# WV Informational Letter No. 186: Providing Essential Health Benefits in West Virginia > West Virginia · Agency guidance · In force URL: https://www.frixlaw.com/law-library/statutes/WV_INS_IL_186 ## Section - **Citation:** WV Informational Letter No. 186 - **Heading:** Providing Essential Health Benefits in West Virginia - **Jurisdiction:** West Virginia - **Kind:** Agency guidance - **Status:** In force - **Text as of:** August 14, 2026 - **Source:** Compiled text - **Location:** West Virginia Offices of the Insurance Commissioner Bulletins and Informational Letters / Providing Essential Health Benefits in West Virginia ## Text [LOGO] STATE OF WEST VIRGINIA Offices of the Insurance Commissioner Earl Ray Tomblin Governor MARCH 2013 Michael D. Riley Insurance Commissioner # WEST VIRGINIA INFORMATIONAL LETTER NO. 186 TO: All Insurance Companies Authorized to Sell Health Insurance Plans in West Virginia's Small Group and Individual Markets RE: Providing Essential Health Benefits in West Virginia In March 2010, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 were signed into law. The two laws are collectively referred to as the Affordable Care Act ("ACA"). Among the many reforms in the ACA, as part of an amendment to the Public Health Services Act ("PHSA"), the ACA requires all qualified health plans ("QHP's") as well as all health care plans sold in the United States in the small group or individual markets to include "essential health benefits" ("EHB"), defined as ten (10) categories of benefits. (See ACA §2707 codified at 42 USC §300gg-6; ACA §1301 codified at 42 USC §18021). Aside from the ten basic categories, discretion on how to define EHB was left to the U.S. Department of Health and Human Services ("HHS"). The HHS ultimately used a "benchmark" approach, permitting each state to select a benchmark plan from various options of plans offered in the state or federal plans. West Virginia did not specifically select a benchmark, therefore, under the HHS procedure, West Virginia's largest small group plan, the "Highmark Blue Cross BlueShield West Virginia $1000 Deductible Super Blue Plus 2000 PPO Plan" was selected. This plan's selection as West Virginia's benchmark plan is set forth in a final rule the HHS promulgated on EHB. (See 45 CFR §§147, 155 and 156.) al plans. West Virginia did not specifically select a benchmark, therefore, under the HHS procedure, West Virginia's largest small group plan, the "Highmark Blue Cross BlueShield West Virginia $1000 Deductible Super Blue Plus 2000 PPO Plan" was selected. This plan's selection as West Virginia's benchmark plan is set forth in a final rule the HHS promulgated on EHB. (See 45 CFR §§147, 155 and 156.) The purpose of this informational letter is to provide all health insurance carriers in West Virginia who issue policies in the QHP¹, small group and individual market some more specific guidance as to how to comply with the ACA EHB requirement based on West Virginia's benchmark. The final EHB rule referenced above clarifies that for a health care policy to be deemed to provide EHB, it must generally "provide benefits that...[a]re substantially equal to the EHB benchmark plan including: (i) Covered benefits; [and] (ii) Limitations on coverage including coverage of benefit amount, duration and scope..." See 45 CFR §156.115. Following the publication of this final rule, the West Virginia Offices of the Insurance Commissioner ("OIC") had communication with officials from the HHS to seek clarity on what "substantially equal" means. The HHS clarified that the purpose of the language was to permit some flexibility among various plans as compared to the benchmark within the states' discretion. The HHS also clarified, however, that the "starting point" for EHB was the actual language of the benchmark policy, not just the general guidelines of the benchmark set forth in the EHB rule (the EHB rule has a matrix of each state's benchmark with some information as to each). ¹ Until 2017, all QHP's are in the individual or small group market; however large group plans may enter the QHP market in 2017. Legal Services Post Office Box 50540 Charleston, West Virginia 25305-0540 "We are an Equal Opportunity Employer" [LOGO] Telephone (304) 558-0401 Facsimile (304) 558-1362 www.wvinsurance.gov as a matrix of each state's benchmark with some information as to each). ¹ Until 2017, all QHP's are in the individual or small group market; however large group plans may enter the QHP market in 2017. Legal Services Post Office Box 50540 Charleston, West Virginia 25305-0540 "We are an Equal Opportunity Employer" [LOGO] Telephone (304) 558-0401 Facsimile (304) 558-1362 www.wvinsurance.gov As such, the OIC directs all health insurance carriers required to provide EHB in West Virginia to use the benefits as outlined in the “Highmark Blue Cross BlueShield West Virginia $1000 Deductible Super Blue Plus 2000 PPO Plan” Certificate of Coverage, attached to this letter as Appendix 1, as a starting point for determining how to provide EHB. However, pursuant to the goal of flexibility embedded in the term “substantially equal”, some deviation is permitted. For example, a carrier may want to slightly alter the number of visits or treatments permitted within a certain benefit type. As long as the deviation is deemed by the OIC to be “substantially equal”, it would be permissible. The OIC will ultimately address whether deviations from the benchmark are “substantially equal” on a case-by-case basis. Carriers may be asked to provide additional justification² for deviating significantly from the benchmark. In addition to the above, carriers who issue policies that must be EHB compliant need to also be aware of the following “backfills” (benefits that had to be “filled in” as the West Virginia benchmark plan did not contain them) for the West Virginia benchmark: equal” on a case-by-case basis. Carriers may be asked to provide additional justification² for deviating significantly from the benchmark. In addition to the above, carriers who issue policies that must be EHB compliant need to also be aware of the following “backfills” (benefits that had to be “filled in” as the West Virginia benchmark plan did not contain them) for the West Virginia benchmark: - Pediatric Dental Benefits – the West Virginia CHIP schedule of benefits needs to be provided consistent with the “WV Children’s Health Insurance Program Dental Provider Guide 2012-2013”, attached to this letter as Appendix 2; - Pediatric Vision Benefits – the vision benefits available to children under the Blue Cross-Blue Shield Federal Employee Program plan need to be provided consistent with the “FEP Blue Vision” document, attached to this letter as Appendix 3; - Habilitative Benefits – These benefits need to be provided consistent with OIC’s Informational Letter No. 184, published on March 28, 2013; - Infertility Treatment – These benefits need to be provided on a limited basis by HMO’s only (consistent with West Virginia law); see OIC’s Informational Letter No. 185, published on March 28, 2013. Questions regarding this informational letter should be directed to Jeremiah Samples, Director of Health Policy for the OIC, at 304-558-6279 ext. 1131 or jeremiah.samples@wvinsurance.gov. Michael D. Riley Michael D. Riley Insurance Commissioner be provided on a limited basis by HMO’s only (consistent with West Virginia law); see OIC’s Informational Letter No. 185, published on March 28, 2013. Questions regarding this informational letter should be directed to Jeremiah Samples, Director of Health Policy for the OIC, at 304-558-6279 ext. 1131 or jeremiah.samples@wvinsurance.gov. Michael D. Riley Michael D. Riley Insurance Commissioner ² As evidenced by the example, this is referring to deviating in amount, duration and scope within a specific type of benefit. In addition to this, the federal EHB rule also permits deviation between benefit types within an EHB category as long as changes provide actuarially equivalent benefits to the benchmark. For example, a carrier could potentially greatly reduce or eliminate benefit type A within an EHB category if they provided a new benefit type and/or grossly increased an existing benefit type in a manner that was actuarially equivalent to the reduction in the other benefit type. Deviation between benefits types such as this must be justified actuarially. Page 2 WVIL 186 # HIGHMARK® West Virginia ![img-0.jpeg](img-0.jpeg) An Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross, Blue Shield and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. # SUPERBLUE Plus SM 2000 # HEALTH CARE CERTIFICATE $1,000 DEDUCTIBLE APPENDIX 1 – WVIL 186 # YOUR HEALTH CARE BENEFITS AND HOW TO USE THEM Super Blue Plus℠ Comprehensive Major Medical Health Care Certificate with Preferred Prescription Drug ; # Table Of Contents # I. Super Blue Plus 2000 Health Care Certificate ... 1 - Group Contract and Certificate ... 1 - Financing Arrangement ... 1 - Criteria For Covered Persons ... 1 - Important Information About This Coverage ... 1 # II. How to Use Your Certificate ... 3 OW TO USE THEM Super Blue Plus℠ Comprehensive Major Medical Health Care Certificate with Preferred Prescription Drug ; # Table Of Contents # I. Super Blue Plus 2000 Health Care Certificate ... 1 - Group Contract and Certificate ... 1 - Financing Arrangement ... 1 - Criteria For Covered Persons ... 1 - Important Information About This Coverage ... 1 # II. How to Use Your Certificate ... 3 - Summary of Benefits ... 3 - Eligibility ... 3 - Benefits ... 3 - Exclusions ... 3 - Coordination of Benefits, Right of Recovery, and Right of Reimbursement/Subrogation ... 3 - General Provisions ... 3 - Definitions ... 3 - Prescription Drug Benefits ... 3 - Statement of ERISA Rights ... 3 - Plan Information ... 3 # III. Super Blue Plus 2000 Summary of Benefits ... 4 - Provider Networks and Directory ... 4 - Out-Of-Pocket Expenses (Member Liability) ... 4 - Benefits Summary ... 5 # IV. Eligibility ... 11 - Applying For Coverage ... 11 - Eligible Employees ... 11 - Eligible Dependents ... 11 - Eligibility Changes ... 12 - Effective Date ... 13 - Identification Cards (ID Cards) ... 13 - Medicare ... 13 - Non-Medicare Retirees ... 14 - How and When Your Benefits May Change ... 14 - How and When Your Coverage Stops ... 14 - Continuation Coverage - Involuntary Lay-Off ... 15 - Continuation Coverage - COBRA ... 15 - Military Service ... 16 - Inpatient Benefits Incurred at and Exceeding Term of Contract ... 17 - Conversion Privilege ... 17 - Guaranteed Availability of Coverage for Employers in the Small Group Market ... 17 - Guaranteed Renewability of Group Coverage ... 17 # V. Health Care Benefits ... 18 - Medical Necessity Requirement ... 18 - Prior Authorization ... 18 - Inpatient Services ... 18 - Preventive Care Services ... Error! Bookmark not defined. ed at and Exceeding Term of Contract ... 17 - Conversion Privilege ... 17 - Guaranteed Availability of Coverage for Employers in the Small Group Market ... 17 - Guaranteed Renewability of Group Coverage ... 17 # V. Health Care Benefits ... 18 - Medical Necessity Requirement ... 18 - Prior Authorization ... 18 - Inpatient Services ... 18 - Preventive Care Services ... Error! Bookmark not defined. - Special Services ...21 - Surgical Services ...21 - Emergency Services ...21 - Home, Office and Other Outpatient Visit ...22 - Hospital-Based Clinics ...22 - Injectable Drugs ...22 - Diagnostic Services ...22 - Allergy Tests and Treatments ...22 - Therapy Services ...22 - Rehabilitation Services ...23 - Maternity Services ...24 - Mental Health Care and Substance Abuse (Drug and Alcohol) Coverage ...24 - Well Baby and Well Child Care Services ...25 - Dental Services for an Accidental Injury ...25 - Ambulance Services ...25 - Private Duty Nursing Services ...25 - Skilled Nursing Facility Services ...26 - Home Health Care Services ...26 - Hospice Services ...26 - Temporomandibular Disorders (TMD)/Craniomandibular Disorders ...27 - Medical Supplies and Equipment ...27 - Prescription Drug Claims ...28 - Organ Transplant Services ...28 - Bone Marrow Procedures ...28 - Clinical Trials Coverage ...29 - Cost Effective Non-Covered Services ...29 # VI. Exclusions ...30 # VII. Coordination of Benefits, Right of Recovery and Right of Reimbursement/Subrogation ...32 - Coordination of Benefits ...32 - Right of Recovery ...33 - Right of Reimbursement and Subrogation ...34 - Work Related Injury and Illness ...35 # VIII. General Provisions ...36 rrow Procedures ...28 - Clinical Trials Coverage ...29 - Cost Effective Non-Covered Services ...29 # VI. Exclusions ...30 # VII. Coordination of Benefits, Right of Recovery and Right of Reimbursement/Subrogation ...32 - Coordination of Benefits ...32 - Right of Recovery ...33 - Right of Reimbursement and Subrogation ...34 - Work Related Injury and Illness ...35 # VIII. General Provisions ...36 - How To Apply For Benefits; Claim Forms ...36 - Pre-Service Claim Conditions ...36 - Initial Claims For Benefits ...37 - Appeal Procedures ...38 - Notice of Adverse Claim/Appeal Decisions ...41 - Prescription Drug Claim Appeals ...41 - Designating An Authorized Representative ...41 - Treatment Plans ...41 - Preexisting Condition Limitations and Exclusion Period ...41 - Our Right To Review Claims ...42 - Payment of Benefits ...42 - How Claims are Paid ...43 - How to Report Fraud ...45 - Limitations of Actions and Venue ...45 - Non-Waiver Provision ...45 - Severability ...45 - Governing Law...45 # IX. Definitions...46 # X. Prescription Drug Benefits ...54 - Prescription Drug Benefits ... Error! Bookmark not defined. - Formulary... Error! Bookmark not defined. - Retail and Mail Order Prescription Drug Management... Error! Bookmark not defined. - Exclusions and Limitations Specific to Prescription Drugs ... Error! Bookmark not defined. - Definitions... Error! Bookmark not defined. # XI. Statement of ERISA Rights...58 - Receive Information About Your Plan and Benefits...58 - Continue Group Health Plan Coverage ...59 - Prudent Actions by Plan Fiduciaries ...59 - Enforce Your Rights...60 - Assistance with Your Questions...60 # XII. Plan Information ...61 \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) Your Questions...60 # XII. Plan Information ...61 \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) # I. Super