clubcorp medical plan...• the plan participates in a preferred provider organization (ppo)...
TRANSCRIPT
ClubCorp
Medical Plan
A Guide to Your
Medical Benefits
Revised as of January 1, 2010
Note: The Medical Plan is administered and includes a PPO network and special features offered through Blue Cross and Blue Shield of Texas, which is referenced throughout this summary plan description. No matter where you live or travel, Blue Cross and Blue Shield of Texas (BCBSTX) works with other Blue Cross and Blue Shield Plans across the country to make sure you have access to contracted providers.
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Table of Contents
Introduction......................................................................................................................... 3
Some Things You Should Know ........................................................................................ 3
Glossary of Terms............................................................................................................... 3
Eligibility ............................................................................................................................ 8
Enrollment........................................................................................................................... 9
Medical Plan Choices ....................................................................................................... 10
When Medical Coverage Begins....................................................................................... 10
Paying for your Benefits ................................................................................................... 10
Preexisting Conditions ...................................................................................................... 13
Medical Plan Features……………………………………………………………………15
Wellness Incentives and Health Care Accounts…………………………………...15 Health Savings Accounts………………………………………………………......16 Disease/Condition Management…………………………………………………...19 Special Beginnings Program (Prenatal Management) …………………………….19 24/7 Nurseline ……………………………………………………………………..19 Managed Care ................................................................................................................... 20 Precertification ........................................................................................................ 20 The Network............................................................................................................ 21 Network Prescription Drug Benefits ...................................................................... 21
Medical Schedule of Benefits ........................................................................................... 23
Covered Medical Expenses............................................................................................... 25
Medical Plan Exclusions................................................................................................... 30
Termination of Coverage .................................................................................................. 32
Coordination of Benefits................................................................................................... 33
Filing A Claim .................................................................................................................. 34
Continuation of Coverage ................................................................................................. 34
Important Plan Information............................................................................................... 38
ERISA Information........................................................................................................... 40
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Introduction
The Company wants to help you provide a secure future for you and your family. The medical benefits offered through the ClubCorp, Inc. Health Benefits Plan (the “Plan”) are designed to help ease some of the burden of medical services should you or one of your family members becomes ill or injured
Read this booklet for information concerning eligibility, enrollment, benefits, and your rights as a participant in the Plan.
This booklet describes only the principal features of the Plan and the Pretax Premium Plan and should not be considered
the Plan documents. The complete terms of the Plan and Pretax Premium Plan are set forth in the Plan documents adopted
by the Company, and if there is any difference between the information in this booklet and the Plan documents, the Plan
documents prevail.
If after reviewing this booklet, you have questions concerning your benefits under the Health Plan, call People Benefits
Strategy at 1-800-800-4615.
Some Things You Should Know…
• Enrollment in the Plan must be completed during specified time periods for you or your dependents to be covered
under the Plan. (see page 9)
• The Company shares in the cost of your medical coverage by contributing to your premium payments.
• You have the choice to select the contribution/deductible levels that are most manageable for you. (see page 23)
• The Plan has some limitations regarding Preexisting Conditions. (see page 13)
• The length of time your Preexisting Condition is not covered may be reduced or eliminated if you can show proof
of “Creditable Coverage.” (see page 14)
• You pay medical contributions under the Plan on a pretax basis and take advantage of related savings.
• You cannot change your coverage until the next Plan year, unless you qualify for Special Enrollment or a Status
Change (see pages 7 and 12).
• As part of the managed care program, the Plan requires precertification of all inpatient hospital admissions. (see
page 20)
• The Plan participates in a preferred provider organization (PPO) network, which is intended to provide medical
services at discounted rates (see page 21).
• Claims must be submitted within twelve months of the date the expense was incurred.
• The Glossary of Terms defines key terms used in this booklet.
Glossary of Terms
These terms have the following definitions when used in this booklet:
Active Service - You are performing in the customary manner all of the regular duties of your employment on a regular
full time basis on a scheduled work day where you normally perform such duties or at some location to which your
employment requires you to travel. You will not be considered in Active Service if you are on a leave of absence. If you
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are not in active service due to a Health Related Factor, you will be considered in active service for purposes of eligibility
under the plan.
Allowable Amount – means the maximum amount determined by the claims administrator (Blue Cross and Blue Shield
of Texas) to be eligible for consideration of payment for a particular service, supply or procedure.
Annual Open Enrollment Period – a recurring time period in each calendar year as determined by the Plan
Administrator in which eligible Employee Partners have the opportunity to enroll themselves and their eligible dependents
in medical coverage under the Plan.
As a Plan participant, you also have the opportunity to change your medical plan deductible, add or drop coverage for you or your eligible dependents during this time period. Complications of Pregnancy
1) Conditions requiring Hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from
pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion (fetus has died prior to 20th completed week of gestation, but the products of
conception are typically retained in the uterus for a period of 8 weeks or longer), and similar medical and surgical
conditions of comparable severity. This does not include false labor or occasional spotting, physician-prescribed rest
during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions
associated with the management of difficult pregnancy not constituting a nosologically distinct complication of
pregnancy.
2) Non-elective Cesarean section (urgent - can’t deliver vaginally), termination of ectopic pregnancy, and spontaneous
termination of pregnancy occurring during a period of gestation in which a viable birth is not possible.
Creditable Coverage - means prior continuous health coverage and includes prior coverage under:
a. another group health plan; b. group or individual health insurance coverage issued by a state regulated insurer or an HMO; c. COBRA; d. Medicaid; e. Medicare; f. State Children’s Health Insurance Program (SCHIP); g. the Active Military Health Program; h. Tricare/CHAMPUS; i. American Indian Health Care Programs; j. a State health benefits risk pool; k. the Federal Employees Health Plan; l. the Peace Corp Health Program; or m. a public health plan, including plans established or maintained by a state, the United States government, a foreign
country, or any political subdivision of a state, the United States government, or a foreign country that provides health coverage to individuals who are enrolled in the plan (for example, coverage through the United States Veterans Administration and coverage from a state or federal penitentiary).
Creditable Coverage does not include Excepted Benefits (see Page 5).
Emergency - Emergency means the sudden onset of an illness or injury requiring immediate attention which could
reasonably be expected to result in:
• placing the patient’s health in serious jeopardy;
• serious impairment to bodily function; or
• serious dysfunction of any bodily organ or part.
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Enrollment Date - The first day of coverage or, if there is a waiting period, the first day of the waiting period. Under this
plan, the enrollment date is:
• the Employee Partner’s original hire date, rehire date or change in eligibility status (i.e. move from part-time to full-
time);
• the Employee Partner and/or dependent’s Special Enrollment date.
• January 1st of the year following the Annual Open Enrollment Period.
Preexisting Conditions will not be covered under the Plan for twelve months, measured from the Enrollment Date.
However, if you have a certificate of creditable coverage from your last coverage and you have not had a 63 day break in
coverage, then the twelve months of preexisting condition exclusion will be reduced by the amount of your prior
creditable coverage.
Excepted Benefits - Excepted benefits means
• the following types of coverage;
- coverage consisting of only accident or disability income insurance or any combination thereof;
- coverage issued as a supplement to liability insurance;
- liability insurance, including general liability insurance and automobile liability insurance
- workers compensation or similar insurance;
- automobile medical payment insurance;
- credit only insurance;
- coverage for on-site medical clinics; and
- other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or
incidental to other insurance benefits;
Or if offered separately;
• limited scope dental or vision benefits;
• benefits for long-term care, nursing home care, home health care, community based care, or any combination
thereof;
• other similar limited benefits as specified in regulations;
Or if offered as independent non-coordinated benefits (separate contract or policy with
non-Coordination of Benefits with any other plan sponsored by the Employer):
• coverage for a specified disease or illness; or
• hospital indemnity or other fixed indemnity insurance
Or if offered as a separate insurance policy; Medicare supplemental health insurance and similar supplemental coverage.
Experimental Treatment - Procedure or treatment which is not approved by American Medical Association or the
appropriate medical specialty society or which includes any procedure or treatment which satisfies any one or more of the
following criteria:
• the treatment or procedure includes the use of a drug or device which has not been approved by the United States
Food and Drug Administration;
• the treatment or procedure involves the use of a drug or device or treatment that is the current subject of a new device,
drug or treatment review by the United States Food and Drug Administration;
• the treatment or procedure is subject of an on-going Phase I, II or III clinical trial or under study to determine its
maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of
treatment or diagnosis;
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• the treatment or procedure is less effective than conventional treatment methods;
• a review of the number of patients who have received this treatment indicates that the patients who have received the
treatment or procedure, received it during Phase I, II, or III of the clinical trial of the development of the treatment or
procedure, and/or the procedure or treatment is currently under going review by the Institutional Review Board for
the treating health care facility;
• statements from published medical literature discussing the treatment or procedure indicate that there is a lack of
information from which to accurately evaluate the efficacy of the treatment or procedure and the need for further
research regarding the treatment or procedure;
• the language appearing in the consent form or in the Hospital protocol for treatment indicates that the Hospital or
Physician regard the treatment or procedure as experimental; or
• published reports and articles in the authoritative medical or scientific literature or the written protocol or protocols of
the treating facility or of another facility studying substantially the same drug, device or medical treatment or
procedure shows that the consensus of opinion of the experts regarding the drug, device or medical treatment or
procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity,
its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis.
Genetic Information - information about genes, gene products, and inherited characteristics that may derive from the
individual or a family member. This includes information regarding carrier status and information derived from laboratory
tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct
analysis of genes or chromosomes.
Health Status-Related Factor - the following factors; health status; medical condition (includes both physical and mental
illnesses); claims experience; receipt of health care; medical history; Genetic Information; evidence of insurability
(including conditions arising out of acts of domestic violence); and disability.
Medically Necessary/Medical Necessity- means services or supplies provided by a hospital, physician or other qualified
provider if they are:
• required for and consistent with the diagnosis, symptom and/or treatment of the particular condition, disease, injury
or illness;
• commonly and usually noted throughout the medical society as proper to treat the diagnosed condition, disease, injury
or illness; and
• the most fitting supply or level of service which can safely be administered.
When assessing the medical necessity of inpatient care, medical symptoms or conditions must require that the proposed
services or supplies cannot safely be delivered on an outpatient basis. A diagnosis, treatment service or supply with
respect to a condition, disease, injury or illness is not Medically Necessary if made, prescribed or delivered solely for
convenience of the patient or provider. The fact that a physician has performed or prescribed a procedure or treatment
does not mean that it is Medically Necessary.
Morbid Obesity means a Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared OR a BMI greater than
or equal to 35kg/meters squared with at least two of the following co-morbid conditions which have not responded to
maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
Hypertension Dyslipidmia Type 2 diabetes Coronary heart disease Sleep apnea
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Physician - Doctor of medicine (M.D.), doctor of optometry, doctor of osteopathy (O.D.), doctor of dentistry, doctor of
podiatry and doctor of chiropractic, or clinical psychologists or counselors who are duly licensed or certified in the state
where the service is rendered. An audiologist or speech language therapist is not a physician under this Plan.
Placed For Adoption - the assumption and retention by the Employee Partner of a legal obligation for total or partial
support of an individual in anticipation of adoption of such child prior to the date on which such individual attains age 18.
The child’s placement with such person terminates upon the termination of such legal obligation.
Preexisting Condition - a condition (whether physical or mental) regardless of the cause of the condition, for which
medical advice, diagnosis, care or treatment was recommended or received within six (6) month’s prior to you or your
dependent’s Enrollment Date.
Residential Treatment Center - An institution that does not qualify as a hospital but that does provide a program of
effective medical and therapeutic treatment for alcoholism, chemical dependency, drug addiction, or mental or nervous
disorders and meets all of the following requirements:
• Is established and operated in accordance with the applicable laws of the jurisdiction in which it is located,
• Provides a program of treatment approved by the physician and the Claims Administrator, and
• Has or maintains a specific and detailed program requiring full-time residence and full-time participation by the patient.
Room and Board Charges - Means room, board and general duty nursing care, but does not include the professional
services of physicians or special nursing services.
Semiprivate Rate - The daily room and board charge which an institution applies to the greatest number of beds and its
semiprivate rooms containing two or more beds. If the institution has no semiprivate rooms, the semiprivate rate will be
the daily board and room rate according to the Allowable Amount. (See page 4)
Special Enrollment Period - You and your dependents may have the opportunity to enroll in the Plan provided you do so
within 31 days of:
• No longer being eligible to continue coverage under another health plan because of a loss of job, divorce,
reduction in hours, transfer of a job that results in a loss of coverage, or if the employer stops contributing towards
you or your dependents’other coverage. You have 60 days within losing coverage under Medicaid or CHIP.
Note: Loss of eligibility under another plan does not include a loss because of failure to pay contributions on a
timely basis or any termination clause (i.e., making fraudulent claim).
