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HomeMy WebLinkAboutCouncil 05/02/2011AGENDA  RENTON CITY COUNCIL  REGULAR MEETING  May 2, 2011  Monday, 7 p.m.   *REVISED* 1.CALL TO ORDER AND PLEDGE OF ALLEGIANCE 2.ROLL CALL 3.PROCLAMATIONS a. Arts Education Month ‐ May 2011  b. Municipal Clerks Week ‐ May 1 to 7, 2011  4.ADMINISTRATIVE REPORT 5.AUDIENCE COMMENT (Speakers must sign up prior to the Council meeting.  Each speaker is allowed five minutes.  The  comment period will be limited to one‐half hour.  The second audience comment period later on in  the agenda is unlimited in duration.)  When you are recognized by the Presiding Officer, please  walk to the podium and state your name and city of residence for the record, SPELLING YOUR LAST  NAME. 6.CONSENT AGENDA The following items are distributed to Councilmembers in advance for study and review, and the  recommended actions will be accepted in a single motion.  Any item may be removed for further  discussion if requested by a Councilmember.  a. Approval of Council minutes of 4/25/2011.  Council concur.  b. City Clerk reports receipt of 60% Petition to Annex for the Tess Annexation, approximately 16.3  acres located in the vicinity of SE 132nd St and 164th Ave SE.  Information.  c. Finance and Information Technology Department requests approval of the proposed financial  plan,  and  authorization  to  set  5/9/2011  as  the  date  for  first  and  second  reading  of  an  ordinance regarding new library development limited tax obligation (LTGO) bonds.  Refer to  Finance Committee.  d. Finance  and  Information  Technology  Department  recommends  approval  of  a  City  Code  amendment clarifying utility bill leak adjustment regulations.  Refer to Finance Committee.  e. Fire  and  Emergency  Services  Department  recommends  approval  of  a  Memorandum  of  Understanding with King County Fire District 20 regarding maintenance and care of amateur  radio equipment.  Council concur.  (See 8.a. for resolution.)  f. Human Resources and Risk Management Department recommends approval to hire the Human  Resources Manager at Grade M30, Step E of the salary range.  Refer to Finance Committee.  g. Human Resources and Risk Management Department recommends approval of the 2011 Group  Health Cooperative medical coverage contracts for LEOFF I retirees and all active employees.   Council concur.  h. Utility  Systems  Division submits  CAG‐10‐072,  Rainier  Stormwater  Pump  Station  Repair; and  requests  approval  of  the  project, commencement  of  a  60‐day  lien  period,  and  release  of  retained amount of $2,168.03 to Cascade Machinery & Electric, LLC, contractor, if all required  Page 1 of 385 releases are obtained. Council concur.  7.UNFINISHED BUSINESS Topics listed below were discussed in Council committees during the past week.  Those topics  marked with an asterisk (*) may include legislation.  Committee reports on any topics may be held  by the Chair if further review is necessary. a. Finance Committee:  Vouchers  b. Public Safety Committee:  Noise Ordinance  c. Utilities Committee:  2010 Long‐Range Wastewater Management Plan*  8.RESOLUTIONS AND ORDINANCES Resolutions: a. Memorandum  of  Understanding  with  King  County  Fire  District  20  concerning  amateur  radio equipment (See 6.e.)  b. 2010 Long‐Range Wastewater Management Plan (See 7.d.)  Ordinance for first reading and advancement to second and final reading: a. Declaring public use and necessity for land and property to be condemned as required for  the Rainier Ave. S. project (Approved via 4/18/2011 Transportation (Aviation) Committee  Report)  9.NEW BUSINESS (Includes Council Committee agenda topics; call 425‐430‐6512 for recorded information.) 10.AUDIENCE COMMENT 11.ADJOURNMENT COMMITTEE OF THE WHOLE AGENDA   (Preceding Council Meeting)     COUNCIL CHAMBERS   May 2, 2011  Monday, 5:00 p.m.    Library System Update; Panhandling     • Hearing assistance devices for use in the Council Chambers are available upon request to the City Clerk •     CITY COUNCIL MEETINGS ARE TELEVISED LIVE ON GOVERNMENT ACCESS CHANNEL 21 AND ARE RECABLECAST:  Tues. & Thurs. at 11 AM & 9 PM, Wed. & Fri at 9 AM & 7 PM and Sat. & Sun. at 1 PM & 9 PM  Page 2 of 385 3a. ‐ Arts Education Month ‐ May 2011 Page 3 of 385 3b. ‐ Municipal Clerks Week ‐ May 1 to 7, 2011 Page 4 of 385 CITY OF RENTON COUNCIL AGENDA BILL Subject/Title: 60% Petition to Annex; Tess Annexation; File A-10- 001 Meeting: Regular Council - 02 May 2011 Exhibits: City Clerk Memo 4/13/2011 60% Petition Submittal Submitting Data: Dept/Div/Board: Executive Staff Contact: Bonnie Walton, City Clerk, x6502 Recommended Action: None; Information Only Fiscal Impact: Expenditure Required: $ Transfer Amendment: $ Amount Budgeted: $ Revenue Generated: $ Total Project Budget: $ City Share Total Project: $ SUMMARY OF ACTION: On April 11, 2011, a 60% Petition to Annex, as authorized by City Council on February 7, 2011, was filed with the City Clerk by Steve Beck. In accordance with RCW 35A.01.040(8) the petition was thereafter submitted to King County for certification of sufficiency. After certification of legal sufficiency of this petition has been received from King County, a public hearing before the City Council will be set to consider the petition. The Tess annexation area consists of approximately 16.3 acres and is generally located east of 160th Avenue SE and south of SE 132nd Street, abutting the current eastern city limits. STAFF RECOMMENDATION: None; Information Only 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 5 of 385 ADMINISTRATIVE, JUDICIAL, AND LEGAL SERVICES DEPARTMENT Office of the City Clerk M E M O R A N D U M DATE:April 13, 2011 TO:Alex Pietsch, CED Department Administrator FROM:Bonnie Walton, City Clerk, x6502 SUBJECT:Tess 60% Annexation Petition - File A-10-001 ______________________________________________________________________________ A Petition to City Council as referenced was received in this office Monday afternoon, as submitted by Steve Beck. In accordance with RCW 35A.01.040(4), the officer certifying the petition must begin determining the Petition’s sufficiency within 3 business days of filing, and must file with the officer receiving the petition a certificate stating the date the determination of legal sufficiency was begun. I attach copy of the petition so that you may expedite submission to King County to commence this process. Once King County has started the determination process, please sign and return a form entitled Certificate of Commencement of Determination of Sufficiency, example of which you have on file, for this particular annexation. According to RCW, the determination of petition sufficiency must be completed “with reasonable promptness.” As soon as received, the original Certification(s) of Sufficiency from King County should be filed with the City Clerk. At that time, CED can also prepare the agenda bill for the purpose of setting the public hearing date, and should attach the issue paper, copy of the Certificate of Sufficiency and copy of the Petition to Annex to the agenda bill. If you have concerns or questions, please feel free to contact me. bw Attachment cc: Angie Mathius 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 6 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 7 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 8 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 9 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 10 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 11 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 12 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 13 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 14 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 15 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 16 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 17 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 18 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 19 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 20 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 21 of 385 6b. ‐ City Clerk reports receipt of 60% Petition to Annex for the Tess  Annexation, approximately 16.3 acres located in the vicinity of SE 132nd  Page 22 of 385 CITY OF RENTON COUNCIL AGENDA BILL Subject/Title: Proposed New Library Development Bonds (LTGO) Meeting: Regular Council - 02 May 2011 Exhibits: Issue Paper Ordinance Renton LTGO 2011 POS Comments Submitting Data: Dept/Div/Board: Finance & Information Technology Staff Contact: Iwen Wang, Administrator Recommended Action: Refer to Finance Committee Fiscal Impact: Expenditure Required: $ Transfer Amendment: $ Amount Budgeted: $ Revenue Generated: $ Total Project Budget: $ City Share Total Project: $ SUMMARY OF ACTION: The City and King County Library System have begun the planning process for the development of two new libraries to replace the existing City library facilities. The proposed financing plan and associated ordinance would authorize the issuance of up to $18 million in general obligation bonds; together with dedicated library resources available in the 2011-2012 budget for a combined funding of $19.8 million for the project. STAFF RECOMMENDATION: Approve the proposed financing plan and present the ordinance for first reading on May 9th. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 23 of 385 FINANCE AND INFORMATION TECHNOLOGY M E M O R A N D U M DATE:April 11, 2011 TO:Terri Briere, Council President Members of the Renton City Council VIA:Denis Law, Mayor FROM:Iwen Wang, FIT Administrator SUBJECT:Proposed 2011 LTGO for Library Development ISSUE Should the City issue up to $18 million in Limited Tax General Obligation (LTGO) Bonds for the development of the new libraries? RECOMMENDATION Staff recommends approval of the proposed financing plan and adoption of the necessary ordinance authorizing the issuance of approximately $18 million of bonds, at an “all-in” true interest cost of approximately 3.5%, with a final maturity in 2022 to finance the development of the two new libraries. BACKGROUND In the Library Master Plan there was recognition that the City’s existing library facilities are both in need of major overhaul/redevelopment. As part of the annexation to the King County Library System (KCLS), the City agreed to use the resources dedicated for library purposes to build two new libraries in Renton. The City and KCLS have now begun the planning process for the development of the two new libraries. The proposed financing is to implement this project. The preliminary financing plan as included in the adopted budget for 2011-2012 contemplated issuing the bonds in two phases, first in late 2011 when the schematic design is complete, and the reminder in late 2012 when the cost can be ascertained. This approach would allow the City to accumulate more cash in hand prior to the bonds that were issued and keep the life of the bonds to 10 years, with maturity in 2022. The combined resources projected to generate $19.7 million in project funds, without considering the interest earning from the bond proceeds. Due to the increased market uncertainty and the outlook of inflation and interest rates, staff consulted with the underwriter and financial advisors, we believe it is advisable for the City to issue the bonds sooner than later. Each 0.5% of rate hike would reduce the amount that can be raised for the project by around $500,000. Based on the current market condition, the proposed bonds will carry an “all-in” (include all issue costs) true interest cost of around 3.5%; with a normal annual debt service payment at around $2 million a year, and final maturity in 2022. The bonds with maturity after 2021 may be called anytime after June 1, 2021. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 24 of 385 Terri Briere, Council President Members of the Renton City Council Page 2 of 2 April 11, 2011 CONCLUSION Staff recommends the Council approve the financing plan and all the associated documents necessary to issue the bonds. Attachments: 1.Financing Summary 2.Draft Bond Ordinance CC:Jay Covington, CAO Marty Wine, Assistant CAO Gina Jarvis, Fiscal Services Director 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 25 of 385 Attachment 1: Financing Summary 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 26 of 385 CITY OF RENTON, WASHINGTON LIMITED TAX GENERAL OBLIGATION BONDS, 2011 ______________________________________ ORDINANCE NO. _______ AN ORDINANCE OF THE CITY OF RENTON, WASHINGTON, PROVIDING FOR THE ISSUANCE OF LIMITED TAX GENERAL OBLIGATION BONDS OF THE CITY IN THE PRINCIPAL AMOUNT OF NOT TO EXCEED $18,000,000 TO FINANCE ALL OR A PORTION OF THE COSTS OF REPAIRING, RENOVATING AND IMPROVING EXISTING LIBRARY FACILITIES AND ACQUIRING LAND FOR AND CONSTRUCTING, IMPROVING AND EQUIPPING TWO NEW PUBLIC LIBRARY FACILITIES; PROVIDING THE FORM AND TERMS OF THE BONDS; AND DELEGATING THE AUTHORITY TO APPROVE THE FINAL TERMS OF THE BONDS. PASSED: MAY 2, 2011 PREPARED BY: PACIFICA LAW GROUP LLP Seattle, Washington 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 27 of 385 - i -04/12/11 CITY OF RENTON ORDINANCE NO. _______ TABLE OF CONTENTS* Page Section 1.Definitions and Interpretation of Terms 4 Section 2.Authorization of the Projects 8 Section 3.Authorization of Bonds and Bond Details 9 Section 4.Registration, Exchange and Payments 9 Section 5.Redemption Prior to Maturity and Purchase of Bonds 14 Section 6.Form of Bonds 18 Section 7.Execution of Bonds 20 Section 8.Application of Bond Proceeds 21 Section 9.Tax Covenants 21 Section 10.Bond Fund and Provision for Tax Levy Payments 24 Section 11.Defeasance 24 Section 12.Sale of Bonds 25 Section 13.Bond Insurance 27 Section 14.Undertaking to Provide Ongoing Disclosure 27 Section 15.Lost, Stolen or Destroyed Bonds 32 Section 16.Severability 32 Section 17.Effective Date of Ordinance 32 * This Table of Contents is provided for convenience only and is not a part of this ordinance. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 28 of 385 CITY OF RENTON, WASHINGTON ORDINANCE NO. _______ AN ORDINANCE OF THE CITY OF RENTON, WASHINGTON, PROVIDING FOR THE ISSUANCE OF LIMITED TAX GENERAL OBLIGATION BONDS OF THE CITY IN THE PRINCIPAL AMOUNT OF NOT TO EXCEED $18,000,000 TO FINANCE ALL OR A PORTION OF THE COSTS OF REPAIRING, RENOVATING AND IMPROVING EXISTING LIBRARY FACILITIES AND ACQUIRING LAND FOR AND CONSTRUCTING, IMPROVING AND EQUIPPING TWO NEW PUBLIC LIBRARY FACILITIES; PROVIDING THE FORM AND TERMS OF THE BONDS; AND DELEGATING THE AUTHORITY TO APPROVE THE FINAL TERMS OF THE BONDS. WHEREAS, pursuant to Ordinance No. 5479 of the City Council (the “Council”) of the City of Renton, Washington (the “City”), adopted on August 3, 2009, the City stated its intent to join the King County Library System (“KCLS”) and called for an election to be held within the City on February 9, 2010; and WHEREAS, the number and proportion of the qualified electors required by law for the adoption thereof voted in favor of a proposition authorizing the annexation of the City into the KCLS; and WHEREAS, pursuant to the terms of an Interlocal Agreement between the City and KCLS, the City has agreed to acquire land, finance costs related to the construction of two public library facilities, and lease the land to KCLS, and KCLS has agreed to own, operate and maintain the public library facilities under the terms of a long-term lease agreement; and WHEREAS, existing City library facilities will be repaired, renovated and improved for other public uses; and WHEREAS, it is hereby found to be in the best interest of the City to provide financing for all or a portion of the costs of acquiring land for and constructing, improving and equipping two public library facilities and repairing, renovating and improving existing libraries for other 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 29 of 385 ORDINANCE NO. _____ - 2 -04/12/11 public uses (the “Projects”); and WHEREAS, the City is authorized by chapters 35A.40 and 39.46 RCW to borrow money and issue general obligation bonds to finance the costs of the Projects; and WHEREAS, the City now desires to construct the Projects and issue and sell such Limited Tax General Obligation Bonds by negotiated sale to Seattle-Northwest Securities Corporation, Seattle, Washington in the principal amount of not to exceed $18,000,000 (the “Bonds”) to finance costs of the Projects; NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF RENTON, WASHINGTON DOES ORDAIN AS FOLLOWS: Section 1.Definitions and Interpretation of Terms. (a)Definitions.As used in this ordinance, the following words shall have the following meanings: Beneficial Owner means any person that has or shares the power, directly or indirectly to make investment decisions concerning ownership of any Bonds (including persons holding Bonds through nominees, depositories or other intermediaries). Bond Fund means the “City of Renton Limited Tax General Obligation Bond Debt Service Fund, 2011” authorized to be created pursuant to Section 10 of this ordinance. Bond Insurance Policy means the municipal bond insurance policy, if any, issued by the Insurer insuring the payment when due of the principal of and interest on the Bonds as provided therein. Bond Purchase Contract means the contract for the purchase of the Bonds between the Underwriter and City, executed pursuant to Section 12 of this ordinance. Bond Register means the registration books showing the name, address and tax 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 30 of 385 ORDINANCE NO. _____ - 3 -04/12/11 identification number of each Registered Owner of the Bonds, maintained pursuant to Section 149(a) of the Code. Bond Registrar means, initially, the fiscal agency of the State of Washington, for the purposes of registering and authenticating the Bonds, maintaining the Bond Register, effecting transfer of ownership of the Bonds and paying interest on and principal of the Bonds. Bond Year means each one-year period that ends on the date selected by the City. The first and last Bond Years may be short periods. If no day is selected by the City before the earlier of the final maturity date of the Bonds or the date that is five years after the date of issuance of the Bonds, Bond Years end on each anniversary of the date of issue and on the final maturity date of the Bonds. Bonds mean the City of Renton, Washington Limited Tax General Obligation Bonds, 2011 issued pursuant to this ordinance. City means the City of Renton, Washington, a municipal corporation duly organized and existing by virtue of the laws of the State of Washington. Code means the Internal Revenue Code of 1986, as amended, and shall include all applicable regulations and rulings relating thereto. Commission means the Securities and Exchange Commission. Council means the City Council as the general legislative authority of the City, as the same shall be duly and regularly constituted from time to time. Designated Representative means the Mayor, the Chief Administrative Officer, or the Finance Director of the City, or any successor to the functions of such office. DTC means The Depository Trust Company, New York, New York, a limited purpose trust company organized under the laws of the State of New York, as depository for the Bonds 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 31 of 385 ORDINANCE NO. _____ - 4 -04/12/11 pursuant to Section 4 of this ordinance. Federal Tax Certificate means the certificate executed by the Designated Representative setting forth the requirements of the Code for maintaining the tax exemption of interest on the bonds. Finance Director shall mean the City’s Finance and Information Services Administrator or the successor to such officer. Government Obligations mean those obligations now or hereafter defined as such in chapter 39.53 RCW. Insurer means the municipal bond insurance company, if any, selected and designated by the Designated Representative, pursuant to Section 13 of this ordinance, or any successor thereto or assignee thereof, as issuer of a Bond Insurance Policy for all or a portion of the Bonds. Letter of Representations means the blanket issuer letter of representations from the City to DTC. MSRB means the Municipal Securities Rulemaking Board or any successors to its functions. Net Proceeds, when used with reference with the Bonds, mean the principal amount of the Bonds, plus accrued interest and original issue premium, if any, and less original issue discount, if any. Private Person means any natural person engaged in a trade or business or any trust, estate, partnership, association, company or corporation. Private Person Use means the use of property in a trade or business by a Private Person if such use is other than as a member of the general public. Private Person Use includes 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 32 of 385 ORDINANCE NO. _____ - 5 -04/12/11 ownership of the property by the Private Person as well as other arrangements that transfer to the Private Person the actual or beneficial use of the property (such as a lease, management or incentive payment contract or other special arrangement) in such a manner as to set the Private Person apart from the general public. Use of property as a member of the general public includes attendance by the Private Person at municipal meetings or business rental of property to the Private Person on a day-to-day basis if the rental paid by such Private Person is the same as the rental paid by any Private Person who desires to rent the property. Use of property by nonprofit community groups or community recreational groups is not treated as Private Person Use if such use is incidental to the governmental uses of property, the property is made available for such use by all such community groups on an equal basis and such community groups are charged only a de minimis fee to cover custodial expenses. Project Fund means the “Library Construction Fund” as described in Section 8 of this ordinance. Projects mean the capital projects described in Section 2 of this ordinance. Registered Owner means the person named as the registered owner of a Bond in the Bond Register. For so long as the Bonds are held in book-entry only form, DTC shall be deemed to be the sole Registered Owner. Rule means the Commission’s Rule 15c2-12 under the Securities Exchange Act of 1934, as the same may be amended from time to time. Underwriter means Seattle-Northwest Securities Corporation, Seattle, Washington. (b)Interpretation. In this ordinance, unless the context otherwise requires: (1)The terms “hereby,” “hereof,” “hereto,” “herein,” “hereunder” and any similar terms, as used in this ordinance, refer to this ordinance as a whole and not to any 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 33 of 385 ORDINANCE NO. _____ - 6 -04/12/11 particular article, section, subdivision or clause hereof, and the term “hereafter” shall mean after, and the term “heretofore” shall mean before, the date of this ordinance; (2)Words of the masculine gender shall mean and include correlative words of the feminine and neuter genders and words importing the singular number shall mean and include the plural number and vice versa; (3)Words importing persons shall include firms, associations, partnerships (including limited partnerships), trusts, corporations and other legal entities, including public bodies, as well as natural persons; (4)Any headings preceding the text of the several articles and sections of this ordinance, and any table of contents or marginal notes appended to copies hereof, shall be solely for convenience of reference and shall not constitute a part of this ordinance, nor shall they affect its meaning, construction or effect; and (5)All references herein to “articles,” “sections” and other subdivisions or clauses are to the corresponding articles, sections, subdivisions or clauses hereof. Section 2.Authorization of the Projects. The Bonds are being issued to finance all or a portion of the costs of acquiring land for and constructing, improving and equipping two public library facilities and repairing, renovating and improving existing libraries for other public uses (together, the “Projects”). Any remaining costs of the Projects shall be paid from other City funds legally available for such purposes. If the Council shall determine that it has become impractical to undertake or complete any portion of the Projects by reason of changed conditions, the City shall not be required to undertake or complete such portions of the Project. If the Projects have been completed or duly provided for, or found to be impractical, the Council may apply the Bond proceeds or any 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 34 of 385 ORDINANCE NO. _____ - 7 -04/12/11 portion thereof to the redemption of the Bonds or to other capital purposes as the Council, in its discretion, shall determine. Section 3.Authorization of Bonds and Bond Details. For the purpose of paying the costs of the Projects and paying costs of issuance of the Bonds, including, but not limited to, the payment of the premium cost for a Bond Insurance Policy, if any, the City shall issue and sell its limited tax general obligation bonds in the aggregate principal amount of not to exceed $18,000,000 (the “Bonds”). The Bonds shall be general obligations of the City, shall be designated “City of Renton, Washington, Limited Tax General Obligation Bonds, 2011”; shall be dated as of their date of delivery; shall be fully registered as to both principal and interest; shall be in the denomination of $5,000 each, or any integral multiple thereof, provided that no Bond shall represent more than one maturity; shall be numbered separately in such manner and with any additional designation as the Bond Registrar deems necessary for purposes of identification; and shall bear interest from their date payable on the first days of each June and December, commencing on December 1, 2011, at rates set forth in the Bond Purchase Contract; and shall mature on the dates and in the principal amounts set forth in the Bond Purchase Contract and as approved by the Designated Representative pursuant to Section 12. The Bonds of any of the maturities may be combined and issued as term bonds, subject to mandatory redemption as provided in the Bond Purchase Contract. Section 4.Registration, Exchange and Payments. (a)Bond Registrar/Bond Register. The City hereby specifies and adopts the system of registration approved by the Washington State Finance Committee from time to time through the appointment of state fiscal agencies. The City shall cause a bond register to be 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 35 of 385 ORDINANCE NO. _____ - 8 -04/12/11 maintained by the Bond Registrar. So long as any Bonds remain outstanding, the Bond Registrar shall make all necessary provisions to permit the exchange or registration or transfer of Bonds at its principal corporate trust office. The Bond Registrar may be removed at any time at the option of the Finance Director upon prior notice to the Bond Registrar and a successor Bond Registrar appointed by the Finance Director. No resignation or removal of the Bond Registrar shall be effective until a successor shall have been appointed and until the successor Bond Registrar shall have accepted the duties of the Bond Registrar hereunder. The Bond Registrar is authorized, on behalf of the City, to authenticate and deliver Bonds transferred or exchanged in accordance with the provisions of such Bonds and this ordinance and to carry out all of the Bond Registrar’s powers and duties under this ordinance. The Bond Registrar shall be responsible for its representations contained in the Certificate of Authentication of the Bonds. (b)Registered Ownership. The City and the Bond Registrar, each in its discretion, may deem and treat the Registered Owner of each Bond as the absolute owner thereof for all purposes (except as provided in Section 14 of this ordinance), and neither the City nor the Bond Registrar shall be affected by any notice to the contrary. Payment of any such Bond shall be made only as described in Section 4(h) hereof, but such Bond may be transferred as herein provided. All such payments made as described in Section 4(h) shall be valid and shall satisfy and discharge the liability of the City upon such Bond to the extent of the amount or amounts so paid. (c)DTC Acceptance/Letters of Representations. The Bonds initially shall be held in fully immobilized form by DTC acting as depository. To induce DTC to accept the Bonds as eligible for deposit at DTC, the City has executed and delivered to DTC a Blanket Issuer Letter of Representations. Neither the City nor the Bond Registrar will have any responsibility or 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 36 of 385 ORDINANCE NO. _____ - 9 -04/12/11 obligation to DTC participants or the persons for whom they act as nominees (or any successor depository) with respect to the Bonds in respect of the accuracy of any records maintained by DTC (or any successor depository) or any DTC participant, the payment by DTC (or any successor depository) or any DTC participant of any amount in respect of the principal of or interest on Bonds, any notice which is permitted or required to be given to Registered Owners under this ordinance (except such notices as shall be required to be given by the City to the Bond Registrar or to DTC (or any successor depository)), or any consent given or other action taken by DTC (or any successor depository) as the Registered Owner. For so long as any Bonds are held in fully-immobilized form hereunder, DTC or its successor depository shall be deemed to be the Registered Owner for all purposes hereunder, and all references herein to the Registered Owners shall mean DTC (or any successor depository) or its nominee and shall not mean the owners of any beneficial interest in such Bonds. If any Bond shall be duly presented for payment and funds have not been duly provided by the City on such applicable date, then interest shall continue to accrue thereafter on the unpaid principal thereof at the rate stated on such Bond until it is paid. (d)Use of Depository. (1)The Bonds shall be registered initially in the name of “Cede & Co.”, as nominee of DTC, with one Bond maturing on each of the maturity dates for the Bonds in a denomination corresponding to the total principal therein designated to mature on such date. Registered ownership of such immobilized Bonds, or any portions thereof, may not thereafter be transferred except (A) to any successor of DTC or its nominee, provided that any such successor shall be qualified under any applicable laws to provide the service proposed to be provided by it; (B) to any substitute depository appointed by the Finance Director pursuant to 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 37 of 385 ORDINANCE NO. _____ - 10-04/12/11 subsection (2) below or such substitute depository’s successor; or (C) to any person as provided in subsection (4) below. (2)Upon the resignation of DTC or its successor (or any substitute depository or its successor) from its functions as depository or a determination by the Finance Director to discontinue the system of book entry transfers through DTC or its successor (or any substitute depository or its successor), the Finance Director may hereafter appoint a substitute depository. Any such substitute depository shall be qualified under any applicable laws to provide the services proposed to be provided by it. (3)In the case of any transfer pursuant to clause (A) or (B) of subsection (1) above, the Bond Registrar shall, upon receipt of all outstanding Bonds, together with a written request on behalf of the Finance Director, issue a single new Bond for each maturity then outstanding, registered in the name of such successor or such substitute depository, or their nominees, as the case may be, all as specified in such written request of the Finance Director. (4)In the event that (A) DTC or its successor (or substitute depository or its successor) resigns from its functions as depository, and no substitute depository can be obtained, or (B) the Finance Director determines that it is in the best interest of the beneficial owners of the Bonds that such owners be able to obtain such bonds in the form of Bond certificates, the ownership of such Bonds may then be transferred to any person or entity as herein provided, and shall no longer be held in fully-immobilized form. The Finance Director shall deliver a written request to the Bond Registrar, together with a supply of definitive Bonds, to issue Bonds as herein provided in any authorized denomination. Upon receipt by the Bond Registrar of all then outstanding Bonds together with a written request on behalf of the Finance Director to the Bond Registrar, new Bonds shall be issued in the appropriate denominations and 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 38 of 385 ORDINANCE NO. _____ - 11-04/12/11 registered in the names of such persons as are requested in such written request. (e)Registration of Transfer of Ownership or Exchange; Change in Denominations. The transfer of any Bond may be registered and Bonds may be exchanged, but no transfer of any such Bond shall be valid unless it is surrendered to the Bond Registrar with the assignment form appearing on such Bond duly executed by the Registered Owner or such Registered Owner’s duly authorized agent in a manner satisfactory to the Bond Registrar. Upon such surrender, the Bond Registrar shall cancel the surrendered Bond and shall authenticate and deliver, without charge to the Registered Owner or transferee therefor, a new Bond (or Bonds at the option of the new Registered Owner) of the same date, maturity and interest rate and for the same aggregate principal amount in any authorized denomination, naming as Registered Owner the person or persons listed as the assignee on the assignment form appearing on the surrendered Bond, in exchange for such surrendered and cancelled Bond. Any Bond may be surrendered to the Bond Registrar and exchanged, without charge, for an equal aggregate principal amount of Bonds of the same date, maturity and interest rate, in any authorized denomination. The Bond Registrar shall not be obligated to register the transfer or to exchange any Bond during the 15 days preceding any interest payment or principal payment date any such Bond is to be redeemed. (f)Bond Registrar’s Ownership of Bonds. The Bond Registrar may become the Registered Owner of any Bond with the same rights it would have if it were not the Bond Registrar, and to the extent permitted by law, may act as depository for and permit any of its officers or directors to act as member of, or in any other capacity with respect to, any committee formed to protect the right of the Registered Owners of Bonds. (g)Registration Covenant. The City covenants that, until all Bonds have been 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 39 of 385 ORDINANCE NO. _____ - 12-04/12/11 surrendered and canceled, it will maintain a system for recording the ownership of each Bond that complies with the provisions of Section 149 of the Code. (h)Place and Medium of Payment. Both principal of and interest on the Bonds shall be payable in lawful money of the United States of America. Interest on the Bonds shall be calculated on the basis of a year of 360 days and twelve 30-day months. For so long as all Bonds are in fully immobilized form, payments of principal and interest thereon shall be made as provided in accordance with the operational arrangements of DTC referred to in the Letter of Representations. In the event that the Bonds are no longer in fully immobilized form, interest on the Bonds shall be paid by check or draft mailed to the Registered Owners at the addresses for such Registered Owners appearing on the Bond Register on the fifteenth day of the month preceding the interest payment date, or upon the written request of a Registered Owner of more than $1,000,000 of Bonds (received by the Bond Registrar at least 15 days prior to the applicable payment date), such payment shall be made by the Bond Registrar by wire transfer to the account within the United States designated by the Registered Owner. Principal of the Bonds shall be payable upon presentation and surrender of such Bonds by the Registered Owners at the principal office of the Bond Registrar. Section 5.Redemption Prior to Maturity and Purchase of Bonds. (a)Mandatory Redemption of Term Bonds and Optional Redemption, if any. The Bonds shall be subject to optional redemption on the dates, at the prices and under the terms set forth in the Bond Purchase Contract approved by the Designated Representative pursuant to Section 12 of this ordinance. The Bonds shall be subject to mandatory redemption to the extent, if any, set forth in the Bond Purchase Contract and as approved by the Designated Representative pursuant to Section 12 of this ordinance. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 40 of 385 ORDINANCE NO. _____ - 13-04/12/11 (b)Purchase of Bonds. The City reserves the right to purchase any of the Bonds offered to it at any time at a price deemed reasonable by the Designated Representative. (c)Selection of Bonds for Redemption. For as long as the Bonds are held in book-entry only form, the selection of particular Bonds within a maturity to be redeemed shall be made in accordance with the operational arrangements then in effect at DTC. If the Bonds are no longer held in uncertificated form, the selection of such Bonds to be redeemed and the surrender and reissuance thereof, as applicable, shall be made as provided in the following provisions of this subsection (c). If the City redeems at any one time fewer than all of the Bonds having the same maturity date, the particular Bonds or portions of Bonds of such maturity to be redeemed shall be selected by lot (or in such manner determined by the Bond Registrar) in increments of $5,000. In the case of a Bond of a denomination greater than $5,000, the City and the Bond Registrar shall treat each Bond as representing such number of separate Bonds each of the denomination of $5,000 as is obtained by dividing the actual principal amount of such Bond by $5,000. In the event that only a portion of the principal sum of a Bond is redeemed, upon surrender of such Bond at the principal office of the Bond Registrar there shall be issued to the Registered Owner, without charge therefor, for the then unredeemed balance of the principal sum thereof, at the option of the Registered Owner, a Bond or Bonds of like maturity and interest rate in any of the denominations herein authorized. (d)Notice of Redemption. (1)Official Notice. For so long as the Bonds are held in uncertificated form, notice of redemption (which notice may be conditional) shall be given in accordance with the operational arrangements of DTC as then in effect, and neither the City nor the Bond Registrar will provide any notice of redemption to any Beneficial Owners. Thereafter (if the Bonds are no 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 41 of 385 ORDINANCE NO. _____ - 14-04/12/11 longer held in uncertificated form), notice of redemption shall be given in the manner hereinafter provided. Unless waived by any owner of Bonds to be redeemed, official notice of any such redemption (which redemption may be conditioned by the Bond Registrar on the receipt of sufficient funds for redemption or otherwise) shall be given by the Bond Registrar on behalf of the City by mailing a copy of an official redemption notice by first class mail at least 20 days and not more than 60 days prior to the date fixed for redemption to the Registered Owner of the Bond or Bonds to be redeemed at the address shown on the Register or at such other address as is furnished in writing by such Registered Owner to the Bond Registrar. All official notices of redemption shall be dated and shall state: (A)the redemption date, (B)the redemption price, (C)if fewer than all outstanding Bonds are to be redeemed, the identification by maturity (and, in the case of partial redemption, the respective principal amounts) of the Bonds to be redeemed, (D)that on the redemption date the redemption price will become due and payable upon each such Bond or portion thereof called for redemption, and that interest thereon shall cease to accrue from and after said date, and (E)the place where such Bonds are to be surrendered for payment of the redemption price, which place of payment shall be the principal office of the Bond Registrar. On or prior to any redemption date, the City shall deposit with the Bond Registrar an amount of money sufficient to pay the redemption price of all the Bonds or portions of Bonds which are to be redeemed on that date. (2)Effect of Notice; Bonds Due. If an unconditional notice of redemption has 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 42 of 385 ORDINANCE NO. _____ - 15-04/12/11 been given as aforesaid, the Bonds or portions of Bonds so to be redeemed shall, on the redemption date, become due and payable at the redemption price therein specified, and from and after such date such Bonds or portions of Bonds shall cease to bear interest. Upon surrender of such Bonds for redemption in accordance with said notice, such Bonds shall be paid by the Bond Registrar at the redemption price. Installments of interest due on or prior to the redemption date shall be payable as herein provided for payment of interest. All Bonds which have been redeemed shall be canceled by the Bond Registrar and shall not be reissued. (3)Additional Notice. In addition to the foregoing notice, further notice shall be given by the City as set out below, but no defect in said further notice nor any failure to give all or any portion of such further notice shall in any manner defeat the effectiveness of a call for redemption if notice thereof is given as above prescribed. Each further notice of redemption given hereunder shall contain the information required above for an official notice of redemption plus (A) the CUSIP numbers of all Bonds being redeemed; (B) the date of issue of the Bonds as originally issued; (C) the rate of interest borne by each Bond being redeemed; (D) the maturity date of each Bond being redeemed; and (E) any other descriptive information needed to identify accurately the Bonds being redeemed. Each further notice of redemption may be sent at least 20 days before the redemption date to each party entitled to receive notice pursuant to Section 14 and to the Underwriter and with such additional information as the City shall deem appropriate, but such mailings shall not be a condition precedent to the redemption of such Bonds. (4)Amendment of Notice Provisions. The foregoing notice provisions of this Section 5, including but not limited to the information to be included in redemption notices and the persons designated to receive notices, may be amended by additions, deletions and 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 43 of 385 ORDINANCE NO. _____ - 16-04/12/11 changes in order to maintain compliance with duly promulgated regulations and recommendations regarding notices of redemption of municipal securities. Section 6.Form of Bonds. The Bonds shall be in substantially the following form: [STATEMENT OF INSURANCE] UNITED STATES OF AMERICA NO. $ ___ STATE OF WASHINGTON CITY OF RENTON LIMITED TAX GENERAL OBLIGATION BOND, 2011 INTEREST RATE: %MATURITY DATE:CUSIP NO.: REGISTERED OWNER:CEDE & CO. PRINCIPAL AMOUNT: The City of Renton, Washington (the “City”), hereby acknowledges itself to owe and for value received promises to pay to the Registered Owner identified above, or registered assigns, on the Maturity Date identified above, the Principal Amount indicated above and to pay interest thereon from ___________, 2011, or the most recent date to which interest has been paid or duly provided for until payment of this bond at the Interest Rate set forth above, payable on December 1, 2011, and semiannually thereafter on the first days of each succeeding June and December. Both principal of and interest on this bond are payable in lawful money of the United States of America. The fiscal agency of the State of Washington has been appointed by the City as the authenticating agent, paying agent and registrar for the bonds of this issue (the “Bond Registrar”). For so long as the bonds of this issue are held in fully immobilized form, payments of principal and interest thereon shall be made as provided in accordance with the operational arrangements of The Depository Trust Company (“DTC”) referred to in the Blanket Issuer Letter of Representations (the “Letter of Representations”) from the City to DTC. The bonds of this issue are issued under and in accordance with the provisions of the Constitution and applicable statutes of the State of Washington and Ordinance No. _______ duly passed by the City Council on May 2, 2011 (the “Bond Ordinance”). Capitalized terms used in this bond have the meanings given such terms in the Bond Ordinance. This bond shall not be valid or become obligatory for any purpose or be entitled to any security or benefit under the Bond Ordinance until the Certificate of Authentication hereon shall have been manually signed by or on behalf of the Bond Registrar or its duly designated agent. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 44 of 385 ORDINANCE NO. _____ - 17-04/12/11 This bond is one of an authorized issue of bonds of like date, tenor, rate of interest and date of maturity, except as to number and amount in the aggregate principal amount of $__________ and is issued pursuant to the Bond Ordinance to provide funds (a) to pay all or a portion of the cost of acquiring land for and constructing, improving and equipping two public library facilities, and repairing, renovating and improving existing libraries for other public uses and (b) to pay costs of issuance. The bonds of this issue are subject to redemption as provided in the Bond Ordinance and the Bond Purchase Contract. The City hereby irrevocably covenants and agrees with the owner of this bond that it will include in its annual budget and levy taxes annually, within and as a part of the tax levy permitted to the City without a vote of the electorate, upon all the property subject to taxation in amounts sufficient, together with other money legally available therefor, to pay the principal of and interest on this bond as the same shall become due. The full faith, credit and resources of the City are hereby irrevocably pledged for the annual levy and collection of such taxes and the prompt payment of such principal and interest. The bonds of this issue have not been designated by the City as “qualified tax-exempt obligations” for investment by financial institutions under Section 265(b) of the Code. The pledge of tax levies for payment of principal of and interest on the bonds may be discharged prior to maturity of the bonds by making provision for the payment thereof on the terms and conditions set forth in the Bond Ordinance. It is hereby certified that all acts, conditions and things required by the Constitution and statutes of the State of Washington to exist, to have happened, been done and performed precedent to and in the issuance of this bond have happened, been done and performed and that the issuance of this bond and the bonds of this issue does not violate any constitutional, statutory or other limitation upon the amount of bonded indebtedness that the City may incur. IN WITNESS WHEREOF, the City of Renton, Washington has caused this bond to be executed by the manual or facsimile signatures of the Mayor and the City Clerk and the seal of the City imprinted, impressed or otherwise reproduced hereon as of this ____ day of ___________, 2011. [SEAL] CITY OF RENTON, WASHINGTON By /s/ manual or facsimile Mayor ATTEST: /s/ manual or facsimile City Clerk 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 45 of 385 ORDINANCE NO. _____ - 18-04/12/11 The Bond Registrar’s Certificate of Authentication on the Bonds shall be in substantially the following form: CERTIFICATE OF AUTHENTICATION This bond is one of the bonds described in the within-mentioned Bond Ordinance and is one of the Limited Tax General Obligation Bonds, 2011 of the City of Renton, Washington, dated ____________, 2011. WASHINGTON STATE FISCAL AGENCY, as Bond Registrar By Section 7.Execution of Bonds. The Bonds shall be executed on behalf of the City with the manual or facsimile signatures of the Mayor and City Clerk of the City and the seal of the City shall be impressed, imprinted or otherwise reproduced thereon. Only such Bonds as shall bear thereon a Certificate of Authentication in the form hereinbefore recited, manually executed by the Bond Registrar, shall be valid or obligatory for any purpose or entitled to the benefits of this ordinance. Such Certificate of Authentication shall be conclusive evidence that the Bonds so authenticated have been duly executed, authenticated and delivered hereunder and are entitled to the benefits of this ordinance. In case either of the officers who shall have executed the Bonds shall cease to be an officer or officers of the City before the Bonds so signed shall have been authenticated or delivered by the Bond Registrar, or issued by the City, such Bonds may nevertheless be authenticated, delivered and issued and upon such authentication, delivery and issuance, shall be as binding upon the City as though those who signed the same had continued to be such officers of the City. Any Bond may be signed and attested on behalf of the City by such persons who at the date of the actual execution of such Bond, are the proper officers of the City, 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 46 of 385 ORDINANCE NO. _____ - 19-04/12/11 although at the original date of such Bond any such person shall not have been such officer of the City. Section 8.Application of Bond Proceeds. The City shall establish a fund designated the “Library Construction Fund” (the “Project Fund”) into which the proceeds of the Bonds (other than accrued interest, if any) shall be deposited. Money in the Project Fund shall be used to pay the costs of the Projects and costs of issuance of the Bonds. The Finance Director may invest money in the Project Fund in legal investments for City funds. Earnings on such investments shall accrue to the benefit of the Project Fund. Any part of the proceeds of the Bonds remaining in the Project Fund after all costs of the Projects have been paid (including costs of issuance) may be used for capital purposes of the City in accordance with the Federal Tax Certificate or may be transferred to the Bond Fund, after consultation with bond counsel to the City. Section 9.Tax Covenants. The City covenants that it will not take or permit to be taken on its behalf any action that would adversely affect the exemption from federal income taxation of the interest on the Bonds and will take or require to be taken such acts as may reasonably be within its ability and as may from time to time be required under applicable law to continue the exemption from federal income taxation of the interest on the Bonds. (a)Arbitrage Covenant. Without limiting the generality of the foregoing, the City covenants that it will not take any action or fail to take any action with respect to the proceeds of sale of the Bonds or any other funds of the City which may be deemed to be proceeds of the Bonds pursuant to Section 148 of the Code and the regulations promulgated thereunder which, if such use had been reasonably expected on the dates of delivery of the Bonds to the initial purchasers thereof, would have caused the Bonds to be treated as “arbitrage bonds” within the 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 47 of 385 ORDINANCE NO. _____ - 20-04/12/11 meaning of such term as used in Section 148 of the Code. The City represents that it has not been notified of any listing or proposed listing by the Internal Revenue Service to the effect that it is an issuer whose arbitrage certifications may not be relied upon. The City will comply with the requirements of Section 148 of the Code and the applicable regulations thereunder throughout the term of the Bonds. (b)Private Person Use Limitation for Bonds. The City covenants that for as long as the Bonds are outstanding, it will not permit: (1)More than 10% of the Net Proceeds of the Bonds to be allocated to any Private Person Use; and (2)More than 10% of the principal or interest payments on the Bonds in a Bond Year to be directly or indirectly: (A) secured by any interest in property used or to be used for any Private Person Use or secured by payments in respect of property used or to be used for any Private Person Use, or (B) derived from payments (whether or not made to the City) in respect of property, or borrowed money, used or to be used for any Private Person Use. The City further covenants that, if: (3)More than five percent of the Net Proceeds of the Bonds are allocable to any Private Person Use; and (4)More than five percent of the principal or interest payments on the Bonds in a Bond Year are (under the terms of this ordinance or any underlying arrangement) directly or indirectly: (A)secured by any interest in property used or to be used for any Private Person Use or secured by payments in respect of property used or to be used for any Private Person Use, or 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 48 of 385 ORDINANCE NO. _____ - 21-04/12/11 (B)derived from payments (whether or not made to the City) in respect of property, or borrowed money, used or to be used for any Private Person Use, then, (i) any Private Person Use of the Projects described in subsection (3) hereof or Private Person Use payments described in subsection (4) hereof that is in excess of the five percent limitations described in such subsections (3) or (4) will be for a Private Person Use that is related to the state or local governmental use of the Projects funded by the proceeds of the Bonds, and (ii) any Private Person Use will not exceed the amount of Net Proceeds of the Bonds allocable to the state or local governmental use portion of the Projects to which the Private Person Use of such portion of the Projects funded by the proceeds of the Bonds relate. The City further covenants that it will comply with any limitations on the use of the Projects funded by the proceeds of the Bonds by other than state and local governmental users that are necessary, in the opinion of its bond counsel, to preserve the tax exemption of the interest on the Bonds. The covenants of this section are specified solely to assure the continued exemption from regular income taxation of the interest on the Bonds. (c)Modification of Tax Covenants. The covenants of this section are specified solely to assure the continued exemption from regular income taxation of the interest on the Bonds. To that end, the provisions of this section may be modified or eliminated without any requirement for formal amendment thereof upon receipt of an opinion of the City’s bond counsel that such modification or elimination will not adversely affect the tax exemption of interest on any Bonds. (d)No Designation under Section 265(b). The City has not designated the Bonds as “qualified tax-exempt obligations” under Section 265(b)(3) of the Code for investment by financial institutions. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 49 of 385 ORDINANCE NO. _____ - 22-04/12/11 Section 10.Bond Fund and Provision for Tax Levy Payments. The City hereby authorizes the creation of a fund to be used for the payment of debt service on the Bonds, designated as the “City of Renton Limited Tax General Obligation Bond Debt Service Fund, 2011” (the “Bond Fund”). No later than the date each payment of principal of and/or interest on the Bonds becomes due and payable, the City shall transmit sufficient funds, from the Bond Fund or from other legally available sources to the Bond Registrar for the payment of such principal and/or interest. Money in the Bond Fund not needed to pay the interest or principal next coming due may be invested in legal investments for City funds. The City hereby irrevocably covenants and agrees for as long as any of the Bonds are outstanding and unpaid that each year it will include in its budget and levy an ad valorem tax upon all the property within the City subject to taxation in an amount that will be sufficient, together with all other revenues and money of the City legally available for such purposes, to pay the principal of and interest on the Bonds when due. The City hereby irrevocably pledges that the annual tax provided for herein to be levied for the payment of such principal and interest shall be within and as a part of the tax levy permitted to cities without a vote of the people, and that a sufficient portion of each annual levy to be levied and collected by the City prior to the full payment of the principal of and interest on the Bonds will be and is hereby irrevocably set aside, pledged and appropriated for the payment of the principal of and interest on the Bonds. The full faith, credit and resources of the City are hereby irrevocably pledged for the annual levy and collection of said taxes and for the prompt payment of the principal of and interest on the Bonds when due. Section 11.Defeasance. In the event that the City, to effect the payment, retirement or redemption of any Bond, sets aside in the Bond Fund or in another special account, cash or 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 50 of 385 ORDINANCE NO. _____ - 23-04/12/11 noncallable Government Obligations, or any combination of cash and/or noncallable Government Obligations, in amounts and maturities which, together with the known earned income therefrom, are sufficient to redeem or pay and retire such Bond in accordance with its terms and to pay when due the interest and redemption premium, if any, thereon, and such cash and/or noncallable Government Obligations are irrevocably set aside and pledged for such purpose, then no further payments need be made into the Bond Fund for the payment of the principal of and interest on such Bond. The owner of a Bond so provided for shall cease to be entitled to any lien, benefit or security of this ordinance except the right to receive payment of principal, premium, if any, and interest from the Bond Fund or such special account, and such Bond shall be deemed to be not outstanding under this ordinance. The City shall give written notice of defeasance to the owners of all Bonds so provided for within 30 days of the defeasance and to each party entitled to receive notice in accordance with Section 14 of this ordinance. Section 12.Sale of Bonds. (a)Bond Sale. The Bonds shall be sold at negotiated sale to the Underwriter pursuant to the terms of the Bond Purchase Contract. The Underwriter has advised the Council that market conditions are fluctuating and, as a result, the most favorable market conditions may occur on a day other than a regular meeting date of the Council. The Council has determined that it would be in the best interest of the City to delegate to the Designated Representative for a limited time the authority to approve the final interest rates, aggregate principal amount, principal amounts of each maturity of the Bonds and redemption rights. The Designated Representative is hereby authorized to approve the final interest rates, aggregate principal amount, principal maturities and redemption rights for the Bonds in the manner 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 51 of 385 ORDINANCE NO. _____ - 24-04/12/11 provided hereafter so long as (a) the aggregate principal amount of the Bonds does not exceed $18,000,000 and (b) the true interest cost for the Bonds (in the aggregate) does not exceed _____%. In determining whether or not to acquire a Bond Insurance Policy and determining the final interest rates, aggregate principal amounts, principal maturities and redemption rights, the Designated Representative shall take into account those factors that, in his or her judgment, will result in the lowest true interest cost on the Bonds to their maturity, including, but not limited to current financial market conditions and current interest rates for obligations comparable in tenor and quality to the Bonds. Subject to the terms and conditions set forth in this Section 12, the Designated Representative is hereby authorized to execute the Bond Purchase Contract. The signature of one of the listed Designated Representatives shall be sufficient. Following the execution of the Bond Purchase Contract, the Designated Representative or the Finance Director shall provide a report to the Council, describing the final terms of the Bonds approved pursuant to the authority delegated in this section. The authority granted to the Designated Representative by this Section 12 shall expire 120 days after the effective date of this ordinance. If a Bond Purchase Contract for the Bonds has not been executed within 120 days after the effective date of this ordinance, the authorization for the issuance of the Bonds shall be rescinded, and the Bonds shall not be issued nor their sale approved unless such Bonds shall have been re-authorized by ordinance of the Council. The ordinance re-authorizing the issuance and sale of such Bonds may be in the form of a new ordinance repealing this ordinance in whole or in part or may be in the form of an amendatory ordinance approving a bond purchase contract or establishing terms and conditions for the authority delegated under this Section 12. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 52 of 385 ORDINANCE NO. _____ - 25-04/12/11 (b)Delivery of Bonds; Documentation. Upon the passage and approval of this ordinance, the proper officials of the City including the Designated Representative, are authorized and directed to undertake all action necessary for the prompt execution and delivery of the Bonds to the Underwriter thereof and further to execute all closing certificates and documents required to effect the closing and delivery of the Bonds in accordance with the terms of the Bond Purchase Contract. (c)Preliminary and Final Official Statements. The Finance Director is hereby authorized to ratify and to deem final the preliminary Official Statement relating to the Bonds for the purposes of the Rule. The Finance Director is further authorized to ratify and to approve for purposes of the Rule, on behalf of the City, the Official Statement relating to the issuance and sale of the Bonds and the distribution of the Official Statement pursuant thereto with such changes, if any, as may be deemed by her to be appropriate. Section 13.Bond Insurance. The Finance Director is hereby further authorized to solicit proposals from municipal bond insurance companies for the issuance of a Bond Insurance Policy. In the event that the Finance Director receives multiple proposals, the Finance Director may select the proposal having the lowest cost and resulting in an overall lower interest cost with respect to the Bonds. The Finance Director may execute a commitment received from the Insurer selected by the Finance Director. The Council further authorizes and directs all proper officers, agents, attorneys and employees of the City to cooperate with the Insurer in preparing such additional agreements, certificates, and other documentation on behalf of the City as shall be necessary or advisable in providing for the Bond Insurance Policy. Section 14.Undertaking to Provide Ongoing Disclosure. (a)Contract/Undertaking. This section constitutes the City’s written undertaking for 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 53 of 385 ORDINANCE NO. _____ - 26-04/12/11 the benefit of the owners, including Beneficial Owners, of the Bonds as required by Section (b)(5) of the Rule. (b)Financial Statements/Operating Data. The City agrees to provide or cause to be provided to the Municipal Securities Rulemaking Board (“MSRB”), the following annual financial information and operating data for the prior fiscal year (commencing in 2011 for the fiscal year ended December 31, 2010): 1.Annual financial statements, which statements may or may not be audited, showing ending fund balances for the City’s general fund prepared in accordance with the Budgeting Accounting and Reporting System prescribed by the Washington State Auditor pursuant to RCW 43.09.200 (or any successor statute) and generally of the type included in the official statement for the Bonds under the heading “General Fund Comparative Statement of Revenues, Expenditures and Changes in Fund Balance”; 2.The assessed valuation of taxable property in the City; 3.Ad valorem taxes due and percentage of taxes collected; 4.Property tax levy rate per $1,000 of assessed valuation; and 5.Outstanding general obligation debt of the City. Items 2-5 shall be required only to the extent that such information is not included in the annual financial statements. The information and data described above shall be provided on or before nine months after the end of the City’s fiscal year. The City’s current fiscal year ends December 31. The City may adjust such fiscal year by providing written notice of the change of fiscal year to the MSRB. In lieu of providing such annual financial information and operating data, the City may cross-reference to other documents available to the public on the MSRB’s internet website or 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 54 of 385 ORDINANCE NO. _____ - 27-04/12/11 filed with the Commission. If not provided as part of the annual financial information discussed above, the City shall provide the City’s audited annual financial statement prepared in accordance with the Budgeting Accounting and Reporting System prescribed by the Washington State Auditor pursuant to RCW 43.09.200 (or any successor statute) when and if available to the MSRB. (c)Listed Events. The City agrees to provide or cause to be provided to the MSRB, in a timely manner not in excess of ten business days after the occurrence of the event, notice of the occurrence of any of the following events with respect to the Bonds: 1.Principal and interest payment delinquencies; 2.Non-payment related defaults, if material; 3.Unscheduled draws on debt service reserves reflecting financial difficulties; 4.Unscheduled draws on credit enhancements reflecting financial difficulties; 5.Substitution of credit or liquidity providers, or their failure to perform; 6.Adverse tax opinions, the issuance by the Internal Revenue Service of proposed or final determinations of taxability, Notices of Proposed Issue (IRS Form 5701-TEB) or other material notices or determinations with respect to the tax status of the Bonds, or other material events affecting the tax status of the Bonds; 7.Modifications to the rights of Bondholders, if material; 8.Optional, contingent or unscheduled Bond calls other than scheduled sinking fund redemptions for which notice is given pursuant to Exchange 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 55 of 385 ORDINANCE NO. _____ - 28-04/12/11 Act Release 34-23856, if material, and tender offers; 9.Defeasances; 10.Release, substitution, or sale of property securing repayment of the Bonds, if material; 11.Rating changes; 12.Bankruptcy, insolvency, receivership or similar event of the City; 13.The consummation of a merger, consolidation, or acquisition involving the City or the sale of all or substantially all of the assets of the City, other than in the ordinary course of business, the entry into a definitive agreement to undertake such an action or the termination of a definitive agreement relating to any such actions, other than pursuant to its terms, if material; and 14.Appointment of a successor or additional trustee or the change of name of a trustee, if material. The City shall promptly determine whether the events described above are material. (d)Format for Filings with the MSRB. All notices, financial information and operating data required by this undertaking to be provided to the MSRB must be in an electronic format as prescribed by the MSRB. All documents provided to the MSRB pursuant to this undertaking must be accompanied by identifying information as prescribed by the MSRB. (e)Notification Upon Failure to Provide Financial Data. The City agrees to provide or cause to be provided, in a timely manner, to the MSRB notice of its failure to provide the annual financial information described in Subsection (b) above on or prior to the date set forth in Subsection (b) above. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 56 of 385 ORDINANCE NO. _____ - 29-04/12/11 (f)Termination/Modification. The City’s obligations to provide annual financial information and notices of certain listed events shall terminate upon the legal defeasance, prior redemption or payment in full of all of the Bonds. Any provision of this section shall be null and void if the City (1) obtains an opinion of nationally recognized bond counsel to the effect that the portion of the Rule that requires that provision is invalid, has been repealed retroactively or otherwise does not apply to the Bonds and (2) notifies the MSRB of such opinion and the cancellation of this section. The City may amend this section with an opinion of nationally recognized bond counsel in accordance with the Rule. In the event of any amendment of this section, the City shall describe such amendment in the next annual report, and shall include, a narrative explanation of the reason for the amendment and its impact on the type (or in the case of a change of accounting principles, on the presentation) of financial information or operating data being presented by the City. In addition, if the amendment relates to the accounting principles to be followed in preparing financial statements, (A) notice of such change shall be given in the same manner as for a listed event under Subsection (c), and (B) the annual report for the year in which the change is made shall present a comparison (in narrative form and also, if feasible, in quantitative form) between the financial statements as prepared on the basis of the new accounting principles and those prepared on the basis of the former accounting principles. (g)Bond Owner’s Remedies Under This Section. The right of any bondowner or Beneficial Owner of Bonds to enforce the provisions of this section shall be limited to a right to obtain specific enforcement of the City’s obligations under this section, and any failure by the City to comply with the provisions of this undertaking shall not be an event of default with respect to the Bonds. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 57 of 385 ORDINANCE NO. _____ - 30-04/12/11 (h)No Default. Except as otherwise disclosed in the City’s official statement relating to the Bonds, the City is not and has not been in default in the performance of its obligations of any prior undertaking for ongoing disclosure with respect to its obligations. Section 15.Lost, Stolen or Destroyed Bonds. In case any Bond or Bonds shall be lost, stolen or destroyed, the Bond Registrar may execute and deliver a new Bond or Bonds of like date, number and tenor to the Registered Owner thereof upon the Registered Owner’s paying the expenses and charges of the City and the Bond Registrar in connection therewith and upon his/her filing with the City evidence satisfactory to the City that such Bond was actually lost, stolen or destroyed and of his/her ownership thereof, and upon furnishing the City and/or the Bond Registrar with indemnity satisfactory to the City and the Bond Registrar. Section 16.Severability. If any one or more of the covenants or agreements provided in this ordinance to be performed on the part of the City shall be declared by any court of competent jurisdiction to be contrary to law, then such covenant or covenants, agreement or agreements, shall be null and void and shall be deemed separable from the remaining covenants and agreements of this ordinance and shall in no way affect the validity of the other provisions of this ordinance or of the Bonds. Section 17.Effective Date of Ordinance. This ordinance shall be effective upon its passage, approval, and thirty (30) days after publication. PASSED BY THE CITY COUNCIL this 2nd day of May, 2011. Bonnie I. Walton, City Clerk APPROVED BY THE MAYOR this 2nd day of May, 2011. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 58 of 385 ORDINANCE NO. _____ - 31-04/12/11 Denis Law, Mayor Approved as to form: Deanna Gregory Pacifica Law Group LLP Bond Counsel Date of Publication: ___________________ 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 59 of 385 ORDINANCE NO. _____ 04/12/11 CERTIFICATE I, the undersigned, City Clerk of the City Council of the City of Renton, Washington (the “City”), DO HEREBY CERTIFY: 1.That the attached Ordinance is a true and correct copy of Ordinance No. ______ of the City Council (the “Ordinance”), duly passed at a regular meeting thereof held on the 2nd day of May, 2011. 2.That said meeting was duly convened and held in all respects in accordance with law, and to the extent required by law, due and proper notice of such meeting was given; that a legal quorum was present throughout the meeting and a legally sufficient number of members of the City Council voted in the proper manner for the passage of the Ordinance; that all other requirements and proceedings incident to the proper passage of the Ordinance have been duly fulfilled, carried out and otherwise observed; and that I am authorized to execute this certificate. IN WITNESS WHEREOF, I have hereunto set my hand this 2nd day of May, 2011. 6c. ‐ Finance and Information Technology Department requests approval  of the proposed financial plan, and authorization to set 5/9/2011 as the Page 60 of 385 CITY OF RENTON COUNCIL AGENDA BILL Subject/Title: Proposed Amendment to Water Leak Billing Adjustment Ordinance Meeting: Regular Council - 02 May 2011 Exhibits: Issue Paper Ordinance Submitting Data: Dept/Div/Board: Finance & Information Technology Staff Contact: Iwen Wang, Administrator Recommended Action: Refer to Finance Committee Fiscal Impact: Expenditure Required: $ Transfer Amendment: $ Amount Budgeted: $ Revenue Generated: $ Total Project Budget: $ City Share Total Project: $ SUMMARY OF ACTION: The City adopted Ordinance 5210 in June 2006 to allow for partial relief of high utility bills caused by water leaks under certain situations. The attached draft ordinance will make certain amendments to clarify the intent and require the customer to take prompt action to determine and make necessary repairs to minimize any water leaks. STAFF RECOMMENDATION: Approve the proposed amendment to the Renton Municipal Code 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 61 of 385 FINANCE AND INFORMATION TECHNOLOGY M E M O R A N D U M DATE:April 18, 2011 TO:Terri Briere, Council President Members of the Renton City Council VIA:Denis Law, Mayor FROM:Iwen Wang, Administrator SUBJECT:Utility Billing – Leak Adjustment Ordinance Amendment ISSUE What is the City’s practice in notifying customers of potential water leaks and the City’s policies and procedures in considering billing adjustments for such water leaks? BACKGROUND The City adopted Ordinance 5210 in June of 2006 to allow for partial relief of high utility bills caused by water leaks under certain situations. 1)Type of leaks: Policy: The City code provides that adjustment is allowed for water leaks that occurred on the customer’s side of the water line, but excludes leaks to irrigation systems, caused by frozen pipes, leaky toilets, and water service for boat docks, hot tubs, pools, fountains, ponds, or other outdoor decorative water features. The customer must submit a written request for this adjustment. Practice: The only area of question is the frozen pipe exclusion which requires determination by the City Water Shop. 2)Notice of Potential Leak: Policy: City code does not specifically prescribe the notification process to be used. Practice: The City sends high consumption notices when the current consumption is 50% over the previous month and the pattern is inconsistent with past usage. But this does not necessarily mean there is a leak, and the notice asks customers to take some simple steps to check if there is a leak, and to contact the City’s Water Shop if they need help. The majority of leaks are detected and corrected at this point. But if the high consumption continues, a special read may be taken to confirm the high consumption is not caused by a faulty register/meter. And if the read is confirmed, an additional notice is sent. 3)Number of Bills Adjusted: 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 62 of 385 Terri Briere, Council President Members of the Renton City Council Page 2 of 4 April 18, 2011 \\renton\depts\fis\finance\council\2011\ip_utility leak adj procedure.doc Policy: Renton Municipal Code (RMC) (8-4-46A for water and 8-5-23A for sewer) provides that “… Adjustments will be calculated over the billing periods when the water leak occurred, up to a maximum of two (2) billing periods (four (4) months).” Practice: Since we now bill both residential and commercial customers monthly but residential meters are only read every other month, the practice has been using the four months (vs. two billing periods) to determine the amount of credit to be issued. 4)Services eligible for adjustment: Policy: Basic monthly charges are not adjusted; single-family sewer and metro are not adjusted as they are a fixed monthly charge and are not based on water consumption. For non single-family sewer accounts, a full adjustment of the sewer bill will be made for all leaked water that did not enter the sanitary sewer system. Practice: RMC did not specifically address metro charges, but the practice has been to apply the same rule as the sewer utility. 5)Timing of Action: Policy: RMC states leak adjustment requests must be “submitted within sixty days of discovery of the water leak and/or sixty (60) days of receipt of the billing that covers the time period when the water leak occurred. The written request must include …a copy of the repair receipt and/or a description of the completed repair…” Practice: Typically, the timing of the discovery and repair of the leak falls within the billing period that the leak occurred, and therefore as long as the written request is made within 60 days of when the leak stopped, this would be considered acceptable. 6)Approval of Adjustment: Policy: RMC requires adjustment over $2,000 to be approved by the Council Finance Committee. Practice: FIT Administrator approves adjustments under $2,000, but all adjustments over $2,000 are presented through the City Council to the Finance Committee for review and approval. CONCLUSION: After comparing the City’s policy and practice with that of the surrounding jurisdictions, the administration recommends making the following changes in our practice: A.Notification: Add a phone call or email to the notification process. For those accounts we do not have a telephone number or email address, we will use a “door hanger” as an additional notice mechanism so the occupants of the property will get a timely notice. B.Adjustment Period: Clarify that the maximum adjustment is for two regular meter reading cycles, or four months for a single family residential, and two months for 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 63 of 385 Terri Briere, Council President Members of the Renton City Council Page 3 of 4 April 18, 2011 \\renton\depts\fis\finance\council\2011\ip_utility leak adj procedure.doc multifamily and commercial accounts whose meters are read monthly. C.Timely Cure: Setting the sixty (60) day repair deadline to the customer from the “first notified by the City” (the telephone/email/door hanger process) unless they can show good faith effort is made to locate and repair the leak. Attachment: Comparison of Leak Adjustment Policy and Procedure with Area Utilities Cc: Jay Covington, CAO Lys Hornsby, Utility Systems Director Gina Jarvis, Fiscal Services Director 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 64 of 385 Comparison of Leak Adjustment Policy of Area Utilities 6 d .   ‐   F i n a n c e   a n d   I n f o r m a t i o n   T e c h n o l o g y   D e p a r t m e n t   r e c o m m e n d s   a p p r o v a l   o f   a   C i t y   C o d e   a m e n d m e n t c l a r i f y i n g   u t i l i t y   b i l l   l e a k   a d j u s t m e n t   P a g e 6 5 o f 3 8 5 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 66 of 385 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 67 of 385 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 68 of 385 6d. ‐ Finance and Information Technology Department recommends  approval of a City Code amendment clarifying utility bill leak adjustment  Page 69 of 385 CITY OF RENTON COUNCIL AGENDA BILL Subject/Title: Amateur Radio Equipment Memorandum of Understanding with King County Fire District 20 Meeting: Regular Council - 02 May 2011 Exhibits: Issue Paper Memorandum of Understanding Resolution Submitting Data: Dept/Div/Board: Fire & Emergency Services Staff Contact: Deborah Needham, Emergency Management Director Recommended Action: Council Concur Fiscal Impact: Expenditure Required: $ 0 Transfer Amendment: $0 Amount Budgeted: $ 0 Revenue Generated: $0 Total Project Budget: $ 0 City Share Total Project: $ 0 SUMMARY OF ACTION: The Fire & Emergency Services Department will work with King County Fire District 20 to increase emergency communication capabilities with the installation of a repeater antenna. We currently have two linked repeater antennas. Due to the topography of the Renton area, there are significant 'dead spots' that are outside repeater range with the current arrangement. The installation of a third antenna will allow for triangulation between the linked antennas and eliminate almost all of the dead spots, providing seamless back-up communication in an emergency. The antenna would be owned by the City of Renton and installed on King County Fire District 20 property. Use and management of the new antenna requires a Memorandum of Understanding. The equipment and installation of the repeater will be funding by Emergency Management Performance Grant funds. The City of Renton's emergency communication capabilities would be markedly increased by the approval of the Memorandum of Understanding with King County Fire District 20 and the corresponding resolution STAFF RECOMMENDATION: Approve the MOU and the supporting resolution. 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 70 of 385 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 71 of 385 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 72 of 385 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 73 of 385 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 74 of 385 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 75 of 385 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 76 of 385 6e. ‐ Fire and Emergency Services Department recommends approval of  a Memorandum of Understanding with King County Fire District 20 Page 77 of 385 CITY OF RENTON COUNCIL AGENDA BILL Subject/Title: Salary grade/step approval for new HR Manager Meeting: Regular Council - 02 May 2011 Exhibits: Issue Paper Submitting Data: Dept/Div/Board: Human Resources Staff Contact: Nancy A. Carlson, HRRM Administrator Recommended Action: Refer to Finance Committee Fiscal Impact: Expenditure Required: $ n/a Transfer Amendment: $ Amount Budgeted: $ This position is already budgeted Revenue Generated: $ Total Project Budget: $ City Share Total Project: $ SUMMARY OF ACTION: HR Manager Eileen Flott retired on January 31, 2011, after 14 years in the City's Human Resources & Risk Management Department. The department has been recruiting for this position since January 3. After holding two rounds of interviews, Cathryn Laird has emerged as our top candidate. She has extensive experience in all aspects of HR management, and has been the City of Bellevue's HR manager for the past 14 years. Ms. Laird will be taking a considerable pay cut of over 20% even at the E step of grade m30. This position was funded in the 2011 budget at the “E” step and will require no additional funding in the 2011 budget. STAFF RECOMMENDATION: Approve new HR Manager salary at grade m30, step E 6f. ‐ Human Resources and Risk Management Department recommends  approval to hire the Human Resources Manager at Grade M30, Step E of  Page 78 of 385 HUMAN RESOURCES AND RISK MANAGEMENT M E M O R A N D U M DATE:April 21, 2011 TO:Marcie Palmer, Council President Members of the Renton City Council FROM:Nancy A. Carlson, Administrator SUBJECT:Approval to hire HR Manager at “E” Step of Salary Grade m30 ISSUE: Should the City Council set the new HR Manager’s compensation at step “E” of salary grade m30? RECOMMENDATION: In recognition of Cathryn Laird’s experience and background, it is recommended that she be placed at step “E” of salary grade m30. BACKGROUND: Under the supervision of the HR Administrator, the HR Manager provides strategic direction, and oversees the delivery of city-wide programs including Labor/Employee Relations, recruitment, selection, and compensation and classification. The responsibilities include supervision of staff members, and advising City departments regarding the above-mentioned programs and other HR matters such as policy implementation and employment law issues (i.e., ADA, FLSA, FMLA, and Title VII). Our recruitment for this position opened January 3, 2011, and did not close until April 14, 2011. The leading candidate after our first round of interviews on February 4, 2011, withdrew her name from consideration. After holding the recruitment open for another two months, we held a second round of interviews with new candidates. Cathryn Laird is our top candidate and has accepted the position pending the successful completion of background and reference checks. Ms. Laird has been an HR Manager in the City of Bellevue for the past 14 years. She has extensive experience in all aspects of HR management, especially employee relations, employment laws such as FMLA and ADA, grievances and investigations, and managing staff responsible for recruitment and selection. She has represented Human Resources on a variety of city-wide committees, such as performance excellence, the recruitment and retention strategic plan, and succession and workload planning. In addition, she has administered the HR budget and acted as the Human Resources Director in the director’s absence. Ms. Laird will be taking a considerable pay cut of over 20% even at the E step of grade m30. 6f. ‐ Human Resources and Risk Management Department recommends  approval to hire the Human Resources Manager at Grade M30, Step E of  Page 79 of 385 Renton City Councilmembers April 18, 2011 p. 2 This position was funded in the 2011 budget at the “E” step and will require no additional funding. Furthermore, this position has been vacant since January 31. CONCLUSION: Staff recommends to approve placement of the new HR Manager at the “E” step of salary grade m30. 