 is your higher coinsurance option. You may consider a Tier 2 covered drug to treat your w t by one tier. Exceptions to the PDL can also include condition if you and your physician decide it is appropriate. treat emotional disturbance or mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the PDL or you Tier 3 drugs are not covered unless they meet the requirements under the PDL exception change health plans. If you would like to request a copy of Medica's PDL exception process, process described in this certificate. call Customer Service at one of the telephone numbers listed inside the front cover. 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. Prior authorization The PDL is also available when you sign in at wphone n numbers listed Certain covered drugs require prior authorization as indicated on the PDL. The provider who Medica utilizes medication request guidelines to determine whether a drug should be prescribes the drug initiates prior authorization. The PDL is made available to providers, considered a covered drug. Medica's medication request guidelines are based on United States payi�ndl the costlof d u as aecei ed ignatedo mail order meet Medic pharmacies. You are responsible for Food and Drug Administration (FDA) approval, Medica's authorization criteria. clinical publications. These medication request guidelines, as well as the P g g y packaging guidelines, and reviewed and modified by Medics. 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. Step therapy Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step Product selection 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 When you receive a Tier 1 prescription drug or supply under your in-network benefit, after you step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. 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 (3/12) 52 1500-100% MIC FOCUSMN HSA(3/12) 53 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Prescription Drug Program Prescription Drug Program Quantity limits these charges. Please see Important member information about out-of-network benefits in Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits How To Access Your Benefits for more information and an example calculation of out-of-pocket indicate the maximum quantity allowed per prescription over a specific time period. Some costs associated with out-of-network benefits. quantity limits are based on packaging, FDA labeling, or clinical guidelines. ** Please note: Some drugs and supplies are not available through the designated mail order Covered See Miscpharmacy.ellaneous Medical Services And Supplies for coverage of insulin pumps. The following table provides important general information concerning in-network, out-of- See Prescription Specialty Drug Program for coverage of specialty prescription drugs. network, and mail order benefits. For specific information concerning benefits and the amounts Prescription unit you pay, see the benefit table at the end of this section. Please note that Prescription Drug Program describes your coinsurance for prescription drugs themselves. An additional coinsurance applies for the provider's services if you require that a provider administer self- Generally, covered drugs will not be dispensed in excess of one prescription unit except as administered drugs, as described in other applicable sections of this certificate including, but not indicated below. One prescription unit is equal to a 31-consecutive-day supply of a covered drug limited to Hospital Services, Infertility Diagnosis, and Professional Services. from your pharmacy (or, in the case of 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 A case of contraceptives, up to a three-cycle su I unless limited b dru manufacturers In network benefits s R r tl ' Out of network benefits* ;Mai; i " g packaging, dosing instructions, or Medica s medication request guidelines, including quantity limits Mail orderrbenefjts as indicated on the PDL. Coinsurance amounts will apply to each prescription unit dispensed. Covered drugs received at a Covered drugs received at a Covered drugs received from network pharmacy; and Three prescription units may be dispensed for covered drugs prescribed to treat chronic non-network pharmacy; and a designated mail order conditions that are received at a network pharmacy that Medica has specifically designated to pharmacy; and dispense multiple prescription units. For the current list of such designated pharmacies, sign in Covered drugs for family See In-network benefits at www.mymedica.com or call Customer Service at one of the telephone numbers listed inside planning services or the Covered drugs for family the front cover. treatment of sexually column. planning services or the transmitted diseases when treatment of sexually prescribed by or received from transmitted diseases when Not covered either a network or a non- prescribed by either a network provider. Family network or a non-network The following are not covered: provider and received from a planning services do not 1. Any amount above what Medica would have paid when you fail to identify yourself to the include infertility treatment designated mail order (Medica will notif y you before enforcement of this provision.) services; and pharmacy. Family planning pharmacy as a member. ( services do not include 2. OTC drugs not listed on the PDL. infertility treatment services; 3. Replacement of a drug due to loss, damage, or theft. and Diabetic equipment and Diabetic equipment and 4. Appetite suppressants. blood Diabetic equipment and 9 supplies, including blood supplies (excluding blood 5. Erectile dysfunction medications. supplies, including 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 6. Non-sedating antihistamines and non-sedating antihistamine/decongestant combinations. and pharmacy. 7. Proton pump inhibitors, except for members twelve (12) years of age and younger, and Tobacco cessation products Tobacco cessation products Not available. those members who have a feeding tube. when prescribed by a provider when prescribed by a provider 8. Tobacco cessation products or services dispensed through a mail order pharmacy. authorized to prescribe the authorized to prescribe the 9. Drugs prescribed by a product and received at a product and received at a non- provider who is not acting within his/her scope of licensure. network pharmacy. network pharmacy. 10. Homeopathic medicine. 11. Infertility drugs. * When out-of-network benefits are received from non-network providers, in addition to the 12. Specialty prescription drugs, except as described in Prescription Specialty Drug Program. deductible and coinsurance, you will be responsible for any charges in excess of the non- 'y P P g P p p y g g network provider reimbursement amount. The out-of-pocket maximum does not apply to See Exclusions for additional drugs, supplies, and associated expenses that are not covered. MIC FOCUSMN HSA (3/12) 54 1500-100% MIC FOCUSMN HSA(3/12) 55 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Prescription Drug Program Prescription Drug Program ■ _ . . , _. � � ,x ., . _Your Benefitsand'th :Arnou , , , _ ,_ -,.,_ . __ e :_ n#s You.Pa- _ and _ s . . .- � � , ,. the.. � _�_ _ � r _,- .__ �. = . You,. . � _ _,x_ _ � � �,. .§� ._ ... .x ,x r..:. .;::. _. -s_ - ,.. T � - r out of-n x , . ., ., .. _ For:out.of.network,benefits sn i r etworkbe , � _ ,_ add#an to,the deductrble and coinsurance you are res onsibie for f. <- • .. �:. nefits in_addr ,: ,. tion_to#hE _ ,: , .- :.. __. = ,Y . p_ -. .:, .,.� deductrb E 4 P , , :� ° � nC ou :. an ,.charges +Y ace res on .,. any.: _ _ y m exce ,. non-network <. . . . _ . ...$ � p srbie.for � a har essm excess�of the non network:. ravrder reimbursernent_amount. Ad r r I -; h <., excess of � <:<xw Y -._ _. .- g p __- � t 4na y,t ese;, .provider ream ursement=am amount. Ad charges � _ , ditronaii ., , es wrii not . _ x.. _.. . these. . char es wrti�not xbe a I�etl:towar a i f r ,_:, , g of be applied _.,Y, P ds t s act on ofFthe tleductrble ortheout-of- ocket maxrmum. redaoward. 5 .., P � �._. .. p I 'g pp _, a x: .;_;'a 4- . � � � < = �-, _ .:. af_-the- deductible == ",-, � uctrb le orUth _ _ ..: ,�. _. In-network , ., . ..* ,, .. r etwork -In network benefits__ „ � benefits' �.,,� r_ .� ., � , Ow# of network-benefits Mart r ,. ._ a its . _,- .< _ .: _. . , �- ri o der fbenef�tsk wt of n -_ '. ork _.,x.-E- f . _ . benefits. : , M ai! r �_ o der: ,,,�- x. T-. ben �_._ ,.w,- _ after;. _ �. <. F_ r-£ , . ,_:: __ efts 5. __ � g deduct _.,._A, ,� __, _x.-_ �.�_ _ �,. .. � after.-dedwctrble � r ,.,., ,. ; x<� �.,_E_ deductible _ _ _ .. � _ f _ . �.__ afte deductrbte , ..-.. ,#falter deductrble._ ..__-- detlu : F..� _ x � fter.deductible � � .... .,.___ _-_ __.,� 4. Drugs and other supplies (other than tobacco cessation products) considered preventive 1. Outpatient covered drugs other than those described below or in Prescription Specialty Drug health services, as specifically defined in Definitions, when prescribed by a provider Program authorized to prescribe such drugs. This group of drugs and supplies is specific and Tier 1: Nothing per 50% coinsurance per limited. For the current list of such drugs and supplies, please refer to the Preventive Drug prescription unit; or p Tier 1: Nothing per prescription unit prescription unit; or and Supply List within the PDL or call Customer Service at one of the telephone numbers listed Tier 2: Nothing per inside the front cover. prescription unit; or Tier 2: Nothing per prescription unit; or Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per Tier 3: No coverage prescription unit; or prescription unit prescription unit; or Tier 3: No coverage 2. Diabetic equipment and supplies, including blood glucose meters Tier 2: Nothing per Tier 2: Nothing per prescription unit; or prescription unit; or Tier 1: Nothing per 50% coinsurance per Tier 1: Nothing per prescription unit; or Tier 3: No coverage Tier 3: No coverage Tier 2: Nothing per The deductible does not The deductible does not prescription unit; or Tier 2: Nothing per apply, apply. prescription unit; or Tier 3: No coverage Tier 3: No coverage 3. 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. I 1 MIC FOCUSMN HSA (3/12) 56 1500-100% MIC FOCUSMN HSA(3/12) 57 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 i Prescription Specialty Drug Program Prescription Specialty Drug Program Medica grants will improve the coverage by only one tier. Exceptions to the SPDL can also R. Prescription Specialty 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 This section describes coverage for specialty prescription drugs received from a designated process, call Customer Service at one of the telephone numbers listed inside the front cover. 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 Prior authorization described below. For purposes of this section, the phrase "professionally administered drugs" pecialty prescription drugs require prior authorization. The provider who prescribes the means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular specialty drug initiates prior authorization. The SPDL is made available to providers, including infection, the phrase "self-administered drugs" means all other drugs. designated specialty pharmacies. You are responsible for paying the cost of specialty See Definitions. Thee words have specific meanings benefits = * prescription drugs you receive if you do not meet Medica's authorization ` �` � Y o zation criteria. deductible;-member, network;_physician; prescription_dru ' gla�m' c°insurance;- Step therapy Designated specialty pharmacies Medica requires step therapy prior to coverage of specific specialty prescription drugs as A designated specialty pharmacy means a specialty pharmacy that has entered into a separate indicated on the SPDL. Step therapy involves trying an alternative covered specialty contract with Medica to provide specialty prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other y prescription drug services to members. For the Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. current list of designated specialty pharmacies, call Customer Service at one of the telephone A lica or T Tier numbers listed inside the front cover or sign in at www.mymedica.com. Applicable p therapy requirements must be met before Medica will cover certain Tier 2 specialty prescription drugs. Specialty preferred drug list Quantity limits Medici 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 Certain specialty prescription drugs are assigned quantity limits as indicated on the SPDL. classified by Medica as a Tier 1 or Tier 2 s ecialt g These limits indicate the maximum quantity allowed per prescription over a specific time period. prescription drugs on Medica's SPDL are eligible for benefits under this certificate.only specialty Some quantity limits are based on packaging, FDA labeling, or clinical guidelines. The applicable coinsurance amounts for coverage of drugs on the SPDL are set forth in the benefit table below. Covered If you have questions about Medica's SPDL or whether a specific specialty For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to covered (and/or the SPDL tier in which the drug may be covered), or if you would rl like to request a specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and copy of the SPDL at no charge, call Customer Service at one of the telephone numbers listed received from a designated specialty pharmacy. 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 This section describes your coinsurance for specialty prescription drugs. An additional should be covered. Medica's medication request guidelines are based on UnitedrStatestlFoodug coinsurance applies for the provider's services if you require that a provider administer self- and Drug Administration (FDA) a administered drugs, as described in other applicable sections of this certificate including, but not ( ) approval, manufacturers' packaging guidelines, and clinical limited to, Hospital Services, Infertility Diagnosis, and Professional Services. 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 Prescription unit effectiveness. Generally, specialty prescription drugs will not be dispensed in excess of one prescription unit. Exceptions to the specialty One prescription unit is equal to a 31-consecutive-day supply of a specialty prescription drug, p y preferred drug list unless limited by the manufacturer's packaging or Medica's medication request guidelines, In certain circumstances your physician may request that Medica make an exception to the including quantity limits as indicated on the SPDL. 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 MIC FOCUSMN HSA (3/12) 58 1500-100% MIC FOCUSMN HSA(3/12) 59 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Prescription Specialty Drug Program Professional Services Not covered The following are not covered: S. Professional Services 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 section describes coverage for professional services received from or directed by a this provision.) physician. 2. Replacement of a specialty drug due to loss, damage, or theft. See Definitions. These words have specific meanings: benefits, coinsurance, convenience 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of care/retail health clinic, deductible, emergency, genetictesting, home clinic, hospital, inpatient, licensure. g p member network:non network, non network provider reimbursement amount p hysician, prevettiVe health service, provider, urgent car;center,virtual care. 4. Prescription drugs, except as described in Prescription Drug Program. Prior authorization. Prior authorization from Medica may be required before you receive 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty pharmacy. 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 6. Infertility drugs. authorization process. 7. Growth hormone. See Exclusions for additional drugs, supplies, and associated expenses that are not Covered covered. For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Your Benefits and the Amounts.You Pays • In-network benefits apply to: 1. Professional services received from a network provider; Benefits You pay after deductible 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 1. Specialty prescription drugs Tier 1 specialty prescription drugs: Nothing per received from a designated prescription unit; or non-network provider; specialty pharmacy Tier 2 specialty 3. Family planning services, for the voluntary planning of the conception and bearing of p y prescription drugs: No coverage 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. MIC FOCUSMN HSA (3/12) 60 1500-100% MIC FOCUSMN HSA (3/12) 61 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Professional Services Not covered Professional Services These services, supplies, and associated expenses Y Your Benefits and the Amounts°You Pay 1 penses are not covered: _ , 1. Drugs provided or administered b �. intravenous infusion or injection,ste y a physician or other provider, except those 4= L for drugs intramuscular injection, requirin Benefits ,£ ;,; - in=network benefits * Out of networkbenef'ts 1 on, or intraocular injection. Coverage ka after deductible after=deductible# � ugs is as described in Prescription Drug Program and Prescription Specialty Program or otherwise described as a specific p benefit in this certificate. p ty Drug � ;�� �° �� �' 2. Diagnostic casts, diagnostic For�out of network benefits, inadditron to the deductibleand comsuranceyouarerespansible for tem oro g stic study models, and bite adjustments any charges in excess of the non network providers reimbursement;ameunt` �Additionatly,.these R p mandibular joint (TMJ) disorder and crani J stmar d related to the treatment of charges will not be applied toward satisfaction of the deductible or theout-of-pocl et maximum omandibular disorder. � ��"' See Exclusions for additional services, supplies, and associated expenses �� �`���� `" ° covered. p nses that are not 4. Urgent care center visits Nothing Covered as an in-network Please note: Some services benefit. received during an urgent care z center visit may be covered under jam . another benefit in this certificate. Your Benefits`and the :- , Amounts You pay The most specific and appropriate Benefits" � - -'. � L' -- '� . - � ; benefit in this certificate will apply $ � � k r � In network benefits - � vEfi during for each service received durin an ,." , after deductible � t of network benefits ' urgent care center visit. deductible, `*For out , - € For example, certain services of network benefits, in addition to:tile deductible and coin` C ` ', l any charges;in excess:of the non:network provider reim surance,Additie resp'thesee for received during an urgent care R center visit may be considered charges will'not be�applied toward�satsfaction of the deductibleFor:tli k� bursement amount Additionally,these�a� e out-of-p surgical or imaging services; see . �; = s ticket maximum € 1. Office visits -.$£ below for coverage of these surgical Nothing - -_, �w�a. Please note: Some services 50% coinsurance or imaging services. In such received during an office visit may instances, both an urgent care be covered under another benefit in center visit coinsurance and this certificate. The most specific outpatient surgical or imaging and appropriate benefit in this services coinsurance apply. certificate will apply for each service Call Customer Service at one of the received during an office visit. telephone numbers listed inside the For example, certain services front cover to determine in advance received during an office visit may whether a specific procedure is a be considered surgical or imaging benefit and the applicable coverage services; see below for coverage of level for each service that you these surgical or imaging services. receive. In such instances, both an office 5. Preventive health care visit coinsurance and outpatient surgical or imaging services Please note: If you receive coinsurance a I preventive and non-preventive pp y health services during the same Call Customer Service at one of the visit, the non preventive health tel numbers listed inside the services may be subject to a front cover to determine in advance coinsurance or deductible, as whether a specific procedure is a described elsewhere in this benefit and the applicable coverage rtt The most specific and level for each service that you appropriate ce e. benefit m in this ce rt ific receive. will apply ifica for each service received ate 2. Virtual care during a visit. 3. Convenience care/retail health Nothing No coverage a. Child health supervision Nothing. The deductible Covered as an in-network clinic visits Nothing 50% coinsurance services, including well-baby does not apply. benefit. care MIC FOCUSMN HSA (3/12) 62 1500-100% MIC FOCUSMN HSA(3/12) 63 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Professional Services Professional Services f �- : - . , _ P� Our , You Pay , '-- . , _� �. Your Benefits Amounts.You . �Aprilefits . . _ .._ two .benefits� ,,� s-. . -. rkb . _ e o _ .. Benefit In, r nef ts_ . . Out f netwo be f . .._..- � _._ . . ��.._ . .� _ _._- -,.. . s x � netwo k be i o rk a its . . , > _ s _ . .. rte_. :.._ -_�__ � . �_ ,�, :. 4:E ,afte uctr L -after ductrb �. ..„.. a-, ,..;:- . rout _ . �x,- = .�:. �__ ,.,._. addition on:#o.. ro,.< _, ,. . _. . . . � > the , , .; . �_.. . �s, .:�k_ > ,� ctrbteand any <,.. coinsurance, in, . char . . : .-� nce _.._, *. Y es_m non-network � ou.are. , _-3 9 excess � ,.. Y s onsr . , .: � ._< r, .. the _ •, :_ P ble;#oc�. Far ou# of network benefits m addrtron to:the deductible and.coinsurance ouare res onsrb(e#or exc ,. a , :provider , . . s Y «. . _ .. .,:,. - . .. reimbursement ru.. . .: - charges :. .. ent amount. . . g.._ r es�wri!- � . . _ . _ . �. .. unt..,,Ad _� .. __ 9 not be: � N _d.._ ditional _ � .. _ .. -.ofah non ne .k rovi breimbursement unt. - �tron 11 - applied toward ,v , . , y,�these : -:_ ,,., ant_ es n-,excess e , twor der amour' ....Add a_ .these .. ._- - , ,.. c!satrsfa � i:.. �_. . Y charges x.- p Y, ctron. e . . o the � . _. . ,. � ._ _ .:.. p maximum , ::gA�: charges will not be applied toward.satisfaction of;the deductible or the out-of-pocket maximum.:;-� = b. Immunizations Nothing. The deductible 50% coinsurance 10. Anesthesia services received Nothing 50% coinsurance does not apply. from a provider during an office c. Early disease detection Nothing. The deductible 50% coinsurance visit or an outpatient hospital or services including physicals does not apply. ambulatory surgical center visit d. Routine screening Nothing, The deductible 50% coinsurance 11. Services received from a Nothing Covered as an in-network procedures for cancer does not apply. physician during an emergency benefit. room visit e. Other preventive health Nothing. The deductible 50% coinsurance services does not apply pp y. 12. Services received from a Nothing 50% coinsurance 6. Allergy shots Nothin ° physician during an inpatient Nothing 50/° coinsurance stay 1 7. Routine annual eye exams Nothing. The deductible 50% coinsurance does not apply. 13. Anesthesia services received Nothing 50% coinsurance from a provider during an 8. Chiropractic services to Nothin 9 inpatient stay diagnose and to treat (by manual 50% coinsurance. manipulation or certain Coverage is limited to a 14. Outpatient lab and pathology Nothing 50% coinsurance therapies) conditions related to maximum of 15 visits per the muscles, skeleton, and calendar year. p 15. Outpatient x-rays and other Nothing 50% coinsurance nerves of the body Please note: This visit limit imag ing services includes chiropractic visits 16. Other outpatient hospital or Nothing 50% coinsurance Please note: Providers may be network providers for chiropractic that you pay for in order to ambulatory surgical center services only, and not otherwise satisfy any part of your deductible. services received from a part of the Medica Focus network. physician When you receive other health services you should verify that your 17. Treatment to lighten or remove Covered at the Covered at the provider is a Medica Focus network the coloration of a port wine stain corresponding in-network corresponding out-of- provider in order to be eligible for in- benefit level, depending network benefit level, network benefits. You can do this on type of services depending on type of by reviewing your provider directory provided. services provided. and contacting Customer Service at one of the telephone numbers listed For example, office visits For example, office visits inside the front cover. are covered at the office are covered at the office 9. Surgical services (as defined in Nothing ° visit in-network benefit visit out-of-network 50/° coinsurance level and surgical benefit level and surgical the Physicians'Current services are covered at services are covered at Procedural Terminology code book) received from a physician the surgical services in- the surgical services out- during an office visit or an network benefit level. of-network benefit level. outpatient hospital or ambulatory surgical center visit MIC FOCUSMN HSA (3/12) 64 1500-100% MIC FOCUSMN HSA(3/12) 65 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Professional Services Professional Services Your Benefits and the Amounts You Pay Your Benefits and the Amounts You Pay Benefits In-network benefits * Out-of-network benefits In-network benefits *Out-of-network benefits Benefits after deductible after deductible = after deductible after deductible *For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for *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 an charges.in excess of the non-network provider reimbursement amount. Additionally,these charges xwill not be applied toward satisfaction of the deductible or the out-of-pocket maximum. charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. 18. Treatment of temporomandibular Covered at the Covered at the 21. Vision therapy and orthoptic Nothing 50% coinsurance joint (TMJ) disorder and corresponding in-network corresponding out-of- and/or pleoptic training, to craniomandibular disorder benefit level, depending network benefit level, establish a home program, for on type of services depending on type of the treatment of strabismus and provided. services provided. other disorders of binocular eye For example, office visits For example, office visits movements. Coverage is limited are covered at the office are covered at the office to a combined in-network and visit in-network benefit visit out-of-network out-of-network total of 5 training level and surgical benefit level and surgical visits and 2 follow-up eye exams services are covered at services are covered at per calendar year. the surgical services in- the surgical services out- Please note: These and and exam limits include e visits and exams that network benefit level. of-network benefit level. you pay for in order to satisfy any Please note: Dental Please note: Dental part of your deductible. . coverage is not provided coverage is not provided 50% coinsurance under this benefit. under this benefit. 22. Genetic counseling, whether pre- Nothing or post-test, and whether 19. Diabetes self-management Nothing 50% coinsurance occurring in an office, clinic, or training and education, including medical nutrition therapy, telephonically received from a provider in a program consistent with national 23. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment educational standards (as decisions or frequency of established by the American screening for a disease, or when Diabetes Association) results of the test will affect 20. Neuropsychological Nothing 50%o coinsurance reproductive choices evaluations/cognitive testing, limited to services necessary for the diagnosis or treatment of a medical illness or injury MIC FOCUSMN HSA (3/12) 66 1500-100% MIC FOCUSMN HSA (3/12) 67 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Reconstructive And Restorative Surgery 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 T. Reconstructive And Restorative Surgery intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Prescription Specialty Drug Program or otherwise described as a specific benefit in this This section describes coverage for professional, hospital, and ambulatory surgical center certificate. services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative See Exclusions for additional services, supplies, and associated expenses that are not surgery services must be medically necessary and not cosmetic. covered. See ..D e f_,i.,.n:,_ i.,t i o n�._s The.:-.;.ese w o rd s h a.__v e s_.pe.._c ifi c m e ani ng's .b e.-nefi ts coinsurance urance cos ure ic :.-. .s i deductible,hospital, inpatient, medically necessary, member, n e tw, ork _no netw r. _m Your�Benefits and.the Amounts You Pay ;netw or 2 rovider reimb r cement amou nt, h s cian, Provider,�reconstru . . virtual ,., Prior authorization. Benefits > ' 5 In network rbenefits Out-of network benefits_- n. Prior authorization from Medica may be required before you receive ; s ' after deductible after deductible services or supplies. Call Customer Service at one of the telephone numbers listed inside the - yg� `l p front cover. See How To Access Your Benefits for more information about the prior For out-of-network benefits, in addition to the deductible and coinsurance,you are responsible for authorization process. 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.' Covered 1. Office visits Nothing 50% coinsurance For benefits and the amounts you pay, see the table in this section. More than one coinsurance 2. Virtual care Nothing No coverage may be required if you receive more than one service or see more than one provider per visit. 3. Outpatient services 1 • In-network benefits apply to reconstructive and restorative surgery services received from a a. Professional services network provider. i. Surgical services (as Nothing 50% coinsurance • Out-of-network benefits apply to reconstructive and restorative surgery services received defined in the from a non-network provider. In addition to the deductible and coinsurance described for Physicians'Current out-of-network benefits, you will be responsible for any charges in excess of the non- Procedural Terminology network provider reimbursement amount. The out-of-pocket maximum does not apply to code book) received these charges. Please see Important member information about out-of-network benefits in from a physician during How To Access Your Benefits for more information and an example calculation of out-of- an office visit or an pocket costs associated with out-of-network benefits. outpatient hospital or ambulatory surgical Not covered center visit ii. Anesthesia services Nothing 50% coinsurance These services, supplies, and associated expenses are not covered: received from a provider 1. Revision of blemishes on skin surfaces and scars (including scar excisions) primarily for during an office visit or cosmetic purposes, unless otherwise covered in Professional Services. an outpatient hospital or ambulatory surgical 2. Repair of a pierced body part and surgical repair of bald spots or loss of hair. center visit 3. Repairs to teeth, including any other dental procedures or treatment, whether the dental iii. Outpatient lab and Nothing 50% coinsurance treatment is needed because of a primary dental problem or as a manifestation of a medical pathology treatment or condition. iv. Outpatient x-rays and Nothing 50% coinsurance 4. Services and procedures primarily for cosmetic purposes. other imaging services 5. Surgical correction of male breast enlargement primarily for cosmetic purposes. v. Other outpatient hospital Nothing 50% coinsurance 6. Hair transplants. or ambulatory surgical center services received from a physician MIC FOCUSMN HSA (3/12) 68 1500-100% MIC FOCUSMN HSA (3/12) 69 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Reconstructive And Restorative Surgery Skilled Nursing Facility Services Your Benefits and the Amounts You Pay U. Skilled Nursing Facility Services Benefits, in-network benefits `' *Out-of-network benefits after deductible after deductible This section describes coverage for use of skilled nursing facility services. Care must be *For out-of-network benefits, in addition to the deductible and coinsurance, you are responsible for provided under the direction of a physician. Coverage of the services described in this section any charges in excess of the non-network provider reimbursement amount. Additionally,these is limited to a maximum benefit of 120 days per person per calendar year. Skilled nursing charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. facility services are eligible for coverage only if you are admitted to a skilled nursing facility within 30 days after a hospital admission of at least three consecutive days for the same illness b. Hospital and ambulatory or condition. surgical center services i. Outpatient lab and Nothing 50/°° See Definitions. These words have specific meanings: benefits, coinsurance, custodial care, coinsurance deductible hospital, inpatient, network, non-network, non-network provider reimbursement .. ii. Outpatient x-rays and Nothing 50% amount, physician, skilled care, skilled nursing facility. other imaging services g 50/o coinsurance Prior authorization. Prior authorization from Medica may be required before you receive iii. Other outpatient hospital Nothing 50%/°° services or supplies. Call Customer Service at one of the telephone numbers listed inside the coinsurance and ambulatory surgical front cover. See How To Access Your Benefits for more information about the prior authorization process. center services 4. Inpatient services Nothing 50% coinsurance Covered 5. Services received from a Nothing 50% coinsurance physician during an inpatient For benefits and the amounts you pay, see the table in this section. More than one coinsurance stay may be required if you receive more than one service or see more than one provider per visit. 6. Anesthesia services received Nothing 50% coinsurance For purposes of this section, room and board includes coverage of health services and supplies. from a provider during an inpatient stay • 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. • MIC FOCUSMN HSA (3/12) 70 1500-100% MIC FOCUSMN HSA (3/12) 71 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Skilled Nursing Facility Services Substance services when there is no reasonable expectation 7. Physical, speech, or occupational therapy Substance Abuse that the member's condition will improve over a predictable period of time ac generally accepted standards in the medical community. cording to 8. Voice training. V. Substance Abuse 9. Group physical, speech, and occupational therapy. 10. Long-term care. 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 Exclusions for additional services, supplies, and associated expenses that See Definitions. These words have specific meanings k enefits, claim, coinsurance, custodial tare not 9b care, deductible, emergency,:hospital, inpatient, medically. necessary member, mental tlisorder, network, non network, non-network: rouider reimbursement amount, physician,` rovider n a :. . .. ........ .. - . e -.,w. i ... ... - .;, p _" .. ....... ".. Your Benefl Prior authorization. For prior authorization re uirements of in-network and out-of-network a , is and-the y , s l; ' ' q . you Pay _ benefits, call Medica's designated mental health and substance abuse rovider at: Ben @fltS 9 p xk g -f - _ In=netw 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center 1 e or . enefits * ; _-a x h *;after:"" "'K` 1-800-855-2880, then ask them to dial Medics Behavioral Health at 1-866-567-0550. Out * .. .- deductible after of network benefits Fo out-o#network- deductible t x For purposes of this section: � be±�e#its, in addition to the�deciucfible arcs ' � } is i th 1. Outpatient services include: any�harges in excess of they non-network provider reimbursement arnoun . char es will*notbe apPl�ed�toward satisfaction of the deductible or t urance,You,are responsible for _� t f poc Tana ly,these a. Diagnostic evaluations. he out of � 1• Daily skilled care or daily skilled pocket maximum Nothing b. Outpatient treatment. 50% coinsurance rehabilitation services, including room and board, up to 120 days c. Intensive outpatient programs, including day treatment and partial programs, which may per person per calendar year include multiple services and modalities, delivered in an outpatient setting. Please note: Such services are •eligible for coverage only if you are d. Services, care, or treatment for a member that has been placed in the Minnesota admitted to a skilled nursing facility Department of Corrections' custody following a conviction for afirst-degree driving while within 30 days after a hospital impaired offense; to be eligible, such services, care, or treatment must be required and admission of at least three provided by the Minnesota Department of Corrections. consecutive days for the same 2. Inpatient services include: illness or condition. This day limit includes days that you pay for in a. Room and board. order to satisfy any part of your deductible. b. Attending physician services. 2. Skilled physical, speech, or c. Hospital or facility-based professional services. occupational therapy when room Nothing and 50% coinsurance d. Services, care, or treatment for a member that has been placed in the Minnesota covered board is not eligible to be 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 3. Services received from a provided by the Minnesota Department of Corrections. physician during an inpatient Nothing ° 50/o coinsurance e. Substance abuse residential treatment services. These are services from a licensed stay in a skilled nursing facility 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 (3/12) 72 1500-100% MIC FOCUSMN HSA (3/12) 73 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 - - - - Substance Abuse Substance Abuse Covered Benefits for more information and an example calculation of out-of-pocket costs associated with out-of-network benefits. For benefits and the amounts you pay, see the table in this section. More than one coinsurance may be required if you receive more than one service or see more than one provider per visit. Not covered • For in-network benefits: These services, supplies, and associated expenses are not covered: 1. Medica's designated mental health and substance abuse provider arranges in-network substance abuse benefits. (Medica and Medica's designated mental health and 1. Services for substance abuse disorders not listed in the current edition of the Diagnostic and substance abuse provider networks are different.) If you require hospitalization, Medica's Statistical Manual of Mental Disorders. designated mental health and substance abuse provider will refer you to one of its hospital 2. Services for a condition when there is no reasonable expectation that the condition will providers (Medica and Medica's designated mental health and substance abuse provider improve. hospital networks are different). 3. Services, care, or treatment that is not medically necessary. 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 4. Services to hold or confine a person under chemical influence when no medical services are first-degree driving while impaired offense. To be eligible, such services, care, or treatment required, regardless of where the services are received. must be required and provided by the Minnesota Department of Corrections. 5. Telephonic substance abuse treatment services. Providers may be network providers for substance abuse services only, and not otherwise 6. Services, including room and board charges, provided by health care professionals or part of the Medica Focus network. When you receive other health services you should verify facilities that are not appropriately licensed, certified, or otherwise qualified under state law that your provider is a Medica Focus network provider in order to be eligible for in-network to provide substance abuse services. This includes, but is not limited to, services provided benefits. You can do this by reviewing your provider directory and contacting Customer by mental health or substance abuse providers who are not authorized under state law to Service at one of the telephone numbers listed inside the front cover. practice independently, and services received from a halfway house, therapeutic group For claims questions regarding in-network benefits, call Medica's designated mental health home, boarding school, or ranch. and substance abuse provider Customer Service at 1-866-214-6829. 7. Room and board charges associated with substance abuse treatment services providing • For out-of-network benefits: 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 1. Substance abuse services from a non-network provider listed below will be eligible for dependency rehabilitation. 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 8. Services to assist in activities of daily living that do not seek to cure and are performed abuse services and practice independently: regularly as a part of a routine or schedule. a. Psychiatrist See Exclusions for additional services, supplies, and associated expenses that are not b. Psychologist covered. c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric and mental health nursing Your Benefits and the Amounts You Pay d. Chemical dependency clinic = � Benefits In network benefits • Out-of-network,benefits .± e. Chemical dependency residential treatment center x eductible after deductible t rd after d � � f. Hospital that provides substance abuse services � a . *For but-of-network benefits n'addition to the deductible and coinsurance,you,are responsible for g. Independent clinical social worker any charges in excess of the non network provider reimbursement amount. Additionally,these t-charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum. y, h. Marriage and family therapist . _ 2. Emergency substance abuse services are eligible for coverage under in-network 1. Office visits, including Nothing 50% coinsurance benefits. evaluations, diagnostic, and In addition to the deductible and coinsurance described for out-of-network benefits, you will primary treatment services be responsible for any charges in excess of the non-network provider reimbursement 2. Intensive outpatient programs Nothing 50% coinsurance amount. The out-of-pocket maximum does not apply to these charges. Please see 3. Opiate replacement therapy Nothing 50% coinsurance Important member information about out-of-network benefits in How To Access Your MIC FOCUSMN HSA (3/12) 74 1500-100% MIC FOCUSMN HSA(3/12) 75 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Substance Abuse Referrals To Non-Network Providers Your Benefits and the Amounts You Pay z_ 3 W.Referrals To Non-Network Providers { Benefits � � � � In network benefits �� °x * Ow utof n etwork be_neb f itE s after deductible =� { after deductible riP.4 This section describes coverage for referrals from network providers to non-network providers. e ., n you o- In-network benefits will apply to referrals from network providers For out-of-network:benefits, in addition to:the�deductble and coinsurance,You responsible for:, '= pp Y p e s to non-network providers when any charges in excess of the non network provider reimbursement amount. Additionally,Ad d i i onally,;these you receive prior authorization from Medica as described in this section. Prior authorization charges will not be applied toward satisfaction of the deductible or the out-of-pocket maximum . i from Medica is required to receive in-network benefits for services from non-network providers. It is to your advantage to seek Medica's prior authorization for referrals to non-network providers 4. Inpatient services (including before you receive services. Medica can then tell you what your benefits will be for the services residential treatment services) you may receive. a. Room and board Nothing 50% coinsurance KSee Definitions These words:have specific meanings.'g°benefits, me,tlical(y necessary, b. Hospital or facility-based Nothin g 50% coinsurance ne_tw ork nonnetwork_physician, provider. professional services If you want to apply for a standing referral to a non-network provider, contact Medica for more c. Attending physician services Nothing 50% coinsurance 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. Request 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. MIC FOCUSMN HSA (3/12) 76 1500-100% MIC FOCUSMN HSA(3/12) 77 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Referrals To Non-Network Providers Harmful Use Of Medical Services 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. X. Harmful Use Of Medical Services 3. Provide coverage for health services that are: a. Otherwise eligible for coverage under this certificate; and This section describes what Medica will do if it is determined you are receiving health services b. Recommended by a network physician. or prescription drugs in a quantity or manner that may harm your health. 