HomeMy WebLinkAboutCity of Tamarac Resolution R-2009-153u
Temp. Reso. #11719 - November 4, 2009
Page 1
CITY OF TAMARAC, FLORIDA
RESOLUTION NO. R-2009- 16-3
A RESOLUTION OF THE CITY COMMISSION OF
THE CITY OF TAMARAC, FLORIDA,
AUTHORIZING THE APPROPRIATE CITY
OFFICIALS TO EXECUTE THE AGREEMENT OF
THE CITY'S HEALTH INSURANCE PROGRAM
WITH UNITED HEALTHCARE INSURANCE
COMPANY FOR PLAN YEAR EFFECTIVE
JANUARY 1, 2010; PROVIDING FOR PLAN
DESIGN AND PREMIUM RATES; PROVIDING
FOR THE CONTINUATION OF THE EXISTING
COST ALLOCATION OF THE HEALTH
INSURANCE PREMIUM BETWEEN THE CITY
AND EMPLOYEES; PROVIDING FOR A WAIVER
REIMBURSEMENT MAXIMUM; PROVIDING FOR
CONFLICTS; PROVIDING FOR SEVERABILITY;
AND PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City's health insurance was awarded to Aetna, Inc.
effective January 1, 2002; and
WHEREAS, the City's contract with Aetna, Inc. is scheduled to expire on
December 31, 2009; and
WHEREAS, on September 15, 2009, the City contracted with Willis
Employee Benefits to competitively market, analyze and recommend alternatives
to the City's health plan; and
WHEREAS, as a result of the marketing of the health plan, Willis
Employee Benefits presented the City with five proposals: Aetna, Inc., AvMed,
Blue Cross Blue Shield, CIGNA and United Healthcare Insurance Company; and
Temp. Reso. #11719 - November 4, 2009
Page 2
WHEREAS, the City reviewed its health insurance plan design and
determined that plan design changes are necessary for 2010, as described in
Exhibit I, 2010 Medical Rates and Benefits, attached hereto and made a part
hereof, and
WHEREAS, the City staff has worked with representatives of Willis
Employee Benefits to evaluate alternatives and negotiate the most
comprehensive and cost effective health insurance plan for the City's employees
and their dependents; and
WHEREAS, after careful evaluation of all aspects of the proposals by the
Benefits Specialist and Director of Human Resources, with assistance from
representatives of Willis Employee Benefits, it
was
determined that
United
Healthcare Insurance Company provided the
most
comprehensive
health
insurance program which matched our coverage with Aetna, Inc. except as
specifically noted in Exhibit I, 2010 Medical Rates and Benefits, attached hereto
and made a part hereof; and
WHEREAS, as a result of these negotiations, the final costs of the health
insurance program in 2010 represents an overall increase of 3.88% from the
approved costs in 2009; and
WHEREAS, available funds exist in the appropriate Governmental Funds
which are in the approved FY2010 Budget; and
WHEREAS, the City shall establish a waiver reimbursement maximum
that will allow employees who elect to purchase insurance through their spouse's
employer or otherwise independently from the City to be reimbursed up to a
Temp. Reso. #11719 - November 4, 2009
Page 3
maximum amount equal to 80% of the commensurate tier of the PPO rate for the
plan year beginning January 1, 2010; and
WHEREAS, the City will continue the existing cost allocation of the health
insurance premium between the City and the employees; and
WHEREAS, it is the recommendation of the City Manager and the Director
of Human Resources that the City execute the employer application, attached as
Exhibit II and made a part hereof, and the health insurance contract documents
with United Healthcare Insurance Company, attached as Exhibits III, IV, V and
VI, attached hereto and made a part hereof, subject to final completion of the
Group Policy and Schedule of Benefits documents, incorporating Exhibit I,
Medical Rates and Benefits, and any revisions as may be negotiated by and
between City staff and United Healthcare Insurance Company and as approved
by the City Manager and the City Attorney effective January 1, 2010; and
WHEREAS, the City Commission has deemed it to be in the best interest
of the health, safety and welfare of citizens and residents of the City of Tamarac
to contract with United Healthcare Insurance Company to provide health
insurance to City of Tamarac employees and their dependents.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE
CITY OF TAMARAC, FLORIDA:
SECTION 1: That the foregoing "WHEREAS" clauses are hereby
ratified and confirmed as being true and correct and are hereby made a specific
Temp. Reso. #11719 - November 4, 2009
Page 4
part of this Resolution. All exhibits attached hereto are incorporated herein and
made a specific part of this Resolution.
SECTION 2: That the appropriate City officials are hereby
authorized to execute the employer application, attached as Exhibit II and made
a part hereof, and the health insurance contract documents with United
Healthcare Insurance Company, attached as Exhibits III, IV, V and VI and
made a part hereof, for City of Tamarac employees subject to final completion
of the Group Policy and Schedule of Benefits documents, incorporating Exhibit
I, 2010 Medical Rates and benefits, and any revisions as may be negotiated by
and between City staff and United Healthcare and as approved by the City
Manager and the City Attorney effective January 1, 2010.
SECTION 3: That the appropriate City officials are hereby
authorized to continue the existing cost allocation of the health insurance
premium between the City and the employees.
SECTION 4: That the appropriate City officials hereby authorize a
waiver reimbursement maximum, to allow employees who elect to purchase
insurance through their spouse's employer or otherwise independently from the
City to be reimbursed up to a maximum amount equal to 80% of the
commensurate tier of the PPO rate for the plan year beginning January 1,
2010.
SECTION 5: That all resolutions or parts of resolutions in conflict
herewith are hereby repealed to the extent of such conflict.
1
F
J
1
Temp. Reso. #11719 - November 4, 2009
Page 5
SECTION 6: That if any clause, section, or other part or
application of this Resolution is held by any court of competent jurisdiction to be
unconstitutional or invalid, in part or application, it shall not affect the validity of
the remaining portions or applications of this Resolution.
SECTION 7: This Resolution shall become effective immediately
upon adoption.
PASSED, ADOPTED AND APPROVED this /0 day of �� 4Z'Z_ ; 2009.
ATTEST:
MARION SWENSON, C
CITY CLERK
I HEREBY CERTIFY that
I have approved this
RESOLUTION as to form.
/W/// ih, P&I"
, AMU L OktN
CITY ATTORNEY
6
BETH FLANSBAUM-TALABISCO
MAYOR
RECORD OF COMMISSION VOTE:
MAYOR FLANSBAUM-TALABISCO
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ERBIT II
Insured Employer Application UnitedHealthcare
A UnaedHealth Group Company
To avoid processing delays, please make sure you:
1. Answer all questions completely and accurately,
2. 00 NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL.
3. Include a deposit check in the amount of the estimated first month's premium; such amount will be returned in the event coverage} does not become
effective and will be applied against the first month's premium if coverage does become effective.
onerall Information Requested Effective Date January 1 2010.
Group's/Company's Legal Name
--._......._.._Cit..Y__._o_.......... Tamar_ac _._._._----.._____..—... _...... __._.— _
Street Address Tax 10
7525 NW 88th Avenue I 591039552
City
Tamarac,
Contact Person
Maria Swanson
Billing Address (if different)
same
Multi -location group/cornpany?
C: Yes X.., No
State
Zip Code County
Telephone Fax I Email Address
954-_597-3600 1 954-597-36101 marias@tamarac.or
# of Locations I Address (as) (or list on additional shoot of paper)
of Years in Business Nature of Business Industry Code
municipality—
# Hours per week Waiting Period 1st of Policy Month following Data of Hire Waiting Period waived for initial
to be eligible for new hires (:: 1st of Policy Month following [months] [clays] of employment enrollees X: Yes No
j Date of Hire (no waiting period)
25 [months] [days] of employment following Date of Hire
Other - ... ----- ---
Number of Persons currently on COBRA/Continuation Number of Employees Termetl Gasses Excluded: ... None 'Union Hourly
(employees/dependents) in last 12 Months Nan -Management Non Owners
' ' • # pplying
# Full Time Employees —._..._ Medical
#Part Time Employees Lifo
Ineligible Employees Dental
Total # Erployees Vision
Other
for:
# Waiving
--
Medical
Life
Dental
Vision
Other
for:_7ntal
Employer %
Employee%
_
Em to er u far De
_.._. �Y _.__._..p---._.._
—
_..- .............
__.
_
_
Vision
i Other
---._
Name of Current Medical Carrier # Yrs with the Current Carrier Name of Current Dental Carrier # Yrs with the Current Carrier
....Aetna ....................._..._...._._.........__......_ _..... _ ---- — 8 Aetna --
Name of Worker's Comp Carrier Names of Owners/Partners not covered by Workers Compensation
Florida League of Cities
Yes XNo In the past 36 months, has the Group/Company or any affiliated entity filed for protection or operated under federal/state bankruptcy
laws'? (Chapter 7 or 11)
Yes No In the past 36 months, has any creditor filed or threatened to file a petition requesting the Group/Company or any affiliated entity be
placed voluntarily into bankruptcy?
Note: Life Insurance premiums for totally disabled insureds are waived for 6 months.
Yes i_ No Acceptance of this application will replace existing life insurance coverage
Coverage Provided by "United Healthcare and Affiliates":
Medical coverage provided by United HealthCare Insurance Company or United HealthCare of Florida, Inc. or Neighborhood Health Partnership, Inc.
Dental coverage provided by United HealthCare Insurance Company or United HealthCare of Florida, Inc. or Neighborhood Health Partnership, Inc.
Life Insurance coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
Vision coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
LGIRVYL 09107 page 1 of 3 213-3640 10/07
Agent Name Agency I Agent Code/Tax ID Number
Printed Agent Name Email Address Social Security st Phone Number Date
Rep Name
Rap
Commissions payable to --..._..__.. _
Agent Commission Schedule _- Std Scale of _-____....
-------- -------._._..—..----_ ....__ _ . ..._..__ ..... _ ._ _..... _ .._..._... --- — --- rida a-
LicenseIDS ----- _........................ - - -.
Agent Signature Flo
Yes No To the best of my knowledge, acceptance of this application will replace existing life insurance coverage.
'See next page for important disclosure regarding agent compensation..
Answer the following questions to the best of your knowledge for all eligible employees and dependents (proprietors, partners, corporate officers, employees, spouses
and dependent children). Please provide details to "Yes" answers in the space provided.
IMPORTANT: Your answers to those questions must include all COBRA and State Continued individuals covered by your present plan,
Yes i No 1. Within the past 5 years, has an employee or dependent filed a claim for short-term disability, long term disability, social security
disability income, workers' compensation, Medicare, or Medicaid benefits or any other type of disability benefits on any policy?
Yes No 2. During the past 5 years, has any employee or dependent had life, disability or health insurance declined, postponed, changed,
cancelled or withdrawn?
Yes ';No 3. Except for a maternity or paternity leave, within the past 5 years, has any employee applied for a family or medical leave of more than 2
weeks due to injury, disability or illness of the employee or dependent?
Yes No 4. Within the past 5 years, has any employee been absent from work for more than 2 consecutive weeks due to injury, disability or illness
Yes No 5. Except for a mental health admission, during the past 5 years, has any employee or dependent had a hospital stay lasting more than 5
days?
Yes No 6. Is any employee or dependent currently hospitalized?
Yes : No 7. Except for allergy -related, birth -control or infertility medication, during the past 5 years, has any employee or dependent taken a
prescription medication for a period lasting more than 6 months.
Yes No 8. Is any employee or dependent currently taking a prescription medication thatwill be taken for more than 6 months?
Yes i No 9, During the past 5 years, has any employee or dependent been treated for OR diagnosed by a physician as having one of the following
Conditions'.
Cancer (any type) Hepatitis
Lung disease or respiratory problem (any type) L Morbid obesity
Heart disease or disorder (any type) Congenital abnormality
Organ, tissue or cell transplant Vascular disease (any type)
Liver disease (any type) ;a Neurological disorder (any type)
1 Kidney disease (any type) : I Immunological disorder (reportable types)
v] Pancreatic disorder (any type) i::::: Alcohol or drug addiction or abuse
Diabetes
If you hove answered "Yes" to any of the questions above, please provide the requested information for each individual. If necessary, use additional sheets of paper.
Question Cheek One Data of Date of Treatment/ Nature of Name of S Amount Prognosis
Number Employee I Der ndont Aga Recovery Condition Medication i Condition of Claims — Current Treatment
page 2 of 3
The Group/Company certifies that the information provided above is complete and accurate. The Group/Company shall notify UnitedHealthcare and Affiliates
promptly of any changes in this information that may affect the eligibility of employees or their deperdents, including the addition of any newly eligible
employees or dependents. Prior to receiving notification of approval, the Group/Company shall notify UnitedHealthcare and Affiliates promptly of any
significant changes in the health status of an eligible employee or dependent including any inpatient hospital admissions. United Healthcare and Affiliates shall
be entitled to rely on the most current information in its possession regarding the eligibility and health status of employees and their dependents in providing
coverage under the policy/policies for which application is being made.
I represent to the best of my knowledge the information I have furnished is accurate, and includes any employees and dependents who have elected
continuation of insurance benefits. I understand that material omissions misrepresentations or misstatements in the information requested on this form can
result in the adjustment of rating or voiding of insurance.
Upon receipt by United Healthcare and Affiliates of this signed employer application and payment of the required policy rharges, the group policy is deemed
executed. the deposit check in the estimated amount of the first month's premium is not considered payment of the required policy charges.
United Healthcare disclosure regarding agent compensation
We pay agents compensation for their services in connection with the sale of our insured products, in compliance with applicable law. We pay "base
commissions" based on factors such as product type, amount of premium, group size and number of employees. These commissions are reflected in the
premium rate. In addition, we may pay bonuses pursuant to bonus programs established from time to tirne which are designed to encourage the introduction
of new products and provide incentives to achieve production targets, persistency levels, growth goals or other objectives. Bonuses are not reflected in the
Premium rate but are paid from our general administrative expenses. In general, our total bonuses are less than 10% of total agent compensation paid. It is our
policy not to pay commissions to agents with respect to a product for which the customer is also paying the agent a commission or other foe. Please note we
also make payments from time to time to agents for services other than those relating to the sale of policies (for example, compensation for services as a
general agent or as a consultant).
Agent. compensation is subject to disclosure on Schedule A of the ERISA Form 5500 for customers governed by FRISA. We provide Schedule A reports to our
customers. We also have taken steps to ensure that agents properly disclose their compensation arrangements to their customers, but we cannot guarantee
the agent's compliance. For general information on our agent payment arrangements, including the approximate percentage of total compensation that total
bonus payments comprise, please go to http://www.uhc,com and click on the drop down box for employers under "View Our Programs - Producer Payment
Programs." For specific information about the compensation payable with respect to your particular policy, please contact your agent.
Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false,
incomplete or misleading information is guilty of a felony of the third degree.
Group/Company Signoture
Date
DO NOT CANCEL, YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL.
page 3 of 3
EXHIBIT III
Group Policy
UnitedHealthcare Insurance Company
(450 Columbus Boulevard)
(Hartford, Connecticut 06115-0450)
[1-800-357-1371 ]
This Policy is entered into by and between UnitedHealthcare Insurance Company and the "Enrolling
Group," as described in Exhibit 1.
When used in this document, the words "we," "us," and "our" are referring to UnitedHealthcare Insurance
Company.
Upon our receipt of the Enrolling Group's signed application and payment of the first Policy Charge, this
Policy is deemed executed.
We agree to provide Benefits for Covered Health Services set forth in this Policy, including the attached
Certificate(s) of Coverage and Schedule(s) of Benefits, subject to the terms, conditions, exclusions, and
limitations of this Policy. The Enrolling Group's application is made a part of this Policy.
This Policy replaces and overrules any previous agreements relating to Benefits for Covered Health
Services between the Enrolling Group and us. The terms and conditions of this Policy will in turn be
overruled by those of any subsequent agreements relating to Benefits for Covered Health Services
between the Enrolling Group and us.
We will not be deemed or construed as an employer or plan administrator for any purpose with respect to
the administration or provision of benefits under the Enrolling Group's benefit plan. We are not
responsible for fulfilling any duties or obligations of an employer or plan administrator with respect to the
Enrolling Group's benefit plan.
This Policy will become effective on the date specified in Exhibit 1 and will be continued in force by the
timely payment of the required Policy Charges when due, subject to termination of this Policy as provided
in Article 5.
When this Policy is terminated, as described in Article 5, this Policy and all Benefits under this Policy will
end at 12:00 midnight on the date of termination.
This Policy is issued as described in Exhibit 1.
Issued By:
UnitedHealthcare Insurance Company
[Signature of authorized company officer]
[Title of authorized company officer]
CHOICE
Article 1: Glossary of Defined Terms
The terms used in this Policy have the same meanings given to those terms in Section 9: Defined Terms
of the attached Certificate(s) of Coverage.
Coverage Classification - one of the categories of coverage described in Exhibit 2 for rating purposes
(for example: Subscriber only, Subscriber and spouse, Subscriber and children, Subscriber and family).
Material Misrepresentation - any oral or written communication or conduct, or combination of
communication and conduct, that is untrue and is intended to create a misleading impression in the mind
of another person. A misrepresentation is material if a reasonable person would attach importance to it in
making a decision or determining a course of action, including but not limited to, the issuance of a policy
or coverage under a policy, calculation of rates, or payment of a claim.
Article 2: Benefits
Subscribers and their Enrolled Dependents are entitled to Benefits for Covered Health Services subject to
the terms, conditions, limitations and exclusions set forth in the Certificate(s) of Coverage and
Schedule(s) of Benefits attached to this Policy. Each Certificate of Coverage and Schedule of Benefits,
including any Riders and Amendments, describes the Covered Health Services, required Copayments,
and the terms, conditions, limitations and exclusions related to coverage.
Article 3: Premium Rates and Policy Charge
3.1 Premiums
Monthly Premiums payable by or on behalf of Covered Persons are specified in the Schedule of Premium
Rates in Exhibit 2 of this Policy or in any attached Notice of Change.
We reserve the right to change the Schedule of Premium Rates as described in Exhibit 1 of this Policy.
We also reserve the right to change the Schedule of Premium Rates at any time if the Schedule of
Premium Rates was based upon a Material Misrepresentation relating to health status that resulted in the
Premium rates being lower than they would have been if the Material Misrepresentation had not been
made. We reserve the right to change the Schedule of Premium Rates for this reason retroactive to the
effective date of the Schedule of Premium Rates that was based on the Material Misrepresentation.
3.2 Computation of Policy Charge
The Policy Charge will be calculated based on the number of Subscribers in each Coverage Classification
that we show in our records at the time of calculation. The Policy Charge will be calculated using the
Premium rates in effect at that time. Exhibit 1 describes the way in which the Policy Charge is calculated.
'Enter the appropriate number of days.
3.3 Adjustments to the Policy Charge
We may make retroactive adjustments for any additions or terminations of Subscribers or changes in
Coverage Classification that are not reflected in our records at the time we calculate the Policy Charge.
We will not grant retroactive credit for any change occurring more than ('30 a 90] days prior to the date we
received notification of the change from the Enrolling Group. We also will not grant retroactive credit for
any calendar month in which a Subscriber has received Benefits.
The Enrolling Group must notify us in writing within ['30 - 90] days of the effective date of enrollments,
terminations, or other changes. The Enrolling Group must notify us in writing each month of any change
in the Coverage Classification for any Subscriber.
If premium taxes, guarantee or uninsured fund assessments, or other governmental charges relating to or
calculated in regard to Premium are either imposed or increased, those charges will automatically be
added to the Premium. In addition, any change in law or regulation that significantly affects our cost of
operation will result in an increase in Premium in an amount we determine.
POL.EPO.09.FL.KA NONRES
3.4 Payment of the Policy Charge
The Policy Charge is payable to us in advance by the Enrolling Group as described under "Payment of
the Policy Charge" in Exhibit 1. The first Policy Charge is due and payable on or before the effective date
of this Policy. Subsequent Policy Charges are due and payable no later than the first day of each
payment period specified in item 6 of Exhibit 1, while this Policy is in force.
All payments shall be made in United States dollars, in immediately available funds, and shall be remitted
to us at the address set forth in the Enrolling Group's application, or at such other address as we may
from time to time designate in writing. The Enrolling Group agrees not to send us payments marked "paid
in full", "without recourse", or similar language. In the event that the Enrolling Group sends such a
payment, we may accept it without losing any of our rights under this Policy and the Enrolling Group will
remain obligated to pay any and all amounts owed to us.
Always include text for fate payment charge because grace period is required.
A late payment charge will be assessed for any Policy Charge not received within 10 calendar days
following the due date. A service charge will be assessed for any non -sufficient -fund check received in
payment of the Policy Charge. All Policy Charge payments must be accompanied by supporting
documentation that states the names of the Covered Persons for whom payment is being made.
The Enrolling Group must reimburse us for attorney's fees and any other costs related to collecting
delinquent Policy Charges.
Florida requires a grace period of at least 10 days.
'Enter the appropriate number of days.
[3.5] [Grace Period]
[A grace period of ['10 - 90] days will be granted for the payment of any Policy Charge not paid when due.
During the grace period, this Policy will continue in force. The grace period will not extend beyond the
date this Policy terminates.
The Enrolling Group is liable for payment of the Policy Charge during the grace period. If we receive
written notice from the Enrolling Group to terminate this Policy during the grace period, we will adjust the
Policy Charge so that it applies only to the number of days this Policy was in force during the grace
period.
This Policy terminates as described in Article 5.1 if the grace period expires and the past due Policy
Charge remains unpaid.]
Article 4: Eligibility and Enrollment
4.1 Eligibility Conditions or Rules
Eligibility conditions or rules for each class are stated in the corresponding Exhibit 2. The eligibility
conditions stated in Exhibit 2 are in addition to those specified in Section 3: When Coverage Begins of the
Certificate of Coverage.
4.2 Initial Enrollment Period
Eligible Persons and their Dependents may enroll for coverage under this Policy during the Initial
Enrollment Period. The Initial Enrollment Period is determined by the Enrolling Group.
include Open Enrollment Period unless a group chooses a closed plan.
[4.3] [Open Enrollment Period]
[An Open Enrollment Period will be provided periodically for each class, as specified in the corresponding
Exhibit 2. During an Open Enrollment Period, Eligible Persons may enroll for coverage under this Policy.]
POL.EPO.09.FL.KA NONRES 3
V"] Effective Date of Coverage
The effective date of coverage for properly enrolled Eligible Persons and their Dependents is stated in
Exhibit 2.
Article 5: Policy Termination
5.1 Conditions for Termination of the Entire Policy
This Policy and all Benefits for Covered Health Services under this Policy will automatically terminate on
the earliest of the dates specified below:
A. On the last day of the grace period if the Policy Charge remains unpaid and written notice of
termination was sent to the Enrolling Group within 45 days after the due date. The Enrolling Group
remains liable for payment of the Policy Charge for the period of time this Policy remained in force
during the grace period.
B. On the date specified by the Enrolling Group, after at least 31 days prior written notice to us that
this Policy is to be terminated.
Include when either contribution or participation rules apply.
'Include when both contribution and participation rules apply. 21nclude when either, contribution or
participation rules apply.
[C.] [On the date we specify; after at least 45 days prior written notice to the Enrolling Group, that this
Policy is to be terminated due to the Enrolling Group's violation of the participation ['and][ `or]
contribution rules as shown in Exhibit 1.]
[D]. On the date we specify, after at least 45 days prior written notice to the Enrolling Group, that this
Policy is to be terminated because the Enrolling Group provided us with false information material
to the execution of this Policy or to the provision of coverage under this Policy or has performed an
act or practice that constitutes fraud or made a material misrepresentation of material fact under
the terms of the Policy. In this case, we have the right to rescind this Policy back to either:
The effective date of this Policy.
