AG 12-043 - GROUP HEALTHRETURN TO: EXT:
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
ORIGINATING DEPT./DIV:
2. ORIGINATING STAFF PERSON: EXT: 3. DATE REQ. BY:
4. TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G.,.RFB, RFP, RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
• PROFESSIONAL SERVICE AGREEMENT
• GOODS AND SERVICE AGREEMENT
• REAL ESTATE DOCUMENT
• ORDINANCE
• CONTRACT AMENDMENT (AG #):
OTHER
• MAINTENANCE AGREEMENT
• HUMAN SERVICES / CDBG
• SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
• RESOLUTION
• INTERLOCAL
5. PROJECT NAME: #'►P[� �— 1 y�I.r / 6c G
6.
NAME OF CONTRACTOR:
ADDRESS:
E -MAIL:
SIGNATURE NAME:
7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS /CERTIFICATE ❑ ALL
OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT /AMENDMENTS
8. TERM: COMMENCEMENT DATE: 1111= COMPLETION DATE:
TOTAL COMPENSATION $ (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED
❑ YES ❑ NO IF YES, $
❑ PURCHASING: PLEASE CHARGE TO:
10. DOCUMENT /CONTRACT REVIEW
❑ PROJECT MANAGER
• DIRECTOR
• RISK MANAGEMENT (IF APPLICABLE)
fi� LAW
11. COUNCIL APPROVAL (IF APPLICABLE)
PAID BY: ❑ CONTRACTOR ❑ CITY
INITIAL / DATE REVIEWED INITIAL/ DATE APPROVED
_TELEPHONE
_ FAX:
TITLE
COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE:
12. CONTRACT SIGNATURE ROUTING
❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D:
❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
I,,LAW DEPARTMENT
• SIGNATORY (MAYOR OR DIRECTOR)
• CITY CLERK
• ASSIGNED AG#
• SIGNED COPY RETURNED
COMMENTS:
11/9
0
GroupHealthv
Group Medical Coverage Agreement
Group Health Cooperative (also referred to as "GHC ") is a nonprofit health maintenance organization furnishing
health care coverage on a prepayment basis. The Group identified below wishes to purchase such coverage. This
Agreement sets forth the terms under which that coverage will be provided, including the rights and responsibilities
of the contracting parties; requirements for enrollment and eligibility; and benefits to which those enrolled under this
Agreement are entitled.
The Agreement between GHC and the Group consists of the following:
• Standard Provisions
• Attached Benefit Booklet
• Signed Group application
• Premium Schedule
Group Health Cooperative
Title: President and Chief Executive Officer
City of Federal Way, 1323400
Title:
This Agreement will continue in effect until terminated or renewed as herein provided for and is
effective January 1, 2012.
PA- 113312
l' 1
Group Medical Coverage Agreement
Group Health Cooperative (also referred to as "GHC ") is a nonprofit health maintenance organization furnishing
health care coverage on a prepayment basis. The Group identified below wishes to purchase such coverage. This
Agreement sets forth the terms under which that coverage will be provided, including the rights and responsibilities
of the contracting parties; requirements for enrollment and eligibility; and benefits to which those enrolled under this
Agreement are entitled.
The Agreement between GHC and the Group consists of the following:
• Standard Provisions
• Attached Benefit Booklet
• Signed Group application
• Premium Schedule
Group Health Cooperative
Title: President and Chief Executive Officer
City of Federal Way, 1323400
Signed:
Title:
This Agreement will continue in effect until terminated or renewed as herein provided for and is
effective January 1, 2012.
PA- 113312
Group Medical Coverage Agreement
Table of Contents
Standard Provisions
Attachment 1 Benefit Booklet
Attachment 2 Premium Schedule
C32810- 1323400 2
Standard Provisions
1. GHC agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group.
2. Monthly Premium Payments. For the initial term of this Agreement, the Group shall submit to GHC for each
Member the monthly premiums set forth in the current Premium Schedule and a verification of enrollment.
Payment must be received on or before the due date and is subject to a grace period of ten (10) days. Premiums
are subject to change by GHC upon thirty (30) days written notice. Premium rates will be revised as a part of
the annual renewal process.
In the event the Group increases or decreases enrollment at least twenty -five percent (25 %) or more, GHC
reserves the right to require re- rating of the Group.
3. Dissemination of Information. Unless the Group has accepted responsibility to do so, GHC will disseminate
information describing benefits set forth in the Benefit Booklet attached to this Agreement.
4. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members enrolled under
this Agreement.
5. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the
administration of this Agreement. This may include, but is not limited to, policies or procedures pertaining to
benefit entitlement and coverage determinations.
6. Modification of Agreement. Except as required by federal and Washington State law, this Agreement may not
be modified without agreement between both parties.
No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this
Agreement, convey or void any coverage, increase or reduce any benefits under this Agreement or be used in
the prosecution or defense of a claim under this Agreement.
7. Indemnification. GHC agrees to indemnify and hold the :Group harmless against all claims, damages, losses
and expenses, including reasonable attorney's fees, arising out of GHC's failure to perform, negligent
performance or willful misconduct of its directors, officers, employees and agents of their express obligations
under this Agreement.
The Group agrees to indemnify and hold GHC harmless against all claims, damages, losses and expenses,
including reasonable attorney's fees, arising out of the Group's failure to perform, negligent performances or
willful misconduct of its directors, officers, employees and agents of their express obligations under this
Agreement.
The indemnifying party shall give the other party prompt notice of any claim covered by this section and
provide reasonable assistance (at its expense). The indemnifying party shall have the right and duty to assume
the control of the defense thereof with counsel reasonably acceptable to the other party. Either party may take
part in the defense at its own expense after the other party assumes the control thereof.
8. Compliance With Law. The Group and GHC shall comply with all applicable state and federal laws and
regulations in performance of this Agreement.
This Agreement is entered into and governed by the laws of Washington State, except as otherwise pre - empted
by ERISA and other federal laws.
9. Governmental Approval. If GHC has not received any necessary government approval by the date when
notice is required under this Agreement, GHC will notify the Group of any changes once governmental
approval has been received. GHC may amend this Agreement by giving notice to the Group upon receipt of
government approved rates, benefits, limitations, exclusions or other provisions, in which case such rates,
benefits, limitations, exclusions or provisions will go into effect as required by the governmental agency. All
C32810- 1323400
amendments are deemed accepted by the Group unless the Group gives GHC written notice of non- acceptance
within thirty (30) days after receipt of amendment, in which event this Agreement and all rights to services and
other benefits terminate the first of the month following thirty (30) days after receipt of non - acceptance.
10. Confidentiality. Each party acknowledges that performance of its obligations under this Agreement may
involve access to and disclosure of data, procedures, materials, lists, systems and information, including
medical records, employee benefits information, employee addresses, social security numbers, e-mail addresses,
phone numbers and other confidential information regarding the Group's employees (collectively the
"information "). The information shall be kept strictly confidential and shall not be disclosed to any third party
other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have
a need to know such information in order to perform the services required of such party pursuant to this
Agreement, or for the proper management and administration of the receiving party, provided that such
representatives are informed of the confidentiality provisions of this Agreement and agree to abide by them, (ii)
pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal,
state or local law, statute, rule or regulation. The disclosing party will provide the other party , with prompt
notice of any request the disclosing party receives to disclose information pursuant to applicable legal
requirements, so that the other party may object to the. request and/or seek an appropriate protective order
against such request. Each party shall maintain the confidentiality of medical records and confidential patient
and employee information as required by applicable law.
11. Arbitration. Any dispute, controversy or difference between GHC and the Group arising out of or relating to
this Agreement, or the breach thereof, shall be settled by arbitration in Seattle, Washington in accordance with
the Commercial Arbitration Rules of the American Arbitration Association, and judgment on the award
rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Except as may be =required
by law, neither party nor arbitrator may disclose the existence, content or results of any arbitration hereunder
without the prior written consent of both parties.
12. H)EPAA.
Definition of Terms. Terms used, but not otherwise defined, in this Section shall have the same meaning as
those terms have in the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").
Transactions Accepted. GHC will accept Standard Transactions, pursuant to HIPAA, if the Group elects to
transmit such transactions. The Group shall ensure that all Standard Transactions transmitted to GHC by the
Group or the Group's business associates are in compliance with HIPAA standards for electronic transactions.
The Group shall indemnify GHC for any breach of this section by the Group.
13. Termination of Entire Agreement. This is a guaranteed renewable Agreement and cannot be terminated
without the mutual approval of each of the parties, except in the circumstances set forth below.
a. Nonpayment;or, Non- Acceptance,of Premium.. Failure to.tnake any monthly premium payment or
contribution in accordance with, subsection 2 above shall result in termination of this Agreement as of the
premium.due date. The .Group's failure to accept the revised premiums provided as.part of the annual
renewal process shall be considered nonpayment, and result in non- renewal of this Agreement. The Group
may terminate this Agreement upon fifteen (15) days written notice of premium increase, as set forth in
subsection 2 above.
b. Misrepresentation. GHC may rescind or terminate this Agreement upon written notice in the event that
intentional misrepresentation, fraud or omission of information was used in order to obtain Group
coverage. Either party may terminate this Agreement in the event of intentional misrepresentation, fraud or
omission of information by the other party in performance of its responsibilities under this Agreement.
c. Underwriting Guidelines. GHC may terminate this Agreement in the event the Group no longei meets
underwriting guidelines established by GHC that were in effect at the time the Group was accepted.
C32810- 1323400
d. Federal or State Law. GHC may terminate this Agreement in the event there is a change in federal or state
law that no longer permits the continued offering of the coverage described in this Agreement.
14. Withdrawal or Cessation of Services.
a. GHC may determine to withdraw from a Service Area or from a segment of its Service Area after GHC has
demonstrated to the Washington State Office of the Insurance Commissioner that GHC's clinical, financial
or administrative capacity to service the covered Members would be exceeded.
b. GHC may determine to cease to offer the Group's current plan and replace the plan with another plan
offered to all covered Members within that line of business that includes all of the health care services
covered under the replaced plan and does not significantly limit access to the services covered under the
replaced plan. GHC may also allow unrestricted conversion to a fully comparable GHC product.
GHC will provide written notice to each covered'Member of the discontinuation or non- renewal of the plan at
least ninety (90) days prior to discontinuation.
C32810- 1323400
Dear Group Health Subscriber:
This booklet contains important information about your healthcare plan.
This is your 2012 Group Health Benefit Booklet (Certificate of Coverage). It explains the services and benefits you
and those enrolled on your contract are entitled to receive from Group Health Cooperative. Sections of this
document may be bolded and italicized, which identifies changes that Group Health has made to the plan. The
benefits reflected in this booklet were approved by your employer or association who contracts with Group Health
for your healthcare coverage. If you are eligible for Medicare, please read Section N.J. as it may affect your
prescription drug coverage.
We recommend you read it carefully so you'll understand not only the benefits, but the exclusions, limitations, and
eligibility requirements of this certificate. Please keep this certificate for as long as you are covered by Group
Health. We will send you revisions if there are any changes in your coverage.
This certificate is not the contract itself,,you;can contact your employer or group administrator if you wish to see a
copy of the contract (Medical Coverage Agreement).
We'll gladly answer any questions you might have about your Group Health benefits. Please call our Group Health
Customer Service Center at (206) 901 -4636 in the Seattle area, or toll -free in Washington, 1- 888 - 9014636.
Thank you for choosing Group Health Cooperative. We look forward to working with you to preserve and enhance
your health.
Very truly yours,
Scott Armstrong
President
PA- 1133al2, CA- 139512, CA- 231212,CA- 136012,CA- 11712,CA- 138512
Benefit Booklet
Table of Contents
Section I. Introduction
A. Accessing Care
B. Cost Shares
C. Subscriber's Liability
D. Claims
Section II. Allowances Schedule
Section III. Eligibility, Enrollment and Termination
A. Eligibility
B. Enrollment
C. Effective Date of Enrollment
D. Eligibility for Medicare
E. Termination of Coverage
F. Services After Termination of Agreement
G. Continuation of Coverage Options
Section IV. Schedule of Benefits
A. Hospital Care
B. Medical and Surgical Care
C. Chemical Dependency Treatment
D. Plastic and Reconstructive Services
E. Home Health Care Services
F. Hospice Care
G. Rehabilitation Services
H. Devices, Equipment and Supplies
I. Tobacco Cessation
J. Drugs, Medicines, Supplies and Devices
K. Mental Health Care Services
L. Emergency/Urgent Care
M. Ambulance Services
N. Skilled Nursing Facility
Section V. General Exclusions
Section VI. Grievance Processes for Complaints and Appeals
Section VII. General Provisions
A. Coordination of Benefits
B. Subrogation and Reimbursement Rights
C. Miscellaneous Provisions
D. Utilization Management
Section VIII. Definitions
C32810- 1323400a
Section I. Introduction
Group Health Cooperative (also referred to as "GHC ") is a nonprofit health maintenance organization furnishing
health care primarily on a prepayment basis.
Read This Benefit Booklet Carefully
This Benefit Booklet is a statement of benefits, exclusions and other provisions, as set forth in the Group Medical
Coverage Agreement ("Agreement ") between GHC and the employer or Group.
A full description of benefits, exclusions, limits and Out -of- Pocket Expenses can be found in the Schedule of
Benefits, Section IV; General Exclusions, Section V; and Allowances Schedule, Section II. These sections must be
considered together to fully understand the benefits available under the Agreement. Words with special meaning are
capitalized. They are defined in Section VIII.
A. Accessing Care
Members are entitled to Covered Services only at GHC Facilities and from GHC Personal Physicians,
except for Emergency care and care pursuant to an Authorization.
Members may refer to Sections IV.A. andIV.C. for more information about inpatient admissions.
Primary Care. GHC recommends that Members select a GHC Personal Physician when enrolling under the
Agreement. One Personal Physician may be selected for an entire family, or a different Personal Physician may
be selected for each family member.
Selecting a Personal Physician or changing from one Personal Physician to another can be accomplished by
contacting GHC Customer Service, or accessing the GHC website at www.ghc.org. The change will be made
within twenty -four (24) hours of the receipt of the request, if the selected physician's caseload permits.
A listing of GHC Personal Physicians, specialists, women's health care providers and GHC - Designated
Specialists is available by contacting GHC Customer Service at (206) 9014636 or (888) 9014636, or by
accessing GHC's website at www.ghc.org.
In the case that the Member's Personal Physician no longer participates in GHC's network, the Member will be
provided access to the Personal Physician for up to sixty (60) days following a written notice offering the
Member a selection of new Personal Physicians from which to choose.
Specialty Care. Unless otherwise indicated in this section, the Allowances Schedule or Section IV.,
Authorizations are required for specialty care and specialists.
GHC - Designated Specialist. Members may make appointments directly with GHC - Designated Specialists at
Group Health -owned or - operated medical centers without an Authorization from their'Personal Physician. The
following specialty care areas are available from GHC - Designated Specialists: allergy, audiology, .cardiology,
chemical dependency, chiropractic /manipulative therapy, dermatology; gastroenterology, general surgery,
hospice, manipulative therapy, mental health, nephrology, neurology, obstetrics and gynecology, occupational
medicine, oncology/hematology, ophthalmology, optometry, orthopedics, otolaryngology '(ear, nose and throat),
physical therapy, smoking cessation, speech/language and learning services and urology.
Women's Health Care Direct Access Providers. Female Members may see a participating General and
Family Practitioner, Physician's Assistant, Gynecologist Certified Nurse Midwife, Licensed Midwife, Doctor
of Osteopathy, Pediatrician, Obstetrician or Advanced Registered Nurse Practitioner who is contracted by GHC
to provide women's health care services directly, without an Authorization from their Personal Physician, for
C32810- 1323400a
Medically Necessary maternity care, covered reproductive health services, preventive care (well care) and
general examinations, gynecological care and follow -up visits for the above services. Women's health care
services are covered as if the Member's Personal Physician had been consulted, subject to any applicable Cost
Shares, as set forth in the Allowances Schedule. If the Member's women's health care provider diagnoses a
condition that requires an Authorization to other specialists or hospitalization, the Member or her chosen
provider must obtain prior authorization and care coordination in accordance with applicable GHC
requirements.
Second Opinions. The Member may access, upon request, a second opinion regarding a medical diagnosis or
treatment plan from a GHC Provider. The Member, or the Member's family, may request an Authorization
from the Member's Personal Physician, or may visit a GHC - Designated Specialist, for a second opinion.
When second opinions are requested or indicated, they are provided by GHC Providers and are covered when
authorized in advance, or when obtained from a GHC - Designated Specialist Coverage is determined by the
Member's medical coverage plan, therefore, coverage for the second opinion does not imply that the services
or treatments recommended will be covered An Authorization for a second opinion does not imply that GHC
will authorize the Member to return to the physician providing the second opinion for any additional
treatment. Services, drugs, devices, etc., prescribed or recommended as a result of the consultation are not
covered unless included as covered under this Agreement.
Emergent and Urgent Care. Emergent care is available at GHC Facilities. If Members cannot get to a GHC
Facility, Members may obtain Emergency services from the nearest hospital. Members or persons assuming
responsibility for a Member must notify GHC by way of the GHC Emergency Notification Line within twenty -
four (24) hours of admission to a non -GHC Facility, or as soon thereafter as medically possible. Members may
refer to Section IV. for more information about coverage of Emergency services.
In the GHC Service Area, urgent care is covered at GHC medical centers, GHC urgent care clinics or GHC
Provider's offices. Urgent care received at any hospital emergency department is not covered unless authorized
in advance by GHC. Care received at urgent care facilities other than those listed above is only covered for
emergency services, subject to the applicable Emergency Cost Share. Members may refer to Section IV. for
more information about coverage of urgent care services.
Outside the GHC Service Area, urgent care is covered at any medical facility. Members may refer to Section
IV. for more information about coverage of urgent care services.
Recommended Treatment. GHC's Medical Director or his/her designee will determine the necessity, nature
and extent of treatment to be covered in each individual case and the judgment, made in good faith, will be
final.
Members have the right to participate in decisions regarding their health care. A Member may refuse any
recommended treatment or diagnostic plan to the extent permitted by law. Members who obtain care not
recommended by GHC, do so with the full understanding that GHC has no obligation for the cost, or liability
for the outcome, of such care. Coverage decisions may be appealed as set forth in Section VI.
Major Disaster or Epidemic: In the event of a major disaster or epidemic, GHC will provide coverage
according to GHC's best judgment, within the limitations of available facilities and personnel. GHC has no
liability for delay or failure to provide or arrange Covered Services to the extent facilities or personnel are
unavailable due to a major disaster or epidemic.
Unusual Circumstances. If the provision of Covered Services is delayed or rendered impossible due to unusual
circumstances such as complete or partial destruction of facilities, military action, civil disorder, labor disputes
or similar causes, GHC shall provide or arrange for services that, in the reasonable opinion of GHC's Medical
Director, or his/her designee, are emergent or urgently needed. In regard to nonurgent and routine services,
GHC shall make a good faith effort to provide services through its then- available facilities and personnel. GHC
shall have the option to defer or reschedule services that are not urgent while its facilities and services are so
affected. In no case shall GHC have any liability or obligation on account of delay or failure to provide or
arrange such services.
C32810- 1323400a
B. Cost Shares
The Subscriber shall be liable for the following Cost Shares when services are received by the Subscriber and
any of his/her Dependents.
1. Copayments. Members shall be required to pay Copayments atthe time of service as set forth in the
Allowances Schedule. Payment of a Copayment does not exclude the possibility of an additional billing if
the service is determined to be a non - Covered Service.
2. Coinsurance. Members shall be required to pay coinsurance for certain Covered Services as set forth in the
Allowances Schedule.
3. Out;-of- Pocket Total Out -of- Pocket Expenses incurred during the same calendar year shall not
exceed-the Out-of PocketLimit set forth in the Allowances Schedule. Out -of= Pocket Expenses which apply
toward the Out -of- Pocket Limit are set forth in the Allowances Schedule.
C. Subscriber's Liability
The Subscriber is liable for (1) payment to the Group of his/her contribution toward the monthly premium, if
any; (2) payment of Cost Share amounts for Covered Services provided to the Subscriber and his/her
Dependents, as set forth in the Allowances Schedule; and (3) payment of any fees charged for non - Covered
Services provided to the Subscriber and his/her Dependents, at the time of service.
Payment of an amount billed by GHC must be received within thirty (30) days of the billing date.
D. Claims
Claims for benefits may be made before or after services' are obtained. To make a claim for benefits under the
Agreement, a Member (or the Member's authorized representative) must contact GHC Customer Service, or
submit a claim for reimbursement as described below. Other inquiries, such as asking a health care provider
about care or coverage, or submitting a prescription to a pharmacy, will not be'considered a claimfor benefits.
If a Member receives a bill for services the Member believes are covered under the Agreement, the Member
must, within ninety (90) days of the date of service, or as soon thereafter as reasonably possible; either (1) ,
contact GHC Customer Service to make a claim or (2) pay the bill and submit a claim for reimbursement of
Covered Services to GHC, P.O. Box 34585, Seattle, WA 98124 -1585. In no event, except in the absence of
legal capacity, shall a claim be accepted later than one (1) year from the date of service.
GHC will generally process claims for benefits within the following timeframes'after GHC receives the claims:
• Pre - service claims — within fifteen (15) days.
• Claims involving urgently needed care — within seventy-two (72) hours.
• Concurrent `care claims — within `twenty -foul (24) hours.
• Post- service claims — within thirty (30) days.
Timeframes for pre- service and post- service claims can be extended by GI4C`for up to an additional fifteen (15)
days. Members will be notified in writing of such extension prior to the expiration of the initial timeframe.
C32810- 1323400a 4
Section II. Allowances Schedule
The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in
the Group Medical Coverage Agreement.
"Welcome" Outpatient Services Waiver
Not applicable.
Annual Deductible
No annual Deductible.
Plan Coinsurance
No Plan Coinsurance.
Lifetime Maximum
No Lifetime Maximum on covered Essential Health Benefits.
Hospital Services
Covered inpatient medical and surgical services, including acute chemical withdrawal (detoxification)
Covered subject to the lesser of GHC's charge or a $100 Copayment per day up to a maximum of four
(4) days per Member per admission; no Copayment on additional days thereafter.
• Covered outpatient hospital surgery (including ambulatory surgical centers)
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment.
Outpatient Services
• Covered outpatient medical and surgical services
Covered subject to the lesser of GHC's charge or a $10 outpatient services Copayment per Member per
visit: "
• Allergy testing
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment.
• Oncology (radiation therapy, chemotherapy)
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment.
Drugs — Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies)
• Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed
in the GHC drug formulary
Covered subject to the lesser of GHC's charge or a $10 Copayment.
• Over - the - counter drugs and medicines
Not covered.
C32810- 1323400a
5
• Injectables
Injectables that can be self - administered are subject to the lesser of GHC's charge or the applicable
prescription drug Cost Share (as set forth above). Other covered injectables are subject to the lesser of
GHC's charge or the applicable outpatient services Cost Share. Injectables necessary for travel are not
covered.
• Mail order drugs and medicines dispensed through the GHC- designated mail order service
Covered subject to the lesser of GHC's charge or two (2) times the applicable prescription drug Cost
Share (as set forth above) for each ninety (90) day supply or less for mail order prescription drugs.
Out -of- Pocket Limit
Limited to an aggregate maximum of $2,000 per Member or $4,000 per family per calendar year. Except as
otherwise noted in this Allowances Schedule, the total Out -of- Pocket Expenses for the following Covered
Services are included in the Out -of- Pocket Limit:
• Inpatient services
• Outpatient services
• Emergency care at a GHC or non -GHC Facility
• Ambulance services
Acupuncture
Covered subject to the lesser of GHC's'charge or the applicable outpatient services Copayment up to a
maximum of eight (8) visits per Member, per medical diagnosis per calendar year. When approved by GHC,
additional visits are covered.
Ambulance Services
• Emergency ground/air transport
Covered at 80 %.
• Non - emergent ground/air interfacility transfer
Covered at 80% for GHC - initiated transfers, except hospital - to-hospital ground transfers covered in
full.
Chemical Dependency
• Inpatient services (including Residential Treatment services)
Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment.
• Outpatient services
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment.
Acute detoxification covered as any other medical service.
Dental Services (including accidental injury to natural teeth)
Not covered, except as set forth in Section IV.B.23.
Devices, Equipment and Supplies (for home use)
C32810- 1323400a 6
Covered in full for:
• Durable medical equipment
• Orthopedic appliances
• Post - mastectomy bras limited to two (2) every six (6) months
• Ostomy supplies
• Prosthetic devices
When provided in lieu of hospitalization as described in Section IV.A.3., benefits will be the greater of
benefits available for devices, equipment and supplies, home health or hospitalization. See Hospice for
durable medical equipment provided in a hospice setting.
Diabetic Supplies
Insulin, needles, syringes, test strips and lancets — see Drugs- Outpatient. External insulin pumps, blood
glucose monitors and related supplies - see Devices, Equipment and Supplies.
Diagnostic Laboratory and Radiology Services
Covered in full.
Emergency Services
• At a GHC Facility
Covered subject to the lesser of GHC's charge or a $50 Copayment per Member per Emergency visit.
Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the
emergency department. Emergency admissions are covered subject to the applicable inpatient services
Cost Share.
• At a non -GHC Facility
Covered subject to the lesser of GHC's charge or a $50 Copayment per Member per Emergency visit.
Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the
emergency department. Emergency admissions are covered subject to the applicable inpatient services
Cost Share.
Hearing Examinations and Hearing Aids
• Hearing examinations to determine hearing loss
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment.
• Hearing aids, including hearing aid examinations
Not covered.
Home Health Services
Covered in full. No visit limit.
Hospice Services
Covered in full. Inpatient respite care is covered for a maximum of five (5) consecutive days per
occurrence.
Infertility Services (including sterility)
C32810- 1323400a 7
Not covered.
Manipulative Therapy
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment for
manipulative therapy of the spine and extremities in accordance with GHC clinical criteria up to a
maximum of ten (10) visits per Member per calendar year.
Maternity and Pregnancy Services
• Delivery and associated Hospital Care
Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment.
• Prenatal and postpartum care
Routine maternity visits covered in full. Non - routine maternity visits covered subject to the lesser of
GHC's charge or the applicable outpatient services Copayment.
• Pregnancy termination
Covered subject to the lesser of GHC's charge or the applicable Copayment for involuntary /voluntary
termination of pregnancy.
Mental Health Services
• Inpatient services
Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment at a
GHC- approved mental health care facility.
• Outpatient services
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment.
Naturopathy
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment up to a
maximum of three (3) visits per Member per medical diagnosis per calendar year. When approved by GHC,
additional visits are covered.
Newborn Services
Newborn services covered the same as for any other condition, subject to the lesser of GHC's charge or
the applicable Cost Share. Any applicable Cost Share for newborn services is separate from that of the
mother.
Initial hospital stay (Le. routine nursery care) — See Hospital Services. Outpatient well caEre — See
Preventive Services.
Nutritional Services
• Phenylketonuria (PKU) supplements
Covered in fudl.
• Enteral therapy (formula)
C32810- 1323400a 8
Covered at 80% for elemental formulas. Necessary equipment and supplies are covered under Devices,
Equipment and Supplies..
• Parenteral therapy (total parenteral nutrition)
Covered in full for parenteral formulas. Necessary equipment and supplies are covered under Devices,
Equipment and Supplies.
Obesity Related Services
Services directly related to obesity, including bariatric surgery, weight loss programs, medications and
related physician visits for medication monitoring are not covered.
On the Job Injuries or Illnesses
Not covered, including injuries or illnesses incurred as a result of self - employment.
Optical Services
• Routine eye examinations
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment once
every twelve (12) months. Eye examinations for eye pathology, including contact lens examinations,
are covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment
as often as Medically Necessary.
• Lenses, including contact lenses, and frames
Not covered except contact lenses for eye pathology are covered in full, including following cataract
surgery.
Organ Transplants
Covered subject to the lesser of GHC's charge or the applicable Copayment.
Plastic and Reconstructive Services (plastic surgery, cosmetic surgery)
• Surgery to correct a congenital disease or anomaly, or conditions following an injury or resulting from
surgery
Covered subject to the lesser of GHC's charge or the applicable Copayment.
• Cosmetic surgery, including complications resulting from cosmetic surgery
Not covered.
Podiatric Services
• Medically Necessary foot care
Covered subject to the lesser of GHC's charge or the applicable Copayment.
• Foot care (routine)
Not covered, except in the presence of a non - related Medical Condition affecting the lower limbs.
Pre - Existing Condition
C32810- 1323400a 9
Covered with no wait.
Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and
prostate /colorectal cancer screening)
Covered in full when in accordance with the well care schedule established by GHC and the Patient
Protection and Affordable Care Act of 2010. Eye refractions are not included under preventive care.
Physicals for travel, employment, insurance or license are not covered. Services provided during a
preventive care visit which are not in accordance with the well care schedule may be subject to the lesser of
GHC's charge or the applicable outpatient services Copayment.
Rehabilitation Services
• Inpatient physical, occupational and restorative speech therapy services combined, including services
for neurodevelopmentally disabled children age six (6) and under
Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment for up to
sixty (60) days per calendar year.
• Outpatient physical, occupational and restorative speech therapy services combined, including services
for neurodevelopmentally disabled children age six (6) and under
Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment for up
to sixty (60) visits per calendar year.
Sexual Dysfunction Services
Not covered.
Skilled Nursing Facility (SNF)
Covered up to sixty (60) days per Member per calendar year.
Sterilization (vasectomy, tubal ligation)
Covered subject to the lesser of GHC's.charge or the applicable Copayment.
Temporomandibular Joint (TM,i) Services
• Inpatient and outpatient TMJ services
Covered subject to the lesser of GHC's charge or the applicable Copayment up to $1,000 maximum
per Member per calendar year.
• Lifetime benefit maximum
Covered up to $5,000 per Member.
Tobacco Cessation
• Individual/group counseling
Covered in full when received through the GHGdesignated tobacco cessation progranc
• Approved pharmacy products
Covered in full when prescribed as part of the GHC - designated tobacco cessation program and
dispensed through the GHC - designated mail order service.
