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Ross Stores - Group Insurance Plan - Ross Stores, Inc.
Exhibit 10.9
GROUP INSURANCE PLAN - ROSS STORES, INC.
MEDICAL
TABLE OF CONTENTS
Certification
THE SCHEDULE
Section 125 Plan
HOW TO FILE YOUR CLAIM
Eligibility - Effective Date
Comprehensive Medical Benefits
Prescription Drug Benefits
General Limitations
Medicare Eligibles
Coordination of Benefits
Conditional Claim
Payment of Benefits
Termination of Insurance
Benefits Extension
Accident and Health Provisions
Summary Plan Description
Definitions
1
SERVICES AVAILABLE IN CONJUNCTION WITH YOUR MEDICAL PLAN The following several pages describe helpful services available in conjunction with your medical plan. You can access these services simply by calling the toll-free number shown on the back of your ID card. These services are provided by Intracorp, a CIGNA Company and can help ensure that you and your covered Dependents benefit fully from your medical coverage. For example:
Through CIGNA'S TOLL-FREE CARE LINE, you can talk to a trained
registered nurse who will help answer general benefit questions and
will provide you with the names of participating providers in your
area and in other cities should you require medical care while away
from home.
CASE MANAGEMENT services help individuals with short-term and
catastrophic medical conditions by offering appropriate treatment
options which meet the patient's needs and keep costs manageable. You are encouraged to maximize the benefits under your medical plan by taking advantage of these important services.
CIGNA'S TOLL-FREE CARE LINE CIGNA's toll-free care line is a medical advisory service provided through Intracorp, a CIGNA company. You can talk to a Registered Nurse (RN) during normal business hours, Monday through Friday, simply by calling the toll-free number shown on your ID card. All calls are confidential. CIGNA's toll-free care line RNs can help answer general benefit questions, such as questions regarding pre-admission certification, and can provide assistance in locating physicians, hospitals and other health care services. CIGNA's toll-free care line personnel can also provide you with the names of participating providers. If you or your dependents need medical care, you may consult your Physician Guide which lists the participating providers in your area or call CIGNA's toll-free number for assistance. And, if you or your dependents need medical care while away from home, you may have access to a national network of participating providers through CIGNA's Away-From-Home Care feature. Call CIGNA's toll-free care line for the names of participating providers in other network areas. Whether you obtain the name of a participating provider from your Physician Guide or through the care line, it is recommended that you call the provider to confirm that he or she is a current participant in the CIGNA Preferred Provider Program prior to making an appointment. CIGNA's toll-free care line personnel cannot: answer specific questions about your medical coverage or claims, provide medical opinions, comment on the competency or reputation of a provider, prescribe medication, give diagnoses or advice about treatment. You may be referred to an appropriate resource for questions related to these topics.
CASE MANAGEMENT Case Management is a service provided through Intracorp, a CIGNA Company, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a hospital or specialized facility. Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending physician to determine appropriate treatment options which will best meet the patient's needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis. Intracorp Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, each trained in a clinical specialty area such as trauma, high risk pregnancy and neonates, oncology, mental health, rehabilitation or general medicine and surgery. A Case Manager trained in the appropriate clinical specialty area will be assigned to you or your dependent. In addition, Case Managers are supported by a panel of physician advisors who offer guidance on up-to-date treatment programs and medical technology. While the Case Manager recommends alternate treatment programs and helps coordinate needed resources, the patient's attending physician remains responsible for the actual medical care.
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CASE MANAGEMENT (cont'd)
1. You, your dependent or an attending physician can request Case
Management services by calling the TOLL-FREE CARE LINE NUMBER shown on
the back of your ID card during normal business hours, Monday through
Friday. In addition, your employer, a claim office or a utilization
review program (see the PAC/CSR section of your certificate) may refer
an individual for Case Management.
2. Intracorp assesses each case to determine whether Case Management is
appropriate.
3. You or your dependent is contacted by an assigned Case Manager who
explains in detail how the program works. Participation in the
program is voluntary - no penalty or benefit reduction is imposed if
you do not wish to participate in Case Management.