The date we received the false information, if later.
[E]. On the anniversary renewal date we specify, after at least 90 days prior written notice to the
Enrolling Group and to each Subscriber, that this Policy is to be terminated because we will no
longer issue this particular type of group health benefit plan within the applicable market.
[E]. On the anniversary renewal date we specify, after at least 180 days prior written notice to the
applicable state authority, to the Enrolling Group and to each Subscriber, that this Policy is to be
terminated because we will no longer issue any employer health benefit plan within the applicable
market.
If we fail to provide the 45 days' notice required under A or C above, this Policy shall remain in effect at
the existing rates until 45 days after the notice is given or until the effective date of replacement coverage
obtained by the Enrolling Group, whichever occurs first.
5.2 Payment and Reimbursement Upon Termination
Upon any termination of this Policy, the Enrolling Group is and will remain liable to us for the payment of
any and all Premiums which are unpaid at the time of termination, including a pro rata portion of the
Policy Charge for any period this Policy was in force during the grace period preceding the termination.
POL.EPO.09.PL.KA NONRES
Article 6: General Provisions
6.1 Entire Policy
This Policy, including the Certificate(s) of Coverage, the Schedule(s) of Benefits, the application of the
Enrolling Group, and any Amendments, Notices of Change, and Riders, constitute the entire Policy
between the parties. All statements made by the Enrolling Group or by a Subscriber will, in the absence
of fraud, be deemed representations and not warranties.
6.2 Dispute Resolution
No legal proceeding or action may be brought until the parties have attempted, in good faith, to resolve
the dispute amongst themselves. In the event the dispute is not resolved within thirty (30) days after one
party has received written notice of the dispute from the other party, and both parties wish to pursue the
dispute further, the dispute may be submitted to arbitration as set forth below,
The parties acknowledge that because this Policy affects interstate commerce, the Federal Arbitration Act
applies. If the Enrolling Group wishes to seek further review of the decision or the complaint or dispute, it
may submit the decision, complaint or dispute to binding arbitration pursuant to the rules of the American
Arbitration Association. This is the only right the Enrolling Group has for further consideration of any
dispute that arises out of or is related to this Policy.
Arbitration will take place in (Hartford County, Connecticut].
The matter should be submitted to binding arbitration within one year of the date notice of the dispute was
received. The arbitrators will have no power to award any punitive or exemplary damages or to vary or
ignore the provisions of this Policy, and will be bound by controlling law.
6.3 Time Limit on Certain Defenses
No statement made by the Enrolling Group, except a fraudulent statement, can be used to void this Policy
after it has been in force for a period of two years.
6.4 Amendments and Alterations
Amendments to this Policy are effective 31 days after we send written notice to the Enrolling Group.
Riders are effective on the date we specify. Other than changes to Exhibit 2 stated in a Notice of Change
to Exhibit 2, no change will be made to this Policy unless made by an Amendment or a Rider which is
signed by one of our authorized executive officers. No agent has authority to change this Policy or to
waive any of its provisions.
6.5 Relationship between Parties
The relationships between us and Network providers, and relationships between us and Enrolling Groups
are solely contractual relationships between independent contractors. Network providers and Enrolling
Groups are not our agents or employees, nor are we or any of our employees an agent or employee of
Network providers or Enrolling Groups.
The relationship between a Network provider and any Covered Person is that of provider and patient. The
Network provider is solely responsible for the services provided by it to any Covered Person. The
relationship between any Enrolling Group and any Covered Person is that of employer and employee,
Dependent, or any other category of Covered Person described in the Coverage Classifications specified
in this Policy.
The Enrolling Group is solely responsible for enrollment and Coverage Classification changes (including
termination of a Covered Person's coverage) and for the timely payment of the Policy Charges.
6.6 Records
The Enrolling Group must furnish us with all information and proofs which we may reasonably require with
regard to any matters pertaining to this Policy. We may at any reasonable time inspect:
POL,EPO.09.FL.KA NONRES 5
All documents furnished to the Enrolling Group by an individual in connection with coverage.
The Enrolling Group's payroll.
Any other records pertinent to the coverage under this Policy.
By accepting Benefits under this Policy, each Covered Person authorizes and directs any person or
institution that has provided services to him or her, to furnish us or our designees any and all information
and records or copies of records relating to the health care services provided to the Covered Person. We
have the right to request this information at any reasonable time. This applies to all Covered Persons,
including Enrolled Dependents whether or not they have signed the Subscriber's enrollment form.
We agree that such information and records will be considered confidential. We have the right to release
any and all records concerning health care services which are necessary to implement and administer the
terms of this Policy including records necessary for appropriate medical review and quality assessment or
as we are required by law or regulation.
During and after the term of this Policy, we and our related entities may use and transfer the information
gathered under this Policy for research and analytic purposes,
6.7 Administrative Services
The services necessary to administer this Policy and the Benefits provided under it will be provided in
accordance with our standard administrative procedures or those standard administrative procedures of
our designee. If the Enrolling Group requests that administrative services be provided in a manner other
than in accordance with these standard procedures, including requests for non-standard reports, the
Enrolling Group must pay for such services or reports at the then current charges for such services or
reports.
Delete if the group is not subject to ERtSA.
[6.8] [Employee Retirement Income Security Act (ERISA)]
[When this Policy is purchased by the Enrolling Group to provide benefits under a welfare plan governed
by the federal Employee Retirement Income Security Act 29 U.S.C., 1001 et seq., we will not be named
as, and will not be, the plan administrator or the named fiduciary of the welfare plan, as those terms are
used in ERISA]
[6.9] Examination of Covered Persons
In the event of a question or dispute concerning Benefits for Covered Health Services, we may
reasonably require that a Network Physician, acceptable to us, examine the Covered Person at our
expense.
[6.10] Clerical Error
'The number here should match the adjustment period number used in Article 3.3,
Clerical error will not deprive any individual of Benefits under this Policy or create a right to Benefits.
Failure to report enrollments will not be considered a clerical error and will not result in retroactive
coverage for Eligible Persons. Failure to report the termination of coverage will not continue the coverage
for a Covered Person beyond the date it is scheduled to terminate according to the terms of this Policy.
Upon discovery of a clerical error, any necessary appropriate adjustment in Premiums will be made.
However, we will not grant any such adjustment in Premiums or coverage to the Enrolling Group for more
than ['30 - 90] days of coverage prior to the date we received notification of the clerical error.
[6.11] Workers' Compensation Not Affected
Benefits provided under this Policy do not substitute for and do not affect any requirements for coverage
by workers' compensation insurance.
POL.EPO.09.FL.KA NONRES
[6.12] Conformity with Law
Any provision of this Policy which, on its effective date, is in conflict with the requirements of state or
federal statutes or regulations (of the jurisdiction in which this Policy is delivered) is deemed to be
amended to conform to the minimum requirements of those statutes and regulations.
[6.13] Notice
When we provide written notice regarding administration of this Policy to an authorized representative of
the Enrolling Group, that notice is deemed notice to all affected Subscribers and their Enrolled
Dependents. The Enrolling Group is responsible for giving notice to Covered Persons on a timely basis.
Any notice sent to us under this Policy and any notice sent to the Enrolling Group must be addressed as
described in Exhibit 1.
[6.14] Continuation Coverage
We agree to provide Benefits under this Policy for those Covered Persons who are eligible to continue
coverage under federal or state law, as described in Section 4: When Coverage Ends of the Certificate of
Coverage.
We will not provide any administrative duties with respect to the Enrolling Group's compliance with federal
or state law. All duties of the plan sponsor or plan administrator remain the sole responsibility of the
Enrolling Group, including but not limited to notification of COBRA and/or state law continuation rights and
billing and collection of Premium.
[6.15] Certification of Coverage Forms
As required by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), we will
produce certification of coverage forms for Covered Persons who lose coverage under this Policy. The
Enrolling Group agrees to provide us with all necessary eligibility and termination data. Certification of
coverage forms will be based on eligibility and termination data that the Enrolling Group provides to our
eligibility systems in accordance with our data specifications, and which is available in our eligibility
systems as of the date the form is generated. The certification of coverage forms will only include periods
of coverage that we administer under this Policy.
'Include when COCs will be not be sent directly to the Subscribers, but will be sent to the Enrolling Group
for it to distribute the COCs to the Subscribers.
[6.16] Subscriber's Individual Certificate
We will issue Certifirate(s) of Coverage, Schedule(s) of Benefits, and any attachments to ['the Enrolling
Group for delivery to] each covered Subscriber. The Certificate(s) of Coverage, Schedule(s) of Benefits,
and any attachments will show the Benefits and other provisions of this Policy. In addition, you may have
access to your Certificate of Coverage(s) and Schedule(s) of Benefits online at [www.myuhc.com].
[6.17] System Access
The term "systems" as used in this provision means our systems that we make available to the Enrolling
Group to facilitate the transfer of information in connection with this Policy.
System Access
We grant the Enrolling Group the nonexclusive, nontransferable right to access and use the functionalities
contained within the systems, under the terms set forth in this Policy. The Enrolling Group agrees that all
rights, title and interest in the systems and all rights in patents, copyrights, trademarks and trade secrets
encompassed in the systems will remain ours. In order to obtain access to the systems, the Enrolling
Group will obtain, and be responsible for maintaining, at no expense to us, the hardware, software and
Internet browser requirements we provide to the Enrolling Group, including any amendments to those
requirements. The Enrolling Group is responsible for obtaining an internet service provider or other
access to the Internet.
POL.EPO.09.FL.KA NONRES
The Enrolling Group will not:
• Access systems or use, copy, reproduce, modify, or excerpt any of the systems documentation
provided by us in order to access or utilize systems, for purposes other than as expressly permitted
under this Policy.
• Share, transfer or lease its right to access and use systems, to any other person or entity which is
not a party to this Policy.
The Enrolling Group may designate any third party to access systems on its behalf, provided the third
party agrees to these terms and conditions of systems access and the Enrolling Group assumes joint
responsibility for such access.
Securitv Procedures
The Enrolling Group will use commercially reasonable physical and software -based measures, and
comply with our security procedures, as may be amended from time to time, to protect the system, its
functionalities, and data accessed through systems from any unauthorized access or damage (including
damage caused by computer viruses). The Enrolling Group will notify us immediately if any breach of the
security procedures, such as unauthorized use, is suspected.
System Access Termination
We reserve the right to terminate the Enrolling Group's system access
On the date the Enrolling Group fails to accept the hardware, software and browser requirements
provided by us, including any amendments to the requirements.
Immediately on the date we reasonably determine that the Enrolling Group has breached, or
allowed a breach of, any applicable provision of this Policy. Upon termination of this Policy, the
Enrolling Group agrees to cease all use of systems, and we will deactivate the Enrolling Group's
identification numbers and passwords and access to the system.
POL.EPO.09.FL.KA NONRES
Exhibit 1
Parties. The parties to this Policy are UnitedHealthcare Insurance Company and
, the Enrolling Group.
'Insert month, day and year.
Effective Date of this Policy. The effective date of this Policy is 12:01 a.m, on [' _
in the time zone of the Enrolling Group's location.
'Include For ERISA groups.
2Include for non-ERiSA groups.
3. Place of Issuance. We are delivering this Policy in the State of Florida. ['This Policy is governed
by ERISA. To the extent that state law applies, the laws of the State of Florida are the laws that
govern this Policy.) [2The laws of the State of Florida are the laws that govern this Policy.]
'Include when premiums are specified in the Cost Summary.
2Include when the group has more than 1 class
3Select the appropriate length of time for prior written notice, based on group requirement.
¢Select the text that describes when we have the right to change premium.
4. Premiums. We reserve the right to change the Schedule of Premium Rates ['or Cost Summary)
specified in [teach) Exhibit 2, after a [331 - 120]-day prior written notice [4on the first anniversary of
the effective date of this Policy specified in the application or on any monthly due date thereafter, or
on any date the provisions of this Policy are amended. We also reserve the right to change the
Schedule of Premium Rates, retroactive to the effective date, if a Material Misrepresentation
relating to health status has resulted in a lower schedule of rates.] [oat any time.]
'Select the paragraph that describes the applicable computation of the Policy Charge.
Computation of Policy Charge. ['A full calendar month's Premiums will be charged for Covered
Persons whose effective date of coverage falls on or before the 15th of that calendar month. No
Premiums will be charged for Covered Persons whose effective date of coverage falls after the
15th of that calendar month. A full calendar month's Premiums will be charged for Covered
Persons whose coverage is terminated after the 15th of that calendar month. No Premiums will be
charged for Covered Persons whose coverage is terminated on or before the 15th of that calendar
month.]
['A pro rata Premium, calculated on the number of days Covered Persons are actually covered
under this Policy, will be charged for Covered Persons whose effective date of coverage fails on a
date other than the first of the month or for Covered Persons whose coverage is terminated on a
date other than the first of the month.)
['A full month's Premium will be charged for any Covered Person who is covered under this Policy
for any portion of a calendar month.]
'Select appropriate payment basis.
6. Payment of the Policy Charge. The Policy Charge is payable to us in advance by the Enrolling
Group on a ['monthly] ['quarterly] ['semi-annual] [ annual] basis
NOTE: At least one of the minimum requirements below will always apply. For Catalyst/Catalyst Choice,
include alternate #7 with combined participation and contribution requirement provision when 100%
participation and contribution requirement applies and delete both separate requirement statements #7
and #8. When 100% combined participation and contribution requirements do not apply to
Catalyst/Catalyst Choice, use separate options #7 and 8 below.
Include combined minimum participation and contribution requirement when the policy is issued for
Catalyst/Catalyst Choice and when 100% participation and contribution requirement applies.
POL.EPO.09.FL.KA NONRES
[7,] [Minimum Participation and Contribution Requirements - [Catalyst] [Catalyst Choice]]
[Participation in the [Catalyst] [Catalyst Choice] underlying medical plan is 100% of Eligible
Persons after waivers for creditable coverage, with a minimum of 50% of all Eligible Persons before
waivers.
The Enrolling Group contributes 100% of employee -only rate.
Participation and contribution requirements do not apply to optional coverage provided under the
[Catalyst] [Catalyst Choice] Rider.]
Include #7 and #8 below with all products except when CatalystlCatalyst Choice is sold (as defined
above).
`Select if a minimum participation requirement is applicable to this group. Minimum participation
requirements are set by us.
2Select if a minimum participation requirement is not applicable to this group.
Select only one option, either number or percentage, but not both.
Select if number applies. If the group policy is issued to a large employer; the numerical requirement is
adjusted to show the upper limit of the number of Eligible Persons included in a small employer group as
defined by UHC. if the Policy is issued to a small employer, the numerical requirement is two, unless state
law requires issuance to one life groups.
Select if percentage applies.
(7.] [Minimum Participation Requirement. ('The minimum participation requirement for the Enrolling
Group is [3 [51 - 101] Eligible Persons.] [[o - 100]% of Eligible Persons excluding spousal waivers
but no less than 50% of all Eligible Persons must be enrolled for coverage under this Policy.][2The
Minimum Participation Requirement does not apply.]
'Select if a minimum contribution requirement is applicable to this group. Minimum contribution
requirements are set by us.
7Select if a minimum contribution requirement is not applicable to this group.
Enter the applicable percentage.
[8.] [Minimum Contribution Requirement.] The Enrolling Group must maintain a minimum
contribution requirement of 3[0 - 100]% of the Premium for each Eligible Person.][2The Minimum
Contribution Requirement does not apply.]
[9.] Notice. Any notice sent to us under this Policy must be addressed to:
(Name of Issuing Entity)
(Address)
(City, State, Zip)
Any notice sent to the Enrolling Group under this Policy must be addressed to:
(Enrolling Group)
(Address)
POL.EPO.09.FL.KA NONRES 10
(City, State, Zip)
110), r Enrolling Group Number]
POL.EPO.09.FL.KA NONRES 11
'include when more than one class of Eligible Persons is covered.
Choose the applicable class number
Exhibit 2 ['Class [21 _I0]]
3Include when the group has more than ? class
[`The provisions included in this Exhibit are applicable only to the class of Eligible Persons described
below.]
'Enter when class description is entered directly in Exhibit 2.
Enter when class description is included by reference to Application.
3Enter applicable class description.
1. Class Description.
1[3All full-time employees.]2[See Application.]
insert eligibility conditions in A and B below. If there are no specific eligibility conditions that apply, the
default will show "none,"
'Include when more than one class of Eligible Persons is covered.
2. Eligibility. The eligibility rules are established by the Enrolling Group. The following eligibility rules
are in addition to the eligibility rules specified in the Employer Application and/or in Section 3:
When Coverage Begins of the Certificate of Coverage ('applicable to this class]:
A. The waiting or probationary period for newly Eligible Persons is as follows:
B. Other:
include Open Enrollment Period unless a group chooses a closed plan.
'include this text if Open Enrollment Period applies to this class.
3Enter the applicable number of days in the Open Entailment Period,
Select the appropriate frequency of the open enrollment for this class.
`'Include this text if Open Enrollment Period does not apply to this class.
(3). [Open Enrollment Period. ['An Open Enrollment Period of at least (230 - 60) days will be provided
by the Enrolling Group during which Eligible Persons may enroll for coverage. The Open
Enrollment Period will be provided on ["an annual basis] ['a quarterly basis]
Open Enrollment Period applies to this class.]]
' Enter effective date of coverage.
2 Select the applicable alternative.
[4]. Effective Date for Eligible Persons. The effective date of coverage for Eligible Persons who are
eligible on the effective date of this Policy is ['
For an Eligible Person who becomes eligible after the effective date of this Policy, his or her
effective date of coverage is [2the day following the last day of the required waiting period.] (2the
first day of the month following the last day of the required waiting period.] [2the date the Eligible
Person joins the Enrolling Group.] [2the first day of the month following the date the Eligible Person
joins the Enrolling Group .][2as determined by the Enrolling Group,
'Insert when rates are shown in Exhibit 2.
POL.EP0.09.FL.KA NONRES 12
2Insert effective date.
3Insert When rates are issued via the Cost Summary.
[5]. Schedule of Premium Elates.
['The Schedule of Premium Rates payable by or on behalf of this class of Covered Persons as of
[2 �] is shown below:
[Coverage Classification
Subscriber Only
Subscriber and Spouse
Subscriber plus one Child
Subscriber plus Family
Monthly Premium
$XXX.XX
$XXX.XX
$XXX. XX
$XXX.XX]
Changes to this Schedule of Premium Rates and/or subsequent Schedules of Premium Rates will
be attached to this Policy by means of a Notice of Change to Exhibit 2.]
['Monthly Premiums payable by or on behalf of Covered Persons are specified in the Cost
Summary]
POL.EPO.09.FL.KA NONRES 13
POL.EPO.09.FL.KA NONRES 14
EXHIBIT IV
UnitedHealthcare [Choice]
United HealthCare Insurance Company
Schedule of Benefits
Accessing Benefits
You must see a Network Physician in order to obtain Benefits. Except as specifically described in this
Schedule of Benefits, Benefits are not available for services provided by non -Network providers. This
Benefit plan does not provide a Non -Network level of Benefits.
Benefits apply to Covered Health Services that are provided by a Network Physician or other Network
provider. Benefits for facility services apply when Covered Health Services are provided at a Network
facility. Benefits include Physician services provided in a Network facility by a Network or a non -Network
anesthesiologist, Emergency room Physician, consulting Physician, pathologist and radiologist.
Emergency Health Services and Covered Health Services received at an Urgent Care Center outside
your geographic area are always paid as Network Benefits.
'Include if the plan design provides Designated Network Benefits in any benefit category.
'Include if the plan design requires a per occurrence deductible.
"Include when the plan design requires an annual maximum benefit. Include when the annual
maximum benefit is included. Include "and" when the annual maximum benefit is not included.
['Designated Network Benefits apply to Covered Health Services that are provided by a Network
Physician or other provider that we have identified as a Designated Facility or Physician. Designated
Network Benefits are available only for specific Covered Health Services as identified in the Schedule of
Benefits table below. When Designated Network Benefits apply, they are included in and subject to the
same Annual Deductible, [2Per Occurrence Deductible,] Out -of -Pocket Maximum [3,] [3and] Maximum
Policy Benefit [3and Annual Maximum Benefit] requirements as all other Covered Health Services
provided by Network providers.]
Include when Tiered Conditional Benefits program is sold.
[You may have an opportunity to elect to receive Covered Health Services from certain Network providers
that we've identified as Designated Physicians or Designated Facilities. When you choose to seek care
from certain Designated providers, the level of Benefits available to you is enhanced. You can determine
the specific situations for which enhanced Benefits are available by going to www.myuhc.com or by
calling Customer Care at the telephone number on your ID card.]
You must show your identification card (ID card) every time you request health care services from a
Network provider. If you do not show your ID card, Network providers have no way of knowing that you
are enrolled under a [UnitedHealthcare] Policy. As a result, they may bill you for the entire cost of the
services you receive.
If there is a conflict between this Schedule of Benefits and any summaries provided to you by the
Enrolling Group, this Schedule of Benefits will control.
Additional information about the network of providers and how your Benefits may be affected
appears at the end of this Schedule of Benefits.
Pre -service Benefit Confirmation
We require notification before you receive certain Covered Health Services. In general, Network providers
are responsible for notifying us before they provide these services to you. There are some Benefits,
SBN.CHC1,EPO.07.FL.KA NONRES Rev3 [1]
however, for which you are responsible for notifying us, Services for which you must provide pre -service
notification are identified below and in the Schedule of Benefits table within each Covered Health Service
category.
To notify us, call the telephone number for Customer Care on your ID card.
Covered Health Services which require pre -service notification:
• Ambulance - non -emergent air and ground.
include when group purchases benefits for clinical trials.
[Clinical trials.]
Include when group purchases benefits for congenital heart disease surgery that includes a designated
network benefit level.
[Congenital heart disease surgery.]
Include when group purchases benefits for accident -related dental services.
[Dental services - accidental.]
Include when group purchases benefits for infertility services.
[Infertility services.]
Include when group purchases benefits for obesity surgery.
[Obesity surgery.]
Transplants.
include paragraphs below if pre -service benefit notification includes determining alternate levels of
benefits.
'Include if Mental Health Benefits are sold.
2Include if Mental Health Benefits are not sold.
[As we determine, if one or more alternative health services that meets the definition of a Covered Health
Service in the Certificate of Coverage under Section 9: Defined Terms are clinically appropriate and
equally effective for prevention, diagnosis or treatment of a Sickness, Injury, ['Mental Illness,] ['mental
illness,) substance abuse or their symptoms, we reserve the right to adjust Eligible Expenses for identified
Covered Health Services based on defined clinical protocols. Defined clinical protocols shall be based
upon nationally recognized scientific evidence and prevailing medical standards and analysis of cost-
effectiveness. After you contact us for pre -service Benefit confirmation. we will identify the Benefit level
available to you.
The process and procedures used to define clinical protocols and cost-effectiveness of a health service
and a listing of services subject to these provisions (as revised from time to time), are available to
Covered Persons on www.myuhc.com or by calling Customer Care at the telephone number on your ID
card, and to Physicians and other health care professionals on UnitedHealthcareOnline.]
If you request a coverage determination at the time notice is provided, the determination will be made
based on the services you report you will be receiving. If the reported services differ from those actually
received, our final coverage determination will be modified to account for those differences, and we will
only pay Benefits based on the services actually delivered to you.
Include when group purchases benefits for mental healthlsubstance abuse services and when prior
authorization applies to any MH/SA benefit purchased.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [2]
[Mental Health and Substance Abuse Services]
[Mental Health and Substance Abuse Services are not subject to the pre -service notification requirements
described above. Instead, you must obtain prior authorization from the Mental Health/Substance Abuse
Designee before you receive Mental Health Services and Substance Abuse Services. You can contact
the Mental Health/Substance Abuse Designee at the telephone number on your ID card.]