4. Notify you of authorization or denial of coverage within ten days of receipt of your request. See Definitions These words have specific meanings: emergency, p benefits, emer enc , hos ital, Medica will inform both you and your provider of Medica's decision within 72 hours from the network, physician, prescription drug, provider 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, or could subject you to severe pain that cannot be When this section applies adequately managed without the care or treatment you are seeking. 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(3/12) 78 1500-100% MIC FOCUSMN HSA (3/12) 79 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Exclusions Exclusions 14. Personal comfort or convenience items or services. Y. Exclusions 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 See Definitions These words have specific meanings claim,cosmetic, custodial care, Transplant �; Member, a Services. emergency, investigative medically necessary, member, non network, physician, provider,' reconstructive,eroutine,foot care. � �� � '� �'� �_ 18. Household equipment, fixtures, home modifications, and vehicle modifications. Medica will not provide coverage for any of the services, treatments, supplies, or items 19. Massage therapy, provided in any setting, even when it is part of a comprehensive described in this section even if it is recommended or prescribed by a physician or it is the only treatment plan. available treatment for your condition. 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular This section describes additional exclusions to the services, supplies, and associated expenses disease, peripheral neuropathies, and significant neurological conditions such as already listed as Not covered in this certificate. These include: Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral 1. Services that are not medically necessary. This includes but is not limited to services sclerosis. inconsistent with the medical standards and accepted practice parameters of the community 21. Services by persons who are family members or who share your legal residence. and services inappropriate-in terms of type, frequency, level, setting, and duration-to the 22. Services for which coverage is available under workers' compensation, employer liability, or diagnosis or condition. any similar law. 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise 23. Services received before coverage under the Contract becomes effective. determined to be reconstructive. 3. Refractive eye surgery, including but not limited to LASIK surgery. 24. Services received after coverage under the Contract ends. 4. The purchase, replacement, or repair of eyeglasses, eyeglass frames, or contact lenses 25. Unless requested by Medica, charges for duplicating and obtaining medical records from non-network providers and non-network dentists. 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 26. Photographs, except for the condition of multiple dysplastic syndrome. bone conduction hearing aids (including internal, external, or implantable hearing aids or 27. Occlusal adjustment or occlusal equilibration. devices), and other devices to improve hearing, and their related fittings, except cochlear 28. Dental implants (tooth replacement), except as described in Medical-Related Dental implants and related fittings and except as described in Durable Medical Equipment And Services. Prosthetics. 6. A drug, device, or medical treatment or procedure that is investigative. 29. Dental prostheses. 7. Genetic testing when performed in the absence of symptoms or high risk factors for a 30. Orthodontic treatment, except as described in Medical-Related Dental Services. genetic disease; genetic testing when knowledge of genetic status will not affect treatment 31. Treatment for bruxism. decisions, frequency of screening for the disease, or reproductive choices; genetic testing 32. Services prohibited by law or regulation, or illegal under Minnesota law. that has been performed in response to direct-to-consumer marketing and not under the direction of your physician. 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). 8. Services or supplies not directly related to care. 9. Autopsies. 34. Exams, other evaluations, or other services received solely for the purpose of employment, insurance, or licensure. 10. Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of 35. Exams, other evaluations, or other services received solely for the purpose of judicial or standard infant formulas, standard baby food, and regular grocery products used in administrative proceedings or research, except emergency examination of a child ordered blenderized formulas are excluded regardless of whether they are the sole source of by judicial authorities. nutrition. 11. Nutritional and electrolyte substances, except as specifically described in Miscellaneous 36. Non-medical self-care or self-help training. Medical Services And Supplies. 37. Educational classes, programs, or seminars, including but not limited to childbirth classes, 12. Physical, occupational, or speech therapy or chiropractic services when there is no except as described in Professional Services. reasonable expectation that the condition will improve over a predictable period of time. 38. Coverage for costs associated with translation of medical records and claims to English. 13. Reversal of voluntary sterilization. 39. Treatment for superficial veins, also referred to as spider veins or telangiectasia. MIC FOCUSMN HSA(3/12) 80 1500-100% MIC FOCUSMN HSA (3/12) 81 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Exclusions How To Submit A Claim 40. Services not received from or under the direction of a physician, except as described in this certificate. Z. How To Submit A Claim 41. Services for the treatment of infertility. 42. Services for or related to vision therapy and orthoptic and/or pleoptic training, except as This section describes the process for submitting a claim. described in Professional Services. See Definitions These words,have specific meanings: benefits, claim, dependent, member, 43. Orthognathic surgery. _ , network, non-network, non-network..provider reimbursement amount,provider. 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 Claims for benefits from network providers Intervention (IBI), and Lovaas therapy. If you receive a bill for any benefit from a network provider, you may submit the claim following 45. Sensory integration, including auditory integration training. the procedures described below, under Claims for benefits from non-network providers or call 46. Health care professional services for maternity labor and delivery in the home. Customer Service at one of the telephone numbers listed inside the front cover. 47. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and Network providers are required to submit claims within 180 days from when you receive a subsequent procedures. 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 48. Infertility drugs. paying the cost of the service you received. 49. Growth hormone. 50. Erectile dysfunction medications. Claims for benefits from non-network providers 51. Cosmetic medications. Claim forms are provided in your enrollment materials. You may request additional claim forms 52. Weight loss medications. 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 53. Acupuncture. the claim form to Medica. You should retain copies of all claim forms and correspondence for 54. Services solely for or related to the treatment of snoring. your records. 55. Interpreter services. 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. 56. Services provided to treat injuries or illness as a result of committing a crime or attempting to commit a crime. Mail to: Medica PO Box 30990 57. Services for private duty nursing, except as described in Home Health Care. Examples of Salt Lake City, UT 84130 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 Upon receipt of your claim for benefits from non-network providers, Medica will generally pay to representative, and not under the direction of a physician. you directly the non-network provider reimbursement amount. Medica will only pay the provider 58. Laboratory testing that has been performed in response to direct-to-consumer marketing of services if: and not under the direction of a physician. 1. The non-network provider is one that Medica has determined can be paid directly; and 59. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), 2. The non-network provider notifies Medica of your signature on file authorizing that payment other than those granted a humanitarian device exemption. be made directly to the provider. 60. Health clubs. Medica will notify you of authorization or denial of the claim within 30 days of receipt of the 61. Long-term care. claim. If your claim does not contain all the information Medica needs to make a determination, Medica 62. Expenses associated with participation in weight loss programs, including but not limited to may request additional information. Medica will notify you of its decision within 15 days of membership fees and the purchase of food, dietary supplements, or publications. 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(3/12) 82 1500-100% MIC FOCUSMN HSA (3/12) 83 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 How To Submit A Claim Coordination Of Benefits Claims for services provided outside the United States Claims for services rendered in a foreign country will require the following additional AA. Coordination Of Benefits documentation: • Claims submitted in English with the currency exchange rate for the date health services This section describes how benefits are coordinated when you are covered under more than were received. one plan. • Itemization of the bill or claim. See Definitions. These words have specific meanings:. benefits, claim,deductible, dependent, emergency, hospital,b medically necessary, member, non network, non network provider • The related medical records (submitted in English). reimbursement amount„provider, subscriber. `� _ • Proof of your payment of the claim. • A complete copy of your passport and airline ticket. 1. Applicability • Such other documentation as Medica may request. a. This coordination of benefits (COB) provision applies to this plan when an employee or For services rendered in a foreign country, Medica will pay you directly. the employee's covered dependent has health care coverage under more than one plan. Medica will not reimburse you for costs associated with translation of medical records or claims. 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 Time limits determined before or after those of another plan. Under Order of benefit determination If you have a complaint or disagree with a decision by Medica, you may follow the complaint rules, the benefits of this plan: procedure outlined in Complaints or you may initiate legal action at any point. i. Shall not be reduced when this plan determines its benefits before another plan; but However, you may not bring legal action more than six years after Medica has made a coverage ii. May be reduced when another plan determines its benefits first. The above determination regarding your claim. 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 (3/12) 84 1500-100% MIC FOCUSMN HSA(3/12) 85 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Coordination Of Benefits Coordination Of Benefits When there are two or more plans covering the person, this plan may be a primary plan b) If both parents have the same birthday, the benefits of the plan which covered as to one or more other plans, and may be a secondary plan as to a different plan or one parent longer are determined before those of the plan which covered the plans. other parent for a shorter period of time. d. Allowable expense means a necessary, reasonable, and customary item of expense for However, if the other plan does not have the rule described in a) immediately health care, when the item of expense is covered at least in part by one or more plans above, but instead has a rule based on the gender of the parent, and if, as a covering the person for whom the claim is made. Allowable expense does not include result, the plans do not agree on the order of benefits, the rule in the other plan the deductible for members with a primary high deductible plan and who notify Medica of will determine the order of benefits. an intention to contribute to a health savings account. iii. Dependent child/separated or divorced parents. If two or more plans cover a person The difference between the cost of a private hospital room and the cost of a semi-private as a dependent child of divorced or separated parents, benefits for the child are hospital room is not considered an allowable expense under the above definition unless determined in this order: the patient's stay in a private hospital room is medically necessary, either in terms of a) First, the plan of the parent with custody of the child; 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 b) Then, the plan of the spouse of the parent with the custody of the child; and reimbursement amount is not considered an allowable expense under the above c) Finally, the plan of the parent not having custody of the child. definition. However, if the specific terms of a court decree state that one of the parents is When a plan provides benefits in the form of services, the reasonable cash value of responsible for the health care expense of the child, and the entity obligated to each service rendered will be considered both an allowable expense and a benefit paid. 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 When benefits are reduced under a primary plan because a covered person does not parent shall be the secondary with the plan provisions, the amount of such reduction will not be considered an p ry plan. This paragraph does not apply with respect to any claim determination period or plan year during which any benefits are allowable expense. Examples of such provisions are those related to second surgical actually paid or provided before the entity has that actual knowledge. opinions, and preferred provider arrangements. e. Claim determination period means a calendar year. However, it does not include any 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 part of a year during which a person has no coverage under this plan, or any part of a health care expenses of the child, the plans covering follow the Order of benefit year before the date this COB provision or a similar provision takes effect. determination rules outlined in 3.b.ii. v. Active/inactive employee. The benefits of a plan which covers a person as an 3. Order of benefit determination rules employee who is neither laid off nor retired (or as that employee's dependent) are a. General. When there is a basis for a claim under this plan and another plan, this plan is 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 a secondary plan which has its benefits determined after those of the other plan, unless: rule, and if, as a result, the plans do not agree on the order of benefits, this rule is i. The other plan has rules coordinating its benefits with the rules of this plan; and ignored. ii. Both the other plan's rules and this plan's rules, in 3.b. below, require that this plan's vi. Workers'compensation. Coverage under any workers' compensation act or similar benefits be determined before those of the other plan. law applies first. You should submit claims for expenses incurred as a result of an b. Rules. This plan determines its order of benefits using the first of the following rules on-duty injury to the employer, before submitting them to Medica. which applies: vii. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance i. Nondependent/dependent. The benefits of the plan that covers the person as an Act or similar law applies first. employee, member, or subscriber (that is, other than as a dependent) are viii. Longer/shorter length of coverage. If none of the above rules determines the order determined before those of the plan which covers the person as a dependent. of benefits, the benefits of the plan which covered an employee, member, or ii. Dependent child/parents not separated or divorced. Except as stated in 3.b.iii. subscriber longer are determined before those of the plan which covered that person for the shorter term. 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 4. Effect on the benefits of this plan determined before those of the plan of the parent whose birthday falls later in that a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit year; but determination rules, this plan is a secondary plan as to one or more other plans. In that MIC FOCUSMN HSA(3/12) 86 1500-100% MIC FOCUSMN HSA(3/12) 87 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Coordination Of Benefits Coordination Of Benefits event, the benefits of this plan may be reduced under this section. Such other plan or b. Insurance companies; or plans are referred to as the other plans in b. immediately below. c. Other organizations. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum The amount of the payments made includes the reasonable cash value of any benefits of: provided in the form of services. i. The benefits that would be payable for the allowable expense under this plan in the Please note: See Right Of Recovery for additional information. 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(3/12) 88 1500-100% MIC FOCUSMN HSA(3/12) 89 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 ! 1 Right Of Recovery Eligibility And Enrollment ,, BB. Right Of Recovery CC. Eligibility And Enrollment This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and This section describes who can enroll and how to enroll. federal law. For information about the effect of Minnesota and federal law on Medica's subrogation rights, contact an attorney. � See Definitions These words have specific meanings: ■benefitscontinuous coverage. ' �` y dependent, late entrant, member, mental disorder, physician, placed for adoption, premium, :- - . - See Definitions. This word has _.. : .;. caber,watt�n enod._ . _- ..,. S.a specifilc:meaning: benefits ._�.. ���__ - .��.o_ ,� qualtfymg coverage,subs t._. -,�9p -� - , . 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 Who can enroll 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 To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract received a full recovery for your illness or injury from another source of compensation for and be a subscriber or dependent as defined in this certificate. See Definitions. your illness or injury. . 2. Medica's subrogation interest is the reasonable cash value of any benefits received by you. How to enroll 3. Medica's right to recover its subrogation interest may be subject to an obligation by Medica You must submit an application for coverage for yourself and any dependents to the employer: 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 1. During the initial enrollment period as described in this section under Initial enrollment; or represented by an attorney. If Medica is represented by an attorney, an agreement p 2. During the open enrollment period as described in this section under Open enrollment; or regarding allocation may be reached. If an agreement cannot be reached, the matter must be submitted to binding arbitration. 3. During a special enrollment period as described in this section under Special enrollment; or 1 4. By accepting coverage under the Contract, you agree: 4. At any other time for consideration as a late entrant as described in this section under Late enrollment. 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 Dependents will not be enrolled without the eligible employee also being enrolled. A child who are obligated to reimburse us for the benefits paid in accordance to Minnesota law. is the subject of a QMCSO can be enrolled as described in this section under Qualified Medical b. To cooperate with Medica or its designee to help protect Medica's legal rights under this Child Support Order(QMCSO) and 6. under Special enrollment. subrogation provision and to provide all information Medica may reasonably request to determine its rights under this provision. Notification c. To provide prompt written notice to Medica when you make a claim against a party for any g injuries. You must notify the employer in writing within 30 days of the effective date of an changes to address or name, addition or deletion of dependents, a dependent child reaching the dependent d. To do nothing to decrease Medica's rights under this provision, either before or after limiting age, or other facts identifying you or your dependents. (For dependent children, the receiving benefits, or under the Contract. 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 e. Medica may take action to preserve its legal rights. This includes bringing suit in your Contract within 30 days from the date of birth, date of placement for adoption, or date of name. adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with f. Medica may collect its subrogation interest from the proceeds of any settlement or the subscriber, and any child who is a member pursuant to a QMCSO will be covered without judgment recovered by you, your legal representative, or the legal representative(s) of application of health screening or waiting periods. your estate or next-of-kin. 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 (3/12) 90 1500-100% MIC FOCUSMN HSA(3/12) 91 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Eligibility And Enrollment Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30-day time ii. Loss of eligibility includes: period does not apply to newborns or children newly adopted or placed for adoption; see • loss of eligibility as a result of legal separation, divorce, death, termination of Special enrollment.) An eligible employee and dependents that enroll during the initial employment, reduction in the number of hours of employment; 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 • cessation of dependent status; enroll for coverage during the next open enrollment, any applicable special enrollment periods, • incurring a claim that causes the eligible employee or dependent to meet or or as a late entrant (if applicable, as described below). exceed the lifetime maximum limit on all benefits; A member who is a child entitled to receive coverage through a QMCSO is not subject to any if the prior coverage was offered through an individual health maintenance initial enrollment period restrictions, except as noted in this section. • organization (HMO), a loss of coverage because the eligible employee or dependent no longer resides or works in the HMO's service area; Open enrollment • if the prior coverage was offered through a group HMO, a loss of coverage 1 because the eligible employee or dependent no longer resides or works in the A minimum 14-day period set by the employer and Medica each year during which eligible HMO's service area and no other coverage option is available; and 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 • the prior coverage no longer offers any benefits to the class of similarly situated dependents. individuals that includes the eligible employee or dependent. Special enrollment iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is eligible for or elects applicable federal or state continuation coverage; Loss of eligibility does not include a loss due to failure of the eligible employee or Special enrollment periods are provided to eligible employees and dependents under certain iv. circumstances. dependent pay de endent to a premiums on a timely basis or termination of coverage for cause; 1. Loss.of other coverage 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. a. A special enrollment period will apply to an eligible employee and dependent if the In the case of a dependent's loss of other coverage, the special enrollment period individual was covered under Medicaid or a State Children's Health Insurance Plan and described above applies only to the dependent who has lost coverage and the eligible lost that coverage as a result of loss of eligibility. The eligible employee or dependent employee. must present evidence of the loss of coverage and request enrollment within 60 days after the date such coverage terminates. 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 In the case of the eligible employee's loss of coverage, this special enrollment period Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or applies to the eligible employee and all of his or her dependents. In the case of a any applicable state continuation laws at the time the eligible employee or dependent dependent's loss of coverage, this special enrollment period applies to both the was eligible to enroll under the Contract, whether during initial enrollment, open dependent who has lost coverage and the eligible employee. enrollment, or special enrollment and declined coverage for that reason. b. A special enrollment period will apply to an eligible employee and dependent if the The eligible employee or dependent must present evidence that the eligible employee or eligible employee or dependent was covered under qualifying coverage other than dependent has exhausted such COBRA or state continuation coverage and has not lost Medicaid or a State Children's Health Insurance Plan at the time the eligible employee or such coverage due to failure of the eligible employee or dependent to pay premiums on dependent was eligible to enroll under the Contract, whether during initial enrollment, a timely basis or for cause, and request enrollment in writing within 30 days of the date open enrollment, or special enrollment, and declined coverage for that reason. of the exhaustion of coverage. The eligible employee or dependent must present either evidence of the loss of prior For purposes of 1.c.: coverage due to loss of eligibility for that coverage or evidence that employer i. Exhaustion of COBRA or state continuation coverage includes: 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 • losing COBRA or state continuation coverage for any reason other than those set contribution toward that coverage terminates, or the date on which a claim is denied due forth in ii. below; to the operation of a lifetime maximum limit on all benefits. For purposes of 1.b.: • losing coverage as a result of the employer's failure to remit premiums on a timely basis; i. Prior coverage does not include federal or state continuation coverage; MIC FOCUSMN HSA (3/12) 92 1500-100% MIC FOCUSMN HSA (3/12) 93 1500-100% B BPL 21317 DOC 23932 BPL 21317 DOC 23932 i • Eligibility And Enrollment Eligibility And Enrollment • losing coverage as a result of the eligible employee or dependent incurring a Late enrollment claim that meets or exceeds the lifetime maximum limit on all benefits and no other COBRA or state continuation coverage is available; or 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 • if the prior coverage was offered through a health maintenance organization special enrollment period will be considered late entrants. (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 Late entrants who have maintained continuous coverage may enroll and coverage will be continuation coverage is available. 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 ii. Exhaustion of COBRA or state continuation coverage does not include a loss due to requests enrollment within 63 days after prior qualifying coverage ends. failure of the eligible employee or dependent to pay premiums on a timely basis or termination of coverage for cause. Individuals who have not maintained continuous coverage may not enroll as late entrants. iii. In the case of the eligible employee's exhaustion of COBRA or state continuation An eligible employee or dependent who: coverage, the special enrollment period described above applies to the eligible 1. does not enroll during an initial or open enrollment period or any applicable special employee and all of his or her dependents. In the case of a dependent's exhaustion enrollment period; and of COBRA or state continuation coverage, the special enrollment period described er, 2, is an enrollee of MCHA at the time Medica offers or renews coverage with the employer, above applies only to the dependent who has lost coverage and the eligible 9 P Y employee. 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 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 determined by Medica. marriage and provided that the eligible employee also enrolls during this special enrollment period; Qualified Medical Child Support Order(QMCSO) 3. The dependent is a new dependent child of the subscriber or eligible employee, provided Medica will provide coverage in accordance with a QMCSO pursuant to the applicable that enrollment is requested in writing within 30 days of the subscriber or eligible employee requirements under Section 609 of the Employee Retirement Income Security Act (FRIBA) and 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 Section 1908 of the Social Security Act. It is the employer's responsibility to determine whether that the eligible employee also enrolls during this special enrollment period; a medical child support order is qualified. Upon receipt of a medical child support order issued by an appropriate court or governmental 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: 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. That spouse is eligible for coverage; and a copy of the order, along with an application for coverage, within the greater of 30 days after b. Is not already enrolled under the Contract; and issuance of the order or the time in which the employer provides notice of its determination to the persons specified in the order. c. Enrollment is requested in writing within 30 days of the dependent child becoming a • Where a QMCSO requires coverage be provided under the Contract for an eligible dependent; and employee's dependent child who is not already a member, such child will be provided a d. The eligible employee also enrolls during this special enrollment period; or special enrollment period. If the eligible employee whose dependent child is the subject of 5. The dependents are eligible dependent children of the subscriber or eligible employee and the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, enrollment is requested in writing within 30 days of a dependent, as described in 2. or 3. the eligible employee must also enroll for coverage under the Contract during the special above, becoming eligible to enroll under the coverage provided the eligible employee also enrollment period. enrolls during this special enrollment period. • Where a QMCSO requires coverage be provided under the Contract for an eligible 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as employee's dependent child who is already a member, such child will continue to be described in this section, Medica will provide the eligible dependent child with a special provided coverage under the Contract pursuant to the terms of the QMCSO. enrollment period provided the eligible employee also enrolls during this special enrollment period. 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 FOCUSMN HSA (3/12) 94 1500-100% MIC FOCUSMN HSA (3/12) 95 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 II Eligibility And Enrollment Ending Coverage 2. For eligible employees and dependents who enroll during the open enrollment period, was held begins on the first day of the Contract year for which the open enrollment period DD. Ending Coverage 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 This section describes when coverage ends under the Contract. When this happens you may case of: exercise your right to continue or convert your coverage as described in Continuation or a. Number 1. or 2. under Special enrollment, coverage begins on the first day of the first Conversion. calendar month following the date on which the request for enrollment is received by See Definitions These words have specific meanings certification of qualifying coverage, r` Medica; claim, dependent, member, premium,subscriber. T b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of You have the right to a certification of qualifying coverage when coverage ends. You will adoption or placement for adoption, date of adoption or placement. In all other cases, receive a certification of qualifying coverage when coverage ends. You may also request a the date the subscriber acquires the dependent child; certification of qualifying coverage at any time while you are covered under the Contract or c. Number 4. under Special enrollment, the date coverage for the dependent child is within the 24 months following the date your coverage ends. To request a certification of effective, as set forth in 3.b. above; 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 d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. as soon as reasonably possible. or 3. under Special enrollment becomes effective; e. Number 6. under Special enrollment, the first day of the first calendar month following When coverage ends the date the completed request for enrollment is received by Medica. 4. For eligible employees and/or dependents who enroll during late enrollment, coverage Unless otherwise specified in the Contract, coverage ends the earliest of the following: begins on the first day of the month following date of Medica's approval of the request for 1. The end of the month in which the Contract is terminated by the employer or Medica in enrollment. • 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 (3/12) 96 1500-100% MIC FOCUSMN HSA (3/12) 97 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Ending Coverage Continuation e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional EE. Continuation 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. This section describes continuation coverage provisions. When coverage ends, members may Upon completion of active military duty, contact the employer for reinstatement of coverage; be able to continue coverage under state law, federal law, or both. All aspects of continuation 8. The date of the death of the member. In the event of the subscriber's death, coverage for coverage administration are the responsibility of the employer. the subscriber's dependents will terminate the end of the month in which the subscriber's death occurred; See Definitions. _These words have zspecific meanings: ;benefits,dependent member,°placed for adoption, premium subscriber, total disabilaity � 9. For a spouse, the end of the month following the date of divorce; The paragraph below describes the continuation coverage provisions. State continuation is 10. For a dependent child, the end of the month in which the child is no longer eligible as a described in 1. and federal continuation is described in 2. dependent; or If your coverage ends, you should review your rights under both state law and federal law with 11. For a child who is entitled to coverage through a QMCSO, the end of the month in which the the employer. If you are entitled to continuation rights under both, the continuation provisions earliest of the following occurs: run concurrently and the more favorable continuation provision will apply to your coverage. a. The QMCSO ceases to be effective; or When your continuation coverage under this section ends, you have the option to enroll in an b. The child is no longer a child as that term is used in ERISA; or individual conversion health plan as described in Conversion. 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 1. Your right to continue coverage under state law as determined by the employer; or Notwithstanding the provisions regarding termination of coverage described in Ending e. The employer terminates family or dependent coverage; or Coverage, you may be entitled to extended or continued coverage as follows: f. The Contract is terminated by the employer or Medica; or a. Minnesota state continuation coverage. Continued coverage shall be provided as required under Minnesota law. Minnesota g. The relevant premium or contribution toward the premium is last paid. 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 the Contract. MIC FOCUSMN HSA(3/12) 98 1500-100% MIC FOCUSMN HSA(3/12) 99 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Continuation Continuation Subscriber's spouse's loss Type of coverage and cost The subscriber's covered spouse has the right to continuation coverage if he or she loses If continuation coverage is elected, the subscriber's employer is required to provide coverage under the Contract for any of the following reasons: coverage that, as of the time coverage is being provided, is identical to the coverage a. Death of the subscriber; 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 b. A termination of the subscriber's employment (for any reason other than gross to the employer of all or part of the premium for continuation coverage. The amount misconduct) or layoff from employment; charged cannot exceed 102 percent of the cost of the coverage. c. Dissolution of marriage from the subscriber; Surviving dependents of a deceased subscriber have 90 days after notice of the d. The subscriber's enrollment for benefits under Medicare. requirement to pay continuation premiums to make the first payment. Subscriber's child's loss Duration The subscriber's dependent child has the right to continuation coverage if coverage under Under the circumstances described above and for a certain period of time, Minnesota law the Contract is lost for any of the following reasons: requires that the subscriber and his or her dependents be allowed to maintain continuation a. Death of the subscriber if the subscriber is the parent through whom the child receives coverage as follows: coverage; a. For instances where coverage is lost due to the subscriber's termination of or layoff from b. Termination of the subscriber's employment (for any reason other than gross employment, coverage may be continued until the earliest of: misconduct) or layoff from employment; i. 18 months after the date of the termination of or layoff from employment; c. The subscriber's dissolution of marriage from the child's other parent; ii. The date the subscriber becomes covered under another group health plan (as an d. The subscriber's enrollment for benefits under Medicare if the subscriber is the parent employee or otherwise) that does not contain any exclusion or limitation with respect through whom the child receives coverage; to any applicable pre-existing condition; or e. The subscriber's child ceases to be a dependent child under the terms of the Contract. iii. The date coverage would otherwise terminate under the Contract. b. For instances where the subscriber's spouse or dependent children lose coverage Responsibility to inform because of the subscriber's enrollment under Medicare, coverage may be continued Under Minnesota law, the subscriber and dependents have the responsibility to inform the until the earliest of: employer of a dissolution of marriage or a child losing dependent status under the Contract i. 36 months after continuation was elected; within 60 days of the date of the event or the date on which coverage would be lost because ii. The date coverage is obtained under another group health plan; or of the event. iii. The date coverage would otherwise terminate under the Contract. Election rights c. For instances where dependent children lose coverage as a result of loss of dependent When the employer is notified that one of these events has happened, the subscriber and eligibility, coverage may be continued until the earliest of: the subscriber's dependents will be notified of the right to continuation coverage. i. 36 months after continuation was elected; Consistent with Minnesota law, the subscriber and dependents have 60 days to elect ii. The date coverage is obtained under another group health plan; or 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: iii. The date coverage would otherwise terminate under the Contract. a. The date coverage would be lost because of one of the events described above; or d. For instances of dissolution of marriage from the subscriber, coverage of the b. The date notice of election rights is received. subscriber's spouse and dependent children may be continued until the earliest of: If continuation coverage is elected within this period, the coverage will be retroactive to the i. The date the former spouse becomes covered under another group health plan; or date coverage would otherwise have been lost. ii. The date coverage would otherwise terminate under the Contract. The subscriber and the subscriber's covered spouse may elect continuation coverage on If dissolution of marriage occurs during the period of time when the subscriber's spouse behalf of other dependents entitled to continuation coverage. Under certain circumstances, is continuing coverage due to the subscriber's termination of or layoff from employment, the subscriber's covered spouse or dependent child may elect continuation coverage even if coverage of the subscriber's spouse may be continued until the earlier of: the subscriber does not elect continuation coverage. i. The date the former spouse becomes covered under another group health plan; or If continuation coverage is not elected, your coverage under the Contract will end. MIC FOCUSMN HSA (3/12) 100 1500-100% MIC FOCUSMN HSA (3/12) 101 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Continuation Continuation ii. The date coverage would otherwise terminate under the Contract. Qualified beneficiary e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent For purposes of this section, a qualified beneficiary is defined as: children may be continued until the earlier of: a. A covered employee (a current or former employee who is actually covered under a i. The date the surviving spouse and dependent children become covered under group health plan and not just eligible for coverage); another group health plan; or b. A covered spouse of a covered employee; or ii. The date coverage would have terminated under the Contract had the subscriber c. A dependent child of a covered employee. (A child placed for adoption with or born to lived. an employee or former employee receiving COBRA continuation coverage is also a Extension of benefits for total disability of the subscriber qualified beneficiary.) Coverage may be extended for a subscriber and his or her dependents in instances where Subscriber's loss the subscriber is absent from work due to total disability, as defined in Definitions. If the The subscriber has the right to elect continuation of coverage if there is a loss of coverage subscriber is required to pay all or part of the premium for the extension of coverage, under the Contract because of termination of the subscriber's employment (for any reason payment shall be made to the employer. The amount charged cannot exceed 100 percent other than gross misconduct), or the subscriber becomes ineligible to participate under the of the cost of the coverage. terms of the Contract due to a reduction in his or her hours of employment. 