Blue Plus 2000 Health Care Certificate # A. GROUP CONTRACT AND CERTIFICATE ( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) \( \therefore m = \frac{3}{11} \) # I. Super Blue Plus 2000 Health Care Certificate # A. GROUP CONTRACT AND CERTIFICATE This Certificate describes the health care benefits available to you as part of a Group Contract (or "Contract"). This Certificate is part of and subject to the terms and conditions of the Group Contract. The actual Group Contract is between Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield West Virginia ("Highmark WV") and the employer or organization that pays or forwards the premiums that pays your claims and administrative costs to Highmark WV. Highmark WV may be referred to throughout this Certificate as we, us, or our. The employer or organization will be called the Group, Plan, Plan Sponsor, or Plan Administrator. The benefits provided under the Contract are referred to as Plan or Group Health Plan. Certain words used in this Certificate have special meaning. They will be capitalized throughout the text so that you will pay special attention to them. They are either defined in Section IX, or where used in the text. Premiums are computed in accordance with Highmark WV's rating formula; which reflects, among other things, costs and charges associated with the selected program of benefits. These rates also include various product enhancements, such as health reimbursement account administration. xt so that you will pay special attention to them. They are either defined in Section IX, or where used in the text. Premiums are computed in accordance with Highmark WV's rating formula; which reflects, among other things, costs and charges associated with the selected program of benefits. These rates also include various product enhancements, such as health reimbursement account administration. The Group shall have the right to return the Contract within 10 days of its delivery and to have the premium refunded if, after examination of the Contract, the Group is not satisfied for any reason. This does not apply to groups with 51 or more employees that are negotiated. In the event the Group exercises this right, Highmark WV shall not be obligated to pay any benefits under the policy for claims submitted to Highmark WV during such 10-day period. # B. FINANCING ARRANGEMENT The benefits are underwritten and insured by Highmark WV through a Contract with your Group. Highmark WV also performs administrative functions related to payment and processing of claims and provides Network access. # C. CRITERIA FOR COVERED PERSONS All persons who meet the following criteria are covered by the Group Contract. They are referred to as Covered Persons, you or your. They must: - Apply for coverage under the Group Contract. - Pay a portion of the premium if necessary. - Satisfy the conditions specified in Section IV. - Be approved by us. # D. IMPORTANT INFORMATION ABOUT THIS COVERAGE access. # C. CRITERIA FOR COVERED PERSONS All persons who meet the following criteria are covered by the Group Contract. They are referred to as Covered Persons, you or your. They must: - Apply for coverage under the Group Contract. - Pay a portion of the premium if necessary. - Satisfy the conditions specified in Section IV. - Be approved by us. # D. IMPORTANT INFORMATION ABOUT THIS COVERAGE 1. Preexisting Condition Limitation and Exclusion Period. This Certificate contains a Preexisting Condition Limitation as described in the General Provisions and in Section III. 2. Not a Provider of Services. We do not furnish Covered Services. We only pay for Covered Services you receive from Providers. We are not liable for any act or omission of any Provider, and we have no responsibility for a Provider's failure or refusal to give Covered Services to you. Any decision to receive care is solely between you and your Provider. Any action by Highmark WV pursuant to any utilization management, referral management, discharge planning, Medical Necessity determination or other functions in no way absolves the Provider of the responsibility to provide appropriate Medical Care to the Covered Person. 1 3. Pre-Certification Review. This Certificate contains a Pre-Certification Review limitation. It is described in Sections III and VIII. Pre-Certification Review is limited solely to determining Medical Necessity. It is not a guarantee of coverage or payment. Remember, in an emergency, always go to the nearest appropriate medical facility. 4. Mastectomy Benefits. See Section V for more information. 5. Highmark WV Discretionary Authority The Group designates Highmark WV to be a fiduciary under the Plan for the following purposes: - Determining questions of eligibility. - Determining the amount and type of benefits payable under the Plan. - For responsibility for claim and appeal procedures established by the Department of Labor under Claims Rules. efits. See Section V for more information. 5. Highmark WV Discretionary Authority The Group designates Highmark WV to be a fiduciary under the Plan for the following purposes: - Determining questions of eligibility. - Determining the amount and type of benefits payable under the Plan. - For responsibility for claim and appeal procedures established by the Department of Labor under Claims Rules. In carrying out these functions, Highmark WV has the exclusive right and discretionary authority to interpret the terms and provisions of the Plan and this Contract and to determine any and all questions arising under the Plan or this Contract. Highmark WV has without limitation, the right to remedy or resolve possible ambiguities, disputes, inconsistencies, or omission by general rule or particular decision. Highmark WV has the exclusive right and discretionary authority to make any finding necessary or appropriate for the purpose of these functions, including, but not limited to, the determination of the eligibility for, and the amount, manner, and time of payment of, any benefit payable under the Plan or this Contract. Benefits will be paid only if Highmark WV decides in its discretion that the claimant is entitled to them. 6. Blue Cross and Blue Shield Association The Group, on behalf of itself and all Certificate Holders, hereby expressly acknowledges its understanding that this agreement constitutes a Contract solely between the Group and Highmark Blue Cross Blue Shield West Virginia ("Highmark WV") which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans (the "Association"), permitting Highmark WV to use the Blue Cross and Blue Shield Service Marks in the State of West Virginia, and that Highmark WV is not contracting as the agent of the Association. t Virginia ("Highmark WV") which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans (the "Association"), permitting Highmark WV to use the Blue Cross and Blue Shield Service Marks in the State of West Virginia, and that Highmark WV is not contracting as the agent of the Association. The Group, on behalf of itself and its Certificate Holders, further acknowledges and agrees that it has not entered into this agreement based upon representations by any person or entity, other than Highmark WV and that no person, entity or organization other than Highmark WV shall be held accountable or liable to the Group for any of Highmark WV's obligations to the Group created under this agreement. This paragraph shall not create any additional obligations whatsoever on the part of Highmark WV other than those obligations created under other provisions of this agreement. 7. Address Highmark Blue Cross Blue Shield West Virginia 614 Market Street Parkersburg, WV 26101 2 ## II. How to Use Your Certificate This Certificate gives you the details you need in order to understand your health care benefits. We have tried to write it in simple terms that are easy to understand. Please read this Certificate carefully. ### III. Summary of Benefits This Section briefly describes how and when your benefits pay. This Section provides additional information such as the amount of Deductibles, Fees, Coinsurances, and benefit limits. ### IV. Eligibility This Section outlines how and when you become eligible for coverage. It also describes how and when your coverage becomes effective and when it terminates. ### V. Benefits This Section explains each type of health care benefit in your coverage. It tells you what services are covered. ### VI. Exclusions This Section lists what Services and Supplies are not covered. *Please review this section carefully* ion outlines how and when you become eligible for coverage. It also describes how and when your coverage becomes effective and when it terminates. ### V. Benefits This Section explains each type of health care benefit in your coverage. It tells you what services are covered. ### VI. Exclusions This Section lists what Services and Supplies are not covered. *Please review this section carefully* ### VII. Coordination of Benefits, Right of Recovery, and Right of Reimbursement/Subrogation This Section describes when and how your benefits may coordinate with other coverage. It also describes certain obligations you have to us for overpayments or when benefits are the responsibility of another party. ### VIII. General Provisions This Section tells you such things as: how to apply for benefits, how claims are paid and other general information. ### IX. Definitions If a word or phrase starts with a capital letter, it either has a special meaning or is a title. If the word or phrase has a special meaning, it is defined in this Section or where used in the text. ### X. Prescription Drug Benefits This Section describes your coverage for Prescription Drugs, if applicable. ### XI. Statement of ERISA Rights This Section explains your rights under the Employee Retirement Security Act of 1974 (ERISA) if your benefits are subject to ERISA. ### XII. Plan Information This Section provides information about your Plan, Plan Administrator and applicable contacts. 3 ### III. Super Blue Plus 2000 Summary of Benefits IMPORTANT - Read this Section carefully. See Section V for a detailed description of benefits. This Section indicates the amounts for Coinsurances, Deductible, Fees, reimbursement percentages, and Benefit Maximums. Should your benefits change you will receive either an amendment describing what has changed or an updated Certificate Book. # A. PROVIDER NETWORKS AND DIRECTORY Summary of Benefits IMPORTANT - Read this Section carefully. See Section V for a detailed description of benefits. This Section indicates the amounts for Coinsurances, Deductible, Fees, reimbursement percentages, and Benefit Maximums. Should your benefits change you will receive either an amendment describing what has changed or an updated Certificate Book. # A. PROVIDER NETWORKS AND DIRECTORY The choice of a Provider is solely yours. All Providers are designated as either Network or Non-Network. In addition, some Providers are further designated as Participating or Non-Participating. The amount of benefits that you will receive for Covered Services will vary depending upon whether the Provider is in the Network and whether it is Participating. Your financial responsibility will vary between these Provider designations. You will receive the most benefits by seeking Covered Services from Network Providers. This section tells you how much we will pay for Covered Services at Network and Non-Network Providers. Remember, in an emergency, always go to the nearest appropriate medical facility. Network Provider online directory information is available by accessing www.highmarkbcbswv.com or you may also obtain network Provider information by logging on to www.mybenefitshome.com or www.bcbs.com/healthtravel/finder/html. The Network status of Providers listed in a directory may change from time to time. You should be sure of the status of the Provider before receiving Covered Services. The number to call to check the status of a Provider is in your Provider Directory and on your ID Card. See Section VIII.K for more information on the meaning of Provider status. # B. OUT-OF-POCKET EXPENSES (MEMBER LIABILITY) The expenses you may incur include, but are not limited to, those briefly defined and described below. Further detail is provided later on in this Section III or Sections VIII and IX. to call to check the status of a Provider is in your Provider Directory and on your ID Card. See Section VIII.K for more information on the meaning of Provider status. # B. OUT-OF-POCKET EXPENSES (MEMBER LIABILITY) The expenses you may incur include, but are not limited to, those briefly defined and described below. Further detail is provided later on in this Section III or Sections VIII and IX. 1. Benefit Accumulation. Some employers may offer more than one health insurance policy through Highmark WV. Should you decide to change policies within the same company, for example, from a $500 Deductible to a $1,000 Deductible option, any Deductibles, Coinsurances and Lifetime Maximums earned on the $500 Deductible option shall apply to the $1,000 Deductible option. This provision does not apply if you change employment and both employers offer group health insurance through Highmark WV. If you have any questions about this provision, contact Customer Service. 2. Benefit Maximums. Benefit Maximums are stated either in dollar amounts, Treatments, or Visits per Benefit Period. Once the Benefit Maximum is met for a Covered Service within the Benefit Period, any additional charges Incurred will be your responsibility. They will not apply to any Fees, Deductibles, Network and Non-Network Coinsurances, or other Covered Person responsibilities. 3. Coinsurance and Coinsurance Limits. This is a percentage of the Reimbursement Allowance or Actual Charge after your Deductible has been satisfied. The percentages may differ when receiving Covered Services from Network Providers (Network Coinsurance) as opposed to Non-Network Providers (Non-Network Coinsurance). Normally you receive greater benefits from Network Providers. There are separate limits for Network Coinsurance (Network Coinsurance Limits) and Non-Network Coinsurance (Non-Network Coinsurance Limits). See Section D below for more detail. 