Care Coordinations""
When we are notified as required, we will work with you to implement the Care Coordinations"' process
and to provide you with information about additional services that are available to you, such as disease
management programs, health education, and patient advocacy.
Special Note Regarding Medicare
If you are enrolled in Medicare on a primary basis (Medicare pays before we pay Benefits under the
Policy), the notification requirements described below do not apply to you. Since Medicare is the primary
payer, we will pay as secondary payer as described in Section 7. Coordination of Benefits. You are not
required to notify us before receiving Covered Health Services.
Benefits
Annual Deductibles are calculated on a [calendar] [Policy] year basis.
Out -of -Pocket Maximums are calculated on a [calendar] [Policy] year basis.
Include only when an Annual Maximum Benefit applies.
[The Annual Maximum Benefit is calculated on a [calendar] [Policy] year basis.]
Include here and in the table header only when a Designated Network Benefit applies for any benefit
category.
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a Designated
Network level of Benefits unless otherwise specifically stated.]
Benefit limits are calculated on a [calendar] [Policy] year basis unless otherwise specifically stated.
Payment Term And Description I Amounts
Annual Deductible
'Include when an Outpatient Prescription Drug Rider is sold Include when separate individual and
and the Annual Deductible applies to any combination of family deductibles apply (non-
medical and RX benefits. embedded).
The amount of Eligible Expenses you pay for Covered Health
Services per year before you are eligible to receive Benefits.
['The Annual Deductible applies to Covered Health Services
under the Policy as indicated in this Schedule of Benefits,
including Covered Health Services provided under the
Outpatient Prescription Drug Rider.]
Include when day/visit limits are reduced by the number of
days/visit used toward meeting the deductible.
[Amounts paid toward the Annual Deductible for Covered
Health Services that are subject to a visit or day limit will also
be calculated against that maximum Benefit limit. As a result,
the limited Benefit will be reduced by the number of days/visits
used toward meeting the Annual Deductible.]
SBN.CHCI.EPO.07.FL.KA NONRES Rev3 [3]
[For single coverage, the Annual
Deductible is $[0 - 7,500] per Covered
Person.
If more than one person in a family is
covered under the Policy, the single
coverage Annual Deductible stated
above does not apply. For family
coverage, the family Annual Deductible
is $[0 - 22,5001. No one in the family is
eligible to receive Benefits until the
family Annual Deductible is satisfied.]
Include when individual deductible
applies (embedded).
Include when dollar limits are reduced by the amount used
[$[0 - 7,500] per Covered Person.]
toward meeting the deductible.
Include when individual (with family
[Amounts paid toward the Annual Deductible for Covered
maximum) deductible applies
Health Services that are subject to a dollar limit will also be
(embedded).
calculated against that maximum Benefit limit. As a result, the
limited Benefit will be reduced by the amount used toward
per Covered Person, not to
[$[0 - T,500] p er Co
meeting the Annual Deductible.]
exceed $[0 - ] for all Covered
Persons in a family.]
`Include when the carry-over provision applies.
Include when there is no annual
[?Any amount you pay for medical expenses in the last three
deductible.
months of the previous year that is applied to the previous
[No Annual Deductible.]
Annual Deductible will be carried over and applied to the
current Annual Deductible. This carry-over feature applies only
to the individual Annual Deductible.]
"'Include paragraph if the roll-over provision applies to a group
in any circumstance.
[When a Covered Person was previously covered under a
group policy that was replaced by the group Policy, any
amount already applied to that annual deductible provision of
the prior policy will apply to the Annual Deductible provision
under the Policy.]
4Include paragraph if the roll-over provision applies to a group
changing from a calendar year to Policy year plan. 51nchide
when this applies only to the individual deductible.
['When the Enrolling Group changes from a calendar year to a
Policy year plan, any amount you pay for medical expenses in
the last three months of the previous calendar year that is
applied to the previous Annual Deductible, will be rolled over
and applied to the current Policy year Annual Deductible. This
roil -over feature applies only to the first Policy year. [SThis roll-
over feature applies only to the individual Annual Deductible.]]
The amount that is applied to the Annual Deductible is
calculated on the basis of Eligible Expenses. The Annual
Deductible does not include any amount that exceeds Eligible
Expenses. Details about the way in which Eligible Expenses
are determined appear at the end of the Schedule of Benefits
table.
Include only when a per occurrence deductible applies.
[The Annual Deductible does not include any applicable Per
Occurrence Deductible.]
Include only when a per occurrence deductible applies.
[Per Occurrence Deductible]
[The amount of Eligible Expenses stated as a set dollar
Include when a per occurrence
amount that you must pay for certain Covered Health Services
deductible applies to CHD surgery
(prior to and in addition to any Annual Deductible) before we
benefits.
will begin paying for Benefits for those Covered Health
[CHD surgery - Inpatient Stay: [$100 -
Services.
1,000] per day.]
You are responsible for paying the lesser of the following:
- --
CHD sur ery_- in -- --. $100 -
pnt _
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [4]
The applicable Per Occurrence Deductible. 2,000] per Inpatient Stay.]
The Eligible Expense.] Include when a per occurrence
deductible applies to inpatient hospital
benefits.
[Hospital - Inpatient Stay: [$100 - 1,000]
per day.]
[Hospital - Inpatient Stay: [$100 - 2,000]
per Inpatient Stay.]
Include when a per occurrence
deductible applies to outpatient surgery
benefits.
[Surgery - Outpatient: [$10 - 1,000] per
date of service.]
Include when a per occurrence
deductible applies to inpatient
transplant benefits.
[Transplant - Inpatient Stay: [$100 -
1,000] per day.]
[Transplant - Inpatient Stay: [$100 -
2,000] per Inpatient Stay.]
Out -of -Pocket Maximum
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [5]
'Include when OOPM includes the Annual Deductible.
include when OOPM includes the Per Occurrence Deductible.
'include when OOPM includes Copayments.
include when an Outpatient Prescription Drug Rider is sold
and the OOPM applies to any combination of medical and RX
benefits.
The maximum you pay per year for ['the Annual Deductible,]
['the Per Occurrence Deductible,] [3Copayments] [1'2'3or]
Coinsurance. Once you reach the Out -of -Pocket Maximum,
Benefits are payable at 100% of Eligible Expenses during the
rest of that year. [The Out -of -Pocket Maximum applies to
Covered Health Services under the Policy as indicated in this
Schedule of Benefits, including Covered Health Services
provided under the Outpatient Prescription Drug Rider.]
`'include only when the plan design does not apply al1
copayments and coinsurance to the OOPM.
[`'Copayments and Coinsurance for some Covered Health
Services will never apply to the Out -of -Pocket Maximum and
those Benefits will never be payable at 100% even when the
Out -of -Pocket Maximum is reached.] Details about the way in
which Eligible Expenses are determined appear at the end of
the Schedule of Benefits table.
The Out -of -Pocket Maximum does not include any of the
following and, once the Out -of -Pocket Maximum has been
reached, you still will be required to pay the following:
• Any charges for non -Covered Health Services.
include bullet if notification requirements apply to any benefit
category in the Schedule of Benefits table and if the plan
design supports not applying penalties to the OOPM.
Include when separate individual and
family maximums apply (non -
embedded).
[For single coverage, the Out -of -Pocket
Maximum is $[0 - 15,0001 per Covered
Person.
If more than one person in a family is
covered under the Policy, the single
coverage Out -of -Packet Maximum
stated above does not apply. For family
coverage, the family Out -of -Pocket
Maximum is $[0 - 45,000].]
Include when individual OOPM applies
(embedded).
[$[0 - 15,000) per Covered Person.]
Include when individual (with family
maximum) applies (embedded).
[$[0 - 15,000] per Covered Person, not
to exceed $[0 - 45,0001 for all Covered
Persons in a family.)
Include when the OOPM includes the
Annual Deductible.
[The Out -of -Packet Maximum includes
the Annual Deductible.]
Include when the OOPM does not
include the Annual Deductible.
[The Out -of -Packet Maximum does not
include the Annual Deductible.]
[The amount Benefits are reduced if you do not notify us include when the OOPM includes the
as required.]
Per Occurrence Deductible,
Charges that exceed Eligible Expenses.
• Copayments or Coinsurance for any Covered Health
Service identified in the Schedule of Benefits table that
does not apply to the Out -of -Pocket Maximum.
Include bullet when an Outpatient Prescription Drug Rider is
sold and copayments/coinsurance do not apply to the overall
OOPM.
[Copayments or Coinsurance for Covered Health
Services provided under the Outpatient Prescription
Drug Rider.]
Maximum Policy Benefit
SBN.CHCI.EPO.07.FL.KA NONRES Rev3 [6]
[The Out -of -Pocket Maximum includes
the Per Occurrence Deductible.]
Include when the OOPM does not
include the Per Occurrence Deductible.
[The Out -of -Pocket Maximum does not
include the Per Occurrence Deductible.]
Include when there is no OOPM.
[No Out -of -Pocket Maximum.]
The maximum amount we will pay for Benefits during the entire
[$[1,000,000-10,000,000] per Covered
period of time you are enrolled under the Policy.
Person.]
[No Maximum Policy Benefit.]
Include only when an annual maximum benefit applies.
[Annual Maximum Benefit]
[The maximum amount we will pay for Benefits during the
[$[2,000 - 500,000] per Covered
year.]
Person.]
Copayment
Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain
Covered Health Services. When Copayments apply, the amount is listed on the following pages next to
the description for each Covered Health Service.
Please note that for Covered Health Services, you are responsible for paying the lesser of:
• The applicable Copayment.
• The Eligible Expense.
Details about the way in which Eligible Expenses are determined appear at the end of the Schedule of
Benefits table.
Coinsurance
Coinsurance is the amount you pay (calculated as a percentage of Eligible Expenses) each time you
receive certain Covered Health Services.
Details about the way in which Eligible Expenses are determined appear at the end of the Schedule of
Benefits table.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 (7]
Benefit Limits
This Benefit plan does not have Benefit limits in addition to those stated below within the Covered Health
Service categories in the Schedule of Benefits table.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [8]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
_...._._
�
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include for groups that purchase
benefits for acupuncture services.
1. [Acupuncture Services]
Include the limit selected by the group.
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[Limited to [10 - 100] visits per year.]
[100% after you pay
[Limited to [10 - 100] visits per year,
a Copayment of $[5 -
not to exceed $[100 - 5,0001 in Eligible
75] per visit)
Expenses per year.]
[Limited to $[100 - $5,000] in Eligible
Expenses per year.]
[2.] Ambulance Services
Pre -service Notification requirement
In most cases, we will initiate and direct non -Emergency ambulance transportation. If you are requesting
non -Emergency ambulance services, you must notify us as soon as possible prior to transport. If you fail
to notify us as required, you will be responsible for paying all charges and no Benefits will be paid.
Emergency Ambulance
Ground Ambulance:
Transportation costs of a newborn to
[[50 - 100]%]
[Yes] [No]
(Yes) [No]
ttx; nearest appropriate facility for
[100% after you pay
treatment are covered up to $1,000 per
a Copayment of $[25
transport.
- 3001 per transport]
[100% after you pay
a Copayment of
$[300 - 1,000] per
day]
Air Ambulance:
[[50 - 100]%]
[Yes] [No]
[Yesj [No]
[100% after you pay
a Copayment of $[25
- 2,500] per transport]
[100% after you pay
a Copayment of
$[2,500 - 10,000] per
day]
Non -Emergency Ambulance
Ground Ambulance:
Ground or air ambulance, as we
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 191
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
determine appropriate.
[[50 - 100]°/a]
[Yes) [No]
[Yes] [No]
'transportation costs of a newborn to
[100% after you pay
the nearest appropriate facility for
a Copayment of $[25
treatment are covered up to $1,000 per
- 300] per transport)
transport.
[100% after you pay
a Copayment of
$[300 - 1,0001 per
day]
Air Ambulance:
[[50 - 100]%)
[Yes] (No]
[Yes] [NO)
[100% after you pay
a Copayment of $[25
- 3001 per transport)
[100% after you pay
a Copayment of
$[2,500 - 10,0001 per
day]
Include for groups that purchase
benefits for clinical trials.
[3.) [Clinical Trials]
[Pre -service Notification Requirement]
[You must notify us as soon as the possibility of participation in a clinical trial arises. If you don't notify us,
you will be responsible for paying all charges and no Benefits will be paid.]
-
.... - ........
[Depending upon the Covered Health
[Depending upon where the Covered Health Service is
Service, Benefit limits are the same as
provided, Benefits will be the same as those stated under each
those stated under the specific Benefit
Covered Health Service category in this Schedule of Benefits.]
category in this Schedule of Benefits.
Benefits are available when the
Covered Health Services are provided
by either Network or non -Network
providers, however the non -Network
provider must agree to accept the
Network level of reimbursement by
signing a network provider agreement
specifically for the patient enrolling in
the trial. (Benefits are not available if
the non -Network provider does not
agree to accept the Network level of
reimbursement.)]
SBN.CHCI.EPO.07.FL.KA NONRES Rev3 [10]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include for groups that purchase
benefits for congenital heart disease
services.
[4.] [Congenital Heart Disease
Surgeries]
Include if pre -service notification is required.
[Pre -service Notification Requirement]
[For Designated Network Benefits you must notify us as soon as the possibility of a Congenital Heart
Disease (CHD) surgery arises. if you do not notify us and if, as a result, the CHD services are not
performed at a Designated Network Facility, Designated Network Benefits will not be paid.]
Include both headings and this row
['Designated
when Designated Network Benefits are
Network)
[Yes] [No]
[Yes] [No)
available.
[[50 - 100]%]
Include paragraph below when
[Yes, after the Per
Designated Network Benefits are
[100% after you pay
Occurrence
available.
a Copayment of
Deductible is
$[100 - 1,000] per
satisfied]
[When performed at a Designated
day]
Facility as part of the evaluation and
o after you pay
treatment of CHD, Covered Health
a Copayment of
a Copayment
Services include diagnostic services,
$[100 - 2,0 per
cardiac catheterization and all non-
inpatient Stay)
surgical management of CHD.]
Include when CHD benefits are sold
[100% after you pay
a Copayment of
and when Network Benefits are
$[100 - 1,000] per
available.
day to a maximum
[Network Benefits under this section
Copayment of $1100 -
inciude only the Congenital Heart
5,000] per Inpatient
Disease (CHD) surgery. Depending
Stay]
upon where the Covered Health
Service is provided, Benefits for
diagnostic services, cardiac
catheterization and non -surgical
management of CHD will be the same
as those stated under each Covered
Health Service category in this
Schedule of Benefits.]
Include when use of a Designated
['Network]
Facility is required.
o
[[50 - 100] /o]
[Yes] [NO]
[Yes] [No]
[CHD surgeries must be received at a
Designated Facility.)
[100/o o after you pay
[Yes, after the Per
a Copayment of
Occurrence
SBN.CHC1.EPO.07.Ft-.KA NONRES Rev3 [11]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include when Benefits are limited and
$[100 - 1,000] per
Deductible is
insert the limit selected by the group.
day]
satisfied]
[Benefits for CHD surgeries that are
[100% after you pay
not received at a Designated Facility
a Copayment of
are limited to $[30,000 - 250,000] per
$[100 - 2,000] per
CHD surgery,]
Inpatient Stay]
[100% after you pay
a Copayment of
$[100 - 1,000) per
day to a maximum
Copayment of $[100 -
5,000] per Inpatient
Stay]
Incitide for groups that purchase
benefits for accident -related dental
services.
[5.] [Dental Services - Accident
Only]
Include when pre -service notification is required.
'Include applicable reduction in Benefits or no Benefits.
[Pre -service Notification Requirement]
[You must notify us five business days before follow-up (post -Emergency) treatment begins. (You do not
have to notify us before the initial Emergency treatment.) If you fail to notify us as required, ['Benefits will
be reduced to [50 - 95]% of Eligible Expenses] ['you will be responsible for paying all charges and no
Benefits will be paid].]
[Limited to $[2,000 - 5,000] per year.
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
Benefits are further limited to a
[100% after you pay
maximum of $[500 - 1,500] per tooth.]
a Copayment of $[5 -
'Diabetes
75] per visit]
[6.] Services
Diabetes Self -Management and
Depending upon where the Covered Health Service is provided,
Training/Diabetic Eye
Benefits for diabetes self -management and training/diabetic eye
Examinations/Foot Care
examinations/foot care will be the same as those stated under
each Covered Health Service category in this Schedule of
Benefits.
Diabetes Self -Management Items
'include when both benefits for durable medical equipment and
include only when benefits for durable
the outpatient prescription drug rider are sold.
medical equipment are sold and when
['Depending upon where the Covered Health Service is
state law does not permit limits on
provided, Benefits for diabetes self -management items will be
SBN.CHC1.EPO.07.FL,KA NONRES Rev3 [12]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We Apply to the Must You Meet
Pay, based on Out -of -Pocket Annual
Covered Health Service Eligible Expenses) Maximum? Deductible?
diabetes equipment,
the same as those stated under Durable Medical Equipment
[Be, it fits for diabetes equipment that
and in the Outpatient Prescription Drug Rider. However
meets the detinitior? of Durable Medical
diabetes self -management items are not subject to any linaits.l
Equipment are not subject to the limit
21nclude when benefits for durable medical equipment are sold,
stated under Ourabie Medical
but the outpatient prescription drug rider is not sold.
Equipment.]
31nclude when sold with a plan that has an annual deductible
and select either "are" or 'are not. "
alnclude when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply. "
[2For diabetes equipment, Benefits will be the same as those
stated under Durable Medical Equipment.
For diabetes supplies the Benefit is [50 - 100]% of Eligible
Expenses [''and Benefits [are] fare nnt] subject to payment of
the Annual Deductible). However diabetes equipment and
supplies are not subject to any limits. [4Coinsurance [applies]
[does not apply] to the Out -of -Pocket Maximum.]]
-'Include when benefits for durable medical equipment are not
sold and the outpatient prescription drug rider is sold.
6include when sold with a plan that has an annual deductible
and select either 'are" or "are not. "
7Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply. "
["For insulin pumps, the Benefit is [50 - 100]% of Eligible
Expenses [rand Benefits [are] [are not] subject to payment of
the Annual Deductible. Insulin pumps are not subject to any
limits], ['Coinsurance [applies] [does not apply] to the Out -of -
Pocket Maximum.]
Benefits for diabetes supplies will be the same as those stated
in the Outpatient Prescription Drug Rider. Diabetes supplies are
not subject to any limits,]
elnclude when neither benefits for durable medical equipment
nor the outpatient prescription drug rider is sold.
"Include when sold with a plan that has an annual deductible
and select either "are" or "are not. "
i0include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply."
rFor insulin pumps and diabetes supplies, the Benefit is [50 -
100]% of Eligible Expenses [Wand Benefits [are] [are not]
subject to payment of the Annual Deductible]. Insulin pumps
and diabetes supplies are not subjed to any limits.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [13]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[ Coinsurance [applies] [does not apply] to the Out -of -Pocket
Maximum.]]
Include for groups that purchase
_
benefits for DME.
[7.] [Durable Medical Equipment]
Include the limit selected by the group.
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
'Include either option as standard plan
design.
['Limited to $[500 - 100,000] in Eligible
Expenses per year. Benefits are limited
to a single purchase of a type of DME
(including repair/replacement) every
[year] [[two -five] years].]
['Limited per year as follows:
• [$[500 - 10,000] in Eligible
Expenses for Tier 1.Tier 1
includes disposable supplies
necessary for the effective use
of covered Durable Medical
Equipment.]
• [$[10,001 - 25,000] in Eligible
Expenses for Tier 2.]
• [$[25,001 - 100,000] in Eligible
Expenses for Tier 3.]
These Tier limits include repair.
Benefits for replacement are limited to
a single purchase of a type of DME
(including repair/replacement) every
[year] [[two -five] years].]
Always include when the DME benefit
is sold.
[You must purchase or rent the
Durable Medical Equipment from the
vendor we identify or purchase it
directly from the prescribing Network
Physician.]
[8.] Emergency Health Services -
Outpatient
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [14]
[When Benefit limits apply, the limit stated includes Covered Wealth Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Note: If you are confined in a non-
[[50 - 1001%]
[Yes] [No]
[Yes] [No]
Network Hospital after you receive
Include bracketed
outpatient Emergency Health Services,
provision
n and select
you must notify us within one business
either or if the
day or on the same day of admission if
reasonably possible. We may elect to
copayment is waived.
transfer you to a Network Hospital as
'Include as standard;
soon as it is medically appropriate to
2Include only to
do so. If you choose to stay in the non-
match prior benefit
Network Hospital after the date we
plans,
decide a transfer is medically
appropriate, Benefits will not be
100% after a
[ you pay
provided.
a Copayment of $[5 -
300] per visit. [If you
Include when covered health services
are admitted as an
performed at an emergency room are
inpatient to a Network
subject to the copayments/coinsurance
Hospital ['directly
stated under other benefit categories,
from the Emergency
in addition to the outpatient emergency
room] [zwithin 24
copayment stated in this section. (This
hours of receiving
will not apply when the emergency
outpatient
benefit is subject to coinsurance only.)
Emergency treatment
[In addition to the Copayment stated in
for the same
this section, the
condition], you will
Copayments/Coinsurance for the
not have to pay this
following services apply when the
Copayment. The
Covered Health Service is performed
Benefits for an
as an Emergency Health Service:
Inpatient Stay in a
Network Hospital will
• [Lab, radiology/X-rays and other
apply instead.]]
diagnostic, services described
under Lab, X-Ray and
Diagnostics - Outpatient.]
• [Major diagnostic and nuclear
medicine described under Lab,
X-Ray and Major Diagnostics -
CT, PET, MRI, MRA and
Nuclear Medicine - Outpatient.]
• [Diagnostic and therapeutic
scopic procedures described
under Scopic Procedures -
Outpatient Diagnostic and
Therapeutic.]
• [Outpatient surgery procedures
described under Surgery -
SBN.CHC1.EP0.07.FL.KA NONRES Rev3 1151
(When Benefit limits apply, the limit
Designated Network level of Benefits
stated includes Covered Health Services provided at a
unless otherwise specifically stated.]
Benefit -
Covered Health Service
(The Amount We Apply to the Must You Meet
Pay, based on Out -of -Pocket Annual
Eligible Expenses) Maximum? Deductible?
Outpatient.)
• [Outpatient therapeutic
procedures described under
Therapeutic Treatments -
Outpatient.]
• [Rehabilitation therapy
procedures described under
Rehabilitation Services -
Outpatient Therapy and
Chiropractic Treatment.]]
Include for groups that purchase
hearing aid benefits.
[9.] [Hearing Aids]
Include the limit selected by the group.
[[50 - 100]%] [Yes] [No] [Yes] [No]
[Limited to $[500 - 5,0001 per year.]
[Limited to $[500 - 5.0001 for each
hearing impaired ear every [24 - 36]
months.]
[Limited to $[500 - 25,000] per Covered
Person during the entire period of time
he or she is enrolled for coverage
under the Policy.]
[[50 - 100]%] [Yes] [No] [Yes] [No]
[10.] Home Health Care
Include the limit selected by the group.
[Limited to [40 - 2001 visits per year.
One visit equals up to four hours
[100% after you pay
of
skilled care services.]
a Copayment of $[5 -
50] per visit]
[Limited to $[500 - 5,0001 per year.]
[Limited to [40 - 200] visits per year to
a maximum of $[500 - 5,000] in Eligible
Expenses per year.]
Include when infusion administration
only is not included in the limit.
[This visit limit does not include any
service which is billed only for the
administration of intravenous infusion.]