2. Your right to continue coverage under federal law Subscriber's spouse's loss The subscriber's covered spouse has the right to choose continuation coverage if he or she Notwithstanding the provisions regarding termination of coverage described in Ending loses coverage under the Contract for any of the following reasons: Coverage, you may be entitled to extended or continued coverage as follows: a. Death of the subscriber; COBRA continuation coverage b. A termination of the subscriber's employment (for any reason other than gross Continued coverage shall be provided as required under the Consolidated Omnibus Budget misconduct) or reduction in the subscriber's hours of employment with the employer; Reconciliation Act of 1985 (COBRA), as amended (as well as the Public Health Service Act c. Divorce or legal separation from the subscriber; or (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 d. The subscriber's entitlement to (actual coverage under) Medicare. General COBRA information in this section. Subscriber's child's loss USERRA continuation coverage The subscriber's dependent child has the right to continuation coverage if coverage under Continued coverage shall be provided as required under the Uniformed Services the Contract is lost for any of the following reasons: Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The a. Death of the subscriber if the subscriber is the parent through whom the child receives employer shall, within the parameters of federal law, establish uniform policies pursuant to coverage; which such continuation coverage will be provided. See General USERRA information in this section. 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; General COBRA information c. The subscriber's divorce or legal separation from the child's other parent; COBRA requires employers with 20 or more employees to offer subscribers and their d. The subscriber's entitlement to (actual coverage under) Medicare if the subscriber is the families (spouse and/or dependent children) the opportunity to pay for a temporary parent through whom the child receives coverage; or extension of health coverage (called continuation coverage) at group rates in certain dependent child under the terms of the Contract.e. The subscriber's child ceases to be a de instances where health coverage under employer sponsored group health plan(s) would p otherwise end. This coverage is a group health plan for purposes of COBRA. Responsibility to inform 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 Under federal law, the subscriber and dependent have the responsibility to inform the be provided than those required by federal law. Take time to read this section carefully. 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(3/12) 102 1500-100% MIC FOCUSMN HSA (3/12) 103 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Continuation Continuation Also, a subscriber and dependent who have been determined to be disabled under the The 18 months may be extended if a second event (e.g., divorce, legal separation, or death) Social Security Act as of the time of the subscriber's termination of employment or reduction I occurs during the initial 18-month period. It also may be extended to 29 months in the case of hours or within 60 days of the start of the continuation period must notify the employer of of an employee or employee's dependent who is determined to be disabled under the Social that determination within 60 days of the determination. If determined under the Social Security Act at the time of the employee's termination of employment or reduction of hours, Security Act to no longer be disabled, he or she must notify the employer within 30 days of or within 60 days of the start of the 18-month continuation period. the determination. 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 Bankruptcy extended to 29 months. If the subscriber becomes entitled to (actually covered under) Rights similar to those described above may apply to retirees (and the spouses and Medicare, the continuation period for the subscriber's dependents is 36 months measured dependents of those retirees), if the subscriber's employer commences a bankruptcy from the date of the subscriber's Medicare entitlement even if that entitlement does not proceeding and these individuals lose coverage. cause the subscriber to lose coverage. Under no circumstances is the total continuation period greater than 36 months from the date Election rights of the original event that triggered the continuation coverage. When notified that one of these events has happened, the employer will notify the Federal law provides that continuation coverage may end earlier for any of the following subscriber and dependents of the right to choose continuation coverage. reasons: Consistent with federal law, the subscriber and dependents have 60 days to elect a. The subscriber's employer no longer provides group health coverage to any of its continuation coverage, measured from the later of: employees; a. The date coverage would be lost because of one of the events described above; or b. The premium for continuation coverage is not paid on time; b. The date notice of election rights is received. c. Coverage is obtained under another group health plan (as an employee or otherwise) If continuation coverage is elected within this period, the coverage will be retroactive to the that does not contain any exclusion or limitation with respect to any applicable pre- date coverage would otherwise have been lost. existing condition; or The subscriber and the subscriber's covered spouse may elect continuation coverage on d. The subscriber becomes entitled to (actually covered under) Medicare. behalf of other dependents entitled to continuation coverage. However, each person entitled to continuation coverage has an independent right to elect continuation coverage. Continuation coverage may also end earlier for reasons which would allow regular coverage to The subscriber's covered spouse or dependent child may elect continuation coverage even be terminated, such as fraud. if the subscriber does not elect continuation coverage. General USERRA information If continuation coverage is not elected, your coverage under the Contract will end. 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 Type of coverage and cost continuation coverage) at group rates in certain instances where health coverage under If the subscriber and the subscriber's dependents elect continuation coverage, the employer employer sponsored group health plan(s) would otherwise end. This coverage is a group is required to provide coverage that, as of the time coverage is being provided, is identical to health plan for the purposes of USERRA. the coverage provided under the Contract to similarly situated employees or employees' This section is intended to inform you, in summary fashion, of your rights and obligations dependents. under the continuation coverage provision of federal law. It is intended that no greater rights Under federal law, a person electing continuation coverage may have to pay all or part of be provided than those required by federal law. Take time to read this section carefully. 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 Employee's loss premium for months after the 18th month of continuation coverage when the additional The employee has the right to elect continuation of coverage if there is a loss of coverage months are due to a disability under the Social Security Act. under the Contract because of absence from employment due to service in the uniformed There is a grace period of at least 30 days for the regularly scheduled premium. 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 Duration of COBRA coverage employer with advance notice of the employee's absence from employment (if it was Federal law requires that you be allowed to maintain continuation coverage for 36 months possible to do so). unless you lost coverage under the Contract because of termination of employment or Service in the uniformed services means the performance of duty on a voluntary or reduction in hours. In that case, the required continuation coverage period is 18 months. 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 (3/12) 104 1500-100% MIC FOCUSMN HSA(3/12) 105 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Continuation Continuation Guard duty, and the time necessary for a person to be absent from employment for an COBRA and USERRA coverage are concurrent examination to determine the fitness of the person to perform any of these duties. If the employer is subject to COBRA and USERRA, and you elect COBRA continuation Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army coverage in addition to USERRA continuation coverage, these coverages run concurrently. 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(3/12) 106 1500-100% MIC FOCUSMN HSA (3/12) 107 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Conversion 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 FF. Conversion within 31 days of the date you were notified of the right to convert coverage, whichever is later. What you must do See Definitions These words'have specific meanings continuous`coverage, dependent, premium, vuaiting period. - 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. Your conversion plan coverage may not provide the same coverage as your previous group 2. Pay premiums to Medica or Medica's designated conversion vendor within 63 days after health plan. Benefits and provider networks may be different. 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 Minnesota residents payment with your enrollment form for conversion coverage. This section describes your right to convert to a Medica individual conversion plan if you are a 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 63 resident of Minnesota on the day that you submit an enrollment form to Medica or Medica's 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 designated conversion vendor. under the Contract at the time of conversion. 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 What the employer must do pre-existing condition limitation. Contact the Minnesota Comprehensive Health Association for The employer is required to notify you of your right to convert coverage. further information: • For deductible plan options call 1-866-894-8053 or TTY: 1-800-841-6753. Residents of a state other than Minnesota • For Medicare Supplement plan options call 1-800-325-3540 or TTY: 1-800-234-8819. This section describes your right to convert to an individual conversion plan if you are a resident Overview of a state other than Minnesota on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. 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: Overview a. Your continuation coverage with Medica, as described in Continuation, is exhausted. You may convert to an individual conversion plan through Medica or Medica's designated b. Your coverage or continuation coverage ends because the Contract is terminated and conversion vendor without proof of good health or waiting periods, in accordance with the laws the Contract is not replaced with other continuous group coverage. of the state in which you reside on the day that you submit an enrollment form to Medica or Medica's designated conversion vendor. c. Your coverage ends under the Contract and you do not have the right to continue coverage as described in Continuation. What you must do 2. Your conversion plan goes into effect the day following the date your other coverage ends. 1. For conversion coverage information, call Customer Service at one of the telephone You may select a qualified 1, 2, or 3 conversion plan. You must maintain continuous numbers listed inside the front cover. coverage when applying for conversion coverage. 2. Pay premiums to Medica or Medica's designated conversion vendor within 31 days after 3. Conversion coverage is not available: your coverage ends or such other period of time as provided under applicable state law. a. When continuous coverage is not maintained; or You will be required to include your first month premium payment with your enrollment form b. If your coverage is terminated due to nonpayment of premium; or for conversion coverage. 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 c. If you have not exhausted your right to continue coverage as described in Continuation; days after your coverage ends or such other period of time as provided under applicable or state law. You may include only those dependents who were enrolled under the Contract at d. If your coverage or continuation coverage ends because the Contract is terminated and the time of conversion. 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 (3/12) 108 1500-100% MIC FOCUSMN HSA (3/12) 109 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Complaints 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 GG. Complaints ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without care or treatment you are requesting, Medica will process your claim as an expedited review. In such cases, Medica will notify you and your attending provider by This section describes what to do if you have a complaint or would like to appeal a decision telephone of its decision no later than 72 hours after receiving the request. made by Medica. 5. If Medica's first level review decision upholds the initial decision made by Medica, you may See Definitions. These words have specific meanings: claim, inpatient, network, provider. have a right to request a second level review or submit a written request for external review You may call Customer Service at one of the telephone numbers listed inside the front cover or as described in this section. 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 Second level of review 1-800-657-3602. If you are not satisfied with Medica's first level of review decision, you may request a second Filing a complaint may require that Medica review your medical records as needed to resolve level of review through either a written reconsideration or a hearing. your complaint. You may appoint an authorized representative to make a complaint on your behalf. You may be 1. Your request can be oral or in writing. It must be provided to Medica within one year required to sign an authorization which will allow Medica to release confidential information to following the date of Medica's first level review decision. If your request is in writing, it must your authorized representative and allow them to act on your behalf during the complaint be sent to the address listed above in First level of review, 2. process. 2. Regardless of the method chosen for review (hearing or a written reconsideration), Upon request, Medica will assist you with completion and submission of your written complaint. testimony, explanation or other information provided by you, Medica staff, providers, and Medica will also complete a complaint form on your behalf and mail it to you for your signature others is reviewed. upon request. 3. Medica will provide written notice of its second level review decision to you within: In addition to directing complaints to Customer Service as described in this section, you may a. 30 calendar days from receipt of written notice of your appeal for required second level direct complaints at any time to the Commissioner of Commerce at the telephone number listed reviews; or at the beginning of this section. b. 45 calendar days from receipt of written notice of your appeal for optional second level reviews. First level of review 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 You may direct any question or complaint to Customer Service by calling one of the telephone optional before you may submit a request for external review. Generally, a second level review numbers listed inside the front cover or by writing to the address listed below. is optional if the complaint requires a medical determination. Medica will inform you in writing 1. If your complaint is regarding an initial decision made by Medica, your complaint must be whether the second level of review is optional or required. 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 External review 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, If you consider Medica's decision to be partially or wholly adverse to you, you may submit a Medica will provide you with a complaint form to submit your complaint in writing. Mail the written request for external review of Medica's decision to the Commissioner of Commerce at: completed form to: Minnesota Department of Commerce Customer Service 85 7th Place East, Suite 500 Route 0501 St. Paul, MN 55101-2198 PO Box 9310 You must include a filing fee of$25 with your written request, unless waived by the Minneapolis, MN 55440-9310 Commissioner. An independent entity contracted with the State Commissioner of 3. Medica will provide written notice of its first level review decision to you and your attending Administration will review your request. The external review decision will not be binding on you provider, when applicable, within 30 calendar days from receipt of your complaint or request. but will be binding on Medica. Medica may seek judicial review on the grounds that the decision 4. When an initial decision by Medica not to grant a prior authorization request is made before was arbitrary and capricious or involved an abuse of discretion. Contact the Commissioner of or during an ongoing service requiring Medica's authorization, and your attending provider Commerce for more information about the external review process. believes that Medica's decision warrants an expedited appeal, you or your attending MIC FOCUSMN HSA(3/12) 110 1500-100% MIC FOCUSMN HSA (3/12) 111 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Complaints General Provisions Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be submitted for external review. HH. General Provisions Civil action If you are dissatisfied with Medica's first or second level review decision or the external review This section describes the general provisions of the Contract. decision, you have the right to file a civil action under section 502(a) of the Employee See°3 Definitions.s;These`words have specific meanings:;benefits,'claim,udependent, member, Retirement Income Security Act (ERISA). network, 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 Medics. 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 (3/12) 112 1500-100% MIC FOCUSMN HSA(3/12) 113 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 General Provisions Definitions Discretionary authority Medica has discretion to interpret and construe all of the terms and conditions of the Contract Definitions and make determinations regarding benefits and coverage under the Contract, provided, however, that this provision shall not be construed to specify a standard of review upon which a court may review a claim denial or any other decision made by Medica with respect to a In this certificate (and in any amendments), some words have specific meanings. Within each member. 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 Prescription Specialty 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. MIC FOCUSMN HSA (3/12) 114 1500-100% MIC FOCUSMN HSA (3/12) 115 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Definitions Definitions Convenience care/retail health clinic. A health care clinic located in a setting such as a retail you must provide Medica with proof of such disability and dependency at the time of the store, grocery store, or pharmacy, which provides treatment of common illnesses and certain dependent's enrollment. preventive health care services. Designated facility. A network hospital that Medica has authorized to provide certain Cosmetic. Services and procedures that improve physical appearance but do not correct or benefits to members, as described in this certificate. improve a physiological function, and that are not medically necessary, unless the service or Emergency. A condition or symptom (including severe pain) that a prudent layperson, who procedure meets the definition of reconstructive. possesses an average knowledge of health and medicine, would believe requires immediate Custodial care. Services to assist in activities of daily living that do not seek to cure, are treatment to: performed regularly as a part of a routine or schedule, and, due to the physical stability of the 1. Preserve your life; or 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 2. Prevent serious impairment to your bodily functions, organs, or parts; or toilet, preparation of special diets, and supervision of medication that can usually be self- 3. Prevent placing your physical or mental health (or, if you are pregnant, the health of your administered. unborn child) in serious jeopardy. Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims Enrollment date. The date of the eligible employee's or dependent's first day of coverage for health services or supplies received from network or non-network providers are under the Contract or, if earlier, the first day of the waiting period for the eligible employee's or reimbursable as in-network or out-of-network benefits under this certificate. dependent's enrollment. Dependent. Unless otherwise specified in the Contract, the following are considered Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if dependents: the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing includes 1. The subscriber's spouse. pharmacogenetic testing. Genetic testing does not include an analysis of proteins or 2. The following dependent children up to the dependent limiting age of 26: 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. a. The subscriber's or subscriber's spouse's natural or adopted child; Home clinic. The primary care clinic site within the Medica Focus network that you choose to b. A child placed for adoption with the subscriber or subscriber's spouse; collaborate with for your healthcare needs. c. A child for whom the subscriber or the subscriber's spouse has been appointed legal Hospital. A licensed facility that provides diagnostic, medical, therapeutic, rehabilitative, and guardian; however, upon request by Medica, the subscriber must provide satisfactory surgical services by, or under the direction of, a physician and with 24-hour R.N. nursing proof of legal guardianship; services. The hospital is not mainly a place for rest or custodial care and is not a nursing d. The subscriber's stepchild; and home or similar facility. e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing upon and resides with the subscriber or subscriber's spouse continuously from birth. 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 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent condition. incapable of self-sustaining employment by reason of developmental disability, mental Investigative. As determined by Medica, a drug, device, diagnostic or screening procedure, or illness, mental disorder, or physical disability and is chiefly dependent upon the subscriber medical treatment or procedure is investigative if reliable evidence does not permit conclusions for support and maintenance. An illness that does not cause a child to be incapable of self- concerning concerning its safety, effectiveness, or effect on health outcomes. Medica will make its sustaining employment will not be considered a physical disability. This dependent may determination based upon an examination of the following reliable evidence, none of which shall 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 be determinative and of itself: provide Medica with proof of such disability and dependency within 31 days of the child 1. Whether there is final approval from the appropriate government regulatory agency, if reaching the dependent limiting age set forth in 2. above. Beginning two years after the required, including whether the drug or device has received final approval to be marketed for child reaches the dependent limiting age, Medica may require annual proof of disability and its proposed use by the United States Food and Drug Administration (FDA), or whether the dependency. treatment is the subject of ongoing Phase I, II, or III trials; For residents of a state other than Minnesota, the dependent limiting age may be higher if 2. Whether there are consensus opinions and recommendations reported in relevant scientific required by applicable state law. and medical literature, peer-reviewed journals, or the reports of clinical trial committees and 4. The subscriber's or subscriber's spouse's disabled dependent who is incapable of self- other technology assessment bodies; and sustaining employment by reason of developmental disability, mental illness, mental 3. Whether there are consensus opinions of national and local health care providers in the disorder, or physical disability and is chiefly dependent upon the subscriber or applicable specialty or subspecialty that typically manages the condition as determined by a subscriber's spouse for support and maintenance. For coverage of a disabled dependent, survey or poll of a representative sampling of these providers. MIC FOCUSMN HSA(3/12) 116 1500-100% MIC FOCUSMN HSA (3/12) 117 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 Definitions i Definitions Notwithstanding the above, a drug being used for an indication or at a dosage that is an Non-network provider reimbursement amount. The amount that Medica will pay to a non- accepted off-label use for the treatment of cancer will not be considered by Medica to be network provider for each benefit is based on one of the following, as determined by Medica: investigative. Medica will determine if a use is an accepted off-label use based on published 1. A percentage of the amount Medicare would pay for the service in the location where the reports in authoritative peer-reviewed medical literature, clinical practice guidelines, or service is provided. Medica generally updates its data on the amount Medicare pays within parameters approved by national health professional boards or associations, and entries in any 30-60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; authoritative compendia as identified by the Medicare program for use in the determination of a or medically accepted indication of drugs and biologicals used off-label. j Late entrant. An eligible employee or dependent who requests enrollment under the Contract 2. A percentage of the provider's billed charge; or other than during: 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 1. The initial enrollment period set by the employer; or service is provided; or 2. The open enrollment period set by the employer; or 4. An amount agreed upon between Medica and the non-network provider. 3. A special enrollment period as described in Eligibility And Enrollment. Contact Customer Service for more information concerning which method above pertains to However, an eligible employee or dependent who is an enrollee of the Minnesota your services, including the applicable percentage if a Medicare-based approach is used. Comprehensive Health Association (MCHA) at the time Medica offers or renews coverage with For certain benefits, you must pay a portion of the non-network provider reimbursement the employer will not be considered a late entrant, provided the eligible employee or amount as a coinsurance. dependent maintains continuous coverage as defined in this certificate. In addition, if the amount billed by the non-network provider is greater than the non-network In addition, a member who is a child entitled to receive coverage through a QMCSO is not provider reimbursement amount, the non-network provider will likely bill you for the subject to any initial or open enrollment period restrictions. difference. This difference may be substantial, and it is in addition to any coinsurance or Medically necessary. Diagnostic testing and medical treatment, consistent with the diagnosis deductible amount you may be responsible for according to the terms described in this of and prescribed course of treatment for your condition, and preventive services. Medically certificate. Furthermore, such difference will not be applied toward the out-of-pocket maximum described in Your Out-Of-Pocket Expenses. Additionally,care must meet the following criteria: p y, you will owe these amounts 1. Be consistent with the medical standards and accepted practice parameters of the 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 community as determined by health care providers in the same or similar general specialty a non-network provider will likely be much higher than if you had received services from a as typically manages the condition, procedure, or treatment at issue; and network provider. 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene- diagnosis or condition; and based information to determine the proper drug and dosage for an individual. 3. Help to restore or maintain your health; or Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared from the body of an individual based on their genetic makeup. 4. Prevent deterioration of your condition; or 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. Physan. 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 Member. A person who is enrolled under the Contract. scope of his or her licensure. Mental disorder. A physical or mental condition having an emotional or psychological origin, Placed for adoption. The assumption and retention of the legal obligation for total or partial as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders support of the child in anticipation of adopting such child. (DSM). (Eligibility for a child placed for adoption with the subscriber ends if the placement is Network. A term used to describe a provider (such as a hospital, physician, home health interrupted before legal adoption is finalized and the child is removed from placement.) agency, skilled nursing facility, or pharmacy) that has entered into a written agreement with Premium. The monthly payment required to be paid by the employer on behalf of or for you. Medica or has made other arrangements with Medica to provide benefits to you. The participation status of providers will change from time to time. Prenatal care. The comprehensive package of medical and psychosocial support provided The Medica Focus network provider directory will be furnished automatically, without charge. 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 Non-network. A term used to describe a provider not under contract as a network provider. 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. MIC FOCUSMN HSA (3/12) 118 1500-100% MIC FOCUSMN HSA(3/12) 119 1500-100% BPL 21317 DOC 23932 BPL 21317 DOC 23932 i Definitions Definitions Preventive health service. The following are considered preventive health services: 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. 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; government, or a foreign country. 2. Immunizations for routine use that have in effect a recommendation from the Advisory Coverage of the following types, including any combination of the following types, are not Committee on Immunization Practices of the Centers for Disease Control and Prevention qualifying coverage: with respect to the member involved; 1. Coverage only for disability or income protection insurance; 3. With respect to members who are infants, children, and adolescents, evidence-informed 2. Automobile medical payment coverage; preventive care and screenings provided for in the comprehensive guidelines supported by 3. Liability insurance or coverage issued as a supplement to liability insurance; the Health Resources and Services Administration; 4. Coverage for a specified disease or illness or to provide payments on a per diem, fixed 4. With respect to members who are women, such additional preventive care and screenings indemnity, or non-expense-incurred basis, if offered as independent, non-coordinated not described in 1. as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. coverage; Contact Customer Service for information regarding specific preventive health services, 5. Credit accident and health insurance as defined under Minnesota law; services that are rated A or B, and services that are included in guidelines supported by the 6. Coverage designed solely to provide dental or vision care; Health Resources and Services Administration. 7. Accident only coverage; Provider. A health care professional or facility licensed, certified, or otherwise qualified under 8. Long-term care coverage as defined under Minnesota law; state law to provide health services. Qualifying coverage. Health coverage provided under one of the following plans: 9. Medicare supplemental health insurance as defined under Minnesota law; 1. A health plan in which a health carrier has issued a policy, contract, or certificate for the 10. Workers' compensation insurance; or coverage of medical and hospital benefits, including blanket accident and sickness 11. Coverage for on-site medical clinics operated by an employer for the benefit of the insurance other than accident only coverage; employer's employees and their dependents, in connection with which the employer does 2. Part A or Part B of Medicare; not transfer risk. 3. A medical assistance medical care plan as defined under Minnesota law; Reconstructive. Surgery to rebuild or correct a: 4. A general assistance medical care plan as defined under Minnesota law; 1. Body part when such surgery is incidental to or following surgery resulting from injury, sickness, or disease of the involved body part; or 5. Minnesota Comprehensive Health Association (MCHA); 2. Congenital disease or anomaly which has resulted in a functional defect as determined by 6. A self-insured health plan; your physician. 7. The MinnesotaCare program as defined under Minnesota law; 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 8. The public employee insurance plan as defined under Minnesota law; appearance shall be considered reconstructive. 9. The Minnesota employees insurance plan as defined under Minnesota law; Restorative. Surgery to rebuild or correct a physical defect that has a direct adverse effect on 10. TRICARE or other similar coverage provided under federal law applicable to the armed the physical health of a body part, and for which the restoration or correction is medically forces; necessary. 11. Coverage provided by a health care network cooperative or by a health provider Routine foot care. Services that are routine foot care may require treatment by a cooperative; professional and include but are not limited to any of the following: 12. The Federal Employees Health Benefits Plan or other similar coverage provided under 1. Cutting, paring, or removing corns and calluses; federal law applicable to government organizations and employees; 2. Nail trimming, clipping, or cutting; and 13. A medical care program of the Indian Health Service or of a tribal organization; 3. Debriding (removing toenails, dead skin, or underlying tissue). 14. A health benefit plan under the Peace Corps Act; Routine foot care may also include hygiene and preventive maintenance such as: 15. State Children's Health Insurance Program; or 1. Cleaning and soaking the feet; and 2. Applying skin creams in order to maintain skin tone. • MIC FOCUSMN HSA(3/12) 120 1500-100% MIC FOCUSMN HSA (3/12) 121 BPL 21317 DOC 23932 BPL 21317 DOC 23932 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. 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. Virtual care. Professional evaluation and medical management services provided to patients through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth services. Virtual care is used to address non-urgent medical symptoms for patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Virtual care does not include telephone calls for reporting normal lab or test results, or solely calling in a prescription to a pharmacy. 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 (3/12) 122 1500-100% BPL 21317 DOC 23932 Medica Choice Passport Certificate of Coverage MEDICA, MIC PP MN (3/12) 100%-15 BPL 85259 DOC 23705 I MEDICA CUSTOMER SERVICE Table Of Contents Table Of Contents Minneapolis/St. Paul Hearing Impaired: Introduction x Metro Area: National Relay Center Medical Loss Ratio (MLR) standards under the federal Public Health Service Act x (952) 945-8000 1 -800-855-2880 then To be eligible for benefits xi ask them to dial Medica Language interpretation xi Outside the Metro Area: at 1 -800-952-3455 Acceptance of coverage xi 1 -800-952-3455 Nondiscrimination policy xii More information about the plan can also be obtained by I A. Member Rights And Responsibilities 1 signing in at www.mymedica.com. Member bill of rights 1 Member responsibilities 1 B. How To Access Your Benefits 3 l '1 Important member information about in-network benefits 3 4t1.9 . csir- -1 yv1t fj_y11-1 i ,:-,tL_,1*..1..IA Ec.nn saM xyxcxa noMOrrth B nepesoJte 3TOc Important member information about out-of-network benefits 5 ',Li. Da& 4...i):,41 4i,ta.c.lc.t,.•-cL',y 45 4�t Hue opMauxn, HO3BOHHTe no rroMepy, yxa3arrxoMy xa o6paTxort cTOpoxe Barn a Continuity of care 7 Medica .l z,...uit a ,L,tt ` °:yu1t Me,reunacxoil xapTOUxn maim Medica. Prior authorization 8 Haddii aad doonayso inAfSoornaali laguugu Gr,ei;ttttsijnr;icinin r>lrunnifrir riscinUi-Niiile tafttiie Certification of qualifying coverage 9 tarjamadda macluumaadkani,oo lacag ct,ttt p afl tVlt 110 fp 1:,in i tt ,`'irr�rii tmT Medica't la'aan ah, Fadlan wac Lambarka ku goran C. How Providers Are Paid By Medica 10 . Kaarka Caafimaadka ee Medica dhabarkiisa. Si usted desca ayuda gratuita Para traducir esta informacion, llame al numero de Network providers 10 Ako zelite i lef besplatano tumacenje ovih teono situado al reverso de su tarjeta p j Non-network providers 10 informacija posovite broj na pozadini vase de identificacion de Medica. D. Your Out-Of-Pocket Expenses 11 Medica kartice_ Neu quy vi muon dirge giup do.dich tai lieu nay mien phi,sin g i sc ghi et rntt sau the Medica cua quy vi. Copayments, coinsurance, and deductibles 11 Yog koj xav tau key pab txhais coy ntaub ntawv no dawb, rau tus xov tooj nyob Dine k'ehji shich`i'hadoodzih niniz.ingo,beesh More information concerning deductibles 12 b nram gab koj daim Medica Khaj (card). bee hane'e binumber naaltsoos bikaahigii bich'i' hodiilnih ei doodaii bee neehozin biniiye I Out-of-pocket maximum 12 nanitinigii bine'dee bikaa doo aldo'. Lifetime maximum amount 13 .ri .na Er-itz bc. dnil° 141r.m•iu 7x11,vi ,•.E,ua�.niitni.3Zu sinta poi'';;..ern ir'r:c;r..ctw:aGl�lu7!..inzcs 3Medica Para sa tulong sa Tagalog,tawagan ang I Out-of-Pocket Expenses 14 numerong kabilang sa dokumentong ito o sa Yoo odeeyssi kun bilashitti afaan keetitti akka likod ng iyong ID card. E. Ambulance Services 15 ¢ sii hiikamu feete lakkoofsa caaardiii meedikaa - _Wril3�INJ , =i #.