• Acquiring a new spouse or dependent child because of marriage, birth of a child, adoption or placement for
adoption. In this event, if you are not already enrolled, you may choose not to enroll your dependents at this.
However, if you choose not to enroll your dependents, the only opportunity to enroll them in the future is during
open enrollment.
• Having a dependent whose dependent status ends under another group health plan.
• Incurring a claim that would meet or exceed the other group health plan’s lifetime limit for all benefits (the
special enrollment right begins when a claim that would exceed a lifetime limit on all benefits is incurred and
continues until at least 31 days after the earliest date that a claim is denied due to operation of the lifetime limit).
• No longer residing, living, or working in another plan’s HMO service area and there is no other benefit package
available to you under that group health plan.
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• Being covered under another group health plan that no longer offers any benefits to a class of similarly situated
individuals.
• Having coverage under an HMO plan that ceases operation.
• Having coverage under another health plan that ends due to cessation of employer contributions.
• Exhausting COBRA continuation, including the failure of the employer or other entity to remit payment timely,
are no longer residing, living, or working in the plan’s HMO service area and there is no other continuation
coverage available; and reaching the group health plan’s lifetime limit for all benefits.
• Changes due to becoming eligible for coverage under Medicaid or CHIP or losing coverage under the same must
be requested within 60 days of the change in eligibility for Medicaid or CHIP.
If coverage is requested within 31 days of the loss of other health coverage as described above (except for Medicaid and
CHIP changes which must be requested within 60 days of the change), coverage under this Plan will become effective on
the day immediately following the last day of other health coverage.
During a special enrollment period that occurs when a dependent is acquired as a result of marriage or birth, adoption, or
adoptive placement of a child, the Employee Partner must request enrollment for himself and/or such dependent(s) within
a 31-day period which begins on the date of marriage, birth, adoption or adoptive placement If coverage for newly
acquired dependents is requested within the 31-day special enrollment period, coverage under this Plan will become
effective on the date of the event.
Proof of dependent status is required for dependent Medical Plan coverage within 31 days of a Special Enrollment
event (or within 60 days for a special enrollment due to a change in eligibility for CHIP or Medicaid).
Eligibility
Eligibility Requirements
To participate in the Plan you must:
• Complete six consecutive months of service and be in Active Service, other than due to a medical condition, (physical
or mental health condition), on that date,
• Be full-time regular at the time of enrollment (normally scheduled to work 30 hours or more per week at one
participating club, resort or entity)
An Employee Partner who is not in Active Service for any reason other than due to a medical condition (physical or
mental health condition) on his/her scheduled effective date of coverage will not become covered under the Plan until the
Employee Partner returns to active employment.
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Dependent Eligibility
All Employee Partners are required to provide written documentation proving the eligibility of their dependents who
are covered or who are requesting coverage under the Medical Plan. Such written proof of eligibility must be received
no later than 31 days after the effective date of coverage in order for Medical Plan coverage to become effective for
your dependents. If proof is not received within 31 days after the effective date of coverage, you will not have another
opportunity to enroll your dependents for medical plan coverage until the next annual open enrollment or within 31
days of a Status Change or Special Enrollment event.
The Plan offers you the opportunity to cover your eligible dependents. Your eligible dependents include:
• Your legal spouse means your husband or wife as defined under Federal Law who is a U.S. citizen or legal resident of
the USA and to whom you are legally married. However, if you live in a state that recognizes common law marriage,
you may be able to enroll your common law spouse. If you need more information about covering a common law
spouse under the Plan, contact People Strategy Benefits at 1-800-800-4615.
• Your unmarried natural, legally adopted children (Including children placed for adoption for whom legal adoption
proceedings have been started), step-children, or a child for whom the eligible Employee Partner has obtained legal
guardianship. Eligible children must be either a U.S. citizens or legal residents in the USA, and primarily dependent
upon you for financial support (unless the dependent child is a recipient under Qualified Medical Child Support Orders,
ordered for the Employee Partner only) and who reside in the Employee Partner’s household who are:
• under age 19,
• between the ages of 19 and 25 and are full-time students (proof is required each semester), or determined to be
certified as medically disabled (i.e., incapable of self-sustaining employment due to complete physical/mental
disability as determined by a licensed physician who reside in the Employee Partner’s household and are primarily
financially dependent upon the Employee Partner for support. For purposes of coverage under the Plan, if a child
loses full-time student status because of a medically necessary leave of absence, the Plan will continue to treat the
child as a full-time student for one year after the start of the medically necessary leave of absence. The Claim
Administrator may require written certification of the medically necessary leave of absence.
• Dependents who are active members of the armed forces are not eligible for participation in the Plan. However, a
Spouse of an Employee who is in the armed forces as either an active or reserve member is eligible to participate in the
Plan.
It is your responsibility to call People Strategy Benefits at 1-800-800-4615, if a Dependent is no longer eligible to
participate in the Plan.
If you or your dependents do not enroll when first eligible, you will only be able to re-enter the Plan during the Annual
Open Enrollment Period, by Special Enrollment (See Glossary of Terms) or if you have a Status Change (see page 12).
Medical eligibility will not be based upon a Health Status-Related Factor, such as Genetic Information of the Employee,
Spouse, Dependent or any family member of such individuals or evidence of insurability.
You and your dependents must continue to meet eligibility requirements to maintain coverage.
Enrollment To be covered under the Plan you must enroll during the following enrollment periods: • Prior to your six month anniversary; • Within 31 days of Status Change (see page 12); or • Within 31 days of a Special Enrollment. (See Glossary of Terms) • Annual Open Enrollment Period
Only those dependents you enroll are covered for benefits under the Plan.
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Medical Plan Choices
Because people have different needs, the Plan gives you the option to select the level of health care coverage that is most
appropriate for you and your family. As you complete the enrollment process, there are two important decisions you need
to make:
• Who to cover; and
• Which deductible option to choose.
More about Deductible Options
Any choice covers the same medical expenses. Depending on the option you choose, you will have a different deductible,
out-of-pocket maximum and bi-weekly contribution. The higher your deductible, the lower your bi-weekly contribution
(see the Schedule of Benefits for dedeductible options). You cannot change your deductible choice until the next Plan
year, unless it’s related to a dependent’s Special Enrollment event (i.e., marriage, birth of a child, adoption or
placement for adoption). See more information about Plan Transfers on page 13.
When Medical Coverage Begins
Once enrolled, you or your dependents’ coverage generally begins:
• The day you complete six consecutive months of service;
• The day of your Status Change provided you enroll within 31 days of the Status Change;
• The day you experience a Special Enrollment, provided enrollment is completed
within 31 days. (See Glossary of Terms)
• January 1st of the year following the Annual Open Enrollment Period, unless otherwise indicated (see Glossary of
Terms).
Special note on Dependent Coverage
Coverage is not automatic. You must submit the enrollment form within the required time periods listed above, in order
to receive full coverage retroactive back to the day of the event (i.e., birth of a child, adoption or placement for adoption,
marriage)
Paying For Your Benefits
Once enrolled, your cost will include:
• Bi-weekly premium - your share of the cost of coverage,
• Deductible(s) - the amount you pay before the Plan pays, and
• Co-insurance or copay- a dollar amount or percentage of your health care bill that you are responsible for,
Premium
Your bi-weekly premium is based upon the deductible option and type of coverage (i.e. Employee Partner only, etc.) you
choose and the most current contribution schedule.
Contributions are paid on a pretax basis and will be automatically deducted from your paycheck each pay period. Your
taxable income is reduced by the amount of your contributions before state income taxes (if applicable), federal income
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taxes and social security (FICA) taxes are computed.
For example: Let’s assume you are an Employee Partner who is married and claims one exemption on your tax return.
Your bi-weekly salary is $769 and your bi-weekly contributions are $29.49:
After-tax Pre-tax
Gross Pay $769.00 $769.00
Pretax Contributions N/A (29.49)
Taxable Gross Pay $769.00 $739.51
Federal Tax (62.00) (56.00)
FICA Tax (58.83) (56.57)
After-tax Contributions (29.49) N/A
Spendable Income $618.68 $626.94
Additional bi-weekly take home pay: $8.26
As you can see in this example, paying contributions with pretax dollars creates a savings of $8.26 or approximately
$210.00 a year. Depending on your situation, your individual tax savings could vary. Because the pretax premium reduces
your FICA wages, it may also reduce your social security benefit.
Because your premium is paid on a pretax basis, the Internal Revenue Service requires that your election remain in effect
for the entire Plan year. This means that you are “locked” into the coverage until the next Annual Open Enrollment
Period, or you or your dependents qualify for Special Enrollment (see Glossary of Terms) or experience a Status Change
(see page 12).
Tax Impact
As previously mentioned, contributions will not be taxed for federal income tax, social security (FICA) and federal
unemployment tax (FUTA). However, cities and states vary in their treatment of pretax contributions. Contact your club
accountant, HR representative or payroll administrator if you have questions about your state.
W-2 Form
For federal purposes, the year-end W-2 will show your adjusted gross wages (gross wages minus pretax contributions) as
taxable earnings. If your state and/or local government does not recognize pretax contributions, then the box indicating
state and local wages, tips, etc., will indicate gross wages and should be more than the adjusted gross wages shown for
federal tax purposes.
Discounted Medical Plan Contributions
Discounted Medical Plan contributions are available for any Employee Partners and covered dependents who certify they
are non-smokers/non-tobacco users. Employee Partners and/or covered dependents who certify they are smokers/tobacco
users will have an opportunity to complete a company-sponsored smoking cessation program. Upon receipt of proof of
participation issued by the smoking cessation program administrator to the employee and/or dependent, the employee will
receive the discounted medical plan contributions.
Any Employee Partner who is unable to provide proof of enrollment in the company-sponsored smoking cessation
program and completion of the approved program will be subject to revocation of the non-smoker discount.
An Employee Partner who intentionally falsifies his/her or covered dependents non-smoking status will be subject to
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immediate revocation of the non-smoker discount and could face a loss of coverage for intentional falsification .
If the required certification is not provided, the covered Employee Partner and dependents will be ineligible for the non-
smoker discount, regardless of their smoking status.
Status Change
A status change includes:
• Change in your legal marital status such as marriage, the death of your spouse, divorce, legal separation, or an
annulment;
• Change in your number of dependents including the birth or death of a child, adoption or Placement for Adoption of a
child with you, or cause the loss of dependency status of your dependents such as attainment of age or student status;
• Change in you, your spouse’s or your dependent’s employment status, including 1) the termination or commencement of
employment; 2) a strike or lockout; 3) commencement or return from an unpaid leave of absence by you, your spouse
or your dependent;
• Change in residence for you, your spouse or your dependent.
• A significant change in health care coverage as a result of your spouse’s or child’s employment.
• Change in work status from part-time regular to full-time regular or vice versa for you, your spouse or your child.
A status change will be consistent with a change in your benefit elections only if status change:
• Results in you or a dependent gaining or losing eligibility for coverage under this plan or a health plan of your spouses’
or dependent’s employer, and
• Corresponds with that gain or loss of coverage.
For example, if a new child is born to you, you may change your benefit election to increase coverage by adding the child.
In this case, the increase in coverage would be consistent with the Status Change. You may not decrease your coverage
because decreasing coverage would not be consistent with adding a new dependent.
Proof of dependent status is required for dependent Medical Plan coverage and must be received within 31 days of a
Status Change event.
• You or your child gain or lose coverage under Medicaid or CHIP and you notify the Plan Administrator within 60 days
of the change.
Deductible
� Your deductible is based on a calendar year.
� Only covered expenses count toward your deductible.
� The amount of your deductible depends on the option you choose.
� Under the $250 and $500 deductible plans for Employee Partners with dependent coverage, one person can meet
the individual deductible. All covered expenses incurred by the family count toward meeting the family
deductible.
� For the High Deductible Health Plan (HDHP), if the Employee Partner has dependent coverage, the family
deductible must be met by one participant or a combination of two or more participants before benefits are paid.
� One “per person” or “family” deductible must be met for both in-network and out-of-network covered charges. If
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you use an out-of-network hospital, there is an additional deductible for each inpatient admission. The medical
deductible must be met separately for both in-network and out-of-network expenses. They do not cross
accumulate.
� Covered prescriptions count toward meeting your deductible, except for prescription drug copays.
The medical deductible must be met separately for both in-network and out-of -network expenses. They do not
cross accumulate.
Plan Transfers
Covered Employee Partners may only transfer between available medical plan options during a Plan Transfer Period. The
Plan Transfer Period occurs during annual enrollment held once each year at a time established by the Plan Sponsor. In
addition, a covered Employee Partner may transfer between available medical plan options if the plan transfer request is
directly related to a dependent’s HIPAA special enrollment event (for example, acquiring a spouse or birth of a child).
