R-89-1282 - 5/25/1989WHEREAS, the City of Round Rock has requested proposals to
provide additional health insurance coverage for City employees, and
WHEREAS, Texas Health Facility Plan has submitted a proposal,
and
WHEREAS, the City Council wishes to accept the proposal of Texas
Health Facility Plan to provide additional health insurance coverage
for the City, Now Therefore,
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK, TEXAS,
That the proposal of Texas Health Facility Plan is hereby
approved, and the Mayor is hereby authorized and directed to execute
on behalf of the City a contract with Texas Health Plan to provide
health insurance coverage for the City.
RESOLVED this 25th day of May, 1989.
ATTEST:
1
1* /t1_/
NE
C42RESTEXAS
y Secretary
RESOLUTION NO. I'2 A
MIKE ROBINSON, Mayor
City of Round Rock, Texas
DATE: May 23, 1989
SUBJECT: Council Agenda, May 25, 1989
ITEM: 13A. Consider a resolution authorizing the Mayor to
enter into a contract with Texas Health Plan for
City health insurance.
STAFF RESOURCE PERSON: Linda Gunther
STAFF RECOMMENDATION: Staff recommends entering into a contract with
Texas Health Plan for City health insurance effective June 1, 1989. This
will allow City employees an option to choose health coverage with current
indemity plan, Blue Cross /Blue Shield or Texas Health Plan. Texas Health
Plan will assure affordability for the City and City employees (lower out
of pocket expense) and guarantee cap on premiums of 10% for the first year
and 15% for the second year. The average increase per year has been in
the 40% range.
ECONOMIC IMPACT: Cost to the City from June 1, 1989 to September
30, 1989: $16,926.00
TEXAS HEALTH PLANS, INC.
8303 MOPAC, SUITE 450
AUSTIN, TEXAS 78759
(512) 338-6100
GROUP ENROLLMENT AGREEMENT
Group# 20419
/o( K;b K.
The Enrolling Group named below hereby applies to Texas Health Plans, Inc. for a Group Contract/Certificate of Coverage to be issued as follows:
1. Group Name: Cit of Round Rock
Address/City/State /Zip: 214 Main Street Round Rock, Texas 78664
Billing Address/City/State/Zip: Same as Above
2. Legal Status: Corporation _ Partnership _ Proprietorship _ Trust X Other: Municipality
3. Employer Tax Identification Number: 74 - 6017485
4. Nature of Business or Industry: City Government
5. Subsidiaries: The following subsidiaries. affiliates, or other related organizations will be included under the Group Contract/Certificate of
Coverage: N/A
6. Eligibility: Eligible employees of the Group and their eligible family members shall be those persons who meet the criteria set forth in the
Group Contract/Certificate of Coverage and such additional requirements as are set forth below:
Subscribers (Employees): All full time employees. New hires effective lst of month following
date of hire. Termination: end of month.
Family Members: Spouses; unmarried dependent children to age 25.
7. Initial Enrollment Period: Individuals who are not eligible on the date the Group Enrollment Agreement takes effect, and who otherwise
become eligible according to the requirements specified in the Group Enrollment Agreement and Group Contract/Certificate of Coverage will
be eligible for enrollment until 31st day following initial enrollment period.
8. Open Enrollment Period: The Open Enrollment Period shall commence each Sept. 1 and continue until Sept . 30
of every year this Agreement is in effect, except as Health Plan and Enrolling Group may otherwise agree to in writing. The Open Enrollment
Period shall be at least 10 days duration.
9. Effective Date: The Group Contract/Certificate of Coverage will be delivered in and govemed by the laws of the State of Texas and shall take
effect on June 1. 1989 but only if the following conditions are satisfied: (a) this Agreement is accepted and signed by Texas
Health Plans, Inc., and (b) Enrolling Group agrees to pay the Premiums on schedule as stipulated below. The Premiums specified in this
Agreement are guaranteed until Sept 30. 1989 .
10. Renewal Date: October 1, 1989
11. Coverage: Plan Code # 5NA Group ContracVCertificate of Coverage # GCC 15 - 1(R)
Amendments: G4(15SFRVARE, GCCBRFATPD, AM- 25(1/89). Letter of Agreement, 0V10(1/89)
Rigirgx N081)750(1/89)
12. Premium Rate Schedule: Total Monthly Premium Subscriber Contribution Group Contribution
A. Employee Only $ 88.28 $ - 0 - $ 88.28
B. Employee and One Dependent $ 207.36 $ 119.08 $ 88.28
or Employee and Spouse
C. Employee and Child(ren) $ 1 56.58 $ 68.30 $ 88.28
D. Employee and Family $ 264.92 $ 176.64 $ 88.28
13. Premium Due Date and Payments: Enrolling Group agrees to the terms stated on the back of this Agreement and in the Group Contract/
Certificate of Coverage.
14. Worker's Compensation Information: Policy No.: Insurance Company Name: GAB
Address: P.O. Rerx 180128 Mint Texan 78718 Phone No.: 343 -1220
15. Enrolling Group hereby agrees and understands that if it fails to tarty or maintain Workers Compensation insurance, it shall be solely
responsible for any resulting expenses due to work related conditions.
16. The Enrolling Group hereby agrees and understands that the Group Contract/Certificate of Coverage issued is based on this Agreement and
that the acceptance of the Group Contract/Certificate of Coverage constitutes Agreement to all terms and conditions of this Agreement and
the Group Contract/Certificate of Coverage. A copy of this Agreement shall be attached to and made a part of the Group Contract/Certificate
of Coverage issued to the Enrolling Group. l-I-
Signed at on the 1(n d �y1�1 p ay of 11 /) LLLt, 19 0 9 .
(address of Enrolling Group) _ _ 11
FOR TH�LLI
Authh onnzed Signature
h/ l 1 l
Title U
GEA 12/88(8)
FOR TEXA ALTH Ps�
Authorized Signature
Fxprntiva Vino President
Title
PREMIUM DUE DATE AND PAYMENTS
Monthly Premium Remittance. The Enrolling Group agrees to remit the entire Premium on a monthly basis and assumes responsibility for
collection of the contributory portion from the Subscriber, if any. The first Premium payment is due and payable on the effective date of this
Contract. Subsequent Premiums are due and payable no later than the last business day (which excludes legal holidays, Saturdays and Sundays)
preceding each Contract Month thereafter that This Contract is in effect.
Retroactive Adjustments. Retroactive adjustments may, at the option of Health Plan, be made for any additions or terminations of Subscribers and
changes in coverage classification not reflected in Health Plan's records at the time the monthly Premium is calculated by Health Plan. However,
at no time shall Health Plan be required to make a retroactive adjustment greater than sixty (60) days. All adjustments are effective as of 12:01
a.m., Central Standard Time, on the first day of the applicable calendar month.
j3ennrting Additions and Deletions. The Enrolling Group shall provide Health Plan with additions and deletions within thirty (30) days of the effective
date of coverage.
Additions. In the event that a Member enrolls hereunder on or before the fifteenth (15th) day of a month, the Enrolling Group agrees to remit to
Health Plan on or before the next Premium Due Date an additional total monthly Premium for such Member for the month in which the Member
enrolled. In the event that a Member enrolls hereunder after the fifteenth (15th) day of a month, no additional Premium payment will be due with
respect to such Member for the month in which the Member enrolled.
Terminations. In the month of a Member's termination, if the Members termination is effective on any given day during the respective month, then
a full month's premium is due.
J ate Payment Charge A late payment charge will be added to all Premium payments due and not paid to Health Plan before the first day of the
coverage month. The late payment charge on late Premiums will be charged at a rate equal to eighteen percent (18 %) per year. The unpaid
Premiums and the late payment charges are due and payable upon notice thereof to the Enrolling Group from Health Plan.
Termination for Non-Payment of Premiums. If the Enrolling Group fails to pay Premiums within the thirty (30) day Grace Period, coverage will be
cancelled after the thirtieth (30th) day. The Enrolling Group will remain liable tor all Premiums and late payment charges accrued but not paid prior
to termination. If the Premiums and late payment charges are not paid within thirty (30) days of the end of the Grace Period, the Member will be
liable for the cost of Health Services received during the Grace Period.
4
r
LETTER OF ACS
Texas Health Plans, Inc. has agreed to provide the City of Round Rock with a
guarantee that the renewal premium rates, effective October 1, 1989 through
September 30, 1990, will not exceed a 10% increase over the current premium
rates. In addition, Texas Health Plans, Inc. will guarantee the October 1,
1990 through September 30, 1991, rates not to exceed a 15% increase over the
10% increase for the period of October 1, 1989 through September 30, 1990.
Please note that the current plan might have to be altered in the following
years to conform with existing Texas Health Plans, Inc. plans being marketed at
that time and with changes in coverage that the State Board of Insurance might
ire.
Secondly, in the event the current indemnity carrier (Blue Cross /Blue Shield)
terminates their contract with the City of Round Rock due to a lack of
participation in the Blue Cross /Blue Shield program, Texas Health Plans, Inc.
will allow those employees participating in Blue Cross /Blue Shield to enroll
into Texas Health Plans, Inc. without providing evidence of insurability.
FOR THE ENROLLING GROUP: FOR TEXAS HEAIBH PLANS, INC:
Authorized Signature
Title Title
Executive Vice President
provide or arrange for the provision of such health care benefits and
services, taking into account the impact of the event.
35. Routine eye refractions unless provided by rider.
36. All surgical or invasive procedures intended primarily fortreatment of
obesity, including gastric bypasses, jejuna) bypasses, and balloon
procedures unless Authorized by Health Plan.
44
TEXAS HEALTH PLANS, INC.
8303 MoPac, Suite 450
Austin, Texas 78759
Phone (512) 338 -6100
Group Contract /Certificate of Coverage
This Group Contract/Certificate of Coverage is a legal contract between the
Enrolling Group and Texas Health Plans, Inc. It sets forth in detail your rights
and obligations as a Member.
It is therefore important that you READ your Group Contract/Certificate of
Coverage CAREFULLY and familiarize yourself with its terms and condi-
tions. For reference purposes, a table of contents has been included.
GCC•15.1(R)
BY:
eter E. Kilissanly, President
and Chief Executive Officer
DATE: 2-1-89
A Texas Health Maintenance Organization
SECTION I
SECTION II
SECTION III
SECTION IV
SECTION V
SECTION VI
SECTION VII
TABLE OF CONTENTS
Definitions 3
Eligibility and Enrollment 10
Effective Date of Coverage and Selection of a 13
Participating Primary Care Physician
Procedures for Reimbursement of Eligible Expenses 15
Incurred with Non - Participating Providers
Coordination of Benefits and Subrogation
Complaint Procedures
Termination of Coverage
SECTION VIII Relationship Between Parties
SECTION IX Premium Payments
SECTION X General Provisions
SECTION XI Schedule of Benefits
15
20
20
23
24
26
29
21. Sex change operations and reversal of elective sterilization proce-
dures.
22. All costs associated with the collection and preservation of spermfor
artificial insemination, including donor fees, unless provided by a
separate rider to this Contract.
23. Physical, occupational, speech and hearing therapy services not
approved in advance by Health Plan.
24. Services in connection with Long -Term physical medicine and reha-
bilitative Therapy services (including Long -Term physical oroccupa-
tional Therapy).
25. Treatment for drug abuse and drug addiction (detoxification, treat-
ment of medical complications, determination of need, and referral to
specialized services are covered).
26. Services in connection with long -term speech and hearing therapy.
27. Prescription medications except as provided in this Section.
28. Routine foot care such as treatment for corns and callouses and the
cutting of toe nails unless approved by Health Plan.
29. All costs associated with the normal delivery of a newborn child
outside the Health Plan Service Area. Complications of pregnancy
for all Members are treated as any other illness.
30. Outpatient medical disposable /consumable supplies and deluxe
Durable Medical Equipment such as motor driven wheelchairs and
beds.
31. Any portion of the cost in excess of the Usual, Reasonable and
Customary Charges for an Emergency Care Out-of -Area Service.
32. Convenience charges for after -hour physician office visit (outside of
the normal office visit hours).
33. Conditions for which state or local law requires treatment in a state
or local governmental facility or for services performed in an institu-
tion owned or operated by the United States of America, when there
is no obligation that the Subscriber or the Family Dependent pay in
the absence of health care coverage.
34. To the extent a natural disaster, war, riot, civil insurrection, epidemic,
or any other Emergency Care or similar event not within Health Plan's
control results in the services, personnel, or financial resources of
Health Plan being unavailable to provide or arrange for the provision
of benefits or services otherwise available under this Contract.
Health Plan shall be required only to make a good -faith effort to
13. Such services as television, telephone, barber or beauty service,
guest service and similar incidental services and supplies which are
not Medically Necessary.
14. Mental Health Services which are (a) extended beyond the period
necessary for evaluation and diagnosis of the psychiatric portion of
leaming and behavioral disabilities or for mental retardation, or (b) for
marriage counseling not associated with Mental Illness, or (c) except
for evaluation and crisis intervention, those Mental Health Services
for psychiatric conditions which are determined by the Medical
Director to be unresponsive to Short-Term Therapy.
Chronic psychosis, intractable personality disorders, mental retarda-
tion, psychiatric therapy on court order as a condition of parole or
probation, hypnotherapy and chronic organic brain syndromes are
excluded, except that Mental Health Services required as a result of
an acute episode due to a chronic organic brain syndrome are
covered.
15. The services of registered nurses and licensed practical nurses with
the same legal residence as, or who are Members of, a family
including spouse, brothers, sisters, parents or children.
16. Health Services rendered by a provider who is a Member of the
family, including spouse, brothers, sisters, parents or children.
17. Physical, psychiatric, psychological examinations or testing, vacci-
nations, immunizations, treatments, or testing not otherwise covered
underthis Contract, when such services are for purposes of obtaining
or maintaining employment or insurance, or otherwise relating to
employment or insurance, or relating to judicial or administrative
proceedings or orders, or which are conducted for purposes of
medical research, or which are conducted 10 obtain or maintain a
license of any type, orwhich are conducted forthe purposes of school
physical exams.
18. Travel and transportation expenses.
19. Outpatient services (including Hospital emergency room services)
not provided by a Participating Primary Care Physician and all
associated expenses which may be obtained during normal physi-
cian office hours, unless Authorized in advance by Health Plan or in
the case of need for Emergency Care services as defined herein.
20. Prosthetic devices, medical equipment and appliances (except as
provided in this Section under D.,8.,c.), including air conditioners, air
filters, humidifiers, dehumidifiers, spas and the repair, replacement
or duplication thereof, even though prescribed by a physician.
42
TEXAS HEALTH PLANS, INC.
8303 MoPac, Suite 450
Austin, Texas 78759
Phone (512) 338 -6100
Group Contract /Certlftcate of Coverage
Texas Health Plans, Inc. (herein called Health Plan) hereby contracts with
the Enrolling Group to provide the Health Services set forth herein to
Members, subject to the exclusions, limitations, conditions and other terms
of this Contract including applicable amendments and riders.
This Contract is made in consideration of the Group Enrollment Agreement
and the Subscriber's enrollment application and payment of the required
Premiums as specified herein. Both the Group Enrollment Agreement and
the Subscriber's enrollment application are part of this Contract.
This Contract shall take effect on the date specified on the Group Enrollment
Agreement and will be continued in force by the timely payment of the
required Premiums when due, subject to termination of this Contract as
provided herein.
All coverage under this Contract shall begin and end at 12:01 a.m., Central
Standard Time.
This Contract is delivered in and govemed by the laws of the State of Texas.
SECTION I
DEFINITIONS
Alcohol Dependency Treatment Facility means a facility which provides a
program for the treatment of alcohol dependency pursuant to a written
treatment plan approved and monitored by a physician and which facility is
also: (1) affiliated with a hospital under a contractual agreement with an
established system for patient referral, or (2) accredited as such a facility by
the Joint Commission on Accreditation of Healthcare Organizations, or (3)
licensed as an alcohol treatment program by the Texas Commission on
Alcoholism, or (4) licensed, certified, or approved as an alcohol dependency
treatment program orcenterby any other state agency having legal authority
to so license, certify, or approve and is also an Approved Health Care
Facility.
Alcohol Dependency Treatment means those services and supplies cov-
ered under the Contract for the diagnosis and treatment of alcoholism.
3
Alcoholism means the disease which is classified as alcoholism in the
International Classification of Diseases of the U.S. Department of Health
and Human Services.
Approved Health Care Facility or Program means a facility or program
which is licensed, certified or otherwise authorized pursuant to the laws of
the State of Texas to provide health care and which is approved by Health
Plan or with whom Health Plan has contracted to provide the care described
in this Contract.
Authorized means that Health Plan, the Medical Director or his designee
has determined that the Health Services provided or to be provided are
Medically Necessary.
Calendar Year means January 1, 12:01 a.m. to January 1, 12:01 a.m. of
the following year.
Congenital Anomaly means a defective development or formation of a part
of the body which is determined by a Participating Physician to have been
present at the time of birth.
Contract means this Group Contract/Certificate of Coverage, Subscriber's
enrollment application, Group Enrollment Agreement and any applicable
amendments, addenda and/or riders attached hereto.
Contract Years and Contract Months are determined from the effective
date of this Contract.
Copayment Charge means the charge, in addition to the Premiums, which
the Member is required to pay for certain Health Services and medical
supplies provided under this Contract. The Member is responsible at the
time of service for the payment of any Copayment Charge directly to the
provider of the Health Services. The maximum amount of Copayment
Charge to be paid by a Member is 50 %of Health Plan's cost forthe provider's
services and shall be limited to 200% of the total annual Premiums required
to be paid for coverage under this Contract in any Calendar Year. It shall be
the responsibility of the Member to maintain a record of Copayment Charges
which have been paid by the Member and to inform Health Plan when the
maximum amount of those Copayment Charges reach such limit. In addi-
tion, it is the responsibility of the Member to maintain a record of Copayment
Charges which have been paid for the purpose of income tax. Health Plan
will not provide the Memberwith a record of Copayment Charges which have
been paid by the Member.
Covered Services means the Hospital Services and Professional Services
described in Section XI or any rider hereto and provided under the terms and
conditions of this Contract.
4
necessary to safeguard the health of a Member because of a specific,
non - dental physiological impairment.
2. Dental services in connection with the treatment of temporomandibu-
lar joint dysfunction (TMJ).
3. Custodial care or rest cures.
4. Cosmetic, medical, or surgical procedures except reconstructive
surgery necessary to repair a functional disorder as a result of
disease, Injury, or Congenital Anomaly. The exclusions to the extent
not Medically Necessary include: surgical excision or reformation of
any sagging skin on any part of the body, including but not limited to,
the eyelids, face, neck, abdomen, arms, legs, or buttocks; any
services performed in connection with the enlargement, reduction,
implantation or change in appearance in a portion of the body
including, but not limited to, the breasts, face, lips, jaw, chin, nose,
ears or genitals; hair transplantation; chemical face peels or abra-
sions of the skin; electrolysis depilation; or any other surgical or non-
surgical procedures which are primarily for cosmetic purposes.
5. In -vitro fertilization (unless provided by rider), intra- tatlopian transfer
treatment and embryo transplants.
6. Experimental medical, surgical or psychiatric procedures and phar-
macological regimes. As used herein, "experimental" means those
procedures and/or treatments which are not generally accepted by
the medical community. Health Plan reserves the right to change the
coverage with respect to experimental procedures, from time to time,
so as to add or delete certain medical, surgical or psychiatric
procedures or treatments or pharmacological regimes.
7. Organ transplants (except kidney and cornea transplants and liver
transplants in minors with biliary atresia).
8. Keratotomies, acupuncture, naturopathy, megavitamin therapy,
psycho- surgery, and nutritional based therapy for Alcoholism.
9. Elective abortions.
10. Circumcisions unless medically indicated.
11. Health Services in such circumstances in which referral services not
Authorized in writing in advance by Health Plan or not provided by or
under the direction of the Participating Primary Care Physician
except in an Emergency Care situation.
12. Vision training, eye exercises, orthoptics and radial keratotomy, eye
glasses and frames, contact lenses, hearing aids orthe fitting thereof.
41
rected or monitored by a Participating Primary Care
Physician, and Authorized in advance by Health
Plan. Such provision of these services must be
expected to result in significant improvement of a
Member's condition within a period of two months,
as determined by the Medical Director.
12. Family Planning Services
Family Planning Services shaft be available to the None
Members on a voluntary basis. These services shall
include but not be limited to:
a. Medical history, physical examination, related None
laboratory tests, information about the use of
contraceptives, and information about the pre-
vention of venereal disease.
b. Medical services connected with surgical sterili-
zation:
1. Vasectomy $75.00
2. Tubal Ligation $200.00
13. Health Education Services
Health Plan will organize, sponsor or conduct pro- None
grams in health education for the benefit of all
Members. Programs offered may include instruc-
tions in the appropriate use of Health Services,
information about the Health Services offered by
Health Plan and the generally accepted medical
standards for the use and frequency of such serv-
ices, and/or instructions on the methods each
Member can take to maintain his own health, such
as personal health care measures and nutritional
education and counseling.
E. General Exclusions. This Contract does not cover any of the following:
1. Dental surgery, treatment or care (including treatment of overbite or
underbite), or dental x -rays, supplies and appliances (including
occlusal splints) and all associated expenses arising out of such
dental surgery, treatment orcare (including hospitalizations), except
for Hospital, dental and physician services and supplies and anes-
thesiology services recommended by a Participating Primary Care
Physician and approved in writing in advance by Health Plan, as are
40
Copayment
Charge
Crisis Stabilization Unit means a 24 hour residential program that is usually
short-term in nature and that provides intensive supervision and highly
structured activities to persons who are demonstrating an acute demon-
strable psychiatric crisis of moderate to severe proportions.
Dentist means any Doctor of Dental Surgery, "D.D.S." or "D.D.M ", who is
duly licensed and qualifiedto provide dental surgery, treatment orcare under
the laws of the state or other jurisdiction in which treatment is received.
Durable Medical Equipment means Medically Necessary equipment which
is not disposable, which is not routinely available in a physician's office and
which is generally not useful to a person in the absence of illness or Injury.
Eligible Expenses are fee schedules for Health Services as established by
Health Plan and covered when Health Services are Medically Necessary
and Authorized by Health Plan as described herein.
Emergency Care means bona fide Emergency Care services provided after
the sudden onset of a medical condition manifesting itself by acute symp-
toms of sufficient severity, including severe pain, such that the absence of
immediate medical attention could reasonably be expected to result in: (1)
placing the patient's health in serious jeopardy; (2) serious impairment to
bodily functions; or (3) serious dysfunction of any bodily organ or part. Heart
attacks, poisonings, loss of consciousness or respiration, convulsions,
excessive uncontrolled bleeding and broken bones are examples of condi-
tions requiring Emergency Care.
Enrolling Group means the employer or party that has entered into a Group
Enrollment Agreement with Health Plan underwhich Health Plan will provide
or arrange Health Services for eligible Members of the Enrolling Group who
enroll hereunder.
Evidence of Good Health means Health Plan's medical information appli-
cation which is completed by applicant when applying for coverage at a time
other than the Open Enrollment Period and/or Initial Enrollment Period when
required by the Enrolling Group as stipulated in Section 11 herein and the
Group Enrollment Agreement.
Family Dependents means those Members of the Subscriber's family who
meet the eligibility requirements of this Contract set forth in Section II and
have been enrolled by the Subscriber.
Grace Period means a period of thirty (30) days beyond the date monthly
Premium payments are due during which period the monthly Premium
payments may be made to Health Plan without lapse of coverage under this
Contract.
5
Group Enrollment Agreement means the agreement between Health
Plan and the Enrolling Group which has been signed by both parties
whereby coverage is elected by the Enrolling Group for those Subscribers
and their Family Dependents enrolled hereunder.
Health Services means health care services or benefits provided for in this
Contract.