— - —
[16]
[11.] Hospice Care
SBN.CHC1,EPO.07.FL,KA NONRES Rev3
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[[50 - 100]%]
[Yes] [No] --
-[Yes] [No]
[100% after you pay
a Copayment of $[5 -
100] per day]
[12.] Hospital - Inpatient Stay
1Include both headings and this row
['Designated
when Designated Network Benefits
Network]
[Yes] [No]
[Yes] [No]
apply
[[50 - 100]%]
[Yes, after the Per
Include when enhanced benefits apply
to specific inpatient services.
[100% after you pay
Occurrence
a Copayment of
Deductible is
'include when Physician's fees are
$[100 - 1,000] per
satisfied]
paid under the facility charge.
day]
[When you choose to seek care from
[100% after you pay
Designated Network facilities for
a Copayment of
certain surgical procedures [or as a
$[100 - 2,0001 per
result of certain diagnoses], your
Inpatient Stay]
Benefits will be enhanced as described
[100% after you pay
below:
a Copayment of
• [The Copayment you pay for the
$[100 - 1,000] per
facility charge rand Physician's
day to a maximum
fees] for services provided at a
Copayment of $[100 -
Designated Network facility will
10,0001 per Inpatient
be reduced to [$0 - 1,000]. [The
Stay]
maximum reduction in
Copayments is $[10 - 1,000].]]
• [The Coinsurance you pay for
the facility charge [land
Physician's fees] for services
provided at a Designated
Network facility will be reduced
to [0 - 50]% or $[10 - 1,000] will
be applied toward any applicable
Annual Deductible if not already
met, to a maximum of $[10 -
1,00%]
You can determine the specific surgical
procedures or diagnoses for which
enhanced Benefits are available by
going to www.myuhc.com or by calling
Customer Care at the telephone
number on your ID card.]
SBN.CHC1.EPO.07.FL,KA NONRES Rev3 [17]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
t Network]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
[Yes, after the Per
a Copayment of
Occurrence
$[100 - 1,000] per
Deductible is
day]
satisfied]
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
[100% after you pay
a Copayment of
$[100 - 1,000] per
day to a maximum
Copayment of $[100 -
10,000] per Inpatient
Stay]
Include for groups that purchase
infertility benefits.
[[13]. Infertility Services]
When this benefit is purchased, pre -service notification will always be required. 'Include applicable
reduction in Benefits or no Benefits.
[Pre -service Notification Requirement]
[You must notify us as soon as the possibility of the need for Infertility Services arises. If you fail to notify
us as required, ['Benefits will be reduced to [50 - 95]% of Eligible Expenses] ['you will be responsible for
paying all charges and no Benefits will be paid].]
'Include both headings and this row
('Designated
when Designated Network Benefits
Network]
[Yes] [No]
[Yes] [No]
apply
[[50 - 1 oo]%]
Include the limit selected by the group.
('Network]
`Include when the maximum benefit is
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
combined with infertility drugs under
the RX rider.
[Limited to $[2,000 - 30,000] per
Covered Person during the entire
period of time he or she is enrolled for
coverage under the Policy. ['This limit
includes Benefits for infertility
medications provided under the
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [18]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Outpatient Prescription Drug Rider.]]
[14.] Lab, X-Ray and Diagnostics -
Outpatient
_.............
'Include both headings and this row
.-........_-._........... ---._....--- -- - .._.._...._.....-----
2Include when group
--
`Include when
when Designated Network Benefits
purchases option to
[Yes] [No]
group purchases
apply.
cover mammograms
option to cover
at 100%.
mammograms at
['Designated
0
100%.
Network]
[Yes] [No]
[[50 - 100]%]
(2Deductible does
[2100% for
not apply to
mammograms]
mammograms.]
['Network]
[50 - 100]%
[Yes] [No]
[Yes] [No]
[2100% for
[2Deductible does
mammograms]
not apply to
mammograms.]
[15.] Lab, X-Ray and Major
Diagnostics - CT, PET, MRI, MRA
and Nuclear Medicine - Outpatient
~'Include
both headings and this row
2Include when group
_
2Include when
when Designated Network Benefits
purchases option to
[Yes] [No]
group purchases
apply
cover mammograms
option to cover
at 100%.
mammograms at
['Designated
1 00 %.
Network]
[Yes] [No]
[[50 - 100]%]
[2Deductible does
[100% after you pay
not apply to
marnmograms.]
a Copayment of $[25
- 500] per service]
[2100% for
mammograms]
[' Network]
[[50 - 100)%]
[Yes] [No]
[Yes] [No]
[100% after you pay
[2Deductible does
a Copayment of $[25
not apply to
- 500] per service]
mammograms.]
SBN.CHCI.EPO.07.FL.KA NONRES Rev3 [19]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
100°/a for
mammograms]
Include for groups that purchase
inpatient and intermediate mental
health/substance abuse benefits.
[[16.] Mental Health and Substance
Abuse Services - Inpatient and
Intermediate]
When this benefit is purchased, prior authorization will always be required.
[Prior Authorization Requirement]
[You must obtain prior authorization through the Mental Health/Substance Abuse Designee in order to
receive Benefits. Without authorization, you will be responsible for paying all charges and no Benefits will
be paid.]
Include the limit selected by the group.
[[50 - 100]%]
[Mental Health Services are limited to
[100% after you pay
[Yes] [No]
[Yes] [No]
[30 - 100] days per year.]
a Copayment of
[Substance Abuse Services are limited
$[100 - 1,0001 per
day]
to [30 - 100] days per year.]
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
[100% after you pay
a Copayment of
$[100 - 1,000] per
day to a maximum
Copayment of $[100 -
5,000] per Inpatient
Stay]
Include for groups that purchase
outpatient mental health/substance
abuse benefits.
[[17.] Mental Health and Substance
Abuse Services - Outpatient]
Include authorization language only for groups that elect the "Employer Coverage" option. Delete
authorization language for groups that elect the "National Service Center" option.
[Prior Authorization Requirement]
[You must obtain prior authorization through the Mental Health/Substance Abuse Designee in order to
receive Benefits. Without authorization, you will be responsible il charges and no Benefits will
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [20]
'When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
be paid.)
Include the limit selected by the group.
[[50 - 100]%]
[Mental Health Services are limited to
[100% after you pay
[Yes) [No]
[Yes] [No]
[30 - 100] visits per year.]
a Copayment of $[5 -
[Substance Abuse Services are limited
75) per visit]
to [44 - 100) visits per year.]
[100% after you pay
a Copayment of $[5 -
75] per individual
visit; $[5 - 75] per
group visit]
Include for groups that purchase
benefits for obesity surgery.
[[18.] Obesity Surgery]
When this benefit is purchased, pre -service notification will always be required. 'Include applicable Benefit
level.
[Pre -service Notification Requirement]
[You must notify us [six months prior to surgery] [or] [as soon as the possibility of obesity surgery arises).
If you fail to notify us as required, Benefits will be reduced to ('50 - 95)% of Eligible Expenses.]
[It is important that you notify us regarding your intention to have surgery. Your notification will
open the opportunity to become enrolled in programs that are designed to achieve the best
outcomes for you.]
'Include headings and this row if
C'Designated Network]
Designated Network Benefits are
available.
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
21nserl the limit selected by the group.
Covered Health Service category in this Schedule of Benefits.]
[Benefits are limited to $C50,000 -
250,000) during the entire period of
time a Covered Person is enrolled for
coverage under the Policy.]
(Network]
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
Include if group purchases benefits for
ostomy supplies.
[[19.] Ostomy Supplies]
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [21]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Wealth Service
Eligible Expenses)
Maximum?
Deductible?
Include the limit selected by the group.
[[50 - 100]%]
[Yes] [No] -- --
[Yes] [No]
[Limited to $[500 - 25,0001 per year.]
[20.] Pharmaceutical Products -
Outpatient
'Include headings and this row when
[Designated
Designated Network Benefits apply
Network]
[Yes] [No]
(Yes) [No]
[[50 - 100]%]
Include when
coinsurance is tiered
and select the
appropriate number
of tiers by plan
design.
[[50 - 1001% - Tier 1 ]
[[50 - 1001% - Tier 21
[[50 - 100]% - Tier 3]
[[50 - 100]% - Tier 41
t Network]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
Include when
coinsurance is tiered
and select the
appropriate number
of tiers by plan
design.
[[50 -100]% -Tier 11
[[50 - 100]% - Tier 21
[[50 - 100]% - Tier 3]
[[50 - 100]% - Tier 4]
[21.] Physician Fees for Surgical and
Medical Services
'Include both headings and this row
['Designated
when Designated Network Benefits
Network]
[Yes] [No]
[Yes] [No]
apply
[[50 - 100]%]
Include when enhanced benefits apply
to specific Physician services.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [22]
(When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.)
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[When you choose to seek care [as a
result of certain diagnoses or] from
Designated Network Physicians as
identified below, your Benefits will be
enhanced as described:
Specialties:
• [Cardiology.]
• [Cardiac/Cardio-thoracic
Surgery.]
• [Orthopedic Surgery.]
• [Neurosurgery.]
• [Allergy.]
• [Nephrology.]
• [Neurology.]
• [Oncology.]
• [Pulmonology.]
• [Rheumatology.]
• [Endocrinology.]
• [Infectious Disease.]
• [Gastroenterology.]
• [Obstetrics/Gynecology.]
• [Reproductive Endocrinology.]
• [All specialties for which we
provide designation.]
Enhanced Benefits:
• [The Coinsurance you pay for
Physician's Fees from a
Designated Network Physician
will be reduced to [0 - 50]% or
$[10 - 1,000] will be applied
toward any applicable Annual
Deductible if not already met, to
a maximum of $[10 - 1,0001.1
You can determine the specific
services for which enhanced Benefits
are available by goingto
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [23]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
www.myutic.com or by calling
Customer Care at the telephone
number on your ID card.]
Network]
[50 - 100]%
[Yes] [No]
I [Yes] [No]
[22.] Physician's Office Services -
Sickness and Injury
Sl3N.CHC1.EP0,07.FLXA NONRES Rev3 [24]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
'include both headings and this row
('Designated
when Designated Network Benefits
Network[
[Yes] [No]
[Yes] [No]
apply
[[50-100]%]
Include when enhanced benefits apply
[100% after you pay
to specific physician office services.
a Copayment of $[5 -
[When you choose to seek care [as a
100] per visit]
result of certain diagnoses or] from
Designated Network Physicians as
[100% after you pay
identified below, your Benefits will be
a Copayment of $[5 -
enhanced as described:
751 per visit for a
Primary Physician
Specialties:
office visit or $[5 -
• [Cardiology.]
100] per visit for a
Specialist Physician
• [Cardiac/Cardin-thoracic
office visit]
Surgery.]
[100% after you pay
• [Orthopedic Surgery.]
a Copayment of $[5 -
75] per visit for a
* [Neurosurgery.) g y•]
Primary Physician
+ [Allergy.]
office visit; [50 -
100]% for a Specialist
• [Nephrology.]
Physician office visit]
+ [Neurology.]
[100% for a Primary
• [Oncology.]
Physician office visit;
[50 - 100]% for a
• [Pulmonology.]
Specialist Physician
Office visit]
• [Rheumatology.]
• [Endocrinology.]
• [Infectious Disease.]
• [Gastroenterology.]
• [Obstetrics/Gynecology.]
• [Reproductive Endocrinology.]
• [All specialties for which we
provide designation.]
Enhanced Benefits:
• [The Copayment you pay for [the
initial office visit] [(1 - 100) office
visit(s)] provided by a
Designated Network Physician
will be reduced to $ 0 - 1,000 .
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [25]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
put -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[The maximum reduction in
Copayments is $[10 - 1,000].])
• [The Coinsurance you pay for
[the initial office visit] [[1 - 100)
office visit(s)] provided by a
Designated Network Physician
will be reduced to [0 - 50]% or
$[10 - 1,000] will be applied
toward any applicable Annual
Deductible if not already met, to
a maximum of $[10 - 1,000].]
You can determine the specific
specialties for which enhanced
Benefits are available by going to
www.myulic.com or by calling
Customer Care at the telephone
number on your ID card.]
Include when covered health services
['Network]
performed in a physician's office are
[[50 - 100]%]
[Yes] [No)
[Yes] [No]
subject to the copaymentslcoinsurance
stated under other benefit categories,
[100% after you pay
in addition to the office visit Copayment
a Copayment of $[5 -
stated in this section. (This will not
100) per visit]
apply when the office visit benefit is
[100% after you pay
subject to coinsurance only.)
a Copayment of $[5 -
[In addition to the office visit
751 per visit for a
Copayment stated in this section, the
Primary Physician
Copayments/Coinsurance for the
office visit or $[5 -
following services apply when the
100] per visit for a
Covered Health Service is performed in
Specialist Physician
a Physician's office:
office visit]
• [Lab, radiology/X-rays and other
[100% after you pay
diagnostic services described
a Copayment of $[5 -
under Lab, X-Ray and
75] per visit for a
Diagnostics - Outpatient.]
Primary Physician
• [Major diagnostic and nuclear
office visit; [50 -
100]% for a Specialist
medicine described under Lab,
physician office visit]
X-Ray and Major Diagnostics -
CT, PET, MRi, MRA and
[100% for a Primary
Nuclear Medicine - Outpatient.)
Physician office visit;
• [Diagnostic and therapeutic
[50 - 100]%for a
Specialist Physician
scopic procedures described
office visit]
under Sco is Procedures -
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [26]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Outpatient Diagnostic and ---
-
—, —
-- --�
Therapeutic.]
• [Outpatient surgery procedures
described under Surgery -
Outpatient]
• [Outpatient therapeutic
procedures described under
Therapeutic Treatments -
Outpatient.]
• [Rehabilitation therapy
I
procedures described under
Rehabilitation Services -
Outpatient Therapy and
Chiropractic Treatment.])
'Always include Maternity Services
benefit except when small groups (14
or fewer employees) choose to
exclude. ''if Maternity Services are
excluded, Complications of Pregnancy
must always be included.
[23.] Pregnancy - ['Maternity
Services] [2Complications of
Pregnancy only]
It is Important that you notify us regarding your Pregnancy. Your notification will open the
opportunity to become enrolled in prenatal programs that are designed to achieve the best
outcomes for you and your baby.
'Include when benefits are provided for maternity services.
31nclude when an annual deductible applies to network benefits.
"Include when services in the Physician's office are subject to a
Copayment.
['Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits [''except
that an Annual Deductible will not apply for a newborn child
whose length of stay in the Hospital is the same as the mother's
length of stay]. [°For Covered Health Services provided in the
Physician's Office, a Copayment will apply only to the initial
office visit.)
`Include when benefits are provided for complications of
pregnancy only.
`Benefits will be the same as those stated under each Covered
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [27)
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Health Service category in this Schedule of Benefits.]
[24.] Preventive Care Services
..........
Physician office services
'Include when group
[Yes] [No]
'Include when
Child Health Supervision Services are
purchases option to
group purchases
riot subject to any Annual Deductible.
cover mammograms
option to cover
Benefits are limited to orie visit.
at 100%.
mammograms at
payable to one: provider, for all of tho
[[50-100]%]
100%.
services provided at each visit.
[100% after you pay
[Yes] [No]
a Copayment of $[5 -
['Deductible does
751 per visit]
not apply to
[100% after you pay
mammograms.]
a Copayment of $[5 -
75] per visit for a
Primary Physician
office visit or $[5 -
100] per visit for a
Specialist Physician
office visit]
[100% after you pay
a Copayment of $[5 -
75] per visit for a
Primary Physician
office visit; [50 -
100]% for a Specialist
Physician office visit]
[100% for a Primary
Physician office visit;
[50 - 1001% for a
Specialist Physician
office visit]
[' 100% for
mammograms]
Lab, X-ray or other preventive tests:
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
['Deductible does
a Copayment of $[5 -
not apply to
100] per service]
mammograms.]
[' 100% for
mammograms]
Include when group purchases benefits
for prosthetic devices.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [28]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated. ]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[25.] [Prosthetic Devices]
Include the limit selected by the group.
[[50-100]%0]
[Yes] [No]
[Yes] [No]
'Include either option as standard.
['Limited to $[2,500 - 100,000) per
year. Benefits are limited to a single
purchase of each type of prosthetic
device every [year] [[two -five) years).)
['Limited per year as follows:
• A maximum of $[10,000 -
30,000) per body part for each
arm, leg, hand or foot.
• A maximum of $[5,000 - 15,000)
per body part for each eye, ear,
nose, face, breast, speech aid
prosthetics or tracheo-
esophageal voice prosthetics.
These limits include repair. Benefits for
replacement are limited to a single
purchase of each type of prosthetic
device every [year) [[two -five] years).
Always include statement below except
when prosthetics are not limited.
[Once this limit is reached, Benefits
continue to be available for items
required by the Women's Health and
Cancer Rights Act of 1998.]
[26.] Reconstructive Procedures
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Include when group does not purchase benefits for prosthetic
devices.
'Include when sold with a plan that has an annual deductible
and select either "are" or "are not."
Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply."
[For breast prosthesis, mastectomy bras and lyrnphedema
stockings for the arms, the Benefit is [50 - 100)% of Eligible
Expenses ['and Benefits [are] are not] subject to payment of
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [29]
(When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
the Annual Deductible]. [ Coinsurance [applies] [does not apply]
to the Out -of -Pocket Maximum.]]
Include entire section when
rehabilitation services benefit is sold.
[[27.] Rehabilitation Services -
Outpatient Therapy and Chiropractic
Treatment]
Include when per therapy limits apply.
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
'Include when vision therapy benefits
[100% after you pay
are sold.
a Copayment of $[5 -
[Limited per year as follows:
75] per visit]
• [10-100] visits of physical
therapy.
• [10-100] visits of occupational
therapy.
• [10-100] visits of Chiropractic
Treatment.
• [10-100] visits of speech
therapy.
• [10-100] visits of pulmonary
rehabilitation therapy.
• [10•-100] visits of cardiac
rehabilitation therapy.
• [10-100] visits of post -cochlear
implant aural therapy.
• [1[10-100] visits of vision
therapy.]]
Include when combined therapy visit
limits apply.
[Any combination of outpatient
rehabilitation services is limited to [10 -
160] visits per year.]
Include when combined therapy dollar
limits apply.
[Any combination of outpatient
rehabilitation services is limited to
$[750 - 12,000] per year.]
SBN.CHCI.EPO.07.FL.KA NONRES Rev3 [30]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[28.1 Scopic Procedures - Outpatient
Diagnostic and Therapeutic
'Include headings and this row when
['Designated
Designated Network Benefits apply.
Network]
[Yes] [No]
[Yes] [No]
[[50 - 100]%]
(Network]
[50 - 100]%
[Yes] [No]
[Yes] [No]
[29.] Skilled Nursing
Facility/inpatient Rehabilitation
Facility Services
Include limit selected by group.
[[50-100]%]
[Yes] [No]
[Yes] [No]
[Limited to [40 - 1801 days per year.]
[100% after you pay
a Copayment of $[5 -
100] per visit]
[100% after you pay
a Copayment of $[50
- 1,000] per day]
Copayment option
below identified as #1
to be tied only to
either of the options
#1 below with an
Inpatient Stay
maximum.
[1 100% after you pay
a Copayment of $[50
- 2,000] per Inpatient
Stay]
[1100% after you pay
a Copayment of $[50
- 1,000] per day to a
maximum
Copayment of $[50 -
5,000] per Inpatient
Stay]
Variable #1 can be
used only with
options numbered #1
above.
'If you are
5BN.CHC1.EP0.07.FLXA NONRES Rev3 [31]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
transferred to a
Skilled Nursing
Facility or Inpatient
Rehabilitation Facility
directly from an acute
facility, any
combination of
Copayments required
for the Inpatient Stay
in a Hospital and the
Inpatient Stay in a
Skilled Nursing
Facility or Inpatient
Rehabilitation Facility
will apply to the
stated maximum
Copayment per
Inpatient Stay.]
[No Copayment
applies if you are
transferred to a
Skilled Nursing
Facility or Inpatient
Rehabilitation Facility
directly from an acute
facility.]
[30.] Surgery - Outpatient
'Include headings and this row when
['Designated
Designated Network Benefits apply.
Network]
[Yes[ [No]
[Yes[ [No]
Include provision below when
[[50 - 100]%]
[Yes, after the Per
enhanced benefits apply to specific
outpatient surgical services.
o
[100 /o after you pay
Occurrence
a Copayment of $[10
Deductible is
1lnclude when Physician's fees are
- 1,000] per date of
satisfied]
paid under the facility charge.
service]
[When you choose to seek care from
Designated Network facilities for
certain surgical procedures, your
Benefits will be enhanced as follows:
• [The Copayment you pay for the
facility charge ['sand Physician's
fees] for outpatient surgery
provided at a Designated
Network facility will be reduced
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [32]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
to [$0 - 1,000]. [The maximum
reduction in Copayments is $[10
- 1,0001.]]
• [The Coinsurance you pay for
the facility charge [?and
Physician's fees] for outpatient
surgery provided at a
Designated Network facility will
be reduced to [0 - 50]% or $[10 -
1,000] will be applied toward any
applicable Annual Deductible if
riot already met, to a maximum
of $[10 - 1,000].]
You can determine the specific surgical
procedures for which enhanced
Benefits are available by going to
www,myuhc.com or by calling
Customer Care at the telephone
number on your ID card.]
t Network]
[[50 - 100]%] [Yes] [No] [Yes] [No]
[[100% after you pay [Yes, after the Per
a Copayment of $[10 Occurrence
- 1,000] per date of Deductible is
service] satisfied]
Include when group purchases TMJ
benefit.
[[31.] Temporomandibular Joint
Services]
Include the limit selected by the group.
[Depending upon where the Covered Health Service is
[Limited to $[1,000 - 20,000] per year.]
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
[32.] Therapeutic Treatments -
Outpatient
---
Include headings and this row when
]'Designated
Designated Network Benefits apply
Network]
[Yes] [No]
[Yes] [No]
[[50 - 100]%]
]'Network]
[50 - 1001%
[Yes] [No]
[Yes] [No]
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [33]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Wealth Service
Eligible Expenses)
Maximum?
Deductible?
[33.) Transplantation Services
Pre -service Notification Requirement
You must notify us as soon as the possibility of a transplant arises (and before the time a pre -
transplantation evaluation is performed at a transplant center). If you don't notify us and if, as a result, the
services are not performed at a Designated Facility, Benefits will not be paid.
-
____ ........... _.__-
Transplantation services must be
[[50 - 100]%]
[Yes] [No]
_..__....
[Yes] [No]
received at a Designated Facility. We
do not require that cornea transplants
[100% after you pay
[Yes, after the Per
be performed at a Designated Facility.
a Copayment of
$[100 - 1,000] per
Occurrence
Deductible is
day]
satisfied]
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
[100% after you pay
a Copayment of
$[100 - 1,0001 per
day to a maximum
Copayment of $[100 -
5,000] per Inpatient
Stay]
[34.] Urgent Care Center Services
SBN.CHCI.EPO.07.FL.KA NONRES Rev3 [34]
(Wen Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.)
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include when covered health services
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
performed at an urgent care center are
[100% after you pay
subject to the copayments/coinsurance
a Copayment of $[5 -
stated under other benefit categories,
150] per visit]
in addition to the urgent care
copayment stated in this section. (This
will not apply when the urgent care
benefit is subject to coinsurance only.)
[In addition to the Copayment stated in
this section, the
Copayments/Coinsurance for the
following services apply when the
Covered Health Service is performed
at an Urgent Care Center:
• [Lab, radiology/X-rays and other
diagnostic services described
under Lab, X-Ray and
Diagnostics - Outpatient.]
