Plan Document Handbook Kaiser Permanente EPO High Plan

Introduction The Episcopal Church Medical Trust* (Medical Trust) maintains a series of benefit plans (referred to herein as “Plan” or the “Plans”) for the employees (and their dependents) of the Protestant Episcopal Church in the United States of America (hereinafter, the Episcopal Church). Since 1978, the Plans sponsored by the Medical Trust have served the dioceses, parishes, schools, missionary districts, seminaries, and other institutions subject to the authority of the Episcopal Church. The Medical Trust now serves more than 22,000 active employees and dependents; and over 9,000 retirees and their dependents. The plans are intended to qualify as “church plans” within the meaning of Section 414(e) of the Internal Revenue Code, and are exempt from the requirements of the Employee Retirement Income Security Act of 1974, as amended (ERISA). The Medical Trust funds certain of its benefit plans through a trust fund known as the Episcopal Church Clergy and Employees’ Benefit Trust (ECCEBT)*. The ECCEBT is intended to qualify as a voluntary employees’ beneficiary association (VEBA) under Section 501(c)(9) of the Internal Revenue Code. The purpose of the ECCEBT is to provide benefits to eligible employees, former employees, and their dependents in the event of illness or expenses for various types of medical care and treatment. The mission of the Medical Trust is to “balance compassionate care with financial stewardship.” This is a unique mission in the world of healthcare benefits, and we believe that our experience and mission to serve the Church offers a level of expertise that is unparalleled. If you have questions about any of our plans, please don’t hesitate to contact us. We’re looking forward to serving you. For more information, please visit our website at www.cpg.org; or call Client Services at (800) 4809967.

* Church Pension Group Services Corporation is the sponsor of this program and is doing business under the name “The Episcopal Church Medical Trust.”

Table of Contents Summary of Benefits and Coverage ................................................................................... 1 Important Notices ............................................................................................................. 7 Eligibility and Enrollment .................................................................................................... 9 Obtaining Services .......................................................................................................... 27 Coverage ........................................................................................................................ 30 Outpatient Care ......................................................................................................................31 Preventive Care ......................................................................................................................33 Hospital Care .........................................................................................................................37 Emergency and Urgent Care ...................................................................................................40 Maternity Care ........................................................................................................................42 Infertility ..................................................................................................................................43 Mental Health and Substance Abuse ......................................................................................44 Transplant Care ......................................................................................................................46 Durable Medical Equipment and Supplies ...............................................................................47 Skilled Nursing Facility Care ....................................................................................................48 Home Health Care ..................................................................................................................49 Hospice Care .........................................................................................................................50 Clinical Trials ..........................................................................................................................51 Wellness and Clinical Management .................................................................................. 53 Exclusions and Limitations ............................................................................................... 60 Pharmacy Benefits .......................................................................................................... 66 Claims and Appeals ........................................................................................................ 68 Coordination of Benefits .................................................................................................. 76 Other Important Plan Provisions ....................................................................................... 78 Binding Arbitration .......................................................................................................... 81 Subrogation and Reimbursement ..................................................................................... 85 Privacy ........................................................................................................................... 90 Glossary ......................................................................................................................... 95 For More Information ......................................................................................................105

Kaiser EPO High Plan What this Plan Covers & What You Pay For Covered Services

Coverage Period: 01/01/2017 – 12/31/2017 Coverage for: All tiers │ Plan Type: EPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the contribution or premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.cpg.org/mtdocs or call (800) 480-9967. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.cpg.org/uniform-glossary or call (800) 480-9967 to request a copy.

Important Questions

Answers

What is the overall deductible?

$0

Are there services covered before you meet your deductible? Are there other deductibles for specific services?

Why This Matters: See the chart starting on page 2 for your costs for services this plan covers.

Not applicable. No.

What is the out-of-pocket limit for this plan?

For network providers, $1,750 individual / $3,500 family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Contributions (Premiums, balancebilling charges, penalties, and healthcare this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See www.kp.org or call (866) 213-3062 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

Yes.

The Plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.

1

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event

Services You May Need Primary care visit to treat an injury or illness

If you visit a health care provider’s office or clinic

If you have a test If you have outpatient surgery If you need immediate medical attention If you have a hospital stay

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) $25 copay/visit Not covered.

Limitations, Exceptions, & Other Important Information None. Chiropractic services limited to 20 visits per year; acupuncture services limited to 12 visits per year. Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics.

Specialist visit

$25 copay/visit

Not covered.

Preventive care/screening/ immunization

No charge.

Not covered.

$50 copay

Not covered.

None.

$50 copay

Not covered.

None.

$100 copay

Not covered.

None.

No charge. $100 copay/visit

Not covered. $100 copay/visit

None.

$0 copay

$0 copay

None.

$50 copay/visit $100 copay per day to Facility fee (e.g., hospital room) maximum of $600

Not covered.

None.

Physician/surgeon fees

Not covered.

Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care Emergency medical transportation Urgent care

No charge.

Not covered.

Prior authorization is required.

2

Common Medical Event

If you need mental health, behavioral health, or substance abuse services.

If you are pregnant

If you need help recovering or have other special health needs

If your child needs dental or eye care

Services You May Need Outpatient services Inpatient services

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) $25 copay/day individual / $10 Not covered. copay/day group $100 copay per day to Not covered. maximum of $600

Colleague Group

30% coinsurance

30% coinsurance

Office visits

$25 copay

Not covered.

Childbirth/delivery professional services Childbirth/delivery facility services

$100 copay per day to maximum of $600

Not covered.

Home health care

No charge.

Not covered.

Rehabilitation services

$25 copay/visit

Not covered.

Habilitation services

$25 copay/visit

Not covered.

Skilled nursing care

No charge.

Not covered.

Durable medical equipment

No charge.

Not covered.

Hospice services

No charge.

Not covered.

Children’s eye exam Children’s glasses Children’s dental check-up

No charge. Not covered. Not covered.

Not covered. Not covered. Not covered.

Limitations, Exceptions, & Other Important Information None. Prior authorization is required. The plan will reimburse 70% up to a maximum reimbursable fee of $40. The member is responsible for all costs above that amount. Copay applies only to the visit to confirm pregnancy. Well-newborn care is covered. Includes nurse visits (2 hours), aide visits (4 hours), therapy visits, and supplies. Limited to 210 visits per plan year. Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per plan year, combined facility and office, per each of the three therapies. Limited to 60 days per plan year, combined with acute rehabilitation. None. Limited to 210 days per lifetime. Prior authorization is required. Additional vision benefits are available through EyeMed Vision Care.

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Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.kp.org.

Services You May Need Generic drugs

What You Will Pay Retail Mail Order $10 for up to a 30-day $10 copay supply, $20 for up to a 90day supply

Limitations, Exceptions, & Other Important Information

You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using the mail order pharmacy.

Preferred brand drugs

$25 copay

$25 for up to a 30-day supply, $50 for up to a 90day supply

Specialty drugs

$25 copay

$25 for up to a 30-day supply, $50 for up to a 90day supply

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic Surgery • Dental care (Adult) • Hearing aids • Non-emergency care when traveling outside the • Long-term care • Routine eye care U.S. • Routine foot care • Weight loss program Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture • Bariatric surgery • Chiropractic care • Infertility treatment • Private-duty nursing Your Rights to Continue Coverage: The Plan’s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call (800) 480-9967 for more information.

1

Under Section 4980B(d) of the Code and Treasury Regulation Section 54.4980 B-2, Q. and A. No. 4.

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Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Kaiser Permanente. Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al (800) 480-9967. [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa (800) 480-9967. [Chinese (中文): 如果需要中文的帮助，请拨打这个号码 (800) 480-9967. [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' (800) 480-9967. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)  The plan’s overall deductible  Specialist [cost sharing]  Hospital (facility) [cost sharing]  Other [cost sharing]

$0 $25 0% $25

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

$12,739

$0 $1,290 $0 $60 $1,350

Managing Joe’s type 2 Diabetes

Mia’s Simple Fracture

(a year of routine in-network care of a wellcontrolled condition)  The plan’s overall deductible  Specialist [cost sharing]  Hospital (facility) [cost sharing]  Other [cost sharing]

(in-network emergency room visit and follow up care) $0 $25 0% $25

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

$7,400

$0 $1,685 $0 $55 $1,740

 The plan’s overall deductible  Specialist [cost sharing]  Hospital (facility) [cost sharing]  Other [cost sharing]

$0 $25 0% $25

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost

$1,925

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

$0 $325 $0 $0 $325

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IMPORTANT NOTICES N EWBORNS’ AND MOTHERS’ H EALTH P ROTECTION A CT OF 1996 The Plan covers physician and hospital care for mother and baby, including prenatal care, delivery and postpartum care. In accordance with the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA), you and your newly born child are covered for a minimum of 48 hours of inpatient care following a vaginal delivery, or 96 hours following a cesarean section. However, your provider may-----after consulting with you-----discharge you earlier than 48 hours after a vaginal delivery, or 96 hours following a cesarean section. W OMEN’S H EALTH AND C ANCER R IGHTS A CT OF 1998 The Plan, as required by the Women’s Health and Cancer Rights Act of 1998 (WHCRA), provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. For more information contact the Plan Administrator. For more information about any of these Notices, please contact the Plan at: The Episcopal Church Medical Trust 19 East 34th Street New York, NY 10016 If you prefer to discuss your questions by phone or email, contact Client Services at (800) 480-9967 or e-mail: [email protected]. N OTICE OF N ONDISCRIMINATION Church Pension Group Services Corporation (“CPGSC”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CPGSC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. CPGSC: • Provides free aids and services to people with disabilities to communicate effectively with us such as qualified interpreters and written information in other formats such as large print materials • Provides free language services to people whose primary language is not English, such as information written in other languages If you believe you need these services or that CPGSC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can obtain a copy of the grievance procedures or file a grievance with: Adriene Clarke, Civil Rights Coordinator, Church Pension Group, 19 East 34th Street, New York, NY 10016, Phone: 212-592-6299, Fax: 212-592-9487, Email: [email protected]. You can file a grievance by mail, fax, or email. If you need help filing a grievance, Adriene Clarke, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. If you prefer to discuss your questions by phone or email, contact Client Services at (800) 480-9967 or e-mail: [email protected]. 7

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-480-9967. 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-4809967. ‫ةظوحلم‬: ‫ةغللا ركذا ثدحتت تنك اذإ‬، ‫ناجملاب كل رفاوتت ةیوغللا ةدعاسملا تامدخ نإف‬. ‫مقرب لصتا‬ .7699-084-008-1 ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1800-480-9967. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-480-9967. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-480-9967. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-480-9967. ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800480-9967. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-480-9967. ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-480-9967. CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1800-480-9967. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-480-9967. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-480-9967. 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-800-480-9967. ‫ھجوت‬: ‫دینک یم وگتفگ یسراف نابز ھب رگا‬، ‫امش یارب ناگیار تروصب ینابز تالیھست‬ 1-800-480-9967 ‫دشاب یم مھارف‬. ‫دیریگب سامت اب‬.

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C HAPTER 2 E LIGIBILITY AND E NROLLMENT ELIGIBILITY FOR THE EPISCOPAL H EALTH P LAN (EHP) The Medical Trust determines eligibility for the Plans. The employer or Group Administrator is responsible for determining whether the Employee is eligible for any employer contributions towards coverage, confirming that Members meet the eligibility criteria described below and for maintaining documentation related to the Members’ enrollment and elections. The Medical Trust may request a copy of required documentation at any time. The terms Eligible Individual and Eligible Dependent, as defined below, are used throughout this document and identified with capital letters. Eligible Individuals and their Eligible Dependents described below must be part of a Participating Group that is participating in the EHP. ELIGIBLE I NDIVIDUALS • • • • •

An Exempt Employee A Non-Exempt Employee normally scheduled to work 1,000 or more compensated hours per plan year or who is treated as a full-time Employee under the Employer Shared Responsibility Provisions under the Affordable Care Act (Pay or Play Rules), but only for the applicable stability period A Seminarian who is a full- time student enrolled at a participating seminary of the Association of Episcopal Seminaries A Member of a Religious Order A Pre-65 Retired Employee, not eligible for Medicare, as long as his/her former employer is participating in the EHP

ELIGIBLE DEPENDENTS • • • • • • •

A Spouse* A Domestic Partner, if Domestic Partner benefits are elected by the Participating Group A Child who is 30 1 years of age or younger on December 31st of the current year** A Disabled Child, 30 years of age or older on December 31st of the current year, provided the disability began before the age of 25** A Pre-65 Dependent, of a Post-65 Retired Employee enrolled in a Medicare Supplement Health Plan (MSHP)*** A Pre-65 Surviving Dependent of a deceased Post-65 Retired Employee or Pre-65 Retired Employee*** A Pre-65 Dependent, of a Pre-65 Retired Employee enrolled in a MSHP**** *For information on the eligibility of a former spouse refer to the Termination of Individual Coverage, under Divorce **The Dependent must be enrolled under the Subscriber’s Plan.

Fully insured plans may not cover children up to age 30; as the eligibility rules of the regional or local plans vary and will apply please confirm prior to enrollment.

1

9

***The Dependent will be enrolled as a Subscriber; however, eligibility is based on the Post-65 Retired Employee’s status. ****The Dependent will be enrolled as a Subscriber; however, eligibility is based on the Pre-65 Retired Employee’s status. I NELIGIBLE I NDIVIDUALS Individuals described below are not eligible to enroll in the EHP. • • • • • • • • • •

A part-time Non-Exempt Employee who is scheduled to work and be compensated for less than 1,000 hours per plan year unless such employee is required to be treated as a Full-Time employee under the Pay or Play Rules A Temporary Employee unless such employee is required to be treated as a Full-Time employee under the Pay or Play Rules A Seasonal Employee unless such employee is required to be treated as a Full-Time employee under the Pay or Play Rules A Seminarian who is not a full-time student or not enrolled at a participating seminary of the Association of Episcopal Seminaries A parent or other relative of a Subscriber, including grandchildren and in-laws, not listed in the Eligible Dependents section above A Post-65 Retired Employee or Pre-65 Retired Employee (or Spouse/Domestic Partner) eligible for Medicare, regardless of whether he or she is actually enrolled in Medicare A volunteer An Employee whose working papers have expired and can no longer legally work An Eligible Individual or Eligible Dependent who refuses to provide a Social Security or Individual Taxpayer Identification number A dependent’s dependent who is not a legal ward, foster child, legally adopted or who has not been placed with the Subscriber/Subscriber’s Spouse/Domestic Partner for adoption

C OVERAGE AND ELIGIBILITY EXCEPTIONS There may be certain circumstances where an individual who does not meet the eligibility requirements listed above may choose to request a special eligibility determination from the Plan. The Bishop or Ecclesiastical Authority with authority over the Participating Group must submit the Coverage and Eligibility Exception Request Form to the Plan in these circumstances. The Plan will review the case presented and provide an individual eligibility determination within 30 days after receipt of the form. If eligibility is granted, the effective date of coverage will be the 1st of the month following the receipt of the enrollment form. I MPORTANT N OTES Waiting Periods The Plan does not require, or allow Participating Groups to require, that an Eligible Individual must be employed or be part of the Participating Group for any length of time before being allowed to participate in the Plan. Additional information on new hires can be found in the Plan Election and Enrollment Guidelines section. Medicare/Medicaid

10

Eligibility for Medicare/Medicaid or the receipt of Medicare/Medicaid benefits will not be taken into account in determining eligibility for participation in the EHP. For participation in the EHP for Qualified Small Employer Exception, eligibility for Medicare will be taken into account in determining eligibility.

11

P LAN ELECTION AND ENROLLMENT G UIDELINES This section addresses the Plan’s rules and requirements related to enrollment and election changes. Topics include effective dates, termination procedures, Significant Life Events, Open Enrollment and other procedures. S UBSCRIBER RESPONSIBILITIES The Plan and its administrators rely on information provided by Subscribers when evaluating the coverage and benefits under the Plan. Subscribers must provide all required information (including their and their enrolled Dependent’s social security number or individual taxpayer identification number) through a Medical Life Participant System (MLPS) submission or with an enrollment form to the Group Administrator. All information provided must be accurate, truthful, and complete. Any fraudulent statement, omission or concealment of facts, misrepresentation or incorrect information will be considered an intentional misrepresentation of a material fact and may result in the denial of a claim, cancellation or rescission of coverage, or any other legal remedy available to the Plan. P LAN ELECTIONS AND C HANGES Eligible Individuals make their Plan elections and Coverage Tier elections upon first becoming eligible to participate in the Plan. Plan elections generally remain in place for the entire plan year, provided the required contributions for coverage are received by the Plan. A Subscriber may not change his/her elected Plan or Coverage Tier except during Open Enrollment, unless there is a Significant Life Event or a HIPAA Special Enrollment Event.

Important Note: the Plan does not allow a member to terminate dental coverage mid-year. S IGNIFICANT LIFE EVENTS A Significant Life Event gives a Subscriber the opportunity to make a change to enrollment. The enrollment change must be made within 30 days of the event and must be consistent with the event. Significant Life Events include: • • • • •

• •

Marital status change (e.g., marriage, divorce, legal separation or annulment of marriage) Qualification or termination of a Domestic Partnership (in Participating Groups offering Domestic Partner coverage) Change in the number of Dependents (e.g., an increase through marriage, birth, adoption or placement for adoption, or a decrease through death or Dependent gaining own health benefits) Change in Dependent status (e.g., becoming ineligible by reaching a limiting age) Change in employment status of a Subscriber or Dependent, that affects Plan eligibility (e.g. termination or commencement of employment, changing from full-time to part-time employment, commencement of or return from an unpaid leave of absence, changing from Employee to Pre-65 Retired Employee or Post-65 Retired Employee) Judgment, decree or order (e.g., Qualified Medical Child Support Order (QMCSO)) Change in residence or work site for a Subscriber or Dependent that affects network access to the current Plan

12

For example, if a Subscriber previously resided in an area in which only the PPO was available and then moved into an area where the HMO and PPO are available, the Subscriber may elect a new Plan. Conversely, if a Subscriber moved out of the HMO service area, and was therefore no longer eligible for the HMO, the Subscriber may elect a new Plan. Significant change in cost or a significant curtailment of medical coverage during a plan year for a Subscriber or Dependent Medicare entitlement (or loss of such entitlement) Medicaid entitlement (or loss of such entitlement) HIPAA Special Enrollment Event (see below) Enrollment in or termination of a Medicare Part D Plan Change in employment or insurance status of Spouse Qualification of a post 65 actively working subscriber or subscriber’s Spouse to participate in the EHP SEE Any other significant life events provided under the applicable regulations and provided for under the employer’s Section 125 Plan o

• • • • • • • •

IMPORTANT NOTE: A healthcare provider’s discontinuation of participation in a plan network is not a Significant Life Event and does not permit an election change. The effective date of coverage for an election change due to a Significant Life Event is the first day of the month following the Significant Life Event (except in the case of birth, adoption or placement for adoption of a child). Election changes must be received by the Plan no later than 30 days after the Significant Life Event (60 days if the change relates to loss or eligibility for Medicaid Plan or State child healthcare plan) and are valid for the remainder of the current plan year. The employer is responsible for providing the Member an SBC for each applicable plan within 90 days of enrollment resulting from a Significant Life Event. HIPAA Special Enrollment Events Certain Significant Life Events are considered to be Special Enrollment Events that would allow an Eligible Individual who is not covered by the Plan to enroll him/herself and his or her Eligible Dependents for coverage under the Plan outside of the Open Enrollment period. Special Enrollment Events include: • • • • o o • •

Marriage Birth of a Child Adoption or placement for adoption of a Child Loss of coverage under another group health plan, including The expiration of COBRA coverage if the other coverage was under a COBRA continuation provision, or If the other coverage was not under COBRA,  Loss of eligibility for the other coverage or  Termination of employer contributions toward the Employee’s other coverage Loss of eligibility for coverage in a Medicaid Plan under Title XIX of the Social Security Act or a state child healthcare plan under Title XXI of the Social Security Act, and Eligibility for assistance with coverage under the Plan through a Medicaid Plan under Title XIX of the Social Security Act or a state child healthcare plan under Title XXI of the Social Security Act

13

Eligible Individuals will generally have 30 days to enroll in the Plan after a Special Enrollment Event, but will have 60 days to enroll in the Plan as a result of a Special Enrollment Event that is a loss of eligibility for coverage under a Medicaid Plan or a state child healthcare plan or eligibility for assistance with coverage under the Plan through a Medicaid Plan or state child healthcare plan. In the case of birth, adoption or placement for adoption of a Child, coverage will be effective retroactive to the date of the event. For all other Special Enrollment Events, coverage will be effective as of the first day of the month following the month in which the request for coverage is processed. The employer is responsible for providing the Member an SBC for each applicable plan within 90 days of enrollment resulting from a HIPAA Special Enrollment Event. Reporting Eligibility and Enrollment Changes The Group Administrator must report all changes that affect Member benefit coverage and plan elections to the Plan when they occur, but no later than 30 days after the occurrence. Examples of what should be reported include: • • • • • • • • • • •

Demographic information change Dependent information change Employment status change Employer change (e.g. transfer to a new church or diocese) Change resulting from a Significant Life Event Change resulting from a HIPAA Special Enrollment Event Death of a Member or Dependent Retirement of an Employee Billing information change Disability of a child Change of gender

The Subscriber or Eligible Individual must notify the Group Administrator when a Significant Life Event or other enrollment change occurs. The Group Administrator should request supporting documentation regarding Dependent eligibility. The Group Administrator must then notify the Plan through an MLPS submission or with an enrollment form within 30 days after the event. Failure by the Group Administrator to perform this task could jeopardize the Subscriber’s or Eligible Individual’s enrollment. The following additional requirements also apply: • • •

Health Plan choice may be restricted if a Subscriber or an Eligible Individual has Eligible Dependents living outside the service area of a particular Plan. If a local managed care plan is elected, additional paper enrollment forms from the local plan option must be submitted to the Plan. Pre-65 Retired Employees and Post-65 Retired Employees who do not receive any contribution assistance from the Participating Group may submit enrollment forms directly to the Plan.

Other changes such as a change of address or phone number can and should be reported to the Plan when they occur. Required Information and Documentation

14

All of the information requested on MLPS or the enrollment form (such as social security number and date of birth) is required in order for a plan election or other change to be processed. The Participating Group is responsible for verifying a Member’s personal data and may be required to provide the Plan with copies of the following documentation: • • • • • • • • • • • •

Birth Certificate Social Security Card Individual Taxpayer Identification Number (ITIN) Card Marriage Certificate Divorce Decree Domestic Partnership Affidavit Statement of Dissolution of Domestic Partnership Child Affidavit Placement or Custody Order from social services, a welfare agency or court of competent jurisdiction Adoption Petition or Decree Medicare Card Driver’s License

15

O PEN ENROLLMENT Open Enrollment is the annual period during which Subscribers of the EHP, the EHP SEE and MSHP and other Eligible Individuals may elect or change health Plans for the following plan year for themselves and their Eligible Dependents, or change Dependents covered by the Plan. Subscribers must complete the enrollment form or use the Open Enrollment website, as appropriate. Generally, Open Enrollment occurs during the fall with changes becoming effective on January 1st of the following plan year. At the beginning of Open Enrollment, Subscribers receive a personalized letter outlining the steps required to make plan election(s) or other changes for the upcoming plan year. The letter contains information about the Open Enrollment website, instructions, a personal login and password, and the dates the Open Enrollment website will be available. The Group Administrator should notify the Plan of other Eligible Individuals who would like to take part in Open Enrollment prior to Open Enrollment. To administer this, the Plan will request a mailing list and other information in advance in order to include them in Open Enrollment. The Open Enrollment website contains: • • • • • • •

Current demographic and coverage information Available medical and/or dental Plans Full contribution rates for each Plan and Coverage Tier 2 Options to add or remove Eligible Dependents The deadline for submitting plan elections Links to Summary of Benefits and Coverage (SBCs) Reference material and other helpful resources

N EWLY ELIGIBLE I NDIVIDUALS ENROLLMENT Newly Eligible Individuals have a period of 30 days immediately following the hire date or date the individual became part of the Participating Group or became an Eligible Individual to elect a health Plan for the remainder of the current plan year. Plan elections, once made, cannot be changed for the remainder of the current plan year, unless the Member experiences a Significant Life Event or HIPAA Special Enrollment Event. The employer must provide the SBCs for all available plans to the Employee no later than the first day the Employee is eligible to enroll in the Plan.