4. Co-Pay may differ when receiving Covered Services from Network Providers (Network Coinsurance) as opposed to Non-Network Providers (Non-Network Coinsurance). Normally you receive greater benefits from Network Providers. There are separate limits for Network Coinsurance (Network Coinsurance Limits) and Non-Network Coinsurance (Non-Network Coinsurance Limits). See Section D below for more detail. 4. Co-Pay. An upfront set amount that is the responsibility of the Covered Person for Office Visits and other Services as specified in this section or on your ID Card. 4 5. Deductible. This is the amount you are required to pay for Covered Services, usually stated in dollars, before we begin to pay. 6. Maximum Out-of-Pocket. The maximum amount of expenses incurred for Deductibles and Coinsurances for a Benefit Period per individual or family. 7. Non-Covered Services. Certain Services that may be Incurred or recommended by a Provider may not be a Covered Service under your Plan. As a result, you will be responsible for the cost of such Services. These Services will not apply towards any Fees, Deductibles, and Coinsurances. 8. Non-Network Liability. In addition to any Deductible and Non-Network Coinsurance, you may be responsible for some, or all, of the amount of Actual Charges in excess of our agreed Network Provider payment rate, when you obtain services from Non-Network Providers. 9. Office Visit Fees. An upfront charge, usually stated in dollars, for Office Visits with Physicians and Professional Other Providers. The Office Visit Fee applies to Charges for the Visit only. This Fee does not apply to other Services received during a Visit, except as specified. Office Visit Fees are in addition to, and do not apply toward any other Deductibles, Fees, or Coinsurances unless there is no Fee indicated. The Office Visit Fee applies per Visit and is payable at the time Covered Services are received. 10. Pre-Certification Review Penalty pplies to Charges for the Visit only. This Fee does not apply to other Services received during a Visit, except as specified. Office Visit Fees are in addition to, and do not apply toward any other Deductibles, Fees, or Coinsurances unless there is no Fee indicated. The Office Visit Fee applies per Visit and is payable at the time Covered Services are received. 10. Pre-Certification Review Penalty. A financial penalty that you are required to pay for most Inpatient Admissions if you do not contact us as required in Section VIII.B. 11. Waivers. In some instances, a Network or Participating Provider may ask you to sign a "waiver" or other document prior to receiving care. This waiver may state that you accept responsibility for the Charges above the applicable Reimbursement Allowance with Highmark WV or for Services deemed not Medically Necessary by Highmark WV. Generally, Network or Participating Providers are prohibited from this practice. See Section V.A for circumstances where you may be responsible for non-Medically Necessary Services. C. SUMMARY OF BENEFITS DESCRIPTIONS The following summary provides details regarding specific benefit amounts and limits, including: 1. Benefit Period 2. Deductible 3. Eligible Dependent Age Limit 4. Office Visit Fee 5. Benefit Maximums In some circumstances, the Benefit Maximums are combined for Network and Non-Network Services. 6. Organ Transplant Services 7. Bone Marrow Procedures 8. Pre-Certification Penalty Refer to Section VIII for additional information and requirements. 9. Treatment Plans Refer to Section VIII for additional information and requirements. 10. Preexisting Condition Limitation and Exclusion Period Refer to Section VIII for additional information and requirements. 5 ## 11. Coinsurances and Coinsurance Limits Except as otherwise specified, after you have paid any applicable Deductibles or Fees, Covered Services will be paid at the percentage applicable to the Provider Network status. VIII for additional information and requirements. 10. Preexisting Condition Limitation and Exclusion Period Refer to Section VIII for additional information and requirements. 5 ## 11. Coinsurances and Coinsurance Limits Except as otherwise specified, after you have paid any applicable Deductibles or Fees, Covered Services will be paid at the percentage applicable to the Provider Network status. a. Non-Network Coinsurance and Liability Limits. The Non-Network Coinsurance is in addition to your Network Coinsurance Limit. Also Non-Network Liability amounts will not be applied to either your Network Coinsurance Limit or Non-Network Coinsurance Limits. b. Exceptions Regarding the Coinsurance Limits. The amounts you pay as a Network or Non-Network Coinsurance for the following services do not apply to your Network or Non-Network Coinsurance limits. - Outpatient Physical Therapy Services, Chiropractic (Spinal Manipulation) Services, or Outpatient Occupational Therapy Services. c. After your Network Coinsurance Limit is met, but before your Non-Network Coinsurance Limit is met, the amount you are responsible to pay is: - For Covered Services provided by a Network Provider No further Coinsurance is required for the remainder of the Benefit Period. Benefits are then payable by Highmark WV at 100% of the Actual Charge or the Reimbursement Allowance, unless otherwise stated. - For Covered Services provided by a Non-Network Provider - but a Participating Provider Covered Services provided by a Non-Network Provider will be paid at the Non-Network percentage as indicated. In addition, you may be responsible for a Non-Network Liability – the difference between the Network Reimbursement Allowance and Participating Reimbursement Allowance. - and Non-Participating Provider Covered Services provided by a Non-Network Provider - but a Participating Provider Covered Services provided by a Non-Network Provider will be paid at the Non-Network percentage as indicated. In addition, you may be responsible for a Non-Network Liability – the difference between the Network Reimbursement Allowance and Participating Reimbursement Allowance. - and Non-Participating Provider Covered Services provided by a Non-Network Provider will be paid at the Non-Network percentage as indicated. In addition, you may be responsible for a Non-Network Liability – the difference between the Network Reimbursement Allowance and Non-Participating Provider's Actual Charge. d. After both your Network and Non-Network Coinsurance Limits are met, benefits for Covered Services provided by a Network or Non-Network Provider are payable by Highmark WV at 100% of the Reimbursement Allowance or Actual Charge, unless otherwise stated. You are responsible though for payment of some or all of the amounts in excess of the Reimbursement Allowance for Covered Services received from a Non-Network Provider (Non-Network Liability). 6 # SuperBlue Plus 2000 ## SUMMARY OF BENEFITS IMPORTANT: PLEASE READ THE SUMMARY OF BENEFITS SECTION. THIS IS PART OF YOUR CERTIFICATE AND SUBJECT TO CHANGE. FOR FURTHER EXPLANATION REFER TO YOUR CERTIFICATE BOOK. | Group Effective Date | | | --- | --- | | Benefit Period (used for Deductible and Coinsurance limits) | January 1 through December 31 (Calendar Year) | | Deductible (Applies to Network and Non-Network Benefits combined) Individual Family (may be met collectively) Note: All services are subject to the Deductible unless otherwise specified FURTHER EXPLANATION REFER TO YOUR CERTIFICATE BOOK. | Group Effective Date | | | --- | --- | | Benefit Period (used for Deductible and Coinsurance limits) | January 1 through December 31 (Calendar Year) | | Deductible (Applies to Network and Non-Network Benefits combined) Individual Family (may be met collectively) Note: All services are subject to the Deductible unless otherwise specified. | $1,000 $2,000 | | Carry-Over Deductible Period | October, November and December | | Network Coinsurance Limit: (Network and Non-Network Coinsurance dollars cross apply.) Individual Family (may be met collectively) | $1,000 $2,000 | | Deductible and Network Coinsurance Limit: Individual Family (may be met collectively) | $2,000 $4,000 | | Non-Network Coinsurance Limit: (In addition to the Deductible and Network Coinsurance limits) Individual Family (may be met collectively) | $2,500 $5,000 | | Maximum Out of Pocket (Deductible, Network and Non-Network Coinsurance Limits combined): Individual Family (may be met collectively) | $4,500 $9,000 | | Lifetime Maximum Benefit for all Covered Services | UNLIMITED | ## BENEFIT HIGHLIGHTS | | NETWORK | NON-NETWORK | | --- | --- | --- | | Medical Office Visit / Office Consultation - Applies to charge for visit only. Does not apply to other services received during visit. Office Visit Fees do not apply to Deductible or Coinsurance limits. Co-pays do not apply for certain preventive visits. See the Preventive section for this information ices | UNLIMITED | ## BENEFIT HIGHLIGHTS | | NETWORK | NON-NETWORK | | --- | --- | --- | | Medical Office Visit / Office Consultation - Applies to charge for visit only. Does not apply to other services received during visit. Office Visit Fees do not apply to Deductible or Coinsurance limits. Co-pays do not apply for certain preventive visits. See the Preventive section for this information. | $10 per Office Visit, 100% thereafter, No Deductible | $10 per Office Visit, 60% thereafter, No Deductible | | Emergency Accident Care and /or Emergency Medical Care provided in the ER | First $500 paid at 100%, No Deductible, 80% thereafter Subject to Deductible | First $500 paid at 100%, No Deductible, 80% thereafter Subject to Deductible | | Prescription Drugs are provided through a Preferred Pharmacy Network – If you the member, choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your coinsurance, unless the physician writes “brand necessary” (DAW) on the prescription, or if no generic equivalent exists. Maximum 34 day supply. | Member pays 30% or $10 minimum Coinsurance, whichever is greater. No Deductible | No Benefits | | Additional Benefits with Prescription (Retail or Mail Order) - Adults: Aspirin, Smoking Cessation, Folic Acid, Children: Iron Supplements and Oral Fluoride (guidelines as determined by certain Governmental Agencies) – You may access this information at www.healthcare.gov. You may also contact Customer Service using the number on the back of your ID Card. | 100%, No Deductible | No Benefits | | Mail Order Drugs – If you, the member, choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your coinsurance, unless the physician writes “brand necessary” (DAW) on the prescription, or if no generic equivalent exists. Maximum 90 day supply. | Member pays 30% or $30 minimum Coinsurance, whichever is greater, No Deductible | No Benefits | 7 ail Order Drugs – If you, the member, choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your coinsurance, unless the physician writes “brand necessary” (DAW) on the prescription, or if no generic equivalent exists. Maximum 90 day supply. | Member pays 30% or $30 minimum Coinsurance, whichever is greater, No Deductible | No Benefits | 7 | PREVENTIVE CARE SERVICES | | | | --- | --- | --- | | | NETWORK | NON-NETWORK | | Annual Gynecological Exam - one per calendar year. Office Visit Co-Pay does not apply to Deductible or Coinsurance limits. | 100%, No Deductible | $10 per Office Visit, 60% thereafter, No Deductible | | Routine Pap Smear - one per calendar year | 100%, No Deductible | 60% | | Routine HPV Testing - one every 3 years age 30 and older | 100%, No Deductible | 60% | | Routine Mammogram - per schedule age 35 and older | 100%, No Deductible | 60% | | Prostate Exam - one per calendar year for males over age 50. | 100%, No Deductible | $10 per Office Visit, 60% thereafter, No Deductible | | Prostate Specific Antigen (PSA) Test - one per calendar year | 100%, No Deductible | 60% | | Colorectal Cancer Exam - for individual's age 50 and older or a symptomatic person under age 50. One per calendar year. | 100%, No Deductible | $10 per Office Visit, 60% thereafter, No Deductible | | Fecal occult blood test - one per calendar year | 100%, No Deductible | 60% | | Flexible Sigmoidoscopy - one every 5 years | 100%, No Deductible | 60% | | Colonoscopy - one every 10 years | 100%, No Deductible | 60% | | Double Contrast Barium Enema - one every 5 years | 100%, No Deductible | 60% | | Routine Screening, Immunization and Diagnostic Services (guidelines as determined by certain Governmental Agencies) - You may access this information at www.healthcare.gov. You may also contact Customer Service. Their number is located on the back of your ID Card one every 10 years | 100%, No Deductible | 60% | | Double Contrast Barium Enema - one every 5 years | 100%, No Deductible | 60% | | Routine Screening, Immunization and Diagnostic Services (guidelines as determined by certain Governmental Agencies) - You may access this information at www.healthcare.gov. You may also contact Customer Service. Their number is located on the back of your ID Card. | 100%, No Deductible | No Benefits | | Diabetes Education & Control - Copay applies to office visit only. All other services will fall under medical benefits. | $10 per Office Visit, 100% thereafter, No Deductible | $10 per Office Visit, 60% thereafter, No Deductible | | WELL BABY / CHILD CARE SERVICES | | | | Well Baby Care - Routine office visits, lab tests and immunizations to age 6. | 100%, No Deductible | 100%, No Deductible | | Well Child Care - Routine office visits and immunizations age 6 through 17. | 100%, No Deductible | 100%, No Deductible | | PHYSICIAN SERVICES | | | | In-Hospital Medical Visit | 80% | 60% | | Surgery, Assistant to Surgery, Anesthesia | 80% | 60% | | Second Surgical Opinion Services (outpatient) | 100%, No Deductible | 100%, No Deductible | | Maternity Care - dependent daughters are covered. | 80% | 60% | | Newborn Care including circumcision. | 80% | 60% | | Occupational, Physical Therapy and Chiropractic Manipulations Note: Limitations are Physician and Outpatient Facility services combined (per calendar year). Network and Non-Network Coinsurance amounts for these services do not apply to your Coinsurance limits. | 80% for the first 20 treatments, 50% thereafter | 80% for the first 20 treatments, 50% thereafter | | Respiratory, Hyperbaric and Pulmonary Therapy | 80% | 60% | | Speech Therapy when necessary due to a medical condition sician and