#T7.tK ,jE;t.A, Covered 15 (Medica) garna dubaarra jiru kana bilbili. --11 f tJ iM�j E3o Not covered 15 urvv,o„ — Ambulance services or ambulance transportation 16 If you want free help translating this information, call the number on the back of your Medica identification card. Non-emergency licensed ambulance service 16 `- J F. Durable Medical Equipment And Prosthetics 17 ' Covered 17 Not covered 18 ©2012 Medica. Medica®is a registered service mark of Medica Health Plans. "Medica"refers to the family of health I plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, MIC PP MN (3/12) III 100%-15 th Medica Self-Insured, and Medica Health Management, LLC. BPL 85259 DOC 23705 Table Of Contents Table Of Contents Durable medical equipment and certain related supplies 18 Covered 30 Repair, replacement, or revision of durable medical equipment 18 Additional information about coverage of maternity services 31 Prosthetics 18 Not covered 31 Hearing aids 19 Prenatal services 31 G. Home Health Care 20 Inpatient hospital stay for labor and delivery services 32 Covered 20 Professional services received during an inpatient stay for labor and delivery 32 Not covered 21 Anesthesia services received during an inpatient stay for labor and delivery 32 Intermittent skilled care 21 Labor and delivery services at a freestanding birth center 32 Skilled physical, speech, or occupational therapy 21 Home health care visit following delivery 33 Home infusion therapy 22 L. Medical-Related Dental Services 34 Services received in your home from a physician 22 Covered 34 • H. Hospice Services 23 Not covered 34 Covered 23 Charges for medical facilities and general anesthesia services 35 Not covered 24 Orthodontia, dental implants, and oral surgery related to cleft lip and palate 35 Hospice services 24 Accident-related dental services 36 I. Hospital Services 25 Oral surgery 36 Covered 25 M. Mental Health 37 Not covered 25 Covered 38 Outpatient services 26 Not covered 39 Services provided in a hospital observation room 26 Office visits, including evaluations, diagnostic, and treatment services 40 Inpatient services 26 Intensive outpatient programs 40 Services received from a physician during an inpatient stay 26 Inpatient services (including residential treatment services) 40 Anesthesia services received from a provider during an inpatient stay 26 N. Miscellaneous Medical Services And Supplies 41 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 27 Covered 41 J. Infertility Diagnosis 28 Not covered 41 Covered 28 Blood clotting factors 42 Not covered 28 Dietary medical treatment of PKU 42 Office visits, including any services provided during such visits 29 Amino acid-based elemental formulas 42 Virtual care 29 Total parenteral nutrition 42 Outpatient services received at a hospital 29 Eligible ostomy supplies 42 Inpatient services 29 Insulin pumps and other eligible diabetic equipment and supplies 42 Services received from a physician during an inpatient stay 29 O. Organ And Bone Marrow Transplant Services 43 Anesthesia services received from a provider during an inpatient stay 29 Covered 43 K. Maternity Services 30 Not covered 44 Newborns' and Mothers' Health Protection Act of 1996 30 I Office visits 44 MIC PP MN (3/12) iv 100%-15 MIC PP MN (3/12) v 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Table Of Contents Table Of Contents Virtual care 44 Specialty prescription drugs received from a designated specialty pharmacy 59 Outpatient services 45 Specialty growth hormone received from a designated specialty pharmacy 59 Inpatient services 46 S. Professional Services 60 Services received from a physician during an inpatient stay 46 Covered 60 Anesthesia services received from a provider during an inpatient stay 46 Not covered 61 Transportation and lodging 46 Office visits 61 P. Physical, Speech, And Occupational Therapies 48 Virtual care 61 Covered 48 Convenience care/retail health clinic visits 62 Not covered 48 Urgent care center visits 62 Physical therapy received outside of your home 49 Preventive health care 63 Speech therapy received outside of your home 49 Allergy shots 63 Occupational therapy received outside of your home 50 Routine annual eye exams 63 Q. Prescription Drug Program 51 Chiropractic services 63 Preferred drug list 51 Surgical services 64 Exceptions to the preferred drug list 51 Anesthesia services received from a provider during an office visit or an outpatient hospital Prior authorization 52 or ambulatory surgical center visit 64 Step therapy 52 Services received from a physician during an emergency room visit 64 Quantity limits 52 Services received from a physician during an inpatient stay 64 Covered Anesthesia services received from a provider during an inpatient stay 64 52 Prescription unit 53 Outpatient lab and pathology 64 Outpatient x-rays and other imaging services 64 Not covered 54 Outpatient covered drugs 55 Other outpatient hospital or ambulatory surgical center services 64 Diabetic equipment and supplies, including blood glucose meters 55 Treatment to lighten or remove the coloration of a port wine stain 65 Tobacco cessation products 55 Treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder 65 Diabetes self-management training and education 65 Drugs and other supplies considered preventive health services 56 66 R. Prescription Specialty Drug Program 57 Neuropsychological evaluations/cognitive testing Designated specialty pharmacies 57 Services related to lead testing 66 Specialty preferred drug list 57 Vision therapy and orthoptic and/or pleoptic training 66 Genetic counseling 66 Exceptions to the specialty preferred drug list 57 Genetic testing 66 Prior authorization 58 Step therapy 58 T. Reconstructive And Restorative Surgery 67 Quantity limits 58 Covered 67 Covered Not covered 67 58 Office visits 68 Prescription unit 58 Virtual care 68 Not covered 59 MIC PP MN (3/12) vi 100%-15 MIC PP MN (3/12) vii 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 T Table Of Contents Table Of Contents Outpatient services 68 Right of recovery 87 Inpatient services 69 BB. Right Of Recovery 88 Services received from a physician during an inpatient stay 69 CC. Eligibility And Enrollment 89 Anesthesia services received from a provider during an inpatient stay 69 Who can enroll 89 U. Skilled Nursing Facility Services 70 How to enroll 89 Covered 70 Notification 89 Not covered 70 Initial enrollment 89 Daily skilled care or daily skilled rehabilitation services 71 Open enrollment 90 Skilled physical, speech, or occupational therapy 71 Special enrollment 90 Services received from a physician during an inpatient stay in a skilled nursing facility Late enrollment 93 V. Substance Abuse 72 Qualified Medical Child Support Order (QMCSO) 93 Covered 73 The date your coverage begins 94 Not covered 74 DD. Ending Coverage 95 Office visits, including evaluations, diagnostic, and treatment services 74 When coverage ends 95 Intensive outpatient programs 74 EE. Continuation 97 Opiate replacement therapy 74 Your right to continue coverage under state law 97 Inpatient services (including residential treatment services) 75 Your right to continue coverage under federal law 100 W. Referrals To Non-Network Providers 76 FF. Conversion 106 What you must do 76 Minnesota residents 106 What Medica will do 76 Residents of a state other than Minnesota 107 X. Harmful Use Of Medical Services 78 GG. Complaints 108 When this section applies 78 First level of review 108 Y. Exclusions 79 Second level of review 109 Z. How To Submit A Claim 82 External review 109 Claims for benefits from network providers 82 Civil action 110 Claims for benefits from non-network providers 82 HH. General Provisions 111 Claims for services provided outside the United States 83 Definitions 113 Time limits 83 AA. Coordination Of Benefits 84 Applicability 84 Definitions that apply to this section 84 Order of benefit determination rules 85 Effect on the benefits of this plan 86 Right to receive and release needed information 87 Facility of payment 87 MIC PP MN (3/12) viii 100%-15 MIC PP MN (3/12) ix 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Introduction Introduction To be eligible for benefits Introduction 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- THIS POLICY IS REGULATED BY MINNESOTA LAW. network benefits; and The benefits of the policy 2. Identify yourself as a Medica member; and p y providing your coverage are governed primarily by the law of a state other than Florida. 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 Many words in this certificate have specific meanings These words are identified in each for health services or be pay required to at the time you receive health services.) However, section and defined in Definitions q Y possession and use of a Medica identification card does not necessarily guarantee e. See Definitions These words have specific m§eamngs benefits, claim, dependent, member, covers g network, premium,°provider. w:; _: = Network providers are required to submit claims within 180 days from when you receive a Medica Insurance Company (Medica) offers Medica Choice Passport. This is a Minnesota service. If your provider asks for your health care identification card and you do not identify number one qualified plan. This Certificate of Coverage (this certificate) describes health yourself as a Medica member within 180 days of the date of service, you may be responsible for services that are eligible for coverage and the procedures you must follow to obtain benefits. paying the cost of the service you received. The Contract refers to the Contract between Medica and the employer. You should contact the ua a Lan interpretation employer to see the Contract. Language p Because many provisions are interrelated, you should read this certificate in its entirety. Language interpretation services will be provided upon request, as needed in connection with Reviewing just one or two sections may not give you a complete understanding of the coverage the interpretation of this certificate. If you would like to request language interpretation services, described. The most specific and appropriate section will apply for those benefits related to the please call Customer Service at one of the telephone numbers listed inside the front cover. treatment of a specific condition. If you have an impairment that requires alternative communication formats such as Braille, large Members are subject to all terms and conditions of the Contract and health services must be print, or audiocassettes, please call Customer Service at one of the telephone numbers listed medically necessary. inside the front cover to request these materials. Medica may arrange for various persons or entities to provide administrative services on its If this certificate is translated into another language or an alternative communication format is behalf, including claims processing, and utilization management services. To ensure efficient used, this written English version governs all coverage decisions. administration of your benefits, you must cooperate with them in the performance of their responsibilities. Acceptance of coverage Additional network administrative support is provided by one or more organizations under contract with Medica. This certificate is not a legal contract between you and Medica. It is simply an explanation of The employer is responsible for remitting the premium to Medica and notifying you of any the benefits covered under the Contract that has been issued in Minnesota between Medica and changes to this certificate as required by applicable law. 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 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. 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 Medical Loss Ratio (MLR) standards under the federal Public Health Service Act by state law; and 2. That the information supplied by you to Medica for purposes of enrollment is accurate and Federal law establishes standards concerning the percentage of premium revenue that insurers complete. pay out for claims expenses and health care quality improvement activities. If the amount an You understand and agree that any omission or incorrect statement concerning a material fact insurer pays out for such expenses and activities is less than the applicable MLR standard, the insurer is required to provide a premium rebate. MLR calculations are based on aggregate intentionally made by you in connection with your enrollment under the Contract may invalidate market data rather than on a group by group basis. In the event Medica is required to pay your coverage. rebates pursuant to federal law, Medica will pay such rebates to your employer unless prohibited by federal law. MIC PP MN (3/12) x 100%-15 MIC PP MN (3/12) xi 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Introduction Member Rights And Responsibilities Nondiscrimination policy Medica's policy is to treat all persons alike, without distinctions based on race, color, creed, A. Member Rights And Responsibilities 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. See Definitions. These words have specific meanings: benefits, emergency, member, If you have questions, call Customer Service at one of the telephone numbers listed inside the network, provider. front cover. 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 PP MN (3/12) xii 100%-15 MIC PP MN (3/12) 1 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 1 Member Rights And Responsibilities How To Access Your Benefits 4. Practicing self-care by knowing: a. How to recognize common health problems and what to do when they occur; and B. How To Access Your Benefits b. When and where to seek appropriate help; and c. How to prevent health problems from recurring; and See Definitions These words have specific meanings: benefits, claim, coinsurance, copayment, deductible, dependent, emergency„enrollment date;:hospital, inpatient, late entrant 5. Practicing preventive health care by: member, netwo rk, non-network, non network provider reimbursement amount, physician, placed a. Having the appropriate tests, exams and immunizations recommended for your gender for adoption, premium, prescription prescrip tion dru g, provider, qualifying coverage, reconstructive, i and age as described in this certificate; and restorative, skilled Nrsing facility, subscriber;virtual care,waiting5 period. b. Engaging in healthy lifestyle choices (such as exercise, proper diet, and rest). Provider network You will find additional information on member responsibilities in this certificate. 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 PP MN (3/12) 2 100%-15 MIC PP MN (3/12) 3 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 How To Access Your Benefits How To Access Your Benefits be eligible for in-network benefits. You must verify that your provider is a network provider 2. Important member information about out-of-network benefits each time you receive health services. The information below describes your covered health services and provides important Exclusions 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 Certain health services are not covered. Read this certificate for a detailed explanation of all general sections of this certificate as well as the section(s)that specifically describe the exclusions. services you are considering, so you are best able to determine the benefits that will apply Mental health and substance abuse to you. Medica's designated mental health and substance abuse provider will arrange your mental Benefits health and substance abuse benefits. Medica's designated mental health and substance Medica pays out-of-network benefits for eligible health services received from non-network abuse provider's hospital network is different from Medica's hospital network. Certain providers. Prior authorization may be required from Medica before you receive certain mental health and substance abuse services require prior authorization by Medica's services, in order to determine whether those services are eligible for coverage under your designated mental health and substance abuse provider. Emergency services do not out-of-network benefits. This certificate defines your benefits and describes procedures you require prior authorization. must follow to obtain out-of-network benefits. • Continuation/conversion 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 You may continue coverage or convert to an individual conversion plan under certain inappropriate utilization of services. circumstances. See Continuation and Conversion for additional information. Emergency services received from non-network providers are covered as in-network Cancellation benefits and are not considered out-of-network benefits. Your coverage may be canceled only under certain conditions. This certificate describes all Additionally, under certain circumstances Medica will authorize your obtaining services from reasons for cancellation of coverage. See Ending Coverage for additional information. 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 Newborn coverage providers. Your dependent newborn is covered from birth. Medica does not automatically know of a Be aware that if you choose to go to a non-network provider and use out-of-network birth or whether you would like coverage for the newborn dependent. Call Customer benefits, you will likely have to pay much more than if you use in-network benefits. Service at one of the telephone numbers listed inside the front cover for more information. To The charges billed by your non-network provider may exceed the non-network provider be eligible for in-network benefits, health services must be provided by a network provider or reimbursement amount, leaving a balance for you to pay in addition to any applicable authorized by Medica. Certain services are covered only upon referral. If additional copayment, coinsurance, and deductible amount. This additional amount you must pay to premium is required, Medica is entitled to all premiums due from the time of the infant's birth the provider will not be applied toward the out-of-pocket maximum amount described in Your until the time you notify Medica of the birth. Medica may reduce payment by the amount of Out-Of-Pocket Expenses and you will owe this amount regardless of whether you previously premium that is past due for any health benefits for the newborn infant until any premium reached your out-of-pocket maximum with amounts paid for other services. Please see the you owe is paid. For more information, see Eligibility And Enrollment. example calculation below. Prescription drugs and medical equipment 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- Enrolling in Medica does not guarantee that a particular prescription drug or piece of medical network provider: equipment will continue to be covered, even if the drug or equipment is covered at the start of the calendar year. • Discuss the expected billed charges with your non-network provider; and • Contact Customer Service to verify the estimated non-network provider reimbursement Post-mastectomy coverage amount for those services, so you are better able to calculate your likely out-of-pocket Medica will cover all stages of reconstruction of the breast on which the mastectomy was expenses; and performed and surgery and reconstruction of the other breast to produce a symmetrical • If you wish to request that Medica authorize the non-network provider's services be appearance. Medica will also cover prostheses and physical complications, including covered at the in-network benefit level, follow the procedure described under Prior lymphedemas, at all stages of mastectomy. authorization in How To Access Your Benefits. MIC PP MN (3/12) 4 100%-15 MIC PP MN (3/12) 5 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 How To Access Your Benefits How To Access Your Benefits An example of how to calculate your out-of-pocket costs* 3. Continuity of care You choose to receive non-emergency inpatient care at a non-network hospital provider To request continuity of care or if you have questions about how this may apply to you, call without an authorization from Medica providing for in-network benefits. The out-of-network Customer Service at one of the telephone numbers listed inside the front cover. 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 In certain situations, you have a right to continuity of care. bills $30,000 for your hospital stay. Medica's non-network provider reimbursement amount a. If your current provider is terminated without cause, you may be eligible to continue care for those hospital services is $15,000. You must pay a portion of the non-network provider with that provider at the in-network benefit level. 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 b. If you are a new Medica member as a result of your employer changing health plans and the non-network provider reimbursement amount. If your coinsurance is 40%, you will be your current provider is not a network provider, you may be eligible to continue care with required to pay: that provider at the in-network benefit level. This applies only if your provider agrees to comply with Medica's prior authorization • 40% coinsurance (40% of$15,000 = $6,000) and requirements, provide all necessary medical information related to your care, and accept • The billed charges that exceed the non-network provider reimbursement amount as payment in full the lesser of the network provider reimbursement or the provider's ($30,000 - $15,000 = $15,000) customary charge for the service. This does not apply when a provider's contract is • The total amount you will owe is $6,000 + $15,000 = $21,000. terminated for cause. • The $6,000 you pay as coinsurance will be applied to the out-of-pocket maximum i. Upon request, Medica will authorize continuity of care for up to 120 days as amount described in Your Out-Of-Pocket Expenses. However, the $15,000 amount you described in a. and b. above for the following conditions: pay for billed charges in excess of the non-network provider reimbursement amount will • an acute condition; 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 • a life-threatening mental or physical illness; you have previously reached your out-of-pocket maximum with amounts paid for other • pregnancy beyond the first trimester of pregnancy; services. • a physical or mental disability defined as an inability to engage in one or more *Note: The numbers in this example are used only for purposes of illustrating how out-of- major life activities, provided that the disability has lasted or can be expected to network benefits are calculated. The actual numbers will depend on the services received. last for at least one year, or can be expected to result in death; or Lifetime maximum amount • a disabling or chronic condition that is in an acute phase. Out-of-network benefits are subject to a lifetime maximum amount payable per member. Authorization to continue to receive services from your current provider may extend See Your Out-Of-Pocket Expenses for a detailed explanation of the lifetime maximum to the remainder of your life if a physician certifies that your life expectancy is 180 amount. days or less. ii. Upon request, Medica will authorize continuity of care for up to 120 days as Exclusions described in a. and b. above in the following situations: 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. • 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 Claims • When you use non-network providers, you will be responsible for filing claims in order to be if you do not speak English and a network provider who can communicate with reimbursed for the non-network provider reimbursement amount. See How To Submit A you, either directly or through an interpreter, is not available. Claim for details. 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 Post-mastectomy coverage 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 Medica will cover all stages of reconstruction of the breast on which the mastectomy was transitioned to a network provider to continue to be eligible for in-network benefits. If your performed and surgery and reconstruction of the other breast to produce a symmetrical request is denied, Medica will explain the criteria used to make its decision. You may appearance. Medica will also cover prostheses and physical complications, including p lymphedemas, at all stages of mastectomy. appeal this decision. Coverage will not be provided for services or treatments that are not otherwise covered under this certificate. MIC PP MN (3/12) 6 100%-15 MIC PP MN (3/12) 7 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 How To Access Your Benefits How To Access Your Benefits 4. Prior authorization 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 Prior authorization from Medica may be required before you receive certain services or reasonably necessary to make a decision has been made available to Medica. supplies in order to determine whether a particular service or supply is medically necessary Both you and your provider will be informed of the decision within 72 hours from the time of and a benefit. Medica uses written procedures and criteria when reviewing your request for the initial request if your attending provider believes that an expedited review is warranted, prior authorization. To determine whether a certain service or supply requires prior or if it is concluded that a delay could seriously jeopardize your life, health, or ability to authorization, please call Customer Service at one of the telephone numbers listed inside regain maximum function, or subject you to severe pain that cannot be adequately managed the front cover or sign in at www.mymedica.com. Emergency services do not require prior without the care or treatment you are requesting. authorization. If Medica does not approve your request for prior authorization, you have the right to appeal Your attending provider, you, or someone on your behalf may contact Customer Service to Medica's decision as described in Complaints. 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 Under certain circumstances, Medica may perform concurrent review to determine whether prior authorization for services or supplies received from a non-network provider. If a services continue to be medically necessary. If Medica determines that services are no network provider fails to obtain prior authorization after you have consulted with them about longer medically necessary, Medica will inform both you and your attending provider in services requiring prior authorization, you are not subject to a penalty for failure to obtain writing of its decision. If Medica does not approve continued coverage, you or your prior authorization. attending provider may appeal Medica's initial decision (see Complaints). Some of the services that may require prior authorization from Medica include: 5. Certification of qualifying coverage • Reconstructive or restorative surgery; • Certain drugs; 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 • Home health care; certification of qualifying coverage at any time while you are covered under the Contract or • Medical supplies and durable medical equipment; 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 • Outpatient surgical procedures; front cover. Upon receipt of your request, the certification of qualifying coverage will be • Certain genetic tests; and issued as soon as reasonably possible. • Skilled nursing facility services. Prior authorization is always required for: • Organ and bone marrow transplant 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 PP MN (3/12) 8 100%-15 MIC PP MN (3/12) 9 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 How Providers Are Paid By Medica Your Out-Of-Pocket Expenses C. How Providers Are Paid By Medica D. Your Out-Of-Pocket Expenses This section describes how providers are generally paid for health services. This section describes the expenses that are your responsibility to pay. These expenses are commonly called out-of-pocket expenses. ,. .: iSee Definitions These words have specific meanings coinsurance, copayment,ment,,deductble hospital nne work non-network physician rov�der. See Definitions. These words h av e: _specific m, anin gigs-, . ben e fits, claim,_._.coinsurance copayment, deductible, dependent, member, network,.non-network,r non-network Network providers reimbursement amount, prescription drug, provider, subscriber. - . � . You are responsible for paying the cost of a service that is not medically necessary or a benefit Network providers are paid using various types of contractual arrangements, which are intended even if the following occurs: to promote the delivery of health care in a cost efficient and effective manner. These 1. A provider performs, prescribes, or recommends the service; or arrangements are not intended to affect your access to health care. These payment methods may include: 2. The service is the only treatment available; or 1. A fee-for-service method, such as per service or percentage of charges; or 3. You request and receive the service even though your provider does not recommend it. 2. A risk-sharing arrangement, such as an amount per day, per stay, (Your network provider is required to inform you or in some instances provide a waiver for y, per episode, per case, you to sign.) per period of illness, per member, or per service with targeted outcome. If you miss or cancel an office visit less than 24 hours before your appointment, your provider The methods by which specific network providers are paid may change from time to time. may bill you for the service. Methods also vary by network provider. The primary method of payment under Medica is fee- for-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. 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 verify coverage before receiving a particular service or supply, call Customer Service at one to a set fee schedule. The amount the network provider receives is the lesser of the fee of the telephone numbers listed inside the front cover. 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 Copayments, coinsurance, and deductibles charge. The amount paid to the network provider, less any applicable copayment, coinsurance, or deductible, is considered to be payment in full. For in-network benefits, you must pay the following: Risk-sharing payment means that the network provider is paid a specific amount for a particular 1. Any applicable copayment or coinsurance as described in this certificate (see the Out-of- unit of service, such as an amount per day, an amount per stay, an amount per episode, an Pocket Expenses table in this section). 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 2. Any charge that is not covered under the Contract. for a member's health services, the network provider may bear some of the shortfall. If the For out-of-network benefits, you must pay the following: amount paid to the network provider is more than the cost of providing or arranging a member's 1. Any applicable copayment, coinsurance, and per member deductible each calendar year as health services, the network provider may keep some of the excess. Y pP P Y Some network providers are authorized to arrange for a member to receive certain health described in this certificate (see the Out-of-Pocket Expenses table in this section). services from other providers. This decision may result in a network provider keeping more or When members in a family unit (a subscriber and his or her dependents) have together paid less of the risk-sharing payment. 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 Non-network providers considered to have satisfied the applicable per member and per family deductible for that calendar year. When a service from a non-network provider is covered, the non-network provider is paid a fee Note that applicable deductibles are determined by the Contract between Medica and the for each covered service that is provided. This payment may be less than the charges billed by employer and may increase when Medica and the employer renew the Contract. If this the non-network provider. If this happens, you are responsible for paying the difference. 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 PP MN (3/12) 10 100%-15 MIC PP MN (3/12) 11 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Your Out-Of-Pocket Expenses Your Out-Of-Pocket Expenses 2. Any charge that exceeds the non-network provider reimbursement amount. This means you When members in a family unit (the subscriber and his or her dependents) have together met are required to pay the difference between the payment to the provider and what the the applicable per family out-of-pocket maximum for benefits received during the calendar year, provider bills. then all members of the family unit are considered to have met the applicable per member and If you use out-of-network benefits, you may incur costs in addition to your copayment, per family out-of-pocket maximum for that calendar year (see the Out-of-Pocket Expenses table in this section). 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 After an applicable out-of-pocket maximum has been met for a particular type of benefit (as paying the difference. In addition, the difference will not be applied toward satisfaction of described in the Out-of-Pocket Expenses table in this section), all other covered benefits of the the deductible or the out-of-pocket maximum (described in this section). 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 To inquire about the non-network provider reimbursement amount for a particular procedure, reimbursement amount. However, you will still be required to pay any applicable copayments, call Customer Service at one of the telephone numbers listed inside the front cover. When coinsurance, and deductibles for other types of benefits received. you call, you will need to provide the following: • The CPT (Current Procedural Terminology) code for the procedure (ask your non- Note that out-of-pocket maximum amounts are determined by the Contract between Medica and network CPT (Current for this); 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, • The name and location of the non-network provider. 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 Customer Service will provide you with an estimate of the non-network provider Contract with Medica is renewed and that you may have additional out-of-pocket expenses as a reimbursement amount based on the information provided at the time of your inquiry. The result. actual amount paid will be based on the information received at the time the claim is Medica refunds the amount over the out-of-pocket maximum during any calendar year when submitted and subject to all applicable benefit provisions, exclusions and limitations, including but not limited to copayments, coinsurance, and deductibles. proof of excess copayments, coinsurance, and deductibles is received and verified by Medica. 3. Any charge that is not covered under the Contract. Lifetime maximum amount More information concerning deductibles 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 The time period used to apply the deductible (calendar year or Contract year) is determined by Medica Health Plans of Wisconsin coverage offered through the same employer is described in the Contract between Medica and the employer. This time period may change when Medica the Out-of-Pocket Expenses table in this section. Any lifetime maximum dollar limit referenced and the employer renew the Contract. If the time period changes, you will receive a new pertains only to those health care services and supplies that are not essential benefits as certificate of coverage that will specify the newly applicable time period. You may have defined in the Patient Protection and Affordable Care Act, including any amendments, additional out-of-pocket expenses associated with this change. regulations, rules, or other guidance issued with respect to the Act. 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 PP MN (3/12) 12 100%-15 MIC PP MN (3/12) 13 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Your Out-Of-Pocket Expenses Ambulance Services Out-of-Pocket Expenses E. Ambulance Services � # ,, � �- In-network ', * Out-of-network ' = I benefits . This section describes coverage for ambulance transportation and related services received for *For out-of-network benefits, m.addition to the deductible co a ,m m ent, and covered medical and medical-related dental services (as described in this certificate). _ � .. : coinsurance, ou are. .�.u o_r....,a9 n Yc_....:..__�_,.,h_.:.ar e.__.s in exc ess o f t h a nory n ne_t.wo_ rk provider_:reimbursement b u_.rsemed n____.t-am o.amount.' t�.,_�... See-Definitions. _.,e fi n-_tt tons. Te„wo rds have specific�c h, ea non s_: b ene fits,coinsur an.: ce co Pa Y�1e _.. , Additionally,th ese charges w�ll�notgbe:a Ppli edu toward sat�sfact�on�ofthe t deducts e or�the:gut _ ctible�emer emergency;3has ital network, non_network anon-network.provider reimbursement . . � amount physician, sk i} tl nursing facility. , . - _.. Copayment or coinsurance See specific benefit for applicable copayment or Prior authorization. Prior authorization from Medica may be required before you receive coinsurance. services or supplies. Call Customer Service at one of the telephone numbers listed inside the Deductible A deductible does not front cover. See How To Access Your Benefits for more information about the prior authorization apply to in-network process. benefits. Per member $3,000 Covered Per family $9,000 For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. Out-of-pocket maximum For non-emergency licensed ambulance services described in the table in this section: Per member $2,000 $9,000 • In-network benefits apply to ambulance services arranged through a physician and received Per family $5,000 Out-of-pocket maximum from a network provider. 1 does not apply. Refer to the per member out-of- • Out-of-network benefits apply to non-emergency ambulance services described in this pocket maximum above. 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 Lifetime maximum amount Unlimited $1,000,000. Applies to reimbursement amount. The out-of-pocket maximum does not apply to these charges. payable per member all benefits you receive Please see Important member information about out-of-network benefits in How To Access under this or any other Your Benefits for more information and an example calculation of out-of-pocket costs Medica, Medica Health associated with out-of-network benefits. Plans, or Medica Health Plans of Wisconsin Not covered coverage offered through the same employer. 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. i See Exclusions for additional services, supplies, and associated expenses that are not covered. • MIC PP MN (3/12) 14 100%-15 MIC PP MN (3/12) 15 BPL 85259 DOC 100%-15 BPL 85259 DOC 23705 j1 Ambulance Services Durable Medical Equipment And Prosthetics �i Your Benefits and the Amounts You Pay � _ �, F. Durable Medical Equipment And Prosthetics Benefits _ t 4 : In network benefits Out-of-network belle,fits s " , after deductible This section describes coverage for durable medical equipment, certain related supplies, and j sue 9 PP prosthetics. *For out-of-network benefits,in addition-to the deductible,copayment, and core auranca,you are etics. p th .responsible�-#o--r am...n charge s haw._.r e s i n excess o t h,, e.non-network-.- ,,_.,.:- ;"Provider..._ . .:.E r_r,e:im�7,bu. r s. em_ ent.am_,_.o.�unt .._ � See Definitions.,o n__..s. These:w ords�hav e P ec Ef� meanings:a n i e s. benefit-s coinsurance, ... c oins ran ce co.._a r is en#�Additionally, w_1l_not-beAa l.ed toward satrs#actronof the deductible_ork, h gout-of 4 .. deductible, durable medical equipment, net wo network, non network provider �pocket maximum:, m . � . �, reimbursement amoun# physician, provider., Y • - �_. - 1. Ambulance services or Nothing Covered as an in-network Prior authorization. Prior authorization from Medica may be required before you receive ambulance transportation to the benefit. services or supplies. Call Customer Service at one of the telephone numbers listed inside the nearest hospital for an front cover. See How To Access Your Benefits for more information about the prior authorization emergency process. 2. Non-emergency licensed . • ambulance service that is Covered arranged through an attending physician, as follows: For benefits and the amounts you pay, see the table in this section. More than one copayment a. Transportation from hospital Nothing 50% coinsurance or coinsurance may be required if you receive more than one service or see more than one to hospital when: provider per visit. Medica covers only a limited selection of durable medical equipment, certain related supplies, and I i. Care for your condition is hearing aids that meet the criteria established by Medica. Some items ordered by your physician, not available at the even if medically necessary, may not be covered. The list of eligible durable medical equipment ' I hospital where you were and certain related supplies is periodically reviewed and modified by Medica. To request a list of first admitted; or Medica's eligible durable medical equipment and certain related supplies, call Customer Service ii. Required by Medica at one of the telephone numbers listed inside the front cover. b. Transportation from hospital Nothing 50% coinsurance Medica determines if durable medical equipment will be purchased or rented. Medica's approval to skilled nursing facility 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 durable medical equipment providers, call Customer Service at one of the telephone numbers listed inside the front cover. 1 • 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 I. associated with out-of-network benefits. MIC PP MN (3/12) 16 100%-15 MIC PP MN (3/12) 17 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 , 1 Durable Medical Equipment And Prosthetics Durable Medical Equipment And Prosthetics Not covered Your Benefits and the Amounts You Pray � � These services, supplies, and associated expenses are not covered: Benefits In network benefits *Out of network benefits 1. Durable medical equipment, supplies, prosthetics, appliances, and hearing aids not on the - a Medica eligible list. = endeductible aft 2. Charges in excess of the Medica standard model of durable medical equipment, prosthetics, *For out-of-network benefits, in addition to.the deductibire,.copayment,=and,coinsurance, You are*, or hearing aids. responsible for any charges in,excess of the non-network provider reimbursement amount r-H . _' Additionally,these charges will not be applied toward satisfaction of the deductible or theout-of _` 3. Repair, replacement, or revision of durable medical equipment, prosthetics, and hearing aids, pocket maximum except when made necessary by normal wear and use. c. Repair, replacement, or 20% coinsurance 50% coinsurance 4. Duplicate durable medical equipment, prosthetics, and hearing aids, including repair, revision of artificial arms, replacement, or revision of duplicate items. legs, feet, hands, eyes, ears, See Exclusions for additional services, supplies, and associated expenses that are not noses, and breast covered. prostheses made necessary by normal wear and use 4. Hearing aids for members 18 20% coinsurance. 50% coinsurance. Your Benefits and the Amounts You Payer 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 Benefits, In network benefits Out of-network benefits_ correctable by other covered every three years. every three years. after deductible procedures Related services must be prescribed by a network *IFor out-of-network benefits,in addition to the deductible,copayment, and coinsurance,you'are . provider. responsible for any charges in excess of the non-network:provider reimbursement amounts Additionally,these charges will not be applied satisfaction of the deductible or the out of pockett maximum... �v 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 PP MN (3/12) 18 100%-15 MIC PP MN (3/12) 19 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Home Health Care Home Health Care Not covered G. Home Health Care 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. This section describes coverage for home health care. Home health care must be directed by a 3. Custodial care and other non-skilled services. physician and received from a home health care agency authorized by the laws of the state in which treatment is received. 4. Physical, speech, or occupational therapy provided in your home for convenience. See Definitions These words have specific meanings: benefits, coinsurance, copayment, 5. Services provided in your home when you are not homebound. custodial care, deductible, dependent, hoipitak network, non-network, non network provider 6. Services primarily educational in nature. reimbursement amount, physician,,-provider,:skilled care,;skillednursing_facility, 7. Vocational and job rehabilitation. Prior authorization. Prior authorization from Medica may be required before you receive 8. Recreational therapy. 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 9. Self-care and self-help training (non-medical). authorization process. 10. Health clubs. Covered 11. Disposable supplies and appliances, except as described in Durable Medical Equipment And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug For benefits and the amounts you pay, see the table in this section. More than one copayment or Program. coinsurance may be required if you receive more than one service or see more than one 12. Physical, speech, or occupational therapy services when there is no reasonable expectation provider per visit. that the member's condition will improve over a predictable period of time according to As described under 1. and 2. in the table in this section, Medica (in accordance with Medicare generally accepted standards in the medical community. guidelines) considers you homebound when it is medically contraindicated for you to leave your 13. Voice training. home (i.e., when leaving your home would directly and negatively affect your physical health). A 14. Home health aide services, except when rendered in conjunction with intermittent skilled dependent child may still be considered "confined to home"when attending school where life care and related to the medical condition under treatment. support specialized equipment and help are available. See Exclusions for additional services, supplies, and associated expenses that are not Benefits covered under 1. and 2. in the table in this section are limited to a combined maximum of covered. 