6f. ‐ Human Resources and Risk Management Department recommends  approval to hire the Human Resources Manager at Grade M30, Step E of  Page 80 of 385 CITY OF RENTON COUNCIL AGENDA BILL Subject/Title: Group Health Contract Renewal Meeting: Regular Council - 02 May 2011 Exhibits: 2011 Group Health Actives 1162600 Contract 2011 Group Health Contract Revisions 2011 Group Health LEOFF Actives 0390400 Contract 2011 Group Health LEOFF Retirees 0057500 4057500 Contract Submitting Data: Dept/Div/Board: Human Resources Staff Contact: Nancy A. Carlson, HRRM Administrator Recommended Action: Council Concur Fiscal Impact: Expenditure Required: $ $184,559 Transfer Amendment: $ Amount Budgeted: $ $184,599 Revenue Generated: $ Total Project Budget: $ City Share Total Project: $ SUMMARY OF ACTION: Council approval is needed for the annual renewal of Group Health Contract No. 0057500; Contract 4057500 for LEOFF 1 Retirees; Contract No. 0390400 for LEOFF 1 Active; and Contract No. 1162600 for all active employees. Funding has been previously approved by Council in the 2011 Budget. The revisions are applicable to all three of the renewal contracts. The City Attorney's Office has reviewed and approved the 2011 contracts, and complete copies of the contracts are attached. STAFF RECOMMENDATION: Approve the annual Group Health Cooperative Medical contracts and authorize the Mayor and City Clerk to sign. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 81 of 385 1 Group Medical Coverage Agreement Group Health Cooperative (also referred to as “GHC”) is a nonprofit health maintenance organization furnishing health care coverage on a prepayment basis. The Group identified below wishes to purchase such coverage. This Agreement sets forth the terms under which that coverage will be provided, including the rights and responsibilities of the contracting parties; requirements for enrollment and eligibility; and benefits to which those enrolled under this Agreement are entitled. The Agreement between GHC and the Group consists of the following:  Standard Provisions  Attached Benefit Booklet  Signed Group application  Premium Schedule Group Health Cooperative Signed: Title: President and Chief Executive Officer City of Renton, 1162600 Signed: Title: This Agreement will continue in effect until terminated or renewed as herein provided for and is effective January 1, 2011. PA-113311 C31669-1162600 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 82 of 385 C31669-1162600 2 Group Medical Coverage Agreement Table of Contents Standard Provisions Attachment 1 Benefit Booklet Attachment 2 Premium Schedule Attachment 3 Medicare Endorsement 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 83 of 385 C31669-1162600 3 Standard Provisions 1. GHC agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group. 2. Monthly Premium Payments. For the initial term of this Agreement, the Group shall submit to GHC for each Member the monthly premiums set forth in the current Premium Schedule and a verification of enrollment. Payment must be received on or before the due date and is subject to a grace period of ten (10) days. Premiums are subject to change by GHC upon thirty (30) days written notice. Premium rates will be revised as a part of the annual renewal process. In the event the Group increases or decreases enrollment at least twenty-five percent (25%) or more, GHC reserves the right to require re-rating of the Group. 3. Dissemination of Information. Unless the Group has accepted responsibility to do so, GHC will disseminate information describing benefits set forth in the Benefit Booklet attached to this Agreement. 4. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members enrolled under this Agreement. 5. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the administration of this Agreement. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. 6. Modification of Agreement. Except as required by federal and Washington State law, this Agreement may not be modified without agreement between both parties. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this Agreement, convey or void any coverage, increase or reduce any benefits under this Agreement or be used in the prosecution or defense of a claim under this Agreement. 7. Indemnification. GHC agrees to indemnify and hold the Group harmless against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of GHC's failure to perform, negligent performance or willful misconduct of its directors, officers, employees and agents of their express obligations under this Agreement. The Group agrees to indemnify and hold GHC harmless against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of the Group’s failure to perform, negligent performances or willful misconduct of its directors, officers, employees and agents of their express obligations under this Agreement. The indemnifying party shall give the other party prompt notice of any claim covered by this section and provide reasonable assistance (at its expense). The indemnifying party shall have the right and duty to assume the control of the defense thereof with counsel reasonably acceptable to the other party. Either party may take part in the defense at its own expense after the other party assumes the control thereof. 8. Compliance With Law. The Group and GHC shall comply with all applicable state and federal laws and regulations in performance of this Agreement. This Agreement is entered into and governed by the laws of Washington State, except as otherwise pre-empted by ERISA and other federal laws. 9. Governmental Approval. If GHC has not received any necessary government approval by the date when notice is required under this Agreement, GHC will notify the Group of any changes once governmental approval has been received. GHC may amend this Agreement by giving notice to the Group upon receipt of government approved rates, benefits, limitations, exclusions or other provisions, in which case such rates, benefits, limitations, exclusions or provisions will go into effect as required by the governmental agency. All 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 84 of 385 C31669-1162600 4 amendments are deemed accepted by the Group unless the Group gives GHC written notice of non-acceptance within thirty (30) days after receipt of amendment, in which event this Agreement and all rights to services and other benefits terminate the first of the month following thirty (30) days after receipt of non-acceptance. 10. Confidentiality. Each party acknowledges that performance of its obligations under this Agreement may involve access to and disclosure of data, procedures, materials, lists, systems and information, including medical records, employee benefits information, employee addresses, social security numbers, e-mail addresses, phone numbers and other confidential information regarding the Group’s employees (collectively the “information”). The information shall be kept strictly confidential and shall not be disclosed to any third party other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have a need to know such information in order to perform the services required of such party pursuant to this Agreement, or for the proper management and administration of the receiving party, provided that such representatives are informed of the confidentiality provisions of this Agreement and agree to abide by them, (ii) pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal, state or local law, statute, rule or regulation. The disclosing party will provide the other party with prompt notice of any request the disclosing party receives to disclose information pursuant to applicable legal requirements, so that the other party may object to the request and/or seek an appropriate protective order against such request. Each party shall maintain the confidentiality of medical records and confidential patient and employee information as required by applicable law. 11. Arbitration. Any dispute, controversy or difference between GHC and the Group arising out of or relating to this Agreement, or the breach thereof, shall be settled by arbitration in Seattle, Washington in accordance with the Commercial Arbitration Rules of the American Arbitration Association, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Except as may be required by law, neither party nor arbitrator may disclose the existence, content or results of any arbitration hereunder without the prior written consent of both parties. 12. HIPAA. Definition of Terms. Terms used, but not otherwise defined, in this Section shall have the same meaning as those terms have in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Transactions Accepted. GHC will accept Standard Transactions, pursuant to HIPAA, if the Group elects to transmit such transactions. The Group shall ensure that all Standard Transactions transmitted to GHC by the Group or the Group’s business associates are in compliance with HIPAA standards for electronic transactions. The Group shall indemnify GHC for any breach of this section by the Group. 13. Termination of Entire Agreement. This is a guaranteed renewable Agreement and cannot be terminated without the mutual approval of each of the parties, except in the circumstances set forth below. a. Nonpayment or Non-Acceptance of Premium. Failure to make any monthly premium payment or contribution in accordance with subsection 2 above shall result in termination of this Agreement as of the premium due date. The Group’s failure to accept the revised premiums provided as part of the annual renewal process shall be considered nonpayment and result in non-renewal of this Agreement. The Group may terminate this Agreement upon fifteen (15) days written notice of premium increase, as set forth in subsection 2 above. b. Misrepresentation. GHC may rescind or terminate this Agreement upon written notice in the event that intentional misrepresentation, fraud or omission of information was used in order to obtain Group coverage. Either party may terminate this Agreement in the event of intentional misrepresentation, fraud or omission of information by the other party in performance of its responsibilities under this Agreement. c. Underwriting Guidelines. GHC may terminate this Agreement in the event the Group no longer meets underwriting guidelines established by GHC that were in effect at the time the Group was accepted. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 85 of 385 C31669-1162600 5 d. Federal or State Law. GHC may terminate this Agreement in the event there is a change in federal or state law that no longer permits the continued offering of the coverage described in this Agreement. 14. Withdrawal or Cessation of Services. a. GHC may determine to withdraw from a Service Area or from a segment of its Service Area after GHC has demonstrated to the Washington State Office of the Insurance Commissioner that GHC’s clinical, financial or administrative capacity to service the covered Members would be exceeded. b. GHC may determine to cease to offer the Group’s current plan and replace the plan with another plan offered to all covered Members within that line of business that includes all of the health care services covered under the replaced plan and does not significantly limit access to the services covered under the replaced plan. GHC may also allow unrestricted conversion to a fully comparable GHC product. GHC will provide written notice to each covered Member of the discontinuation or non-renewal of the plan at least ninety (90) days prior to discontinuation. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 86 of 385 Dear Group Health Subscriber: This booklet contains important information about your healthcare plan. This is your 2011 Group Health Benefit Booklet (Certificate of Coverage). It explains the services and benefits you and those enrolled on your contract are entitled to receive from Group Health Cooperative. Sections of this document may be bolded and italicized, which identifies changes that Group Health has made to the plan. The benefits reflected in this booklet were approved by your employer or association who contracts with Group Health for your healthcare coverage. If you are eligible for Medicare, please read Section IV.J. as it may affect your prescription drug coverage. We recommend you read it carefully so you’ll understand not only the benefits, but the exclusions, limitations, and eligibility requirements of this certificate. Please keep this certificate for as long as you are covered by Group Health. We will send you revisions if there are any changes in your coverage. This certificate is not the contract itself; you can contact your employer or group administrator if you wish to see a copy of the contract (Medical Coverage Agreement). We’ll gladly answer any questions you might have about your Group Health benefits. Please call our Group Health Customer Service Center at (206) 901-4636 in the Seattle area, or toll-free in Washington, 1-888-901-4636. Thank you for choosing Group Health Cooperative. We look forward to working with you to preserve and enhance your health. Very truly yours, Scott Armstrong President PA-1133a11, CA-139511,CA-222011,CA-198411,CA-182411,CA-11711,CA-138511,CA-139711,CA-3768 CA-3712 C31669-1162600a 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 87 of 385 C31669-1162600a 1 Benefit Booklet Table of Contents Section I. Introduction A. Accessing Care B. Cost Shares C. Subscriber’s Liability D. Claims Section II. Allowances Schedule Section III. Eligibility, Enrollment and Termination A. Eligibility B. Enrollment C. Effective Date of Enrollment D. Eligibility for Medicare E. Termination of Coverage F. Services After Termination of Agreement G. Continuation of Coverage Options Section IV. Schedule of Benefits A. Hospital Care B. Medical and Surgical Care C. Chemical Dependency Treatment D. Plastic and Reconstructive Services E. Home Health Care Services F. Hospice Care G. Rehabilitation Services H. Devices, Equipment and Supplies I. Tobacco Cessation J. Drugs, Medicines, Supplies and Devices K. Mental Health Care Services L. Emergency/Urgent Care M. Ambulance Services N. Skilled Nursing Facility Section V. General Exclusions Section VI. Grievance Processes for Complaints and Appeals Section VII. General Provisions A. Coordination of Benefits B. Subrogation and Reimbursement Rights C. Miscellaneous Provisions Section VIII. Definitions Attachment: Group Medicare Coverage 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 88 of 385 C31669-1162600a 2 Group Health Cooperative believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act of 2010. Questions regarding this status may be directed to GHC Customer Service at (888) 901-4636. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at (866) 444-3272 or www.dol.gov/ebsa/healthreform. Section I. Introduction Group Health Cooperative (also referred to as “GHC”) is a nonprofit health maintenance organization furnishing health care primarily on a prepayment basis. Read This Benefit Booklet Carefully This Benefit Booklet is a statement of benefits, exclusions and other provisions, as set forth in the Group Medical Coverage Agreement (“Agreement”) between GHC and the employer or Group. A full description of benefits, exclusions, limits and Out-of-Pocket Expenses can be found in the Schedule of Benefits, Section IV; General Exclusions, Section V; and Allowances Schedule, Section II. These sections must be considered together to fully understand the benefits available under the Agreement. Words with special meaning are capitalized. They are defined in Section VIII. A. Accessing Care Members are entitled to Covered Services only at GHC Facilities and from GHC Personal Physicians. Except as follows:  Emergency care,  Self-Referral to women’s health care providers, as set forth below,  Visits with GHC-Designated Self-Referral Specialists, as set forth below,  Care provided pursuant to a Referral. Referrals must be requested by the Member’s Personal Physician and approved by GHC, and  Other services as specifically set forth in the Allowances Schedule and Section IV. Members may refer to Sections IV.A. and IV.C. for more information about inpatient admissions. Primary Care. GHC recommends that Members select a GHC Personal Physician when enrolling under the Agreement. One Personal Physician may be selected for an entire family, or a different Personal Physician may be selected for each family member. Selecting a Personal Physician or changing from one Personal Physician to another can be accomplished by contacting GHC Customer Service, or accessing the GHC website at www.ghc.org. The change will be made within twenty-four (24) hours of the receipt of the request, if the selected physician’s caseload permits. A listing of GHC Personal Physicians, Referral specialists, women’s health care providers and GHC-Designated Self-Referral Specialists is available by contacting GHC Customer Service at (206) 901-4636 or (888) 901- 4636, or by accessing GHC’s website at www.ghc.org. In the case that the Member’s Personal Physician no longer participates in GHC’s network, the Member will be provided access to the Personal Physician for up to sixty (60) days following a written notice offering the Member a selection of new Personal Physicians from which to choose. Specialty Care. Unless otherwise indicated in this section, the Allowances Schedule or Section IV., Referrals are required for specialty care and specialists. GHC-Designated Self-Referral Specialist. Members may make appointments directly with GHC-Designated Self-Referral Specialists at Group Health-owned or -operated medical centers without a Referral from their 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 89 of 385 C31669-1162600a 3 Personal Physician. Self-Referrals are available for the following specialty care areas: allergy, audiology, cardiology, chemical dependency, chiropractic/manipulative therapy, dermatology, gastroenterology, general surgery, hospice, manipulative therapy, mental health, nephrology, neurology, obstetrics and gynecology, occupational medicine*, oncology/hematology, ophthalmology, optometry, orthopedics, otolaryngology (ear, nose and throat), physical therapy*, smoking cessation, speech/language and learning services* and urology. * Medicare patients need prior authorization for these specialists. Women’s Health Care Direct Access Providers. Female Members may see a participating General and Family Practitioner, Physician’s Assistant, Gynecologist, Certified Nurse Midwife, Licensed Midwife, Doctor of Osteopathy, Pediatrician, Obstetrician or Advanced Registered Nurse Practitioner who is contracted by GHC to provide women’s health care services directly, without a Referral from their Personal Physician, for Medically Necessary maternity care, covered reproductive health services, preventive care (well care) and general examinations, gynecological care and follow-up visits for the above services. Women’s health care services are covered as if the Member’s Personal Physician had been consulted, subject to any applicable Cost Shares, as set forth in the Allowances Schedule. If the Member’s women’s health care provider diagnoses a condition that requires Referral to other specialists or hospitalization, the Member or her chosen provider must obtain preauthorization and care coordination in accordance with applicable GHC requirements. Second Opinions. The Member may access, upon request, a second opinion regarding a medical diagnosis or treatment plan from a GHC Provider. Emergent and Urgent Care. Emergent care is available at GHC Facilities. If Members cannot get to a GHC Facility, Members may obtain Emergency services from the nearest hospital. Members or persons assuming responsibility for a Member must notify GHC by way of the GHC Emergency Notification Line within twenty- four (24) hours of admission to a non-GHC Facility, or as soon thereafter as medically possible. Members may refer to Section IV. for more information about coverage of Emergency services. In the GHC Service Area, urgent care is covered at GHC medical centers, GHC urgent care clinics or GHC Provider’s offices. Urgent care received at any hospital emergency department is not covered unless authorized in advance by a GHC Provider. Care received at urgent care facilities other than those listed above is only covered for emergency services, subject to the applicable Emergency Cost Share. Members may refer to Section IV. for more information about coverage of urgent care services. Outside the GHC Service Area, urgent care is covered at any medical facility. Members may refer to Section IV. for more information about coverage of urgent care services. Recommended Treatment. GHC’s Medical Director or his/her designee will determine the necessity, nature and extent of treatment to be covered in each individual case and the judgment, made in good faith, will be final. Members have the right to participate in decisions regarding their health care. A Member may refuse any recommended treatment or diagnostic plan to the extent permitted by law. Members who obtain care not recommended by GHC, do so with the full understanding that GHC has no obligation for the cost, or liability for the outcome, of such care. Coverage decisions may be appealed as set forth in Section VI. Major Disaster or Epidemic. In the event of a major disaster or epidemic, GHC will provide coverage according to GHC’s best judgment, within the limitations of available facilities and personnel. GHC has no liability for delay or failure to provide or arrange Covered Services to the extent facilities or personnel are unavailable due to a major disaster or epidemic. Unusual Circumstances. If the provision of Covered Services is delayed or rendered impossible due to unusual circumstances such as complete or partial destruction of facilities, military action, civil disorder, labor disputes or similar causes, GHC shall provide or arrange for services that, in the reasonable opinion of GHC's Medical Director, or his/her designee, are emergent or urgently needed. In regard to nonurgent and routine services, GHC shall make a good faith effort to provide services through its then-available facilities and personnel. GHC 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 90 of 385 C31669-1162600a 4 shall have the option to defer or reschedule services that are not urgent while its facilities and services are so affected. In no case shall GHC have any liability or obligation on account of delay or failure to provide or arrange such services. B. Cost Shares The Subscriber shall be liable for the following Cost Shares when services are received by the Subscriber and any of his/her Dependents. 1. Copayments. Members shall be required to pay Copayments at the time of service as set forth in the Allowances Schedule. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non-Covered Service. 2. Coinsurance. Members shall be required to pay coinsurance for certain Covered Services as set forth in the Allowances Schedule. 3. Out-of-Pocket Limit. Total Out-of-Pocket Expenses incurred during the same calendar year shall not exceed the Out-of-Pocket Limit set forth in the Allowances Schedule. Out-of-Pocket Expenses which apply toward the Out-of-Pocket Limit are set forth in the Allowances Schedule. C. Subscriber's Liability The Subscriber is liable for (1) payment to the Group of his/her contribution toward the monthly premium, if any; (2) payment of Cost Share amounts for Covered Services provided to the Subscriber and his/her Dependents, as set forth in the Allowances Schedule; and (3) payment of any fees charged for non-Covered Services provided to the Subscriber and his/her Dependents, at the time of service. Payment of an amount billed by GHC must be received within thirty (30) days of the billing date. D. Claims Claims for benefits may be made before or after services are obtained. To make a claim for benefits under the Agreement, a Member (or the Member’s authorized representative) must contact GHC Customer Service, or submit a claim for reimbursement as described below. Other inquiries, such as asking a health care provider about care or coverage, or submitting a prescription to a pharmacy, will not be considered a claim for benefits. If a Member receives a bill for services the Member believes are covered under the Agreement, the Member must, within ninety (90) days of the date of service, or as soon thereafter as reasonably possible, either (1) contact GHC Customer Service to make a claim or (2) pay the bill and submit a claim for reimbursement of Covered Services to GHC, P.O. Box 34585, Seattle, WA 98124-1585. In no event, except in the absence of legal capacity, shall a claim be accepted later than one (1) year from the date of service. GHC will generally process claims for benefits within the following timeframes after GHC receives the claims:  Pre-service claims – within fifteen (15) days.  Claims involving urgently needed care – within seventy-two (72) hours.  Concurrent care claims – within twenty-four (24) hours.  Post-service claims – within thirty (30) days. Timeframes for pre-service and post-service claims can be extended by GHC for up to an additional fifteen (15) days. Members will be notified in writing of such extension prior to the expiration of the initial timeframe. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 91 of 385 C31669-1162600a 6 Section II. Allowances Schedule The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the Group Medical Coverage Agreement. “Welcome” Outpatient Services Waiver Not applicable. Annual Deductible No annual Deductible. Plan Coinsurance No Plan Coinsurance. Lifetime Maximum No Lifetime Maximum on covered Essential Health Benefits. Hospital Services  Covered inpatient medical and surgical services, including acute chemical withdrawal (detoxification) Covered in full.  Covered outpatient hospital surgery (including ambulatory surgical centers) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Outpatient Services  Covered outpatient medical and surgical services Covered subject to the lesser of GHC's charge or a $25 outpatient services Copayment per Member per visit.  Allergy testing Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Oncology (radiation therapy, chemotherapy) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Drugs – Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed in the GHC drug formulary Covered subject to the lesser of GHC’s charge or a $10 Copayment.  Over-the-counter drugs and medicines Not covered.  Injectables 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 92 of 385 C31669-1162600a 7 Injectables that can be self-administered are subject to the lesser of GHC’s charge or the applicable prescription drug Cost Share (as set forth above). Other covered injectables are subject to the lesser of GHC’s charge or the applicable outpatient services Cost Share. Injectables necessary for travel are not covered.  Mail order drugs and medicines dispensed through the GHC-designated mail order service Covered subject to the lesser of GHC’s charge or the applicable prescription drug Cost Share (as set forth above) for each thirty (30) day supply or less. Out-of-Pocket Limit Limited to an aggregate maximum of $2,000 per Member or $4,000 per family per calendar year. Except as otherwise noted in this Allowances Schedule, the total Out-of-Pocket Expenses for the following Covered Services are included in the Out-of-Pocket Limit:  Inpatient services  Outpatient services  Emergency care at a GHC or non-GHC Facility  Ambulance services Acupuncture Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider up to a maximum of eight (8) visits per Member per medical diagnosis per calendar year. When approved by GHC, additional visits are covered. Ambulance Services  Emergency ground/air transport Covered at 80%.  Non-emergent ground/air interfacility transfer Covered at 80% for GHC-initiated transfers, except hospital-to-hospital ground transfers covered in full. Chemical Dependency  Inpatient services (including Residential Treatment services) Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment.  Outpatient services Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Acute detoxification covered as any other medical service. Dental Services (including accidental injury to natural teeth) Not covered, except as set forth in Section IV.B.23. Devices, Equipment and Supplies (for home use) Covered at 80% for: 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 93 of 385 C31669-1162600a 8  Durable medical equipment  Orthopedic appliances  Post-mastectomy bras limited to two (2) every six (6) months  Ostomy supplies  Prosthetic devices When provided in a home health setting in lieu of hospitalization as described in Section IV.A.3., benefits will be the greater of benefits available for devices, equipment and supplies, home health or hospitalization. See Hospice for durable medical equipment provided in a hospice setting. Diabetic Supplies Insulin, needles, syringes and lancets – see Drugs-Outpatient. External insulin pumps, blood glucose monitors, testing reagents and supplies - see Devices, Equipment and Supplies. Diagnostic Laboratory and Radiology Services Covered in full. Emergency Services  At a GHC Facility Covered subject to the lesser of GHC’s charge or a $75 Copayment per Member per Emergency visit. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services Cost Share.  At a non-GHC Facility Covered subject to the lesser of GHC’s charge or a $125 Copayment per Member per Emergency visit. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services Cost Share. Hearing Examinations and Hearing Aids  Hearing examinations to determine hearing loss Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Hearing aids, including hearing aid examinations Not covered. Home Health Services Covered in full. No visit limit. Hospice Services Covered in full. Inpatient respite care is covered for a maximum of five (5) consecutive days per occurrence. Infertility Services (including sterility) Not covered. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 94 of 385 C31669-1162600a 9 Manipulative Therapy Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider for manipulative therapy of the spine and extremities in accordance with GHC clinical criteria up to a maximum of ten (10) visits per Member per calendar year. Maternity and Pregnancy Services  Delivery and associated Hospital Care Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment.  Prenatal and postpartum care Routine care covered in full. Non-routine care covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Pregnancy termination Covered subject to the lesser of GHC’s charge or the applicable Copayment for involuntary/voluntary termination of pregnancy. Mental Health Services  Inpatient services Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment at a GHC-approved mental health care facility.  Outpatient services Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Naturopathy Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider up to a maximum of three (3) visits per Member per medical diagnosis per calendar year. When approved by GHC, additional visits are covered. Nutritional Services  Phenylketonuria (PKU) supplements Covered in full.  Enteral therapy (formula) Covered at 80% for elemental formulas. Necessary equipment and supplies are covered under Devices, Equipment and Supplies.  Parenteral therapy (total parenteral nutrition) Covered in full for parenteral formulas. Necessary equipment and supplies are covered under Devices, Equipment and Supplies. Obesity Related Services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 95 of 385 C31669-1162600a 10 Covered subject to the lesser of GHC’s charge or the applicable Copayment for bariatric surgery. Weight loss programs, medications and related physician visits for medication monitoring are not covered. On the Job Injuries or Illnesses Not covered, including injuries or illnesses incurred as a result of self-employment. Optical Services  Routine eye examinations Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment once every twelve (12) months. Eye examinations, including contact lens examinations, for eye pathology are covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment as often as Medically Necessary.  Lenses, including contact lenses, and frames Eyeglass frames, lenses (any type), lens options such as tinting, or prescription contact lenses, contact lens evaluations and examinations associated with their fitting - Covered up to $100 per twenty-four (24) month period per Member. The benefit period begins on the date services are first obtained and continues for twenty-four (24) months. Contact lenses for eye pathology, including following cataract surgery - Covered in full. Organ Transplants Covered subject to the lesser of GHC’s charge or the applicable Copayment. Plastic and Reconstructive Services (plastic surgery, cosmetic surgery)  Surgery to correct a congenital disease or anomaly, or conditions following an injury or resulting from surgery Covered subject to the lesser of GHC’s charge or the applicable Copayment.  Cosmetic surgery, including complications resulting from cosmetic surgery Not covered. Podiatric Services  Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable Copayment.  Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 96 of 385 C31669-1162600a 11 Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment when in accordance with the well care schedule established by GHC . Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Rehabilitation Services  Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment for up to sixty (60) days per calendar year.  Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered up to sixty (60) days per Member per calendar year. Sterilization (vasectomy, tubal ligation) Not covered. Temporomandibular Joint (TMJ) Services  Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment up to $1,000 maximum per Member per calendar year.  Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation  Individual/group sessions received through the GHC-designated tobacco cessation program Covered in full.  Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC-designated mail order service. Section III. Eligibility, Enrollment and Termination A. Eligibility 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 97 of 385 C31669-1162600a 12 In order to be accepted for enrollment and continuing coverage under the Agreement, individuals must meet any eligibility requirements imposed by the Group, reside or work in the Service Area and meet all applicable requirements set forth below, except for temporary residency outside the Service Area for purposes of attending school, court-ordered coverage for Dependents or other unique family arrangements, when approved in advance by GHC. GHC has the right to verify eligibility. 1. Subscribers. Bona fide employees who have been continuously employed on a regularly scheduled basis of not less than eighty (80) hours in a calendar month shall be eligible for enrollment. 2. Dependents. The Subscriber may also enroll the following: a. The Subscriber's legal spouse, including state-registered domestic partners as required by Washington state law; b. The Subscriber’s domestic partner, other than a state-registered domestic partner, provided that the Subscriber and domestic partner: i. Share the same regular and permanent residence; ii. Have a close personal relationship; iii. Are jointly responsible for “basic living expenses” as defined by the Group; iv. Are not married to anyone; v. Are each eighteen (18) years of age or older; vi. Are not related by blood closer than would bar marriage in the State of Washington; vii. Were mentally competent to consent to contract when the domestic partnership began; and viii. Are each other’s sole domestic partner and are responsible for each other’s common welfare. Following termination of a domestic partnership a statement of termination must be filed with the Group. Application for another domestic partnership cannot be filed for ninety (90) days following a filing of the statement of termination of domestic partnership with the Group, unless such termination is due to the death of the domestic partner. c. Dependent children who are under the age of twenty-six (26). "Children" means the children of the Subscriber or spouse, including adopted children, stepchildren, children of a domestic partner, or state-registered domestic partner, children for whom the Subscriber has a qualified court order to provide coverage, and any other children for whom the Subscriber is the legal guardian. Eligibility may be extended past the Dependent's limiting age as set forth above if the Dependent is totally incapable of self-sustaining employment because of a developmental or physical disability incurred prior to attainment of the limiting age set forth above, and is chiefly dependent upon the Subscriber for support and maintenance. Enrollment for such a Dependent may be continued for the duration of the continuous total incapacity, provided enrollment does not terminate for any other reason. Medical proof of incapacity and proof of financial dependency must be furnished to GHC upon request, but not more frequently than annually after the two (2) year period following the Dependent's attainment of the limiting age. 3. Temporary Coverage for Newborns. When a Member gives birth, the newborn will be entitled to the benefits set forth in Section IV. from birth through three (3) weeks of age. After three (3) weeks of age, no benefits are available unless the newborn child qualifies as a Dependent and is enrolled under the Agreement. All contract provisions, limitations and exclusions will apply except Section III.F. and III.G. B. Enrollment 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 98 of 385 C31669-1162600a 13 1. Application for Enrollment. Application for enrollment must be made on an application approved by GHC. Applicants will not be enrolled or premiums accepted until the completed application has been approved by GHC. The Group is responsible for submitting completed applications to GHC. GHC reserves the right to refuse enrollment to any person whose coverage under any Medical Coverage Agreement issued by Group Health Cooperative or Group Health Options, Inc. has been terminated for cause, as set forth in Section III.E. below. a. Newly Eligible Persons. Newly eligible Subscribers and their Dependents may apply for enrollment in writing to the Group within thirty-one (31) days of becoming eligible. b. New Dependents. A written application for enrollment of a newly dependent person, other than a newborn or adopted child, must be made to the Group within thirty-one (31) days after the dependency occurs. A written application for enrollment of a newborn child must be made to the Group within sixty (60) days following the date of birth, when there is a change in the monthly premium payment as a result of the additional Dependent. A written application for enrollment of an adoptive child must be made to the Group within sixty (60) days from the day the child is placed with the Subscriber for the purpose of adoption and the Subscriber assumes total or partial financial support of the child, if there is a change in the monthly premium payment as a result of the additional Dependent. When there is no change in the monthly premium payment, it is strongly advised that the Subscriber enroll the newborn or newly adoptive child as a Dependent with the Group to avoid delays in the payment of claims. c. Open Enrollment. GHC will allow enrollment of Subscribers and Dependents, who did not enroll when newly eligible as described above, during a limited period of time specified by the Group and GHC. d. Special Enrollment. 1) GHC will allow special enrollment for persons: a) who initially declined enrollment when otherwise eligible because such persons had other health care coverage and have had such other coverage terminated due to one of the following events:  cessation of employer contributions,  exhaustion of COBRA continuation coverage,  loss of eligibility, except for loss of eligibility for cause; or b) who have had such other coverage exhausted because such person reached a Lifetime Maximum limit. GHC or the Group may require confirmation that when initially offered coverage such persons submitted a written statement declining because of other coverage. Application for coverage under the Agreement must be made within thirty-one (31) days of the termination of previous coverage. 2) GHC will allow special enrollment for individuals who are eligible to be a Subscriber, his/her spouse and his/her Dependents in the event one of the following occurs:  marriage. Application for coverage under the Agreement must be made within thirty-one (31) days of the date of marriage.  birth. Application for coverage under the Agreement for the Subscriber and Dependents other than the newborn child must be made within sixty (60) days of the date of birth.  adoption or placement for adoption. Application for coverage under the Agreement for the Subscriber and Dependents other than the adopted child must be made within sixty (60) days of the adoption or placement for adoption. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 99 of 385 C31669-1162600a 14  eligibility for medical assistance: provided such person is otherwise eligible for coverage under this Agreement, when approved and requested in advance by the Department of Social and Health Services (DSHS).  applicable federal or state law or regulation otherwise provides for special enrollment. 2. Limitation on Enrollment. The Agreement will be open for applications for enrollment as set forth in this Section III.B. Subject to prior approval by the Washington State Office of the Insurance Commissioner, GHC may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that GHC’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. C. Effective Date of Enrollment 1. Provided eligibility criteria are met and applications for enrollment are made as set forth in Sections III.A. and III.B. above, enrollment will be effective as follows:  Enrollment for a newly eligible Subscriber and listed Dependents is effective on the first (1st) of the month following the date of hire provided the Subscriber's application has been submitted to and approved by GHC.  Regular full-time employees who have been laid off due to a lack of work and are then rehired are eligible to make a new plan election effective the first (1st) of the month following date of hire.  Enrollment for a newly dependent person, other than a newborn or adoptive child, is effective on the first (1st) of the month following the date eligibility requirements are met.  Enrollment for newborns is effective from the date of birth.  Enrollment for adoptive children is effective from the date that the adoptive child is placed with the Subscriber for the purpose of adoption and the Subscriber assumes total or partial financial support of the child. 2. Commencement of Benefits for Persons Hospitalized on Effective Date. Members who are admitted to an inpatient facility prior to their enrollment under the Agreement, and who do not have coverage under another agreement, will receive covered benefits beginning on their effective date, as set forth in subsection C.1. above. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility. The Member will be transferred when a GHC Provider, in consultation with the attending physician, determines that the Member is medically stable to do so. If the Member refuses to transfer to a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Member. D. Eligibility for Medicare An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare benefits. Medicare Secondary Payer regulations and guidelines will determine primary/secondary payer status for individuals covered by Medicare. Actively Employed Members and Spouses. The Group is responsible for providing the Member with necessary information regarding Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) eligibility and the selection process, if applicable. A Member who is eligible for Medicare has the option of maintaining both Medicare Parts A and B while continuing coverage under this Agreement. Coverage between this Agreement and Medicare will be coordinated as outlined in Section VII.A. Not Actively Employed Members. If a Member who is not actively employed is eligible for Medicare based on age, he/she must enroll in and maintain both Medicare Parts A and B coverage and enroll in the GHC Medicare Advantage Plan if available. Failure to do so upon the effective date of Medicare eligibility will result in termination of coverage under this Agreement. All applicable provisions of the GHC Medicare Advantage Plan are fully set forth in the Medicare Endorsement(s) attached to the Agreement (if applicable). 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 100 of 385 C31669-1162600a 15 E. Termination of Coverage 1. Termination of Specific Members. Individual Member coverage may be terminated for any of the following reasons: a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section III., and is not enrolled for continuation coverage as described in Section III.G. below, coverage under the Agreement will terminate at the end of the month during which the loss of eligibility occurs, unless otherwise specified by the Group. b. For Cause. Coverage of a Member may be terminated upon ten (10) working days written notice for: i. Material misrepresentation, fraud or omission of information in order to obtain coverage. ii. Permitting the use of a GHC identification card or number by another person, or using another Member’s identification card or number to obtain care to which a person is not entitled. In the event of termination for cause, GHC reserves the right to pursue all civil remedies allowable under federal and state law for the collection of claims, losses or other damages. c. Premium Payments. Nonpayment of premiums or contribution for a specific Member by the Group. Individual Member coverage may be retroactively terminated upon thirty (30) days written notice and only in the case of fraud or intentional misrepresentation of a material fact; or as otherwise allowed under applicable law or regulation. Notwithstanding the foregoing, GHC reserves the right to retroactively terminate coverage for nonpayment of premiums or contributions by the Group, as described under subsection c. above. In no event will a Member be terminated solely on the basis of their physical or mental condition provided they meet all other eligibility requirements set forth in the Agreement. Any Member may appeal a termination decision through GHC’s grievance process as set forth in Section VI. 2. Certificate of Creditable Coverage. Unless the Group has chosen to accept this responsibility, a certificate of creditable coverage (which provides information regarding the Member’s length of coverage under the Agreement) will be issued automatically upon termination of coverage, and may also be obtained upon request. F. Services After Termination of Agreement 1. Members Hospitalized on the Date of Termination. A Member who is receiving Covered Services as a registered bed patient in a hospital on the date of termination shall continue to be eligible for Covered Services while an inpatient for the condition which the Member was hospitalized, until one of the following events occurs:  According to GHC clinical criteria, it is no longer Medically Necessary for the Member to be an inpatient at the facility.  The remaining benefits available under the Agreement for the hospitalization are exhausted, regardless of whether a new calendar year begins.  The Member becomes covered under another agreement with a group health plan that provides benefits for the hospitalization.  The Member becomes enrolled under an agreement with another carrier that would provide benefits for the hospitalization if the Agreement did not exist. This provision will not apply if the Member is covered under another agreement that provides benefits for the hospitalization at the time coverage would terminate, except as set forth in this 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 101 of 385 C31669-1162600a 16 section, or if the Member is eligible for COBRA continuation coverage as set forth in subsection G. below. 2. Services Provided After Termination. The Subscriber shall be liable for payment of all charges for services and items provided to the Subscriber and all Dependents after the effective date of termination, except those services covered under subsection F.1. above. Any services provided by GHC will be charged according to the Fee Schedule. G. Continuation of Coverage Options 1. Continuation Option. A Member no longer eligible for coverage under the Agreement (except in the event of termination for cause, as set forth in Section III.E.) may continue coverage for a period of up to three (3) months subject to notification to and self-payment of premiums to the Group. This provision will not apply if the Member is eligible for the continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). This continuation option is not available if the Group no longer has active employees or otherwise terminates. 2. Leave of Absence. While on a Group approved leave of absence, the Subscriber and listed Dependents can continue to be covered under the Agreement provided: They remain eligible for coverage, as set forth in Section III.A., Such leave is in compliance with the Group’s established leave of absence policy that is consistently applied to all employees, The Group’s leave of absence policy is in compliance with the Family and Medical Leave Act when applicable, and The Group continues to remit premiums for the Subscriber and Dependents to GHC. 3. Self-Payments During Labor Disputes. In the event of suspension or termination of employee compensation due to a strike, lock-out or other labor dispute, a Subscriber may continue uninterrupted coverage under the Agreement through payment of monthly premiums directly to the Group. Coverage may be continued for the lesser of the term of the strike, lock-out or other labor dispute, or for six (6) months after the cessation of work. If the Agreement is no longer available, the Subscriber shall have the opportunity to apply for an individual GHC Group Conversion Plan or, if applicable, continuation coverage (see subsection 4. below), or an Individual and Family Medical Coverage Agreement at the duly approved rates. The Group is responsible for immediately notifying each affected Subscriber of his/her rights of self-payment under this provision. 4. Continuation Coverage Under Federal Law. This section applies only to Groups who must offer continuation coverage under the applicable provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, and only applies to grant continuation of coverage rights to the extent required by federal law. Upon loss of eligibility, continuation of Group coverage may be available to a Member for a limited time after the Member would otherwise lose eligibility, if required by COBRA. The Group shall inform Members of the COBRA election process and how much the Member will be required to pay directly to the Group. Continuation coverage under COBRA will terminate when a Member becomes covered by Medicare or obtains other group coverage, and as set forth under Section III.E.1.b. and c. 5. GHC Group Conversion Plan. Members whose eligibility for coverage under the Agreement, including continuation coverage, is terminated for any reason other than cause, as set forth in Section III.E.1.b., and who are not eligible for Medicare or covered by another group health plan, may convert to GHC’s Group Conversion Plan. If the Agreement terminates, any Member 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 102 of 385 C31669-1162600a 17 covered under the Agreement at termination may convert to a GHC Group Conversion Plan, unless he/she is eligible to obtain other group health coverage within thirty-one (31) days of the termination of the Agreement. An application for conversion must be made within thirty-one (31) days following termination of coverage under the Agreement or within thirty-one (31) days from the date notice of the termination of coverage is received, whichever is later. Coverage under GHC’s Group Conversion Plan is subject to all terms and conditions of such plan, including premium payments. A physical examination or statement of health is not required for enrollment in GHC’s Group Conversion Plan. The Pre-Existing Condition limitation under GHC’s Group Conversion Plan will apply only to the extent that the limitation remains unfulfilled under the Agreement. By exercising Group Conversion rights, the Member may waive guaranteed issue and Pre-Existing Condition waiver rights under Federal regulations. Persons wishing to purchase GHC’s Individual and Family coverage should contact GHC Marketing. Section IV. Schedule of Benefits Benefits are subject to all provisions of the Group Medical Coverage Agreement, including, without limitation, the Accessing Care provisions and General Exclusions. Members must refer to Section II., the Allowances Schedule, for Cost Shares and specific benefit limits that apply to benefits listed in this Schedule of Benefits. Members are entitled to receive only benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by GHC's Medical Director, or his/her designee, and as described herein. All Covered Services are subject to case management and utilization review at the discretion of GHC. A. Hospital Care Hospital coverage is limited to the following services: 1. Room and board, including private room when prescribed, and general nursing services. 2. Hospital services (including use of operating room, anesthesia, oxygen, x-ray, laboratory and radiotherapy services). 3. Alternative care arrangements may be covered as a cost-effective alternative in lieu of otherwise covered Medically Necessary hospitalization, or other covered Medically Necessary institutional care. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Member’s Medical Condition. Coverage must be authorized in advance by GHC as appropriate and Medically Necessary. Such care will be covered to the same extent the replaced Hospital Care is covered under the Agreement. 4. Drugs and medications administered during confinement. 5. Special duty nursing, when prescribed as Medically Necessary. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If the Member refuses to transfer, all further costs incurred during the hospitalization are the responsibility of the Member. B. Medical and Surgical Care Medical and surgical coverage is limited to the following: 1. Surgical services. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 103 of 385 C31669-1162600a 18 2. Diagnostic x-ray, nuclear medicine, ultrasound and laboratory services. 3. Family planning counseling services. 4. Hearing examinations to determine hearing loss. 5. Blood and blood derivatives and their administration. 6. Preventive care (well care) services for health maintenance in accordance with the well care schedule established by GHC and the Patient Protection and Affordable Care Act of 2010. Preventive care includes: routine mammography screening, physical examinations and routine laboratory tests for cancer screening in accordance with the well care schedule established by GHC, and immunizations and vaccinations listed as covered in the GHC drug formulary (approved drug list). A fee may be charged for health education programs. The well care schedule is available in GHC clinics, by accessing GHC’s website at www.ghc.org, or upon request. Covered Services provided during a preventive care visit, which are not in accordance with the GHC well care schedule, may be subject to Cost Shares. 7. Radiation therapy services. 8. Reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or non-dental cysts of the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth; and incision of salivary glands and ducts. 9. Medical implants. Excluded: internally implanted insulin pumps, artificial hearts, artificial larynx and any other implantable device that has not been approved by GHC's Medical Director, or his/her designee. 10. Respiratory therapy. 11. Outpatient total parenteral nutritional therapy; outpatient elemental formulas for malabsorption; and dietary formula for the treatment of phenylketonuria (PKU). Coverage for PKU formula is not subject to a Pre-Existing Condition waiting period, if applicable. Equipment and supplies for the administration of enteral and parenteral therapy are covered under Devices, Equipment and Supplies. Excluded: any other dietary formulas, oral nutritional supplements, special diets, prepared foods/meals and formula for access problems. 12. Visits with GHC Providers, including consultations and second opinions, in the hospital or provider’s office. 13. Optical services. Routine eye examinations and refractions received at a GHC Facility once every twelve (12) months, except when Medically Necessary. Routine eye examinations to monitor Medical Conditions are covered as often as necessary upon recommendation of a GHC Provider. Contact lenses for eye pathology, including contact lens exam and fitting, are covered subject to the applicable Cost Share. When dispensed through GHC Facilities, one contact lens per diseased eye in lieu of an intraocular lens, including exam and fitting, is covered for Members following cataract surgery performed by a GHC Provider, provided the Member has been continuously covered by GHC since such surgery. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 104 of 385 C31669-1162600a 19 Replacement of lenses for eye pathology, including following cataract surgery, will be covered only once within a twelve (12) month period and only when needed due to a change in the Member’s Medical Condition. Replacement for loss or breakage is subject to the Lenses and Frames benefit Allowance. Lenses and Frames Benefits purchased at a Group Health-owned or contracted optical hardware provider may be used toward the following in any combination, over the benefit period, until the benefit maximum is exhausted: Eyeglass frames Eyeglass lenses (any type) including tinting and coating Corrective industrial (safety) lenses Sunglass lenses and frames when prescribed by an eye care provider for eye protection or light sensitivity Corrective contact lenses in the absence of eye pathology, including associated fitting and evaluation examinations Replacement frames, for any reason, including loss or breakage Replacement contact lenses Replacement eyeglass lenses Excluded: evaluations and surgical procedures to correct refractions not related to eye pathology and complications related to such procedures. 14. Maternity care, including care for complications of pregnancy and prenatal and postpartum visits. Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary as determined by GHC’s Medical Director, or his/her designee, and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Hospitalization and delivery, including home births for low risk pregnancies. Voluntary (not medically indicated and nontherapeutic) or involuntary termination of pregnancy. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Pregnancy will not be excluded as a Pre-Existing Condition under the Agreement. Treatment for post-partum depression or psychosis is covered only under the mental health benefit. Excluded: birthing tubs and genetic testing of non-Members for the detection of congenital and heritable disorders. 15. Transplant services, including heart, heart-lung, single lung, double lung, kidney, pancreas, cornea, intestinal/multi-visceral, bone marrow, liver transplants and stem cell support (obtained from allogeneic or autologous peripheral blood or marrow) with associated high dose chemotherapy. Covered Services must be directly associated with, and occur at the time of, the transplant. Services are limited to the following: a. Evaluation testing to determine recipient candidacy, b. Matching tests, c. Inpatient and outpatient medical expenses listed below for transplantation procedures: Hospital charges, Procurement center fees, Professional fees, Travel costs for a surgical team, and 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 105 of 385 C31669-1162600a 20 Excision fees Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees. d. Follow-up services for specialty visits, e. Rehospitalization, and f. Maintenance medications. Excluded: donor costs to the extent that they are reimbursable by the organ donor’s insurance, treatment of donor complications, living expenses and transportation expenses, except as set forth under Section IV.M. 16. Manipulative therapy. Self-Referrals for manipulative therapy of the spine and extremities are covered as set forth in the Allowances Schedule when provided by GHC Providers. Excluded: supportive care rendered primarily to maintain the level of correction already achieved, care rendered primarily for the convenience of the Member, care rendered on a non-acute, asymptomatic basis and charges for any other services that do not meet GHC clinical criteria as Medically Necessary. 17. Medical and surgical services and related hospital charges, including orthognathic (jaw) surgery, for the treatment of temporomandibular joint (TMJ) disorders. Such disorders may exhibit themselves in the form of pain, infection, disease, difficulty in speaking or difficulty in chewing or swallowing food. TMJ appliances are covered as set forth under Section IV.H.1., Orthopedic Appliances. Orthognathic (jaw) surgery for the treatment of TMJ disorders, radiology services and TMJ specialist services, including fitting/adjustment of splints are subject to the benefit limit set forth in the Allowances Schedule. Excluded are the following: orthognathic (jaw) surgery in the absence of a TMJ or severe obstructive sleep apnea diagnosis except for congenital anomalies, treatment for cosmetic purposes, dental services, including orthodontic therapy and any hospitalizations related to these exclusions. 18. Diabetic training and education. 19. Detoxification services for alcoholism and drug abuse. For the purposes of this section, "acute chemical withdrawal" means withdrawal of alcohol and/or drugs from a Member for whom consequences of abstinence are so severe that they require medical/nursing assistance in a hospital setting, which is needed immediately to prevent serious impairment to the Member's health. Coverage for acute chemical withdrawal is provided without prior approval. If a Member is hospitalized in a non-GHC Facility/program, coverage is subject to payment of the Emergency care Cost Share. The Member or person assuming responsibility for the Member must notify GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admission, or as soon thereafter as medically possible. Furthermore, if a Member is hospitalized in a non-GHC Facility/program, GHC reserves the right to require transfer of the Member to a GHC Facility/program upon consultation between a GHC Provider and the attending physician. If the Member refuses transfer to a GHC Facility/program, all further costs incurred during the hospitalization are the responsibility of the Member. 20. Circumcision. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 106 of 385 C31669-1162600a 21 21. Bariatric surgery and related hospitalizations when GHC criteria are met. Excluded: pre and post surgical nutritional counseling and related weight loss programs, prescribing and monitoring of drugs, structured weight loss and/or exercise programs and specialized nutritional counseling. 22. Therapeutic sterilization procedures. 23. General anesthesia services and related facility charges for dental procedures will be covered for Members who are under seven (7) years of age, or are physically or developmentally disabled or have a Medical Condition where the Member’s health would be put at risk if the dental procedure were performed in a dentist’s office. Such services must be authorized in advance by GHC and performed at a GHC hospital or ambulatory surgical facility. Excluded: dentist’s or oral surgeon’s fees. 24. Self-Referrals to GHC for covered acupuncture and naturopathy, as set forth in the Allowances Schedule. Additional visits are covered when approved by GHC. Laboratory and radiology services are covered only when obtained through a GHC Facility. Excluded: herbal supplements, preventive care visits for acupuncture and any services not within the scope of the practitioner’s licensure. 25. Once Pre-Existing Condition wait periods, if any, have been met, Pre-Existing Conditions are covered in the same manner as any other illness. 26. Injections administered by a professional in a clinical setting. C. Chemical Dependency Treatment. Chemical dependency means an illness characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcoholic beverages, and where the user's health is substantially impaired or endangered or his/her social or economic function is substantially disrupted. For the purposes of this section, the definition of Medically Necessary shall be expanded to include those services necessary to treat a chemical dependency condition that is having a clinically significant impact on a Member’s emotional, social, medical and/or occupational functioning. Chemical dependency treatment services are covered as set forth in the Allowances Schedule at a GHC Facility or GHC-approved treatment program. All alcoholism and/or drug abuse treatment services must be: (a) provided at a facility as described above; and (b) deemed Medically Necessary as defined above. Chemical dependency treatment may include the following services received on an inpatient or outpatient basis: inpatient Residential Treatment services, diagnostic evaluation and education, organized individual and group counseling and/or prescription drugs and medicines. Court-ordered treatment shall be covered only if determined to be Medically Necessary as defined above. D. Plastic and Reconstructive Services. Plastic and reconstructive services are covered as set forth below: 1. Correction of a congenital disease or congenital anomaly, as determined by a GHC Provider. A congenital anomaly will be considered to exist if the Member’s appearance resulting from such condition is not within the range of normal human variation. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 107 of 385 C31669-1162600a 22 2. Correction of a Medical Condition following an injury or resulting from surgery covered by GHC which has produced a major effect on the Member's appearance, when in the opinion of a GHC Provider, such services can reasonably be expected to correct the condition. 3. Reconstructive surgery and associated procedures, including internal breast prostheses, following a mastectomy, regardless of when the mastectomy was performed. Members will be covered for all stages of reconstruction on the non-diseased breast to make it equivalent in size with the diseased breast. Complications of covered mastectomy services, including lymphedemas, are covered. Excluded: complications of noncovered surgical services. E. Home Health Care Services. Home health care services, as set forth in this section, shall be covered when provided by and referred in advance by a GHC Provider for Members who meet the following criteria: 1. The Member is unable to leave home due to his/her health problem or illness. Unwillingness to travel and/or arrange for transportation does not constitute inability to leave the home. 2. The Member requires intermittent skilled home health care services, as described below. 3. A GHC Provider has determined that such services are Medically Necessary and are most appropriately rendered in the Member's home. For the purposes of this section, “skilled home health care” means reasonable and necessary care for the treatment of an illness or injury which requires the skill of a nurse or therapist, based on the complexity of the service and the condition of the patient and which is performed directly by an appropriately licensed professional provider. Covered Services for home health care may include the following when rendered pursuant to an approved home health care plan of treatment: nursing care, physical therapy, occupational therapy, respiratory therapy, restorative speech therapy, durable medical equipment and medical social worker and limited home health aide services. Home health services are covered on an intermittent basis in the Member's home. "Intermittent" means care that is to be rendered because of a medically predictable recurring need for skilled home health care services. Excluded: custodial care and maintenance care, private duty or continuous nursing care in the Member's home, housekeeping or meal services, care in any nursing home or convalescent facility, any care provided by or for a member of the patient's family and any other services rendered in the home which do not meet the definition of skilled home health care above or are not specifically listed as covered under the Agreement. F. Hospice Care. Hospice care is covered in lieu of curative treatment for terminal illness for Members who meet all of the following criteria:  A GHC Provider has determined that the Member's illness is terminal and life expectancy is six (6) months or less.  The Member has chosen a palliative treatment focus (emphasizing comfort and supportive services rather than treatment aimed at curing the Member's terminal illness).  The Member has elected in writing to receive hospice care through GHC's Hospice Program or GHC’s approved hospice program.  The Member has available a primary care person who will be responsible for the Member's home care.  A GHC Provider and GHC's Hospice Director, or his/her designee, have determined that the Member's illness can be appropriately managed in the home. Hospice care shall mean a coordinated program of palliative and supportive care for dying Members by an interdisciplinary team of professionals and volunteers centering primarily in the Member's home. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 108 of 385 C31669-1162600a 23 1. Covered Services. Care may include the following as prescribed by a GHC Provider and rendered pursuant to an approved hospice plan of treatment: a. Home Services i. Intermittent care by a hospice interdisciplinary team which may include services by a physician, nurse, medical social worker, physical therapist, speech therapist, occupational therapist, respiratory therapist, limited services by a Home Health Aide under the supervision of a Registered Nurse and homemaker services. ii. Continuous care services in the Member's home when prescribed by a GHC Provider, as set forth in this paragraph. “Continuous care” means skilled nursing care provided in the home during a period of crisis in order to maintain the terminally ill Member at home. Continuous care may be provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse or Home Health Aide under the supervision of a Registered Nurse. Continuous care is covered up to twenty-four (24) hours per day during periods of crisis. Continuous care is covered only when a GHC Provider determines that the Member would otherwise require hospitalization in an acute care facility. b. Inpatient Hospice Services. For short-term care, inpatient hospice services shall be covered in a facility designated by GHC's Hospice Program or GHC-approved hospice program when authorized in advance by a GHC Provider and GHC's Hospice Program or GHC-approved hospice program. Inpatient respite care is covered for a maximum of five (5) consecutive days per occurrence in order to continue care for the Member in the temporary absence of the Member’s primary care giver(s). c. Other covered hospice services may include the following: i. Drugs and biologicals that are used primarily for the relief of pain and symptom management. ii. Medical appliances and supplies primarily for the relief of pain and symptom management. iii. Durable medical equipment. iv. Counseling services for the Member and his/her primary care-giver(s). v. Bereavement counseling services for the family. 2. Hospice Exclusions. All services not specifically listed as covered in this section are excluded, including: a. Financial or legal counseling services. b. Meal services. c. Custodial or maintenance care in the home or on an inpatient basis, except as provided above. d. Services not specifically listed as covered by the Agreement. e. Any services provided by members of the patient's family. All other exclusions listed in Section V., General Exclusions, apply. G. Rehabilitation Services. 1. Rehabilitation services are covered as set forth in this section, limited to the following: physical therapy; occupational therapy; massage therapy and speech therapy to restore function following illness, injury or surgery. Services are subject to all terms, conditions and limitations of the Agreement, including the following: a. All services must be provided at a GHC or GHC-approved rehabilitation facility and require a prescription from a GHC physician and must be provided by a GHC-approved rehabilitation team that may include medical, nursing, physical therapy, occupational therapy, massage therapy and speech therapy providers. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 109 of 385 C31669-1162600a 24 b. Services are limited to those necessary to restore or improve functional abilities when physical, sensori-perceptual and/or communication impairment exists due to injury, illness or surgery. Such services are provided only when GHC's Medical Director, or his/her designee, determines that significant, measurable improvement to the Member's condition can be expected within a sixty (60) day period as a consequence of intervention by covered therapy services described in paragraph a., above. c. Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances Schedule. Excluded: inpatient Residential Treatment services; specialty rehabilitation programs not provided by GHC; long-term rehabilitation programs; physical therapy, occupational therapy and speech therapy services when such services are available (whether application is made or not) through programs offered by public school districts; therapy for degenerative or static conditions when the expected outcome is primarily to maintain the Member's level of functioning (except as set forth in subsection 2. below); recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs; programs for treatment of learning problems; any services not specifically included as covered in this section; and any services that are excluded under Section V. 2. Neurodevelopmental Therapies for Children Age Six (6) and Under. Physical therapy, occupational therapy and speech therapy services for the restoration and improvement of function for neurodevelopmentally disabled children age six (6) and under shall be covered. Coverage includes maintenance of a covered Member in cases where significant deterioration in the Member's condition would result without the services. Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances Schedule. Excluded: inpatient Residential Treatment services; specialty rehabilitation programs not provided by GHC; long-term rehabilitation programs; physical therapy, occupational therapy and speech therapy services when such services are available (whether application is made or not) through programs offered by public school districts; recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs; programs for treatment of learning problems; any services not specifically included as covered in this section; and any services that are excluded under Section V. H. Devices, Equipment and Supplies. Devices, equipment and supplies, which restore or replace functions that are common and necessary to perform basic activities of daily living, are covered as set forth in the Allowances Schedule. Examples of basic activities of daily living are dressing and feeding oneself, maintaining personal hygiene, lifting and gripping in order to prepare meals and carrying groceries. 1. Orthopedic Appliances. Orthopedic appliances, which are attached to an impaired body segment for the purpose of protecting the segment or assisting in restoration or improvement of its function. Excluded: arch supports, including custom shoe modifications or inserts and their fittings except for therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease; and orthopedic shoes that are not attached to an appliance. 2. Ostomy Supplies. Ostomy supplies for the removal of bodily secretions or waste through an artificial opening. 3. Durable Medical Equipment. Durable medical equipment is equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose, is useful only in the presence of an illness or injury and used in the Member’s home. Durable medical equipment includes: hospital beds, wheelchairs, walkers, crutches, canes, glucose monitors, external insulin pumps, oxygen and oxygen equipment. GHC, in its sole discretion, will determine if equipment is made available on a rental or purchase basis. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 110 of 385 C31669-1162600a 25 4. Prosthetic Devices. Prosthetic devices are items which replace all or part of an external body part, or function thereof. When authorized in advance, repair, adjustment or replacement of appliances and equipment is covered. Excluded: items which are not necessary to restore or replace functions of basic activities of daily living; and replacement or repair of appliances, devices and supplies due to loss, breakage from willful damage, neglect or wrongful use, or due to personal preference. I. Tobacco Cessation. When provided through GHC, services related to tobacco cessation are covered, limited to: 1. participation in an individual or group program; 2. educational materials; and 3. approved pharmacy products provided the Member is actively participating in a GHC-designated tobacco cessation program. J. Drugs, Medicines, Supplies and Devices. This benefit, for purposes of creditable coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Eligible Members who are also eligible for Medicare Part D pharmacy benefits can remain covered under the Agreement and not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D pharmacy plan at a later date. The Agreement may include Medicare Part D pharmacy benefits as part of the GHC Medicare Advantage Plan required for Medicare eligible Members who live in the GHC Medicare Advantage Service Area. See Section III.D. for more information. A Member who discontinues coverage under the Agreement must meet eligibility requirements in order to re-enroll. Legend medications are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services), contraceptive drugs and devices, diabetic supplies, including insulin syringes, lancets, urine-testing reagents, blood-glucose monitoring reagents and insulin, are covered as set forth below. All drugs, supplies, medicines and devices must be prescribed by a GHC Provider for conditions covered by the Agreement, obtained at a GHC-designated pharmacy and, unless approved by GHC in advance, be listed in the GHC drug formulary. The prescription drug Cost Share, as set forth in the Allowances Schedule, applies to each thirty (30) day supply. Cost Shares for single and multiple thirty (30) day supplies of a given prescription are payable at the time of delivery. Injectables that can be self-administered are also subject to the prescription drug Cost Share. Drug formulary (approved drug list) is defined as a list of preferred pharmaceutical products, supplies and devices developed and maintained by GHC. A limited supply of prescription drugs obtained at a non-GHC pharmacy is covered when dispensed or prescribed in connection with covered Emergency treatment. Generic drugs will be dispensed whenever available. Brand name drugs will be dispensed if there is not a generic equivalent. In the event the Member elects to purchase brand-name drugs instead of the generic equivalent (if available), or if the Member elects to purchase a different brand-name or generic drug than that prescribed by the Member’s Provider, and it is not determined to be Medically Necessary, the Member will also be subject to payment of the additional amount above the applicable pharmacy Cost Share set forth in the Allowances Schedule. A generic drug is defined as a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 111 of 385 C31669-1162600a 26 strength and effectiveness as the brand name drug. A brand name drug is defined as a prescription drug that has been patented and is only available through one manufacturer. “Standard reference compendia” means the American Hospital Formulary Service-Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia-Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in healthcare journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Excluded: over-the-counter drugs, medicines, supplies and devices not requiring a prescription under state law or regulations; drugs used in the treatment of sexual dysfunction disorders; medicines and injections for anticipated illness while traveling; vitamins, including Legend (prescription) vitamins; and any other drugs, medicines and injections not listed as covered in the GHC drug formulary unless approved in advance by GHC as Medically Necessary. The Member will be charged for replacing lost or stolen drugs, medicines or devices. The Member’s Right to Safe and Effective Pharmacy Services. State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered under the Agreement and what coverage limitations are in the Agreement. Members who would like more information about the drug coverage policies under the Agreement, or have a question or concern about their pharmacy benefit, may contact GHC at (206) 901-4636 or (888) 901-4636. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the Agreement, may contact the Washington State Office of Insurance Commissioner at (800) 562-6900. Members who have a concern about the pharmacists or pharmacies serving them, may call the Washington State Department of Health at (800) 525-0127. K. Mental Health Care Services. Services that are provided by a mental health practitioner will be covered as mental health care, regardless of the cause of the disorder. 1. Outpatient Services. Outpatient mental health services place priority on restoring the Member to his/her level of functioning prior to the onset of acute symptoms or to achieve a clinically appropriate level of stability as determined by GHC’s Medical Director, or his/her designee. Treatment for clinical conditions may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Coverage for each Member is provided according to the outpatient mental health care Allowance set forth in the Allowances Schedule. Psychiatric medical services, including medical management and prescriptions, are covered as set forth in Sections IV.B. and IV.J. 2. Inpatient Services. Charges for services described in this section, including psychiatric Emergencies resulting in inpatient services, are covered as set forth in the Allowances Schedule. This benefit shall include coverage for acute treatment and stabilization of psychiatric Emergencies in GHC-approved hospitals. When medically indicated, outpatient electro-convulsive therapy (ECT) is covered in lieu of inpatient services. Coverage for services incurred at non-GHC Facilities shall exclude any charges that would otherwise be excluded for hospitalization within a GHC Facility. Services provided under involuntary commitment statutes shall be covered at facilities approved by GHC. Services for any involuntary court-ordered treatment program beyond seventy-two (72) hours shall be covered only if determined to be Medically Necessary by GHC's Medical Director, or his/her designee. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 112 of 385 C31669-1162600a 27 Coverage for voluntary/involuntary Emergency inpatient psychiatric services is subject to the Emergency care benefit set forth in Section IV.L., including the twenty-four (24) hour notification and transfer provisions. Outpatient electro-convulsive therapy treatment is covered subject to the outpatient surgery Cost Share. 3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services. Covered Services are limited to those authorized by GHC's Medical Director, or his/her designee, for covered clinical conditions for which the reduction or removal of acute clinical symptoms or stabilization can be expected given the most clinically appropriate level of mental health care intervention. Excluded: inpatient Residential Treatment services; learning, communication and motor skills disorders; mental retardation; academic or career counseling; sexual and identity disorders; and personal growth or relationship enhancement. Also excluded: assessment and treatment services that are primarily vocational and academic; court-ordered or forensic treatment, including reports and summaries, not considered Medically Necessary; work or school ordered assessment and treatment not considered Medically Necessary; counseling for overeating; nicotine related disorders; relationship counseling or phase of life problems (V code only diagnoses); and custodial care. Any other services not specifically listed as covered in this section. All other provisions, exclusions and limitations under the Agreement also apply. L. Emergency/Urgent Care. All services are covered subject to the Cost Shares set forth in the Allowances Schedule. Emergency Care (See Section VIII. for a definition of Emergency.) 1. At a GHC Facility. GHC will cover Emergency care for all Covered Services. 2. At a Non-GHC Facility. Usual, Customary and Reasonable charges for Emergency care for Covered Services are covered subject to: a. Payment of the Emergency care Cost Share; and b. Notification of GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admission, or as soon thereafter as medically possible. 3. Waiver of Emergency Care Cost Share. a. Waiver for Multiple Injury Accident. If two or more Members in the same Family Unit require Emergency care as a result of the same accident, coverage for all Members will be subject to only one (1) Emergency care Copayment. b. Emergencies Resulting in an Inpatient Admission. If the Member is admitted to a GHC Facility directly from the emergency room, the Emergency care Copayment is waived. However, coverage will be subject to the inpatient services Cost Share. 4. Transfer and Follow-up Care. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If the Member refuses to transfer to a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be obtained from GHC Providers, unless a GHC Provider has authorized such follow-up care from a non-GHC Provider in advance. Urgent Care (See Section VIII. for a definition of Urgent Condition.) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 113 of 385 C31669-1162600a 28 Inside the GHC Service Area, care for Urgent Conditions is covered at GHC medical centers, GHC urgent care clinics or GHC Providers’ offices, subject to the applicable Cost Share. Urgent care received at any hospital emergency department is not covered unless authorized in advance by a GHC Provider. Care received at urgent care facilities other than those listed above is only covered for Emergency services, subject to the applicable Emergency care Cost Share. Outside the GHC Service Area, Usual, Customary and Reasonable charges are covered for Urgent Conditions received at any medical facility, subject to the applicable Cost Share. M. Ambulance Services. Ambulance services are covered as set forth below, provided that the service is authorized in advance by a GHC Provider or meets the definition of an Emergency (see Section VIII.). 