C32810- 1323400a 10
Section III. Eligibility, Enrollment and Termination
A. Eligibility
In order to be accepted for enrollment and continuing coverage under the Agreement, individuals must
meet any eligibility requirements imposed by the Group, reside or work in the Service Area and meet
all applicable requirements set forth below, except for temporary residency outside the Service Area
for purposes of attending school, court- ordered coverage for Dependents or other unique family
arrangements, when approved in advance by GHC. GHC has the right to verify eligibility.
I. Subscribers. Bona fide regular part-time and regular full -time employees who have been
continuously employed on a regularly scheduled basis of not less than twenty (20) hours per week
shall be eligible for enrollment.
2. Dependents. The Subscriber may also enroll the following:
a. The Subscriber's legal spouse, including state - registered domestic partners as required by
Washington state law;
b. The Subscriber's domestic partner, other than a state - registered domestic partner, provided
that'the Subscriber and domestic partner:
i. Share the same regular and permanent residence;
ii. Have a close personal relationship;
iii. Are jointly responsible for "basic living expenses" as defined by the Group;
iv. Are not married to anyone;
v. Are each eighteen (18) years of age or older;
vi. Are not related by blood closer than would bar marriage in the State of Washington;
vii. Were mentally competent to consent to contract when the domestic partnership began;
and
viii. Are each other's sole domestic partner and are responsible for each other's common
welfare.
Following termination of a domestic partnership a statement of termination must be filed with
the Group. Application for another domestic partnership cannot be filed for ninety (90) days
following a filing of the statement of termination of domestic partnership with the Group,
unless such termination is due to the death of the domestic partner.
c. Children who are under the age of twenty -six (26).
"Children" means the children of the Subscriber or spouse, including adopted children,
stepchildren, children of a domestic partner, or state - registered domestic partner, children for
whom the Subscriber has a qualified court order to provide coverage, and any other children
for whom the Subscriber is the legal guardian.
EIigibility may be extended past the Dependent's limiting age as set forth above if the
Dependent is totally incapable of self - sustaining employment because of a developmental or
physical disability incurred prior to attainment of the limiting age set forth above, and is
chiefly dependent upon the Subscriber for support and maintenance. Enrollment for such a
Dependent may be continued for the duration of the continuous total incapacity, provided
enrollment does not terminate for any other reason. Medical proof of incapacity and proof of
financial dependency must be furnished to GHC upon request, but not more frequently than
annually after the two (2) year period following the Dependent's attainment of the limiting
age.
C32810- 1323400a 11
3. Temporary Coverage for Newborns. When a Member gives birth, the newborn will be entitled
to the benefits set forth in Section IV. from birth through three (3) weeks of age. After three (3)
weeks of age, no benefits are available unless the newborn child qualifies as a Dependent and is
enrolled under the Agreement. All contract provisions, limitations and exclusions will apply
except Section III.F. and III.G.
B. Enrollment
Application for Enrollment. Application for enrollment must be made on an application
approved by GHC. Applicants will not be enrolled or premiums accepted until the completed
application has been approved by GHC. The Group is responsible for submitting completed
applications to GHC.
GHC reserves the right to refuse enrollment to any person whose coverage under any Medical
Coverage Agreement issued by Group Health Cooperative or Group Health Options, Inc. has been
terminated for cause, as set forth in Section III.E. below.
a. Newly Eligible Persons. Newly eligible Subscribers and their Dependents may apply for
enrollment in writing to the Group within thirty-one (3 1) days of becoming eligible.
b. New Dependents. A written application for enrollment of a newly dependent person, other
than a newborn or adopted child, must be made to the Group within thirty-one (3 1) days after
the dependency occurs.
A written application for enrollment of a newborn child must be made to the Group within
sixty (60) days following the date of birth, when there is "a change in the monthly premium
payment as a result of the additional Dependent.
A written application for enrollment of an adoptive child must be made to the Group within
sixty (60) days from the day the child is placed with the Subscriber for the purpose of
adoption and the Subscriber assumes total or partial financial support of the child, if there is a
change in the monthly premium payment as a result of the additional Dependent.
When there is no change in the monthly premium payment, it is strongly, advised that the
Subscriber enroll the newborn or newly adoptive child as a Dependent with the Group to
avoid delays in the payment of claims.
c. Open Enrollment. GHC will allow enrollment of Subscribers and Dependents, who did not
enroll when newly, eligible as described above, during a limited period of time specified by
the Group and GHC.
d. Special Enrollment.
1) GHC will allow special enrollment "for persons:
a) who initially declined enrollment when otherwise eligible because such persons had
other Health care coverage and have had such other coverage terminated due to one of
the following events:
•` cessation of employer contributions,
• exhaustion of COBRA continuation coverage,
loss of eligibility, except for loss of eligibility for cause; or
b) who have had such other coverage exhausted because such person reached a Lifetime
Maxunum limit.
GHC or the Group may require confirmation that when initially offered coverage such
persons submitted a written statement declining because of other coverage. Application for
coverage under the Agreement must be made within thirty-one (3 1) days of the termination
of previous coverage.
2) GHC will allow special enrollment for individuals who are eligible to be a Subscriber,
his/her spouse and his/her Dependents in the event one of the following occurs:
C32810- 1323400a I2
• marriage. Application for coverage under the Agreement must be made within thirty-
one (3 1) days of the date of marriage.
• birth. Application for coverage under the Agreement for the Subscriber and
Dependents other than the newborn child must be made within sixty (60) days of the
date of birth.
• adoption or placement for adoption. Application for coverage under the Agreement
for the Subscriber and Dependents other than the adopted child must be made within
sixty (60) days of the adoption or placement for adoption.
• eligibility for medical assistance: provided such person is otherwise eligible for
coverage under this Agreement, when approved and requested in advance by the
Department of Social and Health Services (DSHS). The request for special
enrollment must be made within sixty (60) days of DSHSs determination that
enrollment would be cost - effective.
• coverage under a Medicaid or CHIP plan is terminated as a result of loss of
eligibility for such coverage. Application for coverage under the Agreement must
be made within sixty (60) days of the date of termination under Medicaid or CHIP.
• applicable federal or state law or regulation otherwise provides for special
enrollment.
2. Limitation on Enrollment. The Agreement will be open for applications for enrollment as set
forth in this Section III.B. Subject to prior approval by the Washington State Office of the
Insurance Commissioner, GHC may limit enrollment, establish quotas or set priorities for
acceptance of new applications if it determines that GHC's capacity, in relation to its total
enrollment, is not adequate to provide services to additional persons.
C. Effective Date of Enrollment
1. Provided eligibility criteria are met and applications for enrollment are made as set forth in
Sections III.A. and III.B. above, enrollment will be effective as follows:
• Enrollment for a newly eligible Subscriber and listed Dependents is effective on the first (1st)
of-the month following or coinciding with the date of hire provided the Subscriber's
application has been submitted to and approved by GHC.
• The probationary period for part-time employees who become full -time employees begins
retroactive to the original date of hire.
• Enrollment for a newly dependent person, other than a newborn or adoptive child, is effective
on the first (I st) of the month following the date eligibility requirements are met.
• Enrollment for newborns is effective from the date of birth.
• Enrollment for adoptive children is effective from the date that the adoptive child is placed
with the Subscriber for the purpose of adoption and the Subscriber assumes total or partial
financial support of the child.
2. Commencement of Benefits for Persons Hospitalized on Effective Date. Members who are
admitted to an inpatient facility prior to their enrollment under the Agreement, and who do not
have coverage under another agreement, will receive covered benefits beginning on their effective
date, as set forth in subsection C.1. above. If a Member is hospitalized in a non -GHC Facility,
GHC reserves the right to require transfer of the Member to a GHC Facility. The Member will be
transferred when a GHC Provider, in consultation with the attending physician, determines that the
Member is medically stable to do so. If the Member refuses to transfer to a GHC Facility, all
further costs incurred during the hospitalization are the responsibility of the Member.
D. Eligibility for Medicare
An individual shall be deemed eligible for Medicare when he /she has the option to receive Part A
Medicare benefits. Medicare Secondary Payer regulations and guidelines will determine
primary/secondary payer status for individuals covered by Medicare.
The Group is responsible for providing the Member with necessary information regarding Tax Equity
and Fiscal Responsibility Act of 1982 (TEFRA) eligibility and the selection process, if applicable. A
C32810- 1323400a 13
Member who is eligible for Medicare has the option of maintaining both Medicare Parts A and B while
continuing coverage under this Agreement. Coverage between this Agreement and Medicare will be
coordinated as outlined in Section VII.A.
The Group is also responsible for providing GHC with a prospective timely notice of Members'
ineligibility for Medicare Advantage coverage under the Group, as well as providing a prospective
notice to its Members alerting them of the termination event. In the event the Group does not obtain
Medicare Advantage coverage, the loss of Medicare drug coverage, other coverage options that may
be available to the Member, and the possibility of late enrollment penalties if the Member does not
apply for Medicare coverage within the required timeframe will also need to be provided.
E. Termination of Coverage
1. Termination of Specific Members. Individual Member coverage may be terminated for any of
the following reasons:
a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in
Section III., and is not enrolled for continuation coverage as described in Section III.G. below,
coverage under the Agreement will terminate at the end of the month during which the loss of
eligibility occurs, unless otherwise specified by the Group.
b. For Cause. Coverage of a Member maybe terminated upon ten (10) working days written
notice for:
i. Material misrepresentation, fraud or omission of information in order to obtain coverage.
ii. Permitting the use of a GHC identification card or number by another person, or using
another Member's identification card or number to obtain care to which a person is not
entitled.
In the event of termination for cause, GHC reserves the right to pursue all civil remedies
Allowable, under federal and state law for the collection of claims, losses or other damages.
c. Premium Payments. Nonpayment of premiums or contribution for a specific Member by the
Group,
Individual Member coverage may be retroactively terminated upon thirty (30) days written notice
and only in the case of fraud or intentional misrepresentation of a material fact; or as otherwise
allowed under applicable law or regulation. Notwithstanding the foregoing, GHC reserves the '
right to retroactively terminate coverage for nonpayment,of premiums or contributions by the
Group, as described under subsection c. above.
In no event will a Member be terminated solely on the basis of their physical or mental condition
provided they meet all other, eligibility requirements set forth in, the Agreement.
Any Member may appeal a termination decision throng' GHC's grievance process asset forth in
Section VI.
2. Certificate of Creditable Coverage. Unless the Group has chosen to accept this responsibility, a
certificate of creditable coverage (which provides regarding the Member's length of
coverage under the Agreement) will be issued automatically upon termination of coverage, and
may also be obtained upon request.
F. Services After Termination of Agreement
1. Members Hospitalized on the Date of Termination. A Member who is receiving Covered
Services as a registered bed patient in a hospital on the date of termination shall continue to be
eligible for Covered Services while an inpatient for the condition which the Member was
hospitalized, until one of the following events occurs:
C32810- 1323400a 14
• According to GHC clinical criteria, it is no longer Medically Necessary for the Member to be
an inpatient at the facility.
• The remaining benefits available under the Agreement for the hospitalization are exhausted,
regardless of whether a new calendar year begins.
• The Member becomes covered under another agreement with a group health plan that
provides benefits for the hospitalization.
• The Member becomes enrolled under an agreement with another carrier that would provide
benefits for the hospitalization if the Agreement did not exist.
This provision will not apply if the Member is covered under another agreement that provides
benefits for the hospitalization at the time coverage would terminate, except as set forth in this
section, or if the Member is eligible for COBRA continuation coverage as set forth in subsection
G. below.
2. Services Provided After Termination. The Subscriber shall be liable for payment of all charges
for services and items provided to the Subscriber and all Dependents after the effective date of
termination, except those services covered under subsection F.1. above. Any services provided by
GHC will be charged according to the Fee Schedule.
G. Continuation of Coverage Options
1. Continuation Option. A Member no longer eligible for coverage under the Agreement (except in
the event of termination for cause, as set forth in Section III.E.) may continue coverage for a
period of up to three (3) months subject to notification to and self - payment of premiums to the
Group. This provision will not apply if the Member is eligible for the continuation coverage
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). This
continuation option is not available if the Group no longer has active employees or otherwise
terminates.
2. Leave of Absence. While on a Group approved leave of absence, the Subscriber and listed
Dependents can continue to be covered under the Agreement provided:
• They remain eligible for coverage, as set forth in Section III.A.,
• Such leave is in compliance with the Group's established leave of absence policy that is
consistently applied to all employees,
• The Group's leave of absence policy is in compliance with the Family and Medical Leave Act
when applicable, and
• The Group continues to remit premiums for the Subscriber and Dependents to GHC.
3. Self- Payments During Labor Disputes. In the event of suspension or termination of employee
compensation due to a strike, lock -out or other labor dispute, a Subscriber may continue
uninterrupted coverage under the Agreement through payment of monthly premiums directly to
the Group. Coverage may be continued for the lesser of the term of the strike, lock -out or other
labor dispute, or for six (6) months after the cessation of work.
If the Agreement is no longer available, the Subscriber shall have the opportunity to apply for an
individual GHC Group Conversion Plan or, if applicable, continuation coverage (see subsection 4.
below), or an Individual and Family Medical Coverage Agreement at the duly approved rates.
The Group is responsible for immediately notifying each affected Subscriber of his/her
rights of self - payment under this provision.
4. Continuation Coverage Under Federal Law. This section applies only to Groups who must
offer continuation coverage under the applicable provisions of the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA), as amended, and only applies to grant continuation of
coverage rights to the extent required by federal law.
C32810- 1323400a 15
Upon loss of eligibility, continuation of Group coverage may be available to a Member for a
limited time after the Member would otherwise lose eligibility, if required by COBRA. The Group
shall inform Members of the COBRA election process and how much the Member will be
required to pay directly to the Group.
Continuation coverage under COBRA will terminate when a Member becomes covered by
Medicare or obtains other group coverage, and as set forth under Section III.E. Lb. and c.
5. GHC Group Conversion Plan. Members whose eligibility for coverage under the Agreement,
including continuation coverage, is terminated for any reason other than cause, as set forth in
Section III.E.I.b., and who are not eligible for Medicare or covered by another group health plan,
may convert to GHC's Group Conversion Plan. If the Agreement terminates, any Member covered
under the Agreement at termination may convert to a GHC Group Conversion Plan, unless he /she
is eligible to obtain other group health coverage within thirty-one (3 1) days of the termination of
the Agreement. .
An application for conversion must be made within thirty -one (3 1) days following termination of
coverage under the Agreement or within thirty -one (3 1) days from the date notice of the
termination of coverage is received, whichever is later. Coverage under GHC's Group Conversion
Plan is subject to all terms and conditions of such plan, including premium payments. A physical
examination or statement of health is not required for enrollment in GHC's Group Conversion
Plan. The Pre- Existing.Condition limitation under GHC's Group Conversion Plan will apply only
to the extent that the limitation remains unfulfilled under the Agreement.
By exercising Group Conversion rights, the Member may waive guaranteed issue and Pre- Existing
Condition waiver rights under Federal regulations.
Persons wishing to purchase GHC's Individual and Family coverage should contact GHC
Marketing.
Section IV. Schedule of Benefits -
Benefits are subject to all provisions of the Group Medical Coverage Agreement, including, without
limitation, the Accessing Care provisions and General Exclusions. Members must refer to Section H.,
the Allowances Schedule, for Cost Shares and specific benefit limits that apply to benefits listed in
this Schedule of Benefits. Members are entitled to receive only benefits and services that are
Medically Necessary and clinically, appropriate for the treatment, of a Medical Condition as
determined by GHC's Medical Director, or his/her designee, and as described herein. All Covered
Services are subject to case management and,utilization review at the discretion of GHC.
A. Hospital Care
Hospital coverage is limited to the following services:
1. Room and board, including private room when prescribed, and general nursing services.
2. Hospital services `(including use of operating room," anesthesia, oxygen, x -ray, laboratory' and
radiotherapy 'services)'.
3. Alternative care arrangements may be covered as a cost- effective alternative in lieu of otherwise
covered Medically Necessary hospitalization, or other covered Medically Necessary institutional
care. Alternative care arrangements in lieu of covered hospital or other institutional care must be
determined to be appropriate and Medically Necessary based upon the Member's Medical
Condition. - Coverage must be authorized in by GHC as appropriate and Medically
Necessary. Such care will be covered to the same extent the replaced Hospital Care is covered
under the Agreement.
4. Drugs and medications administered during confinement.
C32810- 1323400a 16
5. Special duty nursing, when prescribed as Medically Necessary.
If a Member is hospitalized in a non -GHC Facility, GHC reserves the right to require transfer of the
Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If
the Member refuses to transfer, all further costs incurred during the hospitalization are the
responsibility of the Member.
Excluded. take home drugs, dressings and supplies following hospitalization.
B. Medical and Surgical Care
Medical and surgical coverage is Iimited to the following:
1. Surgical services.
2. Diagnostic x -ray, nuclear medicine, ultrasound and laboratory services.
1 Family planning counseling services.
4. Hearing examinations to determine hearing loss.
Excluded. hearing devices and hearing aids, including related examinations.
5. Blood and blood derivatives and their administration.
6. Preventive care (well care) services for health maintenance in accordance with the well care
schedule established by GHC and the Patient Protection and Affordable Care Act of 2010.
Preventive care includes: routine mammography screening, physical examinations and routine
laboratory tests for cancer screening in accordance with the well care schedule established by
GHC, and immunizations and vaccinations listed as covered in the GHC drug formulary
(approved drug list). A fee may be charged for health education programs. The well care schedule
is available in GHC clinics, by accessing GHC's website at www. c.org or upon request.
Covered Services provided during a preventive care visit, which are not in accordance with the
GHC well care schedule, may be subject to Cost Shares.
7. Radiation therapy services.
8. Reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or non - dental
cysts of the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth; and incision of salivary
glands and ducts.
9. Medical implants.
Excluded: internally implanted insulin pumps, artificial hearts, artificial larynx and any other
implantable device that has not been approved by GHC's Medical Director, or his/her designee.
10. Respiratory therapy.
11. Outpatient total parenteral nutritional therapy; outpatient elemental formulas for malabsorption;
and dietary formula for the treatment of phenylketonuria (PKU). Coverage for PKU formula is not
subject to a Pre- Existing Condition waiting period, if applicable.
Equipment and supplies for the administration of enteral and parenteral therapy are covered under
Devices, Equipment and Supplies.
Excluded: any other dietary formulas, oral nutritional supplements, special diets, prepared
foods /meals and formula for access problems.
C32810- 1323400a 17
12. Visits with GHC Providers, including consultations and second opinions, in the hospital or
provider's office.
13. Optical services.
Routine eye examinations and refractions received at a GHC Facility once every twelve (12)
months, except when Medically Necessary. Routine eye examinations to monitor Medical
Conditions are covered as often as necessary upon recommendation of a GHC Provider.
Contact lenses for eye pathology, including contact lens exam and fitting, are covered subject to
the applicable Cost Share. When dispensed through GHC Facilities, one contact lens per diseased
eye in lieu of an intraocular lens, including exam and fitting, is covered for Members following
cataract surgery performed by a GHC Provider, provided the Member has been continuously
covered by GHC since such surgery.
Replacement of lenses for eye pathology, including following cataract surgery, will be covered
only once within a twelve (I2) month period and only when needed due to a change in the
Member's Medical Condition.
Excluded: eyeglasses, contact lenses and services related to their fitting, orthoptic therapy (Le-,
eye training),evaluations and surgical procedures to correct refractions not related to eye
pathology and complications related to such procedures, and contact lens fittings and related
examinations not related to eye pathology, except as set forth above.
14. Maternity care, including care for complications of pregnancy and preriatal and postpartum visits.
Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary
as determined by GHC's Medical Director, or his/her designee, and in accordance with Board of
Health, standards for screening and diagnostic tests during pregnancy.
Hospitalization and delivery, including home births for low risk pregnancies.
Voluntary (not medically indicated and .nontherapeutic) or involuntary termination of pregnancy.
The Member's physician, in consultation with the Member, will determine the Member's length of
inpatient stay following delivery. Pregnancy will not be excluded as a Pre- Existing Condition
under the Agreement. Treatment for post - partum depression or psychosis is covered only under
the mental health benefit.
Excluded: birthing tubs, genetic testing of non - Members for the detection of congenital and
heritable disorders, fetal ultrasound in the absence of medical indications.
15. Transplant services, including heart, heart -lung, single lung, double lung, kidney, pancreas,
cornea, intestinal/multi- visceral, bone marrow, liver transplants and stem cell support (obtained
from allogeneic or autologous peripheral blood "or marrow) with associated high dose
chemotherapy. Covered Services must be directly associated with, and occur at the time of, the
transplant. Services are limited to the following:
a. Inpatient and outpatient medical expenses listed below for transplantation procedures:
• Evaluation testing to determine recipient candidacy,
• Donor matching tests,
• Hospital charges,
• Procurement center fees,
• Professional fees,
• Travel costs for a surgical team, and
• Excision fees
C32810- 1323400a 18,
Donor costs for a covered organ recipient are limited to procurement center fees, travel costs
for a surgical team and excision fees.
b. Follow -up services for specialty visits,
C. Rehospitalization, and
d. Maintenance medications.
Excluded: donor costs to the extent that they are reimbursable by the organ donor's insurance,
treatment of donor complications, living expenses and transportation expenses, except as set forth
under Section N.M.
16. Manipulative therapy.
Manipulative therapy of the spine and extremities are covered as set forth in the Allowances
Schedule when provided by GHC Providers.
Excluded: supportive care rendered primarily to maintain the level of correction already achieved,
care rendered primarily for the convenience of the Member, care rendered on a non - acute,
asymptomatic basis and charges for any other services that do not meet GHC clinical criteria as
Medically Necessary.
17. Medical and surgical services and related hospital charges, including orthognathic (jaw) surgery,
for the treatment of temporomandibular joint (TMJ) disorders. TMJ appliances are covered as set
forth under Section IV.H.1., Orthopedic Appliances.
Orthognathic (jaw) surgery for the treatment of TMJ disorders, radiology services and TMJ
specialist services, including fitting/adjustment of splints are subject to the benefit limit set forth in
the Allowances Schedule.
Excluded: treatment for cosmetic purposes, bite blocks, dental services including orthodontic
therapy, or any orthognathic (jaw) surgery in the absence of a diagnosis of TMJ, severe
obstructive sleep apnea or congenital anomaly. Any hospitalizations related to these exclusions is
also excluded.
18. Diabetic training and education.
19. Detoxification services for alcoholism and drug abuse.
For the purposes of this section, "acute chemical withdrawal" means withdrawal of alcohol and/or
drugs from a Member for whom consequences of abstinence are so severe that they require
medical/nursing assistance in a hospital setting, which is needed immediately to prevent serious
impairment to the Member's health.
Coverage for acute chemical withdrawal is provided without prior approval. If a Member is
hospitalized in a non -GHC Facility/program, coverage is subject to payment of the Emergency
care Cost Share. The Member or person assuming responsibility for the Member must notify GHC
by way of the GHC Notification Line within twenty-four (24) hours following inpatient
admission, or as soon thereafter as medically possible. Furthermore, if a Member is hospitalized in
a non -GHC Facility/program, GHC reserves the right to require transfer of the Member to a GHC
Facility/program upon consultation between a GHC Provider and the attending physician. If the
Member refuses transfer to a GHC Facility/program, all further costs incurred during the
hospitalization are the responsibility of the Member.
20. Circu mcision.
21. Nutritio nal counseling provided by GHC staff.
22. Sterilization procedures.
C32810- 1323400a 19
Excluded. procedures and services to reverse a therapeutic or nontherapeutic sterilization.
23. General anesthesia services and related facility charges for dental procedures will be covered for
Members who are under seven (7) years of age, or are physically or developmentally disabled or
have a Medical Condition where the Member's health would be put at risk if the dental procedure
were performed in a dentist's office. Such services must be authorized in advance by GHC and
performed at a GHC hospital or ambulatory surgical facility.
Excluded: dentist's or oral surgeon's fees; dental care, surgery, services and appliances,
including. treatment of accidental injury to natural teeth, reconstructive surgery to the jaw in
preparation for dental implants, dental implants, periodontal surgery and any other dental
service not specifically listed as covered. GHC's Medical Director, or his/her designee, will
determine whether the care or treatment required is within the category of dental care or
service.
24. Acupuncture and naturopathy as set forth in the Allowances Schedule. Additional visits are
covered when approved by GHC. Laboratory and radiology services are covered only when
obtained through 'a GHC Facility.
Excluded: herbal supplements, preventive care visits for acupuncture and any services not within
the scope of the practitioner's licensure.
25. Pre- Existing Conditions are covered in the same manner as any other illness.
26. Injections administered by a professional in a clinical setting.
C. Chemical Dependency Treatment.
Chemical dependency means an illness characterized by a physiological or psychological dependency,
or both, on a controlled substance and/or alcoholic beverages, and where the user's health is
substantially impaired or endangered or his /her social or'economic function is substantially disrupted.
For the purposes of this'section, the definition of Medically Necessary shall'te expanded to' include
those services necessary to treat a chemical dependency condition that is having a clinically significant
impact on a Member's emotional, social, medical and/or occupational functioning.
Chemical dependency treatment services are covered as set forth in the Allowances Schedule at a GHC
Facility or GHC- approved treatment program.
'All alcoholism and/or drug abuse treatment services must be: (a) provided at a facility as described
above; and (b) deemed Medically Necessary as defined above. Chemical dependency treatment may
include the following services received on an inpatient or outpatient basis: inpatient'Resideniial
Treatment services, diagnostic evaluation and education, organized`individual and group counseling
and/or prescription drugs and medicines.
Court- ordered treatment shall be covered only if determined to be Medically Necessary as defined
above. "
D. Plastic and Reconstructive Services. Plastic and reconstructive services are `covered' asset forth
below:
Correction of a congenital disease or congenital anomaly, as determined by a GHC Provider. A
congenital anomaly will be considered to exist if the Member's appearance resulting from such
condition is not within the range of normal human variation.
2. Correction of a Medical Condition following an injury or resulting from surgery covered by GHC
which has produced a major effect on the Member's appearance, when in the opinion of a GHC
Provider, such services can reasonably be expected to correct the condition.
C32810- 1323400a 20
3. Reconstructive surgery and associated procedures, including internal breast prostheses, following
a mastectomy, regardless of when the mastectomy was performed.
Members will be covered for all stages of reconstruction on the non - diseased breast to make it
equivalent in size with the diseased breast.
Complications of covered mastectomy services, including lymphedemas, are covered.
Excluded: cosmetic services, including treatment for complications resulting from cosmetic surgery,
and complications of noncovered surgical services.
E. Home Health Care Services. Home health care services, as set forth in this section, shall be covered
when Authorized in advance and provided by a GHC Provider for Members who meet the following
criteria:
1. The Member is unable to leave home due to his/her health problem or illness. Unwillingness to
travel and/or arrange for transportation does not constitute inability to leave the home.
2. The Member requires intermittent skilled home health care services, as described below.
3. A GHC Provider has determined that such services are Medically Necessary and are most
appropriately rendered in the Member's home.
For the purposes of this section, "skilled home health care" means reasonable and necessary care for
the treatment of an illness or injury which requires the skill of a nurse or therapist, based on the
complexity of the service and the condition of the patient and which is performed directly by an
appropriately licensed professional provider.
Covered Services for home health care may include the following when rendered pursuant to an
approved home health care plan of treatment: nursing care, physical therapy, occupational therapy,
respiratory therapy, restorative speech therapy, durable medical equipment and medical social worker
and limited home health aide services. Home health services are covered on an intermittent basis in the
{ . Member's home. "Intermittent" means care that is to be rendered because of a medically predictable
recurring need for skilled home health care services.
Excluded: convalescent care, custodial care and maintenance care, private duty or continuous nursing
care in the Member's home, housekeeping or meal services, care in any nursing home or convalescent
facility, any care provided by or for a member of the patient's family and any other services rendered in
the home which do not meet the definition of skilled home health care above or are not specifically
listed as covered under the Agreement.
F. Hospice Care. Hospice care is covered in lieu of curative treatment for terminal illness for Members
who meet all of the following criteria:
• A GHC Provider has determined that the Member's illness is terminal and life expectancy is six
(6) months or less.
• The Member has chosen a palliative treatment focus (emphasizing comfort and supportive services
rather than treatment aimed at curing the Member's terminal illness).
• The Member has elected in writing to receive hospice care through GHC's Hospice Program or
GHC's approved hospice program.
• The Member has available a primary care person who will be responsible for the Member's home
care.
• A GHC Provider and GHC's Hospice Director, or his/her designee, have determined that the
Member's illness can be appropriately managed in the home.
Hospice care shall mean a coordinated program of palliative and supportive care for dying Members
by an interdisciplinary team of professionals and volunteers centering primarily in the Member's home.
1. Covered Services. Care may include the following as prescribed by a GHC Provider and rendered
pursuant to an approved hospice plan of treatment:
C32810- 1323400a 21
a. Home Services
i. Intermittent care by a hospice interdisciplinary team which may include services by a
physician, nurse, medical social worker, physical therapist, speech therapist, occupational
therapist, respiratory therapist, Iimited services by a Home Health Aide under the
supervision of a Registered Nurse and homemaker services.
ii. Continuous care services in the Member's home when prescribed by a GHC Provider, as
set forth in this paragraph. "Continuous care" means skilled nursing care provided in the
home during a period of crisis in order to maintain the terminally ill Member at home.
Continuous care may be provided for pain or symptom management by a Registered
Nurse, Licensed Practical Nurse or Home Health Aide under the supervision of a
Registered Nurse. Continuous care is covered up to twenty -four (24) hours per day during
periods of crisis. Continuous care is covered only when a GHC Provider determines that
the Member would otherwise require hospitalization in an acute care facility.
b. Inpatient Hospice Services. For short-term care, inpatient hospice services shall be covered
in a facility designated by GHC's Hospice Program or GHC - approved hospice program when
authorized in advance by a GHC Provider and GHC's Hospice Program or GHC- approved
hospice program.
