welcome to amerihealth new jersey€¦ · you and your covered dependents will each receive an...

amerihealthnj.com 1 888-968-7241

HOW YOUR HEALTH PLAN WORKS

WELCOME TO AMERIHEALTH NEW JERSEY

Everything you need to know about your health plan


How your health plan works

Welcome to AmeriHealth New Jersey 4

Introduction to your health plan 5

What is a primary care physician?

Using your ID card

How to receive care 6

Scheduling an appointment

Referrals

Locating a physician or hospital in your network

Using your preventive care benefits

Wellness guidelines 7

Using services that require preapproval and

precertification

Receiving services for mental health or substance

abuse treatment

Care outside normal business hours 8

Emergency care

Urgent care

Retail health clinics

Telemedicine with MDLIVE

Health insurance that’s mobile 9

Using your prescription benefits 10 - 13

AmeriHealth New Jersey Prescription Drug Program

How to fill your prescription at a retail pharmacy

Participating pharmacies

Understanding your prescription

Select Drug Program

Preventive drugs for adults and children

Mail order

Self-Administered Specialty Drug Coverage

Organ and Tissue Donation 14

Member support 15


Welcome to AmeriHealth New Jersey

Our goal at AmeriHealth New Jersey is to provide you with health care coverage that can help you live a healthy life.

This kit will help you understand your benefits so that you can take full advantage of your membership.

To get the most from your coverage, it’s important to become familiar with the benefits and services available to you.

You’ll find valuable information in this kit on:

• how to use your ID card

• what services are covered and are not covered by your health insurance

• how decisions are made about what is covered

• how to use amerihealthexpress.com

• how to get in touch with us if you have a problem

Register for amerihealthexpress.com, and download the free AmeriHealth New Jersey app, AHNJ On the Go, for

easy access to your health information 24/7.

If you have any questions, feel free to call Customer Service at 888-YOUR-AH1 (888-968-7241) and we will be

happy to assist you.

Thank you for being an AmeriHealth New Jersey member. We look forward to providing you with quality health care

coverage.


Introduction to your health plan

What is a primary care physician?

A primary care physician (PCP) helps coordinate the overall medical care for you and your covered dependents.

Your PCP is the doctor that will treat you for your basic health care needs.

Anytime you need to see a specialist, such as a cardiologist or dermatologist, your PCP may refer you to a specialist

participating in the network. PCPs may choose a radiology, physical therapy, or laboratory site to which they refer

their patients. If you need a service your PCP doesn’t provide, such as diagnostic testing or hospitalization, your PCP

may refer you to an in-network facility.

How to search for PCP (HMO, HMO Plus or POS plan members only):

Visit amerihealthnj.com/providerfinder where you can search by specialty (e.g. internal medicine

or pediatrics), location, gender preference, and/or distance.

How to choose or change your PCP (HMO, HMO Plus or POS plan members only):

There are two ways to choose or change your PCP:

• Online: To select or change your doctor, visit amerihealthexpress.com, our simple,

convenient, and secure member website.

• Phone: Call 888-YOUR-AH1 (888-968-7241) and one of our Customer Service associates

will make your PCP selection over the phone.

Please note: POS Plus, PPO or EPO plan members do not need to select a PCP; however it is always recommended that you consult and

seek non-emergency care from your PCP.

Using your ID card

You and your covered dependents will each receive an AmeriHealth New Jersey identification (ID) card. It is

important to take your ID card with you wherever you go because it contains information including what to pay when

visiting your doctor, specialist, or the emergency room (ER). You should present your ID card when you receive care,

including doctor visits or when checking in at the ER.

The back of your ID card provides information about medical services, what to do in an emergency, and how to use your benefits. If any information on your ID card is incorrect, you misplace an ID card, or need to print out a temporary ID card, you may do so through amerihealthexpress.com or by calling 888-968-7241. A digital copy of your ID card is also available on the AHNJ On the Go app.

Questions? Call

888-YOUR-AH1

(888-968-7241)

http://www.amerihealthnj.com/provider_finder


How to receive care

Scheduling an appointment Simply call your doctor’s office and request an appointment. If possible, notify your doctor 24 hours in advance if you

are unable to make it to a scheduled appointment.

Referrals

If you have an HMO or POS plan, you are required to get a referral from your PCP for certain specialty services. You

may check the status of a referral by logging on to amerihealthexpress.com, or on your mobile device through

AHNJ On the Go.

Please note: referrals are not required for members with HMO Plus, POS Plus, EPO or PPO plans; however, it is always recommended that

you consult and seek non-emergency care from your PCP.

Locating a physician or hospital in your network

You have access to our expansive provider network of physicians, specialists, and hospitals. You may search our

provider network by going to amerihealthnj.com/providerfinder and selecting your network and plan from the drop-

down list.

Informative doctor and hospital profiles and nationally recognized quality measurements help you find the doctor that

is right for you. The profiles offer more than just location and phone number. They also show credentials, network

and hospital affiliations, office hours, as well as gender, specialty, language and those who are accepting new

patients. You may also call 888-968-7241 and a Customer Service associate will help you locate a provider.

Using your preventive care benefits

Quality care and prevention are vital to your long-term health and well-being. That’s why we

cover 100% of certain preventive services, including, but not limited to:

• Screenings for:

- breast, cervical, and colon cancer - vitamin deficiencies during pregnancy - diabetes - high cholesterol - high blood pressure

• Routine vaccinations for children, adolescents, and adults as determined by the CDC

• Women’s preventive health services, such as: - well-woman visits (annually) - screening for gestational diabetes - human papillomavirus (HPV) DNA testing - counseling for sexually transmitted infections - counseling and screening for human immunodeficiency virus (HIV) - screening and counseling for interpersonal and domestic violence - breastfeeding support, supplies (breast pumps), and counseling - generic formulary contraceptives, certain brand formulary contraceptives, and FDA-approved over-the-

counter female contraceptives with a prescription

Be sure to consult with your PCP for preventive services and/or screenings.

Quality care and

prevention are vital to

your long-term health

and well-being.

http://www.amerihealthnj.com/providerfinder


Wellness guidelines One of the best ways to stay well is to utilize the preventive services covered by your health plan. Our Wellness

Guidelines are a list of evidence-based wellness recommendations for the average-risk person. These

recommendations are not a statement of benefits and should not be confused with Preventive Care Benefits

identified under Health Care Reform. Some of these services may require cost-sharing. To download our Wellness

Guidelines, log on to amerihealthexpress.com or call 888-968-7241 to request a hard copy.

Using services that require preapproval and precertification

Certain services may require preapproval prior to receiving care to ensure that the services you seek are medically

necessary. Learn more at amerihealthnj.com/precert.

Receiving services for mental health or substance abuse treatment

Magellan Behavioral Health administers your mental health and substance abuse benefits. They can be reached by

calling Customer Service at 888-968-7241. Refer to the terms and conditions of your health plan to find out if you

have coverage for mental health and substance abuse benefits.

*The Wellness Guidelines are a summary of recommendations based on the U.S. Preventive Services Task Force and other nationally

recognized sources. These recommendations have been reviewed by our network health care providers. This information is not a statement of

benefits. Please refer to your health benefit plan contract/member handbook or benefits handbook for terms, limitations, or exclusions of your

health benefits plan. Please contact our Customer Service department with questions about which preventive care benefits apply to you. The

telephone number for Customer Service can be found on your ID card.

http://www.amerihealthnj.com/providerfinder


If you need to seek care outside of normal business hours, the

following options are available:

Emergency care

In the event of an emergency, go immediately to the emergency room. If you believe your

situation is particularly severe, call 911 for assistance.

A medical emergency is thought of as a medical or psychiatric condition in which symptoms

are so severe, that the absence of immediate medical attention could place one’s health in

jeopardy.

For most minor injuries or illness, a hospital emergency room is not the most appropriate place

for you to be treated. Hospital emergency rooms provide emergency care and must prioritize

patients’ needs. The most seriously hurt or ill patients are treated first. If you are not in that

category, you may wait a long time.

Urgent care

Urgent care is necessary treatment for a non-life-threatening, unexpected illness or accidental

injury that requires prompt medical attention when your doctor is unavailable. Examples include

sore throat, fever, sinus infection, ear ache, cuts, rashes, sprains, and broken bones.

You may visit an urgent care center which offers a convenient, safe, and affordable treatment

alternative to emergency room care when you can’t get an appointment with your own doctor.

Retail health clinic

Retail health clinics are another alternative when you can’t get an appointment with your own

doctor for non-emergency care. Retail health clinics use certified nurse practitioners who treat

minor, uncomplicated illness or injury. Some retail health clinics may also offer flu shots and

vaccinations.

Telemedicine with MDLIVE

Use MDLIVE* for 24/7/365 access to on-demand quality health care. Telemedicine provides

you with the option to access non-emergency health care virtually. You can now visit with a

doctor from your home, office, or on-the-go in most states. To activate your MDLIVE account,

call 888-976-7405 or log in to MDLIVE.com/amerihealthnj.

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. MDLIVE phone consultations are available 24/7/365, while video consultations are available during the hours of 7 am to 9 pm ET 7 days a week or by scheduled availability. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

When to go to the ER:

• Heart attack

• Electrical burn

Access to non-emergency

health care 24/7/365 via

phone or video with

MDLIVE.

When to go to an

urgent care center:

• Sore throat

• Ear ache

https://www.mdlive.com/amerihealthnj


Health insurance that’s mobile Manage your health insurance coverage with AmeriHealth New Jersey online account management

systems, personalized tools, and programs, so you get the most out of your benefits.

• AmeriHealth Express and AHNJ On the Go help you make the most of your health plan.

View your claims and benefit information, download a temporary ID card, email or fax

one directly to your doctor, and so much more! Register at amerihealthexpress.com,

and follow the on-screen directions. Be sure to have your ID card present as it has

information that you will need to register. Then, download AHNJ On the Go for your

iPhone or Android device.

• Use the Provider Finder to search for a participating doctor.

Simple navigation helps you get fast and accurate results. When you select your health

plan type, your results are customized based on your network, making it easy to locate a participating doctor,

specialist, hospital, or other medical facility nearby. You’ll even be able to read patient ratings and reviews, in

addition to rating your doctors and writing your own reviews.

• Stay connected and receive updates about your health plan

Important account information, benefit updates, and promotions from AmeriHealth New Jersey via text message.

Text MyAHNJ to 73529 to opt in.

• Start shopping, start saving with AmeriHealth New Jersey Insider.

Find great deals on a wide range of attractions and events, some are even free! Learn how to get discounted

movie tickets and so much more from the Insider Discount program at amerihealthnj.com/discounts.

*Please have your member ID card ready when you text to sign up. Standard message and data rates

may apply. Text STOP to stop and HELP for help. Terms and conditions available at myhelpsite.net/amerihealth. Notification messages within

AmeriHealth New Jersey Wire are sent via automated SMS. Enrollment in AmeriHealth New Jersey Wire is not a requirement to purchase

goods and services from AmeriHealth New Jersey. Wire is a trademark of Relay Network, LLC.

Register to access your

benefits online at

amerihealthexpress.com.

https://www.amerihealth.com/login

https://play.google.com/store/apps/details?id=com.ahnj.ahmobile



http://www.amerihealthnj.com/discounts


Using your prescription drug benefits The information in this section is only applicable to members who have AmeriHealth New Jersey prescription (Rx) coverage.

AmeriHealth New Jersey Prescription Drug Program

If you have an AmeriHealth New Jersey Prescription Drug plan, your benefits are

administered by FutureScripts®. FutureScripts helps you easily and safely obtain the

prescription drugs you need at an affordable price.

Take a look at the advantages:

• Easy to use. A national network of retail pharmacies will recognize and accept your member ID card.

• Low out-of-pocket expenses. When you use a participating pharmacy, your out-of-pocket costs are based on a

discounted price, fixed copayments, or coinsurance.

• No paperwork. You don’t have to file a claim form or wait for reimbursement when you use a participating

pharmacy.

• High level of safety. When you fill a prescription at a participating pharmacy, your pharmacy can identify

harmful drug interactions and other dangers by viewing your drug history.

• To get maintenance drugs needed to treat ongoing or chronic conditions, you have the following options:

- Home delivery. Your program may allow you to receive drugs right at your door when ordered through the

mail order service, eliminating time spent waiting in line at the pharmacy counter.

- Mail order purchases allow you to get a larger supply of drugs than what might be available to you at a

retail pharmacy. Additionally, depending on your plan design, your out-of-pocket expenses may be lower,

and you won’t have to visit the pharmacy as often.

How to fill your prescription at a retail pharmacy

Present your member ID card and your prescription at a FutureScripts-participating pharmacy. The pharmacist will

confirm your eligibility for benefits and determine your share of the cost for your prescription (copay). Your doctor

may also be able to submit your prescription to your pharmacy electronically.

Participating pharmacies

If a pharmacy is in your plan’s network, it is considered to be a participating pharmacy.

When you’re traveling, you will find that most pharmacies in all 50 states accept your

member ID card and can fill your prescription for the same cost that you would pay at your

local pharmacy back home. There is no need to select just one pharmacy to fill your

prescription needs.

Understanding your prescription

Brand drugs are only manufactured by one company, which advertises and sells its product

under a unique trade name. In many cases, brand drugs are quite expensive, which is why

your share of the cost is higher. Generic drugs are typically manufactured by several

companies and are almost always less expensive than the brand drug. Generic drugs are

approved by the U.S. Food and Drug Administration (FDA) to ensure they are as safe and

effective as their brand counterparts. However, not every brand drug has a generic version.

To find a pharmacy visit

amerihealthexpress.com

or call the number on your

ID card.

Brand vs. Generic

Generic drugs are as

effective as brand drugs

and could save you

money. However, consult

your doctor to find out

which drug type is best for

you.


Using your prescription drug benefits

Select Drug Program

The Select Drug Program® provides our members with comprehensive prescription drug coverage. The Select Drug

Program uses a formulary, which includes all generic drugs and a defined list of brand drugs that have been

evaluated for their medical effectiveness, positive results, and value. The formulary is reviewed quarterly to ensure its

continued effectiveness. To check the formulary status of drugs, simply log in to amerihealthexpress.com.

In addition to the Select Drug Program® formulary, you will also find helpful information on these related topics:

• Prior authorization process

• Age and gender limits

• Quantity level limits

If you’re not sure if brand or generic drugs are right for you, talk to your doctor. The pharmacist may discuss with your

physician whether an alternative drug might be appropriate for you. Let your physician know if you have a question

about a change in your prescription(s) or if you prefer the original prescription(s).

Certain controlled substances and other prescribed medications may be subject to dispensing limitations. If you have

any questions regarding your medication, please call Customer Service at 888-968-7241.

Preventive drugs for adults and children

AmeriHealth New Jersey’s prescription drug plans include 100% coverage for preventive medications when received

from an in-network pharmacy. This means that you won’t have to pay copays, coinsurance, or deductibles for certain

preventive medications with a prescription from your doctor. Receiving this preventive care will help you stay healthy

and may improve your overall health.

For a list of preventive drugs eligible, please visit amerihealthexpress.com, or call the number on the back of your

member ID card.

Mail order pharmacy

If your doctor has prescribed a medication that you’ll need to take regularly over a long period of time, the mail order

service is an excellent way to get a long-lasting supply and reduce your out-of-pocket costs.

Mail order is convenient and safe to use

If you choose mail order, you can get up to three times the number of doses at one time, as opposed to picking up

one dose at the pharmacy. Mail order prescriptions have been safely handled through the mail for many years. When

your order is received, a team of registered, licensed pharmacists check your prescription against the record of all

drugs dispensed to you by a FutureScripts network pharmacy. This process ensures that every prescription is

reviewed for safety and accuracy before it is mailed to you. If there are questions about your prescription, a

pharmacist will contact your doctor before your medication is dispensed. Your medication will be sent to your home

within ten days from the date your complete, eligible order is received.

http://www.amerihealthexpress.com/




How to begin using mail order pharmacy:

1. When you are prescribed a chronic or “maintenance” drug therapy, ask your doctor to write the prescription for a

90-day supply, plus refills. Make sure your doctor knows that you have a mail order service so that you get one

90-day prescription and not three 30-day prescriptions, because the cost of the three 30-day prescriptions may

be more than the cost for one 90-day prescription. If you’re taking medication now and would like to begin using

mail order pharmacy, ask your doctor for a new prescription.

2. Complete the FutureScripts Mail Order Form with your first order only. Forms and envelopes are available by

calling the number on your member ID card.

3. Be sure to answer all the questions, and include your member ID number. An incomplete form can cause a delay

in processing. Send the completed Mail Order Form, your original 90-day prescription, and the appropriate

payment to FutureScripts.

4. Your mail order request will be processed and your medication sent to you within ten days from the day you mail

your order, along with instructions for future refills. Standard shipping is free of charge through U.S. Mail.

Narcotic substances and refrigerated medicines will be shipped by FedEx® at no additional cost to you.

You will be dispensed the lower-priced generic drug (if manufactured) unless your doctor writes “brand medically

necessary” or “dispense as written” on your prescription, or if you indicate that you do not want the generic version of

your brand drug on the Mail Order Form. A Mail Order Form and envelope will be included with each mail order

delivery.

Paying for mail order services

Your payment can be in the form of a check or money order (made payable to FutureScripts), or

you can complete the credit card portion of the Mail Order Form. FutureScripts accepts Visa,

MasterCard®, Discover®, and American Express®. Please do not send cash. If you are uncertain

of your payment, call the number on the back of your member ID card. If the payment you

enclose is incorrect, you will be sent either a reimbursement check or an invoice, as

appropriate.

Mail order refills

When you receive a medication through the mail order service, you will also receive a

notice showing the number of refills allowed by your doctor. To avoid the risk of being

without your medication, mail the refill notice and your payment two weeks before you

expect your present supply to run out. You can also manage and order your refills online

through amerihealthexpress.com.

The refill notice will include the date when you should reorder your medication, as well as the number of refills you

have left. Remember, most prescriptions are valid for a maximum of one year.

If you have any questions concerning this program, please contact FutureScripts at 888-678-7012.

Manage and order

your refills at

amerihealthexpress.com.




Self-administered Specialty Drug Coverage

Self-injectables and other oral specialty drugs that can be administered by you, the patient, or by a caregiver outside

of the doctor’s office are covered under your AmeriHealth New Jersey prescription drug benefits administered by

FutureScripts. You may also fill your prescription via the FutureScripts Direct Ship Specialty Pharmacy Program.

The administration of a self-injectable drug by a medical professional is covered under your AmeriHealth New Jersey

medical benefit, even if you obtained the self-injectable drug through the FutureScripts Specialty Pharmacy Program.

However, the drug itself will be covered under your AmeriHealth New Jersey prescription drug benefit.

Unless otherwise noted in your Benefit Booklet, the only self-injectable drugs that are covered under AmeriHealth

New Jersey medical plans include drugs that:

• are required by law to be covered under both medical benefits and pharmacy benefits (e.g., insulin)

• are required for emergency treatment, such as a self-injectable that counteracts allergic reactions (e.g., EpiPen)

An independent pharmacy benefits management (PBM) company, FutureScripts, administers our prescription drug benefits and is responsible

for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with

pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer

based on the volume purchased. AmeriHealth New Jersey anticipates that it will pass on a high percentage of the expected rebates it receives

from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, prescription drugs are subject to a member

copayment.


Organ and tissue donation AmeriHealth New Jersey is required by the Senate and General Assembly of the State of New Jersey to provide you

will information about organ and tissue donation and registration.

Organ donation in New Jersey

The New Jersey Motor Vehicle Commission (MVC) administers the organ donation registrations program. If you are a

New Jersey resident 18 years or older you can register as an organ donor. Once you decide to become a donor, you

should inform your family of your decision. In the event of your death, the hospital will still have questions about your

organ donation wishes, even if you are a registered donor. It is important that your intentions are known, including

which organs and tissues you wish to donate.

Ways to register as an organ donor:

• Online with Donate Life at registerme.org

• In person at your local NJ MVC office whenever you apply or renew your New Jersey driver’s license or state

identification card. Find your local NJ MVC office at dmv.org/nj-new-jersey/dmv-office-finder.php

• By calling the New Jersey Organ and Tissue Sharing Network at 800-742-7365

• Or by calling the Gift of Life Donor Program at 800-366-6771

To change your organ donor information on your NJ driver’s license or state identification card you should visit your

local New Jersey MVC office. You can also update your information at organize.org, or by completing the Change of

Status organ and tissue donation form available at www.state.nj.us/mvc.


Member support

When you need us, we’re here for you. You can contact us to discuss anything pertaining to your health care,

including benefits and eligibility, claims status, requesting a new ID card, or wellness programs.

Email To send a secure email to Customer Service, simply log in to amerihealthexpress.com and click on Contact us.

Mail AmeriHealth New Jersey 1901 Market Street

Philadelphia, PA 19103-1480

Phone

Call 888-968-7241 to speak to one of our Customer Service members Monday through Friday, 8 a.m. to

6 p.m.

Information about your AmeriHealth New Jersey health plan

Your Summary of Benefits and Coverage (SBC) for your 2018 plan, which explains any out-of-pocket costs like

copayments, coinsurance, and deductibles is available by logging in to amerihealthexpress.com. All AmeriHealth

New Jersey Individual 2017 SBCs are also available at amerihealthnj.com.

Please contact Customer Service at 888-968-7241 if you have any questions, or would like to request a paper copy

of any 2018 plan documents.

Member Rights & Responsibilities

To obtain a list of Rights and Responsibilities, go to amerihealthnj.com/html/members/quality_management/

rights_responsibilities.html or call the Customer Service number on your ID Card.


http://www.amerihealthnj.com/html/members/quality_management/rights_responsibilities.html

http://www.amerihealthnj.com/html/members/quality_management/rights_responsibilities.html

SAMPLE

Form No. 16780-BC Group Number:10146718 1

POINT-OF-SERVICE

A COMPREHENSIVE MAJOR MEDICAL GROUP BOOKLET-CERTIFICATE

By and Between

AmeriHealth Insurance Company of New Jersey (Called "the Carrier")

whose main office address is

259 Prospect Plains Road Cranbury, NJ 08512

And

Account Name (Called "the Group")

The Carrier certifies that the Enrolled Employee and Enrolled Dependents, if any, are entitled to the benefits described in this booklet/certificate, subject to the eligibility and Effective Date requirements. This booklet/certificate replaces any and all booklet/certificates previously issued to the Enrolled Employee under any group contracts issued by the Carrier providing the types of benefits described in this booklet/certificate. The Contract is between the Carrier and the Contractholder. This booklet/certificate is a summary of the provisions that affect the Enrolled Employee’s insurance. All benefits and exclusions are subject to the terms of the Group Contract. ATTEST: BY

Michael A. Munoz Senior Vice President Marketing & Sales This booklet/certificate is subject to the laws of the State of New Jersey.

SAMPLE


(THIS PAGE INTENTIONALLY BLANK)

SAMPLE


TABLE OF CONTENTS

Introduction ................................................................................................................................ 1 Important Notices ....................................................................................................................... 2

Regarding Experimental/Investigative Treatment ................................................................... 2 Regarding Treatment Which is Not Medically Appropriate/Medically Necessary .................... 2 Regarding Treatment For Cosmetic Purposes ....................................................................... 2 Regarding Coverage For Emerging Technology..................................................................... 2 Regarding Use of Non-Participating Providers ....................................................................... 3

Defined Terms ........................................................................................................................... 4 The Point of Service Network Plan ............................................................................................26

Payment of Providers ............................................................................................................28 Network Provider Reimbursement .....................................................................................28 Payment Methods .............................................................................................................30

Deductible .............................................................................................................................34 Coinsurance ..........................................................................................................................34 Copayment ............................................................................................................................34 Out-of-Pocket Limit ...............................................................................................................35 Lifetime Maximum .................................................................................................................35 How to File a Claim ...............................................................................................................35

Eligibility Under This Plan .........................................................................................................36 Eligible Person ......................................................................................................................36 Eligible Dependent ................................................................................................................36

Description of Benefits ..............................................................................................................38 Primary and Preventive Care ................................................................................................38

Primary Care .....................................................................................................................38 Preventive Care ................................................................................................................39 Lead Poisoning Screening and Treatment .........................................................................39 Newborn and Infant Screening for Hearing Loss ...............................................................39 Nutrition Counseling for Weight Management ...................................................................39

Inpatient Benefits ..................................................................................................................39 Hospital Services...............................................................................................................40 Inpatient Professional Provider Medical Care ....................................................................41 Skilled Nursing Facility Services ........................................................................................41

Inpatient/Outpatient Benefits .................................................................................................42 Blood .................................................................................................................................42 Diagnosis and Treatment of Autism and Other Developmental Disabilities ........................42 Hospice Services...............................................................................................................43 Maternity/OB-GYN/Family Services ..................................................................................44 Mental Illness Care ............................................................................................................47 Routine Patient Costs Associated with Qualifying Clinical Trials ........................................48 Surgical Services...............................................................................................................48 Transplants .......................................................................................................................50 Treatment for Substance Abuse ........................................................................................51 Treatment for Wilm’s Tumor ..............................................................................................52

Outpatient Benefits ................................................................................................................52 Ambulance Services ..........................................................................................................52 Day Rehabilitation Program ...............................................................................................53

SAMPLE


Diabetic Supplies and Education Program ........................................................................54 Diagnostic Services ...........................................................................................................54 Durable Medical Equipment ..............................................................................................54 Emergency Care and Urgent Care ....................................................................................56 Hearing Aids for Dependents ............................................................................................57 Home Health Care Charges in Lieu of Hospitalization .......................................................57 Inherited Metabolic Diseases, Medical Foods and Low Protein Modified Food Products ...58 Injectable Medications .......................................................................................................58 Non-Surgical Dental Services ............................................................................................59 Orthotic Devices ................................................................................................................59 Podiatric Care ...................................................................................................................59 Private Duty Nursing Services ...........................................................................................60 Prosthetic and Orthotic Appliances ....................................................................................60 Prosthetic Devices .............................................................................................................60 Specialist Office Visits .......................................................................................................62 Spinal Manipulation Services ............................................................................................62 Therapy Services ..............................................................................................................62 Vision Care........................................................................................................................64

What Is Not Covered .................................................................................................................65 Claims .......................................................................................................................................71

Notice of Claim ......................................................................................................................71 Proofs of Loss .......................................................................................................................71 Furnishing Claim Forms ........................................................................................................71 Physical Examinations and Autopsy ......................................................................................71 Time of Payment of Claims ...................................................................................................71 Denial of Claims ....................................................................................................................72 Payment ................................................................................................................................73 Right to Recover Payments in Error ......................................................................................73 Claim Appeal Procedure .......................................................................................................73

General Information ..................................................................................................................74 Benefits to Which a Covered Person is Entitled.....................................................................74 Termination of Coverage Under this Plan ..............................................................................74 Termination of Coverage at Termination of Employer or Membership in the Group ...............75 Conversion for a Dependent Spouse Due to Divorce or Dissolution of the Civil Union ..........75 New Jersey Continuation Rights for Over-Age Dependents ..................................................75 Continuation Rights ...............................................................................................................75 Release of Information ..........................................................................................................83 Consumer Rights ..................................................................................................................83 Limitation of Actions ..............................................................................................................83

Covered Person/Provider Relationship\f C \l .............................................................................83 Coordination of Benefits and Services ...................................................................................86 Special Circumstances ..........................................................................................................92 Benefits for Automobile Related Injuries ................................................................................92

Managed Care ..........................................................................................................................95 Utilization Review Process ....................................................................................................95 Clinical Criteria Guidelines and Resources ............................................................................96 Delegation of Utilization Review Activities and Criteria ..........................................................97 Precertification Review ..........................................................................................................97 Precertification Requirements ............................................................................................. 100 Case Management .............................................................................................................. 102 Disease Management and Decision Support Programs ...................................................... 103

SAMPLE


Resolving Problems ................................................................................................................ 104

SAMPLE


INTRODUCTION This booklet/certificate has been prepared so that the Enrolled Employee and Enrolled Dependents, if any, may become acquainted with the Point-of-Service Health Benefits Plan (this Plan) offered by the employer. Coverage under the employer's Point-of-Service Health Benefits Plan is available to those Employees who are eligible for the Coverage and Enrolled in it. The Point-of-Service Health Benefits Plan described in this booklet/certificate is subject to the terms and conditions of the Group Contract issued by AmeriHealth Insurance Company of New Jersey (the Carrier). Benefits will not be available for services to a greater extent or for a longer period than is Medically Necessary/Medically Appropriate, as described in this booklet/certificate. The amount of benefits for any Covered Service will not exceed the amount charged by the health care Provider, and will not be greater than any Maximum amount or limit described or referred to in this booklet/certificate. Complaints may be resolved by contacting the Carrier’s Customer Service Department at 1-800-877-9829 (TTY:711). Claims related Complaints and Utilization Review Complaints will be addressed as set forth in the Resolving Problems section of this booklet/certificate. See Important Notices. And, read this booklet/certificate carefully.

SAMPLE


IMPORTANT NOTICES REGARDING EXPERIMENTAL/INVESTIGATIVE TREATMENT The Carrier does not cover treatment it determines to be Experimental/Investigative in nature because that treatment is not accepted by the general medical community for the condition being treated or not approved as required by federal or governmental agencies. However, the Carrier acknowledges that situations exist when a Covered Person and his or her Physician agree to utilize Experimental/Investigative treatment. If a Covered Person receives Experimental/Investigative treatment, the Covered Person shall be responsible for the cost of the treatment. A Covered Person or his or her Physician should contact the Carrier to determine whether a treatment is considered Experimental/Investigative. The term "Experimental/Investigative" is defined in the Defined Terms section. This notice does not apply to the “Treatment of Wilm’s Tumor” as set forth in the Description of Benefits. REGARDING TREATMENT WHICH IS NOT MEDICALLY APPROPRIATE/MEDICALLY NECESSARY The Carrier only covers treatment which it determines Medically Appropriate/Medically Necessary. A Network Provider contractually is not permitted to bill the Covered Person for treatment which the Carrier determines is not Medically Appropriate/Medically Necessary unless the Network Provider specifically advises the Covered Person in writing, and the Covered Person agrees in writing that such services are not covered by the Carrier, and that the Covered Person will be financially responsible for such services. A Non-Network Provider, however, is not obligated to accept the Carrier's determination and the Covered Person may not be reimbursed for treatment which the Carrier determines is not Medically Appropriate/Medically Necessary. The Covered Person is responsible for these charges when treatment is received by a Non-Network Provider. These charges can be avoided simply by choosing a Network Provider. The term "Medically Appropriate/Medically Necessary" is defined in the Defined Terms section. REGARDING TREATMENT FOR COSMETIC PURPOSES The Carrier does not cover treatment which it determines is for cosmetic purposes because it is not necessitated as part of the Medically Appropriate/Medically Necessary treatment of an Illness, Injury or congenital birth defect. However, the Carrier acknowledges that situations exist when a Covered Person and his or her Physician decide to pursue a course of treatment for cosmetic purposes. In such cases, the Covered Person is responsible for the cost of the treatment. A Covered Person or his or her Physician should contact the Carrier to determine whether treatment is for cosmetic purposes. The exclusion for services and operations for cosmetic purposes is detailed in the What Is Not Covered section. This notice does not apply to: (a) mastectomy related charges as provided for and defined in the “Surgical Services” section; and (b) care and treatment of medically diagnosed congenital defects and birth abnormalities of newborn children as provided for in the “Maternity/OB-GYN/Family Services” section of the Description of Benefits. REGARDING COVERAGE FOR EMERGING TECHNOLOGY While the Carrier does not cover treatment it determines to be Experimental/Investigative, it routinely performs technology assessments in order to determine when new treatment modalities are safe and effective. A technology assessment is the review and evaluation of

SAMPLE


available clinical and scientific information from expert sources. These sources include but are not limited to articles published by governmental agencies, national peer review journals, national experts, clinical trials, and manufacturer’s literature. The Carrier uses the technology assessment process to assure that new drugs (not approved by the U.S. Food and Drug Administration), procedures or devices (“emerging technology”) are safe and effective before approving them as Covered Services. When new technology becomes available or at the request of a practitioner or Covered Person, the Carrier researches all scientific information available from these expert sources. Following this analysis, the Carrier makes a decision about when a new drug (not approved by the U.S. Food and Drug Administration), procedure or device has been proven to be safe and effective and uses this information to determine when an item becomes a Covered Service for the condition being treated or not approved as required by federal or governmental agencies. A Covered Person or his or her Provider should contact the Carrier to determine whether a proposed treatment is considered “emerging technology”. REMEMBER: Whenever a Provider suggests a new treatment option that may fall under the category of “Experimental/Investigative”, “cosmetic”, or “emerging technology”, the Covered Person, or his or her Provider, should contact the Carrier for a coverage determination. That way the Covered Person and the Provider will know in advance if the treatment will be covered by the Carrier. In the event the treatment is not covered by the Carrier, the Covered Person can make an informed decision about whether to pursue alternative treatment options or be financially responsible for the service. For more information on when to contact the Carrier for coverage determinations, please see the Precertification and Prenotification requirements in the Managed Care section. REGARDING USE OF NON-NETWORK PROVIDERS To receive the maximum benefits available under this Plan, a Covered Person must obtain Covered Services from Network Providers that are part of the Point-of-Service Network. While the Point-of-Service Network is extensive, it may not contain every Provider that a Covered Person needs. Covered Services may be obtained from Non-Network Providers. If a Non-Network Provider is used, a Covered Person will be reimbursed for Covered Services but will incur significantly higher Cost-Sharing and the balance of the Provider’s bill. This is true whether a Non-Network Provider is used by choice, for level of expertise, for convenience, for location, because of the nature of the services or based on the recommendation of a Provider, except as described below. The Carrier may approve Covered Services provided by a Non-Network Provider subject to Network Cost-Sharing, if such Cost-Sharing is applicable to the Plan, if a Covered Person has: (a) first sought and received care from a Network Provider in the same American Board of Medical Specialties (ABMS) recognized specialty as the Non-Network Provider requested; (b) been advised by the Network Provider that there are no Network Providers that can provide the requested Covered Services; and (c) obtained authorization from the Carrier prior to receiving care. The Carrier reserves the right to make a determination as to whether there is a Network Provider that can provide the Covered Services. If the Carrier approves the use of a Non-Network Provider, a Covered Person will not be responsible for the difference between the Provider’s billed charges and the Carrier’s payment to the Provider. Applicable Plan terms including Medical Necessity/Appropriateness and Precertification will apply.

SAMPLE


DEFINED TERMS

The terms below have the following meaning when describing the benefits within this booklet/certificate. They will be helpful in fully understanding these benefits. ACCESSIBILITY – the extent to which a member of a Managed Care Organization can obtain from a Network Provider available Covered Services at the time they are needed. Accessibility to a Network Provider refers to both telephone access and ease of scheduling an appointment. ACCIDENTAL INJURY - bodily Injury which results from an accident directly and independently of all other causes. ACT OF WAR – any act peculiar to military, naval or air operations in time of war. ALTERNATIVE THERAPIES/COMPLEMENTARY MEDICINE – complementary and alternative medicine, as defined by the National Institute of Health’s National Center for Complementary and Alternative Medicine (NCCAM), is a group of diverse medical and health care systems, practices, and products, currently not considered to be part of conventional medicine. NCCAM categorizes complementary medicine and alternative therapies into the following five classifications: (a) alternative medical systems (e.g. homeopathy, naturopathy, Ayurveda, traditional Chinese medicine); (b) mind-body interventions which includes a variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms (e.g. meditation, prayer, mental healing, and therapies that use creative outlets such as art, music or dance); (c) biologically based therapies using natural substances, such as herbs, foods, vitamins or nutritional supplements to prevent and treat Illness (e.g. diets, macrobiotics, megavitamin therapy); (d) manipulative and body-based methods (e.g. massage, equestrian/hippotherapy); and (e) energy therapies, involving the use of energy fields. The energy therapies are of two types: (1) Biofield therapies – intended to affect energy fields that purportedly surround and penetrate the human body. This includes forms of energy therapy that manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include Qi Gong, Reiki, and therapeutic touch; and (2) Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields. AMBULANCE – Local transportation in a specially designed and equipped vehicle used only to transport the Ill or Injured. AMBULATORY SURGICAL FACILITY - a Facility Provider, with an organized staff of Physicians, which is licensed as required and which has been approved by the Joint Commission on Accreditation of Healthcare Organizations, or by the Accreditation Association for Ambulatory Health Care, Inc., or by the Carrier and which: A. Has permanent facilities and equipment for the primary purposes of performing surgical

procedures on an Outpatient basis; B. Provides treatment by or under the supervision of Physicians and nursing services

whenever the patient is in the facility; C. Does not provide Inpatient accommodations; and D. Is not, other than incidentally, a facility used as an office or clinic for the private practice of

a Professional Provider.