Health Plan means Texas Health Plans, Inc., a Texas corporation licensed
by the Texas State Board of Insurance under the Texas Health Maintenance
Organization Act, as amended, which will arrange for Members the health
care services that are set forth in the Schedule of Benefits, Section XI.
HMO means Health Maintenance Organization.
Home Health Agency means a tacility or program that is licensed, certified
or otherwise authorized pursuant to the laws of the State of Texas as a Home
Health Agency and is approved by Health Plan and Medicare, with whom
Health Plan has contracted to provide certain Health Services covered
under this Contract.
Hospital means an acute care facility operated pursuant to state laws
which (1) is accredited as a hospital by the Joint Commission on Accredita-
tion of Healthcare Organizations or by the Medicare program, (2) is primarily
engaged in providing, for compensation from its patients, diagnostic and
surgical facilities for the care and treatment of injured or sick individuals by
or under the supervision of a staff of physicians, (3) has 24 -hour nursing
services by registered nurses (R.N.), and (4) is not primarily a place for rest
or custodial care, nursing home, convalescent home or similar institution.
Hospital Services (except as limited or excluded herein) means those acute -
care services furnished and billed by a Hospital and/or Skilled Nursing
Facility which are Authorized by Health Plan as set forth in Section XI,
Schedule of Benefits.
Individual Treatment Plan means a treatment plan with specific attainable
goals and objectives appropriate to both the patient and the treatment
modality of the treatment program.
Initial Enrollment Period means the period of time specified in the Group
Enrollment Agreement during which a Subscriber may make application for
enrollment in Health Plan for self and eligible dependents without providing
Evidence of Good Health satisfactory to Health Plan as specified in this
Contract.
Injury means bodily damage including all related conditions and recurrent
symptoms.
6
(1) Braces, including necessary adjustment to
shoes to accommodate braces (dental
braces are excluded);
(2) Oxygen and the rental of equipment for the
administration of oxygen;
(3) Wheelchairs;
(4) A hospital -type bed.
d. Mechanical equipment necessary for treatment None
of chronic or acute respiratory failure (except
that air conditioners, humidifiers, dehumidifiers
and other personal comfort items are excluded).
9. Physical Therapy Services
Short-Term Therapy services performed or ren- None
dered on an outpatient basis at a Participating
Hospital or other Approved Health Care Facility or
Program or by a Participating Provider when di-
rected and monitored by a Participating Primary
Care Physician, and Authorized in advance by
Health Plan. Such provision of these services must
be expected to result in the significant improvement
of a Member's condition within a period of two
months, as determined by the Medical Director.
10. Occupational Therapy Services
Short-Term Therapy services performed or ren- None
dered on an outpatient basis at a Participating
Hospital or other Approved Health Care Facility or
Program or by a Participating Primary Care Physi-
cian, and Authorized in advance by Health Plan.
Such provision of these services must be expected
to result in the significant improvement of a Member's
condition within a period of two months, as deter-
mined by the Medical Director.
11. Speech and Hearing Therapy Services
Short-Term Therapy services performed or ren- None
dered on an outpatient basis at a Participating
Hospital or other Approved Health Care Facility or
Program or by a Participating Provider when di-
39
Copayment
Charge
sician at the physician's off ice or other Approved
Health Care Facility or Program.
b. Inpatient services and supplies on a Semipri-
vate Accommodation basis for drug abuse de-
toxification for that period of time deemed Medi-
cally Necessary by a Participating Physician, in
an Approved Health Care Facility or Program.
c. Physician services to determine the need for
and in appropriate cases to obtain a referral to
Non - Participating Provider are covered. The
services provided by that Non - Participating
Provider are not covered.
8. Miscellaneous Health Services
a. Services and supplies provided by a Home None
Health Agency, either at home orinthe Hospital,
when deemed Medically Necessary by the
Participating Physician and Authorized in ad-
vance by Health Plan.
b. Prosthetics:
If provided by or under the direction of a Partici- None
pating Physician, when Authorized In advance
by Health Plan, for use outside a Hospital,
Skilled Nursing Facility, orotherApproved Health
Care Facility or Program, initial purchase of
artificial limbs, artificial eyes, breast prostheses,
and other Authorized prostheses made neces-
sary as a result of Injury or Sickness (except that
repair, replacement and duplicates are not
covered).
c. Durable Medical Equipment:
To the extent that the maximum benefit cover- None
age under this Contract payable per Contract
Year per Member does not exceed $500.00,
rental or purchase at Health Plan's option of the
following Durable Medical Equipment (except
that repair, replacement and duplicates are not
covered):
38
Copayment
Charge
20% of
Eligible
Expenses
for inpatient
services
$20 per
visit
Long -Term means any therapy beyond the two (2) months as defined in
the Schedule of Benefits.
Maternity means ante /postpartum care, childbirth, early involuntary
termination of pregnancy, or any complication arising therefrom for a
Member.
Medical Director means a physician designated by Health Plan to moni-
tor and review the provision of Covered Services to Members.
Medically Necessary means the use of services or supplies as provided by
a Hospital, Skilled Nursing Facility, physician or other provider required to
identify, treat or avoid an illness or Injury and which, as determined by a
Participating Physician and the Medical Director or its utilization review com-
mittee, are:
(1) Consistent with the symptoms or diagnosis and treatment of the
condition, disease, ailment or Injury;
(2) Appropriate with regard to standards of good medical practice;
(3)
Not solely for the convenience of the Member, his or her Participating
Physician, Hospital, or other health care provider; and
(4) The most appropriate supply or level of service which can be safely
provided to the Member. When specifically applied to an inpatient, it
further means that the medical symptom or condition requires that the
diagnosis or treatment cannot be safely provided to the Member as an
outpatient.
Medicare means the insurance program established by Title XVIII, United
States Social Security Act, as originally enacted by the Social Security
Amendments of 1965, or as later amended.
Medicare Subscriber means an employee, retiree, spouse or dependent
child who (1) meets the eligibility requirements of the Enrolling Group: and
(2) is enrolled in both parts A and B of Medicare.
Member means either the Subscriber or his or her eligible Family De-
pendent for whom Premium payment has been made to Health Plan.
Mental Health Services means those services and supplies covered under
this Contract for the diagnosis and treatment of Mental Illness.
Mental Illness means physical or mental condition having an emotional or
psychological origin.
Non - Participating Provider means any provider that is not a Participating
Provider of Health Plan.
Open Enrollment Period means a period of time subsequent to the Initial
Enrollment Period as specified in the application of the Enrolling Group and
determined periodically by Health Plan and the Enrolling Group, during
which Subscribers may enroll themselves and eligible Family Dependents
under this Contract without providing Evidence of Good Health satisfactory
to Health Plan.
Out -of -Area Services means those services provided outside Health
Plan's Service Area. Covered Out -of -Area Services are limited to Emer-
gency Care services and services that are arranged or Authorized by the
Medical Director.
Participating Hospital means a Hospital which has contracted with Health
Plan to provide certain Health Services to Members.
Participating Pharmacy means a pharmacy which has contracted with
Health Plan to provide pharmacy services to Members.
Participating Physician means a physician who, at the time of providing or
arranging for services to a Member, has contracted with or on whose behalf
a contract has been entered into with Health Plan to provide Professional
Services to Members.
Participating Primary Care Physician means a Participating Physician
(general practitioner, family practitioner, internist, or pediatrician) who pro-
vides primary care services to Members and is responsible for referrals of
Members to Participating Referral Consultant Physicians or other Participat-
ing Providers.
Participating Provider means a Participating Hospital, Participating Re-
ferral Consultant Physician, Participating Primary Care Physician, Psychi-
atric Primary Provider, Alcohol Dependency Treatment Facility, Home
Health Agency and any other health service provider who/which has been
approved by Health Plan or with whom Health Plan has contracted to pro-
vide Health Services to Members. A list of Participating Providers and their
locations is available to each Subscriber upon request. Such list shall be
revised from time to time as Health Plan deems necessary. A Participating
Provider's contract may terminate and a Member may be required to utilize
another Participating Provider.
Participating Referral Consultant Physician means a Participating Physi-
cian who is responsible for providing certain physician services upon referral
by a Participating Primary Care Physician and pre - authorization by Health
Plan.
Premium or Premiums means a sum or sums of monies paid monthly to
Health Plan by the Enrolling Group in order for the Members to receive
services and benefits covered by this Contract.
8
determining policy benefits and benefit maximums.
Treatment providedthrough Crisis Stabilization Units
shall be reimbursed as a facility licensed or certified
by the Texas Department of Mental Health and
Mental Retardation.
Copayment
Charge
5. Medical and Hospital Services Related to Recon-
structive Surgery When Authorized by Health Plan
'Reconstructive surgery and all other required Medi- None
cally Necessary services provided by or under the
direction of a Participating Physician in a physician's
office, a Participating Hospital or other Approved
Health Care Facility or Program only when the
reconstructive surgery is necessary to:
a. Correct Congenital Anomalies when required to
restore normal physiological functioning; or
b. Restore normal physiological functioning tolIow-
ing an accident, Injury, disease or surgery.
6. Ambulance Service
a. A Member is entitled to Medically Necessary None
ambulance service within the Service Area, pro-
vided such ambulance service is Authorized by
the Medical Director or his designee, or the use
of such ambu -lance service is determined nec-
essary for Emergency Care.
b. A Member is entitled to ambulance service util- None
ized while outside the Service Area to transport
the Member to the nearest health care facility
when Authorized by the Medical Director or his
designee, or the use of ambulance service is
determined by Health Plan to have been re-
quired because of Emergency Care.
7. Drug Abuse and Drug Addiction Detoxification
The following Health Services are covered when
provided and Authorized in advance by Health Plan
and its Psychiatric Primary Provider:
a. Outpatient diagnosis and medical treatment for $20 per
drug abuse detoxification and services provided visit
by or under the direction of a Participating Phy-
37
Benefits may be used only in situations in which
the Member has a serious Mental Illness which
substantially impairs the person's thought, per-
ception of reality, emotional process orjudgment
or grossly impairs behavior as manifested by
recent disturbed behavior, and which would oth-
erwise necessitate confinement in a Hospital if
such care and treatment were not available
through a Crisis Stabilization Unit or Residential
Treatment Center for children and adolescents.
Coverage under this Section Xl.,4.,d., is limited
to sixty (60) days maximum per Contract Year.
* A combination of benefits for the above- described
services and inpatient services shall not exceed the
maximum benefit as stated for inpatient Mental
Health Services Subparagraph b. above.
The services rendered pursuant to Subparagraph c.
and d. above for which benefits are to be paid must
be based on an Individual Treatment Plan. The
benefits are subject to the same benefit maximums,
durational limits, and Copayment Charges as set
forth in Subparagraph 4. above.
Providers of services for which benefits are to be
paid must be licensed by the appropriate state
agency or board to provide those services.
Treatment in a Residential Treatment Center for
children and adolescents shall be determined as if it
were inpatient care and treatment in a Hospital, and
each two days of treatment in a Residential Treat-
ment Center for children and adolescents will be
considered equal to one day of treatment of mental
or emotional illness or disorder in a Hospital or
inpatient program, necessary care and for the pur-
pose of determining policy benefits and benefit
maximums.Treatment provided through Crisis Sta-
bilization Units shall be determined as if it were
inpatient care and treatment in a Hospital, and two
days in a Crisis Stabilization Unit are considered
equal to one day of treatment for mental or emo-
tional illness or disorder in a Hospital or inpatient
program, necessary care and for the purpose of
36
Copayment
Charge
Professional Services (except as limited or excluded herein) means those
services performed by physicians or health professionals which are Medi-
cally Necessary, generally recognized as appropriate care, within the
Service Area, and set forth in Section XI, Schedule of Benefits. All such
services must be performed, prescribed, directed, or coordinated by a
Participating Physician and to the extent required by Health Plan, Author-
ized by Health Plan.
Psychiatric Primary Provider means the organization or entity with whom
Health Plan contracts and authorizes to evaluate, diagnose, refer and/or
provide Mental Health Services and Drug Abuse and Drug Addiction
Detoxification Services, as described herein.
Residential Treatment Center for children and adolescents means a
child care institution that provides residential care and treatment for emo-
tionally disturbed children and adolescents and that is accredited as a
Residential Treatment Center by the Council on Accreditation, the Joint
Commission on Accreditation of Healthcare Organizations, or the American
Association of Psychiatric Organizations, or the American Association of
Psychiatric Services for Children. The Residential Treatment Center or
Crisis Stabilization Unit must be located within Health Plan's Service Area.
Semiprivate Accommodations means a two or more bed room in a Hospi-
tal, Skilled Nursing Facility or other Approved Health Care Facility or Pro-
gram. The semiprivate bed room charge is the maximum allowable toward
private room accommodations. Charges for a private room will be paid by
Health Plan only if use of a private room is deemed Medically Necessary.
Service Area means a geographic area designated by Health Plan in which
the Member resides and in which Covered Services are provided. The
Service Area for Members residing in the Central Texas Division is com-
prised of Bastrop, Burnet, Caldwell, Hays, Lee, Travis and Williamson
counties, Texas.
Short -Term Therapy means a Participating Physician has determined that
provision of therapy will result in a significant improvement in the condition
within a period of two (2) months from the start of treatment for said condition.
Benefits payable for this therapy are limited to a maximum period of two (2)
months from the time of onset for each Injury or diagnosis.
Sickness means physical illness or disease, but does not include Mental
Illness.
Skilled Nursing Facility means an extended care facility which is licensed
as a Skilled Nursing Facility and operated in accordance with the laws of the
State of Texas, approved by Medicare and has a contract with Health Plan
to provide the care described in this Contract.
9
Sound Natural Teeth means teeth that are free of active or chronic clinical
decay, have at least 50% bony support, are functional in the arch, and have
not been excessively weakened by multiple dental procedures.
Subscriber means any employee or Member of the Enrolling Group who (1)
is eligible on his or her own behalf and not by virtue of being an eligible
dependent to participate in the health benefits provided under this Contract;
(2) resides in the Service Area; (3) meets the group's eligibility requirements
specified in the group's application and other provisions in this Contract; and
(4) is enrolled for coverage under this Contract.
Usual, Customary and Reasonable Charge means the amount charged or
the amount Health Plan determines to be the prevailing charge, whichever
is less, for a particular health service in the geographic area in which it is
performed.
SECTION II
ELIGIBILITY AND ENROLLMENT
A. Eligibility
1. Subscriber. To be eligible to enroll as a Subscriber, a person must
reside in the Service Area and be:
a. An employee of the Enrolling Group who is entitled on his own
behalf to participate in the medical and hospital benefits arranged
by Enrolling Group, including satisfaction of any probationary or
wafting period established by Enrolling Group and other eligibility
criteria established by Enrolling Group; and/or
b. Entitled to coverage under a trust agreement or employment
contract with the Enrolling Group; and/or
c. A retiree who has extended coverage with the Enrolling Group.
2. Eligible Family Dependents. To be eligible to enroll as a Family
Member, a person must be listed on the enrollment application form
completed by the Subscriber, meet all Family Dependent eligibility
criteria established by the Enrolling Group, reside in the Service Area
and be:
a. The Subscriber's present lawful spouse (if common law spouse,
Subscriber shall provide evidence satisfactory to Health Plan).
b. Any unmarried dependent child (including step - child, legally
adopted child or natural child of eitherSubscriberorthe Subscriber's
spouse), who is under age nineteen (19), who lives in the Service
Area and resides in the household of the Subscriber orSubscriber's
10
Health Care Facility or Program unless
specifically excluded in this Section,
Paragraph E. "General Exclusions."
3. Maternity Services
Authorized Maternity related medical, Hospital and None
covered Health Services, deemed Medically Neces-
sary by the Participating Physician shall be provided
as any other illness and/or Injury.
4. Mental Health Services
The following Mental Health Services are covered
when Authorized in advance by Health Plan and its
Psychiatric Primary Provider:
a. Outpatient mental health evaluations and treat- $20 per
ment for mental health conditions which are not visit
chronic or organic in nature and which are re-
sponsive to short-term treatment as determined
by the Medical Director or his designee, and for
crises intervention. Coverage under this Section
XI.,4.,a., is limited to twenty (20) visits per Con-
tract Year. A visit is not to exceed one hour in
duration.
b. Inpatient services and supplies on a Semiprivate
Accommodation basis for that period of time
deemed Medically Necessary in a Participating
Hospital or other Approved Health Care Facility
or Program for conditions listed in Section
XI.,D.,4.,a. Coverage underthis Section XI.,4.,b.,
is limited to thirty (30) days per Contract Year.
c. Services and supplies provided in an approved
psychiatric day treatment facility under the direc-
tion of a Participating Physician for that period of
time deemed Medically Necessary. Each full day
of services shall count as one -half of one day
inpatient Mental Health Services. Coverage under
this Section XI.,4.,c., is limited to sixty (60) days
per Contract Year.
d. Services and supplies for that period of time
deemed Medically Necessary in a Residential
Treatment Center or Crisis Stabilization Unit.
35
Copayment
Charge
20% of
Eligible
Expenses
* 20% of
Eligible
Expenses
20% of
Eligible
Expenses
nursing care are included only when Medically
Necessary and pre - Authorized by the Medical
Director or his designee.
b. Outpatient Services and Supplies.
(1) Emergency Care Services.
(a) Emergency Care services provided on
an outpatient basis by a Participating
Hospital or other Approved Health Care
Facility or Program.
(b) Outpatient prescription medications pro- None
vided by a Participating Hospital or other
Approved Health Care Facility in con-
junction with Hospital emergency serv-
ices for the same condition, not to ex-
ceed a 24 -hour supply.
(2) Non - Emergency Services.
(a) Authorized services and supplies for pre- None
scheduled outpatient surgery provided
under the direction of a Participating
Physician at a Participating Hospital or
other Approved Health Care Facility or
Program.
(b) Authorized diagnostic tests provided None
under the direction of a Participating
Physician at a Participating Hospital or
other Approved Health Care Facility or
Program.
(c) Authorized outpatient infertility services None
and related supplies provided at a Par-
ticipating Hospital or other Approved
34
Copayment
Charge
$25 per visit,
except when
admission for
the same condi-
tion occurs
within 24 hours.
However, the
total amount of
Copayment
Charges
charged shall
not exceed 50%
of the cost of
any single visit.
spouse, who is chiefly dependent upon the Subscriber for sup-
port, and who is eligible to be claimed as a dependent in the most
recent federal income tax retum of the Subscriber, according to
the United States Internal Revenue Code and regulations. A
Family Dependent shall also include a child for whom Subscriber
or Subscriber's spouse is a court appointed legal guardian,
provided proof of such guardianship is submitted with the pro-
spective Family Dependent's enrollment application and pro-
vided the above criteria are satisfied.
c. Any unmarried dependent child who is between nineteen (19) and
twenty -three (23) years of age provided the child is a full -time
student in an accredited educational institution and is eligible to
be claimed as a dependent on the Subscriber's federal income
tax return. Coverage outside the Service Area, however, Is
limited to Emergency Care services as described in Section
Xl.,C.,2.
Upon the request of Health Plan, the Subscriber agrees to provide
proof of full -time student status (a minimum of twelve (12) credit
hours per semester is required). The Subscriber must notify
Health Plan when a Family Dependent is no longer a full -time
student.
d. Any unmarried child who is and continues to be both (1) incapable
of self- sustaining employment by reason of mental or physical
handicap, and (2) chiefly dependent upon the Subscriber for
economic support and maintenance, provided proof of such
incapacity and dependency is fumished to Health Plan by the
Subscriber within thirty -one (31) days before the child's attain-
ment of the applicable limiting age and subsequently as may be
required by Health Plan, but not more frequently than annually
following the child's attainment of the applicable limiting age.
Health Plan's determination of eligibility shall be conclusive,
subject to the grievance procedures described herein.
Any such unmarried child, as defined in this Subsection, must be
a Family Member enrolled hereunder prior to attaining the appli-
cable limiting age of nineteen (19) or 11 a full -time student (as
described in Section II) to the age of twenty-three (23).
e. A foster child, a child who has been placed in the Subscriber's
home, and a grandchild of Subscriber or Subscriber's spouse
shall not be eligible for enrollment under this Contract unless such
child otherwise qualifies as a Family Dependent under Section
II.,A.,2.,b., Section II.,A.,2.,c., and Section II.,A.,2.,d., above.
11
3. If the coverage of an eligible Family Dependent, as described in
Section II., A.,2., ceases under another group health plan due to the
termination of employment, the Family Dependent will be eligible for
enrollment in Health Plan within the thirty (30) day period from the ter-
mination date of the prior group health plan coverage provided that
the Evidence of Good Health form has been submitted to Health Plan
as required by the Enrolling Group.
4. Coverage will be provided under this Contract for the first thirty -one
(31) days from the date of birth for a newbom child of the Subscriber
or Subscriber's spouse. Coverage beyond the first thirty -one (31)
days is contingent upon the Subscriber enrolling the newborn as a
Family Member and paying all applicable Premiums retroactive to the
date of birth.
B. Enrollment
1. Initial Enrollment Period. During the Initial Enrollment Period, each
eligible employee of the Enrolling Group shall be entitled to apply for
coverage as a Subscriber. Eligible Family Dependents must also be
listed on the enrollment application provided or approved by Health
Plan. No Evidence of Good Health, medical history, or physical
examination shall be required during this period.
2. Newly Eligible Employees. Each new employee of the Enrolling
Group who becomes eligible afterthe Enrolling Group's Initial Enroll-
ment Period shall be permitted to apply without Evidence of Good
Health, medical history or physical examination for coverage for
himself or herself and eligible Family Dependents, within thirty -one
(31) days of becoming eligible, subject to the enrollment regulations
determined by the Enrolling Group in accordance with the terms of
the Group Enrollment Agreement.
3. Newly Eligible Family Dependents. Any person attaining eligibility as
a Family Dependent may be enrolled by the Subscriber. The Sub-
scriber must complete and submit to Health Plan a signed Health
Plan change application request form within thirty -one (31) days of
the Family Dependent's eligibility date. No Evidence of Good Health,
medical history, or physical examination shall be required.
4. Open Enrollment Period. An Open Enrollment Period shall be held at
least annually at which time eligible employees and their eligible
Family Dependents may enroll as Members under this Contract
unless ineligible under Subsection II.,E. below. No Evidence of Good
Health shall be required during this period.
5. Limitation. Persons initially or newly eligible for enrollment who do not
enroll within thirty -one (31) days of becoming eligible may only be
12
Copayment
Charge
d. Authorized infertility services for the diagnosis None
and treatment of infertility except as excluded in
Section XI.,E.
e. Authorized allergy testing and services. None
f. Second surgical opinion from a Participating None
Referral Consultant Physician when requested
by Health Plan.
2. Hospital and related services and services of an
Alcohol Dependency Treatment Facility which are
Participating Providers, when referred by a Partici-
pating Primary Care Physician or Health Plan's
Psychiatric Primary Provider, except for the Hospi-
tal Services identified in this Section, D.4., 5., 7., 8.,
and "General Exclusions ".
a.
Inpatient Services.
When Authorized by Health Plan, Medically Nec-
essary inpatient Hospital Services wilt be ar-
ranged by a Participating Primary Care Physi -,
cian or his designee and rendered by a Partici-
pating Hospital. Services shall include semipri-
vate room and board; care and services in an
intensive care unit when Medically Necessary;
administered drugs, medications, biologicals,
fluids and chemo- therapy; special diets; dress-
ings and casts; general nursing care; use of
operating room and related facilities; blood, blood
plasma and the administration of blood transfu-
sions; x -ray, laboratory and other diagnostic
services; anesthesia and oxygen services; Short-
Term Therapy for rehabilitation services and
physical therapy, which in the judgment of Health
Plan Medical Director or his designee can be
expected to result in the significant improvement
of a condition within a period of two months from
the date of first treatment and cannot be pro-
vided on an outpatient basis; inhalation therapy;
radiation therapy; and such other Medically
Necessary services customarily provided in acute
care Hospitals. Private room and special duty
33
None
does not permit such notification within the prescribed time, he
must make the notification as soon as it is reasonably possible to
do so.
b. The claim for reimbursement must be made in writing within sixty
(60) clays of the onset of the need for Emergency Care for which
payment is requested, accompanied by invoices or other appro-
priate evidence of payment which indicate the diagnosis, type of
treatment rendered, date of service, name and address of pro-
vider, charge forcare, receipt and name of patient and Health Plan
identification number. Health Plan is not liable for reimbursement
of claim if claim is received by Health Plan more than sixty (60)
days from either the date of service or receipt of the bill by the
Member, whichever is later.