Inpatient respite care is covered for a maximum of five (5) consecutive days per occurrence in
order to continue care for the Member in the temporary absence of the Member's primary care
giver(s).
c. Other covered hospice services may include the following:
i. Drugs and biologicals that are used primarily for the relief of pain and symptom
management _
, ii. Medical appliances and supplies primarily for the relief of, pain and symptom
management.
iii. Durable:medical. equipment.
iv. Counseling servicesforithe Member and his/her primary care - giver(s).
v. Bereavement counseling services for the family.
2. Hospice Exclusions. All services not specifically listed as covered in this�section are excluded,
including:
a. Financial or legal counseling services.
b. Meal services.
c. Custodial or maintenance care in the home or on an inpatient basis, except as provided above.
d. Services.not specifically listed as covered by the Agreement.
e. Any services provided by members of the patient's family.
f. Convalescent care.
G. Rehabilitation Services.
1. Rehabilitation services are covered as set forth in this section, limited to the.following: physical
therapy; occupational therapy;-massage therapy and speech therapy to restore function following
illness, injury or surgery. Services are subject to all terms,, conditions and limitations of the
Agreement, including the following:
a. All services must be provided at a GHC or GHC - approved rehabilitation facility and require a
prescription from a GHC physician and must be provided by a GHC- approved rehabilitation
team that includes a physician, nurse, physical therapist, occupational therapist, massage
therapist and speech therapist.
b. Services are limited to those necessary to restore or improve fimctional abilities when
physical, sensori - perceptual and/or communication impairment exists due to injury, illness or
surgery. Such services are provided only when GHC's Medical Director, or his/her designee,
C32810- 1323400a 22
determines that significant, measurable improvement to the Member's condition can be
expected within a sixty (60) day period as a consequence of intervention by covered therapy
services described in paragraph a., above.
Coverage for inpatient and outpatient services is limited to the Allowance set forth in the
Allowances Schedule.
Excluded: specialty treatment programs such as cardiac rehabilitation; inpatient Residential
Treatment services; specialty rehabilitation programs not provided by GHC; long -term
rehabilitation programs; physical therapy, occupational therapy and speech therapy services when
such services are available (whether application is made or not) through programs offered by
public school districts; therapy for degenerative or static conditions when the expected outcome is
primarily to maintain the Member's level of functioning (except as set forth in subsection 2.
below); recreational, life- enhancing, relaxation or palliative therapy; implementation of home
maintenance programs; programs for treatment of learning problems; any services not specifically
included as covered in this section; and any services that are excluded under Section V.
2. Neurodevelopmentai Therapies for Children Age Six (6) and Under. Physical therapy,
occupational therapy and speech therapy services for the restoration and improvement of function
for neurodevelopmentally disabled children age six (6) and under shall be covered. Coverage
includes maintenance of a covered Member in cases where significant deterioration in the
Member's condition would result without the services. Coverage for inpatient and outpatient
services is limited to the Allowance set forth in the Allowances Schedule.
Excluded: inpatient Residential Treatment services; specialty rehabilitation programs not provided
by GHC, including "behavior modification programs"; long -term rehabilitation programs;
physical therapy, occupational therapy and speech therapy services when such services are
available (whether application is made or not) through programs offered by public school districts;
recreational, life- enhancing, relaxation or palliative therapy; implementation of home maintenance
programs; programs for treatment of learning problems; any services not specifically. included as
covered in this section; and any services that are excluded under Section V.
, H. - Devices, Equipm'ent'and Supplies.
1. Orthopedic Appliances. Orthopedic appliances, which are attached to an impaired body segment
..for the purpose of protecting the segment or assisting in restoration or improvement of its
function.
Excluded: arch supports, including custom shoe modifications or inserts and their fittings except
for therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease; and
orthopedic shoes that are not attached to an appliance.
2. Ostomy Supplies. Ostomy supplies for the removal of bodily secretions or waste through an
artificial opening.
3. Durable Medical Equipment. Durable medical equipment is equipment which can withstand
repeated use, is primarily and customarily used to serve a medical purpose, is useful only in the
presence of an illness or injury and used in the Member's home. Durable medical equipment
includes: hospital beds, wheelchairs, walkers, crutches, canes, glucose monitors, external insulin
pumps, oxygen and oxygen equipment. GHC, in its sole discretion, will determine if equipment is
made available on a rental or purchase basis.
4. Prosthetic Devices. Prosthetic devices are items which replace all or part of an external body part,
or function thereof.
When authorized in advance, repair, adjustment or replacement of appliances and equipment is
covered.
Excluded: take -home dressings and supplies following hospitalization; any other supplies, dressings,
appliances, devices or services which are not specifically listed as covered above; and replacement or
C32810- 1323400a 23
repair of appliances, devices and supplies due to loss, breakage from willful damage, neglect or
wrongful use, or due to personal preference.
I. Tobacco Cessation. When provided through GHC, services related to tobacco cessation are covered,
limited to participation in individual or group counseling; educational materials; and approved
pharmacy products.
J. Drugs, Medicines, Supplies and Devices. This benefit, for purposes of creditable coverage, is
actuarially equal to or greater than the Medicare Part D prescription drug benefit. Eligible Members
who are also eligible for Medicare Part D pharmacy benefits can remain covered under the Agreement
and not be subject to Medicare- imposed late enrollment penalties should they decide to enroll in a
Medicare Part D pharmacy plan at a later date. A Member who discontinues coverage under the
Agreement must meet eligibility'requirements in order to re- enroll.
Legend medications are drugs which have been approved by the Food and Drug Administration (FDA)
and which can, under federal or state law, be dispensed only pursuant to a prescription order. These
drugs, including off -label use of FDA - approved drugs (provided that such use is documented to be
effective in one of the standard reference compendia; a majority of well designed clinical 'trials
published in peer- reviewed medical literature document improved efficacy or safety of the agent over
standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health
and Human Services), contraceptive drugs and devices, diabetic supplies, including insulin syringes,
lancets, urine- testing reagents, blood- glucose monitoring reagents and insulin, are covered as set forth
below.
All drugs, supplies, medicines and; devices must be prescribed,by a GHC provider for conditions
covered by the Agreement, obtained at a GHC- designated pharmacy and, unless approved by GHC in
advance, be listed in the GHC drug fformulary. The,prescription drug, Cost Share, as set forth in the
Allowances Schedule, applies to each thirty (30) day supply.- Cost Shares for single and multiple thirty
(30) day supplies of a given prescription are payable at. the time of delivery. Injectables that can be
self - administered are also subject to the prescription drug'Cost Share. Drug formulary (approved drug
list) is defined as a list of preferred pharmaceutical products, supplies and devices developed and
maintained by GHC. A limited supply of prescription drugs obtainedtata non- GHCipharmacy is
covered when dispensed or prescribed in connection with covered Emergency treatment.
Generic drugs will be dispensed whenever available. Brand name drugs will be dispensed if there is
not a generic equivalent. In the event the Member elects to purchase brand -name drugs instead of the
generic equivalent (if available), or if the Member elects to purchase a different brand -name or generic
drug than that prescribed sby the Member's Provider, and it is not determined to, be Medically
Necessary, the Member will also, be to payment of the additional amount above the applicable
pharmacy Cost Share set forth in the Allowances Schedule. A generic drug is defined as a drug_ that is
the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been
approved by'the Food and Drug Administration as meeting the same standards of safety., =purity,
strength and effectiveness as the brand name drug. A brand name drug is defined as a prescription drug
that has been patented and is only available through one manufacturer.
"Standard-reference compendia'? nears the American Hospital Formulary Service -Drug Information;
the American Medical Association iDrug Evaluation; the United States Pharmacopoeia -Drug
Information, or other authoritative compendia'as identified from'time to time by the federal secretary
of Health and Human Services. "Peer- reviewed medical literature" means scientific studies printed in
healthcare journals or other publications in which original manuscripts are published only affter having
been critically reviewed for scientific accuracy, validity and reliability by unbiased independent
experts. Peer - reviewed medical literature does not include in -house publications of pharmaceutical
manufacturing companies.
Excluded.' over- the- counterArugs, medicines, supplies and devices not requiring aprescription under
state law or regulations; drugs used in the treatment of sexual dysfunction disorders; medicines and
injections for anticipated illness while traveling; vitamins, including Legend (prescription) vitamins;
any exclusion of drugs, medicines and'injectables, will also exclude their administration.
C32810- 1323400a 24
The Member will be charged for replacing lost or stolen drugs, medicines or devices.
The Member's Right to Safe and Effective Pharmacy Services.
State and federal laws establish standards to assure safe and effective pharmacy services, and to
guarantee Members' right to know what drugs are covered under the Agreement and what coverage
limitations are in the Agreement. Members who would like more information about the drug coverage
policies under the Agreement, or have a question or concern about their pharmacy benefit, may contact
GHC at (206) 9014636 or (888) 9014636.
Members who would like to know more about their rights under the law, or think any services received
while enrolled may not conform to the terms of the Agreement, may contact the Washington State
Office of Insurance Commissioner at (800) 562 -6900. Members who have a concern about the
pharmacists or pharmacies serving them, may call the Washington State Department of Health at (800)
525 -0127.
K Mental Health Care Services. Services that are provided by a mental health practitioner will be
covered as mental health care, regardless of the cause of the disorder.
1. Outpatient Services. Outpatient mental health services place priority on restoring the Member to
his/her level of functioning prior to the onset of acute symptoms or to achieve a clinically
appropriate level of stability as determined by GHC's Medical Director, or his/her designee.
Treatment for clinical conditions may utilize psychiatric, psychological and/or psychotherapy
services to achieve these objectives.
Coverage for each Member is provided according to the outpatient mental health care Allowance
set forth in the Allowances Schedule. Psychiatric medical services, including medical management
and prescriptions, are covered as set forth in Sections N.B. and IV.3.
2. , Inpatient Services. Charges for services described in this section, including psychiatric
- Emergencies resulting in inpatient services, are covered as set forth in the Allowances Schedule.
This benefit shall include coverage for acute treatment and stabilization of psychiatric
Emergencies in GHC - approved hospitals. Coverage for services incurred at non -GHC Facilities
shall exclude any charges that would otherwise be excluded for hospitalization within a GHC
Facility.
Services provided under involuntary commitment statutes shall be covered at facilities approved
by GHC. Services for any involuntary court- ordered treatment program beyond seventy -two (72)
hours shall be covered only if determined to be Medically Necessary by GHC's Medical Director,
or his/her designee.
Coverage for voluntary/involuntary Emergency inpatient psychiatric services is subject to the
Emergency care benefit set forth in Section IV.L., including the twenty -four (24) hour notification
and transfer provisions.
Outpatient electro- convulsive therapy treatment is covered subject to the outpatient surgery Cost
Share.
3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services.
Covered Services are limited to those authorized by GHC's Medical Director, or his/her designee,
for covered clinical conditions for which the reduction or removal of acute clinical symptoms or
stabilization can be expected given the most clinically appropriate level of mental health care
intervention.
Excluded: inpatient Residential Treatment services; learning, communication and motor skills
disorders; mental retardation; academic or career counseling; sexual and identity disorders; and
personal growth or relationship enhancement. Also excluded: assessment and treatment services
that are primarily vocational and academic; court- ordered or forensic treatment, including reports
and summaries, not considered Medically Necessary; work or school ordered assessment and
C32810- 1323400a 25
treatment not considered Medically Necessary; counseling for overeating; specialty treatment
programs such as "behavior modification programs". relationship counseling or phase of life
problems (V code only diagnoses); and custodial care.
Any other services not specifically listed as covered in this section. All other provisions,
exclusions and limitations under the Agreement also apply.
L. Emergency/Urgent Care.
All services are covered subject to the Cost Shares set forth in the Allowances Schedule.
Emergency Care (See Section VIII. for a definition of Emergency.)
1. At a GHC Facility. GHC will cover Emergency care for all Covered Services.
2. At a Non -GHC Facility. Usual, Customary and Reasonable charges for Emergency care for
Covered Services are covered subject to:
a. Payment of the Emergency care Cost Share; and
b. Notification of GHC by way of the GHC Notification Line within twenty -four (24) hours
following inpatient admission, or as soon thereafter as medically possible.
3. Waiver of Emergency Care Cost Share.
a. Waiver for Multiple Injury Accident. If two or more Members in the same Family Unit
require Emergency care as a result of the same accident, coverage for all Members will be
subject to only one (1) Emergency care Copayment. .
b. Emergencies Resulting in an Inpatient Admission. If the,Member is admitted to a GHC
Facility directly from the emergency room, the Emergency care Copayment is waived.
However, coverage will be, subject to the inpatient services Cost Share.
- ma.
4. Transfer and Follow -up Care. If a Member is hospitalized in anon -GHC Facility, GHC reserves
the right to require transfer of,the Member to a GHC Facility, upon consultation between a GHC
Provider and the attending physician. If the Member,refuses to transfer to a GHC Facility, all
further costs incurred during the hospitalization are the responsibility of the Member.
Follow -up care which is a direct result of the Emergency must be obtained from GHC Providers,
unless a GHC Provider has authorized such follow -up care from a non -GHC Provider in advance.
Urgent Care (See Section VIII. for a defmition of Urgent Condition.)
Inside the GHC Service Area, care for Urgent Conditions is covered at GHC medical centers, GHC
urgent care clinics or GHC:Providers'. offices, subject to the applicable Cost Share., Urgent care
received at any hospital emergency department is not covered unless authorized in advance by, a GHC
Provider. Care received at urgent care facilities other than those listed above is only covered for
Emergency services, subject to the applicable Emergency care Cost;Share.:
Outside the GHC Service Area, Usual, Customary and Reasonable charges are covered for Urgent
Conditions received at any medical facility, subject to, the applicable Cost Share.
M. Ambulance Services. Ambulance services are covered as set forth below, provided that the service is
authorized, in advance by a GHC Provider or meets the definition of an Emergency (see Section VIII.).
1. Emergency Transport to any Facility. Each Emergency is covered as set forth in the Allowances
Schedule.
2. Interfacility Transfers. GHC- initiated non - emergent transfers to or from a GHC Facility are
covered as set forth in the Allowances Schedule.
C32810- 1323400a 26
N. Skilled Nursing Facility (SNF). Skilled nursing care in a GHC- approved skilled nursing facility when
full -time skilled nursing care is necessary in the opinion of the attending GHC Provider, is covered as
set forth in the Allowances Schedule.
When prescribed by a GHC Provider, such care may include room and board; general nursing care;
drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility;
and short-term physical therapy, occupational therapy and restorative speech therapy.
Excluded: personal comfort items such as telephone and television, rest cures and custodial,
domiciliary or convalescent care.
Section V. General Exclusions
In addition to exclusions listed throughout the Agreement, the following are not covered:
1. Services or supplies not specifically listed as covered in the Schedule of Benefits, Section IV.
2. Follow -up services related to a non- Covered Service.
3. Complications of non - Covered Services.
4. Services or supplies for which no charge is made, or for which a charge would not have been made if
the Member had no health care coverage or for which the Member is not liable; services provided by a
member of the Member's family.
5. Convalescent or custodial care.
6. Services rendered as a result of work - related injuries, illnesses or conditions, including injuries,
illnesses or conditions incurred as a result of self - employment.
7. Those parts of an examination and associated reports and immunizations required for employment,
unless otherwise noted in Section IV.B., immigration, license, travel or insurance purposes that are not
, deemed Medically Necessary by GHC for early detection of disease.
8.. Services and supplies related to sexual reassignment surgery, such as sex change operations or
transformations and procedures or treatments designed to alter physical characteristics.
9. Diagnostic testing and medical treatment of sterility, infertility and sexual dysfunction, regardless of
origin or cause, unless otherwise noted in Section IV.B.
10. Obesity treatment and treatment for morbid obesity, including any medical services, drugs, supplies or
any bariatric surgery (such as gastroplasty, gastric banding or intestinal bypass), regardless of co-
morbidities, specialty treatment programs such as weight reduction, complications of obesity or any
other Medical Condition, except as set forth in Section W.B.
11. Any services to the extent benefits are "available to the Member as defined herein under the terms of
any vehicle, homeowner's, property or other insurance policy, except for individual or group health
insurance, whether the Member asserts a claim or not, pursuant to medical coverage, medical "no
fault" coverage, Personal Injury Protection coverage or similar medical coverage contained in said
policy. For the purpose of this exclusion, benefits shall be deemed to be "available" to the Member if
the Member is a named insured, comes within the policy definition of insured, or otherwise has the
right to receive benefits under the policy.
The Member and his/her agents must cooperate fully with GHC in its efforts to enforce this exclusion.
This cooperation shall include supplying GHC with information about, or related to, the cause of injury
or illness or the availability of other coverage. The Member and his/her agent shall permit GHC, at
GHC's option, to associate with the Member or to intervene in any action filed against any party
related to the injury. The Member and his/her agents shall do nothing to prejudice GHC's right to
enforce this exclusion. Failure to fully cooperate, including withholding information regarding the
C32810- 1323400a 27
cause of injury or illness or other coverage may result in denial of claims and the Member shall be
responsible for reimbursing GHC for expenses incurred and the value of the benefits provided by GHC
under this Agreement for the care or treatment of the injury or illness sustained by the Member.
If this Agreement is not subject to ERISA and reasonable collections costs (attorney fees and costs)
have been incurred by an attorney for the Injured Person in connection with obtaining recovery under
underinsured or uninsured motor coverage, under certain conditions GHC will not enforce this
exclusion until a reduction from benefits "available" to the Member is made by the amount of an
equitable apportionment of such collection costs between GHC and the Injured Person. This reduction
will be made only if each of the following conditions has been met: (i) GHC receives a list of the fees
and associated costs before settlement and (ii) the Injured Person's attorney's actions were reasonable
and necessary to secure recovery.
12. Services or care needed for injuries or conditions resulting from active or reserve military service,
whether such injuries or conditions result from war or otherwise. This exclusion will not apply to
conditions or injuries resulting from previous military service unless the condition has been determined
by the U.S, Secretary of Veterans Affairs to be a condition or injury incurred during a period of active
duty. Further, this exclusion will not be interpreted to interfere with or preclude - coordination of
benefits under Tri -Care.
13. Services provided by government agencies, except as required by federal or state law.
14. Services covered by the national health plan of any other country.
15. Experimental or investigational services.
GHC consults with GHC's Medical Director and then uses the criteria described below to decide if a
particular service is experimental or investigational.
a. A service is considered experimental or investigational for a Member's condition if anyof the
following statements apply to it the time the service is or will be provided to the Member.
i. The service cannot be legally marketed in the United States- without.the.approval of the Food
and Drug Administration ( "FDA ") and such approval has not been granted.
ii. The service is the subject of a current new drug or new device application on file with the
FDA.
iii. The service is provided as part of a Phase I or Phase II clinical trial, as the experimental or
research arm of a Phase III clinical trial, or in any other manner that is intended to evaluate
the safety, toxicity or efficacy of the service.
iv. The service is provided pursuant to a written protocol or other document that lists an
evaluation of the service's safety, toxicity or efficacy as among its objectives.
v. The service is under continued scientific testing and research concerning the safety, toxicity
or efficacy of services.
vi. The service is provided pursuant to informed consent documents that describe the service as
experimental or investigational, or in other terms that'indicate that the service is
evaluated for its safety, toxicity or efficacy.
vii. The prevailing opinion among experts, as expressed in the published authoritative medical or
scientific literature, is`that (1) the use of such service should be substantially confined to
research settings, or (2) further research is necessary to determine the safety, toxicity or
efficacy of the service.
b. The following sources of information will be exclusively relied upon to determine whether "a
service is experimental or investigational:
L The Member's medical records,
ii. The written protocol(s) or other document(s) pursuant to which the service has been or will be
provided,
iii. Any consent document(s) the Member or Member's representative has executed or will be
asked to execute, to receive the service,
C32810- 1323400a 28
iv. The files and records of the Institutional Review Board (IRB) or similar body that approves or
reviews research at the institution where the service has been or will be provided, and other
information concerning the authority or actions of the IRB or similar body,
v. The published authoritative medical or scientific literature regarding the service, as applied to
the Member's illness or injury, and
vi. Regulations, records, applications and any other documents or actions issued by, filed with or
taken by, the FDA or other agencies within the United States Department of Health and
Human Services, or any state agency performing similar functions.
Appeals regarding GHC denial of coverage can be submitted to the Member Appeal Department, or to
GHC's Medical Director at P.O. Box 34593, Seattle, WA 98124 -1593.
16. Hypnotherapy, and all services related to hypnotherapy.
17. Genetic testing and related services, unless determined Medically Necessary by GHC's Medical
Director, or his/her designee, and in accordance with Board of Health standards for screening and
diagnostic tests, or specifically provided in Section IV.B. Testing for non - Members is also excluded.
18. Routine foot care, except in the presence of a non - related Medical Condition affecting the lower limbs.
19. Autopsy and associated expenses.
Section VI. Grievance Processes for Complaints and Appeals
The grievance processes to express a complaint and appeal a GHC denial of benefits are set forth below.
Filing a Complaint or Appeal
The complaint process is available for a Member to express dissatisfaction about customer service or the
quality or availability of a health service.
The appeals process is available for a Member to seek reconsideration of a denial of benefits.
Complaint Process
Step 1: The Member should contact the person involved, explain his/her concerns and what he /she would
like to have done to resolve the problem. The Member should be specific and make his/her position clear.
Step 2: If the Member is not satisfied, or if he /she prefers not to talk with the person involved, the Member
should call the department head or the manager of the medical center or department where he /she is having
a problem. That person will investigate the Member's concerns. Most concerns can be resolved in this way.
Step 3: If the Member is still not satisfied, he /she should call the GHC Customer Service Center toll free at
(888) 901 -4636. Most concerns are handled by phone within a few days. In some cases the Member will be
asked to write down his/her concerns and state what he /she thinks would be a fair resolution to the problem.
A Customer Service Representative or Member Quality of Care Coordinator will investigate the Member's
concern by consulting with involved staff and their supervisors, and reviewing pertinent records, relevant
plan policies and the Member Rights and Responsibilities statement. This process can take up to thirty (30)
days to resolve after receipt of the Member's written statement.
If the Member is dissatisfied with the resolution of the complaint, he /she may contact the Member Quality
of Care Coordinator or the Customer Service Center.
Appeals Process
The U.S. Department of Health and Human Services has designated the Washington State Office of the
Insurance Commissioner's Consumer Protection Division as the health insurance consumer
ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State
Insurance Commissioner, Consumer Protection Division, P.O. Box 40256, Olympia, WA 98504 -0256 or
toll free at (800) 562 -6900. More information about requesting assistance from the Consumer Protection
C32810- 1323400a 29
Division Office can be found at http ✓/www.insurance. wa.eov/ consumers /liealth/appeaUTable -of-
Contents.shtm
If the Member requests an appeal of a GHC decision denying benefits, GHC will continue to provide
coverage for the disputed benefit pending the outcome of the appeal If the GHC determination stands,
the Member may be responsible for the cost of coverage received during the review period The decision
at the next level of appeal is binding unless other remedies are available under state or federal law. GHC
must provide benefits, including making payment on a claim, pursuant to the final external review
decision without delay, regardless of whether GHC intends to seek judicial review of the external review
decision, and unless or until there is a judicial decision changing the final determination.
Initial Appeal
If the Member wishes to appeal a GHC decision denying benefits, he /she must submit a request for an
appeal either orally or in writing to GHC's Member Appeal Department, specifying why he /she disagrees
with the decision. The appeal must be submitted within 180 days of the denial notice he /sheareceived.
Appeals should be directed to GHC's Member Appeal Department, P.O. Box 34593, Seattle, WA 98124-
1593, toll free (866) 458 -5479.
An Appeal Coordinator will review initial appeal requests. GHC will then notify the Member of its
determination or need for an extension of time within fourteen (14) days of receiving the request for appeal.
Under no circumstances will the review timeframe exceed thirty (30) days without the Member's written
permission.
There is an expedited appeals process in place for cases which meet criteria or where the Member's
provider believes that the standard appeal review process will seriously jeopardize the Member's life,
health or ability to regain maximum function or subject the Member to severe pain that cannot be managed
adequately without the requested care or treatment. The Member can request an expedited appeal in writing
to the above address, or by calling GHC's Member Appeal Department toll free (866) 458 -5479. The
Member's request for an expedited appeal will be processed and a decision issued no later than seventy -two
(72) hours after receipt of sufficient information to determine whether, or to what extent; benefits are
covered or payable under the Agreement. For expedited appeals, the Member has the right toeequest an
appeal through GHC's Member Appeal Department and a review by anwindependent review organization
concurrently.
Next Level of Appeal
If the Member is not satisfied with the decision regarding a GHC denial of benefits, or if GHC fails to
adhere to the requirements of the appeals process, the Member may request a second level review by an
external independent review organization as set forth under subsection A. below. The Member may also
choose to pursue review by an appeal committee prior to requesting a review by an independent review
organization as set forth under subsection B. below. The optional appeal committee review is not a
required step in the appeals process.
A. Request a review by an independent review organization. An independent review organization is not
legally affiliated or controlled by GHC. Once a decision is made through an independent, review
organization; the decision is final and cannot be appealed through GHC. * If the independent review
organization overturns GHC's coverage decision, GHC will promptly comply and notify the Member.
A request for a review by an independent review organization must be made within 180 days after the
date of the initial appeal decision notice, or within, 180 days after the date of a GHC appeal committee
decision notice. GHC will provide the independent review organization all of the Member's case
information within three (3) business days from the date of the request. The Member has five (5)
business days, from the date the Member received notice that the appeal was sent to an IRO, to submit
in writing, directly to the IRO, any additional information to be considered in the review.
The Member may request an expedited external review if the decision regarding a GHC denial of
benefits concerns an admission, availability of care, continued stay, or health care service for which the
Member received emergency services but has not been discharged from a facility; or involves a
medical condition'forwhich the standard review time frame of flirty -five (45) days would
seriously jeopardize the life or health the Member or jeopardize the Member's ability to regain
maximum function. The independent review organization must make its decision to uphold or reverse
C32810- 1323400a 1 30
the decision and notify the Member and GHC of the determination as promptly as possible but within
not more than seventy -two (72) hours after the receipt of the request for expedited external review. If
the notice is not in writing, the independent review organization must provide written confirmation of
the decision within forty -eight (48) hours after the date of the notice of the decision.
For claims involving experimental or investigational treatments, the internal review organization must
ensure that adequate clinical and scientific experience and protocols are taken into account as part of
the external review process.
B. Request an optional hearing by the GHC appeal committee:
The appeal committee hearing is an informal process. The hearing will be conducted within thirty (30)
working days of the Member's request and notification of the appeal committee's decision will be
mailed to the Member within five (5) working days of the hearing.
Members electing the appeal committee maintain their right to appeal further to an independent review
organization as set forth in subsection A. above.
Review by the appeal committee is not available if the appeal request is for an experimental or
investigational exclusion or limitation.
A request for a hearing by the appeal committee must be made within thirty (30) days after the date of
the initial appeal decision notice. The request can be mailed to GHC's Member Appeal Department,
P.O. Box 34593, Seattle, WA 98124 - 1593.*
* If the Member's health plan'is governed by the Employee Retirement Income Security Act, known as
" ERISA" (most employment related health plans, other than those sponsored by governmental entities or
churches — ask employer about plan), the Member has the right to file a lawsuit under Section 502(a) of
ERISA to recover benefits due to the Member under the plan at any point after completion of the initial
appeal process. Members may have other legal rights and remedies available under state or federal law.
Section VII. General Provisions
A. Coordination of Benefits
The coordination of benefits (COB) provision applies when a Member has health care coverage under
more than one plan. Plan is defined below.
The order of benefit determination rules govern the order in which each plan will pay a claim for
benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits
according to its policy terms without regard to the possibility that another plan may cover some
expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan must pay
an amount which, together with the payment made by the primary plan, totals the allowable expense.
In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus
accrued savings.
If the Member is covered by more than one health benefit plan, the Member or the Member's provider
should file all the Member's claims with each plan at the same time. If Medicare is the Member's
primary plan, Medicare may submit the Member's claims to the Member's secondary carrier.
1. Definitions.
a. Plan. A plan is any of the following that provides benefits or services for medical or dental
care or treatment. If separate contracts are used to provide coordinated coverage for Members
of a Group, the separate contracts are considered parts of the same plan and there is no COB
among those separate contracts. However, if COB rules do not apply to all contracts, or to all
benefits in the same contract, the contract or benefit to which COB does not apply is treated
as a separate plan.
C32810- 1323400a 31
1) Plan includes: group, individual or blanket disability insurance contracts and group or
individual contracts issued by health care service contractors or health maintenance
organizations (HMO), closed panel plans or other forms of group coverage; medical care
components of long -term care contracts, such as skilled nursing care; and Medicare or
any other federal governmental plan, as permitted by law.
2) Plan does not include: hospital indemnity or fixed payment coverage or other fixed
indemnity or fixed payment coverage; accident only coverage; specified disease or
specified accident coverage; limited benefit health coverage, as defined by state law;
school accident type coverage; benefits for non - medical components of long -term care
policies; automobile insurance policies required by statute to provide medical benefits;
Medicare supplement policies; Medicaid coverage; or coverage under other federal
governmental plans; unless permitted by law.
Each contract for coverage under subsection 1) or 2) is a separate plan. If a plan has two parts
and COB rules apply only to one of the two, each of the parts is treated as a separate plan.
b. This plan means, in a COB provision, the part of the contract providing the health care
benefits to which the COB provision applies and which may be reduced because of the
benefits of other plans. Any other part of the contract providing health care benefits is
separate from this plan. A contract may apply one COB provision to certain benefits, such as
dental benefits, coordinating only with similar benefits, and may apply another COB
provision to coordinate other benefits.
c. The order of benefit determination rules determine whether this plan is aprimary plan or
secondary plan when the Member has health care coverage under more than one plan.
When this" plan is primary, it determines payment for its benefits first before those of any
other plan without considering any other plan's benefits. When this plan is secondary; it
determines its benefits after those of another plan and must make payment in an amount so
that, when combined with the amount paid by the primary plan, the total benefits paid or
provided by all plans for the claim equal 100% of the total allowable expense for that claim.