SAMPLE


ANCILLARY PROVIDER - an individual or entity that provides services, supplies or equipment (such as, but not limited to, Infusion Therapy, Durable Medical Equipment and Ambulance services), for which benefits are provided under this Plan. ANESTHESIA - consists of the administration of regional anesthetic or the administration of a drug or other anesthetic agent by injection or inhalation, the purpose and effect of which is to obtain muscular relaxation, loss of sensation or loss of consciousness. APPEAL – a request by a Covered Person, or the Covered Person’s representative or Provider, acting on the Covered Person’s behalf upon written consent, to change a previous decision made by the Carrier. APPLICANT - the Employee who applies for coverage under this Plan. APPLICATION - the request, either written or via electronic transfer, of the Applicant for coverage, set forth in a format approved by the Carrier. ASSISTED HATCHING – means a micromanipulation technique in which a hole is artificially created in the outer shell of an embryo to assist with the potential implantation of that embryo. BENEFIT PERIOD - the specified period of time as shown in the Schedule of Benefits during which charges for Covered Services must be Incurred in order to be eligible for payment by the Carrier. A charge shall be considered Incurred on the date the service or supply was provided to a Covered Person. BILLED CHARGE – an amount billed by the Provider for treatment, services or supplies rendered to a Covered Person. BIRTH CENTER - a Facility Provider approved by the Carrier which: (a) is licensed as required in the state where it is situated, (b) is primarily organized and staffed to provide maternity care, and (c) is under the supervision of a Physician or a licensed certified nurse midwife. CALENDAR YEAR - a 12 month period beginning on January 1. CASE MANAGEMENT - Comprehensive Case Management programs serve individuals who have been diagnosed with a complex, catastrophic, or chronic Illness or Injury. The objectives of Case Management are to facilitate access by the Covered Person to ensure the efficient use of appropriate health care resources, link Covered Persons with appropriate health care or support services, assist Providers in coordinating prescribed services, monitor the quality of services delivered, and improve Covered Person outcomes. Case Management supports Covered Persons and Providers by locating, coordinating, and/or evaluating services for a Covered Person who has been diagnosed with a complex, catastrophic or chronic Illness and/or Injury across various levels and sites of care. CERTIFIED PEDORTHIST - means a person certified by the American Board for Certification in Pedorthics, or its successor, in the design, manufacture, fit and modification of shoes and related foot appliances from the ankle and below as prescribed by a licensed doctor of medicine or podiatric medicine for the amelioration of painful or disabling conditions of the foot. CERTIFIED REGISTERED NURSE - a certified registered nurse anesthetist, certified registered nurse practitioner, certified entreostomal therapy nurse, certified community health nurse, certified psychiatric mental health nurse, or certified clinical nurse specialist, certified by the

SAMPLE


state Board of Nursing or a national nursing organization recognized by the State Board of Nursing. This excludes any registered professional nurses employed by a health care facility or by an anesthesiology group. COGNITIVE REHABILITATION THERAPY – Medically prescribed therapeutic treatment approach designed to improve cognitive functioning after acquired central nervous system insult (e.g. trauma, stroke, acute brain insult, and encephalopathy). Cognitive rehabilitation is an integrated multidisciplinary approach that consists of tasks designed to reinforce or re-establish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurological systems. It consists of a variety of therapy modalities which mitigate or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning, and problem solving. Cognitive rehabilitation is performed by a Physician, neuropsychologist, Psychologist as well as a physical, occupational or speech therapist using a team approach. COINSURANCE – a type of Cost-Sharing in which the Covered Person assumes a percentage of the Covered Expense for Covered Services, such as twenty percent (20%). COMPLAINT – any expression of dissatisfaction regarding any aspect of the coverage, operations, or management of the Carrier, including but not limited to the Carrier’s health care services, quality of care and service, choice and Accessibility of practitioners and Providers, and network adequacy, by a Covered Person. CONDITIONS FOR DEPARTMENTS (for Qualifying Clinical Trials) – the conditions in this paragraph, for a study or investigation conducted by the Department of Veteran Affairs, Defense, or Energy, are that the study or investigation has been reviewed and approved through a system of peer review that the U.S. government determines: • To be comparable to the system of peer review of studies and investigation used by the

National Institutes of Health (NIH); and • Assures unbiased review of the highest scientific standards by Qualified Individuals who

have no interest in the outcome of the review CONTRACT YEAR - the period beginning with the date of issue of the Contract to the first anniversary date and each subsequent twelve (12) month period beginning with the anniversary date. COPAYMENT - a type of Cost-Sharing in which the Covered Person pays a flat dollar amount each time a Covered Service is provided (such as a $10 or $15 Copayment per office visit). Copayments, if any, are identified in the Schedule of Benefits. COST-SHARING – amount(s) paid by a Covered Person under this Plan that are Copayment, Deductible and Coinsurance amounts. Cost-Sharing does not include Precertification Penalties or expenses for services and supplies that are excluded. COVERED EXPENSE - refers to the basis on which a Covered Person's Deductibles, Coinsurance, benefit Maximums and benefits are calculated. A. For Covered Services rendered by a Facility Provider, the term “Covered Expense” may

not refer to the actual amount(s) paid by the Carrier to the Provider(s). The amount the Carrier pays at the time of any given claim may be more and it may be less than the

SAMPLE


amount used to calculate the Covered Person's liability. Rather, “Covered Expense” means the following: 1. For most Covered Services rendered by a Network Facility Provider, “Covered

Expense” means of reimbursement for Covered Services the Network Facility Provider has agreed to accept as set forth by contract with the Carrier, or the Billed Charge, whichever is less. However, for selected Covered Services provided by certain Facility Providers, the Carrier may pay a “per member per month” fee that the Facility Provider has agreed to accept as set forth by contract with the Carrier.

2. For Covered Services rendered by a Non-Network Facility Provider that has no contractual arrangement with the Carrier, “Covered Expense” means the lesser of 150% of the Medicare Allowable Payment for Facilities or the Facility Provider's Billed Charge for the Covered Services. For Covered Services that are not recognized or reimbursed by the Medicare traditional program, this amount is determined by reimbursing the lesser of the Carrier’s applicable proprietary fee schedule or the Facility Provider’s Billed Charge. For Covered Services not recognized or reimbursed by the Medicare traditional program or the Carrier’s applicable proprietary fee schedule, this amount is determined by reimbursing fifty percent (50%) of the Facility Provider’s Billed Charge.

B. For Covered Services rendered by a Professional Provider, “Covered Expense” means the

following: 1. For most Covered Services rendered by a Network Professional Provider, “Covered

Expense” means the rate of reimbursement for Covered Services listed in a fee schedule that the Professional Provider has agreed to accept as set forth by contract with the Carrier, or the Billed Charge, whichever is less.

However, for selected Covered Services provided by certain Professional Providers,

the Carrier may pay a “per member per month” fee that the Professional Provider has agreed to accept as set forth by contract with the Carrier.

2. For Covered Services rendered by a Non-Network Professional Provider that has no contractual arrangement with the Carrier, “Covered Expense” means the lesser of150% of the Medicare Professional Allowable Payment or the Professional Provider's Billed Charge for the Covered Services. For Covered Services that are not recognized or reimbursed by the Medicare traditional program, this amount is determined by reimbursing the lesser of the Carrier’s applicable proprietary fee schedule or the Professional Provider’s Billed Charge. For Covered Services not recognized or reimbursed by the Medicare traditional program or the Carrier’s applicable proprietary fee schedule, this amount is determined by reimbursing fifty percent (50%) of the Professional Provider’s Billed Charge.

C. For Covered Services rendered by Ancillary Providers, “Covered Expense” means the following:

1. For Covered Services rendered by a Network Ancillary Provider, “Covered Expense”

means the rate of reimbursement for Covered Services the Ancillary Provider has agreed to accept as set forth by contract with the Carrier, or the Billed Charge, whichever is less.

SAMPLE


2. Except as provided herein with respect to Prosthetic and Orthotic Appliances, for Covered Services rendered by a Non-Network Ancillary Provider, “Covered Expense” means the lesser of 150% of the Medicare Ancillary Allowable Payment or the Ancillary Provider's Billed Charge for the Covered Services. For Covered Services that are not recognized or reimbursed by the Medicare traditional program, this amount is determined by reimbursing the lesser of the Carrier’s applicable proprietary fee schedule or the Ancillary Provider’s Billed Charge. For Covered Services not recognized or reimbursed by the Medicare traditional program or the Carrier’s applicable proprietary fee schedule, this amount is determined by reimbursing fifty percent (50%) of the Ancillary Provider’s Billed Charge.

D. Nothing in this section shall be construed to mean that the Carrier would provide coverage

for services other than Covered Services. COVERED PERSON - an Enrolled Employee or his or her eligible Dependents who have satisfied the specifications of the Eligibility Under This Plan section. COVERED SERVICE - a service or supply specified in this booklet/certificate for which benefits will be provided by the Carrier. CUSTODIAL CARE - provided primarily for Maintenance of the patient or which is designed essentially to assist the patient in meeting his or her activities of daily living and which is not primarily provided for its therapeutic value in the treatment of an Illness, disease, bodily Injury, or condition. Custodial Care includes, but is not limited to, help in walking, bathing, dressing, feeding, preparation of special diets and supervision over self-administration of medications, which do not require the technical skills or professional training of medical or nursing personnel in order to be performed safely and effectively. DAY REHABILITATION PROGRAM – is a level of Outpatient care consisting of four (4) to seven (7) hours of daily rehabilitative therapies and other medical services five (5) days per week. Therapies provided may include a combination of therapies, such as Physical Therapy, Occupational Therapy and Speech Therapy, as otherwise defined in this Plan and other medical services such as nursing services, psychological therapy and Case Management services. Day Rehabilitation sessions also include a combination of one-to-one and group therapy. The Covered Person returns home each evening and for the entire weekend. DECISION SUPPORT – Decision Support describes a variety of services that help Covered Persons make educated decisions about health care and support their ability to follow their Provider’s treatment plans. Some examples of Decision Support services include support for major treatment decisions and information about everyday health concerns. DEDUCTIBLE - a type of Cost-Sharing represented by a specified amount of Covered Expenses for the Covered Services that is Incurred by the Covered Person before the Carrier will assume any liability. DETOXIFICATION - the process by which a person intoxicated by or dependent upon alcohol or other drugs is assisted, in or by a licensed Facility Provider, through the period of time necessary to eliminate the intoxication or dependency factors, by metabolic or other means, as determined by a licensed Physician. A Facility Provider providing this service must meet the minimum standards for such facilities set by the appropriate governmental agency.

SAMPLE


DEVELOPMENTAL DISABILITY - a severe, chronic disability that: A. Is attributable to a mental or physical impairment or a combination of mental and physical

impairments; B. Is manifested before the Covered Person:

1. attains age twenty-two (22) for purposes of the Diagnosis and Treatment of Autism and Other Developmental Disabilities provision; or

2. attains age twenty-six (26) for all other provisions; C. Is likely to continue indefinitely; D. Results in substantial functional limitations in three (3) or more of the following areas of

major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency;

E. Reflects the Covered Person’s need for a combination and sequence of special

interdisciplinary or generic care, treatment or other services which are of lifelong or of extended duration and are individually planned and coordinated. Developmental Disability includes but is not limited to severe disabilities attributable to intellectual disability, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met.

DISEASE MANAGEMENT – a population-based approach to identify Covered Persons who have or are at risk for a particular chronic medical condition, intervene with specific programs of care, and measure and improve outcomes. Disease Management programs use evidence-based guidelines to educate and support Covered Persons and Providers, matching interventions to Covered Persons with greatest opportunity for improved clinical or functional outcomes. Disease Management programs may employ patient education, Provider profiling and feedback, compliance monitoring and reporting, and/or preventive medicine approaches to assist Covered Persons with chronic disease(s). Disease Management interventions are intended to both improve delivery of services in various active stages of the disease process as well as to reduce/prevent relapse or acute exacerbation of the condition. DURABLE MEDICAL EQUIPMENT - is equipment which meets the following criteria: A. It is durable and can withstand repeated use; B. It is medical equipment, meaning it is primarily and customarily used to serve a medical

purpose; C. It generally is not useful to a person in the absence of an Illness or Injury; and D. It is appropriate for use in the home. Durable Medical Equipment includes, but is not limited to: certain diabetic supplies, canes, crutches, walkers, commode chairs, home oxygen equipment, hospital beds, traction equipment and wheelchairs. EFFECTIVE DATE - according to the Eligibility Under This Plan section, the date on which coverage for a Covered Person begins under this Plan. All coverage begins at 12:01 a.m. on the date reflected on the records of the Carrier.

SAMPLE


EMERGENCY - the sudden and unexpected onset of a medical or psychiatric condition manifesting itself in acute symptoms of sufficient severity or severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: A. Placing the Covered Person's health, or in the case of a pregnant Covered Person, the

health of the unborn child, in jeopardy; B. Serious impairment to bodily functions; or C. Serious dysfunction of any bodily organ or part. With respect to a pregnant Covered Person who is having contractions, an Emergency exists where: (a) there is inadequate time to effect a safe transfer to another Hospital before delivery; or (b) the transfer may pose a threat to the health or safety of the Covered Person or the unborn child. EMERGENCY CARE - Covered Services and supplies provided by a Hospital or Facility Provider and/or Professional Provider to a Covered Person in or for an Emergency on an Outpatient basis in a Hospital Emergency Room or Outpatient Emergency Facility. EMPLOYEE or ENROLLED EMPLOYEE - an individual of the Group who meets the eligibility requirements for Enrollment, who is so specified for Enrollment, and in whose name the Identification Card is issued. Employees who are participating in: (a) an employer-employee arrangement established pursuant to a collective bargaining agreement where the employer has contracted with the Carrier; or (b) members of a Health and Welfare Fund which has contracted with the Carrier, to provide coverage are considered to be Employees for the purpose of this Plan. ENROLL or ENROLLMENT – the Applicant’s request for coverage, either written or via electronic transfer, set forth in a format approved by the Carrier. EQUIPMENT FOR SAFETY – items that are not primarily used for the diagnosis, care, or treatment of Illness or Injury, but are primarily utilized to prevent Injury or provide a safe surrounding. Examples include restraints, safety straps, safety enclosures, and car seats. EXPERIMENTAL/INVESTIGATIVE - a drug, biological product, device, medical treatment or procedure which meets any of the following criteria: A. Is the subject of ongoing clinical trials; B. Is the research, experimental, study or investigational arm of on-going clinical trials or is

otherwise under a systematic, intensive investigation to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis;

C. Is not of proven benefit for the particular diagnosis or treatment of the Covered Person’s particular condition;

D. Is not generally recognized by the medical community, as clearly demonstrated by

Reliable Evidence, as effective and appropriate for the diagnosis or treatment of the Covered Person’s particular condition; or

SAMPLE


E. Is generally recognized, based on Reliable Evidence, by the medical community as a diagnostic or treatment intervention for which additional study regarding its safety and efficacy for the diagnosis or treatment of the Covered Person’s particular condition, is recommended.

A drug will not be considered Experimental/Investigative if it has received final approval by the U.S. Food and Drug Administration (FDA) to market with a specific indication for the particular diagnosis or condition present. Any other approval granted as an interim step in the FDA regulatory process, e.g., an Investigational New Drug Exemption (as defined by the FDA), is not sufficient. Once FDA approval has been granted for a particular diagnosis or condition, use of the drug for another diagnosis or condition shall require that one or more of the established referenced compendia identified in the Company’s Medical Policies recognize the usage as appropriate medical treatment. Any biological product, device, medical treatment or procedure is not considered Experimental/Investigative if it meets all of the criteria listed below: A. Reliable Evidence demonstrates that the biological product, device, medical treatment or

procedure has a definite positive effect on health outcomes. B. Reliable Evidence demonstrates that the biological product, device, medical treatment or

procedure leads to measurable improvement in health outcomes; i.e., the beneficial effects outweigh any harmful effects.

C. Reliable Evidence clearly demonstrates that the biological product, device, medical

treatment or procedure is at least as effective in improving health outcomes as established technology, or is usable in appropriate clinical contexts in which established technology is not employable.

D. Reliable Evidence clearly demonstrates that improvement in health outcomes, as defined

above in paragraph C, is possible in standard conditions of medical practice, outside clinical investigatory settings.

E. Reliable Evidence shows that the prevailing opinion among experts regarding the

biological product, device, medical treatment or procedure is that studies or clinical trials have determined its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment for a particular diagnosis.

FACILITY PROVIDER - an institution or entity licensed to provide care. Such facilities include: Alcoholism Detoxification Facility Non-Hospital Facility Ambulatory Surgical Facility Psychiatric Hospital Birth Center Rehabilitation Hospital Free Standing Dialysis Facility Residential Treatment Facility Free Standing Ambulatory Care Facility Short Procedure Unit Home Health Care Agency Skilled Nursing Facility Hospice Urgent Care Center Hospital FAMILY COVERAGE - coverage purchased for the Employee and one or more of the Employee’s Dependents.

SAMPLE


FOLLOW-UP CARE – care scheduled for Medically Appropriate/Medically Necessary follow-up visits that occur following Emergency Care, and is billed for by a Provider, including Emergency Care received outside of the geographic area served by the Point-of-Service Network. Follow-Up Care must be preapproved by the Covered Person’s Primary Care Physician prior to traveling, to be paid at the Network level of benefits. If the Follow-Up Care is not preapproved prior to traveling, then the Follow-Up Care will be paid at the Non-Network level of benefits. This service is available for temporary absences (less than ninety (90) consecutive days) from the Carrier’s Point-of-Service Network. FREE STANDING AMBULATORY CARE FACILITY - a Facility Provider, other than a Hospital, which provides treatment or services on an Outpatient or partial basis and is not, other than incidentally, used as an office or clinic for the private practice of a Physician. This facility shall be licensed by the state in which it is located and be accredited by the appropriate regulatory body. FREE STANDING DIALYSIS FACILITY - a Facility Provider, licensed or approved by the appropriate governmental agency and approved by the Carrier, which is primarily engaged in providing dialysis treatment, maintenance or training to patients on an Outpatient or home care basis. GENERALLY ACCEPTED STANDARDS OF MEDICAL PRACTICE – means standards that are based on: (a) credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community; (b) physician and health care provider specialty society recommendations; (c) the views of physicians and health care providers practicing in relevant clinical areas; and (d) any other relevant factor as determined by the commissioner by regulation. GESTATIONAL CARRIER – a female who has become pregnant with an embryo or embryos that are not part of her genetic or biologic entity, and who intends to give the child to the biological parents after birth. GROUP or ENROLLED GROUP - a group of Covered Persons which has been accepted by the Carrier, consisting of all those Applicants whose charges are remitted by the Applicant's agent together with all the Employees or members of a Health and Welfare Fund, listed on the Applications or amendments thereof, who have been accepted by the Carrier. HEARING AID – a Prosthetic Device that amplifies sound through simple acoustic amplification or through transduction of sound waves into mechanical energy that is perceived as sound. A Hearing Aid is comprised of: (a) a microphone to pick up sound, (b) an amplifier to increase the sound, (c) a receiver to transmit the sound to the ear, and (d) a battery for power. A Hearing Aid may also have a transducer that changes sound energy into a different form of energy. The separate parts of a Hearing Aid can be packaged together into a small self-contained unit, or may remain separate or even require surgical implantation into the ear or part of the ear. Generally, a Hearing Aid will be categorized into one of the following common styles: (a) behind-the-ear, (b) in-the-ear, (c) in-the-canal, (d) completely-in-the-canal, and (e) implantable (can be partial or complete). A Hearing Aid is not a cochlear implant. HOME AREA – the fifty (50) states of the United States of America, the District of Columbia and Canada.

SAMPLE


HOME HEALTH CARE AGENCY - with respect to the Benefit provision entitled "Home Health Care Charges in Lieu of Hospitalization" as provided in the Description of Benefits section, Home Health Care Agency means a Provider which provides skilled nursing care for Ill or Injured people in their home under a home health care program designed to eliminate Hospital stays. The Carrier will recognize it if it is licensed by the state in which it operates, or it is certified to participate in Medicare as a Home Health Care Agency. HOSPICE - a Facility Provider that is engaged in providing palliative care rather than curative care to terminally ill individuals. The Hospice must be: (a) certified by Medicare to provide Hospice services, or accredited as a Hospice by the appropriate regulatory agency; and (b) appropriately licensed in the state where it is located. HOSPITAL - a short-term, acute care, general Hospital which has been approved by the Joint Commission on Accreditation of Healthcare Organizations and/or by the American Osteopathic Hospital Association or by the Carrier and which: A. Is a duly licensed institution; B. Is primarily engaged in providing Inpatient diagnostic and therapeutic services for the

diagnosis, treatment, and care of injured and sick persons by or under the supervision of Physicians;

C. Has organized departments of medicine; D. Provides twenty-four (24)-hour nursing service by or under the supervision of Registered

Nurses; E. Is not, other than incidentally, a: Skilled Nursing Facility; nursing home; Custodial Care

home; health resort, spa or sanitarium; place for rest; place for aged; place for treatment of Mental Illness; place for treatment of Substance Abuse; place for provision of rehabilitation care; place for treatment of pulmonary tuberculosis; place for provision of Hospice care.

HOSPITAL-BASED PROVIDER - A physician who provides Medically Necessary services in a Hospital or Network Facility Provider supplemental to the primary care being provided in the Hospital or Network Facility Provider, for which the Covered Person has limited or no control of the selection of such physician. Hospital-Based Providers include physicians in the specialties of radiology, anesthesiology and pathology and/or other specialties as determined by the Carrier. When these physicians provide services other than in the Hospital or Network Facility, they are not considered Hospital-Based Providers. IDENTIFICATION CARD - the currently effective card issued to the Covered Person by the Carrier which must be presented when a Covered Service is requested. ILLNESS - a sickness or disease suffered by a Covered Person. Illness includes Mental Illness. IMMEDIATE FAMILY - the Covered Person’s spouse, parent, child, stepchild, brother, sister, grandparent, mother-in-law or step-mother, father-in-law or step-father, sister-in-law, brother-in-law, daughter-in-law, son-in-law, or any individual who ordinarily resides in the household of the Covered Person. INCURRED - a charge shall be considered Incurred on the date the Covered Person receives the service or supply for which the charge is made. INDEPENDENT CLINICAL LABORATORY - a laboratory that performs clinical pathology procedure and that is not affiliated or associated with a Hospital, Physician or Facility Provider.

SAMPLE


INFERTILITY - the disease or condition that results in the abnormal function of the reproductive system such that: (a) a Covered Person is not able to carry a pregnancy to live birth; (b) a Covered Person is not able to impregnate another person; (c) a Covered Person is not able to conceive after two (2) years of unprotected intercourse if the female partner is under thirty-five (35) years of age; (d) a Covered Person is not able to conceive after one (1) year of unprotected intercourse if the female partner is thirty-five (35) years of age or older; or (e) one of the partners is considered medically sterile. Infertility will not mean a Covered Person who has been voluntarily sterilized, regardless of whether the Covered Person has attempted to reverse the sterilization. However, this does not include eligible partners of a Covered Person who has successfully reversed sterilization, provided that the partner is infertile, as defined in (a) through (e) above. INHERITED METABOLIC DISEASES - means phenylketonuria, branched-chain ketonuria, galactosemia, hypothyroidism, homocystinuria, and other inherited biochemical disorders which may cause intellectual or other permanent disabilities. INJURY – all damage to a Covered Person’s body due to accident, and all complications arising from that damage. INPATIENT ADMISSION or INPATIENT - a Covered Person’s actual entry into a Hospital, extended care facility or Facility Provider to receive Inpatient services as a registered bed patient in such Hospital, extended care facility or Facility Provider and for whom a room and board charge is made; the Inpatient Admission shall continue until such time as the Covered Person is actually discharged from the facility. INPATIENT CARE FOR SUBSTANCE ABUSE - the provision of medical, nursing, counseling or therapeutic services, for a Covered Person suffering from Substance Abuse twenty-four (24) hours a day in a Hospital or Non-Hospital Facility, according to individualized treatment plans. A Facility Provider providing this service must also meet the minimum standards for such facilities set by the appropriate governmental agency. LICENSED CLINICAL SOCIAL WORKER – a social worker who has graduated from a school accredited by the Council on Social Work Education with a Doctoral or Master’s Degree and is licensed by the appropriate state authority. LICENSED ORTHOTIST - means any person who practices orthotics and who represents himself to the public by title or by description of services, under any title incorporating such terms as “Orthotics,” “Orthotists,” “Orthotic,” or “L.O.,” or any similar title or description of services, provided that the individual has met the eligibility requirements and been duly licensed under the provisions of the Orthotist & Prosthetist Licensing Act. LICENSED PRACTICAL NURSE (LPN) - a nurse who has graduated from a formal practical or nursing education program and is licensed by the appropriate state authority. LICENSED PROSTHETIST - means a person who practices prosthetics and who represents himself to the public by title or by description of services, under any title incorporating such terms as “Prosthetics,” “Prosthetist,” “Prosthetic,” or “L.P.,” or any similar title or description of services, provided that the individual has met the eligibility requirements and been duly licensed pursuant to the provisions of the Orthotist & Prosthetist Licensing Act.

SAMPLE


LIFE-THREATENING DISEASE OR CONDITION (for Qualifying Clinical Trials) – any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. LOW PROTEIN MODIFIED FOOD PRODUCT - means a food product that is specially formulated to have less than one (1) gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an Inherited Metabolic Disease, but does not include a natural food that is naturally low in protein. MAINTENANCE – continuation of care and management of the patient when the maximum therapeutic value of a Medically Appropriate/Medically Necessary treatment plan has been achieved, no additional functional improvement is apparent or expected to occur, the provision of Covered Services for a condition ceases to be of therapeutic value and is no longer Medically Appropriate/Medically Necessary. MANAGED CARE ORGANIZATION (MCO) – a generic term for any organization that manages and controls medical service. It includes HMOs, PPOs and managed indemnity insurance programs. MASTER’S PREPARED THERAPIST (for Mental Illness Care) – a therapist who holds a Master’s Degree in an acceptable human services-related field of study and is licensed as a therapist at an independent practice level by the appropriate state authority to provide therapeutic services for the treatment of Mental Illness Care.

MAXIMUM - a limit on the amount of benefits for Covered Services that a Covered Person may receive. The Maximum may apply to all Covered Services or selected types. A Maximum may be expressed in dollars, number of days or number of services for a specified period of time. There are two (2) types of Maximums, as defined below: A. Benefit Period Maximum - the greatest amount of benefits for a specific Covered Service

that a Covered Person may receive in a Benefit Period. B. Lifetime Maximum - the greatest amount of benefits for Covered Services that a Covered

Person may receive in his or her lifetime. MEDICAL FOOD - means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a Physician. MEDICAL POLICY – Medical Policy is used to determine whether Covered Services are Medically Necessary. Medical Policy is developed based on various sources including, but not limited to, peer-reviewed scientific literature published in journals and textbooks, guidelines promulgated by governmental agencies and respected professional organizations and recommendations of experts in the relevant medical specialty. MEDICALLY APPROPRIATE/MEDICALLY NECESSARY or MEDICAL APPROPRIATENESS/ MEDICAL NECESSITY - means or describes a Covered Service that a Professional Provider, exercising his or her prudent clinical judgment, would provide to a Covered Person for the purpose of evaluating, diagnosing or treating an Illness, Injury, disease or its symptoms and that is: (a) in accordance with the Generally Accepted Standards of

SAMPLE


Medical Practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Person’s Illness, Injury or disease; (c) not primarily for the convenience of the Covered Person or the Professional Provider; and (d) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the Covered Person’s Illness, Injury or disease. MEDICAL SCREENING EVALUATION - an examination and evaluation within the capability of the Hospital’s emergency department, including ancillary services routinely available to the emergency department, performed by qualified personnel. MEDICARE - the programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended. MEDICARE ALLOWABLE PAYMENT FOR FACILITIES – the payment amount as determined by the Medicare program for the Covered Service for a Facility Provider. MEDICARE ANCILLARY ALLOWABLE PAYMENT – the payment amount as determined by the Medicare program for the Covered Service for an Ancillary Provider. MEDICARE PROFESSIONAL ALLOWABLE PAYMENT – the payment amount as determined by the Medicare program for the Covered Service based on the Medicare Par Physician Fee Schedule – New Jersey Locality 01. MENTAL ILLNESS - a behavioral, psychological or biological dysfunction. Mental Illness includes a biologically-based Mental Illness as well as a Mental Illness that is not biologically-based. With respect to Mental Illness that is biologically-based, Mental Illness means a condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the Illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder, paranoia and other psychotic disorders; obsessive-compulsive disorder, panic disorder and Pervasive Developmental Disorders (PDD) or autism. The current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association may be consulted to identify conditions that are considered Mental Illness. NETWORK ANCILLARY PROVIDER – an Ancillary Provider that is part of the Point-of-Service Network and has agreed to a rate of reimbursement determined by contract for the provision of Covered Services to Covered Persons at the Network level of benefits. NETWORK BENEFITS – the benefits shown in the Schedule of Benefits which are provided if the Primary Care Physician provides care, treatment, services, and supplies to the Covered Person or if the Primary Care Physician refers the Covered Person to another Provider for such care, treatment, services, and supplies. NETWORK FACILITY PROVIDER - a Facility Provider that is part of the Point-of-Service Network and has agreed to a rate of reimbursement determined by contract for the provision of Covered Services to Covered Persons at the Network level of benefits.

SAMPLE


NETWORK PROFESSIONAL PROVIDER - a Professional Provider that is part of the Point-of-Service Network and has agreed to a rate of reimbursement determined by contract for the provision of Covered Services to Covered Persons at the Network level of benefits. NETWORK PROVIDER - a Facility Provider, Professional Provider or Ancillary Provider that is part of the Point-of-Service Network and has agreed to a rate of reimbursement determined by contract for the provision of Covered Services to Covered Persons at the Network level of benefits. NON-HOSPITAL FACILITY - a Facility Provider, licensed by the New Jersey Department of Health and approved by the Carrier, for the care or treatment of Drug dependent persons, except for transitional living facilities. Non-Hospital Facilities shall include, but not be limited to, Residential Treatment Facilities and Free Standing Ambulatory Care Facilities for Partial Hospitalization Programs. NON-HOSPITAL RESIDENTIAL TREATMENT - the provision of medical, nursing, counseling, or therapeutic services to Covered Persons suffering from Substance Abuse in a residential environment, according to individualized treatment plans. NON-NETWORK ANCILLARY PROVIDER – an Ancillary Provider that is not part of the Point-of-Service Network. NON-NETWORK BENEFITS – the benefits shown in the Schedule of Benefits which are provided if the Primary Care Physician does not authorize the care, treatment, services, and supplies. NON-NETWORK FACILITY PROVIDER - a Facility Provider that is not part of the Point-of-Service Network. NON-NETWORK PROFESSIONAL PROVIDER - a Professional Provider who has is not part of the Point-of-Service Network. NON-NETWORK PROVIDER – a Facility Provider, Professional Provider or Ancillary Provider that is not part of the Point-of-Service Network. ORTHOTIC APPLIANCE - means a brace or support but does not include fabric and elastic supports, corsets, arch supports, trusses, elastic hose, canes, crutches, cervical collars, dental appliances or other similar devices carried in stock and sold by drug stores, department stores, corset shops or surgical supply facilities. ORTHOTIC DEVICES – means the following orthotics that are not Orthotic Appliances: arch supports where required for the prevention or treatment of complications associated with diabetes; elastic knee braces; prefabricated orthotics; cervical collars; over-the-counter corsets; elastic hose; thoracic rib belts; fabric and elastic supports such as socks; dental orthotics; or other similar devices. OUT-OF-POCKET LIMIT - a specified dollar amount of expense Incurred by a Covered Person for Covered Services in a Benefit Period. The Out-of-Pocket Limits are calculated as follows: A. The Network Out-of-Pocket Limit expense includes Copayments, Coinsurance and

Deductibles, if applicable. The Network Out-of-Pocket Limit is a combined maximum of

SAMPLE


medical and prescription drug benefits, and any pediatric vision and pediatric dental benefits if made a part of this Plan. When the Network Out-of-Pocket Limit is reached, no additional Copayments, Coinsurance or Deductibles, if applicable, will be required for the balance of that Benefit Period.

B. The Non-Network Out-of-Pocket Limit expense includes Coinsurance, but does not include

any Deductible, Penalties, or Copayment amounts. When the Non-Network Out-of-Pocket Limit is reached, the level of benefits is increased as specified in the Schedule of Benefits.

OUTPATIENT CARE or OUTPATIENT - medical, nursing, counseling or therapeutic treatment provided to a Covered Person who does not require an overnight stay in a Hospital or other Inpatient Facility. OUTPATIENT DIABETIC EDUCATION PROGRAM - a program of diabetes self-management education including information on proper diet, provided by a dietitian registered by a nationally recognized professional association of dietitians or a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators or a registered pharmacist qualified with regard to management education for diabetes by any institution recognized by the board of pharmacy of the state of issue of the Contract. Covered Services include Outpatient sessions that include, but may not be limited to, the following information: A. Initial assessment of the patient’s needs; B. Family involvement and/or social support; C. Psychological adjustment for the patient; D. General facts/overview in diabetes; E. Nutrition, including its impact on blood glucose levels; F. Exercise and activity; G. Medications; H. Monitoring and use of the monitoring results; I. Prevention and treatment of complications for chronic diabetes, (i.e., foot, skin and eye

care); J. Use of community resources; and K. Pregnancy and gestational diabetes, if applicable. PARTIAL HOSPITALIZATION - structured and medically supervised day, evening and/or night treatment programs. Therapeutic services are provided to patients at least four (4) hours per day, and are available at least three (3) days per week in a Hospital or other Facility Provider. The program is designed for a patient who does not require Inpatient confinement, but would benefit from more intensive services than are offered in Outpatient treatment. PENALTY - a reduction in benefits payable, which the Covered Person is assessed, for failure to obtain Precertification of certain Covered Services. Penalties, if any, are identified in the Schedule of Benefits and explained in detail in the Managed Care section. PERVASIVE DEVELOPMENTAL DISORDERS (PDD) - disorders characterized by severe and pervasive impairment in several areas of development: reciprocal social interaction skills,

SAMPLE


communication skills, or the presence of stereotyped behavior, interests and activities. Examples are Asperger's syndrome and childhood disintegrative disorder. PHYSICIAN - a person who is a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.), licensed, and legally entitled to practice medicine in all its branches, perform Surgery and dispense drugs. PLAN OF TREATMENT - a plan of care which is prescribed in writing by a Professional Provider for the treatment of an Injury or Illness. The Plan of Treatment should include goals and duration of treatment, and be limited in scope and extent to that care which is Medically Appropriate/Medically Necessary for the Covered Person's diagnosis and condition. POINT-OF-SERVICE NETWORK – the geographical area within which Covered Services are provided for Covered Persons by the Carrier’s Network Providers. PRECERTIFICATION or PRECERTIFY – prior assessment by the Carrier or designated agent that proposed services, such as hospitalization, are Medically Appropriate/Medically Necessary for a Covered Person and covered by this Plan. If the prior assessment is not requested for the proposed services, a Penalty may be applied. Payment for services depends on whether the Covered Person and the category of service are covered under this Plan. PRENOTIFICATION or PRENOTIFY – the requirement that a Covered Person provide prior notice to the Carrier that proposed services, such as maternity care, are scheduled to be performed. No Penalty will be applied for failure to comply with this requirement. Payment for services depends on whether the Covered Person and the category of service are covered under this Plan. PREVENTIVE CARE – Preventive Care means: A. Evidence-based items or services that are rated “A” or “B” in the current recommendations

of the United States Preventive Services Task Force with respect to the Covered Person; B. Immunizations for routine use for Covered Persons of all ages as recommended by the

Advisory Committee on Immunization Practices of the Centers of Disease Control and Prevention with respect to the Covered Person;

C. Evidence-informed preventive care and screenings for Covered Persons who are infants,

children, and adolescents, as included in the comprehensive guidelines supported by the Health Resources and Services Administration;

D. Evidence-informed preventive care and screenings for female Covered Persons as

included in the comprehensive guidelines supported by the Health Resources and Services Administration; and

E. Any other evidence-based or evidence-informed items as determined by the federal and/or

state law. Examples of Preventive Care include, but are not limited to routine physical examinations, including related laboratory tests and X-rays; immunizations and vaccines; well baby care; pap smears; mammography; screening tests, including colorectal cancer and prostate cancer screenings; and bone density tests.

SAMPLE


PRIMARY CARE – basic, routine medical care traditionally provided to individuals with common Illnesses and Injuries and chronic Illnesses. PRIMARY CARE PHYSICIAN - a Network Professional Provider selected by the Covered Person who supervises, coordinates, arranges and provides initial care, Preventive Care, and basic medical services to a Covered Person, initiates a Covered Person’s Referral for Specialist Services; and is responsible for maintaining continuity of patient care. A list of Primary Care Physicians is contained in the Point-of-Service Network directory under "Primary Care Physicians" (General Practice, Family Practice or Internal Medicine) or "Pediatricians". PRIVATE DUTY NURSING - Medically Appropriate/Medically Necessary Outpatient continuous skilled nursing services provided to a Covered Person by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). PROFESSIONAL PROVIDER - a person or practitioner certified, registered or licensed and performing services within the scope of such licensure. The Professional Providers are: Audiologist Optometrist Certified Registered Nurse Physical Therapist Chiropractor Physician Dentist Podiatrist Independent Clinical Laboratory Psychologist Licensed Clinical Social Worker Registered Dietitian Master’s Prepared Therapist Speech-language Pathologist Nurse Midwife Teacher of the hearing impaired For purposes of Applied Behavior Analysis as included in the Diagnosis and Treatment of Autism and Other Developmental Disabilities provision, Professional Provider also includes a person who is credentialed by the national Behavior Analyst Certification Board as either a Board Certified Behavior Analyst – Doctoral or as a Board Certified Behavior Analyst. PROSTHETIC APPLIANCE - means any artificial device that is not surgically implanted and that is used to replace a missing limb, appendage, or any other external human body part including devices such as artificial limbs, hands, fingers, feet and toes, but excluding dental appliances and largely cosmetic devices such as artificial breasts, eyelashes, wigs, or other devices which could not by their use have a significantly detrimental impact upon the musculoskeletal functions of the body. PROSTHETICS or PROSTHETIC DEVICES – devices (except dental prosthetics or Prosthetic Appliances), which replace all or part of: (a) an absent body organ including contiguous tissue; or (b) the function of a permanently inoperative or malfunctioning body organ. PROVIDER - a licensed Facility Provider, licensed Professional Provider or licensed Ancillary Provider. PSYCHIATRIC HOSPITAL - a Facility Provider, approved by the Carrier, which is primarily engaged in providing diagnostic and therapeutic services for the Inpatient treatment of Mental Illness. Such services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing services are provided under the supervision of a Registered Nurse.

SAMPLE


PSYCHOLOGIST - a Psychologist who is licensed in the state in which he practices; or a Psychologist who is otherwise duly qualified to practice by a state in which there is no Psychologist licensure. QUALIFIED INDIVIDUAL (for Qualifying Clinical Trials) – a Covered Person who meets the following conditions: • The Covered Person is eligible to participate in an approved clinical trial according to the

trial protocol with respect to treatment of cancer or other Life-Threatening Disease or Condition; and

• Either: • The referring health care professional is a health care provider participating in the clinical

trial and has concluded that the Covered Person’s participation in such trial would be appropriate based upon the individual meeting the conditions described above; or

• The Covered Person provides medical and scientific information establishing that their participation in such trial would be appropriate based upon the Covered Person meeting the conditions described above.

QUALIFYING CLINICAL TRIAL - a Phase I, II, III, or IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other Life-Threatening Disease or Condition and is described in any of the following: A. Federally funded trials: the study or investigation is approved or funded (which may

include funding through in-kind contributions) by one or more of the following: 1. The National Institutes of Health (NIH); 2. The Centers for Disease Control and Prevention (CDC); 3. The Agency for Healthcare Research and Quality (AHRQ); 4. The Centers for Medicare and Medicaid Services (CMS); 5. Cooperative group or center of any of the entities described in 1 through 4 above, or

the Department of Defense (DOD) or the Department of Veterans Affairs (VA); 6. Any of the following if the Conditions for Departments are met:

a. The Department of Veterans Affairs (VA); b. The Department of Defense (DOD); or c. The Department of Energy (DOE).

B. The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or

C. The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

In the absence of meeting the criteria listed above, the clinical trial must be approved by the Carrier as a Qualifying Clinical Trial. REFERRAL or REFERRED – written or electronic documentation from the Covered Person’s Primary Care Physician that authorizes Covered Services to be rendered by the Network Provider specifically named on the Referral. Referrals to Non-Network Providers must be preapproved by the Carrier as set forth in the The Point-of-Service Network Plan section. A Referral must be issued to the Covered Person prior to receiving Covered Services and is valid for ninety (90) days from the date of issue for an Enrolled Covered Person.