2

Employer/Employee cost share information is not provided. 16

S PECIFIC G UIDELINES AND EFFECTIVE DATES OF C OVERAGE Coverage is effective on the first day of the month following the date Eligible Individuals first become eligible to participate in the Plan or following the Significant Life Event, unless otherwise specified. Completed enrollment forms or MLPS submissions must be received by the Plan within 30 days of the event, (or 60 days if the change relates to loss or eligibility for Medicaid Plan or State child healthcare plan). N EW ELIGIBLE I NDIVIDUAL The effective date of coverage for a new Employee is the first day of the month following the Employee’s date of hire, or date he or she becomes eligible. For example, if the date of hire is Monday, June 2, then coverage is effective July 1. However, if an Employee’s date of hire is the first working day of the month and the first calendar day of the month (e.g. Sunday, June 1), coverage for the Employee will commence on the first day of that month (i.e. Sunday, June 1), provided that the Plan receives an enrollment form or MLPS submission within 30 days of that date. If the Employee does not enroll (or is not automatically enrolled by the Participating Group, if applicable) when initially eligible, the Employee must wait for an applicable Significant Life Event or HIPAA Special Enrollment Event to occur, or wait until the next Open Enrollment period. R ELIGIOUS O RDERS The effective date of coverage for a postulant, novice or professed member of a Religious Order is the first day of the month following the date in which he or she is received or accepted by the Order. However, if a postulant, novice or member is received or accepted by the Order on the first working day of the month and the first calendar day of the month (e.g. Monday, June 1), coverage for the postulant, novice or member will commence on the first day of that month (i.e. Monday, June 1), provided that the Plan receives an enrollment form or MLPS submission within 30 days of that date. Elections must be received by the Plan no later than 30 days after that date. If the postulant, novice or member does not enroll when initially eligible, then he or she must wait for an applicable Significant Life Event or HIPAA Special Enrollment Event to occur or until the next Open Enrollment period. P RE-65 R ETIRED EMPLOYEES A Pre-65 Retired Employee from a Participating Group who retires but is not Medicare-eligible, may continue coverage through the Episcopal Health Plan (EHP) with no change to the coverage effective date, provided an enrollment form or MLPS submission confirming continuation of coverage and change to Pre-65 Retired Employee status is received by the Plan within 30 days of the retirement date. If the Pre-65 Retired Employee wants to make a plan election change as a result of retirement, then the coverage effective date of the new Plan will be the first day of the month following the retirement date. Elections must be received by the Plan no later than 30 days after the retirement date.

17

If the Pre-65 Retired Employee does not make an election change within 30 days of the retirement date, then he or she must wait for an applicable Significant Life Event or HIPAA Special Enrollment Event to occur, or wait until the next Open Enrollment period. Once the Pre-65 Retired Employee becomes Medicare-eligible, he or she must actively switch enrollment to the Medicare Supplement Health Plan (MSHP). If the enrolled Spouse/Domestic Partner is not Medicareeligible at that time, then the enrolled Spouse/Domestic Partner may remain in the EHP until becoming Medicare-eligible, at which time he or she too must actively switch enrollment to the MSHP. The enrolled Children who are not Disabled may remain in the EHP until the end of the year in which they reach age 30. If the Pre-65 Retired Employee has a spouse who becomes age 65 and is not actively working, the Post-65 Spouse of the Pre-65 Retired Employee is allowed to enroll in the MSHP provided he or she is enrolled in Medicare Parts A and B. The Pre-65 Retired Employee remains in the EHP. This reverse split is allowed because the Subscriber is a Pre-65 Retired Employee. IMPORTANT NOTE: An Employee who terminates his/her employment with a Participating Group prior to meeting the eligibility requirements for a Pre-65 Retired Employee will be offered an Extension of Benefits. P RE-65 R ETIRED EMPLOYEE, NOT COVERED UNDER THE EPISCOPAL H EALTH PLAN (EHP) Enrollment in the EHP for Pre-65 Retired Employees who are not currently enrolled in the EHP is limited to those who: a) Waived EHP coverage as a qualified opt out and have subsequently experienced a HIPAA Special Enrollment Event, or b) Join the EHP as part of a new Participating Group’s during their initial enrollment period, provided you were covered by that plan and included in the group census For these limited circumstances, the Pre-65 Retired Employee may enroll in the EHP at the time of a HIPAA Special Enrollment Event or annual open enrollment, and remain in the EHP until such time as he or she becomes Medicare-eligible, at which time the Employee must actively switch enrollment to the MSHP. If the enrolled Spouse/Domestic Partner is not Medicare-eligible at that time, then the enrolled Spouse /Domestic Partner may remain in the EHP until becoming Medicare-eligible, at which time he or she too must actively switch enrollment to the MSHP. The enrolled Children who are not Disabled may also remain in the EHP until the end of the year in which they reach age 30. Health plan elections must be received by the Plan no later than 30 days after a HIPAA Special Enrollment Event. DEPENDENTS The effective date of coverage for an Eligible Dependent is the same date as the Subscriber’s effective date. If the Subscriber does not enroll all Eligible Dependents within 30 days of a Significant Life Event or HIPAA Special Enrollment Event, then the Eligible Dependents may not enroll until the next Open Enrollment period or until another Significant Life Event or HIPAA Special Enrollment Event occurs.

18

N EW C HILDREN A Subscriber’s newborn Child is temporarily covered under the Plan for the first 30 days immediately following birth. However, the Subscriber must enroll the new Child for coverage within 30 days of the birth to ensure claims incurred during the first 30 days are covered and for coverage to continue beyond the 30-day period. The coverage effective date will be the date of birth. If applicable, monthly contribution rates will change to reflect the new Coverage Tier on the first day of the month following the date of birth. If a properly completed enrollment form or MLPS submission is not received by the Plan within the 30-day period, the Child may not be enrolled in the Plan until the next Open Enrollment period or the occurrence of a subsequent Significant Life Event or HIPAA Special Enrollment Event.

Note: The newborn child of a Dependent Child will not be covered by the plan, even for the first 30 days, unless that child is placed for adoption, is a legal ward or foster child of the Subscriber/Subscriber’s Spouse/Domestic Partner. A DOPTED C HILDREN Upon timely notification, coverage for the Child will be effective on the date of adoption, or, if earlier, placement for adoption. The Plan will consider a Child placed for adoption as eligible for enrollment on the date when the Subscriber becomes legally obligated to support that Child prior to that Child’s adoption. If the Subscriber does not enroll the Child within 30 days of that date, then the Child may not enroll until the next Open Enrollment period or until a subsequent Significant Life Event or HIPAA Special Enrollment Event occurs. If a Child placed for adoption is not adopted, all health coverage ceases when the placement ends and will not be continued. The Plan will only cover expenses incurred by the birth mother, including the birth itself, if the birth mother is an enrolled Member on the date of birth. DOMESTIC P ARTNERS A Subscriber may enroll his/her eligible Domestic Partner for coverage under the Plan if the Subscriber meets the Plan’s eligibility requirements and is part of a Participating Group that offers Domestic Partner coverage. The Plan requires a signed affidavit attesting to the Domestic Partnership. If the Subscriber does not enroll his/her eligible Domestic Partner within 30 days after submission of a valid Domestic Partner Affidavit, then the eligible Domestic Partner may not enroll until the next Open Enrollment period or until a Significant Life Event or HIPAA Special Enrollment Event occurs. N ON-MEDICARE-ELIGIBLE DEPENDENTS A Post-65 Retired Employee and his/her Eligible Dependents may split enrollment between the EHP and the MSHP in cases where the Post-65 Retired Employee is eligible for Medicare and the Dependents are not eligible for Medicare and are under age 65. Eligibility in the EHP will end once the Spouse/Domestic Partner becomes Medicare eligible and/or reaches age 65, at which time, he or she must actively switch enrollment to the MSHP. The Subscriber’s enrolled Children who are not Disabled may continue to participate in the EHP until the end of the year in which they reach age 30. DISABLED C HILDREN

19

If the Dependent Child is Disabled prior to his/her 25th birthday and continues to be Disabled on the last day of the year in which the Child reaches age 30, the Child's eligibility will be extended for as long as the parent is a Subscriber, the disability continues and the Child continues to meet the Plan’s eligibility requirements in all aspects other than age. In order for the Plan to confirm the Disabled status for a child, the Subscriber must contact Client Services who will initiate the confirmation process with the Medical Board. Liberty Mutual is the third party administrator who is the Medical Board that will review satisfactory proof of disability and determine the Disabled status of the Child. Liberty Mutual will contact the Subscriber with the request for documentation. Satisfactory proof of disability must be confirmed by the Plan no later than 30 days after the end of the month in which the Child reaches age 25. The Plan may require, at any time, a physician's statement certifying the ongoing physical or mental disability. C HILDREN OF SURVIVING S POUSES OF LIMITED MEANS The Children's Health Insurance Program (CHIP) is a federal program through which the government assists states in providing affordable health insurance to families with Children. The program was designed with the intent to offer health coverage to uninsured Children in families with incomes that are modest but too high to qualify for Medicaid. Surviving Spouses of limited means may find it more financially advantageous to cover their minor Children through CHIP or minor and adult dependent Children through Medicaid. For such persons, Surviving Spouses may opt to (1) cover their minor Children or adult Dependent Children in a government plan, (2) decline coverage from the Plan for the Dependents so covered, and (3) retain the eligibility to re-enroll these Dependents should they lose coverage under the government plan on account of (i) bankruptcy or termination of the government plan, (ii) loss of eligibility under the government plan due to income changes, or (iii) other loss of eligibility for the government plan, not including reaching a limiting age. Dependents must satisfy all other eligibility criteria of the Plan in order to re-enroll. See the HIPAA Special Enrollment section for more details. C HILDREN SUBJECT TO A Q UALIFIED MEDICAL C HILD S UPPORT O RDER (QMCSO) A QMCSO is a judgment, decree or order (including approval of a settlement agreement) or administrative notice that is issued pursuant to a state domestic relations law (including a community property law) or through an administrative process, which directs that a Child must be covered under a health plan. The Plan has delegated to the applicable Participating Group the responsibility to determine if a medical child support order is qualified. If the Participating Group determines that a separated or divorced Spouse or any state child support or Medicaid agency has obtained a QMCSO, and if the Participating Group offers dependent coverage, the Plan will allow the Subscriber to provide coverage for any Children named in the QMCSO. To be qualified, a medical child support order must satisfy all of the following: • •

The order recognizes or creates a Child’s right to receive group health benefits for which the Subscriber is eligible The order specifies the Subscriber’s name and last known address and the Child’s name and last known address, except that the name and address of an official of a state or political subdivision may be substituted for the Child’s mailing address

20

• • •

The order provides a description of the coverage to be provided or the manner in which the type of coverage is to be determined The order states the period to which it applies If the order is a National Medical Support Notice, it meets the requirements above

The QMCSO may not require the Plan to provide any type or form of benefit or option not otherwise provided under the Plan. Children of a Subscriber who must be covered under the Plan in accordance with a QMCSO will be covered beginning on the date the order is approved and continuing until the date or age stipulated. However, Children may not be covered beyond the eligibility age permitted under the Plan. If a QMCSO requires that the Subscriber provide health coverage for his/her Children and the Subscriber does not enroll the Children the Participating Group will enroll the Children upon application from the Subscriber’s separated or divorced Spouse, the state child support agency or Medicaid agency, provided it is required to do so by law. The Participating Group will withhold from the Subscriber’s pay his/her share of the cost of such coverage. If a QMCSO requires a separated or divorced ex-Spouse of a Subscriber to cover a Child, the Subscriber may change elections and drop coverage for the Child. However, the Subscriber may not drop coverage for the Child until the other plan’s coverage begins. Subscribers may not otherwise drop coverage for a Child covered pursuant to a QMCSO unless they submit written evidence to the Participating Group that the QMCSO is no longer in effect. LEAVES OF A BSENCE Leaves of absence encompass all approved leaves with or without pay, including leaves due to Workers' Compensation, Family and Medical Leave Act, and the sentence of suspension or restriction on Ministry of a Priest in accordance with Title IV, Canon 19, Section 7 3. If otherwise permitted by the Subscriber’s employer, a Subscriber on a leave of absence may choose to decrease the Coverage Tier for the duration of the leave or Extension of Benefit and increase it again upon return from leave. It is necessary to notify the Participating Group and the Plan within 30 days of the start date of the leave to decrease the Coverage Tier and also within 30 days of the end date of the leave to increase the Coverage Tier once the Subscriber returns to work. If the leave of absence is paid leave, the Member can retain his/her active coverage. If the leave of absence is unpaid, then the Member will be terminated and a letter will be sent offering an Extension of Benefits. Upon the Member’s return, the employer can reinstate the Member.

3

The Constitution and Canons of the Episcopal Church, 2012 21

TERMINATION OF I NDIVIDUAL C OVERAGE The Group Administrator must submit a request to terminate coverage for a Subscriber through MLPS or an enrollment form no later than 30 days after the termination event. If the Plan receives a termination request thereafter, then the Participating Group (or Subscriber if he or she is billed directly) will be required to pay the applicable monthly contributions to the Plan up to the coverage termination date. Coverage ends the earliest of: • The last day of the month in which: o The Subscriber no longer meets the eligibility requirements (e.g. Employee resigns or Seminarian graduates from seminary) o The Dependent no longer meets the eligibility requirements for any reasons other than death or turning age 30 (e.g. Spouse is no longer eligible due to divorce or Subscriber ceases to be a Dependent’s legal guardian) o Monthly contributions cease o The Participating Group’s participation with the Plan terminates • The last day of the year in which an enrolled Dependent Child reaches age 30, except if the Child is Disabled in accordance with the terms of the Plan • The date the Plan ceases to exist Coverage termination dates resulting from a Significant Life Event where a Subscriber loses or declines coverage will be the last day of the month in which the Significant Life Event occurred, unless otherwise specified. DEATH AND S URVIVING DEPENDENTS Employee/Seminarian When an Employee or Seminarian enrolled in the EHP dies, his/her Surviving Dependents who are also enrolled in the EHP at that time are offered an Extension of Benefits. The coverage termination date will be the last day of the month in which the Subscriber’s death occurred. The new coverage effective date for the Surviving Dependents who choose to enroll in the Extension of Benefits Program will be the first day of the month following the Subscriber’s date of death. Post-65 Retired Employee or Pre-65 Retired Employee Post-65 Retired Employee or Disabled Pre-65 Retired Employee When a Post-65 Retired Employee or a Disabled Pre-65 Retired Employee enrolled in the MSHP dies, Surviving Spouses and Surviving Domestic Partners enrolled in the MSHP at the time of the Member’s death can remain covered in the MSHP. Children enrolled in the EHP may remain in the EHP until the last day of the year in which they turn 30 or later if the Child is Disabled in accordance with the terms of the Plan. If the Surviving Dependents leave the EHP, they may not return to the Plan, unless they are eligible to enroll in the MSHP.

Pre-65 Retired Employee or Disabled Pre-65 Retired Employee

22

When a Pre-65 Retired Employee or a Disabled Pre-65 Retired Employee enrolled in the EHP dies, the Surviving Spouse or Surviving Domestic Partner who is also enrolled in the EHP can remain covered until he or she becomes Medicare-eligible, at which time he or she must actively enroll in the MSHP if eligible. His/her enrolled Children may remain in the EHP until the last day of the year in which they turn 30 or later if the Child is Disabled in accordance with the terms of the Plan. If the Surviving Dependents leave the EHP, they may not return to the Plan, unless they are eligible to enroll in the MSHP. The coverage termination date will be the last day of the month in which the Subscriber’s death occurred. The new coverage effective date for the Surviving Dependents will be the first day of the month following the Subscriber’s death date. If a Surviving Spouse remarries, any new Dependents acquired after the primary Subscriber’s death are ineligible for coverage under the Plan, unless the Dependent is a Child of the Subscriber born up to 12 months after the Subscriber’s death. The same rules apply to Surviving Domestic Partners who engage in a new Domestic Partner relationship. Dependents If an enrolled Dependent dies, the termination date for the deceased Dependent is the end of the month in which the death occurred. The Subscriber’s Coverage Tier and associated monthly contribution may change as a result, beginning on the first day of the month following the death date. DIVORCE The divorced Spouse and/or Subscriber must notify the Participating Group and the Plan of events that may cause a loss of coverage. The coverage termination date is the last day of the month in which the relationship was officially terminated. Employees and Seminarians The Spouse/Domestic Partner enrolled in the EHP or the EHP SEE will be offered an Extension of Benefits only and will not be considered eligible for the MSHP at a later date. Please see the Extension of Benefits section for more details. Post-65 Retired Employees or Pre-65 Retired Employee with Dependents under age 65 The Pre-65 Spouse or Domestic Partner enrolled in the EHP who gets divorced from a Post-65 Retired Employee or Pre-65 Retired Employee can stay enrolled in the EHP. However, if the Spouse or Domestic Partner leaves the EHP, then he or she cannot enroll again with the Plan until he or she becomes eligible for the MSHP. He or she can leave the MSHP and join again at future Open Enrollment periods. Post-65 Retired Employees or Pre-65 Retired Employees with Dependents in the MSHP The Spouse or Domestic Partner enrolled in the MSHP who gets divorced from a Post-65 Retired Employee or Pre-65 Retired Employee can stay enrolled in the MSHP. He or she can leave the MSHP and join again at future Open Enrollment periods.

23

EXTENSION OF B ENEFITS P ROGRAM FOR THE EHP The Plan’s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as “COBRA”) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 4. Nonetheless, Subscribers and/or their enrolled Dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the EHP would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. The option to extend coverage depends on whether the individual was covered as an Employee, Spouse, Domestic Partner or Dependent Child. • •

•

•

Employees who are terminated are offered an extension of 36 months starting on the first day of the month following the termination event. Spouses and Domestic Partners whose coverage is terminated as a result of the Employee’s termination, the Employee’s death, divorce, legal separation or termination of a Domestic Partnership are offered an extension of 36 months starting on the first day of the month following the termination event. o If the couple divorces while on an extension of benefits, the divorced spouse of the former Employee may choose to remain on their own extension for the remaining period of the current extension. Dependent Children whose coverage is terminated for any reason other than due to attaining age 30 are offered an extension of up to 36 months starting on the first day of the month following the termination event. The extension will end after 36 months for Disabled Children. For non-Disabled Children, the extension will end after 36 months or on the last day of the calendar year in which the Child turns age 30, whichever comes first 5. Seminarians who cease to be a Seminarian are offered an extension of 36 months starting on the first day of the month following graduation or other separation event.

Note: Regardless of the type of severance payment agreed upon between the employer and employee (lump sum or monthly payments), coverage under the Extension of Benefits program is effective the first of the month following the termination date in the employee’s record. Newly acquired Dependents during an Extension of Benefits period are eligible for coverage under the extension, provided that the Plan is notified within 30 days of the Significant Life Event. The Plan notifies individuals regarding their eligibility for the extension within 5 business days of receiving a termination notice from the Group Administrator. The notification includes an enrollment form and an invoice for contributions that are due and an explanation of the monthly contributions and duration of the extension. If the current Plan is no longer available, an alternate option may be offered. The termination date is the last day of the month in which the separation event occurred.

4

Under Section 4980B(d) of the Code and Treasury Regulation Section 54.4980 B-2, Q. and A. No. 4.

As such, a Dependent who loses coverage because of attaining age 30 will not be eligible for an Extension of Benefits.

5

24

Recipients of an Extension of Benefits offer have 21 calendar days to respond from the day the offer is mailed by the Plan. Responses must include a payment to cover the contributions that are due. Otherwise, enrollment in the extension is considered declined. Coverage in effect at the time of separation continues until the last day of the month in which the event occurs. Coverage under the Extension of Benefits program is effective the first of the month following the separation event so that there is no coverage gap between the termination date and enrollment in the extension of benefits. The Plan will maintain the coverage and invoice the Member directly, without the involvement of the Group Administrator. Note, however, that the employer is required to provide the SBC for the applicable Plans to the Members on the extension of benefits prior to open enrollment each year. No conversion option is available at the end of the extension of benefits. If the Participating Group ceases to offer the plan at the annual renewal, the Member will be notified during Open Enrollment of the need to change plans for the upcoming year. The Plan will notify Members on an Extension of Benefits of any cost change to the plan in advance of the new plan year. Coverage under the Extension of Benefits program will cease on the earliest of the following: • • • • •

• • •

The date that required monthly contributions to the Plan are 60 days overdue The date the Member becomes a Post-65 Retired Employee The last day of the month of the Extension of Benefit period The last day of the month after the individual submits a written notice to terminate coverage for medical, dental or both (30 days-notice required) The date a Participating Group’s participation in the Plan is terminated (whether by the Participating Group or the Medical Trust) and the Participating Group enrolls in another group health plan. (The Group Administrator will be notified by the Plan of all individuals participating in the Extension of Benefits program) Upon death of the Member The date the Plan ceases to exist The last day of the calendar year in which a Non-Disabled Dependent Child turns age 30

25

I MPORTANT N OTES R EQUIRED MONTHLY C ONTRIBUTIONS The Plan does not pro-rate contribution requirements for any health Plan regardless of the termination date or the effective date. Any monthly contribution rate change will be effective the first day of the month following the change. Contributions for coverage with a retroactive effective date must be paid upon enrollment. O NE TYPE OF C OVERAGE The Plan prohibits two Members who are each enrolled from covering each other in the same Plan (EHP, EHP SEE or MSHP). Therefore, an individual may not participate in the Plan as a Subscriber and as a Dependent in the same Plan. If two Members both work for the Episcopal Church in Participating Groups who offer different Plans, an individual may enroll as the Subscriber in one and as a Dependent in the other (e.g. Subscriber in medical Plan, Dependent in dental Plan). P LAN S PONSOR We maintain contractual relationships with various third-party administrators and local managed care plans on your behalf. The Episcopal Church Medical Trust is the plan sponsor and plan administrator of all plans except for a) Health Savings Accounts under the Consumer-Directed Health Plan/Health Savings Account arrangements, which are maintained by individual Members, and b) any local managed care plan options offered by us. The Medical Trust will be responsible for the preparation and delivery of the Forms 1094-B and 1095-B for members who participate in the plans that we sponsor.