This means that when this plan is secondary, it must pay the amount which, when combined
with what the primary plan paid, totals 100% of the allowable expense.,In addition, if this
plan is secondary, it must calculate its savings (its amount paid subtracted from the amount it
would.have paid had it been the primary plan) and record these savings as a benefit reserve
for the covered Member. This reserve must be used by the secondary to pay any
allowable expenses not otherwise paid, that are incurred by the covered person during the
claim determination period.
d. Allowable Expense. Allowable expense is a care expense, coinsurance or copayments
and mithout reduction, for any applicable deductible, that is covered at least in part by; any plan
covering the person. When a -plan provides benefits in the form, of services, the, reasonable
cash value of each service will be _considered an allowable expense and a benefit paid. An
expense that is not covered by any plan covering the Member is not an allowable expense.
The following are examples of expenses that are not allowable expenses:
1) The difference between the cost of a semi- private hospital room and a private hospital
room is not an allowable expense, unless one of the plans provides coverage for private
hospital room expenses.
2) If a Member is covered by two or more plans that compute their benefit payments on the
basis of usual and customary fees or relative value schedule reimbursement method or
other similar reimbursement method, any amount in excess of the highest reimbursement
amount for a specific benefit is not an allowable expense.
3) If a Member is covered by two or more plans that provide benefits or services on the
basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not
an allowable expense.
4) An expense or a portion of an expense that is not covered by any of the plans covering
the person is not an allowable expense.
C32810- 1323400a 1 1 32
e. Closed panel plan is a plan that provides health care benefits to covered persons in the form of
services through a panel of providers who are primarily employed by the plan, and that
excludes coverage for services provided by other providers, except in cases of emergency or
referral by a panel member.
f. Custodial parent is the parent awarded custody by a court decree or, in the absence of a court
decree, is the parent with whom the child resides more than one half of the calendar year
excluding any temporary visitation.
2. Order of Benefit Determination Rules.
When a Member is covered by two or more plans, the rules for determining the order of benefit
payments are as follows:
a. The primary plan pays or provides its benefits according to its terms of coverage and without
regard to the benefits under any other plan.
b. Except as provided below, a plan that does not contain a coordination of benefits provision
that is consistent with this chapter is always primary unless the provisions of both plans state
that the complying plan is primary.
Coverage that is obtained by virtue of membership in a Group that is designed to supplement
a part of a basic package of benefits and provides that this supplementary coverage is excess
3 to any other parts of the plan provided by the Subscriber. Examples include major medical
coverages that are superimposed over hospital and surgical benefits, and insurance type
coverages that are written in connection with a closed panel plan to provide out of- network
benefits.
c.... A plan may consider the benefits paid or provided by another plan in calculating payment of
its benefits only when it is secondary to that other plan.
-d. -Each plan determines its order of benefits using the first of the following rules that apply:
1) Non - Dependent or Dependent. The plan that covers the Member other than as a
Dependent, for example as an employee, member, policyholder, Subscriber or retiree is
the primary plan and the plan that covers the Member as a Dependent is the secondary
plan. However, if the person is a Medicare beneficiary and, as a result of federal law,
Medicare is secondary to the plan covering the Member as a Dependent, and primary to
the plan covering the Member as other than a Dependent (e.g., a retired employee), then
the order of benefits between the two plans is reversed so that the plan covering the
Member as an employee, member, policyholder, Subscriber or retiree is the secondary
plan and the other plan is the primary plan.
2) Dependent child covered under more than one plan. Unless there is a court decree stating
otherwise, when a dependent child is covered by more than one plan the order of benefits
is determined as follows:
a) For a dependent child whose parents are married or are living together, whether or
not they have ever been married:
• The plan of the parent whose birthday falls earlier in the calendar year is the
primary plan; or
• If both parents have the same birthday, the plan that has covered the parent the
longest is the primary plan.
b) For a dependent child whose parents are divorced or separated or not living together,
whether or not they have ever been married:
(1) If a court decree states that one of the parents is responsible for the dependent
child's health care expenses or health care coverage and the plan of that parent
has actual knowledge of those terms, that plan is primary. This rule applies to
C32810- 1323400a 33
claim determination periods commencing after the plan is given notice of the
court decree;
(2) If a court decree states one parent is to assume primary financial responsibility
for the dependent child but does not mention responsibility for health care
expenses, the plan of the parent assuming financial responsibility is primary;
(3) If a court decree states that both parents are responsible for the dependent
child's health care expenses or health care coverage, the provisions of a) above
determine the order of benefits;
(4) If a court decree states that the parents have joint custody without specifying
that one parent has responsibility for the health care expenses or health care
coverage of the dependent child, the provisions of subsection a) above determine
the order of benefits; or
(5) If there is no court decree allocating responsibility for the dependent child's
health care expenses or health care coverage, the order of benefits for the child
are as follows:
• The plan covering the custodial parent; first;
• The plan covering the spouse of the custodial parent, second;
• The plan covering the non - custodial parent, third; and then
f The plan covering the spouse of the non-custodial parent, last.
c) For a dependent child covered under more than one plan of individuals who are not
the parents of the child, the provisions of subsection a) or b) above determine the
order of benefits as if those individuals were the parents of the child.
3) Active employee or retired or laid -off employee. The. plan that covers a Member as an
active employee, that is, an employee who is neither laid off nor retired, is the primary
plan. The plan covering that same Member as a retired or laid off employee is the
secondary plan. The same would hold true if a Member is a Dependent of an active
employee and that same Member is a Dependent of a retired or laid -off employee. If the
other plan does not have this rule, and as a result, the do not agree on the order of
benefits, this rule is ignored. This rule does not apply if the rule under section d 1) can
determine the order of benefits.
4) COBRA or State Continuation Coverage. If a Member'whose coverage is provided under
COBRA or under a right of continuation provided by state or other federal law is covered
under another plan, the plan covering the Member as an employee, member, Subscriber
or retiree or covering the: Member as a Dependent of an employee; member, Subscriber or
retiree is the primary plan and the COBRA of state or other federal continuation coverage
is the secondary plan. If the other plan does not have this rule, `and as a'result, the plans
do not agree on the order of Benefits, this rule is ignored. This rule does' not apply if the
rule under semion'd'1) can determine the of benefits.
5) Longer or shorter length of coverage:'The plan that covered the Member as an employee,
member, Subscriber or retiree longer is the primary plan and the plan that covered the
'Member the shorter period of time is the secondary plan.
6) If the preceding rules do not determine the order of benefits, the allowable expenses must
be shared equally between the plans meeting the definition of plan. In addition, this plan
will not pay more than it would have paid had it been the primary plan:
3. Effect on the Benefits of this Plan:
When this plan is secondary, it must make payment in an amount so that, when combined with the
amount paid by the primary plan, the total benefits paid or provided' by all plans for the claim
equal one hundred percent of the total allowable expense for that claim. However, in no event
shall the secondary plan be required to pay an amount in excess of its maximum benefit plus
accrued savings. In no event should the Member be responsible for a deductible amount greater
than the highest of the two deductibles. Total allowable expense is the highest allowable expenses
of the primary plan or the secondary plan. In addition, the secondary plan must credit to its plan
C32810- 1323400a 34
deductible any amounts it would have credited to its deductible in the absence of other health care
coverage.
4. Right to Receive and Release Needed Information.
Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable under this plan and other plans. GHC may get the facts it needs from or
give them to other organizations or persons for the purpose of applying these rules and
determining benefits payable under this plan and other plans covering the Member claiming
benefits. GHC need not tell, or get the consent of, any Member to do this. Each Member claiming
benefits under this plan must give GHC any facts it needs to apply those rules and determine
benefits payable.
5. Facility of Payment.
If payments that should have been made under this plan are made by another plan, GHC has the
right, at its discretion, to remit to the other plan the amount it determines appropriate to satisfy the
intent of this provision. The amounts paid to the other plan are considered benefits paid under this
plan. To the extent of such payments, GHC is fully discharged from liability under this plan.
6. Right of Recovery.
GHC has the right to recover excess payment whenever it has paid allowable expenses in excess of
the maximum amount of payment necessary to satisfy the intent of this provision. GHC may
recover excess payment from any person to whom or for whom payment was made or any other
issuers or plans.
Questions about Coordination of Benefits? Contact the State Insurance Department.
7. Effect of Medicare.
Medicare primary/secondary payer guidelines and regulations will determine primary/secondary
payer status, and will be adjudicated by GHC as set forth in this section. When Medicare, Part A
and Part B or Part C are primary, Medicare's allowable amount is the highest allowable expense.
When GHC renders care to a Member who is eligible for Medicare benefits, and Medicare is
deemed to be the primary bill payer under Medicare secondary payer guidelines and regulations,
GHC will seek Medicare reimbursement for all Medicare covered services.
B. Subrogation and Reimbursement Rights
The benefits under this Agreement will be available to a Member for injury or illness caused by
another party, subject to the exclusions and limitations of this Agreement. If GHC provides benefits
under this Agreement for the treatment of the injury or illness, GHC will be subrogated to any rights
that the Member may have to recover compensation or damages related to the injury or illness and the
Member shall reimburse GHC for all benefits provided, from any amounts the Member received or
is entitled to receive from any source on account of such injury or illness, whether by suit,
settlement or otherwise. This section VII.B. more fully describes GHC's subrogation and
reimbursement rights.
"Injured Person" under this section means a Member covered by the Agreement who sustains an injury
or illness and any spouse, dependent or other person or entity that may recover on behalf of such
Member, including the estate of the Member and, if the Member is a minor, the guardian or parent of
the Member. When referred to in this section, "GHC's Medical Expenses" means the expenses
incurred and the value of the benefits provided by GHC under this Agreement for the care or treatment
of the injury or illness sustained by the Injured Person.
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal liability
against the third party and/or payment by the third party to the Injured Person and/or a settlement
between the third party and the Injured Person, GHC shall have the right to recover GHC's Medical
C32810- 1323400a 35
Expenses from any source available to the Injured Person as a result of the events causing the injury,
including but not limited to funds available through applicable third party liability coverage and
uninsured/underinsured motorist coverage. This right is commonly referred to as "subrogation." GHC
shall be subrogated to and may enforce all rights of the Injured Person to the full extent of GHC's
Medical Expenses.
GHC's subrogation and reimbursement rights shall be limited to the excess of the amount required to
fully compensate the Injured Person for the loss sustained, including general damages.
Subject to the above provisions, if the Injured Person is entitled to or does receive money from any
source as a result of the events causing the injury or illness, including but not limited to any liability
insurance or uninsured/underinsured motorist funds, GHC's Medical Expenses are secondary, not
primary.
The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect GHC's
Medical Expenses. This cooperation - includes, but is not limited to, supplying GHC with"information
about the cause of injury or illness; any potentlally liable third parties defendants and/or insurers
related to the Injured Person's claim and informing GHC of any settlement or other payments relating
to the Injured Person's injury. The Injured Person and his/her agents shall permit GHC, at GHC's
option, to associate with the Injured Person or to intervene in any legal, quasi - legal, agency or any
other action or claim filed. If the Injured Person takes no action to recover money from any source,
then the Injured Person agrees to allow GHC to initiate its own direct action for reimbursement or
subrogation.
The Injured Person and his/her agents shall do nothing to prejudice GHC's subrogation and
reimbursement rights. The Injured Person shall promptly notify GHC of any tentative settlement with a
third party and shall not settle a claim without protecting GHC's interest. If the Injured Person fails to
cooperate fully with GHC in recovery of GHC's Medical Expenses, the Injured Person shall be
responsible for directly reimbursing GHC for 100% of GHC's Medical Expenses.
To the extent that the Injured Person recovers funds from any source that may serve to compensate for
medicalinjuries or medical expenses, the Injured Personagreesto hold such monies in trust or4n a
separate identifiable account until GHC's subrogation and reimbursement =rights are fully determined
and that GHClhas an equitable 'lien over such monies to the full extent of GHC's Medical Expenses
and/or the Injured Person agrees to serve as constructive trustee over the monies to the extent of
GHC's Medical Expenses.
If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an
attorney for the Injured Person in connection with obtaining recovery, under certain conditions GHC
will reduce the amount of reimbursement to GHC by the amount of an equitable apportionment - of such
collection costs between GHC and the Injured Person. This reduction will be made only if each of the
following conditions has been met: (iyGHCreceives -a list of thefees and, associated costs before
settlement and the IfijuredPerson's attorney's actions were reasonable and necessary to secure
recovery.
If this Agreement 'is subject to -ERISA and reasonable collections costs have been incurred by the
injured Person for the benefit'of GHC, under special circumstances, the Injured Person may request
and GHC may agree to reduce the amount of reimbursement to GHC by an amount for'reasonable -and
necessary attorney's fees and costs incurred by the Injured Person on behalf of and for the benefit of
GHC, but only if such amount is agreed to in writing by GHC prior to settlement or recovery.
To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by
ERISA, implementation of this section shall be deemed a part of claims administration under the
Agreement and GHC shall therefore have discretion to interpret its terms.
C. Miscellaneous Provisions
1. Identification Cards. GHC will furnish cards, for identification purposes only, to all Members
enrolled under the Agreement.
C32810- 1323400a 36
2. Administration of Agreement. GHC may adopt reasonable policies and procedures to help in the
administration of the Agreement. This may include, but is not limited to, policies or procedures
pertaining to benefit entitlement and coverage determinations.
3. Modification of Agreement. No oral statement of any person shall modify or otherwise affect the
benefits, limitations and exclusions of the Agreement, convey or void any coverage, increase or
reduce any benefits under the Agreement or be used in the prosecution or defense of a claim under
the Agreement.
4. Confidentiality. GHC and the Group shall keep Member information strictly confidential and
shall not disclose any information to any third party other than: (i) representatives of the receiving
party (as permitted by applicable state and federal law) who have a need to know such information
in order to perform the services required of such party pursuant to the Agreement, or for the proper
management and administration of the receiving party, provided that such representatives are
informed of the confidentiality provisions of the Agreement and agree to abide by them, (ii)
pursuant to court order or (iii) to a designated public official or agency pursuant to the
requirements of federal, state or local law, statute, rule or regulation.
5. Nondiscrimination. GHC does not discriminate on the basis of physical or mental disabilities in
its employment practices and services.
D. Utilization Management
All benefits under the Agreement are limited to Covered Services that are Medically Necessary
..and set forth in Section IV.. GHC may review a Member's medical records for the purpose of
verifying delivery and coverage of services and items. Based on a prospective, concurrent or
retrospective review, GHC may deny coverage if, in its determination, such services are not
Medically Necessary. Such determination shall be based on established clinical criteria.
GHC will not deny coverage retroactively for services it has previously authorized and which
have already been provided to the Member.
Section W-III: Definitions
Agreement: The Medical Coverage Agreement between GHC and the Group.
Allowance: The maximum amount payable by GHC for certain Covered Services under the Agreement, as
set forth in the Allowances Schedule.
Authorization: An approval by GHC that entitles a Member to receive Covered Services from a specified
health care provider. Services shall not exceed the limits of the Authorization and are subject to all terms
and conditions of the Agreement Members who have a complex or serious medical or psychiatric
condition may receive a standing Authorization for specialist services.
Contracted Network Pharmacy: A pharmacy that has contracted with GHC to provide covered legend
(prescription) drugs and medicines for outpatient use under the Agreement.
Copayment: The specific dollar amount a Member is required to pay at the time of service for certain
Covered Services under the Agreement, as set forth in the Allowances Schedule.
Cost Share: The portion of the cost of Covered Services the Member is liable for under the Agreement.
Cost Shares for specific Covered Services are set forth in the Allowances Schedule. Cost Share includes
Copayments, coinsurances and/or Deductibles.
Covered Services: The services for which a Member is entitled to coverage under the Agreement.
Deductible: A specific amount a Member is required to pay for certain Covered Services before benefits
are payable under the Agreement. The applicable Deductible amounts are set forth in the Allowances
Schedule.
C32810- 1323400a 37
Dependent: Any member of a Subscriber's family who meets all applicable eligibility requirements, is
enrolled hereunder and for whom the premium prescribed in the Premium Schedule has been paid.
Emergency: The emergent and acute onset of a symptom or symptoms, including severe pain, that would
lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate
medical attention, if failure to provide medical attention would result in serious impairment to bodily
function or serious dysfunction of a bodily organ or part, or would place the Member's health, or if the
Member is pregnant, the health of her unborn child, in serious jeopardy.
Essential Health Benefits: Benefits set forth under the Patient Protection and Affordable Care Act of
2010, including the categories of ambulatory patient services, emergency services, hospitalization,
maternity and newborn care, mental health and substance use disorder services, including behavioral health
treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services,
preventive and wellness services and chronic disease management and pediatric services, including oral
and vision care.
Family Unit: A Subscriber and all his/her Dependents.
Fee Schedule. A fee- for - service schedule adopted by GHC, setting forth the fees for medical and hospital
services.
GHC - Designated Specialist: A GHC specialist specifically identified by GHC.
GHC Facility: A facility (hospital, medical center or health care center) owned, operated or otherwise
designated by GHC.
GHC Personal Physician: A provider who is employed by or contracted=with GHC to provide primary
care services to Members and is selected by each Member to provide or arrange for the provision of all
non - emergent Covered Services, except for services set forth in the Agreement which a Member can access
without an Authorization. Personal Physicians must be capable of and licensed to provide the majority of
primary health care services required by each Member. `
GHC Provider: The medical staff, clinic associate staff and allied health professionals employed by GHC,
and any other health care professional or provider with whom GHC has contracted to provide health care
services to Members enrolled under the Agreement, including, but not limited to physicians, podiatrists,
nurses, physician assistants, social workers, optometrists, psychologists, physical therapists and other
professionals engaged in the delivery of healthcare services who are licensed or certified to practice in
accordance with Title 18 Revised Code of Washington.
Group: An employer, union, welfare trust or bona -fide association which has:entered into a -Group Medical
Coverage Agreement with GHC.
Hospital Care: Those Medically Necessary services, generally provided by acute general hospitals for
admitted patients. Hospital Care does not include convalescent or custodial care, which can, in the opinion
of the ;GHC; Provider; be provided by a• nursing home or convalescent care center.
Lifetime Maximum: The maximum value of benefits provided for Covered Services under the Agreement
after which benefits under the Agreement are no longer available as set forth in the Allowances Schedule.
The value of Covered Services is based on the Fee Schedule, as defined above. The lifetime maximum
applies to this Agreement or in combination with any other medical coverage agreement between GHC and
Group.
Medical Condition: A disease, illness or injury.
Medically Necessary: Appropriate and clinically necessary services, as determined by GHC's Medical
Director, or his/her designee, according to generally accepted principles of good medical practice, which
are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the
standards set forth below. In order to be Medically Necessary, services and supplies -must meet the
following requirements: (a) are not solely for the convenience of the Member, his/her family or the
provider of the services or supplies; (b) are the most appropriate level of service or supply which can be
C32810- 1323400a 38
safely provided to the Member; (c) are for the diagnosis or treatment of an actual or existing Medical
Condition unless being provided under GHC's schedule for preventive services; (d) are not for recreational,
life - enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are
appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in
the State of Washington, could not have been omitted without adversely affecting the Member's condition
or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a
provider's office, the outpatient department of a hospital or a non - residential facility without affecting the
Member's condition or quality of health services rendered; (g) are not primarily for research and data
accumulation; and (h) are not experimental or investigational. The length and type of the treatment program
and the frequency and modality of visits covered shall be determined by GHC's Medical Director, or
his/her designee. In addition to being medically necessary, to be covered, services and supplies must be
otherwise included as a Covered Service as set forth in Section IV. of the Agreement and not excluded
from coverage. The cost of non - covered services and supplies shall be the responsibility of the Member.
Medicare: The federal health insurance program for the aged and disabled.
Member: Any Subscriber or Dependent enrolled under the Agreement.
Out -of- Pocket Expenses: Those Cost Shares paid by the Subscriber or Member for Covered Services
which are applied to the Out -of- Pocket Limit.
Out -of- Pocket Limit: The maximum amount of Out -of- Pocket Expenses incurred and paid during the
calendar year for Covered Services received by the Subscriber and his/her Dependents within the same
calendar year. The Out -of- Pocket Limit amount and Cost Shares that apply are set forth in the Allowances
Schedule. Charges in excess of UCR, services in excess of any benefit level and services not covered by the
Agreement are not applied to the Out -of- Pocket Limit.
Plan Coinsurance: The percentage amount the Member and GHC are required to pay for Covered Services
received under the Agreement. Percentages for Covered Services are set forth in the Allowances Schedule.
A coinsurance percentage not identified as Plan Coinsurance is a benefit specific coinsurance and does not
apply to the Out -of- Pocket Limit except as otherwise specified under Section II.Out of- Pocket Limit.
Pre- Existing Condition: A condition for which there has been diagnosis, treatment or medical advice
within the three (3) month period prior to the effective date of coverage. The Pre - Existing Condition wait
period will begin on the first day of coverage, or the first day of the enrollment waiting period if earlier.
Residential Treatment: A term used to define facility-based treatment, which includes twenty-four (24)
hours per day, seven (7) days per week rehabilitation. Residential Treatment services are provided in a
facility specifically licensed in the state where it practices as a residential treatment center. Residential
treatment centers provide active treatment of patients in a controlled environment requiring at least weekly
physician visits and offering treatment by a multi - disciplinary team of licensed professionals.
Service Area: Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis,
Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman and
Yakima; Idaho counties of Kootenai and Latah; and any other areas designated by GHC.
Subscriber: A person employed by or belonging to the Group who meets all applicable eligibility
requirements, is enrolled under the Agreement and for whom the premium specified in the Premium
Schedule has been paid.
Urgent Condition: The sudden, unexpected onset of a Medical Condition that is of sufficient severity to
require medical treatment within twenty-four (24) hours of its onset.
Usual, Customary and Reasonable (UCR): A term used to define the level of benefits which are payable
by GHC when expenses are incurred from a non -GHC Provider. Expenses are considered Usual,
Customary and Reasonable if the charges are consistent with those normally charged to others by the
provider or organization for the same services or supplies; and the charges are within the general range of
charges made by other providers in the same geographical area for the same services or supplies.
C32810- 1323400a 39
PR F. MTT IM ,vrmF. n T IT. F.
Group Name
City of Federal Wa
Group Number rims
1323400
GROUP HEALTH COOPERATIVE- Group Health benefit description
Inside the Network: Managed Care Providers
Coinsurance
None
Deductible
None
Emergency Co pay
$501$50
Family Ded &c OOP Max
2x
Hospital Inpatient Co pay
$100 co a / er day for up to 4 days
Office Visit Co pay
$10
O tical Rider
Not covered
Out Of Pocket
$2000
Outpatient Surgery Co pay
Same as OV
Prescription Drug Co pay
$10
No PEC Wait
Group Offer in g Sole Carrier
MONTHLY REAL THCARE PREMIUM
This Schedule rejZectsfromr 0110112012 to 0110112013
Subscriber
$450.95
Subscriber and Spouse
$901.90
Subscriber and 1 Child
$679.32
Subscriber and 2+ Children
$907.69
Subscriber Spouse and 1 Child
$1,130.27
Subscriber Spouse and 2+ Children
$1,359.64
0
GroupHealthm
Group Medical Coverage Agreement
Group Health Options, Inc. (also referred to as "GHO ") is a Health Care Service Contractor, duly registered under
the laws of the State of Washington, furnishing health care coverage on a prepayment basis. The Group identified
below wishes to purchase such coverage. This Agreement sets forth the terms under which that coverage will be
provided, including the rights and responsibilities of the contracting parties; requirements for enrollment and
eligibility; and benefits to which those enrolled under this Agreement are entitled.
The Agreement between GHO and the Group consists of the following:
• Standard Provisions
• Attached Benefit Booklet
• Signed Group application
• Premium Schedule
Group Health Options, Inc.
Title: President
�7
City of Federal Way, 5685300
Title:
This Agreement will continue in effect until terminated or renewed as herein provided for and is
effective January 1, 2012.
CA41612, CA- 351212
0
GroupHealth.
Group Medical Coverage Agreement
Group Health Options, Inc. (also referred to as "GHO ") is a Health Care Service Contractor, duly registered under
the laws of the State of Washington, furnishing health care coverage on a prepayment basis. The Group identified
below wishes to purchase such coverage. This Agreement sets forth the terms under which that coverage will be
provided, including the rights and responsibilities of the contracting parties; requirements for enrollment and
eligibility; and benefits to which those enrolled under this Agreement are entitled.
The Agreement between GHO and the Group consists of the following:
• ' Standard Provisions
• Attached Benefit Booklet
• Signed Group application
• Premium Schedule
Title: President
Group Health Options, Inc.
City of Federal Way, 5685300
Signed:
Title:
This Agreement will continue in effect until terminated or renewed as herein provided for and is
effective January 1, 2012.
CA- 41612, CA- 351212
Group Medical Coverage Agreement
Table of Contents
Standard Provisions
Attachment 1 Benefit Booklet
Attachment 2 Premium Schedule
C32811- 5685300 2
Standard Provisions
1. GHO agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group.
2. Monthly Premium Payments. For the initial term of this Agreement, the Group shall submit to GHO for each
Member the monthly premiums set forth in the current Premium Schedule and a verification of enrollment.
Payment must be received on or before the due date and is subject to a grace period of ten (10) days. Premiums
are subject to change by GHO upon thirty (30) days written notice. Premium rates will be revised as a part of
the annual renewal process.
In the event the Group increases or decreases enrollment at least twenty -five percent (25 %) or more, GHO
reserves the right to require re- rating of the Group.
3. Dissemination of Information. Unless the Group has accepted responsibility to do so, GHO will disseminate
information describing benefits set forth in the Benefit Booklet attached to this Agreement.
4. Identification Cards. GHO will furnish cards, for identification purposes only, to all Members enrolled under
this Agreement.
5. Administration of Agreement. GHO may adopt reasonable policies and procedures to help in the
administration of this Agreement. This may include, but is not limited to, policies or procedures pertaining to
benefit entitlement and coverage determinations.
6. Modification of Agreement. Except as required by federal and Washington State law, this Agreement may not
be modified without agreement between both parties.
No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions, of this
Agreement, convey or void any coverage, increase or reduce any benefits under this Agreement or be used in
the prosecution or defense of a claim under this Agreement.
7. Indemnification. GHO agrees to indemnify and hold the Group harmless against all claims, damages, losses
and expenses, including reasonable attorney's fees, arising out of GHO's failure to perform, negligent
performance or willful misconduct of its directors, officers, employees and agents of their express obligations
under this Agreement.
The Group agrees to indemnify and hold GHO harmless against all claims, damages, losses and expenses,
including reasonable attorney's fees, arising out of the Group's failure to perform, negligent performances or
willful misconduct of its directors, officers, employees and agents of their express obligations under this
Agreement.
The indemnifying party shall give the other party prompt notice of any claim covered by this section and
provide reasonable assistance (at its expense). The indemnifying party shall have the right and duty to assume
the control of the defense thereof with counsel reasonably acceptable to the other party. Either party may take
part in the defense at its own expense after the other party assumes the control thereof.
8. Compliance With Law. The Group and GHO shall comply with all applicable state and federal laws and
regulations in performance of this Agreement.
This Agreement is entered into and governed by the laws of Washington State, except as otherwise pre - empted
by ERISA and other federal laws.
4. Governmental Approval. If GHO has not received any necessary government approval by the date when
notice is required under this Agreement, GHO will notify the Group of any changes once governmental
approval has been received. GHO may amend this Agreement by giving notice to the Group upon receipt of
government approved rates, benefits, limitations, exclusions or other provisions, in which case such rates,
benefits, limitations, exclusions or provisions will go into effect as required by the governmental agency. All
C32811- 5685300
amendments are deemed accepted by the Group unless the Group gives GHO written notice of non - acceptance
within thirty (30) days after receipt of amendment, in which event this Agreement and all rights to services and
other benefits terminate the first of the month following thirty (30) days after receipt of non- acceptance.
10. Confidentiality. Each party acknowledges that performance of its obligations under this Agreement may
involve access to and disclosure of data,, procedures, materials, lists, systems and information, including
medical records, employee benefits information, employee addresses, social security numbers, e-mail addresses,
phone numbers and other confidential information regarding the Group's employees (collectively the
"information "). The information shall be kept strictly confidential and shall not be disclosed to any third party
other than: (i) representatives of the receiving party (as permitted by applicable state and federal law) who have
a need to know such information in order to perform the services,required of such party pursuant to this
Agreement, or for the proper management and administration of the receiving party, provided that such
representatives are informed of the confidentiality provisions of this Agreement and agree to abide by them, (ii)
pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of federal,
state or local law, statute, rule or regulation. The disclosing party will provide the other; party with prompt
notice of any request the disclosing party receives to disclose information pursuant to applicable legal
requirements, so that the other party may object to the, request and/or seek an appropriate protective order
against such request. Each party shall maintain the confidentiality of medical records and confidential patient
and employee information as required by applicable law.
11. Arbitration. Any dispute, controversy or difference between GHO and the Group arising out of or relating to
this Agreement, or the breach thereof, shall be settled by arbitration in Seattle, Washington in accordance with
the Commercial Arbitration Rules of the American Arbitration Association, and judgment on the award
rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Except as may be required
by law, neither party nor arbitrator may disclose the existence, content or results of any arbitration hereunder
without the prior written consent of both parties.
12. HIPAA.
Definition of Terms. Terms used, but not otherwise defined, in this Section shall have the same meaning as
those terms, have in the Health Insurance Portability and Accountability, Act of 1996 ( "HIPAA ")..
Transactions Accepted. GHO will accept Standard Transactions, pursuant to HIPAA, if the Group elects to
transmit such transactions. The Group shall ensure that all Standard Transactions transmitted to GHO by the
Group or the Group's business associates are in compliance with HIPAA standards for electronic transactions.
The Group shall indemnify GHO for any breach of this section by the Group.