SAMPLE


REFERRED SPECIALIST – a Provider who provides Covered Specialist Services within his or her specialty and upon Referral from a Primary Care Physician. In the event there is no Network Provider to provide these services, Referral to a Non-Network Provider will be arranged by the Covered Person’s Primary Care Physician with preapproval by the Carrier. See the The Point-of-Service Network Plan section for procedures for obtaining preapproval for use of a Non-Network Provider. A Referred Specialist also includes Network Professional Providers that provide the following designated services without a Referral: (a) obstetrician or gynecologist specialist who provides services to female Covered Persons; and (b) dialysis. REGISTERED DIETITIAN (RD) - a dietitian registered by a nationally recognized professional association of dietitians. A Registered Dietitian (RD) is a food and nutrition expert who has met the minimum academic and professional requirements to qualify for the credential “RD.” REGISTERED NURSE (R.N.) - a nurse who has graduated from a formal program of nursing education (diploma school, associate degree or baccalaureate program) and is licensed by the appropriate state authority. REHABILITATION HOSPITAL - a Facility Provider, approved by the Carrier, which is primarily engaged in providing rehabilitation care services on an Inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by Illness or Injury to achieve the highest possible level of functional ability. Services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing services are provided under the supervision of a Registered Nurse. RELIABLE EVIDENCE – Peer-reviewed reports of clinical studies that have been designed according to accepted scientific standards such that potential biases are minimized to the fullest extent, and generalizations may be made about safety and effectiveness of the technology outside of the research setting. Studies are to be published or accepted for publication, in medical or scientific journals that meet nationally recognized requirements for scientific manuscripts and that are generally recognized by the relevant medical community as authoritative. Furthermore, evidence-based guidelines from respected professional organizations and governmental entities may be considered Reliable Evidence if generally accepted by the relevant medical community. RESIDENTIAL TREATMENT FACILITY - a Facility Provider, licensed and approved by the appropriate government agency and approved by the Carrier, which provides treatment for Mental Illness or for Substance Abuse to partial, Outpatient or live-in patients who do not require acute medical care. This Facility Provider must also meet the New Jersey Department of Health minimum drug standards for client-to-staff ratios and staff qualifications. ROUTINE PATIENT COSTS ASSOCIATED WITH QUALIFYING CLINICAL TRIALS - routine patient costs include all items and services consistent with the coverage provided under this Plan that are typicallly covered for a Qualified Individual who is not enrolled in a clinical trial. Routine patient costs do not include: • The investigative item, device, or service itself; • Items and services that are provided solely to satisfy data collection and analysis needs

and that are not used in the direct clinical management of the patient; and • A service that is clearly inconsistent with widely accepted and established standards of

care for a particular diagnosis.

SAMPLE


SELF-INJECTABLE PRESCRIPTION DRUG or SELF-INJECTABLE DRUG – a Prescription Drug that: (a) is introduced into a muscle or under the skin by means of a syringe and needle; (b) can be administered safely and effectively by the patient or caregiver outside of medical supervision, regardless of whether initial medical supervision and/or instruction is required; and (c) is administered by the patient or caregiver. SEVERE SYSTEMIC PROTEIN ALLERGY – means allergic symptoms to ingested proteins of sufficient magnitude to cause weight loss or failure to gain weight, skin rash, respiratory symptoms, and gastrointestinal symptoms of significant magnitude to cause gastrointestinal bleeding and vomiting. SHORT PROCEDURE UNIT - a unit of a Hospital which is approved by the Carrier and which is designed to handle either lengthy diagnostic or minor surgical procedures on an Outpatient basis which would otherwise have resulted in an Inpatient stay in the absence of a Short Procedure Unit. SKILLED NURSING FACILITY - an institution or a distinct part of an institution, other than one which is primarily for the care and treatment of Mental Illness, tuberculosis, or Substance Abuse, which: A. Is accredited as a Skilled Nursing Facility or extended care facility by the Joint

Commission on Accreditation of Healthcare Organizations; or B. Is certified as a Skilled Nursing Facility or extended care facility under the Medicare Law;

or C. Is otherwise acceptable to the Carrier. SLEEP STUDIES – the continuous and simultaneous monitoring and recording of various physiological and pathophysiologic sleep parameters. Sleep tests are performed to diagnose sleep disorders (e.g., narcolepsy, sleep apnea, parasomnias) and/or evaluate an individual’s response to therapies such as continuous positive airway pressure (CPAP). SPECIALIST SERVICES – all services providing medical or mental health/psychiatric care in any generally accepted medical or surgical specialty or subspecialty. SPECIALTY DRUG – a medication that meets certain criteria, including but not limited to: • The drug is used in the treatment of a rare, complex, or chronic disease (e.g., hemophilia); • A high level of involvement is required by a health care Provider to administer the drug; • Complex storage and/or shipping requirements are necessary to maintain the drug’s

stability; • The drug requires comprehensive patient monitoring and education by a health care

Provider regarding safety, side effects, and compliance; • Access to the drug may be limited. STANDARD INJECTABLE DRUG – a medication that is either injectable or infusible but is not defined by the Carrier as a Self-Injectable Drug or a Specialty Drug. Standard Injectable Drugs include but are not limited to allergy injections and extractions, and injectable medications such as antibiotics and steroid injections that are administered by a Professional Provider.

SAMPLE


SUBSTANCE ABUSE - any use of alcohol, drugs, or narcotics which produces a pattern of pathological use causing impairment in social or occupational functions or which produces physiological dependency evidenced by physical tolerance or withdrawal. SURGERY - the performance of generally accepted operative and cutting procedures including specialized instrumentations, endoscopic examinations and other invasive procedures. Payment for Surgery includes an allowance for related Inpatient preoperative and postoperative care. Treatment of burns, fractures and dislocations are also considered Surgery. SURROGATE – a female who carries an embryo that was formed from her own egg inseminated by the sperm of a designated sperm donor. THERAPY SERVICE - the following services or supplies prescribed by a Physician and used for the treatment of an Illness or Injury to promote the recovery of the Covered Person: A. CARDIAC REHABILITATION THERAPY - medically supervised rehabilitation program

designed to improve a Covered Person’s tolerance for physical activity or exercise. B. CHEMOTHERAPY - treatment of malignant disease by chemical or biological

antineoplastic agents, monoclonal antibodies, bone marrow stimulants, antiemetics, and other related biotech products.

C. DIALYSIS - treatment of an acute renal failure or chronic irreversible renal insufficiency for

removal of waste materials from the body. D. INFUSION THERAPY - treatment including, but not limited to infusion or inhalation,

parenteral and enteral nutrition, antibiotic therapy, pain management and hydration therapy, or any other drug that requires administration by a health care Provider. Infusion Therapy includes all professional services, supplies, and equipment that are required to safely and effectively administer the therapy. Infusion may be provided in a variety of settings (e.g., home, office, Outpatient) depending on the level of skill required to prepare the drug, administer the infusion, and monitor the Covered Person. The type of health care Provider who can administer the infusion depends on whether the drug is considered to be a Specialty Drug infusion or a Standard Injectable Drug infusion, as determined by the Carrier. Also included is the home treatment of bleeding episodes associated with hemophilia, including the purchase of blood products and blood infusion equipment.

E. OCCUPATIONAL THERAPY - medically prescribed treatment concerned with improving

or restoring neuromusculoskeletal functions which have been impaired by Illness or Injury, congenital anomaly or prior therapeutic intervention. Occupational Therapy also includes medically prescribed treatment concerned with improving the Covered Person's ability to perform those tasks required for independent functioning where such function has been permanently lost or reduced by Illness or Injury, congenital anomaly or prior therapeutic intervention. This does not include services specifically directed towards the improvement of vocational skills and social functioning. Exception: For a Covered Person who has been diagnosed with a biologically-based Mental Illness, Occupational Therapy means treatment to develop a Covered Person’s ability to perform the ordinary tasks of daily living.

F. ORTHOPTIC/PLEOPTIC THERAPY - medically prescribed treatment for the correction of

oculomotor dysfunction resulting in the lack of vision depth perception. Such dysfunction

SAMPLE


results from vision disorder, eye Surgery, or Injury. Treatment involves a program which includes evaluation and training sessions.

G. PHYSICAL THERAPY - medically prescribed treatment of physical disabilities or

impairments resulting from disease, Injury, congenital anomaly, or prior therapeutic intervention by the use of therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and the functional activities of daily living. Exception: For a Covered Person who has been diagnosed with a biologically-based Mental Illness, Physical Therapy means treatment to develop a Covered Person’s physical function.

H. PULMONARY REHABILITATION THERAPY - multidisciplinary treatment which combines

Physical Therapy with an educational process directed at stabilizing pulmonary diseases and improving functional status.

I. RADIATION THERAPY - treatment of disease by X-ray, gamma ray, accelerated

particles, mesons, neutrons, radium, radioactive isotopes, or other radioactive substances regardless of the method of delivery.

J. SPEECH THERAPY - medically prescribed treatment of speech and language disorders

due to disease, surgery, Illness or Injury, congenital and developmental anomalies, or previous therapeutic processes that result in communication disabilities and/or swallowing disorders. Exception: For a Covered Person who has been diagnosed with a biologically-based Mental Illness, Speech Therapy means treatment of a speech impairment.

TOTAL DISABILITY or TOTALLY DISABLED - means that an Enrolled Employee, due to Illness or Injury, cannot perform any duty of his or her occupation or any occupation for which the Employee is, or may be, suited by education, training and experience, and the Employee is not, in fact, engaged in any occupation for wage or profit. A Dependent is Totally Disabled if he or she is incapable of self-sustaining employment by reason of intellectual disability or physical handicap. The Totally Disabled person must be under the regular care of a Physician. URGENT CARE – Covered Services provided in order to treat a sudden Illness or Accidental Injury that requires prompt medical attention but is not life threatening. Urgent Care is not the same as Emergency Care. Examples of Urgent Care services include stitches and X-rays. Examples of sudden Illnesses or Accidental Injuries that are considered Urgent Care include fractures, sprains, ear infections, sore throats, and rashes. URGENT CARE CENTER – a Facility Provider designed to offer immediate evaluation and treatment for acute health conditions that require medical attention in a non-Emergency situation. It is recommended that the Covered Person call the Urgent Care Center to confirm that they offer the services the Covered Person may need. WAR – includes, but is not limited to, declared War, and armed aggression by one or more countries resisted on orders of any other country, combination of countries or international organization.

SAMPLE


THE POINT-OF-SERVICE NETWORK PLAN

The Point-of-Service Network Plan is a program, which requires a Covered Person to select a Primary Care Physician (PCP), as outlined in the “Covered Person/Provider Relationship” subsection of the General Information section of this booklet/certificate. The PCP will supervise and coordinate a Covered Person’s health care in the Point-of-Service Network. The PCP must authorize all services and supplies, except those which are reflected in the “Direct Access to Certain Care” subsection that follows. In addition, the PCP will refer the Covered Person to the appropriate Professional Provider and Facility Provider when Medically Appropriate/Medically Necessary. A Covered Person must obtain an authorized Referral from their PCP before visiting another Professional Provider, Ancillary Provider or Facility Provider. Except in the case of Emergency Care or Urgent Care, if a Covered Person does not comply with these requirements, a Covered Person may only be provided Non-Network Benefits. See the “How to Obtain a Specialist Referral” subsection that follows. The Carrier provides Network Benefits for Covered Services furnished to a Covered Person when authorized by the Covered Person’s PCP. The Carrier pays Non-Network Benefits when Covered Services are not authorized by the PCP. However, if the PCP refers a Covered Person to a Non-Network Provider for a service or supply, the service or supply shall be covered as if it was a Network Covered Service . The Carrier is fully responsible for payment to the Provider and a Covered Person is only responsible for any applicable Network Cost-Sharing. When a Covered Person uses the services of a PCP, a Covered Person must present their Identification Card and pay the required Copayment. When the PCP refers the Covered Person to another Network Provider, the Covered Person must pay the Copayment to such Provider. When a Covered Person uses the services of a Non-Network Provider, a Covered Person may need to file a claim. If a Covered Person uses the services of a Provider without having been Referred by their PCP, that Covered Person is not eligible for Network Benefits. Except as stated below, for services which have not been Referred by the PCP, whether provided by a Network Provider or otherwise, a Covered Person will receive Non-Network Benefits. Exception: If a Covered Person is admitted to a Network Facility by a Non-Network Provider, the Network Facility will nevertheless be paid Network Benefits. A directory of the Network Providers who belong to the Point-of-Service Network is available upon request. It will identify the Professional Providers who have agreed to become Network Professional Providers; the Hospitals in the Point-of-Service Network with which the Network Professional Providers are affiliated; and the Ancillary Providers affiliated with the Point-of-Service Network. The directory is updated periodically throughout the year, and the Carrier reserves the right to add or delete Physicians and/or Hospitals at any given time, in accordance with N.J.A.C. 11:24A-4.8(c). It is important to know that continued participation of any one doctor, Hospital or other Provider cannot be guaranteed. For information regarding Providers that participate in the Point-of-Service Network, call 1-800-275-2583 (TTY:711). The Carrier covers only care that is Medically Appropriate/Medically Necessary. Medically Appropriate/Medically Necessary care is care that is needed for a particular condition and that is received at the most appropriate level of service. Examples of different levels of service are Hospital Inpatient care, treatment in Short Procedure Units and Hospital Outpatient Care.

SAMPLE


Some of the services received through this Plan must be Precertified before a Covered Person receives them, to determine whether they are Medically Appropriate/Medically Necessary. Failure to Precertify services to be provided by a Non-Network Provider, when required, may result in a reduction of benefits. Precertification of services is a vital program feature that reviews the Medically Appropriateness/Medically Necessity of certain procedures/admissions. In certain cases, Precertification helps determine whether a different treatment may be available that is equally effective. Precertification also helps determine the most appropriate setting for certain services. Innovations in health care enable doctors to provide services, once provided exclusively in an Inpatient setting, in many different settings – such as an Outpatient department of a Hospital or a doctor’s office. When a Covered Person seeks medical treatment that requires Precertification, that Covered Person is not responsible for obtaining the Precertification if treatment is provided by a Network Provider, i.e., a Provider in the Point-of-Service Network. The Network Provider is responsible for obtaining Precertification. In addition, if the Network Provider fails to obtain a required Precertification of services, the Covered Person will be held harmless from any associated financial Penalties assessed by this Plan as a result. If the request for Precertification is denied, the Covered Person will be notified in writing that the admission/service will not be paid because it is not Medically Appropriate/Medically Necessary. When a Covered Person seeks treatment from a Non-Network Provider, the Covered Person is are responsible for initiating the Precertification process. The Covered Person should instruct the Provider to call the Precertification number listed on the back of their Identification Card, and give the Covered Person’s name, facility’s name, diagnosis, and procedure or reason for admission. Failure to request Precertification for required services will result in a reduction of benefits payable to the Covered Person. More information on Precertification is found in the Managed Care section. A. DIRECT ACCESS TO CERTAIN CARE

The Covered Person does not need a Referral for the following Covered Services: • Emergency Care; • Care from a Network obstetrical/gynecological care specialist; • Mammograms; • Mental Illness Care and Treatment for Substance Abuse; • Inpatient Hospital services that require preapproval (this does not include a maternity

Inpatient stay); • Dialysis services performed in a Network Facility Provider or by a Network

Professional Provider; • Diabetic Education Program visits; and

SAMPLE


• Nutrition Counseling for Weight Management visits

B. HOW TO OBTAIN A SPECIALIST REFERRAL Always consult the PCP first when medical care is needed, except for medical conditions requiring Emergency Care. If a PCP refers a Covered Person to a Network Provider, the Covered Person should follow these steps: 1. The PCP will give the Covered Person a written Referral form or supply an electronic

form which indicates the services authorized. 2. The Referral is valid for ninety (90) days from issue date as long as Covered Person

remains Enrolled in the Plan. 3. The Covered Person can give this form to the Referred Network Provider (specialist),

or it can be sent electronically to the Referred Specialist before the services are performed. Only services authorized on the Referral form will be covered.

4. Any additional Medically Appropriate/Medically Necessary treatment recommended

by the Referred Specialist beyond the ninety (90) days from the date of issue of the initial Referral will require another written or electronic Referral from the PCP.

5. A Covered Person must be Enrolled at the time services are received from a

Referred Specialist in order for such services to be covered.

C. PREAPPROVAL FOR NON-NETWORK PROVIDERS A Covered Person may request the Carrier’s approval to use Non-Network Providers to provide Covered Services where there are no Network Providers that can provide the requested Covered Services. However, the Carrier’s approval is not required to use Non-Network Providers for Emergency Care and Urgent Care. All terms and conditions of this Plan will apply to the Covered Services provided by the Non-Network Provider. A Covered Person should contact their PCP prior to receiving care from a Non-Network Provider. Authorization from the Carrier to receive care from a Non-Network Provider will be arranged by the PCP.

D. PAYMENT OF PROVIDERS 1. Network Provider Reimbursement

Network reimbursement programs for health care Providers are intended to encourage the provision of quality, cost-effective care for Covered Persons. Set forth below is a general description of Point-of-Service reimbursement programs, by type of Point-of-Service Network health care Provider. Please note that these programs may change from time to time, and the arrangements with particular Providers may be modified as new contracts are negotiated. If Covered Persons have any questions about how the health care Provider is compensated, please speak with the healthcare Provider directly or

SAMPLE


contact the Carrier’s Customer Service Department. a. Physicians

Most Primary Care Physicians (PCPs) are paid on a per member per month fee basis that the PCP has agreed to accept as set forth by contract with the Carrier. Certain Point-of-Service Network Physicians, including specialists, are paid on a fee-for-service basis, meaning that payment is made according to the Carrier’s Point-of-Service fee schedule for the specific medical services that the Physician performs.

b. Institutional Providers Hospitals: For most Inpatient medical and surgical services, Hospitals are paid per diem rates, which are specific amounts paid for each day a Covered Person is in the Hospital. These rates usually vary according to the intensity of the Covered Services provided. Some Hospitals are also paid case rates, which are set dollar amounts paid for a complete Hospital stay related to a specific procedure or diagnosis, e.g., transplants. For most Outpatient procedures and Emergency Care, most Hospitals are paid specific rates based on the type of Covered Service performed. For a few Covered Services, Hospitals are paid based on a percentage of Billed Charges. For certain Covered Services, such as radiology and therapy services, the Carrier may pay a “per member per month” fee to selected Outpatient Hospital Departments. Most Hospitals are paid through a combination of the above payment mechanisms for various services. Skilled Nursing Facilities, Rehabilitation Hospitals, and other care facilities: Most Skilled Nursing Facilities and other special care facilities are paid per diem rates, which are specific amounts paid for each day a Covered Person is in the facility. These amounts may vary according to the intensity of the Covered Services provided. Ambulatory Surgical Facilities (ASFs): Most ASFs are paid specific rates based on the type of Covered Service performed. For a few services, some ASFs are paid based on a percentage of Billed Charges.

c. Physician Group Practices, Physician Associations and Integrated Delivery Systems Certain physician group practices, independent physician associations (IPAs) and integrated hospital/physician organizations called Integrated Delivery Systems (IDS) employ or contract with individual physicians to provide medical services. These groups are paid as described in the Physicians Reimbursement section outlined above. These groups may pay their affiliated physicians a salary and/or provide incentives based on production, quality, service, or other performance standards.

d. Ancillary Service Providers, certain Facility Providers and Mental Health/Substance Abuse Providers

SAMPLE


Ancillary service Providers, such as Durable Medical Equipment Providers, laboratory Providers, Home Health Care Agencies, and Mental Illness Care and Substance Abuse Providers are paid on the basis of fee-for-service payments according to the Carrier’s Point-of-Service fee schedule for the specific Covered Services performed. In some cases, such as for Mental Illness Care and Substance Abuse benefits, one (1) vendor arranges for all such services through a contracted set of Providers. The Carrier reimburses some of these contracted Providers of these vendors on a fee-for-service basis. Others, however, are paid on a “per member per month” basis for certain services. An affiliate of AmeriHealth Insurance Company of New Jersey has less than a three percent (3%) ownership interest in this Mental Illness Care and Substance Abuse vendor

2. Payment Methods A Covered Person or the Provider may submit bills directly to the Carrier, and, to the extent that benefits and indemnity are payable within the terms and conditions of this Plan, reimbursement will be furnished as detailed below. The Covered Person’s benefits for Covered Services are based on the rate of reimbursement as defined under “Covered Expense” in the Defined Terms section. a. Facility Providers

(1) Network Facility Providers

Network Facility Providers are part of the Point-of-Service Network and have a contractual arrangement with the Carrier for the provision of services to Covered Persons. Benefits will be provided as specified in the Schedule of Benefits for Covered Services which have been performed by a Network Facility Provider. The Carrier will compensate Network Facility Providers in accordance with the contracts entered into between such Providers and the Carrier. No payment will be made directly to the Covered Person for Covered Services rendered by any Network Facility Provider. If the Covered Person is confined to a Network Facility Provider, benefits provided by a Non-Network Professional Provider will be provided at the Network level detailed in the Schedule of Benefits.

(2) Non-Network Facility Providers Non-Network Facility Providers are not part of the Point-of-Service Network, and do not have a contract with the Carrier. The Carrier will provide benefits for Covered Services provided by a Non-Network Facility Provider at the Non-Network Coinsurance level specified in the Schedule of Benefits. The reimbursement rate is specified under “Covered Expense” in the Defined Terms section. If the Carrier determines that Covered Services were for Emergency Care as defined herein, the Covered Person will not be subject to the Cost-

SAMPLE


Sharing that would ordinarily be applicable to Non-Network services. The Carrier should be notified within two (2) business days of the Emergency admission, or as soon as reasonably possible. Payment for Emergency Care provided by Non-Network Providers will be the greater of (a) the median of amounts paid to Network Providers for Emergency Care; (b) the amount paid to Non-Network Facility Providers; or (3) the amount paid by Medicare.

b. Professional Providers (1) Network Professional Provider Reimbursement

The Carrier is authorized by the Covered Person to make payment directly to the Network Professional Providers furnishing Covered Services for which benefits are provided under this Plan. Network Professional Providers have agreed to accept the rate of reimbursement determined by a contract as payment in full for Covered Services. Network Professional Providers will make no additional charge to Covered Persons for Covered Services except in the case of Cost Sharing as specified under this Plan. The Covered Person is responsible to pay, or make arrangements to pay, such amounts to the Network Professional Provider. Benefit amounts, as specified in the Schedule of Benefits of this coverage, refer to Covered Services rendered by a Professional Provider which are regularly included in such Provider's charges and are billed by and payable to such Provider. Any dispute between the Network Professional Provider and a Covered Person with respect to balance billing shall be submitted to the Carrier for determination.

(2) Emergency Care by Non-Network Providers If the Carrier determines that Covered Services provided by a Non-Network Provider were for Emergency Care, the Covered Person will be subject to the Network Cost-Sharing levels. Penalties that ordinarily would be applicable to Non-Network Covered Services will not be applied. The Carrier should be notified within two (2) business days of the Emergency admission, or as soon as reasonably possible. For Emergency Care, unless benefits have been assigned to the Provider, the Carrier will reimburse the Covered Person for Covered Services at the Network Provider reimbursement rate. For payment of Covered Services provided by a Non-Network Provider, please refer to the definition of “Covered Expense” in the Defined Terms section. Payment for Emergency Care provided by Non-Network Providers will be the greater of (a) the median of amounts paid to Network Providers for Emergency Care; (b) the amount paid to Non-Network Facility Providers; or (3) the amount paid by Medicare. A Non-Network Provider who provided Emergency Care can bill a Covered Person directly for their services, for either the Provider’s charges or amounts in excess of the Carrier’s payment for the Emergency

SAMPLE


Care, i.e., “balance billing.” In such situations, the Covered Person should contact the Carrier’s Customer Service Department at the telephone number listed on the back of the I.D. card. Upon such notification, the Carrier will resolve the balance billing.

(3) Non-Network Hospital-Based Provider Reimbursement When a Covered Person receives Covered Services from a Non-Network Hospital-Based Provider as an Inpatient at a Network Hospital or other Network Facility Provider and is being treated by a Network Professional Provider, the Covered Person will receive the Network level of benefits for the Covered Services provided by the Non-Network Hospital-Based Professional Provider. For such Covered Services, unless benefits have been assigned to the Provider, payment will be made to the Covered Person, who will be responsible for reimbursing the Non-Network Hospital-Based Provider. For payment of Covered Services provided by a Non-Network Professional Provider, please refer to the definition of “Covered Expense” in the Defined Terms section. A Non-Network Hospital-Based Provider can bill a Covered Person directly for their services, for either the Provider’s charges or amounts in excess of the Carrier’s payment to the Non-Network Hospital-Based Providers, i.e., “balance billing.” In such situations, the Covered Person should contact the Carrier’s Customer Service Department at the telephone number listed on the back of the I.D. card. Upon such notification, the Carrier will resolve the balance billing. Note that when a Covered Person elects to see a Non-Network Hospital-Based Provider for follow-up care or any other service where the Covered Person has the ability to select a Network Provider, the Covered Services will be covered at a Non-Network level. Except for Emergency Care, if a Non-Network Provider admits a Covered Person to a Hospital or other Facility Provider, Covered Services provided by a Non-Network Hospital-Based Provider will be reimbursed at the Non-Network level. For such Covered Services, unless benefits have been assigned to the Provider, payment will be made to the Covered Person and the Covered Person will be responsible for reimbursing the Non-Network Professional Provider. For payment of Covered Services provided by a Non-Network Professional Provider, please refer to the definition of Covered Expense in the Defined Terms section.

(4) Inpatient Hospital Consultations by a Non-Network Professional Provider When a Covered Person receives Covered Services for an Inpatient Hospital consultation from a Non-Network Professional Provider as an Inpatient at a Network Facility Provider, and the Covered Services are referred by a Network Professional Provider, the Covered Person will receive the Network level of benefits for the Inpatient Hospital consultation.

SAMPLE


For such Covered Services, unless benefits have been assigned to the Provider, payment will be made to the Covered Person and the Covered Person will be responsible for reimbursing the Non-Network Professional Provider. For payment of Covered Services provided by a Non-Network Professional Provider, please refer to the definition of “Covered Expense” in the Defined Terms section. A Non-Network Professional Provider can bill a Covered Person directly for their services, for either the Provider’s charges or amounts in excess of the Carrier’s payment to the Non-Network Professional Providers, i.e., “balance billing.” In such situations, the Covered Person should contact the Carrier’s Customer Service Department at the telephone number listed on the back of the I.D. card. Upon such notification, the Carrier will resolve the balance billing. Note that when a Covered Person elects to see a Non-Network Professional Provider for follow-up care or any other service when the Covered Person has the ability to select a Network Provider, the Covered Services will be covered at a Non-Network level. Except for Emergency Care, if a Non-Network Professional Provider admits a Covered Person to a Hospital or other Facility Provider, services provided by Non-Network Professional Provider will be reimbursed at the Non-Network level. For such Covered Services, unless benefits have been assigned to the Provider, payment will be made to the Covered Person and the Covered Person will be responsible for reimbursing the Non-Network Professional Provider. For payment of Covered Services provided by a Non-Network Professional Provider, please refer to the definition of “Covered Expense” in the Defined Terms section.

(5) Non-Network Professional Provider Reimbursement Except as set forth above, when a Covered Person seeks care from a Non-Network Professional Provider, benefits will be provided to the Covered Person at the Non-Network Coinsurance level specified in the Schedule of Benefits. For payment of Covered Services provided by a Non-Network Professional Provider, please refer to the definition of “Covered Expense” in the Defined Terms section. When a Covered Person seeks care and receives Covered Services from a Non-Network Professional Provider, the Covered Person will be responsible to reimburse the Non-Network Professional Provider for the difference between the Carrier’s payment and the Non-Network Professional Provider's charge.

c. Ancillary Providers (1) Network Ancillary Providers

Network Ancillary Providers are part of the Point-of-Service Network and have a contractual relationship with the Carrier for the provision of services or supplies to Covered Persons. Benefits will be provided as specified in the Schedule of Benefits for the provision of services or

SAMPLE


supplies provided to Covered Persons by Network Ancillary Providers. The Carrier will compensate Network Ancillary Providers in the Point-of-Service Network in accordance with the contracts entered into between such Providers and the Carrier. No payment will be made directly to the Covered Person for Covered Services rendered by any Network Ancillary Provider.

(2) Non-Network Ancillary Providers Non-Network Ancillary Providers are not part of the Point-of-Service Network. Benefits will be provided to the Covered Person at the Non-Network Coinsurance level specified in the Schedule of Benefits. The Covered Person will be subject to the application of higher Cost-Sharing as detailed in the Schedule of Benefits. For payment of Covered Services provided by a Non-Network Ancillary Provider, please refer to the definition of “Covered Expense” in the Defined Terms section. When a Covered Person seeks care and receives Covered Services from a Non-Network Ancillary Provider, the Covered Person will be responsible to reimburse the Non-Network Ancillary Provider for the difference between the Carrier’s payment and the Non-Network Ancillary Provider's charge.

d. Assignment of Benefits to Providers The right of a Covered Person to receive benefit payments under this Plan is assignable in whole or in part to any Non-Network Provider. A Covered Person can assign benefit payments to the custodial parent of a Dependent covered under this Plan, as required by law.

E. DEDUCTIBLE A Covered Person must pay a portion of the covered medical expenses before the Carrier begins to pay for benefits. Please note that the Non-Network Deductible will apply if a Covered Person chooses to utilize a Network Provider without the required Referral. A Deductible must be met each Benefit Period before payment will be made for Covered Services. See the Schedule of Benefits section for the Deductible amount and the services to which the Deductible is applicable.

F. COINSURANCE Coinsurance is a percentage of the Covered Expenses that must be paid by a Covered Person; it is applied after the Deductible, if any, is met. Coinsurance is applied to most Covered Services, but not to Network Covered Services that require a Copayment. See the Schedule of Benefits for specific Coinsurance amounts.

G. COPAYMENT Copayment is a type of Cost-Sharing in which the Covered Person pays a flat dollar amount each time a Covered Service is provided. See the Schedule of Benefits for specific Copayment amounts. If the Provider’s allowable charge for a Covered Service is less than the Copayment amount, the Covered Person is only responsible to pay the

SAMPLE


Provider’s allowable charge. In such a case, the Provider is required to remit any overpayment directly to the Covered Person.

H. OUT-OF-POCKET LIMIT There is a Maximum placed on the amount of out-of-pocket expenses that a Covered Person is required to pay each Benefit Period. This Maximum is called the Out-of-Pocket Limit. The Network Out-of-Pocket Limit is a combined maximum of medical and prescription drug benefits, and any pediatric vision and pediatric dental benefits if made a part of this Plan. See the Schedule of Benefits for the Network and Non-Network Out-of-Pocket Limit amounts. When the Network or Non-Network Out-of-Pocket Limit is reached, the Carrier will pay 100% of the Covered Expenses for Network or Non-Network Covered Services Incurred during the balance of the Benefit Period. Out-of-Pocket expenses Incurred for Network Covered Services do not count toward the Non-Network Out-of-Pocket Limit. Out-of-Pocket expenses Incurred for Non-Network Covered Services do not count toward the Network Out-of-Pocket Limit. Penalties do not count toward the Non-Network Out-of-Pocket Limit.

I. LIFETIME MAXIMUM See the Schedule of Benefits for the Plan’s Lifetime Maximum.

J. HOW TO FILE A CLAIM A Covered Person is never required to file a claim when Covered Services are provided by Network Providers. When care is received from a Non-Network Provider, a Covered Person may need to file a claim to receive benefits. Call the Carrier’s Customer Service Department at the number listed on the back of the Identification Card for instructions on how to file a claim.

SAMPLE


ELIGIBILITY UNDER THIS PLAN Effective Date: The date the Group agrees that all eligible persons may apply and become covered for the benefits as set forth in this Plan and described in this booklet/certificate. If a person becomes eligible after the Group's Effective Date, that date becomes the eligible person’s Effective Date under this Plan. ELIGIBLE PERSON An Employee is eligible to be covered under this Plan if s/he is determined by the Group as eligible to Enroll for coverage. Eligibility shall not be affected by the Employee’s physical condition and eligibility for the coverage shall be determined by the employer. ELIGIBLE DEPENDENT An Employee’s family is eligible for coverage (Dependent coverage) under this Plan when an Employee is eligible for Employee coverage. An eligible Dependent is defined as: • A spouse under a legally valid existing marriage. A spouse shall include a civil union

partner pursuant to P.L. 2006, c. 103 as well as same sex relationships legally recognized in other jurisdictions when such relationships provide substantially all of the rights and benefits of marriage.

• A Dependent child who is under age twenty-six (26). A Dependent child includes: • a child whose coverage is the Employee’s responsibility under the terms of a

qualified Medical Child Support Order or Release; • a stepchild; • a legally adopted child, including a child pending formal adoption; • a child of the Employee’s civil union partner.

Eligibility will be continued for children who are incapable of self-support because of mental or physical incapacitation and who are dependent on the Employee for over half of their support. The Dependent child's mental or physical incapacitation must have commenced prior to age twenty-six (26). The Carrier may require proof of eligibility under the prior carrier's plan and also from time to time under this Plan. The newborn child(ren) of the Employee or the Employee’s Dependent shall be entitled to the benefits provided by this Plan from the date of birth. Coverage of such newborn children shall include care which is necessary for the treatment of medically diagnosed congenital defects, birth abnormalities, prematurity and routine nursery care. If payment of any additional premium is required to provide coverage for such child, the newborn child must be enrolled as a Dependent and the additional premium must be paid within thirty-one (31) days of birth in order to have the coverage continue beyond such thirty-one (31) day period. A newborn child who does not otherwise qualify for coverage as a Dependent is not eligible for coverage under this Plan beyond thirty-one (31) days after birth.

SAMPLE


A newly acquired Dependent, other than the newborn child(ren) of the Employee or the Employee’s Dependent, shall be eligible for coverage under this Plan on the date the Dependent is acquired provided that the Dependent is Enrolled within thirty-one (31) days after the Dependent is acquired and timely payment of the additional premium, if any, is made. If the Dependent is Enrolled more than thirty-one (31) days after the Dependent is first acquired, coverage shall become effective on the first billing date following thirty (30) days following the date of Enrollment. As required by law, a Dependent child of a custodial parent covered under this Plan may Enroll within sixty (60) days of the issuance of a qualified Medical Child Support Order or Release as long as the release or court order qualifies under the applicable state or federal laws. No Dependent may be eligible for coverage as a Dependent of more than one (1) Employee of the Enrolled Group. No individual may be eligible for coverage hereunder as an Employee and as a Dependent of an Employee at the same time.

SAMPLE


DESCRIPTION OF BENEFITS

Subject to the exclusions, conditions and limitations of this Plan, a Covered Person is entitled to benefits for the Covered Services described in this Description of Benefits section during a Benefit Period, subject to any Cost-Sharing or Out-of-Pocket Limits. These amounts are specified in the Schedule of Benefits. The Carrier provides Network benefits for Covered Services furnished to a Covered Person when authorized or Referred by his or her Primary Care Physician (PCP). The Carrier pays Non-Network benefits when Covered Services are not authorized or Referred by the PCP. The The Point-of-Service Network Plan section provides more detail regarding Network and Non-Network Providers, the Point-of-Service Network, and the reimbursement of Covered Services provided by Facility Providers and Professional Providers. Some Covered Services must be Precertified before the Covered Person receives the services. Precertification of services is a vital program feature that reviews Medical Appropriateness/Medical Necessity of certain procedures and/or admissions. In certain cases, Precertification helps determine whether a different treatment may be available that is equally effective yet less traumatic. Precertification also helps determine the most appropriate setting for certain services. Failure to obtain a required Precertification for a Covered Service could result in a reduction of benefits. More information on Precertification is found in the The Point-of-Service Network Plan and the Managed Care sections. Any Penalties for failure to obtain a Precertification, are specified on the Schedule of Benefits. To obtain a list of Covered Services that require Precertification, Covered Persons can log onto www.amerihealthnj.com or call the telephone number that is listed on their Identification Card. PRIMARY AND PREVENTIVE CARE A Covered Person is entitled to benefits for Primary Care and Preventive Care Covered Services when Medically Appropriate/Medically Necessary and provided or arranged by the Covered Person’s Primary Care Physician (PCP). The PCP will provide a Referral, when one is required, to a Network Professional Provider when the Covered Person’s condition requires Specialist Services. Cost-Sharing is specified in the Schedule of Benefits. Services resulting from Referrals to Non-Network Providers, except for Emergency Care and Urgent Care, will be covered when the Referral is issued by the Covered Person’s PCP and preapproved by the Carrier. The Referral is valid for ninety (90) days from the date of issue. Additional Covered Services recommended by the Referred Specialist will require another written or electronic Referral from the Covered Person’s PCP. Preventive Care is a health care service performed to catch the early warning signs of health problems. Services are performed when the Covered Person has no symptoms of disease. Services performed to treat an Illness or Injury are not covered as Preventive Care under this benefit. Primary Care is a health care service performed to treat an Illness or Injury. A. Primary Care

SAMPLE

http://www.amerihealthnj.com/


Coverage will be provided for office visits for the examination, diagnosis and treatment of an Illness or Injury by a Primary Care Provider. For purposes of this benefit, office visits include medical care visits to a Provider’s office, medical care visits by a Provider to a Covered Person’s residence, or medical care consultations by a Provider on an Outpatient basis.

B. Preventive Care Coverage will be provided for Preventive Care services, including but not limited to routine physical examinations, including related laboratory tests and X-rays; immunizations and vaccines; well baby care; pap smears; mammography; screening tests, including colorectal cancer and prostate cancer screenings; and bone density tests.

C. Lead Poisoning Screening and Treatment

Coverage will be provided for screening by blood lead measurement for lead poisoning for Dependent children, including confirmatory blood lead testing, as specified by the New Jersey Department of Health and medical evaluation and any necessary medical follow-up and treatment for lead poisoned Dependent children.

D. Newborn and Infant Screening for Hearing Loss

Coverage will be provided for hearing loss screening for a Newborn by appropriate Electrophysiologic Screening Measures and periodic monitoring of an Infant for delayed onset hearing loss. With respect to Coverage of Newborn and Infant Screening for Hearing Loss: 1. “Electrophysiologic Screening Measures” means the electrical result of the

application of physiologic agents and includes, but is not limited to, the procedures currently known as Auditory Brainstem Response testing (ABR) and Otoacoustic Emissions testing (OAE) and any other procedure adopted by regulation by the Commissioner.

2. “Infant” means a child age twenty-nine (29) days to thirty-six (36) months old that

qualifies as an “Eligible Dependent” as specified in the Eligibility Under This Plan section.

3. “Newborn ” means a child from birth to twenty-eight (28) days old that qualifies as an

“Eligible Dependent” as specified in the Eligibility Under This Plan section.