4. Following an initial assessment, the Case Manager works with you, your
family and physician to determine the needs of the patient and to
identify what alternate treatment programs are available. (For
example, in-home medical care in lieu of an extended hospital
convalescence.) You are not penalized if the alternate treatment
program is not followed.
5. The Case Manager arranges for alternate treatment services and
supplies, as needed. (For example, nursing services or a hospital bed
and other durable medical equipment for the home.)
6. The Case Manager also acts as a liaison between the insurer, the
patient, his or her family and physician as needed. (For example, by
helping you to understand a complex medical diagnosis or treatment
plan.)
7. Once the alternate treatment program is in place, the Case Manager
continues to manage the case to ensure the treatment program remains
appropriate to the patient's needs. While participation in Case Management is strictly voluntary, Case Management professionals can offer quality, cost-effective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need.
NOTICE HEALTH CARE SERVICES
A denial of claim or a clinical decision regarding health care services will be made by qualified clinical personnel. Notice of denial or determination will include information regarding the basis for denial or determination and any further appeal rights.
AUTHORIZATION
No authorization will be required prior to receiving Emergency Services.
NON-ENGLISH ASSISTANCE
For non-English assistance in speaking to Member Services, please use the translation service provided by AT+T. For a translated document, please contact your Member Services Representative.
CONNECTICUT GENERAL LIFE INSURANCE COMPANY a CIGNA company (called CG) certifies that it insures certain Employees for the benefits provided by the following policy(s):
POLICYHOLDER: ROSS STORES, INC.
GROUP POLICY(S) -- COVERAGE 2244113-05 MEDICAL EXPENSE
CERTIFICATE DATE: January 1, 1998 This certificate describes the main features of the insurance. It does not waive or alter any of the terms of the policy(s). If questions arise, the policy(s) will govern.
This certificate takes the place of any other issued to you on a prior date which described the insurance.
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EXPLANATION OF TERMS
You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms are defined in the Definitions section of your certificate.
THE SCHEDULE
THE SCHEDULE IS A BRIEF OUTLINE OF YOUR MAXIMUM BENEFITS WHICH MAY BE PAYABLE UNDER YOUR INSURANCE. FOR A FULL DESCRIPTION OF EACH BENEFIT, REFER TO THE APPROPRIATE SECTION LISTED IN THE TABLE OF CONTENTS.
COMPREHENSIVE MEDICAL BENEFITS
FOR YOU AND YOUR DEPENDENTS THIS PLAN WILL PAY:
LIFETIME MAXIMUM Unlimited BENEFIT
MAXIMUM BENEFITS
Inpatient Mental Illness 150 days
Maximum (Calendar Year)
Outpatient Mental Illness, 150 visits
Alcohol and Drug Abuse Maximum (Calendar Year)
Lifetime Inpatient and $150,000 Outpatient Alcohol and Drug Abuse Maximum
Outpatient Rehabilitative Unlimited Therapy Maximum
External Prosthesis Maximum Unlimited
Durable Medical Equipment Unlimited Maximum
Preventive Care Maximum Unlimited
Home Health Care Maximum 120 visits per calendar year
Hospice Care Maximum Unlimited
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THE SCHEDULE
COMPREHENSIVE MEDICAL BENEFITS (CONT'D)
FOR YOU AND YOUR DEPENDENTS THIS PLAN WILL PAY:
COVERED EXPENSE DAILY LIMIT
Skilled Nursing 120 days per calendar year Facility Maximum
Infertility Maximum Artifical insemination is limited
to 3 attempts per cycle, 8 cycles
per lifetime
Participating Provider Hospital 100% of the negotiated rate
Non-Participating Provider Hospital 100%
Participating Provider 100% Hospice Facility
Non-Participating Provider 100% Hospice Facility
Skilled Nursing Facility 100% for up to 120 days in a
calendar year
COPAYMENTS/DEDUCTIBLES
Copayments are expenses to be paid by you or your Dependent for the services received.