• [Major diagnostic and nuclear
medicine described under Lab,
X-Ray and Major- Diagnostics -
CT, PET. MRI, MRA and
Nuclear Medicine - Outpatient.]
• [Diagnostic and therapeutic
scopic procedures described
under Scopic Procedures -
Outpatient Diagnostic and
Therapeutic.]
• [Outpatient surgery procedures
described under Surgery -
Outpatient.]
• [Outpatient therapeutic
procedures described under
Therapeutic Treatments -
Outpatient.]
• [Rehabilitation therapy
procedures described under
Rehabilitation Services -
Outpatient Therapy and
Chiropractic Treatment.]]
Include when group purchases benefits
for vision exams.
SPN.CHC1.EP0.07.FL.KA NONRES Rev3 [35]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[[35.] Vision Examinations]
[Limited to [1 exam] [[2-3] exams] per
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
year']
[100% after you pay
[Limited to [1 exam] [[2-31 exams]
a Copayment of [$5 -
every [2 - 3] years.]
75] per visit]
Include when group purchases benefits
for wigs.
[[36.] Wigs]
Include the limit selected by the group.
[[50 - 100]%]
[Yes] [No] T
[Yes] [No]_ -
[Limited to $[100 - 1,000] per year.]
[Limited to $[100 - 5,000] every [24 -
36] months.]
Additional Benefits Required By Florida Law
[37.] Bones, or Joints of the Jaw and
l"acial Region
Notification Requirement
Depending upon where the Covered Health Service is provided. any applicable notification or
;authorization requir(,,w)ents will be the same as those stated under each Covered Health Service category
in this Schedule of Benefits.
'include heading and row when
'Designated Network]
Designated Network Benefits apply
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
['Network]
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
[38.] Cleft Lip/Cleft Palate Treatment
Notification Requirement
Depending upon where the Covered Health Service is provided, any applicable notification or
authorization requirements will be the same as those stated under each Covered Health Service category
in this Schedule of Benefits.
'Include heading and row when
'Designated Network]
SBN.CHCI.EPO.07.FL.KA NONRES Rev3 [36]
[When Benefit limits apply, the limit stated includes Covered Health Services provided at a
Designated Network level of Benefits unless otherwise specifically stated.]
_
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Designated Network Benefits apply
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.)
r Network]
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
[39.) Dental Services - Anesthesia
and Hospitalization
Notification Requirement
Depending upon where the Covered Health Service is provided, any applicable notification or
authorization requirements will be the same as 'those stated under each Coverer! Health Service caiegors,;
in this Schedule of Benefits.
'Include heading and row when
('Designated Network] —
Designated Network Benefits apply
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits]
r Network]
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Include when group purchases.
[40.] [Enteral Formulas]
[Limited to $2,500 for food products --
[50 - 100%.l
[Yes) [No] --_--�
[Yes] I.Nol
modified to be low protein.]
[41.] Osteoporosis Treatment
Notification Requirement
Depending upon where the Covered Health Service is provided, any applicable notification or
authorization requirements will be they saute as those stated under each Covered Health Service category
in this Schedule of benefits.
'include heading and row when
('Designated
Designated Network Benefits apply
Network]
[Yes] [No]
[Yes] [No]
[50 - 100%]
[Network]
[50 - 100%]
[Yes] [No]
[Yes] [No)
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [37]
Eligible Expenses
Eligible Expenses are the amount we determine that we will pay for Benefits. You are not responsible for
any difference between Eligible Expenses and the amount the provider bills. Eligible Expenses are
determined solely in accordance with our reimbursement policy guidelines, as described in the Certificate
of Coverage.
Include paragraph below if pre -service benefit notification includes determining alternate levels of
benefits.
'Include when group purchases MH/SA benefits. 2Include when group does not purchase MF11SA
benefits.
[If one or more alternative health services that meets the definition of Covered Health Service in the
Certificate of Coverage under Section 9: Defined Terms are clinically appropriate and equally effective for
prevention, diagnosis or treatment of a Sickness. Injury, ['Mental Illness,] [2mental illness,] substance
abuse or their symptoms, we reserve the right to adjust Eligible Expenses for identified Covered Health
Services based on defined clinical protocols. Defined clinical protocols shall be based upon nationally
recognized scientific evidence and prevailing medical standards and analysis of cost-effectiveness.]
Eligible Expenses are based on either of the following:
'Include if the plan design provides Designated Network Benefits in any benefit category.
When Covered Health Services are received from a ['Designated Network and] Network provider,
Eligible Expenses are our contracted fee(s) with that provider.
When Covered Health Services are received from a non -Network provider as a result of an
Emergency or as otherwise arranged by us, Eligible Expenses are billed charges unless a lower
amount is negotiated for authorized by state law].
We arrange for health care providers to participate in a Network. Network providers are independent
practitioners. They are not our employees. It is your responsibility to select your provider.
Our credentialing process confirms public information about the providers' licenses and other credentials,
but does not assure the quality of the services provided.
Before obtaining services you should always verify the Network status of a provider. A provider's status
may change. You can verify the provider's status by calling Customer Care. A directory of providers is
available online at www.myuhc.com or by calling Customer Care at the telephone number on your ID card
to request a copy.
It is possible that you might not be able to obtain services from a particular Network provider. The network
of providers is subject to change. Or you might find that a particular Network provider may not be
accepting new patients. If a provider leaves the Network or is otherwise not available to you, you must
choose another Network provider to get Network Benefits.
If you are currently undergoing a course of treatment utilizing a non -Network Physician or health care
facility, you may be eligible to receive transition of care Benefits. This transition period is available for
specific medical services and for limited periods of time. If you have questions regarding this transition of
care reimbursement policy or would like help determining whether you are eligible for transition of care
Benefits, please contact Customer Care at the telephone number on your ID card.
Do not assume that a Network provider's agreement includes all Covered Health Services. Some Network
providers contract with us to provide only certain Covered Health Services, but not all Covered Health
Services. Some Network providers choose to be a Network provider for only some of our products. Refer
to your provider directory or contact us for assistance.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 (38]
Direct Access
Please note that YOU have direct access to the following Network providers and there are no limitations
regarding the number of visits that will be considered Covered Health Services:
dermatologists
obstetricians
gynecologists
• i • a►
If you dispute our response or a Network Physician's opinion to the reasonableness or necessity of
>urgical procedures or you are subject to a serious Sickness, you may obtain a second opinion from one
of the following:
• Network Physician listed in our provider directory or [by going to www,myuhc.com or] by calling
Customer Care at the telephone number on your ID card.
• A non -Network Physician located within our Service Area.
• In the case of a second opinion from a Network Physician, such second opinions are considerc;ci
Covered Health Services. In the case of a second opinion from a non -Network Physician, Coverer,
Health Services shr, if be limited to 60% of Eligible Expenses. If the;. non -Network Physician requires,
any tests during the second opinion process, you must have such tests pearfor'mod by a Nolwork
provider.
• In the event that you seek more than three second opinion referrals in a year and we determine
that' you are unreasonably over -utilizing the second opinion privilege, we may deny reimburse:me}nt
Zf experrse>s incurred :after three referrals.
Designated Facilities and Other Providers
If you have a medical condition that we believe needs special services, we may direct you to a
Designated Facility or Designated Physician chosen by us. If you require certain complex Covered Health
Services for which expertise is limited, we may direct you to a Network facility or provider that is outside
your local geographic area. If you are required to travel to obtain such Covered Health Services from a
Designated Facility or Designated Physician, we may reimburse certain travel expenses at our discretion.
In both cases, Benefits will only be paid if your Covered Health Services for that condition are provided by
or arranged by the Designated Facility, Designated Physician or other provider chosen by us.
You or your Network Physician must notify us of special service needs (such as transplants or cancer
treatment) that might warrant referral to a Designated Facility or Designated Physician. If you do not notify
us in advance, and if you receive services from a non -Network facility (regardless of whether it is a
Designated Facility) or other non -Network provider, Benefits will not be paid.
Health Services from Non -Network Providers
If specific Covered Health Services are not available from a Network provider, you may be eligible for
Benefits when Covered Health Services are received from non -Network providers. In this situation, your
Network Physician will notify us and, if we confirm that care is not available from a Network provider, we
will work with you and your Network Physician to coordinate care through a non -Network provider.
Limitations on Selection of Providers
If we determine that you are using health care services in a harmful or abusive manner, or with harmful
frequency, your selection of Network providers may be limited. If this happens, we may require you to
select a single Network Physician to provide and coordinate all future Covered Health Services.
SBN.CHC1.EPO.07.FL.KA NONRES Rev3 [39]
If you don't make a selection within 31 days of the date we notify you, we will select a single Network
Physician for you.
If you fail to use the selected Network Physician, Benefits will not be paid.
SBN.CNC1.EPO.07.FL.KA NONRES Rev3 [401
EXHIBIT V
Group Policy
UnitedHealthcare Insurance Company
[450 Columbus Boulevard]
[Hartford, Connecticut 06115-04501
[1-800-357-1371 ]
This Policy is entered into by and between UnitedHealthcare Insurance Company and the "Enrolling
Group," as described in Exhibit 1.
When used in this document, the words "we," "us," and "our" are referring to UnitedHealthcare Insurance
Company.
Upon our receipt of the Enrolling Group's signed application and payment of the first Policy Charge, this
Policy is deemed executed.
We agree to provide Benefits for Covered Health Services set forth in this Policy, including the attached
Certificate(s) of Coverage and Schedule(s) of Benefits, subject to the terms, conditions, exclusions. and
limitations of this Policy. The Enrolling Group's application is made a part of this Policy.
This Policy replaces and overrules any previous agreements relatinq to Benefits for Covered Health
Services between the Enrolling Group and us. The terms and conditions of this Policy will in turn be
overruled by those of any subsequent agreements relating to Benefits for Covered Health Services
between the Enrolling Group and us.
We will not be deemed or construed as an employer or plan administrator for any purpose with respect to
the administration or provision of benefits under the Enrolling Group's benefit plan. We are not
responsible for fulfilling any duties or obligations of an employer or plan administrator with respect to the
Enrolling Group's benefit plan.
This Policy will become effective on the date specified in Exhibit 1 and will be continued in force by the
timely payment of the required Policy Charges when due, subject to termination of this Policy as provided
in Article 5.
When this Policy is terminated, as described in Article 5, this Policy and all Benefits under this Policy will
end at 12:00 midnight on the date of termination.
This Policy is issued as described in Exhibit 1.
Issued By:
UnitedHealthcare Insurance Company
[Signature of authorized company officer]
[Title of authorized company officer]
CHOICE PLUS
Article 1: Glossary of Defined Terms
The terms used in this Policy have the same meanings given to those terms in Section 9: Defined Tenns
of the attached Certificate(s) of Coverage.
Coverage Classification - one of the categories of coverage described in Exhibit 2 for rating purposes
(for example: Subscriber only, Subscriber and spouse, Subscriber and children, Subscriber and family).
Material Misrepresentation - any oral or written communication or conduct, or combination of
communication and conduct, that is untrue and is intended to create a misleading impression in the mind
of another person. A misrepresentation is material if a reasonable person would attach importance to it in
making a decision or determining a course of action, including but not limited to, the issuance of a policy
or coverage under a policy, calculation of rates, or payment of a claim.
Article 2: Benefits
Subscribers and their Enrolled Dependents are entitled to Benefits for Covered Health Services subject to
the terms, conditions, limitations and exclusions set forth in the Certificate(s) of Coverage and
Schedule(s) of Benefits attached to this Policy. Each Certificate of Coverage and Schedule of Benefits,
including any Riders and Amendments, describes the Covered Health Services, required Copayments,
and the terms, conditions, limitations and exclusions related to coverage.
Article 3: Premium Rates and Policy Charge
3.1 Premiums
Monthly Premiums payable by or on behalf of Covered Persons are specified in the Schedule of Premium
Rates in Exhibit 2 of this Policy or in any attached Notice of Change.
We reserve the right to change the Schedule of Premium Rates as described in Exhibit 1 of this Policy.
We also reserve the right to change the Schedule of Premium Rates at any time if the Schedule of
Premium Rates was based upon a Material Misrepresentation relating to health status that resulted in the
Premium rates being lower than they would have been if the Material Misrepresentation had not been
made. We reserve the right to change the Schedule of Premium Rates for this reason retroactive to the
effective date of the Schedule of Premium Rates that was based on the Material Misrepresentation.
3.2 Computation of Policy Charge
The Policy Charge will be calculated based on the number of Subscribers in each Coverage Classification
that we show in our records at the time of calculation. The Policy Charge will be calculated using the
Premium rates in effect at that time. Exhibit 1 describes the way in which the Policy Charge is calculated.
'Enter the appropriate number of days.
3.3 Adjustments to the Policy Charge
We may make retroactive adjustments for any additions or terminations of Subscribers or changes in
Coverage Classification that are not reflected in our records at the time we calculate the Policy Charge.
We will not grant retroactive credit for any change occurring more than [130 - 90] days prior to the date we
received notification of the change from the Enrolling Group. We also will not grant retroactive credit for
any calendar month in which a Subscriber has received Benefits.
The Enrolling Group must notify us in writing within ['30 - 901 days of the effective date of enrollments,
terminations, or other changes. The Enrolling Group must notify us in writing each month of any change
in the Coverage Classification for any Subscriber.
If premium taxes, guarantee or uninsured fund assessments, or other governmental charges relating to or
calculated in regard to Premium are either imposed or increased, those charges will automatically be
added to the Premium. In addition, any change in law or regulation that significantly affects our cost of
operation will result in an increase in Premium in an amount we determine.
POL.1.09.FL.KA
3.4 Payment of the Policy Charge
The Policy Charge is payable to us in advance by the Enrolling Group as described under "Payment of
the Policy Charge" in Exhibit 1. The first Policy Charge is due and payable on or before the effective date
of this Policy. Subsequent Policy Charges are due and payable no later than the first day of each
payment period specified in item 6 of Exhibit 1, while this Policy is in force.
All payments shall be made in United States dollars, in immediately available funds, and shall be remitted
to us at the address set forth in the Enrolling Group's application, or at such other address as we may
from time to time designate in writing. The Enrolling Group agrees not to send us payments marked "paid
in full", "without recourse", or similar language. In the event that the Enrolling Group sends such a
payment, we may accept it without losing any of our rights under this Policy and the Enrolling Group will
remain obligated to pay any and all amounts owed to us.
A late payment charge will be assessed for any Policy Charge not received within 10 calendar days
following the due date. A service charge will be assessed for any non -sufficient -fund check received in
payment of the Policy Charge, All Policy Charge payments must be accompanied by supporting
documentation that states the names of the Covered Persons for whom payment is being made.
The Enrolling Group must reimburse us for attorney's fees and any other costs related to collecting
delinquent Policy Charges.
'Enter the appropriate number of days.
3.5 Grace Period
A grace period of ['30 - 90] days will be granted for the payment of any Policy Charge not paid when due
During the grace period, this Policy will continue in force. The grace period will not extend beyond the
date this Policy terminates.
The Enrolling Group is liable for payment of the Policy Charge during the grace period. If we receive
written notice from the Enrolling Group to terminate this Policy during the grace period, we will adjust the
Policy Charge so that it applies only to the number of days this Policy was in force during the grace
period.
This Policy terminates as described in Article 5.1 if the grace period expires and the past due Policy
Charge remains unpaid.
Article 4: Eligibility and Enrollment
4.1 Eligibility Conditions or Rules
Eligibility conditions or rules for each class are stated in the corresponding Exhibit 2. The eligibility
conditions stated in Exhibit 2 are in addition to those specified in Section 3: When Coverage Begins of the
Certificate of Coverage.
4.2 Initial Enrollment Period
Eligible Persons and their Dependents may enroll for coverage under this Policy during the Initial
Enrollment Period. The Initial Enrollment Period is determined by the Enrolling Group.
Include Open Enrollment Period unless a group chooses a closed plan.
[4.3] [Open Enrollment Period]
[An Open Enrollment Period will be provided periodically for each class. as specified in the corresponding
Exhibit 2. During an Open Enrollment Period, Eligible Persons may enroll for coverage under this Policy.]
[4.4] Effective Date of Coverage
The effective date of coverage for properly enrolled Eligible Persons and their Dependents is stated in
Exhibit 2.
POL.1.09.FL.KA
Article 5: Policy Termination
5.1 Conditions for Termination of the Entire Policy
This Policy and all Benefits for Covered Health Services under this Policy will automatically terminate on
the earliest of the dates specified below:
A. On the last day of the grace period if the Policy Charge remains unpaid and written notice of
termination was sent to the Enrolling Group within 45 days after the due date. The Enrolling Group
remains liable for payment of the Policy Charge for the period of time this Policy remained in force
during the grace period.
B. On the date specified by the Enrolling Group, after at least 31 days prior written notice to us that
this Policy is to be terminated.
Include when either contribution or participation rules apply.
'Include when both contribution and participation rules apply. include when either contribution or
participation rules apply.
[C.] [On the date we specify, after at least 45 days prior written notice to the Enrolling Group, that this
Policy is to be terminated due to the Enrolling Group's violation of the participation ['and][`or]
contribution rules as shown in Exhibit 1.]
[D]. On the date we specify, after at least 45 days prior written notice to the Enrolling Group, that this
Policy is to be terminated because the Enrolling Group provided us with false information material
to the execution of this Policy or to the provision of coverage under this Policy or has performed an
act or practice that constitutes fraud or made a material misrepresentation of material fact under
the terms of this Policy. In this case, we have the right to rescind this Policy back to either:
The effective date of this Policy.
The date we received the false information, if later.
[E], On the anniversary renewal date, after at least 90 days prior written notice to the Enrolling Group
and to each Subscriber, that this Policy is to be terminated because we will no longer issue this
particular type of group health benefit plan within the applicable market.
[F]. On the anniversary renewal date, after at least 180 days prior written notice to the applicable state
authority, to the Enrolling Group and to each Subscriber, that this Policy is to be terminated
because we will no longer issue any employer health benefit plan within the applicable market.
If we fail to provide the 45 days' notice required under A or C above, this Policy shall remain in effect at
the existing rates until 45 days after the notice is given or until the effective date of replacement coverage
obtained by the Enrolling Group, whichever occurs first.
5.2 Payment and Reimbursement Upon Termination
Upon any termination of this Policy, the Enrolling Group is and will remain liable to us for the payment of
any and all Premiums which are unpaid at the time of termination, including a pro rata portion of the
Policy Charge for any period this Policy was in force during the grace period preceding the termination.
Article 6: General Provisions
6.1 Entire Policy
This Policy, including the Certificate(s) of Coverage, the Schedule(s) of Benefits, the application of the
Enrolling Group, and any Amendments, Notices of Change, and Riders, constitute the entire Policy
between the parties. All statements made by the Enrolling Group or by a Subscriber will, in the absence
of fraud, be deemed representations and not warranties.
POL.1.09. FL. KA 4
6.2 Dispute Resolution
No legal proceeding or action may be brought until the parties have attempted, in good faith, to resolve
the dispute amongst themselves. In the event the dispute is not resolved within thirty (30) days after one
party has received written notice of the dispute from the other party, and both parties wish to pursue the
dispute further, the dispute may be submitted to arbitration as set forth below.
The parties acknowledge that because this Policy affects interstate commerce, the Federal Arbitration Act
applies. If the Enrolling Group wishes to seek further review of the decision or the complaint or dispute, it
may submit the decision, complaint or dispute to arbitration pursuant to the rules of the American
Arbitration Association. This is the only right the Enrolling Group has for further consideration of any
dispute that arises out of or is related to this Policy.
Arbitration will take place in [Hartford County, Connecticut].
The matter should be submitted to arbitration within one year of the date notice of the dispute was
received. The arbitrators will have no power to award any punitive or exemplary damages or to vary or
ignore the provisions of this Policy, and will be bound by controlling law.
6.3 Time Limit on Certain Defenses
No statement made by the Enrolling Group, except a fraudulent statement, can be used to void this Policy
after it has been in force for a period of two years.
6.4 Amendments and Alterations
Amendments to this Policy are effective 31 days after we send written notice to the Enrolling Group.
Riders are effective on the date we specify. Other than changes to Exhibit 2 stated in a Notice of Change
to Exhibit 2, no change will be made to this Policy unless made by an Amendment or a Rider which is
signed by one of our authorized executive officers. No agent has authority to change this Policy or to
waive any of its provisions
6.5 Relationship between Parties
The relationships between us and Network providers, and relationships between us and Enrolling Groups,
are solely contractual relationships between independent contractors. Network providers and Enrolling
Groups are not our agents or employees, nor are we or any of our employees an agent or employee of
Network providers or Enrolling Groups.
The relationship between a Network provider and any Covered Person is that of provider and patient. The
Network provider is solely responsible for the services provided by it to any Covered Person. The
relationship between any Enrolling Group and any Covered Person is that of employer and employee,
Dependent, or any other category of Covered Person described in the Coverage Classifications specified
in this Policy.
The Enrolling Group is solely responsible for enrollment and Coverage Classification changes (including
termination of a Covered Person's coverage) and for the timely payment of the Policy Charges.
6.6 Records
The Enrolling Group must furnish us with all information and proofs which we may reasonably require with
regard to any matters pertaining to this Policy. We may at any reasonable time inspect:
• All documents furnished to the Enrolling Group by an individual in connection with coverage.
The Enrolling Group's payroll.
Any other records pertinent to the coverage under this Policy.
By accepting Benefits under this Policy, each Covered Person authorizes and directs any person or
institution that has provided services to him or her, to furnish us or our designees any and all information
and records or copies of records relating to the health care services provided to the Covered Person. We
07111111191MI lM:�_�
have the right to request this information at any reasonable time. This applies to all Covered Persons,
including Enrolled Dependents whether or not they have signed the Subscriber's enrollment form.
We agree that such information and records will be considered confidential. We have the right to release
any and all records concerning health care services which are necessary to implement and administer the
terms of this Policy including records necessary for appropriate medical review and quality assessment or
as we are required by law or regulation.
During and after the term of this Policy, we and our related entities may use and transfer the information
gathered under this Policy for research and analytic purposes.
6.7 Administrative Services
The services necessary to administer this Policy and the Benefits provided under it will be provided in
accordance with our standard administrative procedures or those standard administrative procedures of
our designee. If the Enrolling Group requests that administrative services be provided in a manner other
than in accordance with these standard procedures, including requests for non-standard reports, the
Enrolling Group must pay for such services or reports at the then current charges for such services or
reports.
Delete if the group is not subject to ERtSA
[6.8] [Employee Retirement Income Security Act (ERISA)]
[When this Policy is purchased by the Enrolling Group to provide benefits under a welfare plan governed
by the federal Employee Retirement Income Security Act 29 U.S.C., 1001 et seq., we will not be named
as, and will not be, the plan administrator or the named fiduciary of the welfare plan, as those terms are
used in ERISA]
[6.9] Examination of Covered Persons
In the event of a question or dispute concerning Benefits for Covered Health Services, we may
reasonably require that a Network Physician, acceptable to us, examine the Covered Person at our
expense.
[6.10] Clerical Error
'The number here should match the adjustment period number used in Article 3.3.
Clerical error will not deprive any individual of Benefits under this Policy or create a right to Benefits.
Failure to report enrollments will not be considered a clerical error and will not result in retroactive
coverage for Eligible Persons. Failure to report the termination of coverage will not continue the coverage
for a Covered Person beyond the date it is scheduled to terminate according to the terms of this Policy.
Upon discovery of a clerical error, any necessary appropriate adjustment in Premiums will be made.
However, we will not grant any such adjustment in Premiums or coverage to the Enrolling Group for more
than ('30 - 90) days of coverage prior to the date we received notification of the clerical error.