E. Nutrition Counseling for Weight Management Coverage is provided to any Covered Person for nutrition counseling visits for the purpose of weight management, subject to the Maximum visit limit as specified in the Schedule of Benefits, when billed by a Primary Care Provider or Professional Provider in an office setting

INPATIENT BENEFITS

SAMPLE


A Covered Person is entitled to benefits for Covered Services while an Inpatient in a Facility Provider when: (a) Medically Appropriate/Medically Necessary; (b) provided or Referred by the Covered Person’s Primary Care Physician (PCP); and (c) Precertified by the Carrier, when required. Cost-Sharing is specified in the Schedule of Benefits. Services resulting from Referrals to Non-Network Providers, except for Emergency Care and Urgent Care, will be covered when the Referral is issued by the Covered Person’s PCP and preapproved by the Carrier. The Referral is valid for ninety (90) days from the date of issue. Additional Covered Services recommended by the Referred Specialist will require another written or electronic Referral from the Covered Person’s PCP. A. Hospital Services 1. Ancillary Services

Benefits are payable for all ancillary services usually provided and billed for by Hospitals (except for personal convenience items) including, but not limited to, the following:

a. Meals, including special meals or dietary services as required by the Covered

Person’s condition; b. Use of operating, delivery, recovery, or other specialty service rooms and any

equipment or supplies therein; c. Casts, surgical dressings, and supplies, devices or appliances surgically

inserted within the body; d. Oxygen and oxygen therapy; e. Anesthesia when administered by a Hospital employee, and the supplies and

use of anesthetic equipment; f. Cardiac Rehabilitation Therapy, Chemotherapy, Dialysis, Occupational

Therapy, Physical Therapy, Pulmonary Rehabilitation Therapy, Radiation Therapy, respiratory therapy, and Speech Therapy when administered by a person who is appropriately licensed and authorized to perform such services;

g. All drugs and medications (including intravenous injections and solutions) for use while in the Hospital and which are released for general use and are commercially available to Hospitals;

h. Use of special care units, including, but not limited to, intensive or coronary care; and

i. Pre-admission testing. 2. Room and Board

Benefits are payable for general nursing care and such other services as are covered by the Hospital's regular charges for accommodations in the following:

a. A semi-private room, as designated by the Hospital; or a private room, when

designated by the Carrier as semi-private for the purposes of this plan in Hospitals having primarily private rooms;

b. A private room, when Medically Appropriate/Medically Necessary; c. A special care unit, such as intensive or coronary care, when such a

designated unit with concentrated facilities, equipment and supportive services is required to provide an intensive level of care for a critically ill patient;

SAMPLE


d. A bed in a general ward; and e. Nursery facilities.

Benefits are provided up to the number of days specified in the Schedule of Benefits.

In computing the number of days of benefits, the day of admission, but not the date of discharge shall be counted. If the Covered Person is admitted and discharged on the same day, it shall be counted as one (1) day.

Days available shall be allowed only during uninterrupted stays in a Hospital. Benefits shall not be provided during the absence of a Covered Person who interrupts his or her stay and remains past midnight of the day on which the interruption occurred.

B. Inpatient Professional Provider Medical Care

Benefits are provided for medical care rendered by the Professional Provider in charge of the case to a Covered Person who is an Inpatient in a Hospital, Rehabilitation Hospital or Skilled Nursing Facility. Such care includes Inpatient intensive medical care rendered to a Covered Person whose condition requires a Professional Provider's constant attendance and treatment for a prolonged period of time.

1. Concurrent Care

Benefits are provided for services rendered to an Inpatient in a Hospital, Rehabilitation Hospital or Skilled Nursing Facility by a Professional Provider who is not in charge of the case but whose particular skills are required for the treatment of complicated conditions. This does not include observation or reassurance of the Covered Person, standby services, routine preoperative physical examinations or medical care routinely performed in the pre- or post-operative or pre- or post-natal periods or medical care required by a Facility Provider's rules and regulations.

2. Consultations

Benefits are provided for consultation services when rendered to an Inpatient in a Hospital, Rehabilitation Hospital or Skilled Nursing Facility by a Professional Provider at the request of the attending Professional Provider. Consultations do not include staff consultations which are required by Facility Provider's rules and regulations.

C. Skilled Nursing Facility Services

Benefits are provided for services received in a Skilled Nursing Facility, when Medically Appropriate/Medically Necessary as determined by the Carrier, up to the Maximum days specified in the Schedule of Benefits. The Covered Person must require treatment by skilled nursing personnel which can be provided only on an Inpatient basis in a Skilled Nursing Facility.

In computing the number of days of benefits, the day of admission, but not the date of discharge shall be counted. If the Covered Person is admitted and discharged on the same day, it shall be counted as one (1) day.

SAMPLE


Days available shall be allowed only during uninterrupted stays in a Skilled Nursing Facility. Benefits shall not be provided: (a) during the absence of a Covered Person who interrupts his or her stay and remains past midnight of the day on which the interruption occurred; or (b) after the discharge hour that the Covered Person's attending Physician has recommended that further Inpatient care is not required.

Medically Appropriate/Medically Necessary Professional Provider visits in a Skilled Nursing Facility are provided as shown in the Schedule of Benefits.

No Skilled Nursing Facility benefits are payable:

1. When confinement in a Skilled Nursing Facility is intended solely to assist the

Covered Person with the activities of daily living or to provide an institutional environment for the convenience of a Covered Person;

2. For the treatment of Substance Abuse and Mental Illness; or 3. After the Covered Person has reached the maximum level of recovery possible for

his or her particular condition and no longer requires definitive treatment other than routine Custodial Care.

INPATIENT/OUTPATIENT BENEFITS A Covered Person is entitled to benefits for Covered Services either while an Inpatient in a Facility Provider or on an Outpatient basis when: (a) Medically Appropriate/Medically Necessary; (b) provided or Referred by the Covered Person’s Primary Care Physician (PCP); and (c) Precertified by the Carrier, when required. Cost-Sharing is specified in the Schedule of Benefits. Services resulting from Referrals to Non-Network Providers, except for Emergency Care and Urgent Care, will be covered when the Referral is issued by the Covered Person’s PCP and preapproved by the Carrier. The Referral is valid for ninety (90) days from the date of issue. Additional Covered Services recommended by the Referred Specialist will require another written or electronic Referral from the Covered Person’s PCP. A. Blood

Benefits shall be payable for the administration of Blood and Blood processing from donors. Benefits shall be payable for autologous Blood drawing, storage or transfusion - i.e., an individual having his or her own Blood drawn and stored for personal use, such as self-donation in advance of planned Surgery. Benefits shall be payable for whole Blood, Blood plasma and Blood derivatives, which are not classified as drugs in the official formularies and which have not been replaced by a donor.

B. Diagnosis and Treatment of Autism and Other Developmental Disabilities

Benefits are provided for charges for the screening and diagnosis of autism and other Developmental Disabilities.

SAMPLE


If a Covered Person’s primary diagnosis is autism or another Developmental Disability, benefits are provided for the following Medically Appropriate/Medically Necessary therapies as prescribed through a treatment plan: 1. Occupational Therapy where Occupational Therapy refers to treatment to develop a

Covered Person’s ability to perform the ordinary tasks of daily living; 2. Physical Therapy where Physical Therapy refers to treatment to develop a Covered

Person’s physical function; and 3. Speech Therapy where Speech Therapy refers to treatment of a Covered Person’s

speech impairment. The therapy services covered under this provision do not reduce the available therapy visits available under the Therapy Services provision. These therapy services are covered whether or not the therapies are restorative. If a Covered Person’s primary diagnosis is autism, in addition to coverage for the therapy services as described above, this Plan also covers Medically Appropriate/Medically Necessary behavioral interventions based on the principles of applied behavior analysis and related structured behavioral programs as prescribed through a treatment plan. The treatment plan(s) referred to above must be in writing, signed by the treating Physician, and must include: a diagnosis, proposed treatment by type, frequency and duration; the anticipated outcomes stated as goals; and the frequency by which the treatment plan will be updated. The Carrier may request additional information if necessary to determine the coverage under the plan. The Carrier may require the submission of an updated treatment plan once every six months unless the Carrier and the treating Physician agree to more frequent updates. If a Covered Person is: 1. eligible for early intervention services through the New Jersey Early Intervention

System; 2. has been diagnosed with autism or other Developmental Disability; and 3. receives Physical Therapy, Occupational Therapy, Speech Therapy, applied

behavior analysis or related structured behavior services the portion of the family cost share attributable to such services is a Covered Service under this plan. The Deductible, Coinsurance or Copayment as applicable to a non-specialist Physician visit for treatment of an Illness or Injury will apply to the family cost share. The therapy services a Covered Person receives through New Jersey Early Intervention do not reduce the therapy services otherwise available under this Diagnosis and Treatment of Autism and Other Disabilities provision.

C. Hospice Services

When the Covered Person’s attending Physician certifies that the Covered Person has a terminal Illness with a medical prognosis of six (6) months or less and when the Covered Person elects to receive care primarily to relieve pain, the Covered Person shall be eligible for Hospice benefits. Hospice Care is primarily comfort care, including pain relief, physical

SAMPLE


care, counseling and other services that will help the Covered Person cope with a terminal Illness rather than cure it. Hospice Care provides services to make the Covered Person as comfortable and pain-free as possible. When a Covered Person elects to receive Hospice Care, benefits for treatment provided to cure the terminal Illness are no longer provided. However, the Covered Person may elect to revoke the election of Hospice Care at any time. Respite Care: When Hospice Care is provided primarily in the home, such care on a short-term Inpatient basis in a Medicare certified Skilled Nursing Facility will also be covered when the Hospice considers such care necessary to relieve primary caregivers in the Covered Person’s home, up to the Maximum specified in the Schedule of Benefits. Benefits for Covered Hospice Services shall be provided until the earlier of the Covered Person’s death or discharge from Hospice Care. Special Hospice Services Exclusions: No Hospice Care benefits will be provided for: 1. Services and supplies for which there is no charge; 2. Research studies directed to life lengthening methods of treatment; 3. Services or expenses Incurred in regard to the Covered Person's personal, legal and

financial affairs (such as preparation and execution of a will or other dispositions of personal and real property);

4. Care provided by family members, relatives, and friends; and 5. Private Duty Nursing care.

D. Maternity/OB-GYN/Family Services

1. Maternity/Obstetrical Care

Services rendered in the care and management of a pregnancy for an Enrolled Employee, spouse, or Dependent daughter are a Covered Expense under this Plan as specified in the Schedule of Benefits. Prenotification of maternity care should occur within one (1) month of the first prenatal visit to the Physician or midwife. Benefits are payable for: (a) facility services provided by a Hospital or Birth Center; and (b) professional services performed by a Professional Provider or certified nurse midwife. Benefits payable for a delivery shall include pre- and post-natal care. Maternity care Inpatient benefits will be provided for forty-eight (48) hours for vaginal deliveries and ninety-six (96) hours for cesarean deliveries, except where otherwise approved by the Carrier as provided for in the Managed Care section.

In the event of early post-partum discharge from an Inpatient Admission, benefits are provided for Home Health Care as provided for in the Home Health Care benefit.

2. Elective Abortions

Facility services provided by a Hospital or Birth Center and services performed by a Professional Provider for the voluntary termination of a pregnancy by an Enrolled Employee, or spouse, or Dependent daughter are a Covered Expense under this Plan.

SAMPLE


3. Newborn Care

The newborn child of a Covered Person shall be entitled to benefits provided by this Plan from the date of birth up to a maximum of thirty-one (31) days. Such coverage within the thirty-one (31) days shall include care which is necessary for the treatment of medically diagnosed congenital defects, birth abnormalities, prematurity and routine nursery care. Coverage for a newborn may be continued beyond thirty-one (31) days under conditions specified in the Eligibility Under This Plan section.

4. Infertility

Benefits shall be provided, subject to any limits set forth in the Schedule of Benefits, for Medically Appropriate/Medically Necessary Covered Services in connection with the diagnosis and treatment of Infertility (as defined in the Defined Terms section) of a Covered Person. Coverage shall include, but is not limited to, the following services and procedures recognized by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists: a. Diagnosis and diagnostic tests; b. Medications, including oral medicines and injectable Infertility medications; c. Surgery, including microsurgical sperm aspiration; d. Gamete intra-fallopian transfer (GIFT)*; e. Fresh and frozen embryo transfer; f. Intracytoplasmic sperm injection (ICSI); g. Artificial insemination with no limit as to the number of cycles; h. In-vitro fertilization (IVF)*, including IVF using donor eggs or sperm and IVF

where the embryo is transferred to a Gestational Carrier or Surrogate. Note: The medical expenses of a Gestational Carrier which are Incurred in connection with the treatment of such Covered Person’s Infertility, if the Covered Person’s benefits under this booklet/certificate have not been exhausted, will be covered subject to these booklet/certificate provisions, as if they had been Incurred by the Covered Person, including complications related to the Infertility treatments rendered under this booklet/certificate; and the following medical expenses of a Surrogate which are Incurred in connection with the treatment of the Covered Person’s Infertility: egg retrieval in-vitro fertilization laboratory services, embryo transfers and artificial insemination will be covered;

i. Zygote intra-fallopian transfer (ZIFT)*; j. Assisted Hatching; k. Ovulation induction; l. Egg retrievals, up to the Egg Retrieval Lifetime Limit shown in the Schedule of

Benefits; m. Thawing and preparation of frozen sperm and embryos; and n. Costs associated with the initial cryopreservation of sperm and/or embryos.

* With respect to IVF, GIFT and ZIFT services, services are limited to a Covered Person who: (a) has used all reasonable, less expensive and medically appropriate treatments and still be unable to become pregnant

SAMPLE


or carry a pregnancy to live birth; (b) has not reached the Egg Retrieval Lifetime Limit shown in the Schedule of Benefits; and (c) is age forty-five (45) or younger. The Covered Person and their attending Physician must also provide signed certification forms as required by the Carrier.

Infertility drug coverage and Cost-Sharing: a. If the Covered Person has drug coverage available by a rider to this

booklet/certificate, Infertility drugs will be covered as a prescription drug benefit, subject to the Cost-Sharing arrangements applicable to the prescription drug benefit under the rider**.

b. If the Covered Person does not have drug coverage available under this

booklet/certificate, the Covered Person must call the telephone number that is listed on the back of their Identification Card, prior to obtaining the medications, for instructions on how to obtain medications under the Infertility benefit. These benefits are subject to the Cost-Sharing arrangements shown in the Infertility subsection of Schedule of Benefits**. ** Includes Infertility drug coverage for an egg donor and Gestational

Carrier.

The following, and any related, services and supplies are not covered under this Infertility benefit: a. Any Infertility medication for which the Covered Person has coverage under a

medical or prescription drug program provided through the Group; or any medication or supply that is covered as a prescription drug by rider to this booklet/certificate;

b. The purchase and storage of donor gametes or embryos, except that, if the

Covered Person’s benefits under this booklet/certificate have not been exhausted, the medical expenses of a donor which are Incurred in connection with the production and retrieval of gametes or embryos to be used for the treatment of Infertility of such Covered Person, including treatment of any complications associated with the production and retrieval process, will be covered subject to these booklet/certificate provisions, until released by the reproductive endocrinologist, as if they had been Incurred by the Covered Person;

c. Expenses of a Gestational Carrier, except that, if the Covered Person’s

benefits under this booklet/certificate have not been exhausted, the medical expenses of a Gestational Carrier which are Incurred in connection with the treatment of such Covered Person’s Infertility will be covered subject to these booklet/certificate provisions, as if they had been Incurred by the Covered Person;

d. Expenses of a Surrogate, other than the following medical expenses of a

Surrogate which are Incurred in connection with the treatment of the Covered Person’s Infertility: egg retrieval; in-vitro fertilization laboratory services; embryo transfers and artificial insemination;

SAMPLE


e. Reversal of voluntary sterilization or coverage of infertility services following sterilization. However, if the eligible partner of a Covered Person who has successfully reversed sterilization, meets the definition of Infertility, Infertility services directly related to that eligible partner’s diagnosis will be covered;

f. Ovulation indicator kits, or pregnancy indicator kits; g. The services of a Facility that does not conform to the standards established by

the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists;

h. Costs associated with the initial cryopreservation of sperm, eggs and/or

embryos; i. Costs associated with the storage of sperm, eggs and/or embryos; and

j. Services provided to a female person who is not covered for “Maternity/Obstetrical Care” benefits under this booklet/certificate.

E. Mental Illness Care

Benefits for the treatment of Mental Illness are based on the services provided and reported by the Provider. When a Provider renders medical care, other than for Mental Illness Care, for a Covered Person with Mental Illness, payment for such medical care will be based on the medical benefits available.

A Referral from the Covered Person’s PCP is not required to obtain Inpatient or Outpatient Mental Illness Care. The Covered Person should contact their PCP or the behavioral health management company at the phone number on the back of their Identification Card.

Precertification information must be submitted by the Provider to the Carrier for review and evaluation so a Plan of Treatment may be Precertified for the Covered Person. Precertification is required for treatment other than for Emergency Care in order to assure the Medical Appropriateness/Medical Necessity of the proposed treatment based on the nature and severity of the Covered Person's condition. A personal assessment by a Network Professional Provider will be provided by the Carrier at no cost to the Covered Person to accommodate the Precertification process. Emergency Care is exempt from the requirements for Precertification and will be considered Network Care. However, the Carrier should be notified within two (2) business days of the Emergency Care admission or services, or as soon as reasonably possible. 1. Inpatient Treatment

Benefits are provided for an Inpatient Admission for treatment of Mental Illness. For maximum benefits, treatment must be received from a Network Facility Provider and Inpatient visits for the treatment of Mental Illness must be performed by a Network Professional Provider. Covered Services include treatments such as: psychiatric visits, psychiatric consultations, individual and group psychotherapy, electroconvulsive therapy, psychological testing and psychopharmacologic management.

SAMPLE


2. Outpatient Treatment

Benefits are provided for Outpatient treatment of Mental Illness (other than for Serious Mental Illness). For maximum benefits, treatment must be performed by a Network Professional Provider/Facility Provider.

Covered Services include treatments such as: psychiatric visits, psychiatric consultations, individual and group psychotherapy, Licensed Clinical Social Worker visits, Master’s Prepared Therapist visits, electroconvulsive therapy, psychological testing, psychopharmacologic management, and psychoanalysis.

Benefits are not payable for the following services:

1. Vocational or religious counseling; 2. Activities that are primarily of an educational nature; 3. Treatment modalities that have not been incorporated into the commonly accepted

therapeutic repertoire as determined by broad-based professional consensus, such as primal therapy, rolfing or structural integration, bioenergetic therapy, and obesity control therapy.

F. Routine Patient Costs Associated With Qualifying Clinical Trials

Benefits are provided for Routine Patient Costs Associated With Participation in a Qualifying Clinical Trial (see the Defined Terms section). To ensure coverage and appropriate claims processing, the Carrier must be notified in advance of the Covered Person’s participation in a Qualifying Clinical Trial. Benefits are payable if the Qualifying Clinical Trial is conducted by a Participating Professional Provider, and conducted in a Participating Facility Provider. If there is no comparable Qualifying Clinical Trial being performed by a Participating Professional Provider, and in a Participating Facility Provider, then the Carrier will consider the services by a Non-Participating Provider participating in the clinical trial as covered if the clinical trial is deemed a Qualifying Clinical Trial by the Carrier.

G. Surgical Services

Surgery benefits will be provided for services rendered by a Professional Provider and/or Facility Provider for the treatment of disease or Injury. Separate payment will not be made for Inpatient preoperative care or all postoperative care normally provided by the surgeon as part of the surgical procedure. Also covered is: (a) the orthodontic treatment of congenital cleft palates involving the maxillary arch, performed in conjunction with bone graft Surgery to correct the bony deficits associated with extremely wide clefts affecting the alveolus; and (b) reconstructive breast Surgery following a surgical procedure in connection with the treatment of breast cancer in order to achieve symmetry between the two breasts, including Surgery and reconstruction of a healthy breast to produce a symmetrical appearance. This Plan will cover a minimum of seventy-two (72) hours of Inpatient care following a modified radical mastectomy and a minimum of forty-eight (48) hours of Inpatient care following a simple mastectomy. The provisions of this section shall not be construed to require a patient to receive Inpatient care for seventy-two (72) or forty-eight (48) hours, as appropriate, if the Covered

SAMPLE


Person in consultation with the attending Physician determines that a shorter length of stay is medically appropriate.

Covered surgical procedures shall include routine neonatal circumcisions and any voluntary surgical procedure for sterilization.

1. Hospital Admission for Dental Procedures or Dental Surgery

Benefits will be payable for a Hospital admission in connection with dental procedures or Surgery only when the Covered Person has an existing non-dental physical disorder or condition and hospitalization is Medically Appropriate/Medically Necessary to ensure the Covered Person's health. Except, as shown below, coverage for such hospitalization does not imply coverage of the dental procedures or Surgery performed during such a confinement. Only oral surgical procedures specifically identified as covered under the “Oral Surgery” terms of this Plan will be covered during such a confinement.

Benefits are also payable with respect to any Covered Person, who is severely disabled or who is age five (5) or under for expenses Incurred for: general Anesthesia and hospitalization for dental services; or a medical condition covered under this Plan which requires hospitalization or general Anesthesia for dental services rendered by a dentist regardless of where the dental services are provided.

2. Oral Surgery

Benefits will be payable for Covered Services provided by a Professional Provider and/or Facility Provider for: a. Orthognathic Surgery – Surgery on the bones of the jaw (maxilla or mandible)

to correct their position and/or structure for the following clinical indications only: (1) The initial treatment of Accidental Injury/trauma (i.e. fractured facial bones

and fractured jaws), in order to restore proper function. (2) In cases where it is documented that a severe congenital defect (i.e. cleft

palate) results in speech difficulties that have not responded to non-surgical interventions.

(3) In cases where it is documented (using objective measurements) that chewing or breathing function is materially compromised (defined as greater than two (2) standard deviations from normal) where such compromise is not amenable to non-surgical treatments, and where it is shown that orthognathic Surgery will decrease airway resistance, improve breathing, or restore swallowing.

b. Other oral Surgery – defined as Surgery on or involving the teeth, mouth, tongue, lips, gums and contiguous structures. Benefits will be provided only for: (1) Surgical removal of impacted teeth which are partially or completely

covered by bone;

SAMPLE


(2) The surgical treatment of cysts, infections and tumors performed on the structures of the mouth;

(3) Surgical removal of teeth prior to cardiac Surgery, Radiation Therapy or organ transplantation.

3. Assistant at Surgery

Benefits will be payable for Covered Services provided by an assistant surgeon who actively assists the operating surgeon in the performance of covered Surgery. Benefits will be provided for an assistant at Surgery only if an intern, resident, or house staff member is not available.

The condition of the Covered Person or the type of Surgery determines whether the active assistance of an assistant surgeon is Medically Appropriate/Medically Necessary. Surgical assistance is not covered when performed by a Professional Provider who himself performs and bills for another surgical procedure during the same operative session.

4. Anesthesia

Benefits will be payable for the administration of Anesthesia in connection with the performance of Covered Services when rendered by or under the direct supervision of a Professional Provider other than the surgeon, assistant surgeon or attending Professional Provider (except an Obstetrician providing Anesthesia during labor and delivery and an oral surgeon providing services otherwise covered under this booklet/certificate).

5. Second Surgical Opinion (Voluntary)

Benefits will be payable for consultations for Surgery to determine the Medical Appropriateness/Medical Necessity of an elective surgical procedure. Elective Surgery is that Surgery which is not of an Emergency or life threatening nature. Such Covered Services must be performed and billed by a Professional Provider other than the one who initially recommended performing the Surgery. One (1) additional consultation, as a third opinion, is eligible in cases where the second opinion disagrees with the first recommendation. In such instances the Covered Person will be eligible for a maximum of two (2) such consultations involving the elective surgical procedure in question, but limited to one (1) consultation per consultant.

H. Transplants

When a Covered Person is the recipient of transplanted human organs, marrow, or tissues, benefits are provided for all Inpatient and Outpatient transplants which are beyond the Experimental/Investigative stage. This requirement does not apply to the “Treatment of Wilm’s Tumor” as set forth in the Description of Benefits. Benefits are also provided to the Covered Person for those services which are directly and specifically related to the covered transplantation. This includes services for the examination of such transplanted organs, marrow, or tissue and the processing of Blood provided to a Covered Person:

SAMPLE


1. When both the recipient and the donor are Covered Persons, each is entitled to the benefits of this Plan.

2. When only the recipient is a Covered Person, both the donor and the recipient are

entitled to the benefits of this Plan. The donor benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage, or coverage by the Carrier or any government program. Benefits provided to the donor will be charged against the recipient's coverage under this Plan.

3. When only the donor is a Covered Person, no benefits will be provided.

4. If any organ or tissue is sold rather than donated to the Covered Person recipient, no

benefits will be payable for the purchase price of such organ or tissue. I. Treatment for Substance Abuse

Benefits are payable for the care and treatment of Substance Abuse provided by a Hospital or Facility Provider. For maximum benefits, treatment must be received from a Network Provider. A Referral from the Covered Person’s PCP is not required to obtain Inpatient or Outpatient Substance Abuse. The Covered Person should contact their PCP or the behavioral health management company at the phone number on the back of their Identification Card. Precertification information must be submitted by the Provider to the Carrier for review and evaluation so a Plan of Treatment may be Precertified for the Covered Person. Precertification is required for treatment other than for Emergency Care in order to assure the Medical Appropriateness/Medically Necessity of the proposed treatment based on the nature and severity of the Covered Person's condition. A personal assessment by a Network Professional Provider will be provided by the Carrier at no cost to the Covered Person to accommodate the Precertification process. Emergency Care is exempt from the requirements for Precertification. However, the Carrier should be notified within two (2) business days of the Emergency Care admission or services, or as soon as reasonably possible. Precertification is required for Network Plans of Treatment. The Carrier should be notified within two (2) days of the Emergency admission, or as soon as possible.

1. Inpatient Treatment

Benefits are provided for Inpatient Care for treatment of Substance Abuse. Inpatient Care for treatment of Substance Abuse includes coverage for Detoxification and Hospital and Non-Hospital Residential Treatment.

Covered Services include: a. Lodging and dietary services; b. Physician, Psychologist, nurse, certified addictions counselor and trained staff

services; c. Rehabilitation therapy and counseling;

SAMPLE


d. Family counseling and intervention; e. Diagnostic x-rays; f. Psychiatric, psychological and medical laboratory testing; g. Drugs, medicines, use of equipment and supplies.

2. Outpatient Treatment

Benefits are provided for Outpatient treatment of Substance Abuse. Covered Services include: a. Diagnosis and treatment of Substance Abuse b. Physician, Psychologist, nurse, certified addictions counselor and trained staff

services; c. Rehabilitation therapy and counseling; d. Family counseling and intervention; e. Psychiatric, psychological and medical laboratory testing; f. Drugs, medicines, and use of equipment and supplies.

J. Treatment of Wilm’s Tumor

The Carrier pays benefits for Covered Expense Incurred for the treatment of Wilm's tumor in a Covered Person. Treatment can include, but is not limited to, autologous bone marrow transplants when standard Chemotherapy treatment is unsuccessful. The Carrier pays benefits for this treatment even if it is deemed Experimental/Investigational. What the Carrier pays is based on all of the terms of this Plan.

OUTPATIENT BENEFITS A Covered Person is entitled to benefits for Covered Services on an Outpatient basis when: (a) Medically Appropriate/Medically Necessary; (b) provided or Referred by the Covered Person’s Primary Care Physician (PCP); and (c) Precertified by the Carrier, when required. Cost-Sharing is specified in the Schedule of Benefits. Services resulting from Referrals to Non-Network Providers, except for Emergency Care and Urgent Care, will be covered when the Referral is issued by the Covered Person’s PCP and preapproved by the Carrier. The Referral is valid for ninety (90) days from the date of issue. Additional Covered Services recommended by the Referred Specialist will require another written or electronic Referral from the Covered Person’s PCP. A. Ambulance Services

Benefits are provided for Ambulance services that are Medically Appropriate/Medically Necessary, as determined by the Carrier, for transportation in a specially designed and equipped vehicle used only to transport the sick or injured, but only when: (a) the vehicle is licensed as an Ambulance where required by applicable law; (b) the Ambulance transport is appropriate for the patient’s clinical condition; (c) the use of any other method of transportation, such as taxi, private car, wheel-chair van or other type of private or public vehicle transport would be contraindicated (i.e. would endanger the patient’s medical condition); and (d) the Ambulance transport satisfies the destination and other

SAMPLE


requirements state below in either the “For Emergency Ambulance transport” or “For Non-Emergency Ambulance transport” subsection. Benefits are payable for air or sea transportation only if the Carrier determines that the patient's condition, and the distance to the nearest facility able to treat the Covered Person's condition, justify the use of an alternative to land transport. 1. For Emergency Ambulance transport

The Ambulance must be transporting the Covered Person from the Covered Person's home or the scene of an accident or Emergency to the nearest Hospital or other Emergency Care Facility that can provide the Medically Appropriate/Medically Necessary Covered Services for the Covered Person’s condition.

2. For Non-Emergency Ambulance transport All non-Emergency Ambulance transports must be Precertified by the Carrier to determine Medical Appropriateness/Medical Necessity which includes specific origin and destination requirements specified in the Company’s policies. Non-Emergency Ambulance transports are not provided for the convenience of the Covered Person, the family, or the Provider treating the Covered Person. Non-Emergency air transport may be covered to return the Covered Person to a Network Facility Provider within a reasonable distance, as determined by the Carrier, with the capability of treating the condition for which transfer is necessary for required continuing care (when a Covered Service), when such care immediately follows an Inpatient Emergency admission and the Covered Person is not able to return to the Point-of-Service service area by any other means. This type of transportation is provided when the Covered Person’s medical condition requires uninterrupted care and attendance by qualified medical staff during transport that cannot be safely provided by land ambulance. Transportation back to the Point-of-Service service area is not covered for family members or companions.

B. Day Rehabilitation Program

Subject to the limits shown in the Schedule of Benefits, benefits will be provided for a Medically Appropriate/Medically Necessary Day Rehabilitation Program when provided by a Facility Provider under the following conditions: 1. The Covered Person requires intensive Therapy Services, such as Physical,

Occupational and/or Speech Therapy five (5) days per week for four (4) to seven (7) hours per day;

2. The Covered Person has the ability to communicate (verbally or non-verbally) his/her needs; the ability to consistently follow directions and to manage his/her own behavior with minimal to moderate intervention by professional staff;

3. The Covered Person is willing to participate in a Day Rehabilitation Program; and 4. The Covered Person’s family must be able to provide adequate support and

assistance in the home and must demonstrate the ability to continue the rehabilitation program in the home.

SAMPLE


C. Diabetic Supplies and Education Program Benefits are provided for the following Diabetic supplies, if recommended or prescribed by a Physician or nurse practitioner/clinical nurse specialist: blood glucose monitors and blood glucose monitors for the legally blind; test strips for glucose monitors and visual reading and urine testing strips; insulin; injection aids; cartridges for the legally blind; syringes; insulin pumps and appurtenances thereto; insulin infusion devices; and oral agents for controlling blood sugar. Benefits are also provided for an Outpatient Diabetic Education Program when the attending Physician, or nurse practitioner/clinical nurse specialist determines that such a program is medically necessary for the proper self-management and treatment of the Covered Person's diabetic condition. Benefits are payable for a program prescribed:

1. At first diagnosis of diabetes; 2. If upon diagnosis by a Physician, or nurse practitioner/clinical nurse specialist of a

significant change in the Covered Person's symptoms or conditions which necessitate changes in that person's self-management; and

3. Upon determination of the Physician, or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary.

D. Diagnostic Services

Benefits are payable for the following Diagnostic Services when ordered by a Professional Provider and billed by a Professional Provider, and/or a Facility Provider:

1. Routine Diagnostic Services, including routine radiology (consisting of x-rays,

ultrasound, and nuclear medicine), routine medical procedures (consisting of ECG, EEG, and other diagnostic medical procedures approved by the Carrier), and allergy testing (consisting of percutaneous, intracutaneous and patch tests).

2. Non-Routine Diagnostic Services, including MRI/MRA, CT Scans, PET Scans, and Sleep Studies.

3. Diagnostic laboratory and pathology tests. 4. Genetic testing and counseling. Genetic testing and counseling include services

provided to a Covered Person at risk for a specific disease due to family history or because of exposure to environmental factors that are known to cause physical or mental disorders. When clinical usefulness of specific genetic tests has been established by the Carrier, these services are covered for the purposes of diagnosis, screening, predicting the course of a disease, judging the response to a therapy, examining risk for a disease, or reproductive decision-making.

E. Durable Medical Equipment

Benefits will be provided for the rental (but not to exceed the total allowance of purchase) or, at the option of the Carrier, the purchase of Durable Medical Equipment when prescribed by a Professional Provider and required for therapeutic use, when determined to be Medically Appropriate/Medically Necessary by the Carrier. Although an item may be classified as Durable Medical Equipment, it may not be covered in every instance. Therefore, Precertification is required on the rental or purchase of Durable Medical Equipment. For information on Durable Medical Equipment that requires

SAMPLE


Precertification, Covered Persons can log on to www.amerihealthnj.com or call the Customer Service telephone number listed on the back of their Identification Card. Durable Medical Equipment, as defined in the Defined Terms section, includes equipment that meets the following criteria:

1. It is durable and can withstand repeated use. An item is considered durable if it can

withstand repeated use, i.e., the type of item that could normally be rented. Medical supplies of an expendable nature are not considered “durable”. (For examples, see item 4 under “Non-reusable supplies” below.)

2. It customarily and primarily serves a medical purpose. 3. It is generally not useful to a person without an Illness or Injury. The item must be

expected to make a meaningful contribution to the treatment of the Covered Person’s Illness, Injury, or to improvement of a malformed body part.

4. It is appropriate for home use.

Some examples of equipment that do not meet the definition of Durable Medical Equipment are as follows: 1. Comfort and convenience items, such as massage devices, portable whirlpool

pumps, telephone alert systems, bed-wetting alarms, and ramps. 2. Equipment used for environmental control, such as air cleaners, air conditioners,

dehumidifiers, portable room heaters, and heating and cooling plants. 3. Equipment inappropriate for home use. This is an item that generally requires

professional supervision for proper operation, such as diathermy machines, medcolator, pulse tachometer, data transmission devices used for telemedicine purposes, translift chairs and traction units.

4. Non-reusable supplies other than a supply that is an integral part of the Durable Medical Equipment item required for the Durable Medical Equipment function. This means the equipment is not durable or is not a component of the Durable Medical Equipment. Items not covered include, but are not limited to, incontinence pads, lambs wool pads, ace bandages, catheters (non-urinary), face masks (surgical), disposable gloves, disposable sheets and bags, and irrigating kits.

5. Equipment that is not primarily medical in nature. Equipment which is primarily and customarily used for a non-medical purpose may or may not be considered “medical” in nature. This is true even though the item may have some medically related use. Such items include, but are not limited to, ear plugs, Equipment for Safety, exercise equipment,

ice pack, speech teaching machines, strollers, feeding chairs, silverware/utensils, toileting systems, electronically-controlled heating and cooling units for pain relief, toilet seats, bathtub lifts, stairglides, and elevators.

6. Equipment with features of a medical nature which are not required by the Covered Person’s condition, such as a gait trainer. The therapeutic benefits of the item cannot be clearly disproportionate to its cost, if there exists a Medical Appropriate/Medically Necessary and realistically feasible alternative item that serves essentially the same purpose.

7. Duplicate equipment for use when traveling or for an additional residence, whether or not prescribed by a Professional Provider.

8. Services not primarily billed for by a Provider such as delivery, set-up and service activities and installation and labor of rented or purchased equipment.

SAMPLE



9. Modifications to vehicles, dwellings and other structures. This includes any modifications made to a vehicle, dwelling or other structure to accommodate a Covered Person’s disability or any modifications made to a vehicle, dwelling or other structure to accommodate a Durable Medical Equipment item, such as a wheelchair.

The terms and conditions under which the Plan will provide benefits for the replacement and repair of Durable Medical Equipment are as follows: 1. The Carrier will provide benefits for the repair or replacement of Durable Medical

Equipment when the equipment does not function properly and is no longer useful for its intended purpose in the following limited situations: (a) when a change in the Covered Person’s condition requires a change in the

Durable Medical Equipment, the Carrier will provide repair or replacement of the equipment,

(b) when the Durable Medical Equipment is broken due to significant damage,

defect, or wear, the Carrier will provide repair or replacement only if the equipment’s warranty has expired and it has exceeded its reasonable useful life as determined by the Carrier.

If the Durable Medical Equipment breaks while it is under warranty, replacement and repair is subject to the terms of the warranty. Contacts with the manufacturer or other responsible party to obtain replacement or repairs based on the warranty are the responsibility of: 1) the Carrier in the case of rented equipment; and 2) the Covered Person in the case of purchased equipment.

The Carrier will not be responsible if the Durable Medical Equipment breaks during its reasonable useful lifetime for any reason not covered by warranty. For example, the Carrier will not provide benefits for repairs and replacement needed because the equipment was abused or misplaced.

2. The Carrier will provide benefits to repair Durable Medical Equipment when the cost

to repair is less than the cost to replace it. For purposes of replacement or repair of Durable Medical Equipment, replacement means the removal and substitution of Durable Medical Equipment or one of its components necessary for proper functioning. A repair is a restoration of the Durable Medical Equipment or one of its components to correct problems due to wear or damage or defect.

F. Emergency Care and Urgent Care

Benefits for Emergency Care provided by a Hospital Emergency room or other Outpatient Emergency Facility are provided by the Carrier at the Network level of benefits if services are performed within two (2) days of the Emergency, regardless of whether the patient is treated by a Network or Non-Network Provider. If Emergency Care is required, whether the Covered Person is located in or outside the Point-of-Service Network service area, call 911 or seek treatment immediately at the emergency department of the closest Hospital or Outpatient Emergency Facility.

SAMPLE


Emergency Care is any Outpatient service or supply provided by a Hospital or Facility Provider and/or Professional Provider for initial treatment of the Emergency. Examples of an Emergency include heart attack, loss of consciousness or respiration, cardiovascular accident, convulsions, severe accidental Injury, and other acute medical conditions as determined by the Carrier. Benefits are payable for Urgent Care provided by an Urgent Care Center, when Medically Appropriate/Medically Necessary. Urgent Care Centers are designed to offer immediate evaluation and treatment for acute health conditions that require medical attention in a non-Emergency situation. Cost-Sharing for Emergency Care and Urgent Care is specified in the Schedule of Benefits.