26

CHAPTER 3 HOW TO OBTAIN SERVICES As a participant or dependent, you must receive all covered services from network providers inside the service area, except where specifically noted to the contrary in the “Emergency, PostStabilization, and Out-of-Area Urgent Care You Receive from Out-of-Network Providers” section of the Coverage chapter. Kaiser Permanente gives you access to all of the covered services you may need, such as routine care with your own personal network physician, hospital care, laboratory and pharmacy services, emergency care, urgent care, and other benefits described in this handbook. R OUTINE C ARE Routine appointments are for medical needs that are not urgent, such as routine preventive care. Try to make your routine care appointments as far in advance as possible. U RGENT C ARE You may need urgent care if you have an illness or injury that requires prompt medical attention but is not an emergency medical condition. If you think you may need urgent care, call the urgent care or advice nurse telephone number. Note: urgent care received in a Kaiser Permanente Region from an out-of-network emergency department is not covered. For information about Urgent Care outside the Service Area, please refer to the “Emergency, PostStabilization, and Out-of-Area Urgent Care You Receive from Out-of-Network Providers” section of the Coverage chapter. A DVICE N URSES Sometimes it's difficult to know what type of care you need. That's why Kaiser Permanente has telephone advice nurses available to assist you. These advice nurses can help assess medical symptoms and provide advice over the phone, when medically appropriate. They can often answer questions about a minor concern, tell you what to do if a network provider is closed, or advise you about what to do next, including making a same-day appointment for you if it's medically appropriate. To reach an advice nurse, please call the advice nurse phone number listed on the last page (back cover). Y OUR P ERSONAL N ETWORK P HYSICIAN Personal Network Physicians provide primary care and play an important role in coordinating care, including hospital stays and referrals to specialists. For the current list of physicians who are available as personal network physicians, and to find out how to select a personal network physician, please call customer service at the number listed on the last page (back cover). You can change your personal network physician for any reason. G ETTING A R EFERRAL R EFERRALS A written or verbal recommendation by a network physician that you obtain non-covered services (whether Medically Necessary or not) is not considered a referral and is not covered. A referral is limited to a specific service, treatment, series of treatments, and period of time. All referral services must be requested and approved in advance. You will receive a copy of the written referral when it is approved. Your Plan will not pay for any care rendered or recommended by an out-of-network physician beyond the limits of the original referral unless the care is specifically authorized by your network physician 27

and approved in advance. P RIOR A UTHORIZATIONS Certain services require prior authorization in order for the plan to cover them. Your network physician will request prior authorization when it is required, except that you must request prior authorization in order to receive covered post-stabilization care from out-of-network providers, as described in the “Emergency, Post-Stabilization, and Out-of-Area Urgent Care You Receive from Out-of-Network Providers” section of the Coverage chapter. The provider to whom you are referred will receive a notice of Authorization by fax. You will receive a written notice of the Authorization in the mail. This notice will tell you the physician’s name, address and phone number. It will also tell you the time period for which the referral is valid and the Services Authorized.

• • • • •

Required Prior-Authorization List All inpatient and outpatient facility services (excluding emergencies) Office based habilitative/rehabilitative care: Occupational; Speech, and Physical therapies All services provided outside a KP facility All services provided by out-of-network providers Drugs and Durable Medical Equipment not contained on the KP formulary

S ECOND O PINIONS Upon request and subject to payment of any applicable Cost Share, you may obtain a second opinion from: • •

A network physician about any proposed covered services With prior authorization, an out-of-network provider

Y OUR I DENTIFICATION C ARD Your Kaiser Permanente identification card (ID card) has a medical or health record number on it, which you will need when you call for advice, make an appointment, or go to a provider for covered services. When you get care, please bring your Kaiser Permanente ID card and a photo ID. Your medical or health record number is used to identify your medical records and coverage information. Your ID card is for identification only. In order for the Plan to cover Services, you must be a current Participant or Dependent on the date you receive the Services. Anyone who is not a Participant or Dependent will be billed for any Services he or she receives, and the amount billed may be different from the Eligible Charges for the Services. R ECEIVING C ARE IN O THER KAISER PERMANENTE REGIONS You will probably receive most Covered Services in the Service Area of the Kaiser Permanente Region where you live or work. However, if you are in the Service Area of another Kaiser Permanente Region, you will also be able to receive Services from Network Providers in that Region. Referrals or Prior Authorization may differ among Regions. For information about Network Providers in other Kaiser Permanente Regions, please call customer service. MOVING O UTSIDE OF THE S ERVICE AREA If you move to an area not within a Kaiser Permanente Service Area you will be required to change your health plan to one that services your area. Please contact your employer for instruction. 28

G ETTING ASSISTANCE Kaiser Permanente wants you to be satisfied with the health care you receive. If you have any questions or concerns about the care you are receiving, please discuss them with your personal network physician or with any other network providers who are treating you. They want to help you with your questions. You may also call customer service at the number listed on the last page (back cover). I NTERPRETER SERVICES If you need interpreter services when you call or when you get covered services, please let Kaiser Permanente know. Interpreter services are available 24 hours a day, seven days a week, at no cost to you, at network facilities. For more information, please call customer service at the number listed on the last page (back cover). NETWORK FACILITIES At most network facilities, you can usually receive all the covered services you need, including specialty care, pharmacy, and lab work. You are not restricted to a particular network facility, and you are encouraged to use the network facility that will be most convenient for you: • •

• • •

All network hospitals provide inpatient services and are open 24 hours a day, seven days a week. Emergency care is available from network and out-of-network hospital emergency departments (please refer to www.KP.org for emergency department locations in your area). Same-day appointments are available at many locations (please refer to www.KP.org for urgent care locations in your area). Many network facilities have evening and weekend appointments. Many network facilities have a customer services department (refer to www.KP.org for locations in your area).

Network Facilities for your area are listed in greater detail in Welcome to Your Plan and www.KP.org, which describes the types of covered services that are available from each network facility in your area because some network facilities provide only specific types of covered services. It explains how to make appointments, lists hours of operation, and includes a detailed telephone directory for appointments and advice.

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C HAPTER 4 C OVERAGE The Services described in this chapter are covered only if all the following conditions are satisfied: • • • •

You are a Participant or Dependent on the date that you receive the Services A Network Physician determines that the Services are Medically Necessary The Services are provided, prescribed, authorized, or directed by a Network Physician except where specifically noted to the contrary in this Plan Document Handbook You receive the Services from Network Providers inside the Service Area except where specifically noted to the contrary in the following sections for the following Services: o o o o

Authorized referrals as described under “Obtaining Services” Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care as described under Emergency Care in this chapter Care received outside the Service Area as described under “Obtaining Services” Emergency ambulance Service as described under Emergency Care in this chapter

C OST S HARING The Summary of Benefits and Coverage describes the Cost Sharing you must pay for Covered Services. Cost Sharing is due at the time you receive the Services, unless Network Providers agree to bill you. For items ordered in advance, you pay the Cost Sharing in effect on the order date (although the item will not be covered unless you still have coverage for it on the date you receive it). Copayments are applied per provider per day. Unless specified otherwise, when services can be provided in different settings, the cost sharing is applied according to the place of service in which the care is delivered and according to the type of provider providing the service. For example: if the service is provided during a hospital admission, the Hospital Inpatient Services Cost Share is applied. If the same service is performed in an office setting by a specialist, the specialty care office visit cost share is applied. If services are provided in a hospital clinic setting, separate cost shares may apply to the hospital clinic charges and the physician charges; both hospital clinic and physician charges will be subject to applicable deductibles and cost share. P LAN YEAR DEDUCTIBLE You must satisfy a Plan Year Deductible. The single Plan Year Deductible applies separately to each person in the Family and will be due until each person either satisfies their single Deductible or the total payments by the members of the Family applied to their single Deductible reaches the family Deductible amount. Once you satisfy the single or family Annual Deductible you pay the Cost Sharing indicated in the Summary of Benefits and Coverage. The Annual Deductible amounts are listed in the Summary of Benefits and Coverage, as well as services subject to the deductible. P LAN YEAR O UT-O F-P OCKET LIMITS There are limits to the total amount of Cost Sharing you must pay in a Plan Year for certain Covered Services that you receive in the same Plan Year. Those limits can be found in the Summary of Benefits and Coverage. If you are part of a Family that includes at least two people (counting the Participant and any Dependents), you reach the Plan Year out-of-pocket maximum when you meet the maximum per Participant or Dependent, or when your Family meets the maximum for a Family (whichever happens first). After you reach the Plan Year out-of-pocket maximum, you do not have to pay any more Cost Sharing for Service subject to the Plan Year out-of-pocket maximum through the end of the Plan Year.

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O UTPATIENT CARE When you need to visit your health care provider, the Plan makes it easy. You pay only a small copayment for the office visit. There are no claim forms to fill out. Remember, any services performed during the visit will be paid as outlined on the Summary of Benefits and Coverage at the back of this handbook. The following medical services are covered: • • • • • •

• • • • • • • • • •

•

• • • • • • • • •

Primary Care office visits including nutrition visits with Registered Dieticians (R.D.), State licensed nutritionists, and Certified Diabetic Educators (C.D.E). Specialty care office visits, including consultation and second opinions Second and third surgical opinions Termination of pregnancy Allergy services Repair, but not replacement, of sound natural teeth, related to an accidental injury is covered. Services must be started as soon as medically appropriate and received within 12 months of the date of the injury Accidental injury does not include damage as a result of normal activities such as chewing or biting. Chiropractic services (limited as outlined on the Summary of Benefits and Coverage) Radiation therapy Chemotherapy Dialysis services Habilitative and rehabilitative services Cardiac rehabilitation Acupuncture (limited as outlined on the Summary of Benefits and Coverage) Nutritional counseling Consultation requested by the attending physician for advice on an illness or injury Diabetes supplies prescribed by an authorized provider: o Blood glucose monitors o Testing strips o Insulin, syringes, injection aids, cartridges, insulin pumps and appurtenances, and insulin infusion devices Health education and training for self-management when prescribed by a network physician and provided by a qualified non-physician using a standardized curriculum to teach you how to self-manage your disease or condition. Education and training may be provided in group or individual sessions for the following conditions: o Asthma o Diabetes o Coronary artery disease Medically necessary treatment of the feet, including treatment of diabetes or peripheralvascular disease Diagnostic charges for x-rays Diagnostic charges for laboratory services Preadmission testing (PAT) Ultrasounds, including routine pregnancy-related ultrasounds Allergy testing Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography (MRA) Venipuncture

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•

Occupational, speech, or physical therapy, or any combination of these on an outpatient basis, up to the Plan maximums, if: o Given by skilled medical personnel at home, in a therapist’s office, or in an outpatient facility o Performed by a licensed speech/language pathologist, audiologist, or other therapist qualified to perform the services rendered

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P REVENTIVE EXAMS AND S ERVICES Preventive care is an important and valuable part of healthcare. Regular physical checkups and appropriate screenings can help detect illness early and promote wellness. Screenings and others services are covered as preventive care when you have no symptoms and no reason to suspect you might not be healthy. If you get the same service because you have some risk factors or symptoms, and your doctor wants to diagnose what is causing them, the service is not preventive, but instead will be considered under the diagnostic services benefit. The following preventive services are covered under this Plan as required by the Patient Protection Affordable Care Act and are not subject to deductibles, copayments or coinsurance. Consult with your physician to determine what preventive services are appropriate for you. Preventive Services for Adults • • • • • • • • • • • • • •

•

•

Age-appropriate preventive medical examination Discussion with Primary Care Provider regarding alcohol misuse Discussion with Primary Care Provider regarding obesity and weight management Abdominal aortic aneurysm-----one-time screening by ultrasonography in men age 65 to 75 who have ever smoked Blood pressure screening for all adults Cholesterol screening for adults at higher risk of cardiovascular disease Colon cancer screening for adults age 50 to 75, including anesthesia Prostate cancer screening in men age 50 to 75 Depression screening for adults Type 2 diabetes screening for adults with high blood pressure Hepatitis C virus screening for persons at high risk of infection and one-time screening for adults Discussion with Primary Care Provider regarding aspirin for adults at higher risk of cardiovascular disease Discussion with Primary Care Provider regarding diet counseling for adults at higher risk for chronic disease Immunizations for adults (doses, recommended ages, and recommended populations vary) o Hepatitis A o Hepatitis B o Herpes zoster o Human papillomavirus o Influenza o Measles, mumps, rubella o Meningococcal o Pneumococcal o Tetanus, diphtheria, pertussis o Varicella Screening for all adults at higher risk for sexually transmitted infections and counseling for prevention of sexually transmitted infections, including o HIV o Gonorrhea o Syphilis o Chlamydia o Discussion Discussion with Primary Care Provider regarding tobacco cessation

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• • • •

Physical therapy to prevent falls in community-dwelling adults who are at increased risk of falling Over-the-counter drugs when prescribed by a physician for preventive purposes, including o Aspirin to reduce the risk of heart attack o Vitamin D supplements for adults to prevent falls Lung cancer screening including CT scan of the thorax when ordered for smokers Screening for hepatitis B virus infection in adults and adolescents at high risk for infection

Preventive Services for women, including pregnant women • • • • • • • • • • • • • • • • • • • • • • • • • • •

Age-appropriate preventive medical examination Discussion with Primary Care Provider regarding chemoprevention in women at higher risk for breast cancer Discussion with Primary Care Provider regarding inherited susceptibility to breast and/or ovarian cancer Mammography screening for breast cancer Cervical cancer screening for women age 21 to 65 Osteoporosis screening for women age 65 or older and women at higher risk Discussion with Primary Care Provider regarding tobacco cessation Chlamydia infection screening for sexually active women at higher risk Gonorrhea screening for all women at higher risk Anemia screening for pregnant women Urinary tract or other infection screening for pregnant women Hepatitis B screening for pregnant women at their first prenatal visit Discussion with Primary Care Provider about folic acid supplements for women who may become pregnant Rh incompatibility screening for pregnant women and follow-up testing for women at higher risk Routine prenatal care visits Discussion with Primary Care Provider regarding preconception care Discussion with Primary Care Provider about interventions to promote and support breastfeeding and comprehensive lactation support and counseling Provision of breastfeeding equipment Gestational diabetes screening for pregnant women between 24 and 28 weeks of gestation and for pregnant women identified to be at high risk for diabetes Discussion with Primary Care Provider about interpersonal and domestic violence Female sterilizations, including anesthesia Prescribed, FDA-approved, contraceptive devices and contraceptive drugs. Discussion with Primary Care Provider about contraceptive methods and contraceptive device removal Over-the-counter folic acid for women to reduce the risk of birth defects when prescribed by a physician for preventive services For women who have family members with breast, ovarian, tubal, or peritoneal cancer, screening for family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2) Genetic counseling for women with positive screening results BRCA genetic testing when clinically indicated after genetic counseling Breast Cancer Chemoprevention - Consultation and medications prescribed for risk reduction of primary breast cancer in high-risk women

Preventive Services for Children

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• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Age-appropriate preventive medical examination Medical history for all children throughout development Height, weight, and body mass index measurements for children Behavioral assessments for children of all ages by Primary Care Provider Developmental screening for children under 3 years and surveillance throughout childhood by Primary Care Provider Discussion with Primary Care Provider regarding alcohol and drug use assessments for adolescents Autism screening for children at age 18 months and 24 months by Primary Care Provider Cervical dysplasia screening for sexually active females Congenital hypothyroidism screening for newborns Phenylketonuria (PKU) screening in newborns Dyslipidemia screening for children at higher risk of lipid disorders Oral health risk assessment for young children by Primary Care Provider Lead screening for children at risk of exposure Discussion with Primary Care Provider regarding obesity screening and counseling Gonorrhea prevention medication for the eyes of all newborns Hearing screening for all newborns Vision screening for all children Hematocrit or hemoglobin screening for children Hemoglobinopathies or sickle cell screening for newborns Tuberculin testing for children at higher risk of tuberculosis HIV screening Sexually transmitted infection (STI) prevention counseling Discussion with Primary Care Provider regarding fluoride supplements for children who have no fluoride in their water source Application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption through age 5 years Discussion with Primary Care Provider regarding iron supplements for children who are at risk for anemia Over-the-counter drugs when prescribed by a physician for preventive purposes Iron supplements for children to reduce the risk of ademia Oral fluoride for children to reduce the risk of tooth decay Immunizations for children (doses, recommended ages, and recommended populations vary) o Diphtheria, tetanus, pertussis o Haemophilus, influenzae type B o Hepatitis A o Hepatitis B o Human papillomavirus o Inactivated poliovirus o Influenza o Meningococcal o Pneumococcal o Rotavirus o Varicella

Additional Information About Prevent Services Preventive and Other Services Provided During the Same Visit There are some additional things to keep in mind about coverage for mandated preventive services that are provided along with other services during the same visit. The following cost share rules apply when a mandated preventive services is provided during an office visit

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• •

If the preventive service is billed separately (or is tracked as individual encounter data separately) from the office visit, then cost sharing may apply to the office visit If the preventive service is not billed separately (or is not tracked as individual encounter data separately) from the office visit, then o If the primary purpose of the office visit is the delivery of the preventive service, then no cost sharing may apply to the office visit o If the primary purpose of the office visit is not the delivery of the preventive service, then cost sharing may apply to the office visit.

Note: The Preventive List is subject to changes based on new federal recommendations (and clinical interpretations) issued after the date of this handbook.

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H OSPITAL C ARE The Plan covers most or all of the cost of your medically necessary care when you stay at a network hospital for surgery or treatment of an illness or injury. You are also covered for same-day (outpatient) hospital services, such as chemotherapy or radiation therapy, cardiac rehabilitation, and kidney dialysis. Same-day surgery services are surgical or invasive diagnostic procedures that: • • •

Are performed in a same-day or hospital outpatient surgical facility Require the use of both surgical operating and postoperative recovery rooms Require either local or general anesthesia

The following are covered services and limitations for both inpatient and outpatient (same-day) care: • • • • • • • • • • •

Diagnostic charges for x-rays Diagnostic charges for laboratory services and other diagnostic tests such as EKGs, EEGs, or endoscopics Preadmission testing (PAT) Amniocentesis, including the associated genetic counseling and genetic testing Ultrasounds, including routine pregnancy-related ultrasounds Allergy testing Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography (MRA) Venipuncture Oxygen and anesthesia (including equipment for administration) Anesthesiologist, including one consultation before surgery and services during and after surgery Physical therapy, physical medicine, or rehabilitation services, or any combination of these on an inpatient or outpatient basis, up to the Plan maximums, if: o Prescribed by a physician o Designed to improve or restore physical functioning within a reasonable period of time

The following are additional covered services for inpatient care: •

• • • • • • • •

Semi-private room and board when: o The patient is under the care of a physician o A hospital stay is medically necessary. Coverage is for unlimited days, subject to Medical Management Program review, unless otherwise specified. Private room and board expenses when medically necessary or when a semi-private room is not available Intensive care unit and coronary care unit charges Operating and recovery rooms Special diet and nutritional services while in the hospital General nursing care Services of a licensed physician or surgeon employed by the hospital Care related to surgery Miscellaneous hospital services and supplies required for treatment during a hospital confinement

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•

• •

• • • •

•

For dental procedures, general anesthesia in a Network Hospital or ambulatory surgery center and the Services associated with the anesthesia are covered if any of the following are true: o You are under age 7 o You are developmentally disabled o You are not able to have dental care under local anesthesia due to a neurological or medically compromising condition o You have sustained extensive facial or dental trauma Dental evaluation, X-rays, and extractions necessary to prepare your jaw for radiation therapy of cancer in your head or neck are covered. Breast cancer surgery (lumpectomy, mastectomy), including: o Reconstruction following surgery o Surgery on the other breast to produce a symmetrical appearance o Prostheses o Treatment of physical complications at any stage of a mastectomy, including lymphedemas Use of cardiographic equipment Drugs, dressings, and other medically necessary supplies Social, psychological, and pastoral services Reconstructive procedures are covered when the services: o Will result in significant improvement in physical function for conditions as a result of injuries illness, congenital defects or medically necessary surgery. o Will correct significant disfigurement resulting from an injury, illness or congenital defects or medically necessary surgery. o Following medically necessary removal of all or part of a breast, reconstruction of the breast as well as surgery and reconstruction of the other breast to produce a symmetrical appearance is covered. o Correction of congenital hemangioma (known as port wine stain) is limited to hemangiomas of the face and neck for children aged 18 years and younger. Physical, occupational, speech/hearing therapy, including facilities, services, supplies, and equipment

The following are additional covered surgical services • • • • • • • • • • • • • •

Surgeon’s expenses for the performance of a surgical procedure Two or more surgical procedures performed during the same session. Anesthetic services when performed by a licensed anesthesiologist or certified registered nurse anesthetist in connection with a surgical procedure Oral surgery, limited to treatment of an injury to sound and natural teeth Reconstructive surgery when needed to correct damage caused by disease or a birth defect resulting in the malformation or absence of a body part or an accidental injury Breast reconstruction following a total or partial mastectomy. Benefits include prostheses and reconstruction of the non-diseased breast to restore symmetry. Medically necessary removal of breast or other prosthetic implants Surgical treatment of morbid obesity Surgical reproductive sterilization Human organ and tissue transplants. Please refer to the “Transplant Care” section of this handbook for further information. Circumcision, for newborns only within 31 days of birth, whether medically necessary or not (after 31 days, procedure must be medically necessary) Outpatient surgery Penile prosthetic implants Orthognathic surgery

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•

Podiatry surgery

The following are additional covered services for same-day care: • • •

•

Same-day and hospital outpatient surgical facilities Surgeons and surgical assistants Chemotherapy and radiation therapy, including medications, in a hospital outpatient department, doctor’s office, or facility. Medications that are part of outpatient hospital treatment are covered if they are prescribed during a hospital stay and filled by the hospital pharmacy. Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until the patient becomes eligible for end-stage renal disease dialysis benefits under Medicare: o At home, when provided, supervised, and arranged by a physician and the patient has registered with an approved kidney disease treatment center (professional assistance to perform dialysis and any furniture, electrical, plumbing, or other fixtures needed in the home to permit home dialysis treatment are not covered) o In a hospital-based or free-standing facility

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EMERGENCY, POST-S TABILIZATION, AND OUT-OF-A REA URGENT CARE YOU RECEIVE FROM OUT-OFNETWORK PROVIDERS This section explains how to obtain covered emergency, post-stabilization, and out of area Urgent Care from out-of-network providers. The out-of-network provider care discussed in this section is not covered unless it meets both of the following requirements: • •

This section of the handbook says it’s covered The care would be covered if you received the care from a network provider

For example, out-of-network Skilled Nursing Facility care is not covered as part of authorized Post-Stabilization Care unless both of the following are true: • •

Kaiser Permanente authorizes the care and the care meets the definition of PostStabilization Care The care would be covered if you received the care from a Network Skilled Nursing Facility inside the Service Area

You do not need to get Prior Authorization from Kaiser Permanente to get Emergency Services or Urgent Care outside the Service Area from out-of-network providers. However, you (or someone on your behalf) must get Prior Authorization from Kaiser Permanente to get covered Post-Stabilization Care from out-of-network providers. EMERGENCY SERVICES If you have an emergency medical condition, call 911 (where available) or go to the nearest hospital emergency department. You do not need prior authorization for emergency services. When you have an emergency medical condition, we cover emergency services you receive from network providers or out-of-network providers anywhere in the world as long as the services would have been covered under this Plan if you had receiv3ed them from network providers. Emergency services are available from hospital emergency departments 24 hours a day, seven days a week. For ease and continuity of care, you are encouraged to go to a network hospital emergency department if you are inside the service area, but only if it is reasonable to do so, considering your condition or symptoms. If you have been admitted to an out-of-network hospital, your stay will be covered by Kaiser Permanente These emergency services are covered: • • •

Treatment in a hospital emergency room or other emergency care facility for a condition that can be classified as a medical emergency Ambulance services provided by ground or air licensed ambulance is covered when you have an emergency medical condition Treatment in a hospital or other emergency care facility of injuries received in an accident

P OST-STABILIZATION C ARE Post-Stabilization Care is medically necessary services related to your emergency medical condition that you receive after your treating physician determines that your emergency medical condition is clinically stable. Post-stabilization care received from an out-of-network provider, including inpatient care at an out-of-network hospital, is covered only if Kaiser Permanente provides prior authorization for the care. To request prior authorization to receive post-stabilization care from an out-of-network provider, you (or someone on your behalf) must call Kaiser Permanente toll free at the telephone number on your 40

Kaiser Permanente ID card before you receive the care if it is reasonably possible to do so (otherwise, call as soon as reasonably possible). A Kaiser Permanente representative will then discuss your condition with the out-of-network provider. If Kaiser Permanente decides that you require Post-Stabilization Care and that this care would be covered if you received it from a network provider, they will authorize your care from the out-of-network provider or arrange to have a network provider (or other designated provider) provide the care. If Kaiser Permanente decides to have a network hospital, network skilled nursing facility, or designated out-of-network provider provide your care, they may authorize special transportation services that are medically required to get you to the provider. If this occurs, then those special transportation services will be covered, even if they would not be covered under this Plan if a network provider had provided them. Be sure to ask the out-of-network provider to tell you what care (including any transportation) Kaiser Permanente has authorized, because unauthorized post-stabilization care or related transportation provided by out-of-network providers is not covered. Sometimes extraordinary circumstances can delay your ability to call Kaiser Permanente to request authorization for post-stabilization care from an out-of-network provider (for example, if you are unconscious, or if you are a young child without a parent or guardian present). In these cases, you (or someone on your behalf) must call Kaiser Permanente as soon as reasonably possible. O UT OF A REA URGENT CARE If you need prompt medical care due to an unforeseen illness, unforeseen injury, or unforeseen complication of an existing condition (including pregnancy), your Plan covers medically necessary services, including services received from an out-of-network provider outside the service area to prevent serious deterioration of your (or your unborn child's) health if all of the following are true: • •

You receive the services from out-of-network providers while you are temporarily outside the service area You reasonably believed that your (or your unborn child's) health would seriously deteriorate if you delayed treatment until you returned to the service area

Urgent care received in a Kaiser Permanente Region from an out-of-network emergency department or urgent care facility is not covered.