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. Your Benefits and the Amounts-You Pay • In-network benefits apply to home health care services ordered or prescribed by a physician Benefits = = s Iln network benefits *Out-of-network benefits and received from a network home health care agency. �' - after deductible • Out-of-network benefits apply to home health care services that are ordered or prescribed by a >, -. * and received from non-network h For out-of network benefits, in addition to the deductible,copayment,;and:coinsurance you are physician e a home health care agency. In addition to the responsible for any.'char es in,excess reimbursement amount. deductible and copayment or coinsurance described for out-of-network benefits, you will be pz --- y= g ss Of the non-network provider reimb semen, y Additionally;these charges will not be applied toward satisfaction of the deductible or the out-of- responsible for any charges in excess of the non-network provider reimbursement amount. � £� �� � pocket maximum. ra �� � �� � ��, 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 1. Intermittent skilled care when 20% coinsurance 50% coinsurance information and an example calculation of out-of-pocket costs associated with out-of- you are homebound, provided by network benefits. or supervised by a registered Please note: Your place of residence is where you make your home. This may be your own nurse dwelling, a relative's home, an apartment complex that provides assisted living services, or 2. Skilled physical, speech, or 20% coinsurance 50% coinsurance some other type of institution. However, an institution will not be considered your home if it is a occupational therapy when you hospital or skilled nursing facility. are homebound MIC PP MN (3/12) 20 100%-15 MIC PP MN (3/12) 21 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Home Health Care Hospice Services Your Benefits and the Amounts You Pay H. Hospice Services 6 E � k � � ■ Benefits In network benefits *Out-of-network benefits after deductible This section describes coverage for hospice services including respite care. Care must be *For out-of-network benefits, in addition to the deductible,copayment,and coinsurance,you are ordered, provided, or arranged under the direction of a physician and received from a hospice responsible for any charges�n.excessof the non network provider reimbursement amount.. program. r_ 'Additionally,these charges will not,be a , ,lied.toward-satisfacti- s deductible pP..._. ,,. on af_the;d r _ .the ,:>, _ = :- See, maximum. , . -� .� -: .� :.. . �� � � a =x ,,.._ __. � �� �- �.. ._: ,.: _ s See Defecntrons. _.These words havespecific meanings: benefits,:coinsurance,deductible, member, non network provider reimbursement amount, physician, skilietl 3. Home infusion therapy 20% coinsurance 50% coinsurance nursing facility ` . s . � < _ - '' _ 4. Services received in your home 20% coinsurance 50% coinsurance from a physician Covered For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one provider per visit. 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 program. hospice p P 9 • 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. MIC PP MN (3/12) 22 100%-15 MIC PP MN (3/12) 23 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Hospice Services Hospital Services 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 I. Hospital Services program. This section describes coverage for use of hospital and ambulatory surgical center services. A Not covered physician must direct care. These services, supplies, and associated expenses are no covere See Definitions. These words have specific meanings: benefits, coinsurance,:copaym ent, - y y, g testing; inpatient, rim 1. Respite care for more than five consecutive days at a time. deductible,eductible;timer" enc ," enetie tes#ii as ital, iri atient, ember, etwork, nan=netwark, nan- network provider reimbursement amount, physician, provider.: ,. , 2. Home health care and skilled nursing facility services when services are not consistent with p the hospice program's plan of care. Prior authorization. Prior authorization from Medics may be required before you receive services or supplies. Call Customer Service at one of the telephone numbers listed inside the 3. Services not included in the hospice program's plan of care. front cover. See How To Access Your Benefits for more information about the prior authorization 4. Services not provided by the hospice program. process. 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 Covered home. For benefits and the amounts you pay, see the table in this section. More than one copayment 7. Financial or legal counseling services, except when recommended and provided by the or coinsurance may be required if you receive more than one service or see more than one hospice program. provider per visit. 8. Housekeeping or meal services in your home, except when recommended and provide y • In-network benefits apply to hospital services received from a network hospital or ambulatory the hospice program. surgical center. • Out-of-network benefits apply to hospital services received from a non-network hospital or 9. Bereavement counseling, except when recommended and provided by the hospice program. ambulatory surgical center. In addition to the deductible and copayment or coinsurance See Exclusions for additional services, supplies, and associated expenses that are not 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 covered. 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 _ 4 out-of-pocket costs associated with out-of-network benefits. Emergency services from non- .: Your Benefits and the Amounts You Pay 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 Benefits" in-network benefits Out o network benefits, your attending physician agrees it is safe to transfer you to a network facilit wafter deductible y facility. "For out of-network benefits, in addition to the deductible,'copayment,'and coinsurance, you are Not covered responsible fortany charges m excess of the non-network pi'oviderYreimbursement amount `' 1. Drugs received at a hospital on an outpatient basis,charges will not be applied towardsatisfact�on of�the�deductible or the out of � p p , except drugs requiring intravenous ;5 infusion or injection, intramuscular injection, or intraocular injection, or drugs received in an pocket maximum � �° ._. � � ' � coinsura��" ,,- �_.. i a emergency room or a hospital observation room. Coverage for drugs is as described in 1. Hospice services Nothing 50% nce Prescription Drug Program and Prescription Specialty 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. 24 100%-15 MIC PP MN (3/12) 25 100%-15 MIC PP MN (3/12) BPL 85259 DOC 23705 BPL 85259 DOC 23705 • Hospital Services Hospital Services _ _ � .. . ar e .. : , ,... >, ..,. °:�- , 5R '> . . Your Benefits an ,a � . , You $", _.,_� .� __ �_.,� _ s .: .� 4 _.. d he�Amounts.You.Pa. � � _ .h ,..R .. - �. _ . Amounts You Pa. ,._..--� .. .. __: ,_.n � _ , _ s Benefits and the _. _,x .._. ,� _ _ «.. Pay rBenefit wY »- _You _ _ ., _� ,<_ �.. � I . __ x__ g _ ...3 °v . _ Benefits a ._. benefits_n ork� . _ *ar...fOur t_d e fd_nuec twib o rk.b_e_n e.f,i-t.s .,.. E Benefits , ,.� _ ;�...__ - , , In ne_..t_.wo._r_k�. b eneb t�s , � Out_ f_ne t w o'- rk,„b ,benefits� , _ = after deductible _ ,.;. ...,,._ : m.__. _-�:t_,,_. • Fo,c out-of-network u t=-o-..y f:,...ne,z tW��__:nor.�..�,k._..:b.,benefi ts,n f.,=it s, in {..n a.��.d.-_di..,4t,io..=v.n to_,..the deductible,d,uc t ib-�.le w c o.,, P m.�.:_en.,..t, and'co�,ns,�:._ urance,,Y o u a...�r e*_Foc ou tof-net work_benefits,ts in to the co a me t,and coinsurance,you a r e , - responsible for any charges .m excess cif e non_netwo rk, rovaderirei mbursement.amount. C _ra sP on s.ble.for any charges in excess.of_the.non non-network reimbursemen t,amount. Additionally,these char a s will not:be.a Pp 1ied:towar d sat�sfacti n. the deductible Pr-t the out o _ ��Ad dib.ona ll these charges wail not.be_a RP applied owards s atrsfaction.of th deducr le-oc t he out_of� pocket maxim ,_ . , � � � pocket maximum. , _ „ , 6. Treatment of temporomandibular Covered at the Covered at the 1. Outpatient services joint (TMJ) disorder and corresponding in-network corresponding out-of- a. Services provided in a $95/visit Covered as an in-network craniomandibular disorder benefit level, depending network benefit level, hospital or facility-based benefit. on type of services depending on type of emergency room provided. services provided. b. Outpatient lab and pathology Nothing 50% coinsurance For example, office visits For example, office visits c. Outpatient x-rays and other Nothing 50% coinsurance are covered at the office are covered at the office imaging services visit in-network benefit visit out-of-network level and surgical benefit level and surgical d. Genetic testing when test Nothing 50% coinsurance services are covered at services are covered at results will directly affect the surgical services in- the surgical services out- treatment decisions or network benefit level. of-network benefit level. 1 frequency of screening for a Please note: Dental Please note: Dental disease, or when results of coverage is not provided coverage is not provided the test will affect under this benefit. under this benefit. reproductive choices e. Other outpatient services $15/visit 50% coinsurance f. Other outpatient hospital and $15/visit 50% coinsurance ambulatory surgical center services received from a I physician g. 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 1 3. Inpatient services Nothing 50% coinsurance 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 MIC PP MN (3/12) 26 100%-15 MIC PP MN (3/12) 27 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Infertility Diagnosis Infertility Diagnosis J. Infertilit Dia gnosis Your Benefits�and the=Amounts You Pa :' ' , a = z � Benefits = ' In network benefits i *'Ou# of-network benefits t ' r after deductible This section describes coverage for the diagnosis of infertility. Coverage includes benefits fore professional, hospital, and ambulatory surgical center services. Services for the diagnosis of For out-of. ut-ofnetv+ork benefits,;in addition to the'deductible,copayment, and coinsurance,you are infertility must be received from or under the direction of a physician. All services, supplies, and responsible for any charges n excess of the non-network provider reimbursement amount , associated expenses for the treatment of infertility are not covered. Additionally,these charges will not be See app l i.ed„..fowa r d s�a� tisfaction o,r.f the d.e d.:_u. c t ib::l e��or r�t_he out of t ' Definitions These�ords�have specific mean�ngsbenefit benefits,-coinsurance,. urance co a meat� .pocket maximum. : _ 1 __. �.. ._ �. I deductible, hospital:inpatient, member, network_ , non network; non network provider 1. Office visits, including any 20% coinsurance Covered as an in-network re mbursemdnt,amount, physician, provider, v rtual care ' services provided during such benefit. Prior authorization. Prior authorization from Medica may be required before you receive visits services or supplies. Call Customer Service at one of the telephone numbers listed inside the 2. Virtual care $5/visit No coverage �' front cover. See How To Access Your Benefits for more information about the prior 3. Outpatient services received at a 20% coinsurance Covered as an in-network • authorization process. hospital p benefit. 4. Inpatient services 20% coinsurance Covered as an in-network Covered benefit. I Benefits apply to services for the diagnosis of infertility received from a network or non-network 5. Services received from a 20% coinsurance Covered as an in-network provider. More than one copayment or coinsurance may be required if you receive more than physician during an inpatient benefit. I one service or see more than one provider per visit. stay Coverage for infertility services is limited to a maximum of$5,000 per member per calendar year 6. Anesthesia services received 20% coinsurance Covered as an in-network for in-network and out-of-network benefits combined. from a provider during an benefit. inpatient stay 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. I 10. Services for intrauterine insemination (IUI). See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PP MN (3/12) 28 100%-15 MIC PP MN (3/12) 29 100%-15 1 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Maternity Services Maternity Services Additional information about coverage of maternity services K. Maternity Services Not all services that are received during your pregnancy are considered prenatal care. Some of the services that are not considered prenatal care include (but are not limited to)treatment of the following: This section describes coverage for maternity services. Benefits for maternity services include all medical services for prenatal care, labor and delivery, postpartum care, and related complications. 1. Conditions that existed prior to (and independently of)the pregnancy, such as diabetes or lupus, even if the pregnancy has caused those conditions to require more frequent care or See Definitions. These words'have'specific meanings: benefits, coinsurance, copayment, monitoring. deductible, dependent, hospital, inpatient,-member,network, non-network, non-network.provider reimbursement amount, physician, prenatal carer rovider skilled care. k,, w <. 2. Conditions that have arisen concurrently with the pregnancy but are not directly related to care p y , p en° of the pregnancy, such as back and neck pain or skin rash. Prior authorization. Prior authorization from Medica may be required before you receive 3. Miscarriage and ectopic pregnancy. 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 Services that are not considered prenatal care may be eligible for coverage under the most process. specific and appropriate section of this certificate. Please refer to those sections for coverage information. Newborns'and Mothers' Health Protection Act of 1996 Not covered 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 These services, supplies, and associated expenses are not covered: than 96 hours following a cesarean section). However, federal law generally does not prohibit the 1. Health care professional services for maternity labor and delivery in the home. 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 2. Services from a doula. case, Medica may not require a provider to obtain prior authorization from Medica for a length of 3. Childbirth and other educational classes. stay of 48 hours or less (or 96 hours, as applicable). See Exclusions for additional services, supplies, and associated expenses that are not Covered covered. For benefits and the amounts you pay, see the table in this section. More than one copayment §y = to or coinsurance may be required if you receive more than one service or see more than one Your Benefits and the Amounts You Pays provider per visit. Each member's admission is separate from the admission of any other t � member. A separate deductible and copayment or coinsurance will be applied to both you and Benefits * ork benefits In-network Out-of-network benefits your newborn child for inpatient services related to maternity labor and delivery. Please note: � - after deductible We encourage you to enroll your newborn dependent under the Contract within 30 days from ' birth, date of placement for adoption, or date of adoption. Please refer to Eligibility *For out-of-network benefits, in addition to the deductible,copayment and coinsurance, you are the date of b da e o p ac p p 9 y responsible for an charges in excess of the non network provider reimbursement amount. any p And Enrollment for additional information. � Additionally,these charges will not be applied toward satisfaction of the deductible or the out of • In-network benefits apply to maternity services received from a network provider. pocket maximum - . • Out-of-network benefits apply to maternity services received from a non-network provider. In 1. Prenatal services 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 a. Office visits for prenatal care, Nothing 50% coinsurance reimbursement amount. The out-of-pocket maximum does not apply to these charges. including professional Please see Important member information about out-of-network benefits in How To Access services, lab, pathology, Your Benefits for more information and an example calculation of out-of-pocket costs x-rays, and imaging associated with out-of-network benefits. MIC PP MN (3/12) 30 BPL 85259 DOC 100%-15 23705 MIC PP MN (3/12) 31 BPL 85259 DOC 100%-15 23705 Maternity Services I Maternity Services < »I and the pp _; ..:.�;- .,. x _ .� :: _, .. _ , : ,A. _ '� `:;, as - : Amounts :. , _ x_� . __ � °�. ..._ ___ n e You>Pa ,. . _ _. : _:_ > t. ,, ��_ _Your}Benefits,a d #h , . ' Your B nefits�and t e A Y � ,. _ _ , Y e h mounts._ ou�Pa < .>__� � . _ > , , . , ,_. : �n B.._.:,...n ef i s x oI n-s,...n._._..e.t.._. r k_ben,_ ef;...i ts-,.o. Outt o f.,._..n,.-e.-t w, o r-<,k_.., benefits_._. p7 B & . .aftOeur#do ef d nuec tWt EOerk E,. a .�.i ' _ after deductible 1 �,co ia meet and coinsurance ,ouQarer � ;: .:: : _ -, twork benefits, addition to-the:.deduct b e _ , , Y.: 3 6< F r,out-of-network, e addition m for,ou�t of ne ,..pY _... ,... xo ,., b benefits, co a mentxandcaansurance ou te, � ,..,>. . >. >:. _�,. . e r reimbur ement amount. . . R r` ar in:excess_Of.-the noo-network, rov�.de,.. s „ . _ onsble fo an _ch es �:vp .. , - _ a ,- .,�,: ,, . °_ ..,, res onsbleforan ..chat es..m excess of nannetwark rov er.rei bur > ,. res �. . any 9 ,: -- � ,.:. _ _ . . p g _,- � �d m sement amount. � p. Additionally, _. i . _. io a ., . i _ ,o._the .,,. � _. applied toward rdsa�rsfa t�on_of the deduCtrb#e or out � . ,, applied� - na#!, ..char es w.til# net a !edtow c -_, ., . .. Add#�ana##. .these�char,charges ##,notbe .,towacds �sf o - _ _.. Addttio ,_ 9 .,_ _-.#?R ,>: _. -, Y, ,wt . at action f the out of x Y ...,-- ,> 9 toward u deductible >._ ocket maximu m.pocket:maximum. b. Hospital and ambulatory Nothing 50% coinsurance 6. Home health care visit following Nothing 50% coinsurance surgical center services for delivery prenatal care, including Please note: One home health visit professional services is covered if it occurs within 4 days received during an inpatient stay for prenatal care �e received fter 4 dayscplease refer to Home Health Care for benefits. c. Intermittent skilled care or Nothing 50% coinsurance home infusion therapy when you are homebound due to a high risk pregnancy 2. Inpatient hospital stay for labor Nothing 50% coinsurance and delivery services Please note: Maternity labor and delivery services are considered inpatient services regardless of the length of hospital stay. 3. Professional services received Nothing 50% coinsurance during an inpatient stay for labor and delivery 4. Anesthesia services received Nothing 50% coinsurance during an inpatient stay for labor and delivery 5. Labor and delivery services at a freestanding birth center a. Facility services for labor and Nothing 50% coinsurance delivery b. Professional services Nothing 50% coinsurance received for labor and it delivery MIC PP MN (3/12) 32 100%-15 MIC PP MN (3/12) 33 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Medical-Related Dental Services j Medical-Related Dental Services 6. Tooth extractions, except as described in this section. L. Medical-Related Dental Services 7. Any dental procedures or treatment related to periodontal disease. 8. Endodontic procedures and treatment, including root canal procedures and treatment, This section describes coverage for medical-related dental services. Services must be received unless provided as accident-related dental services as described in this section. from a physician or dentist. 9. Routine diagnostic and preventive dental services. This section does not describe coverage for comprehensive dental procedures. Comprehensive See Exclusions for additional services, supplies, and associated expenses that are not dental procedures are services rendered by a dentist to treat teeth, their supporting soft tissue and covered. 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, Your and the Amounts You Pay. deductible, dependent, hospital, member, network, non-network, non-network provider Benefits reimbursement amount, physician, provider. In-network'benefits *Out-of-network benefits Prior authorization. Prior authorization from Medica may be required before you receive after deductible services or supplies. Call Customer Service at one of the telephone numbers listed inside the ■ *For out-of-network benefits, in addition to the deductible,copayment, and coinsurance, you are ,. front cover. See How To Access Your Benefits for more information about the prior authorization responsible for any charges in excess of the non-network provider reirrtbursement amount. Additionally,these charges will not be applied toward satisfaction of the deductible or the out-of- process. I pocket maximum, Covered 1. Charges for medical facilities $15/visit 500/0 coinsurance and general anesthesia services For benefits and the amounts you pay, see the table in this section. More than one copayment that are: or coinsurance may be required if you receive more than one service or see more than one a. by a provider per visit. physician; and • In-network benefits apply to medical-related dental services received from a network b. Received during a dental provider. procedure; and • 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 c. Provided to a member who: out-of-network benefits, you will be responsible for any charges in excess of the non- i. Is a child under age five network provider reimbursement amount. The out-of-pocket maximum does not apply to (prior authorization is not these charges. Please see Important member information about out-of-network benefits in required); or How To Access Your Benefits for more information and an example calculation of out-of- ii. Is severely disabled; or pocket costs associated with out-of-network benefits. iii. Has a medical condition and requires Not covered hospitalization or general anesthesia for dental These services, supplies, and associated expenses are not covered: care treatment 1. Dental services to treat an injury from biting or chewing. Please note: Age, anxiety, I and behavioral conditions 2. Osteotomies and other procedures associated with the fitting of dentures or dental implants. are not considered medical 3. Dental implants (tooth replacement), except as described in this section for the treatment of conditions. cleft lip and palate. 2. For a dependent child, 20% coinsurance 50% coinsurance 4. Any other dental procedures or treatment, whether the dental treatment is needed because orthodontia, dental implants, and of a primary dental problem or as a manifestation of a medical treatment or condition. oral surgery treatment related to cleft lip and palate 5. Any orthodontia, except as described in this section for the treatment of cleft lip and palate. MIC PP MN (3/12) 34 100%-15 MIC PP MN (3/12) 35 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Medical-Related Dental Services Mental Health Your Benefits and the Amounts You Pay M. Mental Health Benefits = .In network benefits ;Out ofk network benefits r= v t' xz afte deductible This section describes coverage for services to diagnose and treat mental disorders listed in the *For out of-network benefits,in addition to the deductible,copayment, and coinsurance, you are current edition of the Diagnostic and Statistical Manual of Mental Disorders. For a description of responsible for any charges benefits, excess of the non network provider reimbursement amount coverage for the diagnosis and primary treatment of substance abuse disorders, see Substance Additionally,these charges will not be applied toward satisfaction of the deductib{le or the out-of- yn um out-of- pocket axi . = Abuse. m Definitions. These words have specific meanings:eanings. benefits, claim, m. o.. coinsurance, 3. Accident-related dental services 20% coinsurance 50% coinsurance copayment,;custodial care, deductible, emergency, hospital, inpatient, medically necessary, member, mental disorder, network,anonnetwork,-non network provider reimbursement amount, to treat an injury to sound, provider. 3 natural teeth and to repair (not �" replace) sound, natural teeth. Prior authorization. For prior authorization requirements of in-network and out-of-network The following conditions apply: 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 a. Coverage is limited to 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. services received within 24 months from the later of: For purposes of this section: i. the date you are first 1. Outpatient services include: covered under the a. Diagnostic evaluations and psychological testing. Contract; or ii. the date of the injury b. Psychotherapy and psychiatric services. b. A sound, natural tooth means c. Intensive outpatient programs, including day treatment, meaning time limited a tooth (including supporting comprehensive treatment plans, which may include multiple services and modalities, structures) that is free from delivered in an outpatient setting (up to 19 hours per week). disease that would prevent d. Treatment for a minor, including family therapy. continual function of the tooth e. Treatment of serious or persistent disorders. for at least one year. f. Diagnostic evaluation for attention deficit hyperactivity disorder(ADHD) or pervasive In the case of primary (baby) development disorders (PDD). teeth, the tooth must have a life expectancy of one year. i g. Services, care, or treatment described as benefits in this certificate and ordered by a court 4. Oral surgery for: 20% coinsurance 50% coinsurance on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. a. Partially or completely h. Treatment of pathological gambling. unerupted impacted teeth; or b. A tooth root without the 2. Inpatient services include: extraction of the entire tooth a. Room and board. (this does not include root b. Attending psychiatric services. canal therapy); or c. The gums and tissues of the c. Hospital or facility-based professional services. mouth when not performed in d. Partial program. This may be in a freestanding facility or hospital based. Active treatment connection with the is provided through specialized programming with medical/psychological intervention and extraction or repair of teeth supervision during program hours. Partial program means a treatment program of 20 hours or more per week and may include lodging. MIC PP MN (3/12) 36 100%-15 MIC PP MN (3/12) 37 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Mental Health Mental Health e. Services, care, or treatment described as benefits in this certificate and ordered by a court In addition to the deductible and copayment or coinsurance described for out-of-network on the basis of a behavioral health care evaluation performed by a physician or licensed benefits, you will be responsible for any charges in excess of the non-network provider psychologist and that includes an individual treatment plan. 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 f. Residential treatment services. These services include either: Your Benefits for more information and an example calculation of out-of-pocket costs i. A residential treatment program serving children and adolescents with severe emotional associated with out-of-network benefits. disturbance, certified under Minnesota Rules parts 2960.0580 to 2960.0700; or ii. A licensed or certified mental health treatment program providing intensive therapeutic Not covered 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, These services, supplies, and associated expenses are not covered: client education, and other services specific to mental health treatment. Also, the 1. Services for mental disorders not listed in the current edition of the Diagnostic and Statistical program must provide an on-site medical/psychiatric assessment within 48 hours of Manual of Mental Disorders. admission, psychiatric follow-up visits at least once per week, and 24-hour nursing coverage. 2. Services for a condition when there is no reasonable expectation that the condition will improve. Covered • 3. Services, care, or treatment that is not medically necessary, unless ordered by a court as specifically described in this section. For benefits and the amounts you pay, see the table in this section. More than one copayment 4. Relationship counseling. or coinsurance may be required if you receive more than one service or see more than one provider per visit. 5. Family counseling services, except as specifically described in this certificate as treatment for a minor. • For in-network benefits: 6. Services for telephone psychotherapy. 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 7. Services beyond the initial evaluation to diagnose mental retardation or learning disabilities, substance abuse provider will refer you to one of its hospital providers (Medica and Medica's as those conditions are defined in the current edition of the American Psychiatric designated mental health and substance abuse provider hospital networks are different). Association's Diagnostic and Statistical Manual of Mental Disorders. For claims questions regarding in-network benefits, call Medica's designated mental health 8. Services, including room and board charges, provided by health care professionals or and substance abuse provider Customer Service at 1-866-214-6829. 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 • For out-of-network benefits: mental health providers who are not authorized under state law to practice independently, 1. Mental health services from a non-network provider listed below will be eligible for coverage and services received from a halfway house, housing with support, therapeutic group home, under out-of-network benefits provided that the health care professional or facility is boarding school, or ranch. licensed, certified, or otherwise qualified under state law to provide the mental health 9. Services to assist in activities of daily living that do not seek to cure and are performed services and practice independently: regularly as a part of a routine or schedule. a. Psychiatrist 10. Room and board charges associated with mental health residential treatment services b. Psychologist 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 c. Registered nurse certified as a clinical specialist or as a nurse practitioner in psychiatric visits at least once per week, and 24-hour nursing coverage. and mental health nursing See Exclusions for additional services, supplies, and associated expenses that are not d. Mental health clinic covered. 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. MIC PP MN (3/12) 38 100%-15 MIC PP MN (3/12) 39 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Mental Health Miscellaneous Medical Services And Supplies = �k � YouBenefi#s and the Amounts You Pay - & 9 N. Miscellaneous Medical Services And Supplies Benefits _ in network.benefits �; -Out-of-network benefits ; after deductible - � � This section describes coverage for miscellaneous medical services and supplies prescribed by the deductible, e a physician. Medica covers only a limited selection of miscellaneous medical services and *For out-of-network madd�tion to the copaymen#, and coinsurance,you are ��, responsible for any charges in excess of the non-network provider reimbursement amount. supplies that meet the criteria established by Medica. Some items ordered by a physician, even Additionally these charges will not be applied toward"satisfaction of the deductible or'the out of i f medically ne ces sary, may no t be covered. pocket .....pimaximum. See D e finit ro ns..t. These wo rds ti h avc e-s e c.fc mearin s. benefits; a coinsurance, co a nent, 1. Office visits, including $15/visit 50% coinsurance deductible, medically necessary,, network, non network, non-network provider„reimbUrsement amount,physician,provider., r evaluations, diagnostic, and -� - treatment services Prior authorization. Prior authorization from Medica may be required before you receive 2. Intensive outpatient programs $15/day 50% coinsurance 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 3. Inpatient services (including j authorization process. residential treatment services) a. Room and board Nothing 50% coinsurance Covered b. Hospital or facility-based Nothing 50% coinsurance professional services For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one c. Attending psychiatrist Nothing 50% coinsurance provider per visit. services • • In-network benefits apply to miscellaneous medical services and supplies received from a d. Partial program Nothing 50% coinsurance I 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 Durable Medical Equipment And Prosthetics, Miscellaneous Medical Services And Supplies, and Prescription Drug Program. See Exclusions for additional services, supplies, and associated expenses that are not covered. MIC PP MN (3/12) 40 100%-15 MIC PP MN (3/12) 41 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Miscellaneous Medical Services And Supplies Organ And Bone Marrow Transplant Services Your Benefits and the Amounts You Pay�� O. Organ And Bone Marrow Transplant Services Benefits In network benefits * Out-of-network benefits I-1' �� after deductible This section describes coverage for certain organ and bone marrow transplant services. .�w ' Services must be provided under the direction of a network physician and received at a For out-of-network benefits;in-addition to the deductible,copayment, and coinsurance,you are p Y designated transplant facility. This section also describes benefits for professional, hospital, responsible for any charges in excess of the non-network-provider reimbursement amount. Additionally,these charges will not.be applied toward satisfactionof the deductible or the out-of and ambulatory surgical center services. 9 pp pocket maximum _ - Coverage is p rovided for certain rtain t yP es of or g an transplants and related services (including 0 0 organ acquisition and procurement) and for certain bone marrow transplant services that are 1. Blood clotting factors 20% coinsurance 50% coinsurance appropriate for the diagnosis, without contraindications, and non-investigative. 2. Dietary medical treatment of 20% coinsurance 50% coinsurance See Definitions These words have specific meanings _benefits, coinsurance, copayment, phenylketonuria (PKU) deductible, hospital;inpatient, investigative,_medically necessary, member, network, non 3. Amino acid-based elemental 20% coinsurance 50% coinsurance network, non-network provider reiMbursement amount;physician, provider virtual care formulas for the following Prior authorization. Prior authorization from Medica is required before you receive services or diagnoses: supplies. Call Customer Service at one of the telephone numbers listed inside the front cover. a. cystic fibrosis; See How To Access Your Benefits for more information about the prior authorization process. b. amino acid, organic acid, and fatty acid metabolic and Covered malabsorption disorders; c. IgE mediated allergies to For benefits and the amounts you pay, see the table in this section. More than one copayment food proteins; or coinsurance may be required if you receive more than one service or see more than one provider per visit. d. food protein-induced enterocolitis syndrome; Medica uses specific medical criteria to determine benefits for organ and bone marrow transplant services. Because medical technology is constantly changing, Medica reserves the e. eosinophilic esophagitis; right to review and update these medical criteria. Benefits for each individual member will be f. eosinophilic gastroenteritis; determined based on the clinical circumstances of the member according to Medica's medical and criteria. g. eosinophilic colitis. 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, Coverage for the diagnoses in kidney, lung, heart, heart/lung, pancreas, liver, allogeneic, autologous, and syngeneic bone 3.c.-g. above is limited to marrow. Bone marrow transplants include the transplant of stem cells from bone marrow, members five years of age and peripheral blood, and umbilical cord blood. younger. 0 o The preceding is not a comprehensive list of eligible organ and bone marrow transplant 4. Total parenteral nutrition 20% coinsurance 50/o coinsurance services. 5. Eligible ostomy supplies 20% coinsurance 40% coinsurance • In-network benefits apply to transplant services provided by a network provider and received Please note: Eligible ostomy at a designated transplant facility. A designated transplant facility means a hospital that has supplies may be received from a entered into a separate contract with Medica to provide certain transplant-related health pharmacy or a durable medical services to members receiving transplants. You be evaluated and listed as a potential equipment provider. 9 p may p recipient at multiple designated facilities for transplant services. 6. Insulin pumps and other eligible 20% coinsurance 40% coinsurance diabetic equipment and supplies 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 PP MN (3/12) 42 100%-15 MIC PP MN (3/12) 43 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services Not covered t � � . Your Benefits and the Amounts You Pay q These services, supplies, and associated expenses are not covered: i E u x tt Benefits In network benefits °a * Out-of networkbenefits 1. Organ and bone marrow transplant services except as described in this section. � after deductible`' � �,� � � , ; 2. Supplies and services related to transplants that would not be authorized by Medica under - K x the medical criteria referenced in this section. '*For out-of-network,benefits, in addition to the deductible,copayment, and coinsurance,you are responsible"for any charges in excess of the non-networkwprovider reimbursement amount. 3. Chemotherapy, radiation therapy, drugs, or any therapy used to damage the bone marrow ° Additionally,these�chaiges will not be applied toward satisfaction of the deductible or the out-of- and related to transplants that would not be authorized by Medica under the medical criteria pocket maximum._ - referenced in this section. 4. Living donor transplants that would not be authorized by Medica under the medical criteria 3. Outpatient services referenced in this section. a. Professional services 5. Islet cell transplants except for autologous islet cell transplants associated with i. Surgical services (as $15/visit No coverage pancreatectomy. defined in the Physicians' Current Procedural 6. Services required to meet the patient selection criteria for the authorized transplant Terminology code book) procedure. This includes treatment of nicotine or caffeine addiction, services and related received from a physician expenses for weight loss programs, nutritional supplements, appetite suppressants, and during an office visit or an supplies of a similar nature not otherwise covered under this certificate. outpatient hospital visit 7. Mechanical, artificial, or non-human organ implants or transplants and related services that ii. Anesthesia services $15/visit No coverage would not be authorized by Medica under the medical criteria referenced in this section. received from a provider 8. Transplants and related services that are investigative. during an office visit or an 9. Private collection and storage of umbilical cord blood for directed use. outpatient hospital or ambulatory surgical 10. Drugs provided or administered by a physician or other provider on an outpatient basis, center visit except those requiring intravenous infusion or injection, intramuscular injection, or iii. Outpatient lab and Nothing No coverage intraocular injection. Coverage for drugs is as described in Prescription Drug Program and pathology Prescription Specialty Drug Program or otherwise described as a specific benefit in this certificate. iv. Outpatient x-rays and Nothing No coverage See Exclusions for additional services, supplies, and associated expenses that are not other imaging services covered. v. Other outpatient hospital $15/visit No coverage services received from a physician _ Your Benefits and the Amounts You Pay �� F vi. Services related to $15/visit No coverage E t human leukocyte antigen Benefits in network benefits * Out-of-network benefits testing for bone marrow after deductible transplants *_For out-of-network,benefits,An adddition to the deductible,co a ment and coinsurance ou are b. Hospital and ambulatory responsible for.any charges in excess of the non network provider reimbursement amount surgical center services Additionally,these charges will not be applied toward satisfaction of the deductible or the out of i i. Outpatient lab and Nothing No coverage pocket maximum ; pathology 1. Office visits $15/visit No coverage ii. Outpatient x-rays and Nothing No coverage 2. Virtual care $5/visit No coverage other imaging services iii. Other outpatient hospital $15/visit No coverage services MIC PP MN (3/12) 44 100%-15 MIC PP MN (3/12) 45 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Organ And Bone Marrow Transplant Services Organ And Bone Marrow Transplant Services .z -_ -... a a. z you �,..n . .___ _ , � ' . � .Your, Benefits and.z the Amounts .Pa ,f � ___ ,., Bene�#s and the AmountsYou^.Pa . f a .. .s.... .,i� ..�- ._. ....- .. Y.�:.... _^--x'.,,....,_-.. ..,q .... _........_ ,>, ....... ,... ,. �.._. ,..., =as ,. ,>.:_ -.- Benefi Benefit is In network,benefits k s :In-n rk= n fit - _._. _. _,rr , _. . _ .Out of networ benefits. . , t _ _ .,,_ ..._. etwo bee s « Outofnetwork benefits � ra ,..., ._ _. ..., ,.$S ...x 3 .-...- _ , .. ,, _.. . _ -- after deductible. , $ , .- afterwde i ... _ - . ._ ____.._ ,, duct ble :: } s-,-:.�-; e:..>: az,..-,:.... :&' .. ., *`L> of i x dam > ., 3 .. _,... _ .. _ ...__ :.. :',-.. , , » .. >°` For_out of_n rk. _ .;.,For ut-of-n r � � �, etwo ,benefits in to the:deductible co a ment .and comsuran a ou re _ ,,,�,_. o etwo k benefits m addition to he,deductibie-co a meat.,and coinsurance,< uT r _e� , s p Y ._- � , ._-, G r_Y a ...;, § ,, , h -Y ��. C s O .a a �. non-network onstbl _f r _ _ �.�res ons�bt _for e,o ,an, mchar es in excess,of the.non network, rovtd r:.r imb rsement:amount•-.a'Y=, ., a an charges m excess the nonn twork rovrder re� buc : � r _ P . Y e e u P � Y 9 e sement,amount• -=,Addit�onall th e h , or the .Additronall thes - � _ _: -.x a es car esw�ll not be a lied<toward satrsfaction._of:the-deductible orahe out of._�.� >._._ i �: e.char es will be applied towardaatrsfactron of. deducts 1 - _ Y,, � 9 . . ,Rp _ _ # Additionally, b eor the outof -. ..,_..._ - - ..,._, ::. .. .. .._._:,. s> ..._ , � r.. _ ... _._.,, � . e�.� ., ,._: x_ ... ,_>.: ,.. ,tea ocket maximum'. r. ^ oc et:maximum. b . <., ... .. ,--- - __ #.,..... -. �...� x. ?.a.4...,_. _. , .« ...a.., __-.... .tea_,,, __.. _.. - 4. Inpatient services Nothing No coverage ii. Lodging for you (while not confined) and one 5. Services received from a Nothing No coverage companion. physician during an inpatient Reimbursement is stay available for a per diem 6. Anesthesia services received Nothing No coverage amount of up to $50 for from a provider during an one person or up to $100 inpatient stay for two people. If you are 7. Transportation and lodging You are responsible for No coverage a minor child, reimbursement for a. As described below, paying all amounts not lodging expenses for two reimbursed under this reimbursement of reasonable benefit. Such amounts companions is available, and necessary expenses for be not count toward your up to a per diem amount travel and lodging for you of$100. and a companion when you out-of-pocket maximum. iii. There is a lifetime receive approved services at maximum of$10,000 per a designated facility for member for all transplant services and you live more than 50 miles from transportation and lodging expenses that designated facility incurred by you and your i. Transportation of you and companion(s) and one companion (traveling reimbursed under the on the same day(s)) to Contract or under any and/or from a designated other Medica, Medica facility for transplant Health Plans, or Medica services for pre- Health Plans of I transplant, transplant, Wisconsin coverage and post-transplant offered through the same services. If you are a employer. minor child, b. Meals are not reimbursable transportation expenses under this benefit. for two companions will be reimbursed. MIC PP MN (3/12) 46 100%-15 MIC PP MN (3/12) 47 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Physical, Speech, And Occupational Therapies Physical, Speech, And Occupational Therapies 7. Group physical, speech, and occupational therapy. P. Physical, Speech, And Occupational Therapies 8. Physical, speech, or occupational therapy services (including but not limited to services for the correction of speech impediments or assistance in the development ofi verbal clarity) when there is no reasonable expectation that the member's condition will improve over a This section describes coverage for physical therapy, speech therapy, and occupational therapy predictable period of time according to generally accepted standards in the medical services provided on an outpatient basis. A physician must direct your care in order for it to be community. eligible for coverage. Coverage for services provided on an inpatient basis is as described 9. Massage therapy, provided in any setting, even when it is part of a comprehensive elsewhere in this certificate. treatment plan. See Definitions. These words have specific'".meanings ;benefits,:coinsurance, copayment, See Exclusions for additional services, supplies, and associated expenses that are not deductible, inpatient, network, non network, non-network provider reimbursernent amount, covered. 