Participating Provider Office Visit Copayment
All Office Visits No charge
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COMPREHENSIVE MEDICAL BENEFITS (cont'd) BENEFIT PERCENTAGE
The Benefit Percentage for Covered Expenses incurred for charges made by a Participating or a Non-Participating Provider is as follows:
PARTICIPATING NON-PARTICIPATING
PROVIDER PROVIDER
Inpatient Alcohol and 100% 100% Drug Abuse
Outpatient Mental Illness, 100% 100% Alcohol and Drug Abuse
Emergency Services 100% 100%
Well-Baby Care 100% 100%
Preventive Care 100% 100%
All Other Covered Expenses 100% 100%
MATERNITY HOSPITAL STAY
Group health plans and health insurance issuers offering group health insurance coverage generally may not, under federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the plan or insurance issuer for prescribing a length of stay not in excess of the above periods. This does not guarantee coverage for childbirth. Please review this Plan for further details on the specific coverage available to you and your Dependents under this Plan.
PAC/CSR REQUIREMENTS. Pre-Admission Certification (PAC) and Continued Stay Review (CSR) refer to the process used to certify the medical necessity and length of any Hospital Confinement as a registered bed patient. PAC and CSR are performed through a utilization review program by a Review Organization with which CG has contracted. PAC should be requested by you or your Dependent for each inpatient Hospital admission. CSR should be requested, prior to the end of the certified length of stay, for continued inpatient Hospital Confinement.
Expenses incurred for which benefits would otherwise be paid under this plan will not include the first $300 of Hospital charges made for each separate admission to the Hospital as a registered bed patient unless PAC is received: (a) prior to the date of admission; or (b) in the case of an emergency admission, by the end of the second scheduled work day after the date of admission.
The amount otherwise payable under this plan for the Hospital charges listed below will be reduced by 50% for:
Hospital charges for Bed and Board, during a Hospital Confinement for
which PAC is performed, which are made for any day in excess of the
number of days certified through PAC or CSR; and
any Hospital charges made during any Hospital Confinement as a
registered bed patient: (a) for which PAC was performed; but (b) which
was not certified as medically necessary.
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PAC/CSR REQUIREMENTS (CONT'D)
In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this plan, except for the "Coordination of Benefits" section.
You should start the PAC process by calling the Review Organization prior to an elective admission, or in the case of an emergency admission, by the end of the first scheduled work day after the admission. For an admission due to pregnancy, you should call the Review Organization by the end of the third month of pregnancy. The Review Organization will continue to monitor the confinement until you are discharged from the Hospital. The results of the review will be communicated to you, the attending Physician, and CG.
The Review Organization is an organization with a staff of Registered Graduate Nurses and other trained staff members who perform the PAC and CSR process in conjunction with consultant Physicians.
PRESCRIPTION DRUG BENEFITS
You and your Dependent must pay a portion of Covered Prescription Drugs to receive Prescription Drug Benefits. That portion is described below.
COPAYMENT
Copayment is that portion of Covered Prescription Drugs which you or your Dependent is required to pay under this benefit.
PARTICIPATING RETAIL PHARMACY COPAYMENT
For each Prescription Order No charge
PARTICIPATING MAIL-ORDER PHARMACY COPAYMENT
For each Prescription Order No charge
SECTION 125 PLAN
Your Employer has agreed to provide benefits according to Section 125 of the Internal Revenue Code. A Section 125 plan is a written group insurance plan which allows Employees a choice among two or more benefits consisting of salary (cash) and non-taxable benefits. Non-taxable benefits may be in the form of salary reduction. Therefore, normally taxable salary remains Employer money and is put toward benefits tax-free. Because your group insurance plan is a Section 125 plan, certain provisions of this certificate are superseded as described below.
NO LONGER IN ACTIVE SERVICE
If you return to Active Service within the same benefit plan year following your termination of employment, Section 125 plan provisions supersede the "Eligibility - Effective Date" section under the "Eligibility For Employee Insurance" provisions of your certificate as follows:
If your insurance ceases due to your termination of employment, your
Employer may allow you to become insured again for your previously
selected benefits upon your return to Active Service.