However, when an Employee Partner transfers between available medical plan options due to a special enrollment period
any applicable deductibles, out-of-pocket maximums, and other limitations that were either satisfied or partially satisfied
under the previous medical plan option prior to the transfer will be applied to the new medical plan option.
Co-insurance/Copay If you choose to use an out-of-network provider, you will be responsible for paying more of the cost. The Plan pays 80% of the Allowable Amount for covered charges when you use in-network providers and 60% of the Allowable Amount when you use out-of-network providers.
� You must meet your deductible first, except as otherwise noted in the Medical Schedule of Benefits. � The amount of your co-insurance or copay depends upon the covered expense as outlined
in the Schedule of Benefits.
Medical Plan Out-of-Pocket Maximum
Your out-of-pocket maximum when using network providers depends on your deductible option. If you use an out-of-
network provider, you will have to meet a separate out-of-pocket maximum for using non-network providers.
• Your out-of-pocket maximum is based on a calendar year.
• Once you meet the out-of-pocket maximum, the Plan pays 100% of most covered expenses for the covered person for
the remainder of the year, subject to the Allowable Amount, and a lifetime maximum of $1,000,000.
• The amount of your out-of-pocket maximum depends upon the deductible option you choose.
• For all deductible plans, the accumulation toward the out-of-pocket maximum for both in-network and out-of-network
covered expenses is separate.
• The out-of-pocket maximum does not include the deductible or the generic prescription drug copay for the $250 and
$500 deductible plans.
Preexisting Conditions
Coverage for expenses related to and for Preexisting Conditions (see Glossary of Terms) will not be covered under the
Plan for twelve (12) months, as measured from you or your dependent’s Enrollment Date.
Preexisting Credit for Prior Coverage
The length of time your Preexisting Condition is not covered under the Plan (twelve months) will be reduced if you and
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your dependents can show proof of Creditable Coverage under another health plan.
How Creditable Coverage Works
Your preexisting wait period of twelve months will be reduced by the number of days of Creditable Coverage you had as
of the Enrollment Date, unless there was a significant break in your coverage.
A significant break in coverage means you or your dependents were not covered under another health plan for 63 or more
consecutive days.
The 6 month wait period before your coverage becomes effective (See Eligibility page 8) does not count as a significant
break in Creditable Coverage. However, you cannot get “credit” for the days in the wait period.
How to apply for Creditable Coverage
If you wish to have your coverage under another health plan considered as Creditable Coverage towards meeting the
Plan’s preexisting wait period (12 months), you must submit a certificate of prior coverage (Certification Notice) to the
Plan Administrator at the time of enrollment. You have the right to request a certificate from a prior plan or issuer and the
Plan Administrator will assist in obtaining a certificate, if necessary.
The Certification Notice should include the following information:
• The date the certificate is issued;
• The name of the group health plan under which you and your dependents were covered;
• The name of each participant and identification number (i.e., social security number) for which the certificate applies;
• The name, address, and telephone number of the Plan Administrator or issuer of the certificate (i.e., claims
administrator); and
• The telephone number of the person to contact for additional information.
The Certification Notice must also either state;
• that the individual has at least 18 months of Creditable Coverage without a 63-day break in coverage; or
• the waiting period (if any) imposed on the individual for coverage under the plan, the date coverage began and ended
(or indicate if it is continuing).
If you are unable to provide a Certification Notice due to reasons beyond your control, or if the certificate’s accuracy is
contested by the Plan Administrator, then you may provide proof of Creditable Coverage to the Plan Administrator
through documents, records, third party statements, including phone calls to a third party provider. Examples of reasons
beyond your control are:
• Your previous plan failed to provide a certificate within the required time period;
• Your previous plan was not required to provide a certificate; or
• You have an urgent medical condition that requires an immediate determination of Creditable Coverage.
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After receipt of your certification paperwork, the Plan Administrator will notify you within 30 days of the determination
and only if it has been determined that a preexisting condition exclusion will still apply. Failure to cooperate with the Plan
Administrator’s efforts to verify coverage will result in a refusal of coverage under the Plan.
Waiver of Preexisting Condition Exclusions
The following will not be considered Preexisting Conditions under the Plan:
• Covered services related to maternity care (you or your spouse);
• Covered services related to a newborn, adopted child or child Placed for Adoption (and under the age of 18) provided
the child becomes covered within 31 days of birth, adoption or Placed for Adoption.
• Covered services related to conditions based on Genetic Information.
This pre-existing exception does not apply after the child has a significant break in coverage (63 or more consecutive days
without coverage).
If you have additional questions about applying for Creditable Coverage or preexisting condition exceptions, call People
Strategy Benefits at 1-800-800-4615.
Medical Plan Features
Wellness Incentives and Health Care Accounts Wellness incentives are offered for the completion of a Health Risk Assessment (HRA), enrolling and participating in the recommended Disease/Condition Management Programs, the Special Beginnings Program and are deposited into a Health Care Account (HCA), to pay for eligible expenses. The following Wellness Incentives are available each Plan year:
• $50 each to the first 400 covered Employee Partners who complete and submit a Health Risk Assessment (HRA) to BCBSTX.
• $50 for the first covered Employee Partner or covered dependent who qualifies, enrolls, and participates in a recommended Disease/Condition Management program (see the Disease/Condition Management information under Medical Plan Features). The second covered person receives $25. The annual maximum incentive per covered family is $75.
• $50 for a covered Employee Partner or a covered spouse, enrolls during the first 12 weeks of pregnancy, and participates in the Special Beginnings prenatal management program.
Eligible Health Care Account (HCA) Expenses
If you participate in the Medical Plan $250 and Plan $500:
If you participate in the High Deductible Medical Plan - $1,250:
Funds in your HCA can be used for medical expenses – such as deductibles, copays, coinsurance and certain preventive care expenses – and other health care expenses not paid for under another health plan or through a regular health care flexible spending account.
Funds in HCA can be used for vision, dental and certain preventive care expenses not paid for under another health plan, through your HSA or a limited-purpose health care flexible spending account.
If you are in Medical Plan $250 and $500, available HCA funds will automatically be applied to deductible and coinsurance amounts. For other eligible expenses, such as a dental deductible or vision plan copay, you may have to submit a request for reimbursement. HCA funds are available for each plan year and do not carry-over to the next plan year.
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Health Savings Accounts
A Health Savings Account (HSA) is an account that you can put money into to save for future medical expenses. There are certain advantages to putting money into these accounts, including favorable tax treatment. HSAs were signed into law by President Bush on December 8, 2003.
Advantages of HSAs
� Lower Premium Cost – By law, HSAs are established with a high-deductible health plan (HDHP) and the premium cost for the high-deductible health plan is lower than other plan options.
� Tax-Free Savings* - You deposit money into the account with pre-tax dollars and you never pay taxes on the money in your account unless you have non-qualified medical expenses.
� Tax-Free Interest** - You earn interest tax-free in your Health Savings Account (HSA) account. � You don’t lose any money in your Health Savings Account (HSA) account - The money you contribute to your
account can be rolled over from year to year and you take it with you if you leave the company. There is no “use it
or lose it” rule. � Investment Options - You can invest your Health Savings Account (HSA) dollars to grow more over time.
� Save it or Spend It – You can decide when to use your HSA dollars. If you prefer the dollars for future medical expenses, you may pay for your medical expense with your personal funds, allowing you the option to build up investment dollars more quickly.
* Information about State Tax Treatment
Most states follow the Federal Government favorable tax treatment of HSAs except for the current following states:
Alabama New Jersey
California Wisconsin
In these states, the amounts that are contributed to the HSA and interest earned on the HSA would be included on the
Employee Partner’s W-2 for state income tax purposes.
** New Hampshire and Tennessee tax HSA earnings only.
Who Can Have an HSA?
Any adult can contribute to an HSA if they:
� Have coverage under an HSA-qualified “high deductible health plan” (HDHP)
� You are NOT covered under another medical plan that is not a high deductible health plan � You are NOT covered under any health care Flexible Spending Account that reimburses medical expenses (even a
spouse’s FSA plan), unless the FSA is used for qualified limited purpose expenses. � Are not enrolled in Medicare.
� Cannot be claimed as a dependent on someone else’s tax return.
Contributions to your HSA can be made by you, or your family members on your behalf, and are limited annually by the IRS.
If you make a contribution outside of your pre-tax payroll contributions, you can deduct the contributions (even if you do not itemize deductions) when completing your federal income tax return. Contributions to the account must stop once you are enrolled in Medicare. However, you can keep the money in your account and use it to pay for qualified medical expenses tax free.
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High Deductible Health Plans (HDHPs)
You must have coverage under an HSA-qualified “high deductible health plan” (HDHP) to open and contribute to an HSA. Federal law requires this.
In general, the deductible must apply to all medical expenses (including prescriptions) covered by the Medical plan.
However, the Medical Plan pays for “preventive care” services on a first-dollar basis up to the annual preventive care maximum. "Preventive care" can include routine pre-natal and well-child care, child and adult immunizations, annual physicals, mammograms, pap smears, etc.
Please refer to the Schedule of Benefits for more information about the benefit coverage under the High Deductible Health Plan.
HSA Contributions
You can make a contribution to your HSA each year that you are eligible. For 2010, you, or anyone you elect to contribute on your behalf, can contribute no more than:
� $3,050 for Employee Partner only coverage � $6,150 for family coverage
Individuals age 55 and older can also make additional “catch-up” contributions. The maximum annual catch-up contribution is as follows:
� 2010 and after - $1,000
If you reach age 55 before the close of the calendar year, you may make a full year’s catch-up contribution, provided you are covered by a qualified HDHP for the entire year. If you are covered by a qualified HDHP for less than the entire year, your catch-up contributions must be pro-rated.
If you contribute, your annual contribution is divided into a per-pay-period sum and automatically deposited to your HSA account via payroll deduction. You also have the option of making a tax-deductible lump-sum deposit at anytime during the year. You may want to carefully consider this option if you are expecting significant health care costs early in the year. Remember that funds must be in your HSA account to be used (it's not like a regular Health Care Flexible Spending Account). Also keep in mind that if you contribute on your own (not through payroll deductions), you'll have to claim any tax advantage on your individual income tax return.
If your regular Health Care FSA balance is $0 at the end of the year, you may begin contributing to your HSA at the first of the new plan year. If you have a balance remaining in your regular FSA at the end of the year, the IRS will not allow you to begin contributions to your HSA until April 1. That's because the FSA tax advantages are still available to you during the first three months of the new plan year.
Determining Your Contribution Effective Date
Your eligibility to contribute to an HSA is determined by the effective date of your HDHP coverage.
You can begin contributing to your HSA on the first pay cycle of month following your HDHP
coverage effective date.
If you participate in a HSA after the start of the plan year (January), you are still able to contribute up to the IRS allowed annual maximum during the remainder of the calendar year. Your HSA contributions will be prorated through the remainder of the calendar year. If you are not eligible to contribute to a HSA for a consecutive 12-month period, any additional contributions you make to a HSA above a prorated amount (the number of months eligible to contribute) are deemed “excess contributions” and are subject to a penalty tax. You must be eligible to contribute to a HSA for 12 consecutive months to preserve the tax-free status of your contributions. Elections to make pre-tax payroll deductions for your HSA can change on a month-by-month basis (unlike salary reduction contributions to an FSA).
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Using Your HSA
You can use the money in the account to pay for any “qualified medical expense” under federal tax law - Internal Revenue Code 213(d). This includes most medical care and services, dental and vision care, and includes over-the-counter drugs such as aspirin.
You can not use the money to pay for medical insurance premiums, except under specific circumstances, including:
� Any health plan coverage while receiving federal or state unemployment benefits.
� COBRA continuation coverage after leaving employment with a company that offers health insurance coverage.
� Qualified long-term care insurance.
� Medicare premiums and out-of-pocket expenses, including deductibles, co-pays, and coinsurance for:
� Part A (hospital and inpatient services)
� Part B (physician and outpatient services)
� Part C (Medicare HMO and PPO plans)
� Part D (prescription drugs)
You can use the money in the HSA account to pay for qualified medical expenses for yourself, your spouse, or your dependent children. You can pay for expenses for your spouse and dependent children even if they are not covered by your HDHP.
Any amounts used for purposes other than to pay for “qualified medical expenses” are taxable as income and subject to an additional 10% tax penalty.
Examples include:
� Medical expenses that are not considered “qualified medical expenses” under federal tax law (e.g., cosmetic surgery).
� Other types of health insurance unless specifically described above.
� Medicare supplemental insurance premiums.
� Expenses that are not medical, dental or health-related.
After you turn age 65, the 10% additional tax penalty no longer applies. If you become disabled and/or enroll in Medicare, the account can be used for other purposes without paying the additional 10% penalty.
You can find additional information on eligible expenses in IRS Publication 502, which is available at www.irs.gov or by calling 1-800-TAX-FORM (1-800-829-3676).