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MATERNITY C ARE Good prenatal care helps promote healthy babies and successful deliveries. Your medical coverage includes: • • •

No charge for maternity office visits with participating doctors once your pregnancy is confirmed A minimum hospital stay of 48 hours following vaginal deliveries and 96 hours following cesarean sections Obstetrical care and delivery (including cesarean section and newborn care)

Note: If you are discharged within 48 hours after delivery (or within 96 hours if delivery is by cesarean section), your physician may order a follow-up visit for you and your newborn to take place within 48 hours after discharge. The following are additional covered services and limitations: • • • • • • • •

Services of a certified nurse-midwife affiliated with a licensed facility. The nurse-midwife’s services must be provided under the direction of a physician. Parent education, and assistance and training in breast or bottle feeding, if available Amniocentesis, including the associated genetic counseling and genetic testing Ultrasounds Circumcision, for newborns prior to discharge after birth (whether medically necessary or not) after discharge, the procedure must be Medically Necessary) Special care for the baby if the baby stays in the hospital longer than the mother Semiprivate room Home care when Medically Necessary

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I NFERTILITY C OVERAGE Once a diagnosis of infertility has been made, the Plan will cover services related to its treatment. This benefit is available to the member and the member’s spouse or domestic partner (where applicable). Inpatient and outpatient infertility services include any necessary procedures, laboratory and radiology services and drugs administered by medical personnel for the further evaluation or treatment of infertility. Treatment of infertility includes correcting the underlying medical condition causing the infertility and artificial insemination. Additional eligible services included advanced reproductive technologies such as in vitro fertilization (IVF); zygote intrafallopian transfer (ZIFT) and variations of these procedures. Exclusions: • • •

Donor semen or eggs, and Services related to their procurement and storage, including long term cryopreservation Any experimental, investigational or unproven infertility procedures or therapies. Infertility services when the infertility is caused by or related to voluntary sterilization

There is a lifetime benefit maximum of $10,000 for services covered under your health plan and a lifetime benefit maximum of $10,000 for services covered under your prescription drug plan. Your cost shares and deductibles do not count against your benefit maximums.

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MENTAL HEALTH AND SUBSTANCE A BUSE Evaluation, crisis intervention, and treatment are covered for mental health and substance abuse conditions. I NPATIENT Inpatient psychiatric and substance abuse care is covered in a network hospital or licensed residential treatment facility. Coverage includes medical management of withdrawal symptoms for substance abuse additions, room and board, drugs, services of network physicians, and services of other network providers who are mental health professionals. O UTPATIENT T HERAPY The following outpatient mental health care is covered: • • • • •

Partial hospitalization, sometimes known as day-night treatment programs Intensive outpatient programs Individual and group visits for diagnostic evaluation and psychiatric treatment Electroconvulsive therapy (ECT) Visits for the purpose of monitoring drug therapy

THERAPIES FOR THE TREATMENT OF A UTISM S PECTRUM DISORDERS For children under the age of 19, the Plan covers the following therapies for the treatment of Autism Spectrum Disorders: • •

Outpatient physical, occupational, and speech therapy in a Network medical Office when prescribed by a Network Physician as Medically Necessary Applied behavior analysis, including consultations, direct care, supervision, or treatment, or any combination thereof by autism services providers, up to the maximum benefit permitted

Speech therapy is limited to treatment for speech impairments due to injury or illness. Many pediatric conditions do not qualify for coverage because they lack a specific organic cause and may be long term and chronic in nature. Occupational therapy is limited to treatment to achieve and maintain improved self-care and other customary activities of daily living. Exclusions include: •

• •

Speech therapy that is not Medically Necessary, such as (a) therapy for educational placement or other educational purposes; or (b) training or therapy to improve articulation in the absence of injury, illness, or medical condition affecting articulation; or (c) therapy for tongue thrust in the absence of swallowing problems. Long-term habilitation, not including treatment for autism spectrum disorders Special education, counseling, therapy or care for learning deficiencies or behavioral problems, whether or not associated with autism

EMPLOYEE A SSISTANCE P ROGRAM (EAP) The Employee Assistance Program (EAP) is managed by Cigna Behavioral Health and covers a vast array of family and personal services. The program is designed to assist our members with information, educational materials, resources, referrals, and ongoing support. EAP services are available 24 hours a day, 7 days a week through the Cigna Behavioral Health web-

44

site or by phone. All services are free and confidential. Equipped with many tools, the EAP staff members are trained to provide you with a multitude of services including: help finding daycare services for your children, support for managing stress, information on adoption, assistance in researching nursing homes, and much more. To access the Cigna EAP services, visit the EAP website at www.cignabehavioral.com or call (866) 395-7794. EAP services are offered solely by Cigna Behavioral Health, and are not available through, nor coordinated with, Kaiser Permanente. P ASTORAL S UPPORT N ETWORK (PSN) The Pastoral Support Network (PSN) offers counseling and support services with a particular sensitivity to the unique issues priests and their families may experience. If there’s an issue for which you’d like assistance, you can talk with a PSN counselor over the phone or get a referral for a counseling professional in your area. The Pastoral Support Network is part of your EAP benefit, and is completely confidential. Neither your congregation/employer nor the Episcopal Church Medical Trust will be notified when you use the services. The Pastoral Support Network is offered at no cost and is available to all the family members in your household. For more information or to talk with a PSN specialist, call (866) 395-7794.

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TRANSPLANT C ARE We wish to provide you and your family with a human organ and tissue transplant benefit that helps you obtain quality care and financially protects you from significant health care expenses. The medical professionals who conduct the program focus their review on the appropriateness of the proposed transplant procedures. Only those procedures that are covered and certified as medically necessary will be eligible under the Plan. Services will be covered if: • •

Kaiser Permanente has determined that you meet certain medical criteria for patients needing transplants Kaiser Permanente provides a written referral to an approved transplant facility. The facility may be located outside the service area. Transplants are covered only at a facility approved by Kaiser Permanente, even if another facility within the service area could perform the transplant.

C OVERED TRANSPLANTS The Plan will provide benefits as outlined on the Summary of Benefits and Coverage only for the services and supplies listed in this section. The following transplants are covered: • • • • • • • • •

Bone Marrow transplant/stem cell rescue Cornea Heart Heart & lung Liver Lung Kidney; Simultaneous kidney & pancreas Pancreas; Pancreas after kidney alone Small bowel; Small bowel & liver

The following services are covered: • • • • • • • • •

•

Pre-transplant evaluation Organ procurement Transplant procedures and associated hospitalization Transplant-related follow-up care provided by the designated transplant facility Pharmacy supplies and services provided by the facility for immunosuppressant and other transplant-related medications while hospitalized Donor expenses, if not covered under any other plan Transplant-related services provided by facility that are associated with the transplant events listed in this section, including laboratory and other diagnostic services Physician services related to the transplant events listed in this section Transportation and lodging expenses (up to a daily dollar limit) outside of the Service Area when approved in advance by Kaiser Permanente. Coverage will include the transplant recipient plus, one parent or guardian if the transplant recipient is a minor or one other person if the transplant recipient is an adult. Transportation, hospital, and lodging expenses (up to a daily dollar limit) of an organ/tissue donor which are directly related to a covered transplant for a member are covered only if such expenses are incurred for services within the United States or Canada. Coverage of expenses for these Services is subject to Donor Service Guidelines.

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DURABLE MEDICAL EQUIPMENT (DME), EXTERNAL P ROSTHETICS, O RTHOTICS, AND SUPPLIES The Plan covers medically necessary prosthetics, and durable medical equipment. Please see the Summary of Benefits and Coverage for the level of coverage. DME must be on Kaiser Permanente’s DME, External Prosthetic and Orthotic formulary to be covered, except wigs required after treatment for a malignancy. Wigs are purchased from an out-ofnetwork provider and a request for reimbursement must be submitted. A formulary is a list of DME, external prosthetics and orthotics which are covered. Examples of covered items include wheelchairs, hospital beds and oxygen. Medical supplies of an expendable nature, such as oxygen tubing, are covered if they are required for the effective use of the DME. Drugs purchased at the pharmacy for use in DME equipment are covered under the “Outpatient Prescription Drug” benefit and not this benefit. In order to have coverage you must meet criteria for use of any equipment and obtain items from a Network Provider. Coverage is limited to the standard item of equipment that adequately meets your medical needs. Kaiser Permanente will decide whether to rent or purchase the covered equipment for your use. You will have to pay for non-covered equipment. Coverage includes fitting and adjustment. When the item continues to be medically necessary, coverage includes repair and replacement of the standard item in cases of loss, irreparable damage, wear, or replacement required because of a change in your medical condition. You must return the equipment or pay the fair market price of the equipment when it is no longer covered. EXTERNAL P ROSTHETICS External Prosthetics must be on Kaiser Permanente’s DME, External Prosthetic and Orthotic formulary to be covered. Examples of external Prosthetic covered items include: • • • •

Artificial arms and legs. Ostomy and urological supplies. Feeding tubes and enteral nutrition that is administered via a feeding tube Contact lenses following cataract surgery and glasses and contacts when the intraocular lens is absent and cannot be replaced such as in aphakia or when all or part of the iris is missing as in aniridia

O RTHOTICS Orthotics must be on Kaiser Permanente’s DME, External Prosthetic and Orthotic formulary to be covered. Services to determine the need for an external Prosthetic or an Orthotic and any subsequent fittings and adjustments are covered under the heading “Outpatient Care”.

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S KILLED N URSING C ARE The Plan provides benefits for skilled nursing care. Skilled inpatient services and supplies must be Services customarily provided by a Skilled Nursing Facility, and must be above the level of custodial or intermediate care. The following services and supplies are covered: • • • • • • • • • •

Network physician and nursing services Room and board Medical social services Prescribed drugs Respiratory therapy Physical, occupational, and speech therapy. Medical equipment ordinarily furnished by the Skilled Nursing Facility Medical supplies Imaging and laboratory Services that SNFs ordinarily provide Blood, blood products and their administration

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H OME HEALTH C ARE If you or your dependents have a serious or extended care illness or injury, home health care can be an alternative to an extended stay in a hospital or a stay in a skilled nursing facility. Skilled, part-time, or intermittent home health services are covered when you are confined to your home. Skilled home health services are those services provided by nurses, medical social workers, and physical, occupational and speech therapists. Medical supplies used during a covered home health visit are also covered. The services are covered only if a network physician determines that you require skilled care and it is feasible to maintain effective supervision and control of your care in your home. Home health aide services are covered only when you are also getting covered home health care from one of the licensed providers mentioned previously. W HAT’S C OVERED Part-time or intermittent home health care visits are defined as follows: • • •

Up to two hours per visit for visits by a nurse and then each additional increment of two hours counts as a separate visit Up to four hours per visit for visits by a home health aide is covered. Each additional increment of four hours counts as a separate visit A visit by other providers such as a medical social worker, or physical, occupational, or speech therapist counts as 1 visit and counts toward the applicable visit limits regardless of the number of hours present

H OME I NFUSION SERVICES Home infusion therapy is the administration of drugs in your home using intravenous, subcutaneous, and epidural routes (into the bloodstream, under the skin, and into the membranes surrounding the spinal cord). Home infusion includes intravenous delivery of parenteral nutrition when nutritional needs cannot be met by the oral or enteral route as determined by a network physician. The infusion therapy must be delivered by a licensed pharmacy. Home services are also provided to ensure proper patient education and training and to monitor the care of the patient in the home. These services may be provided directly by infusion pharmacy nursing staff or by a qualified home health agency. You do not need to be confined to your home to receive home infusion services. The following are covered home infusion Services: • • • • • •

Administration Professional pharmacy services Care coordination All necessary supplies and equipment, including delivery and removal of supplies and equipment Drugs and biologicals. Nursing visits related to infusion

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H OSPICE CARE If a network physician diagnoses you with a terminal illness and determines that your life expectancy is six months or less, you may choose home-based hospice care instead of traditional services that you would otherwise receive for your illness. If you choose hospice care, you are choosing to receive care to reduce or relieve pain and other symptoms associated with the terminal illness, but not to receive care to try to cure the terminal illness. You may continue to receive covered services for conditions other than the terminal illness. You may change your decision to receive hospice care at any time. The following services and supplies are covered on a 24 hour basis: • • • • • • • • • • •

Network Physician and nursing care Medical care given by a hospice doctor Counseling and bereavement Services Physical, occupational, speech or respiratory therapy for purposes of symptom control or to enable you to maintain activities of daily living Medical social services Home health aide and homemaker Services Laboratory tests and x-rays Durable Medical Equipment and Medical supplies Palliative drugs, in accordance with Kaiser Permanente’s drug formulary guidelines. Short-term (no more than 5 days at a time) inpatient care, limited to respite care and care for pain control, and acute and chronic symptom management Dietary counseling

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C LINICAL TRIALS Benefits are available for routine patient care costs incurred during participation in a qualifying clinical trial for the treatment of cancer or other life-threatening disease or condition. For purposes of this benefit, a life threatening disease or condition is one from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat complications arising from participation in a qualifying clinical trial. The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a covered health service and is not otherwise excluded under the Plan. Benefits are available only when the member is clinically eligible for participation in the qualifying clinical trial and the referring healthcare professional is a participating healthcare provider and has concluded that the individual’s participation in such trial would be appropriate, or the member provides medical or scientific information establishing that the individual’s participation in the study would be appropriate. Routine patient care costs for qualifying clinical trials include:

• • •

Covered health services for which benefits are typically provided absent a clinical trial Covered health services required solely for the provision of the investigational item or service, the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications Covered health services needed for reasonable and necessary care arising from the provision of an Investigational item or service

Routine costs for clinical trials do not include:

• • • •

The experimental or investigational service or item Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis Items and services provided by the research sponsors free of charge for any person enrolled in the trial

A qualifying clinical trial means a phase I, phase II, phase III or phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening diseases or conditions and which meets any of the following:

•

Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:

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− − − − − − −

National Institutes of Health (NIH). (Includes National Cancer Institute (NCI)) Centers for Disease Control and Prevention (CDC) Agency for Healthcare Research and Quality (AHRQ) Centers for Medicare and Medicaid Services (CMS) A cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA) A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants The Department of Veterans Affairs, the Department of Defense or the Department of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria:

• •

Comparable to the system of peer review of studies and investigations used by the National Institutes of Health Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review

•

The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration

•

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

•

The clinical trial must have a written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the clinical trial. We may, at any time, request documentation about the clinical trial

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CHAPTER 5 WELLNESS AND CLINICAL M ANAGEMENT Kaiser Permanente’s integrated health care system focuses on total health. Members can enroll in a variety of programs that help them take an active role in their health and make desired lifestyle changes. A wide range of tools (e.g., health classes, online programs, discounted services and products, and preferred rates on fitness programs) help members address problems before they become serious, reach their health goals, and realize the long-term benefits of a healthy lifestyle. HEALTH CLASSES Currently available classes are listed on health classes (kp.org/classes) or call Member Services. Typical classes include: • • • • • • • • • • •

Nutrition counseling (e.g., weight loss and healthy diet) Smoking Cessation program Prenatal counseling and education Substance abuse prevention Alcohol-dependency counseling Stress reduction programs Chronic disease self-management programs Exercise counseling and cardiovascular fitness programs Violence Prevention and Anger Management programs Health risk appraisals Injury prevention program

O NLINE HEALTHY LIFESTYLES P ROGRAMS ®

Customized online programs from Kaiser Permanente in collaboration with HealthMedia Members get the clear steps and ongoing encouragement it takes to reach health goals. www.kp.org/healthylifestyles •

• • • • • • •

Succeed™ is a “Total Health Assessment” online survey, developed by HealthMedia, that evaluates and prioritizes risk based on eight lifestyle areas including: weight management, nutrition, physical activity, tobacco use, stress and well-being, alcohol use, skin protection, and injury prevention. At the Members discretion, results from their Health Risk Assessment (HRA) can be shared (via their fully-integrated medical record) with their provider. Balance™ offers strategies for reaching an ideal weight, helping your employees lose weight and keep it off Breathe™ presents strategies to help your employees quit smoking Relax™ provides strategies for relieving and preventing stress by taking the time to learn about specific individual needs Nourish™ develops strategies for making smart and delicious food choices to increase energy, manage weight, and live a healthier, more productive life Care™ for Your Health focuses on increasing your employee’s confidence to manage his/her chronic condition, as well as providing support and encouragement on living healthily with a long-term condition Care™ for Pain offers support and strategies for individuals living with chronic pain to teach self-management and coping strategies to regain control of their life Care™ for Diabetes teaches strategies to help keep track of the many requirements needed to successfully manage this complex condition and live a healthier and more satisfying life

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• • •

Overcoming™ Depression helps participants find ways to manage symptoms of this painful condition, so they can flourish and enjoy life again. The program can help those suffering depression for the first time, or those with ongoing problems. Overcoming™ Insomnia teaches participants how to adopt thought processes and techniques to achieve peaceful sleep for a more restful and satisfying life Back care delivers personalized strategies for preventing and managing back pain in order to experience enjoyable and productive daily activities

O NLINE S UPPORT For those members who participate in the healthy lifestyle programs outlined above, additional resources such as exercise videos and healthy recipes are available for download to your computer or mp3 player. O NLINE MEMBERS-ONLY WEBSITE (members.kp.org) Members can quickly schedule appointments, view their health records for information such as recent immunization history, locate services, consult with pharmacists and nurses, order prescription refills, join online discussion groups, research health conditions, find links to a health encyclopedia with more than 40,000 pages of medical information, or use one of several “health calculators” to calculate target weight or heart rate and find links to medical Web sites. O NLINE FEATURED HEALTH TOPICS Featured health topics at www.kp.org/featuredhealthtopics provide members with health information, tools, details about medications, treatment options, and practical steps for preventing or managing conditions. O NLINE P ODCASTS Podcasts are downloadable audio programs providing health tools and instruction for pain management, healthy sleep habits, pregnancy and childbirth, menopause, stress reduction, surgery, and weight loss. O NLINE WIDGETS Widgets (www.kpwidgets.org) are online, interactive support tools designed to help stimulate the mind, strengthen the body, and soothe the spirit. Downloading a widget is fast, free, and secure. • Burn It Off! Fitness Calculator: Use to determine the tradeoffs between snacking and the level of activity required to burn off the extra calories. • Yoga: Provides access to yoga poses for all levels of yoga students from beginners to experienced students. • Brain Teaser: Use this widget to sharpen your mind whenever you have a dull moment. O NLINE PEDIATRICS SUPPORT The “Kid Wisdom” site contains music, games, visuals, and resources to help children learn about living a healthy lifestyle, including the new story-based video game, "Snacktown Smackdown” and the award-winning game, “The Incredible Adventures of the Amazing Food Detective.” Visit the site at: http://info.kp.org/richmedia/kidWisdom/.

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10,000 S TEPS® DISCOUNTED P ROGRAM 10,000 Steps is an online program designed to encourage members to increase their activity level with a goal of walking 10,000 steps or more a day. The program and the pedometer and are offered ®

at a discount to our members. (10,000 Steps is a registered trademark of HealthPartners, Inc.) ®

W EIGHT W ATCHERS D ISCOUNTED P ROGRAM With Kaiser Permanente's special rates, we've teamed with Weight Watchers® to help members save money on membership fees. Visit www.kp.org, select the Health & Wellness tab, select the “Member programs and classes,” and select “Member discount programs.” ChooseHealthy TM Discounted Services To provide members with a wider range of safe and effective treatment options, we have arranged with American Specialty Health Networks (ASHN), to offer ChooseHealthy™ to our members. ChooseHealthy provides discounted rates on a variety of health and wellness products and services, including acupuncture, chiropractic care, fitness club memberships, health and fitness books and videos, herbs, vitamins, and supplements, and massage therapy services. To access the ChooseHealthy site from www.kp.org, select the Health & Wellness tab, select the “Member programs and classes,” “Member discount programs,” then the “Complementary health and fitness programs” link. Site may be reached at www.kp.org/choosehealthy. HEALTH C OACHING Health Coaching is tailored to the individual and is available for a fee to both members and nonmembers. Coaches offer a customized exercise and nutrition program while providing assessment, motivation and follow-up. They establish a one-on-one relationship with the member, reviewing their medical history to design a health plan specifically for them. They also refer members to our health education classes to supplement their individualized programs. C LINICAL MANAGEMENT C OMPLETE C ARE All Kaiser Permanente members with a chronic disease are targeted for our disease management program, known as Complete Care. Complete Care programs are designed to help members prevent or manage chronic conditions through a combination of clinical care, health education, and selfmanagement tools. Our “Complete Care” disease management programs include: • • • • • • • • • • • • •

Asthma (adult/pediatric) Diabetes Cardiovascular Disease Chronic Heart Failure (CHF) Chronic Kidney Disease Chronic Obstructive Pulmonary Disease (COPD) Coronary Artery Disease (CAD) Hypertension (integrated with CAD/CHF) Sickle Cell Anemia HIV/AIDS (chronic condition) Low Back problems (chronic condition) Osteoporosis (chronic condition) Obesity / Weight Management – Eating disorders (chronic condition)

Kaiser Permanente members with specific medical conditions do not need to self-enroll in care management programs. Members are automatically identified using disease-specific case identification protocols through our clinical information systems. Care management combines the following elements to ensure high quality care and an effective use of health plan resources: 55

• • • • • •

Integration of care management programs into our delivery system, benefiting low- or moderate-risk as well as well members Permanente physicians lead our care management efforts, not administrators or vendors Clinical information, not claims or billing criteria, is used to build care management patient databases Kaiser Permanente members with specific clinical conditions do not need to self-enroll in programs; they are automatically identified through our clinical information systems Implementation of core practices based on Permanente clinical practice guidelines (CPGs) Established clinical and management teams who share best practices among our service areas

MATERNITY: P RECONCEPTION C OUNSELING The focus of the screening is to address and identify possible medical conditions, habits, and personal situations that could cause problems during a pregnancy. Health and lifestyle screenings include: • • • • • • • • •

• •

Alcohol and drug use Chronic disease management Depression Domestic violence Family medical history Genetic screening and testing Healthy eating and active living Immunizations Presence of reproductive and developmental toxicants and teratogens (including harmful substances such as heavy metals and chemical compounds as well as concentrations of nutrients that can be hazardous to a mother or fetus during pregnancy and may cause birth defects) Sexually transmitted diseases Smoking

MATERNITY: C LASSES AND P ROGRAMS Class information is also available at www.kp.org. Many of our classes are multilingual, conducted in English and other languages, including Spanish and Cantonese. Availability of multilingual instruction will vary by medical center and by region. In addition to the classes, we provide a maternity tour at most of our Medical Centers. We also offer breast feeding support, guided imagery programs and a prenatal manual and handouts at prenatal visits. Our members can also visit our website and download our Healthy Beginnings prenatal newsletter, which describes what the expecting mother experiences during the different phases of her pregnancy. At each Kaiser Permanente medical facility in California (Northern and Southern regions), Colorado (Denver/Boulder/Longmont and Southern regions), Mid-Atlantic States, and the Northwest, the Health Education Departments offer a variety of classes to help women prepare themselves and their partner for pregnancy, birth, and the care of their newborn infant. Topics include: • • • • • • •