D. Benefits. Health Plan will provide the following Medically Necessary
Health Services, subject to the terms and conditions as stated in A of this
Section and in the Group Contract/Certificate of Coverage.
Copayment
Charge
1. Medical Services except for the Medical Services
identified in this Section under D.2., 4., 7., 8., and
"General Exclusions ".
a. Services provided by or under the direction of the None
designated Participating Primary Care Physi-
cian in the physician's office including the follow-
ing: preventive medical care, voluntary family
planning, well child care from birth, periodic
health evaluations, vision screening, speech
screening, immunizations except for allergy (see
Section XI.,D.,1..e.), ear examinations to deter-
mine the need for hearing correction, and Mater-
nity care (see Section XI.,D.,3.).
b. Authorized services and supplies ordered by None
and provided by or under the direction of a
Participating Referral Consultant Physician in
the physician's office.
c. Authorized physician services and other surgi- None
cal and medical care provided by or under the
direction of a Participating Physician in a Partici-
pating Hospital, Skilled Nursing Facility or other
Approved Health Care Facility or Program.
32
enrolled during a subsequent Open Enrollment Period except for
those persons who meet the requirements in Section II.,A.,4.
C. Delivery of Documents. Health Plan will provide to each Subscriber upon
enrollment a Group Contract/Certificate of Coverage and an identifica-
tion card.
D. Notice of Ineligibility. It shall be the Subscriber's responsibility to notify
Health Plan of any changes which will affect his or her eligibility or that
of Family Dependents for services or benefits under this Contract.
E. Specific Causes for Ineligibility. A person will not be entitled to enroll as
a Subscriber or a Family Dependent if:
1. The person was previously a Member of Health Plan and his
membership was terminated for cause as described in Section
VII.,A.,1. through 5.
2. The person was part of an Enrolling Group which had unpaid financial
obligations to Health Plan arising from prior Health Plan Membership.
F. Rules of Eligibility. No eligible person will be refused enrollment or re-
enrollment by Health Plan because of his health status, his age, his
requirements for Health Services, or the existence on the effective date
of coverage under this Contract of a pre- existing physical or mental
condition, including pregnancy. However, no person is eligible to re-
enroll hereunder who has had coverage terminated under Section
VII.,A.,1. through 5.
G. Disclosure. Each Member agrees to disclose to Health Plan at the time
of enrollment, at the time of receipt of services and benefits, and from
time to time as requested by Health Plan the existence of other group
insurance coverage, the identity of the carrier, and the group through
whom provided.
SECTION III
EFFECTIVE DATE OF COVERAGE AND SELECTION OF A
PARTICIPATING PRIMARY CARE PHYSICIAN
A. Effective Date of Coverage. Subject to the payment of applicable
Premium payments by the Enrolling Group for the individual, Health
Plan's receipt of an application from or on behaf of each prospective
Member, and the provisions of this Contract, coverage under this
Contract shall become effective on the later of: (1) the date this Contract
takes effect, (2) on the f irst day of the first month following the conclusion
of the Initial Enrollment Period, or (3) unless otherwise specified in the
Group Enrollment Agreement, as follows:
13
1. When a person makes written application and Health Plan receives
such application after the date of coverage would have otherwise
been effective, coverage shall take effect on the first day of the first
Contract Month following the date of approval by Health Plan of such
Evidence of Good Health as it may require.
2. Coverage shall become effective at birth for newborn children tor
thirty-one (31) days, and continues in effect thereafter if the newborn
is eligible and enrolled by the Subscriber within thirty-one (31) days
of the newbom's birth and 1 Premiums are paid.
3. Except as otherwise agreed to by the Enrolling Group and Health
Plan, when a person makes written application for Membership
during the Open Enrollment Period, coverage will be effective on the
first day of the next calendar month following the date of the Open
Enrollment Period, or as otherwise agreed to by Health Plan and
Enrolling Group.
B. Selection of Participating Primary Care Physician
1. Members must choose (or have chosen on their behalf) a Participat-
ing Primary Care Physician and identify these choices on Health
Plan's enrollment application at the time of enrollment, and on Health
Plan's change application at the time any such Member's Participat-
ing Primary Care Physician ceases to be a Participating Provider. If
the Member does not select a Participating Primary Care Physician
on the enrollment application and notify Health Plan of their selection
within thirty (30) days of the effective date of coverage, Health Plan
will assign a Participating Primary Care Physician for the Member.
Health Plan will maintain and provide to the Subscribers upon
request a list of Participating Primary Care Physicians who will accept
new Subscribers.
2. Members shall be entitled to Covered Services provided by or
arranged by the Member's Participating Primary Care Physician and
Authorized by Health Plan in accordance with their applicable Group
Contract/Certificate of Coverage.
3. Afterthe Member designates a Participating Primary Care Physician,
this selection may not be changed by the Member except by complet-
ing Health Plan's change application request form and obtaining
authorization from Health Plan. Upon Health Plan approval, the
Participating Primary Care Physician selection will become effective
on the first day of the following month.
4. A Member's Participating Primary Care Physician may only be
changed by a Member a total of two (2) times per Contract Year.
14
Primary Care Physician or, upon authorization by Health Plan, at a
Participating Hospital emergency room.
Emergency Care services obtained through Non - Participating Physi-
cians and non- Participating Hospitals are covered provided the
incident requiring care constitutes the need for Emergency Care as
defined in this Contract. Health Plan will pay for, or reimburse
Members for, costs incurred for Covered Services, subject to the
payment and reimbursement provisions set out in Section IV of this
Contract.
Coverage for treatment for Emergencies within the Service Area
rendered by Non - Participating Providers is limited to the care re-
quired before the Member can, without medically harmful or injurious
consequences, be treated by a Participating Physician or a Participat-
ing Hospital.
2. Outside the Service Area. Emergency Care services provided out-
side the Service Area are covered only if the Member's health would
have been jeopardized by returning to the Service Area to receive
treatment and provided that the need for services could not have been
anticipated before departure. The Member is responsible to pay all
applicable Copayment Charges as noted in this Contract at the time
the Out -of -Area Service is rendered.
Coverage for treatment of Emergencies outside the Service Area is
limited to the care required before the Member can, without medically
harmful or injurious consequences, return to the Service Area or be
treated by a Participating Physician or a Participating Hospital and
provided that the need for services could not have been anticipated
before departure. Other continuing or follow -up treatment shall be
provided only within the Service Area.
3. Reimbursement. Payment or reimbursement for Emergency Care
services (see Section IV fora complete description of reimbursement
requirements and conditions) provided by physicians, Hospitals, or
health professionals that have not contracted with Health Plan to
provide services, whether inside or outside of the Service Area, will
be at the lesser of actual costs to the Member or at Health Plan's fee
schedule for comparable services, subject to the Copayment Charges
and exclusions set out in this Contract (Member will be responsible for
balance of charges), as well as the following additional conditions:
a. The Member must notify Health Plan of the service arrangements
within forty -eight (48) hours after the onset of the need for
Emergency Care being rendered and receive authorization for
continued services if they are indicated. If the physical condition
31
4. When the Member requires care by another physician, Hospital,
Alcohol Dependency Treatment Center, or provider, such Health
Services must be requested and recommended to Health Plan by the
Participating Primary Care Physician and Authorized in writing in
advance by Health Plan and are subject to all the terms, conditions,
limitations, and exclusions of this Contract.
The Participating Primary Care Physician will normally make Author-
ized referrals only to Participating Physicians, Participating Hospitals,
Alcohol Dependency Treatment Centers and other Participating
Providers.
B. Referral Health Services Rendered by Non - Participating Providers.
1. In the event that Medically Necessary Health Services cannot be
provided by or through Participating Providers, a Member shall be
entitled to coverage for Eligible Expenses for Medically Necessary
Health Services delivered by Non - Participating Providers, subject to
the terms and conditions of this Section.
2. Such Health Services must be requested of and recommended to
Health Plan by a Participating Primary Care Physician and Authorized
in writing in advance by Health Plan, and are subject to all the terms,
conditions, limitations, and exclusions of this Contract.
3. It is the responsibility of each Member to obtain the required written
approval(s) from Health Plan prior to receiving services from Non -
Participating Providers, Including Hospitals.
Health Plan will mail the Member a written authorization form as soon
as the requested Health Service is approved by Health Plan. Upon
receiving the written authorization form, the Member should then
schedule the appointment with the provider and take the authorization
form to the provider at the time the service is rendered.
Without the required written approval(s) of Health Plan, the Member
will be responsible for all associated costs. Failure of the Participating
Provider to obtain the necessary prior written Health Plan approval(s)
will in no way excuse the responsibility of the Member to obtain Health
Plan's written approval(s), except when it is impossible for the
Member to do so before seeking Emergency Care services from or
through Non - Participating Providers.
C. Emergency Care Services
1. Inside the Service Area. In the case of need for Emergency Care (as
defined in Section I) inside the Service Area, the Member is required
10 obtain Emergency Care services fromthe designated Participating
30
SECTION IV
PROCEDURES FOR REIMBURSEMENT OF ELIGIBLE EXPENSES
INCURRED WITH NON - PARTICIPATING PROVIDERS
A. Notice of Claim. Written notice of Injury, Sickness, Maternity, Mental
Illness or any other condition for which individual claim may be made
must be sent to Health Plan within sixty (60) days after the date any
medical service or supplies were rendered for which Health Plan is liable
hereunder.
B. Payment of Claim. Claims for Covered Services will be paid within a
reasonable amount of time of written receipt by Health Plan. Benefits
under this Contract will be paid to the Subscriber unless paid by Health
Plan to the Non - Participating Provider.
C. Legal Action. No action at law or in equity shall be brought to recover
under this Contract prior to the expiration of sixty (60) days after proof of
loss has been filed in accordance with the requirements of this Contract,
nor shall such action be brought at all unless brought within three (3)
years f rom the expiration of the time within which proof of loss is required
by this Contract.
SECTION V
COORDINATION OF BENEFITS; SUBROGATION
A. Coordination of Benefits (COB). All the benefits provided under this
Contract are subject to these provisions. In the case of duplicate
coverage, Health Plan may recover from the Member or other group
insurance program proceeds consisting of benefits payable to, or on
behalf of, the Member respecting the same Covered Services, up to the
amount of Health Plan's cost or obligation to the extent to which Health
Plan is entitled to recover underthis Contract for such Covered Services.
B. Definitions. The following definitions apply to this Section V.
1. A "Plan" is any group insurance coverage, no -fault automobile insur-
ance coverage, prepayment plan, coverage under union welfare
plan, other plan growing out of employer/employee relationship, and
any other statutory plan.
2. "Allowable Expense" means any usual, necessary, reasonable and
customary item of expense at least a portion of which is covered
under at least one of the Plans covering the person for whom claim
is made. When a Plan provides benefits in the form of services rather
than cash payments, the reasonable cash value of each service
rendered shall be deemed to be both an Allowable Expense and a
benefit paid.
15
C. Non - Duplication.
1. Worker's Compensation. The benefits under this Contract are not
designed to duplicate any benefit to which the Member is entitled
under worker's compensation insurance or laws. Charges for Health
Services arising out of job related injuries are not covered under this
Contract. In the event Health Services are provided, all sums payable
under worker's compensation insurance or laws shall be payable to,
and retained by, Health Plan. Each Member shall complete and
submit to Health Plan such consents, releases, assignments, and
other documents reasonably requested by Health Plan in order to
obtain or assure such reimbursement.
2. Other Plans. If any benefits to which a Member is entitled under this
Contract are also covered by any other Plan, the payable benefits
shall be coordinated with the benefits that are available to the
Member under such other Plan, whether or not a claim is made for the
same.
D. Order of Benefit Determination. The order of benefit determination
between this Contract and any other Plan covering the Member on
whose behalf a claim it made is established as follows:
1. Whenever one Plan does not contain a coordination of benefits
provision, that Plan must be primary; the primary Plan must pay its
benefits before the secondary Plan pays.
2. When two or more Plans contain coordination of benefits clauses, the
Plan that pays first is the primary Plan. The Plan that pays additional
benefits for Allowable Expenses not covered by the primary carrier,
but not to exceed 100°/ of total Allowable Expenses, is the secondary
Plan. The sequence of payments is as follows:
a. The Plan covering the patient as an employee pays before the
Plan covering the patient as a dependent.
b. The benefits of a Plan which covers the person on whose ex-
penses claim is based as a dependent of a person whose date of
birth, excluding year of birth, occurs earlier in a Calendar Year,
shall be determined before the benefits of a Plan which covers
such person as a dependent of a person whose date of birth,
excluding year of birth, occurs later in a Calendar Year.
If either Plan does not coordinate benefits in the same manner as
in this Subparagraph 2.b. regarding dependents, and as a result
each Plan determines its benefits before the other or each Plan
determines its benef its afterthe other, the rule set forth in the Plan
16
SECTION XI
SCHEDULE OF BENEFITS
A. Health Services Rendered By Participating Providers. Each Member
shall select a Participating Primary Care Physician and use the services
of that Participating Primary Care Physician for coordination of Health
Services.
A Member shall be entitled to the Medically Necessary Health Services
described in this Section it provided by or coordinated and requested by
the Participating Primary Care Physician and approved by Health Plan.
These Health Services are subject to (1) the limitations, exclusions and
other provisions of this Contract, (2) payment by the Member of the
Copayment Charge specified for any services, and (3) payment of the
Premiums required for coverage under this Contract.
A Member shall also be entitled to those same Medically Necessary
Health Services when provided by or through Participating Referral
Consultant Physicians with prior written authorization by Health Plan
following a referral by the Participating Primary Care Physician.
Coordination by a Participating Primary Care Physician and prior written
approval by Health Plan will not be required in the case of the need for
Emergency Care. However, Emergency Care services shall be subject
to retrospective review, and should the symptoms at the time of presen-
tation indicate that the need for Emergency Care as defined in Section I
did not exist, payment will be denied and charges will be the financial
responsibility of the Member.
Should a Member receive non- Emergency Care from a physician other
than the designated Participating Primary Care Physician, or care
without necessary prior authorization and written approval from Health
Plan, the Member will be responsible for all costs incurred in such care.
Except in case of need for Emergency Care, services are covered only
if the following conditions are met:
1. Each Member must select a Participating Primary Care Physician
who will be responsible for the Member's health needs including
coordination of Out -of -Area Services, Participating Referral Consult-
ant Physicians, and Hospital admissions.
2. All services must be provided, directed, or coordinated by the Partici-
pating Primary Care Physician.
3. When indicated or required by this Contract, Health Services must be
approved by Health Plan prior to the Member receiving the Health
Services.
29
Memberbeing responsible forall expenses associated with the provider's
services.
J. Pronouns. All personal pronouns used in fhis Contract shaif include either
gender unless the context indicates otherwise.
K. In- Service Area Conversion Privileges.
1. A Subscriber or Family Dependent shall be entitled to have coverage
issued to him, without Evidence of Good Health, an individual
conversion contract in the event coverage under this Contract termi-
nates due to:
a. The Subscriber's termination of full -time employment; or
b. The death of the Subscriber; or
c. The divorce, dissolution or annulment of marriage of the Sub-
scriber; or
d. The Family Dependent no longer qualifies as an eligible depend-
ent, except when the termination is due to the cancellation of this
Contract or the Family Dependent is eligible as a Subscriber; or
e. Termination of coverage provided under the continuation of
coverage option, unless such termination was based upon non-
payment of Premium or Copayment Charges, fraud, failure to
establish a satisfactory patient- physician relationship, misuse of
identification card, or misrepresentation. Termination of the En-
rolling Group's Contract shall not result in eligibility for a Sub-
scriber and /or Family Dependent under the conversion plan.
2. Coverage under the individual conversion contract may be obtained
by requesting in writing from Health Plan an enrollment application
and a copy of the conversion contract. The completed enrollment
application along with the initial quarterly Premium payment (by
money order or cashier's check) for the required Premiums must be
received by Health Plan within thirty-one (31) days after termination
of coverage under this Contract. The effective date of coverage under
the individual conversion contract wit be the first day after the date of
termination of coverage under this Contract.
3. Unless otherwise provided in the conversion contract, a Member
covered under the individual conversion contract will be billed quar-
terly on a calendar basis.
28
which does not have the provision of this Subparagraph 2.b. shall
determine the order of benefits.
c. If the parents are separated or divorced and the parent with
custody of the child has not remarried, the benefits of a Plan which
covers the child as a dependent of the parent with custody of the
child shall be determined before the benefits of a Plan which
covers the child as a dependent of a parent without custody.
d. If the parents are divorced and the parent with custody of the child
has remarried, the benefits of a Plan which covers the child as a
dependent of the parent with custody shall be determined before
the benef its of a Plan which covers that child as a dependent of the
step - parent, and the benefits of a Plan which covers that child as
a dependent of the step -parent shall be determined before the
benefits of a Plan which covers that child as a dependent of the
parent without custody.
e. Notwithstanding the foregoing, it there is a court decree which
would otherwise establish financial responsibility for the medical,
dental, or other health care expenses with respect to the child, the
benefits of a Plan which covers the child as a dependent of the
parent with such financial responsibility shall be determined
before the benefits of any other Plan which covers the child as a
dependent child.
f. When the foregoing rules do not establish an order of benefit de-
termination, the benefits of a Plan which has covered the person
for the longer period of time shall be determined before the
benefits of a Plan which has covered the person the shorter period
of time, except that:
(i) The benefits of a Plan covering the person on whose expenses
claim is based as a laid -off or retired employee, or dependent
of such person, shall be determined after the benefits of any
other Plan covering such person as an active employee, other
than a laid -off or retired employee, or dependent of such
person; and
(ii) If either plan does not have a provision regarding laid -off or
retired employees, and, as a result, each Plan determines its
benefits after the other, then the provisions of this Section in
Subparagraph (i) above do not apply.
3. The primary Plan calculates its benefits as though duplicate coverage
did not exist. The other Plans, in order as determined by Section
V.,C.,2. above, will then reimburse for all Allowable Expenses not
17
covered by the other Plan, provided this amount does not exceed the
benefits payable under the Plan in the absence of duplicate cover-
age.
E. Receipt of Services from Health Plan. None of the above provisions
related to Coordination of Benefits wit be construed to limit or restrict the
Member from receiving Health Services from Health Plan which are
covered under this Contract.
F. Information to be Furnished. Any Member claiming benefits under this
provision must furnish to Health Plan all information necessary by Health
Plan to implement this provision.
G. Right to Receive and Release Information. For the purposes of de-
termining the applicability and implementing the terms of this provision
of this Contract or any provision of similar purpose of any other Plan,
Health Plan may, without the consent of or notice to any other person,
release to or obtain from any other insurance company or other organi-
zation or person any information if permitted by law, with respect to any
person, which Health Plan deems to be necessary for such purposes.
Any person claiming benefits under this Contract shall fumish Health
Plan such information as may be necessary to determine the benefits
payable or coverage to be provided under this Contract.
H. Payments to Certain Organizations. Whenever payments which would
otherwise have been made under this Contract in accordance with this
provision have been made under any other Plans, Health Plan shall have
the right, exercisable alone and in its sole discretion, to determine
whether or not to pay to any organizations making such request, and to
determine the amount of such payment, to satisfy the intent of this
provision, and amounts so paid shall be deemed to be benefits paid
under this Contract, and, to the extent of such payments, Health Plan
shall be fully discharged from liability under this Contract.
I. Right of Recovery. Whenever payments have been made by Health
Plan in excess of the maximum amount of payment necessary to satisfy
the intent of this provision, Health Plan shall have the right to recover
such payments, to the extent of such excess, from among one or more
of the following, as Health Plan shall determine: any persons to, or for,
or with respect to whom, such payments were made, any insurance
companies, and any other person, firm, HMO or organization.
J. Subrogation /Injuries Caused by Third Parties. Subrogation seeks to
shift the expense for injuries suffered by Members to those responsible
for causing them. In retum for Health Plan providing benefits under this
Contract, each Member agrees to assign to Health Plan the right of
18
in full force and effect and in no way shall be affected, impaired, or
invalidated.
E. No Implied Waiver. Failure by party hereto on one or more occasions to
avail itself of a right conferred by this Contract shall in no event be
construed of a waiver of its rights to enforce said right in the future.
F. Notice. All notices shall be in writing and shall be deemed given upon
mailing by registered or certified United States mail, postage prepaid and
return receipt requested, addressed as follows:
If to Health Plan:
Texas Health Plans, Inc.
P.O. Box 9420
Austin, Texas 78766
If to the Enrolling Group or any Subscriber:
At the Enrolling Group's address as designated on the Group
Enrollment Agreement.
Notice given by Health Plan to an authorized representative of the
Enrolling Group shall be deemed notice to all affected Subscribers in the
administration of this Contract, including termination of this Contract or
the termination of individual coverage under this Contract. Upon receipt
of notice from Health Plan, the Enrolling Group shall provide copies of
such notice to all affected Subscribers in the Enrolling Group.
Any writing which may be mailed pursuant to the foregoing may also be
delivered by hand or transmitted by telegraph, telex or telecopier and
notice given other than by mail shall be deemed effective when received
by the addressee. Either party may, from time to time, specify as its
address for purposes of this Contract any other address upon the giving
of 10 days' notice thereof to the other party.
G. Covered Benefits. In no event shall any Member be responsible to pay
for benefits received in accordance with this Contract except for Copay-
ment Charges and other provisions as noted in this Contract.
H. Group Contract/Certificate of Coverage. Health Plan will issue to each
Subscriber a copy of this Certif icate of Coverage describing the coverage
to which he is entitled.
I. Identification Card. Upon enrollment in Health Plan, each Memberwill be
issued an identification card. It is the Member's responsibility to notify
Health Plan if no identification card is received from Health Plan within
three (3) weeks after the Member's effective date of coverage. In
addition, it is the Member's responsibility to present the identification card
to each provider at the time of service. Failure to do so could result in the
27
SECTION X
GENERAL PROVISIONS
A. Entire Contract. This Contract and attachments, Group Enrollment
Agreement and the individual enrollment applications, if any, of the
Members shall constitute the entire contract of coverage between the
parties. This Contract supercedes all other prior contracts and arrange-
ments between the parties.
B. Alterations. No alterations or amendments of this Contract and no waiver
of any of its provisions shall be valid unless evidenced by an endorse-
ment or an amendment attached to this Contract which is signed by an
executive officer of Health Plan. No person other than a duly authorized
officer of Health Plan has authority to act on behalf of Health Plan to
change this Contract, or to waive any of its provisions.
C. Records.
1. The Enrolling Group shall furnish Health Plan with all information and
proof which Health Plan may reasonably require with regard to any
matters pertaining to this Contract. All documents furnished to the
Enrolling Group by an individual in connection with the coverage,
together with the Enrolling Group's payroll records and any other
records which may have a bearing on the coverage under this
Contract, shall be made available for inspection by Health Plan at any
reasonable time.
2. Each Member authorizes and directs any person or institution that
has attended, examined or treated the Member, when permitted by
law, to fumish Health Plan at any reasonable time, upon its request,
any and all intormation and records and copies of records relating to
attendance, examination or treatment rendered to the Member.
Health Plan agrees that such information and records will be consid-
ered confidential. Health Plan shall have the right to submit any and
all records concerning Members' health care services to medical
review bodies and /or physicians as required by law.