G. Hearing Aids for Dependents

Coverage will be provided for Covered Services Incurred in the purchase of a Hearing Aid for a Dependent who is age fifteen (15) or younger. Coverage includes fittings, examinations and hearing tests, dispensing fees, modifications and repairs, ear molds and headbands for bone-anchored hearing implants. Coverage also includes the purchase of one (1) Hearing Aid for each hearing-impaired ear every twenty-four (24) months subject to a maximum amount payable of $1000 for each Hearing Aid. The Hearing Aid must be recommended or prescribed by a Professional Provider certified as an otolaryngologist or a licensed audiologist.

H. Home Health Care Charges in Lieu of Hospitalization

When home health care can take the place of Inpatient care, the Carrier covers such care furnished to a Covered Person under a written home health care plan. The Carrier covers all Medically Appropriate/Medically Necessary services or supplies, such as: 1. Nursing Care (furnished by or under the supervision of a Registered Nurse);

2. Physical Therapy; 3. Occupational Therapy; 4. Medical social work; 5. Nutrition services; 6. Speech Therapy; 7. Home health aide services; 8. Medical appliances and equipment, drugs and medications, laboratory services and

special meals; and 9. Any Diagnostic or therapeutic service, including surgical services performed in a

Hospital Outpatient department, a Physician's office or any other licensed health care Facility, provided such service would have been covered under this Plan if performed as Inpatient Hospital services. But, payment is subject to all of the terms of this Plan and to the following conditions: a. The Covered Person's Physician must certify that home health care is needed

in place of Inpatient care in a recognized Facility.

SAMPLE


b. The services and supplies must be: (1) Ordered by the Covered Person's Physician; (2) Included in the home health care plan; and (3) Furnished by, or coordinated by, a Home Health Care Agency according

to the written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or twenty-four (24) hour service is needed on a short-term basis.

c. The home health care plan must be set up in writing by the Covered Person's

Physician within fourteen (14) days after home health care starts. And it must be reviewed by the Covered Person's Physician at least once every sixty (60) days.

d. Each visit by a home health aide, Nurse, or other recognized Provider whose

services are authorized under the home health care plan can last up to four (4) hours.

e. The Carrier does not pay for:

(1) Services furnished to family members, other than the Covered Person; or (2) Services and supplies not included in the home health care plan.

I. Inherited Metabolic Diseases, Medical Foods and Low Protein Modified Food Products

Benefits shall be payable for the therapeutic treatment of Inherited Metabolic Diseases including the purchase of Medical Foods and Low Protein Modified Food Products. Coverage for the purchase of Medical Foods or Low Protein Modified Food Products is provided when administered on an Outpatient basis either orally or through a tube.

J. Injectable Medications

Benefits will be provided for injectable medications required in the treatment of an Injury or Illness when administered by a Provider. For information on injectable medications that require Precertification, Covered Persons can log on to www.amerihealthnj.com or call the Customer Service telephone number listed on the back of their Identification Card. Specialty Drugs Specialty Drugs refer to a medication that meets certain criteria, including but not limited to: • The drug is used in the treatment of a rare, complex, or chronic disease (e.g.,

hemophilia); • A high level of involvement is required by a health care Provider to administer the

drug;

SAMPLE



• Complex storage and/or shipping requirements are necessary to maintain the drug’s stability;

• The drug requires comprehensive patient monitoring and education by a health care Provider regarding safety, side effects, and compliance;

• Access to the drug may be limited. To obtain a list of Specialty Drugs, Covered Persons can log on to www.amerihealthnj.com or call the Customer Service telephone number listed on the back of their Identification Card. Standard Injectable Drugs Standard Injectable Drugs refer to a medication that is either injectable or infusible but is not defined by the Carrier as a Self-Injectable Drug or a Specialty Drug. Standard Injectable Drugs include but are not limited to allergy injections and extractions, and injectable medications such as antibiotics and steroid injections that are administered by a Professional Provider. Self-Injectable Drugs generally are not covered. For more information on Self-Injectable Prescription Drugs (Self-Injectable Drugs), please refer to the Exclusions section and the Diabetic Supplies and Education Program coverage in the Description of Benefits section.

K. Non-Surgical Dental Services

Benefits will be provided only for the initial treatment of Accidental Injury/trauma (i.e. fractured facial bones and fractured jaws), in order to restore proper function. Restoration of proper function includes the dental services required for the initial restoration or replacement of Sound Natural Teeth, including the first caps, crowns, bridges and dentures (but not including dental implants), required for the initial treatment for the Accidental Injury/trauma. Also covered is the preparation of the jaws and gums required for initial replacement of Sound Natural Teeth. (Sound Natural Teeth are teeth that are stable, functional, free from decay and advanced periodontal disease, in good repair at the time of the Accidental Injury/trauma). Injury as a result of chewing or biting is not considered an Accidental Injury (See the exclusion of dental services in the What Is Not Covered section for more information on what dental services are not covered).

L. Orthotic Devices

Benefits are provided for: 1. The initial purchase and fitting (per medical episode) of Orthotic Devices. 2. The replacement of covered Orthotic Devices for Dependent children when required

due to natural growth. This benefit does not apply to Prosthetic Appliances or Orthotic Appliances as mandated by New Jersey law.

M. Podiatric Care

SAMPLE



Benefits are provided for podiatric care including: capsular or surgical treatment of bunions; ingrown toenail Surgery; and other non-routine Medically Necessary/Medically Appropriate foot care. In addition, for Covered Persons with peripheral vascular and/or peripheral neuropathic diseases, including but not limited to diabetes, benefits for routine foot care services are provided.

N. Private Duty Nursing Services

Benefits will be provided up to the number of hours specified in the Schedule of Benefits for Outpatient services for Private Duty Nursing performed by a Licensed Registered Nurse (RN) or a Licensed Practical Nurse (LPN) when ordered by a Physician. Benefits are not payable for: 1. Nursing care which is primarily custodial in nature; such as care that primarily

consists of: bathing, feeding, exercising, homemaking, moving the patient, giving oral medication;

2. Services provided by a nurse who ordinarily resides in the Covered Person's home or is a member of the Covered Person's Immediate Family; and

3. Services provided by a home health aide or a nurse's aide. O. Prosthetic and Orthotic Appliances

The Carrier pays benefits for Covered Expense Incurred in obtaining an Orthotic or Prosthetic Appliance from any Licensed Orthotist or Licensed Prosthetist, or any Certified Pedorthist, that are Medically Appropriate/Medically Necessary as determined by the Covered Person’s Physician. In paying benefits for Orthotic or Prosthetic Appliances as required by P.L. 2007, c.345, reimbursement shall be at the same rate reimbursement for such Appliances under the federal Medicare schedule. Where an Appliance does not have a federal Medicare reimbursement rate, benefits will be provided at the rate for the most similar Appliance for which there is a federal Medicare reimbursement rate. If the Carrier’s contract rate with a provider of Orthotic and Prosthetic Appliances exceeds the Medicare reimbursement rate, the Carrier’s contract rate should be paid. All other terms of this Plan apply.

P. Prosthetic Devices

Benefits are payable for expenses incurred for Prosthetic Devices (except dental prostheses) required as a result of Illness or Injury. This benefit does not apply to Prosthetic Appliances as mandated by New Jersey law. Expenses for Prosthetic Devices are subject to medical review by the Carrier to determine eligibility and Medical Appropriateness/Medical Necessity.

Such expenses may include, but not be limited to: 1. The purchase, fitting, necessary adjustments and repairs of Prosthetic Devices which

replace all or part of an absent body organ including contiguous tissue or which replace all or part of the function of an inoperative or malfunctioning body organ; and

SAMPLE


2. The supplies and replacement of parts necessary for the proper functioning of the Prosthetic Device;

3. Breast prostheses required to replace the removed breast or portions thereof as a

result of mastectomy and prostheses inserted during reconstructive Surgery incident and subsequent to mastectomy. Coverage limitations on external breast prostheses are as follows: a. Post mastectomy, four (4) bras per Benefit Period are covered. b. The useful lifetime expectancy for silicone breast prostheses is two (2) years. c. The useful lifetime expectancy of fabric, foam or fiber-filled breast prostheses is

six (6) months. 4. Benefits are provided for the following visual Prosthetics when Medically

Appropriate/Medically Necessary and prescribed for one of the following conditions: a. Initial contact lenses prescribed for treatment of infantile glaucoma; b. Initial pinhole glasses prescribed for use after Surgery for detached retina; c. Initial corneal or scleral lenses prescribed:

(1) In connection with the treatment of keratoconus; or (2) To reduce a corneal irregularity other than astigmatism;

d. Initial scleral lenses prescribed to retain moisture in cases where normal tearing is not present or adequate; and

e. Initial pair of basic eyeglasses when prescribed to perform the function of a human lens (aphakia) lost as a result of: (1) Accidental Injury; (2) Trauma; or (3) Ocular Surgery.

Benefits are not provided for: a. Lenses which do not require a prescription; b. Any lens customization such as, but not limited to, tinting, oversize or

progressive lenses, antireflective coatings, U-V lenses or coatings, scratch resistant coatings, mirror coatings, or polarization;

c. Deluxe frames; or d. Eyeglass accessories, such as cases, cleaning solution and equipment. The repair and replacement paragraphs set forth below do not apply to this item.

Benefits for replacement of a Prosthetic Device or its parts will be provided: (a) when there has been a significant change in the Covered Person’s medical condition that requires the replacement, (b) if the prostheses breaks because it is defective, or (c) if the prostheses breaks because it exceeds its life expectancy, as determined by the manufacturer, or (d) for a Dependent child due to the normal growth process when Medically Appropriate/Medically Necessary.

The Carrier will provide benefits to repair Prosthetic Devices when the cost to repair is less than the cost to replace it. For purposes of replacement or repair of a prostheses, replacement means the removal and substitution of the prostheses or one of its components necessary for proper functioning. A repair is a restoration of the prostheses

SAMPLE


or one of its components to correct problems due to wear or damage. However, the Carrier will not provide benefits for repairs and replacements needed because the prostheses was abused or misplaced.

If a Prosthetic Device breaks and is under warranty, it is the responsibility of the Covered Person to work with the manufacturer to replace or repair it.

Q. Specialist Office Visits

Benefits will be provided for Specialist Service medical care provided in the office by a Provider other than a Primary Care Physician. For the purpose of this benefit, “in the office” includes medical care visits to a Provider’s office, medical care visits by a Provider to a Covered Person’s residence, or medical care consultations by a Provider on an Outpatient basis.

R. Spinal Manipulation Services

Benefits shall be provided up to the limits specified in the Schedule of Benefits for spinal manipulations for the detection and correction by manual or mechanical means of structural imbalance or subluxation resulting from or related to distortion, misalignment, or subluxation of or in the vertebral column.

S. Therapy Services

Benefits shall be provided, subject to the Benefit Period Maximums specified in the Schedule of Benefits, for the following services prescribed by a Physician and performed by a Professional Provider, a therapist who is registered or licensed by the appropriate authority to perform the applicable therapeutic service, and/or Facility Provider, which are used in treatment of an Illness or Injury to promote recovery of the Covered Person.

1. Cardiac Rehabilitation Therapy

Refers to a medically supervised rehabilitation program designed to improve a patient's tolerance for physical activity or exercise.

2. Chemotherapy

Chemotherapy means the treatment of malignant disease by chemical or biological antineoplastic agents, monoclonal antibodies, bone marrow stimulants, antiemetics and other related biotech products. Such chemotherapeutic agents are eligible if administered intravenously or intramuscularly (through intra-arterial injection, infusion, perfusion or subcutaneous, intracavitary and oral routes). The cost of drugs, approved by the Federal Food and Drug Administration (FDA) and only for those uses for which such drugs have been specifically approved by the FDA as antineoplastic agents is covered, provided they are administered as described in this paragraph.

New Jersey requires: that drugs which have been approved by the FDA, but not for treatment of the Covered Person's Illness or Injury will be covered, if they have been recognized as appropriate medical treatment for the Covered Person's diagnosis or condition in one or more of the following established reference compendia:

SAMPLE


a. The American Hospital Formulary Service Drug Information; b. The United States Pharmacopeia Drug Information; or recommended by a clinical study or review article in a major peer-reviewed professional journal, provided they are administered as described here.

3. Dialysis

The treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body by hemodialysis, peritoneal Dialysis, hemoperfusion, or chronic ambulatory peritoneal Dialysis (CAPD), or continuous cyclical peritoneal Dialysis (CCPD). Benefits will not be provided to the extent that benefits are payable by Medicare for persons who are Medicare eligible on the basis of end stage renal disease (ESRD) and for whom Medicare must pay as primary carrier.

4. Infusion Therapy

Treatment includes, but is not limited to, infusion or inhalation, parenteral and enteral nutrition, antibiotic therapy, pain management and hydration therapy, or any other drug that requires administration by a health care Provider. Infusion Therapy includes all professional services, supplies, and equipment that are required to safely and effectively administer the therapy. Infusion may be provided in a variety of settings (e.g., home, office, Outpatient) depending on the level of skill required by prepare the drug, administer the infusion, and monitor the Covered Person. The type of health care Provider who can administer the infusion depends on whether the drug is considered to be a Specialty Drug infusion or a Standard Injectable Drug infusion, as determined by the Carrier. Also included is the home treatment of bleeding episodes associated with hemophilia, including the purchase of blood products and blood infusion equipment.

5. Occupational Therapy

Includes treatment by means of constructive activities designed and adapted to promote the restoration of the person's ability to satisfactorily accomplish the ordinary tasks of daily living. Coverage will also include services rendered by a registered, licensed occupational therapist.

6. Orthoptic/Pleoptic Therapy

Includes treatment through an evaluation and training session program for the correction of oculomotor dysfunction as a result of a vision disorder, eye Surgery, or Injury resulting in the lack of vision depth perception.

7. Pulmonary Rehabilitation Therapy

Includes treatment through a multidisciplinary program which combines Physical Therapy with an educational process directed towards the stabilization of pulmonary diseases and the improvement of functional status.

SAMPLE


8. Physical Therapy

Includes treatment by physical means, heat, hydrotherapy or similar modalities, physical agents, bio-mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum function, and prevent disability following disease, Injury, or loss of body part, including the treatment of functional loss following hand and/or foot Surgery.

9. Radiation Therapy

The treatment of disease by x-ray, radium, radioactive isotopes, or other radioactive substances regardless of the method of delivery, including the cost of radioactive materials supplied and billed by the Provider.

10. Speech Therapy

Includes treatment for the correction of a speech impairment resulting from disease, Surgery, Injury, congenital anomalies, or previous therapeutic processes. Coverage will also include services by a speech therapist.

U. VISION CARE

Routine Eye Exam and Refraction

Subject to the limits shown in the Schedule of Benefits, benefits are payable for one (1) routine eye exam and refraction every Benefit Period, from a Network Provider. A list of Network Providers is available through the Carrier’s Customer Service Department.

SAMPLE


WHAT IS NOT COVERED

Except as specifically provided in this booklet/certificate, no benefits will be provided for services, supplies or charges: • Which are not Medically Appropriate/Medically Necessary as determined by the Carrier,

subject to the Resolving Problems section of this booklet/certificate, for the diagnosis or treatment of Illness or Injury;

• Which are Experimental/Investigational, except, as approved by the Carrier, Routine Patient Costs Associated with Qualifying Clinical Trials that meet the definition of a Qualifying Clinical Trial under this Plan. This exclusion does not apply to the “Treatment of Wilm’s Tumor” as set forth in the Description of Benefits;

• Which were Incurred prior to the Covered Person's Effective Date of coverage;

• Which were or are Incurred after the date of termination of the Covered Person's coverage

except as provided in the General Information section;

• For any loss sustained or expenses Incurred during military service while on active duty as a member of the armed forces of any nation; or as a result of: (a) War or Act of War, if the Illness or Injury occurs while the Covered Person is serving in the military, naval or air forces of any country, combination of countries or international organization; and (b) the special hazards incident to service in the military, naval or air forces of any country, combination of countries or international organization, if the Illness or Injury occurs while the Covered Person is serving in such forces and is outside the Home Area;

• For the portion of the Covered Expense that would have been paid under Medicare Part B when the Covered Person is eligible for Medicare Part B, but is not enrolled. However, the balance of the Covered Expense will be covered in accordance with the terms and conditions of this Plan;

• For which a Covered Person would have no legal obligation to pay, or another party has primary responsibility;

• Received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group;

• For any occupational Illness or bodily Injury which occurs in the course of employment if benefits or compensation are or could have been covered, in whole or in part, under workers’ compensation, employer’s liability, occupational disease or similar law. This exclusion does not apply to the following persons for whom coverage under workers’ compensation is optional unless such persons are actually covered for workers’ compensation: a self-employed person or a partner of a limited liability partnership, members of a limited liability company or partners of a partnership who actively perform services on behalf of the self-employed business, the limited liability partnership, limited liability company or the partnership;

SAMPLE


• To the extent a Covered Person is legally entitled to receive when provided by the Veteran's Administration or by the Department of Defense in a government facility reasonably accessible by the Covered Person;

• Which are not billed and performed by a Provider as defined under this Plan as a “Professional Provider”, “Facility Provider” or “Ancillary Provider except as otherwise indicated under the subsections entitled: (a) “Therapy Services” (that identifies covered Therapy Services as provided by licensed therapists); and (b) “Ambulance Services”, in the Description of Benefits section of this booklet/certificate;

• Rendered by a member of the Covered Person's Immediate Family;

• Performed by a Professional Provider enrolled in an education or training program when such services are related to the education or training program and are provided through a Hospital or university;

• For Ambulance services except as specifically provided under this Plan;

• For services and operations for cosmetic purposes which are done to improve the appearance of any portion of the body, and from which no improvement in physiologic function can be expected. However, benefits are payable to correct a condition resulting from an accident. Benefits are also payable to correct functional impairment which results from a covered disease, Injury or congenital birth defect. This exclusion does not apply to mastectomy related charges as provided for and defined in the “Surgical Services” section in the Description of Benefits;

• For telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form;

• For Alternative Therapies/Complementary Medicine, including but not limited to, music therapy, dance therapy, equestrian/hippotherapy, homeopathy, primal therapy, rolfing, psychodrama, vitamin or other dietary supplements and therapy, naturopathy, hypnotherapy, bioenergetic therapy, Qi Gong, Ayurvedic Therapy, aromatherapy, massage therapy, therapeutic touch, recreational, wilderness, educational and sleep therapies. This exclusion will not apply to dietary supplements as set forth in the Description of Benefits section under the subsection "Inherited Metabolic Diseases, Medical Foods and Low Protein Modified Food Products" or specialized non-standard infant formulas as may be provided by a prescription drug rider attached to this booklet/certificate;

• For marriage counseling;

• For Custodial Care, domiciliary care or rest cures;

• For equipment costs related to services performed on high cost technological equipment as defined by the Carrier, such as, but not limited to, computer tomography (CT) scanners, magnetic resonance imagers (MRI) and linear accelerators, unless the acquisition of such equipment by a Professional Provider was approved through, or exempted from approval by, the State’s “Certificate of Need (CON)” process;

SAMPLE


• For dental services related to the care, filling, removal or replacement of teeth (including dental implants to replace teeth or to treat congenital anodontia, ectodermal dysplasia or dentigenesis imperfecta), and the treatment of injuries to or disease of the teeth, gums or structures directly supporting or attached to the teeth, except as otherwise specifically stated in this booklet/certificate. Services not covered include, but are not limited to, apicoectomy (dental root resection), prophylaxis of any kind, root canal treatments, soft tissue impactions, alveolectomy, bone grafts or other procedures provided to augment an atrophic mandible or maxilla in preparation of the mouth for dentures or dental implants, and treatment of periodontal disease unless otherwise indicated, except as may be provided by a dental rider attached to this booklet/certificate;

• For dental implants for any reason;

• For dentures, unless for the initial treatment of an Accidental Injury/trauma;

• For orthodontic treatment, except for appliances used for palatal expansion to treat

congenital cleft palate;

• For Injury as a result of chewing or biting (neither is considered an Accidental Injury);

• For palliative or cosmetic foot care including treatment of bunions (except for capsular or bone surgery), toenails (except surgery for ingrown nails), the treatment of subluxations of the foot, care of corns, calluses, fallen arches, pes planus (flat feet), weak feet, chronic foot strain, and other routine podiatry care, unless associated with the Medically Appropriate/Medically Necessary treatment of peripheral vascular disease and/or peripheral neuropathic disease, including but not limited to diabetes;

• Orthotics that are not Orthotic Appliances or Orthotic Devices;

• For any treatment leading to or in connection with transsexual Surgery except for Illness or Injury resulting from such Surgery;

• For treatment of sexual dysfunction not related to organic disease except for sexual dysfunction resulting from an Injury;

• For treatment of obesity. This exclusion does not apply to surgical procedures specifically intended to result in weight loss (including bariatric surgery) when (1) the Carrier determines the Surgery is Medically Appropriate/Medically Necessary; and (2) the Surgery is limited to one surgical procedure per lifetime regardless or even if a new or different diagnosis is the indication for the Surgery; a new or different type of Surgery is intended or performed; or a revision, repeat of reversal of any previous weight loss Surgery is intended or performed. The exclusion of coverage for a repeat, reversal or revision of a previous Surgery does not apply when the intended procedure is performed to treat technical failure or complication of a prior surgical procedure, which if left untreated, would result in endangering the health of the Covered Person. Failure to maintain weight loss or any condition resulting from or associated with obesity does not constitute technical failure. This exclusion does not apply to nutrition counseling visits as set forth in the Description of Benefits section under the subsection entitled “Nutrition Counseling for Weight Management”;

SAMPLE


• For eyeglasses, lenses or contact lenses, except as may be provided by a vision rider attached to this booklet/certificate;

• For correction of myopia or hyperopia by means of corneal microsurgery, such as keratomileusis, keratophakia, and radial keratotomy and all related services;

• For weight reduction and premarital blood tests. This exclusion does not apply to nutrition visits as set forth in the Description of Benefits section under the subsection entitled “Nutrition Counseling for Weight Management”;

• For diagnostic screening examinations, except as specifically provided for under this Plan;

• For routine physical examinations for non-preventive purposes, such as pre-marital examinations, physicals for college, camp or travel, and examinations for insurance, licensing and employment;

• For travel, whether or not it has been recommended by a Professional Provider or if it is

required to receive treatment at a Provider located outside the geographic area served by the Point-of-Service Network;

• For immunizations required for employment purposes, or for travel; • For care in a nursing home, home for the aged, convalescent home, school, camp,

institution for intellectually disabled children, Custodial Care in a Skilled Nursing Facility; • For counseling or consultation with a Covered Person’s relatives, or Hospital charges for a

Covered Person’s relatives or guests, except as may be specifically provided or allowed in the "Treatment for Substance Abuse " or "Transplants" sections of the Description of Benefits;

• For home blood pressure machines, except for Covered Persons: (a) with pregnancy-

induced hypertension, (b) with hypertension complicated by pregnancy, or (c) with end-stage renal disease receiving home Dialysis;

• As described in the “Durable Medical Equipment” section in the Description of Benefits:

for personal hygiene, comfort and convenience items; equipment and devices of a primarily nonmedical nature; equipment inappropriate for home use; equipment containing features of a medical nature that are not required by the Covered Person’s condition; non-reusable supplies, except for those non-reusable supplies which are diabetic supplies as set forth in the Description of Benefits section under the subsection “Diabetic Supplies and Education Program”; equipment which cannot reasonably be expected to serve a therapeutic purpose; duplicate equipment, whether or not rented or purchased as a convenience; devices and equipment used for environmental control; and customized wheelchairs;

• For medical supplies (other than diabetic supplies) such as but not limited to thermometers,

ovulation kits, early pregnancy or home pregnancy testing kits; • For prescription drugs, except as may be provided by a Prescription Drug, Infertility, or

Orally Administered Anti-Cancer Prescription Drug rider attached to this booklet/certificate.

SAMPLE


This exclusion does not apply to insulin, insulin analogs and pharmacological agents for controlling blood sugar levels as provided for the treatment of diabetes;

• For over-the-counter drugs and any other medications that may be dispensed without a

doctor’s prescription, except for medications administered during an Inpatient Admission; • For Self-Injectable Prescription Drugs, regardless of whether the drugs are provided or

administered by a Provider, except as may be provided by a Prescription Drug or Infertility rider attached to this booklet/certificate. Drugs are considered Self-Injectable Prescription Drugs even when initial medical supervision and/or instruction is required prior to patient self-administration. This exclusion does not apply to Self-Injectable Prescription Drugs that are (a) mandated to be covered by law, such as insulin or any drugs required for the treatment of diabetes, unless these drugs are covered by a Prescription Drug rider or free standing Prescription Drug Contract issued to the Group by the Carrier; or (b) required for Emergency Care that requires a Self-Injectable Drug;

• For appetite suppressants;

• For oral non-elemental nutritional supplements (e.g. Boost, Ensure, PediaSure), casein

hydrolyzed formulas (e.g. Nutramigen, Alimentum, Pregestimil), or other nutritional products, including, but not limited to, basic milk, milk-based, and soy-based products. Also excluded are orally administered elemental (amino acid) formulas (e.g. Neocate®, Elecare®) when such formulas do not represent the sole source of nutrition. This exclusion does not apply to nutritional supplements as set forth in the Description of Benefits section under the subsection entitled "Inherited Metabolic Diseases, Medical Foods and Low Protein Modified Food Products" or specialized non-standard infant formulas as may be provided by a prescription drug rider attached to this booklet/certificate;

• For Inpatient Private Duty Nursing services; • For Maintenance of chronic conditions; • For charges Incurred for expenses in excess of Benefit Maximums as specified in the

Schedule of Benefits; • For any therapy service provided for: the ongoing Outpatient treatment of chronic medical

conditions that are not subject to significant functional improvement; additional therapy beyond this Plan’s limits, if any, shown on the Schedule of Benefits; work hardening; evaluations not associated with therapy; or therapy for back pain in pregnancy without specific medical conditions;

• For Cognitive Rehabilitation Therapy, except when provided integral to other supportive

therapies, such as, but not limited to Physical, Occupational and Speech Therapies in a multidisciplinary, goal-oriented and integrated treatment program designed to improve management and independence following neurological damage to the central nervous system caused by Illness or trauma (e.g. stroke, acute brain insult, encephalopathy);

• For treatment of temporomandibular joint syndrome (TMJ), also known as craniomandibular

disorders (CMD), with intraoral devices or with any non-surgical method to alter vertical dimension;

SAMPLE


• For Hearing Aids, including cochlear electromagnetic hearing devices, and hearing

examinations or tests for the prescription or fitting of Hearing Aids, except as shown in the “Hearing Aids for Dependents” section or as may be provided by a Hearing Aids rider attached to this booklet/certificate. Services and supplies related to these items are not covered;

• For acupuncture;

• For cranial prostheses, including wigs intended to replace hair, except as may be provided by a wig rider attached to this booklet/certificate;

• For any Surgery performed for the reversal of a sterilization procedure.

SAMPLE


CLAIMS

NOTE: If a Covered Person uses a Network Provider, no Claim Form is required, and that Provider will be responsible for providing the required Notice of Claim and Proofs of Loss to the Carrier. A. NOTICE OF CLAIM

Written notice of Illness or Injury must be given to the Carrier within twenty (20) days after the date when such Illness or Injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

B. PROOFS OF LOSS In the case of claim for any loss, written proof of such loss must be furnished to the Carrier within ninety (90) days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible.

C. FURNISHING CLAIM FORMS The Carrier will furnish to the Covered Person making the claim, or to the Group for delivery to such Covered Person, such forms as are required for filing proof of loss. If the Covered Person making claim does not receive such forms before the expiration of fifteen (15) days after the Carrier receives notice of any claim under this Plan, the Covered Person shall be deemed to have complied with the requirements of this Plan as to proof of loss upon submitting within the time fixed in this Plan for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made.

D. PHYSICAL EXAMINATIONS AND AUTOPSY The Carrier shall have the right and opportunity to examine the Covered Person when and so often as it may reasonably require during the pendency of claim under this Plan; and the Carrier shall also have the right and opportunity to make an autopsy in case of death, where it is not prohibited by law.

E. TIME OF PAYMENT OF CLAIMS

All benefits payable under this Plan will be payable: (a) no later than the lesser of: (i) the thirtieth (30th) calendar day following receipt of proof of loss; or (ii) the time limit established for the payment of claims in the Medicare program pursuant to 42 U.S.C. s. 1395u(c)(2)(B) if the claim is submitted by electronic means; or (b) no later than the fortieth (40th) calendar day following receipt of proof of loss if the claim is submitted by other than electronic means if: (1) the Provider is eligible at the date of service; (2) the person who received the Covered Service was covered on the date of service; (3) the claim is for a service or supply covered under the Plan; (4) the claim is submitted with all

SAMPLE


the information requested by the Carrier on the claim form or in other instructions that were distributed in advance to the Provider or Covered Person in accordance with the provisions of Section 4 of P.L. 2005, c. 352 (C. 17B:30-51); and (5) the Carrier has no reason to believe that the claim has been submitted fraudulently.

F. DENIAL OF CLAIMS

1. If a claim or a portion of a claim is not paid within the timeframes outlined above in

the “Time of Payment of Claims” subsection because: (a) the claim submission is incomplete because the required substantiating documentation has not been submitted to the Carrier; (b) the diagnosis coding, procedure coding, or any other required information to be submitted with the claim is incorrect; (c) the Carrier disputes the amount claimed; or (d) there is strong evidence of fraud by the Provider and the Carrier has initiated an investigation into the suspected fraud, the Carrier shall notify the Provider by electronic means and the Covered Person in writing within thirty (30) days after receipt of an electronic claim or notify the Covered Person and Provider in writing within forty (40) days after receipt of a claim submitted by other than electronic means, that: (i) the claim is incomplete with a statement as to what substantiating documentation is required for adjudication of the claim; (ii) the claim contains incorrect information with a statement as to what information must be corrected for adjudication of the claim; (iii) the Carrier disputes the amount claimed in whole or in part with a statement as to the basis of that dispute; or (iv) the Carrier finds there is strong evidence of fraud and has initiated an investigation into the suspected fraud in accordance with the Carrier’s fraud prevention plan established pursuant to Section 1 of P.L. 1993, c. 362 (C. 17:33A-15), or referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to Section 32 of P.L. 1998, c. 21 (C. 17:33A-16).

2. If all or a portion of an electronically submitted claim cannot be adjudicated because the diagnosis coding, procedure coding or any other data required to be submitted with the claim was missing, the Carrier shall electronically notify the Provider or its agent within seven (7) days of that determination and request any information required to complete adjudication of the claim.

3. Any uncontested portion of the claim shall be paid in accordance to the timeframes outlined above in the “Time of Payment of Claims” subsection, after receipt of the claim by the Carrier.

The Carrier, upon receipt of any additional information requested from the Covered Person or the Covered Person's assignee shall pay or deny the contested claim, or contested portion of the claim, within the timeframes outlined above in the “Time of Payment of Claims” subsection.

Payment is deemed to be made on the date a draft, or other valid instrument which is equivalent to payment, is placed in the United States mail in a properly addressed, postpaid envelope or, if not so mailed, on the date of delivery.

4. An overdue payment shall bear simple interest at the rate of twelve percent (12%) per year.

SAMPLE


G. PAYMENT All indemnities of this Plan are payable to the Covered Person, except that at the Covered Person’s request or in the event of the Covered Person’s death, payment of benefits to the extent of expenses Incurred on account of hospitalization may be made by the Carrier to the Hospital and except that this Plan may provide that all or any portion of any benefits on account of Hospital, nursing, medical or surgical services may, at the Carrier’s option, be paid directly to the Hospital or person rendering such services provided, further, that authorization for any such payments has been obtained from the Covered Person.

H. RIGHT TO RECOVER PAYMENTS IN ERROR If the Carrier should pay for any contractually excluded services through inadvertence or error, the Carrier maintains the right to seek recovery of such payment from the Facility Provider, Professional Provider or Covered Person to whom such payment was made. The Carrier shall not seek reimbursement for overpayment of a claim previously paid later than eighteen (18) months after the date the first payment on the claim was made. The Carrier shall not seek more than one reimbursement for overpayment of a particular claim.

I. CLAIMS APPEAL PROCEDURE The procedures to Appeal a claim are explained in detail in the “Appeals” subsection of the Resolving Problems section.

SAMPLE


GENERAL INFORMATION

A. BENEFITS TO WHICH A COVERED PERSON IS ENTITLED

The liability of the Carrier is limited to the benefits specified in this booklet/certificate. The Carrier shall make a determination regarding the applicability of the benefit provisions for the services provided to a Covered Person.

B. TERMINATION OF COVERAGE UNDER THIS PLAN (ALSO SEE THE SECTION ENTITLED CONTINUATION RIGHTS) 1. When Eligibility Ends

When a Covered Person ceases to be an Enrolled Employee or a Dependent ceases to be an eligible Dependent, coverage will terminate. Coverage will terminate regardless of whether the Covered Person is confined as an Inpatient in a Facility such as a Hospital or Skilled Nursing Facility. If benefits under this Plan are provided by and/or approved by the Carrier before the Carrier receives notice of the Covered Person’s termination under this Plan, the cost of such benefits will be the sole responsibility of the Covered Person. In that circumstance, the Carrier will consider the effective date of termination to be not more than thirty (30) days before the first day of the month in which the Group notified the Carrier of such termination.

2. Termination of the Group Contract Termination of the Group Contract automatically terminates all coverage. It is the responsibility of the Group to notify the Covered Person of the termination of the coverage. However, coverage will be terminated regardless of whether the notice is given. Termination due to lapse of the Group Contract shall be without prejudice as to valid claims for covered losses incurred prior to the end of the grace period.

3. Fraud If it is proven that a Covered Person obtained or attempted to obtain benefits or payment for benefits, through fraud or intentional misrepresentation of material fact, the Carrier may, upon notice to the Covered Person, terminate the coverage.

4. If an Enrolled Employee Dies If an Enrolled Employee dies, any Dependents who were insured under this Plan may elect to continue coverage. Subject to the payment of the required premium, coverage may be continued until the earlier of: a. 180 days following the date of the Enrolled Employee’s death; or b. The date the eligible Dependent is no longer eligible under the terms of this

Plan.

5. Divorce of a Dependent Spouse or Dissolution of the Civil Union

SAMPLE


If a Dependent spouse divorces from an Enrolled Employee or terminates a Civil Union, coverage of such Dependent spouse under this Plan shall terminate at the end of the current monthly term.

C. TERMINATION OF COVERAGE AT TERMINATION OF EMPLOYMENT OR MEMBERSHIP IN THE GROUP When a Covered Person ceases to be an Enrolled Employee or Dependent, or the required contribution is not paid, the Covered Person's coverage will terminate at the end of the last month for which payment was made. However, if benefits under this Plan are provided by and/or approved by the Carrier before the Carrier receives notice of the Covered Person’s termination under this Plan, the cost of such benefits will be the sole responsibility of the Covered Person. In that circumstance, the Carrier will consider the effective date of termination of a Covered Person under this Plan to be not more than thirty (30) days before the first day of the month in which the Group notified the Carrier of such termination.

D. CONVERSION FOR A DEPENDENT SPOUSE DUE TO DIVORCE OR DISSOLUTION OF THE CIVIL UNION Conversion coverage shall be made available to a Dependent spouse due to divorce or dissolution of the Civil Union. The terminated spouse shall be entitled to individual coverage of the type for which the terminated spouse is then qualified at the rate then in effect, by applying within thirty (30) days of such termination, referred to as the conversion period. This individual coverage may be different from the coverage provided under this Plan. A Dependent spouse must apply for the individual coverage in writing and pay the first premium for such coverage during the conversion period. Evidence of insurability will not be required for the individual coverage. The individual coverage is effective on the day after a Dependent spouse’s coverage ends under this Plan.

E. NEW JERSEY CONTINUATION RIGHTS FOR OVER-AGE DEPENDENTS Coverage shall be made available to an unmarried child or a child not in a civil union partnership, under the age of thirty-one (31) who has lost coverage due to the attainment of age twenty-six (26) and meets the requirements of N.J.S.A. 17B:27-30.5. To initiate the application process for Over-Age Dependent coverage, please call the Customer Service Department at the number listed on the back of the Identification Card. Over-Age Dependents who elect and are subsequently enrolled for Over-Age Dependent coverage will be subject to the terms and conditions as set forth in the Over-Age Dependent Benefit Amendment Rider.

F. CONTINUATION RIGHTS 1. Coordination Among Continuation Rights Sections

As used in this section, COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985 as enacted, and later amended. A Covered Person may be eligible to continue their group health benefits under this booklet/certificate's "COBRA Continuation Rights (CCR)" section and under other continuation sections of this booklet/certificate at the same time.

SAMPLE


Continuation Under CCR and any other continuation section of this booklet/certificate: If a Covered Person elects to continue their group health benefits under both this booklet/certificate's CCR and any other continuation sections, the continuations: a. Start at the same time; b. Run concurrently; and c. End independently on their own terms. While covered under more than one continuation section, the Covered Person: a. Will not be entitled to duplicate benefits; and b. Will not be subject to the premium requirements of more than one section at

the same time.