1. Emergency Transport to any Facility. Each Emergency is covered as set forth in the Allowances Schedule. 2. Interfacility Transfers. GHC-initiated non-emergent transfers to or from a GHC Facility are covered as set forth in the Allowances Schedule. N. Skilled Nursing Facility (SNF). Skilled nursing care in a GHC-approved skilled nursing facility when full-time skilled nursing care is necessary in the opinion of the attending GHC Provider, is covered as set forth in the Allowances Schedule. When prescribed by a GHC Provider, such care may include room and board; general nursing care; drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility; and short-term physical therapy, occupational therapy and restorative speech therapy. Excluded: personal comfort items such as telephone and television, rest cures and custodial, domiciliary or convalescent care. Section V. General Exclusions In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Services or supplies not specifically listed as covered in the Schedule of Benefits, Section IV. 2. Except as specifically listed and identified as covered in Sections IV.B., IV.D., IV.H. and IV.J., corrective appliances and artificial aids including: eyeglasses; contact lenses and services related to their fitting; hearing devices and hearing aids, including related examinations; take-home drugs, dressings and supplies following hospitalization; and any other supplies, dressings, appliances, devices or services which are not specifically listed as covered in Section IV. 3. Cosmetic services, including treatment for complications resulting from cosmetic surgery, except as provided in Section IV.D. 4. Convalescent or custodial care. 5. Durable medical equipment such as hospital beds, wheelchairs and walk-aids, except while in the hospital or as set forth in Section IV.B., IV.E., IV.F. or IV.H. 6. Services rendered as a result of work-related injuries, illnesses or conditions, including injuries, illnesses or conditions incurred as a result of self-employment. 7. Those parts of an examination and associated reports and immunizations required for employment, unless otherwise noted in Section IV.B., immigration, license, travel or insurance purposes that are not deemed Medically Necessary by GHC for early detection of disease. 8. Services and supplies related to sexual reassignment surgery, such as sex change operations or transformations and procedures or treatments designed to alter physical characteristics. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 114 of 385 C31669-1162600a 29 9. Diagnostic testing and medical treatment of sterility, infertility and sexual dysfunction, regardless of origin or cause, unless otherwise noted in Section IV.B. 10. Any services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, whether the Member asserts a claim or not, pursuant to medical coverage, medical “no fault” coverage, Personal Injury Protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member is a named insured, comes within the policy definition of insured, or otherwise has the right to receive first party benefits under the policy. The Member and his/her agents must cooperate fully with GHC in its efforts to enforce this exclusion. This cooperation shall include supplying GHC with information about, or related to, the cause of injury or illness or the availability of other insurance coverage. The Member and his/her agent shall permit GHC, at GHC’s option, to associate with the Member or to intervene in any action filed against any party related to the injury. The Member and his/her agents shall do nothing to prejudice GHC’s right to enforce this exclusion. Failure to fully cooperate, including withholding information regarding the cause of injury or illness or other insurance coverage may result in denial of claims and the Member shall be responsible for reimbursing GHC for expenses incurred and the value of the benefits provided by GHC under this Agreement for the care or treatment of the injury or illness sustained by the Member. GHC shall not enforce this exclusion as to coverage available under uninsured motorist or underinsured motorist coverage until the Member has been made whole, unless the Member fails to cooperate fully with GHC as described above. If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining recovery, under certain conditions GHC will reduce the amount of reimbursement to GHC by the amount of an equitable apportionment of such collection costs between GHC and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i) the equitable apportionment of attorney fees has been agreed to by GHC prior to settlement or recovery, (ii) the Injured Person’s attorney’s action has benefited GHC in its recovery, and (iii) the Injured Person’s attorney’s actions were reasonable and necessary to secure recovery. GHC’s share of collection costs is subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. Under no circumstance will GHC incur legal fees for services which were not reasonably and necessarily incurred to secure recovery or which do not benefit GHC. If this Agreement is subject to ERISA and reasonable collections costs have been incurred by the Injured Person for the benefit of GHC, the Injured Person may request and GHC may reduce the amount of reimbursement to GHC by an amount for reasonable and necessary attorney’s fees incurred by the Injured Person on behalf of and for the benefit of GHC, but only if such amount is agreed to by GHC prior to settlement or recovery. 11. Late term pregnancy termination except when the health of the mother is at risk. 12. The cost of services and supplies resulting from a Member's loss of or willful damage to appliances, devices, supplies and materials covered by GHC for the treatment of disease, injury or illness. 13. Orthoptic therapy (i.e., eye training). 14. Specialty treatment programs such as weight reduction, “behavior modification programs” and rehabilitation, including cardiac rehabilitation. 15. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 115 of 385 C31669-1162600a 30 duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 16. Procedures and services to reverse a therapeutic or nontherapeutic sterilization. 17. Dental care, surgery, services and appliances, including: treatment of accidental injury to natural teeth, reconstructive surgery to the jaw in preparation for dental implants, dental implants, periodontal surgery and any other dental service not specifically listed as covered in Section IV. GHC’s Medical Director, or his/her designee, will determine whether the care or treatment required is within the category of dental care or service. 18. Drugs, medicines and injectables, except as set forth in Section IV.J. Any exclusion of drugs, medicines and injectables, including those not listed as covered in the GHC drug formulary (approved drug list), will also exclude their administration. 19. Experimental or investigational services. GHC consults with GHC’s Medical Director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member. i. The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. ii. The service is the subject of a current new drug or new device application on file with the FDA. iii. The service is provided as part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial, or in any other manner that is intended to evaluate the safety, toxicity or efficacy of the service. iv. The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. v. The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. vi. The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. vii. The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. In making determinations whether a service is experimental or investigational, the following sources of information will be relied upon exclusively: i. The Member’s medical records, ii. The written protocol(s) or other document(s) pursuant to which the service has been or will be provided, iii. Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service, iv. The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body, v. The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury, and vi. Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 116 of 385 C31669-1162600a 31 Appeals regarding GHC denial of coverage can be submitted to the Member Appeal Department, or to GHC's Medical Director at P.O. Box 34593, Seattle, WA 98124-1593. 20. Chemical dependency, rehabilitation services and mental health care, except as specifically provided in Sections IV.C., IV.G. and IV.K. 21. Hypnotherapy, and all services related to hypnotherapy. 22. Genetic testing and related services, unless determined Medically Necessary by GHC’s Medical Director, or his/her designee, and in accordance with Board of Health standards for screening and diagnostic tests, or specifically provided in Section IV.B. Testing for non-Members is also excluded. 23. Follow-up visits related to a non-Covered Service. 24. Fetal ultrasound in the absence of medical indications. 25. Routine foot care, except in the presence of a non-related Medical Condition affecting the lower limbs. 26. Complications of non-Covered Services. 27. Obesity treatment and treatment for morbid obesity, including any medical services, drugs, supplies or any bariatric surgery (such as gastroplasty or intestinal bypass), regardless of co-morbidities, complications of obesity or any other Medical Condition, except as set forth in Section IV.B. 28. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a member of the Member’s family. 29. Autopsy and associated expenses. 30. Services provided by government agencies, except as required by federal or state law. 31. Services related to temporomandibular joint disorder (TMJ) and/or associated facial pain or to correct congenital conditions, including bite blocks and occlusal equilibration, except as specified as covered in Section IV.B. 32. Services covered by the national health plan of any other country. 33. Pre-Existing Conditions, except as specifically provided in Section IV.B.25. Section VI. Grievance Processes for Complaints and Appeals The grievance processes to express a complaint and appeal a denial of benefits are set forth below. Filing a Complaint or Appeal The complaint process is available for a Member to express dissatisfaction about customer service or the quality or availability of a health service. The appeals process is available for a Member to seek reconsideration of a denial of benefits. Complaint Process Step 1: The Member should contact the person involved, explain his/her concerns and what he/she would like to have done to resolve the problem. The Member should be specific and make his/her position clear. Step 2: If the Member is not satisfied, or if he/she prefers not to talk with the person involved, the Member should call the department head or the manager of the medical center or department where he/she is having 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 117 of 385 C31669-1162600a 32 a problem. That person will investigate the Member’s concerns. Most concerns can be resolved in this way. Step 3: If the Member is still not satisfied, he/she should call the GHC Customer Service Center toll free at (888) 901-4636. Most concerns are handled by phone within a few days. In some cases the Member will be asked to write down his/her concerns and state what he/she thinks would be a fair resolution to the problem. A Customer Service Representative or Member Quality of Care Coordinator will investigate the Member’s concern by consulting with involved staff and their supervisors, and reviewing pertinent records, relevant plan policies and the Member Rights and Responsibilities statement. This process can take up to thirty (30) days to resolve after receipt of the Member’s written statement. If the Member is dissatisfied with the resolution of the complaint, he/she may contact the Member Quality of Care Coordinator or the Customer Service Center. Appeals Process Step 1: If the Member wishes to appeal a decision denying benefits, he/she must submit a request for an appeal either orally or in writing to the Member Appeals Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. Appeals should be directed to GHC’s Member Appeals Department, P.O. Box 34593, Seattle, WA 98124-1593, toll free (866) 458-5479. An Appeals Coordinator will review initial appeal requests. GHC will then notify the Member of its determination or need for an extension of time within fourteen (14) days of receiving the request for appeal. Under no circumstances will the review timeframe exceed thirty (30) days without the Member’s written permission. If the appeal request is for an experimental or investigational exclusion or limitation, GHC will make a determination and notify the Member in writing within twenty (20) working days of receipt of a fully documented request. In the event that additional time is required to make a determination, GHC will notify the Member in writing that an extension in the review timeframe is necessary. Under no circumstances will the review timeframe exceed twenty (20) days without the Member’s written permission. There is an expedited appeals process in place for cases which meet criteria or where the Member’s provider believes that the standard thirty (30) day appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited appeal in writing to the above address, or by calling GHC’s Member Appeals Department toll free (866) 458-5479. The Member’s request for an expedited appeal will be processed and a decision issued no later than seventy-two (72) hours after receipt. Step 2: If the Member is not satisfied with the decision in Step 1 regarding a denial of benefits, or if GHC fails to grant or reject the Member’s request within the applicable required timeframe, he/she may request a second level review by an external independent review organization as set forth under subsection A. below. The Member may also choose to pursue review by an appeals committee prior to requesting a review by an independent review organization as set forth under subsection B. below. This is not a required step in the appeals process. A. Request a review by an independent review organization. An independent review organization is not legally affiliated or controlled by GHC. Once a decision is made through an independent review organization, the decision is final and cannot be appealed through GHC. * A request for a review by an independent review organization must be made within 180 days after the date of the Step 1 decision notice, or within 180 days after the date of a GHC appeals committee decision notice. B. Request an optional hearing by the GHC appeals committee: 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 118 of 385 C31669-1162600a 33 The appeals committee hearing is an informal process. The hearing will be conducted within thirty (30) working days of the Member's request and notification of the appeal committee’s decision will be mailed to the Member within five (5) working days of the hearing. Members electing the appeals committee maintain their right to appeal further to an independent review organization as set forth in paragraph A. above. Review by the appeals committee is not available if the appeal request is for an experimental or investigational exclusion or limitation. A request for a hearing by the appeals committee must be made within thirty (30) days after the date of the Step 1 decision notice. The request can be mailed to GHC’s Member Appeals Department, P.O. Box 34593, Seattle, WA 98124-1593. * * If the Member’s health plan is governed by the Employee Retirement Income Security Act, known as “ERISA” (most employment related health plans, other than those sponsored by governmental entities or churches – ask employer about plan), the Member has the right to file a lawsuit under Section 502(a) of ERISA to recover benefits due to the Member under the plan at any point after completion of Step 1 of the appeals process. Members may have other legal rights and remedies available under state or federal law. Section VII. General Provisions A. Coordination of Benefits The coordination of benefits (COB) provision applies when a Member has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan must pay an amount which, together with the payment made by the primary plan, totals the higher of the allowable expenses. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all the Member’s claims with each plan at the same time. If Medicare is the Member’s primary plan, Medicare may submit the Member’s claims to the Member’s secondary carrier. 1. Definitions. a. Plan. A plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for Members of a Group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts. However, if COB rules do not apply to all contracts, or to all benefits in the same contract, the contract or benefit to which COB does not apply is treated as a separate plan. 1) Plan includes: group, individual or blanket disability insurance contracts and group or individual contracts issued by health care service contractors or health maintenance organizations (HMO), closed panel plans or other forms of group coverage; medical care components of long-term care contracts, such as skilled nursing care; and Medicare or any other federal governmental plan, as permitted by law. 2) Plan does not include: hospital indemnity or fixed payment coverage or other fixed indemnity or fixed payment coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; benefits for non-medical components of long-term care policies; automobile insurance policies required by statute to provide medical benefits; 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 119 of 385 C31669-1162600a 34 Medicare supplement policies; Medicaid coverage; or coverage under other federal governmental plans; unless permitted by law. Each contract for coverage under subsection 1) or 2) is a separate plan. If a plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate plan. b. This plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits. c. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the Member has health care coverage under more than one plan. When this plan is primary, it determines payment for its benefits first before those of any other plan without considering any other plan’s benefits. When this plan is secondary, it determines its benefits after those of another plan and must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal 100% of the total allowable expense for that claim. This means that when this plan is secondary, it must pay the amount which, when combined with what the primary plan paid, totals 100% of the highest allowable expense. In addition, if this plan is secondary, it must calculate its savings (its amount paid subtracted from the amount it would have paid had it been the primary plan) and record these savings as a benefit reserve for the covered Member. This reserve must be used by the secondary plan to pay any allowable expenses not otherwise paid, that are incurred by the covered person during the claim determination period. d. Allowable Expense. Allowable expense is a health care expense, coinsurance or copayments and without reduction for any applicable deductible, that is covered at least in part by any plan covering the person. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any plan covering the Member is not an allowable expense. The following are examples of expenses that are not allowable expenses: 1) The difference between the cost of a semi-private hospital room and a private hospital room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses. 2) If a Member is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement method or other similar reimbursement method, any amount in excess of the highest reimbursement amount for a specific benefit is not an allowable expense. 3) If a Member is covered by two or more plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense. 4) An expense or a portion of an expense that is not covered by any of the plans covering the person is not an allowable expense. e. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services through a panel of providers who are primarily employed by the plan, and that excludes coverage for services provided by other providers, except in cases of emergency or referral by a panel member. f. Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. 2. Order of Benefit Determination Rules. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 120 of 385 C31669-1162600a 35 When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows: a. The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan. b. Except as provided below, a plan that does not contain a coordination of benefits provision that is consistent with this chapter is always primary unless the provisions of both plans state that the complying plan is primary. Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage is excess to any other parts of the plan provided by the Subscriber. Examples include major medical coverages that are superimposed over hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits. c. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits only when it is secondary to that other plan. d. Each plan determines its order of benefits using the first of the following rules that apply: 1) Non-Dependent or Dependent. The plan that covers the Member other than as a Dependent, for example as an employee, member, policyholder, Subscriber or retiree is the primary plan and the plan that covers the Member as a Dependent is the secondary plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the plan covering the Member as a Dependent, and primary to the plan covering the Member as other than a Dependent (e.g., a retired employee), then the order of benefits between the two plans is reversed so that the plan covering the Member as an employee, member, policyholder, Subscriber or retiree is the secondary plan and the other plan is the primary plan. 2) Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, when a dependent child is covered by more than one plan the order of benefits is determined as follows: a) For a dependent child whose parents are married or are living together, whether or not they have ever been married:  The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or  If both parents have the same birthday, the plan that has covered the parent the longest is the primary plan. b) For a dependent child whose parents are divorced or separated or not living together, whether or not they have ever been married: (1) If a court decree states that one of the parents is responsible for the dependent child’s health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. This rule applies to claim determination periods commencing after the plan is given notice of the court decree; (2) If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses, the plan of the parent assuming financial responsibility is primary; (3) If a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, the provisions of a) above determine the order of benefits; (4) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 121 of 385 C31669-1162600a 36 coverage of the dependent child, the provisions of subsection a) above determine the order of benefits; or (5) If there is no court decree allocating responsibility for the dependent child’s health care expenses or health care coverage, the order of benefits for the child are as follows:  The plan covering the custodial parent, first;  The plan covering the spouse of the custodial parent, second;  The plan covering the non-custodial parent, third; and then  The plan covering the spouse of the non-custodial parent, last. c) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the provisions of subsection a) or b) above determine the order of benefits as if those individuals were the parents of the child. 3) Active employee or retired or laid-off employee. The plan that covers a Member as an active employee, that is, an employee who is neither laid off nor retired, is the primary plan. The plan covering that same Member as a retired or laid off employee is the secondary plan. The same would hold true if a Member is a Dependent of an active employee and that same Member is a Dependent of a retired or laid-off employee. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section d 1) can determine the order of benefits. 4) COBRA or State Continuation Coverage. If a Member whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another plan, the plan covering the Member as an employee, member, Subscriber or retiree or covering the Member as a Dependent of an employee, member, Subscriber or retiree is the primary plan and the COBRA or state or other federal continuation coverage is the secondary plan. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section d 1) can determine the order of benefits. 5) Longer or shorter length of coverage. The plan that covered the Member as an employee, member, Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter period of time is the secondary plan. 6) If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the plans meeting the definition of plan. In addition, this plan will not pay more than it would have paid had it been the primary plan. 3. Effect on the Benefits of this Plan. When this plan is secondary, it must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal one hundred percent of the total allowable expense for that claim. However, in no event shall the secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. In no event should the Member be responsible for a deductible amount greater than the highest of the two deductibles. Total allowable expense is the highest allowable expenses of the primary plan or the secondary plan. In addition, the secondary plan must credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage. 4. Right to Receive and Release Needed Information. Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this plan and other plans. GHC may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under this plan and other plans covering the Member claiming benefits. GHC need not tell, or get the consent of, any Member to do this. Each Member claiming 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 122 of 385 C31669-1162600a 37 benefits under this plan must give GHC any facts it needs to apply those rules and determine benefits payable. 5. Facility of Payment. If payments that should have been made under this plan are made by another plan, GHC has the right, at its discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision. The amounts paid to the other plan are considered benefits paid under this plan. To the extent of such payments, GHC is fully discharged from liability under this plan. 6. Right of Recovery. GHC has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this provision. GHC may recover excess payment from any person to whom or for whom payment was made or any other issuers or plans. Questions about Coordination of Benefits? Contact the State Insurance Department. 7. Effect of Medicare. Members Residing Outside the GHC Medicare Advantage Service Area. Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status. When Medicare, Part A and Part B or Part C are primary, Medicare's allowable amount is the highest allowable expense. When GHC renders care to a Member who is eligible for Medicare benefits, and Medicare is deemed to be the primary bill payer under Medicare primary/secondary payer guidelines and regulations, GHC will seek Medicare reimbursement for all Medicare covered services. B. Subrogation and Reimbursement Rights The benefits under this Agreement will be available to a Member for injury or illness caused by another party, subject to the exclusions and limitations of this Agreement. If GHC provides benefits under this Agreement for the treatment of the injury or illness, GHC will be subrogated to any rights that the Member may have to recover compensation or damages related to the injury or illness. This section VII.B. more fully describes GHC’s subrogation and reimbursement rights. “Injured Person” under this section means a Member covered by the Agreement who sustains an injury and any spouse, dependent or other person or entity that may recover on behalf of such Member, including the estate of the Member and, if the Member is a minor, the guardian or parent of the Member. When referred to in this section, “GHC’s Medical Expenses” means the expenses incurred and the value of the benefits provided by GHC under this Agreement for the care or treatment of the injury sustained by the Injured Person. If the Injured Person’s injuries were caused by a third party giving rise to a claim of legal liability against the third party and/or payment by the third party to the Injured Person and/or a settlement between the third party and the Injured Person, GHC shall have the right to recover GHC’s Medical Expenses from any source available to the Injured Person as a result of the events causing the injury, including but not limited to funds available through applicable third party liability coverage and uninsured/underinsured motorist coverage. This right is commonly referred to as “subrogation.” GHC shall be subrogated to and may enforce all rights of the Injured Person to the extent of GHC’s Medical Expenses. GHC’s subrogation and reimbursement rights shall be limited to the excess of the amount required to fully compensate the Injured Person for the loss sustained, including general damages. However, in the case of Medicare Advantage Members, GHC’s right of subrogation shall be the full amount of GHC’s Medical Expenses and is limited only as required by Medicare. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 123 of 385 C31669-1162600a 38 Subject to the above provisions, if the Injured Person is entitled to or does receive money from any source as a result of the events causing the injury, including but not limited to any party’s liability insurance or uninsured/underinsured motorist funds, then GHC’s Medical Expenses provided or to be provided to the Injured Person are secondary, not primary. As a condition of receiving benefits under the Agreement, the Injured Person agrees that acceptance of GHC services is constructive notice of this provision in its entirety and agrees to reimburse GHC for the benefits the Injured Person received as a result of the events causing the injury. The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect GHC’s Medical Expenses. This cooperation includes, but is not limited to, supplying GHC with information about the cause of injury or illness, any third parties, defendants and/or insurers related to the Injured Person’s claim and informing GHC of any settlement or other payments relating to the Injured Person’s injury. The Injured Person and his/her agents shall permit GHC, at GHC’s option, to associate with the Injured Person or to intervene in any legal, quasi-legal, agency or any other action or claim filed. If the Injured Person takes no action to recover money from any source, then the Injured Person agrees to allow GHC to initiate its own direct action for reimbursement or subrogation, including, but not limited to, billing the Injured Person directly for GHC’s Medical Expenses The Injured Person and his/her agents shall do nothing to prejudice GHC’s subrogation and reimbursement rights. The Injured Person shall promptly notify GHC of any tentative settlement with a third party and shall not settle a claim without protecting GHC’s interest. If the Injured Person fails to cooperate fully with GHC in recovery of GHC’s Medical Expenses, the Injured Person shall be responsible for directly reimbursing GHC for GHC’s Medical Expenses and GHC retains the right to bill the Injured Person directly for GHC’s Medical Expenses. To the extent that the Injured Person recovers funds from any source that may serve to compensate for medical injuries or medical expenses, the Injured Person agrees to hold such monies in trust or in their possession until GHC’s subrogation and reimbursement rights are fully determined. If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining recovery, under certain conditions GHC will reduce the amount of reimbursement to GHC by the amount of an equitable apportionment of such collection costs between GHC and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i) the equitable apportionment of attorney fees has been agreed to by GHC prior to settlement or recovery, (ii) the Injured Person’s attorney’s action has benefited GHC in its recovery, and (iii) the Injured Person’s attorney’s actions were reasonable and necessary to secure recovery. GHC’s share of collection costs is subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. Under no circumstance will GHC incur legal fees for services which were not reasonably and necessarily incurred to secure recovery or which do not benefit GHC. If this Agreement is subject to ERISA and reasonable collections costs have been incurred by the Injured Person for the benefit of GHC, the Injured Person may request and GHC may reduce the amount of reimbursement to GHC by an amount for reasonable and necessary attorney’s fees incurred by the Injured Person on behalf of and for the benefit of GHC, but only if such amount is agreed to by GHC prior to settlement or recovery. To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA, implementation of this section shall be deemed a part of claims administration under the Agreement and GHC shall therefore have discretion to interpret its terms. C. Miscellaneous Provisions 1. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members enrolled under the Agreement. 2. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the administration of the Agreement. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 124 of 385 C31669-1162600a 39 3. Modification of Agreement. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of the Agreement, convey or void any coverage, increase or reduce any benefits under the Agreement or be used in the prosecution or defense of a claim under the Agreement. 4. Confidentiality. GHC and the Group shall keep Member information strictly confidential and shall not disclose any information to any third party other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have a need to know such information in order to perform the services required of such party pursuant to the Agreement, or for the proper management and administration of the receiving party, provided that such representatives are informed of the confidentiality provisions of the Agreement and agree to abide by them, (ii) pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal, state or local law, statute, rule or regulation. 5. Nondiscrimination. GHC does not discriminate on the basis of physical or mental disabilities in its employment practices and services. Section VIII. Definitions Agreement: The Medical Coverage Agreement between GHC and the Group. Allowance: The maximum amount payable by GHC for certain Covered Services under the Agreement, as set forth in the Allowances Schedule. Contracted Network Pharmacy: A pharmacy that has contracted with GHC to provide covered legend (prescription) drugs and medicines for outpatient use under the Agreement. Copayment: The specific dollar amount a Member is required to pay at the time of service for certain Covered Services under the Agreement, as set forth in the Allowances Schedule. Cost Share: The portion of the cost of Covered Services the Member is liable for under the Agreement. Cost Shares for specific Covered Services are set forth in the Allowances Schedule. Cost Share includes Copayments, coinsurances and/or Deductibles. Covered Services: The services for which a Member is entitled to coverage under the Agreement. Deductible: A specific amount a Member is required to pay for certain Covered Services before benefits are payable under the Agreement. The applicable Deductible amounts are set forth in the Allowances Schedule. Dependent: Any member of a Subscriber’s family who meets all applicable eligibility requirements, is enrolled hereunder and for whom the premium prescribed in the Premium Schedule has been paid. Emergency: The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part, or would place the Member's health in serious jeopardy. Essential Health Benefits: Benefits set forth under the Patient Protection and Affordable Care Act of 2010, including the categories of ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Family Unit: A Subscriber and all his/her Dependents. Fee Schedule: A fee-for-service schedule adopted by GHC, setting forth the fees for medical and hospital services. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 125 of 385 C31669-1162600a 40 GHC-Designated Self-Referral Specialist: A GHC specialist specifically identified by GHC to whom Members may self-refer. GHC Facility: A facility (hospital, medical center or health care center) owned, operated or otherwise designated by GHC. GHC Medicare Plan: A plan of coverage for persons enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance). GHC Personal Physician: A provider who is employed by or contracted with GHC to provide primary care services to Members and is selected by each Member to provide or arrange for the provision of all non-emergent Covered Services, except for services set forth in the Agreement which a Member can access without a Referral. Personal Physicians must be capable of and licensed to provide the majority of primary health care services required by each Member. GHC Provider: The medical staff, clinic associate staff and allied health professionals employed by GHC, and any other health care professional or provider with whom GHC has contracted to provide health care services to Members enrolled under the Agreement, including, but not limited to physicians, podiatrists, nurses, physician assistants, social workers, optometrists, psychologists, physical therapists and other professionals engaged in the delivery of healthcare services who are licensed or certified to practice in accordance with Title 18 Revised Code of Washington. Group: An employer, union, welfare trust or bona-fide association which has entered into a Group Medical Coverage Agreement with GHC. Hospital Care: Those Medically Necessary services generally provided by acute general hospitals for admitted patients. Hospital Care does not include convalescent or custodial care, which can, in the opinion of the GHC Provider, be provided by a nursing home or convalescent care center. Lifetime Maximum: The maximum value of benefits provided for Covered Services under the Agreement after which benefits under the Agreement are no longer available as set forth in the Allowances Schedule. The value of Covered Services is based on the Fee Schedule, as defined above. The lifetime maximum applies to this Agreement or in combination with any other medical coverage agreement between GHC and Group. Medical Condition: A disease, illness or injury. Medically Necessary: Appropriate and clinically necessary services, as determined by GHC’s Medical Director, or his/her designee, according to generally accepted principles of good medical practice, which are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Member, his/her family or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Member; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under GHC’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Washington, could not have been omitted without adversely affecting the Member’s condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a provider’s office, the outpatient department of a hospital or a non-residential facility without affecting the Member’s condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are not experimental or investigational. The length and type of the treatment program and the frequency and modality of visits covered shall be determined by GHC’s Medical Director, or his/her designee. In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service as set forth in Section IV. of the Agreement and not excluded from coverage. The cost of non-covered services and supplies shall be the responsibility of the Member. Medicare: The federal health insurance program for the aged and disabled. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 126 of 385 C31669-1162600a 41 Member: Any Subscriber or Dependent enrolled under the Agreement. Out-of-Pocket Expenses: Those Cost Shares paid by the Subscriber or Member for Covered Services which are applied to the Out-of-Pocket Limit. Out-of-Pocket Limit: The maximum amount of Out-of-Pocket Expenses incurred and paid during the calendar year for Covered Services received by the Subscriber and his/her Dependents within the same calendar year. The Out-of-Pocket Limit amount and Cost Shares that apply are set forth in the Allowances Schedule. Charges in excess of UCR, services in excess of any benefit level and services not covered by the Agreement are not applied to the Out-of-Pocket Limit. Plan Coinsurance: The percentage amount the Member and GHC are required to pay for Covered Services received under the Agreement. Percentages for Covered Services are set forth in the Allowances Schedule. A coinsurance percentage not identified as Plan Coinsurance is a benefit specific coinsurance and does not apply to the Out-of-Pocket Limit except as otherwise specified under Section II. Out-of-Pocket Limit. Pre-Existing Condition: A condition for which there has been diagnosis, treatment or medical advice within the three (3) month period prior to the effective date of coverage. The Pre-Existing Condition wait period will begin on the first day of coverage, or the first day of the enrollment waiting period if earlier. Referral: A written temporary agreement requested in advance by a GHC Provider and approved by GHC that entitles a Member to receive Covered Services from a specified health care provider. Entitlement to such services shall not exceed the limits of the Referral and is subject to all terms and conditions of the Referral and the Agreement. Members who have a complex or serious medical or psychiatric condition may receive a standing Referral for specialist services. Residential Treatment: A term used to define facility-based treatment, which includes twenty-four (24) hours per day, seven (7) days per week rehabilitation. Residential Treatment services are provided in a facility specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi-disciplinary team of licensed professionals. Self-Referred: Covered Services received by a Member from a designated women’s health care specialist or GHC-Designated Self-Referral Specialist that are not referred by a GHC Personal Physician. Service Area: Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman and Yakima; Idaho counties of Kootenai and Latah; and any other areas designated by GHC. Subscriber: A person employed by or belonging to the Group who meets all applicable eligibility requirements, is enrolled under the Agreement and for whom the premium specified in the Premium Schedule has been paid. Urgent Condition: The sudden, unexpected onset of a Medical Condition that is of sufficient severity to require medical treatment within twenty-four (24) hours of its onset. Usual, Customary and Reasonable (UCR): A term used to define the level of benefits which are payable by GHC when expenses are incurred from a non-GHC Provider. Expenses are considered Usual, Customary and Reasonable if the charges are consistent with those normally charged to others by the provider or organization for the same services or supplies; and the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 127 of 385 1 Group Health Cooperative Medicare Advantage Plan (MA) Following is a brief outline of the benefits available to Group Members who are also enrolled in the Group Health Cooperative Medicare Advantage (MA) plan. In no event shall the benefits of the MA plan duplicate the benefits under the Group Medical Coverage Agreement. The benefits available to persons enrolled in both the Group Health Cooperative Medical Coverage Agreement and the Group Health Cooperative Medicare Advantage Plan will be the higher level of benefit available under the plans, as determined by Group Health Cooperative. Unless otherwise stated, the provisions, limitations and exclusions, including provider access requirements of the Group Medical Coverage Agreement apply to the benefits available under the Group Health Cooperative Medicare Advantage Plan. The benefits described in this outline apply only to Members who are covered under Medicare Part A and Part B, and who are enrolled in the Group Health Cooperative Medicare Advantage Plan as set forth in the Group Medical Coverage Agreement. This includes those Members with Medicare Part B only, who have been continuously enrolled in the Group Health Cooperative Medicare Advantage Plan since December 31, 1998. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 128 of 385 2 SUMMARY OF BENEFITS Group Health Medicare Advantage Clear Care Employer Group Plan (Benefit 2) If you have any questions about this plan's benefits or costs, please contact Group Health Cooperative for details. SECTION II – Summary of Benefits Benefit Category Original Medicare GHC Medicare Plan (Medicare Parts A & B) IMPORTANT INFORMATION 1 – Premium and Other Important Information In 2011 the monthly Part B Premium is $96.40 and the yearly Part B deductible amount is $162. If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income ($85,000 for singles, $170,000 for married couples).For more information about Part B premiums based on income, call Social Security at 1-800-772-1213. TTY users should call 1-800-325- 0778. $2,500 out-of-pocket limit. Contact the plan for services that apply. 2 - Doctor and Hospital Choice (For more information, see Emergency - #15 and Urgently Needed Care - #16.) You may go to any doctor, specialist or hospital that accepts Medicare. You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists for (for certain benefits). You may have to pay a separate copay for certain doctor office visits. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 129 of 385 3 SUMMARY OF BENEFITS INPATIENT CARE 3 - Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services) In 2011 the amounts for each benefit period are: Days 1 - 60: $1,132 deductible Days 61 - 90: $283 per day Days 91 - 150: $566 per lifetime reserve day Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once. A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. In-Network: For Medicare-covered hospital stays you pay the lesser of the Group cost share or the following copayments: Days 1-5: $200 copay per day Days 6-90: $0 copay per day $0 copay for additional hospital days. No limit to the number of days covered by the plan each benefit period. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 4 - Inpatient Mental Health Care Same deductible and copay as inpatient hospital care (see "Inpatient Hospital Care" above). 190 day lifetime limit in a Psychiatric Hospital. For Medicare-covered hospital stays you pay the lesser of the Group cost share or the following copayments: Days 1-5: $200 copay per day Days 6-90: $0 copay per day You get up to 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 5 - Skilled Nursing Facility (in a Medicare-certified skilled nursing facility) In 2011 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $141.50 per day 100 days for each benefit period. A benefit period begins the day you There is no copayment for services received at a Skilled Nursing Facility. No prior hospital stay is required. You are covered for 100 days each benefit period. Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 130 of 385 4 go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 6 - Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay Authorization rules may apply. $0 copay for Medicare-covered home health visits. 7 - Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must receive care from a Medicare-certified hospice. You must receive care from a Medicare-certified hospice. OUTPATIENT CARE 8 - Doctor Office Visits 20% coinsurance General See “Physical Exams” for more information. Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for each primary care doctor office visit for Medicare- covered services. You pay the lesser of the Group cost share or $20 copay for each specialist visit for Medicare-covered services. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 131 of 385 5 9 - Chiropractic Services Routine care not covered. 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. In-Network You pay the lesser of the Group cost share or $20 copay for Medicare- covered visits. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). 10 - Podiatry Services Routine care not covered. 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for Medicare- covered visits. Medicare-covered podiatry benefits are for medically-necessary foot care. 11 - Outpatient Mental Health Care 45% coinsurance for most outpatient mental health services. General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for each Medicare-covered individual or group therapy visit. 12 - Outpatient Substance Abuse Care 20% coinsurance In-Network $0 copay for Medicare-covered visits. 13 - Outpatient Services/Surgery 20% coinsurance for the doctor 20% of outpatient facility charges General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $200 copay for each Medicare-covered ambulatory surgical center visit. You pay the lesser of the Group cost share or $200 copay for each Medicare-covered outpatient hospital facility visit. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 132 of 385 6 14 - Ambulance Services (medically necessary ambulance services) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $150 copay for Medicare- covered ambulance benefits. 15 - Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 20% coinsurance for the doctor 20% of facility charge, or a set copay per emergency room visit. You don’t have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. NOT covered outside the U.S. except under limited circumstances. In-Network You pay the lesser of the Group cost share or $50 for each Medicare- covered emergency room visit. Out-of-Network Worldwide coverage. In and Out-of-Network If you are admitted to the hospital within 1 day for the same condition, you pay $0 for the emergency room visit. 16 - Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) 20% coinsurance, or a set copay NOT covered outside the U.S. except under limited circumstances. You pay the lesser of the Group cost share or $20 copay for each Medicare-covered urgently needed care visit. 17 - Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 for Medicare-covered Occupational Therapy visits. You pay the lesser of the Group cost share or $20 for Medicare-covered Physical and/or Speech/Language Therapy visits. OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 - Durable Medical Equipment (Includes wheelchairs, oxygen, etc.) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items. 19 - Prosthetic Devices (Includes braces, artificial limbs and eyes, 20% coinsurance General Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 133 of 385 7 etc.) In-Network You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items. 20 - Diabetes Self- Monitoring Training, Nutrition Therapy, and Supplies (includes coverage for glucose monitors, test strips, lancets, screening tests, and self- management training) 20% coinsurance Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. General Authorization rules may apply. In-Network $0 copay for Diabetes self-monitoring training. In-Network $0 copay for Nutrition Therapy for Diabetes. You pay the lesser of the Group cost share or 20% of the cost for Diabetes supplies. 21 - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 20% coinsurance for diagnostic tests and X-rays $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol. General Authorization rules may apply. In-Network $0 copay for Medicare-covered:  lab services  diagnostic procedures and tests X-rays  Diagnostic radiology services (not including X-rays)  therapeutic radiology services PREVENTIVE SERVICES 22 - Bone Mass Measurement (for people with Medicare who are at risk) 20% coinsurance Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. General Authorization rules may apply. In-Network $0 copay for Medicare-covered bone mass measurement 23 - Colorectal Screening Exams (for people with 20% coinsurance Covered when you are high risk or General Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 134 of 385 8 Medicare age 50 and older) when you are age 50 and older. In-Network $0 copay for Medicare-covered colorectal screenings. 24 - Immunizations (Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine) $0 copay for Flu and Pneumonia vaccines 20% coinsurance for Hepatitis B vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. General Authorization rules may apply. In-Network $0 copay for Flu and Pneumonia vaccines. $0 copay for Hepatitis B vaccine No referral necessary for Flu and Pneumonia vaccines. Referral required for other immunizations. 25 - Mammograms (Annual Screening) (for women with Medicare age 40 and older) 20% coinsurance No referral needed. Covered once a year for all women with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39. In-Network $0 copay for Medicare-covered screening mammograms. 26 - Pap Smears and Pelvic Exams (for women with Medicare) $0 copay for Pap smears Covered once every 2 years. Covered once a year for women with Medicare at high risk. 20% coinsurance for pelvic exams. In-Network $0 copay for Medicare-covered pap smears and pelvic exams. 27 - Prostate Cancer Screening Exams (For men with Medicare age 50 and older.) 20% coinsurance for the digital rectal exam. $0 for the PSA test; 20% coinsurance for other related services. Covered once a year for all men with Medicare over age 50. General Authorization rules may apply. In-Network $0 copay for Medicare-covered prostate cancer screenings. 28 – End-Stage Renal Disease 20% coinsurance for renal dialysis 20% coinsurance for Nutrition Therapy for End-Stage Renal Disease Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by General Authorization rules may apply. Out-of-area Renal Dialysis services do not require Authorization. In-Network $0 copay for renal dialysis $0 copay for Nutrition Therapy for end-stage renal disease 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 135 of 385 9 a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. 29 - Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Your Employer Group Outpatient Prescription drug benefit applies. Please contact the plan for details. 30 - Dental Services Preventive dental services (such as cleaning) not covered. $0 copay for Medicare-covered dental benefits. In general, preventive dental benefits (such as cleaning) not covered. 31 - Hearing Services Routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. You pay the lesser of the Group cost share or: - $20 for each Medicare-covered hearing exam (diagnostic hearing exams). Your Employer Group hearing benefit applies for routine exams and hearing aids. Please contact the plan for details. 32 – Vision Services 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. Routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Annual glaucoma screenings covered for people at risk. In-Network - $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. - $20 for exams to diagnosis and treat diseases and conditions of the eye). Your Employer Group Vision benefit applies for routine eye exams and glasses. Please contact the plan for details. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 136 of 385 10 33 - Physical Exams 20% coinsurance for one exam within the first 12 months of your new Medicare Part B coverage. When you get Medicare Part B, you can get a one time physical exam within the first 12 months of your new Part B coverage. The coverage does not include lab tests. $0 copay for routine exams. Limited to 1 exam every two years. $0 copay for Medicare-covered benefits. Health/Wellness Education Smoking Cessation: Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco. Each counseling attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies. In-Network This plan covers the following health/wellness education benefits:  Smoking Cessation  Health Club Membership/Fitness Classes  Nursing Hotline $0 copay for each Medicare-covered smoking cessation counseling session Transportation (Routine) Not covered. General Authorization rules may apply. In-Network $150 copay for one-way trips to a Plan-approved location. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 137 of 385 11 SECTION III – Other Benefits Offered By Group Health’s Clear Care Plan My Group Health (when you get care at a Group Health medical center).  Request appointments  View your online medical records  Email your doctor  Get test results  Check your benefits Wellness Programs Consulting Nurse helpline 24/7 Prescription Refills  Online  Mail-order  By phone Senior Caucus Travel Advisory Service Group Health Resource Line Additional Information About Covered Benefits Found in Section II Skilled Nursing Facility (Group Health Covered): When a 3 day Medicare covered hospital stay does not occur and the plan determines that the member otherwise meets all Medicare criteria for an acute inpatient hospital stay at the time of admission to a Medicare Certified Skilled Nursing Facility, the plan may authorize Medicare covered Skilled Nursing Facility Care up to the Medicare Skilled Nursing Facility day limit per benefit period. All Medicare criteria must be met and the stay must be authorized in advance by the plan. Out-Of-Pocket Limit; Stop Loss Provision for Copayments: Total copayment expenses for outpatient services and the outpatient supplies listed in this summary of benefits, hospital emergency room visits, ambulance/transportation services, inpatient hospital stays, and inpatient mental health care stays, are limited to an aggregate annual maximum of $2,500 per calendar year per member. The following items and services aren’t covered under Original Medicare or our MA plan (please refer to your employer group Certificate of Coverage for more information about what is covered and excluded under your employer group plan):  Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as a covered services.  Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare. However, certain services may be covered under a Medicare-approved clinical research study.  Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare.  Private room in a hospital, except when it is considered medically necessary.  Private duty nurses. This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 138 of 385 12  Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television.  Full-time nursing care in your home.  Custodial care, unless it is provided with covered skilled nursing care and/or skilled rehabilitation services. Custodial care, or non-skilled care, is care that helps you with activities of daily living, such as bathing or dressing.  Homemaker services include basic household assistance, including light housekeeping or light meal preparation.  Fees charged by your immediate relatives or members of your household.  Meals delivered to your home.  Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary.  Cosmetic surgery or procedures, unless because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.  Routine dental care, such as cleanings, filings or dentures. However, non-routine dental care received at a hospital may be covered.  Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines.  Routine foot care, except for the limited coverage provided according to Medicare guidelines.  Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease.  Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease.  Hearing aids and routine hearing examinations.  Eyeglasses, routine eye examinations, radial keratotomy, LASIK surgery, vision therapy and other low vision aids. However, eyeglasses are covered for people after cataract surgery, and routine eye examinations are covered under our basic benefit.  Outpatient prescription drugs including drugs for treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.  Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies.  Acupuncture.  Naturopath services (uses natural or alternative treatments).  Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at VA hospital and the VA cost-sharing is more than 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 139 of 385 13 the cost-sharing under our plan. We will reimburse veterans for the difference. Members are still responsible for our cost-sharing amounts.  Any services listed above that aren’t covered will remain not covered even if received at an emergency facility. YOUR RIGHTS AND RESPONSIBILITES SECTION 1 Our plan must honor your rights as a member of the plan To get information from us in a way that works for you, please call Customer Service (phone numbers are on the front cover). Our plan has people and translation services available to answer questions from non- English speaking members. We can also give you information in Braille, in large print, or other alternate formats if you need it. If you are eligible for Medicare because of disability, we are required to give you information about the plan’s benefits that is accessible and appropriate for you. If you have any trouble getting information from our plan because of problems related to language or disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-2048. Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights 1- 800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. Customer Service (phone numbers are on the cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Customer Service can help. We must provide you with details about your rights and responsibilities as a patient and consumer Section 1.2 We must provide information in a way that works for you (in languages other than English that are spoken in the plan service area, in Braille, in large print, or other alternate formats, etc.) Section 1.3 We must treat you with fairness, respect, and dignity at all times Section 1.4 We must ensure that you get timely access to your covered services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 140 of 385 14 As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services. Call Customer Service to learn which doctors are accepting new patients (phone numbers are on the cover of this booklet). You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral. As a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.  Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.  The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice”, that tells about these rights and explains how we protect the privacy of your health information. How do we protect the privacy of your health information?  We make sure that unauthorized people don’t see or change your records.  In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.  There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. o For example, we are required to release health information to government agencies that are checking on quality of care. o Because you are a member of our plan through Medicare, we are required to give Medicare your health information. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations. You can see the information in your records and know how it has been shared with others You have the right to look at your medical records held at the plan, and to get a copy of your records. You also have the right to ask us to make additions or corrections to your Section 1.5 We must provide access to information about the qualifications of the professionals caring for you Section 1.6 We must protect the privacy of your personal health information 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 141 of 385 15 medical records. If you ask us to do this, we will consider your request and decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Customer Service (phone numbers are on the cover of this booklet). As a member of our plan, you have the right to get several kinds of information from us. (As explained above in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.) If you want any of the following kinds of information, please call Customer Service (phone numbers are on the cover of this booklet):  Information about our plan. This includes, for example, information about the plan’s financial condition. It also includes information about the number of appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare Advantage health plans.  Information about our network providers. o For example, you have the right to get information from us about the qualifications of the providers in our network and how we pay the providers in our network. o For a list of the providers in the plan’s network, see the Provider Directory. o For more detailed information about our providers, you can call Customer Service (phone numbers are on the cover of this booklet) or visit our website at www.ghc.org/medicare.  Information about your coverage and rules you must follow in using your coverage. o If you have questions about the rules or restrictions, please call Customer Service (phone numbers are on the cover of this booklet).  Information about why something is not covered and what you can do about it. o If a medical service is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service from an out- of-network provider. Section 1.7 We must give you information about the plan, its network of providers, and your covered services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 142 of 385 16 You have the right to know your treatment options and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand. You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:  To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan.  To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.  The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. Of course, if you refuse treatment, you accept full responsibility for what happens to your body as a result.  To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:  Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.  Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives. If you want to use an “advance directive” to give your instructions, here is what to do: Section 1.8 We must support your right to make decisions about your care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 143 of 385 17  Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Customer Service to ask for the forms (phone numbers are on the cover of this booklet).  Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.  Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.  If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.  If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. What if your instructions are not followed? If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed the instructions in it, you may file a complaint with SHIBA at the Washington State Office of the Insurance Commissioner by writing to SHIBA HelpLine, Office of the Insurance Commissioner, P.O. Box 40256, Olympia, WA 98504-0256, or calling the toll- free SHIBA Helpline at 1-800-562-6900. Section 1.9 You have the right to give consent to–or refuse–care, and be told the consequences of consent or refusal Section 1.10 You have the right to have an honest discussion with your practitioner about all your treatment options, regardless of cost or benefit coverage, presented in a manner appropriate to your medical condition and ability to understand 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 144 of 385 18 You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly. You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Customer Service (phone numbers are on the cover of this booklet). Section 1.11 You have the right to join in decisions to receive, or not receive, life-sustaining treatment including care at the end of life Section 1.12 You have the right to create and update your advance directives and have your wishes honored Section 1.13 You have the right to choose a personal primary care physician affiliated with your health plan Section 1.14 You have the right to expect your personal physician to provide, arrange, and/or coordinate your care Section 1.15 You have the right to change your personal physician for any reason Section 1.16 You have the right to be educated about your role in reducing medical errors and the safe delivery of care Section 1.17 You have the right to voice opinions, concerns, positive comments and complaints and to ask us to reconsider decisions we have made Section 1.18 You have the right to appeal a decision and receive a response within a reasonable amount of time Section 1.19 You have the right to suggest changes to consumer rights and responsibilities and related policies Section 1.20 You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation Section 1.21 You have the right to be free from all forms of abuse, harassment, or discrimination 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 145 of 385 19 If it is about discrimination, call the Office for Civil Rights If you think you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights. Is it about something else? If you think you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:  You can call Customer Service (phone numbers are on the cover of this booklet).  You can call the State Health Insurance Assistance Program. There are several places where you can get more information about your rights:  You can call Customer Service (phone numbers are on the cover of this booklet).  You can call the State Health Insurance Assistance Program.  You can contact Medicare. o You can visit the Medicare website (http://www.medicare.gov) to read or download the publication “Your Medicare Rights & Protections.” o Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. SECTION 2 You have some responsibilities as a member of the plan Section 1.22 You have the right to be free from discrimination, reprisal, or any other negative action when exercising your rights Section 1.23 You have the right to request and receive a copy of your medical records, and request amendment or correction to such documents, in accordance with applicable state and federal laws Section 1.24 What can you do if you think you are being treated unfairly or your rights are not being respected? Section 1.25 How to get more information about your rights Section 2.1 What are your responsibilities? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 146 of 385 20 Things you need to do as a member of the plan are listed below. If you have any questions, please call Customer Service (phone numbers are on the cover of this booklet). We’re here to help.  Get familiar with your covered services and the rules you must follow to get these covered services. Use this booklet to learn what is covered for you and the rules you need to follow to get your covered services.  If you have any other health insurance coverage in addition to our plan, or separate prescription drug coverage, you are required to tell us. Please call Customer Service to let us know. o We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called “coordination of benefits” because it involves coordinating the health benefits you get from our plan with any other benefits available to you. We’ll help you with it.  Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get your medical care.  Use practitioners and providers affiliated with your health plan for health care benefits and services, except where services are authorized or allowed by your health plan, or in the event of emergencies.  Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. o Provide accurate information, to the extent possible, that Group Health requires to care for you. This includes your health history and your current condition. Group Health also needs your permission to obtain needed medical and personal information. This includes your name, address, phone number, marital status, dependents’ status, and names of other insurance companies. o To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon. o If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.  Understand and follow instructions for treatment, and understand the consequences of following or not following instructions.  Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices. This includes arriving on time for appointments, and notifying staff if you cannot make it on time or if you need to reschedule.  Pay what you owe. As a plan member, you are responsible for these payments: o You must pay your plan premiums to continue being a member of our plan. o In order to be eligible for our plan, you must maintain your eligibility for Medicare Part A and Part B. For that reason, some plan members must pay 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 147 of 385 21 a premium for Medicare Part A and most plan members must pay a premium for Medicare Part B to remain a member of the plan. o For some of your medical services covered by the plan, you must pay your share of the cost when you get the service. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). o If you get any medical services that are not covered by our plan or by other insurance you may have, you must pay the full cost.  Understand your health needs and work with your personal physician to develop mutually agreed upon goals about ways to stay healthy or get well when you are sick  Tell us if you move. If you are going to move, it’s important to tell us right away. Call Customer Service (phone numbers are on the cover of this booklet). o If you move outside of our plan service area, you cannot remain a member of our plan. We can help you figure out whether you are moving outside our service area. If you are leaving our service area, we can let you know if we have a plan in your new area. o If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.  Call Customer Service for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan. o Phone numbers and calling hours for Customer Service are on the cover of this booklet. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 148 of 385 22 COVERAGE DECISIONS, APPEALS, COMPLAINTS SECTION 1 Introduction This chapter explains two types of processes for handling problems and concerns:  For some types of problems, you need to use the process for coverage decisions and making appeals.  For other types of problems you need to use the process for making complaints.  Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will help you identify the right process to use. There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To keep things simple, this chapter explains the legal rules and procedures using more common words in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a grievance,” “coverage decision” rather than “organization determination” and “Independent Review Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible. However, it can be helpful – and sometimes quite important – for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations. SECTION 2 You can get help from government organizations that are not connected with us Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step. Perhaps both are true for you. Get help from an independent government organization We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has Section 1.1 What to do if you have a problem or concern Section 1.2 What about the legal terms? Section 2.1 Where to get more information and personalized assistance 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 149 of 385 23 trained counselors in every state. The program is not connected with our plan or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. You can also get help and information from Medicare For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:  You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.  You can visit the Medicare website (http://www.medicare.gov). SECTION 3 To deal with your problem, which process should you use? If you have a problem or concern and you want to do something about it, you don’t need to read this whole chapter. You just need to find and read the parts of this chapter that apply to your situation. The guide that follows will help. Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 150 of 385 24 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide to the basics of coverage decisions and appeals The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We and/or your doctor make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Making an appeal If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. When we have completed the review we give you our decision. If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:  You can call us at Customer Service (phone numbers are on the cover).  To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program (see Section 2 of this chapter).  Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 Appeal on your Section 4.1 Asking for coverage decisions and making appeals: the big picture Section 4.2 How to get help when you are asking for a coverage decision or making an appeal 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 151 of 385 25 behalf. To request any appeal after Level 1, your doctor or other provider must be appointed as your representative.  You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. o There may be someone who is already legally authorized to act as your representative under State law. o If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Service and ask for the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.  You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. There are three different types of situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section: If you’re still not sure which section you should be using, please call Customer Service (phone numbers are on the front cover). You can also get help or information from government organizations such as your State Health Insurance Assistance Program. SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal Section 4.3 Which section of this chapter gives the details for your situation? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 152 of 385 26 ? Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisions and appeals)? If not, you may want to read it before you start this section. This section is about your benefits for medical care and services. These are the benefits described in the Summary on Benefits. To keep things simple, we generally refer to “medical care coverage” or “medical care” in the rest of this section, instead of repeating “medical care or treatment or services” every time. This section tells what you can do if you are in any of the five following situations: 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan. 3. You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care. 4. You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. 5. You are being told that coverage for certain medical care you have been getting will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.  NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation (CORF) services, you need to read a separate section of this chapter because special rules apply to these types of care. Here’s what to read in those situations: o Section 6: How to ask for a longer hospital stay if you think you are being asked to leave the hospital too soon. o Section 7: How to ask our plan to keep covering certain medical services if you think your coverage is ending too soon. This section is about three services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services.  For all other situations that involve being told that medical care you have been getting will be stopped, use this section (Section 5) as your guide for what to do. Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 153 of 385 27 Legal Terms When a coverage decision involves your medical care, it is called an “organization determination.” Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a “fast decision.” Legal Terms A “fast decision” is called an “expedited decision.” How to request coverage for the medical care you want  Start by calling, writing, or faxing our plan to make your request for us to provide coverage for the medical care you want. You, or your doctor, or your representative can do this. Generally we use the standard deadlines for giving you our decision When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 14 days after we receive your request.  However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.  If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (The process for making a complaint is different from the process for coverage decisions and appeals. For Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 154 of 385 28 more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) If your health requires it, ask us to give you a “fast decision”  A fast decision means we will answer within 72 hours. o However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. o If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) We will call you as soon as we make the decision.  To get a fast decision, you must meet two requirements: o You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.) o You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.  If your doctor tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.  If you ask for a fast decision on your own, without your doctor’s support, our plan will decide whether your health requires that we give you a fast decision. o If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead). o This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision. o The letter will also tell how you can file a “fast complaint” about our decision to give you a standard decision instead of the fast decision you requested. (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) Step 2: Our plan considers your request for medical care coverage and we give you our answer. Deadlines for a “fast” coverage decision  Generally, for a fast decision, we will give you our answer within 72 hours. o As explained above, we can take up to 14 more days under certain circumstances. If we decide to take extra days to make the decision, we will tell you in writing. If we take extra days, it is called “an extended time period.” o If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.  If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 155 of 385 29 hours after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Deadlines for a “standard” coverage decision  Generally, for a standard decision, we will give you our answer within 14 days of receiving your request. o We can take up to 14 more days (“an extended time period”) under certain circumstances. If we decide to take extra days to make the decision, we will tell you in writing. o If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.  If our plan says no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.  If you decide to make appeal, it means you are going on to Level 1 of the appeals process (see Section 5.3 below). Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or a “Level 1 Appeal.” An appeal to the plan about a medical care coverage decision is called a plan “reconsideration.” Step 1: You contact our plan and make your appeal. If your health requires a quick response, you must ask for a “fast appeal.” What to do  To start an appeal you, your representative, or in some cases your doctor must contact our plan. Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 156 of 385 30  If you are asking for a standard appeal, make your standard appeal in writing by submitting a signed request.  If you are asking for a fast appeal, make your appeal in writing or call us.  You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.  You can ask for a copy of the information regarding your medical decision and add more information to support your appeal. o You have the right to ask us for a copy of the information regarding your appeal. o If you wish, you and your doctor may give us additional information to support your appeal. If your health requires it, ask for a “fast appeal” (you can make an oral request) Legal Terms A “fast appeal” is also called an “expedited appeal.”  If you are appealing a decision our plan made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”  The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast decision.” To ask for a fast appeal, follow the instructions for asking for a fast decision. (These instructions are given earlier in this section.)  If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal. Step 2: Our plan considers your appeal and we give you our answer.  When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.  We will gather more information if we need it. We may contact you or your doctor to get more information. Deadlines for a “fast” appeal  When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing. o If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 157 of 385 31 section, we tell you about this organization and explain what happens at Level 2 of the appeals process.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.  If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Deadlines for a “standard” appeal  If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. o If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we tell about this review organization and explain what happens at Level 2 of the appeals process.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.  If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2. If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: The Independent Review Organization reviews your appeal. Section 5.4 Step-by-step: How to make a Level 2 Appeal 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 158 of 385 32  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.  You have a right to give the Independent Review Organization additional information to support your appeal.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2  If you had a fast appeal to our plan at Level 1, you will automatically receive a fast appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal.  However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2  If you had a standard appeal to our plan at Level 1, you will automatically receive a standard appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal.  However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. Step 2: The Independent Review Organization gives you their answer. The Independent Review Organization will tell you its decision in writing and explain the reasons for it.  If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization.  If this organization says no to part or all of your appeal, it means they agree with our plan that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”) o The notice you get from the Independent Review Organization will tell you in writing if your case meets the requirements for continuing with the appeals process. For example, to continue and make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 159 of 385 33 requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).  