3. In the event of a question or dispute concerning the provision of
Health Service(s) as a covered benefit(s) under this Contract, Health
Plan may, in addition to any other right or remedy available to Health
Plan, reasonably require that a Member be examined, at Health
Plan's expense, by a Participating Physician reasonably acceptable
to Health Plan and the Member.
D. Severability. 11 any terrn, provision, covenant or condition of this Contract
is held by a court of competent jurisdiction to be invalid, void, or
unenforceable, the remainder of the provision and Contract shall remain
26
recovery against any third party to the extent of benefits received from
or through Health Plan plus costs of suit and attorneys' fees. At the time
such benefits are provided or thereafter as Health Plan may request, the
Member agrees to:
1. Execute aformal written lnjury report and assignments 10 Heatth Plan
of right to recover the reasonable value as determined by Health Plan
of any benefits provided directly by Health Plan under this Contract,
together with costs of suit and attorneys' fees.
2. Reimburse Health Plan for the reasonable value of any benefits and
services provided by Health Plan and in an amount equal to the
charges therefore together with the costs of suit and attorneys' fees,
but not in excess of monetary damages collected, immediately upon
receipt of any monies paid by or on behalf of athird party in settlement
of any claim against such third party. In determining the reasonable
value of benefits and services provided by Health Plan, Health Plan
will consider charges for similar services being made by providers in
the community which possess similar training or capability as well as
unusual circumstances or a medical complication requiring addi-
tional time, skill, experience and/or facilities in connection with a
particular service. The Member hereby grants and assigns to Health
Plan a lien on any recovery from such third party whether by
judgment, settlement, compromise or reimbursement.
3. Execute and deliver such papers and provide such reasonable help
(including authorizing bringing suit against such third party in Member's
name and making court appearances) as may be necessary to
enable Health Plan to recover the reasonable value of benefits and
services provided by Health Plan, together with costs of suit and
attorneys' fees.
K. Government Programs. The benefits under this Contract are not de-
signed to duplicate any benefits to which Members are, or would be,
entitled under government programs for which they are eligible, includ-
ing Medicare. All sums payable under such programs for services
provided pursuant to this Contract shall be payable to, and retained by,
Health Plan. Each Member shall submit to Health Plan such consents,
releases, assignments, and other documents as may be requested by
Health Plan in order to obtain or assure reimbursement under govern-
ment programs for which Members are eligible.
19
SECTION VI
COMPLAINT PROCEDURES
A. Complaint. li a Member has a complaint conceming the provision of
Health Services or benefits under this Contract, a written complaint may
be directed to Texas Health Plans, Inc. at P.O. Box 9420, Austin, Texas
78766.
1. Health Plan shall contact the complainant and attempt to resolve the
complaint through informal discussions, consultations or confer-
ences and shall notify the complainant of the resolution of the
complaint within thirty (30) days following its receipt. Complaints
should be reported in writing to Health Plan within ninety (90) days of
the incident or discovery which forms the basis of the complaint.
2. It further requested in writing by the Member following informal
attempts to resolve the complaint, Health Plan shall direct the
complaint to a Committee appointed by the President of Health Plan.
3. The Committee shall schedule a grievance hearing and advise the
complainant of the date and place of the hearing. The hearing shall
be held within sixty (60) days following the receipt of the written
request fora hearing from the complainant. At the hearing, testimony,
explanation or other intormation will be received from Members, staff
persons, administrators, providers, or other persons as is deemed
necessary by Health Plan for a fair appraisal of the complaint.
4. The Committee shall make a determination as to the resolution of the
complaint and advise the complainant in writing of its findings within
thirty (30) days of the conclusion of the hearing and of the complainant's
right to further legal action.
B. Release of Medical Records. Any Member who files a complaint or
grievance thereby authorizes Health Plan or anyone designated by
Health Plan, as permitted by law, to review or disseminate, as necessary
to the resolution of the complaint or grievance, such Member's individual
medical records, without notice to the Member or any other person.
SECTION VII
TERMINATION OF COVERAGE
A. Coverage of the Member under this Contract shall terminate upon sixty
(60) days written notice from Health Plan or on such date as otherwise
described below:
1. In the case of a Member who fails to pay a required Copayment
Charge at the time Health Services are rendered, Health Plan shall
have the right to terminate the Member's coverage under this Con-
20
C. Monthly Premium Calculation. Each monthly Premium shall be calcu-
lated on the basis of Health Plan's records as to the number of Subscrib-
ers in each coverage classification at the time of calculation, at the rates
then in effect.
D. Monthly Payments. The Enrolling Group agrees to remit the entire
Premium on a monthly basis and assumes responsibility for collection of
the contributory portion from the Subscriber, if any. The first Premium
payment is due and payable on the effective date of this Contract.
Subsequent Premium payments are due and payable no later than the
last business day (which excludes legal holidays, Saturdays and Sun-
days) preceding each Contract Month thereafter that this Contract is in
effect.
E. Retroactive Adjustment. Retroactive adjustments for Premiums may, at
the option of Health Plan, be made for any additions or terminations of
Subscribers and changes in coverage classification not reflected in
Health Plan's records at the time the monthly Premium is calculated by
Health Plan. However, at no time shall Health Plan be required to make
a retroactive adjustment greater than sixty (60) days prior to the time the
adjustment is being made. All adjustments are effective as of 12:01 a.m.,
Central Standard Time, on the first day of the applicable calendar month.
F. Reporting Additions and Deletions. The Enrolling Group shall provide
Health Plan with additions and deletions of Members within thirty (30)
days of the effective date of coverage or termination.
G. Failure to Render Premium Payments.
1. Late Payment Charges. A late payment charge will be added to all
Premium payments due and not paid to Health Plan before the first
day of the coverage month. The late payment charge on late Premi-
ums will be charged a rate equal to eighteen percent (18 %) per year.
The unpaid Premiums and the late payment charges are due and
payable upon notice thereof to the Enrolling Group from Health Plan.
2. Termination for Non - Payment of Premiums. If the Enrolling Group
fails to pay Premiums within the thirty (30) day Grace Period,
coverage will be cancelled after the thirtieth (30th) day. The Enrolling
Group will remain liable for all Premiums and late payment charges
accrued but not paid prior to termination.
If the Premiums and late payment charges are not paid within thirty
(30) days of the end of the Grace Period, the Member will be liable
for the cost of Health Services received during the Grace Period.
25
treatment and Health Plan determines that no professionally accepted
alternative exists, the Member shall be so advised. If the Member still
refuses to acceptthe recommended procedure ortreatment, Health Plan
shall not have any further obligation to arrange the health care service
in question for as long as the Member refuses treatment. Members may
seek other sources of health care service(s) on a self -pay basis with the
full understanding that Health Plan has no obligation for further coverage
of such care including cost.
E. Incontestability. In the absence of fraud, all statements made by a
Subscriber are considered representations and not warranties. During
the first two (2) years, coverage can be voided for material misrepresen-
tation contained in a written application. After two (2) years, coverage
can be voided only in the event of a fraudulent misstatement contained
in written application or Evidence of Good Health application, a copy of
which has been provided to the Member.
SECTION IX
PREMIUM PAYMENTS
A. Premium Charge. The charge for Premium is the base rate. If the State
of Texas or any other taxing authority imposes upon Health Plan any
increase in taxes or license fees which is levied upon or measured by the
base rate or by Health Plan's gross receipts or any portion of either, then
Health Plan may amend this Contract to increase the Premium base rate
by an amount sufficient to cover all taxes or license fees rounded to the
nearest cent, effective as of the date stated in a notice sent to the
Enrolling Group. The effective date shall not be earlier than the date of
the imposition of such tax or license fee increase. Health Plan shall notify
the Enrolling Group by mailing a postage prepaid notice of amendment
to the Group Enrollment Agreement stating the revised charge for
Premium, such notice to be mailed to the Enrolling Group at its address
of record with Health Plan at least thirty (30) days before the effective
date of the amendment.
B. Rate Schedule Changes. Health Plan reserves the right to change the
schedule of rates for Premiums either (1) on the first renewal date
specified in the Group Enrollment Agreement and on any subsequent
renewal date thereafter, or (2) on any date that the provisions of this
Contract are amended.
Written notice of any such change in rates shall be given by Health Plan
to the Enrolling Group at least thirty (30) days prior to the effective date
of the change.
24
tract provided Health Plan gives the Member written notice at least
thirty (30) days prior to such termination.
2. If a Member permits the use of the identification card by any other
person, such card may be confiscated by Health Plan and Health Plan
shall have the right to terminate the Member's coverage under this
Contract provided Health Plan gives the Member written notice at
least fifteen (15) days prior to such termination.
3. IT (a) a Member and a Participating Physician fail to establish a sat-
isfactory patient - physician relationship; and (b) Health Plan has, in
good faith, provided the Member with the opportunity to select an
alternative Participating Physician; and (c) Health Plan notifies Member
in writing that Health Plan considers the patient - physician relation-
ship to be unsatisfactory; and (d) Health Plan specifies the changes
that are necessary to avoid termination. In the event that the specified
changes are not made or the situation is not otherwise made satisfac-
tory to Health Plan, then Health Plan shall have the right to terminate
the Member's coverage under this Contract provided Health Plan
gives the Member written notice at least thirty (30) days prior to such
termination. Examples of unsatisfactory patient- physician relation-
ships include, but are not limited to, abusive or disruptive behavior in
a physician's office, repeated refusals by the Member to accept
Medically Necessary procedures or treatments recommended by a
Participating Physician, or a Member securing services in a manner
that impairs the ability of the Participating Primary Care Physician to
coordinate the care.
4. Misconduct by a Member detrimental to Health Plan operations or the
arrangements orthe delivery of services may, at Health Plan's option,
result in immediate cancellation of coverage.
5. Fraud in the use of services or facilities, or misrepresentation by the
Memberwill result in Health Plan terminating the Member's coverage
under this Contract (except as described in Section VIII.,E.) provided
Health Plan gives the Member written notice at least fifteen (15) days
prior to such termination.
6. Coverage under this Contract shall terminate on the effective date of
the termination of the Group Enrollment Agreement or date specified
by Enrolling Group and agreed to by Health Plan it the Group
Enrollment Agreement is terminated by Enrolling Group.
7. The date on which the Member moves out of the Service Area.
8. The end of the last Contract Month that the required Subscriber
contribution toward the Premium has been paid, 1 the Subscriber is
required to make such a contribution.
21
9. The date this Contract is terminated.
10. The last day of the Contract Month in which the Subscriber becomes
retired or pensioned, unless a specific coverage classification is
specified for retired or pensioned individuals in the Group Enrollment
Agreement. Subscribers afforded coverage under this provision
must enroll in Parts A and B of Medicare.
11. The end of the Contract Month in which the Member ceases to be
eligible as a Subscriber or Family Dependent, orceasesto be eligible
under the Continuation of Coverage Option (as described in Section
VII.,D. below). The Member may be eligible for conversion within
thirty -one (31) days of termination under this Contract.
12. Upon the death of the Member unless the Continuation of Coverage
Option is requested to cover surviving dependents.
13. For a Family Dependent, the date the Subscriber's coverage termi-
nates unless the Continuation of Coverage Option or conversion
applies.
B. Coverage of the Enrolling Group under this Contract shall terminate on
the earliest of the following dates:
1. In the case of non - payment of Premium, Health Plan shall have the
right to terminate coverage under this Contract at the end of the
Grace Period, as stated in Section IX below, provided the Enrolling
Group is given written notice prior to such termination.
2. In the case of fraud on the part of the Enrolling Group, Health Plan
shall have the right to terminate coverage under this Contract pro-
vided Health Plan gives the Enrolling Group written notice at least
fifteen (15) days prior to such termination.
C. Additional Termination Rights. In addition to any other right of termina-
tion, the Health Plan or Enrolling Group may terminate this Contract at
the end of any Contract Month by giving written notice of termination sixty
(60) days prior to the effective date of termination.
Enrolling Group shall be responsible for payment of any Premiums
payable for coverage prior to the effective date of termination. Termina-
tion of this Contract shall be without prejudice to any claim originating
prior to the effective date of termination.
D. Continuation of Coverage Option. If under the provisions of Title X of the
Consolidated OMNIBUS Budget Reconciliation Act of 1985 (COBRA),
Public Law 99 -272, any Member is granted the right to continuation of
coverage beyond the date the Member's coverage would otherwise
terminate, or, if the provisions of COBRA are inapplicable and the
22
provisions of an applicable state statue grant the Member similar rights
to continuation of coverage, this Contract shall be deemed to allow
continuation of coverage to the extent necessary to comply with the
provisions of the applicable statutes. Contact your Enrolling Group for
verification of eligibility and procedures to follow.
E. Payment of Medical Services after Termination of Coverage. Upon
termination of coverage, the Member shall be liable and Health Plan shall
not be liable for the payment of any Health Services provided after the
date of termination.
SECTION VIII
RELATIONSHIP BETWEEN PARTIES
A. Independent Contractor. The relationship between Health Plan and
Participating Providers is a contractual relationship between independ-
ent contractors. Participating Providers are not agents or employees of
Health Plan neither is Health Plan or any employee of Health Plan an
agent or employee of Participating Providers. A Participating Provider's
contract may terminate and a Member may be required to utilize another
Participating Provider.
The relationship between any Participating Physician or other Participat-
ing Provider, and any Member, is that of a physician (or other provider)
with the patient. The Participating Physician is solely responsible for the
medical services provided to any Member. The Participating Hospital,
Skilled Nursing Facility, Home Health Agency, other Participating Pro-
vider, or any other person, firm or organization providing services
hereunder is solely responsible for the services provided to any Member.
B. Other Providers. Health Plan reserves the right to contract with other cor-
porations, associations, partnerships, or individuals to provide the bene-
fits described herein,
C. Assignability. Health Plan may assign this Contract to its successor in
interest or an affiliate.
D. Disagreementwith Recommended Treatment. Member enrolls in Health
Plan with the understanding that the Participating Physician is respon-
sible for determining the treatment appropriate to the case. For personal
or religious reasons, some Members may refuse to accept a procedure
or treatment recommended by the Participating Physician, or a Member
may demand a procedure or treatment that the Participating Physician
judges to be incompatible with proper medical care. A Member has the
right to refuse to accept the recommendation of the Participating Physi-
cian. If a Member refuses to accept a recommended procedure or
23
MAY 24 89 12:41
Ms. Linda Gunther
Personnel Manager
City of Round Rock
221 East Main Street
Round Rock, Texas 78664
Dear Ms. Gunther:
24 May 1989
Texas
Health
Plans, Inc.
A healthy idea
A quality choice
The following would apply to Emergent, Urgent Care for members of
Texas Health Plans, Inc., who present to the Emergency Department
of Round Rock Community Hospital.
(i) In case of a Life or Limb Threatening Emergency as
determined by the Emergency Department Physician,
appropriate care should be rendered by the Emergency
Department while as in your usual practice, efforts are
made to contact the patient's Primary Care Physician.
If for medical reasons, patients are to be transferred
to another Hospital, then the decision should be
jointly made by the Primary Care Physician, the
Emergency Room Physician and the Consulting Physician.
To update you on developments relating to Orthopedic Services at
Round Rock Hospital, please be informed that effective June 1,
1989 that Dr. Stephen Cord who actively practices at Round Rock
Community Hospital or his on-call Associate will be the
designated Orthopedic Consultant for Texas Health Plans
Participating Physicians in the Round Rock area. All referrals
from the Emergency Department for Emergency Consultations should
therefore be made to Doctor Cord.
I anticipate that the above arrangements will finally satisfy
your concerns relating to the use of Round Rock Community
Hospital by Texas Health Plans Participating Physicians and
members.
GRJ /pan
Sincerely
en R Johnson, M.D.
Execud ve Vice President
Medi l Affairs
8303 MoPac Suite 450 Austin, Texas 78759 -8370
P.O. Box 9420 Austin, Texas 78766
(512) 338 -6100
•
TEXAS HEALTH PLANS, INC.
8303 MOPAC, SUITE 450
AUSTIN, TEXAS 78759
(512) 338 -6100
GROUP ENROLLMENT AGREEMENT
Group t 20419
The Enrolling Group named below hereby applies to Texas Health Plans, Inc. for a Group Contract/Certificate of Coverage to be issued as follows:
1. Group Name: City of Round Rock
AddreeslClty /StetetZlp• 214 Main Street Round Rock, Texas 78664
Billing Address/City/State /Zip: Same as Above
2. Legal Status: _Corporation _Partnership _Proprietorship _Trust X Other: Municipality
3. Employer Tax Identification Number: 74- 6017485
4. Nature of Business or Industry: City Government
5. Subsidiaries: The following subsidiaries, affiliates, or other related organizations will be included under the Group Contract/Certificate of
Coverage: N/A
6. Eligibility: Eligible employees of the Group and their eligible family members shall be those persons who meet the criteria set forth In the
Group Contract/Certificate of Coverage and such additional requirements as are set forth below:
Subscribers (Employees): ' A11 full time employees. New hires effective let of month following
date of hire. Termination: end of month.
FamilyMembers: Spouses; unmarried dependent children to age 25.
7. Initial Enrollment Period: Individuals who are not eligible on the dale the Group Enrollment Agreement takes elect, and who otherwise
become eligible according to the requirements specified In the Group Enrollment Agreement and Group Contract/Certificate of Coverage will
be eligible for enrollment until 31st day following initial enrollment period.
8. Open Enrollment Period: The Open Enrollment Period shall commence each Sept. 1 and continue until Sept. 30
of every year this Agreement Is in effect, except as Health Plan and Enrolling Group may otherwise agree to in writing. The Open Enrollment
Period shall be at least 10 days duration.
9. Effective Date: The Group Contract/Certificate of Coverage will be delivered in and govemed by the laws of the State of Texas and shall take
effect on June 1, 1989 but only if the following conditions are satisfied: (a) this Agreement is accepted and signed by Texas
• Health Plans, Inc., and (b) Enrolling Group agrees to pay the Premiums on schedule as stipulated below. The Premiums specified in this
Agreement are guaranteed until Sept . 30. 1989 .
10. Renewal Date: October 1 1989
11. Coverage: Plan Code t SNA Group Contract/Certificate of Coverage t GCC 15 - 1(R)
Amendments: CCC15SFRVARE, CCCBRFAT.PA, AM- 25(1/89). Letter of Agreement, 0V10(1/89),
FltdeNKX HOSP250(1/89)
12, Premium Rate Schedule: Total Monthly Premlum Subscriber Contribution Group Contribution
A. Employee Only $ 88.28 $ -0- $ 88.28
B. Employee and One Dependent $ 207.36 $ 119.08 $ 88.28
or Employee and Spouse
C. Employee and Child(ren) $ 156.58 $ 68.30 $ 88.28
D. Employee and Family $ 264.92 $ 176.64 $ 88.28
13. Premium Due Date and Payments: Enrolling Group agrees to the terms stated on the back of this Agreement and In the Group Contract/
Certificate of Coverage.
14. Worker's Compensation Informaton: Policy No.: Insurance Company Name: GAB
Address: P.O. Box 180128 Austin, Texas 78718 Phone No.: 343 - 1220
15. Enrolling Group hereby agrees and understands that If it fails to carry or maintain Workers Compensation insurance, it shall be solely
responsible for any resulting expenses due to work related conditions.
16. The Enrolling Group hereby agrees and understands that the Group Contract/Certficate of Coverage issued is based on this Agreement and
that the acceptance of the Group Contract/Certificata of Coverage constitutes Agreement to all terms and conditions of this Agreement and
the Group Contract/Certificate of Coverage. A copy of this Agreement shall be attached to and made a part of the Group Contract/Certificate
of Coverage issued to the Enrolling Group. / ' �?'1�1 ///111 ��, YG1
Signed at on the f 0 tlay of f u ` l�-4_ . 19 d /
(address of Enrolling Group) o
•OR THE ENRQIILIN R FOR TEXAS /LTH PLANS, r C,.• /
Authorized Signature Authorized Signature
F.xernrive Vire President
Title Title
GEA 12/88(8)
PREMIUM DUE DATE AND PAYMENTS
ylonthly Premium Rergj((ff0lx +. The Enrolling Group agrees to remit the entire Premium on a monthly basis and assumes responsibility for
collection of the contributory portion from the Subscriber, if any The first Premium payment Is due and payable on the effective date of this
Contract. Subsequent Premiums are due and payable no later than the last business day (which excludes legal holidays, Saturdays and Sundays)
preceding each Contract Month thereafter that this Contract is in effect.
Retroactive Adiustments. Retroactive adjustments may, at the option of Health Plan, be made tor any additions or terminations of Subscribers and
changes in coverage classification not reflected in Health Plan's records at the time the monthly Premium is calculated by Health Plan. However,
at no time shall Health Plan be required to make a retroactive adjustment greater than slaty (60) days. All adjustments are effective as of 12:01
a.m., Central Standard Time, on the first day of the applicable calendar month.
Reoorina Additions and Daletinns. The Enrolling Group shall provide Health Plan with additions and deletions within thirty (30) days of the effective
date of coverage.
Additions. In the event that a Member enrolls hereunder on or before the fifteenth (15th) day of a month, the Enrolling Group agrees to remit to
Health Plan on or before the next Premium Due Date an additional total monthly Premium for such Member for the month in which the Member
enrolled. In the event that a Member enrolls hereunder after the fifteenth (15th) day of a month, no additional Premium payment will be due with
respect to such Member for the month in which the Member enrolled.
Terminations. In the month of a Member's termination, if the Member's termination is effective on any given day during the respective month, then
a full month's premium is due.
) ate Payment Charges A late payment charge will be added to all Premium payments due and not paid to Health Plan before the first day of the
coverage month. The late payment charge on late Premiums will be charged at a rate equal to eighteen percent (16 %) per year. The unpaid
Premiums and the late payment charges are due and payable upon notice thereof to the Enrolling Group from Health Plan.
Termination for Non - Payment of Premiu If the Enrolling Group fails to pay Premiums within the thirty (30) day Grace Period, coverage will be
cancelled after the thirtieth (30th) day. The Enrolling Group will remain liable for all Premiums and late payment charges accrued but not paid prior
to termination. If the Premiums and late payment charges are not paid within thirty (30) days of the end of the Grace Period, the Member will be
liable for the cost of Health Services received during the Grace Period.
•
•
•
•
•
•
Terms Health Plans, Inc. has agreed to provide the City of Round Rock with a
guarantee that the renewal premium rates, effective October 1, 1989 through
September 30, 1990, will not exceed a 10% increase over the current premium
rates. In addition, Texas Health Plans, Inc. will guarantee the October 1,
1990 through September 30, 1991, rates not to exceed a 15% increase over the
10% increase for the period of October 1, 1989 through September 30, 1990.
Please note that the current plan night have to be altered in the following
years to conform with existing Texas Health Plans, Inc. plans being marketed at
that time and with changes in coverage that the State Board of Insurance might
require.
Secondly, in the event the current indemnity carrier (Blue Cross/Blue Shield)
terminates their contract with the City of Round Rock due to a lack of
participation in the Blue Cross/Blue Shield program, Texas Health Plans, Inc.
will allow those employees participating in Blue Cross/Blue Shield to enroll
into Texas Health Plans, Inc. without providing evidence of insurability.
FOR THE ENROLLING GROUP: FOR TEXAS HEALTH PLANS, INC:
241,t
LETTER OF AGREEMENT
Authorized Signature Authorized S
Title Title
Executive Vioe President
•
•
•
AMENDMENT '1'O '1'IIE GROUP CONTRACT /CERTIFICATE OF COVERAGE
GCC- 15 -1(R)
This Amendment shall be included as an addition to the Group
Contract /Certificate of Coverage GCC- 15 -1(R) between your company
and Texas health Plans, Inc. This Amendment Is in effect for all
Members in accordance with the terms of such Contract.
DELETE: SECTION i, DEFINITIONS, "Service Area ".