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 Your Benefits anal the Amounts 77. .Pay front cover. See How To Access Your Benefits for more information about the prior ,-:` a s . authorization process. Benefits - In-neork benefits ° *Out of-network benefits after deductible ; Covered *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. -t For benefits and the amounts you pay, see the table in this section. More than one copayment Additionally,these charges will not[eapplied-toward satisfaction of the deductible or the ou -of- ocketMaximum. ` ..' e +� or coinsurance may be required if you receive more than one service or see more than one Pocket � � � _ provider per visit. � _.... • In-network benefits apply to outpatient physical therapy, speech therapy, .1. Physical therapy received $15/visit 50% coinsurance. py, and occupational outside of your home when Coverage for physical therapy services arranged through a physician and received from the following types of hysical function is impaired due and occupational therapy physical network providers: physical therapist, speech therapist, occupational therapist, or physician. to a medical illness or injury or is limited to a combined developmental limit of 20 visits per develo or congenital• Out-of-network benefits apply to outpatient physical therapy, speech therapy, and con 9 p occupational therapy services arranged through a physician and received from the following conditions that have delayed calendar year. motor development Please note: This visit limit types of non-network providers: physical therapist, speech therapist, occupational therapist, includes physical and or physician. In addition to the deductible and copayment or coinsurance described for out- occupational therapy visits of-network benefits, you are responsible for any charges in excess of the non-network V that you pay for in order to provider reimbursement amount. The out-of-pocket maximum does not apply to these satisfy any part of your charges. Please see Important member information about out-of-network benefits in How deductible. To Access Your Benefits for more information and an example calculation of out-of-pocket 2. Speech therapy associated with out-of-network benefits. P pY received outside $15/visit 50% coinsurance. of your home when speech is Coverage for speech Not covered 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 These services, supplies, and associated expenses are not covered: have delayed speech includes speech therapy 1. Services primarily educational in nature. development visits that you pay for in order to satisfy any part of 2. Vocational and job rehabilitation. your deductible. 3. Recreational therapy. 4. Self-care and self-help training (non-medical). 5. Health clubs. 6. Voice training. 100%-15 I MIC PP MN (3/12) 48 100%-15 MIC PP MN (3/12) 49 BPL 85259 DOC 23705 BPL 85259 DOC 23705 1 Physical, Speech, And Occupational Therapies Prescription Drug Program I Your Benefits the Amounts You Pays Q. Prescription Drug Program Benefits in network"benefits Out of network beneftits after deductible This section describes coverage for prescription drugs and supplies received from a pharmacy r = � or a designated mail order pharmacy. For purposes of this section, the phrase "covered drugs" *For out-of-network benefits, in addition to the deductible,"copayment,arid coinsurance-,,you are g P Y P P P 9 k.- is meant to include those prescription drugs supplies responsible for any charges in excess of the non-network provider reimbursement amount _= P P 9 pp 'es found on the Preferred Drug List (PDL) and prescribed by a provider authorized to prescribe such covered drugs, unless such Additionally,Atl ese charges will not be appliedAtoward satisfaction of the leductible or the_out-of _ ocket maximum � � K prescription drugs and supplies are identified in this certificate as not covered. The phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, 3. Occupational therapy received $15/visit 50% coinsurance. intramuscular injection, or intraocular injection; the phrase "self-administered drugs" means all outside of your home when Coverage for physical other drugs. For the definition and coverage of specialty prescription drugs, see Prescription physical function is impaired due and occupational therapy Specialty Drug Program. to a medical illness or injury or is limited to a combined -m congenital or developmental limit of 20 visits per See Definrtions=These words have specific meanings -benefits claim, coinsurance, 9 P P Y copayment,deductible„durable medical equipment, emergency, hospital, member, network, conditions that have delayed calendar year. • non network, non network provider reimbursement amount, physician prescription drug,; Please note: This visit limit motor development reventive health service,mprovider, urgent,care center. includes physical and p ,_- occupational therapy visits that you pay for in order to Preferred drug list satisfy any part of your deductible. 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 MN (3/12) 50 100%-15 MIC PP MN (3/12) 51 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 I Prescription Drug Program Prescription Drug Program Medica's PDL exception process, call Customer Service at one of the telephone numbers listed inside the front cover. In-network benefits Out-of-network benefits* Mail order benefits** Prior authorization 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 Certain covered drugs require prior authorization as indicated on the PDL. The provider who transmitted diseases when transmitted diseases when prescribes the drug initiates prior authorization. The PDL is made available to providers, prescribed by or received from prescribed by either a including pharmacies and the designated mail order pharmacies. You are responsible for either a network or a non- network or a non-network paying the cost of drugs received if you do not meet Medica's authorization criteria. network provider. Family provider and received from a Step therapy planning services do not designated mail order include infertility treatment pharmacy. Family planning services; and services do not include Medica requires step therapy prior to coverage of specific drugs as indicated on the PDL. Step infertility treatment services; therapy involves trying an alternative covered drug first (typically a Tier 1 drug) before moving and on to a Tier 2 or Tier 3 covered drug for treatment of the same medical condition. Applicable Diabetic equipment and Diabetic equipment and Diabetic equipment and step therapy requirements must be met before Medica will cover Tier 2 or Tier 3 covered drugs. supplies, including blood supplies, including blood supplies (excluding blood Quantity limits 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. Certain covered drugs are assigned quantity limits as indicated on the PDL. These limits Tobacco cessation products Tobacco cessation products Not available. indicate the maximum quantity allowed per prescription over a specific time period. Some when prescribed by a provider when prescribed by a provider quantity limits are based on packaging, FDA labeling, or clinical guidelines. authorized to prescribe the authorized to prescribe the •Covered product and received at a product and received at a non- Covered pharmacy. network pharmacy. The following table provides important general information concerning in-network, out-of- *When out-of-network benefits are received from non-network providers, in addition to the network, and mail order benefits. For specific information concerning benefits and the amounts deductible and copayment or coinsurance, you will be responsible for any charges in excess of you pay, see the benefit table at the end of this section. Please note that Prescription Drug the non-network provider reimbursement amount. The out-of-pocket maximum does not Program describes your copayment or coinsurance for prescription drugs themselves. An apply to these charges. Please see Important member information about out-of-network 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 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. certificate including, but not limited to, Hospital Services, Infertility Diagnosis, and Professional Services. ** Please note: Some drugs and supplies are not available through the designated mail order pharmacy.1 See Miscellaneous llaneous Medics S e Services And Supplies f or coverage o f insulin pumps. In-network benefits Out-of-network benefits* order ord benefits** See Prescription growth and other -- - - -- - - - --,--.: - ee rescription Specialty Drug Program for coverage of gro hormone an o Covered drugs received at a Covered drugs received at a Covered drugs received from specialty prescription drugs. network pharmacy; and non-network pharmacy; and a designated mail order pharmacy; and 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 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 contraceptives, up to a three-cycle supply), unless limited by drug manufacturers' packaging, dosing instructions, or Medica's medication request guidelines, including quantity limits MIC PP MN (3/12) 52 100%-15 MIC PP MN (3/12) 53 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 P Prescription Drug Program Prescription Drug Program as indicated on the PDL. Copayment or coinsurance amounts will apply to each prescription unit _ <,5 dispensed. Your Benefits and the Amounts You Pays Three prescription units may be dispensed for covered drugs prescribed to treat chronic * net - l ,, d it s d • n , y �zFor.out-of network benefiits, maddit�on�ao the deductibte,copayment,�ar�d coinsurance, you are conditions that are received at a network pharmacy that Medica has specifically designated to responsible for an c#ar ges in excess Of the non network provider reimbursement amount y 9 �-. dispense multiple prescription units. For the current list of such designated pharmacies, sign in Additionally,these charges will not be applied toNard satin action of the deductible or the out-of- at www.mymedica.corn or call Customer Service at one of the telephone numbers listed inside pocket maximum - � � �� the front cover. a � In=networkbenefits *gOut-of-network beneftt.s benefits Not covered � .after deductible The following are not covered: 1. Outpatient covered drugs other than those described below or in Prescription Specialty Drug Program 1. Any amount above what Medica would have paid when you fail to identify yourself to the Tier 1: $12 per prescription $90 or 40% coinsurance Tier 1: $24 per prescription pharmacy as a member. (Medica will notify you before enforcement of this provision.) unit; or (whichever is greater) per unit; or 2. OTC drugs not listed on the PDL. Tier 2: $50 per prescription prescription unit Tier 2: $100 per prescription • 3. Replacement of a drug due to loss, damage, or theft. unit; or unit; or 4. Appetite suppressants. Tier 3: $90 per prescription Tier 3: $180 per prescription 5. Erectile dysfunction medications. unit unit 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 2. Diabetic equipment and supplies, including blood glucose meters those members who have a feeding tube. Tier 1: 20% coinsurance 40% coinsurance per Tier 1: 20% coinsurance per 8. Tobacco cessation products or services dispensed through a mail order pharmacy. per prescription unit; or prescription unit prescription unit; or 9. Drugs prescribed by a provider who is not acting within his/her scope of licensure. Tier 2: 20% coinsurance Tier 2: 20% coinsurance per per prescription unit; or prescription unit; or 10. Homeopathic medicine. Tier 3: 40% coinsurance Tier 3: 40% coinsurance per 11. Infertility drugs. per prescription unit prescription unit 12. Specialty prescription drugs, except as described in Prescription Specialty Drug Program. See Exclusions for additional drugs, supplies, and associated expenses that are not 3. Tobacco cessation products covered. 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 PP MN (3/12) 54 100%-15 MIC PP MN (3/12) 55 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Prescription Drug Program Prescription Specialty Drug Program Your Benefits and the Amounts You Pay R. Prescription Specialty Drug Program *For out-o€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 toward satisfaction of the deductible or;the:out-of- This section describes coverage for specialty prescription drugs received from a designated y' 9 - specialty pharmacy. Specialty prescription drugs include, but are not limited to, high technology pocket maximum.t - � prescription drug products for individuals with diseases that require complex therapies. Such In network benefits - �� = *Out-of network benefits Mail order benefits specialty prescription drugs are identified on Medica's Specialty Preferred Drug List (SPDL), as "- m : ' after deductible - = described below. For purposes of this section, the phrase "professionally administered drugs" means drugs requiring intravenous infusion or injection, intramuscular injection, or intraocular 4. Drugs and other supplies (other than tobacco cessation products) considered preventive injection; the phrase "self-administered drugs" means all other drugs. health services, as specifically defined in Definitions, when prescribed by a provider See Definitions These words havens specific meanings: Benefits,claim, coinsurance, authorized to prescribe such drugs. This group of drugs and supplies is specific and p 9 limited. For the current list of such drugs and supplies, please refer to the Preventive Drug copayment,member;,network,.physician, prescription drug provider and Supply List within the PDL or call Customer Service at one of the telephone numbers listed inside the front cover. Designated specialty pharmacies Tier 1: Nothing per $90 or 40% coinsurance Tier 1: Nothing per prescription unit; or (whichever is greater) per prescription unit; or 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 g per prescription unit g per current list of designated specialty pharmacies, call Customer Service at one of the telephone Tier 2: Nothin er Tier 2: Nothin prescription unit; or prescription unit; or numbers listed inside the front cover or sign in at www.mymedica.com. Tier 3: Nothing per Tier 3: Nothing per prescription unit prescription unit 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 copayments 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 9 uidelines, 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 PP MN (3/12) 56 100%-15 MIC PP MN (3/12) 57 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 P Prescription Specialty Drug Program Prescription Specialty Drug Program a copy of Medica's SPDL exception process, call Customer Service at one of the telephone Not covered numbers listed inside the front cover. The following are not covered: Prior authorization 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 Certain specialty prescription drugs require prior authorization. The provider who prescribes the this provision.) specialty drug initiates prior authorization. The SPDL is made available to providers, including 2. Replacement of a specialty drug due to loss, damage, or theft. 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. 3. Specialty prescription drugs prescribed by a provider who is not acting within their scope of licensure. Step therapy 4. Prescription drugs, except as described in Prescription Drug Program. 5. Specialty prescription drugs received from a pharmacy that is not a designated specialty Medica requires step therapy prior to coverage of specific specialty prescription drugs as pharmacy. indicated on the SPDL. Step therapy involves trying an alternative covered specialty prescription drug (typically a Tier 1 specialty prescription drug) before moving on to certain other 6. Infertility drugs. Tier 1 or Tier 2 specialty prescription drugs for treatment of the same medical condition. See Exclusions for additional drugs, supplies, and associated expenses that are not Applicable step therapy requirements must be met before Medica will cover certain Tier 1 or covered. Tier 2 specialty prescription drugs. Quantity limits Your Benefits and the Amounts You Pay p y prescription drugs assigned quantity Benefits ; ; Certain s ecialt rescri tion dru s are assi ned uantit limits as indicated on the SPDL. its '�� � `� � You pay ,� b � 1- 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. 1. Specialty prescription drugs, Tier 1 specialty prescription drugs: 20% other than those described coinsurance up to a maximum of$200 per prescription Covered below, received from a unit; or designated specialty pharmacy Tier 2 specialty prescription drugs: 40% For benefits and the amounts you pay, see the table at the end of this section. Benefits apply to coinsurance per prescription unit specialty prescription drugs prescribed by a provider authorized to prescribe such drugs and received from a designated specialty pharmacy. 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 This section describes your copayment or coinsurance for specialty prescription drugs. An treatment of a demonstrated unit; or additional copayment or coinsurance applies for the provider's services if you require that a growth hormone deficiency and provider administer self-administered drugs, as described in other applicable sections of this received from a designated Tier 2 specialty prescription drugs: 40% certificate including, but not limited to, Hospital Services, Infertility Diagnosis, and Professional specialty pharmacy coinsurance per prescription unit Services. 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 PP MN (3/12) 58 100%-15 MIC PP MN (3/12) 59 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Professional Services Professional Services Not covered S. Professional Services These services, supplies, and associated expenses are not covered: 1. Drugs provided or administered by a physician or other provider, except those requiring This section describes coverage for professional services received from or directed by a intravenous infusion or injection, intramuscular injection, or intraocular injection. Coverage physician. for drugs is as described in Prescription Drug Program and Prescription Specialty Drug Program or otherwise described as a specific benefit in this certificate. See Definitions. These words have specificrmeanings: benefits,.coinsurance, convenience h treatment of care/retail health clinic, copayment, deductible, emergency,genetic:testing, hospital,--inpatient,' 4„ 2. Diagnostic casts, diagnostic study models and bite adjustments related tot a treat nt o ° ` 9 y' g g' member,:network, non network, non network provider reimbursement amount, physi temporomandibular joint (TMJ) disorder and craniomandibulardlsorder.cian,° preventive:health service, provider, urgent care center, virtual care. Exclusions for additional services, supplies, and associated expenses that are not Prior authorization. Prior authorization from Medics may be required before you receive covered. 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. ,. Your Benefits and the A mounts You Pay-q Covered Benefits: in network benefits • *r0t-of network en • befits _ t ,;� � �,� � �� � �a#ter deductible• For benefits and the amounts you pay, see the table in this section. More than one copayment g ` y en , and e = *-For out=of network benefits; m addition the deductible, an coinsurance, you are or coinsurance may be required if you receive more than one service or see more than one responsiblefor any charges in excess of the nor network provider reimbursement amount.: -- per visit. p rovider p Additionally these charges will not be applied toward satisfaction of the-deductible or the out-of- pocket maximum. �& � • In-network benefits apply to: 1. Professional services received from a network provider; 1. Office visits $15/visit 50% coinsurance Please note: Some services 2. Professional services for testing and treatment of a sexually transmitted disease and received during an office visit may testing for AIDS and other HIV-related conditions received from a network provider or a be covered under another benefit in non-network provider; this certificate. The most specific 3. Family planning services, for the voluntary planning of the conception and bearing of and appropriate benefit in this children, received from a network provider or a non-network provider. Family planning certificate will apply for received during an office vis services do not include infertility treatment services. For example, certain services • Out-of-network benefits apply to professional services received from a non-network provider, received during an office visit may In addition to the deductible and copayment or coinsurance, you will be responsible for any be considered surgical or imaging charges in excess of the non-network provider reimbursement amount. The out-of-pocket services; see below for coverage of maximum does not apply to these charges. Please see Important member information these surgical or imaging services. about out-of-network benefits in How To Access Your Benefits for more information and an In such instances, both an office example calculation of out-of-pocket costs associated with out-of-network benefits. visit copayment or coinsurance and Emergency services from non-network providers will be covered as in-network benefits. outpatient surgical or imaging services copayment or coinsurance The most specific and appropriate section of this certificate will apply for professional services apply. related to the treatment of a specific condition. For example, benefits for transplant services are Call Customer Service at one of the described in Organ And Bone Marrow Transplant Services. telephone numbers listed inside the For some services, there may be a facility charge resulting in copayment or coinsurance (see front cover to determine in advance Hospital Services) in addition to the professional services copayment or coinsurance. whether a specific procedure is a benefit and the applicable coverage level for each service that you receive. 2. Virtual care $5/visit No coverage MIC PP MN (3/12) 60 100%-15 MIC PP MN (3/12) 61 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Professional Services Professional Services Yo ur-Benefits a n d..,_a..he A mo u_._ n."tsk Yo ux. P a � -...:._.:. -�:•_, _ ..„. _ . • ...... ..- -,_ b� P _ o UCAB ene#its-an d the-Amounts You_Pa � _ � , � Benefits: , � �. #n-ne#wor kbeoeflts �. Out-of-network. x benefits §B enef its in_network be n fits „ Out-of-network benefits _ afe deductible , _ _ after * out-of-network a o x n fr m add�t�an to the."deductible co a ment::and:co�nsurance you are _,- etwork,benefits.�n addition;to�the�dedu trb(e t -•: For �be ets, p Y, « ,Y _-, ...: c ,copayment,.ment and coinsurance,'you are responsible f or an =charges x.. n excess of the n on-�.,e.:...n.�e.,tw...o rk provider .....:.,..reimbursement�.,,..a,,,_.s,mo�„u n, .._, ._. _� responsible n a ble f o c a n Y;char charges excess fth the.n non-network provider- ro��der,r reimbursement�m�ur seine Vini:t.am' o un t. � Additionally,these charg s will not be a pp lied toward satisfaction^of, he rdedugtt bleor"the.out of Additionally,these,char es will applied toward satisfaction ofthe ded uct out-Of- pocket ble or he = maximum. , . ��x � p ocket maximum. ,_ f .- ^ _ .:, ° ..ts }: 3. Convenience care/retail health $5/visit 50% coinsurance 5. Preventive health care clinic visits Please note: If you receive preventive and non-preventive 4. Urgent care center visits $15/visit Covered as an in-network health services during the same Please note: Some services benefit. visit, the non-preventive health received during an urgent care services may be subject to a center visit may be covered under copayment, coinsurance, or another benefit in this certificate. deductible, as described elsewhere The most specific and appropriate in this certificate. The most specific benefit in this certificate will apply and appropriate benefit in this for each service received during an certificate will apply for each service urgent care center visit. received during a visit. For example, certain services a. Child health supervision Nothing Covered as an in-network received during an urgent care services, including well-baby benefit. center visit may be considered care surgical or imaging services; see below for coverage of these surgical b. Immunizations Nothing 50% coinsurance or imaging services. In such c. Early disease detection Nothing 50% coinsurance instances, both an urgent care y g center visit copayment or services including physicals coinsurance and outpatient surgical d. Routine screening Nothing 50% coinsurance or imaging services copayment or procedures for cancer coinsurance apply. Call Customer Service at one of the e. Other preventive health Nothing 50% coinsurance telephone numbers listed inside the services front cover to determine in advance 6. Allergy shots Nothing 50% coinsurance whether a specific procedure is a benefit and the applicable coverage 7. Routine annual eye exams Nothing 50% coinsurance level for each service that you 8. Chiropractic services to $15/visit 50% coinsurance. receive. diagnose and to treat (by manual Coverage is limited to a j 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 PP MN (3/12) 62 100%-15 MIC PP MN (3/12) 63 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Professional Services Professional Services . .:. .... .. _ _ _.,..., a , :....,. ...E r. ... _:.,,.. .... ::_ .. _ __ _.... Your-Benefits g ... ..,. ;,:. ,-s>.,..<..::� ., - ,.'�:. �...� :.:: .:. -. .:. Amounts .:. �:: { ,-�.: ,�.x_..._. :v,,., :s.,wait.:.. . , . ., .. ,. . _ � �, . ,� _ -_..�. �_ < . :, : E __. . Youcx,Beneflifis-and h Pay' --:., �, ._�� � . .:. ._._ - the.Amounts,You Pa, the Amounts You.Pa ,, _. : --. andth. .. � . _.. sx .. � B_<x e nefits ,� - ._ _ .._ in_ne tw ark benefits n.,....ef lts . .. ��_ O,.,..ut_ of n etwor k r.,be__,nef—_t—s__.�.._ Benefits t..___ s...._-_..._ ..��... .W ..:_ In n . et.wo,s.r_..k.,.. benefits its =_tars..h, _. Out o.-#_ne two r, k .b,_. en fi t s_ ._ , _ after-deduct bie � after . e K _ � _� � � y _ coinsurance,� -of-network,benefits in addition to the deductible co a ment,and ;you are For.out of networr benefits,=m�addition to the deductible,co meet and coinsurance,: QU are responsible for any charges in of the non network.provider reimbursement burse t amount. responsible r any charges in excess of the non-network rovrderreimbursementY amount Additionally,th ch r es,wrll at.be applied toward satisfaction the-deductible or the Additionally,att Y,th ese charges=w►tt not be a Pp tred_toward satisfaction of the deductible o r the out-o f= cke m Pocket maximum _ : .', ..',. 9. Surgical services (as defined in $15/visit 50% coinsurance 17. Treatment to lighten or remove Covered at the Covered at the the Physicians'Current the coloration of a port wine stain corresponding in-network corresponding out-of- Procedural Terminology code benefit level, depending network benefit level, book) received from a physician on type of services depending on type of during an office visit or an provided. services provided. outpatient hospital or For example, office visits For example, office visits ambulatory surgical center visit are covered at the office are covered at the office 10. Anesthesia services received $15/visit 50% coinsurance visit in-network benefit visit out-of-network from a provider during an office level and surgical benefit level and surgical visit or an outpatient hospital or services are covered at services are covered at ambulatory surgical center visit the surgical services in- the surgical services out- 11. Services received from a Nothing Covered as an in-network network benefit level. of-network benefit level. . physician during an emergency benefit. 18. Treatment of temporomandibular Covered at the Covered at the room visit joint (TMJ) disorder and corresponding in-network corresponding out-of- ° craniomandibular disorder benefit level, depending network benefit level, 12. Services received from a Nothing 50% coinsurance physician during an inpatient on type of services depending on type of provided. services provided. stay 13. Anesthesia services received Nothing 50% coinsurance For example, office visits For example, office visits are covered at the office are covered at the office from a provider during an visit in-network benefit visit out-of-network inpatient stay level and surgical benefit level and surgical 14. Outpatient lab and pathology Nothing 50% coinsurance services are covered at services are covered at 15. Outpatient x-rays and other Nothing 50% coinsurance the surgical services in- the surgical services out- network benefit level. of-network benefit level. imaging services Please note: Dental Please note: Dental 16. Other outpatient hospital or $15/visit 50% coinsurance coverage is not provided coverage is not provided ambulatory surgical center under this benefit. under this benefit. services received from a 19. Diabetes self-management $15/visit 50% coinsurance physician 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) MIC PP MN (3/12) 64 100%-15 MIC PP MN (3/12) 65 100%-15 1 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Professional Services Reconstructive And Restorative Surgery _ s Your Benefits and the Amounts You xPay �� �� T. Reconstructive And Restorative Surgery Benefits In-network benefits u# of network benefits after deductible This section describes coverage for professional, hospital, and ambulatory surgical center *For out-of-network benefits, in addition to the deductible,copayment,sand coinsurance,you are . services for reconstructive and restorative surgery. To be eligible, reconstructive and restorative a u ' y sure services must be medically necessary and not cosmetic. responsible for any, charges En�excess:of the provider reiinbursement;:amount surgery Y Y Additionaily,these char es will . not b e applied ed tow a rd satisfaction o n.o of the.deductible uctibl e or,the_au t_ f_ See.D e._f in�t�o- n.s. Thes e..,x w_ords have specific. e c.f�c me x.,a rrn s. benefits,ts c oinsura__�u n. c, e co a merit pocket maxmlum. cosmetic, deductibl , hospital, inpatien t„t, netl�cally necessary, member, retwork .ron network, 20. Neuropsychological $15/visit 50% coinsurance neon netwoi provider reimbursement amount, physician provider,=reconstructive,.restorative, evaluations/cognitive testing, virtual care. A limited to services necessary for Prior authorization. Prior authorization from Medica may be required before you receive the diagnosis or treatment of a services or supplies. Call Customer Service at one of the telephone numbers listed inside the medical illness or injury front cover. See How To Access Your Benefits for more information about the prior 21. Services related to lead testing $15/visit 50% coinsurance authorization process. 22. Vision therapy and orthoptic $15/visit 50% coinsurance and/or pleoptic training, to Covered establish a home program, for the treatment of strabismus and For benefits and the amounts you pay, see the table in this section. More than one copayment other disorders of binocular eye or coinsurance may be required if you receive more than one service or see more than one movements. Coverage is limited provider per visit. to a combined in-network and • In-network benefits apply to reconstructive and restorative surgery services received from a out-of-network total of 5 training network provider. visits and 2 follow-up eye exams per calendar year. • Out-of-network benefits apply to reconstructive and restorative surgery services received Please note: The visit and exam from a non-network provider. In addition to the deductible and copayment or coinsurance limits include visits and exams that described for out-of-network benefits, you will be responsible for any charges in excess of you pay for in order to satisfy any the non-network provider reimbursement amount. The out-of-pocket maximum does not part of your deductible. apply to these charges. Please see Important member information about out-of-network 23. Genetic counseling, whether pre- $15/visit 50% coinsurance benefits in How To Access Your Benefits for more information and an example calculation of or post-test, and whether out-of-pocket costs associated with out-of-network benefits. occurring in an office, clinic, or telephonically Not covered 24. Genetic testing when test results Nothing 50% coinsurance will directly affect treatment These services, supplies, and associated expenses are not covered: decisions or frequency of 1. Revision of blemishes on skin surfaces and scars (including scar excisions) primarily for screening for a disease, or when cosmetic purposes, unless otherwise covered in Professional Services. results of the test will affect 2. Repair of a pierced body part and surgical repair of bald spots or loss of hair. reproductive choices 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 PP MN (3/12) 66 100%-15 MIC PP MN (3/12) 67 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Reconstructive And Restorative Surgery Reconstructive And Restorative Surgery 7. Drugs provided or administered by a physician or other provider on an outpatient basis, ;:ay except those requiring intravenous infusion or injection, intramuscular injection, or Your,Be,nefits and the Amounts ;(01.1'Pay , w' -'- 4 , . intraocular injection. Coverage for drugs is as described in Prescription Drug Program and Prescription Specialty Drug Program or otherwise described as a specific benefit in this Benefits ' � In-network benefits *Out-of-network benefits certificate. after deductible See Exclusions for additional services supplies, and associated expenses that are not a = > u covered. For out ot-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 therdeductible or the outof pocket maximum... . _ �� t . _.:".... = ..-.... .-.-:a• v ,: ,.. .�.. -».._ _._...r.... ..,w ..._... _ =are. __.___ �.__..... the Amounts.You Pay 7 P Your Benefits and;th - y v. Other outpatient hospital 20% coinsurance 50% coinsurance - � � : ' -�� ��� �����. _ or ambulatory surgical E : ft Iii-network benefits , Out-of-network.benefits , �° � � � - � � center services received � r 3 after�deductible from a physician *For out of network benefits, in addition to the deductible,copayment, and coinsurance, you are _ b. Hospital and ambulatory responsible for any charges in excess'ofthe non-network provider reimbursement amount ` surgical center services Additionally these charges will not he applied toward satisfaction of the deductible or t�he out-of i. Outpatient lab and Nothing 50% coinsurance maximum = �, � - pathology 1. Office visits $15/visit 50% coinsurance ii. Outpatient x-rays and Nothing 50% coinsurance 2. Virtual care $5/visit No coverage other imaging services 3. Outpatient services iii. Other outpatient hospital 20% coinsurance 50% coinsurance a. Professional services and ambulatory surgical center services i. Surgical services (as 20% coinsurance 50% coinsurance 4. Inpatient services 20% coinsurance 50% coinsurance defined in the Physicians'Current 5. Services received from a 20% coinsurance 50% coinsurance Procedural Terminology physician during an inpatient code book) received stay from a physician during 6. Anesthesia services received 20% coinsurance 50% coinsurance an office visit or an from a provider during an outpatient hospital or inpatient stay 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 PP MN (3/12) 68 100%-15 MIC PP MN (3/12) 69 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 it Skilled Nursing Facility Services Skilled Nursing Facility Services 7. Physical, speech, or occupational therapy services when there is no reasonable expectation U. Skilled Nursing Facility Services that the member's condition will improve over a predictable period of time according to g y generally accepted standards in the medical community. 8. Voice training. This section describes coverage for use of skilled nursing facility services. Care must be g. Group physical, speech, and occupational therapy. provided under the direction of a physician. Coverage of the services described in this section is limited to a maximum benefit of 120 days per person per calendar year. Skilled nursing 10. Long-term care. facility services are eligible for coverage only if you are admitted to a skilled nursing facility See Exclusions for additional services, supplies, and associated expenses that are not within 30 days after a hospital admission of at least three consecutive days for the same illness covered. or condition. �k e e s Definitions. The__-s e words..--.:h.__.a._v e s ...e_..c iftc me a.y..am.nt:....n.T.s......_ be.:...neflt.:s"..,coins...u.. ran.-c,:e .c copayment,.,_ "... , custodial care, deductible, hospital, inpatient, network, non network n.on network provider Your Benefits and the ou # Y ou Pay retmbursernent:amoun#, physician, skilled care. skilled nuts n Benefits In network:benefits, : x *,Out-of network benefits Prior authorization. Prior authorization from Medica may be required before you receive �. �.x services or supplies. Call Customer Service at one of the telephone numbers listed inside the ' v A after deductible front cover. See How To Access Your Benefits for more information about the prior authorization process. * F 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 Covered pocket maximum..„ fi ?�T For benefits and the amounts you pay, see the table in this section. More than one copayment 1. Daily skilled care or daily skilled 20% coinsurance 50% coinsurance or coinsurance may be required if you receive more than one service or see more than one rehabilitation services, including provider per visit. For purposes of this section, room and board includes coverage of health room and board, up to 120 days services and supplies. per person per calendar year Please note: Such services are • In-network benefits apply to skilled nursing facility services arranged through a physician eligible for coverage only if you are and received from a network skilled nursing facility. admitted to a skilled nursing facility within 30 days after a hospital • Out-of-network benefits apply to skilled nursing facility services arranged through a admission of at least three physician and received from a non-network skilled nursing facility. In addition to the consecutive days for the same deductible and copayment or coinsurance described for out-of-network benefits, you will be illness or condition. This day limit responsible for any charges in excess of the non-network provider reimbursement amount. includes days that you pay for in The out-of-pocket maximum does not apply to these charges. Please see Important order to satisfy any part of your member information about out-of-network benefits in How To Access Your Benefits for more deductible. information and an example calculation of out-of-pocket costs associated with out-of- 2. Skilled physical, speech, or 20% coinsurance 50% coinsurance network benefits. occupational therapy when room and board is not eligible to be Not covered covered 3. Services received from a 20% coinsurance 50% coinsurance These services, supplies, and associated expenses are not covered: physician during an inpatient 1. Custodial care and other non-skilled services. stay in a skilled nursing facility 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. MIC PP MN (3/12) 70 100%-15 MIC PP MN (3/12) 71 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Substance Abuse Substance Abuse Covered V. Substance Abuse For benefits and the amounts you pay, see the table in this section. More than one copayment or coinsurance may be required if you receive more than one service or see more than one This section describes coverage for the diagnosis and primary treatment of substance abuse provider per visit. disorders listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. • For in-network benefits: See Definitions. These words have specific meanings beriefits,:claim, coinsurance, copayment,=' 1. Medica's designated mental health and substance abuse provider arranges in-network custodial care, deductible, emergency, hospital, inpatient, medically necessary, member,'mental substance abuse benefits. If you require hospitalization, Medica's designated mental disorder;network, non network,non network provider reimbursement amount, physician, health and substance abuse provider will refer you to one of its hospital providers (Medica provider. ' ... = � � . -- _-. and Medica's designated mental health and substance abuse provider hospital networks Prior authorization. For prior authorization requirements of in-network and out-of-network are different). benefits, call Medica's designated mental health and substance abuse provider at 2. In-network benefits will apply to services, care or treatment for a member that has been 1-800-848-8327 or for Hearing Impaired members, please contact: National Relay Center placed in any applicable Department of Corrections' custody following a conviction for a 1-800-855-2880, then ask them to dial Medica Behavioral Health at 1-866-567-0550. first-degree driving while impaired offense. To be eligible, such services, care, or For purposes of this section: 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 1. Outpatient services include: and substance abuse provider Customer Service at 1-866-214-6829. a. Diagnostic evaluations. • For out-of-network benefits: b. Outpatient treatment. 1. Substance abuse services from a non-network provider listed below will be eligible for c. Intensive outpatient programs, including day treatment and partial programs, which may coverage under out-of-network benefits provided that the health care professional or include multiple services and modalities, delivered in an outpatient setting. facility is licensed, certified, or otherwise qualified under state law to provide the substance d. Services, care, or treatment for a member that has been placed in any applicable abuse services and practice independently: Department of Corrections' custody following a conviction for a first-degree driving while a. Psychiatrist impaired offense; to be eligible, such services, care, or treatment must be required and b. Psychologist provided by any applicable Department of Corrections. c. Registered nurse certified as a clinical specialist or as a nurse practitioner in 2. Inpatient services include: psychiatric and mental health nursing a. Room and board. d. Chemical dependency clinic b. Attending physician services. e. Chemical dependency residential treatment center c. Hospital or facility-based professional services. f. Hospital that provides substance abuse services d. Services, care, or treatment for a member that has been placed in any applicable g. Independent clinical social worker 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 h. Marriage and family therapist provided by any applicable Department of Corrections. 