Outpatient Facility services combined (per calendar year). Network and Non-Network Coinsurance amounts for these services do not apply to your Coinsurance limits. | 80% for the first 20 treatments, 50% thereafter | 80% for the first 20 treatments, 50% thereafter | | Respiratory, Hyperbaric and Pulmonary Therapy | 80% | 60% | | Speech Therapy when necessary due to a medical condition. | 80% | 60% | | Rehabilitation Services | 80% | 60% | | Temporomandibular Joint Dysfunction / Craniomandibular Disorders | 80% | 60% | | Diagnostic, X-ray, Lab and Testing | 80% | 60% | | Allergy Testing and Treatment | 80% | 60% | | Outpatient Mental Health Services | 80% | 60% | | Outpatient Drug Abuse Services | 80% | 60% | | Outpatient Alcoholism Services | 80% | 60% | 8 | INPATIENT HOSPITAL / FACILITY SERVICES | | | | --- | --- | --- | | | NETWORK | NON-NETWORK | | Unlimited Days Semi-Private Room and Board Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | Ancillaries, Drugs, Therapy Services, X-ray and Lab | 80% | 60% | | General Nursing Care | 80% | 60% | | Surgical Services | 80% | 60% | | Birthing Center Care / Maternity Services - dependent daughters are covered. | 80% | 60% | | Inpatient Mental Health Care Services - Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | Inpatient Drug Abuse Services - Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | Inpatient Alcoholism Services - Note: If admission is not Precertified, you pay a $500 Precertification review penalty patient Mental Health Care Services - Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | Inpatient Drug Abuse Services - Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | Inpatient Alcoholism Services - Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | OUTPATIENT HOSPITAL / FACILITY SERVICES | | | | | NETWORK | NON-NETWORK | | Non-Emergency Medical Care provided in the ER | 80% | 60% | | Pre-Admission Testing | 80% | 60% | | Diagnostic, X-ray, Lab and Testing | 80% | 60% | | Surgery, Operating Room | 80% | 60% | | Radiation and Chemotherapy | 80% | 60% | | Occupational and Physical Therapy Note: Limitations are for Physician and Outpatient Facility services combined (per calendar year). Network and Non-Network Coinsurance amounts for these services do not apply to your Coinsurance limits. | 80% for the first 20 treatments, 50% thereafter | 80% for the first 20 treatments, 50% thereafter | | Respiratory, Hyperbaric and Pulmonary Therapy | 80% | 60% | | Speech Therapy when necessary due to a medical condition. | 80% | 60% | | Rehabilitation Services | 80% | 60% | | Outpatient Mental Health Services | 80% | 60% | | Outpatient Drug Abuse Services | 80% | 60% | | Outpatient Alcoholism Services | 80% | 60% | 9 | OTHER COVERED SERVICES | | | | --- | --- | --- | | | NETWORK | NON-NETWORK | | Private Duty Nursing - $5,000 Maximum per calendar year Note: Maximums are Network and Non-Network combined. | 80% | 60% | | Skilled Nursing Facility Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | Durable Medical Equipment and Oxygen at home | 80% | 60% | | Orthotic Devices and Prosthetic Appliances | 80% | 60% | | Home Health Care - Maximum 100 visits Note: Maximums are Network and Non-Network combined are Network and Non-Network combined. | 80% | 60% | | Skilled Nursing Facility Note: If admission is not Precertified, you pay a $500 Precertification review penalty. | 80% | 60% | | Durable Medical Equipment and Oxygen at home | 80% | 60% | | Orthotic Devices and Prosthetic Appliances | 80% | 60% | | Home Health Care - Maximum 100 visits Note: Maximums are Network and Non-Network combined. | 80% | 60% | | Emergency Ambulance | 100%, No Deductible | 100%, No Deductible | | Other Ambulance Services | 80% | 60% | | Hospice Care | 80% | 60% | | HUMAN ORGAN TRANSPLANT / BONE MARROW PROCEDURES | | | | --- | --- | --- | | Human Organ Transplant • $150 per day to a maximum of $10,000 for transportation, meals and lodging | 80% | 60% | | Bone Marrow Procedures • $150 per day to a maximum of $10,000 for transportation, meals and lodging | 80% | 60% | | Eligible Dependent Age Limitation | Coverage stops at the end of the month of the 26^{th} birthday for an adult dependent who is an Eligible Dependent. | | --- | --- | | Precertification Requirement | Penalty for no Precertification is $500 reduction of benefits per Inpatient admission. | | --- | --- | | Preexisting Condition Limitation (Note: For plan years beginning on or after September 23rd, 2010, preexisting condition limitation does not apply to children under 19 years of age.) | Preexisting Condition Waiting Period: "If you were enrolled in another health insurance policy prior to the hire date of your coverage under this Contract, the length of time you were covered under the previous policy will be applied to the Preexisting Condition Waiting Period. If there is a 63 day lapse in coverage, the 365 day waiting period will apply." | | --- | --- | ALL SERVICES ARE SUBJECT TO A DETERMINATION OF MEDICAL NECESSITY BY HIGHMARK WV BLUE CROSS BLUE SHIELD. PAYMENT IS BASED ON THE ACTUAL CHARGES OR PROVIDER'S REIMBURSEMENT ALLOWANCE. IN ADDITION, YOU WILL BE RESPONSIBLE FOR THE NON-NETWORK LIABILITY. 10 ## IV. Eligibility ng Condition Waiting Period. If there is a 63 day lapse in coverage, the 365 day waiting period will apply." | | --- | --- | ALL SERVICES ARE SUBJECT TO A DETERMINATION OF MEDICAL NECESSITY BY HIGHMARK WV BLUE CROSS BLUE SHIELD. PAYMENT IS BASED ON THE ACTUAL CHARGES OR PROVIDER'S REIMBURSEMENT ALLOWANCE. IN ADDITION, YOU WILL BE RESPONSIBLE FOR THE NON-NETWORK LIABILITY. 10 ## IV. Eligibility # A. APPLYING FOR COVERAGE When you apply for coverage, you will choose one of the following: - Individual coverage. - Employee and child coverage. - Employee and spouse coverage. - Employee and children coverage. - Family coverage. An Application must be completed in all instances. In deciding whether or not to approve an Application, we may request more information. Coverage will not begin until your Application has been approved and you have been provided with an Effective Date. # B. ELIGIBLE EMPLOYEES AND PREMIUM COST SHARING See your Plan Administrator for specific employee eligibility and any employee premium cost sharing requirements. # C. ELIGIBLE DEPENDENTS An Eligible Dependent is defined as: # 1. Spouse The Certificate Holder's legally recognized spouse. # 2. Dependent Children: - The Certificate Holder or spouse's children and stepchildren; - Adopted children or children placed for adoption. - Any dependent children which by court order must be provided health care coverage by the Certificate Holder or the Certificate Holder's spouse. - Children for whom either the Certificate Holder or the Certificate Holder's Spouse is the legal guardian. We will require court or government approval of guardianship. # 3. Age Limits and Disabled Children ted children or children placed for adoption. - Any dependent children which by court order must be provided health care coverage by the Certificate Holder or the Certificate Holder's spouse. - Children for whom either the Certificate Holder or the Certificate Holder's Spouse is the legal guardian. We will require court or government approval of guardianship. # 3. Age Limits and Disabled Children The age limits for all eligible children are specified in Section III. Coverage for Eligible Dependents will continue past the age limit for Eligible Dependents who cannot work to support themselves due to a physical or mental disability. This disability must have started before the age limit was attained and must be medically certified by a Physician. After a two-year period following the Eligible Dependent reaching the age limit, we may annually require further proof of the continuance of such incapacity and dependency. # 4. Adopted Children Any child under the age of 18 who is adopted by you, including a child who is legally 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. # 5. Qualified Medical Child Support Order Note: This provision will be administered according to the current applicable state and/or federal regulations. 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. A Qualified Medical Child Support Order is a judgment, decree or order (including 11 approval of a settlement agreement) issued by a court of competent jurisdiction or state agency, and satisfies all of the following: ild 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. A Qualified Medical Child Support Order is a judgment, decree or order (including 11 approval of a settlement agreement) issued by a court of competent jurisdiction or state agency, and satisfies all of the following: - the order specifies your name and last known address, and the child's name and last known address; - the order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined; - the order states the period to which it applies; and - 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 or option not otherwise provided under the policy. # 6. Custodial Parent Rights If a child has health coverage through an insurer of a noncustodial parent, the custodial parent may be provided information as may be necessary for the child to obtain benefits. The custodial parent, or the Provider with the approval of the custodial parent, may submit claims for Covered Services without the noncustodial parent's approval and payment for such claims may be sent directly to the custodial parent, the Provider or the state Medicaid agency. The payment to the custodial parent, the provider or the state Medicaid agency fully satisfies our obligation to the noncustodial parent under this policy with respect to the covered child's claims. # D. ELIGIBILITY CHANGES It is the Certificate Holder's responsibility to notify the Group of any changes in dependent eligibility. # 1. Dependent Additions and Special Enrollment Available for New Dependents t to the custodial parent, the provider or the state Medicaid agency fully satisfies our obligation to the noncustodial parent under this policy with respect to the covered child's claims. # D. ELIGIBILITY CHANGES It is the Certificate Holder's responsibility to notify the Group of any changes in dependent eligibility. # 1. Dependent Additions and Special Enrollment Available for New Dependents Special Enrollment is available for Dependents if you marry or acquire a child through birth, adoption or placement for adoption. You must notify your Plan Administrator and submit an Application to us within 30 days of the event to add a newly acquired Eligible Dependent. If we receive the Application within 30 days of the event, the Effective Date of the Eligible Dependent's coverage will be the date specified by the Plan Administrator in the Group Contract. If we then accept the Application for Dependent coverage, we will notify you of the Effective Date. If we do not receive the Application within 30 days of the event, acceptance of the Application may be denied. If you have individual coverage, you can change to two-person or family coverage if you marry or acquire a child through birth or adoption or placement for adoption. You must notify your Plan Administrator, who must then notify us of the change within 30 days of the event. # 2. Special Enrollment Rights for Loss of Other Coverage Special Enrollment is available for individuals, provided: a. They remain eligible under the Plan terms; b. They originally declined this coverage because of the other coverage; through birth or adoption or placement for adoption. You must notify your Plan Administrator, who must then notify us of the change within 30 days of the event. # 2. Special Enrollment Rights for Loss of Other Coverage Special Enrollment is available for individuals, provided: a. They remain eligible under the Plan terms; b. They originally declined this coverage because of the other coverage; (i) If the other coverage was COBRA, it has since exhausted; or (ii) If the other coverage was terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or employer contributions toward such coverage were terminated; and c. The employee requests such enrollment not later than 30 days after the date of exhaustion of the other coverage. Special Enrollment is available to an individual if the individual: (i) is no longer eligible for coverage under title XIX of the Social Security Act (Medicaid) or a state children's health plan under title XXI of the Social Security Act (CHIP), provided the individual requests coverage under the Plan within 60 days after the date of termination from this coverage; or (ii) becomes eligible for assistance for Plan coverage under title XIX of the Social Security Act (Medicaid) or state children's health plan under title XXI of the Social Security Act, provided the individual requests coverage under the Plan 12 within 60 days of the date the individual is determined to be eligible for assistance. Such coverage shall be effective on the first day of the month following the date of enrollment. 3. Student on a Medical Leave of Absence: Effective for plan years beginning on or after October 9, 2009 and effective for calendar year plans on January 1, 2010: he individual requests coverage under the Plan 12 within 60 days of the date the individual is determined to be eligible for assistance. Such coverage shall be effective on the first day of the month following the date of enrollment. 3. Student on a Medical Leave of Absence: Effective for plan years beginning on or after October 9, 2009 and effective for calendar year plans on January 1, 2010: Coverage for Eligible Dependents who are enrolled at a post-secondary educational institution and are required to take a medical leave of absence will continue for one year from the first day of the medical leave or until coverage otherwise terminates under the terms of the Plan. The medical leave of absence must: - Be due to a serious illness or injury; - Be certified in writing by the treating Physician, and - Have started after the Dependent is enrolled under the Plan as an Eligible Dependent based on being a student. 