ADD: SECTION I, DEFINITIONS, "Service Area" means a
geographic area designated by Health Plan in which the
Member resides and in which Covered Services are
provided. The Service Area is comprised of Bastrop,
Bell, Brazos, Burleson, Burnet, Caldwell, Coryell,
Falls, Hays, Lee, McLennan, Milam, Robertson, Travis,
Williamson counties and portions of Bosque, Grimes,
Hamilton, Lampasas and Madison counties in Texas.
A list of zip codes and Participating Providers will be
provided to the Members."
GCC15SERVARE
TEXAS HEALTH PLANS, INC.
By:
Peter Kilissanly
President and Chief Executive
Officer
•
•
AMENDMENT TO THE GROUP CONTRACT /CERTIFICATE OF COVERAGE
GCC- 15 -1(R)
This Amendment shall be included as an addition to the Group
contract /Certificate of Coverage GCC- 15 -1(R) between your company
and Texas Health Plans, Inc. This Amendment is in effect for all
Members in accordance with the terms of such Contract.
DELETE: SECTION XI, SCHEDULE OF BENEFITS, D.,8.,b., "...breast
prostheses... ".
ADD: SECTION XI, SCHEDULE OF BENEFITS, E., General
Exclusions:
• GCCBREALPD
36. "... Also excluded are protein sparing modified
fasting nutritional programs and any variants thereof."
TEXAS HEALTH PLANS, INC.
By:
Peter Kilissanly
President and Chief Executive
Officer
•
•
•
This is an amendment to the Group Certificate of Coverage,
Section XI, Schedule of Benefits. This amendment shall be
included as an addition to the Group Certificate of Coverage.
This amendment is in effect for all Enrollees in accordance with
the terms of such Group Certificate of Coverage.
DELETE: SECTION XI, SCHEDULE OF BENEFITS, D. 1, COPAYMENT
CHARGE:
OV10 (1/89)
AMENDMENT TO THE GROUP CERTIFICATE OF COVERAGE
"NONE"
"$10.00"
AMBULATORY OFFICE VISIT COPAYMENT
ADD: SECTION XI, SCHEDULE OF BENEFITS, D. 1, COPAYMENT
CHARGE:
TEXAS HEALTH PLANS, INC.
BY:
K
Peter E. Kilissanly
President and
Chief Executive Officer
• AMENDMENT TO THE GROUP CONTRACT /CERTIFICATE OF COVERAGE
•
INPATIENT HOSPITAL AND RELATED SERVICES COPAYMENT
This is an amendment to the Group Contract /Certificate of
Coverage, section Xi, Schedule of Benefits. • This amendment shall
be included as an addition to the Group Contract /Certificate of
Coverage. This amendment is in effect for all Enrollees in
accordance with the terms of such Group Contract /Certificate of
Coverage.
DELETE: SECTION Xi, SCHEDULE OF BENEFITS, D. 2. a. and D. 5.,
COPAYMENT CHARGE:
•0SP250:1/89
"NONE"
ADD: SECTION XI, SCHEDULE OF BENEFITS, D. 2 a. and D. 5.,
COPAYMENT CHARGE:
"For subscriber only:
$50 copayment per day. $250 maximum copayment per
Contract Year.
For Subscriber and Family Dependent(s):
$50 copayment per day. $250 maximum copayment per
hospitalization for Subscriber or Dependent(s)
with $500 maximum copayment per Contract Year per
family."
•
TEXAS HEILTH PLANS, INC.
BY:
Peter E. Kilissanly
President and
Chief Executive Officer
•
•
AMENDMENT TO THE GROUP CONTRACT /CERTIFICATE OF COVERAGE
GCC- 15 -1(R)
This Amendment shall be included as an addition to the Group
Contract /Certificate of Coverage GCC- 15 -1(R) between your company
and Texas Health Plans, Inc. This Amendment is in effect for all
Members in accordance with the terms of such Contract.
DELETE: SECTION II, ELIGIBILITY AND ENROLLMENT, A., 2.,
"Eligible Family Dependents ", Paragraphs b. and c.
ADD: SECTION II, ELIGIBILITY AND ENROLLMENT, Paragraph 2,
"Eligible Family Dependents ", Subparagraph b.,
"Any unmarried dependent child (including step - child,
legally adopted child or natural child of either
Subscriber or the Subscriber's spouse), who is under
age twenty -five (25). A Family Dependent shall also
include a child for whom Subscriber or Subscriber's
spouse is a court appointed legal guardian, provided
proof of such guardianship is submitted with the
prospective dependent's enrollment application and
provided the above criteria are satisfied. Coverage
outside the Service Area, however, is limited to
Emergency Care services as described in Section XI,
C3
DELETE: SECTION II, ELIGIBILITY AND ENROLLMENT, Paragraph 2,
"Eligible Family Dependents ", Subparagraph d.,
"Any such unmarried child, as defined in this
subsection, must be a Family Member enrolled hereunder
prior to attaining the applicable limiting age of
nineteen (19) or if a full -time student (as described
in Section II) to the age of twenty -three (23)."
CHANGE: SECTION II, ELIGIBILITY AND ENROLLMENT, A., 2.,
"Eligible Family Dependents ", Paragraphs d. and e. to
c. and d.
• AM- 25(1/89)
TEXAS HEALTH PLANS, INC.
By:
Peter E. Kilissanly
President and
Chief Executive Officer
The Enrolling Group named below hereby apples to Texas Health Plans, Inc. for a Group ContracUCenificate of Coverage to be issued as follows:
Group Name: City of Round Rock
Address/City/State/Zip: 214 Main Street Round Rock. Texas 78664
• - Billing Address/Clty/State/Zir Same as Above
2. Legal Status: __Corporation _Partnership Proprietorship _Trust X Other: Municipality
3. Employer Tax identification Number: 74-6017485
4. Nature of Business or Industry: City Government
5. Subsidiaries: The following subsiclaries, affiliates, or other related organizations will be included under the Group Contract/Certificate of
Coverage: N/A
6. Eligibility: Eligible employees of the Group and their eligible family members shall be those persons who meet the criteria set forth in the
t . Group Contract/Certificate of Coverage and such additional requirements as are set forth below:
Subscribers (Employees): ' All full time employees. New hires effective let of month following
date of hire. Termination: end of month.
PamilyMemberc Spouses; unmarried dependent children to age 25.
7. Initial Enrollment Period: Individuals who are not eligible on the date the Group Enrollment Agreement takes effect, and who otherwise
become eligible according to the requirements specified in the Group Enrollment Agreement and Group Contract/Certificate of Coverage will
be eligible for enrollment until 31st dav following initial enrollment period.
. - 8. Open Enrollment Period: The Open Enrollment Period shall commence each Sept . 1 and continue until Sept 30
...-,., , of every year this Agreement is in effect, except as Health Plan and Enrolling Group may otherwise agree to In writing. The Open Enrollment
- Period shall be at least 10 days duration.
...:, 9. , Effective Date: The Group Contract/Certificate of Coverage will be delivered In and governed by the laws of the State of Texas and shall take
effect on June 1. 1989 but only if the following conditions are satisfied: (a) this Agreement is accepted and signed by Texas
?J Health Plans, Inc., and (b) Enrolling Group agrees to pay the Premiums on schedule as stipulated below. The Premiums specified in this
= Agreement are guaranteed until Sept. 30, 1989 .
10. Renewal Date: October I. 1989
., it. Coverage: Plan Code a 5NA Group Contract/Certificate of Coverage a GCC -15-1 (R)
Amendments: err15sPRvAgE, OCCBREALPD. AM-25(1/89). Letter of Agreement. OV1O(1/89).
— wasor n0sp7s0c1 /Ren
...'
12. Premium Rate Schedule: Total Monthly Premium Subscriber Contribution Group Contribution
A. Employee Only $ 88.28 $ -0- $ 88.28
$ 88.28
-1; or Employee and Spouse
B. Employee and One Dependent $ 207.36 $ 119.08
C. Employee and Child(ren) $ 156.58 $ 68.30 g 88.28
. Employee and Family $ 264.92 $ 176.64 $ 88.28
: 13. Premium Due Dale and Payments: Enrolling Group agrees to the terms stated on the back of this Agreement and In the Group Contract/
• Cattlicate of Coverage.
14. Worker's Compensation Information: Policy No.: insurance Company Name: GAB
Address: P o Rnv 180128 Anntin, TPICAR 78718 Phone No.: 343
15. Enroffing Group hereby agrees and understands that if it fails to carry or maintain Worker's Compensation insurance, it shall be solely .. . '
,....,-1.. responsible for any resulting expenses due to work related condidons.
16. The Enrolling Group hereby agrees and understands that the Group Contract/Certificate of Coverage issued is based on this Agreement and
that the acceptance of the Group Contract/Certificate of Coverage constitutes Agreement 10 011 1 terms and conditions of this Agreement and
'' ''''('' the Group Contract/Certificate of Coverage. A copy of this Agreement shall be attached to and made a part of the Group Contract/Cerdficate
of Coverage issued to the Enrolling Group. .
Authorized Signature
TEXAS HEALTH PLANS, INC.
8303 MOPAC, SUITE 450
AUSTIN, TEXAS 78759
(512) 3384100
GROUP ENROLLMENT AGREEMENT
Group a 20419
Sped at on the day of 19
(address of Enrolling Group)
O FOR THE ENROLLING GROUP:
FOR TEXAS
Authorized Signature
Title
TH PLANS
Vvornt4waVire. Prpnident
Texas Health Plans, Inc. has agreed to provide the City of Rind Rock with a
fi- ;guarantee that the renewal premium rates, effective October 1, 1989 through
September 30, 1990, will not exceed a 10% increase over the current premium
.':-.rates. In addition, Texas Health Plans, Inc. will guarantee the October 1,
1990 through September 30, 1991, rates not to exceed a 15% increase over the
10% increase for the period of October 1, 1989 through September 30, 1990.
Please note that the current plan might have to be altered in the following
years to conform with existing Texas Health Plans, Inc. plans being marketed at
that time and with changes in coverage that the State Board of Insurance might
require.
Secondly, in the event the current indemnity carrier (Blue Cross/Blue Shield)
terminates their contract with the City of Round Rock due to a lack of
;articipation in the Blue Cress /Blue Shield program, Texas Health Plans, Inc.
will allow those employees participating in Blue Cross/Blue Shield to enroll
' into Texas Health Plans, Inc. without providing evidence of in usability.
LEITER OF AGREEMENT
Authorized S
PREMIUM DUE DATE AND PAYMENTS
Monthly Premium Remlaance The Enrolling Group agrees to remit the entire Premium on a monthly basis and assumes responsibility for
• collection of the contributory portion from the Subscriber, if any. The first Premium payment is due and payable on the effective date of this
Contract Subsequent Premiums are due and payable no later than the last business day (which excludes legal holidays, Saturdays and Sundays)
preceding each Contract Month thereafter that this Contract is in effect
Retroactive Adiusements. Retroactive a4ustinents may, at the option of Health Plan, be made for any additions or terminations of Subscribers and
changes in coverage classification not reflected In Health Plan's records at the lime the monthly Premium is calculated by Health Plan. However,
at no time shall Health Plan be required to make a retroactive adjustment greater than sixty (60) days. All adjustments are effective as of 12:01
a.m., Central Standard Tune, on the first day of the applicable calendar month.
Reporting Additions and Deletions. The Enrolling Group shall provide Health Plan with additions and deletions within thirty (30) days of the effective
date of coverage. - -
Additions. In the event that a Member enrolls hereunder on or before the fifteenth (15th) day of a month, the Enrolling Group agrees to remit to
Health Plan on or before the next Premium Due Date an additional total monthly Premium for such Member for the month in which the Member
enrolled. In the event that a Member enrolls hereunder after the fifteenth (15th) day of a month, no additional Premium payment will be due with
.respect to such Member for the month in which the Member enrolled.
Terminations. In the month of a Member's termination, if the Members termination Is efedive on any given day during the respective month, then
a lull month's premium is due.
- .. 1 ate Payment Champs A late payment charge wig be added to all Premium payments due and not paid to Health Plan before the first day of the
coverage month. The late payment charge on late Premiums will be charged at a rate equal to eighteen percent (18 %) per year. The unpaid
Premiums and the late payment charges are due and payable upon notice thereof to the Enrolling Group from Health Plan.
Terminetinn for Non-Payment of Premiums. If the Enrolling Group fails to pay Premiums within the thirty (30) day Grace Period, coverage will be
cancelled after the thirtieth (30th) day. The Enrolling Group will remain liable for all Premiums and late payment charges accrued but not paid prior
to termination. If the Premiums and late payment charges are not paid within thirty (30) days of the end of the Grace Period, the Member will be
Gable for the cost of Health Services received during the Grace Period.
AMENDMENT TO '1'IIE GROUP CONTRACT /CERTIFICATE OF COVERAGE
GCC- 15 -1(R)
This Amendment shall be included as an addition to the Group
Contract /Certificate of Coverage GCC- 15 -1(R) between your company
and 'Texas Health Plans, Inc. This Amendment is in effect for all
Members in accordance with the terms of such Contract.
DELETE: SECTION I, DEFINITIONS, "Service Area ".
ADD SECTION I, DEFINITIONS, "Service Area" means a
geographic area designated by health Plan in which the
Member resides and in which Covered Services are
provided. The Service Area is comprised of Bastrop,
Bell, Brazos, Burleson, Burnet, Caldwell, Coryell,
Falls, Nays, Lee, McLennan, Milam, Robertson, Travis,
Williamson counties and portions of Bosque, Grimes,
Hamilton, Lampasas and Madison counties in Texas.
A list of zip codes and Participating Providers will be
provided to the Members."
GCC15SERVARE
TEXAS HEALTH PLANS, INC.
By:
Peter Kilissanly
President and Chief Executive
Officer
This Amendment shall be included as an addition to the Group
Contract /Certificate of Coverage GCC- 15 -1(R) between your company
and Texas Health Plans, Inc. This Amendment is in effect for all
Members in accordance with the terms_ of such Contract.
DELETE:
D:
AMENDMENT TO THE GROUP CONTRACT /CERTIFICATE OF COVERAGE
GCC- 15 -1(R)
GCCBREALPD
SECTION XI, SCHEDULE OF BENEFITS, D.,8.,b., "...breast
prostheses... ".
SECTION XI, SCHEDULE OF BENEFITS, E., General
Exclusions:
36. "... Also excluded are protein sparing modified
fasting nutritional programs and any variants thereof."
TEXAS HEALTH PLANS, INC.
By:
Peter Kilissanly
President and Chief Executive
officer
AMENDMENT TO THE GROUP CERTIFICATE OF COVERAGE
AMBULATORY OFFICE VISIT COPAYMENT
"$10.00"
This is an amendment to the Group Certificate of Coverage,
Section XI, Schedule of Benefits. This amendment shall be
included as an addition to the Group Certificate of Coverage.
This amendment is in effect for all Enrollees in accordance with
the terms of such Group Certificate of Coverage.
DELETE: SECTION XI, SCHEDULE OF BENEFITS, D. 1, COPAYMENT
CHARGE:
"NONE"
ADD: SECTION XI, SCHEDULE OF BENEFITS, D. 1, COPAYMENT
CHARGE:
TEXAS HEALTH PLANS, INC.
BY:
Peter E. Kilissanly
President and
Chief Executive Officer
0 O OSP250:
AMENDMENT TO THE GROUP CONTRACT /CERTIFICATE OF COVERAGE
INPATIENT HOSPITAL AND RELATED SERVICES COPAYMENT
This is an amendment to the Group Contract /Certificate of
Coverage, Section xI, Schedule of Benefits.• This amendment shall
be included as an addition to the Group Contract /Certificate of
Coverage. This amendment is in effect for all Enrollees in
accordance with the terms of such Group Contract /Certificate of
,;mss Coverage .
DELETE: SECTION XI, SCHEDULE OF BENEFITS, D. 2. a. and D. 5.,
COPAYMENT CHARGE:
"NONE"
ADD: SECTION XI, SCHEDULE OF BENEFITS, D. 2 a. and D. 5.,
COPAYMENT CHARGE:
"For Subscriber only:
$50 copayment per day. $250 maximum copayment per
Contract Year.
For Subscriber and Family Dependent(s):
$50 copayment per day. $250 maximum copayment per
Hospitalization for Subscriber or Dependent(s)
with $500 maximum copayment per Contract Year per
family."
•
TEXAS HE PLANS, INC.
BY: E
Peter E. Kilissanly
President and
Chief Executive Officer
AMENDMENT TO THE GROUP CONTRACT /CERTIFICATE OF COVERAGE
GCC- 15 -1(R)
This Amendment shall be included as an addition to the Group
Contract /Certificate of Coverage GCC- 15 -1(R) between your company
and Texas Health Plans, Inc. This Amendment is in effect for all
Members in accordance with the terms of such Contract.
SECTION II, ELIGIBILITY AND ENROLLMENT, A., 2.,
"Eligible Family Dependents ", Paragraphs b. and c.
SECTION II, ELIGIBILITY AND ENROLLMENT, Paragraph 2,
"Eligible Family Dependents ", Subparagraph b.,
"Any unmarried dependent child (including step - child,
legally adopted child or natural child of either
subscriber or the Subscriber's spouse), who is under
age twenty -five (25). A Family Dependent shall also
include a child for whom Subscriber or Subscriber's
spouse is a court appointed legal guardian, provided
proof of such guardianship is submitted with the
prospective dependent's enrollment application and
provided the above criteria are satisfied. Coverage
outside the Service Area, however, is limited to
Emergency Care Services as described in Section XI,
C3."
DELETE: SECTION II, ELIGIBILITY AND ENROLLMENT, Paragraph 2,
"Eligible Family Dependents ", Subparagraph d.,
"Any such unmarried child, as defined in this
subsection, must be a Family Member enrolled hereunder
prior to attaining the applicable limiting age of
nineteen (19) or if a full -time student (as described
in section II) to the age of twenty -three (23)."
CHANGE: SECTION II, ELIGIBILITY AND ENROLLMENT, A., 2.,
"Eligible Family Dependents ", Paragraphs d. and e. to
c. and d.
DELETE:
AM- 25(1/89)
TEXAS HEALTH PLANS, INC.
BY
/ PIA ,
Peter E. Kilissanly'
President and
Chief Executive Officer
This Group Contract/Certificate of Coverage is a legal contract between the
Enrolling Group and Texas Health Plans, Inc. It sets forth in detail your rights
and obligations as a Member.
It is therefore important that you READ your Group Contract/CerWicate of
Coverage CAREFULLY and familiarize yourself with its terms and condi-
tions. For reference purposes, a table of contents has been included. .
GCC- 15 -1(R)
TEXAS HEALTH PLANS, INC.
8303 MoPac, Suite 450
Austin, Texas 78759
Phone (512) 338 -6100
Group Contract /Certificate of Coverage
BY: //
eter E. Kilissanly, President
and Chief Executive Officer
DATE: 2 -1 -89
A Texas Health Maintenance Organization
SECTION I
SECTION II
SECTION III
SECTION IV
SECTION V
SECTION VI
SECTION VII
SECTION VIII
SECTION IX
SECTION X
SECTION XI
Definitions 3
Eligibility and Enrollment 10
Effective Date of Coverage and Selection of a 13
Participating Primary Care Physician
Procedures for Reimbursement of Eligible Expenses 15
Incurred with Non - Participating Providers
Coordination of Benefits and Subrogation 15
Complaint Procedures 20
Termination of Coverage 20
Relationship Between Parties 23
Premium Payments 24
General Provisions 26
Schedule of Benefits 29
TABLE OF CONTENTS
Texas Health Plans, Inc. (herein called Health Plan) hereby contracts with
the Enrolling Group to provide the Health Services set forth herein to
Members, subject to the exclusions, limitations, conditions and other terms
of this Contract including applicable amendments and riders.
This Contract is made in consideration of the Group Enrollment Agreement
and the Subscriber's enrollment application and payment of the required
Premiums as specified herein. Both the Group Enrollment Agreement and
the Subscriber's enrollment application are part of this Contract.
This Contract shall take effect onthe date specified onthe Group Enrollment
Agreement and will be continued In force by the timely payment of the
required Premiums when due, subject to termination of this Contract as
provided herein.
All coverage under this Contract shall begin and end at 12:01 a.m., Central
Standard lime.
This Contract is delivered in and govemed by the laws of the State of Texas.
TEXAS HEALTH PLANS, INC.'
8303 MoPac, Suite 450
Austin, Texas 78759
Phone (512) 338 -6100
Group Contract/Certificate of Coverage
SECTION 1
DEFINITIONS
Alcohol Dependency Treatment Facility means a facility which provides a
program for the treatment of alcohol dependency pursuant to a written
treatment plan approved and monitored by a physician and which facility is
also: (1) affiliated with a hospital under a contractual agreement with an
established system for patient referral, or (2) accredited as such afacility by
the Joint Commission on Accreditation of Healthcare Organizations, or (3)
licensed as an alcohol treatment program by the Texas Commission on
Alcoholism, or (4) licensed, certified, or approved as an alcohol dependency
treatment program or center by any other state agency having legal authority
to so license, certify, or approve and is also an Approved Health Care
Facility.
Alcohol Dependency Treatment means those services and supplies cov-
ered under the Contract for the diagnosis and treatment of alcoholism.
3
Alcoholism means the disease which is classified as alcoholism in the
International Classification of Diseases of the U.S. Department of Health
and Human Services.
Approved Health Care Facility or Program means a facility or program
which is licensed, certified or otherwise authorized pursuant to the laws of
the State of Texas to provide health care and which is approved by Health
Plan or with whom Health Plan has contracted to provide the care described
in this Contract.
Authorized means that Health Plan, the Medical Director or his designee
has determined that the Health Services provided or to be provided are
Medically Necessary.
Calendar Year means January 1, 12:01 a.m. to January 1, 12:01 a.m. of
the following year.
Congenital Anomaly means a defective development or formation of a part
of the body which is determined by a Participating Physician to have been
present at the time of birth.
Contract means this Group Contract/Certificate of Coverage, Subscriber's
enrollment application, Group Enrollment Agreement and any applicable
amendments, addenda and/or riders attached hereto.
Contract Years and Contract Months are determined from the effective
date of this Contract.
Copayment Charge means the charge, in addition to the Premiums, which
the Member is required to pay for certain Health Services and medical
supplies provided under this Contract. The Member Is responsible at the
time of service for the payment of any Copayment Charge directly to the
provider of the Health Services. The maximum amount of Copayment
Charge to be paid bya Member is 50 %of Health Plan's cost for the provider's
services and shall be limited to 200% of the total annual Premiums required
to be paid for coverage under this Contract in any Calendar Year. 11 shall be
the responsibility of the Member to maintain a record of Copayment Charges
which have been paid by the Member and to inform Health Plan when the
maximum amount of those Copayment Charges reach such limit. In addi-
tion, it Is the responsibility of the Member to maintain a record of Copayment
Charges which have been paid for the purpose of income tax. Health Plan
will not provide the Memberwith a record of Copayment Charges which have
been paid by the Member.
Covered Services means the Hospital Services and Professional Services
described in Section XI or any rider hereto and provided under the terms and
conditions of this Contract.
4
Crisis Stabilization Unit means a 24 hour residential program that is usually
short-term in nature and that provides intensive supervision and highly
structured activities to persons who are demonstrating an acute demon-
strable psychiatric crisis of moderate to severe proportions.
Dentist means any Doctor of Dental Surgery, 'D.D.S." or "D.D.M ", who is
duly licensed and qualified to provide dental surgery, treatment or care under
the laws of the state or other jurisdiction in which treatment is received.
Durable Medical Equipment means Medically Necessary equipment which
is not disposable, which is not routinely available in a physician's office and
which is generally not useful to a person in the absence of illness or Injury.
Eligible Expenses are fee schedules for Health Services as established by
Health Plan and covered when Health Services are Medically Necessary
and Authorized by Health Plan as described herein.