Opening Your Health Savings Account
When you enroll in the High Deductible Health Plan, you will receive information from ACS-Mellon, the HSA bank custodian, about two weeks from your enrollment date. This information will explain how to open an HSA. It is up to you to open an account or decide if you want to fund the HSA. Please note, contributions or deposits to your HSA cannot be posted until you complete the ACS-Mellon signature process.
You are allowed a one-time transfer of funds from an IRA to an HSA. The transferred amount, when combined with other HSA contributions for the year, may not exceed the annual maximum contribution limit. Also, after making such a transfer, you must continue to participate in a qualifying HDHP for 13 consecutive months, beginning in the month of the IRA-to-HSA transfer. Otherwise you will be subject to income taxes and a 10 percent penalty tax on the transferred amount, except in the case of death or disability. This kind of transfer may be a good idea if you incur a significant medical expense and do not have the means to make the maximum HSA contribution for the year.
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There is a $15 account set-up fee and a $3.50 monthly account fee for balances under $1000. You are also responsible for any other banking charges, such as additional debit cards or fees for non-sufficient funds.
Other banks, credit unions and financial institutions are permitted to be trustees or custodians of HSAs. You can locate another institution to open your HSA, but only contributions through ClubCorp/ACS – Mellon are setup as pre-tax investments.
Need More Information About HSAs?
The U.S. Treasury’s web site has additional information about Health Savings Accounts, including answers to frequently asked questions, related IRS forms and publications, technical guidance, and links to other helpful Web sites. The U.S. Treasury’s HSA Web site can be found through www.treas.gov (click on “Health Savings Accounts”) or directly at the following address: http://www.treas.gov/offices/public-affairs/hsa/.
This information is for informational purposes only and is not designed to provide or give tax advice. Please consult a
tax professional regarding the impact on your personal tax situation.
Disease/Condition Management If you are living with a chronic health condition, you may face daily challenges in managing your condition. You want to have the best knowledge and tools available to help you stay as health as possible. This voluntary program helps support those who have:
� Asthma � Low Back Pain
� Diabetes � Metabolic Syndrome (high blood pressure, high
cholesterol)
� Congestive Heart Failure � Coronary Artery Disease
� Chronic Obstructive Pulmonary Disease
Special Beginnings
Prenatal education, regular obstetric check-ups, and lifestyle awareness are key factors in helping pregnant women
deliver healthy babies. That's why BCBSTX is proud to offer the Special Beginnings prenatal care program.
The Special Beginnings program provides prenatal risk assessment and education, and coordinates with the patient's
physician to provide case management services to help reduce the chance of low birth weight infants and/or premature
delivery.
Register as soon as find out you are pregnant in order to receive free samples and give aways. Call BCBSTX at 1-
800-462-3275 for more information or to enroll.
24/7 Nurseline
Good health starts by asking the right questions at the right time. And we all know that sometimes those questions
come up unexpectedly, like when the doctor’s office is closed.
Whatever the time, you can get the answers to your health care questions with 24/7 Nurseline from Blue Cross and
Blue Shield of Texas. Call 1-800-462-3275.
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Managed Care
As part of a managed care program, the Plan requires precertification of all inpatient (overnight) hospital admissions
except for admissions due to childbirth (see Maternity Coverage and Precertification). In most areas, the Plan participates
in a preferred provider organization (PPO) intended to provide medical services at a discounted rate.
Precertification
The Plan requires that you “precertify” all inpatient hospital admissions (note exception for maternity precertification,
page 20) to determine whether the hospitalization proposed by your Physician will be treated by the Plan as Medically
Necessary. When your Physician recommends that you or a covered family member be admitted on a non-emergency
basis, you or your Physician must contact Blue Cross Blue Shield of Texas by calling 1-800-441-9188 prior to being
admitted. You or your doctor will need to provide Blue Cross and Blue Shield of Texas with the following information:
• Your name;
• Your unique ID on your ID card
• The name of your club, resort or entity;
• The estimated length of stay in the hospital.
In case of an Emergency admission, you or your doctor must call Blue Cross and Blue Shield of Texas within 48 hours
after you are admitted or prior to your discharge if sooner, in order for you to qualify for full Plan benefits.
It is your responsibility to make sure each inpatient hospital admission is certified. Failure to call for hospital
precertification will result in a reduced payment of benefits.
In addition to precertification of all inpatient hospital admissions, precertification will be required prior to services being
received for the following types of medical treatment and services:
� Home Health � Hospice � Home Infusion Therapy � Outpatient Mental Health
BCBSTX Network providers are required to meet all precertification requirements. There is no penalty for failure to
precertify medical treatments and services other than inpatient hospital admissions when services or medical treatment are
provided by a non-network provider.
Maternity Coverage and Precertification
The Plan may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a
caesarian section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after
consultation with the mother, from discharging the mother or her newborn earlier that 48 hours (or 96 hours, as
applicable.) In any case, plan and issuers may not, under Federal law require that a provider obtain authorization from the
plan or insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Although you are not required to obtain precertification for inpatient hospital admissions related to you or your spouse’s
covered pregnancy for maximum lengths of stay of 48 hours (2 days) following a normal vaginal delivery and 96 hours (3
days) following a caesarean delivery, you will be required to precertify any additional days beyond the criteria outlined
above. Failure to call for precertification will result in a reduced payment of benefits.
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You are encouraged to call Blue Cross and Blue Shield of Texas during the first trimester of your pregnancy to take
advantage of valuable information that can be sent directly to your home as well as determining whether or not your
pregnancy is high risk. For more information, call 1-800-462-3275.
The Network
You have access to Physicians and hospitals that participate in a network that offers health care services at a discounted
rate. You have the option to use in-network or out-of-network Physicians and hospitals. However, when you choose to use
Physicians or hospitals that don’t participate in the network, you pay more of the cost for your health care.
Regardless of where you live, if you are traveling away from home, or off to school out of state, through BlueCard and
BlueCard Worldwide programs, you and your covered family members can receive health care coverage at lower out-of-
pocket costs from contracting doctors and hospitals almost anywhere in the country and around the world.
For PPO network information:
1. Call Blue Cross and Blue Shield of Texas (BCBSTX) at 1-800-521-2227; or
2. Go to www.bcbstx.com
• Have your group and member ID number available (found on your ID card)
• Log in to Blue Access for Members
• Create a user ID and password.
The Plan Schedule of Benefits (pages 23-25) shows how benefits are paid when you choose in-network or out-of-network
providers.
Blue Distinction Centers for Specialty Care – these centers are available through Blue Cross and Blue Shield of Texas and
provide access to medical facilities that have demonstrated expertise in the delivery of quality health care at a better value.
These centers are limited to specialty care for Cardiac Care, Transplants, Bariatric Surgery and Complex and Rare
Cancers. For more information go to the Blue Distinction Center Finder at www.bcbs.com or call BCBSTX at 1-800-521-
2227.
Network Prescription Drug Benefits
The Medical Plan offers you and your covered dependents prescription drug benefits through Blue Cross and Blue Shield of Texas and Prime Therapeutics when prescriptions are purchased at participating retail network pharmacies, through the mail order or injectable drug program. A mail order program helps you save even more on prescriptions you take regularly.
What you need to know before you purchase prescription drugs:
• Find out if a drug is on the Preferred Drug List. The amount you pay for prescription drugs, whether purchased at a retail pharmacy or through the mail order, is based on what type of medication you use – Generic, Preferred or Non-Preferred drugs. If you are covered under the Medical Plan, you should:
1. Review the Preferred Drug List. This list is updated quarterly, please visit www.bcbstx.com for the most recent updates or call BCBSTX at 1-800-521-2227.
2. Talk to you physician about the Preferred Drug List or if there is a generic available for the drug you are prescribed - take the Preferred Drug List with you (see #1 above) when you have an appointment. Only your doctor can advise you about the drugs you take and if one is right for you.
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� Find out if the type of drug you are taking or are prescribed is subject to Step Therapy. Step therapy only applies to certain types of prescription medications. With step therapy, you will receive benefits for drugs subject to step therapy only after trying alternative medications which have been determined to be safe, effective and less costly. In cases where alternative drugs are not appropriate for you to use, your physician can request an exception to the step therapy program.
How Step Therapy Works: 1. Certain types of drugs are grouped in categories: The first step is front-line drugs and back-up drugs. Front-line
drugs should be tried first because they can provide the same health benefit as more expensive drugs, at a lower cost. Back-up drugs are Step 2. Back-up drugs are either lower cost brands or higher cost brand drugs.
2. When you present a prescription to the pharmacist for a drug subject to the step therapy program, if there is no record of you receiving a first-line drug, your pharmacist will advise you to contact your doctor.
3. A toll-free number will be provided for you and your physician to obtain detailed program information. Another way for you and your physician to obtain information is by logging onto the BCBSTX website at www.bcbstx.com and clicking on Providers.
4. It would be a good idea to discuss treatment options with your doctor before going to the pharmacy. To learn more details you can contact the BCBSTX Customer Service line at 1-800-521-2227 and choose the prompt for pharmacy.
How to Obtain Prescriptions at Retail Pharmacies
1. Find a participating network pharmacy by calling BCBSTX at 1-800-521-2227 or going to www.bcbstx.com. � Click on Members � Click on Pharmacy � Click on Pharmacy Locator � Click on BCBS Texas under Health Plan (it doesn’t matter where you live in the United States). � Click on BCBS TX Non-HMO Network. � Enter you zip code.
2. Fill your prescription at a participating network pharmacy. Show the participating pharmacy your BCBSTX Medical Plan ID Card.
3. Pay your share of the cost (the pharmacy will know if it’s a copay, coinsurance or amount applied toward deductible, if applicable).
4. That’s it! The pharmacy will file your claims. How the Mail Order Works
You may use the mail order program for up to a 90-day supply of drugs you take on a regular basis, such as insulin and blood pressure medication. After you enroll in the Medical Plan, you will receive a mail order form and instructions included in the BCBSTX Information Guide.
How the Injectable Drug Program Works
BCBSTX has an arrangement with a Specialty Pharmaceutical provider to supply certain high cost injectable drugs to the office of participating providers. Providers who participate with BCBSTX will have the option of obtaining high cost injectable drugs from the Specialty Pharmaceutical provider. Through this program, providers can submit injectable prescriptions by fax or phone. Needles, syringes, and alcohol swabs will be provided at no charge with every shipment. For more information about the Injectable Drug Program, please contact the BCBSTX Customer Service Department at 1-800-521-2227.
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Medical Schedule of Benefits
The Medical Plan generally covers the Allowable Amount for treatment that is Medically Necessary. All out-of-network charges are subject to the Allowable Amount.
Plan
Deductible Plan*
Per person/Family
In-Network Out-of-Pocket Maximum**
Per Person/Family
Non-Network Out-of-Pocket Maximum**
Per Person/Family
Plan 250 $250/$750 $2,500/$4,000 $4,000/$7,000
Plan 500 $500/$1,500 $3,000/$5,000 $5,000/$9,000
Plan 1,250 (HDHP) (See Note below)
$1,250/$2,500 $3,750/$7,500 $7,500/$15,000
Note: For Plan $1,250 - The family deductible must be met by one participant or a combination of two or
more participants before benefits are paid.
*Deductible - The medical deductible must be met separately for both in-network and out-of-network expenses.
They do not cross accumulate.
**Out-of-pocket maximums for Plans $250 and $500 do not include deductibles. For all deductible plans, the
accumulation toward the out-of-pocket maximum for both in-network and out-of-network covered charges is
separate.
Network Schedule of Benefits
Additional Hospital In-Network Out-of-Network
Admission Deductible None $200
Emergency Room (ER) Visit $200 co-pay/visit $200 co-pay/visit After deductible After deductible (coinsurance applies) (coinsurance applies)
Co-insurance (Plan pays) In-Network Out-of-Network
80% 60%
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Prescription Drugs
purchased:
Plan $250 Plan $500 Plan $1,250 (HDHP)
� At a Retail Network Pharmacy (up to a 30 day supply); or
� Through the Mail Order (up to a 90 day supply).
You Pay:
� $12 copay - Generic, no deductible
� 20%, after deductible, for Preferred Drugs*
� 30%, after deductible, for Non-Preferred Drugs.*
You Pay:
� $12 copay - Generic, no deductible
� 20%, after deductible, for Preferred Drugs*
� 30%, after deductible, for Non-Preferred Drugs.*
You Pay:
� $12 copay - Generic, after deductible
� $30 copay, after deductible, for Preferred Drugs*
� $50 copay, after deductible, for Non-Preferred Drugs.*
*When there is a generic available for a prescribed brand-name drug, you will pay the applicable preferred drug
coinsurance/co-pay, plus the cost difference between the generic and the brand-name drug.