Birthmarks Caring for twins (or more) Choosing child care Circumcision Colic Cradle cap Crib safety

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• • • • • • • • • •

Crying baby Diaper rash Fever Health and safety (birth to 2 years) Immunizations Newborn growth and development Childbirth preparation (Lamaze) Childbirth refresher Premature infant Shaken baby syndrome

After the baby is born we have another series of classes for our new parents: • • • • • • • •

Breast-feeding basics Diabetes in pregnancy: gestational diabetes Expectant parents series Gestational diabetes Guided imagery programs If it's right for you: tubal ligation Infant CPR Living well after gestational diabetes

P REGNANCY AND NEW BABY: O NLINE TOOLS Convenient information on what to expect during pregnancy and on the many programs for mothers, babies, and families is listed on www.kp.org/pregnancy Members can access the following categories: Healthy beginnings newsletters Filled with valuable information from before conception through birth, 12 newsletters are available to help women and their partners understand the physical and emotional journey a woman experiences during pregnancy. Preparing for pregnancy This section provides advice on improving a woman’s health for pregnancy. Members can access helpful information through the HealthMedia® Balance™ weight management program and through HealthMedia® Nourish™ to prepare for pregnancy. During pregnancy This section offers advice and reassurance on the changes a woman’s body undergoes during each phase of her pregnancy. Women are encouraged to work closely with their doctor, ask questions, and raise any concerns they might have. Prenatal screening tests During pregnancy, doctors may suggest many prenatal tests to ensure that the mother is healthy and the baby is developing properly. This section helps familiarize a woman with many of the most common tests and understand what they are and why they might be requested. Possible problems in pregnancy Most women go through pregnancy without any medical problems or complications. However, for those who do have a suspected or diagnosed complication, this section provides concise, easily understood information on a number of common pregnancy-related complications. Preparing for labor and birth

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Many women, their partners, and their families may be anxious about labor, but there are many ways to prepare. Here, members are urged to attend childbirth preparation classes, to develop a birthing plan so that they can discuss childbirth preferences with the doctor, learn the difference between false and actual labor, and even get advice on selecting the infant's first car safety seat. After your baby is born Some of the challenges of motherhood can be overwhelming, and this section of the Web site helps with information such as: • Feeding your baby: Studies show that the best food for the baby is breast milk and breastfeeding can also help the mother return to pre-pregnancy weight sooner. • Dealing with your emotions: “Postpartum blues” are common and can occur from a few days after delivery to anytime during the first year. • Getting back in shape: Finding the time and energy to exercise can be a challenge for new moms, so we offer HealthMedia® Balance™ and HealthMedia® Nourish™, online programs that focus on exercise and good nutrition. Caring for your newborn To help keep new families from getting overwhelmed with caring for their new baby, the “Caring for your newborn” section has information to guide their families through those challenging first months of parenthood. It is here mothers find information on our Healthy Kids, Healthy Futures program. Developed by Kaiser Permanente pediatricians and other experts, Healthy Kids, Healthy Futures provides parents with information on feeding, safety, and newborn behavior. Other assistance here includes: • Working with mothers to make the necessary appointments for their own and their babies’ routine checkups. • Tips on coping with colic. • Help for pregnant women or new mothers, their partners, and their families to quit smoking through HealthMedia® Breathe™. Babies raised in smoking households have four times as many respiratory infections (lung, sinus, and ear infections) as those in nonsmoking households. Newborn care videos Advice on caring for newborns is only an Internet click away. In the Pregnancy and new baby Web section, members can find online videos to help with many problems they may have dealing with their newborns, including: • Bathing your baby • Caring for a colicky baby • Caring for the uncircumcised and circumcised penis • Changing diapers • Feeding your newborn • Soothing a fussy baby • Taking your baby’s temperature • Umbilical cord care Well-Baby/Well-Child/Well-Teen Care Regular well-baby, well-child, and well-teen care is included in our preventive services.. Care and screenings include: • Blood pressure checks • Hearing and vision tests • Immunizations KAISER PERMANENTE VIRTUAL TOURS Virtual on-line tours are available in three Kaiser Permanente regions:

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MAS: http://members.kaiserpermanente.org/kpweb/richmedia/feature/006facdir/Kaiser_VirtualTour.wmv CO:

http://info.kp.org/richmedia/expkp/index.htm

CA: http://xnet.kp.org/centralvalley/flash/standalone_phototour_english/index.html Spanish version: http://xnet.kp.org/centralvalley/flash/standalone_phototour_spanish/index.html

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C HAPTER 6

M EDICAL E XCLUSIONS AND LIMITATIONS The Plan will not provide benefits for any of the services, treatments, items, or supplies described in this section, regardless of medical necessity or recommendation of a health care provider. This list is intended to give you a description of services and supplies not covered by the Plan. This section uses headings to help you find specific exclusions more easily. A LTERNATIVE T REATMENTS • • • • •

Acupressure Aromatherapy Massage therapy, except when provided as a procedure during a covered therapy Rolfing Holistic or homeopathic care

B LOOD •

The cost of whole red blood or red blood cells when they are donated or replaced or billed, except expenses for administration and processing of blood and blood products (except blood factors) covered as part of inpatient and outpatient services

C OMFORT OR C ONVENIENCE • • • • •

• •

Television Telephone Beauty/barber service Guest service Supplies, equipment, and similar incidental services and supplies for personal comfort. Examples include (but are not limited to): o Air conditioners o Air purifiers and filters o Batteries and battery chargers o Dehumidifiers o Humidifiers o Heating pads o Hot water bottles o Water beds o Hot tubs o Any other clothing or equipment that could be used in the absence of an illness or injury Devices and computers to assist in communication and speech Home remodeling to accommodate a health need (such as, but not limited to, ramps, electric chairlifts, and swimming pools)

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D ENTAL • •

• • • • •

Dental care except as described in the Coverage section Preventive Care, diagnosis, treatment of or related to the teeth, jawbones, or gums. Examples include all of the following: o Restoration and replacement of teeth, except as a result of accidental injury o Services to improve dental clinical outcomes Dental implants False teeth Dental braces Treatment of congenitally missing, malpositioned, or super numerary teeth, except as part of a congenital anomaly Surgical treatment of temporomandibular joint (TMJ) dysfunction

DURABLE MEDICAL EQUIPMENT, MEDICAL SUPPLIES, AND APPLIANCES • • • • • • • • • • • •

False teeth Hearing aids Devices used specifically as safety items or to affect performance in sports-related activities Elastic stockings Exercise or hygiene equipment Batteries or replacement batteries, except specialized batteries that are only of use in the DME equipment itself Spare or back-up equipment Repair necessitated by misuse Prescribed or non-prescribed medical supplies. Examples include: o Ace bandages o Gauzes and dressings Orthotic appliances that are not on the Kaiser Permanents formulary Comfort, convenience and luxury items and features Tubings, nasal cannulas, connectors, and masks are not covered except when used with Durable Medical Equipment as described in the coverage

Emergency •

Use of the emergency room: o To treat routine ailments o Because you have no regular physician o Because it is late at night (and the need for treatment is not sudden and serious)

EXPERIMENTAL OR I NVESTIGATIONAL SERVICES OR UNPROVEN SERVICES • • •

Non-referred services in connection to an approved clinical trial and services in connection with a non-approved clinical trial Items and services which are provided solely to satisfy data collection and analytical needs of a clinical trial and are not used in the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan) Items and services customarily provided by the research sponsors free of charge for any enrollee in the trial

Kaiser Permanente, in consultation with Medical Group, determines that a Service is experimental and investigational when:

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• • • • • • • • •

Generally accepted medical standards do not recognize it as safe and effective for treating the condition in question (even if it has been authorized by law for use in testing or other studies on human patients) It requires government approval that has not been obtained when service is to be provided It cannot be legally performed or marketed in the United States without approval from the U.S. Food and Drug Administration (FDA) It is the subject of a current new drug or device application on file with the FDA It has not been approved or granted by the FDA excluding off-label use of FDA approved drugs and devices It 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 It is subject to approval or review of an Institutional Review Board or other body that approves or reviews research It is provided pursuant to informed consent documents that describe the services as experimental or investigational, or indicate that the services are being evaluated for their safety, toxicity or efficacy The prevailing opinion among experts is that use of the services should be substantially confined to research settings or further research is necessary to determine the safety, toxicity or efficacy of the service

Services related to Clinical Trials are considered Experimental and Investigational when • • •

Items and Services are provided solely to satisfy data collection and analytical needs of a clinical trial and are not used in the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan) Items and Services customarily provided by the research sponsors free of charge for any enrollee in the trial Items or Services needed for reasonable and necessary care arising from the provision of an investigational item or service—in particular, for the diagnosis or treatment of complications

F OOT C ARE • •

• • •

Except when needed for severe systemic disease: o Routine foot care (including the cutting or removal of corns and calluses) o Nail trimming, cutting, or debriding Hygienic and preventive maintenance foot care. Examples include (but are not limited to): o Cleaning and soaking the feet o Applying skin creams in order to maintain skin tone o Other services that are performed when there is not a localized illness, injury or symptom involving the foot Foot care except when medically necessary Treatment of flat feet Shoe orthotics except as covered under Kaiser Permanente DME or pharmacy formulary

H OME HEALTH C ARE • • • • • •

Custodial services, including bathing, feeding, changing, or other services that do not require skilled care Services or supplies that are not part of the home health care plan Services of a person who usually lives with you or who is a member of your or your spouse’s family Full-time nursing care in the home Homemaker services and supplies, including meals delivered to your home Home health care that a network physician determines may be more appropriately provided for you in a network facility, network hospital, or a network skilled nursing facility 62

H OSPITAL C ARE - I NPATIENT • • • •

• • • •

Private duty nursing except when medically necessary Private room, except when medically necessary or when a semi-private room is unavailable Diagnostic inpatient stays, unless connected with specific symptoms that, if not treated on an inpatient basis, could result in serious bodily harm or risk to life Services performed in the following: o Nursing or convalescent homes o Institutions primarily for rest or for the aged o Rehabilitation facilities (except for physical therapy) o Spas o Sanitariums o Infirmaries at schools, colleges, or camps Any part of a hospital stay that is primarily custodial Elective cosmetic surgery Hospital services received in clinic settings that do not meet the Plan’s definition of a hospital or other covered facility Inpatient rehabilitation when the member is medically stable and o Does not require skilled nursing care o Does not require the constant availability of a physician o The treatment is for maintenance therapy o The member has no restorative potential o The treatment is for congenital learning or neurological disability/disorder o The treatment is for communication training, educational training or vocational training

M ATERNITY • • •

Days in the hospital that are not medically necessary Services provided by a doula (labor aide) Services that are not medically necessary

O UTPATIENT C ARE • • • • •

Genetic testing unless medically necessary Screening tests done at your place of work at no cost to you Free screening services offered by a government health department Tests done by a mobile screening unit, unless a doctor not affiliated with the mobile unit prescribes the tests Flu vaccines supplied by a government agency, or otherwise provided at no cost to you

P HYSICAL A PPEARANCE •

•

• • • •

Cosmetic surgery, services and supplies, and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance. Surgical treatment of rhinoplasty, blepharoplasty, Orthognathic surgeries, redundant skin surgery, removal of skin tags, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, prolotherapy, and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions Physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility, and diversion or general motivation Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded. Services received from a personal trainer Liposuction 63

P ROVIDERS • • • • •

Care by out-of-network providers except for authorized referrals, emergencies, or services from other Kaiser Permanente plans Treatment not prescribed or recommended by a health care provider Services given by an unlicensed health care provider or performed outside the scope of the provider’s license Services performed by a provider who is a family member by birth or marriage, including spouse, brother, sister, parent, or child. This includes any service the provider may perform on himself or herself. Services performed by a provider with your same legal residence

R EPRODUCTION • • • •

Surrogate parenting Fees or direct payment to a donor for sperm or ovum donations Monthly fees for maintenance and/or storage of frozen embryos Collection or storage of your own semen

SERVICES P ROVIDED UNDER A NOTHER PLAN • • •

Health services for which other coverage is required by federal, state, or local law to be purchased or provided through other arrangements. This includes, but is not limited to, coverage required by workers’ compensation, no-fault auto insurance, or similar legislation. Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you Health services or supplies furnished, paid for, or for which benefits are provided or required by reason of past or present service of any covered person in the armed forces of a government

S KILLED N URSING AND H OSPICE C ARE • • • • • • •

Assistance with daily living activities in a skilled nursing facility Treatment for drug addiction or alcoholism Convalescent care Sanitarium-type care Rest cures Funeral arrangements Financial or legal counseling

T RANSPLANTS • • • •

Health services for organ and tissue transplants, except those described in the coverage section of this document Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person (donor costs for removal are payable for a transplant through the organ recipient’s benefits under the plan) Health services for transplants involving mechanical or animal organs that are experimental or investigational Transplant services that are not performed at a designated facility

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• • •

Any multiple organ transplant not listed as a covered health service in the coverage section of this document, unless determined to be a proven procedure for the involved diagnosis Organ/tissue transplants which are experimental or investigational Kaiser Permanente does not assume responsibility for providing or assuring the availability of a donor or donor tissue organs

VISION AND HEARING • • • • •

Purchase cost of eyeglasses, contact lenses, or hearing aids Fitting charge for hearing aids Eyeglasses or contact lenses, and related fitting charges, unless following cataract surgery Eye exercise (orthoptic) therapy Surgery and other related treatment that is intended to correct nearsightedness, farsightedness, presbyopia, and astigmatism including, but not limited to, procedures such as radial keratotomy, laser, and other refractive eye surgery

O THER E XCLUSIONS • • • • • •

• • • • •

Any services, drugs, or supplies you receive while you are not enrolled in this Plan Educational, vocational, or training services and supplies Expenses for copying or preparing medical reports, itemized bills, or claim forms Mailing and/or shipping and handling expenses (there may be certain exceptions—contact your health plan for more information) Expenses for failure to keep an appointment Physical examinations and other services, and related reports and paperwork, in connection with third-party requests or requirements, such as those for employment, participation in employee programs, insurance, disability, licensing, or on court order or for parole or probation Maintenance care Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks Services usually given without charge, even if charges are billed Expenses in excess of usual, customary, and reasonable fees Services provided outside the United States, other than emergency services, whether or not the services are available in the United States

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C HAPTER 7 PHARMACY BENEFITS Outpatient drugs, supplies, and supplements are covered when all of the following requirements are met: •

The item is prescribed by a network physician or by one of the following out-of-network providers: • A dentist • An out-of-network physician to whom you have been referred by a network physician • An out-of-network physician if you got the prescription in conjunction with covered out-of-area urgent care or emergency services The item is prescribed in accordance with Kaiser Permanente drug formulary guidelines You get the item from a network pharmacy or the Kaiser Permanente mail order service, except that you can get the item from an out-of-network pharmacy if you obtain the prescription in conjunction with covered emergency service outside the service area and it is not possible for you to get the item from a network pharmacy. Please refer to www.kp.org for the locations of network pharmacies in your area. The item is one of the following: • Drugs that require a prescription by law including: o Contraceptive drugs, including the emergency contraceptive pill, and devices, such as diaphragms and cervical caps o Drugs for the treatment of sexual dysfunction o Growth hormone o Smoking cessation products o Drugs used in the treatment of weight control • Drugs that don’t require a prescription but are listed on Kaiser Permanente’s drug formulary • Diabetic supplies such as insulin, syringes, pen delivery devices, blood glucose monitors, test strips and tablets. Other diabetic supplies may be covered under Durable Medical Equipment.

• •

•

Your Plan uses a formulary. A formulary is a list of drugs that have been approved for coverage by the Pharmacy and Therapeutics Committee. The drug formulary guidelines allow you to obtain nonformulary prescription drugs (those not listed on the drug formulary for your condition) if they would otherwise be covered if pharmacy criteria are met. Prescriptions written by dentists are not eligible for a non-formulary exception. The prescribing physician or dentist determines how much of a drug, supply or supplement to prescribe. For purposes of day supply coverage limits, the formulary includes a pre-determined amount of an item that constitutes a Medically Necessary day’s supply. The pharmacy may reduce the day supply dispensed to a 30 day supply in any 30-day period if the pharmacy determines that the item is in limited supply in the market or for specific drugs (the Pharmacy can tell You if a drug You take is one these drugs). Note: episodic drugs prescribed for the treatment of sexual dysfunction disorders may be limited by number of doses within a 30-day period. Mail Order Service, subject to any Limitations, Copayments and Deductibles, is available. Not all drugs are available through the mail order service. Examples of drugs that cannot be mailed include: • • •

Controlled substances as determined by state and/or federal regulations Medications that require special handling Medications affected by temperature

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Refills may be ordered from Kaiser Pharmacies, the mail-order program, or online at www.kp.org. A Kaiser Pharmacy can provide more information about obtaining refills. E XCLUSIONS • • • • • • • • • • •

If a service is not covered under this Plan, any drugs or supplies needed in connection with that service are not covered Compounded products unless the drug is listed on the drug formulary or one of the ingredients requires a prescription by law Drugs used to enhance athletic performance Experimental or investigational drugs Drugs prescribed for cosmetic purposes Replacement of lost, damaged or stolen drugs Drugs that shorten the duration of the common cold Special packaging. Packaging of prescription medications is limited to Kaiser Permanente standard packaging. Drugs which are available over the counter and prescriptions for which drug strength may be realized by the over the counter product Drugs for which there is an over the counter equivalent Drugs and supplies needed solely for travel are not covered

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CHAPTER 8 CLAIMS, APPEALS, AND GRIEVANCES G RIEVANCES You may appoint an authorized representative to help you file your grievance. A written authorization must be received from you before any information will be communicated to your representative. Kaiser Permanente is committed to providing quality care and a timely response to your concerns. You can discuss your concerns with our representatives at most network facilities, or you can call Customer Services at the number on Your ID card. You can file a grievance for any issue. Here are some examples of reasons you might file a grievance: • • •

You are not satisfied with the quality of care you received You are dissatisfied with how long it took to get services, including getting an appointment, in the waiting room, or in the exam room You want to report unsatisfactory behavior by providers or staff, or dissatisfaction with the condition of a facility

Your grievance must explain Your issue, such as the reasons why You are dissatisfied about Services You received. You must submit Your grievance orally or in writing within 180 days of the date of the incident that caused Your dissatisfaction. Grievances may be submitted in one of the following ways: • • •

At a Plan Facility (please refer to kp.org for addresses) By calling Customer Service at the number on the back of Your id card Through kp.org

You will receive a confirmation letter within five days after receipt of your grievance. You will receive a written decision within 30 days after receipt of your grievance. Note: If your issue is resolved to your satisfaction by the end of the next business day after your grievance is received orally, or at kp.org, and a Customer Services representative notifies You orally about our decision, You will not receive a confirmation letter. To obtain payment from the Plan when for services you have paid for or to obtain review of a claims payment decision, you must follow the procedures outlined in this “Claims and Appeals” section. You may appoint an authorized representative to help you file your claim or appeal. A written authorization must be received from you before any information will be communicated to your representative. H OW TO F ILE A C LAIM Network Providers are responsible for submitting claims for their services on your behalf and will be paid directly by the Plan for the services they render. If a network provider bills you for a covered service (other than for cost sharing), please call customer service. For services rendered by Out-of-network providers, where the provider agrees to submit a claim on your behalf, eligible claims payment to the provider will require a valid assignment of benefits. Even if the Out-of-network Provider agrees to bill on your behalf, you are responsible for making sure that the claim is received within 365 days of the date of service and that all information necessary for to process the claim is received. In order to receive reimbursement for services you have paid for, you must complete and mail a claim form or (or write a letter) to the claims administrator at the address listed in the “Customer Ser68

vice Phone Numbers” section, within 365 days after you receive services. The claim form (or letter) must explain the services, the date you received them, where you received them, who provided them, and why you think the Plan should pay for them. Include a copy of the bill and any supporting documents. Your claim form (or letter) and the related documents constitute your claim. Your claim must include all of the following information: • • • • • • • •

Patient name, address, and Kaiser Permanente ID card medical or health record number Date(s) of service Diagnosis Procedure codes and description of the services Charges for each service The name, address, and tax identification number of the provider The date the injury or illness began Any information regarding other medical coverage

To obtain a claim form, visit the Kaiser Permanente website at www.kp.org and log in. That claim form will inform you about other information that you must include with your claim. If the plan pays a post-service claim, it will pay you directly, except that it will pay the provider if one of the following is true: • •

Before the claim is processed, a written notice is received indicating you have assigned your right to payment to the provider Your claim includes a written request that the Plan pay the provider

If you have any questions about submitting a claim for payment for a service from an out-of-network provider, please call customer service at the telephone number listed on your ID card. T IMING OF C LAIMS D ETERMINATION The Plan adheres to certain time limits when processing claims for benefits. If you do not follow the proper procedures for submitting a claim, the Plan will notify you of the proper procedures within the time frames shown in the chart that follows. If additional information is needed to process your claim, the Plan will notify you within the time frames shown in the chart below, and you shall be provided additional time within which to provide the requested information as indicated in the chart below in this “Timing of Claim Determinations” section. The Plan will make a determination on your claim within the time frames indicated based upon the type of claim: Urgent Claim, Pre-Service Claim, Post-Service Claim, or Concurrent Care Claim. An “Urgent Care Claim” is any claim for a Service with respect to which the application of the time periods for making non-urgent care determinations either (a) could seriously jeopardize your life, health, or ability to regain maximum function, or (b) would, in the opinion of a physician with knowledge of your medical condition, subject you to severe pain that cannot be adequately managed without the services that are the subject of the claim.

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A “Pre-Service Claim” is any claim for a service with respect to which the terms of the Plan condition receipt of the Service, in whole or in part, on approval by the Plan of the service in advance. A “Post-Service Claim” is any claim for a service that is not a pre-service claim or an urgent care claim. A “Concurrent Care Claim” is any claim for services that are part of an on-going course of treatment that was previously approved by the Plan for a specific period of time or number of treatments. Type of Notice or Claim Event

Urgent Care Claim

Pre-Service Care Claim

Post-Service Care Claim

Plan Notice of Failure to Follow the Proper Procedure to File a Claim

Not later than 24 hours after receiving the improper claim.

Not later than 5 days after receiving the improper claim.

Not applicable.

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Plan Notice of Initial Claim Decision

If the claim when initially filed is proper and complete, a decision will be made as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receiving the initial claim. If the claim is not complete, the Plan shall notify you as soon as possible, but not later than 24 hours of receipt of the claim. You shall have 48 hours to provide the information necessary to complete the claim. A decision will be made not later than 48 hours after the administrator receives the requested information, or within 48 hours after the expiration of the 48-hour deadline for submitting additional information, whichever is earlier.

If the claim when initially filed is proper and complete, a decision will be made within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after the initial claim is received, unless an extension, of up to 15 days, is necessary due to matters beyond the control of the Plan. You shall be notified within the initial 15 days if an extension will be needed by the Plan. The notice shall state the reason for the extension. A decision will be made not later than 15 days after the initial claim is received, unless additional information is required from you. You will be notified during the initial 15 day period, and shall have 45 days to provide the additional information requested. A decision will be made within 15 days after receiving the additional information, or within 15 days after the expiration of the 45-day deadline for submitting additional information, whichever is earlier.

A decision will be made within a reasonable amount of time, but not later than 30 days after the initial claim is received, unless an extension, of up to 15 days, is necessary due to matters beyond the control of the Plan. You shall be notified within the initial 30 days if an extension will be n eeded by the Plan. The notice shall state the reason for the extension. A decision will be made not later than 30 days after the initial claim is received, unless additional information is required from you. You will be notified during the initial 30 day period, and shall have 45 days to provide the additional information requested. A decision will be made within 15 days after receiving the additional information or, within 15 days after the expiration of the 45-day deadline for submitting additional information, whichever is earlier.