Emergency Care means bona fide Emergency Care services provided after
the sudden onset of a medical condition manifesting itself by acute symp-
toms of sufficient severity, including severe pain, such that the absence of
immediate medical attention could reasonably be expected to result in: (1)
placing the patient's health in serious jeopardy; (2) serious impairment to
bodily functions; or (3) serious dysfunction of any bodily organ or part. Heart
attacks, poisonings, loss of consciousness or respiration, convulsions,
excessive uncontrolled bleeding and broken bones are examples of condi-
tions requiring Emergency Care.
Enrolling Group means the employer or party that has entered into a Group
Enrollment Agreement with Health Plan under which Health Plan will provide
or arrange Health Services for eligible Members of the Enrolling Group who
enroll hereunder.
Evidence of Good Health means Health Plan's medical information appli-
cation which is completed by applicant when applying for coverage at a time
otherthanthe Open Enrollment Period and/or Initial Enrollment Period when
required by the Enrolling Group as stipulated in Section II herein and the
Group Enrollment Agreement.
Family Dependents means those Members of the Subscriber's family who
meet the eligibility requirements of this Contract set forth in Section II and
have been enrolled by the Subscriber.
Grace Period means a period of thirty (30) days beyond the date monthly
Premium payments are due during which period the monthly Premium
payments may be made to Health Plan without lapse of coverage under this
Contract.
5
Group Enrollment Agreement means the agreement between Health
Plan and the Enrolling Group which has been signed by both parties
whereby coverage is elected by the Enrolling Group for those Subscribers
and their Family Dependents enrolled hereunder.
Health Services means health care services or benefits provided for in this
Contract.
Health Plan means Texas Health Plans, Inc., a Texas corporation licensed
by the Texas State Board of Insurance under the Texas Health Maintenance
Organization Act, as amended, which will arrange for Members the health
care services that are set forth in the Schedule of Benefits, Section XI.
HMO means Health Maintenance Organization.
Home Health Agency means a facility or program that is licensed, certified
or otherwise authorized pursuant to the laws of the State of Texas as a Home
Health Agency and is approved by Health Plan and Medicare, with whom
Health Plan has contracted to provide certain Health Services covered
under this Contract.
Hospital means an acute care facility operated pursuant to state laws
which (1) is accredited as a hospital by the Joint Commission on Accredita-
tion of Healthcare Organizations or by the Medicare program, (2) 1s primarily
engaged in providing, for compensation from its patients, diagnostic and
surgical facilities for the care and treatment of injured or sick individuals by
or under the supervision of a staff of physicians, (3) has 24 -hour nursing
services by registered nurses (R.N.), and (4) is not primarily a place for rest
or custodial care, nursing home, convalescent home or similar institution.
Hospital Services (except as limited or excluded herein) means those acute -
care services fumished and billed by a Hospital and/or Skilled Nursing
Facility which are Authorized by Health Plan as set forth in Section XI,
Schedule of Benefits.
Individual Treatment Plan means a treatment plan with specific attainable
goals and objectives appropriate to both the patient and the treatment
modality of the treatment program.
Initial Enrollment Period means the period of time specified in the Group
Enrollment Agreement during which a Subscriber may make application for
enrollment in Health Plan for self and eligible dependents without providing
Evidence of Good Health satisfactory to Health Plan as specified In this
Contract.
Injury means bodily damage including all related conditions and recurrent
symptoms.
Long -Term means any therapy beyond the two (2) months as defined in
the Schedule of Benefits.
Maternity means ante /postpartum care, childbirth, early involuntary
termination of pregnancy, or any complication arising therefrom for a
Member.
Medical Director means a physician designated by Health Plan to moni-
tor and review the provision of Covered Services to Members.
Medically Necessary means the use of services or supplies as provided by
a Hospital, Skilled Nursing Facility, physician or other provider required to
identity, treat or avoid an illness or Injury and which, as determined by a
Participating Physician and the Medical Director or its utilization review com-
mittee, are:
(1) Consistent with the symptoms or diagnosis and treatment of the
condition, disease, ailment or Injury:
(2) Appropriate with regard to standards of good medical practice;
(3)
Not solely for the convenience of the Member, his or her Participating
Physician, Hospital, or other health care provider; and
(4) The most appropriate supply or level of service which can be safely
provided to the Member. When specifically applied to an inpatient, it
further means that the medical symptom or condition requires that the
diagnosis or treatment cannot be safely provic)ed to the Member as an
outpatient.
Medicare means the insurance program established by Title XVIII, United
States Social Security Act, as originally enacted by the Social Security
Amendments 011965, or as later amended.
Medicare Subscriber means an employee, retiree, spouse or dependent
child who (1) meets the eligibility requirements of the Enrolling Group; and
(2) is enrolled in both parts A and B of Medicare.
Member means either the Subscriber or his or her eligible Family De-
pendent for whom Premium payment has been made to Health Plan.
Mental Health Services means those services and supplies covered under
this Contract for the diagnosis and treatment of Mental Illness.
Mental Illness means physical or mental condition having an emotional or
psychological origin.
Non - Participating Provider means any provider that Is not a Participating
Provider of Health Plan.
Open Enrollment Period means a period of time subsequent to the Initial
Enrollment Period as specified in the application of the Enrolling Group and
determined periodically by Health Plan and the Enrolling Group, during
which Subscribers may enroll themselves and eligible Family Dependents
under this Contract without providing Evidence of Good Health satisfactory
to Health Plan.
Out-of -Area Services means those services provided outside Health
Plan's Service Area. Covered Out -of -Area Services are limited to Emer-
gency Care services and services that are arranged or Authorized by the
Medical Director.
Participating Hospital means a Hospital which has contracted with Health
Plan to provide certain Health Services to Members.
Participating Pharmacy means a pharmacy which has contracted with
Health Plan to provide pharmacy services to Members.
Participating Physician means a physician who, at the time of providing or
arranging for services to a Member, has contracted with or on whose behalf
a contract has been entered into with Health Plan to provide Professional
Services to Members.
Participating Primary Care Physician means a Participating Physician
(general practitioner, family practitioner, intemist, or pediatrician) who pro-
vides primary care services to Members and is responsible for referrals of
Members to Participating Referral Consultant Physicians or other Participat-
ing Providers.
Participating Provider means a Participating Hospital, Participating Re-
ferral Consultant Physician, Participating Primary Care Physician, Psychi-
atric Primary Provider, Alcohol Dependency Treatment Facility, Home
Health Agency and any other health service provider who/which has been
approved by Health Plan or with whom Health Plan has contracted to pro-
vide Health Services to Members. A list of Participating Providers and their
bcations is available to each Subscriber upon request. Such list shall be
revised from time to time as Health Plan deems necessary. A Participating
Provider's contract may terminate and a Member may be required to utilize
another Participating Provider.
Participating Referral Consultant Physician means a Participating Physi-
cian who is responsible torprovidingcertain physician services upon referral
by a Participating Primary Care Physician and pre - authorization by Health
Plan.
Premium or Premiums means a sum or sums of monies paid monthly to
Health Pfan by the Enrolling Group in order for the Members to receive
services and benefits covered by this Contract.
8
Professional Services (except as limited or excluded herein) means those
services performed by physicians or health professionals which are Medi-
cally Necessary, generally recognized as appropriate care, within the
Service Area, and set forth in Section XI, Schedule of Benefits. All such
services must be performed, prescribed, directed, or coordinated by a
Participating Physician and to the extent required by Health Plan, Author-
ized by Health Plan.
Psychiatric Primary Provider means the organization or entity with whom
Health Plan contracts and authorizes to evaluate, diagnose, refer and/or
provide Mental Health Services and Drug Abuse and Drug Addiction
Detoxification Services, as described herein.
Residential Treatment Center for children and adolescents means a
child care institution that provides residential care and treatment for emo-
tionally disturbed children and adolescents and that is accredited as a
Residential Treatment Center by the Council on Accreditation, the Joint
Commission on Accreditation of Healthcare Organizations, or the American
Association of Psychiatric Organizations, or the American Association of
Psychiatric Services for Children. The Residential Treatment Center or
Crisis Stabilization Unit must be located within Health Plan's Service Area.
Semiprivate Accommodations means a two or more bed room in a Hospi-
tal, Skilled Nursing Facility or other Approved Health Care Facility or Pro-
gram. The semiprivate bed room charge is the maximum allowable toward
private room accommodations. Charges for a private room will be paid by
Health Plan only if use of a private room is deemed Medically Necessary.
Service Area means a geographic area designated by Health Plan In which
the Member resides and in which Covered Services are provided. The
Service Area for Members residing in the Central Texas Division Is com-
prised of Bastrop, Bumet, Caldwell, Hays, Lee, Travis and Williamson
counties, Texas.
Short -Term Therapy means a Participating Physician has determined that
provision of therapy will result in a significant improvement in the condition
within a period of two (2) months f rom the start of treatment for said condition.
Benefits payable for this therapy are limited to a maximum period of two (2)
months from the time of onset for each Injury or diagnosis.
Sickness means physical illness or disease, but does not include Mental
Illness.
Skilled Nursing Facility means an extended care facility which is licensed
as a Skilled Nursing Facility and operated in accordance with the laws of the
State of Texas, approved by Medicare and has a contract with Health Plan
to provide the care described in this Contract.
9
Sound Natural Teeth means teeth that are free of active or chronic clinical
decay, have at least 50% bony support, are functional in the arch, and have
not been excessively weakened by multiple dental procedures.
Subscriber means any employee or Member of the Enrolling Group who (1)
is eligible on his or her own behalf and not by virtue of being an eligible
dependent to participate in the health benefits provided under this Contract;
(2) resides in the Service Area; (3) meets the group's eligibility requirements
specified in the group's application and other provisions in this Contract; and
(4) is enrolled for coverage under this Contract.
Usual, Customary and Reasonable Charge means the amount charged or
the amount Health Plan determines to be the prevailing charge, whichever
is less, for a particular health service in the geographic area In which it is
performed.
SECTION II
ELIGIBILITY AND ENROLLMENT
A. Eligibility
1. Subscriber. To be eligible to enroll as a Subscriber, a person must
reside in the Service Area and be:
a. An employee of the Enrolling Group who is entitled on his own
behalf to participate in the medical and hospital benefits arranged
by Enrolling Group, including satisfaction of any probationary or
waiting period established by Enrolling Group and other eligibility
criteria established by Enrolling Group; and /or
b. Entitled to coverage under a trust agreement or employment
contract with the Enrolling Group; and/or
c. A retiree who has extended coverage with the Enrolling Group.
2. Eligible Family Dependents. To be eligible to enroll as a Family
Member, a person must be listed on the enrollment application form
completed by the Subscriber, meet all Family Dependent eligibility
criteria established by the Enrolling Group, reside in the Service Area
and be:
a. The Subscriber's present lawful spouse (if common law spouse,
Subscriber shall provide evidence satisfactory to Health Plan).
b. Any unmarried dependent child (Including step - child, legally
adopted child or natural child of eitherSubscriberorthe Subscriber's
spouse), who is under age nineteen (19), who lives in the Service
. Area and resides in the household of the Subscribe ror Subscriber's
10
spouse, who is chiefly dependent upon the Subscriber for sup-
port, and who is eligible to be claimed as a dependent in the most
recent federal income tax return of the Subscriber, according to
the United States Internal Revenue Code and regulations. A
Family Dependent shall also Include a child for whom Subscriber
or Subscriber's spouse is a court appointed legal guardian,
provided proof of such guardianship is submitted with the pro-
spective Family Dependent's enrollment application and pro-
vided the above criteria are satisfied.
c. Any unmarried dependent child who is between nineteen (19) and
twenty -three (23) years of age provided the child is a full -time
student in an accredited educational institution and is eligible to
be claimed as a dependent on the Subscriber's federal income
tax return. Coverage outside the Service Area, however, Is
limited to Emergency Care services as described In Section
XI.,C.,2.
Upon the request of Health Plan, the Subscriber agrees to provide
proof of full -time student status (a minimum of twelve (12) credit
hours per semester is required). The Subscriber must notify
Health Plan when a Family Dependent is no longer a full -time
student.
d. Any unmarried child who is and continues to be both (1) incapable
of self - sustalning employment by reason of mental or physical
handicap, and (2) chiefly dependent upon the Subscriber for
economic support and maintenance, provided proof of such
incapacity and dependency is furnished to Health Plan by the
Subscriber within thirty -one (31) days before the child's attain-
ment of the applicable limiting age and subsequently as may be
required by Health Plan, but not more frequently than annually
following the child's attainment of the applicable limiting age.
Health Plan's determination of eligibility shall be conclusive,
subject to the grievance procedures described herein.
Any such unmarried child, as defined in this Subsection, must be
a Family Member enrolled hereunder prior to attaining the appli-
cable limiting age of nineteen (19) or if a full -time student (as
described in Section II) to the age of twenty -three (23).
e. A foster child, a child who has been placed in the Subscriber's
home, and a grandchild of Subscriber or Subscriber's spouse
shall not be eligible for enrollment under this Contract unless such
child otherwise qualifies as a Family Dependent under Section
II.,A.,2.,b., Section II.,A.,2.,c., and Section II.,A.,2.,d., above.
11
3. If the coverage of an eligble Family Dependent, as described in
Section H., A.,2., ceases under another group health plan due to the
termination of empbyment, the Family Dependent will be eligible for
enrollment in Health Plan within the thirty (30) day period from the ter-
mination date of the prior group health plan coverage provided that
the Evidence of Good Healthform has been submitted to Health Plan
as required by the Enrolling Group.
4. Coverage will be provided under this Contract for the first thirty-one
(31) days from the date of birth for a newborn child of the Subscriber
or Subscriber's spouse. Coverage beyond the first thirty -one (31)
days is contingent upon the Subscriber enrolling the newborn as a
Family Member and paying all applicable Premiums retroactive to the
date of birth.
B. Enrollment
1. initial Enrollment Period. During the Initial Enrollment Period, each
eligible employee of the Enrolling Group shall be entitled to apply for
coverage as a Subscriber. Eligible Family Dependents must also be
listed on the enrollment application provided or approved by Health
Plan. No Evidence of Good Health, medical history, or physical
examination shall be required during this period.
2. Newly Eligible Employees. Each new employee of the Enrolling
Group who becomes eligible after the Enrolling Group's Initial Enroll-
ment Period shall be permitted to apply without Evidence of Good
Health, medical history or physical examination for coverage for
himself or herself and eligible Family Dependents, within thirty -one
(31) days of becoming eligible, subject to the enrollment regulations
determined by the Enrolling Group in accordance with the terms of
the Group Enrollment Agreement.
3. Newly Eligible Family Dependents. Any person attaining eligibility as
a Family Dependent may be enrolled by the Subscriber. The Sub-
scriber must complete and submit to Health Plan a signed Health
Plan change application request form within thirty -one (31) days of
the Family Dependent's eligibility date. No Evidence of Good Health,
medical history, or physical examination shall be required.
4. Open Enrollment Period. An Open Enrollment Period shall be held at
least annually at which time eligible employees and their eligible
Family Dependents may enroll as Members under this Contract
unless ineligible under Subsection IL,E. below. No Evidence of Good
Health shall be required during this period.
5.`' Limitation. Persons initially or newly eligible forenroltmentwho do not
enroll within thirty-one (31) days of becoming eligible may only be
12
enrolled during a subsequent Open Enrollment Period except for
those persons who meet the requirements in Section II.,A.,4.
C. Dellveryot Documents. Health Plan will provide to each Subscriber upon
enrollment a Group Contract/Certificate of Coverage and an identifica-
tion card.
D. Notice of Ineligibility. It shall be the Subscribers responsibility to notify
Health Plan of any changes which will affect his or her eligibility or that
of Family Dependents for services or benefits under this Contract.
E. Specific Causes for Ineligibility. A person will not be entitled to enroll as
a Subscriber or a Family Dependent if:
1. The person was previously a Member of Health Plan and his
membership was terminated for cause as described in Section
VII.,A.,1. through 5.
2. The person was part otan Enrolling Groupwhich had unpaid financial
obligations to Health Plan arising from prior Health Plan Membership.
F. Rules of Eligibility. No eligible person will be refused enrollment or re-
enrollment by Health Plan because of his health status, his age, his
requirements tor Health Services, or the existence on the effective date
of coverage under this Contract of a pre- existing physical or mental
condition, including pregnancy. However, no person is eligible to re-
enroll hereunder who has had coverage terminated under Section
VII.,A.,1. through 5.
G. Disclosure. Each Member agrees to disclose to Health Plan at the time
of enrollment, at the time of receipt of services and benefits, and from
time to time as requested by Health Plan the existence of other group
insurance coverage, the identity of the carrier, and the group through
whom provided.
SECTION III
EFFECTIVE DATE OF COVERAGE AND SELECTION OF A
PARTICIPATING PRIMARY CARE PHYSICIAN
A. Effective Date of Coverage. Subject to the payment of applicable
Premium payments by the Enrolling Group for the individual, Health
Plan's receipt of an application from or on behalf of each prospective
Member, and the provisions of this Contract, coverage under this
Contract shall become effective on the later of: (1) the date this Contract
takes effect, (2) on the first day of the first month following the conclusion
of the Initial Enrollment Period, or (3) unless otherwise specified in the
Group Enrollment Agreement, as follows:
13
1. When a person makes written application and Health Plan receives
such application after the date of coverage would have otherwise
been effective, coverage shall take effect on the first day of the first
Contract Month following the date of approval by Health Plan of such
Evidence of Good Health as it may require.
2. Coverage shall become effective at birth for newborn children for
thirty-one (31) days, and continues in effect thereafter if the newborn
is eligible and enrolled by the Subscriber within thirty-one (31) days
of the newbom's birth and if Premiums are paid.
3. Except as otherwise agreed to by the Enrolling Group and Health
Plan, when a person makes written application for Membership
during the Open Enrollment Period, coverage will be effective on the
first day of the next calendar month following the date of the Open
Enrollment Period, or as otherwise agreed to by Health Plan and
Enrolling Group.
B. Selection of Participating Primary Care Physician
1. Members must choose (or have chosen on their behalf) a Participat-
ing Primary Care Physician and identify these choices on Health
Plan's enrollment application at the time of enrollment, and on Health
Plan's change application at the time any such Member's Participat-
ing Primary Care Physician ceases to be a Participating Provider. If
the Member does not select a Participating Primary Care Physician
on the enrollment application and notify Health Plan of their selection
within thirty (30) days of the effective date of coverage, Health Plan
will assign a Participating Primary Care Physician for the Member.
Health Plan will maintain and provide to the Subscribers upon
request a list of Participating Primary Care Physicians who will accept
new Subscribers.
2. Members shall be entitled to Covered Services provided by or
arranged by the Member's Participating Primary Care Physician and
Authorized by Health Plan in accordance with their applicable Group
ContractCertificate of Coverage.
3. After the Member designates a Participating Primary Care Physician,
this selection may not be changed by the Member except by complet-
ing Health Plan's change application request form and obtaining
authorization from Health Plan. Upon Health Plan approval, the
Participating Primary Care Physician selection will become effective
On the first day of the following month.
!. 4. A Member's Participating Primary Care Physician may only be
changed by a Member a total of two (2) times per Contract Year.
14
SECTION IV
PROCEDURES FOR REIMBURSEMENT OF ELIGIBLE EXPENSES
INCURRED WITH NON - PARTICIPATING PROVIDERS
A. Notice of Claim. Written notice of Injury, Sickness, Maternity, Mental
Illness or any other condition for which individual claim may be made
must be sent to Health Plan within sixty (60) days after the date any
medical service or supplies were rendered for which Health Plan is liable
hereunder.
B. Payment of Claim. Claims for Covered Services will be paid within a
reasonable amount of time of written receipt by Health Plan. Benefits
under this Contract will be paid to the Subscriber unless paid by Health
Plan to the Non - Participating Provider.
C. Legal Action. No action at law or in equity shall be brought to recover
under this Contract prior to the expiration of sixty (60) days after proof of
loss has been filed in accordance with the requirements of this Contract,
nor shall such action be brought at all unless brought within three (3)
years from the expiration of the time within which proof of loss is required
by this Contract.
SECTION V
COORDINATION OF BENEFITS; SUBROGATION
A. Coordination of Benefits (COB). All the benefits provided under this
Contract are subject to these provisions. In the case of duplicate
coverage, Health Plan may recover from the Member or other group
insurance program proceeds consisting of benefits payable to, or on
behalf of, the Member respecting the same Covered Services, up to the
amount of Health Plan's cost or obligation to the extent to which Health
Plan is entitled to recoverunderthis Contract for such Covered Services.
B. Definitions. The following definitions apply to this Section V.
1. A "Plan" is any group insurance coverage, no -fault automobile insur-
ance coverage, prepayment plan, coverage under union welfare
plan, other plan growing out of employer /employee relationship, and
any other statutory plan.
2. "Allowable Expense" means any usual, necessary, reasonable and
customary item of expense at least a portion of which is covered
under at least one of the Plans covering the person for whom claim
is made. When a Plan provides benefits in the form of services rather
than cash payments, the reasonable cash value of each service
rendered shall be deemed to be both an Allowable Expense and a
benefit paid.
15
C. Non - Duplication.
1. Worker's Compensation. The benefits under this Contract are not
designed to duplicate any benefit to which the Member is entitled
under worker's compensation insurance or laws. Charges for Health
Services arising out of job related injuries are not covered under this
Contract. In the event Health Services are provided, all sums payable
under worker's compensation insurance or laws shall be payable to,
and retained by, Health Plan. Each Member shall complete and
submit to Health Plan such consents, releases, assignments, and
other documents reasonably requested by Health Plan in order to
obtain or assure such reimbursement.
2. Other Plans. If any benefits to which a Member is entitled under this
Contract are also covered by any other Plan, the payable benefits
shall be coordinated with the benefits that are available to the
Member under such other Plan, whether or not a claim is made for the
same.
D. Order of Benefit Determination. The order of benefit determination
between this Contract and any other Plan covering the Member on
whose behalf a claim if made is established as follows:
1. Whenever one Plan does not contain a coordination of benefits
provision, that Plan must be primary; the primary Plan must pay its
benefits before the secondary Plan pays.
• 2. When two or more Plans contain coordination of benefits clauses, the
Plan that pays first is the primary Plan. The Plan that pays additional
benefits for Allowable Expenses not covered by the primary carrier,
but not to exceed 100 %of total Allowable Expenses, is the secondary
Plan. The sequence of payments is as follows:
a. The Plan covering the patient as an employee pays before the
Plan covering the patient as a dependent.
b. The benefits of a Plan which covers the person on whose ex-
penses claim is based as a dependent of a person whose date of
birth, excluding year of birth, occurs earlier in a Calendar Year,
shall be determined before the benefits of a Plan which covers
such person as a dependent of a person whose date of birth,
excluding year of birth, occurs later in a Calendar Year.
If either Plan does not coordinate benefits in the same manner as
In this
Subparagraph 2.b, regarding dependents, and as a result
161 - each Plan determines its benefits before the other or each Plan
determines itsbenefits after the other, the rule set forth in the Plan
,^. tr;
16
which does not have the provision of this Subparagraph 2.b. shall
determine the order of benefits.
c. If the parents are separated or divorced and the parent with
custody of the child has not remarried, the benefits of a Plan which
covers the child as a dependent of the parent with custody of the
child shall be determined before the benefits of a Plan which
covers the child as a dependent of a parent without custody.
d. If the parents are divorced and the parent with custody of the child
has remarried, the benefits of a Plan which covers the child as a
dependent of the parent with custody shall be determined before
the benef its of a Plan which covers that child as a dependent of the
step - parent, and the benefits of a Plan which covers that child as
a dependent of the step -parent shall be determined before the
benefits of a Plan which covers that child as a dependent of the
parent without custody.
e. Notwithstanding the foregoing, it there is a court decree which
would otherwise establish financial responsibility for the medical,
dental, or other health care expenses with respect to the child, the
benefits of a Plan which covers the child as a dependent of the
parent with such financial responsibility shall be determined
before the benefits of any other Plan which covers the child as a
dependent child.
f. When the foregoing rules do not establish an order of benefit de-
termination, the benefits of a Plan which has covered the person
for the longer period of time shall be determined before the
benefits of a Plan which has covered the person the shorter period
of time, except that:
(1) The benefits of a Plan covering the person on whose expenses
claim is based as a laid -off or retired employee, or dependent
of such person, shall be determined after the benefits of any
other Plan covering such person as an active employee, other
than a laid -off or retired employee, or dependent of such
person; and
(ii) If either plan does not have a provision regarding laid -off or
retired employees, and, as a result, each Plan determines its
benefits after the other, then the provisions of this Section in
Subparagraph (1) above do not apply.