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TERMINATION OF INSURANCE DUE TO FAILURE TO PAY PREMIUM
If you fail to pay premium resulting in termination of your group insurance coverage, Section 125 plan provisions supersede the "Eligibility - Effective Date'' section under the "Eligibility For Employee Insurance" provisions of your certificate as follows:
If your insurance ceases due to your failure to pay required premium,
unless you are not in Active Service due to qualified leave of absence
under the Family and Medical Leave Act of 1993, you will not be
permitted to elect any coverage until the next Open Enrollment Period. In addition, due to failure to pay premium resulting in termination of your group insurance coverage, Section 125 plan provisions supersede the "Eligibility - - Effective Date" section under the "Late Entrant - Employee" provisions of your certificate as follows:
You may not enroll as a Late Entrant by providing evidence of good
health, if your coverage terminates due to cancellation of your
payroll deduction. You are not considered enrolled in the group
insurance plan. You will not be able to select group insurance
coverage until the next benefit plan year.
CHANGE IN FAMILY STATUS
Due to a change in your family status, which changes your coverage needs, you may be eligible to change your benefits. Section 125 plan provisions supersede the "Eligibility - Effective Date" section under the "Eligibility For Employee Insurance" provisions in your certificate as follows:
You may be eligible to change your original selection of benefits when
a change in your family status occurs. Consult your Employer for
details.
HOW TO FILE YOUR CLAIM
The prompt filing of any required claim form will result in faster payment of your claim.
You may get the required claim forms from your Benefit Plan Administrator. All fully completed claim forms and bills should be sent directly to your servicing CG Claim Office.
Depending on your Group Insurance Plan benefits, file your claim forms as described below.
If you utilize a CIGNA participating provider that provider will usually file the claim on your behalf. If you do not utilize a CIGNA provider, claim submission will be your responsibility.
HOSPITAL CONFINEMENT
If possible, get your Group Medical Insurance claim form before you are admitted to the Hospital. This form will make your admission easier and any cash deposit usually required will be waived.
If you have a Benefit Identification Card, present it at the admission office at the time of your admission. The card certifies that you are insured and tells the Hospital to send its bills directly to CG.
DOCTOR'S BILLS AND OTHER MEDICAL EXPENSES
The first Medical Claim should be filed as soon as you have incurred covered expenses. Itemized copies of your bills should be sent with the claim form. If you have any additional bills after the first treatment, file them periodically.
CLAIM REMINDERS
BE SURE TO USE YOUR SOCIAL SECURITY AND ACCOUNT NUMBER WHEN YOU FILE
CG'S CLAIM FORMS, OR WHEN YOU CALL YOUR CG CLAIM OFFICE.
YOUR ACCOUNT NUMBER IS 2244113.
PROMPT FILING OF ANY REQUIRED CLAIM FORMS RESULTS IN FASTER PAYMENT OF
YOUR CLAIMS.
WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and confinement in prison.
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ELIGIBILITY - EFFECTIVE DATE ELIGIBILITY FOR EMPLOYEE INSURANCE
You will become eligible for insurance on the day you complete the waiting period if:
you are in a Class of Eligible Employees; and
you are an eligible, full-time Employee. Initial Employee Group: You are in the Initial Employee Group if you are employed in a class of employees on the date that class of employees becomes a Class of Eligible Employees as determined by your Employer. New Employee Group: You are in the New Employee Group if you are not in the Initial Employee Group.
ELIGIBILITY FOR DEPENDENT INSURANCE
You will become eligible for Dependent insurance on the later of:
the day you become eligible for yourself; or
the day you acquire your first Dependent.
WAITING PERIOD
Initial Employee Group: None
New Employee Group: Date of hire
CLASSES OF ELIGIBLE EMPLOYEES
All Employees as specified by your Employer
ELIGIBILITY - EFFECTIVE DATE EMPLOYEE INSURANCE
This plan is offered to you as an Employee.
EFFECTIVE DATE OF YOUR INSURANCE
You will become insured on the date you become eligible.
If you are not in Active Service on the date you would otherwise become insured, you will become insured on the date you return to Active Service.