4. Changes in Eligibility When you or a Dependent becomes ineligible, you and your Dependents may be eligible for continuation coverage described in this Section IV. COBRA continuation coverage allows individuals 60 days to notify their Group of such ineligibility from the date they become ineligible. It is important to notify the Group as soon as possible to avoid loss of guaranteed availability rights for other coverage. Coverage other than individual coverage must be changed to individual coverage when only the Certificate Holder is eligible. You must notify your Group of any changes in eligibility (e.g., divorce) or when a Covered Person under your Certificate becomes eligible for Medicare or becomes covered under another health insurance policy. 5. Nondiscrimination eed availability rights for other coverage. Coverage other than individual coverage must be changed to individual coverage when only the Certificate Holder is eligible. You must notify your Group of any changes in eligibility (e.g., divorce) or when a Covered Person under your Certificate becomes eligible for Medicare or becomes covered under another health insurance policy. 5. Nondiscrimination Subject to all limitations within this Contract, individuals may not be excluded from coverage under the terms of the Contract, or charged more for benefits, based on specified factors related to health status, medical condition (both physical and mental), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, or disability. E. EFFECTIVE DATE Coverage starts on the Effective Date: - In accordance with the provisions of the Group Contract; - Upon acceptance by us of your Application; and - Only when premiums are fully paid. No benefits will be provided for Charges Incurred prior to your Effective Date. Coverage will not be delayed or denied due to confinement in a Hospital or other health care institution on your Effective Date. However, a Preexisting Condition Exclusion may apply for Charges Incurred with an Inpatient stay that begins before and continues beyond your Effective Date. F. IDENTIFICATION CARDS (ID CARDS) You will receive an ID Card. It contains information you will need when filing a claim or making an inquiry. Your ID Card is the property of Highmark WV. The ID Card must be returned to Highmark WV if your coverage ends for any reason. Further use of the ID Card is not permitted and may subject you to legal action. G. MEDICARE Upon becoming eligible for Medicare, coverage may be continued in any of several ways. Your Plan Administrator can tell you if any of the following options are available to you. 1. Active Employees property of Highmark WV. The ID Card must be returned to Highmark WV if your coverage ends for any reason. Further use of the ID Card is not permitted and may subject you to legal action. G. MEDICARE Upon becoming eligible for Medicare, coverage may be continued in any of several ways. Your Plan Administrator can tell you if any of the following options are available to you. 1. Active Employees If you are still actively employed, you may be allowed to continue your coverage through your Group on the same basis as prior to your becoming Medicare-eligible. 13 # 2. Retirees If you have retired and coverage is provided to you under your former employer's Group Contract, you may be allowed to participate on the same basis as above. You may be required to pay part of the premium in accordance with your Group Contract. The Group must collect from you your portion of the premium. If your former Group does not provide retiree benefits, coverage may be available with Highmark WV. To be considered for coverage, you must do each of the following. - Apply for and enroll in, Medicare Part A and Part B, and - A Highmark WV Medicare supplement policy; or - Apply for a Medicare Advantage product Important Note: If you are a Medicare eligible resident of West Virginia, you are not eligible for Traditional Medicare Supplemental coverage if you are presently enrolled in a Group Medicare Advantage product (Freedom Blue). # H. NON-MEDICARE RETIREES If you have retired and coverage is not continued under your former employer's Group Contract, and you are not eligible for Medicare, you may be eligible for coverage under our individual conversion product. Coverage under the conversion coverage contract may be different. You must apply in writing no later than 30 days after your coverage stops. roduct (Freedom Blue). # H. NON-MEDICARE RETIREES If you have retired and coverage is not continued under your former employer's Group Contract, and you are not eligible for Medicare, you may be eligible for coverage under our individual conversion product. Coverage under the conversion coverage contract may be different. You must apply in writing no later than 30 days after your coverage stops. You must pay for conversion coverage from the date you stop being a Member under this Contract. If you pay from that date, your coverage under the conversion contract will start on the date the coverage under this Contract stops. Further information is provided in this Section IV. # I. HOW AND WHEN YOUR BENEFITS MAY CHANGE The benefits provided by this Certificate may be changed or revised at any time by amendment to the Group Contract, and if applicable, by approval of the West Virginia Insurance Department. If the benefits are changed or revised, the Plan Administrator will be given notice prior to the changes becoming effective. It is the Plan Administrator's responsibility to notify you of these changes and when they become effective. If you are receiving Covered Services at the time your new benefits become effective, we will only pay for such Services to the extent they continue to be Covered Services under the new benefits. # J. HOW AND WHEN YOUR COVERAGE STOPS 1. When a Covered Person stops being an Eligible Dependent, coverage stops as specified in Section III. 2. When a Covered Person stops being an eligible Certificate Holder, all coverage stops according to the terms of the Group Contract. 3. Termination of the Group Contract by the Plan Administrator automatically ends all of your coverage. It is the responsibility of the Plan Administrator to tell you of such termination. 4. If Highmark WV terminates the Contract, you and the Plan Administrator will be notified 60 days in advance of the coverage termination date. You may be eligible for conversion coverage as indicated in this Section IV. 5 tion of the Group Contract by the Plan Administrator automatically ends all of your coverage. It is the responsibility of the Plan Administrator to tell you of such termination. 4. If Highmark WV terminates the Contract, you and the Plan Administrator will be notified 60 days in advance of the coverage termination date. You may be eligible for conversion coverage as indicated in this Section IV. 5. We have the right to void coverage of any Covered Person who engages in the following fraudulent conduct: - Deception. - Misrepresentation relating to a claim or in obtaining benefits. - Misrepresentation in Application for coverage. - The misuse of an ID Card. 6. When a Group or Covered Person fails to make a required premium payment, coverage stops at the end of the month of the last fully paid premium payment. When coverage stops, you will be provided a Certificate of Creditable Coverage free of charge. You may also request a Creditable Coverage Certificate by contacting Customer Service. 14 To protect your guarantee rights for other coverage after termination of your eligibility for this Plan, be sure to avoid lapses in Creditable Coverage of more than 63 days. # K. CONTINUATION COVERAGE - INVOLUNTARY LAY-OFF State law requires that insurers offer Group coverage, at the same benefit levels and Group rates (up to 100%) for a period of up to 18 months, in the event a Covered Person loses Group coverage due to involuntary lay-off. In addition, when a Group has more than 20 employees, a Covered Person may choose continuation coverage under COBRA as described below. # L. CONTINUATION COVERAGE – COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985, as amended) Your Group Administrator can tell you if your Group Health Plan is subject to the following COBRA regulations and, if so, how these benefits are administered. Your employer is required to provide you with notice of your COBRA rights if your Plan is subject to COBRA. r COBRA as described below. # L. CONTINUATION COVERAGE – COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985, as amended) Your Group Administrator can tell you if your Group Health Plan is subject to the following COBRA regulations and, if so, how these benefits are administered. Your employer is required to provide you with notice of your COBRA rights if your Plan is subject to COBRA. A federal law (Public Law 99-272, Title X) known as COBRA was enacted requiring that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called “continuation coverage”) at group rates in certain instances where coverage under the Plan would otherwise end. This Section is intended to inform you, in a summary fashion, of your rights and obligations under the continuation coverage provisions of the law. Both you and your covered spouse, if applicable, should take the time to read this Section and the notice provided by your employer carefully, and refer to them in the event that any action is required on your part. EMPLOYEE: If you are an employee covered by this Group Health Plan, you may have the right to choose this continuation coverage if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part). EMPLOYEE’S SPOUSE: If you are the covered spouse of an Eligible Employee, you may have the right to choose continuation coverage for yourself if you lose Group Health Plan coverage for any of the following four (4) reasons: 1. The death of the employee; 2. The termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment; 3. Divorce or legal separation from the employee; or 4. The employee becomes entitled to Medicare. to choose continuation coverage for yourself if you lose Group Health Plan coverage for any of the following four (4) reasons: 1. The death of the employee; 2. The termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment; 3. Divorce or legal separation from the employee; or 4. The employee becomes entitled to Medicare. EMPLOYEE’S CHILD: In the case of a covered Eligible Dependent child of an employee (including a child of a covered employee born or adopted during the period of COBRA continuation), he / she has the right to continuation coverage if Group Health Plan coverage is lost for any of the following five (5) reasons: 1. Death of the employee; 2. The termination of the employee’s employment (for reasons other than gross misconduct) or reduction in employee’s hours of employment; 3. Parent’s divorce or legal separation; 4. Employee becomes entitled to Medicare; or 5. The Dependent ceases to be an Eligible “Dependent child” under the terms of the Group Health Plan. You also have a right to elect continuation coverage if you are covered under the Plan as a retiree or spouse or child of a retiree, and lose coverage within one year before or after the employer’s commencement of proceedings under Title 11 (bankruptcy), United States Code. The eligible employee or family member has the responsibility to inform the Plan Administrator of a divorce, legal separation, or a child losing Dependent status within 60 days of the date of the qualifying event which would cause a loss of coverage. The notice must be in writing, and should be sent to the employer’s Plan Administrator. When the employer is notified that one of these events has happened, you will in turn be notified that you and your Eligible Dependents have the right to choose continuation coverage. Under the law, you and your Eligible Dependents have 60 days from the later of the date you 15 would cause a loss of coverage. The notice must be in writing, and should be sent to the employer’s Plan Administrator. When the employer is notified that one of these events has happened, you will in turn be notified that you and your Eligible Dependents have the right to choose continuation coverage. Under the law, you and your Eligible Dependents have 60 days from the later of the date you 15 would lose coverage or from the date of the notice to elect continuation coverage. If and when you and your Eligible Dependents make this election, coverage will become effective on the day after coverage would otherwise be terminated. If you do not choose continuation coverage, your coverage under the Plan will end in accordance with the provisions outlined in this Certificate. If you choose continuation coverage, the Plan Administrator is required to give you coverage, which, as of the time coverage is being provided, is identical to the coverage provided under the Plan to similarly situated employees or Eligible Dependents. If coverage for similarly situated employees and Eligible Dependents is modified after you elect continuation coverage, your coverage will be modified accordingly. The required continuation coverage for employee and Eligible Dependents is up to 18 months for employee's termination or reduction in hours of employment. An extension from 18 months up to 29 months is available under certain circumstances to disabled employees (*) who have been determined by the Social Security Administration (SSA) to have a disability onset date either before the COBRA event or within the first 60 days of COBRA continuation coverage. The required continuation coverage is up to 36 months for Eligible Dependents in the following situations: when employee is entitled to Medicare; divorce or legal separation; death of employee; and cessation of dependent child status. However, the law also provides that your continuation coverage may be terminated for any of the following reasons: the first 60 days of COBRA continuation coverage. The required continuation coverage is up to 36 months for Eligible Dependents in the following situations: when employee is entitled to Medicare; divorce or legal separation; death of employee; and cessation of dependent child status. However, the law also provides that your continuation coverage may be terminated for any of the following reasons: 1. The employer no longer provides Group Health Plan coverage to any of its employees; 2. You do not pay the premium for your continuation coverage in a timely manner; 3. You first become covered, after electing COBRA continuation coverage, under any other group health plan (as