Step Therapy
Prescription drugs are subject to the step therapy prescription program, which only applies to certain types of prescription
medications. With step therapy, you will receive benefits for drugs subject to step therapy only after trying alternative
medications, which have been determined to be safe, effective and less costly. In cases where alternative drugs are not
appropriate for you to use, your physician can request an exception to the step therapy program.
Preventive Care Benefit
Preventive care is covered at 100% up to the calendar year maximum, deductible waived
Preventive Care
Calendar Year
Maximum for:
Plan $250
Plan $500
Plan $1,250
Employee Partner
Only
$350 $350 $600
Employee + Spouse,
Employee +
Child(ren) or
Employee + Family
$700 $700 $1,200
Chiropractic Care $1,000 limit per calendar year
Out-of-pocket maximums Out-of-network out-of-pocket maximum is 2 Times (Double) PLAN-250, PLAN-
500, or PLAN-1,250 for out-of-pocket maximum for the same type of coverage
Annual maximums PLAN-250, PLAN-500, PLAN-1,250 combined for in-network or out-of-network
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Lifetime maximum $1,000,000
Skilled Nursing Facility $10,000 per calendar year
Home Health Care Services $10,000 Lifetime maximum (After the limit is met, additional charges are subject to
case management)
Hospice $5,000 Lifetime maximum
If you are not subject to network guidelines (you do not reside in a network area), your benefits are paid at in-network
rates regardless of your choice of provider. However, if you are subject to network guidelines and you choose an out-of-
network provider, benefits will be paid at out-of-network levels.
Annual common accident deductible
One “per person” deductible PLAN 250, PLAN-500, or
PLAN-1,250
Covered room and board
Private room Semi-private Allowable Amount
Semi-private room Semi-private Allowable Amount
Precertification
Precertification of all inpatient See section on Precertification
hospital admissions is Maternity Coverage
required-except as provided (See page 20)
herein for Maternity Coverage –
failure to precertify will
result in a 30% reduction of
co-insurance percentage
Covered Medical Expenses
This Plan covers a wide range of charges for eligible medical expenses and supplies considered Medically Necessary,
including those for basic hospital, surgical and Physician services provided to you and your eligible Dependents. While
not intended to be exhaustive or complete, this section lists some of the charges eligible for coverage.
Benefits are paid or not paid based on:
• Usual, customary and reasonable charges (UCRC) and the Allowable Amount
(See Glossary of Terms);
• Preexisting Conditions (see page 13); and
• Schedule of Benefits (see 23-25).
Eligible medical expenses include the following:
• Other Hospital services required for medical or surgical care or treatment, excluding any optional facilities such as
television, radio, telephone and any other facility, supply or service provided for the pleasure or convenience of a
Participant or his visitors.
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• Anesthetics and its administration by a Physician who is an anesthesiologist or a certified registered nurse anesthetist in
cases where there are not charges by a Physician for the same procedure are covered.
• X-rays or radium treatments, subject to the Plan exclusions.
• Oxygen and its administration.
• Blood transfusions and the cost of blood not donated.
• Services of a registered nurse or a licensed practical nurse (“LPN”), other than a nurse or LPN who ordinarily resides in
your household or is a member of your Immediate Family.
• Drugs and medicines, if dispensed by prescription by a licensed pharmacist.
• Benefits will be available, up to the Preventative Care Calendar Year Maximum Benefit, for the following services
including, but not limited to: physical exams; office visits; pediatric care; immunizations; vaccinations; TB tine tests;
PKU tests; gynecological exams; PAP smears; mammograms; prostate exams; routine vision screening, routine hearing
screening, and associated diagnostic x-ray and laboratory services (including interpretation by a separate provider), and
procedures such as routine colonoscopies and sigmoidoscopies. Any amount over the Preventive Care Calendar Year
Maximum Benefit will not be covered by the Plan and will be the patient’s responsibility.
• Professional ambulance services, rail or air transportation to the nearest hospital equipped to furnish treatment for the
patient (limited to the continental U.S. and Canada) but not returning from the hospital.
• Registered dieticians at eighty percent (80%) when referred by a Physician, excluding expenses related to the treatment
of obesity.
• Physical therapy, respiratory and speech therapy services provided by a licensed physical therapist, a licensed
occupational therapist, or licensed speech therapist for treatment of an Illness or Injury, but only for the period that
significant and measurable progress occurs. Services must be:
• Specific for the illness or injury sustained
• Prescribed by the treating Physician and;
• Deemed Medically Necessary
• Charges of a licensed, certified acupuncturist if prescribed by a Physician as a substitute for administration of
anesthesia.
• Charges for diagnostic (but not routine) mammography procedures.
• Charges of a licensed audiologist when referred by a Physician.
• Charges for insulin, if the participant is a diabetic, and digitalis or nitroglycerin, if Medically Necessary because of
disease or damage to the heart.
• Biofeedback as a treatment for a Mental or Nervous Disorder if done by a qualified Physician.
• Orthotic devices used to support, align, prevent or correct deformities, or to improve the function of movable parts of
the body, except for supportive devices for the feet (such as arch supports) and orthopedic shoes which are not covered
Repair or replacement of covered orthotic devices will only be covered when required due to growth or development of
a dependent child, medical necessity because of a change in the Covered Person’s physical condition, or deterioration
from normal wear and tear if recommended by the attending physician.
• Certain dental charges related to injuries.
• Charges by a hospital when the participant is admitted to a hospital by a Physician or DO and such participant has a
medical condition that would endanger his life or health if treatment were not given in a Hospital.
• Intestinal by-pass surgery, adjustable gastric banding (adjustable Lap-Band), and gastric by-pass surgery but only if the
Covered Person meets the definition of Morbid Obesity.
• Expenses for the following cosmetic treatment:
• Treatment necessitated by an Injury, provided the treatment begins within twelve (12) months of the date of such
Injury and is completed within twenty-four (24) months following the date treatment commenced;
• Correction of a congenital defect in a child less than nineteen (19) years of age which has resulted in a functional
defect; and
• Charges for reconstructive surgery incidental to or following surgery resulting from trauma, infection, or other
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Illness in the involved part.
• Charges that are for plastic surgery, reconstructive surgery, cosmetic surgery or other services and supplies which
improve, alter or enhance appearance, whether or not for psychological or emotional reasons are not covered
expenses.
� Amniocentesis for pregnancy if it meets the following guidelines:
� If you or your covered spouse is thirty-five (35) years or older; and
� If under 35, you or your covered spouse has a previous afflicted child.
• Charges incurred for nursery care, routine pediatric care and circumcision are covered only for the first three (3) days
after birth in the case of a vaginal delivery and the first four (4) days after birth in the case of a caesarian delivery.
• Charges incurred for an elective abortion of a female participant or spouse, but not of a Dependent daughter. However,
the abortion will be covered in the case of incest or rape resulting in the pregnancy of a daughter under the age of
consent (based on the law of the state in which the daughter resides) or when the daughter is covered as a handicapped
child.
• Allergy testing, allergy injections, and allergy serums dispensed and/or administered at a physician’s office, and the
syringes necessary to administer them.
• Care, treatment and services furnished by a birthing center.
• Skeletal adjustments, manipulation or other treatment in connection with the detection and correction by manual or
mechanical means of structural imbalance or subluxation in the human body performed by a physician (as defined by
the Plan) to remove nerve interference resulting from, or related to, distortion, misalignment or subluxation of, or in,
the vertebral column. These changes are subject to limit of $1,000 per calendar year.
• Voluntary sterilization procedures shall be covered on the same basis as for any other illness for covered Employee
Partners and spouses only. Treatment, services and supplies for reversal or attempted reversal of sterilization are not
covered.
• Services and supplies (including room and board) furnished by a rehabilitation facility. The Covered Participant must
be under the continuous care of a physician and the attending physician must certify that the individual requires nursing
care 24 hours a day. Nursing care must be rendered by a registered nurse or a licensed vocational or practical nurse.
The confinement cannot be primarily for domiciliary, custodial, personal type care, care due to senility, alcoholism,
drug or substance abuse or dependency, blindness, deafness, mental deficiency, tuberculosis, or mental and nervous
disorders. This benefit shall not include charges for vocational therapy or custodial care.
• Treatment of Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD), including
associated diagnostic testing.
• Counseling services will be covered when rendered for a medical condition and performed by a Physician (as defined
by the Plan), including but not limited to: bereavement counseling and nutritional counseling for diabetics. • Oral contraceptives and other birth control methods (excluding birth control devices that are inserted) • Prenatal vitamins. � Coverage for the treatment of conditions arising from or related to substance abuse or chemical dependency or
alcoholism will be restricted to medical management of acute life-threatening intoxication in a hospital, but shall not include any treatment of the addiction or cause of substance abuse or any care after the acute life-threatening condition is alleviated.
Pregnancy
Pregnancy is covered on the same terms and conditions as any other illness under the Plan.
Health Care Facility Room and Board
Health Care Facility room and board, excluding any charges over the most common semiprivate room. A private room
rate will be paid only when required by the Health Care Facility for the safety of all patients. Charges for weekend
admissions are covered only if the weekend admission is Medically Necessary. Room and board in a Health Care Facility
guest room for the parents of a Participant under age 13 are covered if an overnight stay is recommended by a Physician
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and approved by the Plan Administrator.
Multiple Surgical Procedures
The Plan will determine which procedure among multiple surgical procedures will be considered as primary, secondary,
bilateral, add-on, or separate (incidental) procedures for the purposes of your benefits under the Plan. Specific surgical
procedures will be covered in accordance with the following schedule:
Type of Surgical Procedure Amount Covered
Primary procedure, bilateral primary Allowable Amount, or negotiated fee.
procedure, or add-on primary procedure.
Secondary procedure in same operative area. Limited to 50% of the Allowable
Amount, or 50% of negotiated fee.
Bilateral procedure in same operative area. Limited to 50% of the Allowable
Amount, or 50% of negotiated fee.
Add-on secondary procedure in Limited to 50% of the Allowable
same operative area. Amount, or 50% of negotiated fee.
Separate (incidental) procedure in same NOT COVERED
operative area as any of the above.
Separate operative area. Allowable amount, or negotiated fee.
Hospice Benefits
The following Hospice charges to meet the special physical, psychological, spiritual and social needs of a terminally ill
patient (less than one [1] year life expectancy as certified by the attending Physician) and the immediate family of such
patient are covered. The following Hospice charges for the terminally ill patient and his/her immediate family are eligible
for coverage: medical social services, emotional support services, homemaker services, physical therapy in the home, and
bereavement counseling services of a licensed social worker or licensed pastoral counselor for members of the immediate
family during a period of up to three (3) months following the death of the terminally ill individual. Charges are covered
at one hundred percent (100%) subject to limits outlined in the Schedule of Medical Benefits unless the case is managed
by a utilization firm qualified to provide case management and it is a recommended treatment by the utilization firm and
the attending Physician.
Skilled Nursing Facility
Confinement to a Skilled Nursing Facility is covered if it begins after a hospital confinement of three (3) or more days for
the same or a related cause and within fourteen (14) days after discharge from the hospital. This benefit requires the Third
Party Administrator approval. The daily room and board charge for each day of confinement is covered, up to the Skilled
Nursing Facility calendar year limit of $10,000.
Facility’s most common charge for its semiprivate rooms or the prevailing semiprivate charge in the area if the facility
does not have semiprivate rooms. The Skilled Nursing Facility’s other charges incurred for medical care on a day for
which room and board are covered.
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Women’s Cancer Right Act
In accordance with the Women’s Health and Cancer Rights Act of 1998, the Plan provides medical benefits as follows for
covered females who elect breast reconstruction due to a mastectomy:
• Reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and physical complications of all stages of mastectomy, including lymphedemas.
Medicaid
This Plan shall not take into account your eligibility or your Dependent’s eligibility for medical assistance or benefits
payable under a plan under 42 U.S.C. §1396 et seq. when you or your Dependents become enrolled in this Plan or when
payments are made under this Plan.
Qualified Medical Child Support Orders
Dependent coverage will be continued to the extent required by a Qualified Medical Child Support Order (“QMCSO”)
provided that you continue to meet the eligibility requirements of this Plan. A QMCSO is a court order or an
administrative order requiring the Plan and you to provide health coverage for your child. No order will be followed
unless and until it is determined by the Plan Administrator to be a QMCSO.