13. Termination of Entire Agreement: This is a guaranteed renewable Agreement and cannot be terminated
without the mutual approval of each of the parties, except in the circumstances set forth below.
a. Nonpayment or Non - Acceptance ofFremium. Failure to make any monthly premium payment or
contribution in accordance.with 2 above shall result in termination of this Agreement as of the
premium due date. The Group's failure to accept the xevised premiums provided as part of the annual
renewal process shall be.considered nonpayment and result in non- renewal of this Agreement. The. Group
may terminate this Agreement upon fifteen (15) days written notice of premium increase, as set forth in
subsection 2 above.
b. Misrepresentation. GHO may rescind or terminate this Agreement upon written notice in the event that
intentional misrepresentation, fraud or omission of- information was used in order to obtain Group
coverage. Either party may terminate this Agreement in the event of intentional misrepresentation , fraud or
omission of information by the other party in performance of its responsibilities under this Agreement.
c. Underwriting Guidelines. GHO may terminate this Agreement in the event the Group no longer meets
underwriting guidelines established by GHO that were in effect at the time the Group was accepted.
C32811- 5685300 4
d. Federal or State Law. GHO may terminate this Agreement in the event there is a change in federal or state
law that no longer permits the continued offering of the coverage described in this Agreement.
14. Withdrawal or Cessation of Services.
a. GHO may determine to withdraw from a Service Area or from a segment of its Service Area after GHO has
demonstrated to the Washington State Office of the Insurance Commissioner that GHQ's clinical, financial or
administrative capacity to service the covered Members would be exceeded.
b. GHO may determine to cease to offer the Group's current plan and replace the plan with another plan offered
to all covered Members within that line of business that includes all of the health care services covered under
the replaced plan and does not significantly limit access to the services covered under the replaced plan. GHO
may also allow unrestricted conversion to a fully comparable GHO product.
GHO will provide written notice to each covered Member of the discontinuation or non - renewal of the plan at least
ninety (90) days prior to discontinuation.
C32811- 5685300
Dear Group Health Options Subscriber:
This booklet contains important information about your healthcare plan.
This is your 2012 GHO Benefit Booklet (Certificate of Coverage). It explains the services and benefits you and
those enrolled on your contract are entitled to receive from Group Health Options, Inc. Sections of this document
may be bolded and italicized, which identifies changes that Group Health has made to the plan. The benefits
reflected in this booklet were approved by your employer or association who contracts with Group Health Options,
Inc., for your healthcare coverage. If you are eligible for Medicare, please read Section IV.3. as it may affect your
prescription drug coverage.
We recommend you read it carefully so you'll understand -not onlythe benefits, but the exclusions, limitations and
eligibility requirements of this certificate. Please keep this certificate for as long as you are covered by Group Health
Options, Inc. We will send you revisions if there are any changes in your coverage.
This certificate is not the contract itself; you can contact your employer or group administrator if you wish to see a
copy of the contract (Medical Coverage Agreement).
We'll gladly answer any questions you might have about your GHO benefits. Please call our GHO Customer
Service Center at 901 -4636 in the Seattle area, or toll -free in Washington, 1- 888 -901 -4636.
Thank you for choosing Group Health Options. We look forward to working with you to preserve and enhance your
health.
Very truly yours,
Scott Armstrong
President
CA- 416al2, CA- 351212, CA- 312912, CA - 275111, CA- 140312,CA- 108012,CA- 141312,CA- 369812
1
Benefit Booklet
Table of Contents
Section I. Introduction
A. Accessing Care
B. Cost Shares
C. Subscriber's Liability
D. Claims
Section II. Allowances Schedule
Section III.. Eligibility, Enrollment and Termination
A. Eligibility
B. Enrollment
C. Effective Date of Enrollment
D. Eligibility for Medicare
E. Termination of Coverage
F. Services After Termination of Agreement
G. Continuation of Coverage Options
Section IV. Schedule of Benefits
A. Hospital Care
B. Medical and Surgical Care
C. Chemical Dependency Treatment
D. Plastic and Reconstructive Services
E. Home Health Care Services
F. . Hospice Care
G. Rehabilitation Services
H. Devices, Equipment and Supplies
I. Tobacco Cessation
J. Drugs, Medicines, Supplies and Devices
K. Mental Health Care Services
L. Emergency/Urgent Care_
M. Ambulance Services
N. Skilled Nursing Facility
Section V. General Exclusions
Section VI. Grievance Processes for Complaints and Appeals
Section VII. General Provisions
A. Coordination of Benefits
B. Subrogation and Reimbursement Rights
C. Miscellaneous Provisions
D. Utilization Management
Section VIII. Definitions
C32811- 5685300a 2
Section I. Introduction
Group Health Options, Inc. (also referred to as "GHO ") is a Health Care Service Contractor, duly registered under
the laws of the State of Washington, furnishing health care coverage on a prepayment basis.
Read This Benefit Booklet Carefully
This Benefit Booklet is a statement of benefits, exclusions and other provisions, as set forth in the Group Medical
Coverage Agreement ( "Agreement ' ) between GHO and the employer or Group.
A full description of benefits, exclusions, limits and Out -of- Pocket Expenses can be found in the Schedule of
Benefits, Section IV; General Exclusions, Section V; and Allowances Schedule, Section II. These sections must be
considered together to fully understand the benefits available under the Agreement. Words with special meaning are
capitalized. They are defined in Section VIII.
A. Accessing Care
Members are entitled to Covered Services from:
• GHQ's Managed Health Care Network, referred to as "MHCN, ".
• Community Providers or Preferred Community Providers, or
• Qualified worldwide providers (emergentlurgent care only). A qualified worldwide provider is a provider
meeting all applicable licensing and certification requirements established in the state or country where
the provider practices.
Members may choose either health care delivery option at any time during or for differing episodes of illness or
injury, except during a scheduled inpatient admission.
Benefits paid under one option will not be duplicated under the other option.
Under the Agreement, the level of benefits available for services received at the MHCN is generally greater
than the level of benefits available for services received from Community Providers. In order for services to be
covered at the higher benefit level, services must be obtained by MHCN Providers at MHCN Facilities, except
for Emergency care and care pursuant to an Authorization.
All inpatient admissions prescribed by a Community Provider must be authorized in advance by GHO.
Members may refer to Sections IV.A. and N.C. for more information about inpatient admissions.
Primary Care. GHO recommends that Members select a MHCN Personal Physician when enrolling under the
Agreement. One Personal Physician may be selected for an entire family,: or a ; different Personal Physician may
be selected for each family member. A Personal Physician is affiliated with a particular delivery system (for
example, Group Health Cooperative). To receive the maximum level of benefits, the Member must use the
services of specialists within the same delivery system, except for services of MHCN - Designated Specialists. If
an Authorization is not obtained from the MHCN, benefits are paid at the Community Provider level.
Selecting a Personal Physician or changing from one Personal Physician to another can be accomplished by
contacting GHO Customer Service, or accessing the GHO website at www.ghc.org. The change will be made
within twenty-four (24) hours of the receipt of the request, if the selected physician's caseload permits.
A listing of MHCN Personal Physicians, specialists, women's health care providers and MHCN- Designated
Specialists is available by contacting GHO Customer Service at (206) 901 -4636 or (888) 9014636, or by
accessing GHQ's website at www.ghc.org.
C32811- 5685300a 3
In the case that the Member's Personal Physician no longer participates in the MHCN, the Member will be
provided access to the Personal Physician for up to sixty (60) days following a written notice offering the
Member a selection of new Personal Physicians from which to choose.
Specialty Care. Unless otherwise indicated in this section, the Allowances Schedule or Section IV.,
Authorizations are required for specialty care and specialists inside the network.
MHCN- Designated Specialist. Members may make appointments directly with MHCN- Designated Specialists
at Group Health-owned or - operated medical centers without an Authorization from their Personal Physician.
The following specialty care areas are available from MHCN - Designated Specialists: allergy, audiology,
cardiology, chemical dependency, chiropractic /manipulative therapy, dermatology, gastroenterology, general
surgery, hospice, manipulative therapy, mental health, nephrology, neurology, obstetrics and gynecology,
occupational medicine, oncology/hematology, ophthalmology, optometry, orthopedics, otolaryngology (ear,
nose and throat), physical therapy, smoking cessation, speech/language and learning services and urology.
Women's Health Care Direct Access Providers. Female Members may see a participating General and
Family Practitioner, Physician's Assistant, Gynecologist, Certified Nurse Midwife, Licensed Midwife, Doctor
of Osteopathy, Pediatrician, Obstetrician or Advanced Registered Nurse Practitioner who is contracted by GHO
to provide women's health care services directly, without an Authorization from their Personal Physician, for
Medically Necessary maternity care, covered reproductive health services, preventive care (well care) and
general examinations, gynecological care and follow -up visits for the above services. Within the MHCN,
women's health care services are covered as if the Member's Personal Physician had been consulted, subject to
any applicable Cost Shares, as set forth in the Allowances Schedule. Women's health care services obtained
from a Community Provider are covered at the Community Provider benefit level. If the Member's women's
health care provider diagnoses a condition that requires an Authorization to other specialists or hospitalization,
the Member or her chosen provider must obtain prior authorization and care coordination in accordance with
applicable GHO requirements.
Second Opinions. The Member may access, upon request, a second opinion regarding a medical diagnosis or
treatment plan from a MHCN Provider. The Member, or the Member's family, may request an Authorization
from the Member's Personal Physician, or may visit a MHCN - Designated Specialist, for a second opinion.
When second opinions are requested or indicated, they are provided by MHCN Providers and are covered
when authorized in advance, or when obtained from a MHCN- Designated Specialist. Coverage is determined
by the Member's medical coverage plan, therefore, coverage for the second opinion does not imply that the
services or treatments recommended will be covered. An Authorization for a second opinion does not imply
that GHO will authorize the Member to return to the physician providing the second opinion for any
additional treatment. Services, drugs, devices, etc., prescribed or recommended as a result of the consultation
are not covered unless included as covered under this Agreement. The Member may also access a second
opinion from a Community Provider, subject to the Community Provider benefit level.
Emergent and Urgent Care. Members, or persons assuming responsibility for a Member must notify GHO by
way of the GHO Emergency Notification Line within twenty-four (24) hours of any admission. Members may
refer to Section IV. for more information about coverage of Emergency services under the MHCN and
Community Provider options.
Under the MHCN option, urgent care is covered at MHCN medical centers, MHCN urgent care clinics or
MHCN Provider's offices. Urgent care received at any hospital emergency department is not covered unless
authorized in advance GHO. Members may refer to Section IV. for more information about coverage of urgent
care services.
Under the Community Provider option, urgent care is covered at any medical facility. Members may refer to
Section IV. for more information about coverage of urgent care services.
Recommended Treatment. Under the MHCN option, GHQ's Medical Director, or his/her designee will
determine the necessity, nature and extent of treatment to be covered under the MHCN benefit in each
individual case and the judgment, made in good faith, will be final.
C32811- 5685300a 4
Members have the right to participate in decisions regarding their health care. A Member may refuse any
recommended treatment or diagnostic plan to the extent permitted by law. Members who obtain care not
recommended by GHO, do so with the full understanding that such care will not be covered at the MHCN
benefit level. Coverage decisions may be appealed as set forth in Section VI.
Major Disaster or Epidemic. In the event of a major disaster or epidemic, GHO will pay benefits for Covered
Services through the MHCN according to GHO's best judgment, within the limitations of available MHCN
Facilities and personnel. GHO has no liability for delay or failure to provide or arrange Covered Services to the
extent facilities or personnel are unavailable due to a major disaster or epidemic.
Unusual Circumstances. Under the MHCN option, if the provision of Covered Services is delayed or rendered
impossible due to unusual circumstances such as complete or partial.destruction of MHCN Facilities, military
action, civil disorder, labor disputes or similar causes, GHO shall ensure that its MHCN provide and arrange for
services that, in the reasonable opinion of GHQ's Medical Director, or his/her designee, are emergent or
urgently needed. In regard to nonurgent and routine services, GHO shallmake a,good faith effort to makethe
then - existing MHCN Facilities and personnel available. The MHCN shall have the option to defer or reschedule
services that are not urgent while its facilities and services are so affected. In no case shall GHO have any
liability or obligation on account of delay or,failure to provide. or arrange such services.
Under the Community Provider option, if the,provision of Covered Services is delayed or rendered impossible
due -to unusual circumstances such as military action, civil disorder, labor disputes, or similar causes, in no case
shall GHO have anyliability or obligation on account of delay.
B.. Cost Shares
The Subscriber shall be liable for the following Cost Shares when services are received ,by the Subscriber and
any of his/her Dependents.
1. .;Copayments. Members shall mquired;o pay,Copayments:at the time of service as set forth in,the
Allowances Schedule. Payment of a Co payment doe s- not,exclude.the possibility. of antional billing if
the service is determined to be anon - Coveted Service.
2. , Annu al, Deductible. Covered Services,received from Community Provider are subject to the annual
Deductible as.set forth, in the Allowances Schedule.
Charges, subject to the annual. Deductible shall be borne by the Subscriber during each calendar year until
,.the, annualDeductible is met.
There is an individual annual Deductible amount for each Member and a maximum aggregate annual
Deductible amount for each Family- Unit.,Once.the,aggregate. annual Deductible amount is reached, for a
Family in a calendar year, the individual,a_nnual Deductibles are also deemed reache&for each
Member during thatsame calendaryear.
3. Individual Annual Deductible Carryover. Under this Agreement charges from the last three (3) months
of the prior year which were applied toward the individual: annual Deductible will also apply to the current
year , individual annual Deductible. The individual`annual Deductible carryover will apply only when
expenses incurred have been paid in full. The aggregate Family Unit Deductible does not carry over into
the next year.
4. Coinsurance. After the annual Deductible is satisfied, Members shall be required to pay the Plan
Coinsurance for Covered Services received under the Community Provider option as set forth in the
Allowances Schedule.
C32811- 5685300a
A benefit- specific coinsurance may apply to some Covered Services, as set forth in the Allowances
Schedule. Services that are subject to the benefit - specific coinsurance are not subject to the PIan
Coinsurance and do not apply to the Out -of- Pocket Limit.
5. Out -of- Pocket Limit. Under either the MHCN or Community Provider option, total Out-of-Pocket
Expenses incurred during the same calendar year shall not exceed the Out -of- Pocket Limit set forth in the
Allowances Schedule. Out -of- Pocket Expenses which apply toward the Out -of- Pocket Limit are set forth in
the Allowances Schedule.
C. Subscriber's Liability
The Subscriber is liable for (1) payment to the Group of his/her contribution toward the monthly premium, if
any; (2) payment of Cost Share amounts for Covered Services provided to the Subscriber and his/her
Dependents, as set forth in the Allowances Schedule; and (3) payment of any fees charged for non - Covered
Services provided to the Subscriber and his/her Dependents, at the time of service.
Payment of an amount billed by GHO must be received within thirty (30) days of the billing date.
D. Claims
-Maims for benefits may be made before or after services are obtained. To make a claim for benefits under the
Agreement, a Member (or the Member's authorized representative) must contact GHO Customer Service, or
submit a claim for reimbursement as described below. Other inquiries, such as asking a health care provider
about care or coverage, or submitting a prescription to a pharmacy, will not be considered a claim for benefits.
If a Member receives a bill for services the Member believes are covered under the Agreement, the Member
must, within ninety (90) days of the date of service, or as soon thereafter as reasonably possible, either (1)
contact GHO Customer Service to make a claim or (2) pay the bill and submit a claim for reimbursement of
Covered Services to GHO, P.O. Box 34585, Seattle, WA 98124 -1585. In no event, except in the absence of
legal capacity, shall a claim.be accepted later than one (1) year from the date of service.
GHO will generally process claims for benefits within the following timeframes after GHO receives the claims:
• Pre- service claims — within fifteen (15) days.
• Claims involving urgently needed care — within seventy-two (72) hours.
• Concurrent care claims — within twenty-four (24) hours.
• Post - service claims — within thirty (30) days.
Timeframes for pre- service and post- service claims can be extended by GHO for up to an additional fifteen (15)
days. Members will be notified in writing of such extension prior to the expiration of the initial timeframe.
C32811- 5685300a 6
Section II. Allowances Schedule
MHCN: Describes coverage when care is provided by a MHCN Provider. Benefits
paid under the MHCN option will not be duplicated under the Community
Provider option.
Community Provider: Describes coverage when care is provided by a Community Provider or
Preferred Community Provider. Coverage is limited to the Preferred
Community Provider Contracted Rate or Usual, Customary and
Reasonable (UCR) charges, less any applicable Cost Share amounts as
noted below. Benefits paid under the Community Provider option will not
be duplicated under the MHCN option.
The benefits described in this schedule are subject to all provisions, limitations'and exclusions set forth in the
Group Medical Coverage Agreement.
"Welcome" Outpatient Services Waiver
Not applicable.
Annual Deductible
MHCN: No annual- Deductible.
Community..Provider: $100 per Member or $300 per Family Unit per calendar year.
Plan. Coinsurance
MHCN: No Plan Coinsurance. m r
Community Provider: Plan Coinsurance share is 90% of the Preferred. Community Provider Contracted Rate or
Usual, Customary and Reasonable charges; Member coinsurance share is 10 %, after the annual Deductible is
satisfied.
Lifetime Maximum
No Lifetime Maximum on covered Essential Health Benefits.
Hospital Services
• Covered inpatient medical and surgical services, including acute chemical withdrawal (detoxification)
MHCN: Covered subject to the lesser of the MHCN's charge or a $100 Copayment per day up to a maximum
of five (5) days per admission.
Community Provider: Covered subject to the lesser of the allowed charge or a $100 Copayment per day up to
a maximum of five (5) days per admission and at the Plan Coinsurance after the annual Deductible is satisfied.
Prior authorization is required for scheduled admissions as set forth in Section N.A.
0 Covered outpatient hospital surgery (including ambulatory surgical centers)
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
C32811- 5685300a
Outpatient Services
• Covered outpatient medical and surgical services
MHCN: Covered subject to the lesser of the MHCN's charge or a $10 outpatient services Copayment per
Member per visit.
Community Provider: Covered subject to the lesser of the allowed charge or a $10 outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
• Allergy testing
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
• Oncology (radiation therapy, chemotherapy)
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
Drugs - Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies)
• Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed in the
GHO drug formulary
MHCN: Covered subject to the lesser of the MHCN's charge or a $10 Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or a $15 Copayment.
• Over- the - counter drugs and medicines
Not covered.
• Injectables
MHCN: Injectables that can be self - administered are subject to the lesser of the MHCN's charge or the
applicable prescription drug Cost Share (as set forth above). Other covered injectables are subject to the lesser
of the MHCN's charge or the applicable outpatient services Cost Share. Injectables necessary for travel are not
covered.
Community Provider: Injectables that can be self - administered are subject to the lesser of the allowed charge
or the applicable prescription drug Cost Share (as set forth above). Other covered injectables are subject to the
lesser of the allowed charge or the applicable outpatient services Cost Share. Injectables necessary for travel are
not covered.
0 Mail order drugs and medicines dispensed through the GHO- designated mail order service
Covered subject to the lesser of the MHCN's charge or a $5 discount from the applicable prescription drug Cost
Share (as set forth above) for each thirty (30) day supply or less.
C32811- 5685300a
Out -of- Pocket Limit
MHCN and Community Provider maximums are not combined
MHCN: Limited to an aggregate maximum of $1,000 per Member or $3,000 per family per calendar year. Except
as otherwise noted in this Allowances Schedule, the total Out -of- Pocket Expenses for the following Covered
Services are included in the Out -of- Packet Limit:
• Inpatient services
• Outpatient services
• Emergency care at a MHCN Facility
• Ambulance services
Community Provider: Limited town aggregate maximum of $1,000 per Member or $3,000 per family per calendar
year. Except as otherwise noted in this AIlowances Schedule, the total Out -of- Pocket Expenses for the following
Covered Services are included in the Out -of- Pocket Limit:
• Plan Coinsurance
• Emergency care at a non -MHCN Facility
Acupuncture
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment up to
a maximum of eight (8) visits per Member per medical diagnosis per calendar`year. When approved by GHO,
additional visits are covered.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services '
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
Ambulance Services
• Emergency ground/air transport
MHCN: Covered at 80% for transport to a MHCN Facility.
Community Provider: Covered at 80% for transport to a non -MHCN Facility. Not subject to the annual
Deductible.
• Non - emergent ground/air interfacility transfer
MHCN: Covered at 80% for MHCN- initiated transfers, except hospital-to-hospital-ground transfers covered in
full.
Community Provider: Covered at 80% for transport from one medical facility to the nearest facility equipped
to render further Medically Necessary treatment when prescribed by the attending physician. Not subject to the
annual Deductible.
Chemical Dependency
• Inpatient services (including Residential Treatment services)
f
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable inpatient services Copayment.
C32811- 5685300a �9
Community Provider: Covered subject to the lesser of the allowed charge or the applicable inpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
• Outpatient services
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
Acute detoxification covered as any other medical service.
Dental Services (including accidental injury to natural teeth)
MHCN: Not covered, except as set forth in Section IV.13.23.
Community Provider: Not covered, except as set forth in Section IV.B.23.
Devices, Equipment and Supplies (for home use)
• Durable medical equipment
•
- appliances
• Post - mastectomy bras limited to two (2) every six (6) months
• Ostomy supplies
• Prosthetic devices
MHCN: Covered in full.
Community Provider: Covered in full after the annual Deductible is satisfied.
When provided in lieu of hospitalization as described in Section IV.A.3., benefits will be the greater of benefits
available for devices, equipment and supplies, home health or hospitalization. See Hospice for durable medical
equipment provided in a hospice setting.
Diabetic Supplies
MHCN: Insulin, needles, syringes, test strips and lancets - see Drugs - Outpatient. External insulin pumps, blood
glucose monitors and related supplies - see Devices, Equipment and Supplies.
Community Provider: Insulin, needles, syringes, test strips and lancets - see Drugs - Outpatient. External insulin
pumps, blood glucose monitors and related supplies - see Devices, Equipment and Supplies.
Diagnostic Laboratory and Radiology Services
MHCN: Covered in full.
Community Provider: Covered at the Plan Coinsurance after the annual Deductible is satisfied.
Emergency Services
MHCN: Covered subject to the lesser of the MHCN's charge or a $75 Copayment per Member per Emergency visit
at a MHCN Facility. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from
the emergency department. Emergency admissions are covered subject to the applicable inpatient services Cost
Share.
C32811- 5685300a 10
Community Providers Covered subject to a $75 Copayment or total charge of services, whichever is less, at a non -
MHCN Facility. Emergency admissions are covered subject to the applicable inpatient services Cost Share.
Copayment is waived if the Member is admitted as an inpatient to a non -MHCN hospital directly from the
emergency department. The Member must notify GHO within twenty-four (24) hours following admission and agree
to have care managed by the MHCN in order to have inpatient services covered at the MHCN benefit level. If the
Member does not notify GHO within twenty-four (24) hours following admission, or declines to have care managed
by the MHCN, all inpatient services the Member receives are covered subject to the applicable inpatient services
Cost Share.
Hearing Examinations and Hearing Aids
• Hearing examinations to determine hearing loss
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
• Hearing aids, including hearing aid examinations
MHCN: Not covered.
Community Provider: Not covered.
Home Health Services
MHCN: Covered in full. No visit limit.
Community Provider: Covered at the Plan Coinsurance after the annual Deductible is satisfied.
Hospice Services
MHCN: Covered in full. Inpatient respite care is covered for a maximum of five (5) consecutive days per
occurrence.
Community,Provider: Covered at the Plan Coinsurance, after the annual. Deductible is satisfied. Inpatient respite
care is covered for a maximum of five (5) consecutive days per occurrence. Prior authorization is required-for
scheduled hospice admissions, as set forth in Section W.A.
Infertility Services (including sterility).
MHCN: Not covered.
Community Provider: Not covered.
Manipulative Therapy
MHCN and Community Provider benefit limits are combined and cannot be duplicated.
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment for
manipulative therapy of the spine and extremities in accordance with GHO clinical criteria up to a maximum of ten
(10) visits per Member per calendar year.
C32811- 5685300a I I III
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance for manipulative therapy of the spine or extremities up to a maximum of ten
(10) visits per Member per calendar year, after the annual Deductible is satisfied
Maternity and Pregnancy Services
• Delivery and associated Hospital Care
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable inpatient services Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable inpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
Prenatal and postpartum care
MHCN: Routine maternity visits covered in full. Non - routine maternity visits covered subject to the lesser of
the MHCN's charge or the applicable outpatient services Copayment.
Community Provider: Routine maternity visits covered at the Plan Coinsurance after the annual Deductible is
satisfied. Non - routine maternity visits covered subject to the lesser of the allowed charge or the applicable
outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
• Pregnancy termination
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable Copayment for
involuntary/voluntary termination of pregnancy.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable Copayment and at
the Plan Coinsurance for involuntary/voluntary termination of pregnancy after the annual Deductible is
satisfied.
Mental Health Services
0 Inpatient services
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable inpatient services Copayment at
a GHO- approved mental health care facility.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable inpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
• Outpatient services
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
Naturopathy
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment up to
a maximum of three (3) visits per Member per medical diagnosis per calendar year. When approved by GHO,
additional visits are covered.
C32811- 5685300a 12
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance after the annual Deductible is satisfied.
Newborn Services
MHCN: Newborn services covered the same as for any other condition, subject to the lesser of the MHCN's
charge or the applicable Cost Share. Any applicable Cost Share for newborn services is separate from that of the
mother.
Initial hospital stay (le. routine nursery care) — See Hospital Services. Outpatient well care — See Preventive
Services.
Community. Provider. Newborn services covered the same as for any other condition, subject to the lesser of the
allowed charge or the applicable Cost Share. Any applicable Cost Share for newborn services is separate from
that of the mother.
Initial hospital stay (Le. routine nursery care) —See Hospital Services. Outpatient well care —See Preventive
Services.
Nutritional Services
• Phenylketonuria (PKU) supplements
MHCN: Covered in full.
Community Provider: Covered at the Plan Coinsurance after the annual Deductible is satisfied.
• Enteral therapy (formula)
MHCN: Covered at 80% for elemental formulas. Necessary equipment acid supplies are covered under Devices,
Equipment and Supplies.
Community Provider: Covered at the Plan Coinsurance for elemental formulas after the annual Deductible is
satisfied. Necessary equipment and supplies are covered under Devices, Equipment and Supplies. Coinsurance
does not apply to the Out -of- Pocket Limit.
• Parenteral therapy (total parenteral nutrition)
MHCN: Covered in full for parenteral formulas. Necessary equipment and supplies are covered under Devices,
Equipment and Supplies.
Community Provider: Covered at the Plan Coinsurance for parenteral formulas after the annual Deductible is
satisfied. Necessary equipment and supplies are covered under Devices, Equipment and Supplies.
Obesity Related Services
MHCN: Services directly related to obesity, including bariatric surgery, weight loss programs, medications and
related physician visits for medication monitoring are not covered.
Community Provider: Services directly related to obesity, including bariatric surgery, weight loss programs,
medications and related physician visits for medication monitoring are not covered.
On the Job Injuries or Illnesses
MHCN: Not covered, including injuries or illnesses incurred as a result of self - employment.
C32811- 5685300a - 13
Community Provider: Not covered, including injuries or illnesses incurred as a result of self - employment.
Optical Services
• Routine eye examinations
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment
once every twelve (12) months. Eye examinations for eye pathology, including contact lens examinations, are
covered subject to the lesser of the MHCN's charge or the applicable outpatient services Copayment as often
as Medically Necessary.
Community Provider: Not covered.
• Lenses, including contact lenses, and frames
MHCN: Not covered, except contact lenses for eye pathology are covered in full, including following cataract
surgery.
Community Provider: Not covered, except contact lenses for eye pathology are covered at the Plan
Coinsurance after the annual Deductible is satisfied, including following cataract surgery.
Organ Transplants
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the, applicable Copayment and at the
Plan Coinsurance after the annual Deductible is satisfied.
Ptastic`and Reconstructive Services (plastic surgery, cosmetic surgery)
• Surgery to correct a congenital disease or anomaly, or conditions following an injury or resulting from surgery
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable Copayment and at
the Plan Coinsurance after the annual Deductible is satisfied.
• Cosmetic surgery, including complications resulting from cosmetic surgery
MHCN: Not covered.
Community Provider: Not covered.
Podiatric Services
• Medically Necessary foot care
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable Copayment and at
the Plan Coinsurance after the annual Deductible is satisfied.
• Foot care (routine)
C32811- 5685300a 14
MHCN: Not covered, except in the presence of a non - related Medical Condition affecting the lower limbs.
Community Provider: Not covered, except in the presence of a non - related Medical Condition affecting the
lower limbs.
Pre- Existing Condition
Covered with no wait.
Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and
prostate /colorectal cancer screening)
MHCN: Covered in full when in accordance with the well care schedule established by GHO and the Patient
Protection and Affordable Care Act of 2010. Eye refractions are not included under preventive care. Physicals for
travel, employment, insurance or license are not covered. Services provided during a preventive care visit which are
not in accordance with the well care schedule may be subject to the lesser of the MHCN's charge or the applicable
outpatient services Copayment.
Community Provider: Covered in full when in accordance with the well care schedule established by GHO.
Routine mammography services are covered in full. Not subject to the annual Deductible or Plan Coinsurance.
Rehabilitation Services
• Inpatient physical, occupational and restorative speech therapy services combined, including services for
neurodevelopmentally disabled children age six (6) and under
MHCN and Community Provider benefit limits are combined and cannot be duplicated.
MHCN: Covered subject to the lesser of the MHCN's charge or the appli6able inpatient services Copayment
for up to sixty (60) days per calendar year.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable inpatient services
Copayment and at the Plan Coinsurance for up to sixty (60) days per calendar year after the annual Deductible
is satisfied. Prior authorization is required (see Section IV.G.).
• Outpatient physical, occupational and restorative speech therapy services combined, including services for
neurodevelopmentally disabled children age six (6) and under -
MHCN and Community Provider benefit limits are combined and cannot be duplicated.
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable outpatient "services Copayment
for up to sixty (60) visits per calendar year.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services
Copayment and at the Plan Coinsurance for up to sixty (60) visits per calendar year after the annual Deductible,
is satisfied.