EFFECTIVE DATE OF DEPENDENT INSURANCE
Insurance for your Dependents will become effective on the date you become eligible for Dependent Insurance. All of your Dependents as defined will be included.
Your Dependents will be insured only if you are insured.
EXCEPTION FOR NEWBORNS
Any Dependent child born while you are insured for Medical Insurance will become insured for Medical Insurance on the date of his birth if you elect Dependent Medical Insurance no later than 31 days after his birth. If you do not elect to insure your newborn child within such 31 days, coverage for that child will end on the 31st day. No benefits for expenses incurred beyond the 31st day will be payable. If you acquire a new Dependent through marriage, birth, adoption or placement for adoption, you may enroll yourself and your Dependents provided you request enrollment by the last day of the 30-day period which begins on the day of the event. Coverage will be effective for a spouse, on the first day of the month after enrollment, and for a child, on the date of birth, adoption, or placement for adoption. If you are covered by a plan which includes a Pre-existing Condition limitation, the limitation will apply to you and your Dependents upon enrollment, reduced by prior Creditable Coverage.
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REQUIREMENTS OF THE OMNIBUS BUDGET RECONCILIATION ACT OF 1993 (OBRA'93) THESE HEALTH COVERAGE REQUIREMENTS DO NOT APPLY TO ANY BENEFITS FOR LOSS OF LIFE, DISMEMBERMENT OR LOSS OF INCOME.
Any other provisions in this certificate that provide for: (a) the definition of an adopted child and the effective date of eligibility for coverage of that child; and (b) eligibility requirements for a child for whom a court order for medical support is issued; are superseded by these provisions required by the federal Omnibus Budget Reconciliation Act of 1993, where applicable.
A. ELIGIBILITY FOR COVERAGE UNDER A QUALIFIED MEDICAL CHILD SUPPORT ORDER
If a Qualified Medical Child Support Order is issued for your child, that child will be eligible for coverage as required by the order and you will not be considered a Late Entrant for Dependent Insurance.
You must notify your Employer and elect coverage for that child as soon as reasonably possible.
QUALIFIED MEDICAL CHILD SUPPORT ORDER
A Qualified Medical Child Support Order is a judgment, decree or order (including approval of a settlement agreement) issued by a court of competent jurisdiction, and satisfies all of the following:
1. the order specifies your name and last known address, and the child's
name and last known address;
2. the order provides a description of the coverage to be provided, or
the manner in which the type of coverage is to be determined;
3. the order states the period to which it applies; and
4. the order specifies each plan that it applies to.
The Qualified Medical Child Support Order may not require the health insurance policy to provide coverage for any type or form of benefit not otherwise provided under the policy.
B. ELIGIBILITY FOR COVERAGE FOR ADOPTED CHILDREN
Any child under the age of 18 who is adopted by you, including a child who is placed with you for adoption, will be eligible for Dependent Insurance upon the date of placement with you. A child will be considered placed for adoption when you become legally obligated to support that child, totally or partially, prior to that child's adoption.
If a child placed for adoption is not adopted, all health coverage ceases when the placement ends, and will not be continued.
The provisions in the "Exceptions for Newborns" section of this certificate that describe requirements for enrollment and effective date of insurance will also apply to an adopted child or a child placed with you for adoption.
COMPREHENSIVE MEDICAL BENEFITS FOR YOU AND YOUR DEPENDENTS
If you or any one of your Dependents, while insured for these benefits, incurs Covered Expenses, CG will pay an amount determined as follows:
The Benefit Percentage of Covered Expenses incurred as shown in The
Schedule.
Payment of any benefits will be subject to: (a) any applicable Copayments, deductibles and maximum benefits shown in The Schedule; (b) the Maximum Benefit Provision; and (c) any Mental Illness, Alcohol and Drug Abuse Maximums.
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COMPREHENSIVE MEDICAL BENEFITS MAXIMUM BENEFIT PROVISION
The total amount of Comprehensive Medical Benefits payable for all expenses incurred during a person's lifetime will not exceed the Maximum Benefit shown in The Schedule.