3. The primary Plan calculates its benefits as though duplicate coverage
did not exist. The other Plans, in order as determined by Section
V.,C.,2. above, will then reimburse for all Allowable Expenses not
17
covered by the other Plan, provided this amount does not exceed the
benefits payable under the Plan in the absence of duplicate cover-
age.
E. Receipt of Services from Health Plan. None of the above provisions
related to Coordination of Benefits will be construed to limit or restrict the
Member from receiving Health Services from Health Plan which are
covered under this Contract.
F. information to be Fumished. Any Member claiming benefits under this
provision must f urnish to Health Plan all information necessary by Health
Plan to implement this provision.
G. Right to Receive and Release Information. For the purposes of de-
termining the applicability and implementing the terms of this provision
of this Contract or any provision of similar purpose of any other Plan,
Health Plan may, without the consent of or notice to any other person,
release to or obtain from any other insurance company or other organi-
zation or person any information if permitted by law, with respect to any
person, which Health Plan deems to be necessary for such purposes.
Any person claiming benefits under this Contract shall fumish Health
Plan such information as may be necessary to determine the benefits
payable or coverage to be provided under this Contract.
H. Payments to Certain Organizations. Whenever payments which would
otherwise have been made under this Contract in accordance with this
provision have been made under any other Plans, Health Plan shall have
the right, exercisable alone and in its sole discretion, to determine
whether or not to pay to any organizations making such request, and to
determine the amount of such payment, to satisfy the intent of this
provision, and amounts so paid shall be deemed to be benefits paid
under this Contract, and, to the extent of such payments, Health Plan
- shall be fully discharged from liability under this Contract.
I. Right of Recovery. Whenever payments have been made by Health
Plan in excess of the maximum amount of payment necessary to satisfy
the intent of this provision, Health Plan shall have the right to recover
such payments, to the extent of such excess, from among one or more
of the following, as Health Plan shall determine: any persons to, or for,
or with respect to whom, such payments were made, any insurance
companies, and any other person, firm, HMO or organization.
J. Subrogation/lnjuries Caused by Third Parties. Subrogation seeks to
shift the expense for injuries suffered by Members to tfifb8e responsible
for causing them. In retum for Health Plan providing benefits under this
Contract, each Member agrees to assign to Health Plan the right of
to. ,
18
recovery against any third party to the extent of benefits received from
or through Health Plan plus costs of suit and attorneys' fees. At the time
such benefits are provided orthereafter as Health Plan may request, the
Member agrees to:
1. Execute aformal written tnjury report and assignmentsto Health Plan
of right to recover the reasonable value as determined by Health Plan
of any benefits provided directly by Health Plan under this Contract,
together with costs of suit and attomeys' fees.
2. Reimburse Health Plan for the reasonable value of any benefits and
services provided by Health Plan and in an amount equal to the
charges therefore together with the costs of suit and attorneys' fees,
but not in excess of monetary damages collected, Immediately upon
receipt of any monies paid by or on behalf of a third party in settlement
of any claim against such third party. In determining the reasonable
value of benefits and services provided by Health Plan, Health Plan
will consider charges for similar services being made by providers in
the community which possess similar training or capability as well as
unusual circumstances or a medical complication requiring addi-
tional time, skill, experience and/or facilities in connection with a
particular service. The Member hereby grants and assigns to Health
Plan a lien on any recovery from such third party whether by
judgment, settlement, compromise or reimbursement.
3. Execute and deliver such papers and provide such reasonable help
(including authorizing bringing suit against such third party in Member's
name and making court appearances) as may be necessary to
enable Health Plan to recover the reasonable value of benefits and
services provided by Health Plan, together with costs of suit and
attorneys' fees.
K. Government Programs. The benefits under this Contract are not de-
signed to duplicate any benefits to which Members are, or would be,
entitled under government programs for which they are eligible, includ-
ing Medicare. All sums payable under such programs for services
provided pursuant to this Contract shall be payable to, and retained by,
Health Plan. Each Member shall submit to Health Plan such consents,
releases, assignments, and other documents as may be requested by
Health Plan in order to obtain or assure reimbursement under govern-
ment programs for which Members are eligible.
19
SECTION VI
COMPLAINT PROCEDURES
A. Complaint. If a Member has a complaint conceming the provision of
Health Services or benefits under this Contract, awritten complaint may
be directed to Texas Health Plans, Inc. at P.O. Box 9420, Austin, Texas
78766.
1. Health Plan shall contact the complainant and attempt to resolve the
complaint through informal discussions, consultations or confer-
ences and shall notify the complainant of the resolution of the
complaint within thirty (30) days following its receipt. Complaints
should be reported in writing to Health Plan within ninety (90) days of
the incident or discovery which forms the basis of the complaint.
2. If further requested in writing by the Member following informal
attempts to resolve the complaint, Health Plan shall direct the
complaint to a Committee appointed by the President of Health Plan.
3. The Committee shall schedule a grievance hearing and advise the
complainant of the date and place of the hearing. The hearing shall
be held within sixty (60) days following the receipt of the written
request fora hearing from the complainant. At the hearing, testimony,
explanation or other information will be received from Members, staff
persons, administrators, providers, or other persons as is deemed
necessary by Health Plan for a fair appraisal of the complaint.
4. The Committee shall make a determination as to the resolution of the
complaint and advise the complainant in writing of its findings within
thirty (30) days of the conclusion of the hearing and of the complainant's
right to further legal action.
B. Release of Medical Records. Any Member who files a complaint or
grievance thereby authorizes Health Plan or anyone designated by
Health Plan, as permitted by law, to review or disseminate, as necessary
to the resolution of the complaint or grievance, such Member's individual
medical records, without notice to the Member or any other person.
SECTION VII
TERMINATION OF COVERAGE
A. Coverage of the Member under this Contract shall terminate upon sixty
(80) days written notice from Health Plan or on such date as otherwise
descf rI DOOM:
1. In the case of a Member who fails to pay a required Copayment
Charge at the time Health Services are rendered, Health Plan shall
have the right to terminate the Member's coverage under this Con-
20
tract provided Health Plan gives the Member written notice at least'
thirty (30) days prior to such termination.
2. If a Member permits the use of the identification card by any other
person, such card may be confiscated by Health Plan and Health Plan
shall have the right to terminate the Member's coverage under this
Contract provided Health Plan gives the Member written notice at
least fifteen (15) days prior to such termination.
3. If (a) a Member and a Participating Physician fail to establish a sat-
isfactory patient- physician relationship; and (b) Health Plan has, in
good faith, provided the Member with the opportunity to select an
alternative Participating Physician; and (c) Health Plan notif ies Member
in writing that Health Plan considers the patient- physician relation-
ship to be unsatisfactory; and (d) Health Plan specifies the changes
that are necessary to avoid termination. In the event that the specified
changes are not made or the situation is not otherwise made satisfac-
tory to Health Plan, then Health Plan shall have the right to terminate
the Member's coverage under this Contract provided Health Plan
gives the Member written notice at least thirty (30) days prior to such
termination. Examples of unsatisfactory patient- physician relation-
ships include, but are not limited to, abusive or disruptive behavior in
a physician's office, repeated refusals by the Member to accept
Medically Necessary procedures or treatments recommended by a
Participating Physician, or a Member securing services in a manner
that impairs the ability of the Participating Primary Care Physician to
coordinate the care.
4. Misconduct by a Member detrimental to Health Plan operations or the
arrangements orthe delivery of services may, at Health Plan's option,
result in immediate cancellation of coverage.
5. Fraud in the use of services or facilities, or misrepresentation by the
Member will result in Health Plan terminating the Member's coverage
under this Contract (except as described in Section VIII.,E.) provided
Health Plan gives the Member written notice at least fifteen (15) days
prior to such termination.
6. Coverage under this Contract shall terminate on the effective date of
the termination of the Group Enrollment Agreement or date specified
by Enrolling Group and agreed to by Health Plan if the Group
Enrollment Agreement is terminated by Enrolling Group.
7. The date on which the Member moves out of the Service Area.
8. The end of the last Contract Month that the required Subscriber
contribution toward the Premium has been paid, if the Subscriber is
required to make such a contribution.
21
9. The date this Contract is terminated.
10. The last day of the Contract Month in which the Subscriber becomes
retired or pensioned, unless a specific coverage classification is
specified for retired or pensioned individuals in the Group Enrollment
Agreement. Subscribers afforded coverage under this provision
must enroll in Parts A and B of Medicare.
11. The end of the Contract Month in which the Member ceases to be
eligible as a Subscriber or Family Dependent, orceases to be eligible
under the Continuation of Coverage Option (as described in Section
VII.,D. below). The Member may be eligible for conversion within
thirty-one (31) days of termination under this Contract.
12. Upon the death of the Member unless the Continuation of Coverage
Option is requested to cover surviving dependents.
13. Fora Family Dependent, the date the Subscriber's coverage termi-
nates unless the Continuation of Coverage Option or conversion
applies.
B. Coverage of the Enrolling Group under this Contract shall terminate on
the earliest of the following dates:
1. In the case of non - payment of Premium, Health Plan shall have the
right to terminate coverage under this Contract at the end of the
Grace Period, as stated in Section IX below, provided the Enrolling
Group is given written notice prior to such termination.
2. In the case of fraud on the part of the Enrolling Group, Health Plan
shall have the right to terminate coverage under this Contract pro-
vided Health Plan gives the Enrolling Group written notice at least
fifteen (15) days prior to such termination.
C. Additional Termination Rights. In addition to any other right of termina-
tion, the Health Plan or Enrolling Group may terminate this Contract at
the end of any Contract Month by giving written notice of termination sixty
(60) days prior to the effective date of termination.
Enrolling Group shall be responsible for payment of any Premiums
payable for coverage prior to the effective date of termination. Termina-
tion of this Contract shall be without prejudice to any claim originating
prior to the effective date of termination.
D. Continuation of Coverage Option. It under the provisions of Title X of the
Consolidated OMNIBUS Budget Reconciliation Act of 1985 (COBRA),
Public Law 99 -272, any Member is granted the right to continuation of
coverage beyond the date the Members coverage would otherwise
terminate, or, if the provisions of COBRA are inapplicable and the
22
1
J
provisions of an applicable state statue grant the Member similar rights
to continuation of coverage, this Contract shall be deemed to allow
continuation of coverage to the extent necessary to comply with the
provisions of the applicable statutes. Contact your Enrolling Group for
verification of eligibility and procedures to follow.
E. Payment of Medical Services after Termination of Coverage. Upon
termination of coverage, the Member shall be liable and Health Plan shall
not be liable for the payment of any Health Services provided atter the
date of termination.
SECTION VIII
RELATIONSHIP BETWEEN PARTIES
A. Independent Contractor. The relationship between Health Plan and
Participating Providers is a contractual relationship between independ-
ent contractors. Participating Providers are not agents or employees of
Health Plan neither is Health Plan or any employee of Health Plan an
agent or employee of Participating Providers. A Participating Provider's
contract may terminate and a Member may be required to utilize another
Participating Provider.
The relationship between any Participating Physician or other Participat-
ing Provider, and any Member, is that of a physician (or other provider)
with the patient. The Participating Physician is solely responsible for the
medical services provided to any Member. The Participating Hospital,
Skilled Nursing Facility, Home Health Agency, other Participating Pro-
vider, or any other person, firm or organization providing services
hereunder is solely responsible for the services provided to any Member.
B. Other Providers. Health Plan reserves the right to contract with other cor-
porations, associations, partnerships, or individuals 10 provide the bene-
fits described herein.
C. Assignability. Health Plan may assign this Contract to its successor in
interest or an affiliate.
D. Disagreement with Recommended Treatment. Member enrolls in Health
Plan with the understanding that the Participating Physician is respon-
sible for determining the treatment appropriate to the case. For personal
or religious reasons, some Members may refuse to accept a procedure
or treatment recommended by the Participating Physician, or a Member
may demand a procedure or treatment that the Participating Physician
judges to be incompatible with proper medical care. A Member has the
right to refuse to accept the recommendation of the Participating Physi-
cian. If a Member refuses to accept a recommended procedure or
23
treatment and Health Plan determines that no professionally accepted
alternative exists, the Member shall be so advised. If the Member still
refuses to accept the recommended procedure or treatment, Health Plan
shall not have any further obligation to arrange the health care service
in question for as long as the Member refuses treatment. Members may
seek other sources of health care service(s) on a self -pay basis with the
full understanding that Health Plan has no obligation for further coverage
of such care including cost.
E. Incontestability. In the absence of fraud, all statements made by a
Subscriber are considered representations and not warranties. During
the first two (2) years, coverage can be voided for material misrepresen-
tation contained in a written application. After two (2) years, coverage
can be voided only in the event of a fraudulent misstatement contained
in written application or Evidence of Good Health application, a copy of
which has been provided to the Member.
SECTION IX
PREMIUM PAYMENTS
A. Premium Charge. The charge for Premium is the base rate. If the State
of Texas or any other taxing authority imposes upon Health Plan any
increase in taxes or license fees which is levied upon or measured by the
base rate or by Health Plan's gross receipts or any portion of either, then
Health Plan may amend this Contract to increase the Premium base rate
by an amount sufficient to cover all taxes or license fees rounded to the
nearest cent, effective as of the date stated in a notice sent to the
Enrolling Group. The effective date shall not be earlier than the date of
the imposition of such tax or license fee increase. Health Plan shall notify
the Enrolling Group by mailing a postage prepaid notice of amendment
to the Group Enrollment Agreement stating the revised charge for
Premium, such notice to be mailed to the Enrolling Group at its address
of record with Health Plan at least thirty (30) days before the effective
date of the amendment.
B. Rate Schedule Changes. Health Plan reserves the right to change the
schedule of rates for Premiums either (1) on the first renewal date
specified in the Group Enrollment Agreement and on any subsequent
renewal date thereafter, or (2) on any date that the provisions of this
Contract are amended.
Written notice of any such change in rates shall be given by Health Plan
to the Enrolling Group at least thirty (30) days prior to the effective date
;; of the change.
24
C. Monthly Premium Calculation. Each monthly Premium shall be calcu
lated on the basis of Health Plan's records as to the number of Subscrib-
ers in each coverage classification at the time of calculation, at the rates
then in effect.
D. Monthly Payments. The Enrolling Group agrees to remit the entire
Premium on a monthly basis and assumes responsibility for collection of
the contributory portion from the Subscriber, if any. The first Premium
payment is due and payable on the effective date of this Contract.
Subsequent Premium payments are due and payable no later than the
last business day (which excludes legal holidays, Saturdays and Sun-
days) preceding each Contract Month thereafter that this Contract is in
effect.
E. Retroactive Adjustment. Retroactive adjustments for Premiums may, at
the option of Health Plan, be made for any additions or terminations of
Subscribers and changes in coverage classification not reflected in
Health Plan's records at the time the monthly Premium is calculated by
Health Plan. However, at no time shall Health Plan be required to make
a retroactive adjustment greater than sixty (60) days prior to the time the
adjustment is being made. All adjustments are eff ective as of 12:01 a.m.,
Central Standard Time, on the first day of the applicable calendar month.
F. Reporting Additions and Deletions. The Enrolling Group shall provide
Health Plan with additions and deletions of Members within thirty (30)
days of the effective date of coverage or termination.
G. Failure to Render Premium Payments.
1. Late Payment Charges. A late payment charge will be added to all
Premium payments due and not paid to Health Plan before the first
day of the coverage month. The late payment charge on late Premi-
ums will be charged a rate equal to eighteen percent (18 %) per year.
The unpaid Premiums and the late payment charges are due and
payable upon notice thereof to the Enrolling Group from Health Plan.
2. Termination for Non - Payment of Premiums. If the Enrolling Group
fails to pay Premiums within the thirty (30) day Grace Period,
coverage will be cancelled after the thirtieth (30th) day. The Enrolling
Group will remain liable for all Premiums and late payment charges
accrued but not paid prior to termination.
If the Premiums and late payment charges are not paid within thirty
(30) days of the end of the Grace Period, the Member will be liable
for the cost of Health Services received during the Grace Period.
25
SECTION X ,U: '..,..
GENERAL PROVISIONS "- : -=1 "t
A. Entire Contract. This Contract and attachments, Group Enrollment
Agreement and the individual enrollment applications, if any, of the
Members shall constitute the entire contract of coverage between the
parties. This Contract supercedes all other prior contracts and arrange-
ments between the parties.
B. Alterations. No alterations or amendments of this Contract and no waiver
of any of its provisions shall be valid unless evidenced by an endorse-
ment or an amendment attached to this Contract which is signed by an
executive officer of Health Plan. No person other than a duly authorized
officer of Health Plan has authority to act on behalf of Health Plan to
change this Contract, or to waive any of its provisions.
C. Records.
1. The Enrolling Group shall furnish Heafth Plan with all information and
proof which Health Plan may reasonably require with regard to any
matters pertaining to this Contract. All documents furnished to the
Enrolling Group by an individual in connection with the coverage,
together with the Enrolling Group's payroll records and any other
records which may have a bearing on the coverage under this
Contract, shall be made available for inspection by Health Plan at any
reasonable time.
2. Each Member authorizes and directs any person or institution that
has attended, examined or treated the Member, when permitted by
law, to furnish Health Plan at any reasonable time, upon its request,
any and all information and records and copies of records relating to
attendance, examination or treatment rendered to the Member.
Health Plan agrees that such information and records will be consid-
ered confidential. Health Plan shall have the right to submit any and
all records concerning Members' health care services to medical
review bodies and/or physicians as required by law.
3. In the event of a question or dispute conceming the provision of
Health Service(s) as a covered benefit(s) underthis Contract, Health
Plan may, in addition to any other right or remedy available to Health
Plan, reasonably require that a Member be examined, at Health
Plan's expense, by a Participating Physician reasonably acceptable
to Health Plan and the Member.
e'.
D. Severability. If any term, provision, covenant or condition of this Contract
is held by a court of competent jurisdiction to be invalid, void, or
unenforceable, the remainder of the provision and Contract shall remain
26
in full force and effect and in no way shall be affected, impaired, or
invalidated.
E. No Implied Waiver. Failure by party hereto on one or more occasions to
avail itself of a right conferred by this Contract shall in no event be
construed of a waiver of its rights 10 enforce said right in the future.
F. Notice. All notices shall be In writing and shall be deemed given upon
mailing by registered or certified United States mail, postage prepaid and
return receipt requested, addressed as follows:
If to Health Plan:
Texas Health Plans, Inc.
P.O. Box 9420
Austin, Texas 78766
If to the Enrolling Group or any Subscriber:
At the Enrolling Group's address as designated on the Group
Enrollment Agreement.
Notice given by Health Plan to an authorized representative of the
Enrolling Group shall be deemed notice to all affected Subscribers in the
administration of this Contract, including termination of this Contract or
the termination of individual coverage under this Contract. Upon receipt
of notice from Health Plan, the Enrolling Group shall provide copies of
such notice to all affected Subscribers in the Enrolling Group.
Any writing which may be mailed pursuant to the foregoing may also be
delivered by hand or transmitted by telegraph, telex or telecopier and
notice given other than by mail shall be deemed effective when received
by the addressee. Either party may, from time to time, specify as its
address for purposes of this Contract any other address upon the giving
of 10 days' notice thereof to the other party.
G. Covered Benefits. In no event shall any Member be responsible to pay
for benefits received in accordance with this Contract except for Copay-
ment Charges and other provisions as noted in this Contract.
H. Group Contract/Certificate of Coverage. Health Plan will issue to each
Subscriber a copy of this Certificate of Coverage describing the coverage
to which he is entitled.
I. Identification Card. Upon enrollment in Health Plan, each Member will be
issued an identification card. it Is the Member's responsibility to notify
Health Plan if no identification card is received from Health Plan within
three (3) weeks after the Member's effective date of coverage. In
addition, it is the Member's responsibility to present the identification card
to each provider at the time of service. Failure to do so could result in the
27
Member being responsible for all expenses associatedwIththe provider's
services.
J. Pronouns. All personal pronouns used in this Contract shall include either
gender unless the context indicates otherwise.
K. In-Service Area Conversion Privileges.
1. A Subscriber or Family Dependent shall be entitled to have coverage
issued to him, without Evidence of Good Health, an individual
conversion contract in the event coverage under this Contract termi-
nates due to:
a. The Subscriber's termination of full -time employment; or
b. The death of the Subscriber; or
c. The divorce, dissolution or annulment of marriage of the Sub-
scriber; or
d. The Family Dependent no longer qualifies as an eligible depend-
ent, except when the termination is due to the cancellation of this
Contract or the Family Dependent is eligible as a Subscriber; or
e. Termination of coverage provided under the continuation of
coverage option, unless such termination was based upon non-
payment of Premium or Copayment Charges, fraud, failure to
establish a satisfactory patient - physician relationship, misuse of
identification card, or misrepresentation. Termination of the En-
rolling Group's Contract shall not result in eligibility for a Sub-
scriber and/or Family Dependent under the conversion plan.
2. Coverage under the individual conversion contract may be obtained
by requesting in writing from Health Plan an enrollment application
and a copy of the conversion contract. The completed enrollment
application along with the initial quarterly Premium payment (by
money order or cashier's check) for the required Premiums must be
received by Health Plan within thirty-one (31) days after termination
of coverage under this Contract. The effective dale of coverage under
the individual conversion contract will be the first day after the date of
termination of coverage under this Contract.
3. Unless otherwise provided In the conversion contract, a Member
covered under the individual conversion contract will be billed guar-
, terly on a calendar basis.
28
SECTION XI
SCHEDULE OF BENEFITS .
A. Health Services Rendered By Participating Providers. Each Member
shall select a Participating Primary Care Physician and use the services
of that Participating Primary Care Physician for coordination of Health
Services.
A Member shall be entitled to the Medically Necessary Health Services
described in this Section if provided by or coordinated and requested by
the Participating Primary Care Physician and approved by Health Plan.
These Health Services are subject to (1) the limitations, exclusions and
other provisions of this Contract, (2) payment by the Member of the
Copayment Charge specified for any services, and (3) payment of the
Premiums required for coverage under this Contract.
A Member shall also be entitled to those same Medically Necessary
Health Services when provided by or through Participating Referral
Consultant Physicians with prior written authorization by Health Plan
following a referral by the Participating Primary Care Physician.
Coordination by a Participating Primary Care Physician and prior written
approval by Health Plan will not be required in the case of the need for
Emergency Care. However, Emergency Care services shall be subject
to retrospective review, and should the symptoms at the time of presen-
tation indicate that the need for Emergency Care as defined in Section I
did not exist, payment will be denied and charges will be the financial
responsibility of the Member.
Should a Member receive non - Emergency Care from a physician other
than the designated Participating Primary Care Physician, or care
without necessary prior authorization and written approval from Health
Plan, the Member will be responsible for all costs incurred in such care.
Except in case of need for Emergency Care, services are covered only
it the following conditions are met:
1. Each Member must select a Participating Primary Care Physician
who will be responsible for the Member's health needs including
coordination of Out -of -Area Services, Participating Referral Consult-
ant Physicians, and Hospital admissions.
2. All services must be provided, directed, or coordinated by the Partici-
pating Primary Care Physician.
3. When indicated or required by this Contract, Health Services must be
approved by Health Plan prior to the Member receiving the Health
Services.
29
4. When the Member requires care by another physician, Hospital,
Alcohol Dependency Treatment Center, or provider, such Health
Services must be requested and recommended to Health Plan by the
Participating Primary Care Physician and Authorized in writing in
advance by Health Plan and are subject to all the terms, conditions,
limitations, and exclusions of this Contract.