Sexual Dysfunction Services
MHCN: Not covered.
Community Provider: Not covered.
Skilled Nursing Facility (SNF)
C32811- 5685300a 1 1 15
MHCN and Community Provider benefit limits are combined and cannot be duplicated.
MHCN: Covered in full up to sixty (60) days per Member per calendar year.
Community Provider: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year,
after the annual Deductible is satisfied. Prior authorization is required (see Section IV.A.).
Sterilization (vasectomy, tubal ligation)
MHCN: Covered subject to the lesser of the MHCN's charge or the applicable Copayment.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable Cost Share.
Temporomandibular Joint (TMJ) Services
• Inpatient and outpatient TMJ services
MHCN and Community Provider benefit limits are combined and cannot be duplicated.
MHCN: Covered subject to the Iesser of the MHCN's charge or the applicable Copayments for up to $1,000
maximum per Member per calendar year.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable Copayments and at
the Plan Coinsurance for up to $1,000 maximum per Member per calendar year after the annual Deductible is
satisfied.
• Lifetime benefit maximum
MHCN and Community Provider benefit limits are combined and cannot be duplicated.
MHCN: Covered up to $5,000 per Member.
Community Provider: Covered up to $5,000 per Member.
Tobacco Cessation
• Individual/group counseling
MHCN: Covered in full when received through the GHO- designated tobacco cessation program.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient
services Cost Share.
• Approved pharmacy products
MHCN: Covered in full when prescribed as part of the GHO- designated tobacco cessation program and
dispensed through the GHO- designated mail order service.
Community Provider: Covered subject to the lesser of the allowed charge or the applicable prescription
drug Cost Share
C32811- 5685300a 16
Section III. Eligibility, Enrollment and Termination
A. Eligibility
In order to be accepted for enrollment and continuing coverage under the Agreement, individuals must meet any
eligibility requirements imposed by the Group, reside or work in the Service Area and meet all applicable
requirements set forth below, except for temporary residency outside the Service Area for purposes of attending
school, court- ordered coverage for Dependents or other unique family arrangements, when approved in advance
by GHO. GHO has the right to verify eligibility.
1. Subscribers. Bona tide regular part-time and regular full -time employees who have been continuously
employed on a regularly scheduled basis of not less than twenty (20) hours per week shall be eligible for
enrollment.
2. Dependents. The Subscriber may also enroll the following:
a. The Subscriber's legal spouse, including state- registered domestic partners as required by Washington
state law;
b. The Subscriber's domestic partner, other than a state - registered domestic.partner, provided that the
Subscriber and domestic partner:
i. Share the same regular and permanent residence;
ii. Have a close personal relationship;
iii. Are jointly responsible for "basic living expenses" as defined by the Group;
iv. Are not married to anyone;
v. Are each eighteen (18) years of age or older;
vi. Are not related by blood closer than would bar marriage in the State of Washington;
vii. Were mentally; competent to consent to contract when the,domestie partnership began;, and
viii. Are each other's sole domestic partner and are responsible for each other's common welfare.
Following termination of a domestic partnership a statement of termination must be filed with the
Group. Application for another domestic partnership cannot be filed: for ninety (40) days following a
filing of the statement of termination of domestic partnership with the Group, unless such termination
is due to the death of the domestic partner.
c. Children who are under the age of twenty -six (26).
"Children" means the children of the Subscriber, or spouse, including adopted children, stepchildren,
children of a domestic partner, or state- registered domestic partner, children for whom the Subscriber
has a qualified:court orderto provide coverage; and any other children for whorixthe Subscriber is the
legal guardian.
Eligibility may be extended past the Dependents limiting age as set forth above if the'Dependent is
totally incapable of self - sustaining employment because of a developmental or physical disability
incurred prior to attainment of the limiting age set forth above, and is chiefly dependent upon the
Subscriber for support and maintenance. Enrollment for such a Dependent may be continued for the
duration of the continuous total incapacity, provided enrollment does not terminate for any other
reason. Medical proof of incapacity and proof of financial dependency must be furnished to GHO upon
request, but not more frequently than annually after the two (2) year period following the Dependent's
attainment of the limiting age.
3. Temporary Coverage for Newborns. When a Member gives birth, the newborn will be entitled to the
benefits set forth in Section IV. from birth through three (3) weeks of age. After three (3) weeks of age, no
C32811- 5685300a 1 -7
benefits are available unless the newborn child qualifies as a Dependent and is enrolled under the
Agreement. All contract provisions, limitations and exclusions will apply except Section III.F. and III.G.
B. Enrollment
1. Application for Enrollment. Application for enrollment must be made on an application approved by
GHO. Applicants will not be enrolled or premiums accepted until the completed application has been
approved by GHO. The Group is responsible for submitting completed applications to GHO.
GHO reserves the right to refuse enrollment to any person whose coverage under any Medical Coverage
Agreement issued by Group Health Options, Inc. or Group Health Cooperative has been terminated for
cause, as set forth in Section III.E. below.
a. Newly Eligible Persons. Newly eligible Subscribers and their Dependents may apply for enrollment in
writing to the Group within thirty-one (31) days of becoming eligible.
b. New Dependents. A written application for enrollment of a newly dependent person, other than a
newborn or adopted child, must be made to the Group within thirty-one (3 1) days after the dependency
occurs.
A written application for enrollment of a newborn child must be made to the Group within sixty (60)
days following the date of birth, when there is a change in the monthly premium payment as a result of
the additional Dependent.
A written application for enrollment of an adoptive child must be made to the Group within sixty (60)
days from the day the child is placed with the Subscriber for the purpose of adoption and the
Subscriber assumes total or partial financial support of the child, if there is a change in the monthly
premium payment as a result of the additional Dependent.
When there is no change in the monthly premium payment, it is strongly advised that the Subscriber
., enroll the newborn or newly adoptive child as a Dependent with the Group to avoid delays in the
payment of claims.
c. Open Enrollment. GHO will allow enrollment of Subscribers and Dependents, who did not enroll
when newly eligible as described above, during a limited period of time specified by the Group and
GHO.
d. Special Enrollment.
1) GHO will allow special enrollment for persons:
a) who initially declined enrollment when otherwise eligible because such persons had other health
care coverage and have had such other coverage terminated due to one of the following events:
• cessation of employer contributions,
• exhaustion of COBRA continuation coverage,
• loss of eligibility, except for loss of eligibility for cause; or
b) who have had such other coverage exhausted because such person reached a Lifetime Maximum
limit.
GHQ or the Group may require confirmation that when initially offered coverage such persons
submitted a written statement declining because of other coverage. Application for coverage under
the Agreement must be made within thirty-one (3 1) days of the termination of previous coverage.
2) GHO will allow special enrollment for individuals who are eligible to be a Subscriber, his/her
spouse and his/her Dependents in the event one of the following occurs:
• marriage. Application for coverage under the Agreement must be made within thirty-one (3 1)
days of the date of marriage.
C32811- 5685300a 18
• birth. Application for coverage under the Agreement for the Subscriber and Dependents other
than the newborn child must be made within sixty (60) days of the date of birth.
• adoption or placement for adoption. Application for coverage under the Agreement for the
Subscriber and Dependents other than the adopted child must be made within sixty (60) days
of the adoption or placement for adoption.
• eligibility for medical assistance: provided such person is otherwise eligible for coverage
under this Agreement, when approved and requested in advance by the Department of Social
and Health Services (DSHS). The request for special enrollment must be made within sixty
(60) days of DSHSs determination that enrollment would be cost - effective'.
• coverage under a Medicaid or CHIPplan is terminated as a result of loss of eligibility for
such coverage. Application for coverage under the Agreement must be made within sixty
(60) days of the date of termination under Medicaid or CHIP.
• applicable federal or state law or regulation otherwise provides for special enrollment.
2. Limitation on Enrollment. The Agreement will be open for applications' for enrollment as forth in this
Section III.B. Subject to prior approval by the Washington State Office of the Insurance Commissioner,
GHO may limit enrollment, establish quotas or set priorities for acceptance 'of new applications if it
determines that GHQ's capacity, in relation to its total enrollment, is not adequate to provide services to
additional persons.
C. Effective Date of Enrollment
Provided_ eligibility criteria are met and applications for enrollment are made as set forth in Sections III.A.
and III.B. above, enrollment will be effective as follows:
• Enrollment for a newly eligible Subscriber and listed Dependents' is effective on the first (1st) of the
month following or coinciding with the date of hire provided the Subscriber's application has been
submitted to and approved by GHO.
• The probationary period for part -time employees who become full -time employees begins retroactive
to the, original date of hire -
• Enrollment for a newly dependent person, other than a newborn or adoptive child, is effective on the
first (I st) of the month following the date eligibility requirements are met.
• Enrollment for newborns is effective from the date of birth.
• Enrollment for adoptive children is effective from the date that the adoptive child is placed with the
Subscriber for the purpose of adoption and the Subscriber assumes total or partial financial support of
the child.
2. Commencement of Benefts for Persons Hospitalized on Effective Date. Members who are admitted to
an inpatient facility prior to their enrollment under the Agreement, and who do,not have coverage under
another agreement, will receive covered benefits beginning on their effective date, as set forth in subsection
C.1. above. If a Member is hospitalized in a non -MHCN Facility, GHO reserves the right to require transfer
of the Member to a MHCN Facility. The Member will be transferred when a MHCN Provider, in
consultation with the attending physician, determines that the Member is medically stable to do so. If the
Member refuses to transfer to a'MHCN Facility, all services received will be covered under the Community
Provider option of the Inpatient Hospital Services section set forth in the Allowances Schedule.
D. Eligibility for Medicare
An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare
benefits. Medicare Secondary Payer regulations and guidelines will'determine primary/secondary payer status
for individuals covered by Medicare.
The Group is responsible for providing the Member with necessary information regarding Tax Equity and
Fiscal Responsibility Act of 1982 (TEFRA) eligibility and the selection process, if applicable. If a Member is
eligible for Medicare, he /she has the option of maintaining both Medicare Parts A and B while continuing
C32811- 5685300a 19:
coverage under this Agreement. Coverage between this Agreement and Medicare will be coordinated as
outlined in Section VII.A.
E. Termination of Coverage
1. Termination of Specific Members. Individual Member coverage maybe terminated for any of the
following reasons:
a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section III.,
and is not enrolled for continuation coverage as described in Section III.G. below, coverage under the
Agreement will terminate at the end of the month during which the loss of eligibility occurs, unless
otherwise specified by the Group.
b. For Cause. Coverage of a Member maybe terminated upon ten (10) working days written notice for:
i. Material misrepresentation, fraud or omission of information in order to obtain coverage.
ii. Permitting the use of a GHO identification card or number by another person, or using another
Member's identification card or number to obtain care to which a person is not entitled...
In the event of termination for cause, GHO reserves the right to pursue all civil remedies allowable
under federal and state law for the collection of claims, losses or other damages.
c. Premium Payments. Nonpayment of premiums or contribution for a specific Member by the Group.
P � Individual Member coverage may be retroactively terminated upon thirty (30) days written notice and only
in the case of fraud or intentional misrepresentation of a material fact; or as otherwise allowed under
applicable law or regulation. Notwithstanding the foregoing, GHO reserves the right to retroactively
terminate coverage for nonpayment of premiums or contributions by the Group as described under
subsection c. above.
In no event will a Member be terminated solely on the basis of their physical or mental condition provided
they meet all other eligibility requirements set forth in the Agreement.
Any Member may appeal a termination decision through GHO's grievance process as set forth in Section
VI.
2. Certificate of Creditable Coverage. Unless the Group has chosen to accept this responsibility, a
certificate of creditable coverage (which provides information regarding the Member's length of coverage
under the Agreement) will be issued automatically upon termination of coverage, and may also be obtained
upon request.
F. Services After Termination of Agreement
1. Members Hospitalized on the Date of Termination. A Member who is receiving Covered Services as a
registered bed patient in a hospital on the date of termination shall continue to be eligible for Covered
Services while an inpatient for the condition which the Member was hospitalized, until one of the following
events occurs:
• According to GHO clinical criteria, it is no longer Medically Necessary for the Member to be an
inpatient at the facility.
• The remaining benefits available under the Agreement for the hospitalization are exhausted, regardless
of whether a new calendar year begins.
• The Member becomes covered under another agreement with a group health plan that provides benefits
for the hospitalization.
• The Member becomes enrolled under an agreement with another carrier that would provide benefits for
the hospitalization if the Agreement did not exist.
C32811- 5685300a 20
This provision will not apply if the Member is covered under another agreement that provides benefits for
the hospitalization at the time coverage would terminate, except as set forth in this section, or if the
Member is eligible for COBRA continuation coverage as set forth in subsection G. below.
2. Services Provided After Termination. The Subscriber shall be liable for payment of all charges for
services and items provided to the Subscriber and all Dependents after the effective date of termination,
except those services covered under subsection F.1. above. Any services provided by the MHCN will be
charged according to the Fee Schedule.
G. Continuation of Coverage Options
Continuation Option. A Member no longer eligible for coverage under the Agreement (except in the event
of termination for cause, as set forth in Section III.E.) may continue coverage for a period of up to three (3)
months subject to notification to and self - payment of premiums to the Group. This provision will not apply
if the Member is eligible for the continuation coverage provisions of the Consolidated Omnibus Budget
Reconciliation Act of 199.5 (COBRA). This continuation option is not available if the Group no longer has
active employees or otherwise terminates.
2. Leave of Absence. While on a Group approved leave of absence, the Subscriber and listed Dependents can
continue to be covered under the Agreement provided:
• They remain eligible for coverage, as set forth in Section III.A.,
• Such leave is in compliance with the Group's established leave of absence policy that is consistently
applied to all employees,
• The Group's leave of absence policy is in compliance with the Family and Medical Leave Act when
applicable,,and
The Group continues to remit premiums for the Subscriber and Dependents to GHO.
3. Self- Payments During Labor Disputes. In the event of suspension or termination of employee
compensation due to a strike, lock -out or other labor.dispute, a Subscriber way continue uninterrupted
coverage under the Agreement through payment of monthly premiums directly to the Group. Coverage may
be continued for the lesser of the term of the strike, lock -out or other labor dispute, or for six (6) months
after the cessation of work.
If the Agreement is no longer available, the Subscriber shall have the opportunity to apply for an individual
GHO Group Conversion Plan or, if applicable, continuation coverage (see subsection 4. below), or an
Individual and Family Medical Coverage Agreement at the duly approved rates.
The Group is responsible for immediately notifying each affected Subscriber of his/her rights of self -
payment under this provision.
4. Continuation Coverage Under Federal Law: This section applies only to Groups who must , offer"
continuation coverage under the applicable provisions of the Consolidated Omnibus Budget Reconciliation
Act of 1985 (COBRA), 'as iu ended, and only applies to grant continuation of coverage rights to the extent
required by federal law.
Upon loss of eligibility, continuation of Group coverage may be available to a Member for a limited time
after the Member would otherwise lose eligibility, if required by COBRA. The Group shall inform
Members of the COBRA election process and how much the Member will be required to pay directly to the
Group.
Continuation coverage under COBRA will terminate when a Member becomes covered by Medicare or
obtains other group coverage, and as set forth under Section III.E.I.b. and c.
C32811- 5685300a 21
5. GHO Group Conversion Plan. Members whose eligibility for coverage under the Agreement, including
continuation coverage, is terminated for any reason other than cause, as set forth in Section III.E. l .b., and
who are not eligible for Medicare or covered by another group health plan, may convert to GHQ's Group
Conversion Plan. If the Agreement terminates, any Member covered under the Agreement at termination
may convert to a GHO Group Conversion Plan, unless he /she is eligible to obtain other group health
coverage within thirty-one (3 1) days of the termination of the Agreement.
An application for conversion must be made within thirty-one (3 1) days following termination of coverage
under the Agreement or within thirty-one (31) days from the date notice of the termination of coverage is
received, whichever is later. Coverage under GHQ's Group Conversion Plan is subject to all terms and
conditions of such plan, including premium payments. A physical examination or statement of health is not
required for enrollment in GHQ's Group Conversion Plan. The Pre- Existing Condition limitation under
GHQ's Group Conversion Plan will apply only to the extent that the limitation remains unfulfilled under
the Agreement.
By exercising Group Conversion rights, the Member may waive guaranteed issue and Pre- Existing
Condition waiver rights under Federal regulations.
Persons wishing to purchase GHO's Individual and Family coverage should contact Group Health
Marketing.
Section IV. Schedule of Benefits
Benefits are subject to all provisions of the Group Medical Coverage Agreement, including, without
limitation, the Accessing Care provisions and General Exclusions. Members must refer to Section H., the .
Allowances Schedule, for Cost Shares and specific benefit limits that apply to benefits listed in this Schedule
of Benefits. Members are entitled to receive only benefits and services that are Medically Necessary and
clinically appropriate for the treatment of a Medical Condition as determined by GHO's Medical Director, or
his/her designee, and as described herein. All Covered Services are subject to case management and
utilization review at the discretion of GHQ
A. Hospital Care
The following hospital services are covered, (1) under the MHCN option when provided or authorized by the
MHCN, or (2) under the Community Provider option when authorized in advance by GHO:
1. Room and board, including private room when prescribed, and general nursing services.
2. Hospital services (including use of operating room, anesthesia, oxygen, x -ray, laboratory and radiotherapy
services).
3. Alternative care arrangements may be covered as a cost - effective alternative in lieu of otherwise covered
Medically Necessary hospitalization, or other covered Medically Necessary institutional care. Alternative
care arrangements in lieu of covered hospital or other institutional care must be determined to be
appropriate and Medically Necessary based upon the Member's Medical Condition. Coverage must be
authorized in advance by GHO as appropriate and Medically Necessary. Such care will be covered to the
same extent the replaced Hospital Care is covered under the Agreement.
4. Drugs and medications administered during confinement.
5. Special duty nursing, when prescribed as Medically Necessary.
Except as specifically provided below, all inpatient admissions prescribed by a Community Provider must be
authorized by GHO at least seventy-two (72) hours in advance.
C32811- 5685300a 22
Members receiving the following nonscheduled services are required to notify GHO by way of the GHO
Notification Line within twenty-four (24) hours following a nonscheduled admission, or as soon thereafter as
medically possible: labor and delivery, Emergency care services, and inpatient admissions needed for treatment
of Urgent Conditions that cannot reasonably be delayed until prior authorization can be obtained.
Members may not transfer to a MHCN hospital during a nonemergent, scheduled admission to a non -MHCN
hospital. Coverage for Emergency care in a non -MHCN Facility and subsequent transfer to a MHCN Facility is
set forth in Section N.L.
Excluded. take home drugs, dressings and supplies following hospitalization.
B. Medical and Surgical Care
The following medical and surgical services are covered (1) under the MHCN option when provided or
authorized by a MHCN Provider, or (2) under the Community Provider option when provided by a Community
Provider:
1. Surgical services.
2. Diagnostic x -ray, nuclear medicine, ultrasound and laboratory services. Under the Community Provider
option, high end radiology imaging services such as CT; MR and PET must be determined Medically
Necessary and require prior authorization except when associated with Emergency care or inpatient
services.
3. Family planning counseling services.
4. Hearing examinations to determine hearing loss.
Excluded. hearing devices and hearing aids, including related examinations.
5. Blood and blood derivatives and their administration.
6. Preventive care (well care) services for health maintenance in accordance with the well care schedule
established by GHO for the following:
MHCN: Routine mammography screening, physical examinations and routine laboratory tests for cancer
screening in accordance with the well care schedule established by GHO and the Patient Protection and
Affordable Care Act of 2010, and immunizations and vaccinations listed as covered in the GHO drug
formulary (approved drug list). A fee may be charged for health education programs. The well care
schedule is available in Group Health clinics, by accessing GHQ's website at www.ghc.org, or upon
request.
Covered Services provided during a preventive care visit; which are not in accordance with the GHO well
care schedule, may be subject to Cost Shares.
Community Provider: Routine mammography screening, routine physical examinations for detection of
disease and immunizations and vaccinations in accordance with the well care schedule established by
GHO.
7. Radiation therapy services.
8. Reduction of a fracture or dislocation of the jaw or facial bones; excision of tumors or non - dental cysts of
the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth; and incision of salivary glands and ducts.
9. Medical implants.
C32811- 5685300a 23
Excluded: internally implanted insulin pumps, artificial hearts, artificial larynx and any other implantable
device that has not been approved by GHQ's Medical Director, or his/her designee.
10. Respiratory therapy.
11. Outpatient total parenteral nutritional therapy; outpatient elemental formulas for malabsorption; and dietary
formula for the treatment of phenylketonuria (PKU). Coverage for PKU formula is not subject to a Pre -
Existing Condition waiting period, if applicable.
Equipment and supplies for the administration of enteral and parenteral therapy are covered under Devices,
Equipment and Supplies.
Excluded: any other dietary formulas, oral nutritional supplements, special diets, prepared foods/meals and
formula for access problems.
12. Visits with providers, including consultations and second opinions, in the hospital or provider's office.
13. Optical services.
MHCN :'Routine eye examinations and refractions received at a MHCN Facility once every twelve (12)
months, except when Medically Necessary. Routine eye examinations to monitor Medical Conditions are
covered as often as necessary upon recommendation of a MHCN Provider.
Contact lenses for eye pathology, Including contact lens exam and fitting, are covered subject to the
applicable Cost Share. When dispensed through MHCN Facilities, one contact lens per diseased eye in lieu
of an intraocular lens, including exam and fitting, is covered for Members following cataract surgery
performed by a MHCN Provider, provided the Member has been continuously covered by GHO since such
surgery. Replacement of lenses for eye pathology, including following cataract surgery, will be covered
only once within a twelve (12) month period and only when heeded due to a change in the Member's
Medical Condition.
Excluded: eyeglasses, contact lenses and services related to their felting, orthoptic therapy (Z e-, eye
training), evaluations and surgical procedures to correct refractions not related to eye pathology and
complications related to such procedures, and contact lens fittings and related examinations not related to
eye pathology, except as set forth above.
Community Provider: Eye examinations for eye pathology when Medically Necessary. Routine eye
examinations to monitor Medical Conditions are covered when Medically Necessary.
One contact lens per diseased eye in lieu of an intraocular lens, including exam and fitting, is covered for
Members following cataract surgery, provided the Member has been continuously covered by GHO since
such surgery. Replacement of tenses for eye pathology, including following cataract surgery, will be
covered only once within a twelve (12) month period and only when needed due to a change in the
Member's Medical Condition.
Excluded: routine eye examinations and refractions, eyeglasses, contact lenses and services related to their
fitting, orthoptic therapy (Le., eye training), evaluations and surgical procedures to correct refractions not
related to eye pathology and complications related to such procedures, and contact lens fittings and related
examinations not related to eye pathology, except as set forth above.
14. Maternity care, including care for complications of pregnancy and prenatal and postpartum visits.
C32811- 5685300a 24
Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary as
determined by GHQ's Medical Director, or his/her designee, and in accordance with Board of Health
standards for screening and diagnostic tests during pregnancy.
Hospitalization and delivery, including home births for low risk pregnancies.
Voluntary (not medically indicated and nontherapeutic) or involuntary termination of pregnancy.
The Member's physician, in consultation with the Member, will determine the Member's length of
inpatient stay following delivery. Pregnancy will not be excluded as a Pre- Existing Condition under the
Agreement. Treatment for post- partum depression or psychosis is covered only under the mental health
benefit.
Excluded: birthing tubs, genetic testing of non- Members for the detection of congenital and heritable
disorders, fetal ultrasound In the absence of medical indications.
15. Transplant services, including heart, heart -lung, single lung, double lung, kidney, pancreas, cornea,
intestinal/multi- visceral, bone marrow, Iiver transplants and stem cell support (obtained from allogeneic or
autologous peripheral blood or marrow) with associated high dose chemotherapy. Covered Services must
be directly associated with, and occur at the time of, the transplant. Services are limited to the following:
a. Inpatient and outpatient medical expenses listed below for transplantation ' procedures:
• Evaluation testing to determine recipient candidacy,
• Donor matching tests,
• Hospital charges,
• Procurement center fees,
• Professional fees,
• Travel costs:for.a surgical team, and
• Excision fees
Donor costs for a covered organ recipient are limited,to procurement . center fees, travel costs for a
surgical team and excision fees.
b. Follow -up services for specialty visits,
c. Rehospitalization, and
d.. :Maintenance medications.
Under the Community Provider option, transplant services must be authorized in advance by GHO.
Excluded: donor costs to the extentrthat they are reimbursable by the organ, donor's insurance,,treatment of
donor complications, living_ expenses and transportation expenses, except,as set forth under Section IV.M.
r
16. Manipulative therapy.
MHCN: Manipulative therapy of the, spine and extremities are covered as set forth in the Allowances
Schedule when provided by MHCN Providers.
Community Provider: Manipulative therapy is covered as set forth in the Allowances Schedule.
Excluded: supportive care rendered primarily to maintain the level of correction already achieved, care
rendered primarily for the convenience of the Member, care rendered on a non - acute, asymptomatic basis
and charges for any other services that do not meet GHO clinical criteria as Medically Necessary.
C32811- 5685300a 25
17. Medical and surgical services and related hospital charges, including orthognathic (jaw) surgery, for the
treatment of temporomandibular joint (TMJ) disorders. TMJ appliances are covered as set forth under
Section IV.H.I., Orthopedic Appliances.
Orthognathic (jaw) surgery for the treatment of TMJ disorders, radiology services and TMJ specialist
services, including fitting /adjustment of splints are subject to the benefit limit set forth in the Allowances
Schedule.
Excluded: treatment for cosmetic purposes, bite blocks, dental services including orthodontic therapy, or
any orthognathic (jaw) surgery in the absence of a diagnosis of TMJ, severe obstructive sleep apnea or
congenital anomaly. Any hospitalizations related to these exclusions is also excluded.
18. Diabetic training and education.
19. Detoxification services for alcoholism and drug abuse.
For the purposes of this section, "acute chemical withdrawal" means withdrawal of alcohol and/or drugs
from a Member for whom consequences of abstinence are so severe that they require medical/nursing
assistance in a hospital setting, which is needed immediately to prevent serious impairment to the
Member's health.
Coverage for acute chemical withdrawal is provided without prior approval. If a Member is hospitalized in
a non -MHCN Facility /program, coverage is subject to payment of the Emergency care Cost Share. The
Member or person assuming responsibility for the Member must notify GHO by way of the GHO
Notification Line within twenty-four (24) hours following inpatient admission, or as soon thereafter as
medically possible. Furthermore, if a Member is hospitalized in a non -MHCN Facility/program, GHO
reserves the right to require transfer of the Member to a MHCN Facility/program upon consultation
between a MHCN Provider and the attending physician. If the Member refuses transfer to a MHCN
Facility/program, all services received will be covered under the Community Provider option.
20. Circu incision.
21. Nutritional counseling provided by MHCN staff.
22. Sterilization procedures.
Excluded. procedures and services to reverse a therapeutic or nontherapeutic sterilization.
23. General anesthesia services and related facility charges for dental procedures will be covered for Members
who are under seven (7) years of age, or are physically or developmentally disabled or have _a Medical
Condition where the Member's health would be put at risk if the dental procedure were performed in a
dentist's office. Such services must be authorized in advance by GHO and, under the MHCN option,
performed at a MHCN hospital or ambulatory surgical facility.
Excluded: dentist's or oral surgeon's fees; dental care, surgery, services and appliances, including.
treatment of accidental injury to natural teeth, reconstructive surgery to the jaw in preparation for
dental implants, dental implants, periodontal surgery and any other dental service not specifically listed
as covered GHQ's Medical Director, or his/her designee, will determine whether the care or treatment
required is within the category of dental care or service.
24. Acupuncture and naturopathy, as set forth in the AIlowances Schedule.
For coverage under the MHCN option, Covered Services must be provided by a MHCN Provider.
Additional visits are covered when approved by GHO. Laboratory and radiology services are covered only
when obtained through a MHCN Facility.
C32811- 5685300a 26
Excluded: herbal supplements, preventive care visits for acupuncture and any services not within the scope
of the practitioner's licensure.
25. Pre - Existing Conditions are covered in the same manner as any other illness.
26. Injections administered by a professional in a clinical setting.
C. Chemical Dependency Treatment.
Chemical dependency means an illness characterized by a physiological or psychological dependency; or both,
on a controlled substance and/or alcoholic beverages, and where the user's health is substantially impaired or
endangered or his/her social or economic function is substantially disrupted.
For the purposes of this section the definition of Medically Necessary shall be expanded to include those
services necessary to treat a chemical dependency condition that is having a clinically significant impact on a
Member's emotional, social, medical and/or occupational functioning.
Chemical dependency treatment services are covered as set forth in the Allowances Schedule (1) under the
MHCN option when provided at a MHCN Facility or MHCN- approved treatment program, or (2) under the
Community Provider option when provided at an approved treatment facility.
All alcoholism and/or drug abuse treatment services mustbe: (a) provided: at a facility as described above; and
(b) deemed Medically Necessary as defined above. Chemical dependency:treatment may, include the following
services receivedon an inpatient or outpatient basis: inpatient Residential Treatment services., diagnostic
evaluation and education, organized individual and group counseling, and/or prescription,drugs and.medicines.
Court- ordered treatment shall be covered only if determined to be Medically Necessary as defined above.
Under the Community Provider option, non- Washington. State alcoholism andlor drug treatment service
providers must meet the equivalent licensing and certification requirements established in the state where the
provider's practice is located.
D. Plastic and Reconstructive Services. Plastic and reconstructive services are covered asset forth below:
1. Correction of a congenital disease or congenital anomaly. A congenital anomaly will be considered to exist
if the Member's appearance resulting from such condition is not within the range of normal human
variation.
2. Correction of a Medical Condition following an, injury or resulting from surgery covered by GHO which
has produced a major effect on the Member's appearance, when in the opinion. of,GHO's Medical Director,
or his/her designee, such services can reasonably be expected to correct the condition.,
3. Reconstructive surgery and associated procedures, including internal breast prostheses, following a
mastectomy, regardless of when the mastectomy was performed.