2. Emergency substance abuse services are eligible for coverage under in-network e. Residential treatment services. These are services from a licensed chemical dependency benefits. rehabilitation program that provides intensive therapeutic services following detoxification. In addition to the deductible and copayment or coinsurance described for out-of-network In addition to room and board, at least 30 hours per week per individual of chemical benefits, you will be responsible for any charges in excess of the non-network provider dependency services must be provided, including group and individual counseling, client reimbursement amount. The out-of-pocket maximum does not apply to these charges. education, and other services specific to chemical dependency rehabilitation. 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 PP MN (3/12) 72 100%-15 MIC PP MN (3/12) 73 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Substance Abuse Substance Abuse Not covered N� r , ; Your Benefits and the Amounts You Pay These services, supplies, and associated expenses are not covered: Benefits In-network benefits * Out-of-network benefits 1. Services for substance abuse disorders not listed in the current edition of the Diagnostic and after deductible &� g A zG Statistical Manual of Mental Disorders. 2. Services for a condition when there is no reasonable expectation that the condition will *For:out-of-network benefits, in addition to the deductible, copayment, and coinsurance,;you are p responsible for any charges in excess of the non-network provider reimbursement amount improve. Additionally,these charges will not be applied toward satisfaction of the deductible or the out of 3. Services, care,care or treatment that is not medically necessary pocket Maximum. , 4. Services to hold or confine a person under chemical influence when no medical services are 4. Inpatient services (including required, regardless of where the services are received. residential treatment services) 5. Telephonic substance abuse treatment services. a. Room and board Nothing 50% coinsurance 6. Services, including room and board charges, provided by health care professionals or b. Hospital or facility-based Nothing 50% coinsurance facilities that are not appropriately licensed, certified, or otherwise qualified under state law professional services 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 c. Attending physician services Nothing 50% coinsurance 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 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,beapplied toward satisfaction of the deductible ort he out-of- pocket maximum ;y 1. Office visits, including $15/visit 50% coinsurance evaluations, diagnostic, and treatment services 2. Intensive outpatient programs $15/day 50% coinsurance 3. Opiate replacement therapy Nothing 50% coinsurance MIC PP MN (3/12) 74 100%-15 MIC PP MN (3/12) 75 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 • • Referrals To Non-Network Providers Referrals To Non-Network Providers 3. Provide coverage for health services that are: W.Referrals To Non-Network Providers a. Otherwise eligible for coverage under this certificate; and b. Recommended by a network physician. This section describes coverage for referrals from network providers to non-network providers. 4. Notify you of authorization or denial of coverage within ten days of receipt of your request. In-network benefits will apply to referrals from network providers to non-network providers as Medica will inform both you and your provider of Medica's decision within 72 hours from the described in this section. It is to your advantage to seek Medica's authorization for referrals to time of the initial request if your attending provider believes that an expedited review is non-network providers before you receive services. Medica can then tell you what your benefits warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or will be for the services you may receive. ability to regain maximum function, or could subject you to severe pain that cannot be adequately managed without the care or treatment you are seeking. See 1Definrtions, These wards have specific meanings'benefits, medicahy necessary F ; network, nonnetwork,'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 Ii 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 PP MN (3/12) 76 100%-15 MIC PP MN (3/12) 77 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Harmful Use Of Medical Services Exclusions X. Harmful Use Of Medical Services Y. Exclusions This section describes what Medica will do if it is determined you are receiving health services See Definitions These words have specific meanings claim, cosmetic, custodial care, or prescription drugs in a quantity or manner that may harm your health. durable medical equipment, emergency, investigative, medically necessary,member, non: k physician, provider, reconstructive, routine .. . >. ,..._ . . . non- network,, P y , p _ ct , utine,,,foot care.. See Definitions. These words.phave specific meanings:; benefits, emergency, hospital, network, physician,..prescription drug, provider _' 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 When this section applies available treatment for your condition. This section describes additional exclusions to the services, supplies, and associated expenses After Medica notifies you that this section applies, you have 30 days to choose one network already listed as Not covered in this certificate. These include: physician, hospital, and pharmacy to be your coordinating health care providers. 1. Services that are not medically necessary. This includes but is not limited to services If you do not choose your coordinating health care providers within 30 days, Medica will choose inconsistent with the medical standards and accepted practice parameters of the community • for you. Your in-network benefits are then restricted to services provided by or arranged and services inappropriate—in terms of type, frequency, level, setting, and duration—to the through your coordinating health care providers. diagnosis or condition. Failure to receive services from or through your coordinating health care providers will result in 2. Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise a denial of coverage. determined to be reconstructive. You must obtain a referral from your coordinating health care provider if your condition requires 3. Refractive eye surgery, including but not limited to LASIK surgery. care or treatment from a provider other than your coordinating health care provider. 4. The purchase, replacement, or repair of eyeglasses, eyeglass frames, or contact lenses Medica will send you specific information about: when prescribed solely for vision correction, and their related fittings. 1. How to obtain approval for benefits not available from your coordinating health care 5. Services provided by an audiologist when not under the direction of a physician, air and providers; 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 2. How to obtain emergency care; and implants and related fittings and except as described in Durable Medical Equipment And 3. When these restrictions end. 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 genetic 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 PP MN (3/12) 78 100%-15 MIC PP MN (3/12) 79 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Exclusions Exclusions 14. Personal comfort or convenience items or services. 40. Services not received from or under the direction of a physician, except as described in this 15. Custodial care, unskilled nursing, or unskilled rehabilitation services. certificate. 16. Respite or rest care, except as otherwise covered in Hospice Services. 41. Orthognathic surgery. 17. Travel, transportation, or living expenses, except as described in Organ And Bone Marrow 42. Sensory integration, including auditory integration training. Transplant Services. 43. Services for or related to vision therapy and orthoptic and/or pleoptic training, except as 18. Household equipment, fixtures, home modifications, and vehicle modifications. described in Professional Services. 44. Services for or related to intensive behavior therapy treatment programs for the treatment of 19. Massage therapy, provided in any setting, even when it is part of a comprehensive autism spectrum disorders. Examples of such services include, but are not limited to, treatment plan. Intensive Early Intervention Behavior Therapy Services (IEIBTS), Intensive Behavioral 20. Routine foot care, except for members with diabetes, blindness, peripheral vascular Intervention (IBI), and Lovaas therapy. disease, peripheral neuropathies, and significant neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and amyotrophic lateral 45. Health care professional services for maternity labor and delivery in the home. sclerosis. 46. Surgery for weight loss or morbid obesity, including initial procedures, surgical revisions, and 21. Services by persons who are family members or who share your legal residence. subsequent procedures. 22. Services for which coverage is available under workers' compensation, employer liability, or 47. Services for the treatment of infertility. any similar law. 48. Infertility drugs. 23. Services received before coverage under the Contract becomes effective. 49. Acupuncture. 24. Services received after coverage under the Contract ends. 50. Services solely for or related to the treatment of snoring. 25. Unless requested by Medica, charges for duplicating and obtaining medical records from 51. Interpreter services. non-network providers and non-network dentists. 52. Services provided to treat injuries or illness that are the result of committing a crime or 26. Photographs, except for the condition of multiple dysplastic syndrome. attempting to commit a crime. 27. Occlusal adjustment or occlusal equilibration. 53. 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 28. Dental implants (tooth replacement), except as described in Medical-Related Dental provided by an independent nurse who is ordered by the member or the member's Services. representative, and not under the direction of a physician. 29. Dental prostheses. 54. Laboratory testing that has been performed in response to direct-to-consumer marketing 30. Orthodontic treatment, except as described in Medical-Related Dental Services. and not under the direction of a physician. 31. Treatment for bruxism. 55. Medical devices that are not approved by the U.S. Food and Drug Administration (FDA), other than those granted a humanitarian device exemption. 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 56. Health clubs. result of war or any act of war (whether declared or undeclared). 57. Long-term care. y purpose 58. Expenses associated with participation in weight loss programs, including but not limited to 34. Exams, other evaluations, or other services received solely for the ur ose of insurance, or licensure. membership fees and the purchase of food, dietary supplements, or publications. 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. 39. Treatment for superficial veins, also referred to as spider veins or telangiectasia. MIC PP MN (3/12) 80 100%-15 MIC PP MN (3/12) 81 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 How To Submit A Claim How To Submit A Claim Claims for services provided outside the United States Z. How To Submit A Claim Claims for services rendered in a foreign country will require the following additional documentation: This section describes the process for submitting a claim. • Claims submitted in English with the currency exchange rate for the date health services were received. See Definitions These words have specific meanings: benefits, claim, dependent, member, v • Itemization of the bill or claim. = network;non-network;:non-network provider reimbursement amount, provider. • The related medical records (submitted in English). Claims for benefits from network providers • Proof of your payment of the claim. If you receive a bill for any benefit from a network provider, you may submit the claim following • A complete copy of your passport and airline ticket. 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 Such other documentation as Medica may request. may also be obtained by signing in at www.mymedica.com. For services rendered in a foreign country, Medica will pay you directly. Network providers are required to submit claims within 180 days from when you receive a Medica will not reimburse you for costs associated with translation of medical records or claims. 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 Time limits paying the cost of the service you received. If you have a complaint or disagree with a decision by Medica, you may follow the complaint Claims for benefits from non-network providers procedure outlined in Complaints or you may initiate legal action at any point. Claim forms are provided in your enrollment materials. You may request additional claim forms However, you may not bring legal action more than six years after Medica has made a coverage P Y Y q determination regarding your claim. 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 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 PP MN (3/12) 82 100%-15 MIC PP MN (3/12) 83 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Coordination Of Benefits 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 AA. Coordination Of Benefits plans. d. Allowable expense means a necessary, reasonable, and customary item of expense for This section describes how benefits are coordinated when you are covered under more than 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 one plan. the deductible for members with a primary high deductible plan and who notify Medics of See Definitions. These words have speafic meanings ..benefits, claim, deductible,_dependent,m an intention to contribute to a health savings account. emergency, hospital member, non-network, non network provider'reimb treement amount;; The difference between the cost of a private hospital room and the cost of a semi-private provider, subscriber. m a. . 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 1. Applicability generally accepted medical practice or as specifically defined in the plan. a. This coordination of benefits (COB) provision applies to this plan when an employee or 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 the employee's covered dependent has health care coverage under more than one plan. definition. Plan and this plan are defined below. b. If this coordination of benefits provision applies, Order of benefit determination rules When a plan provides benefits in the form of services, the reasonable cash value of should be looked at first. Those rules determine whether the benefits of this plan are each service rendered will be considered both an allowable expense and a benefit paid. determined before or after those of another plan. Under Order of benefit determination When benefits are reduced under a primary plan because a member does not comply rules, the benefits of this plan: with the plan provisions, the amount of such reduction will not be considered an i. Shall not be reduced when this plan determines its benefits before another plan; but allowable expense. Examples of such provisions are those related to second surgical opinions, and preferred provider arrangements. ii. May be reduced when another plan determines its benefits first. The above e. Claim determination period means a calendar year. However, it does not include any reduction is described in Effect on the benefits of this plan. 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. 2. Definitions that apply to this section a. Plan is any of these which provides benefits or services for, or because of, medical or 3. Order of benefit determination rules dental care or treatment: a. General. When there is a basis fora claim under this plan and another plan, this plan is i. Group insurance or group-type coverage, whether insured or uninsured, or individual a secondary plan which has its benefits determined after those of the other plan, unless: coverage. This includes prepayment, group practice, or individual practice coverage. i. The other plan has rules coordinating its benefits with the rules of this plan; and It also includes coverage other than school accident-type coverage. ii. Both the other plan's rules and this rules, in 3.b. below, require that this plan's ii. Coverage under a governmental plan, or coverage required or provided by law. This q P does not include a state plan under Medicaid (Title XIX, Grants to States for Medical benefits be determined before those of the other plan. Assistance Programs, of the United States Social Security Act, as amended from b. Rules. This plan determines its order of benefits using the first of the following rules I time to time). which applies: Each Contract or other arrangement for coverage under i. or ii. is a separate plan. Also, i. Nondependent/dependent. The benefits of the plan that covers the person as an if an arrangement has two parts and COB rules apply only to one of the two, each of the employee, member or subscriber (that is, other than as a dependent) are determined parts is a separate plan. before those of the plan, which covers the person as a dependent. b. This plan is the part of the Contract that provides benefits for health care expenses. ii. Dependent child/parents not separated or divorced. Except as stated in 3.b.iii. c. Primary plan/secondary plan. The Order of benefit determination rules state whether below, when this plan and another plan cover the same child as a dependent of different persons, called parents: 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 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 plan and without considering the other plan's benefits. year; but 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 PP MN (3/12) 84 100%-15 MIC PP MN (3/12) 85 100 0/0-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Coordination Of Benefits Coordination Of Benefits b) If both parents have the same birthday, the benefits of the plan which covered event, the benefits of this plan may be reduced under this section. Such other plan or one parent longer are determined before those of the plan which covered the plans are referred to as the other plans in b. immediately below. other parent for a shorter period of time. b. Reduction in this plan's benefits. The benefits of this plan will be reduced when the sum However, if the other plan does not have the rule described in (a) immediately above, of: but instead has a rule based on the gender of the parent, and if, as a result, the i. The benefits that would be payable for the allowable expense under this plan in the plans do not agree on the order of benefits, the rule in the other plan will determine absence of this COB provision; and the order of benefits. i ii. The benefits that would be payable for the allowable expenses under the other plans, iii. Dependent child/separated or divorced parents. If two or more plans cover a person in the absence of provisions with a purpose like that of this COB provision, whether as a dependent child of divorced or separated parents, benefits for the child are or not claim is made, exceeds those allowable expenses in a claim determination determined in this order: period. In that case, the benefits of this plan will be reduced so that they and the a) First, the plan of the parent with custody of the child; benefits payable under the other plans do not total more than those allowable expenses. b) Then, the plan of the spouse of the parent with the custody of the child; and When the benefits of this plan are reduced as described above, each benefit is reduced c) Finally, the plan of the parent not having custody of the child. in proportion. It is then charged against any applicable benefit limit of this plan. 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 5. Right to receive and release needed information 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 Certain facts are needed to apply these COB rules. Medica has the right to decide which shall be the secondary plan. This paragraph does not apply with respect to any facts it needs. It may get needed facts from or give them to any other organization or claim determination period or plan year during which any benefits are actually paid or person. Medica need not tell, or get the consent of, any person to do this. Unless provided before the entity has that actual knowledge. applicable federal or state law prevents disclosure of the information without the consent of iv. Joint custody. If the specific terms of a court decree state that the parents shall . the patient or the patient's representative, each person claiming benefits under this plan share joint custody, without stating that one of the parents is responsible for the must give Medica any facts it needs to pay the claim. health care expenses of the child, the plans covering follow the Order of benefit determination rules outlined in 3.b.ii. 6. Facility of payment 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 A payment made under another plan may include an amount, which should have been paid determined before those of a plan which covers that person as a laid off or retired under this plan. If it does, Medica may pay that amount to the organization which made that employee (or as that employee's dependent). If the other plan does not have this payment. That amount will then be treated as though it were a benefit paid under this plan. rule, and if, as a result, the plans do not agree on the order of benefits, this rule is Medica will not have to pay that amount again. The term payment made includes providing ignored. benefits in the form of services, in which case payment made means reasonable cash value vi. Workers'compensation. Coverage under any workers' compensation act or similar of the benefits provided in the form of services. 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. 7. Right of recovery vii. No-fault automobile insurance. Coverage under the No-Fault Automobile Insurance If the amount of the payments made by Medica is more than it should have paid under this Y p t Act or similar law applies first. COB provision, it may recover the excess from one or more of the following: viii. Longer/shorter length of coverage. If none of the above rules determines the order a. The persons it has paid or for whom it has paid; or 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 b. Insurance companies; or for the shorter term. c. Other organizations. The amount of the payments made includes the reasonable cash value of any benefits 4. Effect on the benefits of this plan provided in the form of services. a. When this section applies. This 4. applies when, in accordance with 3. Order of benefit Please note: See Right Of Recovery for additional information. determination rules, this plan is a secondary plan as to one or more other plans. In that 1 MIC PP MN (3/12) 86 100%-15 MIC PP MN (3/12) 87 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 1 Right Of Recovery Eligibility And Enrollment BB. Right Of Recovery CC. Eligibility And Enrollment This section describes Medica's right of recovery. Medica's rights are subject to Minnesota and This section describes who can enroll and how to enroll. federal law. For information about the effect of applicable state and federal law on Medica's See Definitions These words have specific meanings` benefits, continuous coverage, . : x subrogation rights, contact an attorney. dependent,late entrant, member, rnental disorder, phystciar, placed for adopt on, premium, See Definitions. This E word has a m ean m .� benef it s.� qualifying Y 9 c overa a 'subscriber Waiting; r iod _ � a �_ 1 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 Who can enroll 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 To be eligible to enroll for coverage you must meet the eligibility requirements of the Contract received a full recovery for your illness or injury from another source of compensation for and be a subscriber or dependent as defined in this certificate. See Definitions. your illness or injury. 2. Medica's subrogation interest is the reasonable cash value of any benefits received by you. How to enroll 3. Medica's right to recover its subrogation interest may be subject to an obligation by Medica You must submit an application for coverage for yourself and any dependents to the employer: 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 1. During the initial enrollment period as described in this section under Initial enrollment; or represented by an attorney. If Medica is represented by an attorney, an agreement 2. During the open enrollment period as described in this section under Open enrollment; or regarding allocation may be reached. If an agreement cannot be reached, the matter must be submitted to binding arbitration. 3. During a special enrollment period as described in this section under Special enrollment; or Y 4. By accepting coverage under the Contract, you agree: 4. At any other time for consideration as a late entrant as described in this section under Late enrollment. a. That if Medica pays benefits for medical expenses you incur as a result of any act by a Dependents will not be enrolled without the eligible employee also being enrolled. A child who third party for which the third party is or may be liable, and you later obtain full recovery, is the sub ect of a QMCSO can be enrolled as described in this section under Qualified Medical you are obligated to reimburse Medica for the benefits paid in accordance to Minnesota 1 law. Child Support Order(QMCSO) and 6. under Special enrollment. 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 Notification determine its rights under this provision. You must notify the employer in writing within 30 days of the effective date of any changes to c. To provide prompt written notice to Medica when you make a claim against a party for p p p Y 9 p Y address or name, addition or deletion of dependents, a dependent child reaching the dependent injuries. limiting age, or other facts identifying you or your dependents. (For dependent children, the d. To do nothing to decrease Medica's rights under this provision, either before or after notification period is not limited to 30 days for newborns or children newly adopted or newly receiving benefits, or under the Contract. 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 e. Medica may take action to preserve its legal rights. This includes bringing suit in your adoption.) Your newborn child, your newly adopted child, a child newly placed for adoption with name. the subscriber, and any child who is a member pursuant to a QMCSO will be covered without f. Medica may collect its subrogation interest from the proceeds of any settlement or application of health screening or waiting periods. judgment recovered by you, your legal representative, or the legal representative(s) of The employer must notify Medica, as set forth in the Contract, of your initial enrollment your estate or next-of-kin. 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 PP MN (3/12) 88 100%-15 MIC PP MN (3/12) 89 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 I Eligibility And Enrollment Eligibility And Enrollment period for coverage to begin the date he or she was first eligible to enroll. (The 30-day time ii. Loss of eligibility includes: 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 loss of eligibility as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment; 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 • cessation of dependent status; enroll for coverage during the next open enrollment, any applicable special enrollment periods, • incurring a claim that causes the eligible employee or dependent to meet or or as a late entrant (if applicable, as described below). exceed the lifetime maximum limit on all benefits; 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. • 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; Open enrollment • if the prior coverage was offered through a group HMO, a loss of coverage A minimum 14-day period set by the employer and Medics each year during which eligible because the eligible employee or dependent no longer resides or works in the employees and de dependents who are not covered under the Contract may elect coverage for the HMO's service area and no other coverage option is available; and P Y 9 upcoming Contract year. An application must be submitted to the employer for yourself and any • the prior coverage no longer offers any benefits to the class of similarly situated dependents. individuals that includes the eligible employee or dependent. iii. Loss of eligibility occurs regardless of whether the eligible employee or dependent is Special enrollment eligible for or elects applicable federal or state continuation coverage; Special enrollment periods are provided to eligible employees and dependents under certain iv. Loss of eligibility does not include a loss due to failure of the eligible employee or circumstances. 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 1. Loss of other coverage period described above applies to the eligible employee and all of his or her dependents. a. A special enrollment period will apply to an eligible employee and dependent if the In the case of a dependent's loss of other coverage, the special enrollment period individual was covered under Medicaid or a State Children's Health Insurance Plan and described above applies only to the dependent who has lost coverage and the eligible lost that coverage as a result of loss of eligibility. The eligible employee or dependent employee. must present evidence of the loss of coverage and request enrollment within 60 days c. A special enrollment period will apply to an eligible employee and dependent if the after the date such coverage terminates. eligible employee or dependent was covered under benefits available under the In the case of the eligible employee's loss of coverage, this special enrollment period Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or applies to the eligible employee and all of his or her dependents. In the case of a any applicable state continuation laws at the time the eligible employee or dependent dependent's loss of coverage, this special enrollment period applies to both the was eligible to enroll under the Contract, whether during initial enrollment, open dependent who has lost coverage and the eligible employee. enrollment, or special enrollment and declined coverage for that reason. b. A special enrollment period will apply to an eligible employee and dependent if the The eligible employee or dependent must present evidence that the eligible employee or eligible employee or dependent was covered under qualifying coverage other than dependent has exhausted such COBRA or state continuation coverage and has not lost time the eligible employee or Medicaid or a State Children's Health Insurance Plan at the t e such coverage due g to failure of the eligible employee g o . g p yee or dependent to pay premiums on P YP dependent was eligible to enroll under the Contract, whether during initial enrollment, a timely basis or for cause, and request enrollment in writing within 30 days of the date open enrollment, or special enrollment, and declined coverage for that reason. of the exhaustion of coverage. The eligible employee or dependent must present either evidence of the loss of prior For purposes of 1.c.: coverage due to loss of eligibility for that coverage or evidence that employer contributions toward the prior coverage have terminated, and request enrollment in i. Exhaustion of COBRA or state continuation coverage includes: writing within 30 days of the date of the loss of coverage or the date the employer's • losing COBRA or state continuation coverage for any reason other than those set contribution toward that coverage terminates, or the date on which a claim is denied due forth in ii. below; to the operation of a lifetime maximum limit on all benefits. • losing coverage as a result of the employer's failure to remit premiums on a For purposes of 1.b.: timely basis; i. Prior coverage does not include federal or state continuation coverage; MIC PP MN (3/12) 90 100%-15 MIC PP MN (3/12) 91 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Eligibility And Enrollment Eligibility And Enrollment • losing coverage as a result of the eligible employee or dependent incurring a In the case of the eligible employee becoming eligible for premium assistance, this special claim that meets or exceeds the lifetime maximum limit on all benefits and no enrollment period applies to the eligible employee and all of his or her dependents. In the other COBRA or state continuation coverage is available; or case of a dependent becoming eligible for premium assistance, this special enrollment period applies to both that dependent and the eligible employee. • 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 Late enrollment continuation coverage is available. An eligible employee or an eligible employee and dependents who do not enroll for coverage ii. Exhaustion of COBRA or state continuation coverage does not include a loss due to offered through the employer during the initial or open enrollment period or any applicable failure of the eligible employee or dependent to pay premiums on a timely basis or special enrollment period will be considered late entrants. termination of coverage for cause. Late entrants who have maintained continuous coverage may enroll and coverage will be iii. In the case of the eligible employee's exhaustion of COBRA or state continuation effective the first day of the month following date of Medica's approval of the request for coverage, the special enrollment period described above applies to the eligible enrollment. Continuous coverage will be determined to have been maintained if the late entrant employee and all of his or her dependents. In the case of a dependent's exhaustion requests enrollment within 63 days after prior qualifying coverage ends. of COBRA or state continuation coverage, the special enrollment period described above applies only to the dependent who has lost coverage and the eligible Individuals who have not maintained continuous coverage may not enroll as late entrants. employee. An eligible employee or dependent who: 2. The dependent is a new spouse of the subscriber or eligible employee, provided that the 1. does not enroll during an initial or open enrollment period or any applicable special marriage is legal and enrollment is requested in writing within 30 days of the date of enrollment period; and marriage and provided that the eligible employee also enrolls during this special enrollment 2. is an enrollee of MCHA at the time Medica offers or renews coverage with the employer, period; provided the eligible subscriber or dependent maintains continuous coverage, 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 will not be considered a late entrant and will be allowed to enroll. Coverage will be effective as acquiring the dependent (for dependent children, the notification period is not limited to 30 determined by Medica. 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; _ Qualified Medical Child Support Order(QMCSO) 4. The dependent is the spouse of the subscriber or eligible employee through whom the Medica will provide coverage in accordance with a QMCSO pursuant to the applicable dependent child described in 3. above claims dependent status and: requirements under Section 609 of the Employee Retirement Income Security Act (ERISA) and a. That spouse is eligible for coverage; and p 9� g Section 1908 of the Social Security Act. It is the employer's responsibility to determine whether b. Is not already enrolled under the Contract; and a medical child support order is qualified. c. Enrollment is requested in writing within 30 days of the dependent child becoming a Upon receipt of a medical child support order issued by an appropriate court or governmental dependent; and 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 d. The eligible employee also enrolls during this special enrollment period; or a copy of the order, along with an application for coverage, within the greater of 30 days after 5. The dependents are eligible dependent children of the subscriber or eligible employee and issuance of the order or the time in which the employer provides notice of its determination to enrollment is requested in writing within 30 days of a dependent, as described in 2. or 3. the persons specified in the order. above, becoming eligible to enroll under the coverage provided the eligible employee also • Where a QMCSO requires coverage be provided under the Contract for an eligible enrolls during this special enrollment period. employee's dependent child who is not already a member, such child will be provided a 6. When the employer provides Medica with notice of a QMCSO and a copy of the order, as special enrollment period. If the eligible employee whose dependent child is the subject of described in this section, Medica will provide the eligible dependent child with a special the QMCSO is not a subscriber at the time enrollment for the dependent child is requested, enrollment period provided the eligible employee also enrolls during this special enrollment the eligible employee must also enroll for coverage under the Contract during the special period. enrollment period. 7. When the eligible employee or dependent becomes eligible for group health plan premium • Where a QMCSO requires coverage be provided under the Contract for an eligible assistance provided by Medicaid or a State Children's Health Insurance Plan, the eligible employee's dependent child who is already a member, such child will continue to be employee must request enrollment within 60 days after the date the employee or dependent provided coverage under the Contract pursuant to the terms of the QMCSO. is determined to be eligible for premium assistance. MIC PP MN (3/12) 92 100%-15 MIC PP MN (3/12) 93 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Eligibility And Enrollment Ending Coverage The date your coverage begins Your coverage begins at 12:01 a.m. on the effective date of your enrollment. DD. Ending Coverage 1. For eligible employees and dependents who enroll during the initial enrollment period, coverage begins on the effective date specified in the Contract. This section describes when coverage ends under the Contract. When this happens you may 2. For eligible employees and dependents who enroll during the open enrollment period, exercise your right to continue or convert your coverage as described in Continuation or coverage begins on the first day of the Contract year for which the open enrollment period Conversion. was held. See Definitions, These words have specific meanings: of qualifying coverage, 3. For eligible employees and/or dependents who enroll during a special enrollment period, claim, dependent, member, pr-emium, subscriber coverage begins on the date indicated below for the particular special enrollment. In the You have the right to a certification of qualifying coverage when coverage ends. You will case of: receive a certification of qualifying coverage when coverage ends. You may also request a a. Number 1., 2., or 7. under Special enrollment, coverage begins on the first day of the certification of qualifying coverage at any time while you are covered under the Contract or first calendar month following the date on which the request for enrollment is received by within the 24 months following the date your coverage ends. To request a certification of Medica; 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 b. Number 3. under Special enrollment, in the case of birth, the date of birth; in the case of as soon as reasonably possible. adoption or placement for adoption, date of adoption or placement. In all other cases, the date the subscriber acquires the dependent child; When coverage ends c. Number 4. under Special enrollment, the date coverage for the dependent child is effective, as set forth in 3.b. above; Unless otherwise specified in the Contract, coverage ends the earliest of the following: d. Number 5. under Special enrollment, the date coverage for the dependent identified in 2. 1. The end of the month in which the Contract is terminated by the employer or Medica in or 3. under Special enrollment becomes effective; p accordance with the terms of the Contract. If terminated by Medica, Medica will notify each e. Number 6. under Special enrollment, the first day of the first calendar month following subscriber at least 30 days in advance of the termination; the date the completed request for enrollment is received by Medica. 2. The end of the month for which the subscriber last paid his or her contribution toward the 4. For eligible employees and/or dependents who enroll during late enrollment, coverage premium; begins on the first day of the month following date of Medica's approval of the request for 3. The end of the month in which the subscriber retires or is pensioned, unless Medica and the enrollment. 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 PP MN (3/12) 94 100%-15 MIC PP MN (3/12) 95 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Ending Coverage Continuation e. Submitting fraudulent claims; Medica reserves its right to pursue other civil remedies in the event of fraud or intentional EE. Continuation 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. This section describes continuation coverage provisions. When coverage ends, members may Upon completion of active military duty, contact the employer for reinstatement of coverage; be able to continue coverage under state law, federal law, or both. All aspects of continuation 8. The date of the death of the member. In the event of the subscriber's death, coverage for coverage administration are the responsibility of the employer. the subscriber's dependents will terminate the end of the month in which the subscriber's See Definitions, These words have specific meanings: benefits, dependent, member, placed death occurred; for adoption, premium, subscriber, total disability. 9. For a spouse, the end of the month following the date of divorce; The paragraph below describes the continuation coverage provisions. State continuation is 10. For a dependent child, the end of the month in which the child is no longer eligible as a described in 1. and federal continuation is described in 2. dependent; or If your coverage ends, you should review your rights under both state law and federal law with 11. For a child who is entitled to coverage through a QMCSO, the end of the month in which the the employer. If you are entitled to continuation rights under both, the continuation provisions earliest of the following occurs: 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 a. The QMCSO ceases to be effective; or individual conversion health plan as described in Conversion. 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 1. Your right to continue coverage under state law d. The employee who is ordered by the QMCSO to provide coverage is no longer eligible as determined by the employer; or Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: e. The employer terminates family or dependent coverage; or a. Minnesota state continuation coverage. f. The Contract is terminated by the employer or Medica; or Continued coverage shall be provided as required under Minnesota law. Minnesota g. The relevant premium or contribution toward the premium is last paid. 