an employee or otherwise) which does not contain any exclusion or limitation which would apply to the COBRA covered individual with respect to any Preexisting Condition; or 4. You first become entitled to Medicare, after electing COBRA continuation coverage. You do not have to show that you are insurable to choose continuation coverage. However, you will have to pay all of the cost, the Group rate premium plus a 2% administrative fee, for your continuation coverage. At the end of the 18-month, 29-month, or 36-month continuation coverage period, you must be allowed to enroll in an individual conversion health plan provided under the current group health plan, if the plan provides a conversion privilege. In addition, under the Health Insurance Portability & Accountability Act (HIPAA, 1996), in certain circumstances, such as when you exhaust COBRA coverage, you may have the right to buy individual health coverage with no Pre-Existing Condition exclusion without having to give evidence of good health. lth plan provided under the current group health plan, if the plan provides a conversion privilege. In addition, under the Health Insurance Portability & Accountability Act (HIPAA, 1996), in certain circumstances, such as when you exhaust COBRA coverage, you may have the right to buy individual health coverage with no Pre-Existing Condition exclusion without having to give evidence of good health. If you have any questions about COBRA, please contact your Plan Administrator. In addition, if you have changed your marital status or you, your spouse, or any eligible covered Dependent have changed address; please notify your Plan Administrator in writing. If any covered child is at a different address, please notify your Plan Administrator in writing so that a separate notice may be sent. (*) Note: A qualified beneficiary who is determined under Title II or XVI of the Social Security Act to have been disabled as of the date of the COBRA event or within 60 days of COBRA coverage, may be eligible to continue coverage for an additional 11 months (29 months total). You must notify the employer within 60 days of the determination of disability by the Social Security Administration and prior to the end of the 18-month continuation period. You must provide a copy of the SSA determination of disability. The employer can charge up to 150% of the applicable premium during the 11-month extension. The disabled individual must notify the employer within 30 days of any final determination that he or she is no longer disabled. If the coverage is extended to a total of 29 months, extended coverage will cease upon a final determination that the qualified beneficiary is no longer disabled. # M. MILITARY SERVICE ployer can charge up to 150% of the applicable premium during the 11-month extension. The disabled individual must notify the employer within 30 days of any final determination that he or she is no longer disabled. If the coverage is extended to a total of 29 months, extended coverage will cease upon a final determination that the qualified beneficiary is no longer disabled. # M. MILITARY SERVICE If you are called up for active military service, commissioned corps of the Public Health Service and certain non-military emergency responders, you may be entitled to military coverage under the Uniformed Services Employment and Reemployment Rights Act (USERRA). USERRA may also entitle you reenrollment upon returning from active military service without any Waiting Periods, any Pre-Existing Condition exclusions, or a significant break in coverage. 16 # N. INPATIENT BENEFITS INCURRED BEFORE TERMINATION AND EXCEEDING THE TERM OF CONTRACT If you are an Inpatient of a Hospital or Skilled Nursing Facility on the day your coverage stops, the benefits listed under the Inpatient Services Section, subsections Bed, Board and General Nursing Services and Ancillary Services only, will continue until the earliest of the following: 1. We pay your maximum benefits. 2. You leave the Hospital or Skilled Nursing Facility. 3. The end of the Benefit Period in which your coverage stopped. 4. You have other group health care coverage for the condition that requires your Inpatient Hospital or Skilled Nursing Facility care. No other benefits will be provided once your coverage stops. # O. CONVERSION PRIVILEGE iest of the following: 1. We pay your maximum benefits. 2. You leave the Hospital or Skilled Nursing Facility. 3. The end of the Benefit Period in which your coverage stopped. 4. You have other group health care coverage for the condition that requires your Inpatient Hospital or Skilled Nursing Facility care. No other benefits will be provided once your coverage stops. # O. CONVERSION PRIVILEGE If you or a Dependent, (if the Dependent was covered at the time of termination) stop being a Covered Person, you and your Dependents may be eligible for conversion to a non-group policy offered by Highmark WV if there was continual coverage under this policy for three months immediately prior to the termination of this policy. You are eligible for conversion coverage if the Group coverage is terminated (including discontinuance of the group policy in its entirety), with the exception of the following reasons: 1. You fail to pay any required contribution for your group health care coverage; 2. You obtain other group health insurance coverage within 31 days of termination of coverage under the Group Contract; 3. You become covered under Medicare; or 4. You have similar coverage under any group or non-group health benefits plan, or are provided similar benefits pursuant to, or in accordance with, the requirements of any state or federal law. The conversion coverage may be different than the coverage provided under this Contract. However, we will not require evidence of insurability for eligibility under the conversion coverage and there will not be any Preexisting Condition exclusions on the conversion coverage beyond those already excluded under the previous Group Contract. You must apply in writing and make the first premium payment to us for such coverage no later than 31 days after your coverage under this Contract ends. # P. GUARANTEED AVAILABILITY OF COVERAGE FOR EMPLOYERS IN THE SMALL GROUP MARKET (This provision applies only to small employers as defined by the laws of the State of West Virginia.) yond those already excluded under the previous Group Contract. You must apply in writing and make the first premium payment to us for such coverage no later than 31 days after your coverage under this Contract ends. # P. GUARANTEED AVAILABILITY OF COVERAGE FOR EMPLOYERS IN THE SMALL GROUP MARKET (This provision applies only to small employers as defined by the laws of the State of West Virginia.) Health insurance issuers that offer coverage in the small group market are required to offer to any small employer in the state all products that are approved for sale in the small group market and the issuer is actively marketing, and must accept any employer that applied for any of those products. In addition, issuers must accept for enrollment every eligible individual who applies for enrollment during the period in which the individual first becomes eligible to enroll under the terms of the group health plan. "Eligible Individual" means an individual who is eligible (1) to enroll in group health insurance coverage offered to a group health plan maintained by a small employer, in accordance with the terms of the group health plan; (2) for coverage under the rules of the health insurance issuer which are uniformly applicable in the state to small employers in the small group market; and (3) for coverage in accordance with all applicable state laws governing the issuer and the small group market. Network plans may limit employers to those with eligible individuals within the network service area and deny coverage where capacity is not adequate. # Q. GUARANTEED RENEWABILITY OF GROUP COVERAGE ch are uniformly applicable in the state to small employers in the small group market; and (3) for coverage in accordance with all applicable state laws governing the issuer and the small group market. Network plans may limit employers to those with eligible individuals within the network service area and deny coverage where capacity is not adequate. # Q. GUARANTEED RENEWABILITY OF GROUP COVERAGE A health insurance issuer offering health insurance coverage in the small or large group market is required to renew or continue in force the coverage at the option of the plan sponsor except in situations involving nonpayment of premiums, fraud, violation of participation or contribution rules, termination of the plan, enrollee's movement outside the service area, association membership ceases, or discontinuance of a product or all coverage. 17 # V. Health Care Benefits This Section describes the Covered Services available to you. Please refer to Section III for specific payment details, benefit maximums and limitations. Note: For assistance in obtaining more specific benefit information on what procedures or tests are covered, call the Customer Service number on your ID Card. Certain Covered Services may also require Prior Authorization. For additional information, go to Section VIII, www.highmarkbcbswv.com or contact Customer Service. # A. MEDICAL NECESSITY REQUIREMENT All Covered Services must be Medically Necessary unless otherwise specified. Medical Necessity is determined by qualified Highmark WV personnel. Generally, Network and Participating Providers are prohibited from billing you for Services determined by Highmark WV to not be Medically Necessary. However, you could be responsible for such Charges in certain circumstances. Among other things, the Network or Participating Provider must provide you with advance notice, in writing, that the Service or Supply may not be Medically Necessary along with estimated Charges nd Participating Providers are prohibited from billing you for Services determined by Highmark WV to not be Medically Necessary. However, you could be responsible for such Charges in certain circumstances. Among other things, the Network or Participating Provider must provide you with advance notice, in writing, that the Service or Supply may not be Medically Necessary along with estimated Charges. You must also agree in writing to proceed with such Services and Supplies and to assume the cost thereof. In addition to the preceding requirements, Highmark WV requires some Network and Participating Providers to specifically request a determination in advance that a Service or Supply is not Medically Necessary. For more information, refer to Section VIII. Non-Network and Non-Participating Providers may bill you for Services deemed by us as not Medically Necessary. # B. PRIOR AUTHORIZATION Certain Covered Services require Prior Authorization. For more information, go to Section VIII, call Customer Service or visit Highmark WV's website at www.highmarkbcbswv.com. The authorization list is located under the Provider drop-down tab. # C. INPATIENT SERVICES # 1. Bed, Board and General Nursing Services - A semiprivate room. - A private room (a room with one bed). We will pay only the Hospital's average semiprivate room rate. - A bed in a special care unit approved by us. The unit must have facilities, equipment, and supportive services for the intensive care of critically ill patients. # 2. Ancillary Services, including: - Operating, delivery, treatment rooms, and equipment. - Prescription Drugs. - Whole blood, blood derivatives, blood plasma and blood components, including administration and blood processing. - Anesthesia, anesthesia supplies and services given by an employee of Hospital or Facility Other Provider. - Oxygen and other gasses. - Medical and surgical dressing, supplies, casts, and splints. - Diagnostic Services. - Therapy Services. rooms, and equipment. - Prescription Drugs. - Whole blood, blood derivatives, blood plasma and blood components, including administration and blood processing. - Anesthesia, anesthesia supplies and services given by an employee of Hospital or Facility Other Provider. - Oxygen and other gasses. - Medical and surgical dressing, supplies, casts, and splints. - Diagnostic Services. - Therapy Services. 3. Medical Care Visits. The personal examination given to you by your Physician or Professional Other Provider. Consultations are not a part of this benefit. Benefits are provided for one Visit for each day you are an Inpatient. 4. Intensive Medical Care. Constant attendance and treatment when your condition requires it. 5. Concurrent Care. Care for a medical condition by a Physician who is not your surgeon while you are in the Hospital for Surgery. Concurrent Care is also care by two or more Physicians during one Hospital stay for two or more unrelated conditions. 18 6. Diagnostic Surgical Procedures. Surgical procedures to diagnose your condition while you are in the Hospital. 