Upon request, you may obtain a copy of the Plan’s QMCSO procedures free of charge from the Plan Administrator
Organ and Tissue Transplantation
Living Transplant Donor: All services eligible for coverage for the Transplant Recipient are also eligible for coverage for the Transplant Donor, unless they are specifically excluded. Transplant Recipient: The following services may be eligible for coverage:
• Hospitalization for a covered transplant;
• Evaluation tests requiring hospitalization to determine the suitability of both potential and actual donors (tissue typing), when such tests cannot be safely and effectively performed on an outpatient basis;
• Hospital services, such as room and board, nursing services, surgical rooms, supplies, use of equipment, special care units (coronary and intensive care or private rooms for isolation purposes), and ancillary services;
• Physicians' services for surgery, technical assistance, administration of anesthetics, and medical care;
• Acquisition, preparation, transportation (within the United States and Canada), and storage*, including short term (as storage may be an exclusion under some member's contracts) of the organ or tissue;
• Diagnostic services; and
• Pharmaceuticals. NOTE: *Storage implies temporary, short-term storage for use in a patient already approved for an imminent transplant. However, the following elements that may be considered a part of an organ and tissue transplantation are not eligible for coverage. These elements are:
• Those services listed above when cost is reimbursed or funded by a governmental, foundation, or charitable grant;
• Organs sold rather than donated to the recipient;
• Donor search costs, including potential donor typing costs;
• Procedures, services, supplies, equipment and/or room use for the procurement or harvesting of organs or tissues from a cadaver donor*, if the donor was covered by another commercial health care carrier (not Blue Cross and Blue Shield of Texas) or the member's contract specifically excludes procurement coverage;
• An organ or tissue transplant from a species other than human, such as monkey bone marrow cells;
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• An artificial organ or tissue, whether temporary or permanent;
• Living and/or travel expenses of the living donor, recipient, and family members;
• Physician and hospital expenses related to maintenance of life for purpose of organ donation (This includes the travel time and related expenses required by a provider.);
• Any services provided to any individual who is not the recipient or actual donor; and,
• Long term storage costs for future possible anticipated transplantation, not scheduled or of time certain. NOTE: A cadaver donor* can never be covered by a contract as the contract ends at the time of death.
Family & Medical Leave Act
If you are eligible to take a FMLA Leave, your medical coverage will continue, provided you continue to pay your share
of the contributions.
A FMLA Leave of Absence is a leave of absence that you are entitled to take and do take in conformance with the rights
and requirements of the Family Medical Leave Act of 1993 and the family medical leave policy of the Company. To
determine if you are eligible for a family medical leave, see your Director of Club Accounting, Payroll Administrator, HR
Representative or refer to your Employee Partner Handbook. An FMLA Leave of Absence can be for a period totaling up
to 12 weeks (or 26 weeks with respect to leave to care for a qualifying exigency, as defined below) per year for specific
personal or family health and child care needs. A “qualifying exigency,” as defined under the FMLA, for military
reserves or National Guard in support of a “contingency operation” declared by the U.S. Secretary of Defense, President
or Congress, as required by law (“Military Emergency Leave”).
You may take up to a total of twenty-six (26) weeks of leave in a single 12-month period when the FMLA leave is to care
for a spouse, child, parent or next of kin (as defined under the FMLA) – who is an Armed Foreces member (including the
military reserves and national Guard) undergoing medical treatment, recuperation, or therapy, is otherwise in an outpatient
status, or is otherwise on the temporary disability retired list – with a serious injury or illness incurred in the line of duty
while on active duty that may render the individual medically unfit to perform his or her military duties (“Military
Caregiver Leave”).
Upon return to active service after an FMLA Leave, an Employee Partner who did not continue coverage during the
FMLA Leave shall be reinstated with the benefits that such Employee Partner had immediately prior to the FMLA Leave,
subject to any changes that took place affecting Employee Partners generally. An Employee Partner who did continue
coverage during the FMLA Leave and returns to active service shall be similarly reinstated, subject to any coverage
election changes made by the Employee Partner during the FMLA Leave of Absence.
When you notify the Company of your intention not to return from the FMLA Leave, coverage shall cease immediately.
In addition, the Company shall have the right to recover any contributions paid for your coverage during the FMLA Leave
unless failure to return is due to the continuation, recurrence, or onset of a serious health condition that entitles you to an
FMLA Leave or other circumstances beyond your control, as determined by the Plan Administrator in good faith.
Military Leave
The Plan provides health benefits for military leaves of absence taken in accordance with the Uniformed Services
Employment and Re-employment Rights Act.
Medical Plan Exclusions
While not intended to be exhaustive or complete, this section lists certain commonly claimed items that are not eligible for coverage under the Plan. The Plan does not cover charges:
• In excess of the Allowable Amount and charges for services performed, or materials furnished and tests which are not
31
considered Medically Necessary, or are considered inappropriate care by the Claims Administrator.
• Which are not Medically Necessary for the treatment of bodily injury sustained or sickness contracted.
• Resulting from accidental bodily injury or sickness arising out of or in the course of employment, caused directly or
indirectly by war, declared or undeclared, riot, by any act of war or service in the military, naval or air force of any
country or any civilian non-combatant unit serving with such forces or from a disease compensatory under any
Workers’ Compensation or Occupational Disease Act or Law.
• Resulting from alleged participation in or attempt to commit an assault or felony or an illegal act regardless of whether
formal charges are filed against the covered person, unless attributable to a physical mental health condition or
domestic violence.
• While confined in a hospital which is operated by or under the direction of the federal government or a hospital which
is operated by or under the direction of a state (where there could be no charges made were coverage not in force)
except as required by federal statutes.
• Charges incurred for routine eye examinations, except as stated in the “Medical Schedule of Benefits”, eye refractions
(except in connection with glaucoma treatment), contact lenses, or eyeglasses, or the fitting of either to the eye (unless
for a first pair of glasses or contact lenses which are necessary following eye surgery for a disease), orthoptics, or visual
therapy or radial keratotomy.
• Which are not performed or prescribed by a Physician (see page 7), or received from a registered nurse (R.N.) or
licensed practical nurse (L.P.N.) if not requiring the skill and training of an R.N.
• For travel for health purposes.
• For routine hearing tests, except as stated in the “Medical Schedule of Benefits.” However, hearing aids (including
charges for initial examination and fitting) are covered when necessary for correction of hearing loss because of an
accident, illness or congenital birth defect, if the coverage requirements are met. Only 1 pair of hearing aids shall be
covered every three years.
• Made by a close relative or person who normally lives in your household.
• Where a dependent would be entitled to benefits under the Plan by reason of having been covered as an Employee
Partner.
• Incurred for self-destruction, or any attempt there at, or any intentional, self-inflicted injury, unless attributable to a
physical mental health condition or domestic violence.
• For facial surgery (mandibular or maxillofacial) to correct growth defects, jaw disproportions or malocclusions.
• For appliances or restorations used solely to increase vertical dimension, reconstruct occlusion, or treat
temporomandibular joint dysfunction (TM or TMJ pain syndrome).
• For weight reduction, weight control or dietetic control, except as otherwise noted under “Covered Medical Expenses.”
• For services for which the person receiving them is not required to make payment, or where payment is received as the
result of legal action or settlement. (See page 33)
• For nonprescription drugs (over the counter).
• For infertility testing and diagnosis, artificial insemination, in vitro fertilization, sperm bank or embryo implantation or
sterilization reversal. However, the resulting pregnancy is not necessarily excluded.
• For custodial care, meaning care comprised of services and supplies, including room and board and other institutional
services primarily to assist in activities of daily living.
• For a Preexisting Condition. (See page 13)
• For any experimental service or supply. For example, autologous bone marrow transplant.
• For care through a home health agency or Skilled Nursing Facility that is:
not legally qualified (i.e., properly licensed) in the state or locality in which it operates;
where services are not supervised by a Physician; and
used primarily for custodial care of the aged, rest care (extended care facility) or mainly for treatment of mental,
nervous or emotional conditions (home health agency).
• Cosmetic surgery.
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• For treatment of academic or marital problems.
• Charges incurred for speech therapy, except for charges of a licensed speech therapist when specific problems are a
direct result of an illness or injury and only for the period that significant and measurable progress occurs.
• For charges for any prescription prescribed or ordered to treat a substance abuse or chemical dependency diagnosis,
except medical management of acute life threatening intoxication in a hospital until such acute life-threatening
condition is alleviated.
• For maternity expense for a dependent child other than for Complications of Pregnancy. (See Glossary of Terms). • For family planning, except office visits related to contraception. � For the care or treatment of substance abuse, chemical dependency or addiction, except for medical management of
acute life-threatening intoxication in a hospital to stabilize the individual and alleviate the life-threatening intoxication.
Termination of Coverage
Subject to COBRA rights, your coverage terminates under the Plan on the earliest of the date:
• You are no longer eligible for coverage;
• The Plan is terminated;
• Your club, resort or entity ceases to participate in the Plan;
• Required contributions are not made on a timely basis;
• Your Active Service ends unless you remain employed, but stop active work
because of:
• An approved non-medical leave of absence for a period not to exceed 90 days. You may continue coverage
providing payment of contributions remains timely.
• An approved medical leave of absence (i.e., workers’ comp, salary continuation or long-term disability) or FMLA
Leave of Absence. You may continue coverage for up to six months providing payment of contributions remains
timely. If the leave is covered by FMLA, you may continue coverage for the period of covered leave, provided your
payment of premium remains timely.
• The date the Plan Administrator determines you have a fraudulent claim.
Coverage for your dependents under the Plan terminates on the earliest of:
• The date your coverage terminates;
• The date your dependent is no longer eligible for coverage;
• The date the Plan is terminated; or
• The date required contributions are not made on a timely basis
Once you or your dependent’s coverage has ended and the Plan Administrator has been notified, you will receive a
certificate of Creditable Coverage which provides information about your specific coverage under this Plan.
If you remain employed and you and/or your dependents drop coverage, you will not be able to re-enter the Plan, until the
Annual Open Enrollment Period or you qualify for Special Enrollment. (See Glossary of Terms)
See Continuation of Coverage section (page 34) for your COBRA rights.
33
Coordination of Benefits
You may be covered by more than one group medical plan. If so, the Plan has a provision which clarifies how benefits are paid.
Since it is not intended that greater benefits be paid than actual expenses incurred, the amount of benefits payable under
the Plan may be affected by any benefits payable by other plans under which you are covered. In a calendar year, the Plan
always pays either its regular benefits in full, or it will pay a reduced amount, which, when combined with the benefits
payable by the other plan or plans, will equal what the Plan would have paid had it been the primary plan.
Primary Plan
To determine whether the regular benefit payable under the Plan will be reduced, it is necessary to determine the order in
which the various plans pay benefits. This is generally determined as follows:
• A plan with no provision for coordination of benefits pays its benefits before a plan which contains such provision. The
plan that pays first is called the “primary plan.” The plan which pays second is called the “secondary plan.”
• Employee Partners and Spouses:
• A plan which covers the person other than as a dependent is the primary plan and pays its benefits first. The plan that
covers that person as a dependent pays its benefits second.
• A plan which covers the person as an active Employee Partner pays its benefits before a plan that covers the person
as a retired Employee Partner or a laid-off Employee Partner.
• Children: If a child is covered for benefits by both parents, the following rules apply:
• The plan of the parent who was born earlier in the calendar year pays first, and the other parent’s coverage pays
second. If both parents have the same birthday, the plan of the parent who has been covered longer pays first. This is
known as the “birthday rule.”
• If the child’s parents are separated or divorced and there is a court decree that makes one parent responsible for the
health care expenses of the child(ren), that parent’s plan pays first.
• If the child’s parents are separated or divorced and there is no court decree:
• The benefits of a dependent child of separated or divorced parents (who have not remarried) are paid by the plan
covering the child as a dependent of the parent with custody prior to the plan of the parent without custody.
• Benefits of the plan covering the dependent child of a remarried parent with custody are paid by that parent’s plan.
Benefits are then paid by the plan covering the child as a dependent of a step-parent. And finally, benefits are paid
by the plan covering the child as a dependent of the natural parent without custody.
When the rules above do not establish the order of payment, the plan under which the person has been covered for the
longer period of time pays its benefits before the plan which has covered the person for the shorter period of time. In
addition, the laws governing Medicare, Medicaid and CHAMPUS will be followed, not withstanding the rules described
above.
Subrogation By accepting benefits under this Plan you agree to (1) cooperate with the Plan in its efforts for reimbursement of benefits
paid upon settlement with or judgment against a third party and (2) that if you or your covered dependents seek damages
from a third party, the Plan must be reimbursed for the benefit it has paid to or for you or your covered dependent out of
any proceeds you or your covered dependent receives. By accepting benefits under this Plan you agree that you and your
covered dependents shall agree to execute any subrogation agreement requested by the Plan and agree to pursue or permit
34
the Plan to pursue in your place any recovery that may be available to you for a claim for an injury or illness from a third
party or insured. The Plan shall have an equitable lien of the first priority on any proceeds you or your covered
dependents receive. You and your covered dependents shall hold any proceeds you receive in a constructive trust for the
benefit of the Plan.
Filing A Claim
Claim filing is not required for PPO claims. The provider will file all claims.