2. COBRA Continuation Rights (CCR) Important Notice: For purposes of this section, “qualified continuee” means any person who, on the day before any event which would qualify them for continuation under this section, is covered for group health benefits under this Plan as: a. You, a covered Employee; b. Your spouse; or c. Your Dependent child. In addition, any child born to or placed for adoption with you during COBRA continuation will be a qualified continuee. Any person other than a child born to or placed for adoption with you during COBRA continuation that becomes covered under this Plan during COBRA continuation will not be a qualified continuee. If An Employee Terminates Employment or Has a Reduction of Work Hours: If your group benefits end due to your termination of employment or reduction of work hours, you may elect to continue such benefits for up to eighteen (18) months, if: a. Your termination of employment was not due to gross misconduct; and b. You are not entitled to Medicare on or before the date of the COBRA election. The continuation will cover you and any other qualified continuee who loses coverage because of your termination of employment (for reasons other than gross misconduct) or reduction of work hours, subject to the “When Continuation Ends” paragraph of this subsection. Extra Continuation for Disabled Qualified Continuees: If a qualified continuee is determined to be disabled under Title II or Title XVI of the United States Social Security Act on the day before the qualified continuee’s health benefits would otherwise end due to your termination of employment (for reasons other than gross misconduct) or reduction of work hours or within sixty (60) days of that date, the qualified continuee and any other affected qualified continuees may elect to extend

SAMPLE


the eighteen (18) month continuation period described above for up to an extra eleven (11) months. To elect the extra eleven (11) months of continuation, the plan administrator must be given written proof of Social Security’s determination of the qualified continuee’s disability before the earlier of: a. The end of the eighteen (18) month continuation period; and b. Sixty (60) days after the date the qualified continuee is determined to be

disabled. If, during the eleven (11) month continuation period, the qualified continuee is determined to be no longer disabled under the United States Social Security Act, he or she must notify the plan administrator within thirty (30) days of such determination, and continuation will end, as explained in the “When Continuation Ends” paragraph of this subsection. If an Employee Dies: If you (the covered Employee) die, any qualified continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to thirty-six (36) months, subject to the “When Continuation Ends” paragraph of this subsection. If an Employee’s Marriage Ends: If your marriage ends due to legal divorce or legal separation, any qualified continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to thirty-six (36) months, subject to the “When Continuation Ends” paragraph of this subsection. If an Employee Becomes Entitled to Medicare: If you become entitled to Medicare after terminating employment (for reasons other than gross misconduct) or experiencing a reduction of work hours, any qualified continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to thirty-six (36) months from the date the initial eighteen (18) month continuation period started, subject to the “When Continuation Ends” paragraph of this subsection. If you become entitled to Medicare before terminating employment (for reasons other than gross misconduct) or are experiencing a reduction of work hours and, during the subsequent eighteen (18) month period, you terminate employment (for reasons other than gross misconduct) or have your work hours reduced, all qualified continuees other than you whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to eighteen (18) months, but may be extended until thirty-six (36) months from the date you became entitled to Medicare, subject to the “When Continuation Ends” paragraph of this subsection. If a Dependent Loses Eligibility: If your Dependent child’s group health benefits end due to their loss of dependent eligibility as defined in this booklet/certificate, other than your coverage ending, they may elect to continue such benefits. However, such Dependent child must be a qualified continuee. The continuation can

SAMPLE


last for up to thirty-six (36) months, subject to the “When Continuation Ends” paragraph of this subsection. Concurrent Continuations: If your Dependent who is a qualified continuee elects to continue their group health benefits due to your termination of employment (for reasons other than gross misconduct) or reduction of work hours, your Dependent may elect to extend their eighteen (18) month continuation period to up to thirty-six (36) months, if during the eighteen (18) month continuation period your Dependent becomes eligible for thirty-six (36) months of group health benefits due to any of the reasons stated above. The thirty-six (36) month continuation period starts on the date the initial eighteen (18) month continuation period started, and the two (2) continuation periods will be deemed to have run concurrently. The Qualified Continuee’s Responsibilities: A person eligible for continuation under this section must notify the plan administrator, in writing, of: a. Your legal divorce or legal separation from your spouse; or b. Your Dependent child’s loss of Dependent eligibility, as defined in this

booklet/certificate. The notice must be given to the plan administrator within sixty (60) days of either of these events. In addition, a disabled qualified continuee must notify the plan administrator, in writing, of any final determination that the qualified continuee is no longer disabled under Title II or Title XVI of the United States Social Security Act. Such notice must be given to the plan administrator within thirty (30) days of such final determination. The Employer’s Responsibilities: Your employer must notify the plan administrator, in writing, of: a. Your termination of employment (for reasons other than gross misconduct) or

reduction of work hours; b. Your death; or c. Your entitlement to Medicare. The notice must be given to the plan administrator within sixty (60) days of any of these events. The Plan Administrator’s Responsibilities: The plan administrator must notify the qualified continuee, in writing, of: a. The qualified continuee’s right to continue the group health benefits described

in this booklet/certificate; b. The monthly premium the qualified continuee must pay to continue such

benefits; and c. The times and manner in which such monthly payments must be made.

SAMPLE


If the plan administrator is the employer, such written notice must be given to the qualified continuee within forty-four (44) days of: a. Your termination of employment (for reasons other than gross misconduct) or

reduction of work hours, your death, or your entitlement to Medicare; or b. The date the qualified continuee notifies the employer, in writing, of your legal

divorce or legal separation from your spouse, or your Dependent child’s loss of eligibility.

If the plan administrator is not the employer, such written notice must be given to the qualified continuee within fourteen (14) days of: a. The date the employer notifies the plan administrator, in writing, of your

termination of employment (for reasons other than gross misconduct) or reduction of work hours, your death, or your entitlement to Medicare; or

b. The date the qualified continuee notifies the plan administrator, in writing, of your legal divorce or legal separation from your spouse, or your Dependent child’s loss of eligibility.

The Employer’s Liability: Your employer will be liable for the qualified continuee’s continued group health benefits to the same extent as, and in the place of, the Carrier, if: a. The Employer fails to remit a qualified continuee’s timely premium payment to

the Carrier on time, thereby causing the qualified continuee’s group health benefits to end; or

b. The plan administrator fails to notify the qualified continuee of the qualified continuee’s continuation rights, as described above.

Election of Continuation: To continue the qualified continuee’s group health benefits, the qualified continuee must give the plan administrator written notice that the qualified continuee elects to continue benefits under the coverage. This must be done within sixty (60) days of the date a qualified continuee receives notice of their continuation rights from the plan administrator as described above or sixty (60) days of the date the qualified continuee’s group health benefits end, if later. Furthermore, the qualified continuee must pay the first month’s premium in a timely manner. The subsequent premiums must be paid to the plan administrator by the qualified continuee, in advance, at the time and in the manner set forth by the plan administrator. No further notice of when premiums are due will be given. The monthly premium will be the total rate which would have been charged for the group health benefits had the qualified continuee stayed insured under this benefit plan on a regular basis. It includes any amount that would have been paid by the employer. An additional charge of two percent (2%) of the total premium charge may also be required by the employer. Qualified continuees who receive the extended coverage due to disability described above may be charged an additional fifty percent (50%) of the total premium charge during the extra eleven (11) month continuation period.

SAMPLE


If the qualified continuee fails to give the plan administrator notice of their intent to continue, or fails to pay any required premiums in a timely manner, they waive their continuation rights. Grace in Payment of Premiums: A qualified continuee’s premium payment is timely if made within the timeframes outlined in 26 CFR §54.4980B-8. When Continuation Ends: A qualified continuee’s continued group health benefits under the Plan end on the first to occur of the following: a. With respect to continuation upon your termination of employment or reduction

of work hours, the end of the eighteen (18) month period which starts on the date the group health benefits would otherwise end;

b. With respect to a disabled qualified continuee and their family members who

are qualified continuees who have elected an additional eleven (11) months of continuation, the earlier of:

(1) The end of the twenty-nine (29) month period which starts on the date the

group health benefits would otherwise end; or (2) The first day of the month which coincides with or next follows the date

which is thirty (30) days after the date on which a final determination is made that a disabled qualified continuee is no longer disabled under Title II or Title XVI of the United States Social Security Act;

c. With respect to continuation upon your death, your legal divorce or legal

separation, or the end of your covered Dependent’s eligibility, the end of the thirty-six (36) month period which starts on the date the group health benefits would otherwise end;

d. With respect to your Dependent whose continuation is extended due to your

entitlement to Medicare: (1) After your termination of employment or reduction of work hours, the end

of the thirty-six (36) month period beginning on the date coverage would otherwise end due to your termination of employment or reduction of work hours; and

(2) Before, your termination of employment or reduction of work hours where,

during the eighteen (18)-month period following Medicare entitlement, you terminate employment or have a reduction of work hours, at least to the end of the eighteen (18) month period beginning on the date coverage would otherwise end due to your termination of employment or reduction of work hours, but not less than thirty-six (36) months from the date you become entitled to Medicare.

e. The date coverage under this Plan ends; f. The end of the period for which the last premium payment is made;

SAMPLE


g. The date the qualified continuee becomes covered under any other group health plan (as an employee or otherwise) which contains no limitation or exclusion with respect to any pre-existing condition of the qualified continuee or contains a pre-existing conditions exclusion or limitation that is eliminated through the qualified continuee’s total period of creditable coverage;

h. The date the qualified continuee becomes entitled to Medicare. A divorced spouse whose continued health benefits end as described above may elect to convert some of these benefits to an individual insurance policy. THE CARRIER’S RESPONSIBILITIES RELATIVE TO THE PROVISION OF CONTINUATION COVERAGE UNDER THIS COVERAGE ARE LIMITED TO THOSE SET FORTH IN THIS SECTION OF THIS BOOKLET/CERTIFICATE. THE CARRIER IS NOT THE PLAN ADMINISTRATOR UNDER THE COVERAGE OR FOR PURPOSES OF ERISA OR ANY OTHER FEDERAL OR STATE LAW. IN THE ABSENCE OF THE DESIGNATION OF ANOTHER PARTY AS PLAN ADMINISTRATOR, THE PLAN ADMINISTRATOR SHALL BE THE EMPLOYER.

3. Continuation of Incapacitated Child If a child is incapable of self-support because of mental or physical incapacity and is dependent on an enrolled Employee for over half of his or her support, application may be made to the Carrier to continue coverage of such child under this Plan upon such terms and conditions as set forth below. Coverage of such Dependent child shall terminate upon their marriage. Continuation of benefits under this provision will only apply if the child was eligible as a Dependent and mental or physical incapacity commenced prior to age twenty-six (26). The disability must be certified by the attending Physician; furthermore, the disability is subject to annual medical review.

4. Continuation of Coverage at Termination Termination of Employment or Membership Due to Total Disability If coverage under this Plan would have otherwise terminated because of an Enrolled Employee’s termination of employment or membership due to Total Disability, coverage can be continued under this Plan for the Enrolled Employee and Dependents, subject to all of this Plan's terms and conditions, subject to the following conditions: a. Continuation shall only be available if the Enrolled Employee has been

continuously covered under the group policy during the entire three (3) months' period ending with such termination.

b. Continuation shall be available for any person who is covered by or eligible for

Medicare, subject to any nonduplication of benefits provisions in this Plan.

SAMPLE


c. If continuation is elected, the Enrolled Employee shall pay to the Group or the employer, on a monthly basis in advance, the amount of contribution required by the Group or the employer, but not more than the group rate for the coverage being continued under this Plan on the due date of each payment. Written election for continuation, together with the first contribution required to establish contributions on a monthly basis in advance, shall be given to the Group or the employer within thirty-one (31) days of the date coverage would otherwise terminate.

d. Continuation of coverage under this Plan for any person shall terminate at the

first to occur of the following: (1) Failure to make timely payment of a required contribution. Termination

shall occur at the end of the period for which contributions were made. (2) The date the Enrolled Employee again becomes employed and eligible

for benefits under another group plan providing health care expense benefits, or in the case of a qualified Dependent, the date such qualified Dependent becomes employed and eligible for such benefits.

(3) The date on which this Plan is terminated or the date the employer

terminates participation under this Plan, provided that: (a) The Enrolled Employee shall have the right to become covered

under any new group policy contracted for by the employer, for the balance of the period that the Enrolled Employee would have remained covered under the prior group policy had a termination of the Group not occurred;

(b) The minimum level of benefits to be provided by the other group policy shall be the applicable level of benefits of the prior group policy reduced by any benefits payable under this Plan; and

(c) The prior group policy shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits, as if the replacement had not occurred.

Extended Benefits Provision: If a Covered Person is Totally Disabled on the date of termination of this Plan, coverage will be extended for the Illness or Injury that caused such disability, until the earlier of: a. The date the Total Disability ends; or b. The end of a period of twelve (12) consecutive months following the date the

Covered Person’s coverage under this Plan terminated. During the extension the provisions of coverage will apply as if the Covered Person were still a Covered Person provided benefits remain under this Plan, except that there will be no automatic restoration of part or all of any applicable Lifetime Benefit Maximum.

SAMPLE


Total Disability or Totally Disabled Defined Except as otherwise set forth in this booklet/certificate, Total Disability or Totally Disabled means that the Enrolled Employee, due to Illness or Injury, cannot perform any duty of his or her occupation or any occupation for which s/he is, or may be, suited by education, training and experience, and are not, in fact, engaged in any occupation for wage or profit. A Dependent is Totally Disabled if s/he cannot engage in the normal activities of a person in good health and of like age and sex. An Enrolled Employee or Dependent must be under the regular care of a Physician.

G. RELEASE OF INFORMATION Each Covered Person agrees that any person or entity having information relating to an Illness or Injury for which benefits are claimed under this Plan may furnish to the Carrier, upon its request, any information (including copies of records relating to the Illness or Injury). In addition, the Carrier may furnish similar information to other entities providing similar benefits at their request. The Carrier may also furnish other plans or plan sponsored entities with membership and/or coverage information for the purpose of claims processing or facilitating patient care. When the Carrier needs to obtain consent for the release of personal health information, authorization of care and treatment, or to have access to information from a Covered Person who is unable to provide it, the Carrier will obtain consent from the parent, legal guardian, next of kin, or other individual with appropriate legal authority to make decisions on behalf of the Covered Person.

H. CONSUMER RIGHTS Each Covered Person has the right to access, review and copy their own health and membership records and request amendments to their records. This includes information pertaining to claim payments, payment methodology, reduction or denial, medical information secured from other agents, plans or providers. For more information about accessing, reviewing or copying records, call the Carrier’s Customer Service Department at the toll-free number on the Identification Card.

I. LIMITATION OF ACTIONS No legal action may be taken to recover benefits within sixty (60) days after notice of claim has been given as specified above, and no such action may be taken later than three (3) years after the date proof of loss was required to have been submitted to the Carrier.

J. COVERED PERSON/PROVIDER RELATIONSHIP 1. Selection of a Primary Care Physician

a. Prior to the time a Covered Person’s coverage becomes effective in

accordance with the provisions of this Plan, the Covered Person must choose a

SAMPLE


Primary Care Physician from which the Covered Person wishes to receive Covered Services under this Plan.

b. If a Covered Person fails to select a Primary Care Physician within thirty (30)

days of Enrollment, the Carrier reserves the right to assign a Covered Person to a Primary Care Physician subject to the Covered Person’s right to change Primary Care Physicians as described in 2. below.

2. Changing a Primary Care Physician

a. If a Covered Person wishes to transfer to a different Primary Care Physician, a

request must be submitted in writing or by telephone to the Carrier’s Customer Service Department. The change will become effective within fifteen (15) days from the date the request is received.

b. Changing a Primary Care Physician is limited to two (2) transfers per year. c. A Primary Care Physician may request, in writing to the Carrier, that care for a

Covered Person be transferred to another Primary Care Physician. However, a Primary Care Physician shall not seek to have a Covered Person transferred because of the amount of Covered Services required by the Covered Person or because of the physical condition of the Covered Person.

d. If the participating status of the Covered Person’s Primary Care Physician

changes, the Covered Person will be notified in order to select another Primary Care Physician.

3. Changing a Referred Specialist

a. A Covered Person may change the Referred Specialist to whom they were

Referred to by their Primary Care Physician. To do so, the Covered Person would ask their Primary Care Physician to recommend another Referred Specialist before services are performed. Or, the Covered Person may call the Carrier’s Customer Member Service Department at the number listed on the back of their Identification Card. Only services authorized on the Referral form will be covered.

b. If the participating status of a Referred Specialist that a Covered Person regularly visit changes, the Covered Person will be notified to select another Referred Specialist.

4. Continuation of Treatment

a. The Covered Person has the option, if the Covered Person’s Physician agrees

to be bound by certain terms and conditions as required by the Carrier, of continuing an ongoing course of treatment with that Physician as follows: (1) If the Covered Person is receiving post-operative follow-up care,

oncological treatment, psychiatric treatment or obstetrical care by a Physician who is a Network Provider at the time the treatment is initiated, the Covered Person may continue to be treated by that Physician for the duration of the treatment in the event that the Physician is no longer a Network Provider as follows:

SAMPLE


(a) For a period not to exceed six (6) months in the case of post-

operative follow-up care; (b) For a period not to exceed one (1) year in the case of oncological

treatment and psychiatric treatment; and (c) Through the duration of a pregnancy and up to six (6) weeks after

delivery in the case of obstetrical care. (2) If the Covered Person is receiving Medically Appropriate/Medically

Necessary treatment, other than (a), (b) or (c) shown in (1) above, by a Physician who is a Network Provider at the time the treatment is initiated, the Covered Person may continue to be treated by that Physician for the duration of the treatment in the event that the Physician is no longer a Network Provider for up to four (4) months.

(3) During the period of time the Covered Person is continuing to receive

treatment pursuant to Items (1) or (2) above by a Physician who is no longer a Network Provider, benefits will be provided for any treatment received in an acute care Hospital, regardless of whether the acute care Hospital is under contract with the Carrier.

(4) The Carrier will not be liable for any inappropriate treatment provided to

the Covered Person by a Physician who is no longer a Network Provider; These provisions will not apply to Physicians who are the subject of disciplinary action by the State Board of Medical Examiners or who are terminated for reasons which would endanger the Covered Person, public health or safety, breach of contract or fraud. For Items (1) and (2) above, Benefits or services will be provided for the treatment of the condition under the same terms and conditions that applied when the Physician was a Network Provider.

b. The Covered Person must follow these steps to initiate continuation of

treatment benefits: (1) Call the Carrier’s Customer Service Department at the number on the

Identification Card and ask for a “Care Management and Coordination Request for Continuation of Care” form.

(2) The “Care Management and Coordination Request for Continuation of Care” form will be mailed or faxed to the Covered Person.

(3) The Covered Person must complete the form and send it to Care Management and Coordination at the address that appears on the form.

c. If the Covered Person’s Physician agrees to continue to provide ongoing care,

the Physician must also agree to be bound by the same terms and conditions as apply to Network Providers.

SAMPLE


d. The Covered Person will be notified when the participating status of the Covered Person’s Primary Care Physician changes so that they can select another Primary Care Physician.

5. The Carrier does not furnish Covered Services but only makes payment for Covered

Services received by persons covered under this Plan. The Carrier is not liable for any act or omission of any Provider. The Carrier has no responsibility for a Provider's failure or refusal to render Covered Services to a Covered Person.

K. COORDINATION OF BENEFITS AND SERVICES

1. Purpose Of This Provision

A Covered Person may be covered for health benefits or services by more than one Plan. For instance, he or she may be covered by this Plan as an Employee and by another plan as a Dependent of his or her spouse. If he or she is covered by more than one Plan, this provision allows the Carrier to coordinate what the Carrier pays or provides with what another Plan pays or provides. This provision sets forth the rules for determining which is the primary plan and which is the secondary plan. Coordination of benefits is intended to avoid duplication of benefits while at the same time preserving certain rights to coverage under all Plans under which the Covered Person is covered.

2. Definitions The words shown below have special meanings when used in this provision. Please read these definitions carefully. a. Allowable Expense: The charge for any health care service, supply or other

item of expense for which the Covered Person is liable when the health care service, supply or other item of expense is covered at least in part under any of the Plans involved, except where a statute requires another definition, or as otherwise stated below. When this Plan is coordinating benefits with a Plan that provides benefits only for dental care, vision care, prescription drugs or Hearing Aids, Allowable Expense is limited to like items of expense. The Carrier will not consider the difference between the cost of a private hospital room and that of a semi-private Hospital room as an Allowable Expense unless the stay in a private room is Medically Appropriate/Medically Necessary. When this Plan is coordinating benefits with a Plan that restricts coordination of benefits to a specific coverage, the Carrier will only consider corresponding services, supplies or items of expense to which coordination of benefits applies as an Allowable Expense.

b. Claim Determination Period: A Calendar Year, or any portion of a Calendar

Year, during which a Covered Person is covered by this Plan and at least one other Plan and incurs one or more Allowable Expense(s) under such plans.

SAMPLE


c. Plan: Coverage with which coordination of benefits is allowed.

Plan includes: (1) Group insurance and group subscriber contracts, including insurance

continued pursuant to a Federal or State continuation law; (2) Self-funded arrangements of group or group-type coverage, including

insurance continued pursuant to a Federal or State continuation law; (3) Group or group-type coverage through a health maintenance organization

(HMO) or other prepayment, group practice and individual practice plans, including insurance continued pursuant to a Federal or State continuation law;

(4) Group hospital indemnity benefit amounts that exceed $150 per day; (5) Medicare or other governmental benefits, except when, pursuant to law,

the benefits must be treated as in excess of those of any private insurance plan or non-governmental plan.

Plan does not include: (1) Individual or family insurance contracts or subscriber contracts; (2) Individual or Family Coverage through a health maintenance organization

or under any other prepayment, group practice and individual practice plans;

(3) Group or group-type coverage where the cost of coverage is paid solely by the Covered Person except that coverage being continued pursuant to a Federal or State continuation law shall be considered a Plan;

(4) Group hospital indemnity benefit amounts of $150 per day or less; (5) School accident –type coverage; (6) A State plan under Medicaid.

d. Primary Plan: A Plan whose benefits for a Covered Person’s health care

coverage must be determined without taking into consideration the existence of any other Plan. There may be more than one Primary Plan. A Plan will be the Primary Plan if either

(1) or (2) below exist: (1) The Plan has no order of benefit determination rules, or it has rules that

differ from those contained in this Coordination of Benefits and Services provision; or

(2) All Plans which cover the Covered Person use order of benefit determination rules consistent with those contained in the Coordination of Benefits and Services provision and under those rules, the plan determines its benefits first.

e. Reasonable and Customary: An amount that is not more than the usual or

customary charge for the service or supply as determined by the Carrier, based on a standard which is most often charged for a given service by a Provider within the same geographic area.

SAMPLE


f. Secondary Plan: A Plan which is not a Primary Plan. If a Covered Person is covered by more than one Secondary Plan, the order of benefit determination rules of this Coordination of Benefits and Services provision shall be used to determine the order in which the benefits payable under the multiple Secondary Plans are paid in relation to each other. The benefits of each Secondary Plan may take into consideration the benefits of the Primary Plan or Plans and the benefits of any other Plan which, under this Coordination of Benefits and Services provision, has its benefits determined before those of that Secondary Plan.

3. Primary and Secondary Plan

The Carrier considers each Plan separately when coordinating payments. The Primary Plan pays or provides services or supplies first, without taking into consideration the existence of a Secondary Plan. If a Plan has no coordination of benefits provision, or if the order of benefit determination rules differ from those set forth in these provisions, it is the Primary Plan. A Secondary Plan takes into consideration the benefits provided by a Primary Plan when, according to the rules set forth below, the Plan is the Secondary Plan. If there is more than one Secondary Plan, the order of benefit determination rules determine the order among the Secondary Plans. The Secondary Plan(s) will pay up to the remaining unpaid allowable expenses, but no Secondary Plan will pay more than it would have paid if it had been the Primary Plan. The method the Secondary Plan uses to determine the amount to pay is set forth below in the “Procedures to be Followed by the Secondary Plan to Calculate Benefits” section of this provision. The Secondary Plan shall not reduce Allowable Expenses for Medically Appropriate/Medically Necessary services or supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed.

4. Rules for the Order of Benefit Determination The benefits of the Plan that covers the Covered Person as an Employee, member, subscriber or retiree shall be determined before those of the Plan that covers the Covered Person as a Dependent. The coverage as an Employee, member, subscriber or retiree is the Primary Plan. The benefits of the Plan that covers the Covered Person as an Employee who is neither laid off nor retired, or as a Dependent of such person, shall be determined before those for the Plan that covers the Covered Person as a laid off or retired employee, or as such a person’s Dependent. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. The benefits of the Plan that covers the Covered Person as an Employee, member, subscriber or retiree, or Dependent of such person, shall be determined before those of the Plan that covers the Covered Person under a right of continuation pursuant to Federal or State law. If the other Plan does not contain this rule, and as a result the

SAMPLE


Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. If a child is covered as a Dependent under Plans through both parents, and the parents are neither separated nor divorced, the following rules apply: (1) The benefits of the Plan of the parent whose birthday falls earlier in the

Calendar Year shall be determined before those of the parent whose birthday falls later in the Calendar Year.

(2) If both parents have the same birthday, the benefits of the Plan which covered the parent for a longer period of time shall be determined before those of the plan which covered the other parent for a shorter period of time.

(3) “Birthday”, as used above, refers only to month and day in a calendar year, not the year in which the parent was born.

(4) If the other Plan contains a provision that determines the order of benefits based on the gender of the parent, the birthday rule in this provision shall be ignored.

If a child is covered as a Dependent under Plans through both parents, and the parents are separated or divorced, the following rules apply: (1) The benefits of the Plan of the parent with custody of the child shall be

determined first. (2) The benefits of the Plan of the spouse of the parent with custody shall be

determined second. (3) The benefits of the Plan of the parent without custody shall be determined last. (4) If the terms of a court decree state that one of the parents is responsible for the

health care expenses for the child, and if the entity providing coverage under that Plan has actual knowledge of the terms of the court decree, then the benefits of that Plan shall be determined first. The benefits of the Plan of the other parent shall be considered as secondary. Until the entity providing coverage under the Plan has knowledge of the terms of the court decree regarding health care expenses, this portion of this provision shall be ignored.

If the above order of benefits does not establish which Plan is the Primary Plan, the benefits of the Plan that covers the Employee, member or subscriber for a longer period of time shall be determined before the benefits of the Plan(s) that covered the person for a shorter period of time. Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow it is necessary to consider: (1) The basis on which the Primary Plan and the Secondary Plan pay benefits; and (2) Whether the Provider who provides or arranges the services and supplies is in

the network of either the Primary Plan or the Secondary Plan. Benefits may be based on the Reasonable and Customary Charge (R&C), or some similar term. This means that the Provider bills a charge and the Covered Person may be held liable for the full amount of the Billed Charge. In this section, a Plan that bases benefits on a reasonable and customary charge is called an “R&C Plan”.

SAMPLE


Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a Provider, called a network Provider, bills a charge, the Covered Person may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan”. If the Covered Person uses the services of a non-network Provider, the Plan will be treated as an R&C Plan even though the Plan under which he or she is covered allows for a fee schedule. Payment to the Provider may be based on a “capitation”. This means that the HMO pays the Provider a fixed amount per Covered Person. The Covered Person is liable only for the applicable Deductible, Coinsurance or Copayment. If the Covered Person uses the services of a non-network Provider, the HMO will only pay benefits in the event of Emergency Care or Urgent Care. In this section, a Plan that pays Providers based upon capitation is called a “Capitation Plan”. In the rules below, “Provider” refers to the Provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan. Primary Plan is R&C Plan and Secondary Plan is R&C Plan The Secondary Plan shall pay the lesser of: (1) The difference between the amount of the Billed Charges and the amount paid

by the Primary Plan; or (2) The amount the Secondary Plan would have paid if it had been the Primary

Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the Provider is a network Provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: (1) The amount of any Deductible, Coinsurance or Copayment required by the

Primary Plan; or (2) The amount the Secondary Plan would have paid if it had been the Primary

Plan. The total amount the Provider receives from the Primary Plan, the Secondary Plan and the Covered Person shall not exceed the fee schedule of the Primary Plan. In no event shall the Covered Person be responsible for any payment in excess of the Copayment, Coinsurance or Deductible of the Secondary Plan. Primary Plan is R&C Plan and Secondary Plan is Fee Schedule Plan If the Provider is a network Provider in the Secondary Plan, the Secondary Plan shall pay the lesser of:

SAMPLE


(1) The difference between the amount of the Billed Charges for the Allowable

Expenses and the amount paid by the Primary Plan; or (2) The amount the Secondary Plan would have paid if it had been the Primary

Plan. The Covered Person shall only be liable for the Copayment, Deductible or Coinsurance under the Secondary Plan if the Covered Person has no liability for Copayment, Deductible or Coinsurance under the Primary Plan and the total payments by both the Primary and Secondary Plans are less than the provider’s Billed Charges. In no event shall the Covered Person be responsible for any payment in excess of the Copayment, Coinsurance or Deductible of the Secondary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is R&C Plan If the Provider is a network Provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: (1) The amount of any Deductible, Coinsurance or Copayment required by the


Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is R&C Plan or Fee Schedule Plan If the Primary Plan is an HMO plan that does not allow for the use of non-network Providers except in the event of Urgent Care or Emergency Care and the service or supply the Covered Person receives from a non-network Provider is not considered as Urgent Care or Emergency Care, the Secondary Plan shall pay benefits as if it were the Primary Plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or R&C Plan If the Covered Person receives services or supplies from a Provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: (1) The amount of any Deductible, Coinsurance or Copayment required by the


Plan. Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is Capitation Plan

SAMPLE


If the Covered Person receives services or supplies from a Provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the Provider and shall not be liable to pay the Deductible, Coinsurance or Copayment imposed by the Primary Plan. The Covered Person shall not be liable to pay any Deductible, Coinsurance or Copayments of either the Primary Plan or the Secondary Plan. Primary Plan is an HMO and Secondary Plan is an HMO If the Primary Plan is an HMO plan that does not allow for the use of non-network Providers except in the event of Urgent Care or Emergency Care and the service or supply the Covered Person receives from a non-network Provider is not considered as Urgent Care or Emergency Care, but the Provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan, except that the Primary Plan shall pay out-of-network services, if any, authorized by the Primary Plan.

5. Disabled Covered Persons

Benefits will be provided to the extent that benefits are payable by Medicare for Covered Persons who are Medicare eligible based on the basis of meeting the definition of disability as outlined in section 223 under Title XVII of the federal Social Security Act (Medicare); and for whom Medicare must pay as primary carrier.

L. SPECIAL CIRCUMSTANCES In the event that Special Circumstances result in a severe impact to the availability of providers and services, to the procedures required for obtaining benefits for Covered Services under this coverage (e.g., obtaining Precertification and use of Network Providers), or to the administration of this benefit program by the Carrier, the Carrier may on a selective basis, waive certain procedural requirements of this coverage. Such waiver shall be specific as to the requirements that are waived and shall last for such period as required by the Special Circumstances as defined below. The Carrier shall make a good faith effort to provide access to Covered Services in so far as practical and according to its best judgment. Neither the Carrier nor Providers in the Carrier’s Point-of-Service Network shall incur liability or obligation for delay, or failure to provide or arrange for Covered Services if such failure or delay is caused by Special Circumstances. Notwithstanding, Contractholders may not be liable for premium for the period during which the Carrier does not provide or arrange for Covered Services due to Special Circumstances. Special Circumstances, as recognized in the community, and by the Carrier and appropriate regulatory authority, are extraordinary circumstances not within the control of the Carrier, including but not limited to: (a) major disaster; (b) epidemic; (c) pandemic; (d) the complete or partial destruction of facilities; (e) riot; or (f) civil insurrection.

M. BENEFITS FOR AUTOMOBILE RELATED INJURIES This section will be used to determine a person's benefits under this Plan when expenses are Incurred as a result of an Automobile Related Injury.

SAMPLE


Definitions: "Automobile Related Injury" means bodily Injury sustained by a Covered Person as a result of an accident: 1. While occupying, entering, leaving or using an automobile; or 2. As a pedestrian; caused by an automobile or by an object propelled by or from an automobile. "Allowable Expense" means a Medically Appropriate/Medically Necessary, reasonable and customary item of expense covered at least in part as an eligible expense by: 1. This Plan; 2. PIP; or 3. OSAIC. "Eligible Expense" means that portion of expense Incurred for treatment of an Injury which is covered under this Plan without application of Deductibles, Copayments or Coinsurance, if any. "Out-of-State Automobile Insurance Coverage" or "OSAIC" means any coverage for medical expenses under an automobile insurance policy other than PIP. OSAIC includes automobile insurance policies issued in another state or jurisdiction. "PIP" means personal Injury protection coverage provided as part of an automobile insurance policy issued in New Jersey. PIP refers specifically to provisions for medical expense coverage. Determination of primary or secondary coverage: This Plan provides secondary coverage to PIP unless health coverage has been elected as primary coverage by or for the Covered Person under this Plan. This election is made by the named insured under a PIP policy. Such election affects that person's family members who are not themselves named insureds under another automobile policy. This Plan may be primary for one Covered Person, but not for another if the person has separate automobile policies and have made different selections regarding primacy of health coverage. This Plan is secondary to OSAIC, unless the OSAIC contains provisions which make it secondary or excess to the Group's plan. In that case this Plan will be primary. If there is a dispute as to which policy is primary, this Plan will pay benefits as if it were primary. Benefits this Plan will pay if it is primary to PIP or OSAIC: If this Plan is primary to PIP or OSAIC it will pay benefits for eligible expenses in accordance with its terms.

SAMPLE


The rules of the “Coordination of Benefits and Services” section of this Plan will apply if: 1. The Covered Person is insured under more than one insurance plan; and 2. Such insurance plans are primary to automobile insurance coverage. Benefits this Plan will pay if it is secondary to PIP or OSAIC: If this Plan is secondary to PIP or OSAIC the actual benefits payable will be the lesser of: 1. The allowable expenses left uncovered after PIP or OSAIC has provided coverage

after applying Deductibles and Copayments, or 2. The benefits that would have been paid if this Plan had been primary. Medicare: If this Plan supplements coverage under Medicare it can be primary to automobile insurance only to the extent that Medicare is primary to automobile insurance.

SAMPLE


MANAGED CARE

A. UTILIZATION REVIEW PROCESS

A basic condition of the Carrier’s benefit Plan coverage is that in order for a health care service to be covered or payable, the services must be Medically Appropriate/Medically Necessary. To assist the Carrier in making coverage determinations for requested health care services, the Carrier uses established Carrier Medical Policies and medical guidelines based on clinically credible evidence to determine the Medical Appropriateness/Medical Necessity of the requested services. The appropriateness of the requested setting in which the services are to be performed is part of the assessment. The process of determining the Medical Appropriateness/Medical Necessity of requested health care services for coverage determinations based on the benefits available under a Covered Person’s benefit Plan is called utilization review. It is not practical to verify Medical Appropriateness/Medical Necessity on all procedures on all occasions; therefore, certain procedures may be determined by the Carrier to be Medically Appropriate/Medically Necessary and automatically approved based on the accepted Medical Appropriateness/Medical Necessity of the procedure itself, the diagnosis reported or an agreement with the performing Provider. An example of such automatically approved services is an established list of services received in an emergency room which has been approved by the Carrier based on the procedure meeting Emergency criteria and the severity of diagnosis reported (e.g. rule out myocardial infarction, or major trauma). Other requested services, such as certain elective Inpatient or Outpatient procedures may be reviewed on a procedure specific or setting basis. Utilization review generally includes several components which are based on when the review is performed. When the review is required before a service is performed it is called a Precertification review. Reviews occurring during a Hospital stay are called a concurrent review, and those reviews occurring after services have been performed are called either retrospective or post-service reviews. The Carrier follows applicable state and federally required standards for the timeframes in which such reviews are to be performed. Generally, where a requested service is not automatically approved and must undergo Medical Appropriateness/Medical Necessity review, nurses perform initial case review and evaluation for coverage approval using the Carrier’s Medical Policies, established guidelines and evidence-based clinical criteria and protocols; however only a Medical Director employed by the Carrier may deny coverage for a procedure based on Medical Appropriateness/Medical Necessity. The evidence-based clinical protocols evaluate the Medical Appropriateness/Medical Necessity of specific procedures and the majority are computer-based. Information provided in support of the request is entered into the computer-based system and evaluated against the clinical protocols. Nurses apply applicable benefit Plan policies and procedures, taking into consideration the individual Covered Person’s condition and applying sound professional judgment. When the clinical criteria are not met, the given service request is referred to a Medical Director for further review for approval or denial. Independent medical consultants may also be engaged to provide clinical review of specific cases or for specific conditions. Should a procedure be denied for coverage based on lack of Medical Appropriateness/Medical Necessity, a letter is sent to the requesting Provider and Covered Person in accordance with applicable law.

SAMPLE


The Carrier’s utilization review program encourages peer dialogue regarding coverage decisions based on Medical Appropriateness/Medical Necessity by providing Physicians with direct access to the Carrier’s Medical Directors to discuss coverage of a case. Medical Directors and nurses are salaried, and contracted external Physician and other professional consultants are compensated on a per case reviewed basis, regardless of the coverage determination. The Carrier does not specifically reward or provide financial incentives to individuals performing utilization review services for issuing denials of coverage. There are no financial incentives for such individuals which would encourage utilization review decisions that result in underutilization.

B. CLINICAL CRITERIA, GUIDELINES AND RESOURCES The following guidelines, clinical criteria and other resources are used to help make Medically Appropriate/Medical Necessity coverage decisions: Clinical Decision Support Criteria: Clinical Decision Support Criteria is an externally validated and computer-based system used to assist the Carrier in determining Medical Appropriateness/Medical Necessity. The evidence-based, Clinical Decision Support Criteria is nationally recognized and validated. Using a model based on evaluating intensity of service and severity of Illness, these criteria assist the Carrier’s clinical staff evaluating the Medical Appropriateness/Medical Necessity of coverage based on a Covered Person’s specific clinical needs. Clinical Decision Support Criteria helps promote consistency in the Carrier’s Plan determinations for similar medical issues and requests, and reduces practice variation among the Carrier’s clinical staff to minimize subjective decision-making. Clinical Decision Support Criteria may be applied for Covered Services including, but not limited to the following: • Some elective Surgeries - settings for Inpatient and Outpatient procedures (e.g.

hysterectomy and sinus surgery) • Inpatient hospitalizations • Inpatient Rehabilitation • Home Health • Durable Medical Equipment • Skilled Nursing Facility Centers for Medicare and Medicaid Services (CMS) Guidelines: A set of guidelines adopted and published by CMS for coverage of services by Medicare for Medicare members. The Carrier’s Medical Policies: the Carrier maintains an internally developed set of policies that document the coverage and conditions for certain medical/surgical procedures and ancillary services. Covered Services for which the Carrier’s Medical Polices are applied include, but are not limited to: • Ambulance Services

SAMPLE


• Infusion • Speech Therapy • Occupational Therapy • Durable Medical Equipment • Review of potential cosmetic procedures The Carrier’s Internally Developed Guidelines: A set of guidelines developed specifically for the Carrier, as needed, with input by clinical experts based on accepted practice guidelines within the specific fields and reflecting the Carrier’s Medical Policies for coverage.

C. DELEGATION OF UTILIZATION REVIEW ACTIVITIES AND CRITERIA The Carrier delegates its utilization review process to the Carrier’s affiliate, Independence Healthcare Management (IHM). IHM is a state licensed utilization review entity and is responsible for the Carrier’s utilization review process. In certain instances, the Carrier has delegated certain utilization review activities, including Precertification review, concurrent review, and Case Management, to integrated delivery systems and/or entities with an expertise in medical management of a certain membership population (such as, Neonates/premature infants) or type of benefit or service (such as Mental Illness/Substance Abuse or radiology). In such instances, a formal delegation and oversight process is established in accordance with applicable law and nationally-recognized accreditation standards. In such cases, the delegate’s utilization review criteria are generally used, with the Carrier’s approval.

Utilization Review and Criteria for Mental Illness/Substance Abuse Services Utilization Review activities for Mental Illness/Substance Abuse services have been delegated by the Carrier to a behavioral health management company, which administers the Mental Illness/Substance Abuse benefits for the majority of the Carrier’s Covered Persons.