7. Inpatient Consultation. A personal bedside examination by another Physician or Professional Other Provider, performing within the scope of their license, when requested by your Physician. The Physician or Professional Other Provider rendering the consulting service must be board-eligible, if applicable, and possess the knowledge, training, and skill needed to provide this service. Consultation services are not covered if the consultant subsequently takes charge of the patient. At that point, we will consider him the treating Physician. We will not provide coverage for both the treating Physician and initial treating Physician for services rendered during the same time period. Staff consultations required by Hospital rules are not covered. # 8. Newborns rovide this service. Consultation services are not covered if the consultant subsequently takes charge of the patient. At that point, we will consider him the treating Physician. We will not provide coverage for both the treating Physician and initial treating Physician for services rendered during the same time period. Staff consultations required by Hospital rules are not covered. # 8. Newborns - Inpatient Newborn Care. Routine care of a newborn, including circumcision while the mother remains an Inpatient for the maternity admission or if the newborn is added to your Contract within the time limit specified in Section IV. Coverage must be in effect for the newborn care to be a Covered Service. Each new dependent must be added to your contract within 30 days of acquiring the new dependent, regardless of the type of coverage in effect at the time you acquire the new dependent. Refer to the Section IV for information on how to apply for the necessary coverage. - Newborn Hearing Impairment Testing. In West Virginia, health care providers present at or immediately after childbirth are required to perform a test for hearing loss on the infant unless the infant's parents refuse. If delivery takes place in a non-covered facility including home birth, a West Virginia health care provider shall inform the parents of the need to obtain this service within the first month of life. The newborn testing shall be a covered benefit. providers present at or immediately after childbirth are required to perform a test for hearing loss on the infant unless the infant's parents refuse. If delivery takes place in a non-covered facility including home birth, a West Virginia health care provider shall inform the parents of the need to obtain this service within the first month of life. The newborn testing shall be a covered benefit. - Detection and Control of Diseases in Newborns. West Virginia law requires the hospital or birthing center in which the infant is born, the parents or legal guardians, the Physician attending the newborn child, or any person attending the newborn child not under the care of a Physician, to ensure that the newborn be tested for phenylketonuria, galactosemia, hypothyroidism, sickle-cell anemia, congenital adrenal hyperplasia, cystic fibrosis, biotinidase deficiency, isovaleric acidemia, glutaric acidemia type I, 3-Hydroxy-3-methylglutaric acidura, multiple carboxylase deficiency, methylmalonic acidemia-mutase deficiency form, 3-methylcrotonyl-CoA carboxylase deficiency, methylmalonic acidemia, Cbl A and Cbl B forms, propionic acidemia, beta-ketothiolase deficiency, medium-chain acyl-CpA, dehydrogenase deficiency, very long-chain acyl-CpA dehydrogenase deficiency, long-chain hydroxyacyl-CpA dehydrogenase deficiency, trifunctional protein deficiency, carnitine uptake defeat, maple syrup urine deficiency, homocystinuria, citrullinemia type I, argininosuccinate acidemia, tyrosimenia type I, hemoglobin S/Beta-thalassemis, sickle C disease and hearing deficiency and certain other disease specified by the Bureau of Public Health. # D. PREVENTIVE CARE SERVICES Note: In addition to the Covered Services listed below, there are other routine screening, immunization and diagnostic services covered as afforded by the Patient Protection and Affordability Care Act (PPACA). For additional information, go to www.healthcare.gov or contact Customer Service. Their phone number is on the back of your ID Card. Bureau of Public Health. # D. PREVENTIVE CARE SERVICES Note: In addition to the Covered Services listed below, there are other routine screening, immunization and diagnostic services covered as afforded by the Patient Protection and Affordability Care Act (PPACA). For additional information, go to www.healthcare.gov or contact Customer Service. Their phone number is on the back of your ID Card. # 1. Routine Gynecological Services - Pap smears (including related office visits) - annually or more often if recommended by a Physician. - Human Papilloma Virus (HPV) Testing - one every 3 years age 30 and older. - Mammograms according to the following schedule: Age 35 through 39 years of age - one baseline mammogram Age 40 through 49 years of age - every two years or more often if recommended by physician 19 50 and over – one per calendar year Note: As required by West Virginia law, female enrollees have direct access to a women's health care provider of their choice. 2. Diabetic Services - Services provided or performed for the treatment of both insulin dependent and non-insulin dependent diabetes includes: - Blood glucose monitors and monitor supplies; (paid under your durable medical equipment (DME) benefits) - Insulin infusion devices; (paid under your DME benefits) - Insulin, syringes (paid under your prescription drug benefits), and insulin injection aids or devices; - Pharmacological agents for controlling blood sugar (paid under your prescription drug benefits); - Urine ketone testing strips; - Urine micro albumin test; - Blood pressure monitoring device; - Podiatric appliances and therapeutic footwear; - Foot Orthotics; and - Orthopedic appliances including canes, crutches and walkers, and other items as may be medically necessary. You may directly access any Network Provider for one annual diabetic retinal exam. under your prescription drug benefits); - Urine ketone testing strips; - Urine micro albumin test; - Blood pressure monitoring device; - Podiatric appliances and therapeutic footwear; - Foot Orthotics; and - Orthopedic appliances including canes, crutches and walkers, and other items as may be medically necessary. You may directly access any Network Provider for one annual diabetic retinal exam. Diabetes self-management education to ensure the proper self-management and treatment, including diet education, is a Covered Service. However, this education is limited to only those services considered medically necessary, and - Visits medically necessary upon diagnosis of diabetes; - Visits necessitated by a significant change in the patient's symptoms or conditions resulting in a change in the patient's self-management; and - When a new medicine or therapeutic process relating to treatment or management of the patient's condition has been identified as medically necessary. Education services may be provided by: - A licensed pharmacist when providing instruction on the proper use of equipment covered by this contract or supplies and medication prescribed by a licensed Physician; - A diabetes educator certified by a national diabetes educator certification program; - A registered dietitian registered by a nationally recognized professional association of dieticians. National diabetes education certification or any professional association of dietitians must be certified to the Insurance Commissioner by the West Virginia Health Department. 3. Prostate screening exam and prostate specific antigen (PSA) test for males over age 50 - one per calendar year. 4. Colorectal Cancer Screening for individuals age 50 and older, symptomatic person under age 50 or a person under age 50 with high risk factors (e.g. family history). l association of dietitians must be certified to the Insurance Commissioner by the West Virginia Health Department. 3. Prostate screening exam and prostate specific antigen (PSA) test for males over age 50 - one per calendar year. 4. Colorectal Cancer Screening for individuals age 50 and older, symptomatic person under age 50 or a person under age 50 with high risk factors (e.g. family history). - Exam - one per calendar year. - Fecal Occult Test - one per calendar year. - Flexible Sigmoidoscopy - one every 5 years. - Colonoscopy - one every 10 years. - Double Contrast Barium Enema - one every 5 years. 5. Annual Kidney disease screening and laboratory testing; including any combination of blood pressure testing, urine albumin or urine protein testing, and serum creatinine testing. 20 # E. SPECIAL SERVICES 1. Pre-Admission Testing. Outpatient tests and studies required for your scheduled Hospital admission as an Inpatient, which would have been covered as an Inpatient. 2. Mastectomy Benefits. - Reconstruction of breast on which the mastectomy was performed; - Reconstructive surgery of the other breast to present symmetrical appearance; - Prostheses and coverage for physical complications at all stages of the mastectomy procedure, including lymphedemas in a manner determined in consultation with the attending physician and the patient. - Minimum stay of 24 hours of Inpatient care following a total mastectomy or partial with lymph node dissection for treatment of breast cancer. - Minimum stay of 48 hours of Inpatient care for a radical or modified mastectomy. # F. SURGICAL SERVICES 1. Surgery. This must be done by a Physician or Professional Other Provider performing within the scope of their license. Benefits include Medical Care visits before and after Surgery. 2. Special Surgery total mastectomy or partial with lymph node dissection for treatment of breast cancer. - Minimum stay of 48 hours of Inpatient care for a radical or modified mastectomy. # F. SURGICAL SERVICES 1. Surgery. This must be done by a Physician or Professional Other Provider performing within the scope of their license. Benefits include Medical Care visits before and after Surgery. 2. Special Surgery - Sterilization, regardless of Medical Necessity. - Removal of impacted teeth. Partial and Full-boney impacted teeth are covered under your medical benefits; all soft tissue impactions would be covered under your Dental benefits, if applicable. - Mandibular staple implant due to trauma and/or accidental injury. - Maxillary or mandibular frenectomy. - Kidney transplants 3. Multiple Surgical Procedures. When more than one surgical procedure is performed through the same body opening during one operation, you are covered for the most complex procedure. When more than one surgical procedure is performed through more than one body opening during one operation, you are covered for the most complex procedure and for one-half of the benefit for additional procedures, if Medically Necessary. 4. Assistant at Surgery. A Physician's help to your surgeon in performing covered Surgery when no qualified house staff member, intern, or resident exists. 5. Anesthesia. Administration of anesthesia, done in connection with a Covered Service, by a Physician or certified registered nurse anesthetist who is not the surgeon or the assistant at Surgery. This benefit includes care before and after the administration. The services of a standby anesthesiologist are covered during coronary angioplasty Surgery. ouse staff member, intern, or resident exists. 5. Anesthesia. Administration of anesthesia, done in connection with a Covered Service, by a Physician or certified registered nurse anesthetist who is not the surgeon or the assistant at Surgery. This benefit includes care before and after the administration. The services of a standby anesthesiologist are covered during coronary angioplasty Surgery. 6. Second Surgical Opinion. A second Physician's opinion and related Diagnostic Services to help determine the need for elective covered Surgery services recommended by your first Physician is a Covered Service. The second opinion must be provided by someone other than the first Physician who recommended the Surgery. This benefit is not payable while you are an Inpatient of a Hospital. We cover a third opinion if the first two opinions conflict. The Surgery is a Covered Service even if the Physicians' opinions conflict. # G. EMERGENCY SERVICES Coverage shall be provided for Emergency Medical Services to the extent necessary to screen and Stabilize an Emergency Medical Condition. Emergency Services are those provided to evaluate and treat an Emergency Medical Condition, a condition manifesting itself by the sudden, and unexpected onset of acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health or with respect to a pregnant woman the health of the unborn child, serious impairments to bodily functions or serious dysfunction of any bodily part or organ based on a Prudent Layperson standard. Emergency 21 Medical Conditions include, but are not limited to, heart attacks, strokes, loss of consciousness or respiration, convulsions and other acute conditions, which we determine to be a Medical Emergency only if: pregnant woman the health of the unborn child, serious impairments to bodily functions or serious dysfunction of any bodily part or organ based on a Prudent Layperson standard. Emergency 21 Medical Conditions include, but are not limited to, heart attacks, strokes, loss of consciousness or respiration, convulsions and other acute conditions, which we determine to be a Medical Emergency only if: - Severe symptoms occur suddenly and unexpectedly; - Immediate care is secured; and - The illness or condition, as finally diagnosed or as indicated by its symptoms, is one, which would normally require immediate Medical Care. Prior Authorization is not required for treatment of Emergency Medical Conditions. If a member seeks treatment at a Hospital emergency room and receives services that are not Medically Necessary, this Certificate will not reimburse the cost of such services, other than a Medical Screening Exam to determine if an Emergency Medical Condition exists or, if based on retrospective review, a Prudent Layperson would have believed an Emergency Medical Condition exists (in any case, less any applicable Coinsurances and Deductibles). Note. Emergency Care received in a Physician's office will be paid as any other Office Visit. # Emergency Care Covered emergency services for the treatment of Emergency Medical Conditions include pre-hospital services to the extent necessary to screen and stabilize your condition, such as: - Outpatient Hospital services; - Medical, surgical and anesthesia services; - Diagnostic Services; - Tetanus toxoid immunizations; and. - Rabies vaccine. # H. HOME, OFFICE AND OTHER OUTPATIENT VISIT Medical Care, not falling within the Emergency Services Benefit, to examine, diagnose and treat an injury, condition, disease, or illness. # I. HOSPITAL-BASED CLINICS A non-emergency Outpatient Visit in a Hospital-based clinic setting may apply to your Outpatient facility benefit and not to your Office Visit benefits. # J. INJECTABLE DRUGS vaccine. # H. HOME, OFFICE AND OTHER OUTPATIENT VISIT Medical Care, not falling within the Emergency Services Benefit, to examine, diagnose and treat an injury, condition, disease, or illness. # I. HOSPITAL-BASED CLINICS A non-emergency Outpatient Visit in a Hospital-based clinic setting may apply to your Outpatient facility benefit and not to your Office Visit benefits. # J. INJECTABLE DRUGS Certain injectable drugs may require pre-authorization. Contact Medical Management for additional information. Their phone number is located on the back of your ID Card. # K. DIAGNOSTIC SERVICES Diagnostic Services include: - Radiology, ultrasound and nuclear medicine, - Laboratory and pathology services, - EKG, EEG, and other electronic diagnostic medical procedures. # L. ALLERGY TESTS AND TREATMENT Allergy tests that are performed and related to a specific diagnosis are Covered Services. Desensitization treatments are also Covered Services. # M. THERAPY SERVICES Services or supplies used to promote the recovery from an illness or injury include: 1. Radiation Therapy. The treatment of disease by X-ray, radium, or radioactive isotopes. 