[6.11] Workers' Compensation Not Affected
Benefits provided under this Policy do not substitute for and do not affect any requirements for coverage
by workers' compensation insurance.
[6.12] Conformity with Law
Any provision of this Policy which; on its effective date, is in conflict with the requirements of state or
federal statutes or regulations (of the jurisdiction in which this Policy is delivered) is deemed to be
amended to conform to the minimum requirements of those statutes and regulations.
POL.1.09.FL.KA
[6.13] Notice
When we provide written notice regarding administration of this Policy to an authorized representative of
the Enrolling Group, that notice is deemed notice to all affected Subscribers and their Enrolled
Dependents. The Enrolling Group is responsible for giving notice to Covered Persons on a timely basis.
Any notice sent to us under this Policy and any notice sent to the Enrolling Group must be addressed as
described in Exhibit 1.
[6.14] Continuation Coverage
We agree to provide Benefits under this Policy for those Covered Persons who are eligible to continue
coverage under federal or state law. as described in Section 4: When Coverage Ends of the Certificate of
Coverage.
We will not provide any administrative duties with respect to the Enrolling Group's compliance with federal
or state law. All duties of the plan sponsor or plan administrator remain the sole responsibility of the
Enrolling Group, including but not limited to notification of COBRA and/or state law continuation rights and
billing and collection of Premium.
[6.15] Certification of Coverage Forms
As required by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), we will
produce certification of coverage forms for Covered Persons who lose coverage under this Policy. The
Enrolling Group agrees to provide us with all necessary eligibility and termination data. Certification of
coverage forms will be based on eligibility and termination data that the Enrolling Group provides to our
eligibility systems in accordance with our data specifications, and which is available in our eligibility
systems as of I:M'date the form is generated. The certification of coverage forms will only include periods
of coverage that we administer under this Policy.
'Include when COCs will not be sent directly to the Subscribers, but will be sent to the Enrolling Group for
it to distribute the COCs to the Subscribers.
[6.16] Subscriber's Individual Certificate
We will issue Certificate(s) of Coverage, Schedule(s) of Benefits, and any attachments to ['the Enrolling
Group for delivery to] each covered Subscriber. The Certificate(s) of Coverage, Schedule(s) of Benefits,
and any attachments will show the Benefits and other provisions of this Policy. In addition, you may have
access to your Certificate of Coverage(s) and Schedule(s) of Benefits online at [www.myuhc.com].
[6.17] System Access
The term "systems" as used in this provision means our systems that we make available to the Enrolling
Group to facilitate the transfer of information in connection with this Policy.
System Access
We grant the Enrolling Group the nonexclusive, nontransferable right to access and use the functionalities
contained within the systems, under the terms set forth in this Policy. The Enrolling Group agrees that all
rights, title and interest in the systems and all rights in patents, copyrights, trademarks and trade secrets
encompassed in the systems will remain ours. In order to obtain access to the systems, the Enrolling
Group will obtain, and be responsible for maintaining, at no expense to us, the hardware, software and
Internet browser requirements we provide to the Enrolling Group, including any amendments to those
requirements. The Enrolling Group is responsible for obtaining an internet service provider or other
access to the Internet.
The Enrolling Group will not:
Access systems or use, copy, reproduce, modify, or excerpt any of the systems documentation
provided by us in order to access or utilize systems, for purposes other than as expressly permitted
under this Policy.
POL.1.09. FL.KA
• Share, transfer or lease its right to access and use systems, to any other person or entity which is
not a party to this Policy.
The Enrolling Group may designate any third party to access systems on its behalf, provided the third
party agrees to these terms and conditions of systems access and the Enrolling Group assumes joint
responsibility for such access.
Security Procedures
The Enrolling Group will use commercially reasonable physical and software -based measures, and
comply with our security procedures, as may be amended from time to time, to protect the system, its
functionalities, and data accessed through systems from any unauthorized access or damage (including
damage caused by computer viruses). The Enrolling Group will notify us immediately if any breach of the
security procedures, such as unauthorized use, is suspected.
System Access Termination
We reserve the right to terminate the Enrolling Group's system access:
On the date the Enrolling Group fails to accept the hardware, software and browser requirements
provided by us, including any amendments to the requirements.
Immediately on the date we reasonably determine that the Enrolling Group has breached, or
allowed a breach of, any applicable provision of this Policy. Upon termination of this Policy, the
Enrolling Group agrees to cease all use of systems; and we will deactivate the Enrolling Group's
identification numbers and passwords and access to the system.
PO L. I.09. FL. KA 8
Exhibit 1
Parties. The parties to this Policy are UnitedNealthcare Insurance Company and
, the Enrolling Group.
'Insert month, day and year.
Effective Date of this Policy. The effective date of this Policy is 12:01 a.m. on
in the time zone of the Enrolling Group's location.
'include For ERISA groups.
2lnclude for non-ERISA groups.
Place of Issuance. We are delivering this Policy in the State of Florida. ['This Policy is governed
by ERISA. To the extent that state law applies, the laws of the State of Florida are the laws that
govern this Policy.) [ZThe laws of the State of Florida are the laws that govern this Policy.]
'Include when premiums are specified in the Cost Summary.
2lnclude when the group has more than 1 class
3Select the appropriate length of time for prior written notice, based on group requirement.
4. Premiums. We reserve the right to change the Schedule of Premium Rates ['or Cost Summary]
specified in [teach] Exhibit 2, after a [331 - 120]-day prior written notice on the first anniversary of
the effective date of this Policy specified in the application or on any monthly due date thereafter, or
on any date the provisions of this Policy are amended. We also reserve the right to change the
Schedule of Premium Rates, retroactive to the effective date, if a Material Misrepresentation
relating to health status has resulted in a lower schedule of rates.
'Select the paragraph that describes the applicable computation of the Policy Charge.
5. Computation of Policy Charge. ['A full calendar month's Premiums will be charged for Covered
Persons whose effective date of coverage falls on or before the 15th of that calendar month. No
Premiums will be charged for Covered Persons whose effective date of coverage falls after the
15th of that calendar month. A full calendar month's Premiums will be charged for Covered
Persons whose coverage is terminated after the 15th of that calendar month. No Premiums will be
charged for Covered Persons whose coverage is terminated on or before the 15th of that calendar
month.]
['A pro rata Premium, calculated on the number of days Covered Persons are actually covered
under this Policy, will be charged for Covered Persons whose effective date of coverage falls on a
date other than the first of the month or for Covered Persons whose coverage is terminated on a
date other than the first of the month.]
['A full month's Premium will be charged for any Covered Person who is covered under this Policy
for any portion of a calendar month.]
'Select appropriate payment basis.
S. Payment of the Policy Charge. The Policy Charge is payable to us in advance by the Enrolling
Group on a ['monthly] ['quarterly] ['semi-annual] ['annual] basis
NOTE: At least one of the minimum requirements below will always apply. For CatalystlCatalyst Choice,
include alternate #7 with combined participation and contribution requirement provision when 100%
participation and contribution requirement applies and delete both separate requirement statements #7
and #8. When 100% combined participation and contribution requirements do not apply to
Catalyst/Catalyst Choice, use separate options #7 and 8 below.
Include combined minimum participation and contribution requirement when the policy is issued for-
Catalyst/Catalyst Choice and when 100% participation and contribution requirement applies.
[7.] [Minimum Participation and Contribution Requirements - [Catalyst] [Catalyst Choice]]
POL.1.09.FL.KA
[Participation in the [Catalyst] [Catalyst Choice] underlying medical plan is 100% of Eligible
Persons after waivers for creditable coverage, with a minimum of 50% of all Eligible Persons before
waivers.
The Enrolling Group contributes 100% of employee -only rate.
Participation and contribution requirements do not apply to optional coverage provided under the
[Catalyst] [Catalyst Choice] Rider.]
Include #7 and #8 below with aH products except when Catalyst/Catalyst Choice is sold (as defined
above).
'Select if a minimum participation requirement is applicable to this group. Minimum participation
requirements are set by us.
2Select if a minimum participation requirement is not applicable to this group.
Select only one option, either number or percentage, but not both.
"Select if number applies.
4Select if percentage applies.
[7.] [Minimum Participation Requirement.] d The minimum participation requirement for the Enrolling
Group is [" [51 - 101] Eligible Persons.] [ [0 - 1001% of Eligible Persons excluding spousal waivers
but no less than 50% of all Eligible Persons must be enrolled for coverage under this policy.][2The
Minimum Participation Requirement does not apply.]
'Select if a minimum contribution requirement is applicable to this group. Minimum, contribution
requirements are set by us.
2Select if a minimum contribution requirement is not applicable to this group.
"Enter the applicable percentage.
[8.] [Minimum Contribution Requirement.] ['The Enrolling Group must maintain a minimum
contribution requirement of 10 - 100]% of the Premium for each Eligible Person.][2The Minimum
Contribution Requirement does not apply.]
[9.] Notice. Any notice sent to us under this Policy must be addressed to:
(Name of Issuing Entity)
(Address)
(City. State, Zip)
Any notice sent to the Enrolling Group under this Policy must be addressed to:
(Enrolling Group)
(Address)
(City, State, Zip)
[10]. [_ Enrolling Group Number]
POL. I.09. FL. KA 10
'Include when more than one class of Eligible Persons is covered.
2Choose the applicable class number
Exhibit 2 ['Class [21-1011
3Include when the group has more than 1 class
[3The provisions included in this Exhibit are applicable only to the class of Eligible Persons described
below.]
'Enter when class description is entered directly in Exhibit 2.
2Enter when class description is included by reference to Application.
"Enter applicable class description.
1. Class Description.
`["All full-time employees.] 2[See Application.]
Insert eligibility conditions in A and B below. If there are no specific eligibility conditions that apply, the
default will show "none."
'Include when more than one class of Eligible Persons is covered.
2. Eligibility. The eligibility rules are established by the Enrolling Group. The following eligibility rules
are in addition to the eligibility rules specified in the Employer Application and/or in Section 3:
When Coverage Begins of the Certificate of Coverage [`applicable to this class]:
A. The waiting or probationary period for newly Eligible Persons is as follows:
]
B. Other:
Include Open Enrollment Period unless a group chooses a closed plan.
'Include this text if Open Enrollment Period applies to this class.
2Enter the applicable number of days in the Open Enrollment Period.
3Select the appropriate frequency of the open enrollment for this class.
4Include this text if Open Enrollment Period does not apply to this class.
[3]. [Open Enrollment Period. ['An Open Enrollment Period of at least [230 - 60] days will be provided
by the Enrolling Group during which Eligible Persons may enroll for coverage. The Open
Enrollment Period will be provided on [3anannual basis] [3a quarterly basis]
[3 l.j[4No Open Enrollment Period applies to this class.]]
' Enter effective date of coverage.
2 Select the applicable alternative.
[4]. Effective Date for Eligible Persons. The effective date of coverage for Eligible Persons who are
eligible on the effective date of this Policy is [' 1.
For an Eligible Person who becomes eligible after the effective date of this Policy, his or her
effective date of coverage is [2the day following the last day of the required waiting period.] [2the
first day of the month following the last day of the required waiting period.] [2the date the Eligible
Person joins the Enrolling Group.] [2the first day of the month following the date the Eligible Person
joins the Enrolling Group.][2as determined by the Enrolling Group,
'insert when rates are shown in Exhibit 2.
POL.1.09.FL.KA 12
PO L. I.09. F L. KA 11
POL l.09.PL.KA 14
2Insert effective date.
Insert When rates are issued via the Cost Summary.
[5]. Schedule of Premium Rates.
['The Schedule of Premium Rates payable by or on behalf of this class of Covered Persons as of
[2 ] is shown below'.
[Coverage Classification
Subscriber Only
Subscriber and Spouse
Subscriber plus one Child
Subscriber plus Family
Monthly Premium
$XXX.XX
$XXX.XX
$XXX.XX
$XXX.XX]
Changes to this Schedule of Premium Rates and/or subsequent Schedules of Premium Rates will
be attached to this Policy by means of a Notice of Change to Exhibit 2.1
[3Monthiy Premiums payable by or on behalf of Covered Persons are specified in the Cost
Summary]
POL.1.09.FL.KA 13
EXHIBIT VI
UnitedHealthcare [Choice Plus]
United HealthCare Insurance Company
Schedule of Benefits
Accessing Benefits
'Include here and in the header for the Schedule of Benefits table if the plan design provides Designated
Network Benefits in any benefit category.
You can choose to receive ['Designated Network Benefits,] Network Benefits or Non -Network Benefits.
['Designated Network Benefits apply to Covered Health Services that are provided by a Network
Physician or other provider that we have identified as a Designated Facility or Physician. Designated
Network Benefits are available only for specific Covered Health Services as identified in the Schedule of
Benefits table below.]
'Include and delete #2 if RAPLs are paid under the facility charge.
'include and delete #1if RAPLs are paid under the physician fee (inpatient/outpatient) category.
['Network Benefits apply to Covered Health Services that are provided by a Network Physician or other
Network provider. For facility services, these are Benefits for Covered Health Services that are provided
at a Network facility under the direction of either a Network or non -Network Physician or other provider.
Network Benefits include Physician services provided in a Network facility by a Network or a non -Network
anesthesiologist, Emergency room Physician, consulting Physician, pathologist and radiologist.
Emergency Health Services are always paid as Network Benefits.]
[2Network Benefits apply to Covered Health Services that are provided by a Network Physician or other
Network provider. For facility services, these are Benefits for Covered Health Services that are provided
at a Network facility. Emergency Health Services, including the services of either a Network or non -
Network Emergency room Physician, are always paid as Network Benefits.]
Non -Network Benefits apply to Covered Health Services that are provided by a non -Network Physician
or other non -Network provider, or Covered Health Services that are provided at a non -Network facility.
Include when Tiered Conditional Benefits program is sold.
[You may have an opportunity to elect to receive Covered Health Services from certain Network providers
that we've identified as Designated Physicians or Designated Facilities. When you choose to seek care
from certain Designated providers, the level of Benefits available to you is enhanced. You can determine
the specific situations for which enhanced Benefits are available by going to www.myuhc.com or by
calling Customer Care at the telephone number on your ID card.]
'Always include unless the Shared Savings Program does not apply to Benefits under this CCC. "Shared
Savings Program" is bracketed to accommodate possible name change.
Depending on the geographic area and the service you receive, you may have access ['through our
[Shared Savings Program]] to non -Network providers who have agreed to discount their charges for
Covered Health Services. If you receive Covered Health Services from these providers, the Coinsurance
will remain the same as it is when you receive Covered Health Services from non -Network providers who
have not agreed to discount their charges; however, the total that you owe may be less ['when you
receive Covered Health Services from [Shared Savings Program] providers than from other non -Network
providers] because the Eligible Expense may be a lesser amount.
SBN.CHP1.1.07.F1_.KA Rev3 [1]
You must show your identification card (ID card) every time you request health care services from a
Network provider. if you do not show your ID card, Network providers have no way of knowing that you
are enrolled under a [UnitedHealthcare] Policy. As a result, they may bill you for the entire cost of the
services you receive.
If there is a conflict between this Schedule of Benefits and any summaries provided to you by the
Enrolling Group, this Schedule of Benefits will control.
Additional information about the network of providers and how your Benefits may be affected
appears at the end of this Schedule of Benefits.
Pre -service Benefit Confirmation
We require notification before you receive certain Covered Health Services. in general, Network providers
are responsible for notifying us before they provide these services to you. There are some Network
Benefits, however, for which you are responsible for notifying us. Services for which you must provide
pre -service notification are identified below and in the Schedule of Benefits table within each Covered
Health Service category.
When you choose to receive certain Covered Health Services from non -Network providers, you
are responsible for notifying us before you receive these services.
To notify us, call the telephone number for Customer Care on your ID card.
Covered Health Services which require pre -service notification:
Ambulance - non -emergent air and ground.
Include when group purchases benefits for clinical trials.
• [Clinical trials.]
Include when group purchases benefits for congenital heart disease surgery.
* [Congenital heart disease surgery.]
Include when group purchases benefits for accident -related dental services.
[Dental services - accidental.]
Include when group does not purchase benefits for durable medical equipment.' Include if notification
applies only to insulin pumps that exceed a specific dollar amount and insert appropriate dollar amount.
[Diabetes equipment - insulin pumps ['over $[1,000 - 5,000]].1
Include when group purchases benefits for DME. 'Include if notification applies only to DME that exceeds
a specific dollar amount and insert appropriate dollar amount
[Durable Medical Equipment ['over $[1,000 - 5.000]].1
Include when notification is required for home health care.
[Home health care.]
Include when notification is required for hospice care.
[Hospice care - inpatient.]
'Include when full maternity benefits are sold.
sold.
`Include when complications of pregnancy benefits are
Hospital inpatient care - all scheduled admissions ['and maternity stays exceeding 48 hours for
normal vaginal delivery or 96 hours for a cesarean section delivery] [land stays for Complications
Of Pregnancy exceeding 96 hours for a cesarean section delivery].
Include when group purchases benefits for infertility services.
SBN.CHP1.1.07.FL.KA Rev3 [2]
• [Infertility services.]
include when notification is required for Lab/X-ray.
• [Lab, X-ray and diagnostics - sleep studies.]
Include when notification is required for Lab/X-ray-Major Diagnostics.
[Lab, X-ray and major diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine.]
Include when group purchases benefits for obesity surgery.
• [Obesity surgery.]
Include when notification is required for Pharmaceutical Products.
[Pharmaceutical Products - IV infusions only.]
Include when group purchases benefits for prosthetics. 'Include if notification applies only to prosthetics
that exceed a specific dollar amount and insert appropriate dollar amount
• [Prosthetic devices ['over $[1,000 - 5,000]1.]
'Include when group purchases benefits for breast reduction surgery.
• Reconstructive procedures [', including breast reduction surgery].
Include when group purchases benefits for rehabilitation services and when notification is required for any
service. Chiropractic Treatment must be included like any other service - not opiional. include in fist if all
services require notification.
[Rehabilitation services and Chiropractic Treatment - [physical therapy] [,] [and] [occupational
therapy] [,] [and] ['Chiropractic Treatment] [ J [and] [speech therapy] [,] [and) [pulmonary
rehabilitation therapy] [,] [and) [cardiac rehabilitation therapy] [,J [and] [past -cochlear implant aural
therapy] [,J [and] [vision therapy].]
Include when notification is required for scopic procedures.
• [Scopic procedures - outpatient diagnostic and therapeutic.)
• Skilled Nursing Facility and Inpatient Rehabilitation Facility services.
Include when notification is required for outpatient surgeries.
• [Surgery - [all outpatient surgeries] [only for the following outpatient surgeries: [blepharoplasty] [,]
[and] [cardiac catheterization] [,) [and] [cochlear implants] [,J [and] [uvulopalatopharyngoplasty] [,J
[and] [pacemaker insertion] [,) [and] [pain management procedures] [,] [and] [vein procedures] [,J
[and] [spine surgery] [,] [and] [total joint replacements] [,] [and] [implantable cardioverter
defibrillators]].]
Include when group purchases benefits for TMJ services and notification is required.
[Temporomandibular joint services.)
Include when notification is required for outpatient therapeutics.
• [Therapeutics - [all outpatient therapeutics] [only for the following services: [dialysis] [,] [and]
[chemotherapy] [,] [and] [IV infusion] [,) [and] [radiation oncology] [,) [and] hyperbaric oxygen
therapy].]
• Transplants.
Include paragraphs below if pre -service benefit notification includes determining alternate levels of
benefits.
'Include if Mental Health Benefits are sold.
SBN.CHP1.i.07,FL.KA Rev3 [3]
`Include if Mental Health Benefits are not sold.
[As we determine, if one or more alternative health services that meets the definition of a Covered Health
Service in the Certificate of Coverage under Section 9: Defined Terms are clinically appropriate and
equally effective for prevention, diagnosis or treatment of a Sickness, Injury, ['Mental Illness,] [2mental
illness,] substance abuse or their symptoms, we reserve the right to adjust Eligible Expenses for identified
Covered Health Services based on defined clinical protocols. Defined clinical protocols shall be based
upon nationally recognized scientific evidence and prevailing medical standards and analysis of cost-
effectiveness. After you contact us for pre -service Benefit confirmation, we will identify the Benefit level
available to you.
The process and procedures used to define clinical protocols and cost-effectiveness of a health service
and a listing of services subject to these provisions (as revised from time to time), are available to
Covered Persons on www.myuhc.com or by calling Customer Care at the telephone number on your ID
card, and to Physicians and other health care professionals on UnitedHealthcareOnline.]
For all other services, when you choose to receive services from non -Network providers, we urge you to
confirm with us that the services you plan to receive are Covered Health Services. That's because in
some instances, certain procedures may not meet the definition of a Covered Health Service and
therefore are excluded. In other instances, the same procedure may meet the definition of Covered
Health Services. By calling before you receive treatment, you can check to see if the service is subject to
limitations or exclusions.
If you request a coverage determination at the time notice is provided, the determination will be made
based on the services you report you will be receiving. If the reported services differ from those actually
received, our final coverage determination will be modified to account for those differences, and we will
only pay Benefits based on the services actually delivered to you.
Include when group purchases benefits for mental health/substance abuse services and when prior
authorization applies to any MH/SA benefit purchased.
[Mental Health and Substance Abuse Services]
[Mental Health and Substance Abuse Services are not subject to the pre -service notification requirements
described above. Instead, you must obtain prior authorization from the Mental Health/Substance Abuse
Designee before you receive Mental Health Services and Substance Abuse Services. You can contact
the Mental Health/Substance Abuse Designee at the telephone number on your ID card.]
Care Coordinationsm
When we are notified as required, we will work with you to implement the Care Coordinations"' process
and to provide you with information about additional services that are available to you, such as disease
management programs, health education, and patient advocacy.
Special Note Regarding Medicare
If you are enrolled in Medicare on a primary basis (Medicare pays before we pay Benefits under the
Policy), the notification requirements described below do not apply to you. Since Medicare is the primary
payer, we will pay as secondary payer as described in Section 7: Coordination of Benefits. You are not
required to notify us before receiving Covered Health Services.
Benefits
Annual Deductibles are calculated on a [calendar] [Policy] year basis.
Out -of -Pocket Maximums are calculated on a [calendar] [Policy] year basis.
Include only when an Annual Maximum Benefit applies.
[The Annual Maximum Benefit is calculated on a [calendar] [Policy] year basis.]
SBN.CHP1.1.07.Ft_.KA Rev3 [4]
'Include here and in the header for the Schedule of Benefits table if the plan design provides Designated
Network Benefits in any benefit category.
When Benefit limits apply, the limit stated refers to any combination of ['Designated Network Benefits.]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit limits are calculated on a [calendar] [Policy] year basis unless otherwise specifically stated.
Payment Term And Description
Amounts
Annual Deductible
'Include when the Annual Deductible applies only to Non-
'Include separate Network and Non -
Network Benefits.
Network headings and statements
`Include when an Outpatient Prescription Drug Rider is sold
when Annual Deductible provision
applies separately to Network and Non-
and the Annual Deductible applies to any combination of
Network Benefits and delete the
medical and RX benefits.
combined Network and Non -Network'
3Include when there is a deductible for Designated and
provision below.
Network Benefits and the network and non -network amounts
?include when Designated Network
apply to the Designated Network and Network Annual
Benefits apply to any category.