D. PRECERTIFICATION REVIEW When required, Precertification review evaluates the Medical Necessity, including the Medical Appropriateness of the setting, of proposed services for coverage under the Covered Person’s benefit plan. Examples of these services include planned or elective Inpatient Admissions and selected Outpatient procedures. Precertification review may be initiated by the Provider or the Covered Person depending on whether the Provider is a Point-of-Service Network Provider. Where Precertification review is required, the Carrier’s coverage of the proposed procedure is contingent upon the review being completed and receipt of the approval certification. Coverage penalties may be applied where Precertification review is required for a procedure but is not obtained. While the majority of services requiring Precertification review are reviewed for Medical Appropriateness of the requested procedure setting (e.g., Inpatient, Short Procedure Unit or Outpatient setting), other elements of the Medical Appropriateness/Medical Necessity of the procedure may not always be evaluated and may be automatically approved based on the procedure or diagnosis for which the procedure is requested or an agreement with the

SAMPLE


performing Provider. Precertification review is not required for Emergency Care and is not performed where an agreement with the Network Provider does not require such review. The following information provides more specific information of this Plan’s Precertification requirements. 1. Inpatient Precertification Review

a. Network Inpatient Admissions

In accordance with the criteria and procedures described above, Inpatient Admissions, other than an Emergency or maternity admission, must be Precertified in accordance with the standards of the Carrier as to the Medical Appropriateness/Medical Necessity of the admission. The Precertification requirements for Emergency admissions are set forth in the “Emergency Admission Review” subsection of this Managed Care section. A Network Hospital, Skilled Nursing Facility, or other Facility Provider in the Point-of-Service Network will verify the Precertification at or before the time of admission. The Carrier will not authorize payment to the Hospital, Skilled Nursing Facility or other Facility Provider admission if Precertification is required and is not obtained in advance. The Carrier will hold the Covered Person harmless and the Covered Person will not be financially responsible for admissions to Hospitals, Skilled Nursing Facilities or other Facility Providers in the Point-of-Service Network which fail to conform to the Precertification requirements unless the Hospital, Skilled Nursing Facility or other Facility Provider provides prior written notice to the Covered Person that the admission will not be paid by the Carrier.

b. Non-Network Inpatient Admissions For a Non-Network Inpatient Admission, the Covered Person is responsible to request Precertification of an admission (other than for an Emergency or maternity admission). (1) To obtain Precertification, the Covered Person is responsible to contact or

have the admitting Physician or other Facility Provider contact the Carrier prior to admission to the Hospital, Skilled Nursing Facility, or other Facility Provider. The Carrier will notify the Covered Person, admitting Physician and the Facility Provider of the determination. The Covered Person is eligible for Inpatient benefits at the Non-Network level shown in the Schedule of Benefits if the Inpatient admission has been approved as Medically Appropriate/Medically Necessary in accordance with the provisions of this booklet/certificate.

(2) If such Precertification for a Medically Appropriate/Medically Necessary Inpatient Admission has not been requested, there will be a Penalty for non-compliance and the amount, as shown in the Schedule of Benefits, will be deemed not to be Covered Services under this coverage. Such Penalty, and any difference in what is covered by the Carrier and the

SAMPLE


Covered Person's obligation to the Provider, will be the sole responsibility of, and payable by, the Covered Person. If a Covered Person elects to be admitted to the Facility Provider after review and notification that the reason for admission is not approved for an Inpatient level of care, Inpatient benefits will not be provided and the Covered Person will be financially liable for non-covered Inpatient charges.

(3) If the Carrier denies the request for an Inpatient admission, the Covered Person, the Physician or the Facility Provider may appeal the determination and submit information in support of the claim for Inpatient benefits. A determination will be made concerning eligibility for Inpatient benefits and the Covered Person, Physician, or Facility Provider will be so notified.

2. Emergency Admission Review a. Network Admissions

It is the responsibility of the Network Provider to notify the Carrier of the Network Emergency admission.

b. Non-Network Admissions (1) Covered Persons are responsible for notifying the Carrier of a Non-

Network Emergency admission within two (2) business days of the admission, or as soon as reasonably possible.

(2) Failure to initiate Emergency admission review will result in a reduction in

Covered Expense for Non-Network services. Such Penalty, as shown in the Schedule of Benefits, will be the sole responsibility of, and payable by, the Covered Person.

(3) If the Covered Person elects to remain hospitalized after the Carrier and

the attending Physician have determined that an Inpatient level of care is not Medically Appropriate/Medically Necessary, the Covered Person will be financially liable for non-covered Inpatient charges from the date of notification.

3. Concurrent and Retrospective Review

Concurrent review may be performed while services are being performed. This may occur during an Inpatient stay and typically evaluates the expected and current length of stay to determine if continued hospitalization is Medically Appropriate/Medically Necessary. When performed, the review assesses the level of care provided to the Covered Person and coordinates discharge planning. Concurrent review continues until the Covered Person is discharged. Not all Inpatient stays are reviewed concurrently. Concurrent Review is generally not performed where an Inpatient Facility is paid based on a per case or diagnosis-related basis, or where an agreement with the Facility does not require such review.

SAMPLE


Retrospective/Post Service review: Retrospective/Post-service review occurs after services have been provided. This may be for a variety of reasons, including the Carrier not being notified of a Covered Person’s admission until after discharge or where medical charts are unavailable at the time of concurrent review. Certain services are only reviewed on a retrospective/post-service basis. In addition to these standard utilization reviews, the Carrier also may determine coverage of certain procedures and other benefits available to Covered Persons through Prenotification as required by the Covered Person’s benefit plan, and discharge planning. Prenotification. Prenotification is advance notification to the Carrier of an Inpatient admission or Outpatient service where no Medical Appropriateness/Medical Necessity review is required, such as maternity admissions/deliveries. Prenotification is primarily used to identify Covered Persons for Concurrent review needs, to ascertain discharge planning needs proactively, and to identify Covered Persons who may benefit from Case Management programs. Discharge Planning. Discharge Planning is performed during an Inpatient admission and is used to identify and coordinate a Covered Person’s needs and benefits coverage following the Inpatient stay, such as covered home care, Ambulance transport, acute rehabilitation, or Skilled Nursing Facility placement. Discharge Planning involves the Carrier’s authorization of covered post-Hospital services and identifying and referring Covered Persons to Disease Management or Case Management benefits. Selective Medical Review. In addition to the foregoing requirements, the Carrier reserves the right, under its utilization and quality management programs, to perform a medical review prior to, during or following the performance of certain Covered Services (“Selective Medical Review”) that are otherwise not subject to review as described above. In addition, the Carrier reserves the right to waive medical review for certain Covered Services for certain Providers, if the Carrier determines that those Providers have an established record of meeting the utilization and/or quality management standards for these Covered Services. Coverage penalties are not applied to Covered Persons where required Selective Medical Review is not obtained by the Provider.

E. PRECERTIFICATION REQUIREMENTS

Precertification is required by the Carrier in advance for certain services. To obtain a list of services that require Precertification, Covered Persons can log on to www.amerihealthnj.com or call the Customer Service telephone number listed on the back of their Identification Card. When a Covered Person plans to receive any of these listed procedures, the Carrier will review the Medical Appropriateness/Medical Necessity for the procedure or treatment in accordance with the criteria and procedures described above and grant prior approval of benefits accordingly.

SAMPLE

http://www.amerihealth.com/


Surgical, diagnostic and other procedures shown on the Precertification requirements list that are performed during an Emergency, as determined by the Carrier, do not require Precertification. However, the Carrier should be notified within two (2) business days of receiving Emergency Care for such procedures, or as soon as reasonably possible.

1. Network Care

Network Providers in the Point-of-Service Network must contact the Carrier to initiate Precertification. The Carrier will verify the results of the Precertification with the Covered Person and with the Network Provider. If Precertification is not requested and the Covered Person undergoes the surgical, diagnostic or other procedure or treatment shown on the Precertification requirements list, the Carrier will hold the Network Provider financially liable for the benefits provided. The Carrier will hold the Covered Person harmless and the Covered Person will not be financially responsible for the Network Provider's failure to comply with the Precertification requirements. If the Carrier determines that the surgical, diagnostic or other procedure or treatment is not Medically Appropriate/Medically Necessary, a Covered Person has the option to elect to receive the treatment from a Network Provider after the Network Provider provides the Covered Person with written notification that the procedure is not covered as Medically Appropriate/Medically Necessary. In those instances where the Carrier has made such a determination, benefits will not be provided and the Covered Person will be financially liable for non-covered charges.

2. Non-Network Care For Non-Network Care the Covered Person is responsible to have the Provider performing the service contact the Carrier to initiate Precertification. The Carrier will verify the results of the Precertification with the Covered Person and the Provider. If Precertification is not requested and the Covered Person undergoes the surgical, diagnostic or other procedure or treatment that requires Precertification, then benefits will be provided for Medically Appropriate/Medically Necessary treatment, but the Provider's charge less any applicable Cost-Sharing shall be subject to a Penalty, as shown in the Schedule of Benefits. Such Penalty, and any difference in what is covered by the Carrier and the Covered Person's obligation to the Provider, will be the sole responsibility of, and payable by, the Covered Person.

3. If the Covered Person does not agree with the determination made by the Carrier regarding the Precertification of Network or Non-Network Care, the Covered Person may appeal the determination in accordance with the procedures outlined in the Resolving Problems section.

4. Precertification Penalty The Covered Person may be responsible for financial penalties if Precertification is not obtained for services that require Precertification and the services are provided by an Out-of-Network Provider. The Penalty amount is shown on the Schedule of Benefits.

SAMPLE


In addition to the Precertification requirements shown above, the Covered Person should contact the Carrier for certain categories of treatment (listed below) so that the Covered Person will know prior to receiving treatment whether it is a Covered Service. This applies to Network Providers in the Point-of-Service Network or Non-Network Providers. Those categories of treatment (in any setting) include:

1. Any surgical procedure that may be considered potentially cosmetic; 2. Any procedure, treatment, drug or device that represents “new or emerging

technology”, and 3. Services that might be considered Experimental/Investigative. The Covered Person’s Provider should be able to assist in determining whether a proposed treatment falls into one (1) of these three (3) categories. Also, the Carrier encourages the Covered Person’s Provider to place the call for the Covered Person. For more information, please see the Important Notices placed in the front pages of this booklet/certificate that pertain to Experimental/Investigative services, Cosmetic services, Medically Appropriate/Medically Necessary services and Emerging Technology.

F. CASE MANAGEMENT Any Covered Person who suffers from a catastrophic Illness or Injury may be eligible for Case Management (CM). CM focuses on the reduction of Inpatient Hospital utilization and is designed to address the needs of selected high-risk patients by coordinating the delivery of quality and cost-effective treatment modalities commensurate with the Covered Person's needs. CM involves individual benefits management for complex long-term medical needs. The Carrier will identify cases where CM may be appropriate for a Covered Person who suffers from a catastrophic Illness or Injury. Then the Carrier will assess the Covered Person's anticipated medical needs, after consultation with the attending Physician, the Covered Person and the Covered Person's family, where necessary. However, CM will be made available to the Covered Person if, and only if, all of the following criteria are met: 1. The Carrier determines that, without CM, the Covered Person will have to remain in

a more costly setting to receive the appropriate quality or intensity of care; 2. The attending Physician determines that a different course of treatment or services is

responsive to the needs of the Covered Person; and 3. The Plan of Treatment will be implemented only with the concurrence of the Carrier,

the Group, the attending Physician, the Covered Person and the Covered Person's family, where applicable.

Following implementation, CM will continue until: 1. The Covered Person's medical goals (as identified in the approved Plan of

Treatment) are met and additional services are not Medically Appropriate/Medically Necessary, as determined by the Carrier;

2. In the opinion of the attending Physician, the Covered Person's condition no longer requires the services provided under the approved Plan of Treatment, and a different course of treatment is appropriate;

SAMPLE


3. The Covered Person exhausts benefits provided under this Plan or under the approved Plan of Treatment; or

4. The Group, the Covered Person (or the Covered Person's family, where necessary) or the Carrier terminates CM upon appropriate notice.

G. DISEASE MANAGEMENT AND DECISION SUPPORT PROGRAMS Disease Management and Decision Support programs help Covered Persons to be effective partners in their health care by providing information and support to Covered Persons with certain chronic conditions as well as those with everyday health concerns. Disease Management is a systematic, population-based approach that involves identifying Covered Persons with certain chronic diseases, intervening with specific information or support to follow Provider’s treatment plan, and measuring clinical and other outcomes. Decision Support involves identifying Covered Persons who may be facing certain treatment option decisions and offering them information to assist in informed, collaborative decisions with their Physicians. Decision Support also includes the availability of general health information, personal health coaching, Provider information, or other programs to assist in health care decisions. Disease Management interventions are designed to help Covered Persons manage their chronic condition in partnership with their Physicians. Disease Management programs, when successful, may help such Covered Persons avoid long term complications, as well as relapses of their condition, and experience improved clinical outcomes. Disease Management programs also include outreach to Covered Persons to obtain needed preventive services, or other services recommended for chronic conditions. Information and support may occur in the form of telephonic health coaching, print, audio library or videotape, or Internet formats. The Carrier will utilize medical information such as claims data to operate the Disease Management or Decision Support program, e.g. to identify Covered Persons with chronic disease, to predict which Covered Persons would most likely benefit from these services, and to communicate results to Covered Person’s treating Physician(s). The Carrier will decide what chronic conditions are included in the Disease Management or Decision Support program. Participation by a Covered Person in Disease Management or Decision Support programs is voluntary. A Covered Person may continue in the Disease Management or Decision Support program until any of the following occurs: 1. The Covered Person notifies the Carrier that he/she declines participation; or 2. The Carrier determines that the program, or aspects of the program, will not

continue.

SAMPLE


RESOLVING PROBLEMS

(Complaints/Appeals)

Complaint Process Complaints fall into one of two categories: Administrative Complaints and quality Complaints. Administrative Complaints include the following: coverage limitations, participating or non-participating Provider status, Cost-Sharing requirements. Administrative Complaints follow the Internal Standard Appeals Process below. The Carrier has a process for Covered Persons to express informal quality Complaints. To register a quality Complaint (as opposed to an Internal Appeal as discussed below), Covered Persons can either call the Customer Service Department at the telephone number on the back of their Identification Card or write to the Carrier at the following address:

AmeriHealth NJ Appeals Unit 259 Prospect Plains Road, Bldg M Cranbury, NJ 08512 Phone: 1-877-585-5731 Prompt #2 (TTY:711) Fax: 609-662-2480

Most concerns are resolved informally at this level. However, if the Carrier is unable to immediately resolve the Complaint, it will be investigated, and the Covered Person will receive a response in writing within thirty (30) days. If the Covered Person is dissatisfied with the resolution reached through the Carrier’s Internal Appeal process, the Covered Person may contact the Department of Banking and Insurance at the following address:

Department of Banking and Insurance Consumer Protection Services Office of Managed Care P.O. Box 329 Trenton, NJ 08625-0329 (888) 393-1062 (TTY:711)

Appeal Process Authorizing a Representative. At any time, a Covered Person may choose a third party to be a representative in their Internal Appeal such as a Provider, lawyer, relative, friend, another individual, or a person who is part of an organization. The law states that the Covered Person’s written authorization or consent is required in order for this third party, called an “authorized representative”, to pursue an Internal Appeal on the Covered Person’s behalf. An authorized representative may make all decisions regarding the Internal Appeal, provide and obtain correspondence, and authorize the release of medical records and any other information related to an Appeal. In addition, if a Covered Person chooses to authorize an Appeal representative,

SAMPLE


the Covered Person has the right to limit their authority to release and receive medical records or other appeal information in any other way identified by the Covered Person. In order to authorize someone to be an authorized representative, the Covered Person must complete valid authorization forms. The required forms are sent to Covered Persons or to the parents, guardians or other legal representatives of minor or incompetent Covered Persons who appeal and indicate that they want an appeal representative. Authorization forms can be obtained by calling or writing to the address listed below:

AmeriHealth NJ Appeals Unit 259 Prospect Plains Road, Bldg M Cranbury, NJ 08512 Phone: 1-877-585-5731 Prompt #2 (TTY:711) Fax: 609-662-2480

Except in the case of an Expedited Internal Appeal, the Carrier must receive completed, valid authorization forms before an Appeal can be processed. (For information on Expedited Internal Appeals, see the definition below.) A Covered Person has the right to withdraw or rescind authorization of an authorized representative at any time during the process. If a Provider files an Internal Appeal on the Covered Person’s behalf, the Carrier will verify that the Provider is acting as the Covered Person’s authorized representative with the Covered Person’s permission by obtaining valid authorization forms. A Covered Person who authorizes the filing of an Internal Appeal by a Provider cannot file a separate Internal Appeal. GENERAL INFORMATION ABOUT THE APPEALS PROCESS Continued Coverage. The Carrier shall provide continued coverage of an ongoing course of treatment pending the outcome of a Stage 1 Internal Appeal, a Stage 2 Internal Appeal and an External Appeal. An Appeal may be filed within one hundred eighty (180) days of the receipt of a decision from the Carrier stating an adverse benefit determination. At any time during the Internal Appeal process, a Covered Person may request the help of a Carrier employee in preparing or presenting their Appeal; this assistance will be available at no charge. The Carrier employee designated to assist the Covered Person will not have participated in the previous decision for the issue in dispute and will not be a subordinate of the original reviewer. Please note that during the Stage 1 Internal Appeal, a Covered Person or the Covered Person’s authorized representative may speak, regarding an adverse benefit determination, with the Carrier’s medical director or the medical director’s designee who rendered the adverse benefit determination. The Covered Person or other authorized representative may request an Internal Appeal by calling or writing to the Carrier, as defined in the letter notifying the Covered Person of the decision or as follows:

AmeriHealth NJ Appeals Unit 259 Prospect Plains Road, Bldg M Cranbury, NJ 08512 Phone: 1-877-585-5731 Prompt #2 (TTY:711)

SAMPLE


Fax: 609-662-2480 Full and Fair Review. The Covered Person or authorized representative is entitled to a full and fair review. Specifically, at all levels of Internal Appeal the Covered Person or authorized representative may submit additional information pertaining to the case to the Carrier. The Covered Person or authorized representative may specify the remedy or corrective action being sought. At the Covered Person’s request, the Carrier will provide access to and copies of all relevant documents, records, and other information that are not confidential, proprietary, or privileged. The Carrier will automatically provide the Covered Person or authorized representative with any new or additional evidence considered, relied upon, or generated by the Carrier in connection with the Appeal, which is used to formulate the rationale. Such evidence is provided as soon as possible and in advance of the date the final internal adverse benefit determination is issued. This information is provided to the Covered Person or authorized representative at no charge. Types of Appeals. Following are the two types of Appeals and the issues they address: • Administrative Appeal. A dispute or objection by a Covered Person regarding the

following: coverage limitations, participating or non-participating Provider status, Cost-Sharing requirements, and rescission of coverage (except for failure to pay premiums or coverage contributions), that has not been resolved by the Carrier. The Level 1 Administrative Appeal decision-maker is a Plan medical director or Physician designee. This individual has had no previous involvement with the case and is not a subordinate of anyone involved with a previous adverse determination. Level 1 and Level 2 Administrative Appeals are available and described below. A Level 2 Administrative Appeal determination is final. External Review is not available for Administrative Appeal issues.

• Medical Necessity Appeal. An Appeal by or on behalf of a Covered Person that focuses on

issues of Medical Necessity and requests the Carrier to change its decision to deny or limit the provision of a Covered Service. Medical Necessity Appeals include Appeals of adverse benefit determinations based on the exclusions for Experimental/Investigative or cosmetic services. The standard Stage 1 Internal Appeal decision-maker is a Plan medical director who is a matched specialist or the decision-maker receives input from a consultant who is a matched specialist. A matched specialist or “same or similar specialty Physician” is a licensed Physician or Psychologist who is in the same or similar specialty as typically manages the care under review. The decision-maker has had no previous involvement in the case, is not a subordinate of the person who made the original determination, and holds an active unrestricted license to practice medicine. Stage 1 and Stage 2 Medical Necessity Appeals and External Review are available and described below.

Urgent/Expedited Care. An Urgent/Expedited Internal Appeal is any Appeal for medical care or treatment with respect to which the application of the time periods for making non-urgent determinations could seriously jeopardize the life or health of the Covered Person or the ability of the Covered Person to regain maximum function, or in the opinion of a Physician with knowledge of the Covered Person’s medical condition, would subject the Covered Person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the Appeal. Covered Persons with Urgent Care conditions or who are receiving an on-going course of treatment may proceed with an expedited External Review at the same time as the Expedited Internal Appeals process.

SAMPLE


Appeal Decision Letter. If the Appeal is upheld, the letter states the reason(s) for the decision. If a benefit provision, internal rule, guideline, protocol, or other similar criterion is used in making the determination, the Covered Person may request copies of this information at no charge. If the decision is to uphold the denial, there is an explanation of the scientific or clinical judgment for the determination. The letter also indicates the qualifications of the individual who decided the Appeal and their understanding of the nature of the Appeal. The letter will have instructions of the Appeal process, and, if applicable, any forms required to initiate a next level Appeal. The Covered Person or authorized representative may request in writing, at no charge, the name of the individual who participated in the decision to uphold the denial. The initial adverse benefit determination, as well as an adverse benefit determination following a Stage 1 or Stage 2 Medical Necessity Appeal, shall be culturally and linguistically appropriate. It shall include information sufficient to identify the claim involved, including date of service, health care Provider, claim amount (if applicable) and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and treatment code and its corresponding meaning. Any such request for such diagnosis and treatment information following an initial adverse benefit determination shall be responded to as soon as practicable, and the request itself shall not be considered a request for a Stage 1, Stage 2 or External Review. Standard Internal Administrative Appeals Level 1 Standard Administrative Appeal The Appeal must be filed within one hundred-eighty (180) days of receipt of the initial adverse benefit determination.

Pre-service Appeal. An Appeal for benefits that, under the terms of this plan, must be Precertified or pre-approved (either in whole or in part) before medical care is obtained in order for coverage to be available. A Level 1 Pre-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within fifteen (15) days of receipt of Appeal request. Post-service Appeal. An Appeal for benefits that is not pre-service in nature. (Post-service Appeals concerning claims for services that the Covered Person has already obtained do not qualify for review as Urgent/Expedited Appeals.) A Level 1 Post-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within thirty (30) days of receipt of Appeal request.

Level 2 Standard Administrative Appeal If not satisfied with the decision from the Level 1 Appeal, a Covered Person may file a Level 2 Appeal within sixty (60) calendar days of receipt of the Level 1 Appeal decision from the Carrier for pre- and post-service. To file a Level 2 Appeal, call, write or fax the AmeriHealth NJ Appeals Unit Department at the address and numbers listed above. A Covered Person has the right to present their Appeal before the panel. The Appeal can also be presented by the Covered Person’s Provider or authorized representative. (See Authorizing a Representative above for information about authorizations.) The Level 2 Appeal Panel is composed of Plan management staff who have had no previous involvement with the case and who are not subordinate to the original reviewer.

SAMPLE


The Level 2 Appeal Panel will review and render a decision on the Appeal within fifteen (15) calendar days from receipt of a Pre- or Post-service Appeal. The Level 2 Appeal Panel meetings are a forum through which Covered Persons each have the opportunity to present their issues in an informal setting that is not open to the public. Members of the press may only attend in their personal capacity as a Covered Person’s authorized representative or to provide general, personal assistance. The committee proceedings may not be electronically recorded. A Covered Person will be sent the decision of the Level 2 Appeal Panel in writing within the timeframes noted above. The Level 2 decision is final. External Review is not available for administrative issues. Standard Internal Medical Necessity Appeals Stage 1 Standard Medical Necessity Appeal The Appeal must be filed within one hundred-eighty (180) days of receipt of the initial utilization management determination.

Pre-service Appeal. An Appeal for benefits that, under the terms of this Plan, must be Precertified or pre-approved (either in whole or in part) before medical care is obtained in order for coverage to be available. A Stage 1 Pre-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within five (5) days of receipt of Appeal request. Post-service Appeal. An Appeal for benefits that is not pre-service in nature. (Post-service Appeals concerning claims for services that the Covered Person has already obtained do not qualify for review as Urgent/Expedited Appeals.) A Stage 1 Post-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within five (5) business days of receipt of Appeal request.

Stage 2 Standard Medical Necessity Appeal If not satisfied with the decision from the Stage 1 Appeal, a Covered Person may file a Stage 2 Appeal within 180 calendar days of receipt of the Stage 1 Appeal decision from the Carrier for pre- and post-service. To file a Stage 2 Appeal, call, write or fax the AmeriHealth NJ Appeals Unit Department at the address and numbers listed above. A Covered Person has the right to present their Appeal before the panel. The Appeal can also be presented by the Covered Person’s Provider or another authorized representative. (See Authorizing a Representative above for information about authorizations.) The Stage 2 Appeal Panel is composed of persons who have had no previous involvement with the case and who are not subordinate to the original reviewer. For Medical Necessity issues, at least one of these Panel members is a medical director employed by the Carrier. This Physician holds an active, unrestricted license to practice medicine. The Stage 2 Appeal Panel will review and render a decision on the Appeal within fifteen (15) calendar days from receipt of a Pre- or Post-service Appeal.

SAMPLE


The Stage 2 Appeal Panel meetings are a forum through which Covered Persons each have the opportunity to present their issues in an informal setting that is not open to the public. Members of the press may only attend in their personal capacity as a Covered Person’s authorized representative or to provide general, personal assistance. Covered Persons may not audiotape or videotape the committee proceedings. A Covered Person will be sent the decision of the Stage 2 Appeal Panel in writing within the timeframes noted above. The decision is final unless the Covered Person chooses to file an External Review for medical judgment and for issues involving rescissions of coverage (except for non-payment of premiums). The External Review process is noted below. Please note that an External Review is not available for administrative issues. Internal Urgent/ Expedited Appeals The Internal Urgent/Expedited Appeals process mirrors the Standard Internal Appeal process with the exception of timeframes. An Appeal concerning an Urgent/Expedited Care claim may be submitted orally or in writing. The expedited review is completed promptly based on the Covered Person’s health condition, but no later than seventy two (72) hours after receipt of the Expedited Appeal request by the Carrier with twenty-four (24) hours allotted for Stage 1 and forty-eight (48) hours for Stage 2 Urgent/Expedited Appeals. The Carrier notifies the Covered Person or authorized representative by telephone of the determination. The determination is sent in writing within twenty-four (24) hours after the Covered Person or authorized representative has received the verbal notification. If not satisfied with the Standard Internal or Urgent/Expedited Appeal decision from the Carrier, the Covered Person or authorized representative has the right to initiate an External Review as described below. External Review. Available for any adverse determination that involves medical judgment as determined by the external reviewer and for rescissions of coverage (except for non-payment of premiums). If not satisfied with the outcome of the Stage 2 Appeal, the Covered Person or authorized representative may initiate an External Review. For most health plans, External Review is conducted by an Independent Utilization Review Organization (IURO) consistent with processes mandated by New Jersey state laws. For plans subject to New Jersey state-mandated requirements, the Covered Person or authorized representative may initiate the External Review within four (4) months of receipt of the Stage 2 determination to an IURO. If the IURO accepts the External Review, it will issue a decision within forty-five (45) days of receiving all necessary documentation to complete the review. A decision reached by an IURO is binding. A Covered Person or authorized representative may appeal directly to the IURO if the Carrier waives its right to an Internal Appeal or fails to meet the timeframes for completing Stage 1 or Stage 2 of the Internal Appeals process.

SAMPLE


To request an External Review, follow the instructions in the decision letter for the Carrier’s Stage 2 Internal Appeal.

*** Also, please note that the Appeal procedures stated above may change due to changes in the applicable state and federal laws and regulations, to satisfy standards of certain recognized accrediting organizations or to otherwise improve the Appeals process.

If this Plan is subject to the requirements of the Employee Retirement Income Security Act (ERISA), following an Appeal a Covered Person may have the right to bring civil action under Section 502(a) of the Act. For questions about a Covered Person’s rights, this notice, or for assistance, contact the Employee Benefits Security Administration at 1-866-444-EBSA (TTY:711). Additionally, a consumer assistance program may be able to assist at:

Department of Banking and Insurance Consumer Protection Services Office of Managed Care P.O. Box 329 Trenton, NJ 08625-0329 (888) 393-1062 (TTY:711) http://www.state.nj.us/dobi/consumer.htm [email protected]

If the Carrier fails to “strictly adhere” to the Internal Appeals process, a Covered Person may initiate an External Review or file appropriate legal action under state law or ERISA unless:

• Violation was de minimis (minimal). • Did not cause (or likely to cause) prejudice or harm to the claimant. • Was for good cause or due to matters beyond the control of the insurer/plan. • In the context of a good faith exchange of information with the claimant. • Not part of a pattern or practice of violations.

SAMPLE

http://www.state.nj.us/dobi/consumer.htm

mailto:[email protected]

Form No. 16780-BC SB 1

SCHEDULE OF BENEFITS Subject to the exclusions, conditions and limitations of this Plan, a Covered Person is entitled to benefits for the Covered Services described in this Schedule of Benefits during a Benefit Period, subject to any Cost-Sharing or Out-of-Pocket Limits. The percentages for Coinsurance and Covered Services shown in this Schedule of Benefits are not always calculated on actual charges. For an explanation on how Coinsurance is calculated, see the Covered Expense definition in the Defined Terms section. The Carrier provides Network benefits for Covered Services furnished to a Covered Person when authorized or Referred by his or her Primary Care Physician (PCP). The Carrier pays Non-Network benefits when Covered Services are not authorized or Referred by the PCP. The Point-of-Service Network Plan section provides more detail regarding Network and Non-Network Providers and the Point-of-Service Network. Some Covered Services must be Precertified before the Covered Person receives the services. Precertification of services is a vital program feature that reviews Medical Appropriateness/Medical Necessity of certain procedures and/or admissions. In certain cases, Precertification helps determine whether a different treatment may be available that is equally effective yet less traumatic. Precertification also helps determine the most appropriate setting for certain services. Failure to obtain a required Precertification for a Covered Service could result in a reduction of benefits. More information on Precertification is found in The Point-of-Service Network Plan and the Managed Care sections. To obtain a list of Covered Services that require Precertification, Covered Persons can log onto www.amerihealthnj.com or call the telephone number that is listed on their Identification Card BENEFIT PERIOD

Calendar Year (1/1 – 12/31), except as otherwise specified in the following pages.

PROGRAM DEDUCTIBLE* (Covered Person’s Responsibility) Covered Person’s Deductible Network Care Non-Network Care * Please note – If a Covered

Person receives services from a Network Provider without a Referral, the Non-Network Deductible will apply.

$2,000 per Covered Person per Benefit Period for Network Covered Services. This Deductible applies to all Network Covered Services except as otherwise specified in the following pages. $4,000 per Covered Person per Benefit Period for Non-Network Covered Services. This Deductible applies to all Non-Network Covered Services except as otherwise specified in the following pages.

SAMPLE



PROGRAM DEDUCTIBLE (Continued) Family Deductible

Network Care

The family Deductible amount is equal to two (2) times the Covered Person’s Network Deductible. In each Benefit Period, it will be applied to all Covered Persons under a Family Coverage. A Network Deductible will not be applied to any Covered Person in a family once that Covered Persons has satisfied their Network Deductible, or the family Deductible has been satisfied for all Covered Persons combined.

Non-Network Care

The family Deductible amount is equal to two (2) times the Covered Person’s Non-Network Deductible. In each Benefit Period, it will be applied to all Covered Persons under a Family Coverage. A Non-Network Deductible will not be applied to any Covered Person in a family once that Covered Person has satisfied their Non-Network Deductible, or the family Deductible has been satisfied for all Covered Persons combined.

Deductible Carryover

Expenses Incurred for Covered Expenses in the last three (3) months of a Benefit Period which were applied to that Benefit Period’s Deductible will be applied to the Deductible of the next Benefit Period.

SAMPLE


COINSURANCE (Covered Person’s Responsibility)

Network Care

70% for Network Covered Services, except as may otherwise be indicated by the coverage percentages set forth in the following pages.

Non-Network Care

50% for Non-Network Covered Services, except as may otherwise be indicated by the coverage percentages set forth in the following pages.

OUT-OF-POCKET LIMIT

Network Care

When a Covered Person Incurs $3,500 of Copayment, Deductible and Coinsurance expense in one (1) Benefit Period for Network Covered Services, the Coinsurance percentages will be reduced to 0% and no additional Copayments, Deductibles or Coinsurance will be required for the balance of that Benefit Period. After two (2) times the Network Out-of-Pocket Limit amount has been Incurred for Covered Services by Covered Persons under the same Family Coverage in a Benefit Period, the Coinsurance percentages will be reduced to 0% and no additional Copayments, Deductibles and Coinsurance will be required for the balance of that Benefit Period. However, no one Covered Person will contribute more than the Network Out-of-Pocket Limit amount for one Covered Person. The Network Out-of-Pocket Limit is a combined maximum of medical and prescription drug benefits, and any pediatric vision and pediatric dental benefits if made a part of this Plan; this amount will never be more than federal and state law allow.

Non-Network Care

When a Covered Person Incurs $7,000 of Copayments, Deductible and Coinsurance expense in one (1) Benefit Period for Non-Network Covered Services, all Coinsurance percentages will be reduced to 0% for the balance of that Benefit Period. After two (2) times the Non-Network Out-of-Pocket Limit amount has been Incurred for Covered Services by Covered Persons under the same Family Coverage in a Benefit Period, all Coinsurance percentages will be reduced to 0% for the balance of that Benefit Period. However, no one Covered Person will contribute more than the Non-Network Out-of-Pocket Limit amount for one Covered Person. The dollar amounts specified shall not include any expense Incurred for any Penalty amount.

SAMPLE


APPLICATION OF COINSURANCE AND COPAYMENT

Network Coinsurance will not be applied to any service or supply to which a Network Copayment is applied. Network Copayments will not be applied to any service or supply to which a Network Coinsurance is applied.

PRECERTIFICATION PENALTY

Inpatient and Outpatient Benefits: Failure to request Precertification for Non-Network services may result in a 20% reduction in benefits payable.

LIFETIME MAXIMUM Network Care Non-Network Care

Unlimited. Unlimited.

SAMPLE


PRIMARY AND PREVENTIVE CARE

If the Covered Person uses a Network Provider with the required Referral, if any, the Plan will pay:

If the Covered Person uses a Non-Network Provider or a Network Provider without the required Referral, the Plan will pay:

PRIMARY CARE

70%, after a Copayment of

$30 per visit. Deductible does not apply

100%

Deductible does not apply.

PREVENTIVE CARE

100%

Deductible does not apply

50%


LEAD POISONING SCREENING AND TREATMENT

100%


100%

Deductible does not apply.

NEWBORN AND INFANT SCREENING FOR HEARING LOSS

100%


100%


NUTRITION COUNSELING FOR WEIGHT MANAGEMENT

Maximum of 6 visits per Benefit Period.

100%


50%

SAMPLE


INPATIENT BENEFITS

If the Covered Person uses a Network Provider with the

required Referral, if any, the Plan will pay:

If the Covered Person uses a Non-Network Provider or a Network Provider without

the required Referral, the Plan will pay:

HOSPITAL SERVICES The number of days for Inpatient Hospital Services includes Inpatient treatment for all medical and surgical care.

70%

Benefit Period Maximum: Unlimited Network Inpatient days.

50%

Benefit Period Maximum: 365 Non-Network Inpatient days. This maximum is part of, not separate from, Network days maximum.

INPATIENT PROFESSIONAL PROVIDER MEDICAL CARE

70%

50%

SKILLED NURSING FACILITY

Maximum of 0 Network/Non-Network Inpatient days per Benefit Period.

70%

50%

SAMPLE


INPATIENT/OUTPATIENT BENEFITS





BLOOD

70%

50%

DIAGNOSIS AND TREATMENT OF AUTISM AND OTHER DEVELOPMENTAL DISORDERS

Diagnosis and Treatment of Autism and Other Developmental Disorders is covered on the same basis as any other medical condition. No special restrictions apply. See also the Therapy Services section of this Schedule of Benefits.

Diagnosis and Treatment of Autism and Other Developmental Disorders is covered on the same basis as any other medical condition. No special restrictions apply. See also the Therapy Services section of this Schedule of Benefits.

HOSPICE SERVICES

Respite Care: Maximum of 7 days every 6 months.

70%

50%

SAMPLE


INPATIENT/OUTPATIENT BENEFITS (Continued)





MATERNITY/OB-GYN/FAMILY SERVICES Maternity/Obstetrical Care

Professional Service

70%

50%

Facility Service

70% 50%

Elective Abortions Professional Service *

Outpatient Facility Charges *

* Only one Copayment will apply, depending upon place of service.

70%

70%

50%

50%

Newborn Care Infertility

70%

Covered on the same basis as any other medical condition. No special restrictions apply.

50%

Covered on the same basis as any other medical condition. No special restrictions apply.

There is a limit of four (4) insured egg retrievals per lifetime of the Covered Person

(Egg Retrieval Lifetime Limit)*. All egg retrievals for which benefits were paid or payable under the Group’s plan, on or after November 29, 2001, count toward the Egg Retrieval Lifetime Limit. * Benefits provided for in-vitro fertilization (IVF), and gamete intra-fallopian transfer

(GIFT), and zygote intra-fallopian transfer (ZIFT) services are limited to a Covered Person who: (1) has used all reasonable less expensive medically appropriate treatments and still be unable to become pregnant or carry a pregnancy to live birth; (2) has not reached the Egg Retrieval Lifetime Limit shown above; and (3) is age forty-five (45) or younger. The Covered Person and their attending Physician must also provide signed certification forms as required by the Carrier.

SAMPLE







MENTAL ILLNESS CARE Inpatient Treatment

70%


50%

Benefit Period Maximum: 365 Non-Network Inpatient days. This maximum is part of, not separate from, Network days maximum.

Outpatient Treatment

70%

50%

SURGICAL SERVICES

Outpatient Facility Charges

70%

50%

Outpatient Professional Charge

70%

50%

Outpatient Anesthesia

70%

50%

Second Surgical Opinion

70% 50%

If more than one (1) surgical procedure is performed by the same Professional

Provider during the same operative session, the Carrier will pay 100% of the Covered Service for the primary procedure and 50% of the Covered Services for each additional procedure.

SAMPLE







TRANSPLANTS Inpatient Facility Charges

70%

50%

Outpatient Facility Charges

70% 50%

TREATMENT FOR SUBSTANCE ABUSE Inpatient Treatment

70%


50%

Benefit Period Maximum: 365 Non-Network Inpatient days.

This maximum is part of, not separate from, Network days maximum.

Outpatient Treatment

70% 50%

TREATMENT OF WILM’S TUMOR

Treatment of Wilm’s Tumor is covered on the same basis as any other medical condition. No special restrictions apply.

Treatment of Wilm’s Tumor is covered on the same basis as any other medical condition. No special restrictions apply.

SAMPLE


OUTPATIENT BENEFITS





AMBULANCE SERVICES Emergency

70%

70%

Non-Emergency

70%

50%

DAY REHABILITATION PROGRAM

Benefit Period Maximum: 30 Network/Non-Network sessions.