Limitation on filing a claim
Claims must be filed within twelve months of the date the expense was incurred except that the Health Care
Financing Administration shall have the minimum time period required by law to seek recovery of a mistaken
payment made by Medicare as the Primary Plan when this Plan should have been primary regardless of this Plan’s
one year claim filing period. Failure to do so will forfeit payment.
How to File a Claim
When you file a claim, use the following procedures, attaching the required information as outlined below:
• Complete all the information requested on the claim form. Be sure to submit a separate claim form for each family
member receiving treatment.
• Attach your itemized bill to the claim form. Your Physician or dentist does not need to complete the claim form as all
information should appear on the itemized bill.
• If another insurance company is the primary plan, it is necessary for you to submit your claim to that insurance
company first. Be sure to include the primary insurance company’s Explanation of Benefits (EOB) when you submit
your claim.
• If you have prescription drug expenses, attach your itemized original receipt to the claim form.
How to Obtain Claim Forms
For Medical Plan claims, call Blue Cross and Blue Shield of Texas at 1-800-521-2227.
Where to Send Completed Claim Forms
Mail your medical claim forms to:
Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044
Continuation of Coverage
COBRA is a temporary extension of coverage under a group health plan. The right to COBRA continuation coverage was created by federal law called the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it.
The Plan Administrator (see the end of this section or page 39 for Plan Administrator information) is responsible for
administering COBRA continuation coverage.
35
COBRA Continuation Coverage COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” COBRA continuation coverage must be offered to each person who is a “qualified beneficiary”. A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, Employee Partners, spouses of Employee Partners and dependent children of Employee Partners may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an Employee Partner, you will become a qualified beneficiary if you lose your coverage under the Plan because
either one of the following qualifying events happens:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.
• An employer from whose employment you retired from is involved in a bankruptcy proceeding
If you are the spouse of an Employee Partner, you will become a qualified beneficiary if you lose your coverage under the
Plan because any of the following qualifying events happens:
• Your spouse dies;
• Your spouse’s hours of employment are reduced;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes enrolled in Medicare;
• Your spouse’s employer from whose employment he/she retired from is involved in a bankruptcy proceeding; or
• You become divorced or legally separated from your spouse. In the event your spouse eliminates or reduces your
coverage in anticipating of a divorce or legal separation, there will be no coverage (or if applicable, reduced
coverage) between the time of the elimination or reduction and the time of the qualifying event. However, your
COBRA continuation coverage may begin at the time of the qualifying event.
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the
following qualifying events happens:
• The parent-Employee Partner dies;
• The parent-Employee Partner’s hours of employment are reduced;
• The parent-Employee Partner’s employment ends for any reason other than his or her gross misconduct;
• The parent-Employee Partner becomes enrolled in Medicare;
• The parent-Employee Partner’s employer from whose employment he/she retired from is involved in a
bankruptcy proceeding; •
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the plan as a “dependent child”.
36
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been
notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours
of employment, death of the Employee Partner, or enrollment of the Employee Partner in Medicare, the Employer must
notify the Plan Administrator of the qualifying event within 31 days of any of these events.
For the other qualifying events (divorce or legal separation of the Employee Partner and spouse or a dependent
child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator. The Plan
requires you to notify the Plan Administrator within 60 days after the qualifying event occurs. You must send this
written notice (by hand delivery or postmarked) to the Plan Administrator. If notice is not sent to the Plan Administrator
within 60 days after the later of the qualifying event or the date coverage for the spouse (or former spouse) or dependent
children would end on account of the qualifying event, the group health plan will not offer COBRA continuation
coverage.
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be
offered to each of the qualified beneficiaries. For each qualified beneficiary who elects COBRA continuation coverage,
COBRA continuation coverage will begin on the date of the qualifying event.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is death of the
Employee Partner, enrollment of the Employee Partner in Medicare, your divorce or legal separation, or a dependent child
losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months.
When the qualifying event is the end of employment or reduction of the Employee Partner’s hours of employment,
COBRA continuation coverage lasts for up to 18 months. There are two ways in which this 18-month period of COBRA
continuation coverage can be extended.
When the qualifying event is that the employer is involved in bankruptcy proceedings, the Employee Partner and covered
dependents may elect to continue coverage until the Employee Partner’s death. If the Employee Partner dies while
covered under continuation coverage, then COBRA coverage for the dependents ends 36 months from the date of the
Employee Partner’s death.
Disability Extension of 18-month Period of Continuation Coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled
at any time during the first 60 days of COBRA continuation coverage, and you notify the Plan Administrator in a timely
fashion, you and your entire family can receive up to an additional 11 months of COBRA continuation coverage, for a
total maximum of 29 months. You must make sure that the Plan Administrator is notified of the Social Security
Administration’s determination within 60 days of the date of the determination and before the end of the 18-month
period of COBRA continuation coverage. This written notice must be sent (by hand delivery or postmarked) to the
Plan Administrator. If the notice is not sent to the Plan Administrator within 60 days after the determination date and
before the expiration of the 18-month period of COBRA continuation coverage, the Plan will not offer an extension of
COBRA coverage.
Second Qualifying Event Extension of 18-month Period of Continuation Coverage
If your family experiences another qualifying event while receiving COBRA continuation coverage, the spouse and
dependent children in your family can get additional months of COBRA continuation coverage, up to a maximum of 36
months. This extension is available to the spouse and dependent children if the former Employee Partner dies, enrolls in
Medicare or gets divorced or legally separated.
37
The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent
child. In addition, the extension is available to the spouse and dependent children of an Employee Partner who enrolls in
Medicare before termination of employment or hours of employment are reduced. This extension will end on the later of
36 months after the covered Employee Partner became entitled to Medicare benefits, or the end of the 18/29-month period
of COBRA continuation coverage. In all of these cases, you must make sure that the Plan Administrator is notified
of the second qualifying event within 60 days of the second qualifying event. This written notice must be sent (by
hand delivery or postmarked) to the Plan Administrator. If the notice is not sent to the Plan Administrator within 60 days
after the later of the date of the second qualifying event or the date coverage for the spouse or dependent children would
end on account of the initial qualifying event, the Plan will not offer an extension of COBRA continuation coverage.
Cost of Continuation Coverage
The qualified beneficiary must pay the total cost of COBRA continuation coverage. This cost will be 102% of the cost of
identical coverage for similarly situated participants. If a qualified beneficiary is disabled and elects an additional 11
months of continuation coverage, the cost for the additional 11-month period of COBRA coverage for the disabled
qualified beneficiary and any dependents will be 150% of the cost of identical coverage for similarly situated participants.
The initial premium must be paid within 45 days after the date the qualified beneficiary elects COBRA
continuation coverage. Subsequent contributions must be paid monthly, with a 30-day grace period. The Plan
Administrator will advise you of the monthly payment date. Payment is considered made on the date the payment is sent
(by hand delivery or postmarked) to the Plan Administrator.
Special COBRA Subsidy
You may be entitled to a subsidy of a portion of your COBRA premium if you were involuntarily terminated between
September 1, 2008 and December 31, 2009, or such later deadline if the duration is extended by legislation. The subsidy
of a portion of your COBRA continuation coverage premium, if you are eligible, will continue for the lesser of: (1) 9
months, (2) until the date the COBRA coverage would have expired had you elected COBRA coverage at the time of
your original COBRA election period, or (3) until the event specified in the section entitled “Terminating COBRA
Coverage” below.
Terminating COBRA Coverage
Generally, continuation coverage terminates at the end of the initial 18/29/36 -month period of continuation coverage.
However, continuation coverage may end before the expiration of the 18/29/36 - month continuation period for any of the
following reasons:
• The Employer no longer offers a group health plan to any of its Employee Partners;
• The premium for continuation coverage is not timely paid;
• After electing continuation coverage, the qualified beneficiary becomes covered under another group health plan,
unless a pre-existing condition limitation or exclusion applies to the qualified beneficiary;
• An additional 11 months of continuation coverage was elected on account of a disability and the qualified
beneficiary is determined to no longer be disabled;
• After electing continuation coverage, the qualified beneficiary first becomes enrolled in Medicare; or
• Termination for cause (for example, misrepresentation in a claim for benefits).
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If You Have Questions
If you have questions about your COBRA continuation coverage, you should contact:
1. The Plan Administrator: ClubCorp Benefits, 3030 LBJ Freeway, Suite 600, Dallas, TX 75234 or (972) 243-
6191; or Health Care Service Corporation, COBRA Administrator, at 1-888-541-7107; OR
2. The nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available
through EBSA’s website at www.dol.gov/ebsa.
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses
of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Important Plan Information
Assignments: The coverage and benefits provided under the Plan are not assignable without the Company’s consent.
Misstatements: If any facts relevant to the existence or amount of coverage is misstated, the true facts determine whether
or not, and how much, coverage is in force.
Change or discontinuance of Plan: The Plan may be amended or terminated, in whole or in part, at any time by
ClubCorp International, Inc. If an individual incurs a claim payable under this Plan before this Plan is amended or
terminated, the individual will be entitled to the benefits under this Plan for only those expenses incurred before
amendment or termination. If the Plan is amended to improve benefits, the amendment will only apply to individuals who
are entitled to benefits after the effective date of the amendment unless the amendment specifies otherwise.
Plan Document: This booklet describes only the principal features of the Plan and the Pretax Premium Plan and should
not be considered the Plan documents. The complete terms of the Plans are set forth in the Plan documents adopted by the
Company, and if there is any difference between the information in this booklet and the Plan documents, the Plan
documents prevail. In the event of any question regarding the interpretation of the booklet or the proper payment of
benefits, further information may be obtained from the Plan Administrator and you may review the Plan documents.
Multiple coverage: You will not be eligible for multiple coverage under the Plan if you are in the employ of, or
connected with, two or more participating employers.
Plan name: ClubCorp Health Benefits Plan
Type of Plan: A welfare plan providing medical benefits.
Employer identification number (plan sponsor): 75-2778488
Plan number: 501
Plan sponsor: ClubCorp, Inc.
3030 LBJ Freeway, Suite 600
Dallas, Texas 75234
(972) 243-6191
39
Employers: A complete list of the participating clubs and resorts is available on written request to the Plan Administrator
and is available for examination by participants at the Company during normal business hours.
Plan Administrator: ClubCorp Benefits
Department of ClubCorp, Inc.
P. O. Box 819012
Dallas, Texas 75381
(972) 243-6191
Service of legal process may be made on the Plan Administrator at the above address.
Claims Administrator: Blue Cross and Blue Shield of Texas for the Medical Plan. While Blue Cross and Blue Shield
of Texas adjudicates the claims, the Plan is self-insured and the Employee Partners’
contributions and the Company fund the payment of claims.
Plan year: The Plan Year for the Plan begins on January 1 and ends on the following December 31.
Type of administration: This Plan is administered by the Plan Administrator with the help of a Claims Administrator,
with whom you should file all claims (see page 34 for information about how to obtain claim forms).
Mail your medical claim forms to:
Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044
Funding: This Plan is self-funded by Employee Partners and the Company and not by insurance. All Employee Partner
contributions to the Plan are kept in a separate bank account maintained by the Plan Sponsor.
Circumstances Resulting in Loss or Reduction of Benefits
There are circumstances, which may result in ineligibility or in denial, loss, suspension, offset, reduction or recovery of
your benefits that you might reasonably expect the Plan to provide. These circumstances include, but are not limited to:
• Subrogation, reimbursement and third party recovery rights of the Plan;
• Coordination of benefits when you or your dependents are enrolled in more than one plan and this Plan is not the
primary plan;
• Possible reductions when private hospital rooms are used and for certain multiple surgical procedures;
• reductions due to charges that exceed usual and customary allowances;
• reductions or denials due to services that are not generally accepted as appropriate, and/or which are not medically
necessary, and/or which are considered as over utilization;
• treatment, services and supplies that are excluded from coverage by the Plan, whether or not medically necessary;
• non-compliance with the Plan’s certification requirements;
• non-compliance with the Plan’s claims filing deadline.
40
ERISA Information
General Information
Primary responsibility for the administration of the Plans is placed with the Plan Administrator. The Plan Administrator
may designate responsibilities for the operation and administration of the Plan as deemed appropriate.
Claims for benefits from the Plans must be filed with the Claims Administrator. Forms may be obtained by calling People
Strategy Benefits at 1-800-800-4615.