Deductible.4Include bracketed Designated Network reference
when Designated Network Benefits apply to any category.
r f Designated Network and]
The amount of Eligible Expenses you pay for Covered Health
Network]
Services per year before you are eligible to receive ['Non-
include when separate individual and
Network] Benefits. [2The Annual Deductible applies to Covered
family deductibles apply (non -
Health Services under the Policy as indicated in this Schedule
embedded).
of Benefits, including Covered Health Services provided under
[For single coverage, the Annual
the Outpatient Prescription Drug Rider.] ['The Annual
Deductible is $[0-15,000) per Covered
Deductible for ["Designated Network and] Network Benefits
Person.
includes the amount you pay for both Network and Non -
Network Benefits for outpatient prescription drug products
If more than one person in a family is
provided under the Outpatient Prescription Drug Rider.]
covered under the Policy, the single
include when day/visit limits are reduced by the number of
coverage Annual Deductible stated
above does not apply. For family
days/visit used toward meeting the deductible.
coverage, the family Annual Deductible
[Amounts paid toward the Annual Deductible for Covered
is $[0 - 45,000], No one in the family is
Health Services that are subject to a visit or day limit will also
eligible to receive Benefits until the
be calculated against that maximum Benefit limit. As a result,
family Annual Deductible is satisfied.]
the limited Benefit will be reduced by the number of days/visits
Include when individual deductible
used toward meeting the Annual Deductible.]
applies (embedded).
Include when dollar limits are reduced by the amount used
[$[0-15,000] per Covered Person.]
toward meeting the deductible.
[Amounts paid toward the Annual Deductible for Covered
Include when individual (with family
maximum) deductible applies
Health Services that are subject to a dollar limit will also be
(embedded).
calculated against that maximum Benefit limit. As a result, the
limited Benefit will be reduced by the amount used toward
[$[0 - 15,000] per Covered Person, not
meeting the Annual Deductible.]
to exceed $[0 - 45,000] for all Covered
'include when the carry-over provision applies.
Persons in a family.]
['Any amount you pay for medical expenses in the last three
include when there is no annual
deductible for network benefits.
months of the previous year that is applied to the previous
Annual Deductible will be carried over and applied to the
[No Annual Deductible.]
current Annual Deductible. This carry-over feature applies only
,
[ Non -Network]
SBN.CHP1.1.07.FL.KA Rev3 [5]
to the individual Annual Deductible.] —
Include when separate individual and
family deductibles apply (11017-
'Include paragraph if the roll-over provision applies to a group
embedded).
in any circumstance.
[For single coverage, the Annual
rWhen a covered Person was previously covered under a
Deductible is $[0 - 15,0001 per Covered
group policy that was replaced by the group Policy, any
Person.
amount already applied to that annual deductible provision of
the prior policy will apply to the Annual Deductible provision
If more than one person in a family is
under the Policy.]
covered under the Policy, the single
coverage Annual Deductible stated
7 Include paragraph it the roll-over provision applies to a group
81riclude
above does not apply. For family
changing froma calendar year to Policy year plan.
coverage, the family Annual Deductible
when this applies only to the individual deductible.
is $[0 - 45,0001. No one in the family is
[When the Enrolling Group changes from a calendar year to a
in
eligible to receive Benefits until the
family Annual Deductible is satisfied.]
Policy year plan, any amount you pay for medical expenses
the last three months of the previous calendar year that is
Include when individual deductible
applied to the previous Annual Deductible, will be rolled over
applies (embedded).
and applied to the current Policy year Annual Deductible. This
roll-over feature applies only to the first Policy year. ("This roll-
[$[0 - 15,000] per Covered Person.]
over feature applies only to the individual Annual Deductible.]]
Include when individual (with family
The amount that is applied to the Annual Deductible is
maximum) deductible applies
calculated on the basis of Eligible Expenses. The Annual
(embedded).
Deductible does not include any amount that exceeds Eligible
[$[0 -15,0001 per Covered Person, not
Expenses. Details about the way in which Eligible Expenses
to exceed $[0 - 45,000] for all Covered
are determined appear at the end of the Schedule of Benefits
Persons in a family.]
table.
Include when there is no annual
Include only when a per occurrence deductible applies.
deductible for network benefits.
[The Annual Deductible does not include any applicable Per
[No Annual Deductible.]
Occurrence Deductible.]
'Include the combined Network and
Non -Network heading and statements
when Annual Deductible provision
applies separately to combined Network
and Non -Network Benefits and delete
the separate "Network" and "Non -
Network" provisions above.
2 Include when Designated Network
Benefits apply to any category.
Pf Designated Network,] Network
and Non -Network]
Include when separate individual and
family deductibles apply (non -
embedded).
[For single coverage, the Annual
Deductible is $[0 - 15,0001 per Covered
Person.
If more than one person in a family is
covered Linder the Policy, the single
coverage Annual Deductible stated
above does not apply. For family
coverage, the family Annual Deductible
SBN.CHPI.1,07.FL.KA Rev3 [6]
is $[0 - 45,000]. No one in the family is
eligible to receive Benefits until the
family Annual Deductible is satisfied.]
Include when individual deductible
applies (embedded).
[$[0-15,0001 per Covered Person.]
include when individual (with family
maximum) deductible applies
(embedded).
[$[0-15,000] per Covered Person, not
to exceed $[0 - 45,0001 for all Covered
Persons in a family.]
Include only when a per occurrence deductible applies.
[Per Occurrence Deductible]
[The amount of Eligible Expenses stated as a set dollar
'include when Designated Network
amount that you must pay for certain Covered Health Services
Benefits apply to either category.
(prior to and in addition to any Annual Deductible) before we
[['Designated Network and] Network]
will begin paying for Benefits for those Covered Health
Services.
Include when a per occurrence
You are responsible for paying the lesser of the fallowing:
deductible applies to CHD surgerybenefits,
• The applicable Per Occurrence Deductible.
(CHD surgery - Inpatient Stay: [$100 -
• The Eligible Expense.]
1,000) per day.]
[CHD surgery - Inpatient Stay: [$100 -
2,000] per Inpatient Stay.]
Include when a per occurrence
deductible applies to inpatient hospital
benefits.
[Hospital - Inpatient Stay: [$100 - 1,0001
per day.]
[Hospital - Inpatient Stay: [$100 - 2,0001
per Inpatient Stay.]
include when a per occurrence
deductible applies to outpatient surgery
benefits.
[Surgery - Outpatient: [$10 - 1,000] per
date of service.]
include when a per occurrence
deductible applies to inpatient
transplant benefits.
[Transplant - Inpatient Stay: [$100 -
1,000] per day.]
[Transplant - Inpatient Stay: [$100 -
2,000] per Inpatient Stay.]
[Nan -Network]
SBN.CHP1.1.07.FL.KA Rev3 [7]
Include when a per occurrence
deductible applies to CHD surgery
benefits.
[CHID surgery - Inpatient Stay: [$100 -
1,000] per day.]
[CHD surgery - Inpatient Stay: [$100 -
2,00Q] per Inpatient Stay.]
Include when a per occurrence
deductible applies to inpatient hospital
benefits.
[Hospital - Inpatient Stay:. [$100-1,000]
per day.]
[Hospital - Inpatient Stay: [$100 - 2,0001
per Inpatient Stay.]
Include when a per occurrence
deductible applies to outpatient surgery
benefits.
[Surgery - Outpatient: [$50 - 800] per
date of service.]
Include when a per occurrence
deductible applies to inpatient
transplant benefits.
[Transplant - Inpatient Stay: [$100 -
1,000] per day.]
[Transplant - Inpatient Stay: [$100 -
2,000] per Inpatient Stay.]
Out -of -Pocket Maximum
SBN.CHP1.1.07.FL.KA Rev3 [8]
'Include when OOPM includes the Annual Deductible.
'include separate Network and Non-
2 Include when OOPM includes the Per Occurrence Deductible.
Network headings and statements
when OOPM provision applies
Include when OOPM includes Copayments.
separately to Network and Non -Network
Include when an Outpatient Prescription Drug Rider is said
Benefits and delete the combined
^Network and Non -Network" provision
and the OOPM applies to any combination of medical and RX
below.
benefits.
''Include when there is an OOPM for Designated and Network
Include when Designated Network
Benefits apply to any category.
Benefit and the network and non -network amounts paid under
the RX rider apply to the Designated Network and Network
ffDesignated Network and]
OOPM.
Network]
Glnclude bracketed Designated Network reference when
Include when separate individual and
Designated Network Benefits apply to any category.
family maximums apply (non -
The maximum you pay per year for ['the Annual Deductible,]
embedded).
['the Per Occurrence Deductible,] [3Copayments] [1,2,3or]
[For single coverage, the Out -of -Packet
Coinsurance. Once you reach the Out -of -Pocket Maximum,
Maximum is $[0 - 45,000] per Covered
Benefits are payable at 100% of Eligible Expenses during the
Person.
rest of that year. [``The Out -of -Pocket Maximum applies to
If more than one person in a family is
Covered Health Services under the Policy as indicated in this
covered under the Policy, the single
Schedule of Benefits, including Covered Health Services
under the Outpatient Prescription Drug Rider.] [ The
coverage Out -of -Pocket Maximum
Out -of -Pocket Maximum for [Designated Network and]
For f
stated above does not apply. For family
t apply.
Network Benefits includes the amount you pay for both
ut of -
coverage, the family Out-of-Pocket
Maximum t f - family
Network and Non -Network Benefits for outpatient prescription
drug products provided under the Outpatient Prescription Drug
Include when individual OOPM applies
Rider.]
(embedded).
7Include only when the plan design does not apply all
[$[0 - 45,000] per Covered Person.]
Copayments and coinsurance to the OOPM.
Include when individual (with family
[`Copayments and Coinsurance for some Covered Health
maximum) applies (embedded).
Services will never apply to the Out -of -Pocket Maximum and
[$[0 - 45,000] per Covered Person, not
those Benefits will never be payable at 100% even when the
to exceed $[0-135,000] for all Covered
Out -of -Pocket Maximum is reached.] Details about the way in
persons in a family.]
which Eligible Expenses are determined appear at the end of
the Schedule of Benefits table.
Include when the OOPM includes the
The Out -of -Pocket Maximum does not include any of the
Annual Deductible.
following and, once the Out -of -Pocket Maximum has been
[The Out -of -Pocket Maximum includes
reached, you still will be required to pay the following:
the Annual Deductible.]
• Any charges for non -Covered Health Services.
Include when the OOPM does not
Include bullet if notification requirements apply to any benefit
include the Annual Deductible.
category in the Schedule of Benefits table and if the plan
[The Out -of -Pocket Maximum does not
design supports not applying penalties to the OOPM.
include the Annual Deductible.]
[The amount Benefits are reduced if you do not notify us Include when the OOPM includes the
as required.] I Per Occurrence Deductible.
Charges that exceed Eligible Expenses. [The Out -of -Pocket Maximum includes
Copayments or Coinsurance for any Covered Health the Per Occurrence Deductible.]
Service identified in the Schedule of Benefits table that Include when the OOPM does not
does not apply to the Out -of -Pocket Maximum. ( include the Per Occurrence Deductible.
Include bullet when an
SBN.CHP1.1.07.FL.KA Rev3
Rider is I [The Out -of -Pocket Maximum does not
N
sold and copaymentslcoinsurance do not apply to the overall
include the Per Occurrence Deductible.]
OOPM.
include when there is no OOPM.
[Copayments or Coinsurance for Covered Health
[No Out -of -Pocket Maximum.]
Services provided under the Outpatient Prescription
(Non -Network]
Drug Rider.]
Include when separate individual and
family maximums apply (non -
embedded).
[For single coverage, the Out -of -Pocket
Maximum is $[0 - 45,0001 per Covered
Person
If more than one person in a family is
covered under the Policy, the single
coverage Out -of -Pocket Maximum
stated above does not apply. For family
coverage, the family Out -of -Pocket
Maximum is $[0-135,0001.1
Include when individual OOPM applies
(embedded).
[$[0 - 45,000] per Covered Person.]
Include when individual (with family
maximum) applies (embedded).
[$[0 - 45,0001 per Covered Person, riot
to exceed $[0-135,000] for all Covered
Persons in a family.]
Include when the OOPM includes the
Annual Deductible.
[The Out -of -Pocket Maximum includes
the Annual Deductible.]
Include when the OOPM does not
include the Annual Deductible,
[The Out -of -Pocket Maximum does not
include the Annual Deductible.]
Include when the OOPM includes the
Per Occurrence Deductible.
[The Out -of -Pocket Maximum includes
the Per Occurrence Deductible.]
Include when the OOPM does not
include the Per Occurrence Deductible.
[The Out -of -Pocket Maximum does not
include the Per Occurrence Deductible.]
Include when there is no OOPM.
[No Out -of -Pocket Maximum.]
3Include combined Network and Non-
Netwnrk heading and statements below
SBN.CHP1.1.07.FL.KA Rev3 [10]
when OOPM provision applies to
combined Network and Non -Network
Benefits and delete the separate
"Network" and "Non -Network"
provisions above.
`Include when Designated Network
Benefits apply to any category.
Pf Designated Network,] Network
and Non -Network]
Include when separate individual and
family maximums apply (non -
embedded).
[For single coverage, the Out -of -Pocket
Maximum is $[0 - 45,000] per Covered
Person.
If more than one person in a family is
covered under the Policy, the single
coverage Out -of -Pocket Maximum
stated above does not apply. For family
coverage, the family Out -of -Pocket
Maximum is $[0 - 135,000].]
Include when individual OOPM applies
(embedded).
[$[0 - 45,000] per Covered Person.]
Include when individual (with family
maximum) applies (embedded).
[$[0 - 45,000) per Covered Person, not
to exceed $[0-135,0001 for all Covered
Persons in a family.]
Include when the OOPM includes the
Annual Deductible.
[The Out -of -Pocket Maximum includes
the Annual Deductible]
Include when the OOPM does not
include the Annual Deductible.
[The Out -of -Pocket Maximum does not
include the Annual Deductible.]
Include when the OOPM includes the
Per Occurrence Deductible.
[The Out -of -Pocket Maximum includes
the Per Occurrence Deductible.]
Include when the OOPM does not
include the Per Occurrence Deductible,
[The Out -of -Pocket Maximum does not
include the Per Occurrence Deductible.]
SBN.CHP1.1.07.FL.KA Rev3 [11)
Include when there is no OOPM.
[No Out -of -Pocket Maximum.]
Maximum Policy Benefit
The maximum amount we will pay for Benefits during theentire'Include
when separate Network and
period of time you are enrolled under the Policy.
Non -Network Maximums apply.
Include when Designated Network
Benefits apply to any category.
ff Designated Network and]
Network]
[$[1,000,000 - 10,000,000] per Covered
Person.]
[No Maximum Policy Benefit.]
tNon-Network]
[$[1,000,000 - 10,000,000] per Covered
Person.]
[No Maximum Policy Benefit.]
3 include when combined Network and
Non -Network Maximums applies,
rfDesignated Network,) Network
and Non -Network]
[$[1,000,000 - 10,000,000] per Covered
Person,]
Include only when an annual maximum benefit applies.
[Annual Maximum Benefit]
SBN.CHP1.1.07.FL.KA Rev3 [12]
[The maximum amount we will pay for Benefits during the
'Include when separate Network and
year.]
Non -Network Maximums apply
2include when Designated Network
Benefits apply to any category.
(' j2Designated Network and]
Network]
[$[2,000 - 500,0001 per Covered
Person.]
r Non -Network]
[$[2,000 - 500,0001 per Covered
Person.]
31nclude when combined Network and
Non -Network Maximums applies.
f (Designated Network,] Network
and Non -Network]
[$[2,000 - 500,0001 per Covered
Person.]
Copayment
Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain
Covered Health Services. When Copayments apply, the amount is listed on the following pages next to
the description for each Covered Health Service.
Please note that for Covered Health Services, you are responsible for paying the lesser of:
• The applicable Copayment.
• The Eligible Expense.
Details about the way in which Eligible Expenses are determined appear at the end of the Schedule of
Benefits table.
Coinsurance
Coinsurance is the amount you pay (calculated as a percentage of Eligible Expenses) each time you
receive certain Covered Health Services.
Details about the way in which Eligible Expenses are determined appear at the end of the Schedule of
Benefits table.
Benefit Limits
This Benefit plan does not have Benefit limits in addition to those stated below within the Covered Health
Service categories in the Schedule of Benefits table.
SBN.CHP1.1.07.FL.KA Rev3 [13]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,j
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include for groups that purchase
benefits for acupuncture services.
1. [Acupuncture Services]
Include the limit selected by the group.
[Network]
[Limited to [10 - 100] visits per year.]
[[50 - 1001%]
[Yes] [No]
[Yes] [No]
[Limited to [10 - 1001 visits per year.
[100% after you pay
not to exceed $[100 - 5,000] in Eligible
a Copayment of $[5 -
Expenses per year.]
75] per visit]
[Limited to $(100 - $5,000) in Eligible
Expenses per year.]
[Non -Network]
[[50-100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[5 -
75] per visit]
[2.] Ambulance Services
Pre -service Notification Requirement
In most cases, we will initiate and direct non -Emergency ambulance transportation. If you are requesting
non -Emergency ambulance services, you must notify us as soon as possible prior to transport. if you fail
to notify us as required, you will be responsible for paying all charges and no Benefits will be paid.
Emergency Ambulance
Network
Transportation costs of a newborn to
Ground Ambulance:
[Yes] [No]
[Yes] [No]
the nearest appropriate facility for
[[50 - 100)%]
treatment are covered up to $1,000 per
transport,
[100% after you pay
a Copayment of $[25
- 3001 per transport]
[100% after you pay
a Copayment of
$[300-1,000] per
day]
Air Ambulance:
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $ 25
SBN.CHP1.I.07.FL.KA Rev3 [14]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
- 2,5001 per transport]
[100% after you pay
a Copayment of
$[2,500-10,000] per
day]
Non -Network
Same as Network
Same as Network
Same as Network
Non -Emergency Ambulance
Network
Ground or air ambulance, as we
Ground Ambulance:
[Yes] [No]
[Yes] [No]
determine appropriate. Transportation
[[50 - 100]%]
costs of a newborn to the nearest
appropriate facility for treatment are
[100% after you pay
covered up to $1,000 per transport.
a Copayment of $[25
- 300] per transport]
[100% after you pay
a Copayment of
$[300 - 1,0001 per
day]
Air Ambulance:
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[25
- 2,500] per transport]
[100% after you pay
a Copayment of
$[2,500 - 10,000) per
day]
Non -Network
Same as Network
Same as Network
Same as Network
Include for groups that purchase
benefits for clinical trials.
[3.] [Clinical Trials]
[Pre -service Notification Requirement]
[You must notify us as soon as the possibility of participation in a clinical trial arises. If you don't notify us,
you will be responsible for paying all charges and no Benefits will be paid.]
[Depending upon the Covered Health
[Network]
Service, Benefit limits are the same as
[Dependingu on where the Covered Health Service is
SBN.CHP1.1.07.FL.KA Rev3 [15]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Covered Health Service
Pay, based on
Eligible Expenses)
taut -of -Packet
Maximum?
Annual
Deductible?
those stated under the specific Benefit
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
category in this Schedule of Benefits.
Benefits are available when the
[Non -Network]
Covered Health Services are provided
[Depending upon where the Covered Health Service is
by either Network or non -Network
provided, Benefits will be the same as those stated under each
providers.]
Covered Health Service category in this Schedule of Benefits.]
..............
Include for groups that purchase
benefits for congenital heart disease
services.
[4.1 [Congenital Heart Disease
Surgeries]
Include if pre -service notification is required.
[Pre -service Notification Requirement]
[For Designated Network Benefits you must notify us as soon as the possibility of a Congenital Heart
Disease (CHD) surgery arises. If you do not notify us and if, as a result, the CHD services are not
Network Facility, Designated Network Benefits will not be paid. Non -Network
performed at a Designated
Benefits will apply.]
Include when notification is required.
`Include applicable reduction in Benefits.
[For Non -Network Benefits you must notify us as soon as the possibility of a Congenital Heart Disease
(CHD) surgery arises. If you don't notify us, Benefits will be reduced to ['50 - 951% of Eligible Expenses].
Include when Designated Network
[Designated
Benefits are available.
Network]
[Yes] [No]
[Yes] [No]
[When performed at a Designated
[[50 - 100]%]
[Yes, after the Per
Facility as part of the evaluation and
[100% after you pay
Occurrence
treatment of CHD, Covered Health
a Copayment of
Deductible is
Services include diagnostic services,
$[l00 - 1,0001 per
satisfied]
cardiac catheterization and all non-
day]
surgical management of CHD.]
Include when CHD benefits are sold
[100% after you pay
a Copayment of
and when both Network and Non-
$[100 - 2,0001 per
Network Benefits are available.
Inpatient Stay]
[Network and Non -Network Benefits
[100% after you pay
under this section include only the
a Copayment of
Congenital Heart Disease (CHD)
$[100-1,000] per
surgery. Depending upon where the
day to a maximum
Covered Health Service is provided,
Copayment of $[100 -
Benefits for diagnostic services,
5,0001 per Inpatient
cardiac catheterization and non-
SBN.CHP1.1.07.FL.KA Rev3
[15]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
surgical management of CHD will be
Stay]
the same as those stated under each
Covered Health Service category in
this Schedule of Benefits.]
Include when use of a Designated
[Network]
Facility is required in order to receive
[[50 - 100]%)
[Yes) [No]
[Yes] [No)
Network Benefits.
[10° after you pay
[Yes, after the Per
[For Network Benefits, CHD sur eries
g
opayment of
a Copayment
a C
Occurrence
must be received at a Designated
$[10Q - 1,000] per
Deductible is
Facility.
day)
satisfied]
Non -Network Benefits include services
[100% after you pay
provided at a Network facility that is not
a Copayment of
a Designated Network Facility and
$[100 - 2,0001 per
services provided at a non -Network
Inpatient Stay)
facility.
Non -Network Benefits under this
after you pay
a Copayment
a opayment of
section include only the CHD surgery.
$[100 - 1,000] per
Depending upon where the Covered
day to a maximum
Health Services is provided, Benefits
Copayment of $[100 -
for diagnostic services, cardiac
5,000] per Inpatient
catheterization and non -surgical
Stay]
management of CHD will be the same
as those stated under each Covered
Health Service category in this
Schedule of Benefits.]
Include when Network and Non-
[Non -Network]
Network Benefits are limited and insert
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
the limit selected by the group.
[100% after you pay
[Yes, after the Per
[Network and Non -Network Benefits
a Copayment of
Occurrence
are limited to $[30,000 - 250,0001 per
$[100 - 1,000] per
Deductible is
CHD surgery.]
day)
satisfied)
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
[100% after you pay
a Copayment of
$[100 - 1,000] per
day to a maximum
Copayment of $[100 -
5,000] per Inpatient
Stay]
SBN.CHP1.1.07.FL.KA Rev3 [17]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Covered Health Service
Pay, based on
Eligible Expenses)
Out -of -Pocket
Maximum?
Annual
Deductible?
Include for groups that purchase
benefits for accident -related dental
services.
[5.] [Dental Services- Accident
Only]
Include when pre -service notification is required.
'Include applicable reduction in Benefits or no Benefits.
[Pre -service Notification Requirement]
[For Network and Non -Network Benefits you must notify us five business days before follow-up (post -
Emergency) treatment begins. (You do not have to notify us before the initial Emergency treatment.) If
you fail to notify us as required, ['Benefits will be reduced to [50 - 95]% of Eligible Expenses] ['you will be
responsible for paying all charges and no Benefits will be paid].]
[Limited to $[2,000 - 5,000] per year.
[Network]
Benefits are further limited to a
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
maximum of $[500 - 1,500] per tooth.]
[100°to after you pay
a Copayment of $[5 -
75] per visit]
[Non -Network]
[Same as Network]
[Same as
[Same as Network]
Network]
[6.] Diabetes Services
'Include when the durable medical equipment benefit is sold.
`Include when the durable medical equipment benefit is not sold.