70%

50%

DIABETIC SUPPLIES AND EDUCATION Drugs and Supplies purchased from a pharmacy Supplies purchased from a Durable Medical Equipment Supplier

Other Covered Expense, including Education

70%

70%

70%

50%

50%

50%

SAMPLE


OUTPATIENT BENEFITS (Continued)





DIAGNOSTIC SERVICES

Routine Diagnostic/Radiology Services

Facility Charges

70%

50%

Non-Routine Diagnostic/Radiology Services (including MRI/MRA, CT scans, PET scans, Sleep Studies)

Facility Charges

70%

50%

Laboratory and Pathology Tests Facility Charges

70%

50%

DURABLE MEDICAL EQUIPMENT

70%

50%

SAMPLE







EMERGENCY CARE & URGENT CARE

Emergency Care

70% Copayment waived if

admitted.

50%

Urgent Care Center

70% 50%

HEARING AIDS FOR DEPENDENTS Age 15 or younger Benefits are limited to a maximum of $1000 per Hearing Aid per hearing impaired ear in a 24 month period.

100%, after a Copayment of

$30 per visit.

50%

HOME HEALTH CARE CHARGES IN LIEU OF HOSPITALIZATION

70%

50%

INHERITED METABOLIC DISEASES, MEDICAL FOODS AND LOW PROTEIN MODIFIED FOOD PRODUCTS

Equipment purchased from a Durable Medical Equipment Supplier

70%

50%

Other Covered Expenses

70%

50%

INJECTABLE MEDICATIONS

70%

50%

SAMPLE







NON-SURGICAL DENTAL SERVICES

70%

50%

ORTHOTIC APPLIANCES

70%

50%

ORTHOTIC DEVICES

70%

50%

PODIATRIC CARE

70%

50%

PRIVATE DUTY NURSING SERVICES

Benefit Period Maximum: 0 In-Network/Out-of-Network hours.

70%

50%

PROSTHETIC APPLIANCES

70%

50%

PROSTHETIC DEVICES

70%

50%

SAMPLE







SPECIALIST OFFICE VISITS

70% 50%

SAMPLE







THERAPY SERVICES

Cardiac Rehabilitation Therapy

Benefit Period Maximum: 0 In-Network/Out-of-Network sessions.

70%

50%

Chemotherapy

70% 50%

Dialysis

70%

50%

Infusion Therapy

70% 50%

Orthoptic/Pleoptic Therapy

Lifetime Maximum: 8 In-Network/Out-of-Network sessions.

70%

50%

Pulmonary Rehabilitation Therapy

Benefit Period Maximum: 0 In-Network/Out-of-Network sessions.

70%

50%

SAMPLE







THERAPY SERVICES (Continued)

Physical Therapy/Occupational Therapy/Speech Therapy provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision

70%

50%

Physical Therapy/Occupational Therapy

Benefit Period Maximum: 0 In-Network/Out-of-Network visits of Physical Therapy and Occupational Therapy combined.

70%

50%

SAMPLE







THERAPY SERVICES (Continued)

Radiation Therapy

70%

50%

Speech Therapy

Benefit Period Maximum: 0 In-Network/Out-of-Network visits.

70%

50%

SAMPLE

16780-RXRIDER-Rev.6.15 1

AMERIHEALTH INSURANCE COMPANY OF NEW JERSEY

PRESCRIPTION DRUG AMENDMENT RIDER This Amendment is issued to form part of AmeriHealth Insurance Company of New Jersey's Comprehensive Major Medical Health Care Group Contract (Form No. 16780). This Amendment changes the provisions, conditions or other terms of said Contract and booklet/certificate to provide Prescription Drug benefits as follows: I. The Defined Terms section is revised as follows.

A. For the purposes of this rider, the definition of “Covered Expense” is enlarged to include the following:

D. For Covered Services rendered by Pharmacies, "Covered Expense" means the

following: 1. For Covered Services rendered by a Network Pharmacy, “Covered Expense”

means the amount that the Carrier has negotiated to pay the Network Pharmacy as total reimbursement for covered Prescription Drugs.

2. For Covered Services rendered by a Non-Network Pharmacy, “Covered Expense” means the lesser of the Non-Network Pharmacy’s Billed Charge for the covered Prescription Drug, or 150% of the average wholesale price for the same covered Prescription Drug.

B. The definitions of “Non-Network Provider”, “Network Provider” and “Provider” are revised

to include “Pharmacy”.

C. The following definitions are added.

BRAND NAME or BRAND NAME DRUG – a covered Prescription Drug produced by a manufacturer awarded the original patent for that specific drug or combination of drugs and satisfying requirements of the U.S. Food and Drug Administration (FDA) and applicable state law and regulations. For a formula to be considered a brand formula, it must be protected by secrecy, patent, or copyright against free competition as to name, product, composition, or process of manufacture. For purposes of this coverage, the term “Brand Name” or “Brand Name Drug” shall also mean devices known as spacers for metered dose inhalers that are used to enhance the effectiveness of inhaled medicines. CHRONIC DRUGS - a covered Prescription Drug recognized by the Carrier for the treatment of chronic or long term conditions including, but not limited to, cardiac disease, hypertension, diabetes, lung disease and arthritis. For purposes of this Plan, the following diabetic supplies that may not require a Prescription Order may also be treated as "Chronic Drugs": insulin syringes, diabetic blood testing strips and lancets. GENERIC DRUG - any form of a particular drug which is: (a) sold by a manufacturer other than the original patent holder; (b) approved by the Federal Food and Drug Administration as generically equivalent; and (c) in compliance with applicable state laws and regulations.

SAMPLE


NON-PREFERRED MAIL ORDER PHARMACY - a Pharmacy, other than a Network Retail or Network Retail Plus Pharmacy, that is part of the Point-of-Service Network to provide Prescription Drugs to Covered Persons through the mail or directly at its location where permitted by the Carrier. NETWORK PHARMACY - a Network Retail, Network Retail Plus or Network Mail Order Pharmacy. NETWORK RETAIL PHARMACY - a Pharmacy, other than a Network Mail Order Pharmacy, that is part of the Point-of-Service Network to provide Prescription Drugs to Covered Persons directly. NETWORK RETAIL PLUS PHARMACY - a Pharmacy, other than a Network Retail or Network Mail Order Pharmacy, that is not part of the Point-of-Service Network but has agreed, in writing, to provide Prescription Drugs to Covered Persons directly under all of the same terms, conditions, price and service provisions as apply to the Carrier’s Network Mail Order Pharmacies. NON-NETWORK MAIL ORDER PHARMACY - a Mail Order Pharmacy that is not part of the Point-of-Service Network. NON-NETWORK PHARMACY - a Pharmacy that is not part of the Point-of-Service Network. PHARMACIST - an individual who is legally licensed to practice the profession of Pharmacology and who regularly practices such profession in a Pharmacy. PHARMACY - any establishment which is registered and licensed as a Pharmacy with the appropriate State licensing agency and in which Prescription Drugs are regularly compounded and dispensed by a Pharmacist. PHARMACY AND THERAPEUTICS COMMITTEE – a group composed of health care professionals with recognized knowledge and expertise in clinically appropriate prescribing, dispensing and monitoring of Outpatient drugs or drug use review, evaluation and intervention. The membership of the committee consists of at least two-thirds licensed and actively practicing Physicians and Pharmacists and shall consist of at least one Pharmacist. PRESCRIPTION DRUG - any medication, including Self-Injectable Drugs, which by Federal and or state laws may be dispensed with a Prescription Order. As required by New Jersey P.L. 2001, c.361, for the purposes of the benefits provided under this Plan, specialized non-standard infant formulas will be considered Prescription Drugs, provided that: A. any such infant formula is prescribed for an infant age twelve (12) months or younger,

who is diagnosed as having multiple food protein intolerance, and who qualifies as an “Eligible Dependent” under the Eligibility Under This Plan provision (hereafter referred to as a Covered Infant); and

B. the prescribing Physician has determine that such formula is Medically Appropriate/Medically Necessary for the Covered Infant; and

C. the Covered Infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk.

SAMPLE


PRESCRIPTION ORDER or PRESCRIPTION REFILL - the request in accordance with applicable laws and regulations for medication issued by a Professional Provider. SELF-INJECTABLE PRESCRIPTION DRUG or SELF-INJECTABLE DRUG – a Prescription Drug that: (a) is introduced into a muscle or under the skin by means of a syringe and needle; (b) can be administered safely and effectively by the patient or caregiver outside of medical supervision, regardless of whether initial medical supervision and/or instruction is required; and (c) is administered by the patient or caregiver.

II. The Schedule of Benefits section is revised.

A. All Prescription Drug Cost-Sharing will count toward the Out-of-Pocket Limit of the

Covered Person’s medical plan.

B. Deductible and Coinsurance amounts shown in the Point-of-Service Health Benefits Plan booklet/certificate will not apply to Prescription Drugs.

C. The description of the benefits payable for “Diabetic Supplies and Education” is

revised to provide that with respect to Drugs and Supplies Purchased from a Pharmacy, the benefit will be subject to the benefit limits and terms applicable to Outpatient Prescription Drugs/Medicines.

D. The following is added to the “Outpatient Benefits” subsection of the Schedule of

Benefits. Subject to the exclusions, conditions and limitations of this Plan as set forth in this rider and in the booklet/certificate, a Covered Person is entitled to the following benefits for Prescription Drugs.

OUTPATIENT BENEFITS

If the Covered Person

uses a Network Provider, the Plan will pay:

If the Covered Person uses a Non-Network

Provider, the Plan will pay:

PRESCRIPTION DRUGS

Retail Pharmacy:

Brand Name Formulary Drugs: (even if there is no Generic equivalent)

Generic Formulary Drugs:

1-30 day supply covered at 100%, after a Copayment of 50%. 31-90 day supply covered at 100%, after a Copayment of 50%. 1-30 day supply covered at 100%, after a Copayment of $7.

50%

50%

50%

SAMPLE


31-90 day supply covered at 100%, after a Copayment of $14.

50%

Retail Plus Pharmacies:



1-30 day supply covered at 100%, after a Copayment of 50%. 31-90 day supply covered at 100%, after a Copayment of 50%. 1-30 day supply covered at 100%, after a Copayment of $7. 31-90 day supply covered at 100%, after a Copayment of $14.

50%

50%

50%

50%

Mail Order Pharmacies:



1-30 day supply covered at 100%, after a Copayment of 50%. 31-90 day supply covered at 100%, after a Copayment of 50%. 1-30 day supply covered at 100%, after a Copayment of $7. 31-90 day supply covered at 100%, after a Copayment of $14.

50%

50%

50%

50%

E. The description of the benefits payable for “Inherited Metabolic Diseases, Medical

Foods and Low Protein Modified Food Products” is revised to provide that Prescription Drugs purchased from a Pharmacy, and used for the therapeutic treatment of Inherited Metabolic Diseases, will be subject to the benefit limits and terms applicable to Outpatient Prescription Drugs/Medicines.

III. The following is added to the “Payment of Providers” subsection of the The Point-of-

Service Network Plan section.

SAMPLE


REIMBURSEMENT OF PHARMACIES The Covered Person or the Pharmacy may submit bills directly to the Carrier and, to the extent that benefits and indemnity are payable within the terms and conditions of the plan, reimbursement will be furnished as follows: A. Network Pharmacies

With respect to Network Pharmacies, benefits will be provided as specified in the Schedule

of Benefits (contained in Section II of this Amendment) for the provision of Network services or supplies. The Carrier will compensate Network Pharmacies in accordance with the agreements in effect with respect to services or supplies provided to Covered Persons. No payment will be made directly to the Covered Person for Covered Services rendered by any Network Pharmacy. A pharmacy benefits management company (PBM), which is affiliated with the Carrier, administers the Carrier’s Prescription Drug benefits, and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. The Carrier anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, Prescription Drugs are subject to a Covered Person’s Cost-Sharing, as applicable.

B. Non-Network Pharmacies With respect to Non-Network Pharmacies, benefits will be provided at the Non-Network Coinsurance level specified in the Schedule of Benefits (contained in Section II of this Amendment). Any applicable Cost-Sharing specified in the Schedule of Benefits (contained in Section II of this Amendment) will be applied to the Covered Expense amount. The Covered Person will be responsible for a higher level of Cost-Sharing as detailed in the Schedule of Benefits. A Non-Network Pharmacy is entitled to collect from the Covered Person any Cost-Sharing obligation and the remaining balance due.

IV. The following is added to the “Outpatient Benefits” subsection of the Description of Benefits section. Outpatient Prescription Drugs/Medicines Benefits, as set forth in the Schedule of Benefits (contained in Section II of this Amendment), will be provided for covered Prescription Drugs and medicines prescribed by a Physician and dispensed by a licensed Pharmacy. Benefits for Prescription Drugs are available for up to a ninety (90) day supply, or the appropriate quantity level limit* , when dispensed from a retail Pharmacy.

SAMPLE


Benefits will also be provided for orally administered anti-cancer Prescription Drugs that are Medically Appropriate/Medically Necessary. These drugs are used to kill or slow the growth of cancerous cells. Coverage will be provided to the Covered Person with no Cost-Sharing. Benefits shall also be provided for covered Chronic Drugs ordered by mail if a Covered Person or the prescribing Physician submits to a Network Mail Order Pharmacy a written Prescription Drug Order specifying the amount of the covered Chronic Drug to be supplied. Benefits shall be available for up to a ninety (90) day supply, or the appropriate quantity level limit*, whichever is less, of a covered Chronic Drug, subject to the amount specified in the Prescription Drug Order and applicable law. * Quantity level limits for covered Prescription Drugs are established by AmeriHealth’s

Pharmacy and Therapeutics Committee and comply with FDA approved product labeling standards and guidelines. However, any quantity level limit for covered prescription Drugs as identified by AmeriHealth’s Pharmacy and Therapeutics Committee will comply with the ninety (90) day supply limit requirement established under New Jersey law.

Certain types of Prescription Drugs may not be available through Mail Order Pharmacies, for instance: A. Prescription Drugs that cannot be dispensed in accordance the dispensing protocols

of the Carrier, or the Mail Order Pharmacy. B. Non-standard infant formulas even if they would otherwise qualify as Prescription

Drugs; C. Prescription Drugs that pose safety and/or stability issues, such as medications that

contain dangerous or flammable chemicals, bio-hazardous drugs, or drugs that require monitoring;

D. Prescription Drugs that require special record-keeping procedures; and E. Prescription Drugs that require specialized compounding equipment. If the Carrier determines there may be Prescription Drug usage by a Covered Person that exceeds what is generally considered appropriate under the circumstances, the Carrier shall have the right to direct that Covered Person to one Pharmacy for all future Prescription Drug Covered Services. In certain cases the Carrier may determine that the use of certain Prescription Drugs for a Covered Person's medical condition requires Precertification for Medical Appropriateness/Medical Necessity. If a Physician writes a Prescription Order for a drug that requires Precertification, and Precertification has not already been obtained by the Physician, a Network Retail Pharmacy is instructed to release a ninety-six (96)-hour supply of the drug to the Covered Person without prior authorization. No Cost-Sharing will apply. On the following business day, the Carrier’s Pharmacy Services Department calls the Covered Person’s Physician (whether a Preferred Provider or a Non-Preferred Provider) to request that he or she submit the documentation that would have supported Precertification of the drug. As soon as such Precertification documentation has been verified by the Carrier, the order for a Prescription Drug (not otherwise excluded under the Plan) will be filled and no penalty will be applied. Appropriate Cost-Sharing will apply. If the Pharmacy is not a Preferred Retail Pharmacy, the Covered Person may have to pay in full and may have to submit a claim for reimbursement. If Precertification has not already been obtained, the claim will deny for failure to obtain Precertification. At that time the

SAMPLE


Covered Person must ask the prescribing Physician to submit documentation that would have supported Precertification of the drug. As soon as such Precertification documentation has been verified by the Carrier, the benefit payment for a Prescription Drug (not otherwise excluded under the Plan) will be processed and no penalty will be applied. Appropriate Cost-Sharing will apply.

The Plan’s appeal process is also open to the Covered Person. The Carrier also reserves the right to establish eligible quantity level limits for certain Prescription Drugs above which the Carrier will pay no benefit. Any eligible quantity level limits, for certain covered Prescription Drugs as identified by AmeriHealth’s Pharmacy and Therapeutics Committee, will comply with FDA approved product labeling standards and guidelines. However, any quantity level limit for covered prescription Drugs as identified by AmeriHealth’s Pharmacy and Therapeutics Committee will comply with the ninety (90) day supply limit requirement established under New Jersey law. The following Prescription Drugs are covered under this Plan. Prescription Drugs: A. Which by law may be dispensed with a Prescription Order; B. Which are approved by the Carrier and approved for distribution by the Federal Food

and Drug Administration; C. Which are Medically Appropriate/Medically Necessary for the care of the Covered

Person; and D. Which have been approved for treatment of the Covered Person's Illness or Injury by

the Federal Food and Drug Administration; and E. Which have not been approved for treatment of the Covered Person's Illness or

Injury by the Federal Food and Drug Administration, but which have been recognized as appropriate medical treatment for the Covered Person's diagnosis or condition in one or more of the following established reference compendia: 1. The American Hospital Formulary Service Drug Information; 2. The United States Pharmacopoeia Drug Information; or 3. Recommended by a clinical study or review article in a major peer-reviewed

professional journal.

The list of covered Prescription Drugs is subject to change from time to time. The Carrier does not prohibit a Network Pharmacy from charging a Covered Person for services that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services for which a Pharmacy may impose additional charges are subject to the approval of the Board of Pharmacy. Prior to dispensing a drug, the Pharmacy must disclose to the Covered Person all charges for additional services in connection with dispensing that drug, and the Covered Person’s out-of-pocket cost for those services. A Pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law. Benefits will not be payable for: • Drugs used for Experimental or Investigative purposes; • Drugs prescribed or used for cosmetic purposes, such as wrinkle removal or hair

growth, unless prescribed to treat medically diagnosed congenital defects and birth abnormalities;

SAMPLE


• Prescription Drugs covered without charge under federal, state or local programs

including Worker’s Compensation and Occupational Disease laws; • Medication furnished by any other medical service for which no charge is made to

the Covered Person; • Any covered Prescription Drug which is administered at the time and place of the

Prescription Drug Order; • Prescription Refills resulting from loss or theft, or any unauthorized Prescription

Refills; • Health foods, dietary supplements, pharmacological therapy for weight reduction or

diet agents or appetite suppressants. This exclusion will not apply to dietary supplements as set forth in the Description of Benefits section under the subsection "Inherited Metabolic Diseases, Medical Foods and Low Protein Modified Food Products" of the booklet/certificate;

• Vitamins, unless they require a Prescription Order and are Medically

Appropriate/Medically Necessary for the treatment of a specific illness, as determined by the Carrier;

• Prescription Drugs for which there is an equivalent that does not require a

Prescription Order, (i.e., over-the-counter medicines). This exclusion does not apply to insulin or over-the-counter drugs that are prescribed by a Physician in accordance with applicable law;

• Specialized, non-standard infant formula that is purchased without a Prescription

Order or otherwise fails to satisfy the requirements for coverage stated in this Rider; • All infant formulas, nutritional formulas and nutritional supplements, except

specialized, non-standard infant formulas that satisfy the requirements for coverage stated in this Rider;

• Drugs which have no currently accepted medical use for treatment in the United

States; • Drugs dispensed to a Covered Person while a patient in a Hospital, nursing home or

other institution; • Prescription Drugs not approved by the Carrier or prescribed drug amounts

exceeding the quantity level limits. However, any quantity level limit for covered Prescription Drugs as identified by AmeriHealth’s Pharmacy and Therapeutics Committee will comply with the ninety (90) day supply limit requirement established under New Jersey law;

• Drugs obtained through mail order prescription drug services of a Non-Network Mail Order Pharmacy;

• Drugs that are covered elsewhere under the medical portion of the plan and are not

otherwise excluded under the plan;

SAMPLE


• Injectable drugs, including Infusion Therapy drugs, that are covered elsewhere under

the medical portion of the Plan when administered and/or monitored by a Physician, or a licensed health care Facility and are not otherwise excluded under the Plan;

• Injectables used for the treatment of Infertility, except when purchased from a

Pharmacy and self-administered in connection with the diagnosis and treatment of a Covered Person who is not able to: (a) impregnate another person; (b) conceive after two (2) years of unprotected intercourse if the female partner is under thirty-five (35) years of age, or one (1) year of unprotected intercourse if the female partner is thirty-five (35) years of age or older or one of the partners is considered medically sterile; or (c) carry a pregnancy to live birth, provided that no coverage will be provided in connection with the reversal of sterilization or with treatment because of prior sterilization;

• Administration or injection of drugs; • Devices of any type, even though such devices may require a Prescription Order.

This includes, but is not limited to: ovulation indicator kits; pregnancy test kits; therapeutic devices or appliances, hypodermic needles, syringes or similar devices. This exclusion does not apply to devices known as spacers for metered dose inhalers that are used to enhance the effectiveness of inhaled.

V. The General Information section is revised.

The provisions reflected in subsection entitled “Coordination of Benefits and Services” will not apply to any Prescription Drug Benefits contained within this Rider.

All other terms of the Contract and booklet/certificate shall remain in effect.

Michael A. Munoz Senior Vice President Marketing & Sales

SAMPLE

AMERIHEALTH NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATION _______________________

PLEASE REVIEW IT CAREFULLY.

AmeriHealth2 values you as a customer, and protection of your privacy is very important to us. In conducting our business, we will create and maintain records that contain protected health information about you and the health care provided to you as a member of our health plans.

Note: “Protected health information” or “PHI” is information about you, including information that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care.

We protect your privacy by:

• limiting who may see your PHI;• limiting how we may use or disclose your PHI;• informing you of our legal duties with respect to your PHI;• explaining our privacy policies; and• adhering to the policies currently in effect.

This Notice describes our privacy practices, which include how we may use, disclose, collect, handle, and protect our members’ protected health information. We are required by certain federal and state laws to maintain the privacy of your protected health information. We also are required by the federal Health Insurance Portability and Accountability Act (or “HIPAA” Privacy Rule to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information.

________________________ 1 If you are enrolled in a self-insured group benefit program, this Notice is not applicable. If you are enrolled in such a program, you should contact your Group Benefit Manager for information about your group’s privacy practices. If you are enrolled in the Federal Employee’s Service Benefit Plan, you will receive a separate Notice.

2 For purposes of this Notice, “AmeriHealth’ refers to the following companies: AmeriHealth HMO, Inc., AmeriHealth Insurance Company of New Jersey, and QCC Insurance Company d/b/a AmeriHealth Insurance Company.

Page 1 of 9

of 9

This revised Notice took effect on July 18, 2017, and will remain in effect until we replace or modify it.

Copies of this Notice You may request a copy of our Notice at any time. If you want more information about our privacy practices, or have questions or concerns, please contact Member Services by calling the telephone number on the back of your Member Identification Card, or contact us using the contact information at the end of this Notice.

Changes to this Notice The terms of this Notice apply to all records that are created or retained by us which contain your PHI. We reserve the right to revise or amend the terms of this Notice. A revised or amended Notice will be effective for all of the PHI that we already have about you, as well as for any PHI we may create or receive in the future. We are required by law to comply with whatever Privacy Notice is currently in effect. You will be notified of any material change to our Privacy Notice before the change becomes effective. When necessary, a revised Notice will be mailed to the address that we have on record for the contract holder of your member contract, and will also be posted on our web site at www.amerihealth.com.

Potential Impact of State Law The HIPAA Privacy Rule generally does not “preempt” (or take precedence over) state privacy or other applicable laws that provide individuals greater privacy protections. As a result, to the extent state law applies, the privacy laws of a particular state, or other federal laws, rather than the HIPAA Privacy Rule, might impose a privacy standard under which we will be required to operate. For example, where such laws have been enacted, we will follow more stringent state privacy laws that relate to uses and disclosures of the protected health information concerning HIV or AIDS, mental health, substance abuse/chemical dependency, genetic testing, reproductive rights, etc.

How We May Use and Disclose Your Protected Health Information (PHI) In order to administer our health benefit programs effectively, we will collect, use and disclose PHI for certain of our activities, including payment of covered services and health care operations.

The following categories describe the different ways in which we may use and disclose your PHI. Please note that every permitted use or disclosure of your PHI is not listed below. However, the different ways we will, or might, use or disclose your PHI do fall within one of the permitted categories described below.

Treatment: We may disclose information to doctors, pharmacies, hospitals and other health care providers who take care of you to assist in your treatment or the coordination of your care.

Payment: We may use and disclose your PHI for all payment activities including, but not limited to, collecting premiums or to determine or fulfill our responsibility to provide health care coverage under our health plans. This may include coordinating benefits with other health care programs or insurance carriers, such as Medicare or Medicaid. For example, we may use and disclose your PHI to pay claims for services provided to you by doctors or hospitals which are covered by your health plan(s), or to determine if requested services are covered under your health plan. We may also use and disclose your PHI to conduct business with other AmeriHealth affiliate companies.


Health Care Operations: We may use and disclose your PHI to conduct and support our business and management activities as a health insurance issuer. For example, we may use and disclose your PHI to determine our premiums for your health plan, to conduct quality assessment and improvement activities, to conduct business planning activities, to conduct fraud detection programs, to conduct or arrange for medical review, or to engage in care coordination of health care services.

We may also use and disclose your PHI to offer you one of our value added programs like smoking cessation or discounted health related services, or to provide you with information about one of our disease management programs or other available AmeriHealth health products or health services.

We may also use and disclose your PHI to provide you with reminders to obtain preventive health services, and to inform you of treatment alternatives and/or health related benefits and services that may be of interest to you.

Marketing: Your PHI will not be sold, used or disclosed for marketing purposes without your authorization except where permitted by law. Such exceptions may include: a marketing communication to you that is in the form of (a) a face-to-face communication, or (b) a promotional gift of nominal value.

Release of Information to Plan Sponsors: Plan sponsors are employers or other organizations that sponsor a group health plan. We may disclose PHI to the plan sponsor of your group health plan as follows:

• We may disclose “summary health information” to your plan sponsor to use to obtainpremium bids for providing health insurance coverage or to modify, amend or terminateits group health plan. “Summary health information” is information that summarizesclaims history, claims expenses, or types of claims experience for the individuals whoparticipate in the plan sponsor’s group health plan;

• We may disclose PHI to your plan sponsor to verify enrollment/disenrollment in yourgroup health plan;

• We may disclose your PHI to the plan sponsor of your group health plan so that theplan sponsor can administer the group health plan; and

• If you are enrolled in a group health plan, your plan sponsor may have met certainrequirements of the HIPAA Privacy Rule that will permit us to disclose PHI to the plansponsor. Sometimes the plan sponsor of a group health plan is the employer. In thosecircumstances, we may disclose PHI to your employer. You should talk to youremployer to find out how this information will be used.

Research: We may use or disclose your PHI for research purposes if certain conditions are met. Before we disclose your PHI for research purposes without your written permission, an Institutional Review Board (a board responsible under federal law for reviewing and approving research involving human subjects) or Privacy Board reviews the research proposal to ensure that the privacy of your PHI is protected, and to approve the research.

Page 3 of 9

Required by Law: We may disclose your PHI when required to do so by applicable law. For example, the law requires us to disclose your PHI:

• When required by the Secretary of the U.S. Department of Health and Human Servicesto investigate our compliance efforts; and

• To health oversight agencies, to allow them to conduct audits certain Health OversightActivities described below..

Public Health Activities: We may disclose your PHI to public health agencies for public health activities that are permitted or required by law, such as to:

• prevent or control disease, injury or disability;• maintain vital records, such as births and deaths;• report child abuse and neglect;• notify a person about potential exposure to a communicable disease;• notify a person about a potential risk for spreading or contracting a disease or condition;• report reactions to drugs or problems with products or devices;• notify individuals if a product or device they may be using has been recalled; and• notify appropriate government agency(ies) and authority(ies) about the potential abuse

or neglect of an adult patient, including domestic violence.

Health Oversight Activities: We may disclose your PHI to a health oversight agency for activities authorized by law, such as: audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Health oversight agencies seeking this information include government agencies that oversee: (i) the health care system; (ii) government benefit programs; (iii) other government regulatory programs; and (iv) compliance with civil rights laws.

Lawsuits and Other Legal Disputes: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process once we have met all administrative requirements of the HIPAA Privacy Rule.

Law Enforcement: We may disclose your PHI to law enforcement officials under certain conditions. For example, we may disclose PHI:

• to permit identification and location of witnesses, victims, and fugitives;• in response to a search warrant or court order;• as necessary to report a crime on our premises;• to report a death that we believe may be the result of criminal conduct; or• in an emergency, to report a crime.

Coroners, Medical Examiners, or Funeral Directors: We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We also may disclose, as authorized by law, information to funeral directors so that they may carry out their duties.

Organ and Tissue Donation: We may use or disclose your PHI to organizations that handle organ and tissue donation and distribution, banking, or transplantation.

Page 4 of 9

To Prevent a Serious Threat to Health or Safety: As permitted by law, we may disclose your PHI if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Military and National Security: We may disclose to military authorities the PHI of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials PHI required for lawful intelligence, counter-intelligence, and other national security activities.

Inmates: If you are a prison inmate, we may disclose your PHI to the prison or to a law enforcement official for: (1) the prison to provide health care to you; (2) your health and safety, and the health and safety of others; or (3) the safety and security of the prison.

Underwriting: We will not use genetic information about you for underwriting purposes.

Workers’ Compensation: As part of your workers’ compensation claim, we may have to disclose your PHI to a worker’s compensation carrier.

To You: When you ask us to, we will disclose to you your PHI that is in a “designated record set.” Generally, a designated record set contains medical, enrollment, claims and billing records we may have about you, as well as other records that we use to make decisions about your health care benefits. You can request the PHI from your designated record set as described in the section below called “Your Privacy Rights Concerning Your Protected Health Information.”

To Your Personal Representative: If you tell us to, we will disclose your PHI to someone who is qualified to act as your personal representative according to any relevant state laws. In order for us to disclose your PHI to your personal representative, you must send us a completed AmeriHealth Personal Representative Designation Form and documentation that supports the person’s qualification according to state law (such as a power of attorney or guardianship). To request the AmeriHealth Personal Representative Designation Form, please contact Member Services at the telephone number listed on the back of your Member Identification card, print the form from our web site at www.amerihealth.com, or write us at the address at the end of this Notice. However, the HIPAA Privacy Rule permits us to choose not to treat that person as your personal representative when we have a reasonable belief that: (i) you have been, or may be, subjected to domestic violence, abuse or neglect by the person; (ii) treating the person as your personal representative could endanger you; or (iii) in our professional judgment, it is not in your best interest to treat the person as your personal representative.

To Family and Friends: Unless you object, we may disclose your PHI to a friend or family member who has been identified as being involved in your health care. We also may disclose your PHI to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. If you are not present or able to agree to these disclosures of your PHI, then we may, using our professional judgment, determine whether the disclosure is in your best interest.

Parents as Personal Representatives of Minors: In most cases, we may disclose your minor child’s PHI to you. However, we may be required to deny a parent’s access to a minor’s PHI according to applicable state law.

Page 5 of 9


Health Information Exchanges

We share your health information electronically through certain Health Information Exchanges (“HIEs”). A HIE is a secure electronic data sharing network. In accordance with applicable federal and state privacy and security requirements, regional health care providers participate in HIEs to exchange patient information in real-time to help facilitate delivery of health care, avoid duplication of services, and more efficiently coordinate care. As a participant in HIEs, Independence shares your health information we may have received when a claim has been submitted for services you have received among authorized participating providers, such as physicians, hospitals, and health systems for the purpose of treatment, payment and health care operations as permitted by law. During an emergency, patients and their families may forget critical portions of their medical history which may be very important to the treating physician who is trying to make a quick, accurate diagnosis in order to treat the sick patient. Independence, through its participation in an HIE, makes pertinent medical history, including diagnoses, studies, lab results, medications and the treating physicians we may receive on a claim available to participating emergency room physicians while the patient is receiving care. This is invaluable to the physician, expediting the diagnosis and proper treatment of the patient.

Your treating providers who participate with an HIE, and also submit health information with the HIE, will have the ability to access your health information through the HIE and send records to your treating physicians. Through direct requests to the HIE, we will receive various types of protected health information such as pharmacy or laboratory services, or information when you have been discharged from a hospital which may be used to coordinate your care, provide case management services, or otherwise reduce duplicative services and improve the overall quality of care to our members. All providers that participate in HIEs agree to comply with certain privacy and security standards relating to their use and disclosure of the health information available through the HIE.

As an Independence member, you have the right to opt-out which means your health information will not be accessible through the HIE. Through the regional HIE (www.hsxsepa.org/patient-options-opt-out-back) website or the State HIE (www.dhs.pa.gov/citizens/healthinformationexchange/) website consumers or providers can access an online, fax, or mail form permitting patients to remove themselves (opt-out) or reinstate themselves (opt back in) to the HIE. It will take approximately one business day to process an opt-out request. If you choose to opt-out of the HIE, your health care providers will not be able to access your information through the HIE. Even if you opt-out, this will not prevent your health information from being made available and released through other means (i.e. fax, secure email) to authorized individuals, such as network providers for paying claims, coordinating care, or administering your health benefits in accordance with the law and in the normal course of conducting our business as permitted under applicable law. For more information on HIEs, please go to www.hsxsepa.org/consumers-0 or to www.paehealth.org.

Page 6 of 9

http://www.hsxsepa.org/patient-options-opt-out-back











http://www.dhs.pa.gov/citizens/healthinformationexchange/



http://www.hsxsepa.org/consumers-0




http://www.paehealth.org/

http://www.paehealth.org/

Right to Provide an Authorization for Other Uses and Disclosures

• Other uses and disclosures of your PHI that are not described above will bemade only with your written authorization.

• You may give us written authorization permitting us to use your PHI or disclose it toanyone for any purpose.

• We will obtain your written authorization for uses and disclosures of your PHI that arenot identified by this Notice, or are not otherwise permitted by applicable law.

Any authorization that you provide to us regarding the use and disclosure of your PHI may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your authorization. We may also be required to disclose PHI as necessary for purposes of payment for services received by you prior to the date when you revoked your authorization.

Your authorization must be in writing and contain certain elements to be considered a valid authorization. For your convenience, you may use our approved AmeriHealth Authorization Form. To request the AmeriHealth Authorization Form, please contact Member Services at the telephone number listed on the back of your Member Identification card, print the form from our web site at www.amerihealth.com, or write us at the address at the end of this Notice.

Your Privacy Rights Concerning Your Protected Health Information (PHI) You have the following rights regarding the PHI that we maintain about you. Requests to exercise your rights as listed below must be in writing. For your convenience, you may use our approved AmeriHealth form(s). To request a form, please contact Member Services at the telephone number listed on the back of your Member Identification card or write to us at the address listed at the end of this Notice.

Right to Access Your PHI: You have the right to inspect or get copies of your PHI contained in a designated record set. Generally, a “designated record set” contains medical, enrollment, claims and billing records we may have about you, as well as other records that we may use to make decisions about your health care benefits. However, you may not inspect or copy psychotherapy notes or certain other information that may be contained in a designated record set.

You may request that we provide copies of your PHI in a format other than photocopies such as by electronic means in certain situations. We will use the format you request unless we cannot practicably do so. We may charge a reasonable fee for copies of PHI (based on our costs), for postage, and for a custom summary or explanation of PHI. You will receive notification of any fee(s) to be charged before we release your PHI, and you will have the opportunity to modify your request in order to avoid and/or reduce the fee. In certain situations we may deny your request for access to your PHI. If we do, we will tell you our reasons in writing, and explain your right to have the denial reviewed.

Right to Amend Your PHI: You have the right to request that we amend your PHI if you believe there is a mistake in your PHI, or that important information is missing. Approved amendments made to your PHI will also be sent to those who need to know, including (where appropriate) AmeriHealth’s vendors (known as "Business Associates"). We may also deny your request if, for instance, we did not create the information you want amended. If we deny your request to amend your PHI, we will tell you our reasons in writing, and explain your right to file a written statement of disagreement.

Page 7 of 9


Right to an Accounting of Certain Disclosures: You may request, in writing, that we tell you when we or our Business Associates have disclosed your PHI (an “Accounting”). Any accounting of disclosures will not include those we made:

• for payment, or health care operations;• to you or individuals involved in your care;• with your authorization;• for national security purposes;• to correctional institution personnel; or• before April 14, 2003.

The first accounting in any 12-month period is without charge. We may charge you a reasonable fee (based on our cost) for each subsequent accounting request within a 12-month period. If a subsequent request is received, we will notify you of any fee to be charged, and we will give you an opportunity to withdraw or modify your request in order to avoid or reduce the fee.

Right to Request Restrictions: You have the right to request, in writing, that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to your request. However, if we do agree, we will be bound by our agreement except when required by law, in emergencies, or when information is necessary to treat you. An approved restriction continues until you revoke it in writing, or until we tell you that we are terminating our agreement to a restriction.

Right to Request Confidential Communications: You have the right to request that we use alternate means or an alternative location to communicate with you in confidence about your PHI. For instance, you may ask that we contact you by mail, rather than by telephone, or at work, rather than at home. Your written request must clearly state that the disclosure of all or part of your PHI at your current address or method of contact we have on record could be an endangerment to you. We will require that you provide a reasonable alternate address or other method of contact for the confidential communications. In assessing reasonableness, we will consider our ability to continue to receive payment and conduct health care operations effectively, and the subscriber’s right to payment information. We may exclude certain communications that are commonly provided to all members from confidential communications. Examples of such communications include benefit booklets and newsletters.

Right to a Paper Copy of This Notice: You have the right to receive a paper copy of our Notice of Privacy Practices. You can request a copy at any time, even if you have agreed to receive this Notice electronically. To request a paper copy of this Notice, please contact Member Services at the telephone number on the back of your Member Identification Card.

Right to Notification of a Breach of Your PHI: You have the right to and will be notified following a breach of your unsecured PHI or if a security breach occurs involving your PHI.

Your Right to File a Privacy Complaint If you believe your privacy rights have been violated, or if you are dissatisfied with AmeriHealth’s privacy practices or procedures, you may file a complaint with the AmeriHealth Privacy Office and with the Secretary of the U.S. Department of Health and Human Services.

You will not be penalized for filing a complaint.

Page 8 of 9

To file a privacy complaint with us, you may contact Member Services at the telephone number on the back of your member ID card, or you may contact the Privacy Office as follows:

AmeriHealth Privacy Office P.O. Box 41762 Philadelphia, PA 19101 – 1762 Fax: 215-241-4023 or 1-888-678-7006 (toll-free) E-mail: [email protected]: 215-241-4735 or 1-888-678-7005 (toll-free)

Page 9 of 9

SAMPLE

welcome to amerihealth new jersey€¦ · you and your covered dependents will each receive an...

Documents