If you have a Concurrent Care Claim that is also an Urgent Care Claim to extend a previously approved on-going course of treatment provided over a period of time or number of treatments, the Plan will make a determination as soon as possible, taking into account the medical exigencies, and notify you of the determination within 24 hours after receipt of the claim, provided that the claim was made to Plan at least 24 hours prior to the expiration of the prescribed period of time or number of treatments previously approved. If your request for extended treatment is not made at least 24 hours prior to the end of the prescribed period of time or number of treatments, the request will be treated as an Urgent Care Claim and decided according to the time frames described above. If your Concurrent Care Claim is not an Urgent Care Claim, and there is a reduction or termination of the previously approved on-going course of treatment provided over a period of time or number of treatments (other than by Plan amendment or termination) before the end of the period of time or number of treatments, you will be notified by the Plan sufficiently in advance of the reduction or termination to allow you to appeal the denial and receive a determination on appeal before the reduction or termination of the benefit.

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I F A C LAIM I S D ENIED If all or part of your claim is denied, Plan will send you a written notice. If the notice of denial involves an Urgent Care Claim, the notice may be provided orally (a written or electronic confirmation will follow within 3 days). This notice will explain: • • •

•

•

The reasons for the denial, including references to specific Plan provisions upon which the denial was based If the claim was denied because you did not furnish complete information or documentation, the notice will specify the additional materials or information needed to support the claim and an explanation of why the information or materials are necessary. If the claim is denied based on an internal rule, guideline, protocol, or other similar criterion, the notice will either (a) state the specific rule, guideline, protocol, or other similar criterion, or (b) include a statement that the rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of the rule, guideline, protocol, or other criterion will be provided free of charge upon request. If the claim is denied based on a medical necessity or experimental treatment or a similar exclusion or limit, the notice will also include an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the medical circumstances, or include a statement that this explanation will be provided free of charge upon request. The notice will also state how and when to request a review of the denied claim.

H OW TO APPEAL A DENIED CLAIM You may appeal a denied claim by submitting a written request for review to the Plan. You must make the appeal request within 180 days after the date of the denial notice. Send the written request to the Plan at: Kaiser Permanente Insurance Company – Appeals 3701 Boardman-Canfield Road Canfield Ohio 44406 You may instead fax your appeal to (614) 212-7110. To appeal a pharmacy claim, submit your form to: Kaiser Permanente Attn: SFAS National Self Funding 38990 Murphy Canyon Rd Suite 200 San Diego, CA 92123 Fax# (858) 614-7912 The request must explain why you believe a review is in order and it must include supporting facts and any other pertinent information. The Plan may require you to submit such additional facts, documents, or other material as it may deem necessary or appropriate in making its review. D EEMED E XHAUSTION If the Plan does not adhere to the Appeals process as described below, it will be deemed that you have exhausted the appeals process. This means that you are no longer required to stay within the mandated internal appeal process. Exceptions include: • • •

Violations which do not cause and are not likely to cause prejudice or harm Can be demonstrated were for good cause or due to matters beyond the control of the Plan The violation occurred in the context of an on-going, good faith exchange of information between the Plan and you. 72

You may request a written explanation of the violation and it will be provided to You within 10 days of Your request. Such explanation will include a specific description of the basis, if any, on which the appeal process is not deemed to be exhausted. If an external review organization or court determines Your appeal is not deemed exhausted, You have the right to resubmit Your appeal request and continue the internal appeal process. P ROCEDURES ON A PPEAL As part of the review procedure, you may submit written comments, documents, records, and other information relating to the claim. Upon request and free of charge, you will be provided reasonable access to, and copies of, all documents, records, and other information (other than legally or medically privileged documents) relevant to your claim. The Plan will review the claim, taking into account all comments, documents, records, and other information submitted relating to the claim, without regard to whether that information was submitted or considered in the initial benefit determination. The review shall not afford deference to the initial claim denial and shall be conducted by the Claims Fiduciary, who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of that individual. In deciding an appeal that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary, the Claims Fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, and that health care professional shall not be the individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal (nor the subordinate of that individual). Upon request, the Plan will provide for the identification of any medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination. T IMING OF I NITIAL A PPEAL D ETERMINATIONS Plan will act upon each request for a review within the time frames indicated in the chart below: Urgent Care Claim Not later than 72 hours after receiving the appeal.

Pre-Service Claim Not later than 15 days after receiving the appeal

Post-Service Claim Not later than 30 days after receiving the appeal.

N OTICE OF DETERMINATION ON INITIAL APPEAL Within the time prescribed in the “Timing of Initial Appeal Determinations” section, the Plan will provide you with written notice of its decision. If the Plan determines that benefits should have been paid, the Plan will take whatever action is necessary to pay them as soon as possible. If your claim is denied on review, the notice shall state: • •

The reasons for the denial, including references to specific Plan provisions upon which the denial was based That you are entitled to receive, upon request and free of charge, reasonable access to, 73

•

•

• •

and copies of, all documents, records, and other information (other than legally or medically privileged documents) relevant to your claim If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, the notice will either (a) state the specific rule, guideline, protocol, or other similar criterion, or (b) include a statement that the rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of the rule, guideline, protocol, or other criterion will be provided free of charge upon request. If the claim is denied based on a medical necessity, experimental, or similar exclusion or limit, the notice will also include an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the medical circumstances, or include a statement that such explanation will be provided free of charge upon request. For pre-service claims and post-service claims, the notice will also state how and when to request a review of the denial of the initial appeal. For urgent care claims, the notice will also describe any voluntary appeal procedures offered by the Plan and your right to obtain the information about those procedures.

H OW TO F ILE A F INAL A PPEAL For Pre-Service Claims and Post-Service Claims, you may appeal the denial of your initial appeal by submitting a written request for review to the Episcopal Church Medical Trust. You must make the appeal request within 60 days after the date of notice that your appeal is denied. Send the written request to: The Episcopal Church Medical Trust PO Box 2745 New York, NY 10163 Attn: Clinical Department To appeal a pharmacy claim, submit your form to: Kaiser Permanente Attn: SFAS National Self Funding 38990 Murphy Canyon Rd Suite 200 San Diego, CA 92123 Fax# (858) 614-7912 TIMING OF FINAL APPEAL DETERMINATIONS For Pre-Service Claims and Post-Service Claims, the Plan will act upon each request for a review of the denial of your initial appeal within the time frames indicated in the chart below: Pre-Service Claim Not later than 15 days after the appeal is received.

Post-Service Claim Not later than 30 days after the appeal is received.

N OTICE OF D ETERMINATION OF F INAL A PPEAL

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Within the time prescribed in the “Timing of Final Appeal Determinations” section, the Medical Trust will provide you with written notice of its decision. If the Medical Trust determines that benefits should have been paid, the Plan will take whatever action is necessary to pay them as soon as possible. If your claim is denied on review, the notice shall state the reasons for the denial, including reference to specific plan provisions upon which the denial is based.

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CHAPTER 9

C OORDINATION OF BENEFITS When a Member is covered under more than one group health plan that provides coverage for the same expense as the Plan, the Plan will coordinate the benefits it pays with the payments from the other plan(s). This coordination is to prevent duplicative payments for any service or supply. One plan will be considered “primary” and responsible for paying expenses first, and the other plan will be considered “secondary” and responsible for paying expenses second. When the Plan is primary, it will pay benefits according to Plan rules. When the Plan is secondary, the Plan will adjust its payments so that the total amount paid from both plans, combined, does not exceed the amount this Plan would have paid if it were primary. The term “group health plan,” as it relates to coordination of benefits, includes employer or group plans and most government or tax-supported plans, including Medicare and TRICARE. It also includes group insurance and subscriber contracts, such as union welfare plans and benefits provided under any group or individual automobile no-fault or fault-type policy or contract. Benefits are not coordinated with personal, individual insurance policies, unless otherwise described in this handbook. Members must inform the Plan any time the Member has other group health plan coverage. The Plan follows specific rules to establish which plan is primary and which plan is secondary in determining the order in which benefits will be paid. Rules may vary as a result of specific situations, based on the coordination of benefits provisions of each plan and due to generally accepted industry criteria. For persons eligible for Medicare, for example, Medical Trust benefits will generally be primary only as required by federal Medicare rules and regulations and will not be primary for any employee whose employment status has been terminated (such employees must enroll in Medicare Parts A and B as soon as they qualify; otherwise, benefits may be reduced). Further, in determining the benefits payable under the Plan, the Plan will not take into account the fact that you or any eligible dependent(s) are eligible for or receive benefits under a Medicaid Plan. Typically, the following rules apply to coordinate benefits, in the order stated below, until it is clear which plan is primary: G ENERAL R ULES Any group health plan that does not contain a coordination of benefits provision will be the primary plan. When all plans covering a Member contain a coordination of benefits provision, benefits will be coordinated based on the following rules: The plan covering a person other than as a dependent (e.g., an active employee or retiree) is primary and the plan covering a person as a dependent is secondary. If a person is covered by two group health plans and Medicare, and under federal law, Medicare is secondary to the plan covering the person as a dependent and primary to the plan covering the person as other than a dependent (e.g., a retiree), then the order of payment is reversed so the plan covering the individual as a dependent is primary, and the other plan is secondary. The plan covering a person as an active employee is primary and the plan covering the person as a retiree is secondary. C HILD C OVERED UNDER MORE THAN O NE P LAN The order of benefits when a dependent child is covered by more than one plan is as follows: The primary plan is the plan of the parent whose birthday (month and day) is earlier in the calendar year if either: 76

• • •

The parents are married The parents are not separated (regardless of whether they ever have been married) A court decree awards joint custody without specifying that one parent has the responsibility to provide healthcare coverage

If both parents have the same birthday (month and day), the plan that has covered either of the parents longer is primary. If the specific terms of a court decree state that one of the parents is responsible for the child’s healthcare coverage or expenses and the plan of that parent has knowledge of the decree, that plan is primary. If the parent designated by the decree has no coverage for the child, but that parent’s spouse does, the spouse’s plan is primary. If the parents are not married, are separated (regardless of whether they were ever married), or are divorced and there is no court decree allocating responsibility for the child’s healthcare coverage or expenses, then the order of benefit determination among the plans is as follows: • • • •

The plan of the custodial parent; then The plan of the spouse of the custodial parent; then The plan of the noncustodial parent; then The plan of the spouse of the noncustodial parent

A CTIVE OR I NACTIVE EMPLOYEE The plan that covers a person as an active employee (or the person’s dependents) who is not laid off, terminated or retired is primary. The plan that covers a person (or the person’s dependents) as a laid-off, terminated or retired employee is secondary. If both the person and the person’s dependents are covered as retirees, the dependent’s retiree coverage is primary for the dependent’s claims. If the other plan does not have this rule and if, as a result, the plans do not agree on the order of benefits, this rule is ignored. C ONTINUATION C OVERAGE If a person whose coverage is provided under a right of continuation required by federal or state law or by the Medical Trust’s continuation of coverage provisions is also covered under another plan, the plan covering the person as an employee, Member or retiree (or as that individual’s dependent) is primary and the continuation coverage is secondary. If the other plan does not have this rule and if, as a result, the plans do not agree on the order of benefits, this rule is ignored. LONGER OR S HORTER LENGTH OF C OVERAGE The plan that has covered the person for the longer period of time is primary. If none of the above rules determine which plan is the primary plan, the allowable expenses will be shared equally between the plans. This Plan will never pay more than it would have paid had it been primary. This Plan provides benefits relating to medical expenses incurred as a result of an automobile accident on a secondary basis only. Benefits payable under this Plan will be coordinated with, and secondary to, benefits provided or required by any no-fault automobile insurance statute, whether or not a no-fault policy is in effect, and/or any other automobile insurance. Any benefits provided by this Plan will be subject to the Plan’s reimbursement and/or subrogation provisions. Whenever payments that should have been made by this Plan have been made by any other plan(s), this Plan has the right to pay the other plan(s) any amount necessary to satisfy the terms of the plan’s coordination of benefits provision. Amounts paid will be considered benefits paid under this Plan, and, to the extent of such payments, the Plan will be fully released from any liability regarding the person for whom the payment was made. 77

CHAPTER 10 OTHER IMPORTANT PLAN PROVISIONS ASSIGNMENT OF BENEFITS When a plan participant uses an in-network healthcare provider, the plan will pay benefits to the in-network provider directly. To the extent that the in-network provider disputes a determination as to a claim, including but not limited to the amount of the payment, such dispute shall be treated as a contractual dispute between the provider and the vendor that manages the provider network. The provider shall have no right to appeal a benefit determination under the plan's claim procedures and shall have no right to file a lawsuit against the plan. If you disagree with any determination under the plan, you may, as a plan participant, appeal the determination in accordance with the rules set forth for such appeals. When a plan participant assigns his or her right to receive benefits to an out-of-network provider, the plan will recognize the assignment, but only for purposes of the initial payment of the claim to the provider. If the initial claim is approved for payment, the plan will pay the approved amount in benefits to the provider directly. If the initial claim is denied, in whole or in part, the out-of-network provider will have no right to appeal the denial or partial denial of the claim through the plan's claim procedures or to bring a lawsuit against the plan. The assignment will not be recognized for such purposes. Absent the plan's express written consent, every assignment given to an out-of-network provider is subject to these limitations. If the provider seeks payment of any amount from you or you otherwise disagree with a claim determination, you may, as a participant in the plan, appeal such determination in accordance with the rules set forth for such appeals. SPECIAL ELECTION FOR EMPLOYEES AND SPOUSES AGE 65 AND OVER If a Member remains actively employed after reaching age 65, the Member and/or spouse may choose to remain covered under the Plan without reduction for Medicare benefits. A Member and/or spouse may also choose to end coverage under the Plan and enroll only in Medicare; however, benefits that are payable under this Plan may not be covered by Medicare. If coverage remains under the Plan, the Plan will be the primary payer of benefits, and Medicare will be secondary. If the Member is under age 65 and the Member’s spouse is over age 65, the spouse can make his or her own choice to remain covered under the Plan or to terminate coverage and enroll only in Medicare. However, the spouse may not choose to enroll in a Medicare Supplement Health Plan sponsored by the Medical Trust. UNCLAIMED P ROPERTY If the Plan cannot provide benefits to a Member because after a reasonable search, the Plan cannot locate the Member within a period of two years after the payment of benefits becomes due, such amounts otherwise due to the Member shall be “unclaimed property.” Unclaimed property amounts will be considered forfeitures that are deemed to occur as of the end of the two-year period. All forfeitures shall be and remain Plan assets, and in no event shall any such forfeiture escheat to, or otherwise be paid to, any governmental unit under any escheat or unclaimed property law. RELIANCE ON

DOCUMENTS AND I NFORMATION

Information required by the Medical Trust may be provided in any form or document that the Medical Trust considers acceptable and reliable. The Medical Trust relies on the information provided by individuals when evaluating coverage and benefits under the Plan. All such information, therefore, must be accurate, truthful, and complete. The Medical Trust is entitled to conclusively rely upon, and will be protected for any action taken in good faith in relying upon, any information the Member or dependents provide to the Medical Trust. In addition, any fraudulent statement, omission or concealment of facts, misrepresentation, or incorrect infor78

mation may result in the denial of the claim, cancellation or rescission of coverage, or any other legal remedy available to the Plan. N O W AIVER The failure of the Medical Trust to enforce strictly any term or provision of the Plan will not be construed as a waiver of such term or provision. The Medical Trust reserves the right to enforce strictly any term or provision of the Plan at any time. N O G UARANTEE OF TAX C ONSEQUENCES Although the Plan intends to offer some benefits on a tax-favored basis, there is no guarantee that any particular tax result will apply. Nothing in this Plan Document Handbook constitutes tax, medical, financial or legal advice. If you have questions about the tax, financial or legal consequences of a benefit, you should consult your personal tax, legal or financial advisor. P HYSICIAN / P ATIENT RELATIONSHIP This Plan is not intended to disturb the physician/patient relationship. Physicians and other healthcare providers are not agents or delegates of the employer, the Medical Trust, the ECCEBT, or any claims administrator. Nothing contained in the Plan will require a Member or dependent to commence or continue medical treatment by a particular provider. Furthermore, nothing in the Plan will limit or otherwise restrict a physician’s judgment with respect to the physician’s ultimate responsibility for patient care in the provision of medical services to the Member or dependent. THE P LAN I S N OT A C ONTRACT OF EMPLOYMENT Nothing contained in the Plan will be construed as a contract or condition of employment between the employer and any employee. P LAN ADMINISTRATION In administering the Plan(s), the Medical Trust has full discretion and authority to interpret Plan provisions, make factual determinations, and address other issues that may arise. Subject to any right that a Member has to appeal a decision, the Medical Trust determinations are final and binding. To the extent that the Medical Trust delegates administrative authority under the Plan(s) to another party, such as a Claims Administrator, that party shall act with the same discretion and authority as the Medical Trust.

P LAN I NFORMATION AND RIGHTS The Plan(s) described in this Plan Document Handbook are sponsored and administered by the Church Pension Group Services Corporation (“CPGSC”), also known as the Episcopal Church Medical Trust (the “Medical Trust”). The Plans that are self-funded are funded by the Episcopal Church Clergy and Employees’ Benefit Trust (“ECCEBT”), a voluntary employees’ beneficiary association within the meaning of section 501(c)(9) of the Internal Revenue Code. This Plan Document Handbook is intended for informational purposes only. It should not be viewed as a contract, an offer of coverage, or investment, tax, medical, or other advice. In the event of a conflict between this Plan Document Handbook and the official Plan documents (summary of coverage, Summary Plan Description, booklet, booklet-certificate), the official Plan documents will govern. 79

The Church Pension Fund and its affiliates, including but not limited to the Medical Trust and ECCEBT (collectively, “CPG”), retain the right to amend, terminate, or modify the terms of the Plan, as well as any post-retirement health subsidy, at any time, for any reason, and unless required by law, without notice. The Plan is a church plan within the meaning of section 3(33) of the Employee Retirement Income Security Act and section 414(e) of the Internal Revenue Code. Not all Plans are available in all areas of the United States, and not all Plans are available on both a self-funded and fully insured basis. The Plan does not cover all healthcare expenses, and Members should read the official Plan documents carefully to determine which benefits are covered, as well as any applicable exclusions, limitations, and procedures. CPG does not provide any healthcare services and therefore cannot guarantee any results or outcomes. Healthcare providers and vendors are independent contractors in private practice and are neither employees nor agents of CPG. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change.

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CHAPTER 11 BINDING ARBITRATION Binding Arbitration for Participants and Dependents Assigned to a Kaiser Permanente California Region This “Binding Arbitration for Participants and Dependents Assigned to a Kaiser Permanente California Region” section applies only to Participants and Dependents who are assigned to the Kaiser Permanente California Region. For all claims subject to this “Binding Arbitration for Participants and Dependents Assigned to a Kaiser Permanente California Region” section, both Claimants and Respondents give up the right to a jury or court trial and accept the use of binding arbitration. S COPE OF A RBITRATION Any dispute shall be submitted to binding arbitration if all of the following requirements are met: • The claim arises from or is related to an alleged violation of any duty incident to or arising out of or relating to a Participant or Dependent Party’s relationship to Kaiser Permanente or KPIC as a Participant or Dependent, a member, or a patient, including any claim for medical or hospital malpractice (a claim that medical services or items were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the delivery of services or items, irrespective of the legal theories upon which the claim is asserted • The claim is asserted by one or more Participant or Dependent Parties against one or more Kaiser Permanente Parties or by one or more Kaiser Permanente Parties against one or more Participant or Dependent Parties • The claim is not within the jurisdiction of the Small Claims Court • The claim is not a benefit-related request that constitutes a "benefit claim" in Section 502(a)(1)(B) of ERISA As referred to in this “Binding Arbitration for Participants and Dependents Assigned to the Kaiser Permanente California Region” section, "Participant or Dependent Parties" include: • A Participant or Dependent • A Participant’s or Dependent’s heir, relative, or personal representative • Any person claiming that a duty to him or her arises from a Participant’s or Dependent's relationship to one or more Kaiser Permanente Parties "Kaiser Permanente Parties" include: • • • • • • • • • •

Kaiser Permanente Insurance Company (KPIC) Kaiser Foundation Health Plan, Inc. Kaiser Foundation Hospitals (KFH) KP Cal, LLC (KP Cal) The Permanente Medical Group, Inc. (TPMG) Southern California Permanente Medical Group (SCPMG) The Permanente Federation, LLC The Permanente Company, LLC Any KFH, TPMG, or SCPMG physician Any individual or organization whose contract with any of the organizations identified above requires arbitration of claims brought by one or more Participant or Dependent Parties

• Any employee or agent of any of the foregoing 81

"Claimant" refers to a Participant or Dependent Party or a Kaiser Permanente Party who asserts a claim as described above. "Respondent" refers to a Participant or Dependent Party or a Kaiser Permanente Party against whom a claim is asserted. I NITIATING A RBITRATION Claimants shall initiate arbitration by serving a Demand for Arbitration. The Demand for Arbitration shall include the basis of the claim against the Respondents; the amount of damages the Claimants seek in the arbitration; the names, addresses, and telephone numbers of the Claimants and their attorney, if any; and the names of all Respondents. Claimants shall include all claims against Respondents that are based on the same incident, transaction, or related circumstances in the Demand for Arbitration. S ERVING D EMAND FOR A RBITRATION KPIC, Kaiser Foundation Health Plan, Inc., KFH, KP Cal, TPMG, SCPMG, The Permanente Federation, LLC, and The Permanente Company, LLC, shall be served with a Demand for Arbitration by mailing the Demand for Arbitration addressed to that Respondent in care of one of the following: If the claim relates to a Participant or Dependent who is assigned to the Kaiser Permanente Northern California Region: Kaiser Foundation Health Plan, Inc. Legal Department 1950 Franklin St., 17th Floor Oakland, CA 94612 If the claim relates to a Participant or Dependent who is assigned to the Kaiser Permanente Southern California Region: Kaiser Foundation Health Plan, Inc. Legal Department 393 E. Walnut St. Pasadena, CA 91188 Service on that Respondent shall be deemed completed when received. All other Respondents, including individuals, must be served as required by the California Code of Civil Procedure for a civil action. F ILING F EE The Claimants shall pay a single, nonrefundable filing fee of $150 per arbitration payable to "Arbitration Account" regardless of the number of claims asserted in the Demand for Arbitration or the number of Claimants or Respondents named in the Demand for Arbitration. Any Claimant who claims extreme hardship may request that the Office of the Independent Administrator waive the filing fee and the neutral arbitrator's fees and expenses. A Claimant who seeks such waivers shall complete the Fee Waiver Form and submit it to the Office of the Independent Administrator and simultaneously serve it upon the Respondents. The Fee Waiver Form sets forth the criteria for waiving fees and is available by calling Customer Service at the telephone number listed on your ID card. N UMBER OF A RBITRATORS The number of Arbitrators may affect the Claimant's responsibility for paying the neutral arbitrator's fees and expenses. 82