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 the Contract. 96 100%-15 MIC PP MN (3/12) 97 MIC PP MN (3/12) 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Continuation Continuation Subscriber's spouse's loss Type of coverage and cost The subscriber's covered spouse has the right to continuation coverage if he or she loses If continuation coverage is elected, the subscriber's employer is required to provide coverage under the Contract for any of the following reasons: 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. a. Death of the subscriber; Under Minnesota law, a person continuing coverage may have to make a monthly payment b. A termination of the subscriber's employment (for any reason other than gross to the employer of all or part of the premium for continuation coverage. The amount misconduct) or layoff from employment; charged cannot exceed 102 percent of the cost of the coverage. c. Dissolution of marriage from the subscriber; Surviving dependents of a deceased subscriber have 90 days after notice of the d. The subscriber's enrollment for benefits under Medicare. requirement to pay continuation premiums to make the first payment. Subscriber's child's loss Duration The subscriber's dependent child has the right to continuation coverage if coverage under Under the circumstances described above and for a certain period of time, Minnesota law the Contract is lost for any of the following reasons: requires that the subscriber and his or her dependents be allowed to maintain continuation coverage as follows: a. Death of the subscriber if the subscriber is the parent through whom the child receives coverage; 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: b. Termination of the subscriber's employment (for any reason other than gross misconduct) or layoff from employment; i. 18 months after the date of the termination of or layoff from employment; c. The subscriber's dissolution of marriage from the child's other parent; 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 d. The subscriber's enrollment for benefits under Medicare if the subscriber is the parent to any applicable pre-existing condition; or through whom the child receives coverage; • e. The subscriber's child ceases to be a dependent child under the terms of the Contract. iii. The date coverage would otherwise terminate under the Contract. b. For instances where the subscriber's spouse or dependent children lose coverage Responsibility to inform because of the subscriber's enrollment under Medicare, coverage may be continued Under Minnesota law, the subscriber and dependents have the responsibility to inform the until the earliest of: employer of a dissolution of marriage or a child losing dependent status under the Contract i. 36 months after continuation was elected; within 60 days of the date of the event or the date on which coverage would be lost because ii. The date coverage is obtained under another group health plan; or of the event. iii. The date coverage would otherwise terminate under the Contract. Election rights c. For instances where dependent children lose coverage as a result of loss of dependent When the employer is notified that one of these events has happened, the subscriber and eligibility, coverage may be continued until the earliest of: the subscriber's dependents will be notified of the right to continuation coverage. i. 36 months after continuation was elected; Consistent with Minnesota law, the subscriber and dependents have 60 days to elect ii. The date coverage is obtained under another group health plan; or 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: iii. The date coverage would otherwise terminate under the Contract. For instances of dissolution of marriage from the subscriber, coverage of the a. The date coverage would be lost because of one of the events described above; or d. subscriber's spouse and dependent children may be continued until the earliest of: b. The date notice of election rights is received. i. The date the former spouse becomes covered under another group health plan; or If continuation coverage is elected within this period, the coverage will be retroactive to the date coverage would otherwise have been lost. ii. The date coverage would otherwise terminate under the Contract. The subscriber and the subscriber's covered spouse may elect continuation coverage on If a dissolution of marriage occurs during the period of time when the subscriber's behalf of other dependents entitled to continuation coverage. Under certain circumstances, spouse is continuing coverage due to the subscriber's termination of or layoff from the subscriber's covered spouse or dependent child may elect continuation coverage even if employment, coverage of the subscriber's spouse may be continued until the earlier of: the subscriber does not elect continuation coverage. i. The date the former spouse becomes covered under another group health plan; or If continuation coverage is not elected, your coverage under the Contract will end. MIC PP MN (3/12) 98 100%-15 MIC PP MN (3/12) 99 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 • Continuation Continuation ii. The date coverage would otherwise terminate under the Contract. Qualified beneficiary e. Upon the death of the subscriber, the coverage of a subscriber's spouse or dependent For purposes of this section, a qualified beneficiary is defined as: children may be continued until the earlier of: a. A covered employee (a current or former employee who is actually covered under a i. The date the surviving spouse and dependent children become covered under group health plan and not just eligible for coverage); another group health plan; or b. A covered spouse of a covered employee; or ii. The date coverage would have terminated under the Contract had the subscriber c. A dependent child of a covered employee. (A child placed for adoption with or born to lived. an employee or former employee receiving COBRA continuation coverage is also a When your continuation coverage under this section ends, you have the option to enroll in an qualified beneficiary.) individual conversion health plan (as described in Conversion). Subscriber's loss Extension of benefits for total disability of the subscriber The subscriber has the right to elect continuation of coverage if there is a loss of coverage Coverage may be extended for a subscriber and his or her dependents in instances where under the Contract because of termination of the subscriber's employment (for any reason the subscriber is absent from work due to total disability, as defined in Definitions. If the other than gross misconduct), or the subscriber becomes ineligible to participate under the subscriber is required to pay all or part of the premium for the extension of coverage, terms of the Contract due to a reduction in his or her hours of employment. payment shall be made to the employer. The amount charged cannot exceed 100 percent of the cost of the coverage. Subscriber's spouse's loss The subscriber's covered spouse has the right to choose continuation coverage if he or she 2. Your right to continue coverage under federal law loses coverage under the Contract for any of the following reasons: a. Death of the subscriber; Notwithstanding the provisions regarding termination of coverage described in Ending Coverage, you may be entitled to extended or continued coverage as follows: 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; COBRA continuation coverage c. Divorce or legal separation from the subscriber; or Continued coverage shall be provided as required under the Consolidated Omnibus Budget d. The subscriber's entitlement to (actual coverage under) Medicare. 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 Subscriber's child's loss uniform policies pursuant to which such continuation coverage will be provided. See General COBRA information in this section. The subscriber's dependent child has the right to continuation coverage if coverage under the Contract is lost for any of the following reasons: USERRA continuation coverage a. Death of the subscriber if the subscriber is the parent through whom the child receives Continued coverage shall be provided as required under the Uniformed Services coverage; Employment and Reemployment Rights Act of 1994 (USERRA), as amended. The b. The subscriber's termination of employment (for any reason other than gross employer shall, within the parameters of federal law, establish uniform policies pursuant to misconduct) or reduction in the subscriber's hours of employment with the employer; which such continuation coverage will be provided. See General USERRA information in this section. 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 General COBRA information parent through whom the child receives coverage; or COBRA requires employers with 20 or more employees to offer subscribers and their e. The subscriber's child ceases to be a dependent child under the terms of the Contract. 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 Responsibility to inform 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. 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 This section is intended to inform you, in summary fashion, of your rights and obligations Contract within 60 days of the date of the event, or the date on which coverage would be under the continuation coverage provision of federal law. It is intended that no greater rights lost because of the event. be provided than those required by federal law. Take time to read this section carefully. MIC PP MN (3/12) 100 100%-15 MIC PP MN (3/12) 101 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Continuation Continuation Also, a subscriber and dependent who have been determined to be disabled under the The 18 months may be extended if a second event (e.g., divorce, legal separation, or death) Social Security Act as of the time of the subscriber's termination of employment or reduction occurs during the initial 18-month period. It also may be extended to 29 months in the case of hours or within 60 days of the start of the continuation period must notify the employer of of an employee or employee's dependent who is determined to be disabled under the Social that determination within 60 days of the determination. If determined under the Social Security Act at the time of the employee's termination of employment or reduction of hours, Security Act to no longer be disabled, he or she must notify the employer within 30 days of or within 60 days of the start of the 18-month continuation period. the determination. If an employee or the employee's dependent is entitled to 29 months of continuation Bankruptcy 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) Rights similar to those described above may apply to retirees (and the spouses and Medicare, the continuation period for the subscriber's dependents is 36 months measured dependents of those retirees), if the subscriber's employer commences a bankruptcy from the date of the subscriber's Medicare entitlement even if that entitlement does not proceeding and these individuals lose coverage. cause the subscriber to lose coverage. Election rights Under no circumstances is the total continuation period greater than 36 months from the date of the original event that triggered the continuation coverage. When notified that one of these events has happened, the employer will notify the subscriber and dependents of the right to choose continuation coverage. Federal law provides that continuation coverage may end earlier for any of the following reasons: Consistent with federal law, the subscriber and dependents have 60 days to elect continuation coverage, measured from the later of: a. The subscriber's employer no longer provides group health coverage to any of its employees; a. The date coverage would be lost because of one of the events described above; or b. The premium for continuation coverage is not paid on time; b. The date notice of election rights is received. c. Coverage is obtained under another group health plan (as an employee or otherwise) If continuation coverage is elected within this period, the coverage will be retroactive to the that does not contain any exclusion or limitation with respect to any applicable pre- date coverage would otherwise have been lost. existing condition; or The subscriber and the subscriber's covered spouse may elect continuation coverage on d. The subscriber becomes entitled to (actually covered under) Medicare. behalf of other dependents entitled to continuation coverage. However, each person entitled to continuation coverage has an independent right to elect continuation coverage. Continuation coverage may also end earlier for reasons which would allow regular coverage to The subscriber's covered spouse or dependent child may elect continuation coverage even be terminated, such as fraud. if the subscriber does not elect continuation coverage. General USERRA information If continuation coverage is not elected, your coverage under the Contract will end. USERRA requires employers to offer employees and their families (spouse and/or Type of coverage and cost 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 If the subscriber and the subscriber's dependents elect continuation coverage, the employer under employer sponsored group health plan(s) would otherwise end. This coverage is a is required to provide coverage that, as of the time coverage is being provided, is identical to group health plan for the purposes of USERRA. the coverage provided under the Contract to similarly situated employees or employees' This section is intended to inform you, in summary fashion, of your rights and obligations dependents. under the continuation coverage provision of federal law. It is intended that no greater rights Under federal law, a person electing continuation coverage may have to pay all or part of be provided than those required by federal law. Take time to read this section carefully. 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 Employee's loss premium for months after the 18th month of continuation coverage when the additional The employee has the right to elect continuation of coverage if there is a loss of coverage months are due to a disability under the Social Security Act. under the Contract because of absence from employment due to service in the uniformed There is a grace period of at least 30 days for the regularly scheduled premium. 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 Duration of COBRA coverage employer with advance notice of the employee's absence from employment (if it was I„ Federal law requires that you be allowed to maintain continuation coverage for 36 months possible to do so). unless you lost coverage under the Contract because of termination of employment or j Service in the uniformed services means the performance of duty on a voluntary or reduction in hours. In that case, the required continuation coverage period is 18 months. 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 PP MN (3/12) 102 100%-15 MIC PP MN (3/12) 103 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Continuation Continuation Guard duty, and the time necessary for a person to be absent from employment for an COBRA and USERRA coverage are concurrent examination to determine the fitness of the person to perform any of these duties. If the employer is subject to COBRA and USERRA, and you elect COBRA continuation Uniformed services means the U.S. Armed Services, including the Coast Guard, the Army coverage in addition to USERRA continuation coverage, these coverages run concurrently. 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 PP MN (3/12) 104 100%-15 MIC PP MN (3/12) 105 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Conversion 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 FF. Conversion within 31 days of the date you were notified of the right to convert coverage, whichever is later. What you must do See Definitions These words have specific meanings benefits continuous coverage, dependent,network,°premium,°provider, waiting period. y - 1. For conversion coverage information, call Customer Service at one of the telephone numbers listed inside the front cover. Your conversion plan coverage may not provide the same coverage as your previous group health plan. Benefits and provider networks may be different. 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 Minnesota residents payment with your enrollment form for conversion coverage. This section describes your right to convert to an individual conversion plan if you are a resident 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 63 of Minnesota on the day that you submit an enrollment form to Medica or Medica's designated days after your coverage ends or within 31 days of the date you were notified of your right to conversion vendor. convert, whichever is later. You may include only those dependents who were enrolled under the Contract at the time of conversion. 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 What the employer must do pre-existing condition limitation. Contact the Minnesota Comprehensive Health Association for The employer is required to notify you of your right to convert coverage. further information: • For deductible plan options call 1-866-894-8053 or TTY: 1-800-841-6753. Residents of a state other than Minnesota • For Medicare Supplement plan options call 1-800-325-3540 or TTY: 1-800-234-8819. This section describes your right to convert to an individual conversion plan if you are a resident Overview of a state other than Minnesota on the day that you submit an enrollment form to Medica or 1. You may convert to an individual conversion plan through Medica or Medica's designated Medica's designated conversion vendor. conversion vendor without proof of good health or waiting periods at the following times: Overview a. Your continuation coverage with Medica, as described in Continuation, is exhausted. You may convert to an individual conversion plan through Medics or Medica's designated b. Your coverage or continuation coverage ends because the Contract is terminated and conversion vendor without proof of good health or waiting periods, in accordance with the laws the Contract is not replaced with other continuous group coverage. of the state in which you reside on the day that you submit an enrollment form to Medica or c. Your coverage ends under the Contract and you do not have the right to continue Medica's designated conversion vendor. coverage as described in Continuation. What you must do 2. Your conversion plan goes into effect the day following the date your other coverage ends. 1. For conversion coverage information, call Customer Service at one of the telephone You may select a qualified 1, 2, or 3 conversion plan. You must maintain continuous numbers listed inside the front cover. coverage when applying for conversion coverage. 3. Conversion coverage is not available: 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. a. When continuous coverage is not maintained; or You will be required to include your first month premium payment with your enrollment form b. If your coverage is terminated due to nonpayment of premium; or for conversion coverage. c. If you have not exhausted your right to continue coverage as described in Continuation; 3. Submit an enrollment form to Medica or Medica's designated conversion vendor within 31 or 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 d. If your coverage or continuation coverage ends because the Contract is terminated and the time of conversion. 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 PP MN (3/12) 106 100%-15 MIC PP MN (3/12) 107 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Complaints 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 GG. Complaints ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without care or treatment you are requesting, Medica will process your claim as an expedited review. In such cases, Medica will notify you and your attending provider by This section describes what to do if you have a complaint or would like to appeal a decision telephone of its decision no later than 72 hours after receiving the request. made by Medica. 5 Medica, you may Medica's first level review decision upholds the initial decision made by Med See Definitions These words have specific meanings: claim inpatient, network, provider. 7 .' have a right to request a second level review or submit a written request for external review You may call Customer Service at one of the telephone numbers listed inside the front cover or as described in this section. 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 Second level of review 1-800-657-3602. If you are not satisfied with Medica's first level of review decision, you may request a second Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. level of review through either a written reconsideration or a hearing. You may appoint an authorized representative to make a complaint on your behalf. You may be 1. Your request can be oral or in writing. It must be provided to Medica within one year required to sign an authorization which will allow Medica to release confidential information to following the date of Medica's first level review decision. If your request is in writing, it must your authorized representative and allow them to act on your behalf during the complaint be sent to the address listed above in First level of review, 2. process. 2. Regardless of the method chosen for review (hearing or a written reconsideration), Upon request, Medica will assist you with completion and submission of your written complaint. testimony, explanation, or other information provided by you, Medica staff, providers, and Medica will also complete a complaint form on your behalf and mail it to you for your signature others is reviewed. upon request. 3. Medica will provide written notice of its second level of review decision to you within: In addition to directing complaints to Customer Service as described in this section, you may a. 30 calendar days from receipt of written notice of your appeal for required second level direct complaints at any time to the Commissioner of Commerce at the telephone number listed reviews; or at the beginning of this section. b, 45 calendar days from receipt of written notice of your appeal for optional second level reviews. First level of review 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 You may direct any question or complaint to Customer Service by calling one of the telephone optional before you may submit a request for external review. Generally, a second level review numbers listed inside the front cover or by writing to the address listed below. is optional if the complaint requires a medical determination. Medica will inform you in writing 1. If your complaint is regarding an initial decision made by Medica, your complaint must be whether the second level of review is optional or required. 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 External review 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, If you consider Medica's decision to be partially or wholly adverse to you, you may submit a it Medica will provide you with a complaint form to submit your complaint in writing. Mail the written request for external review of Medica's decision to the Commissioner of Commerce at: completed form to: Minnesota Department of Commerce Customer Service 85 7th Place East, Suite 500 Route 0501 St. Paul, MN 55101-2198 PO Box 9310 You must include a filing fee of$25 with your written request, unless waived by the Minneapolis, MN 55440-9310 Commissioner. An independent entity contracted with the State Commissioner of 3. Medica will provide written notice of its first level review decision to you and your attending Administration will review your request. The external review decision will not be binding on you provider, when applicable, within 30 calendar days from receipt of your complaint or request. but will be binding on Medica. Medica may seek judicial review on grounds that the decision 4. When an initial decision by Medica not to grant a prior authorization request is made before was arbitrary and capricious or involved an abuse of discretion. Contact the Commissioner of or during an ongoing service requiring Medica's authorization, and your attending provider Commerce for more information about the external review process. believes that Medica's decision warrants an expedited appeal, you or your attending MIC PP MN (3/12) 108 100%-15 MIC PP MN (3/12) 109 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Complaints General Provisions Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be submitted for external review. HH. General Provisions Civil action This section describes the general provisions of the Contract. If you are dissatisfied with Medica's first or second level review decision or the external review See Definition decision, you have the right to file a civil action under section 502(a) of the Employee s. These:words have specific meanings: benefits,claim, dependent, member, Income Security Act (ERlSA). 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 PP MN (3/12) 110 100%-15 MIC PP MN (3/12) 111 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 General Provisions Definitions Discretionary authority Medica has discretion to interpret and construe all of the terms and conditions of the Contract Definitions and make determinations regarding benefits and coverage under the Contract; provided, however, that this provision shall not be construed to specify a standard of review upon which a court may review a claim denial or any other decision made by Medica with respect to a In this certificate (and in any amendments), some words have specific meanings. Within each member. 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 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 Prescription Specialty 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. MIC PP MN 3/12 ( ) 112 100%-15 MIC PP MN (3/12) 113 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 • T Definitions Definitions Convenience care/retail health clinic. A health care clinic located in a setting such as a retail remain covered under the Contract regardless of age and without application of health store, grocery store, or pharmacy, which provides treatment of common illnesses and certain screening or waiting periods. To continue coverage for a disabled dependent, you must preventive health care services. provide Medica with proof of such disability and dependency within 31 days of the child Copavment. The fixed dollar amount you must pay to the provider for benefits received. Full 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 copayments may apply to scheduled appointments canceled less than 24 hours before the dependency. appointment time or to missed appointments. For residents of a state other than Minnesota, the dependent limiting age may be higher if When you receive eligible health services from a network provider and a copayment applies, required by applicable state law. 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 4. The subscriber's or subscriber's spouse's disabled dependent who is incapable of self- provider. The copayment may not exceed the retail charge billed by the provider for the sustaining employment by reason of developmental disability, mental illness, mental benefit. disorder, or physical disability and is chiefly dependent upon the subscriber or For out-of-network benefits, in addition to any copayment, coinsurance, and deductible 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 amounts, you are responsible for any charges in excess of the non-network provider dependent's enrollment. reimbursement amount. Cosmetic. Services and procedures that improve physical appearance but do not correct or Emergency. A condition or symptom (including severe pain) that a prudent layperson, who improve a physiological function, and that are not medically necessary, unless the service or possesses an average knowledge of health and medicine, would believe requires immediate procedure meets the definition of reconstructive. treatment to: Custodial care. Services to assist in activities of daily living that do not seek to cure, are 1. Preserve your life; or performed regularly as a part of a routine or schedule, and, due to the physical stability of the 2. Prevent serious impairment to your bodily functions, organs, or parts; or p 9 Y P p Y � Y p Y Y 9 p 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 3. Prevent placing your physical or mental health (or, if you are pregnant, the health of your p g, g g g° g g g unborn child) in serious jeopardy. toilet, preparation of special diets, and supervision of medication that can usually be self- administered. 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 Deductible. The fixed dollar amount you must pay for eligible services or supplies before claims dependent's enrollment. for health services or supplies received from non-network providers are reimbursable as out-of- network benefits under this certificate. Genetic testing. An analysis of human DNA, RNA, chromosomes, proteins, or metabolites if Dependent. Unless otherwise specified in the Contract, the following are considered the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing includes pharmacogenetic testing. Genetic testing does not include an analysis of proteins or dependents: metabolites that is directly related to a manifested disease, disorder, or pathological condition. 1. The subscriber's spouse. For example, an HIV test, complete blood count, or cholesterol test is not a genetic test. 2. The following dependent children up to the dependent limiting age of 26: 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 a. The subscriber's or subscriber's spouse's natural or adopted child; services. The hospital is not mainly a place for rest or custodial care, and is not a nursing b. A child placed for adoption with the subscriber or subscriber's spouse; home or similar facility. c. A child for whom the subscriber or the subscriber's spouse has been appointed legal Inpatient. An uninterrupted stay, following formal admission to a hospital, skilled nursing guardian; however, upon request by Medica, the subscriber must provide satisfactory facility, or licensed acute care facility. Inpatient services in a licensed residential treatment proof of legal guardianship; facility for treatment of emotionally disabled children will be covered as any other health d. The subscriber's stepchild; and condition. Investigative. As determined by Medica, a drug, device, diagnostic or screening procedure, or e. The subscriber's or subscriber's spouse's unmarried grandchild who is dependent medical treatment or procedure is investigative if reliable evidence does not permit conclusions upon and resides with the subscriber or subscriber's spouse continuously from birth. concerning its safety, effectiveness, or effect on health outcomes. Medica will make its 3. The subscriber's or subscriber's spouse's unmarried disabled child who is a dependent determination based upon an examination of the following reliable evidence, none of which shall incapable of self-sustaining employment by reason of developmental disability, mental be determinative in and of itself: 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- 1. Whether there is final approval from the appropriate government regulatory agency, if sustaining employment will not be considered a physical disability. This dependent may required, including whether the drug or device has received final approval to be marketed for MIC PP MN (3/12) 114 100%-15 MIC PP MN (3/12) 115 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 ii Definitions Definitions its proposed use by the United States Food and Drug Administration (FDA), or whether the Network. A term used to describe a provider (such as a hospital, physician, home health treatment is the subject of ongoing Phase I, II, or III trials; agency, skilled nursing facility, or pharmacy) that has entered into a written agreement to 2. Whether there are consensus opinions and recommendations reported in relevant scientific provide benefits to you. The participation status of providers will change from time to time. and medical literature, peer-reviewed journals, or the reports of clinical trial committees and The network provider directory will be furnished automatically, without charge. other technology assessment bodies; and Non-network. A term used to describe a provider not under contract as a network provider. 3. Whether there are consensus opinions of national and local health care providers in the Non-network provider reimbursement amount. The amount that Medica will pay to a non- applicable specialty or subspecialty that typically manages the condition as determined by a network provider for each benefit is based on one of the following, as determined by Medica: survey or poll of a representative sampling of these providers. 1. A percentage of the amount Medicare would pay for the service in the location where the Notwithstanding the above, a drug being used for an indication or at a dosage that is an service is provided. Medica generally updates its data on the amount Medicare pays within accepted off-label use for the treatment of cancer will not be considered by Medica to be 30-60 days after the Centers for Medicare and Medicaid Services updates its Medicare data; or 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 2. A percentage of the provider's billed charge; or parameters approved by national health professional boards or associations, and entries in any 3. A nationwide provider reimbursement database that considers prevailing reimbursement authoritative compendia as identified by the Medicare program for use in the determination of a rates and/or marketplace charges for similar services in the geographic area in which the medically accepted indication of drugs and biologicals used off-label. service is provided; or Late entrant. An eligible employee or dependent who requests enrollment under the Contract 4. An amount agreed upon between Medica and the non-network provider. other than during: Contact Customer Service for more information concerning which method above pertains to 1. The initial enrollment period set by the employer; or your services, including the applicable percentage if a Medicare-based approach is used. 2. The open enrollment period set by the employer; or For certain benefits, you must pay a portion of the non-network provider reimbursement 3. A special enrollment period as described in Eligibility And Enrollment. amount as a copayment or coinsurance. However, an eligible employee or dependent who is an enrollee of the Minnesota In addition, if the amount billed by the non-network provider is greater than the non-network Comprehensive Health Association (MCHA) at the time Medica offers or renews coverage with provider reimbursement amount, the non-network provider will likely bill you for the the employer will not be considered a late entrant, provided the eligible employee or difference. This difference may be substantial, and it is in addition to any copayment, dependent maintains continuous coverage as defined in this certificate. coinsurance, or deductible amount you may be responsible for according to the terms In addition, a member who is a child entitled to receive coverage through a QMCSO is not 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 subject to any initial or open enrollment period restrictions. amounts regardless of whether you previously reached your out-of-pocket maximum with Medically necessary. Diagnostic testing and medical treatment, consistent with the diagnosis amounts paid for other services. As a result, the amount you will be required to pay for services of and prescribed course of treatment for your condition, and preventive services. Medically received from a non-network provider will likely be much higher than if you had received necessary care must meet the following criteria: services from a network provider. 1. Be consistent with the medical standards and accepted practice parameters of the Pharmacogenetic testing. A type of genetic testing that attempts to use personal gene- community as determined by health care providers in the same or similar general specialty based information to determine the proper drug and dosage for an individual. as typically manages the condition, procedure or treatment at issue; and Pharmacogenetic testing seeks to determine how a drug is absorbed, metabolized, or cleared 2. Be an appropriate service, in terms of type, frequency, level, setting, and duration, to your from the body of an individual based on their genetic makeup. diagnosis or condition; and Physician. A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry 3. Help to restore or maintain your health; or (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.) practicing within the scope of his or her licensure. 4. Prevent deterioration of your condition; or Placed for adoption. The assumption and retention of the legal obligation for total or partial 5. Prevent the reasonably likely onset of a health problem or detect an incipient problem. support of the child in anticipation of adopting such child. Member. A person who is enrolled under the Contract. (Eligibility for a child placed for adoption with the subscriber ends if the placement is Mental disorder. A physical or mental condition having an emotional or psychological origin, interrupted before legal adoption is finalized and the child is removed from placement.) as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders Premium. The monthly payment required to be paid by the employer on behalf of or for you. (DSM). 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 MIC PP MN (3/12) 116 100%-15 MIC PP MN (3/12) 117 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Definitions Definitions assessment, serial surveillance, prenatal education, and use of specialized skills and j 13. A medical care program of the Indian Health Service or of a tribal organization; technology, when needed, as defined by Standards for Obstetric-Gynecologic Services issued 14. A health benefit plan under the Peace Corps Act; by the American College of Obstetricians and Gynecologists. Prescription drug. A drug approved by the FDA for the prescribed use and route of 15. State Children's Health Insurance Program; or administration. 16. A public health plan similar to any of the above plans established or maintained by a state, Preventive health service. The following are considered preventive health services: the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country. 1. Evidence-based items or services that have in effect a rating of A or B in the current Coverage of the following types, including any combination of the following types, are not recommendations of the United States Preventive Services Task Force; qualifying coverage: 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 1. Coverage only for disability or income protection insurance; with respect to the member involved; 2. Automobile medical payment coverage; 3. With respect to members who are infants, children, and adolescents, evidence-informed 3. Liability insurance or coverage issued as a supplement to liability insurance; preventive care and screenings provided for in the comprehensive guidelines supported by 4. Coverage for a specified disease or illness or to provide payments on a per diem, fixed the Health Resources and Services Administration; indemnity, or non-expense-incurred basis, if offered as independent, non-coordinated 4. With respect to members who are women, such additional preventive care and screenings coverage; not described in 1. as provided for in comprehensive guidelines supported by the Health 5. Credit accident and health insurance as defined under Minnesota law; Resources and Services Administration. Contact Customer Service for information regarding specific preventive health services, 6. Coverage designed solely to provide dental or vision care; services that are rated A or B, and services that are included in guidelines supported by the 7. Accident only coverage; Health Resources and Services Administration. 8. Long-term care coverage as defined under Minnesota law; Provider. A health care professional or facility licensed, certified, or otherwise qualified under 9. Medicare supplemental health insurance as defined under Minnesota law; state law to provide health services. 10. Workers' compensation insurance; or Qualifying coverage. Health coverage provided under one of the following plans: 11. Coverage for on-site medical clinics operated by an employer for the benefit of the 1. A health plan in which a health carrier has issued a policy, contract, or certificate for the I employer's employees and their dependents, in connection with which the employer does coverage of medical and hospital benefits, including blanket accident and sickness not transfer risk. insurance other than accident only coverage; Reconstructive. Surgery to rebuild or correct a: 2. Part A or Part B of Medicare; 1. Body part when such surgery is incidental to or following surgery resulting from injury, 3. A medical assistance medical care plan as defined under Minnesota law; sickness, or disease of the involved body part; or 4. A general assistance medical care plan as defined under Minnesota law; 2. Congenital disease or anomaly which has resulted in a functional defect as determined by 5. Minnesota Comprehensive Health Association (MCHA); your physician. 6. A self-insured health plan; 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 7. The MinnesotaCare program as defined under Minnesota law; appearance shall be considered reconstructive. 8. The public employee insurance plan as defined under Minnesota law; Restorative. Surgery to rebuild or correct a physical defect that has a direct adverse effect on 9. The Minnesota employees insurance plan as defined under Minnesota law; the physical health of a body part, and for which the restoration or correction is medically 10. TRICARE or other similar coverage provided under federal law applicable to the armed necessary. forces; Routine foot care. Services that are routine foot care may require treatment by a 11. Coverage provided by a health care network cooperative or by a health provider professional and include but are not limited to any of the following: cooperative; 1. Cutting, paring, or removing corns and calluses; 12. The Federal Employees Health Benefits Plan or other similar coverage provided under 2. Nail trimming, clipping, or cutting; and federal law applicable to government organizations and employees; 3. Debriding (removing toenails, dead skin, or underlying tissue). MIC PP MN (3/12) 118 100%-15 MIC PP MN (3/12) 119 100%-15 BPL 85259 DOC 23705 BPL 85259 DOC 23705 Definitions 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: I� 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. Virtual care. Professional evaluation and medical management services provided to patients through e-mail, telephone, or webcam. Virtual care includes interactive audiovisual telehealth services. Virtual care is used to address non-urgent medical symptoms for patients describing new or ongoing symptoms to which providers respond with substantive medical advice. Virtual care does not include telephone calls for reporting normal lab or test results, or solely calling in a prescription to a pharmacy. 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 PP MN (3/12) 120 100%-15 BPL 85259 DOC 23705