INPATIENT MENTAL ILLNESS, ALCOHOL AND DRUG ABUSE Maximums (Calendar Year)
The total number of days for which benefits are payable for all expenses incurred in any calendar year while a person is Confined in a Hospital due to mental illness, alcohol or drug abuse will not exceed any Inpatient Maximums as shown in The Schedule for those causes.
OUTPATIENT MENTAL ILLNESS, ALCOHOL AND DRUG ABUSE Maximums (Calendar Year)
The total number of visits for which benefits are payable or the maximum amount payable for all expenses incurred in any calendar year due to mental illness, alcohol or drug abuse while a person is not Confined in a Hospital will not exceed any Outpatient Maximums as shown in The Schedule for those causes.
LIFETIME INPATIENT AND OUTPATIENT ALCOHOL AND DRUG ABUSE MAXIMUMS
The total amount of Comprehensive Medical Benefits payable for all expenses incurred for a person in his lifetime due to mental illness, alcohol or drug abuse will not exceed any Lifetime Inpatient and Outpatient Alcohol and Drug Abuse Maximums as shown in The Schedule for those causes.
COMPREHENSIVE MEDICAL BENEFITS COVERED EXPENSES
The term Covered Expenses means the expenses incurred by or on behalf of a person for the charges listed below, if they are incurred after he becomes insured for these benefits. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and are essential for the necessary care and treatment of an Injury or a Sickness.
COVERED EXPENSES
charges made by a Hospital, on its own behalf, for Bed and Board and
other Necessary Services and Supplies; except that for any day of
Hospital Confinement, Covered Expenses will not include that portion
of charges for Bed and Board which is more than the Bed and Board
Limits shown in The Schedule.
charges made by a Hospital for inpatient care for a mother and newborn
for at least 48 hours following a vaginal delivery or at least 96
hours following a cesarean section. The mother has the option of being
discharged early. Services may be rendered by a certified
nurse-midwife, a licensed facility, or a Physician. These services
include parent education, assistance in feeding the newborn, and
maternal and newborn clinical assessments. If discharge is prior to 48
or 96 hours, at least 1 home health care visit will be covered in full
if made within 24 hours of discharge.
charges for licensed ambulance service to or from the nearest Hospital
where the needed medical care and treatment can be provided.
charges made by a Hospital, on its own behalf, for medical care and
treatment received as an outpatient.
charges made by a Free-Standing Surgical Facility, on its own behalf,
for medical care and treatment.
charges made by a Skilled Nursing Facility, on its own behalf, for
medical care and treatment; except that Covered Expenses will not
include that portion which is more than the Skilled Nursing Facility
Limit shown in The Schedule.
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COMPREHENSIVE MEDICAL BENEFITS
COVERED EXPENSES (CONT'D)
charges made for surgical implants of any type including any
prosthetic device attached to it.
charges made by a facility licensed to furnish mental health services,
on its own behalf, for care and treatment of mental illness provided
on an outpatient basis.
charges made by a facility licensed to furnish treatment of alcohol
and drug abuse, on its own behalf, for care and treatment provided on
an outpatient basis.
charges made by a Physician or a Psychologist for professional
services.
charges made by a Nurse for professional nursing service.
charges made for anesthetics and their administration; diagnostic
x-ray and laboratory examinations; x-ray, radium, and radioactive
isotope treatment; chemotherapy; blood transfusions and blood not
donated or replaced; oxygen and other gases and their administration;
rental or, at CG's option, purchase of Durable Medical Equipment;
therapy provided by a licensed physical, occupational or speech
therapist; prosthetic appliances including devices to restore a method
of speaking following a laryngectomy other than electronic voice
producing machines; dressings.
charges made for or in connection with approved organ transplant
services, including immunosuppressive medication; organ procurement
costs; and donor's medical costs. The amount payable for donor's
medical costs will be reduced by the amount payable for those costs
from any other Plan. Certain transplants will not be covered based on
General Limitations. Contact CG before you incur any such costs.
charges made for or in connection with a mammogram for breast cancer
screenings or diagnostic purposes.
charges made by a Participating Provider for: (a) an annual routine
physical examination and (b) immunizations.
expenses eligible for reimbursement under Internal Revenue Code 502.
charges made for artificial insemination limited to three attempts per
cycle, eight cycles per lifetime.
charges made by a licensed social worker, a registered Nurse licensed
in psychiatric-mental health or a licensed marriage, family or child
counselor, for professional services in connection with mental illness
when such services are recommended by a Physician.
charges made for or in connection with an annual Papanicolaou
screening test.