If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal.  The Level 3 Appeal is handled by an administrative law judge. Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Asking for reimbursement is asking for a coverage decision from our plan If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage decision (for more information about coverage decisions, see Section 4.1 of this chapter). To make this coverage decision, we will check to see if the medical care you paid for is a covered service. We will also check to see if you followed all the rules for using your coverage for medical care. We will say yes or no to your request  If the medical care you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of your medical care within 60 calendar days after we receive your request. Or, if you haven’t paid for the services, we will send the payment directly to the provider. When we send the payment, it’s the same as saying yes to your request for a coverage decision.)  If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why. (When we turn down your request for payment, it’s the same as saying no to your request for a coverage decision.) What if you ask for payment and we say that we will not pay? If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment. To make this appeal, follow the process for appeals that we describe in part 5.3 of this section. Go to this part for step-by-step instructions. When you are following these instructions, please note:  If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we receive your appeal. (If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.) Section 5.5 What if you are asking our plan to pay you for our share of a bill you have received for medical care? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 160 of 385 34  If the Independent Review Organization reverses our decision to deny payment, we must send the payment you have requested to you or to the provider within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days. SECTION 6 How to ask us to cover a longer hospital stay if you think the doctor is discharging you too soon When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury. For more information about our coverage for your hospital care, including any limitations on this coverage, see the Summary of Benefits. During your hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for care you may need after you leave.  The day you leave the hospital is called your “discharge date.” Our plan’s coverage of your hospital stay ends on this date.  When your discharge date has been decided, your doctor or the hospital staff will let you know.  If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. This section tells you how to ask. During your hospital stay, you will be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they are admitted to a hospital. Someone at the hospital is supposed to give it to you within two days after you are admitted. 1. Read this notice carefully and ask questions if you don’t understand it. It tells you about your rights as a hospital patient, including:  Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them.  Your right to be involved in any decisions about your hospital stay, and know who will pay for it.  Where to report any concerns you have about quality of your hospital care.  What to do if you think you are being discharged from the hospital too soon. Legal Terms The written notice from Medicare tells you how you can “make an appeal.” Making an appeal is a formal, legal way to ask for a delay in your discharge date so that your hospital care will be covered for a longer time. (Section 7.2 below tells how to make this appeal.) Section 6.1 During your hospital stay, you will get a written notice from Medicare that tells about your rights 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 161 of 385 35 2. You must sign the written notice to show that you received it and understand your rights.  You or someone who is acting on your behalf must sign the notice. (Section 4 of this chapter tells how you can give written permission to someone else to act as your representative.)  Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date (your doctor or hospital staff will tell you your discharge date). Signing the notice does not mean you are agreeing on a discharge date. 3. Keep your copy of the signed notice so you will have the information about making an appeal (or reporting a concern about quality of care) handy if you need it.  If you sign the notice more than 2 days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged.  To look at a copy of this notice in advance, you can call Customer Service or 1- 800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also see it online at http://www.cms.hhs.gov. If you want to ask for your hospital services to be covered by our plan for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.  Follow the process. Each step in the first two levels of the appeals process is explained below.  Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do.  Ask for help if you need it. If you have questions or need help at any time, please call Customer Service (phone numbers are on the front cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you. Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or a “Level 1 Appeal.” Step 1: Contact the Quality Improvement Organization in your state and ask for a “fast review” of your hospital discharge. You must act quickly. Legal Terms A “fast review” is also called an “immediate review” or an “expedited review.” What is the Quality Improvement Organization? Section 6.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 162 of 385 36  This organization is a group of doctors and other health care professionals who are paid by the Federal government. These experts are not part of our plan. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare. How can you contact this organization?  The written notice you received (An Important Message from Medicare) tells you how to reach this organization. Act quickly:  To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. (Your “planned discharge date” is the date that has been set for you to leave the hospital.) o If you meet this deadline, you are allowed to stay in the hospital after your discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization. o If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date.  If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details about this other way to make your appeal, see Section 6.4. Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review?  Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.  The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and our plan has given to them.  By noon of the day after the reviewers informed our plan of your appeal, you will also get a written notice that gives your planned discharge date and explains the reasons why your doctor, the hospital, and our plan think it is right (medically appropriate) for you to be discharged on that date. Legal Terms This written explanation is called the “Detailed Notice of Discharge.” You can get a sample of this notice by calling Customer Service or 1-800-MEDICARE (1-800- 633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you can get see a sample notice online at http://www.cms.hhs.gov/BNI/ 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 163 of 385 37 Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes?  If the review organization says yes to your appeal, our plan must keep providing your covered hospital services for as long as these services are medically necessary.  You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered hospital services. What happens if the answer is no?  If the review organization says no to your appeal, they are saying that your planned discharge date is medically appropriate. (Saying no to your appeal is also called turning down your appeal.) If this happens, our plan’s coverage for your hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal.  If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal  If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to “Level 2” of the appeals process. If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review  You must ask for this review within 60 calendar days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation Section 6.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 164 of 385 38  Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 calendar days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. If the review organization says yes:  Our plan must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. Our plan must continue providing coverage for your hospital care for as long as it is medically necessary.  You must continue to pay your share of the costs and coverage limitations may apply. If the review organization says no:  It means they agree with the decision they made to your Level 1 Appeal and will not change it. This is called “upholding the decision.” It is also called “turning down your appeal.”  The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If the review organization turns down your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. You can appeal to our plan instead As explained above in Section 6.2, you must act quickly to contact the Quality Improvement Organization to start your first appeal of your hospital discharge. (“Quickly” means before you leave the hospital and no later than your planned discharge date). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Legal Terms A “fast” review (or “fast appeal”) is also called an “expedited” review (or “expedited appeal”). Section 6.4 What if you miss the deadline for making your Level 1 Appeal? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 165 of 385 39 Step 1: Contact our plan and ask for a “fast review.”  Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Step 2: Our plan does a “fast” review of your planned discharge date, checking to see if it was medically appropriate.  During this review, our plan takes a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will check to see if the decision about when you should leave the hospital was fair and followed all the rules.  In this situation, we will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review. Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).  If our plan says yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)  If our plan says no to your fast appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your hospital services ends as of the day we said coverage would end.  If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. You will be responsible for the cost of care starting from noon on the day after our plan says no to your appeal. Step 4: If our plan says no to your fast appeal, your case will automatically be sent on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process. Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 166 of 385 40 Step 1: We will automatically forward your case to the Independent Review Organization.  We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 9 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge.  If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.  If this organization says no to your appeal, it means they agree with our plan that your planned hospital discharge date was medically appropriate. (This is called “upholding the decision.” It is also called “turning down your appeal.”) o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge. Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 7 How to ask us to keep covering certain medical services if you think your coverage is ending too soon This section is about the following types of care only: Section 7.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 167 of 385 41  Home health care services you are getting.  Skilled nursing care you are getting as a patient in a skilled nursing facility.  Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation. When you are getting any of these types of care, you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. For more information on your covered services, including your share of the cost and any limitations to coverage that may apply, see the Summary of Benefits. When our plan decides it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, our plan will stop paying its share of the cost for your care. If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask. 1. You receive a notice in writing. At least two days before our plan is going to stop covering your care, the agency or facility that is providing your care will give you a notice.  The written notice tells you the date when our plan will stop covering the care for you. Legal Terms In this written notice, we are telling you about a “coverage decision” we have made about when to stop covering your care. (For more information about coverage decisions, see Section 4 in this chapter.)  The written notice also tells what you can do if you want to ask our plan to change this decision about when to end your care, and keep covering it for a longer period of time. Legal Terms In telling what you can do, the written notice is telling how you can “make an appeal.” Making an appeal is a formal, legal way to ask our plan to change the coverage decision we have made about when to stop your care. (Section 8.3 below tells how you can make an appeal.) Legal Terms The written notice is called the “Notice of Medicare Non-Coverage.” To get a sample copy, call Customer Service or 1-800-MEDICARE (1- 800-633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.). Or see a copy online at http://www.cms.hhs.gov/BNI/ Section 7.2 We will tell you in advance when your coverage will be ending 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 168 of 385 42 2. You must sign the written notice to show that you received it.  You or someone who is acting on your behalf must sign the notice. (Section 4 tells how you can give written permission to someone else to act as your representative.)  Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan that it’s time to stop getting the care. If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.  Follow the process. Each step in the first two levels of the appeals process is explained below.  Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint. Section 9 of this chapter tells you how to file a complaint.)  Ask for help if you need it. If you have questions or need help at any time, please call Customer Service (phone numbers are on the front cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and decides whether to change the decision made by our plan. Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or “Level 1 Appeal.” Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization in your state and ask for a review. You must act quickly. What is the Quality Improvement Organization?  This organization is a group of doctors and other health care experts who are paid by the Federal government. These experts are not part of our plan. They check on the quality of care received by people with Medicare and review plan decisions about when it’s time to stop covering certain kinds of medical care. How can you contact this organization?  The written notice you received tells you how to reach this organization. What should you ask for?  Ask this organization to do an independent review of whether it is medically appropriate for our plan to end coverage for your medical services. Section 7.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 169 of 385 43 Your deadline for contacting this organization.  You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.  If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details about this other way to make your appeal, see Section 8.4. Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review?  Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.  The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them.  By the end of the day the reviewers informed our plan of your appeal, you will also get a written notice from the plan that gives our reasons for wanting to end the plan’s coverage for your services. Legal Terms This notice explanation is called the “Detailed Explanation of Non- Coverage.” Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. What happens if the reviewers say yes to your appeal?  If the reviewers say yes to your appeal, then our plan must keep providing your covered services for as long as it is medically necessary.  You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services. What happens if the reviewers say no to your appeal?  If the reviewers say no to your appeal, then your coverage will end on the date we have told you. Our plan will stop paying its share of the costs of this care.  If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 170 of 385 44  This first appeal you make is “Level 1” of the appeals process. If reviewers say no to your Level 1 Appeal – and you choose to continue getting care after your coverage for the care has ended – then you can make another appeal.  Making another appeal means you are going on to “Level 2” of the appeals process. If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review.  You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation.  Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes to your appeal?  Our plan must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. Our plan must continue providing coverage for the care for as long as it is medically necessary.  You must continue to pay your share of the costs and there may be coverage limitations that apply. What happens if the review organization says no?  It means they agree with the decision they made to your Level 1 Appeal and will not change it. (This is called “upholding the decision.” It is also called “turning down your appeal.”)  The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further.  There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to Section 7.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 171 of 385 45 accept that decision or to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. You can appeal to our plan instead As explained above in Section 7.3, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Here are the steps for a Level 1 Alternate Appeal: Legal Terms A “fast” review (or “fast appeal”) is also called an “expedited” review (or “expedited appeal”). Step 1: Contact our plan and ask for a “fast review.”  Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Step 2: Our plan does a “fast” review of the decision we made about when to end coverage for your services.  During this review, our plan takes another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan’s coverage for services you were receiving.  We will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review. (Usually, if you make an appeal to our plan and ask for a “fast review,” we are allowed to decide whether to agree to your request and give you a “fast review.” But in this situation, the rules require us to give you a fast response if you ask for it.) Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).  If our plan says yes to your fast appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)  If our plan says no to your fast appeal, then your coverage will end on the date we have told you and our plan will not pay after this date. Our plan will stop paying its share of the costs of this care. Section 7.5 What if you miss the deadline for making your Level 1 Appeal? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 172 of 385 46  If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If our plan says no to your fast appeal, your case will automatically go on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process. Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: We will automatically forward your case to the Independent Review Organization.  We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 9 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.  If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.  If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it. (This is called “upholding the decision.” It is also called “turning down your appeal.”) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 173 of 385 47 o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal. Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.  There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 8 Taking your appeal to Level 3 and beyond This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 Appeal A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an “Administrative Law Judge.”  If the Administrative Law Judge says yes to your appeal, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 4. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 3 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the judge’s decision. o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal request with any accompanying documents. We may wait for the Level 4 Appeal decision before authorizing or providing the service in dispute.  If the Administrative Law Judge says no to your appeal, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you can continue to the next level of the review process. If the administrative law judge says no to your Section 8.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 174 of 385 48 appeal, the notice you get will tell you what to do next if you choose to continue with your appeal. Level 4 Appeal The Medicare Appeals Council will review your appeal and give you an answer. The Medicare Appeals Council works for the Federal government.  If the answer is yes, or if the Medicare Appeals Council denies our request to review a favorable Level 3 Appeal decision, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 4 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the Medicare Appeals Council’s decision. o If we decide to appeal the decision, we will let you know in writing.  If the answer is no or if the Medicare Appeals Council denies the review request, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Medicare Appeals Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 Appeal A judge at the Federal District Court will review your appeal.  This is the last step of the administrative appeals process. MAKING COMPLAINTS SECTION 9 How to make a complaint about quality of care, waiting times, customer service, or other concerns ? If your problem is about decisions related to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 4 of this chapter. This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process. Section 9.1 What kinds of problems are handled by the complaint process? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 175 of 385 49 Quality of your medical care  Are you unhappy with the quality of the care you have received (including care in the hospital)? Respecting your privacy  Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential? Disrespect, poor customer service, or other negative behaviors  Has someone been rude or disrespectful to you?  Are you unhappy with how our Member Services has dealt with you?  Do you feel you are being encouraged to leave our plan? Waiting times  Are you having trouble getting an appointment, or waiting too long to get it?  Have you been kept waiting too long by doctors or other health professionals?  Or by Member Services or other staff at our plan?  Examples include waiting too long on the phone, in the waiting room, or in the exam room. Cleanliness  Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office? Information you get from our plan  Do you believe we have not given you a notice that we are required to give?  Do you think written information we have given you is hard to understand? These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals The process of asking for a coverage decision and making appeals is explained in sections 4-8 of this chapter. If you are asking for a decision or making an appeal, you use that process, not the complaint process. However, if you have already asked for a coverage decision or made an appeal, and you think that our plan is not responding quickly enough, you can also make a complaint about our slowness. Here are examples:  If you have asked us to give you a “fast response” for a coverage decision or appeal, and we have said we will not, you can make a complaint. If you have any of these kinds of problems, you can “make a complaint” 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 176 of 385 50  If you believe our plan is not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.  When a coverage decision we made is reviewed and our plan is told that we must cover or reimburse you for certain medical services, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.  When your plan does not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint. Legal Terms  What this section calls a “complaint” is also called a “grievance.”  Another term for “making a complaint” is “filing a grievance.”  Another way to say “using the process for complaints” is “using the process for filing a grievance.” Step 1: Contact us promptly – either by phone or in writing.  Usually, calling Customer Service is the first step. If there is anything else you need to do, Customer Service will let you know. Customer Service may be reached by calling 1-888-901-4600 (TTY only, call 1-800-833-6388 or 711). Hours are Monday-Friday, 8 a.m.-8 p.m. From November 15 through March 1, hours are daily, 8 a.m.-8 p.m.  If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works: o For this process your grievance requests must be in writing, and mailed to Group Health Medicare Customer Service Medicare Grievance, P.O. Box 34590, Seattle WA 98124-1590 or fax: 206-901-6205, or From www.ghc.org click “Contact Us.” We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.  Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.  If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours. Legal What this section calls a “fast complaint” is also called a “fast Section 9.2 The formal name for “making a complaint” is “filing a grievance” Section 9.3 Step-by-step: Making a complaint 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 177 of 385 51 Terms grievance.” Step 2: We look into your complaint and give you our answer.  If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.  Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.  If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. You can make your complaint about the quality of care you received to our plan by using the step-by-step process outlined above. When your complaint is about quality of care, you also have two extra options:  You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). If you make a complaint to this organization, we will work with them to resolve your complaint.  Or, you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. Section 9.4 You can also make complaints about quality of care to the Quality Improvement Organization 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 178 of 385 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 179 of 385 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 180 of 385 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 181 of 385 1 Group Medical Coverage Agreement Group Health Cooperative (also referred to as “GHC”) is a nonprofit health maintenance organization furnishing health care coverage on a prepayment basis. The Group identified below wishes to purchase such coverage. This Agreement sets forth the terms under which that coverage will be provided, including the rights and responsibilities of the contracting parties; requirements for enrollment and eligibility; and benefits to which those enrolled under this Agreement are entitled. The Agreement between GHC and the Group consists of the following:  Standard Provisions  Attached Benefit Booklet  Signed Group application  Premium Schedule Group Health Cooperative Signed: Title: President and Chief Executive Officer City of Renton, 0390400 Signed: Title: This Agreement will continue in effect until terminated or renewed as herein provided for and is effective January 1, 2011. PA-113311 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 182 of 385 2 Group Medical Coverage Agreement Table of Contents Standard Provisions Attachment 1 Benefit Booklet Attachment 2 Premium Schedule Attachment 3 Medicare Endorsement 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 183 of 385 3 Standard Provisions 1. GHC agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group. 2. Monthly Premium Payments. For the initial term of this Agreement, the Group shall submit to GHC for each Member the monthly premiums set forth in the current Premium Schedule and a verification of enrollment. Payment must be received on or before the due date and is subject to a grace period of ten (10) days. Premiums are subject to change by GHC upon thirty (30) days written notice. Premium rates will be revised as a part of the annual renewal process. In the event the Group increases or decreases enrollment at least twenty-five percent (25%) or more, GHC reserves the right to require re-rating of the Group. 3. Dissemination of Information. Unless the Group has accepted responsibility to do so, GHC will disseminate information describing benefits set forth in the Benefit Booklet attached to this Agreement. 4. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members enrolled under this Agreement. 5. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the administration of this Agreement. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. 6. Modification of Agreement. Except as required by federal and Washington State law, this Agreement may not be modified without agreement between both parties. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this Agreement, convey or void any coverage, increase or reduce any benefits under this Agreement or be used in the prosecution or defense of a claim under this Agreement. 7. Indemnification. GHC agrees to indemnify and hold the Group harmless against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of GHC's failure to perform, negligent performance or willful misconduct of its directors, officers, employees and agents of their express obligations under this Agreement. The Group agrees to indemnify and hold GHC harmless against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of the Group’s failure to perform, negligent performances or willful misconduct of its directors, officers, employees and agents of their express obligations under this Agreement. The indemnifying party shall give the other party prompt notice of any claim covered by this section and provide reasonable assistance (at its expense). The indemnifying party shall have the right and duty to assume the control of the defense thereof with counsel reasonably acceptable to the other party. Either party may take part in the defense at its own expense after the other party assumes the control thereof. 8. Compliance With Law. The Group and GHC shall comply with all applicable state and federal laws and regulations in performance of this Agreement. This Agreement is entered into and governed by the laws of Washington State, except as otherwise pre-empted by ERISA and other federal laws. 9. Governmental Approval. If GHC has not received any necessary government approval by the date when notice is required under this Agreement, GHC will notify the Group of any changes once governmental approval has been received. GHC may amend this Agreement by giving notice to the Group upon receipt of government approved rates, benefits, limitations, exclusions or other provisions, in which case such rates, benefits, limitations, exclusions or provisions will go into effect as required by the governmental agency. All 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 184 of 385 4 amendments are deemed accepted by the Group unless the Group gives GHC written notice of non-acceptance within thirty (30) days after receipt of amendment, in which event this Agreement and all rights to services and other benefits terminate the first of the month following thirty (30) days after receipt of non-acceptance. 10. Confidentiality. Each party acknowledges that performance of its obligations under this Agreement may involve access to and disclosure of data, procedures, materials, lists, systems and information, including medical records, employee benefits information, employee addresses, social security numbers, e-mail addresses, phone numbers and other confidential information regarding the Group’s employees (collectively the “information”). The information shall be kept strictly confidential and shall not be disclosed to any third party other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have a need to know such information in order to perform the services required of such party pursuant to this Agreement, or for the proper management and administration of the receiving party, provided that such representatives are informed of the confidentiality provisions of this Agreement and agree to abide by them, (ii) pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal, state or local law, statute, rule or regulation. The disclosing party will provide the other party with prompt notice of any request the disclosing party receives to disclose information pursuant to applicable legal requirements, so that the other party may object to the request and/or seek an appropriate protective order against such request. Each party shall maintain the confidentiality of medical records and confidential patient and employee information as required by applicable law. 11. Arbitration. Any dispute, controversy or difference between GHC and the Group arising out of or relating to this Agreement, or the breach thereof, shall be settled by arbitration in Seattle, Washington in accordance with the Commercial Arbitration Rules of the American Arbitration Association, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Except as may be required by law, neither party nor arbitrator may disclose the existence, content or results of any arbitration hereunder without the prior written consent of both parties. 12. HIPAA. Definition of Terms. Terms used, but not otherwise defined, in this Section shall have the same meaning as those terms have in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Transactions Accepted. GHC will accept Standard Transactions, pursuant to HIPAA, if the Group elects to transmit such transactions. The Group shall ensure that all Standard Transactions transmitted to GHC by the Group or the Group’s business associates are in compliance with HIPAA standards for electronic transactions. The Group shall indemnify GHC for any breach of this section by the Group. 13. Termination of Entire Agreement. This is a guaranteed renewable Agreement and cannot be terminated without the mutual approval of each of the parties, except in the circumstances set forth below. a. Nonpayment or Non-Acceptance of Premium. Failure to make any monthly premium payment or contribution in accordance with subsection 2 above shall result in termination of this Agreement as of the premium due date. The Group’s failure to accept the revised premiums provided as part of the annual renewal process shall be considered nonpayment and result in non-renewal of this Agreement. The Group may terminate this Agreement upon fifteen (15) days written notice of premium increase, as set forth in subsection 2 above. b. Misrepresentation. GHC may rescind or terminate this Agreement upon written notice in the event that intentional misrepresentation, fraud or omission of information was used in order to obtain Group coverage. Either party may terminate this Agreement in the event of intentional misrepresentation, fraud or omission of information by the other party in performance of its responsibilities under this Agreement. c. Underwriting Guidelines. GHC may terminate this Agreement in the event the Group no longer meets underwriting guidelines established by GHC that were in effect at the time the Group was accepted. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 185 of 385 5 d. Federal or State Law. GHC may terminate this Agreement in the event there is a change in federal or state law that no longer permits the continued offering of the coverage described in this Agreement. 14. Withdrawal or Cessation of Services. a. GHC may determine to withdraw from a Service Area or from a segment of its Service Area after GHC has demonstrated to the Washington State Office of the Insurance Commissioner that GHC’s clinical, financial or administrative capacity to service the covered Members would be exceeded. b. GHC may determine to cease to offer the Group’s current plan and replace the plan with another plan offered to all covered Members within that line of business that includes all of the health care services covered under the replaced plan and does not significantly limit access to the services covered under the replaced plan. GHC may also allow unrestricted conversion to a fully comparable GHC product. GHC will provide written notice to each covered Member of the discontinuation or non-renewal of the plan at least ninety (90) days prior to discontinuation. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 186 of 385 Dear Group Health Subscriber: This booklet contains important information about your healthcare plan. This is your 2011 Group Health Benefit Booklet (Certificate of Coverage). It explains the services and benefits you and those enrolled on your contract are entitled to receive from Group Health Cooperative. Sections of this document may be bolded and italicized, which identifies changes that Group Health has made to the plan. The benefits reflected in this booklet were approved by your employer or association who contracts with Group Health for your healthcare coverage. If you are eligible for Medicare, please read Section IV.J. as it may affect your prescription drug coverage. We recommend you read it carefully so you’ll understand not only the benefits, but the exclusions, limitations, and eligibility requirements of this certificate. Please keep this certificate for as long as you are covered by Group Health. We will send you revisions if there are any changes in your coverage. This certificate is not the contract itself; you can contact your employer or group administrator if you wish to see a copy of the contract (Medical Coverage Agreement). We’ll gladly answer any questions you might have about your Group Health benefits. Please call our Group Health Customer Service Center at (206) 901-4636 in the Seattle area, or toll-free in Washington, 1-888-901-4636. Thank you for choosing Group Health Cooperative. We look forward to working with you to preserve and enhance your health. Very truly yours, Scott Armstrong President PA-1133a11, CA-139511,CA-222011,CA-198411,CA-182411,CA-11711,CA-138511,CA-139711,CA-670011,CA- 3768 CA-3712 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 187 of 385 a 1 Benefit Booklet Table of Contents Section I. Introduction A. Accessing Care B. Cost Shares C. Subscriber’s Liability D. Claims Section II. Allowances Schedule Section III. Eligibility, Enrollment and Termination A. Eligibility B. Enrollment C. Effective Date of Enrollment D. Eligibility for Medicare E. Termination of Coverage F. Services After Termination of Agreement G. Continuation of Coverage Options Section IV. Schedule of Benefits A. Hospital Care B. Medical and Surgical Care C. Chemical Dependency Treatment D. Plastic and Reconstructive Services E. Home Health Care Services F. Hospice Care G. Rehabilitation Services H. Devices, Equipment and Supplies I. Tobacco Cessation J. Drugs, Medicines, Supplies and Devices K. Mental Health Care Services L. Emergency/Urgent Care M. Ambulance Services N. Skilled Nursing Facility Section V. General Exclusions Section VI. Grievance Processes for Complaints and Appeals Section VII. General Provisions A. Coordination of Benefits B. Subrogation and Reimbursement Rights C. Miscellaneous Provisions Section VIII. Definitions Attachment: Group Medicare Coverage 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 188 of 385 a 2 Group Health Cooperative believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act of 2010. Questions regarding this status may be directed to GHC Customer Service at (888) 901-4636. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at (866) 444-3272 or www.dol.gov/ebsa/healthreform. Section I. Introduction Group Health Cooperative (also referred to as “GHC”) is a nonprofit health maintenance organization furnishing health care primarily on a prepayment basis. Read This Benefit Booklet Carefully This Benefit Booklet is a statement of benefits, exclusions and other provisions, as set forth in the Group Medical Coverage Agreement (“Agreement”) between GHC and the employer or Group. A full description of benefits, exclusions, limits and Out-of-Pocket Expenses can be found in the Schedule of Benefits, Section IV; General Exclusions, Section V; and Allowances Schedule, Section II. These sections must be considered together to fully understand the benefits available under the Agreement. Words with special meaning are capitalized. They are defined in Section VIII. A. Accessing Care Members are entitled to Covered Services only at GHC Facilities and from GHC Personal Physicians. Except as follows:  Emergency care,  Self-Referral to women’s health care providers, as set forth below,  Visits with GHC-Designated Self-Referral Specialists, as set forth below,  Care provided pursuant to a Referral. Referrals must be requested by the Member’s Personal Physician and approved by GHC, and  Other services as specifically set forth in the Allowances Schedule and Section IV. Members may refer to Sections IV.A. and IV.C. for more information about inpatient admissions. Primary Care. GHC recommends that Members select a GHC Personal Physician when enrolling under the Agreement. One Personal Physician may be selected for an entire family, or a different Personal Physician may be selected for each family member. Selecting a Personal Physician or changing from one Personal Physician to another can be accomplished by contacting GHC Customer Service, or accessing the GHC website at www.ghc.org. The change will be made within twenty-four (24) hours of the receipt of the request, if the selected physician’s caseload permits. A listing of GHC Personal Physicians, Referral specialists, women’s health care providers and GHC-Designated Self-Referral Specialists is available by contacting GHC Customer Service at (206) 901-4636 or (888) 901- 4636, or by accessing GHC’s website at www.ghc.org. In the case that the Member’s Personal Physician no longer participates in GHC’s network, the Member will be provided access to the Personal Physician for up to sixty (60) days following a written notice offering the Member a selection of new Personal Physicians from which to choose. Specialty Care. Unless otherwise indicated in this section, the Allowances Schedule or Section IV., Referrals are required for specialty care and specialists. GHC-Designated Self-Referral Specialist. Members may make appointments directly with GHC-Designated Self-Referral Specialists at Group Health-owned or -operated medical centers without a Referral from their 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 189 of 385 a 3 Personal Physician. Self-Referrals are available for the following specialty care areas: allergy, audiology, cardiology, chemical dependency, chiropractic/manipulative therapy, dermatology, gastroenterology, general surgery, hospice, manipulative therapy, mental health, nephrology, neurology, obstetrics and gynecology, occupational medicine*, oncology/hematology, ophthalmology, optometry, orthopedics, otolaryngology (ear, nose and throat), physical therapy*, smoking cessation, speech/language and learning services* and urology. * Medicare patients need prior authorization for these specialists. Women’s Health Care Direct Access Providers. Female Members may see a participating General and Family Practitioner, Physician’s Assistant, Gynecologist, Certified Nurse Midwife, Licensed Midwife, Doctor of Osteopathy, Pediatrician, Obstetrician or Advanced Registered Nurse Practitioner who is contracted by GHC to provide women’s health care services directly, without a Referral from their Personal Physician, for Medically Necessary maternity care, covered reproductive health services, preventive care (well care) and general examinations, gynecological care and follow-up visits for the above services. Women’s health care services are covered as if the Member’s Personal Physician had been consulted, subject to any applicable Cost Shares, as set forth in the Allowances Schedule. If the Member’s women’s health care provider diagnoses a condition that requires Referral to other specialists or hospitalization, the Member or her chosen provider must obtain preauthorization and care coordination in accordance with applicable GHC requirements. Second Opinions. The Member may access, upon request, a second opinion regarding a medical diagnosis or treatment plan from a GHC Provider. Emergent and Urgent Care. Emergent care is available at GHC Facilities. If Members cannot get to a GHC Facility, Members may obtain Emergency services from the nearest hospital. Members or persons assuming responsibility for a Member must notify GHC by way of the GHC Emergency Notification Line within twenty- four (24) hours of admission to a non-GHC Facility, or as soon thereafter as medically possible. Members may refer to Section IV. for more information about coverage of Emergency services. In the GHC Service Area, urgent care is covered at GHC medical centers, GHC urgent care clinics or GHC Provider’s offices. Urgent care received at any hospital emergency department is not covered unless authorized in advance by a GHC Provider. Care received at urgent care facilities other than those listed above is only covered for emergency services, subject to the applicable Emergency Cost Share. Members may refer to Section IV. for more information about coverage of urgent care services. Outside the GHC Service Area, urgent care is covered at any medical facility. Members may refer to Section IV. for more information about coverage of urgent care services. Recommended Treatment. GHC’s Medical Director or his/her designee will determine the necessity, nature and extent of treatment to be covered in each individual case and the judgment, made in good faith, will be final. Members have the right to participate in decisions regarding their health care. A Member may refuse any recommended treatment or diagnostic plan to the extent permitted by law. Members who obtain care not recommended by GHC, do so with the full understanding that GHC has no obligation for the cost, or liability for the outcome, of such care. Coverage decisions may be appealed as set forth in Section VI. Major Disaster or Epidemic. In the event of a major disaster or epidemic, GHC will provide coverage according to GHC’s best judgment, within the limitations of available facilities and personnel. GHC has no liability for delay or failure to provide or arrange Covered Services to the extent facilities or personnel are unavailable due to a major disaster or epidemic. Unusual Circumstances. If the provision of Covered Services is delayed or rendered impossible due to unusual circumstances such as complete or partial destruction of facilities, military action, civil disorder, labor disputes or similar causes, GHC shall provide or arrange for services that, in the reasonable opinion of GHC's Medical Director, or his/her designee, are emergent or urgently needed. In regard to nonurgent and routine services, GHC shall make a good faith effort to provide services through its then-available facilities and personnel. GHC 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 190 of 385 a 4 shall have the option to defer or reschedule services that are not urgent while its facilities and services are so affected. In no case shall GHC have any liability or obligation on account of delay or failure to provide or arrange such services. B. Cost Shares The Subscriber shall be liable for the following Cost Shares when services are received by the Subscriber and any of his/her Dependents. 1. Copayments. Members shall be required to pay Copayments at the time of service as set forth in the Allowances Schedule. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non-Covered Service. 2. Coinsurance. Members shall be required to pay coinsurance for certain Covered Services as set forth in the Allowances Schedule. 3. Out-of-Pocket Limit. Total Out-of-Pocket Expenses incurred during the same calendar year shall not exceed the Out-of-Pocket Limit set forth in the Allowances Schedule. Out-of-Pocket Expenses which apply toward the Out-of-Pocket Limit are set forth in the Allowances Schedule. C. Subscriber's Liability The Subscriber is liable for (1) payment to the Group of his/her contribution toward the monthly premium, if any; (2) payment of Cost Share amounts for Covered Services provided to the Subscriber and his/her Dependents, as set forth in the Allowances Schedule; and (3) payment of any fees charged for non-Covered Services provided to the Subscriber and his/her Dependents, at the time of service. Payment of an amount billed by GHC must be received within thirty (30) days of the billing date. D. Claims Claims for benefits may be made before or after services are obtained. To make a claim for benefits under the Agreement, a Member (or the Member’s authorized representative) must contact GHC Customer Service, or submit a claim for reimbursement as described below. Other inquiries, such as asking a health care provider about care or coverage, or submitting a prescription to a pharmacy, will not be considered a claim for benefits. If a Member receives a bill for services the Member believes are covered under the Agreement, the Member must, within ninety (90) days of the date of service, or as soon thereafter as reasonably possible, either (1) contact GHC Customer Service to make a claim or (2) pay the bill and submit a claim for reimbursement of Covered Services to GHC, P.O. Box 34585, Seattle, WA 98124-1585. In no event, except in the absence of legal capacity, shall a claim be accepted later than one (1) year from the date of service. GHC will generally process claims for benefits within the following timeframes after GHC receives the claims:  Pre-service claims – within fifteen (15) days.  Claims involving urgently needed care – within seventy-two (72) hours.  Concurrent care claims – within twenty-four (24) hours.  Post-service claims – within thirty (30) days. Timeframes for pre-service and post-service claims can be extended by GHC for up to an additional fifteen (15) days. Members will be notified in writing of such extension prior to the expiration of the initial timeframe. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 191 of 385 a 6 Section II. Allowances Schedule The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the Group Medical Coverage Agreement. “Welcome” Outpatient Services Waiver Not applicable. Annual Deductible No annual Deductible. Plan Coinsurance No Plan Coinsurance. Lifetime Maximum No Lifetime Maximum on covered Essential Health Benefits. Hospital Services  Covered inpatient medical and surgical services, including acute chemical withdrawal (detoxification) Covered in full.  Covered outpatient hospital surgery (including ambulatory surgical centers) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Outpatient Services  Covered outpatient medical and surgical services Covered subject to the lesser of GHC's charge or a $25 outpatient services Copayment per Member per visit.  Allergy testing Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Oncology (radiation therapy, chemotherapy) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Drugs – Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed in the GHC drug formulary Covered subject to the lesser of GHC’s charge or a $10 Copayment.  Over-the-counter drugs and medicines Not covered.  Injectables 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 192 of 385 a 7 Injectables that can be self-administered are subject to the lesser of GHC’s charge or the applicable prescription drug Cost Share (as set forth above). Other covered injectables are subject to the lesser of GHC’s charge or the applicable outpatient services Cost Share. Injectables necessary for travel are not covered.  Mail order drugs and medicines dispensed through the GHC-designated mail order service Covered subject to the lesser of GHC’s charge or the applicable prescription drug Cost Share (as set forth above) for each thirty (30) day supply or less. Out-of-Pocket Limit Limited to an aggregate maximum of $2,000 per Member or $4,000 per family per calendar year. Except as otherwise noted in this Allowances Schedule, the total Out-of-Pocket Expenses for the following Covered Services are included in the Out-of-Pocket Limit:  Inpatient services  Outpatient services  Emergency care at a GHC or non-GHC Facility  Ambulance services Acupuncture Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider up to a maximum of eight (8) visits per Member per medical diagnosis per calendar year. When approved by GHC, additional visits are covered. Ambulance Services  Emergency ground/air transport Covered at 80%.  Non-emergent ground/air interfacility transfer Covered at 80% for GHC-initiated transfers, except hospital-to-hospital ground transfers covered in full. Chemical Dependency  Inpatient services (including Residential Treatment services) Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment.  Outpatient services Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Acute detoxification covered as any other medical service. Dental Services (including accidental injury to natural teeth) Not covered, except as set forth in Section IV.B.23. Devices, Equipment and Supplies (for home use) Covered at 80% for: 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 193 of 385 a 8  Durable medical equipment  Orthopedic appliances  Post-mastectomy bras limited to two (2) every six (6) months  Ostomy supplies  Prosthetic devices When provided in a home health setting in lieu of hospitalization as described in Section IV.A.3., benefits will be the greater of benefits available for devices, equipment and supplies, home health or hospitalization. See Hospice for durable medical equipment provided in a hospice setting. Diabetic Supplies Insulin, needles, syringes and lancets – see Drugs-Outpatient. External insulin pumps, blood glucose monitors, testing reagents and supplies - see Devices, Equipment and Supplies. Diagnostic Laboratory and Radiology Services Covered in full. Emergency Services  At a GHC Facility Covered subject to the lesser of GHC’s charge or a $75 Copayment per Member per Emergency visit. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services Cost Share.  At a non-GHC Facility Covered subject to the lesser of GHC’s charge or a $125 Copayment per Member per Emergency visit. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services Cost Share. Hearing Examinations and Hearing Aids  Hearing examinations to determine hearing loss Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Hearing aids, including hearing aid examinations Not covered. Home Health Services Covered in full. No visit limit. Hospice Services Covered in full. Inpatient respite care is covered for a maximum of five (5) consecutive days per occurrence. Infertility Services (including sterility) Not covered. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 194 of 385 a 9 Manipulative Therapy Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider for manipulative therapy of the spine and extremities in accordance with GHC clinical criteria up to a maximum of ten (10) visits per Member per calendar year. Maternity and Pregnancy Services  Delivery and associated Hospital Care Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment.  Prenatal and postpartum care Routine care covered in full. Non-routine care covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Pregnancy termination Covered subject to the lesser of GHC’s charge or the applicable Copayment for involuntary/voluntary termination of pregnancy. Mental Health Services  Inpatient services Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment at a GHC-approved mental health care facility.  Outpatient services Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Naturopathy Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider up to a maximum of three (3) visits per Member per medical diagnosis per calendar year. When approved by GHC, additional visits are covered. Nutritional Services  Phenylketonuria (PKU) supplements Covered in full.  Enteral therapy (formula) Covered at 80% for elemental formulas. Necessary equipment and supplies are covered under Devices, Equipment and Supplies.  Parenteral therapy (total parenteral nutrition) Covered in full for parenteral formulas. Necessary equipment and supplies are covered under Devices, Equipment and Supplies. Obesity Related Services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 195 of 385 a 10 Covered subject to the lesser of GHC’s charge or the applicable Copayment for bariatric surgery. Weight loss programs, medications and related physician visits for medication monitoring are not covered. On the Job Injuries or Illnesses Not covered, including injuries or illnesses incurred as a result of self-employment. Optical Services  Routine eye examinations Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment once every twelve (12) months. Eye examinations, including contact lens examinations, for eye pathology are covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment as often as Medically Necessary.  Lenses, including contact lenses, and frames Eyeglass frames, lenses (any type), lens options such as tinting, or prescription contact lenses, contact lens evaluations and examinations associated with their fitting - Covered up to $100 per twenty-four (24) month period per Member. The benefit period begins on the date services are first obtained and continues for twenty-four (24) months. Contact lenses for eye pathology, including following cataract surgery - Covered in full. Organ Transplants Covered subject to the lesser of GHC’s charge or the applicable Copayment. Plastic and Reconstructive Services (plastic surgery, cosmetic surgery)  Surgery to correct a congenital disease or anomaly, or conditions following an injury or resulting from surgery Covered subject to the lesser of GHC’s charge or the applicable Copayment.  Cosmetic surgery, including complications resulting from cosmetic surgery Not covered. Podiatric Services  Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable Copayment.  Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 196 of 385 a 11 Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment when in accordance with the well care schedule established by GHC . Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Rehabilitation Services  Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment for up to sixty (60) days per calendar year.  Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered up to sixty (60) days per Member per calendar year. Sterilization (vasectomy, tubal ligation) Not covered. Temporomandibular Joint (TMJ) Services  Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment up to $1,000 maximum per Member per calendar year.  Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation  Individual/group sessions received through the GHC-designated tobacco cessation program Covered in full.  Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC-designated mail order service. Uniformed Personnel Coverage as stated below is provided only to uniformed personnel who are LEOFF Plan 1 members and is limited to treatment of occupational injuries arising out of employment as a LEOFF Plan 1 member. Emergency care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 197 of 385 a 12 Covered in full. Ambulance services Covered in full. Skilled nursing facility Covered in full up to thirty (30) days per condition. Section III. Eligibility, Enrollment and Termination A. Eligibility In order to be accepted for enrollment and continuing coverage under the Agreement, individuals must meet any eligibility requirements imposed by the Group, reside or work in the Service Area and meet all applicable requirements set forth below, except for temporary residency outside the Service Area for purposes of attending school, court-ordered coverage for Dependents or other unique family arrangements, when approved in advance by GHC. GHC has the right to verify eligibility. 1. Subscribers. Bona fide employees who have been continuously employed on a regularly scheduled basis of not less than eighty (80) hours in a calendar month shall be eligible for enrollment. 2. Temporary Coverage for Newborns. When a Member gives birth, the newborn will be entitled to the benefits set forth in Section IV. from birth through three (3) weeks of age. After three (3) weeks of age, no benefits are available unless the newborn child qualifies as a Dependent and is enrolled under the Agreement. All contract provisions, limitations and exclusions will apply except Section III.F. and III.G. B. Enrollment 1. Application for Enrollment. Application for enrollment must be made on an application approved by GHC. Applicants will not be enrolled or premiums accepted until the completed application has been approved by GHC. The Group is responsible for submitting completed applications to GHC. GHC reserves the right to refuse enrollment to any person whose coverage under any Medical Coverage Agreement issued by Group Health Cooperative or Group Health Options, Inc. has been terminated for cause, as set forth in Section III.E. below. a. Newly Eligible Persons. Newly eligible Subscribers may apply for enrollment in writing to the Group within thirty-one (31) days of becoming eligible. b. Open Enrollment. GHC will allow enrollment of Subscribers who did not enroll when newly eligible as described above, during a limited period of time specified by the Group and GHC. c. Special Enrollment. 1) GHC will allow special enrollment for persons: a) who initially declined enrollment when otherwise eligible because such persons had other health care coverage and have had such other coverage terminated due to one of the following events:  cessation of employer contributions,  exhaustion of COBRA continuation coverage,  loss of eligibility, except for loss of eligibility for cause; or b) who have had such other coverage exhausted because such person reached a Lifetime Maximum limit. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 198 of 385 a 13 GHC or the Group may require confirmation that when initially offered coverage such persons submitted a written statement declining because of other coverage. Application for coverage under the Agreement must be made within thirty-one (31) days of the termination of previous coverage. 2) GHC will allow special enrollment for individuals who are eligible to be a Subscriber, in the event one of the following occurs:  marriage. Application for coverage under the Agreement must be made within thirty-one (31) days of the date of marriage.  birth. Application for coverage under the Agreement for the Subscriber and Dependents other than the newborn child must be made within sixty (60) days of the date of birth.  adoption or placement for adoption. Application for coverage under the Agreement for the Subscriber and Dependents other than the adopted child must be made within sixty (60) days of the adoption or placement for adoption.  eligibility for medical assistance: provided such person is otherwise eligible for coverage under this Agreement, when approved and requested in advance by the Department of Social and Health Services (DSHS).  applicable federal or state law or regulation otherwise provides for special enrollment. 2. Limitation on Enrollment. The Agreement will be open for applications for enrollment as set forth in this Section III.B. Subject to prior approval by the Washington State Office of the Insurance Commissioner, GHC may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that GHC’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. C. Effective Date of Enrollment 1. Provided eligibility criteria are met and applications for enrollment are made as set forth in Sections III.A. and III.B. above, enrollment will be effective as follows:  Enrollment for a newly eligible Subscriber is effective on the first (1st) of the month following the date of hire provided the Subscriber's application has been submitted to and approved by GHC. 2. Commencement of Benefits for Persons Hospitalized on Effective Date. Members who are admitted to an inpatient facility prior to their enrollment under the Agreement, and who do not have coverage under another agreement, will receive covered benefits beginning on their effective date, as set forth in subsection C.1. above. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility. The Member will be transferred when a GHC Provider, in consultation with the attending physician, determines that the Member is medically stable to do so. If the Member refuses to transfer to a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Member. D. Eligibility for Medicare An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare benefits. Medicare Secondary Payer regulations and guidelines will determine primary/secondary payer status for individuals covered by Medicare. Actively Employed Members. The Group is responsible for providing the Member with necessary information regarding Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) eligibility and the selection process, if applicable. A Member who is eligible for Medicare has the option of maintaining both Medicare Parts A and B while continuing coverage under this Agreement. Coverage between this Agreement and Medicare will be coordinated as outlined in Section VII.A. Not Actively Employed Members. If a Member who is not actively employed is eligible for Medicare based on age, he/she must enroll in and maintain both Medicare Parts A and B coverage and enroll in 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 199 of 385 a 14 the GHC Medicare Advantage Plan if available. Failure to do so upon the effective date of Medicare eligibility will result in termination of coverage under this Agreement. All applicable provisions of the GHC Medicare Advantage Plan are fully set forth in the Medicare Endorsement(s) attached to the Agreement (if applicable). E. Termination of Coverage 1. Termination of Specific Members. Individual Member coverage may be terminated for any of the following reasons: a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section III., and is not enrolled for continuation coverage as described in Section III.G. below, coverage under the Agreement will terminate at the end of the month during which the loss of eligibility occurs, unless otherwise specified by the Group. b. For Cause. Coverage of a Member may be terminated upon ten (10) working days written notice for: i. Material misrepresentation, fraud or omission of information in order to obtain coverage. ii. Permitting the use of a GHC identification card or number by another person, or using another Member’s identification card or number to obtain care to which a person is not entitled. In the event of termination for cause, GHC reserves the right to pursue all civil remedies allowable under federal and state law for the collection of claims, losses or other damages. c. Premium Payments. Nonpayment of premiums or contribution for a specific Member by the Group. Individual Member coverage may be retroactively terminated upon thirty (30) days written notice and only in the case of fraud or intentional misrepresentation of a material fact; or as otherwise allowed under applicable law or regulation. Notwithstanding the foregoing, GHC reserves the right to retroactively terminate coverage for nonpayment of premiums or contributions by the Group, as described under subsection c. above. In no event will a Member be terminated solely on the basis of their physical or mental condition provided they meet all other eligibility requirements set forth in the Agreement. Any Member may appeal a termination decision through GHC’s grievance process as set forth in Section VI. 2. Certificate of Creditable Coverage. Unless the Group has chosen to accept this responsibility, a certificate of creditable coverage (which provides information regarding the Member’s length of coverage under the Agreement) will be issued automatically upon termination of coverage, and may also be obtained upon request. F. Services After Termination of Agreement 1. Members Hospitalized on the Date of Termination. A Member who is receiving Covered Services as a registered bed patient in a hospital on the date of termination shall continue to be eligible for Covered Services while an inpatient for the condition which the Member was hospitalized, until one of the following events occurs:  According to GHC clinical criteria, it is no longer Medically Necessary for the Member to be an inpatient at the facility.  The remaining benefits available under the Agreement for the hospitalization are exhausted, regardless of whether a new calendar year begins.  The Member becomes covered under another agreement with a group health plan that provides benefits for the hospitalization. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 200 of 385 a 15  The Member becomes enrolled under an agreement with another carrier that would provide benefits for the hospitalization if the Agreement did not exist. This provision will not apply if the Member is covered under another agreement that provides benefits for the hospitalization at the time coverage would terminate, except as set forth in this section, or if the Member is eligible for COBRA continuation coverage as set forth in subsection G. below. 2. Services Provided After Termination. The Subscriber shall be liable for payment of all charges for services and items provided to the Subscriber and all Dependents after the effective date of termination, except those services covered under subsection F.1. above. Any services provided by GHC will be charged according to the Fee Schedule. G. Continuation of Coverage Options 1. Continuation Option. A Member no longer eligible for coverage under the Agreement (except in the event of termination for cause, as set forth in Section III.E.) may continue coverage for a period of up to three (3) months subject to notification to and self-payment of premiums to the Group. This provision will not apply if the Member is eligible for the continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). This continuation option is not available if the Group no longer has active employees or otherwise terminates. 2. Leave of Absence. While on a Group approved leave of absence, the Subscriber and listed Dependents can continue to be covered under the Agreement provided: They remain eligible for coverage, as set forth in Section III.A., Such leave is in compliance with the Group’s established leave of absence policy that is consistently applied to all employees, The Group’s leave of absence policy is in compliance with the Family and Medical Leave Act when applicable, and The Group continues to remit premiums for the Subscriber and Dependents to GHC. 3. Self-Payments During Labor Disputes. In the event of suspension or termination of employee compensation due to a strike, lock-out or other labor dispute, a Subscriber may continue uninterrupted coverage under the Agreement through payment of monthly premiums directly to the Group. Coverage may be continued for the lesser of the term of the strike, lock-out or other labor dispute, or for six (6) months after the cessation of work. If the Agreement is no longer available, the Subscriber shall have the opportunity to apply for an individual GHC Group Conversion Plan or, if applicable, continuation coverage (see subsection 4. below), or an Individual and Family Medical Coverage Agreement at the duly approved rates. The Group is responsible for immediately notifying each affected Subscriber of his/her rights of self-payment under this provision. 4. Continuation Coverage Under Federal Law. This section applies only to Groups who must offer continuation coverage under the applicable provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, and only applies to grant continuation of coverage rights to the extent required by federal law. Upon loss of eligibility, continuation of Group coverage may be available to a Member for a limited time after the Member would otherwise lose eligibility, if required by COBRA. The Group shall inform Members of the COBRA election process and how much the Member will be required to pay directly to the Group. Continuation coverage under COBRA will terminate when a Member becomes covered by Medicare or obtains other group coverage, and as set forth under Section III.E.1.b. and c. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 201 of 385 a 16 5. GHC Group Conversion Plan. Members whose eligibility for coverage under the Agreement, including continuation coverage, is terminated for any reason other than cause, as set forth in Section III.E.1.b., and who are not eligible for Medicare or covered by another group health plan, may convert to GHC’s Group Conversion Plan. If the Agreement terminates, any Member covered under the Agreement at termination may convert to a GHC Group Conversion Plan, unless he/she is eligible to obtain other group health coverage within thirty-one (31) days of the termination of the Agreement. An application for conversion must be made within thirty-one (31) days following termination of coverage under the Agreement or within thirty-one (31) days from the date notice of the termination of coverage is received, whichever is later. Coverage under GHC’s Group Conversion Plan is subject to all terms and conditions of such plan, including premium payments. A physical examination or statement of health is not required for enrollment in GHC’s Group Conversion Plan. The Pre-Existing Condition limitation under GHC’s Group Conversion Plan will apply only to the extent that the limitation remains unfulfilled under the Agreement. By exercising Group Conversion rights, the Member may waive guaranteed issue and Pre-Existing Condition waiver rights under Federal regulations. Persons wishing to purchase GHC’s Individual and Family coverage should contact GHC Marketing. Section IV. Schedule of Benefits Benefits are subject to all provisions of the Group Medical Coverage Agreement, including, without limitation, the Accessing Care provisions and General Exclusions. Members must refer to Section II., the Allowances Schedule, for Cost Shares and specific benefit limits that apply to benefits listed in this Schedule of Benefits. Members are entitled to receive only benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by GHC's Medical Director, or his/her designee, and as described herein. All Covered Services are subject to case management and utilization review at the discretion of GHC. A. Hospital Care Hospital coverage is limited to the following services: 1. Room and board, including private room when prescribed, and general nursing services. 2. Hospital services (including use of operating room, anesthesia, oxygen, x-ray, laboratory and radiotherapy services). 3. Alternative care arrangements may be covered as a cost-effective alternative in lieu of otherwise covered Medically Necessary hospitalization, or other covered Medically Necessary institutional care. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Member’s Medical Condition. Coverage must be authorized in advance by GHC as appropriate and Medically Necessary. Such care will be covered to the same extent the replaced Hospital Care is covered under the Agreement. 4. Drugs and medications administered during confinement. 5. Special duty nursing, when prescribed as Medically Necessary. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If the Member refuses to transfer, all further costs incurred during the hospitalization are the responsibility of the Member. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 202 of 385 a 17 B. Medical and Surgical Care Medical and surgical coverage is limited to the following: 1. Surgical services. 2. Diagnostic x-ray, nuclear medicine, ultrasound and laboratory services. 3. Family planning counseling services. 4. Hearing examinations to determine hearing loss. 5. Blood and blood derivatives and their administration. 6. Preventive care (well care) services for health maintenance in accordance with the well care schedule established by GHC and the Patient Protection and Affordable Care Act of 2010. Preventive care includes: routine mammography screening, physical examinations and routine laboratory tests for cancer screening in accordance with the well care schedule established by GHC, and immunizations and vaccinations listed as covered in the GHC drug formulary (approved drug list). A fee may be charged for health education programs. The well care schedule is available in GHC clinics, by accessing GHC’s website at www.ghc.org, or upon request. Covered Services provided during a preventive care visit, which are not in accordance with the GHC well care schedule, may be subject to Cost Shares. 7. Radiation therapy services. 8. Reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or non-dental cysts of the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth; and incision of salivary glands and ducts. 9. Medical implants. Excluded: internally implanted insulin pumps, artificial hearts, artificial larynx and any other implantable device that has not been approved by GHC's Medical Director, or his/her designee. 10. Respiratory therapy. 11. Outpatient total parenteral nutritional therapy; outpatient elemental formulas for malabsorption; and dietary formula for the treatment of phenylketonuria (PKU). Coverage for PKU formula is not subject to a Pre-Existing Condition waiting period, if applicable. Equipment and supplies for the administration of enteral and parenteral therapy are covered under Devices, Equipment and Supplies. Excluded: any other dietary formulas, oral nutritional supplements, special diets, prepared foods/meals and formula for access problems. 12. Visits with GHC Providers, including consultations and second opinions, in the hospital or provider’s office. 13. Optical services. Routine eye examinations and refractions received at a GHC Facility once every twelve (12) months, except when Medically Necessary. Routine eye examinations to monitor Medical Conditions are covered as often as necessary upon recommendation of a GHC Provider. Contact lenses for eye pathology, including contact lens exam and fitting, are covered subject to the applicable Cost Share. When dispensed through GHC Facilities, one contact lens per diseased 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 203 of 385 a 18 eye in lieu of an intraocular lens, including exam and fitting, is covered for Members following cataract surgery performed by a GHC Provider, provided the Member has been continuously covered by GHC since such surgery. Replacement of lenses for eye pathology, including following cataract surgery, will be covered only once within a twelve (12) month period and only when needed due to a change in the Member’s Medical Condition. Replacement for loss or breakage is subject to the Lenses and Frames benefit Allowance. Lenses and Frames Benefits purchased at a Group Health-owned or contracted optical hardware provider may be used toward the following in any combination, over the benefit period, until the benefit maximum is exhausted: Eyeglass frames Eyeglass lenses (any type) including tinting and coating Corrective industrial (safety) lenses Sunglass lenses and frames when prescribed by an eye care provider for eye protection or light sensitivity Corrective contact lenses in the absence of eye pathology, including associated fitting and evaluation examinations Replacement frames, for any reason, including loss or breakage Replacement contact lenses Replacement eyeglass lenses Excluded: evaluations and surgical procedures to correct refractions not related to eye pathology and complications related to such procedures. 14. Maternity care, including care for complications of pregnancy and prenatal and postpartum visits. Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary as determined by GHC’s Medical Director, or his/her designee, and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Hospitalization and delivery, including home births for low risk pregnancies. Voluntary (not medically indicated and nontherapeutic) or involuntary termination of pregnancy. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Pregnancy will not be excluded as a Pre-Existing Condition under the Agreement. Treatment for post-partum depression or psychosis is covered only under the mental health benefit. Excluded: birthing tubs and genetic testing of non-Members for the detection of congenital and heritable disorders. 15. Transplant services, including heart, heart-lung, single lung, double lung, kidney, pancreas, cornea, intestinal/multi-visceral, bone marrow, liver transplants and stem cell support (obtained from allogeneic or autologous peripheral blood or marrow) with associated high dose chemotherapy. Covered Services must be directly associated with, and occur at the time of, the transplant. Services are limited to the following: a. Evaluation testing to determine recipient candidacy, b. Matching tests, c. Inpatient and outpatient medical expenses listed below for transplantation procedures: 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 204 of 385 a 19 Hospital charges, Procurement center fees, Professional fees, Travel costs for a surgical team, and Excision fees Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees. d. Follow-up services for specialty visits, e. Rehospitalization, and f. Maintenance medications. Excluded: donor costs to the extent that they are reimbursable by the organ donor’s insurance, treatment of donor complications, living expenses and transportation expenses, except as set forth under Section IV.M. 16. Manipulative therapy. Self-Referrals for manipulative therapy of the spine and extremities are covered as set forth in the Allowances Schedule when provided by GHC Providers. Excluded: supportive care rendered primarily to maintain the level of correction already achieved, care rendered primarily for the convenience of the Member, care rendered on a non-acute, asymptomatic basis and charges for any other services that do not meet GHC clinical criteria as Medically Necessary. 17. Medical and surgical services and related hospital charges, including orthognathic (jaw) surgery, for the treatment of temporomandibular joint (TMJ) disorders. Such disorders may exhibit themselves in the form of pain, infection, disease, difficulty in speaking or difficulty in chewing or swallowing food. TMJ appliances are covered as set forth under Section IV.H.1., Orthopedic Appliances. Orthognathic (jaw) surgery for the treatment of TMJ disorders, radiology services and TMJ specialist services, including fitting/adjustment of splints are subject to the benefit limit set forth in the Allowances Schedule. Excluded are the following: orthognathic (jaw) surgery in the absence of a TMJ or severe obstructive sleep apnea diagnosis except for congenital anomalies, treatment for cosmetic purposes, dental services, including orthodontic therapy and any hospitalizations related to these exclusions. 18. Diabetic training and education. 19. Detoxification services for alcoholism and drug abuse. For the purposes of this section, "acute chemical withdrawal" means withdrawal of alcohol and/or drugs from a Member for whom consequences of abstinence are so severe that they require medical/nursing assistance in a hospital setting, which is needed immediately to prevent serious impairment to the Member's health. Coverage for acute chemical withdrawal is provided without prior approval. If a Member is hospitalized in a non-GHC Facility/program, coverage is subject to payment of the Emergency care Cost Share. The Member or person assuming responsibility for the Member must notify GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admission, or as soon thereafter as medically possible. Furthermore, if a Member is hospitalized in a non-GHC Facility/program, GHC reserves the right to require transfer of the Member to a GHC Facility/program upon consultation between a GHC Provider and the attending physician. If 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 205 of 385 a 20 the Member refuses transfer to a GHC Facility/program, all further costs incurred during the hospitalization are the responsibility of the Member. 20. Circumcision. 21. Bariatric surgery and related hospitalizations when GHC criteria are met. Excluded: pre and post surgical nutritional counseling and related weight loss programs, prescribing and monitoring of drugs, structured weight loss and/or exercise programs and specialized nutritional counseling. 22. Therapeutic sterilization procedures. 23. General anesthesia services and related facility charges for dental procedures will be covered for Members who are under seven (7) years of age, or are physically or developmentally disabled or have a Medical Condition where the Member’s health would be put at risk if the dental procedure were performed in a dentist’s office. Such services must be authorized in advance by GHC and performed at a GHC hospital or ambulatory surgical facility. Excluded: dentist’s or oral surgeon’s fees. 24. Self-Referrals to GHC for covered acupuncture and naturopathy, as set forth in the Allowances Schedule. Additional visits are covered when approved by GHC. Laboratory and radiology services are covered only when obtained through a GHC Facility. Excluded: herbal supplements, preventive care visits for acupuncture and any services not within the scope of the practitioner’s licensure. 25. Once Pre-Existing Condition wait periods, if any, have been met, Pre-Existing Conditions are covered in the same manner as any other illness. 26. Injections administered by a professional in a clinical setting. 