Members will be covered for all stages of reconstruction on the non - diseased breast to make it.equivalent in
size with the- diseased breast.
Complications of covered mastectomy services, including lymphedemas, are covered.
Excluded: cosmetic services, including treatment for complications resulting from cosmetic surgery, and
complications of noncovered surgical services.
E. Home Health Care Services. Home health care services, as set forth in this section, shall be covered (1) under
the MHCN option, when Authorized in advance and provided by MHCN's Home Health Services or by GHO,
C32811- 5685300a 27
or (2) under the Community Provider option, when provided by a State - licensed home health agency, prescribed
by a Community Provider and authorized in advance by GHO's Medical Director, or his/her designee.
In order to be covered, the following criteria must be met:
1. The Member is unable to leave home due to his/her health problem or illness. Unwillingness to travel
and/or arrange for transportation does not constitute inability to leave the home.
2. The Member requires intermittent skilled home health care services, as described below.
3. A MHCN Provider under the MHCN option, or GHO's Medical Director, or his/her designee, under the
Community Provider option, has determined that such services are Medically Necessary and are most
appropriately rendered in the Member's home.
For the purposes of this section, "skilled home health care' means reasonable and necessary care for the
treatment of an illness or injury which requires the skill of a nurse or therapist, based on the complexity of the
service and the condition of the patient and which is performed directly by an appropriately licensed
professional provider.
Covered Services for home health care may include the following when rendered pursuant to an approved home
health care plan of treatment: nursing care, physical therapy, occupational therapy, respiratory therapy,
restorative speech therapy, durable medical equipment and medical social worker and limited home health aide
services. Home health services are covered on an intermittent basis in the Member's home. "Intermittent"
means care that is to be rendered because of a medically predictable recurring need for skilled home health care
services.
Excluded: convalescent care, custodial care and maintenance care, private duty or continuous nursing care in
the Member's home, housekeeping or meal services, care in any nursing home or convalescent facility, any care
provided or for a member of the patient's family and any other services rendered in the home which do not
meet the definition of skilled home health care above or are not specifically listed as covered under the
Agreement.
F. Hospice Care. Hospice care, as set forth in this section, shall be covered (1) under the MHCN option when
provided by MHCN's Hospice Program or when authorized in advance by GHO, or (2) under the Community
Provider option when provided by a licensed non -MHCN hospice agency. Hospice care is covered in lieu of
curative treatment for terminal illness for Members who meet all of the following criteria:
• A physician has determined that the Member's illness is terminal and life expectancy is six (6) months or
less.
• The Member has chosen a palliative treatment focus (emphasizing comfort and supportive services rather
than treatment aimed at curing the Member's terminal illness).
• The Member has elected in writing to receive hospice care through a hospice program.
• The Member has available a primary care person who will be responsible for the Member's home care.
• A physician and the hospice agency have determined that the Member's illness can be appropriately
managed in the home.
Hospice care shall mean a coordinated program of palliative and supportive care for dying Members by an
interdisciplinary team of professionals and volunteers centering primarily in the Member's home.
1. Covered Services. Care may include the following as prescribed by a physician and rendered pursuant to
an approved hospice plan of treatment:
a. Home Services
i. Intermittent care by a hospice interdisciplinary team which may include services by a physician,
nurse, medical social worker, physical therapist, speech therapist, occupational therapist,
C32811- 5685300a 28
respiratory therapist, limited services by a Home Health Aide under the supervision of a
Registered Nurse and homemaker services.
ii. Continuous care services in the Member's home when prescribed by a physician, as set forth in
this paragraph. "Continuous care" means skilled nursing care provided in the home during a
period of crisis in order to maintain the terminally ill Member at home. Continuous care may be
provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse or
Home Health Aide under the supervision of a Registered Nurse. Continuous care is covered up to
twenty -four (24) hours per day during periods of crisis. Continuous care is covered only when a
physician determines that the Member would otherwise require hospitalization in an acute care
facility.
b. Inpatient Hospice Services. For short -term care, inpatient hospice services shall be covered according
to the provisions set forth in Section IV.A.
Inpatient- respite care is- covered °for a maximum of five (5) consecutive days per occurrence in order to
continue care for the Member in the temporary absence of the Member's primary care giver(s).
c. Other covered hospice services may include the following:
i. Drugs and biologicals that are used primarily for the reliefof pain and management.
ii. Medical appliances and supplies primarily for the relief of pain and symptom management:
iii. Durable medical equipment.
iv. Counseling services for the Member andhis/her primary care- giver(s).
v. Bereavement counseling services for the family.
2. Hospice Exclusions. All services not specifically listed as covered in this section are excluded, including:
a. Financial orlegal counseling services.
b. Meal services.
c. Custodial or maintenance care in the home or on an inpatient basis, except as provided above.
d. Services not specifically listed as covered by the Agreement.
e. Any services provided by members of the patient's family.
f. Convalescent care.
G. Rehabilitation Services.
1. Rehabilitation services are covered as set forth in this section, limited to the following: =physical therapy;
occupational therapy; massage therapy and speech therapy to restore function following illness, injury or
surgery. Services are subject to all terms, conditions and limitations of the Agreement including the
following:
a. All services require a prescription from,either a MHCN or community physician and must be provided
by a MHCN- approved or Community Provider rehabilitation team that includes a physician, nurse,
physical therapist, occupational therapist, massage therapist and speech therapist.
b. Under the Community Provider option, inpatient rehabilitation services must be authorized in advance
by GHO.
c. Services are limited to those necessary to restore or improve functional abilities when physical,
sensori- perceptual and/or communication impairment exists due to injury, illness or surgery. Such
services are provided only when significant, measurable improvement to the Member's condition can
be expected within a sixty (60) day period as a consequence of intervention by covered therapy
services described in paragraph a., above.
C32811- 5685300a 29
d. Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances
Schedule.
Excluded: specialty treatment programs such as cardiac rehabilitation; inpatient Residential Treatment
services; specialty rehabilitation programs; long -term rehabilitation programs; physical therapy,
occupational therapy and speech therapy services when such services are available (whether application is
made or not) through programs offered by public school districts; therapy for degenerative or static
conditions when the expected outcome is primarily to maintain the Member's level of functioning (except
as set forth in subsection 2. below); recreational, life - enhancing, relaxation or palliative therapy;
implementation of home maintenance programs; programs for treatment of learning problems; any services
not specifically included as covered in this section; and any services that are excluded under Section V.
2. Neurodevelopmental Therapies for Children Age Six (6) and Under. Physical therapy, occupational
therapy and speech therapy services for the restoration and improvement of function for
neurodevelopmentally disabled children age six (6) and under shall be covered. Coverage includes
maintenance of a covered Member in cases where significant deterioration in the Member's condition
would result without the services. Coverage for inpatient and outpatient services is limited to the
Allowances set forth in the Allowances Schedule.
Excluded: inpatient Residential Treatment services; specialty rehabilitation programs, including "behavior
modification programs "; long -term rehabilitation programs; physical therapy, occupational therapy and
speech therapy services when such services are available (whether application is made or not) through
programs offered by public school districts; recreational, life - enhancing, relaxation or palliative therapy;
implementation of home maintenance programs; programs for treatment of learning problems; any services
not specifically included as covered in this section; and any services that are excluded under Section V.
H. Devices, Equipment and Supplies.
1. Orthopedic Appliances. Orthopedic appliances, which are attached to an impaired body segment for the
purpose of protecting the segment or assisting in restoration or improvement of its fimction.
Excluded: arch supports, including custom shoe modifications or inserts and their fittings except for
therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease; and orthopedic shoes that
are not attached to an appliance.
2. Ostomy Supplies. Ostomy supplies for the removal of bodily secretions or waste through an artificial
opening.
3. Durable Medical Equipment. Durable medical equipment is equipment which can withstand repeated use,
is primarily and customarily used to serve a medical purpose, is useful only in the presence of an illness or
injury and used in the Member's home. Durable medical equipment includes: hospital beds, wheelchairs,
walkers, crutches, canes, glucose monitors, external insulin pumps, oxygen and oxygen equipment. GHO,
in its sole discretion, will determine if equipment is made, available on a rental or purchase basis.
4. Prosthetic Devices. Prosthetic devices are items which replace all or part of an external body part, or
function thereof.
When authorized in advance, repair, adjustment or replacement of appliances and equipment is covered.
Excluded: take -home dressings and supplies following hospitalization; any other supplies, dressings,
appliances, devices or services which are not specifically listed as covered above; and replacement or repair of
appliances, devices and supplies due to loss, breakage from willful damage, neglect or wrongful use, or due to
personal preference.
I. Tobacco Cessation.
C32811- 5685300a 30
Services related to tobacco cessation are covered, limited to participation in individual or group counseling;
educational materials; and approved pharmacy products.
I Drugs, Medicines, Supplies and Devices. This benefit, for purposes of creditable coverage, is actuarially equal
to or greater than the Medicare Part D prescription drug benefit. Eligible Members who are also eligible for
Medicare Part D pharmacy benefits can remain covered under the Agreement and not be subject to Medicare -
imposed late enrollment penalties should they decide to enroll in a Medicare Part D pharmacy plan at a later
date. A Member who discontinues coverage under the Agreement must meet eligibility requirements in order to
re- enroll.
Legend medications are drugs which have been approved by the Food and Drug Administration (FDA) and
which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs,
including off -label use of FDA - approved drugs (provided that such use is documented to be effective in one of
the standard reference compendia; a majority of well- designed clinical trials ,published in peer- reviewed
medical literature document improved, efficacy or safety of the agent over standard therapies, or over placebo if
no standard therapies exist; or by the federal secretary of Health and Human . Services), contraceptive drugs and
devices, diabetic supplies; including insulin syringes, lancets, urine - testing. reagents, blood - glucose monitoring
reagents and insulin, are covered as set forth below.
The prescription drug Cost Share, as set forth in the Allowances. Schedule, applies to each thirty (30) day
supply. Cost Shares for single and multiple thirty (30) day supplies of a given prescription-are payable at the
time of delivery.
Generic drugs will be dispensed whenever available. Brand name drugs Will be dispensed, ifthere is not a
generic equivalent. In the event the Member elects to purchase brand -name drugs instead of the generic
equivalent (if available), or if the Member elects to purchase a different brand - name or generic drug than that
prescribed by the Member's Provider, and it is not determined to be Medically Necessary, the Member will also
be subject to payment of the additional amount above: the applicable- pharmacy CostShare,set forth in the
Allowances Schedule. .A generic drug is defined as.a drug that is the pharmaceutical:equivalent to, one or more
brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the
same standards of safety, purity, strength and effectiveness as the brand name drug: A;brand name drug is
defined as a prescription drug that has been patented and is only available through one manufacturer.
"Standard reference compendia" means the American Hospital Formulary Service -Drug Information; the
American Medical Association. Drug Evaluation; the United States Pharmacopoeia -Drug Information, or other
authoritative compendia as identified from time to time by the federal secretary of Health and Human Services.
"Peer- reviewed medical literature" means scientific studies printed in healthcare journals or other publications
in which original manuscripts are published only -after having been critically reviewed for scientific accuracy,
validity and reliability by unbiased independent experts. Peer - reviewed medical literature does not include in-
house publications of pharmaceutical .manufacturing companies.
Under the MHCN option; all drugs, supplies, medicines and devices must be obtained at a MHCN pharmacy
and, unless approved by GHO in advance, be listed in the GHO drug formulary. Injectables that can be self-
administered also subjectto the prescription drug Cost Share. Drug formulary (approved-drug list) is defined
as a list of preferred pharmaceutical products, supplies and devices developed and maintained by` GHO'
Under the Community Provider option,`all drugs, supplies, medicines and devices must be'obtained at a
Contracted Network Pharmacy, except when a Contracted Network Pharmacy is not available within a thirty
(30) mile radius or for drugs dispensed by a provider for Emergency care.
Excluded: over - the - counter drugs, medicines, supplies and devices not requiring a prescription under state law
or regulations; drugs used in the treatment of sexual dysfimction disorders; medicines and injections for
anticipated illness while traveling; vitamins, including Legend (prescription) vitamins; any exclusion of drugs,
medicines and injectables, will also exclude their administration.
C32811- 5685300a 31
The Member will be charged for replacing lost or stolen drugs, medicines or devices.
The Member's Right to Safe and Effective Pharmacy Services.
State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee
Members' right to know what drugs are covered under the Agreement and what coverage limitations are in the
Agreement. Members who would like more information about the drug coverage policies under the Agreement,
or have a question or concern about their pharmacy benefit, may contact GHO at (206) 9014636 or (888) 901-
4636.
Members who would like to know more about their rights under the law, or think any services received while
enrolled may not conform to the terms of the Agreement, may contact the Washington State Office of Insurance
Commissioner at (800) 562 -6900. Members who have a concern about the pharmacists or pharmacies serving
them, may call the Washington State Department of Health at (800) 525 -0127.
K Mental Health Care Services. Services that are provided by a mental health practitioner will be covered as
mental health care, regardless of the cause of the disorder.
1. Outpatient Services. Outpatient mental health services place priority on restoring the Member to his/her
level of functioning prior to the onset of acute symptoms or to achieve a clinically appropriate level of
stability as determined by GHO's Medical Director, or his/her designee. Treatment for clinical conditions
may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives.
Coverage for each Member is provided according to the outpatient mental health care Allowance set forth
in the Allowances Schedule. Psychiatric medical services, including medical management and
prescriptions, are covered as set forth in Sections IV.B. and IV.J.
Under'the Community Provider option, outpatient mental health services are limited to the services
rendered by a physician (licensed under RCW 18.71 and RCW 18.57); a psychologist (licensed under RCW
1 &83);�a community mental health agency licensed by the Washington State Department of Social and
Health Services (pursuant to RCW 71.24); a master's level therapist (licensed under RCW 18.225.090), an
advanced practice psychiatric nurse (licensed under RCW 18.79) or, in the case of non - Washington State
providers, those providers meeting equivalent licensing and certification requirements established in the
state where the provider's practice is located.
2. Inpatient Services. Charges for services described in this section, including psychiatric Emergencies
resulting in inpatient services, are covered as set forth in the Allowances Schedule. This benefit shall
include coverage for acute treatment and stabilization of psychiatric Emergencies provided in a (a) MHCN-
approved hospital under the MHCN option, and (b) hospital or facility approved specifically for treatment
of mental or nervous disorders under the Community Provider option. Under the Community Provider
option, all inpatient mental health care must be authorized in advance by GHO.
Services provided under involuntary commitment statutes shall be covered at facilities approved by GHO.
Services for any involuntary court- ordered treatment program beyond seventy-two (72) hours shall be
covered only if determined to be Medically Necessary by GHO's Medical Director, or his/her designee.
Coverage for voluntary/involuntary Emergency inpatient psychiatric services is subject to the Emergency
care benefit set forth in Section IV.L., including the twenty-four (24) hour notification and transfer
provisions.
Outpatient electro- convulsive therapy treatment is covered subject to the outpatient surgery Cost Share.
Under the Community Provider option, inpatient mental health services are limited to the services rendered
by a physician (licensed under RCW 18.71 and RCW 18.57); a psychologist (licensed under RCW 18.83);
a community mental health agency licensed by the Washington State Department of Social and Health
C32811- 5685300a 32
Services (pursuant to RCW 71.24); a master's level therapist (licensed under RCW 18.225.090), an
advanced practice psychiatric nurse (licensed under RCW 18.79) or, in the case of non - Washington State
providers, those providers meeting equivalent licensing and certification requirements established in the
state where the provider's practice is located.
3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services. Covered
Services are limited to those authorized by (a) GHQ's Medical Director, or his/her designee under the
MHCN option, or (b) the attending mental health provider and GHO's Medical Director, or his/her
designee, under the Community Provider option, for covered clinical conditions for which the reduction or
removal of acute clinical symptoms or stabilization can be expected given the most clinically appropriate
level of mental health care intervention.
Excluded: inpatient Residential Treatment services; learning, communication and motor skills disorders;
mental retardation; academic or career counseling; sexual and identity disorders; and personal growth or
relationship enhancement. Also excluded: assessment and treatment services that are primarily vocational
and academic; court- ordered or forensic treatment, including reports and summaries, not considered
Medically Necessary; work or school ordered assessment and treatment not considered Medically
Necessary; counseling for overeating; specialty treatment programs such as "behaviormodrication
programs'; relationship counseling or phase of life problems (V code only diagnoses); and custodial care.
Any other services not specifically listed as covered in this section. All other provisions, exclusions and
limitations under the Agreement also apply.
L. Emergency/Urgent Care.
All services are covered subject to the Cost Shares set forth in the Allowances Schedule.
Emergency Care (See Section VIII. for a definition of Emergency.)
1. At a MHCN Facility. GHO will cover Emergency care for all Covered Services.
Inpatient Emergency care received.at a:MHCN Facility is also subject to:
a. Notification of GHO by way of the GHO Notification Line within twenty-four (24) hours following
inpatient admission, or as soon thereafter as medically possible;
b. Transfer of care to a MHCN Provider; and
c. Transfer to another MHCN Facility if transferability is medically possible as determined by the
MHCN.
2. At a Non -MHCN Facility. Usual, Customary and Reasonable charges for Emergency care for Covered
Services are covered subject to:
a. Payment of the Emergency care Cost Share; and
b. Notification of GHO by way of the GHO Notification Line within twenty-four (24) hours following
inpatient admission, or as soon thereafter as medically possible.
3. Waiver of Emergency Care Cost Share.
a. Waiver for Multiple Injury Accident. If two or more Members in the same Family Unit require
Emergency care as a result of the same accident, coverage for all Members will be subject to only one
(1) Emergency care Copayment.
b. Emergencies Resulting in an Inpatient Admission. If the Member is admitted to a MHCN Facility
directly from the emergency room, the Emergency care Copayment is waived. However, coverage will
be subject to the inpatient services Cost Share.
C32811- 5685300a 1 33
4. Transfer and Follow -up Care. If a Member is hospitalized in a non -MHCN Facility, GHO reserves the
right to require transfer of the Member to a MHCN Facility, upon consultation between a MHCN Provider
and the attending physician. If the Member refuses to transfer to a MHCN Facility, all services received
will be covered under the Community Provider option of the Inpatient Hospital Services section set forth in
the Allowances Schedule.
Under the MHCN option, follow -up care which is a direct result of the Emergency must be received from
MHCN Providers, unless a MHCN Provider has authorized such follow -up care from a non -MHCN
Provider in advance. Follow -up care for services received under the Community Provider option, that is a
direct result of the Emergency, is covered subject to the Cost Shares set forth in the Allowances Schedule.
Urgent Care (See Section VIII. for a definition of Urgent Condition.)
Under the MHCN option, care for Urgent Conditions is covered at MHCN medical centers, MHCN urgent care
clinics or MHCN Providers' offices, subject to the applicable Cost Share. Urgent care received at any hospital
emergency department is not covered unless authorized in advance by a MHCN Provider.
Under the Community Provider option, charges for Urgent Conditions received at any medical facility are
covered subject to the applicable Cost Share.
M. Ambulance.Services.
1. Emergency Transport to any Facility. Each Emergency is covered as set forth in the Allowances
Schedule. Ambulance services under the MHCN option are covered provided that the service is authorized
in advance by GHO or meets the definition of an Emergency (see Section VIII.).
2. Interfacility Transfers.
a. MHCN- Initiated Transfers. MHCN- initiated non- emergent transfers to or from a MHCN Facility are
covered as set forth in the Allowances Schedule.
b. Community Provider- Initiated Transfers. When prescribed by the attending physician, transport
from a medical facility to the nearest facility equipped to render further Medically Necessary treatment
is covered as set forth in the Allowances Schedule.
N. Skilled Nursing Facility (SNF). Skilled nursing care in a GHO- approved skilled nursing facility when full -
time skilled nursing care is necessary in the opinion of the attending physician, is covered as set forth in the
Allowances Schedule. Under the Community Provider option, skilled nursing care must be authorized in
advance by GHO.
When prescribed by the Member's physician, such care may include room and board; general nursing care;
drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility; and
short-term physical therapy, occupational therapy and restorative speech therapy.
Excluded: personal comfort items such as telephone and television, rest cures and custodial, domiciliary or
convalescent care.
Section V. General Exclusions
In addition to exclusions listed throughout the Agreement, the following are not covered:
1. Services or supplies not specifically listed as covered in the Schedule of Benefits, Section IV.
2. Follow -up services related to a non - Covered Service.
3. Complications of non - Covered Services.
C32811- 5685300a 34
4. Services or supplies for which no charge is made, or for which a charge would not have been made if the
Member had no health care coverage or for which the Member is not liable; services provided by a member of
the Member's family.
5. Convalescent or custodial care.
6. Services rendered as a result of work - related injuries, illnesses or conditions, including injuries, illnesses or
conditions incurred as a result of self - employment.
7. Those parts of an examination and associated reports and immunizations required for employment, unless
otherwise noted in Section IV.B., immigration, license, travel or insurance purposes that are not deemed
Medically Necessary by GHO for early detection of disease.
8. Services and supplies related to sexual reassignment surgery,! such as sex change operations or transformations
and procedures or treatments designed to alter physical characteristics.
9. Diagnostic testing and medical treatment of sterility, infertility and sexual dysfunction, regardless of origin or
cause, unless otherwise noted in Section IV.B.
10. Obesity treatment and treatment for morbid obesity, including any medical services, drugs; supplies or any
bariatric surgery (such as gastroplasty, gastric banding or intestinal bypass), regardless of co- morbidities,
specialty treatment programs_such as weight reduction, of obesity or any other Medical
Condition, except as set forth in Section IV.B.
11. Any services to the extent benefits are "available" to the Member as defined herein under the terms of any
vehicle, homeowner's, property or other insurance policy, except for individual or ' 'health insurance,
whether the Member asserts a claim or not, pursuant to medical coverage, medical "no fault' coverage, Personal
Injury' Protection coverage or similar medical coverage contained 'in''said'policy.`For'the purpose '6f this
exclusion, benefits shall be deemed to be "available tome Member if the Member is a natned insured, comes
within the policy definition of insured, or otherwise has the right to receive benefits under the policy.
The Member and his/her agents' must cooperate fully with GHO in its efforts to this exclusion. This
cooperation shall include supplying GHO with information about; or'related to the cause of injury or illness or
the availability of other coverage. The Member and his/her agent shall permit GHO, at GHQ's option, to
associate with the Member or to intervene in any action filed against any party related to the injury. The
Member and his/her agents shall do nothing to prejudice GHQ's right to enforce this exclusion. Failure to fully
cooperate, including withholding information regarding the cause of injury or illness or other coverage may
result in denial of claims and the Member shall be responsible for reimbursing GHO for expenses incurred and
the value of the benefits provided by GHO under this Agreement for the care or treatment of the injury or illness
sustained by the Member. x
If this Agreement is not subject to ERISA and reasonable °collections costs` (attorney fees and costs) have been
incurred by an attorney for the Injured Person in connection with obtaining recovery under underinsured or
uninsured motor coverage, under certain conditions GHO will not enforce this exclusion until a reduction
from benefits "available" to the Member is made by the amount of an equitable apportionment of such
collection costs between GHO and the Injured Person. This reduction will be made only if each of the following
conditions has been met: (i) GHO receives a list of the fees and associated costs before settlement and (ii) the
Injured Person's attorney's actions were reasonable and necessary to secure recovery.
12. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such
injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries
resulting from previous military service unless the condition has been determined by the U.S. Secretary of
Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will
not be interpreted to interfere with or preclude coordination of benefits under Tri -Care.
C32811- 5685300a 35
13. Services provided by government agencies, except as required by federal or state law.
14. Services covered by the national health plan of any other country.
15. Experimental or investigational services.
GHO consults with GHQ's Medical Director and then uses the criteria described below to decide if a particular
service is experimental or investigational.
a. A service is considered experimental or investigational for a Member's condition if any of the following
statements apply to it at the time the service is or will be provided to the Member.
i. The service cannot be legally marketed in the United States without the approval of the Food and Drug
Administration ( "FDA ") and such approval has not been granted.
ii. The service is the subject of a current new drug or new device application on file with the FDA.
iii. The service is provided as part of a Phase I or Phase II clinical trial, as the experimental or research
arm of a Phase III clinical trial, or in any other manner that is intended to evaluate the safety, toxicity
or efficacy of the service.
iv. The service is provided pursuant to a written protocol or other document that lists an evaluation of the
service's safety, toxicity or efficacy as among its objectives.
v. The service is under continued scientific testing and research concerning the safety, toxicity or efficacy
of services.
vi. The service is provided pursuant to informed consent documents that describe the service as
experimental or investigational, or in other terms that indicate that the service is being evaluated for its
safety, toxicity or efficacy.
vii. The prevailing opinion among experts, as expressed in the published authoritative medical or scientific
literature, is that (1) the use of such service should be substantially confined to research settings, or (2)
further research is necessary to determine the safety, toxicity or efficacy of the service.
b. The following sources of information will be exclusively relied upon to determine whether a service is
experimental or investigational:
i. ._The. Member's medical records,
ii. The written protocol(s) or other documents) pursuant to which the service has been or will be
provided,
iii. Any consent document(s) the Member or Member's representative has executed or will be asked to
execute, to receive the service,
iv. The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews
research at the institution where the service has been or will be provided, and other information
concerning the authority or actions of the IRB or similar body,
v. The published authoritative medical or scientific literature regarding the service, as applied to the
Member's illness or injury, and
vi. Regulations, records, applications and any other documents or actions issued by, filed with or taken by,
the FDA or other agencies within the United States Department of Health and Human Services, or any
state agency performing similar functions.
Appeals regarding GHO denial of coverage can be submitted to the Member Appeal Department, or to GHQ's
Medical Director at P.O. Box 34593, Seattle, WA 98124 -1593.
16. Hypnotherapy, and all services related to hypnotherapy.
17. Genetic testing and related services, unless determined Medically Necessary by GHQ's Medical Director, or
his/her designee, and in accordance with Board of Health standards for screening and diagnostic tests, or
specifically provided in Section IV.B. Testing for non - Members is also excluded.
18. Routine foot care, except in the presence of a non - related Medical Condition affecting the lower limbs.
19. Autopsy and associated expenses.
C32811- 5685300a 36
Section VI. Grievance Processes for Complaints and Appeals
The grievance processes to express a complaint and appeal a GHO denial of benefits are set forth below.
Filing a Complaint or Appeal
The complaint process is available for a Member to express dissatisfaction about customer service or the quality or
availability of a health service.
The appeals process is available for a Member to seek reconsideration of a' denial of benefits.
Complaint Process
Step 1: The Member should contact the person involved, °explaiwhis/her concerns and what he /she would like to
have done to resolve the problem. The Member should be specific and make his/her position clear.
Step 2: If the Member is not satisfied, or if he /she prefers not to talk with the person involved, the Member should
call the department head or the manager of the medical center or department where he /she is having a problem. That
person will investigate the Member's concerns. Most concerns can be resolved in this way.
Step 3: If the Member is still not satisfied, he /she shouldcall'the GHO Customer Service Center toll free at (888)
9014636. Most concerns are handled by phone within a few days. In some cases the Member will be asked to write
down his/her concerns and state what he /she thinks would be a fair resolution to the problem. A Customer Service
Representative or Member Quality of Care Coordinator will investigate the Member's concern by consulting with
involved staff and their supervisors, and reviewing pertinent records, relevantplan policies and the Member Rights
and Responsibilities statement. This process can take tip to thirty (30) days to resolve after receipt of the Member's
written statement.
If the Member is dissatisfied with the resolution of the complaint, he /she may °c6hiact the MemberQuality. of Care
Coordinator or the Customer Service Center.
Appeals Process
The U.S. Department of Health and Human Services has designated the Washington State Office of the
Insurance Commissioner's Consumer Protection Division as the health insurance consumer ombudsman. The
Consumer Protection Division Office cad be reached by mail at Washington State Insurance Commissioner,
Consumer Protection Division, P.O. Box 40256, Olympia,' WA W504-0256 or toll free at (800) 562 -6900. More
information about requesting assistance from the Consumer Protection Division Office can be found at
http: / /www. insurance- wa.pov/ consumers / health /apneallTable- ofContents.shtm
If the Member requests an appeal of a GHO decision denyingjbertefits, GHO will continue to provide coverage
for the disputed benefit pending the outcome of the appeal. If the GHO determination stands, the Member may be
responsible for the cost of coverage received during the review period. The decision at the next level of appeal is
binding unless other `remedies are available under' state or federal law.` GHO must provdebenefits,`including
making payment on a claim, pursuant to the fmal external review decision wthoutdelay, regardless of whether
GHO intends to seek judicial review of the external review decision, and unless or until there is a judicial
decision changing the final determination.
Initial Appeal
If the Member wishes to appeal a GHO decision denying benefits, he /she must submit a request for an appeal either
orally or in writing to GHQ's Member Appeal Department, specifying why he /she disagrees with the decision. The
appeal must be submitted within 180 days of the denial notice he /she received. Appeals should be directed to GHQ's
Member Appeal Department, P.O. Box 34593, Seattle, WA 98124-1593, toll free (866) 458 -5479.
C32811- 5685300a 37
An Appeal Coordinator will review initial appeal requests. GHQ will then notify the Member of its determination or
need for an extension of time within fourteen (14) days of receiving the request for appeal. Under no circumstances
will the review timeframe exceed thirty (30) days without the Member's written permission.
There is an expedited appeals process in place for cases which meet criteria or where the Member's provider
believes that the standard appeal review process will seriously jeopardize the Member's life, health or ability to
regain maximum function or subject the Member to severe pain that cannot be managed adequately without the
requested care or treatment. The Member can request an expedited appeal in writing to the above address, or by
calling GHQ's Member Appeal Department toll free (866) 458 -5479. The Member's request for an expedited appeal
will be processed and a decision issued no later than seventy -two (72) hours after receipt of sufficient information to
determine whether, or to what extent, benefits are covered or payable under the Agreement. For expedited appeals,
the Member has the right to request an appeal through GHQ's Member Appeal Department and a review by an
independent review organization concurrently.