22 2. Chemotherapy. The treatment of malignant disease by chemical or biological antineoplastic agents. 3. Dialysis Treatments. The treatment by dialysis methods of an acute or chronic kidney ailment, including chronic ambulatory peritoneal dialysis, which may include the supportive use of an artificial kidney machine. 4. Physical Therapy. The treatment given to relieve pain, restore maximum function and to prevent disability following disease, injury, or loss of a body part. Such services include physical treatments, hydrotherapy, heat or similar modalities, physical agents, biomechanical and neurophysiological principles and may include devices if we determine that they are Medically Necessary. - Benefits are also provided for chiropractic (spinal) manipulations. - Benefits are also available for aquatic therapy. ty following disease, injury, or loss of a body part. Such services include physical treatments, hydrotherapy, heat or similar modalities, physical agents, biomechanical and neurophysiological principles and may include devices if we determine that they are Medically Necessary. - Benefits are also provided for chiropractic (spinal) manipulations. - Benefits are also available for aquatic therapy. 5. Respiratory Therapy. Introduction of dry or moist gasses into the lungs for treatment purposes. 6. Hyperbaric and Pulmonary Therapy. The administration of oxygen in a pressurized chamber. Under pressurization, oxygen levels are increased. Certain conditions should be reviewed for Medical Necessity. 7. Outpatient Speech Therapy. In order to be considered a Covered Service, this therapy must be performed by a certified/licensed therapist and be Medically Necessary due to a medical condition such as: - A stroke. - Aphasia. - Dysphasia. - Post-laryngectomy. 8. Outpatient Occupational Therapy. In order to be considered a Covered Service, this therapy must be Medically Necessary and must be expected to improve the level of functioning within a reasonable period of time. # N. REHABILITATION SERVICES 1. For Services provided at a: - A hospital duly licensed by the state of West Virginia that meets the requirements for rehabilitation Hospitals as described in the Medicare Provider Reimbursement Manual, Part 1; - A distinct part rehabilitation unit in a Hospital duly licensed by the state of West Virginia; or - A hospital duly licensed by the state of West Virginia that meets the requirements for cardiac rehabilitation; or - Similar facilities located outside of the state. 2. Benefits will be provided for Rehabilitation Services for the following conditions: - Stroke; - Spinal cord injury; - Congenital deformity; - Amputation; - Major multiple traumas; - Fracture of femur; - Brain injury; - Polyarthritis, including rheumatoid arthritis; - Neurological disorders; - Cardiac disorders; and - Burns. 23 bilitation; or - Similar facilities located outside of the state. 2. Benefits will be provided for Rehabilitation Services for the following conditions: - Stroke; - Spinal cord injury; - Congenital deformity; - Amputation; - Major multiple traumas; - Fracture of femur; - Brain injury; - Polyarthritis, including rheumatoid arthritis; - Neurological disorders; - Cardiac disorders; and - Burns. 23 Rehabilitation services do not include services for mental health, chemical dependency, vocational rehabilitation, long-term maintenance or custodial services. Your Physician must certify that there is reasonable likelihood that Rehabilitation Services will correct or restore you to your optimal physical, medical, psychological, social, emotional, vocational and economic status. Your Physician's certification and recommended course of treatment are subject to review for Medical Necessity. # O. MATERNITY SERVICES Hospital, medical and surgical services for a normal pregnancy, complications of pregnancy, miscarriage, and therapeutic and elective abortions are Covered Services. These are Covered Services for the Certificate Holder and all Eligible Dependents. If this group health plan provides for maternity or newborn infant coverage, under Federal Law, it may not restrict such 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 the issuer for prescribing lengths of stay not in excess of the above periods. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours or 96 hours as applicable. Precertification is required only when the Inpatient stay exceeds 48 hours and 96 hours respectively. he issuer for prescribing lengths of stay not in excess of the above periods. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours or 96 hours as applicable. Precertification is required only when the Inpatient stay exceeds 48 hours and 96 hours respectively. # P. MENTAL HEALTH CARE AND SUBSTANCE ABUSE (DRUG AND ALCOHOL) COVERAGE # 1. Mental Health Care In addition to other Covered Services, the following services are payable for the treatment of Mental Illness: - Individual psychotherapy. - Group psychotherapy. - Family counseling; counseling with family members to assist with diagnosis and treatment. This coverage will provide payment for Covered Services only for those family members who are considered Covered Persons under this Contract. Charges will be applied to the Covered Person who is receiving family counseling services, not necessarily the patient. - Electroshock therapy or convulsive drug therapy and related anesthesia only if given in a Hospital or Psychiatric Hospital. - Psychological testing. - Intensive Outpatient Services (IOP). - Partial Hospital (PH). - Psychiatric Inpatient hospitalization. In addition to other Covered Services, West Virginia law requires coverage of Serious Mental Illness which is defined as an illness that is included in the sub classification of: - Schizophrenia and other psychotic disorders; - Bipolar disorders. - Depressive disorders. - Substance-related disorders with the exception of caffeine, nicotine related disorders. - Anxiety related disorders. - Anorexia and bulimia # 2. Drug Abuse and Alcoholism Service Covered Services for Drug Abuse and Alcoholism rehabilitation include: - Individual psychotherapy Schizophrenia and other psychotic disorders; - Group psychotherapy 24 s; - Bipolar disorders. - Depressive disorders. - Substance-related disorders with the exception of caffeine, nicotine related disorders. - Anxiety related disorders. - Anorexia and bulimia # 2. Drug Abuse and Alcoholism Service Covered Services for Drug Abuse and Alcoholism rehabilitation include: - Individual psychotherapy Schizophrenia and other psychotic disorders; - Group psychotherapy 24 - Family counseling; counseling with family members to assist with diagnosis and treatment. This coverage will provide payment for Covered Services only for those family members who are considered Covered Persons under this Contract. Charges will be applied to the Covered Person who is receiving family counseling services, not necessarily the patient. - Covered Services also include Inpatient detoxification services. Services beyond the evaluation or to diagnose conditions related to mental deficiency, retardation, an autistic disease of childhood, learning disabilities or mental retardation are not covered. We do not pay benefits for Mental Illness that cannot be treated. We will, however, pay benefits to determine if the disorder or illness can be treated. Your Physician must certify that there is a reasonable likelihood that your treatment will be of substantial benefit and substantial improvement is likely. # Q. WELL BABY AND WELL CHILD CARE SERVICES # 1. Well Baby Care Services. Routine office visits and immunizations for ages one month to six years are Covered Services. Allowable office visits, lab tests and immunizations will follow the schedule recommended by the American Academy of Pediatrics (AAP). You may access this information at www.aap.org or contact Customer Service. Their phone number is located on the back of your ID Card. # 2. Well Child Care Service. ces. Routine office visits and immunizations for ages one month to six years are Covered Services. Allowable office visits, lab tests and immunizations will follow the schedule recommended by the American Academy of Pediatrics (AAP). You may access this information at www.aap.org or contact Customer Service. Their phone number is located on the back of your ID Card. # 2. Well Child Care Service. Routine office visits and immunizations for ages six through seventeen years are Covered Services. Allowable office visits and immunizations will follow the schedule recommended by the American Academy of Pediatrics (AAP). You may access this information at www.aap.org or contact Customer Service. Their phone number is located on the back of your ID Card. # R. DENTAL SERVICES FOR AN ACCIDENTAL INJURY Dental services will be covered only when due to an accidental injury to the jaws, sound natural teeth, mouth or face. Such services must be Incurred within one year from the date of the accident. Injury as a result of chewing or biting shall not be considered an accidental injury. # S. AMBULANCE SERVICES Ambulance services include local ground transportation by a vehicle designed, equipped, and used only to transport the sick and injured: - From your home, scene of an accident or Medical Emergency to a Hospital. (See also, Emergency Care services Section.) - Between Hospitals. - Between a Hospital and a Skilled Nursing Facility. - From a Hospital or Skilled Nursing Facility to your home. Trips must be to the closest facility that can give Covered Services appropriate for your condition. Transportation will also be covered when provided by a professional ambulance service for other than local ground transportation. Special treatment must be required and the transportation must be to the nearest Hospital qualified to provide the special treatment. # T. PRIVATE DUTY NURSING SERVICES Trips must be to the closest facility that can give Covered Services appropriate for your condition. Transportation will also be covered when provided by a professional ambulance service for other than local ground transportation. Special treatment must be required and the transportation must be to the nearest Hospital qualified to provide the special treatment. # T. PRIVATE DUTY NURSING SERVICES Skilled Care rendered by a registered, licensed vocational or licensed practical nurse when ordered by a Physician. Care that is primarily non-medical or Custodial Care is not covered. Such services must be certified initially and every 30 days by your Physician for Medical Necessity. Inpatient Services are Services that we decide are of such a nature or degree of complexity that the Provider's regular nursing staff cannot give them. 25 # U. SKILLED NURSING FACILITY SERVICES Benefits for the same services available to an Inpatient of a Hospital are also covered for an Inpatient of a Skilled Nursing Facility. Such services must be Skilled Care and authorized and provided pursuant to your Physician's Plan of Treatment. Your Physician must certify initially and every two weeks that you are receiving Skilled Care and not merely Custodial Care. No benefits are payable: - Once a patient can no longer significantly improve from treatment for the current condition as determined by us. - For Custodial Care. - Solely for the treatment of pulmonary tuberculosis. # V. HOME HEALTH CARE SERVICES The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: - Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife. - Physical therapy, occupational therapy or speech therapy. - Medical and surgical supplies. - Prescription Drugs. - Oxygen and its administration. - Medical social services. - Home health aide visits when you are also receiving Skilled Care or Therapy Services. - Laboratory tests. - Home infusion therapy. rmittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife. - Physical therapy, occupational therapy or speech therapy. - Medical and surgical supplies. - Prescription Drugs. - Oxygen and its administration. - Medical social services. - Home health aide visits when you are also receiving Skilled Care or Therapy Services. - Laboratory tests. - Home infusion therapy. We do not pay Home Health Care benefits for any services or supplies not specifically listed above. Non-covered examples include, but are not limited to: - Dietician services. - Homemaker services. - Food or home delivered meals. - Custodial Care. - Maintenance therapy. - Routine prenatal care. - Private duty nursing. - Personal comfort items. # W. HOSPICE SERVICES Hospice care consists of health care benefits provided to a terminally ill Covered Person. Benefits will begin when the prognosis of life expectancy is estimated to be six months or less. A Treatment Plan must be developed and submitted to us for our approval by the Covered Person's Physician and the Hospice Provider. A licensed Hospice organization or a Hospice program sponsored by a Hospital or Home Health Care Agency and approved by us must provide all Covered Services. The Covered Services listed in the Home Health Care Services Section are also considered Hospice services. In addition, your coverage includes: - Acute Inpatient hospice care. - Respite care. - Dietary guidance. - Durable medical equipment. - Home Health aide visits. 26 Approved Prescription Drugs will be limited to a two-week supply per Prescription Order or Refill. These Prescription Drugs must be required for palliative or supportive care. In addition to the excluded services listed in the Home Health Care Services Section, no Hospice services will be provided for: - Physician Visits. - Volunteer services. - Spiritual counseling. - Bereavement counseling for family mem [Text truncated at 120,000 characters. 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