26. The following benefits apply only to uniformed personnel who establish membership in the Law Enforcement Officers and Firefighters Retirement System (LEOFF) on or before September 30, 1977, and are subject to RCW 41.26.150 - Sick or Disability Benefits – Medical Services (LEOFF Plan 1 members). The Group is responsible for identifying LEOFF Plan 1 members, and providing written notification to GHC at the time the employee is enrolled with GHC. Coverage shall be limited to treatment of occupational injuries arising out of employment as a LEOFF 1 Plan member. Benefits shall be reduced by amounts receivable by the LEOFF Plan 1 member under workers’ compensation or from any other source. Coverage described below does not apply to Dependents. In the event of an occupational injury which, in the opinion of the officer in charge, needs treatment that cannot be delayed for transportation to GHC Facilities, GHC will bear the cost of Covered Services for Emergency treatment at a non-GHC Facility and related ambulance service to GHC or non-GHC Facilities. Covered Services for an occupational injury provided subsequent to the initial injury, including follow-up care, are covered only when provided at GHC, unless a GHC Provider has authorized such care at a non-GHC Facility in advance. Covered Services provided in a GHC-approved skilled nursing facility for occupational injuries will be covered for each condition when authorized by a GHC Provider. Coverage or non-coverage of Pre-Existing Conditions under the Agreement will have no bearing on the coverage and limitations under this section. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 206 of 385 a 21 Excluded: Covered Services for occupational injuries which occurred prior to enrollment under the Agreement or prior to the Group’s acceptance of a Uniformed Personnel benefit. C. Chemical Dependency Treatment. Chemical dependency means an illness characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcoholic beverages, and where the user's health is substantially impaired or endangered or his/her social or economic function is substantially disrupted. For the purposes of this section, the definition of Medically Necessary shall be expanded to include those services necessary to treat a chemical dependency condition that is having a clinically significant impact on a Member’s emotional, social, medical and/or occupational functioning. Chemical dependency treatment services are covered as set forth in the Allowances Schedule at a GHC Facility or GHC-approved treatment program. All alcoholism and/or drug abuse treatment services must be: (a) provided at a facility as described above; and (b) deemed Medically Necessary as defined above. Chemical dependency treatment may include the following services received on an inpatient or outpatient basis: inpatient Residential Treatment services, diagnostic evaluation and education, organized individual and group counseling and/or prescription drugs and medicines. Court-ordered treatment shall be covered only if determined to be Medically Necessary as defined above. D. Plastic and Reconstructive Services. Plastic and reconstructive services are covered as set forth below: 1. Correction of a congenital disease or congenital anomaly, as determined by a GHC Provider. A congenital anomaly will be considered to exist if the Member’s appearance resulting from such condition is not within the range of normal human variation. 2. Correction of a Medical Condition following an injury or resulting from surgery covered by GHC which has produced a major effect on the Member's appearance, when in the opinion of a GHC Provider, such services can reasonably be expected to correct the condition. 3. Reconstructive surgery and associated procedures, including internal breast prostheses, following a mastectomy, regardless of when the mastectomy was performed. Members will be covered for all stages of reconstruction on the non-diseased breast to make it equivalent in size with the diseased breast. Complications of covered mastectomy services, including lymphedemas, are covered. Excluded: complications of noncovered surgical services. E. Home Health Care Services. Home health care services, as set forth in this section, shall be covered when provided by and referred in advance by a GHC Provider for Members who meet the following criteria: 1. The Member is unable to leave home due to his/her health problem or illness. Unwillingness to travel and/or arrange for transportation does not constitute inability to leave the home. 2. The Member requires intermittent skilled home health care services, as described below. 3. A GHC Provider has determined that such services are Medically Necessary and are most appropriately rendered in the Member's home. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 207 of 385 a 22 For the purposes of this section, “skilled home health care” means reasonable and necessary care for the treatment of an illness or injury which requires the skill of a nurse or therapist, based on the complexity of the service and the condition of the patient and which is performed directly by an appropriately licensed professional provider. Covered Services for home health care may include the following when rendered pursuant to an approved home health care plan of treatment: nursing care, physical therapy, occupational therapy, respiratory therapy, restorative speech therapy, durable medical equipment and medical social worker and limited home health aide services. Home health services are covered on an intermittent basis in the Member's home. "Intermittent" means care that is to be rendered because of a medically predictable recurring need for skilled home health care services. Excluded: custodial care and maintenance care, private duty or continuous nursing care in the Member's home, housekeeping or meal services, care in any nursing home or convalescent facility, any care provided by or for a member of the patient's family and any other services rendered in the home which do not meet the definition of skilled home health care above or are not specifically listed as covered under the Agreement. F. Hospice Care. Hospice care is covered in lieu of curative treatment for terminal illness for Members who meet all of the following criteria:  A GHC Provider has determined that the Member's illness is terminal and life expectancy is six (6) months or less.  The Member has chosen a palliative treatment focus (emphasizing comfort and supportive services rather than treatment aimed at curing the Member's terminal illness).  The Member has elected in writing to receive hospice care through GHC's Hospice Program or GHC’s approved hospice program.  The Member has available a primary care person who will be responsible for the Member's home care.  A GHC Provider and GHC's Hospice Director, or his/her designee, have determined that the Member's illness can be appropriately managed in the home. Hospice care shall mean a coordinated program of palliative and supportive care for dying Members by an interdisciplinary team of professionals and volunteers centering primarily in the Member's home. 1. Covered Services. Care may include the following as prescribed by a GHC Provider and rendered pursuant to an approved hospice plan of treatment: a. Home Services i. Intermittent care by a hospice interdisciplinary team which may include services by a physician, nurse, medical social worker, physical therapist, speech therapist, occupational therapist, respiratory therapist, limited services by a Home Health Aide under the supervision of a Registered Nurse and homemaker services. ii. Continuous care services in the Member's home when prescribed by a GHC Provider, as set forth in this paragraph. “Continuous care” means skilled nursing care provided in the home during a period of crisis in order to maintain the terminally ill Member at home. Continuous care may be provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse or Home Health Aide under the supervision of a Registered Nurse. Continuous care is covered up to twenty-four (24) hours per day during periods of crisis. Continuous care is covered only when a GHC Provider determines that the Member would otherwise require hospitalization in an acute care facility. b. Inpatient Hospice Services. For short-term care, inpatient hospice services shall be covered in a facility designated by GHC's Hospice Program or GHC-approved hospice program when authorized in advance by a GHC Provider and GHC's Hospice Program or GHC-approved hospice program. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 208 of 385 a 23 Inpatient respite care is covered for a maximum of five (5) consecutive days per occurrence in order to continue care for the Member in the temporary absence of the Member’s primary care giver(s). c. Other covered hospice services may include the following: i. Drugs and biologicals that are used primarily for the relief of pain and symptom management. ii. Medical appliances and supplies primarily for the relief of pain and symptom management. iii. Durable medical equipment. iv. Counseling services for the Member and his/her primary care-giver(s). v. Bereavement counseling services for the family. 2. Hospice Exclusions. All services not specifically listed as covered in this section are excluded, including: a. Financial or legal counseling services. b. Meal services. c. Custodial or maintenance care in the home or on an inpatient basis, except as provided above. d. Services not specifically listed as covered by the Agreement. e. Any services provided by members of the patient's family. All other exclusions listed in Section V., General Exclusions, apply. G. Rehabilitation Services. 1. Rehabilitation services are covered as set forth in this section, limited to the following: physical therapy; occupational therapy; massage therapy and speech therapy to restore function following illness, injury or surgery. Services are subject to all terms, conditions and limitations of the Agreement, including the following: a. All services must be provided at a GHC or GHC-approved rehabilitation facility and require a prescription from a GHC physician and must be provided by a GHC-approved rehabilitation team that may include medical, nursing, physical therapy, occupational therapy, massage therapy and speech therapy providers. b. Services are limited to those necessary to restore or improve functional abilities when physical, sensori-perceptual and/or communication impairment exists due to injury, illness or surgery. Such services are provided only when GHC's Medical Director, or his/her designee, determines that significant, measurable improvement to the Member's condition can be expected within a sixty (60) day period as a consequence of intervention by covered therapy services described in paragraph a., above. c. Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances Schedule. Excluded: inpatient Residential Treatment services; specialty rehabilitation programs not provided by GHC; long-term rehabilitation programs; physical therapy, occupational therapy and speech therapy services when such services are available (whether application is made or not) through programs offered by public school districts; therapy for degenerative or static conditions when the expected outcome is primarily to maintain the Member's level of functioning (except as set forth in subsection 2. below); recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs; programs for treatment of learning problems; any services not specifically included as covered in this section; and any services that are excluded under Section V. 2. Neurodevelopmental Therapies for Children Age Six (6) and Under. Physical therapy, occupational therapy and speech therapy services for the restoration and improvement of function for neurodevelopmentally disabled children age six (6) and under shall be covered. Coverage 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 209 of 385 a 24 includes maintenance of a covered Member in cases where significant deterioration in the Member's condition would result without the services. Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances Schedule. Excluded: inpatient Residential Treatment services; specialty rehabilitation programs not provided by GHC; long-term rehabilitation programs; physical therapy, occupational therapy and speech therapy services when such services are available (whether application is made or not) through programs offered by public school districts; recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs; programs for treatment of learning problems; any services not specifically included as covered in this section; and any services that are excluded under Section V. H. Devices, Equipment and Supplies. Devices, equipment and supplies, which restore or replace functions that are common and necessary to perform basic activities of daily living, are covered as set forth in the Allowances Schedule. Examples of basic activities of daily living are dressing and feeding oneself, maintaining personal hygiene, lifting and gripping in order to prepare meals and carrying groceries. 1. Orthopedic Appliances. Orthopedic appliances, which are attached to an impaired body segment for the purpose of protecting the segment or assisting in restoration or improvement of its function. Excluded: arch supports, including custom shoe modifications or inserts and their fittings except for therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease; and orthopedic shoes that are not attached to an appliance. 2. Ostomy Supplies. Ostomy supplies for the removal of bodily secretions or waste through an artificial opening. 3. Durable Medical Equipment. Durable medical equipment is equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose, is useful only in the presence of an illness or injury and used in the Member’s home. Durable medical equipment includes: hospital beds, wheelchairs, walkers, crutches, canes, glucose monitors, external insulin pumps, oxygen and oxygen equipment. GHC, in its sole discretion, will determine if equipment is made available on a rental or purchase basis. 4. Prosthetic Devices. Prosthetic devices are items which replace all or part of an external body part, or function thereof. When authorized in advance, repair, adjustment or replacement of appliances and equipment is covered. Excluded: items which are not necessary to restore or replace functions of basic activities of daily living; and replacement or repair of appliances, devices and supplies due to loss, breakage from willful damage, neglect or wrongful use, or due to personal preference. I. Tobacco Cessation. When provided through GHC, services related to tobacco cessation are covered, limited to: 1. participation in an individual or group program; 2. educational materials; and 3. approved pharmacy products provided the Member is actively participating in a GHC-designated tobacco cessation program. J. Drugs, Medicines, Supplies and Devices. This benefit, for purposes of creditable coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Eligible Members who are also eligible for Medicare Part D pharmacy benefits can remain covered under the Agreement and not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D pharmacy plan at a later date. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 210 of 385 a 25 The Agreement may include Medicare Part D pharmacy benefits as part of the GHC Medicare Advantage Plan required for Medicare eligible Members who live in the GHC Medicare Advantage Service Area. See Section III.D. for more information. A Member who discontinues coverage under the Agreement must meet eligibility requirements in order to re-enroll. Legend medications are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services), contraceptive drugs and devices, diabetic supplies, including insulin syringes, lancets, urine-testing reagents, blood-glucose monitoring reagents and insulin, are covered as set forth below. All drugs, supplies, medicines and devices must be prescribed by a GHC Provider for conditions covered by the Agreement, obtained at a GHC-designated pharmacy and, unless approved by GHC in advance, be listed in the GHC drug formulary. The prescription drug Cost Share, as set forth in the Allowances Schedule, applies to each thirty (30) day supply. Cost Shares for single and multiple thirty (30) day supplies of a given prescription are payable at the time of delivery. Injectables that can be self-administered are also subject to the prescription drug Cost Share. Drug formulary (approved drug list) is defined as a list of preferred pharmaceutical products, supplies and devices developed and maintained by GHC. A limited supply of prescription drugs obtained at a non-GHC pharmacy is covered when dispensed or prescribed in connection with covered Emergency treatment. Generic drugs will be dispensed whenever available. Brand name drugs will be dispensed if there is not a generic equivalent. In the event the Member elects to purchase brand-name drugs instead of the generic equivalent (if available), or if the Member elects to purchase a different brand-name or generic drug than that prescribed by the Member’s Provider, and it is not determined to be Medically Necessary, the Member will also be subject to payment of the additional amount above the applicable pharmacy Cost Share set forth in the Allowances Schedule. A generic drug is defined as a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. A brand name drug is defined as a prescription drug that has been patented and is only available through one manufacturer. “Standard reference compendia” means the American Hospital Formulary Service-Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia-Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in healthcare journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Excluded: over-the-counter drugs, medicines, supplies and devices not requiring a prescription under state law or regulations; drugs used in the treatment of sexual dysfunction disorders; medicines and injections for anticipated illness while traveling; vitamins, including Legend (prescription) vitamins; and any other drugs, medicines and injections not listed as covered in the GHC drug formulary unless approved in advance by GHC as Medically Necessary. The Member will be charged for replacing lost or stolen drugs, medicines or devices. The Member’s Right to Safe and Effective Pharmacy Services. State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered under the Agreement and what coverage 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 211 of 385 a 26 limitations are in the Agreement. Members who would like more information about the drug coverage policies under the Agreement, or have a question or concern about their pharmacy benefit, may contact GHC at (206) 901-4636 or (888) 901-4636. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the Agreement, may contact the Washington State Office of Insurance Commissioner at (800) 562-6900. Members who have a concern about the pharmacists or pharmacies serving them, may call the Washington State Department of Health at (800) 525-0127. K. Mental Health Care Services. Services that are provided by a mental health practitioner will be covered as mental health care, regardless of the cause of the disorder. 1. Outpatient Services. Outpatient mental health services place priority on restoring the Member to his/her level of functioning prior to the onset of acute symptoms or to achieve a clinically appropriate level of stability as determined by GHC’s Medical Director, or his/her designee. Treatment for clinical conditions may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Coverage for each Member is provided according to the outpatient mental health care Allowance set forth in the Allowances Schedule. Psychiatric medical services, including medical management and prescriptions, are covered as set forth in Sections IV.B. and IV.J. 2. Inpatient Services. Charges for services described in this section, including psychiatric Emergencies resulting in inpatient services, are covered as set forth in the Allowances Schedule. This benefit shall include coverage for acute treatment and stabilization of psychiatric Emergencies in GHC-approved hospitals. When medically indicated, outpatient electro-convulsive therapy (ECT) is covered in lieu of inpatient services. Coverage for services incurred at non-GHC Facilities shall exclude any charges that would otherwise be excluded for hospitalization within a GHC Facility. Services provided under involuntary commitment statutes shall be covered at facilities approved by GHC. Services for any involuntary court-ordered treatment program beyond seventy-two (72) hours shall be covered only if determined to be Medically Necessary by GHC's Medical Director, or his/her designee. Coverage for voluntary/involuntary Emergency inpatient psychiatric services is subject to the Emergency care benefit set forth in Section IV.L., including the twenty-four (24) hour notification and transfer provisions. Outpatient electro-convulsive therapy treatment is covered subject to the outpatient surgery Cost Share. 3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services. Covered Services are limited to those authorized by GHC's Medical Director, or his/her designee, for covered clinical conditions for which the reduction or removal of acute clinical symptoms or stabilization can be expected given the most clinically appropriate level of mental health care intervention. Excluded: inpatient Residential Treatment services; learning, communication and motor skills disorders; mental retardation; academic or career counseling; sexual and identity disorders; and personal growth or relationship enhancement. Also excluded: assessment and treatment services that are primarily vocational and academic; court-ordered or forensic treatment, including reports and summaries, not considered Medically Necessary; work or school ordered assessment and treatment not considered Medically Necessary; counseling for overeating; nicotine related disorders; relationship counseling or phase of life problems (V code only diagnoses); and custodial care. Any other services not specifically listed as covered in this section. All other provisions, exclusions and limitations under the Agreement also apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 212 of 385 a 27 L. Emergency/Urgent Care. All services are covered subject to the Cost Shares set forth in the Allowances Schedule. Emergency Care (See Section VIII. for a definition of Emergency.) 1. At a GHC Facility. GHC will cover Emergency care for all Covered Services. 2. At a Non-GHC Facility. Usual, Customary and Reasonable charges for Emergency care for Covered Services are covered subject to: a. Payment of the Emergency care Cost Share; and b. Notification of GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admission, or as soon thereafter as medically possible. 3. Waiver of Emergency Care Cost Share. a. Waiver for Multiple Injury Accident. If two or more Members in the same Family Unit require Emergency care as a result of the same accident, coverage for all Members will be subject to only one (1) Emergency care Copayment. b. Emergencies Resulting in an Inpatient Admission. If the Member is admitted to a GHC Facility directly from the emergency room, the Emergency care Copayment is waived. However, coverage will be subject to the inpatient services Cost Share. 4. Transfer and Follow-up Care. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If the Member refuses to transfer to a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be obtained from GHC Providers, unless a GHC Provider has authorized such follow-up care from a non-GHC Provider in advance. Urgent Care (See Section VIII. for a definition of Urgent Condition.) Inside the GHC Service Area, care for Urgent Conditions is covered at GHC medical centers, GHC urgent care clinics or GHC Providers’ offices, subject to the applicable Cost Share. Urgent care received at any hospital emergency department is not covered unless authorized in advance by a GHC Provider. Care received at urgent care facilities other than those listed above is only covered for Emergency services, subject to the applicable Emergency care Cost Share. Outside the GHC Service Area, Usual, Customary and Reasonable charges are covered for Urgent Conditions received at any medical facility, subject to the applicable Cost Share. M. Ambulance Services. Ambulance services are covered as set forth below, provided that the service is authorized in advance by a GHC Provider or meets the definition of an Emergency (see Section VIII.). 1. Emergency Transport to any Facility. Each Emergency is covered as set forth in the Allowances Schedule. 2. Interfacility Transfers. GHC-initiated non-emergent transfers to or from a GHC Facility are covered as set forth in the Allowances Schedule. N. Skilled Nursing Facility (SNF). Skilled nursing care in a GHC-approved skilled nursing facility when full-time skilled nursing care is necessary in the opinion of the attending GHC Provider, is covered as set forth in the Allowances Schedule. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 213 of 385 a 28 When prescribed by a GHC Provider, such care may include room and board; general nursing care; drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility; and short-term physical therapy, occupational therapy and restorative speech therapy. Excluded: personal comfort items such as telephone and television, rest cures and custodial, domiciliary or convalescent care. Section V. General Exclusions In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Services or supplies not specifically listed as covered in the Schedule of Benefits, Section IV. 2. Except as specifically listed and identified as covered in Sections IV.B., IV.D., IV.H. and IV.J., corrective appliances and artificial aids including: eyeglasses; contact lenses and services related to their fitting; hearing devices and hearing aids, including related examinations; take-home drugs, dressings and supplies following hospitalization; and any other supplies, dressings, appliances, devices or services which are not specifically listed as covered in Section IV. 3. Cosmetic services, including treatment for complications resulting from cosmetic surgery, except as provided in Section IV.D. 4. Convalescent or custodial care. 5. Durable medical equipment such as hospital beds, wheelchairs and walk-aids, except while in the hospital or as set forth in Section IV.B., IV.E., IV.F. or IV.H. 6. Services rendered as a result of work-related injuries, illnesses or conditions, including injuries, illnesses or conditions incurred as a result of self-employment. 7. Those parts of an examination and associated reports and immunizations required for employment, unless otherwise noted in Section IV.B., immigration, license, travel or insurance purposes that are not deemed Medically Necessary by GHC for early detection of disease. 8. Services and supplies related to sexual reassignment surgery, such as sex change operations or transformations and procedures or treatments designed to alter physical characteristics. 9. Diagnostic testing and medical treatment of sterility, infertility and sexual dysfunction, regardless of origin or cause, unless otherwise noted in Section IV.B. 10. Any services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, whether the Member asserts a claim or not, pursuant to medical coverage, medical “no fault” coverage, Personal Injury Protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member is a named insured, comes within the policy definition of insured, or otherwise has the right to receive first party benefits under the policy. The Member and his/her agents must cooperate fully with GHC in its efforts to enforce this exclusion. This cooperation shall include supplying GHC with information about, or related to, the cause of injury or illness or the availability of other insurance coverage. The Member and his/her agent shall permit GHC, at GHC’s option, to associate with the Member or to intervene in any action filed against any party related to the injury. The Member and his/her agents shall do nothing to prejudice GHC’s right to enforce this exclusion. Failure to fully cooperate, including withholding information regarding the cause of injury or illness or other insurance coverage may result in denial of claims and the Member shall be responsible for reimbursing GHC for expenses incurred and the value of the benefits provided by GHC under this Agreement for the care or treatment of the injury or illness sustained by the Member. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 214 of 385 a 29 GHC shall not enforce this exclusion as to coverage available under uninsured motorist or underinsured motorist coverage until the Member has been made whole, unless the Member fails to cooperate fully with GHC as described above. If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining recovery, under certain conditions GHC will reduce the amount of reimbursement to GHC by the amount of an equitable apportionment of such collection costs between GHC and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i) the equitable apportionment of attorney fees has been agreed to by GHC prior to settlement or recovery, (ii) the Injured Person’s attorney’s action has benefited GHC in its recovery, and (iii) the Injured Person’s attorney’s actions were reasonable and necessary to secure recovery. GHC’s share of collection costs is subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. Under no circumstance will GHC incur legal fees for services which were not reasonably and necessarily incurred to secure recovery or which do not benefit GHC. If this Agreement is subject to ERISA and reasonable collections costs have been incurred by the Injured Person for the benefit of GHC, the Injured Person may request and GHC may reduce the amount of reimbursement to GHC by an amount for reasonable and necessary attorney’s fees incurred by the Injured Person on behalf of and for the benefit of GHC, but only if such amount is agreed to by GHC prior to settlement or recovery. 11. Late term pregnancy termination except when the health of the mother is at risk. 12. The cost of services and supplies resulting from a Member's loss of or willful damage to appliances, devices, supplies and materials covered by GHC for the treatment of disease, injury or illness. 13. Orthoptic therapy (i.e., eye training). 14. Specialty treatment programs such as weight reduction, “behavior modification programs” and rehabilitation, including cardiac rehabilitation. 15. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 16. Procedures and services to reverse a therapeutic or nontherapeutic sterilization. 17. Dental care, surgery, services and appliances, including: treatment of accidental injury to natural teeth, reconstructive surgery to the jaw in preparation for dental implants, dental implants, periodontal surgery and any other dental service not specifically listed as covered in Section IV. GHC’s Medical Director, or his/her designee, will determine whether the care or treatment required is within the category of dental care or service. 18. Drugs, medicines and injectables, except as set forth in Section IV.J. Any exclusion of drugs, medicines and injectables, including those not listed as covered in the GHC drug formulary (approved drug list), will also exclude their administration. 19. Experimental or investigational services. GHC consults with GHC’s Medical Director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 215 of 385 a 30 i. The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. ii. The service is the subject of a current new drug or new device application on file with the FDA. iii. The service is provided as part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial, or in any other manner that is intended to evaluate the safety, toxicity or efficacy of the service. iv. The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. v. The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. vi. The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. vii. The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. In making determinations whether a service is experimental or investigational, the following sources of information will be relied upon exclusively: i. The Member’s medical records, ii. The written protocol(s) or other document(s) pursuant to which the service has been or will be provided, iii. Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service, iv. The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body, v. The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury, and vi. Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding GHC denial of coverage can be submitted to the Member Appeal Department, or to GHC's Medical Director at P.O. Box 34593, Seattle, WA 98124-1593. 20. Chemical dependency, rehabilitation services and mental health care, except as specifically provided in Sections IV.C., IV.G. and IV.K. 21. Hypnotherapy, and all services related to hypnotherapy. 22. Genetic testing and related services, unless determined Medically Necessary by GHC’s Medical Director, or his/her designee, and in accordance with Board of Health standards for screening and diagnostic tests, or specifically provided in Section IV.B. Testing for non-Members is also excluded. 23. Follow-up visits related to a non-Covered Service. 24. Fetal ultrasound in the absence of medical indications. 25. Routine foot care, except in the presence of a non-related Medical Condition affecting the lower limbs. 26. Complications of non-Covered Services. 27. Obesity treatment and treatment for morbid obesity, including any medical services, drugs, supplies or any bariatric surgery (such as gastroplasty or intestinal bypass), regardless of co-morbidities, complications of obesity or any other Medical Condition, except as set forth in Section IV.B. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 216 of 385 a 31 28. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a member of the Member’s family. 29. Autopsy and associated expenses. 30. Services provided by government agencies, except as required by federal or state law. 31. Services related to temporomandibular joint disorder (TMJ) and/or associated facial pain or to correct congenital conditions, including bite blocks and occlusal equilibration, except as specified as covered in Section IV.B. 32. Services covered by the national health plan of any other country. 33. Pre-Existing Conditions, except as specifically provided in Section IV.B.25. Section VI. Grievance Processes for Complaints and Appeals The grievance processes to express a complaint and appeal a denial of benefits are set forth below. Filing a Complaint or Appeal The complaint process is available for a Member to express dissatisfaction about customer service or the quality or availability of a health service. The appeals process is available for a Member to seek reconsideration of a denial of benefits. Complaint Process Step 1: The Member should contact the person involved, explain his/her concerns and what he/she would like to have done to resolve the problem. The Member should be specific and make his/her position clear. Step 2: If the Member is not satisfied, or if he/she prefers not to talk with the person involved, the Member should call the department head or the manager of the medical center or department where he/she is having a problem. That person will investigate the Member’s concerns. Most concerns can be resolved in this way. Step 3: If the Member is still not satisfied, he/she should call the GHC Customer Service Center toll free at (888) 901-4636. Most concerns are handled by phone within a few days. In some cases the Member will be asked to write down his/her concerns and state what he/she thinks would be a fair resolution to the problem. A Customer Service Representative or Member Quality of Care Coordinator will investigate the Member’s concern by consulting with involved staff and their supervisors, and reviewing pertinent records, relevant plan policies and the Member Rights and Responsibilities statement. This process can take up to thirty (30) days to resolve after receipt of the Member’s written statement. If the Member is dissatisfied with the resolution of the complaint, he/she may contact the Member Quality of Care Coordinator or the Customer Service Center. Appeals Process Step 1: If the Member wishes to appeal a decision denying benefits, he/she must submit a request for an appeal either orally or in writing to the Member Appeals Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. Appeals should be directed to GHC’s Member Appeals Department, P.O. Box 34593, Seattle, WA 98124-1593, toll free (866) 458-5479. An Appeals Coordinator will review initial appeal requests. GHC will then notify the Member of its determination or need for an extension of time within fourteen (14) days of receiving the request for appeal. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 217 of 385 a 32 Under no circumstances will the review timeframe exceed thirty (30) days without the Member’s written permission. If the appeal request is for an experimental or investigational exclusion or limitation, GHC will make a determination and notify the Member in writing within twenty (20) working days of receipt of a fully documented request. In the event that additional time is required to make a determination, GHC will notify the Member in writing that an extension in the review timeframe is necessary. Under no circumstances will the review timeframe exceed twenty (20) days without the Member’s written permission. There is an expedited appeals process in place for cases which meet criteria or where the Member’s provider believes that the standard thirty (30) day appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited appeal in writing to the above address, or by calling GHC’s Member Appeals Department toll free (866) 458-5479. The Member’s request for an expedited appeal will be processed and a decision issued no later than seventy-two (72) hours after receipt. Step 2: If the Member is not satisfied with the decision in Step 1 regarding a denial of benefits, or if GHC fails to grant or reject the Member’s request within the applicable required timeframe, he/she may request a second level review by an external independent review organization as set forth under subsection A. below. The Member may also choose to pursue review by an appeals committee prior to requesting a review by an independent review organization as set forth under subsection B. below. This is not a required step in the appeals process. A. Request a review by an independent review organization. An independent review organization is not legally affiliated or controlled by GHC. Once a decision is made through an independent review organization, the decision is final and cannot be appealed through GHC. * A request for a review by an independent review organization must be made within 180 days after the date of the Step 1 decision notice, or within 180 days after the date of a GHC appeals committee decision notice. B. Request an optional hearing by the GHC appeals committee: The appeals committee hearing is an informal process. The hearing will be conducted within thirty (30) working days of the Member's request and notification of the appeal committee’s decision will be mailed to the Member within five (5) working days of the hearing. Members electing the appeals committee maintain their right to appeal further to an independent review organization as set forth in paragraph A. above. Review by the appeals committee is not available if the appeal request is for an experimental or investigational exclusion or limitation. A request for a hearing by the appeals committee must be made within thirty (30) days after the date of the Step 1 decision notice. The request can be mailed to GHC’s Member Appeals Department, P.O. Box 34593, Seattle, WA 98124-1593. * * If the Member’s health plan is governed by the Employee Retirement Income Security Act, known as “ERISA” (most employment related health plans, other than those sponsored by governmental entities or churches – ask employer about plan), the Member has the right to file a lawsuit under Section 502(a) of ERISA to recover benefits due to the Member under the plan at any point after completion of Step 1 of the appeals process. Members may have other legal rights and remedies available under state or federal law. Section VII. General Provisions A. Coordination of Benefits The coordination of benefits (COB) provision applies when a Member has health care coverage under more than one plan. Plan is defined below. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 218 of 385 a 33 The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan must pay an amount which, together with the payment made by the primary plan, totals the higher of the allowable expenses. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all the Member’s claims with each plan at the same time. If Medicare is the Member’s primary plan, Medicare may submit the Member’s claims to the Member’s secondary carrier. 1. Definitions. a. Plan. A plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for Members of a Group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts. However, if COB rules do not apply to all contracts, or to all benefits in the same contract, the contract or benefit to which COB does not apply is treated as a separate plan. 1) Plan includes: group, individual or blanket disability insurance contracts and group or individual contracts issued by health care service contractors or health maintenance organizations (HMO), closed panel plans or other forms of group coverage; medical care components of long-term care contracts, such as skilled nursing care; and Medicare or any other federal governmental plan, as permitted by law. 2) Plan does not include: hospital indemnity or fixed payment coverage or other fixed indemnity or fixed payment coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; benefits for non-medical components of long-term care policies; automobile insurance policies required by statute to provide medical benefits; Medicare supplement policies; Medicaid coverage; or coverage under other federal governmental plans; unless permitted by law. Each contract for coverage under subsection 1) or 2) is a separate plan. If a plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate plan. b. This plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits. c. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the Member has health care coverage under more than one plan. When this plan is primary, it determines payment for its benefits first before those of any other plan without considering any other plan’s benefits. When this plan is secondary, it determines its benefits after those of another plan and must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal 100% of the total allowable expense for that claim. This means that when this plan is secondary, it must pay the amount which, when combined with what the primary plan paid, totals 100% of the highest allowable expense. In addition, if this plan is secondary, it must calculate its savings (its amount paid subtracted from the amount it would have paid had it been the primary plan) and record these savings as a benefit reserve for the covered Member. This reserve must be used by the secondary plan to pay any 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 219 of 385 a 34 allowable expenses not otherwise paid, that are incurred by the covered person during the claim determination period. d. Allowable Expense. Allowable expense is a health care expense, coinsurance or copayments and without reduction for any applicable deductible, that is covered at least in part by any plan covering the person. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any plan covering the Member is not an allowable expense. The following are examples of expenses that are not allowable expenses: 1) The difference between the cost of a semi-private hospital room and a private hospital room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses. 2) If a Member is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement method or other similar reimbursement method, any amount in excess of the highest reimbursement amount for a specific benefit is not an allowable expense. 3) If a Member is covered by two or more plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense. 4) An expense or a portion of an expense that is not covered by any of the plans covering the person is not an allowable expense. e. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services through a panel of providers who are primarily employed by the plan, and that excludes coverage for services provided by other providers, except in cases of emergency or referral by a panel member. f. Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. 2. Order of Benefit Determination Rules. When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows: a. The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan. b. Except as provided below, a plan that does not contain a coordination of benefits provision that is consistent with this chapter is always primary unless the provisions of both plans state that the complying plan is primary. Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage is excess to any other parts of the plan provided by the Subscriber. Examples include major medical coverages that are superimposed over hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits. c. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits only when it is secondary to that other plan. d. Each plan determines its order of benefits using the first of the following rules that apply: 1) Non-Dependent or Dependent. The plan that covers the Member other than as a Dependent, for example as an employee, member, policyholder, Subscriber or retiree is the primary plan and the plan that covers the Member as a Dependent is the secondary 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 220 of 385 a 35 plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the plan covering the Member as a Dependent, and primary to the plan covering the Member as other than a Dependent (e.g., a retired employee), then the order of benefits between the two plans is reversed so that the plan covering the Member as an employee, member, policyholder, Subscriber or retiree is the secondary plan and the other plan is the primary plan. 2) Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, when a dependent child is covered by more than one plan the order of benefits is determined as follows: a) For a dependent child whose parents are married or are living together, whether or not they have ever been married:  The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or  If both parents have the same birthday, the plan that has covered the parent the longest is the primary plan. b) For a dependent child whose parents are divorced or separated or not living together, whether or not they have ever been married: (1) If a court decree states that one of the parents is responsible for the dependent child’s health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. This rule applies to claim determination periods commencing after the plan is given notice of the court decree; (2) If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses, the plan of the parent assuming financial responsibility is primary; (3) If a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, the provisions of a) above determine the order of benefits; (4) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subsection a) above determine the order of benefits; or (5) If there is no court decree allocating responsibility for the dependent child’s health care expenses or health care coverage, the order of benefits for the child are as follows:  The plan covering the custodial parent, first;  The plan covering the spouse of the custodial parent, second;  The plan covering the non-custodial parent, third; and then  The plan covering the spouse of the non-custodial parent, last. c) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the provisions of subsection a) or b) above determine the order of benefits as if those individuals were the parents of the child. 3) Active employee or retired or laid-off employee. The plan that covers a Member as an active employee, that is, an employee who is neither laid off nor retired, is the primary plan. The plan covering that same Member as a retired or laid off employee is the secondary plan. The same would hold true if a Member is a Dependent of an active employee and that same Member is a Dependent of a retired or laid-off employee. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section d 1) can determine the order of benefits. 4) COBRA or State Continuation Coverage. If a Member whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another plan, the plan covering the Member as an employee, member, Subscriber or retiree or covering the Member as a Dependent of an employee, member, Subscriber or 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 221 of 385 a 36 retiree is the primary plan and the COBRA or state or other federal continuation coverage is the secondary plan. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section d 1) can determine the order of benefits. 5) Longer or shorter length of coverage. The plan that covered the Member as an employee, member, Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter period of time is the secondary plan. 6) If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the plans meeting the definition of plan. In addition, this plan will not pay more than it would have paid had it been the primary plan. 3. Effect on the Benefits of this Plan. When this plan is secondary, it must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal one hundred percent of the total allowable expense for that claim. However, in no event shall the secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. In no event should the Member be responsible for a deductible amount greater than the highest of the two deductibles. Total allowable expense is the highest allowable expenses of the primary plan or the secondary plan. In addition, the secondary plan must credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage. 4. Right to Receive and Release Needed Information. Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this plan and other plans. GHC may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under this plan and other plans covering the Member claiming benefits. GHC need not tell, or get the consent of, any Member to do this. Each Member claiming benefits under this plan must give GHC any facts it needs to apply those rules and determine benefits payable. 5. Facility of Payment. If payments that should have been made under this plan are made by another plan, GHC has the right, at its discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision. The amounts paid to the other plan are considered benefits paid under this plan. To the extent of such payments, GHC is fully discharged from liability under this plan. 6. Right of Recovery. GHC has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this provision. GHC may recover excess payment from any person to whom or for whom payment was made or any other issuers or plans. Questions about Coordination of Benefits? Contact the State Insurance Department. 7. Effect of Medicare. Members Residing Outside the GHC Medicare Advantage Service Area. Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status. When Medicare, Part A and Part B or Part C are primary, Medicare's allowable amount is the highest allowable expense. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 222 of 385 a 37 When GHC renders care to a Member who is eligible for Medicare benefits, and Medicare is deemed to be the primary bill payer under Medicare primary/secondary payer guidelines and regulations, GHC will seek Medicare reimbursement for all Medicare covered services. B. Subrogation and Reimbursement Rights The benefits under this Agreement will be available to a Member for injury or illness caused by another party, subject to the exclusions and limitations of this Agreement. If GHC provides benefits under this Agreement for the treatment of the injury or illness, GHC will be subrogated to any rights that the Member may have to recover compensation or damages related to the injury or illness. This section VII.B. more fully describes GHC’s subrogation and reimbursement rights. “Injured Person” under this section means a Member covered by the Agreement who sustains an injury and any spouse, dependent or other person or entity that may recover on behalf of such Member, including the estate of the Member and, if the Member is a minor, the guardian or parent of the Member. When referred to in this section, “GHC’s Medical Expenses” means the expenses incurred and the value of the benefits provided by GHC under this Agreement for the care or treatment of the injury sustained by the Injured Person. If the Injured Person’s injuries were caused by a third party giving rise to a claim of legal liability against the third party and/or payment by the third party to the Injured Person and/or a settlement between the third party and the Injured Person, GHC shall have the right to recover GHC’s Medical Expenses from any source available to the Injured Person as a result of the events causing the injury, including but not limited to funds available through applicable third party liability coverage and uninsured/underinsured motorist coverage. This right is commonly referred to as “subrogation.” GHC shall be subrogated to and may enforce all rights of the Injured Person to the extent of GHC’s Medical Expenses. GHC’s subrogation and reimbursement rights shall be limited to the excess of the amount required to fully compensate the Injured Person for the loss sustained, including general damages. However, in the case of Medicare Advantage Members, GHC’s right of subrogation shall be the full amount of GHC’s Medical Expenses and is limited only as required by Medicare. Subject to the above provisions, if the Injured Person is entitled to or does receive money from any source as a result of the events causing the injury, including but not limited to any party’s liability insurance or uninsured/underinsured motorist funds, then GHC’s Medical Expenses provided or to be provided to the Injured Person are secondary, not primary. As a condition of receiving benefits under the Agreement, the Injured Person agrees that acceptance of GHC services is constructive notice of this provision in its entirety and agrees to reimburse GHC for the benefits the Injured Person received as a result of the events causing the injury. The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect GHC’s Medical Expenses. This cooperation includes, but is not limited to, supplying GHC with information about the cause of injury or illness, any third parties, defendants and/or insurers related to the Injured Person’s claim and informing GHC of any settlement or other payments relating to the Injured Person’s injury. The Injured Person and his/her agents shall permit GHC, at GHC’s option, to associate with the Injured Person or to intervene in any legal, quasi-legal, agency or any other action or claim filed. If the Injured Person takes no action to recover money from any source, then the Injured Person agrees to allow GHC to initiate its own direct action for reimbursement or subrogation, including, but not limited to, billing the Injured Person directly for GHC’s Medical Expenses The Injured Person and his/her agents shall do nothing to prejudice GHC’s subrogation and reimbursement rights. The Injured Person shall promptly notify GHC of any tentative settlement with a third party and shall not settle a claim without protecting GHC’s interest. If the Injured Person fails to cooperate fully with GHC in recovery of GHC’s Medical Expenses, the Injured Person shall be responsible for directly reimbursing GHC for GHC’s Medical Expenses and GHC retains the right to bill the Injured Person directly for GHC’s Medical Expenses. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 223 of 385 a 38 To the extent that the Injured Person recovers funds from any source that may serve to compensate for medical injuries or medical expenses, the Injured Person agrees to hold such monies in trust or in their possession until GHC’s subrogation and reimbursement rights are fully determined. If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining recovery, under certain conditions GHC will reduce the amount of reimbursement to GHC by the amount of an equitable apportionment of such collection costs between GHC and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i) the equitable apportionment of attorney fees has been agreed to by GHC prior to settlement or recovery, (ii) the Injured Person’s attorney’s action has benefited GHC in its recovery, and (iii) the Injured Person’s attorney’s actions were reasonable and necessary to secure recovery. GHC’s share of collection costs is subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. Under no circumstance will GHC incur legal fees for services which were not reasonably and necessarily incurred to secure recovery or which do not benefit GHC. If this Agreement is subject to ERISA and reasonable collections costs have been incurred by the Injured Person for the benefit of GHC, the Injured Person may request and GHC may reduce the amount of reimbursement to GHC by an amount for reasonable and necessary attorney’s fees incurred by the Injured Person on behalf of and for the benefit of GHC, but only if such amount is agreed to by GHC prior to settlement or recovery. To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA, implementation of this section shall be deemed a part of claims administration under the Agreement and GHC shall therefore have discretion to interpret its terms. C. Miscellaneous Provisions 1. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members enrolled under the Agreement. 2. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the administration of the Agreement. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. 3. Modification of Agreement. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of the Agreement, convey or void any coverage, increase or reduce any benefits under the Agreement or be used in the prosecution or defense of a claim under the Agreement. 4. Confidentiality. GHC and the Group shall keep Member information strictly confidential and shall not disclose any information to any third party other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have a need to know such information in order to perform the services required of such party pursuant to the Agreement, or for the proper management and administration of the receiving party, provided that such representatives are informed of the confidentiality provisions of the Agreement and agree to abide by them, (ii) pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal, state or local law, statute, rule or regulation. 5. Nondiscrimination. GHC does not discriminate on the basis of physical or mental disabilities in its employment practices and services. Section VIII. Definitions Agreement: The Medical Coverage Agreement between GHC and the Group. Allowance: The maximum amount payable by GHC for certain Covered Services under the Agreement, as set forth in the Allowances Schedule. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 224 of 385 a 39 Contracted Network Pharmacy: A pharmacy that has contracted with GHC to provide covered legend (prescription) drugs and medicines for outpatient use under the Agreement. Copayment: The specific dollar amount a Member is required to pay at the time of service for certain Covered Services under the Agreement, as set forth in the Allowances Schedule. Cost Share: The portion of the cost of Covered Services the Member is liable for under the Agreement. Cost Shares for specific Covered Services are set forth in the Allowances Schedule. Cost Share includes Copayments, coinsurances and/or Deductibles. Covered Services: The services for which a Member is entitled to coverage under the Agreement. Deductible: A specific amount a Member is required to pay for certain Covered Services before benefits are payable under the Agreement. The applicable Deductible amounts are set forth in the Allowances Schedule. Dependent: Any member of a Subscriber’s family who meets all applicable eligibility requirements, is enrolled hereunder and for whom the premium prescribed in the Premium Schedule has been paid. Emergency: The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part, or would place the Member's health in serious jeopardy. Essential Health Benefits: Benefits set forth under the Patient Protection and Affordable Care Act of 2010, including the categories of ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Family Unit: A Subscriber and all his/her Dependents. Fee Schedule: A fee-for-service schedule adopted by GHC, setting forth the fees for medical and hospital services. GHC-Designated Self-Referral Specialist: A GHC specialist specifically identified by GHC to whom Members may self-refer. GHC Facility: A facility (hospital, medical center or health care center) owned, operated or otherwise designated by GHC. GHC Medicare Plan: A plan of coverage for persons enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance). GHC Personal Physician: A provider who is employed by or contracted with GHC to provide primary care services to Members and is selected by each Member to provide or arrange for the provision of all non-emergent Covered Services, except for services set forth in the Agreement which a Member can access without a Referral. Personal Physicians must be capable of and licensed to provide the majority of primary health care services required by each Member. GHC Provider: The medical staff, clinic associate staff and allied health professionals employed by GHC, and any other health care professional or provider with whom GHC has contracted to provide health care services to Members enrolled under the Agreement, including, but not limited to physicians, podiatrists, nurses, physician assistants, social workers, optometrists, psychologists, physical therapists and other professionals engaged in the delivery of healthcare services who are licensed or certified to practice in accordance with Title 18 Revised Code of Washington. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 225 of 385 a 40 Group: An employer, union, welfare trust or bona-fide association which has entered into a Group Medical Coverage Agreement with GHC. Hospital Care: Those Medically Necessary services generally provided by acute general hospitals for admitted patients. Hospital Care does not include convalescent or custodial care, which can, in the opinion of the GHC Provider, be provided by a nursing home or convalescent care center. Lifetime Maximum: The maximum value of benefits provided for Covered Services under the Agreement after which benefits under the Agreement are no longer available as set forth in the Allowances Schedule. The value of Covered Services is based on the Fee Schedule, as defined above. The lifetime maximum applies to this Agreement or in combination with any other medical coverage agreement between GHC and Group. Medical Condition: A disease, illness or injury. Medically Necessary: Appropriate and clinically necessary services, as determined by GHC’s Medical Director, or his/her designee, according to generally accepted principles of good medical practice, which are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Member, his/her family or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Member; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under GHC’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Washington, could not have been omitted without adversely affecting the Member’s condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a provider’s office, the outpatient department of a hospital or a non-residential facility without affecting the Member’s condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are not experimental or investigational. The length and type of the treatment program and the frequency and modality of visits covered shall be determined by GHC’s Medical Director, or his/her designee. In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service as set forth in Section IV. of the Agreement and not excluded from coverage. The cost of non-covered services and supplies shall be the responsibility of the Member. Medicare: The federal health insurance program for the aged and disabled. Member: Any Subscriber or Dependent enrolled under the Agreement. Out-of-Pocket Expenses: Those Cost Shares paid by the Subscriber or Member for Covered Services which are applied to the Out-of-Pocket Limit. Out-of-Pocket Limit: The maximum amount of Out-of-Pocket Expenses incurred and paid during the calendar year for Covered Services received by the Subscriber and his/her Dependents within the same calendar year. The Out-of-Pocket Limit amount and Cost Shares that apply are set forth in the Allowances Schedule. Charges in excess of UCR, services in excess of any benefit level and services not covered by the Agreement are not applied to the Out-of-Pocket Limit. Plan Coinsurance: The percentage amount the Member and GHC are required to pay for Covered Services received under the Agreement. Percentages for Covered Services are set forth in the Allowances Schedule. A coinsurance percentage not identified as Plan Coinsurance is a benefit specific coinsurance and does not apply to the Out-of-Pocket Limit except as otherwise specified under Section II. Out-of-Pocket Limit. Pre-Existing Condition: A condition for which there has been diagnosis, treatment or medical advice within the three (3) month period prior to the effective date of coverage. The Pre-Existing Condition wait period will begin on the first day of coverage, or the first day of the enrollment waiting period if earlier. Referral: A written temporary agreement requested in advance by a GHC Provider and approved by GHC that entitles a Member to receive Covered Services from a specified health care provider. Entitlement to such services shall not exceed the limits of the Referral and is subject to all terms and conditions of the 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 226 of 385 a 41 Referral and the Agreement. Members who have a complex or serious medical or psychiatric condition may receive a standing Referral for specialist services. Residential Treatment: A term used to define facility-based treatment, which includes twenty-four (24) hours per day, seven (7) days per week rehabilitation. Residential Treatment services are provided in a facility specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi-disciplinary team of licensed professionals. Self-Referred: Covered Services received by a Member from a designated women’s health care specialist or GHC-Designated Self-Referral Specialist that are not referred by a GHC Personal Physician. Service Area: Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman and Yakima; Idaho counties of Kootenai and Latah; and any other areas designated by GHC. Subscriber: A person employed by or belonging to the Group who meets all applicable eligibility requirements, is enrolled under the Agreement and for whom the premium specified in the Premium Schedule has been paid. Urgent Condition: The sudden, unexpected onset of a Medical Condition that is of sufficient severity to require medical treatment within twenty-four (24) hours of its onset. Usual, Customary and Reasonable (UCR): A term used to define the level of benefits which are payable by GHC when expenses are incurred from a non-GHC Provider. Expenses are considered Usual, Customary and Reasonable if the charges are consistent with those normally charged to others by the provider or organization for the same services or supplies; and the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 227 of 385 1 Group Health Cooperative Medicare Advantage Plan (MA) Following is a brief outline of the benefits available to Group Members who are also enrolled in the Group Health Cooperative Medicare Advantage (MA) plan. In no event shall the benefits of the MA plan duplicate the benefits under the Group Medical Coverage Agreement. The benefits available to persons enrolled in both the Group Health Cooperative Medical Coverage Agreement and the Group Health Cooperative Medicare Advantage Plan will be the higher level of benefit available under the plans, as determined by Group Health Cooperative. Unless otherwise stated, the provisions, limitations and exclusions, including provider access requirements of the Group Medical Coverage Agreement apply to the benefits available under the Group Health Cooperative Medicare Advantage Plan. The benefits described in this outline apply only to Members who are covered under Medicare Part A and Part B, and who are enrolled in the Group Health Cooperative Medicare Advantage Plan as set forth in the Group Medical Coverage Agreement. This includes those Members with Medicare Part B only, who have been continuously enrolled in the Group Health Cooperative Medicare Advantage Plan since December 31, 1998. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 228 of 385 2 SUMMARY OF BENEFITS Group Health Medicare Advantage Clear Care Employer Group Plan (Benefit 2) If you have any questions about this plan's benefits or costs, please contact Group Health Cooperative for details. SECTION II – Summary of Benefits Benefit Category Original Medicare GHC Medicare Plan (Medicare Parts A & B) IMPORTANT INFORMATION 1 – Premium and Other Important Information In 2011 the monthly Part B Premium is $96.40 and the yearly Part B deductible amount is $162. If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income ($85,000 for singles, $170,000 for married couples).For more information about Part B premiums based on income, call Social Security at 1-800-772-1213. TTY users should call 1-800-325- 0778. $2,500 out-of-pocket limit. Contact the plan for services that apply. 2 - Doctor and Hospital Choice (For more information, see Emergency - #15 and Urgently Needed Care - #16.) You may go to any doctor, specialist or hospital that accepts Medicare. You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists for (for certain benefits). You may have to pay a separate copay for certain doctor office visits. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 229 of 385 3 SUMMARY OF BENEFITS INPATIENT CARE 3 - Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services) In 2011 the amounts for each benefit period are: Days 1 - 60: $1,132 deductible Days 61 - 90: $283 per day Days 91 - 150: $566 per lifetime reserve day Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once. A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. In-Network: For Medicare-covered hospital stays you pay the lesser of the Group cost share or the following copayments: Days 1-5: $200 copay per day Days 6-90: $0 copay per day $0 copay for additional hospital days. No limit to the number of days covered by the plan each benefit period. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 4 - Inpatient Mental Health Care Same deductible and copay as inpatient hospital care (see "Inpatient Hospital Care" above). 190 day lifetime limit in a Psychiatric Hospital. For Medicare-covered hospital stays you pay the lesser of the Group cost share or the following copayments: Days 1-5: $200 copay per day Days 6-90: $0 copay per day You get up to 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 5 - Skilled Nursing Facility (in a Medicare-certified skilled nursing facility) In 2011 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $141.50 per day 100 days for each benefit period. A benefit period begins the day you There is no copayment for services received at a Skilled Nursing Facility. No prior hospital stay is required. You are covered for 100 days each benefit period. Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 230 of 385 4 go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 6 - Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay Authorization rules may apply. $0 copay for Medicare-covered home health visits. 7 - Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must receive care from a Medicare-certified hospice. You must receive care from a Medicare-certified hospice. OUTPATIENT CARE 8 - Doctor Office Visits 20% coinsurance General See “Physical Exams” for more information. Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for each primary care doctor office visit for Medicare- covered services. You pay the lesser of the Group cost share or $20 copay for each specialist visit for Medicare-covered services. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 231 of 385 5 9 - Chiropractic Services Routine care not covered. 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. In-Network You pay the lesser of the Group cost share or $20 copay for Medicare- covered visits. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). 10 - Podiatry Services Routine care not covered. 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for Medicare- covered visits. Medicare-covered podiatry benefits are for medically-necessary foot care. 11 - Outpatient Mental Health Care 45% coinsurance for most outpatient mental health services. General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for each Medicare-covered individual or group therapy visit. 12 - Outpatient Substance Abuse Care 20% coinsurance In-Network $0 copay for Medicare-covered visits. 13 - Outpatient Services/Surgery 20% coinsurance for the doctor 20% of outpatient facility charges General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $200 copay for each Medicare-covered ambulatory surgical center visit. You pay the lesser of the Group cost share or $200 copay for each Medicare-covered outpatient hospital facility visit. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 232 of 385 6 14 - Ambulance Services (medically necessary ambulance services) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $150 copay for Medicare- covered ambulance benefits. 15 - Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 20% coinsurance for the doctor 20% of facility charge, or a set copay per emergency room visit. You don’t have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. NOT covered outside the U.S. except under limited circumstances. In-Network You pay the lesser of the Group cost share or $50 for each Medicare- covered emergency room visit. Out-of-Network Worldwide coverage. In and Out-of-Network If you are admitted to the hospital within 1 day for the same condition, you pay $0 for the emergency room visit. 16 - Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) 20% coinsurance, or a set copay NOT covered outside the U.S. except under limited circumstances. You pay the lesser of the Group cost share or $20 copay for each Medicare-covered urgently needed care visit. 17 - Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 for Medicare-covered Occupational Therapy visits. You pay the lesser of the Group cost share or $20 for Medicare-covered Physical and/or Speech/Language Therapy visits. OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 - Durable Medical Equipment (Includes wheelchairs, oxygen, etc.) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items. 19 - Prosthetic Devices (Includes braces, artificial limbs and eyes, 20% coinsurance General Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 233 of 385 7 etc.) In-Network You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items. 20 - Diabetes Self- Monitoring Training, Nutrition Therapy, and Supplies (includes coverage for glucose monitors, test strips, lancets, screening tests, and self- management training) 20% coinsurance Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. General Authorization rules may apply. In-Network $0 copay for Diabetes self-monitoring training. In-Network $0 copay for Nutrition Therapy for Diabetes. You pay the lesser of the Group cost share or 20% of the cost for Diabetes supplies. 21 - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 20% coinsurance for diagnostic tests and X-rays $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol. General Authorization rules may apply. In-Network $0 copay for Medicare-covered:  lab services  diagnostic procedures and tests X-rays  Diagnostic radiology services (not including X-rays)  therapeutic radiology services PREVENTIVE SERVICES 22 - Bone Mass Measurement (for people with Medicare who are at risk) 20% coinsurance Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. General Authorization rules may apply. In-Network $0 copay for Medicare-covered bone mass measurement 23 - Colorectal Screening Exams (for people with 20% coinsurance Covered when you are high risk or General Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 234 of 385 8 Medicare age 50 and older) when you are age 50 and older. In-Network $0 copay for Medicare-covered colorectal screenings. 24 - Immunizations (Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine) $0 copay for Flu and Pneumonia vaccines 20% coinsurance for Hepatitis B vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. General Authorization rules may apply. In-Network $0 copay for Flu and Pneumonia vaccines. $0 copay for Hepatitis B vaccine No referral necessary for Flu and Pneumonia vaccines. Referral required for other immunizations. 25 - Mammograms (Annual Screening) (for women with Medicare age 40 and older) 20% coinsurance No referral needed. Covered once a year for all women with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39. In-Network $0 copay for Medicare-covered screening mammograms. 26 - Pap Smears and Pelvic Exams (for women with Medicare) $0 copay for Pap smears Covered once every 2 years. Covered once a year for women with Medicare at high risk. 20% coinsurance for pelvic exams. In-Network $0 copay for Medicare-covered pap smears and pelvic exams. 27 - Prostate Cancer Screening Exams (For men with Medicare age 50 and older.) 20% coinsurance for the digital rectal exam. $0 for the PSA test; 20% coinsurance for other related services. Covered once a year for all men with Medicare over age 50. General Authorization rules may apply. In-Network $0 copay for Medicare-covered prostate cancer screenings. 28 – End-Stage Renal Disease 20% coinsurance for renal dialysis 20% coinsurance for Nutrition Therapy for End-Stage Renal Disease Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by General Authorization rules may apply. Out-of-area Renal Dialysis services do not require Authorization. In-Network $0 copay for renal dialysis $0 copay for Nutrition Therapy for end-stage renal disease 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 235 of 385 9 a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. 29 - Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Your Employer Group Outpatient Prescription drug benefit applies. Please contact the plan for details. 30 - Dental Services Preventive dental services (such as cleaning) not covered. $0 copay for Medicare-covered dental benefits. In general, preventive dental benefits (such as cleaning) not covered. 31 - Hearing Services Routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. You pay the lesser of the Group cost share or: - $20 for each Medicare-covered hearing exam (diagnostic hearing exams). Your Employer Group hearing benefit applies for routine exams and hearing aids. Please contact the plan for details. 32 – Vision Services 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. Routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Annual glaucoma screenings covered for people at risk. In-Network - $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. - $20 for exams to diagnosis and treat diseases and conditions of the eye). Your Employer Group Vision benefit applies for routine eye exams and glasses. Please contact the plan for details. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 236 of 385 10 33 - Physical Exams 20% coinsurance for one exam within the first 12 months of your new Medicare Part B coverage. When you get Medicare Part B, you can get a one time physical exam within the first 12 months of your new Part B coverage. The coverage does not include lab tests. $0 copay for routine exams. Limited to 1 exam every two years. $0 copay for Medicare-covered benefits. Health/Wellness Education Smoking Cessation: Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco. Each counseling attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies. In-Network This plan covers the following health/wellness education benefits:  Smoking Cessation  Health Club Membership/Fitness Classes  Nursing Hotline $0 copay for each Medicare-covered smoking cessation counseling session Transportation (Routine) Not covered. General Authorization rules may apply. In-Network $150 copay for one-way trips to a Plan-approved location. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 237 of 385 11 SECTION III – Other Benefits Offered By Group Health’s Clear Care Plan My Group Health (when you get care at a Group Health medical center).  Request appointments  View your online medical records  Email your doctor  Get test results  Check your benefits Wellness Programs Consulting Nurse helpline 24/7 Prescription Refills  Online  Mail-order  By phone Senior Caucus Travel Advisory Service Group Health Resource Line Additional Information About Covered Benefits Found in Section II Skilled Nursing Facility (Group Health Covered): When a 3 day Medicare covered hospital stay does not occur and the plan determines that the member otherwise meets all Medicare criteria for an acute inpatient hospital stay at the time of admission to a Medicare Certified Skilled Nursing Facility, the plan may authorize Medicare covered Skilled Nursing Facility Care up to the Medicare Skilled Nursing Facility day limit per benefit period. All Medicare criteria must be met and the stay must be authorized in advance by the plan. Out-Of-Pocket Limit; Stop Loss Provision for Copayments: Total copayment expenses for outpatient services and the outpatient supplies listed in this summary of benefits, hospital emergency room visits, ambulance/transportation services, inpatient hospital stays, and inpatient mental health care stays, are limited to an aggregate annual maximum of $2,500 per calendar year per member. The following items and services aren’t covered under Original Medicare or our MA plan (please refer to your employer group Certificate of Coverage for more information about what is covered and excluded under your employer group plan):  Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as a covered services.  Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare. However, certain services may be covered under a Medicare-approved clinical research study.  Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare.  Private room in a hospital, except when it is considered medically necessary.  Private duty nurses. This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 238 of 385 12  Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television.  Full-time nursing care in your home.  Custodial care, unless it is provided with covered skilled nursing care and/or skilled rehabilitation services. Custodial care, or non-skilled care, is care that helps you with activities of daily living, such as bathing or dressing.  Homemaker services include basic household assistance, including light housekeeping or light meal preparation.  Fees charged by your immediate relatives or members of your household.  Meals delivered to your home.  Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary.  Cosmetic surgery or procedures, unless because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.  Routine dental care, such as cleanings, filings or dentures. However, non-routine dental care received at a hospital may be covered.  Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines.  Routine foot care, except for the limited coverage provided according to Medicare guidelines.  Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease.  Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease.  Hearing aids and routine hearing examinations.  Eyeglasses, routine eye examinations, radial keratotomy, LASIK surgery, vision therapy and other low vision aids. However, eyeglasses are covered for people after cataract surgery, and routine eye examinations are covered under our basic benefit.  Outpatient prescription drugs including drugs for treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.  Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies.  Acupuncture.  Naturopath services (uses natural or alternative treatments).  Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at VA hospital and the VA cost-sharing is more than 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 239 of 385 13 the cost-sharing under our plan. We will reimburse veterans for the difference. Members are still responsible for our cost-sharing amounts.  Any services listed above that aren’t covered will remain not covered even if received at an emergency facility. YOUR RIGHTS AND RESPONSIBILITES SECTION 1 Our plan must honor your rights as a member of the plan To get information from us in a way that works for you, please call Customer Service (phone numbers are on the front cover). Our plan has people and translation services available to answer questions from non- English speaking members. We can also give you information in Braille, in large print, or other alternate formats if you need it. If you are eligible for Medicare because of disability, we are required to give you information about the plan’s benefits that is accessible and appropriate for you. If you have any trouble getting information from our plan because of problems related to language or disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-2048. Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights 1- 800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. Customer Service (phone numbers are on the cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Customer Service can help. We must provide you with details about your rights and responsibilities as a patient and consumer Section 1.2 We must provide information in a way that works for you (in languages other than English that are spoken in the plan service area, in Braille, in large print, or other alternate formats, etc.) Section 1.3 We must treat you with fairness, respect, and dignity at all times Section 1.4 We must ensure that you get timely access to your covered services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 240 of 385 14 As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services. Call Customer Service to learn which doctors are accepting new patients (phone numbers are on the cover of this booklet). You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral. As a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.  Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.  The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice”, that tells about these rights and explains how we protect the privacy of your health information. How do we protect the privacy of your health information?  We make sure that unauthorized people don’t see or change your records.  In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.  There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. o For example, we are required to release health information to government agencies that are checking on quality of care. o Because you are a member of our plan through Medicare, we are required to give Medicare your health information. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations. You can see the information in your records and know how it has been shared with others You have the right to look at your medical records held at the plan, and to get a copy of your records. You also have the right to ask us to make additions or corrections to your Section 1.5 We must provide access to information about the qualifications of the professionals caring for you Section 1.6 We must protect the privacy of your personal health information 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 241 of 385 15 medical records. If you ask us to do this, we will consider your request and decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Customer Service (phone numbers are on the cover of this booklet). As a member of our plan, you have the right to get several kinds of information from us. (As explained above in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.) If you want any of the following kinds of information, please call Customer Service (phone numbers are on the cover of this booklet):  Information about our plan. This includes, for example, information about the plan’s financial condition. It also includes information about the number of appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare Advantage health plans.  Information about our network providers. o For example, you have the right to get information from us about the qualifications of the providers in our network and how we pay the providers in our network. o For a list of the providers in the plan’s network, see the Provider Directory. o For more detailed information about our providers, you can call Customer Service (phone numbers are on the cover of this booklet) or visit our website at www.ghc.org/medicare.  Information about your coverage and rules you must follow in using your coverage. o If you have questions about the rules or restrictions, please call Customer Service (phone numbers are on the cover of this booklet).  Information about why something is not covered and what you can do about it. o If a medical service is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service from an out- of-network provider. Section 1.7 We must give you information about the plan, its network of providers, and your covered services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 242 of 385 16 You have the right to know your treatment options and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand. You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:  To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan.  To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.  The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. Of course, if you refuse treatment, you accept full responsibility for what happens to your body as a result.  To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:  Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.  Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives. If you want to use an “advance directive” to give your instructions, here is what to do: Section 1.8 We must support your right to make decisions about your care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 243 of 385 17  Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Customer Service to ask for the forms (phone numbers are on the cover of this booklet).  Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.  Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.  If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.  If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. What if your instructions are not followed? If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed the instructions in it, you may file a complaint with SHIBA at the Washington State Office of the Insurance Commissioner by writing to SHIBA HelpLine, Office of the Insurance Commissioner, P.O. Box 40256, Olympia, WA 98504-0256, or calling the toll- free SHIBA Helpline at 1-800-562-6900. Section 1.9 You have the right to give consent to–or refuse–care, and be told the consequences of consent or refusal Section 1.10 You have the right to have an honest discussion with your practitioner about all your treatment options, regardless of cost or benefit coverage, presented in a manner appropriate to your medical condition and ability to understand 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 244 of 385 18 You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly. You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Customer Service (phone numbers are on the cover of this booklet). Section 1.11 You have the right to join in decisions to receive, or not receive, life-sustaining treatment including care at the end of life Section 1.12 You have the right to create and update your advance directives and have your wishes honored Section 1.13 You have the right to choose a personal primary care physician affiliated with your health plan Section 1.14 You have the right to expect your personal physician to provide, arrange, and/or coordinate your care Section 1.15 You have the right to change your personal physician for any reason Section 1.16 You have the right to be educated about your role in reducing medical errors and the safe delivery of care Section 1.17 You have the right to voice opinions, concerns, positive comments and complaints and to ask us to reconsider decisions we have made Section 1.18 You have the right to appeal a decision and receive a response within a reasonable amount of time Section 1.19 You have the right to suggest changes to consumer rights and responsibilities and related policies Section 1.20 You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation Section 1.21 You have the right to be free from all forms of abuse, harassment, or discrimination 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 245 of 385 19 If it is about discrimination, call the Office for Civil Rights If you think you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights. Is it about something else? If you think you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:  You can call Customer Service (phone numbers are on the cover of this booklet).  You can call the State Health Insurance Assistance Program. There are several places where you can get more information about your rights:  You can call Customer Service (phone numbers are on the cover of this booklet).  You can call the State Health Insurance Assistance Program.  You can contact Medicare. o You can visit the Medicare website (http://www.medicare.gov) to read or download the publication “Your Medicare Rights & Protections.” o Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. SECTION 2 You have some responsibilities as a member of the plan Section 1.22 You have the right to be free from discrimination, reprisal, or any other negative action when exercising your rights Section 1.23 You have the right to request and receive a copy of your medical records, and request amendment or correction to such documents, in accordance with applicable state and federal laws Section 1.24 What can you do if you think you are being treated unfairly or your rights are not being respected? Section 1.25 How to get more information about your rights Section 2.1 What are your responsibilities? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 246 of 385 20 Things you need to do as a member of the plan are listed below. If you have any questions, please call Customer Service (phone numbers are on the cover of this booklet). We’re here to help.  Get familiar with your covered services and the rules you must follow to get these covered services. Use this booklet to learn what is covered for you and the rules you need to follow to get your covered services.  If you have any other health insurance coverage in addition to our plan, or separate prescription drug coverage, you are required to tell us. Please call Customer Service to let us know. o We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called “coordination of benefits” because it involves coordinating the health benefits you get from our plan with any other benefits available to you. We’ll help you with it.  Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get your medical care.  Use practitioners and providers affiliated with your health plan for health care benefits and services, except where services are authorized or allowed by your health plan, or in the event of emergencies.  Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. o Provide accurate information, to the extent possible, that Group Health requires to care for you. This includes your health history and your current condition. Group Health also needs your permission to obtain needed medical and personal information. This includes your name, address, phone number, marital status, dependents’ status, and names of other insurance companies. o To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon. o If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.  Understand and follow instructions for treatment, and understand the consequences of following or not following instructions.  Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices. This includes arriving on time for appointments, and notifying staff if you cannot make it on time or if you need to reschedule.  Pay what you owe. As a plan member, you are responsible for these payments: o You must pay your plan premiums to continue being a member of our plan. o In order to be eligible for our plan, you must maintain your eligibility for Medicare Part A and Part B. For that reason, some plan members must pay 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 247 of 385 21 a premium for Medicare Part A and most plan members must pay a premium for Medicare Part B to remain a member of the plan. o For some of your medical services covered by the plan, you must pay your share of the cost when you get the service. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). o If you get any medical services that are not covered by our plan or by other insurance you may have, you must pay the full cost.  Understand your health needs and work with your personal physician to develop mutually agreed upon goals about ways to stay healthy or get well when you are sick  Tell us if you move. If you are going to move, it’s important to tell us right away. Call Customer Service (phone numbers are on the cover of this booklet). o If you move outside of our plan service area, you cannot remain a member of our plan. We can help you figure out whether you are moving outside our service area. If you are leaving our service area, we can let you know if we have a plan in your new area. o If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.  Call Customer Service for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan. o Phone numbers and calling hours for Customer Service are on the cover of this booklet. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 248 of 385 22 COVERAGE DECISIONS, APPEALS, COMPLAINTS SECTION 1 Introduction This chapter explains two types of processes for handling problems and concerns:  For some types of problems, you need to use the process for coverage decisions and making appeals.  For other types of problems you need to use the process for making complaints.  Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will help you identify the right process to use. There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To keep things simple, this chapter explains the legal rules and procedures using more common words in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a grievance,” “coverage decision” rather than “organization determination” and “Independent Review Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible. However, it can be helpful – and sometimes quite important – for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations. SECTION 2 You can get help from government organizations that are not connected with us Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step. Perhaps both are true for you. Get help from an independent government organization We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has Section 1.1 What to do if you have a problem or concern Section 1.2 What about the legal terms? Section 2.1 Where to get more information and personalized assistance 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 249 of 385 23 trained counselors in every state. The program is not connected with our plan or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. You can also get help and information from Medicare For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:  You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.  You can visit the Medicare website (http://www.medicare.gov). SECTION 3 To deal with your problem, which process should you use? If you have a problem or concern and you want to do something about it, you don’t need to read this whole chapter. You just need to find and read the parts of this chapter that apply to your situation. The guide that follows will help. Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 250 of 385 24 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide to the basics of coverage decisions and appeals The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We and/or your doctor make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Making an appeal If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. When we have completed the review we give you our decision. If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:  You can call us at Customer Service (phone numbers are on the cover).  To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program (see Section 2 of this chapter).  Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 Appeal on your Section 4.1 Asking for coverage decisions and making appeals: the big picture Section 4.2 How to get help when you are asking for a coverage decision or making an appeal 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 251 of 385 25 behalf. To request any appeal after Level 1, your doctor or other provider must be appointed as your representative.  You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. o There may be someone who is already legally authorized to act as your representative under State law. o If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Service and ask for the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.  You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. There are three different types of situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section: If you’re still not sure which section you should be using, please call Customer Service (phone numbers are on the front cover). You can also get help or information from government organizations such as your State Health Insurance Assistance Program. SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal Section 4.3 Which section of this chapter gives the details for your situation? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 252 of 385 26 ? Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisions and appeals)? If not, you may want to read it before you start this section. This section is about your benefits for medical care and services. These are the benefits described in the Summary on Benefits. To keep things simple, we generally refer to “medical care coverage” or “medical care” in the rest of this section, instead of repeating “medical care or treatment or services” every time. This section tells what you can do if you are in any of the five following situations: 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan. 3. You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care. 4. You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. 5. You are being told that coverage for certain medical care you have been getting will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.  NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation (CORF) services, you need to read a separate section of this chapter because special rules apply to these types of care. Here’s what to read in those situations: o Section 6: How to ask for a longer hospital stay if you think you are being asked to leave the hospital too soon. o Section 7: How to ask our plan to keep covering certain medical services if you think your coverage is ending too soon. This section is about three services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services.  For all other situations that involve being told that medical care you have been getting will be stopped, use this section (Section 5) as your guide for what to do. Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 253 of 385 27 Legal Terms When a coverage decision involves your medical care, it is called an “organization determination.” Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a “fast decision.” Legal Terms A “fast decision” is called an “expedited decision.” How to request coverage for the medical care you want  Start by calling, writing, or faxing our plan to make your request for us to provide coverage for the medical care you want. You, or your doctor, or your representative can do this. Generally we use the standard deadlines for giving you our decision When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 14 days after we receive your request.  However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.  If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (The process for making a complaint is different from the process for coverage decisions and appeals. For Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 254 of 385 28 more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) If your health requires it, ask us to give you a “fast decision”  A fast decision means we will answer within 72 hours. o However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. o If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) We will call you as soon as we make the decision.  To get a fast decision, you must meet two requirements: o You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.) o You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.  If your doctor tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.  If you ask for a fast decision on your own, without your doctor’s support, our plan will decide whether your health requires that we give you a fast decision. o If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead). o This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision. o The letter will also tell how you can file a “fast complaint” about our decision to give you a standard decision instead of the fast decision you requested. (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) Step 2: Our plan considers your request for medical care coverage and we give you our answer. Deadlines for a “fast” coverage decision  Generally, for a fast decision, we will give you our answer within 72 hours. o As explained above, we can take up to 14 more days under certain circumstances. If we decide to take extra days to make the decision, we will tell you in writing. If we take extra days, it is called “an extended time period.” o If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.  If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 255 of 385 29 hours after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Deadlines for a “standard” coverage decision  Generally, for a standard decision, we will give you our answer within 14 days of receiving your request. o We can take up to 14 more days (“an extended time period”) under certain circumstances. If we decide to take extra days to make the decision, we will tell you in writing. o If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.  If our plan says no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.  If you decide to make appeal, it means you are going on to Level 1 of the appeals process (see Section 5.3 below). Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or a “Level 1 Appeal.” An appeal to the plan about a medical care coverage decision is called a plan “reconsideration.” Step 1: You contact our plan and make your appeal. If your health requires a quick response, you must ask for a “fast appeal.” What to do  To start an appeal you, your representative, or in some cases your doctor must contact our plan. Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 256 of 385 30  If you are asking for a standard appeal, make your standard appeal in writing by submitting a signed request.  If you are asking for a fast appeal, make your appeal in writing or call us.  You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.  You can ask for a copy of the information regarding your medical decision and add more information to support your appeal. o You have the right to ask us for a copy of the information regarding your appeal. o If you wish, you and your doctor may give us additional information to support your appeal. If your health requires it, ask for a “fast appeal” (you can make an oral request) Legal Terms A “fast appeal” is also called an “expedited appeal.”  If you are appealing a decision our plan made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”  The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast decision.” To ask for a fast appeal, follow the instructions for asking for a fast decision. (These instructions are given earlier in this section.)  If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal. Step 2: Our plan considers your appeal and we give you our answer.  When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.  We will gather more information if we need it. We may contact you or your doctor to get more information. Deadlines for a “fast” appeal  When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing. o If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 257 of 385 31 section, we tell you about this organization and explain what happens at Level 2 of the appeals process.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.  If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Deadlines for a “standard” appeal  If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. o If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we tell about this review organization and explain what happens at Level 2 of the appeals process.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.  If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2. If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: The Independent Review Organization reviews your appeal. Section 5.4 Step-by-step: How to make a Level 2 Appeal 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 258 of 385 32  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.  You have a right to give the Independent Review Organization additional information to support your appeal.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2  If you had a fast appeal to our plan at Level 1, you will automatically receive a fast appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal.  However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2  If you had a standard appeal to our plan at Level 1, you will automatically receive a standard appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal.  However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. Step 2: The Independent Review Organization gives you their answer. The Independent Review Organization will tell you its decision in writing and explain the reasons for it.  If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization.  If this organization says no to part or all of your appeal, it means they agree with our plan that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”) o The notice you get from the Independent Review Organization will tell you in writing if your case meets the requirements for continuing with the appeals process. For example, to continue and make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 259 of 385 33 requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).  If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal.  The Level 3 Appeal is handled by an administrative law judge. Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Asking for reimbursement is asking for a coverage decision from our plan If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage decision (for more information about coverage decisions, see Section 4.1 of this chapter). To make this coverage decision, we will check to see if the medical care you paid for is a covered service. We will also check to see if you followed all the rules for using your coverage for medical care. We will say yes or no to your request  If the medical care you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of your medical care within 60 calendar days after we receive your request. Or, if you haven’t paid for the services, we will send the payment directly to the provider. When we send the payment, it’s the same as saying yes to your request for a coverage decision.)  If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why. (When we turn down your request for payment, it’s the same as saying no to your request for a coverage decision.) What if you ask for payment and we say that we will not pay? If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment. To make this appeal, follow the process for appeals that we describe in part 5.3 of this section. Go to this part for step-by-step instructions. When you are following these instructions, please note:  If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we receive your appeal. (If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.) Section 5.5 What if you are asking our plan to pay you for our share of a bill you have received for medical care? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 260 of 385 34  If the Independent Review Organization reverses our decision to deny payment, we must send the payment you have requested to you or to the provider within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days. SECTION 6 How to ask us to cover a longer hospital stay if you think the doctor is discharging you too soon When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury. For more information about our coverage for your hospital care, including any limitations on this coverage, see the Summary of Benefits. During your hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for care you may need after you leave.  The day you leave the hospital is called your “discharge date.” Our plan’s coverage of your hospital stay ends on this date.  When your discharge date has been decided, your doctor or the hospital staff will let you know.  If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. This section tells you how to ask. During your hospital stay, you will be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they are admitted to a hospital. Someone at the hospital is supposed to give it to you within two days after you are admitted. 1. Read this notice carefully and ask questions if you don’t understand it. It tells you about your rights as a hospital patient, including:  Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them.  Your right to be involved in any decisions about your hospital stay, and know who will pay for it.  Where to report any concerns you have about quality of your hospital care.  What to do if you think you are being discharged from the hospital too soon. Legal Terms The written notice from Medicare tells you how you can “make an appeal.” Making an appeal is a formal, legal way to ask for a delay in your discharge date so that your hospital care will be covered for a longer time. (Section 7.2 below tells how to make this appeal.) Section 6.1 During your hospital stay, you will get a written notice from Medicare that tells about your rights 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 261 of 385 35 2. You must sign the written notice to show that you received it and understand your rights.  You or someone who is acting on your behalf must sign the notice. (Section 4 of this chapter tells how you can give written permission to someone else to act as your representative.)  Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date (your doctor or hospital staff will tell you your discharge date). Signing the notice does not mean you are agreeing on a discharge date. 3. Keep your copy of the signed notice so you will have the information about making an appeal (or reporting a concern about quality of care) handy if you need it.  If you sign the notice more than 2 days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged.  To look at a copy of this notice in advance, you can call Customer Service or 1- 800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also see it online at http://www.cms.hhs.gov. If you want to ask for your hospital services to be covered by our plan for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.  Follow the process. Each step in the first two levels of the appeals process is explained below.  Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do.  Ask for help if you need it. If you have questions or need help at any time, please call Customer Service (phone numbers are on the front cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you. Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or a “Level 1 Appeal.” Step 1: Contact the Quality Improvement Organization in your state and ask for a “fast review” of your hospital discharge. You must act quickly. Legal Terms A “fast review” is also called an “immediate review” or an “expedited review.” What is the Quality Improvement Organization? Section 6.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 262 of 385 36  This organization is a group of doctors and other health care professionals who are paid by the Federal government. These experts are not part of our plan. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare. How can you contact this organization?  The written notice you received (An Important Message from Medicare) tells you how to reach this organization. Act quickly:  To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. (Your “planned discharge date” is the date that has been set for you to leave the hospital.) o If you meet this deadline, you are allowed to stay in the hospital after your discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization. o If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date.  If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details about this other way to make your appeal, see Section 6.4. Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review?  Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.  The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and our plan has given to them.  By noon of the day after the reviewers informed our plan of your appeal, you will also get a written notice that gives your planned discharge date and explains the reasons why your doctor, the hospital, and our plan think it is right (medically appropriate) for you to be discharged on that date. Legal Terms This written explanation is called the “Detailed Notice of Discharge.” You can get a sample of this notice by calling Customer Service or 1-800-MEDICARE (1-800- 633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you can get see a sample notice online at http://www.cms.hhs.gov/BNI/ 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 263 of 385 37 Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes?  If the review organization says yes to your appeal, our plan must keep providing your covered hospital services for as long as these services are medically necessary.  You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered hospital services. What happens if the answer is no?  If the review organization says no to your appeal, they are saying that your planned discharge date is medically appropriate. (Saying no to your appeal is also called turning down your appeal.) If this happens, our plan’s coverage for your hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal.  If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal  If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to “Level 2” of the appeals process. If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review  You must ask for this review within 60 calendar days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation Section 6.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 264 of 385 38  Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 calendar days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. If the review organization says yes:  Our plan must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. Our plan must continue providing coverage for your hospital care for as long as it is medically necessary.  You must continue to pay your share of the costs and coverage limitations may apply. If the review organization says no:  It means they agree with the decision they made to your Level 1 Appeal and will not change it. This is called “upholding the decision.” It is also called “turning down your appeal.”  The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If the review organization turns down your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. You can appeal to our plan instead As explained above in Section 6.2, you must act quickly to contact the Quality Improvement Organization to start your first appeal of your hospital discharge. (“Quickly” means before you leave the hospital and no later than your planned discharge date). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Legal Terms A “fast” review (or “fast appeal”) is also called an “expedited” review (or “expedited appeal”). Section 6.4 What if you miss the deadline for making your Level 1 Appeal? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 265 of 385 39 Step 1: Contact our plan and ask for a “fast review.”  Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Step 2: Our plan does a “fast” review of your planned discharge date, checking to see if it was medically appropriate.  During this review, our plan takes a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will check to see if the decision about when you should leave the hospital was fair and followed all the rules.  In this situation, we will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review. Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).  If our plan says yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)  If our plan says no to your fast appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your hospital services ends as of the day we said coverage would end.  If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. You will be responsible for the cost of care starting from noon on the day after our plan says no to your appeal. Step 4: If our plan says no to your fast appeal, your case will automatically be sent on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process. Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 266 of 385 40 Step 1: We will automatically forward your case to the Independent Review Organization.  We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 9 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge.  If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.  If this organization says no to your appeal, it means they agree with our plan that your planned hospital discharge date was medically appropriate. (This is called “upholding the decision.” It is also called “turning down your appeal.”) o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge. Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 7 How to ask us to keep covering certain medical services if you think your coverage is ending too soon This section is about the following types of care only: Section 7.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 267 of 385 41  Home health care services you are getting.  Skilled nursing care you are getting as a patient in a skilled nursing facility.  Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation. When you are getting any of these types of care, you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. For more information on your covered services, including your share of the cost and any limitations to coverage that may apply, see the Summary of Benefits. When our plan decides it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, our plan will stop paying its share of the cost for your care. If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask. 1. You receive a notice in writing. At least two days before our plan is going to stop covering your care, the agency or facility that is providing your care will give you a notice.  The written notice tells you the date when our plan will stop covering the care for you. Legal Terms In this written notice, we are telling you about a “coverage decision” we have made about when to stop covering your care. (For more information about coverage decisions, see Section 4 in this chapter.)  The written notice also tells what you can do if you want to ask our plan to change this decision about when to end your care, and keep covering it for a longer period of time. Legal Terms In telling what you can do, the written notice is telling how you can “make an appeal.” Making an appeal is a formal, legal way to ask our plan to change the coverage decision we have made about when to stop your care. (Section 8.3 below tells how you can make an appeal.) Legal Terms The written notice is called the “Notice of Medicare Non-Coverage.” To get a sample copy, call Customer Service or 1-800-MEDICARE (1- 800-633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.). Or see a copy online at http://www.cms.hhs.gov/BNI/ Section 7.2 We will tell you in advance when your coverage will be ending 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 268 of 385 42 2. You must sign the written notice to show that you received it.  You or someone who is acting on your behalf must sign the notice. (Section 4 tells how you can give written permission to someone else to act as your representative.)  Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan that it’s time to stop getting the care. If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.  Follow the process. Each step in the first two levels of the appeals process is explained below.  Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint. Section 9 of this chapter tells you how to file a complaint.)  Ask for help if you need it. If you have questions or need help at any time, please call Customer Service (phone numbers are on the front cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and decides whether to change the decision made by our plan. Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or “Level 1 Appeal.” Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization in your state and ask for a review. You must act quickly. What is the Quality Improvement Organization?  This organization is a group of doctors and other health care experts who are paid by the Federal government. These experts are not part of our plan. They check on the quality of care received by people with Medicare and review plan decisions about when it’s time to stop covering certain kinds of medical care. How can you contact this organization?  The written notice you received tells you how to reach this organization. What should you ask for?  Ask this organization to do an independent review of whether it is medically appropriate for our plan to end coverage for your medical services. Section 7.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 269 of 385 43 Your deadline for contacting this organization.  You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.  If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details about this other way to make your appeal, see Section 8.4. Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review?  Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.  The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them.  By the end of the day the reviewers informed our plan of your appeal, you will also get a written notice from the plan that gives our reasons for wanting to end the plan’s coverage for your services. Legal Terms This notice explanation is called the “Detailed Explanation of Non- Coverage.” Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. What happens if the reviewers say yes to your appeal?  If the reviewers say yes to your appeal, then our plan must keep providing your covered services for as long as it is medically necessary.  You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services. What happens if the reviewers say no to your appeal?  If the reviewers say no to your appeal, then your coverage will end on the date we have told you. Our plan will stop paying its share of the costs of this care.  If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 270 of 385 44  This first appeal you make is “Level 1” of the appeals process. If reviewers say no to your Level 1 Appeal – and you choose to continue getting care after your coverage for the care has ended – then you can make another appeal.  Making another appeal means you are going on to “Level 2” of the appeals process. If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review.  You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation.  Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes to your appeal?  Our plan must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. Our plan must continue providing coverage for the care for as long as it is medically necessary.  You must continue to pay your share of the costs and there may be coverage limitations that apply. What happens if the review organization says no?  It means they agree with the decision they made to your Level 1 Appeal and will not change it. (This is called “upholding the decision.” It is also called “turning down your appeal.”)  The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further.  There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to Section 7.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 271 of 385 45 accept that decision or to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. You can appeal to our plan instead As explained above in Section 7.3, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Here are the steps for a Level 1 Alternate Appeal: Legal Terms A “fast” review (or “fast appeal”) is also called an “expedited” review (or “expedited appeal”). Step 1: Contact our plan and ask for a “fast review.”  Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Step 2: Our plan does a “fast” review of the decision we made about when to end coverage for your services.  During this review, our plan takes another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan’s coverage for services you were receiving.  We will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review. (Usually, if you make an appeal to our plan and ask for a “fast review,” we are allowed to decide whether to agree to your request and give you a “fast review.” But in this situation, the rules require us to give you a fast response if you ask for it.) Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).  If our plan says yes to your fast appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)  If our plan says no to your fast appeal, then your coverage will end on the date we have told you and our plan will not pay after this date. Our plan will stop paying its share of the costs of this care. Section 7.5 What if you miss the deadline for making your Level 1 Appeal? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 272 of 385 46  If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If our plan says no to your fast appeal, your case will automatically go on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process. Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: We will automatically forward your case to the Independent Review Organization.  We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 9 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.  If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.  If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it. (This is called “upholding the decision.” It is also called “turning down your appeal.”) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 273 of 385 47 o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal. Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.  There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 8 Taking your appeal to Level 3 and beyond This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 Appeal A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an “Administrative Law Judge.”  If the Administrative Law Judge says yes to your appeal, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 4. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 3 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the judge’s decision. o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal request with any accompanying documents. We may wait for the Level 4 Appeal decision before authorizing or providing the service in dispute.  If the Administrative Law Judge says no to your appeal, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you can continue to the next level of the review process. If the administrative law judge says no to your Section 8.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 274 of 385 48 appeal, the notice you get will tell you what to do next if you choose to continue with your appeal. Level 4 Appeal The Medicare Appeals Council will review your appeal and give you an answer. The Medicare Appeals Council works for the Federal government.  If the answer is yes, or if the Medicare Appeals Council denies our request to review a favorable Level 3 Appeal decision, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 4 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the Medicare Appeals Council’s decision. o If we decide to appeal the decision, we will let you know in writing.  If the answer is no or if the Medicare Appeals Council denies the review request, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Medicare Appeals Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 Appeal A judge at the Federal District Court will review your appeal.  This is the last step of the administrative appeals process. MAKING COMPLAINTS SECTION 9 How to make a complaint about quality of care, waiting times, customer service, or other concerns ? If your problem is about decisions related to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 4 of this chapter. This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process. Section 9.1 What kinds of problems are handled by the complaint process? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 275 of 385 49 Quality of your medical care  Are you unhappy with the quality of the care you have received (including care in the hospital)? Respecting your privacy  Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential? Disrespect, poor customer service, or other negative behaviors  Has someone been rude or disrespectful to you?  Are you unhappy with how our Member Services has dealt with you?  Do you feel you are being encouraged to leave our plan? Waiting times  Are you having trouble getting an appointment, or waiting too long to get it?  Have you been kept waiting too long by doctors or other health professionals?  Or by Member Services or other staff at our plan?  Examples include waiting too long on the phone, in the waiting room, or in the exam room. Cleanliness  Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office? Information you get from our plan  Do you believe we have not given you a notice that we are required to give?  Do you think written information we have given you is hard to understand? These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals The process of asking for a coverage decision and making appeals is explained in sections 4-8 of this chapter. If you are asking for a decision or making an appeal, you use that process, not the complaint process. However, if you have already asked for a coverage decision or made an appeal, and you think that our plan is not responding quickly enough, you can also make a complaint about our slowness. Here are examples:  If you have asked us to give you a “fast response” for a coverage decision or appeal, and we have said we will not, you can make a complaint. If you have any of these kinds of problems, you can “make a complaint” 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 276 of 385 50  If you believe our plan is not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.  When a coverage decision we made is reviewed and our plan is told that we must cover or reimburse you for certain medical services, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.  When your plan does not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint. Legal Terms  What this section calls a “complaint” is also called a “grievance.”  Another term for “making a complaint” is “filing a grievance.”  Another way to say “using the process for complaints” is “using the process for filing a grievance.” Step 1: Contact us promptly – either by phone or in writing.  Usually, calling Customer Service is the first step. If there is anything else you need to do, Customer Service will let you know. Customer Service may be reached by calling 1-888-901-4600 (TTY only, call 1-800-833-6388 or 711). Hours are Monday-Friday, 8 a.m.-8 p.m. From November 15 through March 1, hours are daily, 8 a.m.-8 p.m.  If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works: o For this process your grievance requests must be in writing, and mailed to Group Health Medicare Customer Service Medicare Grievance, P.O. Box 34590, Seattle WA 98124-1590 or fax: 206-901-6205, or From www.ghc.org click “Contact Us.” We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.  Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.  If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours. Legal What this section calls a “fast complaint” is also called a “fast Section 9.2 The formal name for “making a complaint” is “filing a grievance” Section 9.3 Step-by-step: Making a complaint 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 277 of 385 51 Terms grievance.” Step 2: We look into your complaint and give you our answer.  If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.  Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.  If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. You can make your complaint about the quality of care you received to our plan by using the step-by-step process outlined above. When your complaint is about quality of care, you also have two extra options:  You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). If you make a complaint to this organization, we will work with them to resolve your complaint.  Or, you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. Section 9.4 You can also make complaints about quality of care to the Quality Improvement Organization 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 278 of 385 1 Group Medical Coverage Agreement Group Health Cooperative (also referred to as “GHC”) is a nonprofit health maintenance organization furnishing health care coverage on a prepayment basis. The Group identified below wishes to purchase such coverage. This Agreement sets forth the terms under which that coverage will be provided, including the rights and responsibilities of the contracting parties; requirements for enrollment and eligibility; and benefits to which those enrolled under this Agreement are entitled. The Agreement between GHC and the Group consists of the following:  Standard Provisions  Attached Benefit Booklet  Signed Group application  Premium Schedule Group Health Cooperative Signed: Title: President and Chief Executive Officer City of Renton, 0057500, 4057500 Signed: Title: This Agreement will continue in effect until terminated or renewed as herein provided for and is effective January 1, 2011. PA-113311 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 279 of 385 C31620-0057500 2 Group Medical Coverage Agreement Table of Contents Standard Provisions Attachment 1 Benefit Booklet Attachment 2 Premium Schedule Attachment 3 Medicare Endorsement 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 280 of 385 C31620-0057500 3 Standard Provisions 1. GHC agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group. 2. Monthly Premium Payments. For the initial term of this Agreement, the Group shall submit to GHC for each Member the monthly premiums set forth in the current Premium Schedule and a verification of enrollment. Payment must be received on or before the due date and is subject to a grace period of ten (10) days. Premiums are subject to change by GHC upon thirty (30) days written notice. Premium rates will be revised as a part of the annual renewal process. In the event the Group increases or decreases enrollment at least twenty-five percent (25%) or more, GHC reserves the right to require re-rating of the Group. 3. Dissemination of Information. Unless the Group has accepted responsibility to do so, GHC will disseminate information describing benefits set forth in the Benefit Booklet attached to this Agreement. 4. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members enrolled under this Agreement. 5. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the administration of this Agreement. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. 6. Modification of Agreement. Except as required by federal and Washington State law, this Agreement may not be modified without agreement between both parties. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this Agreement, convey or void any coverage, increase or reduce any benefits under this Agreement or be used in the prosecution or defense of a claim under this Agreement. 7. Indemnification. GHC agrees to indemnify and hold the Group harmless against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of GHC's failure to perform, negligent performance or willful misconduct of its directors, officers, employees and agents of their express obligations under this Agreement. The Group agrees to indemnify and hold GHC harmless against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of the Group’s failure to perform, negligent performances or willful misconduct of its directors, officers, employees and agents of their express obligations under this Agreement. The indemnifying party shall give the other party prompt notice of any claim covered by this section and provide reasonable assistance (at its expense). The indemnifying party shall have the right and duty to assume the control of the defense thereof with counsel reasonably acceptable to the other party. Either party may take part in the defense at its own expense after the other party assumes the control thereof. 8. Compliance With Law. The Group and GHC shall comply with all applicable state and federal laws and regulations in performance of this Agreement. This Agreement is entered into and governed by the laws of Washington State, except as otherwise pre-empted by ERISA and other federal laws. 9. Governmental Approval. If GHC has not received any necessary government approval by the date when notice is required under this Agreement, GHC will notify the Group of any changes once governmental approval has been received. GHC may amend this Agreement by giving notice to the Group upon receipt of government approved rates, benefits, limitations, exclusions or other provisions, in which case such rates, benefits, limitations, exclusions or provisions will go into effect as required by the governmental agency. All 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 281 of 385 C31620-0057500 4 amendments are deemed accepted by the Group unless the Group gives GHC written notice of non-acceptance within thirty (30) days after receipt of amendment, in which event this Agreement and all rights to services and other benefits terminate the first of the month following thirty (30) days after receipt of non-acceptance. 10. Confidentiality. Each party acknowledges that performance of its obligations under this Agreement may involve access to and disclosure of data, procedures, materials, lists, systems and information, including medical records, employee benefits information, employee addresses, social security numbers, e-mail addresses, phone numbers and other confidential information regarding the Group’s employees (collectively the “information”). The information shall be kept strictly confidential and shall not be disclosed to any third party other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have a need to know such information in order to perform the services required of such party pursuant to this Agreement, or for the proper management and administration of the receiving party, provided that such representatives are informed of the confidentiality provisions of this Agreement and agree to abide by them, (ii) pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal, state or local law, statute, rule or regulation. The disclosing party will provide the other party with prompt notice of any request the disclosing party receives to disclose information pursuant to applicable legal requirements, so that the other party may object to the request and/or seek an appropriate protective order against such request. Each party shall maintain the confidentiality of medical records and confidential patient and employee information as required by applicable law. 11. Arbitration. Any dispute, controversy or difference between GHC and the Group arising out of or relating to this Agreement, or the breach thereof, shall be settled by arbitration in Seattle, Washington in accordance with the Commercial Arbitration Rules of the American Arbitration Association, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Except as may be required by law, neither party nor arbitrator may disclose the existence, content or results of any arbitration hereunder without the prior written consent of both parties. 12. HIPAA. Definition of Terms. Terms used, but not otherwise defined, in this Section shall have the same meaning as those terms have in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Transactions Accepted. GHC will accept Standard Transactions, pursuant to HIPAA, if the Group elects to transmit such transactions. The Group shall ensure that all Standard Transactions transmitted to GHC by the Group or the Group’s business associates are in compliance with HIPAA standards for electronic transactions. The Group shall indemnify GHC for any breach of this section by the Group. 13. Termination of Entire Agreement. This is a guaranteed renewable Agreement and cannot be terminated without the mutual approval of each of the parties, except in the circumstances set forth below. a. Nonpayment or Non-Acceptance of Premium. Failure to make any monthly premium payment or contribution in accordance with subsection 2 above shall result in termination of this Agreement as of the premium due date. The Group’s failure to accept the revised premiums provided as part of the annual renewal process shall be considered nonpayment and result in non-renewal of this Agreement. The Group may terminate this Agreement upon fifteen (15) days written notice of premium increase, as set forth in subsection 2 above. b. Misrepresentation. GHC may rescind or terminate this Agreement upon written notice in the event that intentional misrepresentation, fraud or omission of information was used in order to obtain Group coverage. Either party may terminate this Agreement in the event of intentional misrepresentation, fraud or omission of information by the other party in performance of its responsibilities under this Agreement. c. Underwriting Guidelines. GHC may terminate this Agreement in the event the Group no longer meets underwriting guidelines established by GHC that were in effect at the time the Group was accepted. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 282 of 385 C31620-0057500 5 d. Federal or State Law. GHC may terminate this Agreement in the event there is a change in federal or state law that no longer permits the continued offering of the coverage described in this Agreement. 14. Withdrawal or Cessation of Services. a. GHC may determine to withdraw from a Service Area or from a segment of its Service Area after GHC has demonstrated to the Washington State Office of the Insurance Commissioner that GHC’s clinical, financial or administrative capacity to service the covered Members would be exceeded. b. GHC may determine to cease to offer the Group’s current plan and replace the plan with another plan offered to all covered Members within that line of business that includes all of the health care services covered under the replaced plan and does not significantly limit access to the services covered under the replaced plan. GHC may also allow unrestricted conversion to a fully comparable GHC product. GHC will provide written notice to each covered Member of the discontinuation or non-renewal of the plan at least ninety (90) days prior to discontinuation. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 283 of 385 Dear Group Health Subscriber: This booklet contains important information about your healthcare plan. This is your 2011 Group Health Benefit Booklet (Certificate of Coverage). It explains the services and benefits you and those enrolled on your contract are entitled to receive from Group Health Cooperative. Sections of this document may be bolded and italicized, which identifies changes that Group Health has made to the plan. The benefits reflected in this booklet were approved by your employer or association who contracts with Group Health for your healthcare coverage. If you are eligible for Medicare, please read Section IV.J. as it may affect your prescription drug coverage. We recommend you read it carefully so you’ll understand not only the benefits, but the exclusions, limitations, and eligibility requirements of this certificate. Please keep this certificate for as long as you are covered by Group Health. We will send you revisions if there are any changes in your coverage. This certificate is not the contract itself; you can contact your employer or group administrator if you wish to see a copy of the contract (Medical Coverage Agreement). We’ll gladly answer any questions you might have about your Group Health benefits. Please call our Group Health Customer Service Center at (206) 901-4636 in the Seattle area, or toll-free in Washington, 1-888-901-4636. Thank you for choosing Group Health Cooperative. We look forward to working with you to preserve and enhance your health. Very truly yours, Scott Armstrong President PA-1133a11, CA-139511,CA-135311,CA-222011,CA-198411,CA-182411,CA-11711,CA-138511,CA-139711 CA-3712, CA-3768 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 284 of 385 C31620-0057500a 1 Benefit Booklet Table of Contents Section I. Introduction A. Accessing Care B. Cost Shares C. Subscriber’s Liability D. Claims Section II. Allowances Schedule Section III. Eligibility, Enrollment and Termination A. Eligibility B. Enrollment C. Effective Date of Enrollment D. Eligibility for Medicare E. Termination of Coverage F. Services After Termination of Agreement G. Continuation of Coverage Options Section IV. Schedule of Benefits A. Hospital Care B. Medical and Surgical Care C. Chemical Dependency Treatment D. Plastic and Reconstructive Services E. Home Health Care Services F. Hospice Care G. Rehabilitation Services H. Devices, Equipment and Supplies I. Tobacco Cessation J. Drugs, Medicines, Supplies and Devices K. Mental Health Care Services L. Emergency/Urgent Care M. Ambulance Services N. Skilled Nursing Facility Section V. General Exclusions Section VI. Grievance Processes for Complaints and Appeals Section VII. General Provisions A. Coordination of Benefits B. Subrogation and Reimbursement Rights C. Miscellaneous Provisions Section VIII. Definitions Attachment: Group Medicare Coverage 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 285 of 385 C31620-0057500a 2 Group Health Cooperative believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act of 2010. Questions regarding this status may be directed to GHC Customer Service at (888) 901-4636. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at (866) 444-3272 or www.dol.gov/ebsa/healthreform. Section I. Introduction Group Health Cooperative (also referred to as “GHC”) is a nonprofit health maintenance organization furnishing health care primarily on a prepayment basis. Read This Benefit Booklet Carefully This Benefit Booklet is a statement of benefits, exclusions and other provisions, as set forth in the Group Medical Coverage Agreement (“Agreement”) between GHC and the employer or Group. A full description of benefits, exclusions, limits and Out-of-Pocket Expenses can be found in the Schedule of Benefits, Section IV; General Exclusions, Section V; and Allowances Schedule, Section II. These sections must be considered together to fully understand the benefits available under the Agreement. Words with special meaning are capitalized. They are defined in Section VIII. A. Accessing Care Members are entitled to Covered Services only at GHC Facilities and from GHC Personal Physicians. Except as follows:  Emergency care,  Self-Referral to women’s health care providers, as set forth below,  Visits with GHC-Designated Self-Referral Specialists, as set forth below,  Care provided pursuant to a Referral. Referrals must be requested by the Member’s Personal Physician and approved by GHC, and  Other services as specifically set forth in the Allowances Schedule and Section IV. Members may refer to Sections IV.A. and IV.C. for more information about inpatient admissions. Primary Care. GHC recommends that Members select a GHC Personal Physician when enrolling under the Agreement. One Personal Physician may be selected for an entire family, or a different Personal Physician may be selected for each family member. Selecting a Personal Physician or changing from one Personal Physician to another can be accomplished by contacting GHC Customer Service, or accessing the GHC website at www.ghc.org. The change will be made within twenty-four (24) hours of the receipt of the request, if the selected physician’s caseload permits. A listing of GHC Personal Physicians, Referral specialists, women’s health care providers and GHC-Designated Self-Referral Specialists is available by contacting GHC Customer Service at (206) 901-4636 or (888) 901- 4636, or by accessing GHC’s website at www.ghc.org. In the case that the Member’s Personal Physician no longer participates in GHC’s network, the Member will be provided access to the Personal Physician for up to sixty (60) days following a written notice offering the Member a selection of new Personal Physicians from which to choose. Specialty Care. Unless otherwise indicated in this section, the Allowances Schedule or Section IV., Referrals are required for specialty care and specialists. GHC-Designated Self-Referral Specialist. Members may make appointments directly with GHC-Designated Self-Referral Specialists at Group Health-owned or -operated medical centers without a Referral from their 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 286 of 385 C31620-0057500a 3 Personal Physician. Self-Referrals are available for the following specialty care areas: allergy, audiology, cardiology, chemical dependency, chiropractic/manipulative therapy, dermatology, gastroenterology, general surgery, hospice, manipulative therapy, mental health, nephrology, neurology, obstetrics and gynecology, occupational medicine*, oncology/hematology, ophthalmology, optometry, orthopedics, otolaryngology (ear, nose and throat), physical therapy*, smoking cessation, speech/language and learning services* and urology. * Medicare patients need prior authorization for these specialists. Women’s Health Care Direct Access Providers. Female Members may see a participating General and Family Practitioner, Physician’s Assistant, Gynecologist, Certified Nurse Midwife, Licensed Midwife, Doctor of Osteopathy, Pediatrician, Obstetrician or Advanced Registered Nurse Practitioner who is contracted by GHC to provide women’s health care services directly, without a Referral from their Personal Physician, for Medically Necessary maternity care, covered reproductive health services, preventive care (well care) and general examinations, gynecological care and follow-up visits for the above services. Women’s health care services are covered as if the Member’s Personal Physician had been consulted, subject to any applicable Cost Shares, as set forth in the Allowances Schedule. If the Member’s women’s health care provider diagnoses a condition that requires Referral to other specialists or hospitalization, the Member or her chosen provider must obtain preauthorization and care coordination in accordance with applicable GHC requirements. Second Opinions. The Member may access, upon request, a second opinion regarding a medical diagnosis or treatment plan from a GHC Provider. Emergent and Urgent Care. Emergent care is available at GHC Facilities. If Members cannot get to a GHC Facility, Members may obtain Emergency services from the nearest hospital. Members or persons assuming responsibility for a Member must notify GHC by way of the GHC Emergency Notification Line within twenty- four (24) hours of admission to a non-GHC Facility, or as soon thereafter as medically possible. Members may refer to Section IV. for more information about coverage of Emergency services. In the GHC Service Area, urgent care is covered at GHC medical centers, GHC urgent care clinics or GHC Provider’s offices. Urgent care received at any hospital emergency department is not covered unless authorized in advance by a GHC Provider. Care received at urgent care facilities other than those listed above is only covered for emergency services, subject to the applicable Emergency Cost Share. Members may refer to Section IV. for more information about coverage of urgent care services. Outside the GHC Service Area, urgent care is covered at any medical facility. Members may refer to Section IV. for more information about coverage of urgent care services. Recommended Treatment. GHC’s Medical Director or his/her designee will determine the necessity, nature and extent of treatment to be covered in each individual case and the judgment, made in good faith, will be final. Members have the right to participate in decisions regarding their health care. A Member may refuse any recommended treatment or diagnostic plan to the extent permitted by law. Members who obtain care not recommended by GHC, do so with the full understanding that GHC has no obligation for the cost, or liability for the outcome, of such care. Coverage decisions may be appealed as set forth in Section VI. Major Disaster or Epidemic. In the event of a major disaster or epidemic, GHC will provide coverage according to GHC’s best judgment, within the limitations of available facilities and personnel. GHC has no liability for delay or failure to provide or arrange Covered Services to the extent facilities or personnel are unavailable due to a major disaster or epidemic. Unusual Circumstances. If the provision of Covered Services is delayed or rendered impossible due to unusual circumstances such as complete or partial destruction of facilities, military action, civil disorder, labor disputes or similar causes, GHC shall provide or arrange for services that, in the reasonable opinion of GHC's Medical Director, or his/her designee, are emergent or urgently needed. In regard to nonurgent and routine services, GHC shall make a good faith effort to provide services through its then-available facilities and personnel. GHC 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 287 of 385 C31620-0057500a 4 shall have the option to defer or reschedule services that are not urgent while its facilities and services are so affected. In no case shall GHC have any liability or obligation on account of delay or failure to provide or arrange such services. B. Cost Shares The Subscriber shall be liable for the following Cost Shares when services are received by the Subscriber and any of his/her Dependents. 1. Copayments. Members shall be required to pay Copayments at the time of service as set forth in the Allowances Schedule. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non-Covered Service. 2. Coinsurance. Members shall be required to pay coinsurance for certain Covered Services as set forth in the Allowances Schedule. 3. Out-of-Pocket Limit. Total Out-of-Pocket Expenses incurred during the same calendar year shall not exceed the Out-of-Pocket Limit set forth in the Allowances Schedule. Out-of-Pocket Expenses which apply toward the Out-of-Pocket Limit are set forth in the Allowances Schedule. C. Subscriber's Liability The Subscriber is liable for (1) payment to the Group of his/her contribution toward the monthly premium, if any; (2) payment of Cost Share amounts for Covered Services provided to the Subscriber and his/her Dependents, as set forth in the Allowances Schedule; and (3) payment of any fees charged for non-Covered Services provided to the Subscriber and his/her Dependents, at the time of service. Payment of an amount billed by GHC must be received within thirty (30) days of the billing date. D. Claims Claims for benefits may be made before or after services are obtained. To make a claim for benefits under the Agreement, a Member (or the Member’s authorized representative) must contact GHC Customer Service, or submit a claim for reimbursement as described below. Other inquiries, such as asking a health care provider about care or coverage, or submitting a prescription to a pharmacy, will not be considered a claim for benefits. If a Member receives a bill for services the Member believes are covered under the Agreement, the Member must, within ninety (90) days of the date of service, or as soon thereafter as reasonably possible, either (1) contact GHC Customer Service to make a claim or (2) pay the bill and submit a claim for reimbursement of Covered Services to GHC, P.O. Box 34585, Seattle, WA 98124-1585. In no event, except in the absence of legal capacity, shall a claim be accepted later than one (1) year from the date of service. GHC will generally process claims for benefits within the following timeframes after GHC receives the claims:  Pre-service claims – within fifteen (15) days.  Claims involving urgently needed care – within seventy-two (72) hours.  Concurrent care claims – within twenty-four (24) hours.  Post-service claims – within thirty (30) days. Timeframes for pre-service and post-service claims can be extended by GHC for up to an additional fifteen (15) days. Members will be notified in writing of such extension prior to the expiration of the initial timeframe. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 288 of 385 C31620-0057500a 6 Section II. Allowances Schedule The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the Group Medical Coverage Agreement. “Welcome” Outpatient Services Waiver Not applicable. Annual Deductible No annual Deductible. Plan Coinsurance No Plan Coinsurance. Lifetime Maximum No Lifetime Maximum on covered Essential Health Benefits. Hospital Services  Covered inpatient medical and surgical services, including acute chemical withdrawal (detoxification) Covered in full.  Covered outpatient hospital surgery (including ambulatory surgical centers) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Outpatient Services  Covered outpatient medical and surgical services Covered subject to the lesser of GHC's charge or a $25 outpatient services Copayment per Member per visit.  Allergy testing Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Oncology (radiation therapy, chemotherapy) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Drugs – Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed in the GHC drug formulary Covered subject to the lesser of GHC’s charge or a $10 Copayment.  Over-the-counter drugs and medicines Not covered.  Injectables 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 289 of 385 C31620-0057500a 7 Injectables that can be self-administered are subject to the lesser of GHC’s charge or the applicable prescription drug Cost Share (as set forth above). Other covered injectables are subject to the lesser of GHC’s charge or the applicable outpatient services Cost Share. Injectables necessary for travel are not covered.  Mail order drugs and medicines dispensed through the GHC-designated mail order service Covered subject to the lesser of GHC’s charge or the applicable prescription drug Cost Share (as set forth above) for each thirty (30) day supply or less. Out-of-Pocket Limit Limited to an aggregate maximum of $2,000 per Member or $4,000 per family per calendar year. Except as otherwise noted in this Allowances Schedule, the total Out-of-Pocket Expenses for the following Covered Services are included in the Out-of-Pocket Limit:  Inpatient services  Outpatient services  Emergency care at a GHC or non-GHC Facility  Ambulance services Acupuncture Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider up to a maximum of eight (8) visits per Member per medical diagnosis per calendar year. When approved by GHC, additional visits are covered. Ambulance Services  Emergency ground/air transport Covered at 80%.  Non-emergent ground/air interfacility transfer Covered at 80% for GHC-initiated transfers, except hospital-to-hospital ground transfers covered in full. Chemical Dependency  Inpatient services (including Residential Treatment services) Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment.  Outpatient services Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Acute detoxification covered as any other medical service. Dental Services (including accidental injury to natural teeth) Not covered, except as set forth in Section IV.B.23. Devices, Equipment and Supplies (for home use) Covered at 80% for: 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 290 of 385 C31620-0057500a 8  Durable medical equipment  Orthopedic appliances  Post-mastectomy bras limited to two (2) every six (6) months  Ostomy supplies  Prosthetic devices When provided in a home health setting in lieu of hospitalization as described in Section IV.A.3., benefits will be the greater of benefits available for devices, equipment and supplies, home health or hospitalization. See Hospice for durable medical equipment provided in a hospice setting. Diabetic Supplies Insulin, needles, syringes and lancets – see Drugs-Outpatient. External insulin pumps, blood glucose monitors, testing reagents and supplies - see Devices, Equipment and Supplies. Diagnostic Laboratory and Radiology Services Covered in full. Emergency Services  At a GHC Facility Covered subject to the lesser of GHC’s charge or a $75 Copayment per Member per Emergency visit. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services Cost Share.  At a non-GHC Facility Covered subject to the lesser of GHC’s charge or a $125 Copayment per Member per Emergency visit. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services Cost Share. Hearing Examinations and Hearing Aids  Hearing examinations to determine hearing loss Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Hearing aids, including hearing aid examinations Not covered. Home Health Services Covered in full. No visit limit. Hospice Services Covered in full. Inpatient respite care is covered for a maximum of five (5) consecutive days per occurrence. Infertility Services (including sterility) Not covered. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 291 of 385 C31620-0057500a 9 Manipulative Therapy Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider for manipulative therapy of the spine and extremities in accordance with GHC clinical criteria up to a maximum of ten (10) visits per Member per calendar year. Maternity and Pregnancy Services  Delivery and associated Hospital Care Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment.  Prenatal and postpartum care Routine care covered in full. Non-routine care covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment.  Pregnancy termination Not covered. Mental Health Services  Inpatient services Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment at a GHC-approved mental health care facility.  Outpatient services Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Naturopathy Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for Self- Referrals to a GHC Provider up to a maximum of three (3) visits per Member per medical diagnosis per calendar year. When approved by GHC, additional visits are covered. Nutritional Services  Phenylketonuria (PKU) supplements Covered in full.  Enteral therapy (formula) Covered at 80% for elemental formulas. Necessary equipment and supplies are covered under Devices, Equipment and Supplies.  Parenteral therapy (total parenteral nutrition) Covered in full for parenteral formulas. Necessary equipment and supplies are covered under Devices, Equipment and Supplies. Obesity Related Services Covered subject to the lesser of GHC’s charge or the applicable Copayment for bariatric surgery. Weight loss programs, medications and related physician visits for medication monitoring are not covered. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 292 of 385 C31620-0057500a 10 On the Job Injuries or Illnesses Not covered, including injuries or illnesses incurred as a result of self-employment. Optical Services  Routine eye examinations Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment once every twelve (12) months. Eye examinations, including contact lens examinations, for eye pathology are covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment as often as Medically Necessary.  Lenses, including contact lenses, and frames Eyeglass frames, lenses (any type), lens options such as tinting, or prescription contact lenses, contact lens evaluations and examinations associated with their fitting - Covered up to $100 per twenty-four (24) month period per Member. The benefit period begins on the date services are first obtained and continues for twenty-four (24) months. Contact lenses for eye pathology, including following cataract surgery - Covered in full. Organ Transplants Covered subject to the lesser of GHC’s charge or the applicable Copayment. Plastic and Reconstructive Services (plastic surgery, cosmetic surgery)  Surgery to correct a congenital disease or anomaly, or conditions following an injury or resulting from surgery Covered subject to the lesser of GHC’s charge or the applicable Copayment.  Cosmetic surgery, including complications resulting from cosmetic surgery Not covered. Podiatric Services  Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable Copayment.  Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment when in accordance with the well care schedule established by GHC . Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 293 of 385 C31620-0057500a 11 Rehabilitation Services  Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment for up to sixty (60) days per calendar year.  Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered up to sixty (60) days per Member per calendar year. Sterilization (vasectomy, tubal ligation) Not covered. Temporomandibular Joint (TMJ) Services  Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment up to $1,000 maximum per Member per calendar year.  Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation  Individual/group sessions received through the GHC-designated tobacco cessation program Covered in full.  Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC-designated mail order service. Section III. Eligibility, Enrollment and Termination A. Eligibility In order to be accepted for enrollment and continuing coverage under the Agreement, individuals must meet any eligibility requirements imposed by the Group, reside or work in the Service Area and meet all applicable requirements set forth below, except for temporary residency outside the Service Area 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 294 of 385 C31620-0057500a 12 for purposes of attending school, court-ordered coverage for Dependents or other unique family arrangements, when approved in advance by GHC. GHC has the right to verify eligibility. 1. Subscribers. Bona fide retirees who were enrolled under the Agreement for active employees on the date of retirement shall be eligible. A bona fide retiree is defined as an individual who is no longer working on a full- or part-time basis for a Group. B. Enrollment 1. Application for Enrollment. Application for enrollment must be made on an application approved by GHC. Applicants will not be enrolled or premiums accepted until the completed application has been approved by GHC. The Group is responsible for submitting completed applications to GHC. GHC reserves the right to refuse enrollment to any person whose coverage under any Medical Coverage Agreement issued by Group Health Cooperative or Group Health Options, Inc. has been terminated for cause, as set forth in Section III.E. below. a. Newly Eligible Persons. Newly eligible Subscribers may apply for enrollment in writing to the Group within thirty-one (31) days of becoming eligible. b. Open Enrollment. GHC will allow enrollment of Subscribers, who did not enroll when newly eligible as described above, during a limited period of time specified by the Group and GHC. c. Special Enrollment. 1) GHC will allow special enrollment for persons: a) who initially declined enrollment when otherwise eligible because such persons had other health care coverage and have had such other coverage terminated due to one of the following events:  cessation of employer contributions,  exhaustion of COBRA continuation coverage,  loss of eligibility, except for loss of eligibility for cause; or b) who have had such other coverage exhausted because such person reached a Lifetime Maximum limit. GHC or the Group may require confirmation that when initially offered coverage such persons submitted a written statement declining because of other coverage. Application for coverage under the Agreement must be made within thirty-one (31) days of the termination of previous coverage. 2) GHC will allow special enrollment for individuals who are eligible to be a Subscriber, his/her spouse and his/her Dependents in the event one of the following occurs:  marriage. Application for coverage under the Agreement must be made within thirty-one (31) days of the date of marriage.  birth. Application for coverage under the Agreement for the Subscriber and Dependents other than the newborn child must be made within sixty (60) days of the date of birth.  adoption or placement for adoption. Application for coverage under the Agreement for the Subscriber and Dependents other than the adopted child must be made within sixty (60) days of the adoption or placement for adoption.  eligibility for medical assistance: provided such person is otherwise eligible for coverage under this Agreement, when approved and requested in advance by the Department of Social and Health Services (DSHS).  applicable federal or state law or regulation otherwise provides for special enrollment. 