Next Level of Appeal
If the Member is not satisfied with the decision regarding a GHO denial of benefits, or if GHO fails to adhere to the
requirements of the appeals process, the Member may request a second level review by an external independent
review organization as set forth under subsection A. below. The Member may also choose to pursue review by an
appeal committee prior to requesting a review by an independent review organization as set forth under subsection
B. below. The optional appeal committee review is not a required step in the appeals process.
A. Request a review by an independent review organization. An independent review organization is not legally
affiliated or controlled by GHO. Once a decision is made through an independent review organization, the
decision is final and cannot be appealed through GHO.* If the independent review organization overturns
GHO's coverage decision, GHO will promptly comply and notify the Member.
A request for a review by an independent review organization must be made within 180 days after the date of
the initial appeal decision notice, or within 180 days after the date of a GHO appeal committee decision notice.
GHO will provide the independent review organization all of the Member's case information within three (3)
business days from the date of the request. The Member has five (5) business days, from the date the Member
received notice that the appeal was sent to an IRO, to submit in writing, directly to the IRO, any additional
information to be considered in the review.
The Member may request an expedited external review if the decision regarding a GHO denial of benefits
concerns an admission, availability of care, continued stay, or health care service for which the Member
received emergency services but has not been discharged from a facility; or involves a medical condition for
which the standard external review time frame of forty-five (45) days would seriously jeopardize the life or
health of the Member or jeopardize the Member's ability to regain maximum function. The independent review
organization must make its decision to uphold or reverse the decision and notify the Member and GHO of the
determination as promptly as possible but within not more than seventy -two (72) hours after the receipt of the
request for expedited external review. If the notice is not in writing, the independent review organization must
provide written confirmation of the decision within forty -eight (48) hours after the date of the notice of the
decision.
For claims involving experimental or investigational treatments, the internal review organization must ensure
that adequate clinical and scientific experience and protocols are taken into account as part of the external
review process.
B.. Request an optional hearing by the GHO appeal committee:
The appeal committee hearing is an informal process. The hearing will be conducted within thirty (30) working
days of the Member's request and notification of the appeal committee's decision will be mailed to the Member
within five (5) working days of the hearing.
Members electing the appeal committee maintain their right to appeal further to an independent review
organization as set forth in subsection A. above.
C32811- 5685300a 38
Review by the appeal committee is not available if the appeal request is for an experimental or investigational
exclusion or limitation.
A request for a hearing by the appeal committee must be made within thirty (30) days after the date of the initial
appeal decision notice. The request can be mailed to GHO's Member Appeal Department, P.O. Box 34593,
Seattle, WA 98124 -1593. *
* If the Member's health plan is governed by the Employee Retirement Income Security Act, known as "ERISA"
(most employment related health plans, other than those sponsored by governmental entities or churches — ask
employer about plan), the Member has the right to file a lawsuit under Section 502(a) of ERISA to recover benefits
due to the Member, under the plan at any point after completion of the initial appeal process. Members may have
other legal rights and remedies available under state or federal law.
Section VII. General Provisions
A. Coordination of Benefits
The coordination of benefits (COB) provision applies when a Member has health care coverage under more
than one plan. Plan is defined below.
The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The
plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms
withoutsegard to the -possibility that another plan may .coversome expenses. The..plan that.pays after the
primary plan is the secondary plan. The secondary plan must pay an amount which, together with the payment
made by the primary plan, totals the allowable expense. In no event will a secondary plan be required to pay an
amount in excess of its maximum benefit plus accrued savings.
If the Member is covered by more than one health benefit plan, the Member or fhe Member's provider should
file all`the Member's claims with each plan at the same timer If Medicare is`the Member's primary plan,
Medicare may submit the Member's claims to the Member's secondary carrier.
1. Definitions.
a. Plan. A plan is any of the following that provides benefits or services for medical or dental care or
treatment. If separate contracts are used to provide coordinated coverage 'for Members of a Group, the
separate contracts are considered parts of the same plan and there is no COB among those separate
contracts. However, if COB rules do not apply to all contracts, or to' all benefits in the same contract,
the'contract or benefit to which COB does not apply is treated as a separate, plan.
1) Plan includes: group, individual or blanket disability ' insurance contracts and group or individual
contracts issued by health' care service contractors or health maintenance organizations (HMO),
closed panel plans or other forms of group coverage; medical care components of long -term care
contracts, such as skilled nursing care; and Medicare or any other federal governmental plan, as
permitted by law.
2) Plan does not include: hospital indemnity or fixed payment coverage or other fixed'indemnity or
fixed payment coverage; accident only coverage; specified disease or specified accident coverage;
limited benefit health coverage, as defined`by state law; school accident type coverage; benefits
for non- medical components of long -term, care policies; automobile insurance policies required by
statute to provide medical benefits; Medicare supplement' policies; Medicaid coverage; or
coverage under other federal governmental plans; unless permitted by law.
Each contract for coverage under subsection 1) or 2) is a separate plan. If a plan has two parts and
COB rules apply only to one of the two, each of the parts is treated as a separate plan.
C32811- 5685300a 39
b. This plan means, in a COB provision, the part of the contract providing the health care benefits to
which the COB provision applies and which may be reduced because of the benefits of other plans.
Any other part of the contract providing health care benefits is separate from this plan. A contract may
apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar
benefits, and may apply another COB provision to coordinate other benefits.
The order of benefit determination rules determine whether this plan is a primary plan or secondary
plan when the Member has health care coverage under more than one plan.
When this plan is primary, it determines payment for its benefits first before those of any other plan
without considering any other plan's benefits. When this plan is secondary, it determines its benefits
after those of another plan and must make payment in an amount so that, when combined with the
amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal
100% of the total allowable expense for that claim. This means that when this plan is secondary, it
must pay the amount which, when combined with what the primary plan paid, totals 100% of the
allowable expense. In addition, if this plan is secondary, it must calculate its savings (its amount paid
subtracted from the amount it would have paid had it been the primary plan) and record these savings
as a benefit reserve for the covered Member. This reserve must be used by the secondary plan to pay
any allowable expenses not otherwise paid, that are incurred by the covered person during the claim
determination period.
d. Allowable Expense. Allowable expense is a health care expense, coinsurance or copayments and
without reduction for any applicable deductible, that is covered at least in part by any, plan covering the
person. When a plan provides benefits in the form of services, the reasonable cash value of each
service will be considered an allowable expense and a benefit paid. An expense that is not covered by
any plan covering the Member is not an allowable expense.
The following are examples of expenses that are not allowable expenses:
1) The difference between the'cost of a semi- private hospital room and a private hospital room is not
an allowable expense, unless one of the plans provides coverage for private hospital room
expenses.
2) If a Member is covered by two or more plans that compute their benefit payments on the basis of
usual and customary fees or relative value schedule reimbursement method or other similar
reimbursement method, any amount in excess of the highest reimbursement amount for a specific
benefit is not an allowable expense.
3) If a Member is covered by two or more plans that provide benefits or services on the basis of
negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable
expense.
4) An expense or a portion of an expense that is not covered by any of the plans covering the person
is not an allowable expense.
e. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services
through a panel of providers who are primarily employed by the plan, and that excludes coverage for
services provided by other providers, except in cases of emergency or referral by a panel member.
f. Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is
the parent with whom the child resides more than one half of the calendar year excluding any
temporary visitation.
2. Order of Benefit Determination Rules.
When a Member is covered by two or more plans, the rules for determining the order of benefit payments
are as follows:
C32811- 5685300a 40
a. The primary plan pays or provides its benefits according to its terms of coverage and without regard to
the benefits under any other plan.
b. Except as provided below, a plan that does not contain a coordination of benefits provision that is
consistent with this chapter is always primary unless the provisions of both plans state that the
complying plan is primary.
Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of
a basic package of benefits and provides that this supplementary coverage is excess to any other parts
of the plan provided by the Subscriber. Examples include major medical coverages that are
superimposed over hospital and surgical benefits, and insurance type coverages that are written in
connection with a closed panel plan to provide out -of- network benefits.
c. A plan may consider the`benefits paid or provided by another plan in calculating payment of its
benefits`only when it is secondary to that other plan.
d. Each plan determines its order of benefits using the first of the following rules that apply:
1) Non- Dependent or Dependent. The plan that covers the Member other than as a Dependent, for
example as an employee, member, policyholder, Subscriber or retiree is the primary plan and the
plan that covers the Member as a Dependent is the secondary plan. However, if the person is a
Medicare beneficiary and, as a result of federal law, Medicare is secondary to the plan covering
the Member as a Dependent, and primary to the plan covering the Member as other than a
Dependent (e.g., a retired employee), then the order of benefits between the two plans is reversed
so that the plan covering the Member as an employee, member, policyholder, Subscriber or retiree
is the secondary plan and the other plan is the primary plan.
2) Dependent child covered under more than one plan. Unless there is a court decree stating
otherwise, when a dependent child is covered by more than one plan the order of benefits is
determined as follows: ..
a) For a dependent child whose parents are married or are living together, whether or not they
have ever been married:
• The plan of the parent whose birthday falls earlier in the calendar year is the primary
plan; or
• If both parents have the same birthday, the plan that has covered the parent the longest is
the primary plan.
b) For a dependent child whose parents are divorced or separated or not living together, whether
or not they have ever been married:
(1) If a court decree states that one of the parents is responsible for the dependent child's
health care expenses or health care coverage and the plan of that parent has actual
knowledge of those terms; that plan is primary. This rule applies to claim determination
periods commencing after the plan is given notice ofthe court decree; '
(2)` If a courtidecree states one is to assume primary financial responsibility for the
dependent child but does not mention responsibility for health care expenses, the plan of
" r
Aent assumin financial ' res onsibili is
p . r . gm p �;� IfiftiarY; .
(3) If a court decree states that both parents are'responsible for the dependent child's health
care expenses or health care coverage, the provisions of a) above determine the order of
benefits;
(4) If a court decree states that the parents have joint custody without specifying that one
parent has responsibility for the health care expenses or health care coverage of the
dependent child, the provisions of subsection a) above determine the order of benefits; or
(5) If there is no court decree allocating responsibility for the dependent child's health care
expenses or health care coverage, the order of benefits for the child are as follows:
• The plan covering the custodial parent, first;
032811- 5685300a 1 41
• The plan covering the spouse of the custodial parent, second;
• The plan covering the non - custodial parent, third; and then
• The plan covering the spouse of the non - custodial parent, last.
c) For a dependent child covered under more than one plan of individuals who are not the
parents of the child, the provisions of subsection a) or b) above determine the order of benefits
as if those individuals were the parents of the child.
3) Active employee or retired or laid -off employee. The plan that covers a Member as an active
employee, that is, an employee who is neither laid off nor retired, is the primary plan. The plan
covering that same Member as a retired or laid off employee is the secondary plan. The same
would hold true if a Member is a Dependent of an active employee and that same Member is a
Dependent of a retired or laid -off employee. If the other plan does not have this rule, and as a
result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply
if the rule under section d 1) can determine the order of benefits.
4) COBRA or State Continuation Coverage. If a Member whose coverage is provided under COBRA
or under a right of continuation provided by state or other federal law is covered under another
plan, the plan covering the Member as an employee, member, Subscriber or retiree or covering the
Member as a Dependent of an employee, member, Subscriber or retiree is the primary plan and the
COBRA or state or other federal continuation coverage is the secondary plan. If the other plan
does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is
ignored. This rule does not apply if the rule under section d 1) can determine the order of benefits.
5) " Longer or shorter length of coverage. The plan that covered the Member as an employee, member,
Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter
period of time is the secondary plan.
" 6) '' If the preceding rules do not determine the order of benefits, the allowable expenses must be
shared equally between the plans meeting the definition of plan. In addition, this plan will not pay
more than it would have paid had it been the primary plan.
3. Effect on the Benefits of this Plan.
When this plan is secondary, it must make payment in an amount so that, when combined with the amount
paid by the primary plan, the total benefits paid or provided by all plans for the claim equal one hundred
percent of the total allowable expense for that claim. However, in no event shall the secondary plan be
required to pay an amount in excess of its maximum benefit plus accrued savings. In no event should the
Member be responsible for a deductible amount greater than the highest of the two deductibles. Total
allowable expense is the highest allowable expenses of the primary plan or the secondary plan. In addition,
the secondary plan must credit to its plan deductible any amounts it would have credited to its deductible in
the absence of other health care coverage.
4. Right to Receive and Release Needed Information.
Certain facts about health care coverage and services are needed to apply these COB rules and to determine
benefits payable under this plan and other plans. GHO may get the facts it needs from or give them to other
organizations or persons for the purpose of applying these rules and determining benefits payable under this
plan and other plans covering the Member claiming benefits. GHO need not tell, or get the consent of, any
Member to do this. Each Member claiming benefits under this plan must give GHO any facts it needs to
apply those rules and determine benefits payable.
5. Facility of Payment.
If payments that should have been made under this plan are made by another plan, GHO has the right, at its
discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this
C32811- 5685300a " 42
provision. The amounts paid to the other plan are considered benefits paid under this plan. To the extent of
such payments, GHO is fully discharged from liability under this plan.
6. Right of Recovery.
GHO has the right to recover excess payment whenever it has paid allowable expenses in excess of the
maximum amount of payment necessary to satisfy the intent of this provision. GHO may recover excess
payment from any person to whom or for whom payment was made or any other issuers or plans.
Questions about Coordination of Benefits? Contact the State Insurance Department.
7. Effect of Medicare.
Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer
status, and will be adjudicated by GHO as set forth in this section. When Medicare, Part A and Part B or
Part C are primary, Medicare's allowable amount is the highest allowable expense.
When the MHCN renders care to a Member who is eligible for Medicare benefits, and Medicare is
deemed to be the primary bill payer under Medicare secondary payer guidelines and regulations, GHO
will seek Medicare reimbursement for all Medicare covered services.
b. When a Member, who is a Medicare beneficiary and for whom Medicare has been determined to be the
primary bill payer under Medicare secondary payer guidelines and regulations, seeks care from
Community Providers, GHO has no obligation to provide any benefits except as specifically outlined
in the Community Provider option under Section IV.
B. Subrogation and Reimbursement Rights
The benefits under this Agreement will be available to a Member for injury or illness caused by another party,
subject to the and, imitations. of this Agreement. If GHO provides benefits<under this Agreement for
the treatment of the injury or illness, GHO will be subrogated to any rights that the Member-may have to
recover compensation or damages related to the injury or illness and the Member shall reimburse GHO for all
benefits provided, from any amounts the Member received or is entitled to receive from any source on
account of such injury or illness, whether by suit, settlement or otherwise. This section VII.B. more fully
describes GHO's subrogation and reimbursement rights.
"Injured Person's under this section means a Member covered by the Agreement who sustains an injury or
illness and any spouse, dependent or other person or entity that may recover on behalf of such Member
including the estate, of the Member and, if the Member is a minor, the guardian or parent of the Member. When
referred to in this section, "GHQ's Medical Expenses" means the expenses incurred and the value of the benefits
provided. by GHO under this Agreement. for the care or treatment of the injury or illness sustained by the
Injured Person.
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal liability against the
third party and/or payment by the third party to the Injured Person and/or a settlement between the third party
and the Injured Person, GHO shall have the right to recover GHO's Medical Expenses from any source available
to the Injured`Person as a result of the events causing the injury, including but not limited to fimds available
through applicable third party liability coverage and uninsured/underinsured motorist coverage. This right is
commonly referred to as "subrogation. "' GHO shall be subrogated to and may enforce all rights of the Injured
Person to the full extent of GHO's Medical Expenses.
GHQ's subrogation and reimbursement rights shall be limited to the excess of the amount required to fully
compensate the Injured Person for the Ioss sustained, including general damages.
C32811- 5685300a 43
Subject to the above provisions, if the Injured Person is entitled to or does receive money from any source as
result of the events causing the injury or illness, including but not limited to any liability insurance or
uninsured/underinsured motorist funds, GHQ's Medical Expenses are secondary, not primary.
The Injured Person and his/her agents shall cooperate fully with GHO in its efforts to collect GHO's Medical
Expenses. This cooperation includes, but is not limited to, supplying GHO with information about the cause of
injury or illness, any potentially liable third parties, defendants and/or insurers related to the Injured Person's
claim and informing GHO of any settlement or other payments relating to the Injured Person's injury. The
Injured Person and his/her agents shall permit GHO, at GHO's option, to associate with the Injured Person or to
intervene in any legal, quasi - legal, agency or any other action or claim filed. If the Injured Person takes no
action to recover money from any source, then the Injured Person agrees to allow GHO to initiate its own direct
action for reimbursement or subrogation.
The Injured Person and his/her agents shall do nothing to prejudice GHO's subrogation and reimbursement
rights. The Injured Person shall promptly notify GHO of any tentative.settlement with a third party and shall not
settle a claim without protecting GHQ's interest. If the Injured Person fails to cooperate fully with GHO in
recovery of GHO's Medical Expenses, the Injured Person shall be responsible for directly reimbursing GHO for
100% of GHQ's Medical Expenses.
To the extent that the Injured Person recovers fiords from any source that may serve to compensate for medical
injuries or medical expenses, the Injured Person agrees to hold such monies in trust or in a separate identifiable
account until GHQ's subrogation and reimbursement rights are fully determined and that GHO has an
equitable lien over such monies to the full extent of GHO's Medical Expenses and/or the Injured Person
agrees to serve as constructive trustee over the monies to the extent of GHO's Medical Expenses.
If this Agreement is not subject to ERISA and reasonable collections costs have been incurred by an attorney for
the Injured Person in connection with obtaining recovery, under certain conditions GHO will reduce the amount
of reimbursement to GHO by the amount of an equitable apportionment of such collection costs between GHO
and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i)
GHO receives a list of the fees and associated costs before settlement and (ii) the Injured Person's attorney's
actions were reasonable and necessary to secure recovery.
If this Agreement is subject to ERISA and reasonable collections costs have been incurred by the Injured Person
for the benefit of GHO, under special circumstances, the Injured Person may request and GHO may agree to
reduce the amount of reimbursement to GHO by an amount for reasonable and necessary attorney's fees and
costs incurred by the Injured Person on behalf of and for the benefit of GHO, but only if such amount is agreed
to in writing by GHO prior to settlement or recovery.
To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA,
implementation of this section shall be deemed a part of claims administration under the Agreement and GHO
shall therefore have discretion to interpret its terms.
C. Miscellaneous Provisions
1. Identification Cards. GHO will furnish cards, for identification purposes only, to all Members enrolled
under the Agreement.
2. Administration of Agreement. GHO may adopt reasonable policies and procedures to help in the
administration of the Agreement. This may include, but is not limited to, policies or procedures pertaining
to benefit entitlement and coverage determinations.
3. Modification of Agreement. No oral statement of any person shall modify or otherwise affect the benefits,
limitations and exclusions of the Agreement, convey or void any coverage, increase or reduce any benefits
under the Agreement or be used in the prosecution or defense of a claim under the Agreement.
C32811- 5685300a 44
4. Confidentiality. GHO and the Group shall keep Member information strictly confidential and shall not
disclose any information to any third party other than: (i) representatives of the receiving party (as
permitted by applicable state and federal law) who have a need to know such information in order to
perform the services required of such party pursuant to the Agreement, or for the proper management and
administration of the receiving party, provided that such representatives are informed of the confidentiality
provisions of the Agreement and agree to abide by them, (ii) pursuant to court order or (iii) to a designated
public official or agency pursuant to the requirements of federal, state or local law, statute, rule or
regulation.
5. Nondiscrimination. GHO does not discriminate on the basis of physical or mental disabilities in its
employment practices and services.
D. Utilization Management
All benefits under the Agreement are limited to Covered Services that are Medically Necessary and set forth in
Section IV. GHO'may review a Member's medical records for the purpose of verifying delivery and coverage
of services and items. Based on a prospective, concurrent or retrospective review; GHO may deny coverage if,
in its determination, such services are not Medically Necessary and in the case of out of network services,
Usual, Customary and Reasonable. Such determination shall be based on established clinical criteria.
GHO will not deny coverage retroactively for services it has previously authorized and which have already been
provided to the Member. -
Section VIII. Definitions
Agreement: The Medical Coverage Agreement between GHO and the Group.
Allowance: The maximum amount payable by GHO for certain Covered Services under the Agreement, as set forth
in the Allowances Schedule.
Authorization: An approval by GHO that entitles a Meer to receive Coved ed'Servlcjs from a specfted health
careprovider at the MHCN benefit level Services shall not exceed the limits of the Authorization and are subject
to all terms and conditions of the Agreement Members who have a complex or serious medical or psychiatric
condition may receive a standing Authorization for specialist services
Community Provider: Physicians licensed under 18.71 or 18.57 RCW, registered nurses licensed under 18.79
RCW, midwives licensed under 18.79 RCW, naturopaths licensed under 18.36A RCW, acupuneturists'iicensed
under 18.06 RCW, podiatrists licensed under 18.22 RCW or, in the case of non - Washington State providers, those
providers meeting equivalent licensing and certification requirements established in the state where the' provider's
practice is'located. For purposes of the Agreement, Community Providers do not include individuals employed by or
under contract with the MHCN or who provide a service or treat `Members outside the scope of their licenses.
Contracted Network Pharmacy: A pharmacy that has contracted with GHO to provide covered legend
(prescription) drugs and medicines for outpatient use under the Agreement.
Copayment: The specific dollar amount a Member is required to pay at the time of service for certain Covered
Services under the Agreement, as set forth in the Allowances Schedule.
Cost Share: The portion of the cost of Covered Services the Member is liable for under the Agreement. Cost Shares
for specific Covered Services are set forth in the Allowances Schedule. Cost Share includes Copayments,
coinsurances and/or Deductibles.
Covered Services: The services for which a Member is entitled to coverage under the Agreement.
Deductible: A specific amount a Member is required to pay for certain Covered Services before benefits are payable
under the Agreement. The applicable Deductible amounts are set forth in the Allowances Schedule.
C32811- 5685300a 45
Dependent: Any member of a Subscriber's family who meets all applicable eligibility requirements, is enrolled
hereunder and for whom the premium prescribed in the Premium Schedule has been paid.
Emergency: The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a
prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical
attention, if failure to provide medical attention would result in serious impairment to bodily function or serious
dysfunction of a bodily organ or part, or would place the Member's health, or if the Member is pregnant, the health
of her unborn child, in serious jeopardy.
Essential Health Benefits: Benefits set forth under the Patient Protection and Affordable Care Act of 2010, including
the categories of ambulatory patient services, emergency services, hospitalization, maternity and newborn care,
mental health and substance use disorder services, including behavioral health treatment, prescription drugs,
rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic
disease management and pediatric services, including oral and vision care.
Family Unit: A Subscriber and all his/her Dependents.
Fee Schedule: A fee - for - service schedule adopted by the MHCN, setting forth the fees for the MHCN medical and
hospital services.
Group: An employer, union, welfare trust or bona -fide association which has entered into a Group Medical
Coverage Agreement with GHO.
Hospital Care: Those Medically Necessary services generally provided by acute general hospitals for admitted
patients. Hospital Care does not include convalescent or custodial care, which can, in the opinion of the provider, be
provided by a nursing home of convalescent care center.
Lifetime Maximum: The maximum value of benefits provided for Covered Services under the Agreement after
which benefits under the Agreement are no longer available as set forth in the Allowances Schedule. The value of
Covered.Services received from the MHCN is based on the MHCN Fee Schedule, as defined above. The Lifetime
Maximum of Covered Services received from a Community Provider is based on benefits paid. The lifetime
maximum applies to this Agreement or in combination with any other medical coverage agreement between GHO
and Group.
Managed Health Care Network (MHCN): The participating provider with which GHO has entered into a written
participating provider agreement for the provision of Covered Services. GHO's participating providers currently
include providers in multiple delivery systems, such as Group Health Cooperative, and are subject to change as
designated by GHO.
Medical Condition: A disease, illness or injury.
Medically Necessary: Appropriate and clinically necessary services, as determined by GHO's Medical Director, or
his/her designee, according to generally accepted principles of good medical practice, which are rendered to a
Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In
order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for
the convenience of the Member, his/her family or the provider of the services or supplies; (b) are the most
appropriate level of service or supply which can be safely provided to the Member; (c) are for the diagnosis or
treatment of an actual or existing Medical Condition unless being provided under GHO's schedule for preventive
services; (d) are not for recreational, life - enhancing, relaxation or palliative therapy, except for treatment of terminal
conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical
standards in the State of Washington, could not have been omitted without adversely affecting the Member's
condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a
provider's office, the outpatient department of a hospital or a non - residential facility without affecting the Member's
condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are
not experimental or investigational. The length and type of the treatment program and the frequency and modality of
C32811- 5685300a 46
visits covered shall be determined by GHQ's Medical Director, or his/her designee. In addition to being medically
necessary, to be covered, services and supplies must be otherwise included as a Covered Service as set forth in
Section IV. of the Agreement and not excluded from coverage. The cost of non - covered services and supplies shall
be the responsibility of the Member.
Medicare: The federal health insurance program for the aged and disabled.
Member: Any Subscriber or Dependent enrolled under the Agreement.
MHCN- Designated Specialist: A MHCN specialist specifically identified by GHO.
MHCN Facility: A facility (hospital, medical center or health care center) owned, operated or otherwise designated
by the MHCN.
MHCN Personal Physician: A provider who is employed by or contracted with the MHCN to provide primary care
services to Members and is selected by each Member to provide or arrange for the provision of all non - emergent
Covered Services, except for services set forth in the Agreement which a Member can access without an
Authorization. Personal Physicians must be capable of and licensed to provide the majority of primary health care
services required by each Member.
MHCN Provider: The medical staff, clinic associate staff and allied health professionals employed by the MHCN
and any other health care professional or provider with whom the MHCN has contracted to provide health care
services to Members enrolled under the Agreement, including, but not limited to, physicians, podiatrists, nurses,
physician assistants, social workers, optometrists, psychologists, physical therapists and other professionals engaged
in the delivery of healthcare services.who are licensed or certified to practice in accordance with Title I& Revised
Code of Washington.
Out -of- Pocket Expenses: Those Cost Shares paid by the Subscriber or Member for Covered Services which are
applied:to the,Out- oftP,ocket.Limit:
Out- ofPocketLimit: The maximum amount:ofOut- of-PocketExpenses incurred ;andpaid ;during the :calendaryear
for Covered: Services received by the Subscriber and his/her Dependents within the same calendar year. The Out -of-
Pocket Limit amount and Cost Shares that apply are set forth in the Allowances'Schedule. Charges in excess of
UCR, services in excess of any benefit level and services not covered by the Agreement are not applied. to the Out-
of-Pocket Limit.
Plan Coinsurance: The percentage amount the Member and GHO are required to pay for Covered Services
received under the Agreement. Percentages. for Covered Services are set forth in the Allowances Schedule. A
coinsurance percentage not identified as Plan Coinsurance is a benefit specific coinsurance and does not apply to the
Out -of- Pocket Limit except as otherwise noted under Section 11. Out-of-Pocket Limit.
Pre - Existing Condition: A condition for which there has been diagnosis, treatment or medical advice within the
three (3) month period prior to the effective date of coverage. The Pre- Existing Condition wait period will begin on
the first day of coverage, or the first day of the enrollment waiting period if earlier.
Preferred Community Provider: A Community Provider that has agreed to accept from GHO a contracted rate for
Covered Services under Section IV. Services received from •a Preferred Community Provider are subject to a
discounted rate, less any Cost Shares set forth in the Allowances Schedule.
Preferred Community Provider Contracted Rate: The discounted rate that the Preferred Community Provider
has agreed to accept from GHO for medical services received by Members.
Residential Treatment: A term used to define facility- based treatment, which includes twenty-four (24) hours per
day, seven'(7) days per week'rehabilitation Residential Treatment services are provided in a facility specifically
licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active
C32811- 5685300a 47
treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by
a multi- disciplinary team of licensed professionals.
Service Area: Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason,
Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman and Yakima; Idaho
counties of Kootenai and Latah; and any other areas designated by GHO.
Subscriber: A person employed by or belonging to the Group who meets all applicable eligibility requirements, is
enrolled under the Agreement and for whom the premium specified in the Premium Schedule has been paid.
Urgent Condition: The sudden, unexpected onset of a Medical Condition that is of sufficient severity to require
medical treatment within twenty-four (24) hours of its onset.
Usual, Customary and Reasonable (UCR): Expenses are considered Usual, Customary and Reasonable if the
charges are consistent with those normally charged to others by the provider or organization for the same services or
supplies; and the charges are within the general range of charges made by other providers in the same geographical
area for the same services or supplies. Amounts charged by a Community Provider in excess of UCR rates are the
responsibility of the Subscriber and/or Member.
C32811- 5685300a 48
PR FM771M .CCNFn 717. F.
Group Name
City of Federal Wa
Group Number rime
5685300
GROUP HEALTH OPTIONS INC. - Alliant Plus benefit description
Inside the Network: Manage Care Providers
Outside the Network: No Managed Care Providers
Coinsurance
None
Coinsurance
90/10%
Deductible
None
Deductible
$100*
Emergency Co pay
$75
Emorgmcy Co pay
$75.
Family Ded & OOP Max
3x
Family Ded & OOP Max
3x
Hospital Inpatient Co
$100/5 days/admit
Hospital Inpatient Co pay
$100/5 days/admit
Office Visit Co pay
$10
Office Visit Co pay
$10
Optical Rider
Not covered
Optical Rider
Not covered
Out Of Pocket
$1000
Out Of Pocket Threshold
$1000
Outpatient Surgery Co pay
Same as OV
Outpatient Surgery Co pay
Same as OON OV
Prescription Drug Co pay
$10
Prescription Drug Co pay
$15
No PEC Wait
Group Offering
Sole Carrier
MONTHLYHEALTHCARE PREMIUM
This Schedule reflectsfronc 0110112012 to 0110112013
Subscriber
$475.19
Subscriber and Spouse
$950.37
Subscriber and 1 Child
$715.83
Subscriber and 2+ Children
$956.47
Subscriber Spouse and 1 Child
$1,191.01
Subscriber Spouse and 2+ Children
$1,431.65