If the Demand for Arbitration seeks total damages of $200,000 or less, the dispute shall be heard and determined by one neutral arbitrator, unless the parties otherwise agree in writing that the arbitration shall be heard by two party arbitrators and one neutral arbitrator. The neutral arbitrator shall not have authority to award monetary damages that are greater than $200,000. If the Demand for Arbitration seeks total damages of more than $200,000, the dispute shall be heard and determined by one neutral arbitrator and two party arbitrators, one jointly appointed by all Claimants and one jointly appointed by all Respondents. Parties who are entitled to select a party arbitrator may agree to waive this right. If all parties agree, these arbitrations will be heard by a single neutral arbitrator. P AYMENT OF A RBITRATORS ' F EES AND E XPENSES Kaiser Foundation Health Plan, Inc., will pay the fees and expenses of the neutral arbitrator under certain conditions as set forth in the Rules for Kaiser Permanente Member Arbitrations Overseen by the Office of the Independent Administrator ("Rules of Procedure"). In all other arbitrations, the fees and expenses of the neutral arbitrator shall be paid one-half by the Claimants and one-half by the Respondents. If the parties select party arbitrators, Claimants shall be responsible for paying the fees and expenses of their party arbitrator and Respondents shall be responsible for paying the fees and expenses of their party arbitrator. C OSTS Except for the aforementioned fees and expenses of the neutral arbitrator, and except as otherwise mandated by laws that apply to arbitrations under this “Binding Arbitration for Participants and Dependents Assigned to a Kaiser Permanente California Region” section, each party shall bear the party's own attorneys' fees, witness fees, and other expenses incurred in prosecuting or defending against a claim regardless of the nature of the claim or outcome of the arbitration. R ULES OF P ROCEDURE Arbitrations shall be conducted according to the Rules of Procedure developed by the Office of the Independent Administrator in consultation with Kaiser Permanente and the Arbitration Oversight Board. Copies of the Rules of Procedure may be obtained from Customer Service at the telephone number listed at the back of this Plan Document Handbook. G ENERAL P ROVISIONS A claim shall be waived and forever barred if (1) on the date the Demand for Arbitration of the claim is served, the claim, if asserted in a civil action, would be barred as to the Respondents served by the applicable statute of limitations, (2) Claimants fail to pursue the arbitration claim in accord with the Rules of Procedure with reasonable diligence, or (3) the arbitration hearing is not commenced within five years after the earlier of (a) the date the Demand for Arbitration was served in accord with the procedures prescribed herein, or (b) the date of filing of a civil action based upon the same incident, transaction, or related circumstances involved in the claim. A claim may be dismissed on other grounds by the neutral arbitrator based on a showing of a good cause. If a party fails to attend the arbitration hearing after being given due notice thereof, the neutral arbitrator may proceed to determine the controversy in the party's absence. The California Medical Injury Compensation Reform Act of 1975 (including any amendments thereto), including sections establishing the right to introduce evidence of any insurance or disability benefit payment to the patient, the limitation on recovery for non-economic losses, and the right to have an award for future damages conformed to periodic payments, shall apply to any claims for professional negligence or any other claims as permitted or required by law. 83

Arbitrations shall be governed by this “Binding Arbitration for Participants and Dependents Assigned to a Kaiser Permanente California Region” section, Section 2 of the Federal Arbitration Act, and the California Code of Civil Procedure provisions relating to arbitration that are in effect at the time the statute is applied, together with the Rules of Procedure, to the extent not inconsistent with this “Binding Arbitration for Participants and Dependents Assigned to a Kaiser Permanente California Region” section. In accord with the rule that applies under sections 3 and 4 of the Federal Arbitration Act, the right to arbitration under this “Binding Arbitration for Participants and Dependents Assigned to a Kaiser Permanente California Region” section shall not be denied, stayed, or otherwise impeded because a dispute between a Participant or Dependent Party and a Kaiser Permanente Party involves both arbitrable and nonarbitrable claims or because one or more parties to the arbitration is also a party to a pending court action with a third party that arises out of the same or related transactions and presents a possibility of conflicting rulings or findings. A RBITRATION A GREEMENT FOR P ARTICIPANTS AND D EPENDENTS A SSIGNED TO THE K AISER P ERMANENTE C OLORADO R EGION I understand that if I am assigned to the Kaiser Permanente Colorado Region, then except for Small Claims Court cases, cases subject to a Medicare appeals procedure, cases subject to the Health Care Availability Act, and certain disputes (including benefit-related disputes) that are subject to ERISA, any dispute between myself, my heirs or relatives, or other associated parties on the one hand and Kaiser Permanente Parties on the other hand (Kaiser Permanente Insurance Company, Kaiser Foundation Health Plan of Colorado, Kaiser Foundation Hospitals, Colorado Permanente Medical Group, P.C., or other associated parties), for alleged violation of any duty relating to or arising from a relationship to any of the Kaiser Permanente Parties as a participant in this medical plan, a member, or a patient, including any claim for premises liability, or relating to the delivery of services or items, irrespective of legal theory, must be decided by binding arbitration under Colorado law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up my right to a jury trial and accept the use of binding arbitration.

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CHAPTER 12 SUBROGATION AND REIMBURSEMENT The Plan has a right to subrogation and reimbursement. References to “you” or “your” in this Subrogation and Reimbursement section shall include you, your estate and your heirs and beneficiaries unless otherwise stated. Subrogation applies when the Plan has paid benefits on your behalf for a sickness or injury for which any third party is allegedly responsible. The right to subrogation means the Plan is substituted to and shall succeed to any and all legal claims that you may be entitled to pursue against any third party for the benefits the Plan has paid that are related to the sickness or injury for which any third party is considered responsible. The right to reimbursement means that if it is alleged that a third party caused or is responsible for a sickness or injury for which you receive a settlement, judgment, or other recovery from any third party, You must use those proceeds to fully return to the Plan 100% of any benefits you received for that sickness or injury. The right of reimbursement shall apply to any benefits received at any time until the rights are extinguished, resolved, or waived in writing. The following persons and entities are considered third parties: • • • •

• •

A person or entity alleged to have caused you to suffer a sickness, injury or damages, or who is legally responsible for the Sickness, injury or damages. Any insurer or other indemnifier of any person or entity alleged to have caused or who caused the sickness, injury or damages. The Plan sponsor in a workers’ compensation case or other matter alleging liability. Any person or entity who is or may be obligated to provide benefits or payments to you, including benefits or payments for underinsured or uninsured motorist protection, no-fault or traditional auto insurance, medical payment coverage (auto, homeowners or otherwise), workers' compensation coverage, other insurance carriers or third party administrators. Any person or entity against whom you may have any claim for professional and/or legal malpractice arising out of or connected to a Sickness or Injury you allege or could have alleged were the responsibility of any third party. Any person or entity that is liable for payment to you on any equitable or legal liability theory.

You agree as follows: • You will cooperate with KPIC in protecting our legal and equitable rights to subrogation and reimbursement in a timely manner, including, but not limited to: o o o o o o o

Notifying KPIC, in writing, of any potential legal claim(s) you may have against any third party for acts which caused benefits to be paid or become payable. Providing any relevant information requested by KPIC. Signing and/or delivering such documents as the Plan or our agents reasonably request to secure the subrogation and reimbursement claim. Responding to requests for information about any accident or injuries. Making court appearances. Obtaining our consent or our agents' consent before releasing any party from liability or payment of medical expenses. Complying with the terms of this section.

Your failure to cooperate with KPIC is considered a breach of contract. As such, the Plan has the right to terminate your benefits, deny future benefits, take legal action against you, and/or set off from any future benefits the value of benefits we have paid relating to any sickness or injury alleged to have been caused or caused by any third party to the extent not recovered by the Plan due to You or your representative not cooperating with The Plan or our agents. If the Plan incurs attorneys' fees and costs in order to collect third party settlement funds held by you or your representative, the Plan has the right to recover those fees and costs from You. You will also be required to pay interest on any amounts you hold which should have been re- turned to the Plan. 85

The Plan has a first priority right to receive payment on any claim against a third party before you receive payment from that third party. Further, this first priority right to payment is superior to any and all claims, debts, or liens asserted by any medical providers, including but not limited to hospitals or emergency treatment facilities, that assert a right to payment from funds payable from or recovered from an allegedly responsible third party and/or insurance carrier. The Plan’s subrogation and reimbursement rights apply to full and partial settlements, judgments, or other recoveries paid or payable to you or your representative, your estate, your heirs and beneficiaries, no matter how those proceeds are captioned or characterized. Payments include, but are not limited to, economic, non-economic, pecuniary, consortium, and punitive damages. The Plan is not required to help you to pursue your claim for damages or personal injuries and no amount of associated costs, including attorneys’ fees, shall be deducted from the Plan’s recovery without the Plan’s express written consent. No so-called “Fund Doctrine” or “Common Fund Doctrine” or “Attorney’s Fund Doctrine” shall defeat this right. Regardless of whether you have been fully compensated or made whole, the Plan may collect from you the proceeds of any full or partial recovery that you or your legal representative obtain, whether in the form of a settlement (either before or after any determination of liability) or judgment, no matter how those proceeds are captioned or characterized. Proceeds from which the Plan may collect include, but are not limited to, economic, non-economic, and punitive damages. No "collateral source" rule, any “Made-Whole Doctrine” or “Make-Whole Doctrine,” claim of unjust enrichment, nor any other equitable limitation shall limit the Plan’s subrogation and reimbursement rights. Benefits paid by the Plan may also be considered to be benefits advanced. If you receive any payment from any party as a result of sickness or injury, and the Plan alleges some or all of those funds are due and owed to the Plan, you and/or your representative shall hold those funds in trust, either in a separate bank account in your name or in your representative’s trust account. The Plan’s rights to recovery will not be reduced due to your own negligence. • By participating in and accepting benefits from the Plan, you agree to assign to the Plan any benefits, claims or rights of recovery you have under any automobile policy – including no-fault benefits, PIP benefits and/or medical payment benefits – other coverage or against any third party, to the full extent of the benefits the Plan has paid for the sickness or injury. By agreeing to provide this assignment in exchange for participating in and accepting benefits, you acknowledge and recognize the Plan’s right to assert, pursue and recover on any such claim, whether or not you choose to pursue the claim, and you agree to this assignment voluntarily. The Plan may, at its’ option, take necessary and appropriate action to preserve its’ rights under these provisions, including but not limited to, providing or exchanging medical payment information with an insurer, the insurer’s legal representative or other third party; filing a reimbursement lawsuit to recover the full amount of medical benefits you receive for the sickness or injury out of any settlement, judgment or other recovery from any third party considered responsible; and filing suit in your name or your estate’s name, which does not obligate us in any way to pay you part of any recovery The Plan might obtain. You may not accept any settlement that does not fully reimburse the Plan, without its written approval. The Plan has the authority and discretion to resolve all disputes regarding the interpretation of the language stated herein. In the case of your death, giving rise to any wrongful death or survival claim, the provisions of this section apply to your estate, the personal representative of your estate, and your heirs or beneficiaries. In the case of your death the Plan’s right of reimbursement and right of subrogation shall apply if a claim can be brought on behalf of you or your estate that can include a claim for past medical expenses or damages. The obligation to reimburse the Plan is not extinguished by a release of claims or settlement agreement of any kind. No allocation of damages, settlement funds or any other recovery, by you, Your estate, the personal representative of your estate, a n d your heirs or beneficiaries. or any other person or party, shall 86

be valid if it does not reimburse the Plan for 100% of its interest unless the Plan provides written consent to the allocation. The provisions of this section apply to the parents, guardian, or other representative of a dependent child who incurs a sickness or injury caused by any third party. If a parent or guardian may bring a claim for damages arising out of a minor's sickness or injury, the terms of this subrogation and reimbursement clause shall apply to that claim. If any third party causes or is alleged to have caused you to suffer a sickness or injury while you are covered under this Plan, the provisions of this section continue to apply, even after you are no longer covered. In the event that you do not abide by the terms of the Plan pertaining to reimbursement, the Plan may terminate benefits to you, your dependents, or the subscriber, deny future benefits, take legal action against you, and/or set off from any future benefits the value of benefits we have paid relating to any sickness or injury alleged to have been caused or caused by any third party to the extent not recovered by the Plan due to your failure to abide by the terms of the Plan. If we incur attorneys’ fees and costs in order to collect third party settlement funds held by you or your representative, we have the right to recover those fees and costs from you. You will also be required to pay interest on any amounts you hold which should have been returned to the Plan. The Plan and all Administrators administering the terms and conditions of the Plan’s subrogation and reimbursement rights have such powers and duties as are necessary to discharge its duties and functions, including the exercise of its discretionary authority to (1) construe and enforce the terms of the Plan’s subrogation and reimbursement rights and (2) make determinations with respect to the subrogation amounts and reimbursements owed to the Plan. Within 30 days after submitting or filing a claim or legal action against any third party, you must send written notice of the claim or legal action to: Harrington Health 3701 Boardman-Canfield Rd. Bldg B Canfield, OH. 44406-7005 In order for the plan to determine the existence of any rights the Plan may have and to satisfy those rights, you must complete and send all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney, the third party, and the third party's liability insurer to pay the Plan directly. You may not agree to waive, release, or reduce the Plan’s rights under this provision without the Plan’s prior written consent. If Your estate, parent, guardian, or conservator asserts a claim against a third party based on your injury or illness, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to the Plan’s liens and other rights to the same extent as if you had asserted the claim against the third party. The Plan may as- sign its rights to enforce liens and other rights. If you are entitled to Medicare, Medicare law may apply with respect to Services covered by Medicare. S URROGACY A RRANGEMENTS If you enter into a Surrogacy Arrangement, you must pay us charges for covered services you receive related to conception, pregnancy, delivery, or postpartum care in connection with that arrangement ("Surrogacy Health Services"), except that the amount you must pay will not exceed the payments or other compensation you and any other payee are entitled to receive under the Surrogacy Arrangement. A Surrogacy Arrangement is one in which a woman agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), whether or not the woman receives payment for being a surrogate. Note: This "Surrogacy arrangements" section does not affect 87

your obligation to pay Cost Sharing for these Services; you will be credited any such payments toward the amount you must reimburse the Plan under this paragraph. After you surrender a baby to the legal parents, you are not obligated to pay for any Services that the baby receives (the legal parents are financially responsible for any Services that the baby receives). By accepting Surrogacy Health Services, you automatically assign to the Plan Your right to receive payments that are payable to you or any other payee under the Surrogacy Arrangement, regardless of whether those payments are characterized as being for medical expenses. To secure the Plan’s rights, the Plan will also have an equitable lien on those payments and on any escrow account, trust, or any other account that holds those payments. Those payments (and amounts in any escrow account, trust, or other account that holds those payments) shall first be applied to satisfy our lien. The assignment and the Plan’s lien will not exceed the total amount of your obligation to the Plan under the preceding paragraph. Within 30 days after entering into a Surrogacy Arrangement, you must send written notice of the arrangement, including all of the following information: • • •

• •

Names, addresses, and telephone numbers of the other parties to the arrangement Names, addresses, and telephone numbers of any escrow agent or trustee Names, addresses, and telephone numbers of the intended parents and any other parties who are financially responsible for Services the baby (or babies) receive, including names, addresses, and telephone numbers for any health insurance that will cover Services that the baby (or babies) receive A signed copy of any contracts and other documents explaining the arrangement Any other information the Plan may request in order to satisfy its rights to: Harrington Health 3701 Boardman-Canfield Rd., Bldg B Canfield, OH. 44406-7005

You must complete and send all consents, releases, authorizations, lien forms, and other documents that are reasonably necessary to determine the existence of any rights the Plan may have under this "Surrogacy arrangements" section and to satisfy those rights. You may not agree to waive, release, or reduce the Plan’s rights under this "Surrogacy Arrangements" section without the Plan’s prior, written consent. If Your estate, parent, guardian, or conservator asserts a claim against a third party based on the Surrogacy Arrangement, Your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. The Plan may assign its rights to enforce its liens and other rights. U.S. DEPARTMENT OF VETERANS A FFAIRS For any Services for conditions arising from military service that the law requires the Department of Veterans Affairs to provide, the Plan will not pay the Department of Veterans Affairs, and when the Plan covers any such Services the Plan may recover the value of the Services from the Department of Veterans Affairs. W ORKER’S C OMPENSATION OR EMPLOYER’S LIABILITY BENEFITS You may be eligible for payments or other benefits, including amounts received as a settlement (collectively referred to as "Financial Benefit"), under workers’ compensation or employer’s liability law. The Plan will provide covered Services even if it is unclear whether you are entitled to a Financial Benefit, but the Plan may recover the value of any covered Services from the following sources: 88

• •

From any source providing a Financial Benefit or from whom a Financial Benefit is due From you, to the extent that a Financial Benefit is provided or payable or would have been required to be provided or payable if you had diligently sought to establish Your rights to the Financial Benefit under any workers’ compensation or employer’s liability law.

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Chapter 13 Privacy Joint Notice of Privacy Practices This chapter describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Introduction Church Pension Group Services Corporation, doing business as The Episcopal Church Medical Trust (Medical Trust), is the plan sponsor of certain group health plans (each a Plan and together the Plans) that are subject to the Health Insurance Portability and Accountability Act of 1996 and the regulations enacted thereunder (HIPAA). HIPAA places certain restrictions on the use and disclosure of Protected Health Information (PHI) and requires the Medical Trust to provide this Joint Notice of Privacy Practices (the Notice) to you. PHI is your individually identifiable health information that is created, received, transmitted or maintained by the Plans or its business associates, regardless of the form of the information. It does not include employment records held by your employer in its role as an employer. This chapter describes how your PHI may be used and disclosed by the Plans and by employees of the Medical Trust that are responsible for internal administration of the Plans. It also describes your rights regarding the use and disclosure of such PHI and how you can gain access to it. What This Notice Applies To This Notice applies only to health benefits offered under the Plans. The health benefits offered under the Plans include, but may not be limited to, medical benefits, prescription drug benefits, dental benefits, the health care flexible spending account, and any health care or medical services offered under the employee assistance program benefit. This Notice does not apply to benefits offered under the Plans that are not health benefits. Some of the Plans provide benefits through the purchase of insurance. If you are enrolled in an insured Plan, you will also receive a separate notice from that Plan, which applies to your rights under that Plan. Duties and Obligations of the Plans The privacy of your PHI is protected by HIPAA. The Plans are required by law to: • • •

Maintain the privacy of your PHI Provide you with a notice of the Plans’ legal duties and privacy practices with respect to your PHI Abide by the terms of the Notice currently in effect

When the Plans May Use and Disclose Your PHI The following categories describe the ways the Plans are required to use and disclose your PHI without obtaining your written authorization: Disclosures to You. The Plans will disclose your PHI to you or your personal representative within the legally specified period following a request. Government Audit. The Plans will make your PHI available to the U.S. Department of Health and Human Services when it requests information relating to the privacy of PHI.

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As Required By Law. The Plans will disclose your PHI when required to do so by federal, state or local law. For example, the Plans may disclose your PHI when required by national security laws or public health disclosure laws. The following categories describe the ways that the Plans may use and disclose your PHI without obtaining your written authorization: • •

• • • • • • • • • •

• • •

•

Treatment. The Plans may disclose your PHI to your providers for treatment, including the provision of care or the management of that care. For example, the Plans might disclose PHI to assist in diagnosing a medical condition or for pre-certification activities. Payment. The Plans may use and disclose your PHI to pay benefits. For example, the Plans might use or disclose PHI when processing payments, sending explanations of benefits (EOBs) to you, reviewing the Medical Necessity of services rendered, conducting claims appeals and coordinating the payment of benefits between multiple medical plans. Health Care Operations. The Plans may use and disclose your PHI for Plan operational purposes. For example, the Plans may use or disclose PHI for quality assessment and claim audits. Public Health Risks. The Plans may disclose your PHI for certain required public health activities (such as reporting disease outbreaks) or to prevent serious harm to you or other potential victims where abuse, neglect or domestic violence is involved. National Security and Intelligence Activities. The Plans may disclose your PHI for specialized government functions (such as national security and intelligence activities). Health Oversight Activities. The Plans may disclose your PHI to health oversight agencies for activities authorized by law (such as audits, inspections, investigations and licensure). Lawsuits and Disputes. The Plans may disclose your PHI in the course of any judicial or administrative proceeding in response to a court’s or administrative tribunal’s order, subpoena, discovery request or other lawful process. Law Enforcement. The Plans may disclose your PHI for a law enforcement purpose to a law enforcement official, if certain legal conditions are met (such as providing limited information to locate a missing person). Research. The Plans may disclose your PHI for research studies that meet all privacy law requirements (such as research related to the prevention of disease or disability). To Avert a Serious Threat to Health or Safety. The Plans may disclose your PHI to avert a serious threat to the health or safety of you or any other person. Workers’ Compensation. The Plans may disclose your PHI to the extent necessary to comply with laws and regulations related to workers’ compensation or similar programs. Coroners, Medical Examiners and Funeral Directors. The Plans may disclose your PHI to coroners, medical examiners or funeral directors for purposes of identifying a decedent, determining a cause of death or carrying out their respective duties with respect to a decedent. Organ and Tissue Donation. If you are an organ donor, the Plans may release your PHI to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Military and Veterans. If you are a member of the armed forces, the Plans may release your PHI as required by military command authorities. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, the Plans may release your PHI to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Business Associates. The Plans may contract with other businesses for certain plan administrative services. The Plans may release your PHI to one or more of their business associ-

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•

ates for plan administration if the business associate agrees in writing to protect the privacy of your information. Plan Sponsor. ECMT, as sponsor of the Plans, will have access to your PHI for plan administration purposes. Unless you authorize the Plans otherwise in writing (or your individual identifying data is deleted from the information), your PHI will be available only to the individuals who need this information to conduct these plan administration activities, but this release of your PHI will be limited to the minimum disclosure required, unless otherwise permitted or required by law.

The following categories describe the ways that the Plans may use and disclose your PHI upon obtaining your written authorization: • • •

Most uses and disclosures of psychotherapy notes Uses and disclosures of PHI for marketing purposes Uses and disclosures that constitute a sale of PHI

Any other use or disclosure of your PHI not identified in this chapter will be made only with your written authorization. Authorizing Release of Your PHI To authorize release of your PHI, you must complete a medical information authorization form. An authorization form is available at www.cpg.org or by calling (800) 480-9967. You have the right to limit the type of information that you authorize the Plans to disclose and the persons to whom it should be disclosed. You may revoke your written authorization at any time. The revocation will be followed to the extent action on the authorization has not yet been taken. Interaction with State Privacy Laws If the state in which you reside provides more stringent privacy protections than HIPAA, the more stringent state law will still apply to protect your rights. If you have a question about your rights under any particular federal or state law, please contact the Church Pension Group Privacy Officer. Contact information is included at the end of this chapter. Fundraising The Plans may contact you to support their fundraising activities. You have the right to opt out of re-ceiving such communications. Underwriting The Plans are prohibited from using or disclosing PHI that is genetic information for underwriting purposes. Your Rights With Respect to Your PHI You have the following rights regarding PHI the Plans maintain about you: Right to Request Restrictions. You have the right to request that the Plans restrict their uses and disclosures of your PHI. You will be required to provide specific information as to the disclosures that you wish to restrict and the reasons for your request. The Plans are not required to agree to a requested restriction, but may in certain circumstances. To request a restriction, please write to the

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Church Pension Group Privacy Officer and provide specific information as to the disclosures that you wish to restrict and the reasons for your request. Right to Request Confidential Communications. You have the right to request that the Plans’ confidential communications of your PHI be sent to another location or by alternative means. For example, you may ask that all EOBs be sent to your office rather than your home address. The Plans are not required to accommodate your request unless your request is reasonable and you state that the ordinary communication process could endanger you. To request confidential communications, please submit a written request to the Church Pension Group Privacy Officer. Right to Inspect and Copy. You have the right to inspect and obtain a copy of the PHI held by the Plans. However, access to psychotherapy notes, information compiled in reasonable anticipation of or for use in legal proceedings, and under certain other, relatively unusual circumstances, may be denied. Your request should be made in writing to the Church Pension Group Privacy Officer. A reasonable fee may be imposed for copying and mailing the requested information. You may contact the Medical Trust Plan Administration at [email protected] for a full explanation of ECMT’s fee structure. Right to Amend. You have the right to request that the Plans amend your PHI or record if you believe the information is incorrect or incomplete. To request an amendment, you must submit a written request to the Medical Trust Plan Administration at [email protected]. Your request must list the specific PHI you want amended and explain why it is incorrect or incomplete and be signed by you or your authorized representative. All amendment requests will be considered carefully. However, your request may be denied if the PHI or record that is subject to the request: • • • •

Is not part of the medical information kept by or for the Plans Was not created by or on behalf of the Plans or its third party administrators, unless the person or entity that created the information is no longer available to make the amendment Is not part of the information that you are permitted to inspect and copy Is accurate and complete

Right to an Accounting of Disclosures. You have the right to receive information about when your PHI has been disclosed to others. Certain exceptions apply to this rule. For example, a Plan does not need to account for disclosures made to you or with your written authorization, or for disclosures that occurred more than six years before your request. To request an accounting of disclosures, you must submit your request in writing to the Medical Trust-Plan Administration at [email protected] and indicate in what form you want the accounting (e.g., paper or electronic). Your request must state a time period of no longer than six years and may not include dates before your coverage became effective. The Medical Trust Plan Administrator will then notify you of any additional information required for the accounting request. A Plan will provide you with the date on which a disclosure was made, the name of the person or entity to whom PHI was disclosed, a description of the PHI that was disclosed, the reason for the disclosure and certain other information. If you request this accounting more than once in a 12-month period, you may be charged a reasonable, cost-based fee for responding to these additional requests. You may contact Medical Trust Plan Administration at [email protected] for a full explanation of the Medical Trust’s fee structure. Breach Notification. You have the right to receive a notification from the Plans if there is a breach of your unsecured PHI. Right to a Paper Copy of This Notice. You are entitled to get a paper copy of this Notice at any time, even if you have agreed to receive it electronically. To obtain a paper copy of this Notice, please contact the Church Pension Group Privacy Officer.