2. Limitation on Enrollment. The Agreement will be open for applications for enrollment as set forth in this Section III.B. Subject to prior approval by the Washington State Office of the Insurance Commissioner, GHC may limit enrollment, establish quotas or set priorities for 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 295 of 385 C31620-0057500a 13 acceptance of new applications if it determines that GHC’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. C. Effective Date of Enrollment 1. Provided eligibility criteria are met and applications for enrollment are made as set forth in Sections III.A. and III.B. above, enrollment will be effective as follows: Enrollment for a newly retired Subscriber is effective on the first (1st) of the month following the date of retirement, provided the Subscriber's application has been submitted to and approved by GHC. 2. Commencement of Benefits for Persons Hospitalized on Effective Date. Members who are admitted to an inpatient facility prior to their enrollment under the Agreement, and who do not have coverage under another agreement, will receive covered benefits beginning on their effective date, as set forth in subsection C.1. above. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility. The Member will be transferred when a GHC Provider, in consultation with the attending physician, determines that the Member is medically stable to do so. If the Member refuses to transfer to a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Member. D. Eligibility for Medicare An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare benefits. Medicare Secondary Payer regulations and guidelines will determine primary/secondary payer status for individuals covered by Medicare. Actively Employed Members. The Group is responsible for providing the Member with necessary information regarding Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) eligibility and the selection process, if applicable. A Member who is eligible for Medicare has the option of maintaining both Medicare Parts A and B while continuing coverage under this Agreement. Coverage between this Agreement and Medicare will be coordinated as outlined in Section VII.A. Not Actively Employed Members. If a Member who is not actively employed is eligible for Medicare based on age, he/she must enroll in and maintain both Medicare Parts A and B coverage and enroll in the GHC Medicare Advantage Plan if available. Failure to do so upon the effective date of Medicare eligibility will result in termination of coverage under this Agreement. All applicable provisions of the GHC Medicare Advantage Plan are fully set forth in the Medicare Endorsement(s) attached to the Agreement (if applicable). E. Termination of Coverage 1. Termination of Specific Members. Individual Member coverage may be terminated for any of the following reasons: a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section III., and is not enrolled for continuation coverage as described in Section III.G. below, coverage under the Agreement will terminate at the end of the month during which the loss of eligibility occurs, unless otherwise specified by the Group. b. For Cause. Coverage of a Member may be terminated upon ten (10) working days written notice for: i. Material misrepresentation, fraud or omission of information in order to obtain coverage. ii. Permitting the use of a GHC identification card or number by another person, or using another Member’s identification card or number to obtain care to which a person is not entitled. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 296 of 385 C31620-0057500a 14 In the event of termination for cause, GHC reserves the right to pursue all civil remedies allowable under federal and state law for the collection of claims, losses or other damages. c. Premium Payments. Nonpayment of premiums or contribution for a specific Member by the Group. Individual Member coverage may be retroactively terminated upon thirty (30) days written notice and only in the case of fraud or intentional misrepresentation of a material fact; or as otherwise allowed under applicable law or regulation. Notwithstanding the foregoing, GHC reserves the right to retroactively terminate coverage for nonpayment of premiums or contributions by the Group, as described under subsection c. above. In no event will a Member be terminated solely on the basis of their physical or mental condition provided they meet all other eligibility requirements set forth in the Agreement. Any Member may appeal a termination decision through GHC’s grievance process as set forth in Section VI. 2. Certificate of Creditable Coverage. Unless the Group has chosen to accept this responsibility, a certificate of creditable coverage (which provides information regarding the Member’s length of coverage under the Agreement) will be issued automatically upon termination of coverage, and may also be obtained upon request. F. Services After Termination of Agreement 1. Members Hospitalized on the Date of Termination. A Member who is receiving Covered Services as a registered bed patient in a hospital on the date of termination shall continue to be eligible for Covered Services while an inpatient for the condition which the Member was hospitalized, until one of the following events occurs:  According to GHC clinical criteria, it is no longer Medically Necessary for the Member to be an inpatient at the facility.  The remaining benefits available under the Agreement for the hospitalization are exhausted, regardless of whether a new calendar year begins.  The Member becomes covered under another agreement with a group health plan that provides benefits for the hospitalization.  The Member becomes enrolled under an agreement with another carrier that would provide benefits for the hospitalization if the Agreement did not exist. This provision will not apply if the Member is covered under another agreement that provides benefits for the hospitalization at the time coverage would terminate, except as set forth in this section, or if the Member is eligible for COBRA continuation coverage as set forth in subsection G. below. 2. Services Provided After Termination. The Subscriber shall be liable for payment of all charges for services and items provided to the Subscriber and all Dependents after the effective date of termination, except those services covered under subsection F.1. above. Any services provided by GHC will be charged according to the Fee Schedule. G. Continuation of Coverage Options 1. Continuation Option. A Member no longer eligible for coverage under the Agreement (except in the event of termination for cause, as set forth in Section III.E.) may continue coverage for a period of up to three (3) months subject to notification to and self-payment of premiums to the Group. This provision will not apply if the Member is eligible for the continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). This continuation option is not available if the Group no longer has active employees or otherwise terminates. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 297 of 385 C31620-0057500a 15 2. Continuation Coverage Under Federal Law. This section applies only to Groups who must offer continuation coverage under the applicable provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, and only applies to grant continuation of coverage rights to the extent required by federal law. Upon loss of eligibility, continuation of Group coverage may be available to a Member for a limited time after the Member would otherwise lose eligibility, if required by COBRA. The Group shall inform Members of the COBRA election process and how much the Member will be required to pay directly to the Group. Continuation coverage under COBRA will terminate when a Member becomes covered by Medicare or obtains other group coverage, and as set forth under Section III.E.1.b. and c. 3. GHC Group Conversion Plan. Members whose eligibility for coverage under the Agreement, including continuation coverage, is terminated for any reason other than cause, as set forth in Section III.E.1.b., and who are not eligible for Medicare or covered by another group health plan, may convert to GHC’s Group Conversion Plan. If the Agreement terminates, any Member covered under the Agreement at termination may convert to a GHC Group Conversion Plan, unless he/she is eligible to obtain other group health coverage within thirty-one (31) days of the termination of the Agreement. An application for conversion must be made within thirty-one (31) days following termination of coverage under the Agreement or within thirty-one (31) days from the date notice of the termination of coverage is received, whichever is later. Coverage under GHC’s Group Conversion Plan is subject to all terms and conditions of such plan, including premium payments. A physical examination or statement of health is not required for enrollment in GHC’s Group Conversion Plan. The Pre-Existing Condition limitation under GHC’s Group Conversion Plan will apply only to the extent that the limitation remains unfulfilled under the Agreement. By exercising Group Conversion rights, the Member may waive guaranteed issue and Pre-Existing Condition waiver rights under Federal regulations. Persons wishing to purchase GHC’s Individual and Family coverage should contact GHC Marketing. Section IV. Schedule of Benefits Benefits are subject to all provisions of the Group Medical Coverage Agreement, including, without limitation, the Accessing Care provisions and General Exclusions. Members must refer to Section II., the Allowances Schedule, for Cost Shares and specific benefit limits that apply to benefits listed in this Schedule of Benefits. Members are entitled to receive only benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by GHC's Medical Director, or his/her designee, and as described herein. All Covered Services are subject to case management and utilization review at the discretion of GHC. A. Hospital Care Hospital coverage is limited to the following services: 1. Room and board, including private room when prescribed, and general nursing services. 2. Hospital services (including use of operating room, anesthesia, oxygen, x-ray, laboratory and radiotherapy services). 3. Alternative care arrangements may be covered as a cost-effective alternative in lieu of otherwise covered Medically Necessary hospitalization, or other covered Medically Necessary institutional care. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Member’s Medical 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 298 of 385 C31620-0057500a 16 Condition. Coverage must be authorized in advance by GHC as appropriate and Medically Necessary. Such care will be covered to the same extent the replaced Hospital Care is covered under the Agreement. 4. Drugs and medications administered during confinement. 5. Special duty nursing, when prescribed as Medically Necessary. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If the Member refuses to transfer, all further costs incurred during the hospitalization are the responsibility of the Member. B. Medical and Surgical Care Medical and surgical coverage is limited to the following: 1. Surgical services. 2. Diagnostic x-ray, nuclear medicine, ultrasound and laboratory services. 3. Family planning counseling services. 4. Hearing examinations to determine hearing loss. 5. Blood and blood derivatives and their administration. 6. Preventive care (well care) services for health maintenance in accordance with the well care schedule established by GHC and the Patient Protection and Affordable Care Act of 2010. Preventive care includes: routine mammography screening, physical examinations and routine laboratory tests for cancer screening in accordance with the well care schedule established by GHC, and immunizations and vaccinations listed as covered in the GHC drug formulary (approved drug list). A fee may be charged for health education programs. The well care schedule is available in GHC clinics, by accessing GHC’s website at www.ghc.org, or upon request. Covered Services provided during a preventive care visit, which are not in accordance with the GHC well care schedule, may be subject to Cost Shares. 7. Radiation therapy services. 8. Reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or non-dental cysts of the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth; and incision of salivary glands and ducts. 9. Medical implants. Excluded: internally implanted insulin pumps, artificial hearts, artificial larynx and any other implantable device that has not been approved by GHC's Medical Director, or his/her designee. 10. Respiratory therapy. 11. Outpatient total parenteral nutritional therapy; outpatient elemental formulas for malabsorption; and dietary formula for the treatment of phenylketonuria (PKU). Coverage for PKU formula is not subject to a Pre-Existing Condition waiting period, if applicable. Equipment and supplies for the administration of enteral and parenteral therapy are covered under Devices, Equipment and Supplies. Excluded: any other dietary formulas, oral nutritional supplements, special diets, prepared foods/meals and formula for access problems. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 299 of 385 C31620-0057500a 17 12. Visits with GHC Providers, including consultations and second opinions, in the hospital or provider’s office. 13. Optical services. Routine eye examinations and refractions received at a GHC Facility once every twelve (12) months, except when Medically Necessary. Routine eye examinations to monitor Medical Conditions are covered as often as necessary upon recommendation of a GHC Provider. Contact lenses for eye pathology, including contact lens exam and fitting, are covered subject to the applicable Cost Share. When dispensed through GHC Facilities, one contact lens per diseased eye in lieu of an intraocular lens, including exam and fitting, is covered for Members following cataract surgery performed by a GHC Provider, provided the Member has been continuously covered by GHC since such surgery. Replacement of lenses for eye pathology, including following cataract surgery, will be covered only once within a twelve (12) month period and only when needed due to a change in the Member’s Medical Condition. Replacement for loss or breakage is subject to the Lenses and Frames benefit Allowance. Lenses and Frames Benefits purchased at a Group Health-owned or contracted optical hardware provider may be used toward the following in any combination, over the benefit period, until the benefit maximum is exhausted: Eyeglass frames Eyeglass lenses (any type) including tinting and coating Corrective industrial (safety) lenses Sunglass lenses and frames when prescribed by an eye care provider for eye protection or light sensitivity Corrective contact lenses in the absence of eye pathology, including associated fitting and evaluation examinations Replacement frames, for any reason, including loss or breakage Replacement contact lenses Replacement eyeglass lenses Excluded: evaluations and surgical procedures to correct refractions not related to eye pathology and complications related to such procedures. 14. Maternity care, including care for complications of pregnancy and prenatal and postpartum visits. Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary as determined by GHC’s Medical Director, or his/her designee, and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Hospitalization and delivery, including home births for low risk pregnancies. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Pregnancy will not be excluded as a Pre-Existing Condition under the Agreement. Treatment for post-partum depression or psychosis is covered only under the mental health benefit. Excluded: voluntary (not medically indicated and nontherapeutic) termination of pregnancy, birthing tubs and genetic testing of non-Members for the detection of congenital and heritable disorders. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 300 of 385 C31620-0057500a 18 15. Transplant services, including heart, heart-lung, single lung, double lung, kidney, pancreas, cornea, intestinal/multi-visceral, bone marrow, liver transplants and stem cell support (obtained from allogeneic or autologous peripheral blood or marrow) with associated high dose chemotherapy. Covered Services must be directly associated with, and occur at the time of, the transplant. Services are limited to the following: a. Evaluation testing to determine recipient candidacy, b. Matching tests, c. Inpatient and outpatient medical expenses listed below for transplantation procedures: Hospital charges, Procurement center fees, Professional fees, Travel costs for a surgical team, and Excision fees Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees. d. Follow-up services for specialty visits, e. Rehospitalization, and f. Maintenance medications. Excluded: donor costs to the extent that they are reimbursable by the organ donor’s insurance, treatment of donor complications, living expenses and transportation expenses, except as set forth under Section IV.M. 16. Manipulative therapy. Self-Referrals for manipulative therapy of the spine and extremities are covered as set forth in the Allowances Schedule when provided by GHC Providers. Excluded: supportive care rendered primarily to maintain the level of correction already achieved, care rendered primarily for the convenience of the Member, care rendered on a non-acute, asymptomatic basis and charges for any other services that do not meet GHC clinical criteria as Medically Necessary. 17. Medical and surgical services and related hospital charges, including orthognathic (jaw) surgery, for the treatment of temporomandibular joint (TMJ) disorders. Such disorders may exhibit themselves in the form of pain, infection, disease, difficulty in speaking or difficulty in chewing or swallowing food. TMJ appliances are covered as set forth under Section IV.H.1., Orthopedic Appliances. Orthognathic (jaw) surgery for the treatment of TMJ disorders, radiology services and TMJ specialist services, including fitting/adjustment of splints are subject to the benefit limit set forth in the Allowances Schedule. Excluded are the following: orthognathic (jaw) surgery in the absence of a TMJ or severe obstructive sleep apnea diagnosis except for congenital anomalies, treatment for cosmetic purposes, dental services, including orthodontic therapy and any hospitalizations related to these exclusions. 18. Diabetic training and education. 19. Detoxification services for alcoholism and drug abuse. For the purposes of this section, "acute chemical withdrawal" means withdrawal of alcohol and/or drugs from a Member for whom consequences of abstinence are so severe that they require 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 301 of 385 C31620-0057500a 19 medical/nursing assistance in a hospital setting, which is needed immediately to prevent serious impairment to the Member's health. Coverage for acute chemical withdrawal is provided without prior approval. If a Member is hospitalized in a non-GHC Facility/program, coverage is subject to payment of the Emergency care Cost Share. The Member or person assuming responsibility for the Member must notify GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admission, or as soon thereafter as medically possible. Furthermore, if a Member is hospitalized in a non-GHC Facility/program, GHC reserves the right to require transfer of the Member to a GHC Facility/program upon consultation between a GHC Provider and the attending physician. If the Member refuses transfer to a GHC Facility/program, all further costs incurred during the hospitalization are the responsibility of the Member. 20. Circumcision. 21. Bariatric surgery and related hospitalizations when GHC criteria are met. Excluded: pre and post surgical nutritional counseling and related weight loss programs, prescribing and monitoring of drugs, structured weight loss and/or exercise programs and specialized nutritional counseling. 22. Therapeutic sterilization procedures. 23. General anesthesia services and related facility charges for dental procedures will be covered for Members who are under seven (7) years of age, or are physically or developmentally disabled or have a Medical Condition where the Member’s health would be put at risk if the dental procedure were performed in a dentist’s office. Such services must be authorized in advance by GHC and performed at a GHC hospital or ambulatory surgical facility. Excluded: dentist’s or oral surgeon’s fees. 24. Self-Referrals to GHC for covered acupuncture and naturopathy, as set forth in the Allowances Schedule. Additional visits are covered when approved by GHC. Laboratory and radiology services are covered only when obtained through a GHC Facility. Excluded: herbal supplements, preventive care visits for acupuncture and any services not within the scope of the practitioner’s licensure. 25. Once Pre-Existing Condition wait periods, if any, have been met, Pre-Existing Conditions are covered in the same manner as any other illness. 26. Injections administered by a professional in a clinical setting. C. Chemical Dependency Treatment. Chemical dependency means an illness characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcoholic beverages, and where the user's health is substantially impaired or endangered or his/her social or economic function is substantially disrupted. For the purposes of this section, the definition of Medically Necessary shall be expanded to include those services necessary to treat a chemical dependency condition that is having a clinically significant impact on a Member’s emotional, social, medical and/or occupational functioning. Chemical dependency treatment services are covered as set forth in the Allowances Schedule at a GHC Facility or GHC-approved treatment program. All alcoholism and/or drug abuse treatment services must be: (a) provided at a facility as described above; and (b) deemed Medically Necessary as defined above. Chemical dependency treatment may 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 302 of 385 C31620-0057500a 20 include the following services received on an inpatient or outpatient basis: inpatient Residential Treatment services, diagnostic evaluation and education, organized individual and group counseling and/or prescription drugs and medicines. Court-ordered treatment shall be covered only if determined to be Medically Necessary as defined above. D. Plastic and Reconstructive Services. Plastic and reconstructive services are covered as set forth below: 1. Correction of a congenital disease or congenital anomaly, as determined by a GHC Provider. A congenital anomaly will be considered to exist if the Member’s appearance resulting from such condition is not within the range of normal human variation. 2. Correction of a Medical Condition following an injury or resulting from surgery covered by GHC which has produced a major effect on the Member's appearance, when in the opinion of a GHC Provider, such services can reasonably be expected to correct the condition. 3. Reconstructive surgery and associated procedures, including internal breast prostheses, following a mastectomy, regardless of when the mastectomy was performed. Members will be covered for all stages of reconstruction on the non-diseased breast to make it equivalent in size with the diseased breast. Complications of covered mastectomy services, including lymphedemas, are covered. Excluded: complications of noncovered surgical services. E. Home Health Care Services. Home health care services, as set forth in this section, shall be covered when provided by and referred in advance by a GHC Provider for Members who meet the following criteria: 1. The Member is unable to leave home due to his/her health problem or illness. Unwillingness to travel and/or arrange for transportation does not constitute inability to leave the home. 2. The Member requires intermittent skilled home health care services, as described below. 3. A GHC Provider has determined that such services are Medically Necessary and are most appropriately rendered in the Member's home. For the purposes of this section, “skilled home health care” means reasonable and necessary care for the treatment of an illness or injury which requires the skill of a nurse or therapist, based on the complexity of the service and the condition of the patient and which is performed directly by an appropriately licensed professional provider. Covered Services for home health care may include the following when rendered pursuant to an approved home health care plan of treatment: nursing care, physical therapy, occupational therapy, respiratory therapy, restorative speech therapy, durable medical equipment and medical social worker and limited home health aide services. Home health services are covered on an intermittent basis in the Member's home. "Intermittent" means care that is to be rendered because of a medically predictable recurring need for skilled home health care services. Excluded: custodial care and maintenance care, private duty or continuous nursing care in the Member's home, housekeeping or meal services, care in any nursing home or convalescent facility, any care provided by or for a member of the patient's family and any other services rendered in the home which do not meet the definition of skilled home health care above or are not specifically listed as covered under the Agreement. F. Hospice Care. Hospice care is covered in lieu of curative treatment for terminal illness for Members who meet all of the following criteria: 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 303 of 385 C31620-0057500a 21  A GHC Provider has determined that the Member's illness is terminal and life expectancy is six (6) months or less.  The Member has chosen a palliative treatment focus (emphasizing comfort and supportive services rather than treatment aimed at curing the Member's terminal illness).  The Member has elected in writing to receive hospice care through GHC's Hospice Program or GHC’s approved hospice program.  The Member has available a primary care person who will be responsible for the Member's home care.  A GHC Provider and GHC's Hospice Director, or his/her designee, have determined that the Member's illness can be appropriately managed in the home. Hospice care shall mean a coordinated program of palliative and supportive care for dying Members by an interdisciplinary team of professionals and volunteers centering primarily in the Member's home. 1. Covered Services. Care may include the following as prescribed by a GHC Provider and rendered pursuant to an approved hospice plan of treatment: a. Home Services i. Intermittent care by a hospice interdisciplinary team which may include services by a physician, nurse, medical social worker, physical therapist, speech therapist, occupational therapist, respiratory therapist, limited services by a Home Health Aide under the supervision of a Registered Nurse and homemaker services. ii. Continuous care services in the Member's home when prescribed by a GHC Provider, as set forth in this paragraph. “Continuous care” means skilled nursing care provided in the home during a period of crisis in order to maintain the terminally ill Member at home. Continuous care may be provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse or Home Health Aide under the supervision of a Registered Nurse. Continuous care is covered up to twenty-four (24) hours per day during periods of crisis. Continuous care is covered only when a GHC Provider determines that the Member would otherwise require hospitalization in an acute care facility. b. Inpatient Hospice Services. For short-term care, inpatient hospice services shall be covered in a facility designated by GHC's Hospice Program or GHC-approved hospice program when authorized in advance by a GHC Provider and GHC's Hospice Program or GHC-approved hospice program. Inpatient respite care is covered for a maximum of five (5) consecutive days per occurrence in order to continue care for the Member in the temporary absence of the Member’s primary care giver(s). c. Other covered hospice services may include the following: i. Drugs and biologicals that are used primarily for the relief of pain and symptom management. ii. Medical appliances and supplies primarily for the relief of pain and symptom management. iii. Durable medical equipment. iv. Counseling services for the Member and his/her primary care-giver(s). v. Bereavement counseling services for the family. 2. Hospice Exclusions. All services not specifically listed as covered in this section are excluded, including: a. Financial or legal counseling services. b. Meal services. c. Custodial or maintenance care in the home or on an inpatient basis, except as provided above. d. Services not specifically listed as covered by the Agreement. e. Any services provided by members of the patient's family. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 304 of 385 C31620-0057500a 22 All other exclusions listed in Section V., General Exclusions, apply. G. Rehabilitation Services. 1. Rehabilitation services are covered as set forth in this section, limited to the following: physical therapy; occupational therapy; massage therapy and speech therapy to restore function following illness, injury or surgery. Services are subject to all terms, conditions and limitations of the Agreement, including the following: a. All services must be provided at a GHC or GHC-approved rehabilitation facility and require a prescription from a GHC physician and must be provided by a GHC-approved rehabilitation team that may include medical, nursing, physical therapy, occupational therapy, massage therapy and speech therapy providers. b. Services are limited to those necessary to restore or improve functional abilities when physical, sensori-perceptual and/or communication impairment exists due to injury, illness or surgery. Such services are provided only when GHC's Medical Director, or his/her designee, determines that significant, measurable improvement to the Member's condition can be expected within a sixty (60) day period as a consequence of intervention by covered therapy services described in paragraph a., above. c. Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances Schedule. Excluded: inpatient Residential Treatment services; specialty rehabilitation programs not provided by GHC; long-term rehabilitation programs; physical therapy, occupational therapy and speech therapy services when such services are available (whether application is made or not) through programs offered by public school districts; therapy for degenerative or static conditions when the expected outcome is primarily to maintain the Member's level of functioning (except as set forth in subsection 2. below); recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs; programs for treatment of learning problems; any services not specifically included as covered in this section; and any services that are excluded under Section V. 2. Neurodevelopmental Therapies for Children Age Six (6) and Under. Physical therapy, occupational therapy and speech therapy services for the restoration and improvement of function for neurodevelopmentally disabled children age six (6) and under shall be covered. Coverage includes maintenance of a covered Member in cases where significant deterioration in the Member's condition would result without the services. Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances Schedule. Excluded: inpatient Residential Treatment services; specialty rehabilitation programs not provided by GHC; long-term rehabilitation programs; physical therapy, occupational therapy and speech therapy services when such services are available (whether application is made or not) through programs offered by public school districts; recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs; programs for treatment of learning problems; any services not specifically included as covered in this section; and any services that are excluded under Section V. H. Devices, Equipment and Supplies. Devices, equipment and supplies, which restore or replace functions that are common and necessary to perform basic activities of daily living, are covered as set forth in the Allowances Schedule. Examples of basic activities of daily living are dressing and feeding oneself, maintaining personal hygiene, lifting and gripping in order to prepare meals and carrying groceries. 1. Orthopedic Appliances. Orthopedic appliances, which are attached to an impaired body segment for the purpose of protecting the segment or assisting in restoration or improvement of its function. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 305 of 385 C31620-0057500a 23 Excluded: arch supports, including custom shoe modifications or inserts and their fittings except for therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease; and orthopedic shoes that are not attached to an appliance. 2. Ostomy Supplies. Ostomy supplies for the removal of bodily secretions or waste through an artificial opening. 3. Durable Medical Equipment. Durable medical equipment is equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose, is useful only in the presence of an illness or injury and used in the Member’s home. Durable medical equipment includes: hospital beds, wheelchairs, walkers, crutches, canes, glucose monitors, external insulin pumps, oxygen and oxygen equipment. GHC, in its sole discretion, will determine if equipment is made available on a rental or purchase basis. 4. Prosthetic Devices. Prosthetic devices are items which replace all or part of an external body part, or function thereof. When authorized in advance, repair, adjustment or replacement of appliances and equipment is covered. Excluded: items which are not necessary to restore or replace functions of basic activities of daily living; and replacement or repair of appliances, devices and supplies due to loss, breakage from willful damage, neglect or wrongful use, or due to personal preference. I. Tobacco Cessation. When provided through GHC, services related to tobacco cessation are covered, limited to: 1. participation in an individual or group program; 2. educational materials; and 3. approved pharmacy products provided the Member is actively participating in a GHC-designated tobacco cessation program. J. Drugs, Medicines, Supplies and Devices. This benefit, for purposes of creditable coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Eligible Members who are also eligible for Medicare Part D pharmacy benefits can remain covered under the Agreement and not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D pharmacy plan at a later date. The Agreement may include Medicare Part D pharmacy benefits as part of the GHC Medicare Advantage Plan required for Medicare eligible Members who live in the GHC Medicare Advantage Service Area. See Section III.D. for more information. A Member who discontinues coverage under the Agreement must meet eligibility requirements in order to re-enroll. Legend medications are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services), contraceptive drugs and devices, diabetic supplies, including insulin syringes, lancets, urine-testing reagents, blood-glucose monitoring reagents and insulin, are covered as set forth below. All drugs, supplies, medicines and devices must be prescribed by a GHC Provider for conditions covered by the Agreement, obtained at a GHC-designated pharmacy and, unless approved by GHC in advance, be listed in the GHC drug formulary. The prescription drug Cost Share, as set forth in the Allowances Schedule, applies to each thirty (30) day supply. Cost Shares for single and multiple thirty (30) day supplies of a given prescription are payable at the time of delivery. Injectables that can be 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 306 of 385 C31620-0057500a 24 self-administered are also subject to the prescription drug Cost Share. Drug formulary (approved drug list) is defined as a list of preferred pharmaceutical products, supplies and devices developed and maintained by GHC. A limited supply of prescription drugs obtained at a non-GHC pharmacy is covered when dispensed or prescribed in connection with covered Emergency treatment. Generic drugs will be dispensed whenever available. Brand name drugs will be dispensed if there is not a generic equivalent. In the event the Member elects to purchase brand-name drugs instead of the generic equivalent (if available), or if the Member elects to purchase a different brand-name or generic drug than that prescribed by the Member’s Provider, and it is not determined to be Medically Necessary, the Member will also be subject to payment of the additional amount above the applicable pharmacy Cost Share set forth in the Allowances Schedule. A generic drug is defined as a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. A brand name drug is defined as a prescription drug that has been patented and is only available through one manufacturer. “Standard reference compendia” means the American Hospital Formulary Service-Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia-Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in healthcare journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Excluded: over-the-counter drugs, medicines, supplies and devices not requiring a prescription under state law or regulations; drugs used in the treatment of sexual dysfunction disorders; medicines and injections for anticipated illness while traveling; vitamins, including Legend (prescription) vitamins; and any other drugs, medicines and injections not listed as covered in the GHC drug formulary unless approved in advance by GHC as Medically Necessary. The Member will be charged for replacing lost or stolen drugs, medicines or devices. The Member’s Right to Safe and Effective Pharmacy Services. State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered under the Agreement and what coverage limitations are in the Agreement. Members who would like more information about the drug coverage policies under the Agreement, or have a question or concern about their pharmacy benefit, may contact GHC at (206) 901-4636 or (888) 901-4636. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the Agreement, may contact the Washington State Office of Insurance Commissioner at (800) 562-6900. Members who have a concern about the pharmacists or pharmacies serving them, may call the Washington State Department of Health at (800) 525-0127. K. Mental Health Care Services. Services that are provided by a mental health practitioner will be covered as mental health care, regardless of the cause of the disorder. 1. Outpatient Services. Outpatient mental health services place priority on restoring the Member to his/her level of functioning prior to the onset of acute symptoms or to achieve a clinically appropriate level of stability as determined by GHC’s Medical Director, or his/her designee. Treatment for clinical conditions may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Coverage for each Member is provided according to the outpatient mental health care Allowance set forth in the Allowances Schedule. Psychiatric medical services, including medical management and prescriptions, are covered as set forth in Sections IV.B. and IV.J. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 307 of 385 C31620-0057500a 25 2. Inpatient Services. Charges for services described in this section, including psychiatric Emergencies resulting in inpatient services, are covered as set forth in the Allowances Schedule. This benefit shall include coverage for acute treatment and stabilization of psychiatric Emergencies in GHC-approved hospitals. When medically indicated, outpatient electro-convulsive therapy (ECT) is covered in lieu of inpatient services. Coverage for services incurred at non-GHC Facilities shall exclude any charges that would otherwise be excluded for hospitalization within a GHC Facility. Services provided under involuntary commitment statutes shall be covered at facilities approved by GHC. Services for any involuntary court-ordered treatment program beyond seventy-two (72) hours shall be covered only if determined to be Medically Necessary by GHC's Medical Director, or his/her designee. Coverage for voluntary/involuntary Emergency inpatient psychiatric services is subject to the Emergency care benefit set forth in Section IV.L., including the twenty-four (24) hour notification and transfer provisions. Outpatient electro-convulsive therapy treatment is covered subject to the outpatient surgery Cost Share. 3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services. Covered Services are limited to those authorized by GHC's Medical Director, or his/her designee, for covered clinical conditions for which the reduction or removal of acute clinical symptoms or stabilization can be expected given the most clinically appropriate level of mental health care intervention. Excluded: inpatient Residential Treatment services; learning, communication and motor skills disorders; mental retardation; academic or career counseling; sexual and identity disorders; and personal growth or relationship enhancement. Also excluded: assessment and treatment services that are primarily vocational and academic; court-ordered or forensic treatment, including reports and summaries, not considered Medically Necessary; work or school ordered assessment and treatment not considered Medically Necessary; counseling for overeating; nicotine related disorders; relationship counseling or phase of life problems (V code only diagnoses); and custodial care. Any other services not specifically listed as covered in this section. All other provisions, exclusions and limitations under the Agreement also apply. L. Emergency/Urgent Care. All services are covered subject to the Cost Shares set forth in the Allowances Schedule. Emergency Care (See Section VIII. for a definition of Emergency.) 1. At a GHC Facility. GHC will cover Emergency care for all Covered Services. 2. At a Non-GHC Facility. Usual, Customary and Reasonable charges for Emergency care for Covered Services are covered subject to: a. Payment of the Emergency care Cost Share; and b. Notification of GHC by way of the GHC Notification Line within twenty-four (24) hours following inpatient admission, or as soon thereafter as medically possible. 3. Waiver of Emergency Care Cost Share. a. Waiver for Multiple Injury Accident. If two or more Members in the same Family Unit require Emergency care as a result of the same accident, coverage for all Members will be subject to only one (1) Emergency care Copayment. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 308 of 385 C31620-0057500a 26 b. Emergencies Resulting in an Inpatient Admission. If the Member is admitted to a GHC Facility directly from the emergency room, the Emergency care Copayment is waived. However, coverage will be subject to the inpatient services Cost Share. 4. Transfer and Follow-up Care. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If the Member refuses to transfer to a GHC Facility, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be obtained from GHC Providers, unless a GHC Provider has authorized such follow-up care from a non-GHC Provider in advance. Urgent Care (See Section VIII. for a definition of Urgent Condition.) Inside the GHC Service Area, care for Urgent Conditions is covered at GHC medical centers, GHC urgent care clinics or GHC Providers’ offices, subject to the applicable Cost Share. Urgent care received at any hospital emergency department is not covered unless authorized in advance by a GHC Provider. Care received at urgent care facilities other than those listed above is only covered for Emergency services, subject to the applicable Emergency care Cost Share. Outside the GHC Service Area, Usual, Customary and Reasonable charges are covered for Urgent Conditions received at any medical facility, subject to the applicable Cost Share. M. Ambulance Services. Ambulance services are covered as set forth below, provided that the service is authorized in advance by a GHC Provider or meets the definition of an Emergency (see Section VIII.). 1. Emergency Transport to any Facility. Each Emergency is covered as set forth in the Allowances Schedule. 2. Interfacility Transfers. GHC-initiated non-emergent transfers to or from a GHC Facility are covered as set forth in the Allowances Schedule. N. Skilled Nursing Facility (SNF). Skilled nursing care in a GHC-approved skilled nursing facility when full-time skilled nursing care is necessary in the opinion of the attending GHC Provider, is covered as set forth in the Allowances Schedule. When prescribed by a GHC Provider, such care may include room and board; general nursing care; drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility; and short-term physical therapy, occupational therapy and restorative speech therapy. Excluded: personal comfort items such as telephone and television, rest cures and custodial, domiciliary or convalescent care. Section V. General Exclusions In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Services or supplies not specifically listed as covered in the Schedule of Benefits, Section IV. 2. Except as specifically listed and identified as covered in Sections IV.B., IV.D., IV.H. and IV.J., corrective appliances and artificial aids including: eyeglasses; contact lenses and services related to their fitting; hearing devices and hearing aids, including related examinations; take-home drugs, dressings and supplies following hospitalization; and any other supplies, dressings, appliances, devices or services which are not specifically listed as covered in Section IV. 3. Cosmetic services, including treatment for complications resulting from cosmetic surgery, except as provided in Section IV.D. 4. Convalescent or custodial care. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 309 of 385 C31620-0057500a 27 5. Durable medical equipment such as hospital beds, wheelchairs and walk-aids, except while in the hospital or as set forth in Section IV.B., IV.E., IV.F. or IV.H. 6. Services rendered as a result of work-related injuries, illnesses or conditions, including injuries, illnesses or conditions incurred as a result of self-employment. 7. Those parts of an examination and associated reports and immunizations required for employment, unless otherwise noted in Section IV.B., immigration, license, travel or insurance purposes that are not deemed Medically Necessary by GHC for early detection of disease. 8. Services and supplies related to sexual reassignment surgery, such as sex change operations or transformations and procedures or treatments designed to alter physical characteristics. 9. Diagnostic testing and medical treatment of sterility, infertility and sexual dysfunction, regardless of origin or cause, unless otherwise noted in Section IV.B. 10. Any services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, whether the Member asserts a claim or not, pursuant to medical coverage, medical “no fault” coverage, Personal Injury Protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member is a named insured, comes within the policy definition of insured, or otherwise has the right to receive first party benefits under the policy. The Member and his/her agents must cooperate fully with GHC in its efforts to enforce this exclusion. This cooperation shall include supplying GHC with information about, or related to, the cause of injury or illness or the availability of other insurance coverage. The Member and his/her agent shall permit GHC, at GHC’s option, to associate with the Member or to intervene in any action filed against any party related to the injury. The Member and his/her agents shall do nothing to prejudice GHC’s right to enforce this exclusion. Failure to fully cooperate, including withholding information regarding the cause of injury or illness or other insurance coverage may result in denial of claims and the Member shall be responsible for reimbursing GHC for expenses incurred and the value of the benefits provided by GHC under this Agreement for the care or treatment of the injury or illness sustained by the Member. GHC shall not enforce this exclusion as to coverage available under uninsured motorist or underinsured motorist coverage until the Member has been made whole, unless the Member fails to cooperate fully with GHC as described above. If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining recovery, under certain conditions GHC will reduce the amount of reimbursement to GHC by the amount of an equitable apportionment of such collection costs between GHC and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i) the equitable apportionment of attorney fees has been agreed to by GHC prior to settlement or recovery, (ii) the Injured Person’s attorney’s action has benefited GHC in its recovery, and (iii) the Injured Person’s attorney’s actions were reasonable and necessary to secure recovery. GHC’s share of collection costs is subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. Under no circumstance will GHC incur legal fees for services which were not reasonably and necessarily incurred to secure recovery or which do not benefit GHC. If this Agreement is subject to ERISA and reasonable collections costs have been incurred by the Injured Person for the benefit of GHC, the Injured Person may request and GHC may reduce the amount of reimbursement to GHC by an amount for reasonable and necessary attorney’s fees incurred by the Injured Person on behalf of and for the benefit of GHC, but only if such amount is agreed to by GHC prior to settlement or recovery. 11. Late term pregnancy termination except when the health of the mother is at risk. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 310 of 385 C31620-0057500a 28 12. The cost of services and supplies resulting from a Member's loss of or willful damage to appliances, devices, supplies and materials covered by GHC for the treatment of disease, injury or illness. 13. Orthoptic therapy (i.e., eye training). 14. Specialty treatment programs such as weight reduction, “behavior modification programs” and rehabilitation, including cardiac rehabilitation. 15. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 16. Procedures and services to reverse a therapeutic or nontherapeutic sterilization. 17. Dental care, surgery, services and appliances, including: treatment of accidental injury to natural teeth, reconstructive surgery to the jaw in preparation for dental implants, dental implants, periodontal surgery and any other dental service not specifically listed as covered in Section IV. GHC’s Medical Director, or his/her designee, will determine whether the care or treatment required is within the category of dental care or service. 18. Drugs, medicines and injectables, except as set forth in Section IV.J. Any exclusion of drugs, medicines and injectables, including those not listed as covered in the GHC drug formulary (approved drug list), will also exclude their administration. 19. Experimental or investigational services. GHC consults with GHC’s Medical Director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member. i. The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. ii. The service is the subject of a current new drug or new device application on file with the FDA. iii. The service is provided as part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial, or in any other manner that is intended to evaluate the safety, toxicity or efficacy of the service. iv. The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. v. The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. vi. The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. vii. The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. In making determinations whether a service is experimental or investigational, the following sources of information will be relied upon exclusively: i. The Member’s medical records, ii. The written protocol(s) or other document(s) pursuant to which the service has been or will be provided, 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 311 of 385 C31620-0057500a 29 iii. Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service, iv. The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body, v. The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury, and vi. Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding GHC denial of coverage can be submitted to the Member Appeal Department, or to GHC's Medical Director at P.O. Box 34593, Seattle, WA 98124-1593. 20. Chemical dependency, rehabilitation services and mental health care, except as specifically provided in Sections IV.C., IV.G. and IV.K. 21. Hypnotherapy, and all services related to hypnotherapy. 22. Genetic testing and related services, unless determined Medically Necessary by GHC’s Medical Director, or his/her designee, and in accordance with Board of Health standards for screening and diagnostic tests, or specifically provided in Section IV.B. Testing for non-Members is also excluded. 23. Follow-up visits related to a non-Covered Service. 24. Fetal ultrasound in the absence of medical indications. 25. Routine foot care, except in the presence of a non-related Medical Condition affecting the lower limbs. 26. Complications of non-Covered Services. 27. Obesity treatment and treatment for morbid obesity, including any medical services, drugs, supplies or any bariatric surgery (such as gastroplasty or intestinal bypass), regardless of co-morbidities, complications of obesity or any other Medical Condition, except as set forth in Section IV.B. 28. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a member of the Member’s family. 29. Autopsy and associated expenses. 30. Services provided by government agencies, except as required by federal or state law. 31. Services related to temporomandibular joint disorder (TMJ) and/or associated facial pain or to correct congenital conditions, including bite blocks and occlusal equilibration, except as specified as covered in Section IV.B. 32. Services covered by the national health plan of any other country. 33. Pre-Existing Conditions, except as specifically provided in Section IV.B.25. Section VI. Grievance Processes for Complaints and Appeals The grievance processes to express a complaint and appeal a denial of benefits are set forth below. Filing a Complaint or Appeal The complaint process is available for a Member to express dissatisfaction about customer service or the quality or availability of a health service. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 312 of 385 C31620-0057500a 30 The appeals process is available for a Member to seek reconsideration of a denial of benefits. Complaint Process Step 1: The Member should contact the person involved, explain his/her concerns and what he/she would like to have done to resolve the problem. The Member should be specific and make his/her position clear. Step 2: If the Member is not satisfied, or if he/she prefers not to talk with the person involved, the Member should call the department head or the manager of the medical center or department where he/she is having a problem. That person will investigate the Member’s concerns. Most concerns can be resolved in this way. Step 3: If the Member is still not satisfied, he/she should call the GHC Customer Service Center toll free at (888) 901-4636. Most concerns are handled by phone within a few days. In some cases the Member will be asked to write down his/her concerns and state what he/she thinks would be a fair resolution to the problem. A Customer Service Representative or Member Quality of Care Coordinator will investigate the Member’s concern by consulting with involved staff and their supervisors, and reviewing pertinent records, relevant plan policies and the Member Rights and Responsibilities statement. This process can take up to thirty (30) days to resolve after receipt of the Member’s written statement. If the Member is dissatisfied with the resolution of the complaint, he/she may contact the Member Quality of Care Coordinator or the Customer Service Center. Appeals Process Step 1: If the Member wishes to appeal a decision denying benefits, he/she must submit a request for an appeal either orally or in writing to the Member Appeals Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. Appeals should be directed to GHC’s Member Appeals Department, P.O. Box 34593, Seattle, WA 98124-1593, toll free (866) 458-5479. An Appeals Coordinator will review initial appeal requests. GHC will then notify the Member of its determination or need for an extension of time within fourteen (14) days of receiving the request for appeal. Under no circumstances will the review timeframe exceed thirty (30) days without the Member’s written permission. If the appeal request is for an experimental or investigational exclusion or limitation, GHC will make a determination and notify the Member in writing within twenty (20) working days of receipt of a fully documented request. In the event that additional time is required to make a determination, GHC will notify the Member in writing that an extension in the review timeframe is necessary. Under no circumstances will the review timeframe exceed twenty (20) days without the Member’s written permission. There is an expedited appeals process in place for cases which meet criteria or where the Member’s provider believes that the standard thirty (30) day appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited appeal in writing to the above address, or by calling GHC’s Member Appeals Department toll free (866) 458-5479. The Member’s request for an expedited appeal will be processed and a decision issued no later than seventy-two (72) hours after receipt. Step 2: If the Member is not satisfied with the decision in Step 1 regarding a denial of benefits, or if GHC fails to grant or reject the Member’s request within the applicable required timeframe, he/she may request a second level review by an external independent review organization as set forth under subsection A. below. The Member may also choose to pursue review by an appeals committee prior to requesting a review by an independent review organization as set forth under subsection B. below. This is not a required step in the appeals process. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 313 of 385 C31620-0057500a 31 A. Request a review by an independent review organization. An independent review organization is not legally affiliated or controlled by GHC. Once a decision is made through an independent review organization, the decision is final and cannot be appealed through GHC. * A request for a review by an independent review organization must be made within 180 days after the date of the Step 1 decision notice, or within 180 days after the date of a GHC appeals committee decision notice. B. Request an optional hearing by the GHC appeals committee: The appeals committee hearing is an informal process. The hearing will be conducted within thirty (30) working days of the Member's request and notification of the appeal committee’s decision will be mailed to the Member within five (5) working days of the hearing. Members electing the appeals committee maintain their right to appeal further to an independent review organization as set forth in paragraph A. above. Review by the appeals committee is not available if the appeal request is for an experimental or investigational exclusion or limitation. A request for a hearing by the appeals committee must be made within thirty (30) days after the date of the Step 1 decision notice. The request can be mailed to GHC’s Member Appeals Department, P.O. Box 34593, Seattle, WA 98124-1593. * * If the Member’s health plan is governed by the Employee Retirement Income Security Act, known as “ERISA” (most employment related health plans, other than those sponsored by governmental entities or churches – ask employer about plan), the Member has the right to file a lawsuit under Section 502(a) of ERISA to recover benefits due to the Member under the plan at any point after completion of Step 1 of the appeals process. Members may have other legal rights and remedies available under state or federal law. Section VII. General Provisions A. Coordination of Benefits The coordination of benefits (COB) provision applies when a Member has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan must pay an amount which, together with the payment made by the primary plan, totals the higher of the allowable expenses. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all the Member’s claims with each plan at the same time. If Medicare is the Member’s primary plan, Medicare may submit the Member’s claims to the Member’s secondary carrier. 1. Definitions. a. Plan. A plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for Members of a Group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts. However, if COB rules do not apply to all contracts, or to all benefits in the same contract, the contract or benefit to which COB does not apply is treated as a separate plan. 1) Plan includes: group, individual or blanket disability insurance contracts and group or individual contracts issued by health care service contractors or health maintenance 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 314 of 385 C31620-0057500a 32 organizations (HMO), closed panel plans or other forms of group coverage; medical care components of long-term care contracts, such as skilled nursing care; and Medicare or any other federal governmental plan, as permitted by law. 2) Plan does not include: hospital indemnity or fixed payment coverage or other fixed indemnity or fixed payment coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; benefits for non-medical components of long-term care policies; automobile insurance policies required by statute to provide medical benefits; Medicare supplement policies; Medicaid coverage; or coverage under other federal governmental plans; unless permitted by law. Each contract for coverage under subsection 1) or 2) is a separate plan. If a plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate plan. b. This plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits. c. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the Member has health care coverage under more than one plan. When this plan is primary, it determines payment for its benefits first before those of any other plan without considering any other plan’s benefits. When this plan is secondary, it determines its benefits after those of another plan and must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal 100% of the total allowable expense for that claim. This means that when this plan is secondary, it must pay the amount which, when combined with what the primary plan paid, totals 100% of the highest allowable expense. In addition, if this plan is secondary, it must calculate its savings (its amount paid subtracted from the amount it would have paid had it been the primary plan) and record these savings as a benefit reserve for the covered Member. This reserve must be used by the secondary plan to pay any allowable expenses not otherwise paid, that are incurred by the covered person during the claim determination period. d. Allowable Expense. Allowable expense is a health care expense, coinsurance or copayments and without reduction for any applicable deductible, that is covered at least in part by any plan covering the person. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any plan covering the Member is not an allowable expense. The following are examples of expenses that are not allowable expenses: 1) The difference between the cost of a semi-private hospital room and a private hospital room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses. 2) If a Member is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement method or other similar reimbursement method, any amount in excess of the highest reimbursement amount for a specific benefit is not an allowable expense. 3) If a Member is covered by two or more plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense. 4) An expense or a portion of an expense that is not covered by any of the plans covering the person is not an allowable expense. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 315 of 385 C31620-0057500a 33 e. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services through a panel of providers who are primarily employed by the plan, and that excludes coverage for services provided by other providers, except in cases of emergency or referral by a panel member. f. Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. 2. Order of Benefit Determination Rules. When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows: a. The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan. b. Except as provided below, a plan that does not contain a coordination of benefits provision that is consistent with this chapter is always primary unless the provisions of both plans state that the complying plan is primary. Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage is excess to any other parts of the plan provided by the Subscriber. Examples include major medical coverages that are superimposed over hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits. c. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits only when it is secondary to that other plan. d. Each plan determines its order of benefits using the first of the following rules that apply: 1) Non-Dependent or Dependent. The plan that covers the Member other than as a Dependent, for example as an employee, member, policyholder, Subscriber or retiree is the primary plan and the plan that covers the Member as a Dependent is the secondary plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the plan covering the Member as a Dependent, and primary to the plan covering the Member as other than a Dependent (e.g., a retired employee), then the order of benefits between the two plans is reversed so that the plan covering the Member as an employee, member, policyholder, Subscriber or retiree is the secondary plan and the other plan is the primary plan. 2) Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, when a dependent child is covered by more than one plan the order of benefits is determined as follows: a) For a dependent child whose parents are married or are living together, whether or not they have ever been married:  The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or  If both parents have the same birthday, the plan that has covered the parent the longest is the primary plan. b) For a dependent child whose parents are divorced or separated or not living together, whether or not they have ever been married: (1) If a court decree states that one of the parents is responsible for the dependent child’s health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. This rule applies to 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 316 of 385 C31620-0057500a 34 claim determination periods commencing after the plan is given notice of the court decree; (2) If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses, the plan of the parent assuming financial responsibility is primary; (3) If a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, the provisions of a) above determine the order of benefits; (4) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subsection a) above determine the order of benefits; or (5) If there is no court decree allocating responsibility for the dependent child’s health care expenses or health care coverage, the order of benefits for the child are as follows:  The plan covering the custodial parent, first;  The plan covering the spouse of the custodial parent, second;  The plan covering the non-custodial parent, third; and then  The plan covering the spouse of the non-custodial parent, last. c) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the provisions of subsection a) or b) above determine the order of benefits as if those individuals were the parents of the child. 3) Active employee or retired or laid-off employee. The plan that covers a Member as an active employee, that is, an employee who is neither laid off nor retired, is the primary plan. The plan covering that same Member as a retired or laid off employee is the secondary plan. The same would hold true if a Member is a Dependent of an active employee and that same Member is a Dependent of a retired or laid-off employee. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section d 1) can determine the order of benefits. 4) COBRA or State Continuation Coverage. If a Member whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another plan, the plan covering the Member as an employee, member, Subscriber or retiree or covering the Member as a Dependent of an employee, member, Subscriber or retiree is the primary plan and the COBRA or state or other federal continuation coverage is the secondary plan. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section d 1) can determine the order of benefits. 5) Longer or shorter length of coverage. The plan that covered the Member as an employee, member, Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter period of time is the secondary plan. 6) If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the plans meeting the definition of plan. In addition, this plan will not pay more than it would have paid had it been the primary plan. 3. Effect on the Benefits of this Plan. When this plan is secondary, it must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal one hundred percent of the total allowable expense for that claim. However, in no event shall the secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. In no event should the Member be responsible for a deductible amount greater than the highest of the two deductibles. Total allowable expense is the highest allowable expenses of the primary plan or the secondary plan. In addition, the secondary plan must credit to its plan 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 317 of 385 C31620-0057500a 35 deductible any amounts it would have credited to its deductible in the absence of other health care coverage. 4. Right to Receive and Release Needed Information. Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this plan and other plans. GHC may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under this plan and other plans covering the Member claiming benefits. GHC need not tell, or get the consent of, any Member to do this. Each Member claiming benefits under this plan must give GHC any facts it needs to apply those rules and determine benefits payable. 5. Facility of Payment. If payments that should have been made under this plan are made by another plan, GHC has the right, at its discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision. The amounts paid to the other plan are considered benefits paid under this plan. To the extent of such payments, GHC is fully discharged from liability under this plan. 6. Right of Recovery. GHC has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this provision. GHC may recover excess payment from any person to whom or for whom payment was made or any other issuers or plans. Questions about Coordination of Benefits? Contact the State Insurance Department. 7. Effect of Medicare. Members Residing Outside the GHC Medicare Advantage Service Area. Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status. When Medicare, Part A and Part B or Part C are primary, Medicare's allowable amount is the highest allowable expense. When GHC renders care to a Member who is eligible for Medicare benefits, and Medicare is deemed to be the primary bill payer under Medicare primary/secondary payer guidelines and regulations, GHC will seek Medicare reimbursement for all Medicare covered services. B. Subrogation and Reimbursement Rights The benefits under this Agreement will be available to a Member for injury or illness caused by another party, subject to the exclusions and limitations of this Agreement. If GHC provides benefits under this Agreement for the treatment of the injury or illness, GHC will be subrogated to any rights that the Member may have to recover compensation or damages related to the injury or illness. This section VII.B. more fully describes GHC’s subrogation and reimbursement rights. “Injured Person” under this section means a Member covered by the Agreement who sustains an injury and any spouse, dependent or other person or entity that may recover on behalf of such Member, including the estate of the Member and, if the Member is a minor, the guardian or parent of the Member. When referred to in this section, “GHC’s Medical Expenses” means the expenses incurred and the value of the benefits provided by GHC under this Agreement for the care or treatment of the injury sustained by the Injured Person. If the Injured Person’s injuries were caused by a third party giving rise to a claim of legal liability against the third party and/or payment by the third party to the Injured Person and/or a settlement between the third party and the Injured Person, GHC shall have the right to recover GHC’s Medical Expenses from any source available to the Injured Person as a result of the events causing the injury, including but not limited to funds available through applicable third party liability coverage and 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 318 of 385 C31620-0057500a 36 uninsured/underinsured motorist coverage. This right is commonly referred to as “subrogation.” GHC shall be subrogated to and may enforce all rights of the Injured Person to the extent of GHC’s Medical Expenses. GHC’s subrogation and reimbursement rights shall be limited to the excess of the amount required to fully compensate the Injured Person for the loss sustained, including general damages. However, in the case of Medicare Advantage Members, GHC’s right of subrogation shall be the full amount of GHC’s Medical Expenses and is limited only as required by Medicare. Subject to the above provisions, if the Injured Person is entitled to or does receive money from any source as a result of the events causing the injury, including but not limited to any party’s liability insurance or uninsured/underinsured motorist funds, then GHC’s Medical Expenses provided or to be provided to the Injured Person are secondary, not primary. As a condition of receiving benefits under the Agreement, the Injured Person agrees that acceptance of GHC services is constructive notice of this provision in its entirety and agrees to reimburse GHC for the benefits the Injured Person received as a result of the events causing the injury. The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect GHC’s Medical Expenses. This cooperation includes, but is not limited to, supplying GHC with information about the cause of injury or illness, any third parties, defendants and/or insurers related to the Injured Person’s claim and informing GHC of any settlement or other payments relating to the Injured Person’s injury. The Injured Person and his/her agents shall permit GHC, at GHC’s option, to associate with the Injured Person or to intervene in any legal, quasi-legal, agency or any other action or claim filed. If the Injured Person takes no action to recover money from any source, then the Injured Person agrees to allow GHC to initiate its own direct action for reimbursement or subrogation, including, but not limited to, billing the Injured Person directly for GHC’s Medical Expenses The Injured Person and his/her agents shall do nothing to prejudice GHC’s subrogation and reimbursement rights. The Injured Person shall promptly notify GHC of any tentative settlement with a third party and shall not settle a claim without protecting GHC’s interest. If the Injured Person fails to cooperate fully with GHC in recovery of GHC’s Medical Expenses, the Injured Person shall be responsible for directly reimbursing GHC for GHC’s Medical Expenses and GHC retains the right to bill the Injured Person directly for GHC’s Medical Expenses. To the extent that the Injured Person recovers funds from any source that may serve to compensate for medical injuries or medical expenses, the Injured Person agrees to hold such monies in trust or in their possession until GHC’s subrogation and reimbursement rights are fully determined. If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining recovery, under certain conditions GHC will reduce the amount of reimbursement to GHC by the amount of an equitable apportionment of such collection costs between GHC and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i) the equitable apportionment of attorney fees has been agreed to by GHC prior to settlement or recovery, (ii) the Injured Person’s attorney’s action has benefited GHC in its recovery, and (iii) the Injured Person’s attorney’s actions were reasonable and necessary to secure recovery. GHC’s share of collection costs is subject to a maximum responsibility of GHC equal to one-third of the amount recovered on behalf of GHC. Under no circumstance will GHC incur legal fees for services which were not reasonably and necessarily incurred to secure recovery or which do not benefit GHC. If this Agreement is subject to ERISA and reasonable collections costs have been incurred by the Injured Person for the benefit of GHC, the Injured Person may request and GHC may reduce the amount of reimbursement to GHC by an amount for reasonable and necessary attorney’s fees incurred by the Injured Person on behalf of and for the benefit of GHC, but only if such amount is agreed to by GHC prior to settlement or recovery. To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA, implementation of this section shall be deemed a part of claims administration under the Agreement and GHC shall therefore have discretion to interpret its terms. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 319 of 385 C31620-0057500a 37 C. Miscellaneous Provisions 1. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members enrolled under the Agreement. 2. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the administration of the Agreement. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. 3. Modification of Agreement. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of the Agreement, convey or void any coverage, increase or reduce any benefits under the Agreement or be used in the prosecution or defense of a claim under the Agreement. 4. Confidentiality. GHC and the Group shall keep Member information strictly confidential and shall not disclose any information to any third party other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have a need to know such information in order to perform the services required of such party pursuant to the Agreement, or for the proper management and administration of the receiving party, provided that such representatives are informed of the confidentiality provisions of the Agreement and agree to abide by them, (ii) pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal, state or local law, statute, rule or regulation. 5. Nondiscrimination. GHC does not discriminate on the basis of physical or mental disabilities in its employment practices and services. Section VIII. Definitions Agreement: The Medical Coverage Agreement between GHC and the Group. Allowance: The maximum amount payable by GHC for certain Covered Services under the Agreement, as set forth in the Allowances Schedule. Contracted Network Pharmacy: A pharmacy that has contracted with GHC to provide covered legend (prescription) drugs and medicines for outpatient use under the Agreement. Copayment: The specific dollar amount a Member is required to pay at the time of service for certain Covered Services under the Agreement, as set forth in the Allowances Schedule. Cost Share: The portion of the cost of Covered Services the Member is liable for under the Agreement. Cost Shares for specific Covered Services are set forth in the Allowances Schedule. Cost Share includes Copayments, coinsurances and/or Deductibles. Covered Services: The services for which a Member is entitled to coverage under the Agreement. Deductible: A specific amount a Member is required to pay for certain Covered Services before benefits are payable under the Agreement. The applicable Deductible amounts are set forth in the Allowances Schedule. Dependent: Any member of a Subscriber’s family who meets all applicable eligibility requirements, is enrolled hereunder and for whom the premium prescribed in the Premium Schedule has been paid. Emergency: The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part, or would place the Member's health in serious jeopardy. Essential Health Benefits: Benefits set forth under the Patient Protection and Affordable Care Act of 2010, including the categories of ambulatory patient services, emergency services, hospitalization, 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 320 of 385 C31620-0057500a 38 maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Family Unit: A Subscriber and all his/her Dependents. Fee Schedule: A fee-for-service schedule adopted by GHC, setting forth the fees for medical and hospital services. GHC-Designated Self-Referral Specialist: A GHC specialist specifically identified by GHC to whom Members may self-refer. GHC Facility: A facility (hospital, medical center or health care center) owned, operated or otherwise designated by GHC. GHC Medicare Plan: A plan of coverage for persons enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance). GHC Personal Physician: A provider who is employed by or contracted with GHC to provide primary care services to Members and is selected by each Member to provide or arrange for the provision of all non-emergent Covered Services, except for services set forth in the Agreement which a Member can access without a Referral. Personal Physicians must be capable of and licensed to provide the majority of primary health care services required by each Member. GHC Provider: The medical staff, clinic associate staff and allied health professionals employed by GHC, and any other health care professional or provider with whom GHC has contracted to provide health care services to Members enrolled under the Agreement, including, but not limited to physicians, podiatrists, nurses, physician assistants, social workers, optometrists, psychologists, physical therapists and other professionals engaged in the delivery of healthcare services who are licensed or certified to practice in accordance with Title 18 Revised Code of Washington. Group: An employer, union, welfare trust or bona-fide association which has entered into a Group Medical Coverage Agreement with GHC. Hospital Care: Those Medically Necessary services generally provided by acute general hospitals for admitted patients. Hospital Care does not include convalescent or custodial care, which can, in the opinion of the GHC Provider, be provided by a nursing home or convalescent care center. Lifetime Maximum: The maximum value of benefits provided for Covered Services under the Agreement after which benefits under the Agreement are no longer available as set forth in the Allowances Schedule. The value of Covered Services is based on the Fee Schedule, as defined above. The lifetime maximum applies to this Agreement or in combination with any other medical coverage agreement between GHC and Group. Medical Condition: A disease, illness or injury. Medically Necessary: Appropriate and clinically necessary services, as determined by GHC’s Medical Director, or his/her designee, according to generally accepted principles of good medical practice, which are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Member, his/her family or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Member; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under GHC’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Washington, could not have been omitted without adversely affecting the Member’s condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a provider’s office, the outpatient department of a hospital or a non-residential facility without affecting the 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 321 of 385 C31620-0057500a 39 Member’s condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are not experimental or investigational. The length and type of the treatment program and the frequency and modality of visits covered shall be determined by GHC’s Medical Director, or his/her designee. In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service as set forth in Section IV. of the Agreement and not excluded from coverage. The cost of non-covered services and supplies shall be the responsibility of the Member. Medicare: The federal health insurance program for the aged and disabled. Member: Any Subscriber or Dependent enrolled under the Agreement. Out-of-Pocket Expenses: Those Cost Shares paid by the Subscriber or Member for Covered Services which are applied to the Out-of-Pocket Limit. Out-of-Pocket Limit: The maximum amount of Out-of-Pocket Expenses incurred and paid during the calendar year for Covered Services received by the Subscriber and his/her Dependents within the same calendar year. The Out-of-Pocket Limit amount and Cost Shares that apply are set forth in the Allowances Schedule. Charges in excess of UCR, services in excess of any benefit level and services not covered by the Agreement are not applied to the Out-of-Pocket Limit. Plan Coinsurance: The percentage amount the Member and GHC are required to pay for Covered Services received under the Agreement. Percentages for Covered Services are set forth in the Allowances Schedule. A coinsurance percentage not identified as Plan Coinsurance is a benefit specific coinsurance and does not apply to the Out-of-Pocket Limit except as otherwise specified under Section II. Out-of-Pocket Limit. Pre-Existing Condition: A condition for which there has been diagnosis, treatment or medical advice within the three (3) month period prior to the effective date of coverage. The Pre-Existing Condition wait period will begin on the first day of coverage, or the first day of the enrollment waiting period if earlier. Referral: A written temporary agreement requested in advance by a GHC Provider and approved by GHC that entitles a Member to receive Covered Services from a specified health care provider. Entitlement to such services shall not exceed the limits of the Referral and is subject to all terms and conditions of the Referral and the Agreement. Members who have a complex or serious medical or psychiatric condition may receive a standing Referral for specialist services. Residential Treatment: A term used to define facility-based treatment, which includes twenty-four (24) hours per day, seven (7) days per week rehabilitation. Residential Treatment services are provided in a facility specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi-disciplinary team of licensed professionals. Self-Referred: Covered Services received by a Member from a designated women’s health care specialist or GHC-Designated Self-Referral Specialist that are not referred by a GHC Personal Physician. Service Area: Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman and Yakima; Idaho counties of Kootenai and Latah; and any other areas designated by GHC. Subscriber: A person employed by or belonging to the Group who meets all applicable eligibility requirements, is enrolled under the Agreement and for whom the premium specified in the Premium Schedule has been paid. Urgent Condition: The sudden, unexpected onset of a Medical Condition that is of sufficient severity to require medical treatment within twenty-four (24) hours of its onset. Usual, Customary and Reasonable (UCR): A term used to define the level of benefits which are payable by GHC when expenses are incurred from a non-GHC Provider. Expenses are considered Usual, Customary and Reasonable if the charges are consistent with those normally charged to others by the provider or organization for the same services or supplies; and the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 322 of 385 1 Group Health Cooperative Medicare Advantage Plan (MA) Following is a brief outline of the benefits available to Group Members who are also enrolled in the Group Health Cooperative Medicare Advantage (MA) plan. In no event shall the benefits of the MA plan duplicate the benefits under the Group Medical Coverage Agreement. The benefits available to persons enrolled in both the Group Health Cooperative Medical Coverage Agreement and the Group Health Cooperative Medicare Advantage Plan will be the higher level of benefit available under the plans, as determined by Group Health Cooperative. Unless otherwise stated, the provisions, limitations and exclusions, including provider access requirements of the Group Medical Coverage Agreement apply to the benefits available under the Group Health Cooperative Medicare Advantage Plan. The benefits described in this outline apply only to Members who are covered under Medicare Part A and Part B, and who are enrolled in the Group Health Cooperative Medicare Advantage Plan as set forth in the Group Medical Coverage Agreement. This includes those Members with Medicare Part B only, who have been continuously enrolled in the Group Health Cooperative Medicare Advantage Plan since December 31, 1998. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 323 of 385 2 SUMMARY OF BENEFITS Group Health Medicare Advantage Clear Care Employer Group Plan (Benefit 2) If you have any questions about this plan's benefits or costs, please contact Group Health Cooperative for details. SECTION II – Summary of Benefits Benefit Category Original Medicare GHC Medicare Plan (Medicare Parts A & B) IMPORTANT INFORMATION 1 – Premium and Other Important Information In 2011 the monthly Part B Premium is $96.40 and the yearly Part B deductible amount is $162. If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income ($85,000 for singles, $170,000 for married couples).For more information about Part B premiums based on income, call Social Security at 1-800-772-1213. TTY users should call 1-800-325- 0778. $2,500 out-of-pocket limit. Contact the plan for services that apply. 2 - Doctor and Hospital Choice (For more information, see Emergency - #15 and Urgently Needed Care - #16.) You may go to any doctor, specialist or hospital that accepts Medicare. You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists for (for certain benefits). You may have to pay a separate copay for certain doctor office visits. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 324 of 385 3 SUMMARY OF BENEFITS INPATIENT CARE 3 - Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services) In 2011 the amounts for each benefit period are: Days 1 - 60: $1,132 deductible Days 61 - 90: $283 per day Days 91 - 150: $566 per lifetime reserve day Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once. A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. In-Network: For Medicare-covered hospital stays you pay the lesser of the Group cost share or the following copayments: Days 1-5: $200 copay per day Days 6-90: $0 copay per day $0 copay for additional hospital days. No limit to the number of days covered by the plan each benefit period. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 4 - Inpatient Mental Health Care Same deductible and copay as inpatient hospital care (see "Inpatient Hospital Care" above). 190 day lifetime limit in a Psychiatric Hospital. For Medicare-covered hospital stays you pay the lesser of the Group cost share or the following copayments: Days 1-5: $200 copay per day Days 6-90: $0 copay per day You get up to 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 5 - Skilled Nursing Facility (in a Medicare-certified skilled nursing facility) In 2011 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $141.50 per day 100 days for each benefit period. A benefit period begins the day you There is no copayment for services received at a Skilled Nursing Facility. No prior hospital stay is required. You are covered for 100 days each benefit period. Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 325 of 385 4 go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 6 - Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay Authorization rules may apply. $0 copay for Medicare-covered home health visits. 7 - Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must receive care from a Medicare-certified hospice. You must receive care from a Medicare-certified hospice. OUTPATIENT CARE 8 - Doctor Office Visits 20% coinsurance General See “Physical Exams” for more information. Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for each primary care doctor office visit for Medicare- covered services. You pay the lesser of the Group cost share or $20 copay for each specialist visit for Medicare-covered services. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 326 of 385 5 9 - Chiropractic Services Routine care not covered. 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. In-Network You pay the lesser of the Group cost share or $20 copay for Medicare- covered visits. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). 10 - Podiatry Services Routine care not covered. 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for Medicare- covered visits. Medicare-covered podiatry benefits are for medically-necessary foot care. 11 - Outpatient Mental Health Care 45% coinsurance for most outpatient mental health services. General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 copay for each Medicare-covered individual or group therapy visit. 12 - Outpatient Substance Abuse Care 20% coinsurance In-Network $0 copay for Medicare-covered visits. 13 - Outpatient Services/Surgery 20% coinsurance for the doctor 20% of outpatient facility charges General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $200 copay for each Medicare-covered ambulatory surgical center visit. You pay the lesser of the Group cost share or $200 copay for each Medicare-covered outpatient hospital facility visit. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 327 of 385 6 14 - Ambulance Services (medically necessary ambulance services) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $150 copay for Medicare- covered ambulance benefits. 15 - Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 20% coinsurance for the doctor 20% of facility charge, or a set copay per emergency room visit. You don’t have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. NOT covered outside the U.S. except under limited circumstances. In-Network You pay the lesser of the Group cost share or $50 for each Medicare- covered emergency room visit. Out-of-Network Worldwide coverage. In and Out-of-Network If you are admitted to the hospital within 1 day for the same condition, you pay $0 for the emergency room visit. 16 - Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) 20% coinsurance, or a set copay NOT covered outside the U.S. except under limited circumstances. You pay the lesser of the Group cost share or $20 copay for each Medicare-covered urgently needed care visit. 17 - Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or $20 for Medicare-covered Occupational Therapy visits. You pay the lesser of the Group cost share or $20 for Medicare-covered Physical and/or Speech/Language Therapy visits. OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 - Durable Medical Equipment (Includes wheelchairs, oxygen, etc.) 20% coinsurance General Authorization rules may apply. In-Network You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items. 19 - Prosthetic Devices (Includes braces, artificial limbs and eyes, 20% coinsurance General Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 328 of 385 7 etc.) In-Network You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items. 20 - Diabetes Self- Monitoring Training, Nutrition Therapy, and Supplies (includes coverage for glucose monitors, test strips, lancets, screening tests, and self- management training) 20% coinsurance Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. General Authorization rules may apply. In-Network $0 copay for Diabetes self-monitoring training. In-Network $0 copay for Nutrition Therapy for Diabetes. You pay the lesser of the Group cost share or 20% of the cost for Diabetes supplies. 21 - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 20% coinsurance for diagnostic tests and X-rays $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol. General Authorization rules may apply. In-Network $0 copay for Medicare-covered:  lab services  diagnostic procedures and tests X-rays  Diagnostic radiology services (not including X-rays)  therapeutic radiology services PREVENTIVE SERVICES 22 - Bone Mass Measurement (for people with Medicare who are at risk) 20% coinsurance Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. General Authorization rules may apply. In-Network $0 copay for Medicare-covered bone mass measurement 23 - Colorectal Screening Exams (for people with 20% coinsurance Covered when you are high risk or General Authorization rules may apply. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 329 of 385 8 Medicare age 50 and older) when you are age 50 and older. In-Network $0 copay for Medicare-covered colorectal screenings. 24 - Immunizations (Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine) $0 copay for Flu and Pneumonia vaccines 20% coinsurance for Hepatitis B vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. General Authorization rules may apply. In-Network $0 copay for Flu and Pneumonia vaccines. $0 copay for Hepatitis B vaccine No referral necessary for Flu and Pneumonia vaccines. Referral required for other immunizations. 25 - Mammograms (Annual Screening) (for women with Medicare age 40 and older) 20% coinsurance No referral needed. Covered once a year for all women with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39. In-Network $0 copay for Medicare-covered screening mammograms. 26 - Pap Smears and Pelvic Exams (for women with Medicare) $0 copay for Pap smears Covered once every 2 years. Covered once a year for women with Medicare at high risk. 20% coinsurance for pelvic exams. In-Network $0 copay for Medicare-covered pap smears and pelvic exams. 27 - Prostate Cancer Screening Exams (For men with Medicare age 50 and older.) 20% coinsurance for the digital rectal exam. $0 for the PSA test; 20% coinsurance for other related services. Covered once a year for all men with Medicare over age 50. General Authorization rules may apply. In-Network $0 copay for Medicare-covered prostate cancer screenings. 28 – End-Stage Renal Disease 20% coinsurance for renal dialysis 20% coinsurance for Nutrition Therapy for End-Stage Renal Disease Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by General Authorization rules may apply. Out-of-area Renal Dialysis services do not require Authorization. In-Network $0 copay for renal dialysis $0 copay for Nutrition Therapy for end-stage renal disease 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 330 of 385 9 a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. 29 - Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Your Employer Group Outpatient Prescription drug benefit applies. Please contact the plan for details. 30 - Dental Services Preventive dental services (such as cleaning) not covered. $0 copay for Medicare-covered dental benefits. In general, preventive dental benefits (such as cleaning) not covered. 31 - Hearing Services Routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. You pay the lesser of the Group cost share or: - $20 for each Medicare-covered hearing exam (diagnostic hearing exams). Your Employer Group hearing benefit applies for routine exams and hearing aids. Please contact the plan for details. 32 – Vision Services 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. Routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Annual glaucoma screenings covered for people at risk. In-Network - $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. - $20 for exams to diagnosis and treat diseases and conditions of the eye). Your Employer Group Vision benefit applies for routine eye exams and glasses. Please contact the plan for details. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 331 of 385 10 33 - Physical Exams 20% coinsurance for one exam within the first 12 months of your new Medicare Part B coverage. When you get Medicare Part B, you can get a one time physical exam within the first 12 months of your new Part B coverage. The coverage does not include lab tests. $0 copay for routine exams. Limited to 1 exam every two years. $0 copay for Medicare-covered benefits. Health/Wellness Education Smoking Cessation: Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco. Each counseling attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies. In-Network This plan covers the following health/wellness education benefits:  Smoking Cessation  Health Club Membership/Fitness Classes  Nursing Hotline $0 copay for each Medicare-covered smoking cessation counseling session Transportation (Routine) Not covered. General Authorization rules may apply. In-Network $150 copay for one-way trips to a Plan-approved location. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 332 of 385 11 SECTION III – Other Benefits Offered By Group Health’s Clear Care Plan My Group Health (when you get care at a Group Health medical center).  Request appointments  View your online medical records  Email your doctor  Get test results  Check your benefits Wellness Programs Consulting Nurse helpline 24/7 Prescription Refills  Online  Mail-order  By phone Senior Caucus Travel Advisory Service Group Health Resource Line Additional Information About Covered Benefits Found in Section II Skilled Nursing Facility (Group Health Covered): When a 3 day Medicare covered hospital stay does not occur and the plan determines that the member otherwise meets all Medicare criteria for an acute inpatient hospital stay at the time of admission to a Medicare Certified Skilled Nursing Facility, the plan may authorize Medicare covered Skilled Nursing Facility Care up to the Medicare Skilled Nursing Facility day limit per benefit period. All Medicare criteria must be met and the stay must be authorized in advance by the plan. Out-Of-Pocket Limit; Stop Loss Provision for Copayments: Total copayment expenses for outpatient services and the outpatient supplies listed in this summary of benefits, hospital emergency room visits, ambulance/transportation services, inpatient hospital stays, and inpatient mental health care stays, are limited to an aggregate annual maximum of $2,500 per calendar year per member. The following items and services aren’t covered under Original Medicare or our MA plan (please refer to your employer group Certificate of Coverage for more information about what is covered and excluded under your employer group plan):  Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as a covered services.  Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare. However, certain services may be covered under a Medicare-approved clinical research study.  Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare.  Private room in a hospital, except when it is considered medically necessary.  Private duty nurses. This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 333 of 385 12  Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television.  Full-time nursing care in your home.  Custodial care, unless it is provided with covered skilled nursing care and/or skilled rehabilitation services. Custodial care, or non-skilled care, is care that helps you with activities of daily living, such as bathing or dressing.  Homemaker services include basic household assistance, including light housekeeping or light meal preparation.  Fees charged by your immediate relatives or members of your household.  Meals delivered to your home.  Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary.  Cosmetic surgery or procedures, unless because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.  Routine dental care, such as cleanings, filings or dentures. However, non-routine dental care received at a hospital may be covered.  Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines.  Routine foot care, except for the limited coverage provided according to Medicare guidelines.  Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease.  Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease.  Hearing aids and routine hearing examinations.  Eyeglasses, routine eye examinations, radial keratotomy, LASIK surgery, vision therapy and other low vision aids. However, eyeglasses are covered for people after cataract surgery, and routine eye examinations are covered under our basic benefit.  Outpatient prescription drugs including drugs for treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.  Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies.  Acupuncture.  Naturopath services (uses natural or alternative treatments).  Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at VA hospital and the VA cost-sharing is more than 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 334 of 385 13 the cost-sharing under our plan. We will reimburse veterans for the difference. Members are still responsible for our cost-sharing amounts.  Any services listed above that aren’t covered will remain not covered even if received at an emergency facility. YOUR RIGHTS AND RESPONSIBILITES SECTION 1 Our plan must honor your rights as a member of the plan To get information from us in a way that works for you, please call Customer Service (phone numbers are on the front cover). Our plan has people and translation services available to answer questions from non- English speaking members. We can also give you information in Braille, in large print, or other alternate formats if you need it. If you are eligible for Medicare because of disability, we are required to give you information about the plan’s benefits that is accessible and appropriate for you. If you have any trouble getting information from our plan because of problems related to language or disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-2048. Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights 1- 800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. Customer Service (phone numbers are on the cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Customer Service can help. We must provide you with details about your rights and responsibilities as a patient and consumer Section 1.2 We must provide information in a way that works for you (in languages other than English that are spoken in the plan service area, in Braille, in large print, or other alternate formats, etc.) Section 1.3 We must treat you with fairness, respect, and dignity at all times Section 1.4 We must ensure that you get timely access to your covered services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 335 of 385 14 As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services. Call Customer Service to learn which doctors are accepting new patients (phone numbers are on the cover of this booklet). You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral. As a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.  Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.  The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice”, that tells about these rights and explains how we protect the privacy of your health information. How do we protect the privacy of your health information?  We make sure that unauthorized people don’t see or change your records.  In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.  There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. o For example, we are required to release health information to government agencies that are checking on quality of care. o Because you are a member of our plan through Medicare, we are required to give Medicare your health information. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations. You can see the information in your records and know how it has been shared with others You have the right to look at your medical records held at the plan, and to get a copy of your records. You also have the right to ask us to make additions or corrections to your Section 1.5 We must provide access to information about the qualifications of the professionals caring for you Section 1.6 We must protect the privacy of your personal health information 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 336 of 385 15 medical records. If you ask us to do this, we will consider your request and decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Customer Service (phone numbers are on the cover of this booklet). As a member of our plan, you have the right to get several kinds of information from us. (As explained above in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.) If you want any of the following kinds of information, please call Customer Service (phone numbers are on the cover of this booklet):  Information about our plan. This includes, for example, information about the plan’s financial condition. It also includes information about the number of appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare Advantage health plans.  Information about our network providers. o For example, you have the right to get information from us about the qualifications of the providers in our network and how we pay the providers in our network. o For a list of the providers in the plan’s network, see the Provider Directory. o For more detailed information about our providers, you can call Customer Service (phone numbers are on the cover of this booklet) or visit our website at www.ghc.org/medicare.  Information about your coverage and rules you must follow in using your coverage. o If you have questions about the rules or restrictions, please call Customer Service (phone numbers are on the cover of this booklet).  Information about why something is not covered and what you can do about it. o If a medical service is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service from an out- of-network provider. Section 1.7 We must give you information about the plan, its network of providers, and your covered services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 337 of 385 16 You have the right to know your treatment options and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand. You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:  To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan.  To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.  The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. Of course, if you refuse treatment, you accept full responsibility for what happens to your body as a result.  To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:  Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.  Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives. If you want to use an “advance directive” to give your instructions, here is what to do: Section 1.8 We must support your right to make decisions about your care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 338 of 385 17  Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Customer Service to ask for the forms (phone numbers are on the cover of this booklet).  Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.  Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.  If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.  If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. What if your instructions are not followed? If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed the instructions in it, you may file a complaint with SHIBA at the Washington State Office of the Insurance Commissioner by writing to SHIBA HelpLine, Office of the Insurance Commissioner, P.O. Box 40256, Olympia, WA 98504-0256, or calling the toll- free SHIBA Helpline at 1-800-562-6900. Section 1.9 You have the right to give consent to–or refuse–care, and be told the consequences of consent or refusal Section 1.10 You have the right to have an honest discussion with your practitioner about all your treatment options, regardless of cost or benefit coverage, presented in a manner appropriate to your medical condition and ability to understand 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 339 of 385 18 You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly. You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Customer Service (phone numbers are on the cover of this booklet). Section 1.11 You have the right to join in decisions to receive, or not receive, life-sustaining treatment including care at the end of life Section 1.12 You have the right to create and update your advance directives and have your wishes honored Section 1.13 You have the right to choose a personal primary care physician affiliated with your health plan Section 1.14 You have the right to expect your personal physician to provide, arrange, and/or coordinate your care Section 1.15 You have the right to change your personal physician for any reason Section 1.16 You have the right to be educated about your role in reducing medical errors and the safe delivery of care Section 1.17 You have the right to voice opinions, concerns, positive comments and complaints and to ask us to reconsider decisions we have made Section 1.18 You have the right to appeal a decision and receive a response within a reasonable amount of time Section 1.19 You have the right to suggest changes to consumer rights and responsibilities and related policies Section 1.20 You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation Section 1.21 You have the right to be free from all forms of abuse, harassment, or discrimination 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 340 of 385 19 If it is about discrimination, call the Office for Civil Rights If you think you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights. Is it about something else? If you think you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:  You can call Customer Service (phone numbers are on the cover of this booklet).  You can call the State Health Insurance Assistance Program. There are several places where you can get more information about your rights:  You can call Customer Service (phone numbers are on the cover of this booklet).  You can call the State Health Insurance Assistance Program.  You can contact Medicare. o You can visit the Medicare website (http://www.medicare.gov) to read or download the publication “Your Medicare Rights & Protections.” o Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. SECTION 2 You have some responsibilities as a member of the plan Section 1.22 You have the right to be free from discrimination, reprisal, or any other negative action when exercising your rights Section 1.23 You have the right to request and receive a copy of your medical records, and request amendment or correction to such documents, in accordance with applicable state and federal laws Section 1.24 What can you do if you think you are being treated unfairly or your rights are not being respected? Section 1.25 How to get more information about your rights Section 2.1 What are your responsibilities? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 341 of 385 20 Things you need to do as a member of the plan are listed below. If you have any questions, please call Customer Service (phone numbers are on the cover of this booklet). We’re here to help.  Get familiar with your covered services and the rules you must follow to get these covered services. Use this booklet to learn what is covered for you and the rules you need to follow to get your covered services.  If you have any other health insurance coverage in addition to our plan, or separate prescription drug coverage, you are required to tell us. Please call Customer Service to let us know. o We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called “coordination of benefits” because it involves coordinating the health benefits you get from our plan with any other benefits available to you. We’ll help you with it.  Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get your medical care.  Use practitioners and providers affiliated with your health plan for health care benefits and services, except where services are authorized or allowed by your health plan, or in the event of emergencies.  Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. o Provide accurate information, to the extent possible, that Group Health requires to care for you. This includes your health history and your current condition. Group Health also needs your permission to obtain needed medical and personal information. This includes your name, address, phone number, marital status, dependents’ status, and names of other insurance companies. o To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon. o If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.  Understand and follow instructions for treatment, and understand the consequences of following or not following instructions.  Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices. This includes arriving on time for appointments, and notifying staff if you cannot make it on time or if you need to reschedule.  Pay what you owe. As a plan member, you are responsible for these payments: o You must pay your plan premiums to continue being a member of our plan. o In order to be eligible for our plan, you must maintain your eligibility for Medicare Part A and Part B. For that reason, some plan members must pay 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 342 of 385 21 a premium for Medicare Part A and most plan members must pay a premium for Medicare Part B to remain a member of the plan. o For some of your medical services covered by the plan, you must pay your share of the cost when you get the service. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). o If you get any medical services that are not covered by our plan or by other insurance you may have, you must pay the full cost.  Understand your health needs and work with your personal physician to develop mutually agreed upon goals about ways to stay healthy or get well when you are sick  Tell us if you move. If you are going to move, it’s important to tell us right away. Call Customer Service (phone numbers are on the cover of this booklet). o If you move outside of our plan service area, you cannot remain a member of our plan. We can help you figure out whether you are moving outside our service area. If you are leaving our service area, we can let you know if we have a plan in your new area. o If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.  Call Customer Service for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan. o Phone numbers and calling hours for Customer Service are on the cover of this booklet. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 343 of 385 22 COVERAGE DECISIONS, APPEALS, COMPLAINTS SECTION 1 Introduction This chapter explains two types of processes for handling problems and concerns:  For some types of problems, you need to use the process for coverage decisions and making appeals.  For other types of problems you need to use the process for making complaints.  Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will help you identify the right process to use. There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To keep things simple, this chapter explains the legal rules and procedures using more common words in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a grievance,” “coverage decision” rather than “organization determination” and “Independent Review Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible. However, it can be helpful – and sometimes quite important – for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations. SECTION 2 You can get help from government organizations that are not connected with us Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step. Perhaps both are true for you. Get help from an independent government organization We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has Section 1.1 What to do if you have a problem or concern Section 1.2 What about the legal terms? Section 2.1 Where to get more information and personalized assistance 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 344 of 385 23 trained counselors in every state. The program is not connected with our plan or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. You can also get help and information from Medicare For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:  You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.  You can visit the Medicare website (http://www.medicare.gov). SECTION 3 To deal with your problem, which process should you use? If you have a problem or concern and you want to do something about it, you don’t need to read this whole chapter. You just need to find and read the parts of this chapter that apply to your situation. The guide that follows will help. Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 345 of 385 24 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide to the basics of coverage decisions and appeals The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We and/or your doctor make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Making an appeal If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. When we have completed the review we give you our decision. If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:  You can call us at Customer Service (phone numbers are on the cover).  To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program (see Section 2 of this chapter).  Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 Appeal on your Section 4.1 Asking for coverage decisions and making appeals: the big picture Section 4.2 How to get help when you are asking for a coverage decision or making an appeal 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 346 of 385 25 behalf. To request any appeal after Level 1, your doctor or other provider must be appointed as your representative.  You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. o There may be someone who is already legally authorized to act as your representative under State law. o If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Service and ask for the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.  You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. There are three different types of situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section: If you’re still not sure which section you should be using, please call Customer Service (phone numbers are on the front cover). You can also get help or information from government organizations such as your State Health Insurance Assistance Program. SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal Section 4.3 Which section of this chapter gives the details for your situation? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 347 of 385 26 ? Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisions and appeals)? If not, you may want to read it before you start this section. This section is about your benefits for medical care and services. These are the benefits described in the Summary on Benefits. To keep things simple, we generally refer to “medical care coverage” or “medical care” in the rest of this section, instead of repeating “medical care or treatment or services” every time. This section tells what you can do if you are in any of the five following situations: 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan. 3. You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care. 4. You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. 5. You are being told that coverage for certain medical care you have been getting will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.  NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation (CORF) services, you need to read a separate section of this chapter because special rules apply to these types of care. Here’s what to read in those situations: o Section 6: How to ask for a longer hospital stay if you think you are being asked to leave the hospital too soon. o Section 7: How to ask our plan to keep covering certain medical services if you think your coverage is ending too soon. This section is about three services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services.  For all other situations that involve being told that medical care you have been getting will be stopped, use this section (Section 5) as your guide for what to do. Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 348 of 385 27 Legal Terms When a coverage decision involves your medical care, it is called an “organization determination.” Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a “fast decision.” Legal Terms A “fast decision” is called an “expedited decision.” How to request coverage for the medical care you want  Start by calling, writing, or faxing our plan to make your request for us to provide coverage for the medical care you want. You, or your doctor, or your representative can do this. Generally we use the standard deadlines for giving you our decision When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 14 days after we receive your request.  However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.  If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (The process for making a complaint is different from the process for coverage decisions and appeals. For Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 349 of 385 28 more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) If your health requires it, ask us to give you a “fast decision”  A fast decision means we will answer within 72 hours. o However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. o If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) We will call you as soon as we make the decision.  To get a fast decision, you must meet two requirements: o You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.) o You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.  If your doctor tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.  If you ask for a fast decision on your own, without your doctor’s support, our plan will decide whether your health requires that we give you a fast decision. o If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead). o This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision. o The letter will also tell how you can file a “fast complaint” about our decision to give you a standard decision instead of the fast decision you requested. (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.) Step 2: Our plan considers your request for medical care coverage and we give you our answer. Deadlines for a “fast” coverage decision  Generally, for a fast decision, we will give you our answer within 72 hours. o As explained above, we can take up to 14 more days under certain circumstances. If we decide to take extra days to make the decision, we will tell you in writing. If we take extra days, it is called “an extended time period.” o If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.  If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 350 of 385 29 hours after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Deadlines for a “standard” coverage decision  Generally, for a standard decision, we will give you our answer within 14 days of receiving your request. o We can take up to 14 more days (“an extended time period”) under certain circumstances. If we decide to take extra days to make the decision, we will tell you in writing. o If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.  If our plan says no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.  If you decide to make appeal, it means you are going on to Level 1 of the appeals process (see Section 5.3 below). Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or a “Level 1 Appeal.” An appeal to the plan about a medical care coverage decision is called a plan “reconsideration.” Step 1: You contact our plan and make your appeal. If your health requires a quick response, you must ask for a “fast appeal.” What to do  To start an appeal you, your representative, or in some cases your doctor must contact our plan. Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 351 of 385 30  If you are asking for a standard appeal, make your standard appeal in writing by submitting a signed request.  If you are asking for a fast appeal, make your appeal in writing or call us.  You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.  You can ask for a copy of the information regarding your medical decision and add more information to support your appeal. o You have the right to ask us for a copy of the information regarding your appeal. o If you wish, you and your doctor may give us additional information to support your appeal. If your health requires it, ask for a “fast appeal” (you can make an oral request) Legal Terms A “fast appeal” is also called an “expedited appeal.”  If you are appealing a decision our plan made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”  The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast decision.” To ask for a fast appeal, follow the instructions for asking for a fast decision. (These instructions are given earlier in this section.)  If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal. Step 2: Our plan considers your appeal and we give you our answer.  When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.  We will gather more information if we need it. We may contact you or your doctor to get more information. Deadlines for a “fast” appeal  When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing. o If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 352 of 385 31 section, we tell you about this organization and explain what happens at Level 2 of the appeals process.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.  If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Deadlines for a “standard” appeal  If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. o If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we tell about this review organization and explain what happens at Level 2 of the appeals process.  If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.  If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2. If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: The Independent Review Organization reviews your appeal. Section 5.4 Step-by-step: How to make a Level 2 Appeal 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 353 of 385 32  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.  You have a right to give the Independent Review Organization additional information to support your appeal.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2  If you had a fast appeal to our plan at Level 1, you will automatically receive a fast appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal.  However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2  If you had a standard appeal to our plan at Level 1, you will automatically receive a standard appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal.  However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. Step 2: The Independent Review Organization gives you their answer. The Independent Review Organization will tell you its decision in writing and explain the reasons for it.  If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization.  If this organization says no to part or all of your appeal, it means they agree with our plan that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”) o The notice you get from the Independent Review Organization will tell you in writing if your case meets the requirements for continuing with the appeals process. For example, to continue and make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 354 of 385 33 requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).  If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal.  The Level 3 Appeal is handled by an administrative law judge. Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Asking for reimbursement is asking for a coverage decision from our plan If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage decision (for more information about coverage decisions, see Section 4.1 of this chapter). To make this coverage decision, we will check to see if the medical care you paid for is a covered service. We will also check to see if you followed all the rules for using your coverage for medical care. We will say yes or no to your request  If the medical care you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of your medical care within 60 calendar days after we receive your request. Or, if you haven’t paid for the services, we will send the payment directly to the provider. When we send the payment, it’s the same as saying yes to your request for a coverage decision.)  If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why. (When we turn down your request for payment, it’s the same as saying no to your request for a coverage decision.) What if you ask for payment and we say that we will not pay? If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment. To make this appeal, follow the process for appeals that we describe in part 5.3 of this section. Go to this part for step-by-step instructions. When you are following these instructions, please note:  If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we receive your appeal. (If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.) Section 5.5 What if you are asking our plan to pay you for our share of a bill you have received for medical care? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 355 of 385 34  If the Independent Review Organization reverses our decision to deny payment, we must send the payment you have requested to you or to the provider within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days. SECTION 6 How to ask us to cover a longer hospital stay if you think the doctor is discharging you too soon When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury. For more information about our coverage for your hospital care, including any limitations on this coverage, see the Summary of Benefits. During your hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for care you may need after you leave.  The day you leave the hospital is called your “discharge date.” Our plan’s coverage of your hospital stay ends on this date.  When your discharge date has been decided, your doctor or the hospital staff will let you know.  If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. This section tells you how to ask. During your hospital stay, you will be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they are admitted to a hospital. Someone at the hospital is supposed to give it to you within two days after you are admitted. 1. Read this notice carefully and ask questions if you don’t understand it. It tells you about your rights as a hospital patient, including:  Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them.  Your right to be involved in any decisions about your hospital stay, and know who will pay for it.  Where to report any concerns you have about quality of your hospital care.  What to do if you think you are being discharged from the hospital too soon. Legal Terms The written notice from Medicare tells you how you can “make an appeal.” Making an appeal is a formal, legal way to ask for a delay in your discharge date so that your hospital care will be covered for a longer time. (Section 7.2 below tells how to make this appeal.) Section 6.1 During your hospital stay, you will get a written notice from Medicare that tells about your rights 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 356 of 385 35 2. You must sign the written notice to show that you received it and understand your rights.  You or someone who is acting on your behalf must sign the notice. (Section 4 of this chapter tells how you can give written permission to someone else to act as your representative.)  Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date (your doctor or hospital staff will tell you your discharge date). Signing the notice does not mean you are agreeing on a discharge date. 3. Keep your copy of the signed notice so you will have the information about making an appeal (or reporting a concern about quality of care) handy if you need it.  If you sign the notice more than 2 days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged.  To look at a copy of this notice in advance, you can call Customer Service or 1- 800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also see it online at http://www.cms.hhs.gov. If you want to ask for your hospital services to be covered by our plan for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.  Follow the process. Each step in the first two levels of the appeals process is explained below.  Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do.  Ask for help if you need it. If you have questions or need help at any time, please call Customer Service (phone numbers are on the front cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you. Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or a “Level 1 Appeal.” Step 1: Contact the Quality Improvement Organization in your state and ask for a “fast review” of your hospital discharge. You must act quickly. Legal Terms A “fast review” is also called an “immediate review” or an “expedited review.” What is the Quality Improvement Organization? Section 6.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 357 of 385 36  This organization is a group of doctors and other health care professionals who are paid by the Federal government. These experts are not part of our plan. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare. How can you contact this organization?  The written notice you received (An Important Message from Medicare) tells you how to reach this organization. Act quickly:  To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. (Your “planned discharge date” is the date that has been set for you to leave the hospital.) o If you meet this deadline, you are allowed to stay in the hospital after your discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization. o If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date.  If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details about this other way to make your appeal, see Section 6.4. Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review?  Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.  The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and our plan has given to them.  By noon of the day after the reviewers informed our plan of your appeal, you will also get a written notice that gives your planned discharge date and explains the reasons why your doctor, the hospital, and our plan think it is right (medically appropriate) for you to be discharged on that date. Legal Terms This written explanation is called the “Detailed Notice of Discharge.” You can get a sample of this notice by calling Customer Service or 1-800-MEDICARE (1-800- 633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you can get see a sample notice online at http://www.cms.hhs.gov/BNI/ 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 358 of 385 37 Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes?  If the review organization says yes to your appeal, our plan must keep providing your covered hospital services for as long as these services are medically necessary.  You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered hospital services. What happens if the answer is no?  If the review organization says no to your appeal, they are saying that your planned discharge date is medically appropriate. (Saying no to your appeal is also called turning down your appeal.) If this happens, our plan’s coverage for your hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal.  If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal  If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to “Level 2” of the appeals process. If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review  You must ask for this review within 60 calendar days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation Section 6.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 359 of 385 38  Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 calendar days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. If the review organization says yes:  Our plan must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. Our plan must continue providing coverage for your hospital care for as long as it is medically necessary.  You must continue to pay your share of the costs and coverage limitations may apply. If the review organization says no:  It means they agree with the decision they made to your Level 1 Appeal and will not change it. This is called “upholding the decision.” It is also called “turning down your appeal.”  The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If the review organization turns down your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. You can appeal to our plan instead As explained above in Section 6.2, you must act quickly to contact the Quality Improvement Organization to start your first appeal of your hospital discharge. (“Quickly” means before you leave the hospital and no later than your planned discharge date). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Legal Terms A “fast” review (or “fast appeal”) is also called an “expedited” review (or “expedited appeal”). Section 6.4 What if you miss the deadline for making your Level 1 Appeal? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 360 of 385 39 Step 1: Contact our plan and ask for a “fast review.”  Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Step 2: Our plan does a “fast” review of your planned discharge date, checking to see if it was medically appropriate.  During this review, our plan takes a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will check to see if the decision about when you should leave the hospital was fair and followed all the rules.  In this situation, we will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review. Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).  If our plan says yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)  If our plan says no to your fast appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your hospital services ends as of the day we said coverage would end.  If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. You will be responsible for the cost of care starting from noon on the day after our plan says no to your appeal. Step 4: If our plan says no to your fast appeal, your case will automatically be sent on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process. Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 361 of 385 40 Step 1: We will automatically forward your case to the Independent Review Organization.  We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 9 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge.  If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.  If this organization says no to your appeal, it means they agree with our plan that your planned hospital discharge date was medically appropriate. (This is called “upholding the decision.” It is also called “turning down your appeal.”) o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge. Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further  There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 7 How to ask us to keep covering certain medical services if you think your coverage is ending too soon This section is about the following types of care only: Section 7.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 362 of 385 41  Home health care services you are getting.  Skilled nursing care you are getting as a patient in a skilled nursing facility.  Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation. When you are getting any of these types of care, you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. For more information on your covered services, including your share of the cost and any limitations to coverage that may apply, see the Summary of Benefits. When our plan decides it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, our plan will stop paying its share of the cost for your care. If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask. 1. You receive a notice in writing. At least two days before our plan is going to stop covering your care, the agency or facility that is providing your care will give you a notice.  The written notice tells you the date when our plan will stop covering the care for you. Legal Terms In this written notice, we are telling you about a “coverage decision” we have made about when to stop covering your care. (For more information about coverage decisions, see Section 4 in this chapter.)  The written notice also tells what you can do if you want to ask our plan to change this decision about when to end your care, and keep covering it for a longer period of time. Legal Terms In telling what you can do, the written notice is telling how you can “make an appeal.” Making an appeal is a formal, legal way to ask our plan to change the coverage decision we have made about when to stop your care. (Section 8.3 below tells how you can make an appeal.) Legal Terms The written notice is called the “Notice of Medicare Non-Coverage.” To get a sample copy, call Customer Service or 1-800-MEDICARE (1- 800-633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.). Or see a copy online at http://www.cms.hhs.gov/BNI/ Section 7.2 We will tell you in advance when your coverage will be ending 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 363 of 385 42 2. You must sign the written notice to show that you received it.  You or someone who is acting on your behalf must sign the notice. (Section 4 tells how you can give written permission to someone else to act as your representative.)  Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan that it’s time to stop getting the care. If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.  Follow the process. Each step in the first two levels of the appeals process is explained below.  Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint. Section 9 of this chapter tells you how to file a complaint.)  Ask for help if you need it. If you have questions or need help at any time, please call Customer Service (phone numbers are on the front cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and decides whether to change the decision made by our plan. Legal Terms When you start the appeal process by making an appeal, it is called the “first level of appeal” or “Level 1 Appeal.” Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization in your state and ask for a review. You must act quickly. What is the Quality Improvement Organization?  This organization is a group of doctors and other health care experts who are paid by the Federal government. These experts are not part of our plan. They check on the quality of care received by people with Medicare and review plan decisions about when it’s time to stop covering certain kinds of medical care. How can you contact this organization?  The written notice you received tells you how to reach this organization. What should you ask for?  Ask this organization to do an independent review of whether it is medically appropriate for our plan to end coverage for your medical services. Section 7.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 364 of 385 43 Your deadline for contacting this organization.  You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.  If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details about this other way to make your appeal, see Section 8.4. Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review?  Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.  The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them.  By the end of the day the reviewers informed our plan of your appeal, you will also get a written notice from the plan that gives our reasons for wanting to end the plan’s coverage for your services. Legal Terms This notice explanation is called the “Detailed Explanation of Non- Coverage.” Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. What happens if the reviewers say yes to your appeal?  If the reviewers say yes to your appeal, then our plan must keep providing your covered services for as long as it is medically necessary.  You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services. What happens if the reviewers say no to your appeal?  If the reviewers say no to your appeal, then your coverage will end on the date we have told you. Our plan will stop paying its share of the costs of this care.  If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal. 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 365 of 385 44  This first appeal you make is “Level 1” of the appeals process. If reviewers say no to your Level 1 Appeal – and you choose to continue getting care after your coverage for the care has ended – then you can make another appeal.  Making another appeal means you are going on to “Level 2” of the appeals process. If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review.  You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation.  Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes to your appeal?  Our plan must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. Our plan must continue providing coverage for the care for as long as it is medically necessary.  You must continue to pay your share of the costs and there may be coverage limitations that apply. What happens if the review organization says no?  It means they agree with the decision they made to your Level 1 Appeal and will not change it. (This is called “upholding the decision.” It is also called “turning down your appeal.”)  The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further.  There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to Section 7.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 366 of 385 45 accept that decision or to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. You can appeal to our plan instead As explained above in Section 7.3, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Here are the steps for a Level 1 Alternate Appeal: Legal Terms A “fast” review (or “fast appeal”) is also called an “expedited” review (or “expedited appeal”). Step 1: Contact our plan and ask for a “fast review.”  Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Step 2: Our plan does a “fast” review of the decision we made about when to end coverage for your services.  During this review, our plan takes another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan’s coverage for services you were receiving.  We will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review. (Usually, if you make an appeal to our plan and ask for a “fast review,” we are allowed to decide whether to agree to your request and give you a “fast review.” But in this situation, the rules require us to give you a fast response if you ask for it.) Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).  If our plan says yes to your fast appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)  If our plan says no to your fast appeal, then your coverage will end on the date we have told you and our plan will not pay after this date. Our plan will stop paying its share of the costs of this care. Section 7.5 What if you miss the deadline for making your Level 1 Appeal? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 367 of 385 46  If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If our plan says no to your fast appeal, your case will automatically go on to the next level of the appeals process.  To make sure we were following all the rules when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process. Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed. Legal Terms The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: We will automatically forward your case to the Independent Review Organization.  We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 9 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.  The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.  Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.  If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.  If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it. (This is called “upholding the decision.” It is also called “turning down your appeal.”) 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 368 of 385 47 o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal. Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.  There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge.  Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 8 Taking your appeal to Level 3 and beyond This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 Appeal A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an “Administrative Law Judge.”  If the Administrative Law Judge says yes to your appeal, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 4. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 3 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the judge’s decision. o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal request with any accompanying documents. We may wait for the Level 4 Appeal decision before authorizing or providing the service in dispute.  If the Administrative Law Judge says no to your appeal, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you can continue to the next level of the review process. If the administrative law judge says no to your Section 8.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 369 of 385 48 appeal, the notice you get will tell you what to do next if you choose to continue with your appeal. Level 4 Appeal The Medicare Appeals Council will review your appeal and give you an answer. The Medicare Appeals Council works for the Federal government.  If the answer is yes, or if the Medicare Appeals Council denies our request to review a favorable Level 3 Appeal decision, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 4 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the Medicare Appeals Council’s decision. o If we decide to appeal the decision, we will let you know in writing.  If the answer is no or if the Medicare Appeals Council denies the review request, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Medicare Appeals Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 Appeal A judge at the Federal District Court will review your appeal.  This is the last step of the administrative appeals process. MAKING COMPLAINTS SECTION 9 How to make a complaint about quality of care, waiting times, customer service, or other concerns ? If your problem is about decisions related to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 4 of this chapter. This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process. Section 9.1 What kinds of problems are handled by the complaint process? 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 370 of 385 49 Quality of your medical care  Are you unhappy with the quality of the care you have received (including care in the hospital)? Respecting your privacy  Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential? Disrespect, poor customer service, or other negative behaviors  Has someone been rude or disrespectful to you?  Are you unhappy with how our Member Services has dealt with you?  Do you feel you are being encouraged to leave our plan? Waiting times  Are you having trouble getting an appointment, or waiting too long to get it?  Have you been kept waiting too long by doctors or other health professionals?  Or by Member Services or other staff at our plan?  Examples include waiting too long on the phone, in the waiting room, or in the exam room. Cleanliness  Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office? Information you get from our plan  Do you believe we have not given you a notice that we are required to give?  Do you think written information we have given you is hard to understand? These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals The process of asking for a coverage decision and making appeals is explained in sections 4-8 of this chapter. If you are asking for a decision or making an appeal, you use that process, not the complaint process. However, if you have already asked for a coverage decision or made an appeal, and you think that our plan is not responding quickly enough, you can also make a complaint about our slowness. Here are examples:  If you have asked us to give you a “fast response” for a coverage decision or appeal, and we have said we will not, you can make a complaint. If you have any of these kinds of problems, you can “make a complaint” 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 371 of 385 50  If you believe our plan is not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.  When a coverage decision we made is reviewed and our plan is told that we must cover or reimburse you for certain medical services, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.  When your plan does not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint. Legal Terms  What this section calls a “complaint” is also called a “grievance.”  Another term for “making a complaint” is “filing a grievance.”  Another way to say “using the process for complaints” is “using the process for filing a grievance.” Step 1: Contact us promptly – either by phone or in writing.  Usually, calling Customer Service is the first step. If there is anything else you need to do, Customer Service will let you know. Customer Service may be reached by calling 1-888-901-4600 (TTY only, call 1-800-833-6388 or 711). Hours are Monday-Friday, 8 a.m.-8 p.m. From November 15 through March 1, hours are daily, 8 a.m.-8 p.m.  If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works: o For this process your grievance requests must be in writing, and mailed to Group Health Medicare Customer Service Medicare Grievance, P.O. Box 34590, Seattle WA 98124-1590 or fax: 206-901-6205, or From www.ghc.org click “Contact Us.” We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.  Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.  If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours. Legal What this section calls a “fast complaint” is also called a “fast Section 9.2 The formal name for “making a complaint” is “filing a grievance” Section 9.3 Step-by-step: Making a complaint 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 372 of 385 51 Terms grievance.” Step 2: We look into your complaint and give you our answer.  If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.  Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.  If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. You can make your complaint about the quality of care you received to our plan by using the step-by-step process outlined above. When your complaint is about quality of care, you also have two extra options:  You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). If you make a complaint to this organization, we will work with them to resolve your complaint.  Or, you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. Section 9.4 You can also make complaints about quality of care to the Quality Improvement Organization 6g. ‐ Human Resources and Risk Management Department recommends  approval of the 2011 Group Health Cooperative medical coverage Page 373 of 385 CITY OF RENTON COUNCIL AGENDA BILL Subject/Title: Project Acceptance for CAG-10-072, Rainier Stormwater Pump Station Repair Project, SWP-27-3038 Meeting: Regular Council - 02 May 2011 Exhibits: Notice of Completion Form Submitting Data: Dept/Div/Board: Public Works Staff Contact: Ron Straka, Surface Water Utility Supervisor, x7248, Steve Lee, Surface Water Engineer, x7205 Recommended Action: Council Concur Fiscal Impact: Expenditure Required: $ N/A Transfer Amendment: $ Amount Budgeted: $ 43,368.57 Revenue Generated: $ Total Project Budget: $ 43,368.57 City Share Total Project: $ SUMMARY OF ACTION: Cascade Machinery & Electric, LLC. started repairs to the Rainier Pump Station Repair project on June 4, 2010, and completed the construction work on September 15, 2010. The contract work was needed to refurbish the existing stormwater pumps and motors that were at or near the end of their useful service life. The Rainier Pump Station Repair project included disconnecting and pulling out the old pumps and motors with a crane, refurbishing with new motor windings, new bearings, new shaft, new impellers, and reusing what could be reused to restore maximum operating efficiency back to the system. The project was funded by the Surface Water Utility’s Capital Improvement Program Small Drainage Projects budget (427.475015) with the original contract amount of $43,368.57 and the final contract amount of $43,368.57. The approved 2010 CIP budget for the project was $43,368.57. STAFF RECOMMENDATION: Accept the Rainier Stormwater Pump Station project and release the retainage of $2,168.03 after 60 days, and after all the required releases from the state have been obtained. 6h. ‐ Utility Systems Division submits CAG‐10‐072, Rainier Stormwater  Pump Station Repair; and requests approval of the  Page 374 of 385 Yes No $ $$ $$ $$ $ $$ If Retainage is Bonded, List Surety's Name (or attach a copy) Contractor's Name Cascade Machinery & Electric, Inc. Surety Agent's Address Liquidated Damages 0.0043,368.57TOTAL Please List all Subcontractors Below: (If various rates apply, please send a breakdown) Amount of Sales Tax Paid at TOTAL Subcontractor's Name:UBI Number:Affidavit ID (if known) 4600 East Marginal Way South, Seattle, WA 98134-2320 The purpose of the contract was to refurbish the mechanical and motor components of the Rainier Avenue South stormwater pump system that were at or near the end of their useful service life. In addition, voltage monitors were replaced and final testing was conducted after the pumps were in operation. NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT (206) 762-0500 Date: 578-029-286 20-Apr-11 Renton, WA 98057 Notice is hereby given relative to the completion of contract or project described below UBI Number: Name & Address of Public Agency Contractor Address City of Renton (Attn: Natalie Wissbrod) 1055 S Grady Way Description of Work Done/Include Jobsite Address(es) Job Order Contracting Date Work Commenced Date Work Completed 15-Sep-10 Reductions ( - ) 28-Jun-10 Contract Amount Additions ( + ) Date Work Accepted Amount Disbursed Amount Retained 05/02/2011 Date Contract Awarded Continued on page 2 91-6001271 06/04/2010 REV 31 0020e (11/9/10) F215-038-000 11-2010 Department Use Only Assigned to: Date Assigned: 43,368.57Sub-Total NOTE: These two totals must be equal 43,368.57 Project Name Rainier Stormwater Pump Station Repair Project Contract Number CAG-10-072 Telephone Number Contractor's UBI Number: 6h. ‐ Utility Systems Division submits CAG‐10‐072, Rainier Stormwater  Pump Station Repair; and requests approval of the  Page 375 of 385 Contact Name: Note: The Disbursing Officer must submit this completed notice immediately after acceptance of the work done under this contract. NO PAYMENT SHALL BE MADE FROM RETAINED FUNDS until receipt of all release certificates. Submitting Form: Please submit the completed form to all three agencies below. For a faster response, please submit by e-mail. (430) 430-7205 Project Manager Email Address:slee@rentonwa.gov Phone Number: Steve Lee Title: For tax assistance or to request this document in an alternate format, visit http://dor.wa.gov or call 1-800-647-7706. Teletype (TTY) users may call (360) 705-6718. F215-038-000 11-2010 Comments: REV 31 0020e (11/9/10) Subcontractor's Name:UBI Number:Affidavit ID (if known) Please List all Subcontractors Below: Washington State Department of Revenue Public Works Section PO Box 47474 Olympia W A 98504-7474 (360)725-7588 FAX (360) 664-4159 PW C@dor.wa.gov Washington State Department of Labor and Industries Contract Release PO Box 44274 Olympia, W A 98504-4272 (360)902-4754 FAX (360) 902-6897 ContractRelease@lni.wa.gov Washington State Employment Security Department Specialized Collections Unit PO Box 9046 Olympia WA 98507-9046 (360) 902-9780 Fax (360) 902-9287 publicworks@esd.wa.gov 6h. ‐ Utility Systems Division submits CAG‐10‐072, Rainier Stormwater  Pump Station Repair; and requests approval of the  Page 376 of 385 CITY OF RENTON, WASHINGTON RESOLUTION NO. A RESOLUTION OF THE CITY OF RENTON, WASHINGTON, AUTHORIZING THE MAYOR AND CITY CLERK TO ENTER INTO A MEMORANDUM OF UNDERSTANDING WITH KING COUNTY FIRE DISTRICT 20, CONCERNING THE PLACEMENT, MAINTENANCE AND CARE OF AMATEUR RADIO EQUIPMENT. WHEREAS, the City of Renton and King County Fire District 20 (hereinafter collectively "the parties") have determined that there is a need for back-up communications capabilities to serve the greater Renton community during an event which overwhelms existing communication resources; and WHEREAS, the parties understand that pre-positioning radio equipment in various strategic locations will maximize the functionality and scope of these back-up communications capabilities; and WHEREAS, the parties understand that being prepared to respond to communications related emergencies and disasters will require pre-event coordination between neighboring jurisdictions; and WHEREAS, it is necessary to document the terms and conditions under which the parties cooperatively place, maintain and care for back-up communications equipment; NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF RENTON, WASHINGTON, DOES RESOLVE AS FOLLOWS: SECTION I. The above recitals are found to be true and correct in all respects. SECTION II. The Mayor and City Clerk are hereby authorized to enter into a memorandum of understanding with King County Fire District 20, concerning the placement, maintenance and care of amateur radio equipment. 8a. ‐ Memorandum of Understanding with King County Fire District 20  concerning amateur radio equipment (See 6.e.)Page 377 of 385 RESOLUTION NO. PASSED BY THE CITY COUNCIL this day of. _, 2011. Bonnie I. Walton, City Clerk APPROVED BY THE MAYOR this day of. , 2011. Approved as to form: Lawrence J. Warren, City Attorney Denis Law, Mayor RES.1500:4/14/ll:scr 8a. ‐ Memorandum of Understanding with King County Fire District 20  concerning amateur radio equipment (See 6.e.)Page 378 of 385 CITY OF RENTON, WASHINGTON RESOLUTION NO. A RESOLUTION OF THE CITY OF RENTON, WASHINGTON, ADOPTING THE 2010 LONG-RANGE WASTEWATER MANAGEMENT PLAN (SANITARY SEWER COMPREHENSIVE PLAN). WHEREAS, the City Council was presented the 2010 Long-Range Wastewater Management Plan; and WHEREAS, the plan was discussed at a meeting of the Utilities Committee; and WHEREAS, the plan is compatible with the intent of the City's adopted Comprehensive Plan; NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF RENTON, WASHINGTON, DOES RESOLVE AS FOLLOWS: SECTION I. The above recitals are found to be true and correct in all respects. SECTION II. The 2010 Long-Range Wastewater Management Plan is hereby adopted by the City of Renton. PASSED BY THE CITY COUNCIL this day of. _, 2011. Bonnie I. Walton, City Clerk APPROVED BY THE MAYOR this day of. _, 2011. Denis Law, Mayor 8b. ‐ 2010 Long‐Range Wastewater Management Plan (See 7.d.) Page 379 of 385 RESOLUTION NO. Approved as to form: Lawrence J. Warren, City Attorney RES.1493:l/20/ll:scr 8b. ‐ 2010 Long‐Range Wastewater Management Plan (See 7.d.) Page 380 of 385 CITY OF RENTON, WASHINGTON ORDINANCE NO. AN ORDINANCE OF THE CITY OF RENTON, WASHINGTON, DECLARING PUBLIC USE AND NECESSITY FOR LAND AND PROPERTY TO BE CONDEMNED AS REQUIRED FOR THE RAINIER AVENUE SOUTH (SR 167)-S GRADY WAY TO S 2nd STREET-PROJECT, AUTHORIZING THE ACQUISITION OF CERTAIN PROPERTY AND PROPERTY RIGHTS BY EMINENT DOMAIN AND PROVIDING FOR THE PAYMENT THEREOF FROM THE CITY'S TRANSPORTATION CAPITAL IMPROVEMENT PROGRAM FUND, AVAILABLE GRANT FUNDS AND COST FUNDING FROM SOUND TRANSIT; AND AUTHORIZING THE CITY ATTORNEY TO PREPARE A PETITION FOR CONDEMNATION IN THE SUPERIOR COURT IN AND FOR THE COUNTY OF KING AND FOR THE PROSECUTION THEREOF FOR THE ACQUISITION OF SUCH PROPERTY AND PROPERTY RIGHTS. WHEREAS, the City Council has previously approved the preparation of the final plans for roadway improvements to Rainier Avenue South (SR 167) between S Grady Way to S 2nd Street; and WHEREAS, the project consists of widening the arterial roadway known as Rainier Avenue South (SR 167), along with construction of related improvements, including but not limited to curb, gutter and sidewalk, street lighting, storm drainage improvements, landscaping and other related improvements (commonly known as the "Rainier Avenue South (SR 167)-S Grady Way to S 2nd Street--Project" and referred to in this ordinance as the "Project"); and WHEREAS, the Project is necessary to meet the City's adopted transportation plans to provide enhanced traffic and pedestrian safety, transit mobility, traffic flow and emergency vehicle access; and WHEREAS, land, properties, structures and easements along the alignment of the Project must be acquired in order to provide the necessary right-of-way for construction of the Project; and 8a. ‐ Declaring public use and necessity for land and property to be  condemned as required for the Rainier Ave. S. project (Approved via Page 381 of 385 ORDINANCE NO. WHEREAS, efforts are now on-going to acquire the properties necessary for this public use by negotiation and settlement agreements; and WHEREAS, in the event that negotiated acquisition is not fully successful in advance of the anticipated commencement of construction, it is essential that the City be prepared to initiate condemnation proceedings so that the Project can be timely and efficiently constructed; and WHEREAS, payment of just compensation and costs of litigation should be made from the City's Transportation Capital Improvement Program fund, grants or cost funding from Sound Transit (Central Puget Sound Regional Transit Authority); and WHEREAS, the Project is a priority for the City; and WHEREAS, the City has provided notice of the planned final action described below to property owners in the manner provided for in RCW 8.12.005 and 8.25.290; NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF RENTON, WASHINGTON, DOES ORDAIN AS FOLLOWS: SECTION I. Project is a Public Use. The Project consisting of road widening and related improvements to curbs, gutters, sidewalks, street lighting, storm water drainage and landscape improvements to that roadway known as Rainier Avenue South (SR 167) between S Grady Way and S 2nd Street in the City of Renton is a public use. The improvements will be owned by the City of Renton and will be open for vehicle, pedestrian, and bicycle travel by members of the public. SECTION II. Determination of Necessity. The City Council finds acquisition of the properties depicted on the drawings attached as Exhibit A hereto and legally described on 8a. ‐ Declaring public use and necessity for land and property to be  condemned as required for the Rainier Ave. S. project (Approved via Page 382 of 385 ORDINANCE NO. Exhibit B hereto, both of which are attached to and incorporated herein by this reference (the "Properties"), is necessary to construct the Project, which is a public use and for a public purpose as set forth in Section I above. If the Properties are not acquired and the Project is not constructed, then transportation and emergency access to a major north-south roadway corridor in the City will be negatively impacted and be inconsistent with the City's roadway planning improvement objectives. SECTION III. Condemnation. Pursuant to RCW 8.12.040, the Properties shall be condemned and acquired by the City of Renton after just compensation having been first made or paid into court for the owner(s) in the manner prescribed by law. SECTION IV. Authorization. The City Attorney and/or his designees are hereby authorized and directed to commence condemnation proceedings for the Properties and against the owners and all other parties in interest of the Properties, as provided by law, to determine and make or pay just compensation, and to take such other steps as deemed necessary to complete acquisition of the Properties. In so doing, the City Attorney and/or his designees are authorized to adjust the extent of the Properties taken or acquired to facilitate implementation of this ordinance, provided that such adjustment shall not be inconsistent with the Project. Further, the City Attorney and/or his designees are authorized to prepare the necessary petition for condemnation and to commence, file and prosecute such action in the Superior Court in and for the County of King. SECTION V. Compensation. Compensation to be paid to the owners of the Properties identified in Exhibits A and B attached hereto and incorporated herein, referred to in Section II above, and costs of litigation, shall be paid from the City's Transportation Capital Improvement 8a. ‐ Declaring public use and necessity for land and property to be  condemned as required for the Rainier Ave. S. project (Approved via Page 383 of 385 ORDINANCE NO. Program fund, grants, and cost funding from Sound Transit (Central Puget Sound Regional Transit Authority). SECTION VI. Severability. Should any section, paragraph, sentence, clause or phrase of this ordinance, or its application to any person or circumstance, be declared unconstitutional or otherwise invalid for any reason, or should any portion of this ordinance be pre-empted by state or federal law or regulation, such decision or pre-emption shall not affect the validity of the remaining portions of this ordinance or its application to other persons or circumstances. SECTION VII. Effective Date. This ordinance shall be effective upon its passage, approval, and five (5) days after publication. PASSED BY THE CITY COUNCIL this day of. _, 2011. Bonnie I. Walton, City Clerk APPROVED BY THE MAYOR this this day of. _, 2011. Approved as to form: Denis Law, Mayor Lawrence J. Warren, City Attorney Date of Publication: ORD.1700:3/25/ll:scr 8a. ‐ Declaring public use and necessity for land and property to be  condemned as required for the Rainier Ave. S. project (Approved via Page 384 of 385 Exhibits on File at City Clerk's office 8a. ‐ Declaring public use and necessity for land and property to be  condemned as required for the Rainier Ave. S. project (Approved via Page 385 of 385