The Participating Primary Care Physician will normally make Author-
ized referrals only to Participating Physicians, Participating Hospitals,
Alcohol Dependency Treatment Centers and other Participating
Providers.
B. Referral Health Services Rendered by Non - Participating Providers.
1. In the event that Medically Necessary Health Services cannot be
provided by or through Participating Providers, a Member shall be
entitled to coverage for Eligible Expenses for Medically Necessary
Health Services delivered by Non - Participating Providers, subject to
the terms and conditions of this Section.
2. Such Health Services must be requested of and recommended to
Health Plan by a Participating Primary Care Physician and Authorized
in writing in advance by Health Plan, and are subject to all the terms,
conditions, limitations, and exclusions of this Contract.
3. It is the responsibility of each Member to obtain the required written
approval(s) from Health Plan prior to receiving services from Non -
Participating Providers, including Hospitals.
Health Plan will mail the Member a written authorization form as soon
as the requested Health Service is approved by Health Plan. Upon
receiving the written authorization form, the Member should then
schedule the appointment with the providerand take the authorization
form to the provider at the time the service is rendered.
Without the required written approval(s) of Health Plan, the Member
will be responsible for all associated costs. Failure of the Participating
Provider to obtain the necessary prior written Health Plan approval(s)
will in no way excuse the responsibility of the Member to obtain Health
Plan's written approval(s), except when it is impossible for the
Member to do so before seeking Emergency Care services from or
through Non - Participating Providers.
C. Emergency Care Services
1. Inside the Service Area. In the case of need for Emergency Care (as
rti:,.,„1 defined in Section I) inside the Service Area, the Member is required
to obtain Emergency Care services tromthe designated Participating
30
Primary Care Physician or, upon authorization by Health Plan, at a
Participating Hospital emergency room. -
Emergency Care services obtained through Non - Participating Physi-
cians and non- Participating Hospitals are covered provided the
incident requiring care constitutes the need for Emergency Care as
defined in this Contract. Health Plan will pay for, or reimburse
Members for, costs incurred for Covered Services, subject to the
payment and reimbursement provisions set out in Section IV of this
Contract.
Coverage for treatment for Emergencies within the Service Area
rendered by Non - Participating Providers is limited to the care re-
quired before the Member can, without medically harmful or injurious
consequences, be treated by a Participating Physicianora Participat-
ing Hospital.
2. Outside the Service Area. Emergency Care services provided out-
side the Service Area are covered only if the Member's health would
have been jeopardized by returning to the Service Area to receive
treatment and provided that the need for services could not have been
anticipated before departure. The Member is responsible to pay all
applicable Copayment Charges as noted in this Contract at the time
the Out -of -Area Service is rendered.
Coverage for treatment of Emergencies outside the Service Area is
limited to the care required before the Member can, without medically
harmful or injurious consequences, return to the Service Area or be
treated by a Participating Physician or a Participating Hospital and
provided that the need for services could not have been anticipated
before departure. Other continuing or follow -up treatment shall be
provided only within the Service Area.
3. Reimbursement. Payment or reimbursement for Emergency Care
services (see Section IV fora complete description of reimbursement
requirements and conditions) provided by physicians, Hospitals, or
health professionals that have not contracted with Health Plan to
provide services, whether inside or outside of the Service Area, will
be at the lesser of actual costs to the Member or at Health Plan's fee
scheduleforcomparable services, subject to the Copayment Charges
and exclusions set out in this Contract (Memberwill be responsible for
balance of charges), as well as the following additional conditions:
a. The Member must notify Health Plan of the service arrangements
within forty -eight (48) hours after the onset of the need for
Emergency Care being rendered and receive authorization for
continued services if they are indicated. If the physical condition
31
does not permit such notification within the presorted time, he
must make the notification as soon as it is reasonably possible to
do so.
b. The claim for reimbursement must be made in writing within sixty
(60) days of the onset of the need for Emergency Care for which
payment is requested, accompanied by invoices or other appro-
priate evidence of payment which indicate the diagnosis, type of
treatment rendered, date of service, name and address of pro-
vider, charge for care, receipt and name of patient and Health Plan
identification number. Health Plan is not liable for reimbursement
of claim if claim is received by Health Plan more than sixty (60)
days from either the date of service or receipt of the bill by the
Member, whichever is later.
D. Benefits. Health Plan will provide the following Medically Necessary
Health Services, subject to the terms and conditions as stated in A of this
Section and in the Group Contract/Certilicate of Coverage.
Copayment
Charge
1. Medical Services except for the Medical Services
identified in this Section under D.2., 4., 7., 8., and
"General Exclusions ".
a. Services provided by or underthe direction of the . None
designated Participating Primary Care Physi-
cian in the physician's office including the follow-
ing: preventive medical care, voluntary family
planning, well child care from birth, periodic
health evaluations, vision screening, speech
screening, immunizations except for allergy (see
Section XI.,D.,1.,e.), ear examinations to deter-
mine the need for heating correction, and Mater-
nity care (see Section XI.,D.,3.).
b. Authorized services and supplies ordered by None
and provided by or under the direction of a
Participating Referral Consultant Physician in
the physician's office.
c. Authorized physician services and other surgi- None
cal and medical care provided by or under the
direction Of a Paf IClptiting Physician In a Partici-
pacing Hospital, Skilled Nursing Facility or other
Approved Health Care Facility or Program.
32
Copayment,
Charge
d. Authorized infertility services for the diagnosis None
and treatment of infertility except as excluded in
Section Xl.,E.
e. Authorized allergy testing and services. None
1. Second surgical opinion from a Participating None
Referral Consultant Physician when requested
by Health Plan.
2. Hospital and related services and services of an
Alcohol Dependency Treatment Facility which are
Participating Providers, when referred by a Partici-
pating Primary Care Physician or Health Plan's
Psychiatric Primary Provider, except for the Hospi-
tal Services identified in this Section, D.4., 5., 7., 8.,
and "General Exclusions ".
a. Inpatient Services.
When Authorized by Health Plan, Medically Nec-
essary inpatient Hospital Services will be ar-
ranged by a Participating Primary Care Physi -,
cian or his designee and rendered by a Partici-
pating Hospital. Services shall include semipri-
vate room and board; care and services in an
intensive care unit when Medically Necessary;
administered drugs, medications, biologicals,
fluids and chemo- therapy; special diets; dress-
ings and casts; general nursing care; use of
operating room and related facilities; blood, blood
plasma and the administration of blood transfu-
sions; x -ray, laboratory and other diagnostic
services; anesthesia and oxygen services; Short-
Term Therapy for rehabilitation services and
physical therapy, which in the judgment of Health
Plan Medical Director or his designee can be
expected to result in the significant improvement
of a condition within a period of two months from
the date of first treatment and cannot be pro-
vided on an outpatient basis; inhalation therapy;
radiation therapy; and such other Medically
Necessary services customarily provided in acute
care Hospitals. Private room and special duty
33
None
Copayment
Charge
nursing care are included only when Medically
Necessary and pre - Authorized by the Medical
Director or his designee.
b. Outpatient Services and Supplies.
(1) Emergency Care Services.
(a) Emergency Care services provided on
an outpatient basis by a Participating
Hospital or other Approved Health Care
Facility or Program.
(b) Outpatient prescription medications pro- None
vided by a Participating Hospital or other
Approved Health Care Facility in con-
junction with Hospital emergency serv-
ices for the same condition, not to ex-
ceed a 24 -hour supply.
(2) Non - Emergency Services.
(a) Authorized services and supplies f or pre- None
scheduled outpatient surgery provided
under the direction of a Participating
Physician at a Participating Hospital or
other Approved Health Care Facility or
Program.
(b) Authorized diagnostic tests provided None
under the direction of a Participating
Physician at a Participating Hospital or
other Approved Health Care Facility or
Program.
(c) Authorized outpatient infertility services None
and related supplies provided at a Par-
ticipating Hospital or other Approved
34
$25 per visit,
except when
admission for
the same condi-
tion occurs
within 24 hours.
However, the
total amount of
Copayment
Charges
charged shall
not exceed 50%
of the cost of
any single visit.
Health Care Facility or Program unless
specifically excluded in this Section,
Paragraph E., "General Exclusions."
3. Maternity Services
Authorized Matemity related medical, Hospital and None
covered Health Services, deemed Medically Neces-
sary by the Participating Physician shall be provided
as any other illness and/or Injury.
4. Mental Health Services
The following Mental Health Services are covered
when Authorized in advance by Health Plan and its
Psychiatric Primary Provider:
a. Outpatient mental health evaluations and treat- $20 per
ment for mental health conditions which are not visit
chronic or organic in nature and which are re-
sponsive to short-term treatment as determined
by the Medical Director or his designee, and for
crises intervention. Coverage under this Section
XI.,4.,a., is limited to twenty (20) visits per Con-
tract Year. A visit is not to exceed ohe hour in
duration.
b. Inpatient services and supplies on a Semiprivate 20% of
Accommodation basis for that period of time Eligible
deemed Medically Necessary in a Participating Expenses
Hospital or other Approved Health Care Facility
or Program for conditions listed in Section
XI.,D.,4.,a. Coverage underthis Section Xl.,4.,b.,
is limited to thirty (30) days per Contract Year.
c. Services and supplies provided in an approved " 20% of
psychiatric day treatment f acility underthe direc- Eligible
tion of a Participating Physician for that period of Expenses
time deemed Medically Necessary. Each full day
of services shall count as one -half of one day
inpatient Mental Health Services. Coverage under
this Section XI.,4.,c., is limited to sixty (60) days
per Contract Year.
d. Services and supplies for that period of time • 20% of
deemed Medically Necessary in a Residential Eligible
Treatment Center or Crisis Stabilization Unit. Expenses
35
Copayment
Charge
Benefits may be used only in situations in which
the Member has a serious Mental Illness which
substantially impairs the person's thought, per -
ceptionof reality, emotional processorjudgment
or grossly impairs behavior as manifested by
recent disturbed behavior, and which would oth-
erwise necessitate confinement in a Hospital if
such care and treatment were not available
through a Crisis Stabilization Unit or Residential
Treatment Center for children and adolescents.
Coverage under this Section XI.,4.,d., is limited
to sixty (60) days maximum per Contract Year.
• A combination of benef its for the above- described
services and inpatient services shall not exceed the
maximum benefit as stated for inpatient Mental
Health Services Subparagraph b. above.
The services rendered pursuant to Subparagraph c.
and d. above for which benefits are to be paid must
be based on an Individual Treatment Plan. The
benefits are subject to the same benefit maximums,
durational limits, and Copayment Charges as set
forth in Subparagraph 4. above.
Providers of services for which benefits are to be
paid must be licensed by the appropriate state
agency or board to provide those services.
Treatment in a Residential Treatment Center for
children and adolescents shall be determined as if it
were inpatient care and treatment in a Hospital, and
each two days of treatment in a Residential Treat-
ment Center for children and adolescents will be
considered equal to one day of treatment of mental
or emotional illness or disorder in a Hospital or
inpatient program, necessary care and for the pur-
pose of determining policy benefits and benefit
maximums.Treatment provided through Crisis Sta-
bilization Units shall be determined as if it were
inpatient care and treatment in a Hospital, and two
days in a Crisis Stabilization Unit are considered
equal to one day of treatment for mental or emo-
tional illness or disorder in a Hospital or inpatient
program, necessary care and for the purpose of
36
Copayment
Charge
determining policy benefits and benefit maximums.
Treatment provided through Crisis Stabilization Units
shall be reimbursed as a facility licensed or certified
by the Texas Department of Mental Health and
Mental Retardation.
Copayment-
Charge
5. Medical and Hospital Services Related to Recon-
structive Surgery When Authorized by Health Plan
Reconstructive surgery and all other required Medi- None
cally Necessary services provided by or under the
direction of a Participating Physician in a physician's
office, a Participating Hospital or other Approved
Health Care Facility or Program only when the
reconstructive surgery is necessary to:
a. Correct Congenital Anomalies when required to
restore normal physiological functioning; or
b. Restore normal physiological functioning follow-
ing an accident, Injury, disease or surgery.
6. Ambulance Service
a. A Member is entitled to Medically Necessary None
ambulance service within the Service Area, pro-
vided such ambulance service is Authorized by
the Medical Director or his designee, or the use
of such ambu -lance service Is determined nec-
essary for Emergency Care.
b. A Member is entitled to ambulance service util- None
ized while outside the Service Area to transport
the Member to the nearest health care facility
when Authorized by the Medical Director or his
designee, or the use of ambulance service is
determined by Health Plan to have been re-
quired because of Emergency Care.
7. Drug Abuse and Drug Addiction Detoxification
The following Health Services are covered when
provided and Authorized in advance by Health Plan
and its Psychiatric Primary Provider:
a. Outpatient diagnosis and medical treatment for $20 per
drug abuse detoxification and services provided visit
by or under the direction of a Participating Phy-
37
sician at the physician's office or other Approved 'f
Health Care Facility or Program.
b. Inpatient services and supplies on a Semipri - 20% of
vate Accommodation basis for drug abuse de- Eligible
toxification forthat period of time deemed Medi- Expenses
cally Necessary by a Participating Physician, in for inpatient
an Approved Health Care Facility or Program. services
c. Physician services to determine the need for $20 per
and in appropriate cases to obtain a referral to visit
Non - Participating Provider are covered. The
services provided by that Non - Participating
Provider are not covered.
8. Miscellaneous Health Services
a. Services and supplies provided by a Home None
Health Agency, either at home or in the Hospital,
when deemed Medically Necessary by the
Participating Physician and Authorized in ad-
vance by Health Plan.
b. Prosthetics:
If provided by or under the direction of a Partici- None
pacing Physician, when Authorized in advance
by Health Plan, for use outside a Hospital,
Skilled Nursing Facility, orotherApproved Health
Care Facility or Program, initial purchase of
artificial limbs, artificial eyes, breast prostheses,
and other Authorized prostheses made neces-
sary as a result of Injury or Sickness (except that
repair, replacement and duplicates are not
covered).
c. Durable Medical Equipment:
To the extent that the maximum benefit cover- None
age under this Contract payable per Contract
Year per Member does not exceed $500.00,
rental or purchase at Health Plan's option of the
following Durable Medical Equipment (except
that repair, replacement and duplicates are not
covered):
38
Copayment
Charge
(1) Braces, including necessary adjustment to
shoes to accommodate braces (dental
braces are excluded);
(2) Oxygen and the rental of equipment for the
administration of oxygen;
(3) Wheelchairs;
(4) A hospital -type bed.
d. Mechanical equipment necessary for treatme nt None
of chronic or acute respiratory failure (except
that air conditioners, humidifiers, dehumidifiers
and other personal comfort items are excluded).
9. Physical Therapy Services
Short-Term Therapy services performed or ren- None
dered on an outpatient basis at a Participating
Hospital or other Approved Health Care Facility or
Program or by a Participating Provider when di-
rected and monitored by a Participating Primary
Care Physician, and Authorized in advance by
Health Plan. Such provision of these services must
be expected to result in the significant improvement
of a Member's condition within a period of two
months, as determined by the Medical Director.
10. Occupational Therapy Services
Short-Term Therapy services performed or ren- None
dered on an outpatient basis at a Participating
Hospital or other Approved Health Care Facility or
Program or by a Participating Primary Care Physi-
cian, and Authorized in advance by Health Plan.
Such provision of these services must be expected
to result in the significant improvement of a Members
condition within a period of two months, as deter-
mined by the Medical Director.
11. Speech and Hearing Therapy Services
Short-Term Therapy services performed or ren- None
dered on an outpatient basis at a Participating
Hospital or other Approved Health Care Facility or
Program or by a Participating Provider when di-
39
Copayment
Charge
rected or monitored by a Participating Primary Care
Physician, and Authorized in advance by Health
Plan. Such provision of these services must be
expected to result in significant improvement of a
Member's condition within a period of two months,
as determined by the Medical Director.
12. Family Planning Services
Family Planning Services shall be available to the None
Members on avoluntary basis. These services shall
include but not be limited to:
a. Medical history, physical examination, related None
laboratory tests, information about the use of
contraceptives, and information about the pre-
vention of venereal disease.
b. Medical services connected with surgical sterili-
zation:
1. Vasectomy
2. Tuba! Ligation
13. Health Education Services
40
Copayment
Charge
necessary to safeguard the health of a Memberbecause of a specific,
non - dental physiological impairment.
2, Dental services in connection with the treatment of temporomandibu-
lar joint dysfunction (TMJ).
3. Custodial care or rest cures.
4. Cosmetic, medical, or surgical procedures except reconstructive
surgery necessary to repair a functional disorder as a result of
disease, Injury, or Congenital Anomaly. The exclusions to the extent
not Medically Necessary include: surgical excision or reformation of
any sagging skin on any part of the body, including but not limited to,
the eyelids, face, neck, abdomen, arms, legs, or buttocks; any
services performed in connection with the enlargement, reduction,
implantation or change in appearance in a portion of the body
including, but not limited to, the breasts, face, lips, jaw, chin, nose,
ears or genitals; hair transplantation; chemical face peels or abra-
sions of the skin; electrolysis depilation; or any other surgical or non-
surgical procedures which are primarily for cosmetic purposes.
5. In -vitro fertilization (unless provided by rider), intra- fallopian transfer
$75.00 treatment and embryo transplants.
$200.00
Health Plan will organize, sponsor or conduct pro- None
grams in health education for the benefit of all
Members. Programs offered may include instruc-
tions in the appropriate use of Health Services,
information about the Health Services offered by
Health Plan and the generally accepted medical
standards for the use and frequency of such serv-
ices, and/or instructions on the methods each
Member can take to maintain his own health, such
as personal health care measures and nutritional
education and counseling.
E. General Exclusions. This Contract does not cover any of the following:
1. Dental surgery, treatment or care (including treatment of overbite or
underbite), or dental x -rays, supplies and appliances (including
occlusal splints) and all associated expenses arising out of such
dental surgery, treatment or care (including hospitalizations), except
for Hospital, dental and physician services and supplies and anes-
thesiology services recommended by a Participating Primary Care
Physician and approved in writing in advance by Health Plan, as are
6. Experimental medical, surgical or psychiatric procedures and phar-
macological regimes. As used herein, "experimental" means those
procedures and /or treatments which are not generally accepted by
the medical community. Health Plan reserves the right to change the
coverage with respect to experimental procedures, from time to time,
so as to add or delete certain medical, surgical or psychiatric
procedures or treatments or pharmacological regimes.
7. Organ transplants (except kidney and cornea transplants and liver
transplants in minors with biliary atresia).
8. Keratotomies, acupuncture, naturopathy, megavitamin therapy,
psycho- surgery, and nutritional based therapy for Alcoholism.
9. Elective abortions.
10. Circumcisions unless medically indicated.
11. Health Services in such circumstances in which referral services not
Authorized in writing in advance by Health Plan or not provided by or
under the direction of the Participating Primary Care Physician
except in an Emergency Care situation.
12. Vision training, eye exercises, orthoptics and radial keratotomy, eye
glasses and frames, contact lenses, hearing aids or the fitting thereof.
41
13. Such services as television, telephone, barber or beauty service,
guest service and similar incidental services and supplies which are
not Medically Necessary.
14. Mental Health Services which are (a) extended beyond the period
necessary for evaluation and diagnosis of the psychiatric portion of
leaming and behavioral disabilities or for mental retardation, or (b) for
marriage counseling not associated with Mental Illness, or (c) except
for evaluation and crisis intervention, those Mental Health Services
for psychiatric conditions which are determined by the Medical
Director to be unresponsive to Short-Term Therapy.
Chronic psychosis, intractable personality disorders, mental retarda-
tion, psychiatric therapy on court order as a condition of parole or
probation, hypnotherapy and chronic organic brain syndromes are
excluded, except that Mental Health Services required as a result of
an acute episode due to a chronic organic brain syndrome are
covered.
15. The services of registered nurses and licensed practical nurses with
the same legal residence as, or who are Members of, a family
including spouse, brothers, sisters, parents or children.
16. Health Services rendered by a provider who is a Member of the
family, including spouse, brothers, sisters, parents or children.
17. Physical, psychiatric, psychological examinations or testing, vacci-
nations, immunizations, treatments, or testing not otherwise covered
under this Contract, when such services are for purposes of obtaining
or maintaining employment or insurance, or otherwise relating to
employment or insurance, or relating to Judicial or administrative
proceedings or orders, or which are conducted for purposes of
medical research, or which are conducted to obtain or maintain a
license of any type, or which are conducted forthe purposes of school
physical exams.
18. Travel and transportation expenses.
19. Outpatient services (including Hospital emergency room services)
not provided by a Participating Primary Care Physician and all
associated expenses which may be obtained during normal physi-
cian office hours, unless Authorized in advance by Health Plan or in
the case of need for Emergency Care services as defined herein.
20. Prosthetic devices, medical etUutphtent and appliances (except as
provided in this Section under D.,8.,c.), including air conditioners, air
I y `, filters, humidifiers, dehumidifiers, spas and the repair, replacement
or duplication thereof, even though prescribed by a physician.
42
21. Sex change operations and reversal of elective sterilization proce-
dures.
22. All costs associated with the collection and preservation of sperm for
artificial Insemination, including donor fees, unless provided by a
separate rider to this Contract.
23. Physical, occupational, speech and hearing therapy services not
approved in advance by Health Plan.
24. Services in connection with Long -Term physical medicine and reha-
bilitative Therapy services (including Long -Term physical oroccupa-
tional Therapy).
25. Treatment for drug abuse and drug addiction (detoxification, treat-
ment of medical complications, determination of need, and referral to
specialized services are covered).
26. Services in connection with long -term speech and hearing therapy.
27. Prescription medications except as provided in this Section.
28. Routine foot care such as treatment for corns and callouses and the
cutting of toe nails unless approved by Health Plan.
29. All costs associated with the normal delivery of a newborn child
outside the Health Plan Service Area. Complications of pregnancy
for all Members are treated as any other illness.
30. Outpatient medical disposable /consumable supplies and deluxe
Durable Medical Equipment such as motor driven wheelchairs and
beds.
31. Any portion of the cost in excess of the Usual, Reasonable and
Customary Charges for an Emergency Care Out -of -Area Service.
32. Convenience charges for after -hour physician office visit (outside of
the normal office visit hours).
33. Conditions for which state or local law requires treatment in a state
or local governmental facility or for services performed in an institu-
tion owned or operated by the United States of America, when there
is no obligation that the Subscriber or the Family Dependent pay in
the absence of health care coverage.
34. To the extent a natural disaster, war, riot, civil insurrection, epidemic,
or any other Emergency Care or similar event not within Health Plan's
control results in the services, personnel, or financial resources of
Health Plan being unavailable to provide or arrange for the provision
of benefits or services otherwise available under this Contract.
Health Plan shall be required only to make a good -faith effort to
43
provide or arrange for the provision of such health care benefits and
services, taking into account the impact of the event.
35. Routine eye refractions unless provided by rider.
36. All surgical or invasive procedures intended primarily for treatment of
obesity, including gastric bypasses, jejuna) bypasses, and balloon
procedures unless Authorized by Health Plan.
44
GCC- 15 -1(R)
TEXAS HEALTH PLANS, INC.
8303 MoPac, Suite 450
Austin, Texas 78759
Phone (512) 338 -6100
Group Contract/Certificate of Coverage
This Group Contract/Certificate of Coverage is a legal contract between the
Enrolling Group and Texas Health Plans, Inc. It sets forth in detail your rights
and obligations as a Member.
It is therefore important that you READ your Group Contract/Certificate of
Coverage CAREFULLY and familiarize yourself with its terms and condi-
tions. For reference purposes, a table of contents has been included.
BY:
ete rEV �nI • id
eter E. Kllissanly, President
and Chief Executive Officer
DATE: 2-1 -89
A Texas Health Maintenance Organization