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If You Believe Your Privacy Rights Have Been Violated If you believe your privacy rights have been violated by any Plan, you may file a complaint with the Church Pension Group Privacy Officer and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be filed in writing. You will not be retaliated against for filing a complaint. To contact the Church Pension Group Privacy Officer: Privacy Officer The Church Pension Group 19 East 34th Street New York, NY 10016 (212) 592-8365 [email protected] To contact the Secretary of the U.S. Department of Health and Human Services: U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue, SW Washington, DC 20201 (202) 619-0257 | (877) 696-6775 (toll-free) www.hhs.gov/contactus.html Effective Date This Notice is effective as of August 24, 2015. Changes Each Plan sponsored by the Medical Trust reserves the right to change the terms of this Notice and information practices and to make the new provisions effective for all PHI it maintains, including any PHI it currently maintains as well as PHI it receives or holds in the future, as permitted by applicable law. Any material amendment to the terms of this Notice and these information practices will be provided to you via mail or electronically with your prior written consent.

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CHAPTER 14 GLOSSARY A NNUAL DEDUCTIBLES A deductible is the amount of covered expenses each covered individual must pay during each year before the Plan will consider expenses for reimbursement. The individual deductible applies separately to each covered person. The family deductible applies collectively to all covered persons in the same family. When the family deductible is satisfied, no further deductible will be applied for any covered family member during the remainder of that year, except in the case of an inpatient hospital deductible. The annual individual and family out-of-network deductible amounts, and the inpatient hospital deductibles, are shown on the Summary of Benefits and Coverage. B ENEFITS Your right to payment for Covered Health Services that is available under the Plan. Your right to benefits is subject to the terms, conditions, limitations and exclusions of the Plan, including this handbook and any applicable riders and amendments. B ENEFIT MAXIMUMS In certain cases, total Plan payments for each covered person are limited to certain maximum benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit maximum amount also applies to a specific time period, such as annual or lifetime. Whenever the word “lifetime” appears in this handbook in reference to benefit maximums, it refers to the period of time you or your eligible dependents participate in this Plan or any other plan sponsored by the Medical Trust. B ILLED G ROUP A Participating Group or one of its congregations, schools or other bodies, including Employees and Pre-65 Retired Employees or Post-65 Retired Employees, that is billed by the Plan and responsible for paying monthly contributions. Also sometimes called a “List Bill.” C LAIMS A DMINISTRATOR The company, or its affiliate, that provides certain claim administration services for the Plan. C OINSURANCE Coinsurance percentages represent the portion of covered expenses paid by you and the Plan after satisfaction of any applicable deductible. These percentages apply only to covered expenses that do not exceed reasonable and customary charges. You are responsible for all non-covered expenses, including any amount that exceeds the reasonable and customary charge for covered expenses. C ONGENITAL A NOMALY A physical developmental defect that is present at birth and is identified within the first twelve months of birth. C OSMETIC P ROCEDURES Procedures or services that change or improve appearance without significantly improving physiological function, as determined by the Claims Administrator. Reshaping a nose with a prominent bump is one example of a cosmetic procedure because appearance would be improved, but there would be no improvement in function, such as breathing.

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C OVERAGE TIER Coverage Tiers represent coverage classifications based on the number of Members covered. Contribution rates correspond to the Coverage Tier type (Single, Subscriber + Spouse/Domestic Partner, subscriber + Child, Subscriber + Children, Family) C OVERED HEALTH S ERVICE(S) Covered health services are those health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, or their symptoms. A covered health service is a healthcare service or supply described in the coverage section as a covered health service, which is not excluded in the Exclusions and Limitations section, including Experimental or Investigational Services and unproven services. Covered Health Services must be provided: • • •

When the Plan is in effect Prior to the effective date of any of the individual termination conditions set forth in this handbook Only when the person who receives services is a covered person and meets all eligibility requirements specified in the Plan

Decisions about whether to cover new technologies, procedures and treatments will be consistent with conclusions of prevailing medical research, based on well-conducted randomized trials or cohort studies. C OPAYMENTS Copayments (“copays”) are the first-dollar amounts you must pay for certain covered services under the Plan that are usually paid at the time the service is performed (e.g., physician office visits or emergency room visits). The copayment amounts are shown on the Summary of Benefits and Coverage. C USTODIAL C ARE Custodial care includes activities of daily living such as bathing, feeding, administration of oral medicines, or other services that can be provided by persons without the training of a healthcare provider. DENOMINATIONAL HEALTH PLAN A Church-wide program of healthcare benefit plans authorized by General Convention and administered by The Church Pension Fund (CPF), with benefits provided through the Medical Trust. DEPENDENT A Spouse, Domestic Partner, or Child of a Subscriber who meets the qualifications listed in the eligibility chapter. Child(ren) A Subscriber’s or Subscriber’s Spouse’s natural child, stepchild, legal ward, foster child 7, legally adopted child or child who has been placed with the Subscriber/Subscriber’s Spouse for adoption, and if Domestic Partner benefits are permitted by the Participating Group, a Domestic Partner’s Child. Domestic Partner Two adults who have chosen to share one another’s lives in a mutually exclusive partnership that resembles marriage. The Plan requires completion of the Domestic Partnership Affidavit to confirm that the re7

A foster child is an individual who is placed with the Subscriber by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction. 96

quirements of the Plan are met. Spouse A person’s lawfully married husband or wife evidenced by a marriage certificate or in the case of a common-law spouse, evidenced by a written court order. Surviving Child A Child of a Subscriber who meets the qualifications listed in the eligibility chapter and is enrolled in the Plan at the time of the Subscriber’s death. A Surviving Child shall include a Child of a Subscriber born or adopted within 12 months of the Subscriber’s death. Surviving Domestic Partner A Domestic Partner of a Subscriber who meets the qualifications listed in the eligibility chapter and is enrolled in the Plan at the time of the Subscriber’s death. Surviving Spouse A Spouse of a Subscriber who meets the qualifications listed in the eligibility chapter and is enrolled in the Plan at the time of the Subscriber’s death. DISABLED A medically determinable physical or mental impairment that can be expected to result in death or be of long continued and indefinite duration, as determined by the Medical Board. DURABLE MEDICAL EQUIPMENT Medical equipment that is all of the following: • • • • • •

Used to serve a medical purpose with respect to treatment of a sickness, injury, or their symptoms Not disposable Not of use to a person in the absence of a sickness, injury, or their symptoms Durable enough to withstand repeated use Not implantable within the body Appropriate for use—and primarily used—within the home

ELIGIBLE DEPENDENT This definition can be found in the Eligibility and Enrollment chapter of this handbook. ELIGIBLE EXPENSES Eligible expenses for Covered Health Services, incurred while the Plan is in effect, are determined as stated below. The Plan has delegated to the Claims Administrator the discretion and authority to initially determine on our behalf whether a treatment or supply is a covered health service and how the eligible expense will be determined. For network benefits, eligible expenses are based on either of the following: • •

When Covered Health Services are received from network providers, eligible expenses are the contracted fee(s) with that provider. When Covered Health Services are received from out-of-network providers as a result of an emergency or as otherwise arranged by the Claims Administrator, eligible expenses are the fee(s) that are negotiated with the out-of-network provider.

When you receive Covered Health Services from network providers, you are responsible for the copayment and amounts in excess of any Plan maximum, but you are not responsible for any difference between the eligible expenses and the amount the provider bills. 97

For out-of-network benefits, eligible expenses are determined by either: • •

Calculating eligible expenses based on available data resources of competitive fees in that geographic area Applying the negotiated rates agreed to by the out-of-network provider and either the Claims Administrator or one of its vendors, affiliates or subcontractors.

Eligible expenses are determined solely in accordance with the Claims Administrator's reimbursement policy guidelines. The reimbursement policy guidelines are developed, in the Claims Administrator's discretion, following evaluation and validation of all provider billings in accordance with one or more of the following methodologies: • • • •

As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association As reported by generally recognized professionals or publications As used for Medicare As determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that the Claims Administrator accepts

ELIGIBLE I NDIVIDUAL This definition can be found in the Eligibility for the Episcopal Health Plan (EHP) and the Episcopal Health Plan for Qualified Small Employer Exception Members (EHP SEE) of the handbook. EMERGENCY A serious medical condition or symptom resulting from injury, sickness or mental illness which is both of the following: • •

Arises suddenly In the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health

EMPLOYEE An individual whose income must be reported on a Form W-2 or international equivalent by a Participating Group, including individuals on an approved leave of absence, short-term disability, or long-term disability. Exempt Employee An Employee who is not subject to the overtime provisions of the Fair Labor Standards Act 8 or other applicable state law due to the nature of the work, education requirements of the position and salary range, as determined solely by the employer. Non-Exempt Employee An individual who is entitled to overtime compensation under the Fair Labor Standards Act or other applicable state law, as determined solely by the employer. Pre-65 Retired Employee A former Employee of a Participating Group of the EHP: a) Who at the time of separation from active employment was either participating in the EHP or eligible to participate in the EHP as an Exempt Employee or a Non-Exempt Employee who was normally scheduled to work and was compensated for 1,000 or more hours per year, and

8

www.dol.gov/whd/overtime_pay.htm. For purposes of these definitions, it is assumed that the Fair Labor Standards Act applies to the employer. 98

b) At the time of separation from employment with The Episcopal Church was at least 55 years of age, or if younger, was eligible for a disability retirement benefit under a pension plan sponsored by The Church Pension Fund or its affiliates, and c) If a lay Employee, has five (5) or more years of continuous service with The Episcopal Church OR if a cleric, has a vested benefit under The Church Pension Fund Clergy Pension Plan Priest An individual ordained to the priesthood in the Episcopal Church pursuant to the Constitution and Canons or a person who has been received as a Priest into the Episcopal Church from another Christian denomination in accordance with the Constitution and Canons. Post-65 Retired Employee Clergy A former Employee who: a) Is age 65 or older, and b) Has a vested benefit under The Church Pension Fund Clergy Pension Plan. Lay A former Employee who: a) Is age 65 or older and b) Who at the time of separation from active employment was either an Exempt Employee or a Non-Exempt Employee who was normally scheduled to work and was compensated for 1,000 or more hours per year for a minimum of 5 years AND either (1) Participated in a pension plan sponsored by The Church Pension Fund for a minimum of 5 years OR (2) as a former Employee of a Participating Group of the EHP. Member of Religious Order who: a) Is age 65 or older and b) Either (1) Participated in a pension plan sponsored by The Church Pension Fund for a minimum of 5 years OR (2) is a former Member of a Religious Order that is a Participating Group of the EHP. Seasonal Employee An Employee, who normally performs work during certain seasons or periods of the year, whose compensated employment is scheduled to last less than 5 months in a year, and who is compensated for less than 1,000 hours per Plan Year. Temporary Employee An Employee who is scheduled to be employed for a limited time only or whose work is contemplated or intended for a particular project or need, usually of a short duration such as 3 months, and who is compensated for less than 1,000 hours per Plan Year. EPISCOPAL C HURCH C LERGY AND EMPLOYEE’S B ENEFIT TRUST (ECCEBT) The Plan funds certain of its benefit plans through this trust fund that is intended to qualify as a voluntary employees’ beneficiary association (VEBA) under Section 501(c)(9) of the Internal Revenue Code. The purpose of the ECCEBT is to provide health benefits to eligible Employees, former Employees, and/or their Dependents. EXPERIMENTAL OR I NVESTIGATIONAL SERVICES Medical, surgical, diagnostic, psychiatric, substance abuse or other healthcare services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time the Plan makes a determination regarding coverage in a particular case, are determined to be any of the following:

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• • •

Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use Subject to review and approval by any institutional review board for the proposed use The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight

G ROUP A DMINISTRATOR The individual authorized by the Participating Group to administer its Employee benefits program. H EALTH I NSURANCE P ORTABILITY AND A CCOUNTABILITY A CT OF 1996 (HIPAA) The Health Insurance Portability and Accountability Act of 1996, as amended, and the regulations issued there under. HIPAA is a federal law that, among other things, provides rights and protections for participants and beneficiaries in group health plans by regulating the portability and continuity of group health coverage. HIPAA limits exclusions based on preexisting conditions, prohibits discrimination based on health status factors, and gives individuals a special opportunity to enroll in a group health plan in certain circumstances. The Administrative Simplification Provisions of HIPAA address the privacy and security of certain health information. H EALTHCARE P ROVIDERS The Plan provides benefits only for Covered Serivces and supplies rendered by a physician, practitioner, nurse, hospital, or specialized treatment facility. MEDICARE Parts A, B, C and D of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended. MEDICAL LIFE P ARTICIPANT SYSTEM (MLPS) The Medical Life Participant System (MLPS) is a web-based tool designed to make the administration of benefits easy and efficient. MLPS processes health and group life benefits enrollments in real time, and allows Group Administrators to view bills and payment histories, create reports, and generate mailing lists. MEDICAL N ECESSITY “Medically Necessary” or “Medical Necessity” shall mean healthcare services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and (c) not primarily for the convenience of the patient, physician, or other healthcare provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors. MEDICARE S ECONDARY P AYER (MSP) The term used when Medicare pays secondary to an active plan covering a Medicare beneficiary. MEDICARE S ECONDARY P AYER (MSP) – S MALL EMPLOYER EXCEPTION (SEE) An exception to the MSP rules that applies to an eligible small employer. If eligible for the SEE, Medicare becomes the primary payer and the Medical Trust will pay secondary. 100

MEMBER A Subscriber or enrolled Dependent MEMBER OF A R ELIGIOUS O RDER A postulant, novice or professed member of Episcopal Religious Orders, as defined in Title III, Canon 14, 1 9 who has been accepted or received by the Religious Order. MENTAL H EALTH SERVICES Covered health services for the diagnosis and treatment of mental illnesses. The fact that a condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a Covered Health Service. N ETWORK When used to describe a provider of healthcare services, this means a provider that has a participation agreement in effect with the Claims Administrator or an affiliate (directly or through one or more other organizations) to provide Covered Health Services to covered persons. A provider may enter into an agreement to provide only certain Covered Health Services, but not all Covered Health Services, or to be a network provider for only some products. In this case, the provider will be a network provider for the health services and products included in the participation agreement, and an out-of-network provider for other health services and products. The participation status of providers will change from time to time. N ETWORK B ENEFITS Benefits for Covered Health Services that are provided by (or directed by) a network physician or other network provider in the provider's office or at a network or out-of-network facility. O PEN ENROLLMENT The annual period of time during which Subscribers and other Eligible Individuals may elect and/or change Plans for the following Plan Year for themselves and their Eligible Dependents. Active Open Enrollment During an Active Open Enrollment, a Subscriber or Eligible Individual is required by the Plan to take specific actions to prevent any loss of coverage. An Active Open Enrollment generally takes place for a Participating Group upon first joining the Plan, or when a plan ceases to be available for the upcoming Plan Year, or when there is a significant change to the existing Plan options. Passive Open Enrollment During a Passive Open Enrollment, a Subscriber or Eligible Individual is not required by the Plan to take any action 10. However, the Plan encourages Subscribers and Eligible Individuals to log on to the Open Enrollment website to verify demographic information and existing coverage and to update any data that is not accurate. O UT-OF-N ETWORK B ENEFITS Benefits for Covered Health Services that are provided by or directed by an out-of-network physician either at a 9

The Constitution and Canons of the Episcopal Church, 2012

10

Note, however, that some states may require a new signed authorization from the employee when the amount of the payroll deduction increases. 101

network facility or at an out-of-network facility. N ON-PPO DEDUCTIBLES A non-PPO deductible is the amount of covered expenses each covered individual must pay during each year before the Plan will consider expenses for reimbursement. The individual deductible applies separately to each covered person. The family deductible applies collectively to all covered persons in the same family. When the family deductible is satisfied, no further deductible will be applied for any covered family member during the remainder of that year. O UT-OF-P OCKET MAXIMUM An out-of-pocket maximum is the maximum amount of covered expenses you must pay during a year before the coinsurance percentage of the Plan increases. The individual out-of-pocket maximum applies separately to each covered person. When a covered person reaches the annual out-of-pocket maximum, the Plan will pay 100% of additional covered expenses for that individual during the remainder of that year. The family out-of-pocket maximum applies collectively to all covered persons in the same family. When the annual family out-of-pocket maximum is reached, the Plan will pay 100% of covered expenses for any covered family member during the remainder of that year. The following costs will never apply to the out-of-pocket maximum: • • • • •

Any charges for non-Covered Health Services Copayments for Covered Health Services available by an optional rider The amount of any reduced benefits if you don't precertify services when required Charges that exceed eligible expenses Penalties

P ARTICIPATING G ROUP A diocese, congregation, agency, school, organization, or other body subject to the authority of and/or associated or affiliated with The Episcopal Church, which has elected to participate in the Plan. P LAN The medical and dental plans (health plans) maintained by the Medical Trust for the benefit of Members. The Plan is intended to qualify as a “church plan” as defined by Section 414(e) of the Internal Revenue Code, and is exempt from the requirements of the Employee Retirement Income Security Act of 1974, as amended (ERISA). Episcopal Health Plan (EHP) A program of medical and dental plan options through which Eligible Individuals and Eligible Dependents of The Episcopal Church are provided health benefits. Benefits are provided through the Medical Trust. Episcopal Health Plan (EHP) for qualified Small Employer Exception (SEE) Members A program of medical Plans through which Eligible Individuals and Eligible Dependents of the Episcopal Church are provided health benefits. Benefits are provided through the Medical Trust. This plan is applicable only to those small employers and individuals enrolled in Medicare who apply and are certified by the Centers for Medicare & Medicaid Services (CMS) as meeting the criteria to participate as a result of meeting the Small Employer definition and the benefits coordinating with Medicare. Medicare Supplement Health Plan (MSHP) A program of supplemental medical and dental plan options through which Eligible Individuals and Eligible Dependents of The Episcopal Church are provided health benefits. Benefits are provided through the Medical Trust. A Medicare Supplement Health Plan provides coverage for medical expenses not covered or partially covered by the Original Medicare Plan (Parts A and B). It may also provide benefits for expenses not covered by the Original Medicare Plan such as pharmacy

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benefits and vision care. The Medicare Supplemental Health Plan only works with the Original Medicare Plan, where Medicare pays first (primary) for a medical claim, and the Medicare Supplemental Health Plan pays for the medical claim after (secondary to) the Original Medicare Plan. The Original Medicare Plan and the MSHP only pay claims for services that are provided in the United States. P LAN YEAR The word “year”, as used in this handbook, refers to the Plan Year which is the 12-month period beginning January 1 and ending December 31. All benefit maximums and annual deductibles accumulate during the Plan Year. P REVENTIVE C ARE Routine healthcare, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems. S EMINARIAN A full-time student, as defined by the seminary, enrolled at a participating seminary of the Association of Episcopal Seminaries. S IGNIFICANT LIFE EVENT An event as described in the Eligibility and Enrollment chapter, where as a result of the event, the Subscriber is eligible to make a mid-year election change. S UBSCRIBER The primary individual enrolled in the Plan who meets the qualifications listed in the eligibility section. S UBSTANCE A BUSE SERVICES Covered health services for the diagnosis and treatment of alcoholism and substance abuse disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a covered health service. USUAL AND C USTOMARY C HARGES The Plan provides benefits only for covered expenses that are equal to or less than the usual and customary charge in the geographic area where services or supplies are provided. Any amounts that exceed the usual and customary charge are not recognized by the Plan for any purpose. In determining the reasonable charge for a service or supply that is: • • •

Unusual Not often provided in the area Provided by only a small number of providers in the area

The Claims Administrator may take into account factors such as: • • • •

The complexity The degree of skill needed The type of specialty of the provider The prevailing charge in other areas

In some circumstances, the Claims Administrator may have an agreement with a provider (either directly, or indi103

rectly through a third party) that sets the rate that will be paid for a service or supply. In these instances, in spite of the methodology described above, the Usual and Customary charge is the rate established in such an agreement. For covered individuals participating in a PPO plan option, usual and customary charges do not apply to PPO healthcare providers, or any non-PPO anesthesiology, diagnostic testing, x-ray, and laboratory services. URGENT C ARE C ENTER A facility, other than a hospital, that provides Covered Health Services that are required to prevent serious deterioration of your health, and that are required as a result of an unforeseen sickness, injury, or the onset of acute or severe symptoms.

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FOR MORE INFORMATION Here are some additional resources, should you have any questions after reviewing all of the information in this Handbook. THE EPISCOPAL CHURCH MEDICAL TRUST www.cpg.org (800) 480-9967 e-mail: [email protected] Monday through Friday, except holidays, 8:30 a.m.– 8:00 p.m. ET KAISER PERMANENTE http://.my.kp.org/ecmt Colorado: (877) 883-6698 Georgia: (866) 800-1486 Mid-Atlantic States: (877) 740-4117 Northwest (866) 800-3402 Northern California: (800) 663-1771 Southern California: (800) 533-1833 Ohio: (877) 721-2199 TTY: (877) 870-0283 (Monday – Friday, 7:00 a.m. – 9:00 p.m. EST) EYEMED VISION CARE www.eyemedvisioncare.com (866) 723-0513 Monday through Saturday, 8:00 a.m. – 11:00 p.m. EST, and Sunday, 11:00 a.m. – 8:00 p.m. EST EMPLOYEE ASSISTANCE PROGRAM (THROUGH Cigna BEHAVIORAL HEALTH ONLY) www.cignabehavioral.com (800) 926-2273 (24 hours a day, 7 days a week) HEALTH ADVOCATE www.healthadvocate.com (866) 695-8622 (24 hours a day, 7 days a week)

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The Plan(s) described in this handbook are sponsored and administered by the Church Pension Group Services Corporation (“CPGSC”), also known as the Episcopal Church Medical Trust (the “Medical Trust”). The Plans that are self-funded are funded by the Episcopal Church Clergy and Employees’ Benefit Trust (“ECCEBT”), a voluntary employees’ beneficiary association within the meaning of section 501(c)(9) of the Internal Revenue Code. This handbook contains only a partial description of the Plans intended for informational purposes only. It should not be viewed as a contract, an offer of coverage, or investment, tax, medical, or other advice. The Church Pension Fund and its affiliates, including but not limited to the Medical Trust, CPGSC and ECCEBT (collectively, “CPG”), retain the right to amend, terminate, or modify the terms of the Plans, as well as any post-retirement health subsidy, at any time, for any reason and unless required by law, without notice. The Plans are church plans within the meaning of section 3(33) of the Employee Retirement Income Security Act and section 414(e) of the Internal Revenue Code. Not all Plans are available in all areas of the United States, and not all Plans are available on both a self-funded and fully insured basis. The Plans do not cover all healthcare expenses, and Members should read the official Plan document carefully to determine which benefits are covered, as well as any applicable exclusions, limitations, and procedures. CPG does not provide any healthcare services and therefore cannot guarantee any results or outcomes. Healthcare providers and vendors are independent contractors in private practice and are neither employees nor agents of CPG. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change.