Claims and Review Procedures
Claims Procedure for Medical Benefits
Pre-Service Claims
Urgent Care Claims: If you (“claimant”) or your duly authorized representative, as determined by the Claims
Administrator, files a “pre-service claim” which is a “urgent care claim” under the Plan, the Claims Administrator shall
notify the claimant of the benefit determination as soon as possible, taking into account the medical exigencies, but not
later than 72 hours after receipt of the claim unless the claimant fails to provide sufficient information for the Plan to
make a determination. A “pre-service claim” means any claim for medical benefits under the Plan with respect to which
the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of
obtaining medical care. A “urgent care claim” is any claim for medical care or treatment with respect to which the
application of the time periods for making non-urgent care determinations:
Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe
pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
If the information received by the Claims Administrator is insufficient for the Plan to make a determination, the Claims
Administrator shall notify the claimant as soon as possible, but not later than 24 hours after receipt of the claim of the
specific information necessary to complete the claim. In such case, the claimant shall be afforded at least 48 hours to
provide the specified information. The Claims Administrator shall notify the claimant of the Plan’s determination as soon
as possible, but in no case later than 48 hours after the earlier of:
• the Claim’s Administrators receipt of the specified information; or
• the end of the period afforded the claimant to provide the specified additional information.
The Claims Administrator may notify the claimant of the Plan’s decision orally within the applicable 48 hour time period
described above; provided, however, that in the case of oral notification, the Claims Administrator shall provide written or
electronic notification to the claimant not later than three (3) days after the oral notification. Otherwise, the Claims
Administrator must notify the claimant by written or electronic notification within the applicable 48 hour time period
described above. All notices shall be either written or electronic.
Non-Urgent Care Claims: A person or his duly authorized representative, as determined by the Claims Administrator,
may file a written claim with the Claims Administrator for a determination of benefits for a “pre-service claim” that is not
a “urgent care claim.”
41
The Claims Administrator will notify the claimant of the Plan’s decision. Notification of a claim denial will be given
within a reasonable time, but not later than fifteen (15) days after the claim is received by the Claims Administrator. If
the claimant does not receive written notice that the claim has been denied within the initial fifteen (15) day period, or
prior to the expiration of an extension period, if applicable, the claim will be deemed to have been denied as of the last
day of such period, and the claimant may request a review of his claim.
Failure to Follow Pre-Service Claims Procedures: If a person or his duly authorized representative, as determined by
the Claims Administrator, submits the claimant’s name, specific medical condition, and specific treatment, service or
product to a person or unit customarily responsible for handling benefits matters, but fails to follow the Plan’s procedures
for pre-service claims, the claimant shall be notified of the failure and the proper procedures to be followed in filing a
claim for benefits. This notification shall be provided to the claimant, as soon as possible, but not later than five (5) days
(24 hours in the case of a failure to file a urgent care claim) following the failure. Notification may be oral unless written
notification is requested by the claimant.
Concurrent Care Claims
A person or his duly authorized representative, as determined by the Claims Administrator, may file a claim with the
Claims Administrator for a determination of benefits for “concurrent care.” “Concurrent care” means any ongoing course
of treatment approved by the Plan to be provided over a period of time or number of treatments.
Non-Urgent Care Claim: If there is any reduction or termination by the Plan of concurrent care (other than by plan
amendment or termination) before the end of such approved period of time or number of treatments which does not
involve an urgent care claim, the Claims Administrator will notify the claimant of such reduction or termination in writing
or electronically within a reasonable period of time not less than fifteen (15) days before any such reduction or
termination.
Urgent Care Claim: If a claimant makes a request to extend the course of treatment beyond the period of time or
number of treatments for a urgent care claim, the Claims Administrator shall make a claim determination as soon as
possible, taking into account the medical exigencies, but not later than 24 hours after receipt of the claim by the provided
that any such claim must be made at least 24 hours prior to the expiration of the prescribed period of time or number of
treatments.
The Claims Administrator may notify the claimant of its decision orally within the 24 hour time period described above;
provided, however, that in the case of oral notification, the Claims Administrator shall provide written or electronic
notification to the claimant not later than three (3) days after the oral notification. Otherwise, the Claims Administrator
must notify the claimant by written or electronic notification within the 24 hour time period described above.
Post-Service Claims
If any person believes that he is being denied any rights to benefits under the Plan for a “post-service claim,” such person
or his duly authorized representative may file a written claim with the Claims Administrator. “Post-service claim” means
any claim for medical benefits under the Plan which is not a “pre-service claim” as defined above.
Notification of a claim denial will be given within a reasonable time, but not later than thirty (30) days after the claim is
received by the Claims Administrator. If the claimant does not receive written notice that the claim has been denied within
the initial thirty (30) day period, or prior to the expiration of an extension period, if applicable, the claim will be deemed
to have been denied as of the last day of such period, and the claimant may request a review of his claim.
42
Extensions in the Case of Initial Determinations of Post-Service Claims and Non-Urgent Pre-Service Claims
For post-service claims and non-urgent pre-service claims, the claim denial time period may be extended once for up to
fifteen (15) days, provided that the Claims Administrator both determined (i) that such extension is needed and beyond the
Claims Administrator’s control and (ii) notifies the claimant prior to the expiration of the initial fifteen (15) day period of
the circumstances requiring the extension of time and the date the Claims Administrator expects to render a decision. If
such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the
notice of extension, shall specifically describe the required information, and the claimant shall be afforded at least forty-
five (45) days from receipt of the notice within which to provide the specified information. The benefit determination
period shall be put on hold from the date of the notice of extension until the earlier of (i) the date the claimant responds to
the request for additional information, or (ii) the last day of the forty-five (45) day period. Once the claimant has provided
the additional information or, if earlier, the forty-five (45) day period has ended, the benefit determination period shall
recommence.
The claimant and the Claims Administrator may extend any claim filing deadline by mutual written consent.
Notification Requirements
If any claim is wholly or partially denied, the notification will be set forth in a manner calculated to be understood by the
claimant and must contain: (i) the specific reason or reasons for the adverse determination, (ii) the specific reference to
Plan provisions on which the determination is based, (iii) a description of any additional material or information necessary
for the person to perfect his claim and an explanation of why such material or information is necessary, (iv) information as
to the steps to be taken if the claimant wishes to submit a request for review, including applicable time limits and the
claimant’s right to bring a civil action under section 502(a) of ERISA. If the benefit determination was adverse, the
notification must also contain any internal rule, guideline, protocol or other similar criterion (collectively “Protocols”) that
were relied upon in making the adverse determination and that a copy of such Protocols will be available to the claimant,
free of charge, upon his request. For medical claims only, if the benefit determination is based on a medical necessity or
experimental treatment or similar exclusion or limit, the notification must also contain either (A) an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan, as applicable, to the claimant’s
medical circumstances, or (B) a statement that such explanation will be provided free of charge upon request. For all
urgent claims for medical benefits, the notification must also contain a description of the expedited review process
applicable to such claims.
Review Procedures
Time Period for Review
Within one hundred and eighty (180) days after the date that the claimant receives notice of a claim denial for medical
benefits under the Plan, or if applicable, within one hundred and eighty (180) days after the date on which such denial is
deemed to have occurred, the claimant or his duly authorized representative may file a written request to review a denied
claim.
For concurrent claims, the claimant or his duly authorized representative may file a written request with the Claims
Administrator for a review of a denied claim on or before the date benefits are reduced or terminated. Such request must
be filed within a reasonable time before a concurrent claim benefit is reduced or terminated.
The claimant may request an expedited review of an urgent care claim by contacting the Claims Administrator orally or in
writing if an urgent care claim has been wholly or partially denied. If the claimant requests an expedited review, all
necessary information, including the Plan’s benefit determination on review, shall be transmitted expeditiously to the
claimant.
43
Review Standards
In order for a claimant to pursue his rights as explained in the “Rights After Appeal” section below, he must first exhaust
his administrative remedies as described in this section.
The claimant and/or his authorized representative may inspect or request, free of charge, relevant documents and submit
written comments, documents, records, and other information to the Claims Administrator for review of his claim. The
review of the claimant’s appeal shall be reviewed without affording deference to the initial adverse benefit determination
and will not be conducted by the individual who made the initial review, nor a subordinate of such individual. If a
decision is based in whole or part on a medical judgment, the appropriate person(s) determining the appeal shall consult
with a healthcare professional (not consulted in the initial claim that is being appealed nor a subordinate of such
healthcare professional) who has appropriate training and experience in the field of medicine involved in the medical
judgment and shall provide the claimant with such information regarding such health care professionals as as appropriate.
The claimant shall be provided with the identification of medical or vocational experts who were consulted for the appeal,
without regard to whether the expert’s advice was relied upon in the benefit determination.
Notification of Decision on Review
The Claims Administrator will notify the claimant of the Plan’s decision. If an expedited method such as telephone
notification is used, it must be followed up with written or electronic transmission of the Plan’s decision. Electronic
notification shall comply with standards imposed by the Claims Administrator consistent with applicable guidance. This
written or electronic notification can be included as part of the expedited method used as provided above (for example, if
facsimile transmission is used). Notifications will be set forth in a manner calculated to be understood by the claimant
and will contain: (i) the specific reason or reasons for the denial, (ii) specific references to Plan provisions on which the
benefit determination is based, (iii) a statement that the claimant is entitled to receive, upon request and free of charge,
reasonable access to and copies of all material and required information relevant to the claim for benefits, (iv) a statement
describing any voluntary appeals offered by the Plan, including information concerning the procedures of the voluntary
appeal that would allow the claimant to make an informed decision about whether to appeal and such other information
that is appropriate regarding alternative dispute resolution options, (v) a statement of the claimant’s right to bring an
action under section 502(a) of ERISA, (vi) a description of the Protocols, if any, used to make the decision and that a copy
of the Protocols will be available free of charge upon request, (vii) a statement that an explanation of the clinical and
scientific judgment used in making the determination will be available free of charge upon request by the claimant, and
(viii) the statement:
One way to find out what may be available is to contact your local U.S. Department of Labor Office.
Response Dates on Appeal
For an urgent, pre-service claim, the decision on review will be made as soon as possible, taking into account the medical
exigencies, but not later than 72 hours after receipt of the claimant’s request for review. If the claimant does not receive
notice of the decision within the 72 hour period, the claim shall be deemed to have been denied on review.
For a non-urgent, pre-service claim, the decision will be made within fifteen (15) days after the request for review is
received. If the claimant does not receive notice of the decision within the fifteen (15) day period, the claim shall be
deemed to have been denied on review.
For concurrent claims, the decision on review will be made before the concurrent claim benefit is reduced or terminated.
44
For a post-service claim, the decision on review will be made within thirty (30) days after the request for review is
received. If the claimant does not receive notice of the decision within the thirty (30) day period, the claim shall be
deemed to have been denied on review.
Rights After Appeal
If the claimant has exhausted his administrative remedies described in the “Review Procedures” section above and is
dissatisfied with the decision on the review, the claimant has the right to file suit in a federal or state court, which suit
must be filed within twelve (12) calendar months immediately following the date of such adverse benefit determination.
No action may be brought for benefits provided by this Plan or to enforce any right hereunder until after a claim has been
submitted to the Plan and all appeal rights under the Plan have been exhausted. All claims under this must be appealed
before any suit for benefits may be filed by the claimant in federal or state court. Thereafter, the only action which may
be brought is one to enforce the decision of the Plan. The claimant’s beneficiary should follow the same claims procedure
in the event of the claimant’s death.
The Plan Administrator with the advice of the Claims Administrator shall be the final authority for all adverse benefit
determinations on appeal made by the Plan.
Your ERISA Rights
As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to:
Receive Information About Your Plan and Benefits
Examine, without charge, at the Plan administrator’s office and at other specified locations, such as worksites and union
halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of
the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public
Disclosure Room of the Employee Benefits Security Administration.
Obtain, upon written request to the Plan administrator, copies of documents governing the operation of the Plan, including
insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and
updated summary plan description. The administrator may make a reasonable charge for the copies.
Receive a summary of the Plan’s annual financial report. The Plan administrator is required by law to furnish each
participant with a copy of this summary annual report.
Continue Group Health Plan Coverage
Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of
a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description
and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if
you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of
charge, from your group health plan or health insurance issuer when you lose coverage under the Plan, when you become
entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before
losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you
may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment
date in your coverage.
45
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the
operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to
do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer,
your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from
obtaining a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done,
to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time
schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan
documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal
court. In such a case, the court may require the Plan administrator to provide the materials and pay you up to $110 a day
until you receive the materials, unless the materials were not sent because of reasons beyond the control of the
administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, and you do not agree with
the decision and you have used all of your appeal rights under the Plan, you must file suit in a state or Federal court to
dispute the denial any further. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified
status of a domestic relations order or a medical child support order, and you have used all of your appeal rights under the
Plan, you must file suit in Federal court to dispute the denial any further. If it should happen that Plan fiduciaries misuse
the Plan’s money, or if you are discriminated against for asserting your rights and you have exhausted the Plan’s claim
and appeal process, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court.
The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you
have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it
finds your claim is frivolous.
Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan administrator. If you have any questions about this
statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan
administrator, you should contact the nearest office of the Benefits Security Administration, U.S. Department of Labor,
listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also
obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the
Employee Benefits Security Administration.