In addition, Covered Expenses will include expenses incurred at any of the Approximate Age Intervals shown below for a Dependent child from birth to age 19 for charges made for Preventive Care for children consisting of the following services delivered or supervised by a Physician, in keeping with prevailing medical standards as determined by the American Academy of Pediatrics: (a) postnatal Hospital visit by a Physician, while the Dependent Child is an
inpatient; and (b) well-child visits to a Physician which will include:
a medical history;
a complete physical examination;
developmental assessment;
anticipatory guidance;
appropriate immunizations; and
laboratory tests when ordered at the time of a visit and performed in
the practitioner's office or in a clinical laboratory;
excluding any charges for:
services for which benefits are otherwise provided under this
Comprehensive Medical Benefits section;
services for which benefits are not payable according to the Expenses
Not Covered section.
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COMPREHENSIVE MEDICAL BENEFITS COVERED EXPENSES (CONT'D) Approximate Age Intervals are: Birth, 2 or 3 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years, one visit every 2 years from age 6 to age 12, and one visit every 3 years from age 12 to age 18.
charges for a drug that has been prescribed for the treatment of a
type of cancer for which it has not been approved by the Food and Drug
Administration (FDA), only if such drug is recognized for the
treatment of the specific type of cancer for which the drug has been
prescribed in one of the established reference compendia: (i) the
American Medical Association Drug Evaluations; (ii) the American
Hospital Formulary Service Drug Information; (iii) the United States
Pharmacopeia Drug Information; or (iv) recommended by a review article
or editorial comment in a major peer-reviewed professional journal;
charges for medically necessary nutritional supplements (formulas that
enable the body to process or metabolize amino acids) for the
treatment of phenylketonuria (PKU), branched-chain ketonuria,
galactosemia, and homocystinuria when administered under the direction
of a Physician;
charges made by a Physician or member of his office staff, certified
diabetes nurse-educator, certified nutritionist, or licensed dietitian
for a program which provides instruction for a person with diabetes,
for the purpose of instructing such person about the disease and its
control. Training will be provided in group sessions, where
practicable. If medically necessary, training will be provided in the
person's home;
charges for glucometers, blood glucose-monitors, monitors for the
legally blind, insulin pumps, infusion devices and related
accessories;
charges made by a Home Health Care Agency for the following medical
services and supplies provided under the terms of a Home Health Care
Plan for the person named in that plan:
part-time or intermittent nursing care by or under the supervision of
a Registered Graduate Nurse;
part-time or intermittent services of a Home Health Aide;
physical, occupational, or speech therapy;
medical supplies; drugs and medicines lawfully dispensed only on the
written prescription of a Physician; and laboratory services; but only
to the extent that such charges would have been considered Covered
Expenses had a person required confinement in the Hospital as a
registered bed patient or confinement in a Skilled Nursing Facility;
excluding any charges for:
home health care visits during a calendar year, in excess of the Home
Health Care Maximum shown in The Schedule. (To determine the benefits
payable, each visit by an employee of a Home Health Care Agency will
be considered one home health care visit and each 4 hours of Home
Health Aide services will be considered one home health care visit.);
the services of a person who is a member of your family or your
Dependent's family or who normally lives in your home or your
Dependent's home;
a period when a person is not under the continuing care of a
Physician.
charges made due to Terminal Illness for the following Hospice Care
Services provided under a Hospice
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COMPREHENSIVE MEDICAL BENEFITS COVERED EXPENSES (CONT'D)
Care Program:
by a Hospice Facility for Bed and Board and Services and Supplies,
except that, for any day of confinement in a private room, Covered
Expenses will not include that portion of charges which is more than
the Hospic...
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