3include when notification applies only to equipment that exceeds a minimum dollar amount and insert
applicable dollar amount.
4include applicable reduction in Benefits or no Benefits.
Pre -service Notification Requirement
For Non -Network Benefits you must notify us before obtaining any [Durable Medical Equipment]
$[1,000 - 5,0001 in
[?diabetes equipment] for the management and treatment of diabetes [ that exceeds
rental of a single item)].ifyouto us as
cost (either purchase price or cumulative
far pfy
beil
[ Benefits will be reduced to [50 - 95] /o of Eligible Expenses] ry aying all
charges and no Benefits will be paid].
Diabetes Self -Management and
Network
Training/Diabetic Eye
Depending upon where the Covered Health Service is provided,
Examinations/Foot Care
Benefits for diabetes self -management and training/diabetic eye
examinations/foot care will be the same as those stated under
SBN.CHP1.1.07.FL.KA Rev3 [18]
When Benefit limits apply, the limit refers to any combination of [Designated Network Beneirts,j
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We Apply to the Must You Meet
Pay, based on Out -of -Pocket Annual
Covered Health Service Eligible Expenses) Maximum? Deductible?
each Covered Health Service category in this Schedule of
Benefits.
Non -Network
Depending upon where the Covered Health Service is provided,
Benefits for diabetes self -management and training/diabetic eye
examinations/foot care will be the same as those stated under
each Covered Health Service category in this Schedule of
Benefits.
Diabetes Self -Management Items
Network
Include only when benefits for durable
?Include when both benefits for durable medical equipment and
medical equipment are sold and when
the outpatient prescription drug rider are sold.
state law (foes not permit limits on
['Depending upon where the Covered Health Service is
diabetes equipment.
provided, Benefits for diabetes self -management items will be
[Benefits for diabetes equipment that
the same as those stated under Durable Medical Equipment
meets the definition of Durable Medical
and in the Outpatient Prescription Drug Rider. However
Equipment are not subject to the limit
diabetes self -management items are; not subject to any limits.]
stated under Durable Medical
2Include when benefits for durable medical equipment are sold,
Equipment.]
but the outpatient prescription drug rider is not sold.
Include when sold with a plan that has an annual deductible
and select either "are" or "are not."
°Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply. "
CFor diabetes equipment, Benefits will be the same as those
stated under Durable Medical Equipment.
For diabetes supplies the Benefit is [50 - 100]% of Eligible
Expenses rand Benefits [are] [are not] subject to payment of
the Annual Deductible]. However diabetes equipment and
supplies are not subject to any limits. [Coinsurance [applies]
[does not apply] to the Out -of -Pocket Maximum.]]
5include when benefits for durable medical equipment are not
sold and the outpatient prescription drug rider is sold.
61nclude when sold with a plan that has an annual deductible
and select either "are" or "are not. "
7Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply. "
[5For insulin pumps, the Benefit is [50 - 100)% of Eligible
Expenses [sand Benefits [are] [are not] subject to payment of
the Annual Deductible]. Insulin pumps are not subject to any
limits.] ['Coinsurance [applies] [does not apply] to the Out-of-
SBN.CHP1.1.07.FL.KA Rev3 [19]
When Benefit limits apply, the limit refers to any combination of ('Designated Network Benefits,)
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We Apply to the Must You Meet
Pay, based on Out -of -Packet Annual
Covered Health Service Eligible Expenses) Maximum? Deductible?
Pocket Maximum.]
Benefits for diabetes supplies will be the same as those stated
in the Outpatient Prescription Drug Rider. Diabetes supplies are
not subject to any limits.]
8lnclude when neither benefits for durable medical equipment
nor the outpatient prescription drug rider is sold.
glnclude when sold with a plan that has an annual deductible
and select either "are" or "are not."
'Oinclude when sold with a plan that has an out-of-pocket
maximum and select either "applies"or"does not apply."
[BFor insulin pumps and diabetes supplies, the Benefit is [50 -
100]% of Eligible Expenses [Sand Benefits [are] [are not]
subject to payment of the Annual Deductible]. Insulin pumps
and diabetes supplies are not subject to any limits.
[10Coinsurance [applies] [does not apply] to the Out -of -Pocket
Maximum,]]
Non -Network
'Include when both benefits for durable medical equipment and
the outpatient prescription drug rider are sold.
['Depending upon where the Covered Health Service is
provided, Benefits for diabetes self -management items will be
the same as those stated under Durable Medical Equipment
and in the Outpatient Prescription Drug Rider. However
diabetes self -management items are not subject to any limits.]
'Include when benefits for durable medical equipment are sold,
but the outpatient prescription drug rider is not sold.
Include when sold with a plan that has an annual deductible
and select either "are" or "are not.
4Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply.'
CFor diabetes equipment, Benefits will be the same as those
stated under Durable Medical Equipment.
For diabetes supplies the Benefit is [50 -1001% of Eligible
Expenses rand Benefits [are] [are not] subject to payment of
the Annual Deductible]. However diabetes equipment and
supplies are not subject to any limits. [°Coinsurance [applies]
[does not apply] to the Out -of -Pocket Maximum.]]
51nclude when benefits for durable medical equipment are not
sold and the outpatient prescription drug rider is sold.
SBN.CHP1.1.07.FL.KA Rev3 1201
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,[
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
out-of-pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
-7Include
when sold with a plan that has an annual deductible
and select either "are" or "are not. "
7 Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply.
rFor insulin pumps, the Benefit is [50 - 100]% of Eligible
Expenses [sand Benefits [are] [are not] subject to payment of
the Annual Deductible]. Insulin pj,.1mp,,,_are not subject to any
limits.] ['Coinsurance [applies] [does not apply] to the Out -of -
Pocket Maximum.]
Benefits for diabetes supplies will be the same as those stated
in the Outpatient Prescription Drug Rider. Diabet(,'�-; supplies rare
not subject to any limits.]
alriclude when neither benefits for durable medical equipment
nor the outpatient prescription drug rider is sold.
91nclude when sold with a plan that has an annual deductible
and select either "are" or "are not."
'('Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply. "
[For insulin pumps and diabetes supplies, the Benefit is [50 -
100]% of Eligible Expenses [9and Benefits [are] [are not]
subject to payment of the Annual Deductible]. Insulin purrips,
and diabetes supplies are not subject to any lirnils.
[10Coinsurance [applies] [does not apply] to the Out -of -Pocket
Maximum]]
Include for groups that purchase
benefits for DME.
[7.] [Durable Medical Equipment]
'Include when notification applies only to DME that exceeds a minimum dollar amount and insert
applicable dollar amount,
`Include applicable reduction in Benefits or no Benefits.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us before obtaining any Durable Medical Equipment ['that
exceeds $[1,000 - 5,000] in cost (either purchase price or cumulative rental of a single item}]. If you fail to
notify us as required, [`Benefits will be reduced to [50 - 95]% of Eligible Expenses] [2yoU will be
responsible for paying all charges and no Benefits will be paid].]
Include the limit selected by the group.
[Network]
"Include either option as standard plan
[[50 - 1001%]
[Yes] [No]
[Yes] [No]
design.
SBN.CHP1.I.07.F1_.KA Rev3 [21]
When Benefit limits apply, the limit refers
to any combination
of [Designated Network
Benefits,[
Network Benefits and Non -Network Benefits
unless otherwise
specifically stated
Benefit
(The Amount We
Apply to the
must You Meet
Covered Health Service
Pay, based on
Eligible Expenses)
out -of -Pocket
Maximum?
Annual
Deductible?
['Limit oo - 100.000] in Eligible
Expenses per year. Benefits are limited
to a single purchase of a type of DME
(including repairlreplacement) every
[year] [[two -five] years].]
['Limited per year as follows:
[$[500 - 10,0001 in Eligible
Expenses for Tier 1.Tier 1
includes disposable supplies
necessary for the effective use
of covered Durable Medical
Equipment.]
[$[10,001 - 25,0001 in Eligible
Expenses for Tier 2.]
[$[25,001 - 100,0001 in Eligible
Expenses for Tier 3.]
These Tier limits include repair.
Benefits for replacement are limited to
a single purchase of a type of DME
(including repair/replacement) every
[year] [[two -five] years].]
Always include when the DME benefit
[Non -Network]
is sold.
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[To receive Network Benefits, you must
purchase or rent the Durable Medical
Equipment from the vendor we identify
or purchase it directly from the
prescribing Network Physician.]
[8.] Emergency Health Services -
Outpatient
Note: If you are confined in a non-
Network
Network Hospital after you receive
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
outpatient Emergency Health Services,
you must notify us within one business
Include bracketed
day or on the same day of admission if
provision and select
reasonably possible. We may elect to
either #1 or 42 if the
transfer you to a Network Hospital as
copayment is waived.
soon as it is medically appropriate to
'Include as Standard;
do so. If you choose to stay in the non-
2 Include only to
Network Hospital after the date we
match prior benefit
decide a transfer is medically
plans.
appropriate, Network Benefits will not
I
SBN,CHP1 .1.07.FL.KA Rev3
[22]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,)
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out-of-pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
be provided. Non -Network Benefits
[100% after you pay
may be available if the continued stay
a Copayment of $[5 -
is determined to be a Covered Health
300] per visit. [If you
Service.
are admitted as an
Include when covered health services
inpatient to a Network
Hospital ['directly
performed at an emergency room are
rge ncy
from the Emergency
eithin ge
subject to the copayments/coinsurance
room] j� 24
stated under other benefit categories,
hours of receiving
in addition to the outpatient emergency
outpatient
copayment stated in this section. (This
Emergency treatment
will not apply when the emergency
for the same
benefit is subject to coinsurance only.)
condition], you will
[In addition to the Copayment stated in
not have to pay this
this section, the
Copayment. The
Copayments/Coinsurance for the
Benefits for an
following services apply when the
Inpatient Stay in a
Covered Health Service is performed
Network Hospital will
as an Emergency Health Service:
apply instead.]]
• [Lab, radiology/X-rays and other
diagnostic services described
under Lab, X-Ray and
Diagnostics - Outpatient.]
• [Major diagnostic and nuclear
medicine described under Lab,
X-Ray and Major Diagnostics -
CT. PET, MRI, MRA and
Nuclear Medicine - Outpatient.]
• [Diagnostic and therapeutic
scopic procedures described
under Scopic Procedures -
Outpatient Diagnostic and
Therapeutic.]
• [Outpatient surgery procedures
described under Surgery -
Outpatient. ]
• [Outpatient therapeutic
procedures described under
Therapeutic Treatments -
Outpatient.]
• [Rehabilitation therapy
procedures described under
Rehabilitation Services -
Outpatient Fherapy and
SBN.CHP1.1.07.FL.KA Rev3 [23]
SBN.CHP1107,FLKARev3 t24
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
per year. One visit equals up to four
hours of skilled care services.]
Include when infusion administration
only is not included in the limit.
[This visit limit does not include any
service which is billed only for the
administration of intravenous infusion.]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[5 -
50] per visit]
[11.] Hospice Care
Include if pre -service notification is required.
`Include applicable reduction in Benefits.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us five business days before admission for an Inpatient Stay in
a hospice facility or as soon as is reasonably possible. If you fail to notify us as required. Benefits will be
reduced to ['50 - 951% of Eligible Expenses.]
Include if pre -admission notification is required.
[In addition, for Non -Network Benefits, you must contact us within 24 hours of admission for an Inpatient
Stay in a hospice facility.]
Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[5 -
100] per day]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[5 -
100] per day]
[12.] Hospital - Inpatient Stay
SBN.CHP1.1.07.FL.KA Rev3 [25]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,)
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We Apply to the Must You Meet
Pay, based on Out-of-pocket Annual
Covered Health Service Eligible Expenses) Maximum? Deductible?
'Include applicable Benefit level.
Pre -service Notification Requirement
For Non -Network Benefits for a scheduled admission, you must notify us five business days before
admission, or as soon as is reasonably possible for non-scheduled admissions (including Emergency
admissions). If you fail to notify us as required, Benefits will be reduced to ['50 - 951% of Eligible
Expenses.
Include if pre -admission notification is required.
[In addition, for Non -Network Benefits you must contact us 24 hours before admission for scheduled
admissions or as soon as is reasonably possible for non-scheduled admissions (including Emergency
admissions).]
'Include heading and row when ['Designated
Designated Network Benefits apply Network] [Yes] [No]
Include when enhanced benefits apply
to specific inpatient services.
'include when Physician's fees are
paid under the facility charge.
[When you choose to seek care from
Designated Network facilities for
certain surgical procedures [or as a
result of certain diagnoses], your
Benefits will be enhanced as described
below:
[The Copayment you pay for the
facility charge [sand Physician's
fees] for services provided at a
Designated Network facility will
be reduced to [$0-1.000]. [The
maximum reduction in
Copayments is $[10 - 1,0001.11
+ [The Coinsurance you pay for
the facility charge [ and
Physician's fees] for services
provided at a Designated
Network facility will be reduced
to [0 - 501% or $[10 - 1,0001 will
be applied toward any applicable
Annual Deductible if not already
met, to a maximum of $[10 -
1,0001.]
You can determine the specific surgical
procedures or diagnoses for which
[[50 - 1001%
[100% after you pay
a Copayment of
$[100 - 1,000] per
day]
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
[100% after you pay
a Copayment of
$[100 - 1,000] per
day to a maximum
Copayment of $[100 -
10.0001 per Inpatient
Stay]
SBN.CHP1.1.07.FL.KA Rev3 [26]
[Yes] [No]
[Yes, after the Per
Occurrence
Deductible is
satisfied]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
enhanced Benefits are available by
going to www.myuhc.com or by calling
Customer Care at the telephone
number on your ID card.]
Network
[[50-100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
[Yes, after the Per
a Copayment of
Occurrence
$[100 - 1,0001 per
Deductible is
day]
satisfied]
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
[100% after you pay
a Copayment of
$[100-1,000] per
day to a maximum
Copayment of $[100 -
10,000] per Inpatient
Stay]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
[Yes, after the Per
a Copayment of
Occurrence
$[100 - 1,0001 per
Deductible is
day]
satisfied]
[100% after you pay
a Copayment of
$[100 - 2,0001 per
Inpatient Stay]
[100% after you pay
a Copayment of
$[100 - 1,000] per
day to a maximum
Copayment of $[100 -
10,000] per Inpatient
Stay]
SBN.CHP1.1.07.FL.KA Rev3 [27]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits1i
Network Benetits and Non -Network Benefits unless otherwise specirically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
out-of-pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible'?
Include for groups that purchase
infertility benefits.
[[13]. Infertility Services]
When this benefit is purchased, pre -service notification will always be required, 'Include applicable
reduction in Benefits or no Benefits.
[Pre -service Notification Requirement)
[You must notify us as soon as the possibility of the need for Infertility Services arises. if you fail to notify
us as required, ['Benefits will be reduced to [50 - 95]% of Eligible Expenses] you will be responsible for
paying all charges and no Benefits will be paid].]
linclude heading and row when
[Designated
Designated Network Benefits apply
Network]
[Yes] [No]
[Yes) [No]
[[50 - 100)%]
Include the limit selected by the group.
[Network]
'Include when the maximum benefit is
[[50 - 1001%)
[Yes] [No]
[Yes] [No]
combined with infertility drugs under
the RX rider.
[Limited to $[2,000 - 30,0001 per
Covered Person during the entire
period of time he or she is enrolled for
coverage under the Policy. ['This limit
includes Benefits for infertility
medications provided under the
Outpatient Prescription Drug Riderj]
[Non -Network]
[[50 - 1001%)
1yesl [No]
[Yes] [N o
t14.1 Lab, X-Ray and Diagnostics -
I
Outpatient
-
Include when pre -service notification is required for sloop studies.
'Include applicable reduction in Benefits.
[Pre -service Notification Requirement]
[For Non -Network Benefits for sleep studies, you must notify us five business days before scheduled
services are received. If you fail to notify us as required. Benefits will be reduced to ['50 - 951% of Eligible
Expenses.]
'Inclu e heading and row when
rDesignated
Designated Network Benefits apply.
Network]
[Yes] [No]
[Yes] [No]
[[50 - 100]%]
SBN.CHPI.I.07.FL.KA Rev3 [281
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,J
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Network
[50 - 100]%
[Yes] [No]
[Yes] [No]
Non -Network
[50 - 100]%
[Yes] [No]
[Yes] [No]
[15.] Lab, X-Ray and Major
Diagnostics - CT, PET, MRI, MRA
and Nuclear Medicine - Outpatient
Include when pre -service notification is required for CT, PET, MRI, MRA and nuclear medicine.
'Include applicable reduction in Benefits.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us five business days before scheduled services are received
or, for non-scheduled services, within one business day or as soon as is reasonably possible. If you fail to
notify us as required, Benefits will be reduced to ['50 - 95]% of Eligible Expenses.]
'Include heading and row when
['Designated
Designated Network Benefits apply
Network)
[Yes] [No]
[Yes] [No]
[[50 - 100]%]
[100% after you pay
a Copayment of $[25
- 5001 per service]
Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[25
- 5001 per service]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[25
- 500] per service]
SBN.CHP1.1.07.FLKA Rev3 [29]
Wh - e - n Benefit limits apply, the limit refers to any combination of [Designated Network BenefitsJ
A
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include for groups that purchase
inpatient and intermediate mental
health/substance abuse benefits.
[[16.] Mental Health and Substance
Abuse Services - Inpatient and
Intermediate]
—When this benefit is purchased, prior authorization will always be required.
[Prior Authorization Requirement]
[You must obtain prior authorization through the Mental Health/Substance Abuse Designee in order to
and no Benefits will
receive Benefits. Without authorization, you will be responsible for paying all charges
be paid.]
Include the limit selected by the group.
[Network]
[Network Benefits for Mental Health
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
Services are limited to [30 - 1001 days
[100% after you pay
per year.]
a Copayment of
[Network Benefits for Substance Abuse
$(100 - 1,0001 per
Services are limited to [30 - 1001 days
day]
per year.)
[100% after you pay
[Mental Health Services are limited to
a Copayment of
[30 - 100] days per year]
$[100 - 2,000] per
[Substance Abuse Services are limited
Inpatient Stay]
to ['30 - 100] days per year.]
[100% after you pay
a Copayment of
$[100 - 1,0001 per
day to a maximum
Copayment of $[100 -
5,000) per Inpatient
Stay]
I'Non-Network Benefits for Mental
[Non -Network]
Health Services are limited to [30 -
[[50 - 100]%]
[Yes) (No]
[Yes] [No]
1001 days per year.]
[Non -Network Benefits for Substance
[100% after you pay
a Copayment of
Abuse Services are limited to [30 - 1001
$[l 00 - 1,0001 per
days per year.]
day]
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
100% aft r you pay
SBN,CHP1.1.07.FL.KA Rev3 [30)
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Packet
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
a Copayment of
$[100 - 1,000] per
day to a maximum
Copayment of $[100 -
5,000] per Inpatient
Stay]
Include for groups that purchase
outpatient mental healthlsubstance
abuse benefits.
[[17.] Mental Health and Substance
Abuse Services - Outpatient]
Include authorization language only for groups that elect the "Employer Coverage" option. Delete
authorization language for groups that elect the "National Service Center" option.
[Prior Authorization Requirement]
[You must obtain prior authorization through the Mental Health/Substance Abuse Designee in order to
receive Benefits. Without authorization, you will be responsible for paying all charges and no Benefits will
be paid.]
Include the limit selected by the group.
[Network]
[Network Benefits for Mental Health
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
Services are limited to [30 - 1001 visits
[100% after you pay
per year.]
a Copayment of $[5 -
[Network Benefits for Substance Abuse
75] per visit]
Services are limited to [44 - 100] visits
[100% after you pay
per year.]
a Copayment of $[5 -
[Mental Health Services are limited to
75] per individual
[30 -100] visits per year.]
visit; $[5 - 75] per
[Substance Abuse Services are limited
group visit]
to [44 - 100] visits per year.]
[Non -Network Benefits for Mental
[Non -Network]
Health Services are limited to (30 -
[[50 - 100]%0]
[Yes] [No]
[Yes] [No]
100] visits per year.]
[Non -Network Benefits for Substance
[100% after you pay
a Copayment of $[5 -
Abuse Services are limited to (44 - 100]
75] per visit]
visits per year.]
[100% after you pay
a Copayment of $[5 -
75] per individual
visit; $[5 - 751 per
group visit]
SBN.CHP1.1.07.FL..KA Rev3 [31]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefitsd
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include for groups that purchase
benefits for obesity surgery.
[[18.] Obesity Surgery]
When this benefit is purchased, pre-servico notification will always be required. 'Include applicable Benefit
level.
[Pre -service Notification Requirement]
[You must notify us [six months prior to surgery] [or] [as soon as the possibility of obesity surgery arises].
If you fail to notify us as required, Benefits will be reduced to ['50 - 95]% of Eligible Expenses.]
Include if pre -admission notification is required.
[in addition, for Non -Network Benefits you must contact us 24 hours before admission for an Inpatient
Stay.]
[it is important that you notify us regarding your intention to have surgery. Your notification will
open the opportunity to become enrolled in programs that are designed to achieve the best
outcomes for you.)
'Include heading and row when
[Designated Network]
Designated Network Benefits apply
[Depending upon where the Covered Health Service is
21nclude when Designated Network
provided, Benefits will be the same as those stated under each
Benefits apply
Covered Health Service category in this Schedule of Benefits.]
31nclude when Network Benefits are
available.
4 Insert the limit selected by the group.
[Any combination of [2 Designated
Network Benefits] [3 , Network Benefits]
and Non -Network Benefits is limited to
$r50,OOO - 250,000) during the entire
period of time a Covered Person is
enrolled for coverage under the Policy.]
[Network]
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
Include when there is not a Network
[Non -Network]
level of benefits available.
[Depending upon where the Covered Health Service is
[Non -Network Benefits include services
provided, Benefits will be the same as those stated under each
provided at a Network facility that is not
Covered Health Service category in this Schedule of Benefits.)
a Designated Network Facility and
services provided at a non -Network
facility.]
SBN.CHP1.1.07.FL.KA Rev3 1321
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include if group purchases benefits for
ostomy supplies.
[[19.] Ostomy Supplies]
Include the limit selected by the group.
[Network]
[Limited to $[500 - 25,000] per year.]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[Non -Network]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[20.] Pharmaceutical Products -
Outpatient
Include when notification is required for IV infusions.
'Include applicable reduction in Benefits.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us five business days before scheduled intravenous infusions
are received or, for non-scheduled services, within one business day or as soon as is reasonably
possible. If you fail to notify us as required, Benefits will be reduced to [ 50 - 951% of Eligible Expenses.]
'Include heading and row when
['Designated
Designated Network Benefits apply
Network]
[Yes] [No]
[Yes] [No]
[[50-100]%]
Include when
coinsurance is tiered
and select the
appropriate number
of tiers by plan
design.
[[50 - 1001% - Tier I]
[[50 - 100]% -Tier 2]
[[50 - 100]% -Tier 3]
[[50 - 100]% - Tier d]
Network
[[50-100]%]
[Yes] [No]
[Yes] [No]
Include when
coinsurance is tiered
and select the
a ro riate number
SBN.CHP1.l,07.FL.KA Rev3 [33]
When Benefit limits apply, the limit refers to any combination of (Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
of tiers by plan
design.
[[50 - 1001%Q - Tier 11
[[50 -100]% - Tier 2]
[[50-100]%0 - Tier 31
[[50-100]% - Tier 41
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
Include when
coinsurance is tiered
and select the
appropriate number
of tiers by plan
design.
[[50 - 100]% - Tier 1 ]
[[50 -100]% - Tier 21
[[50 - 100]% - Tier 31
[[50-100]%0 - Tier 41
[21.] Physician Fees for Surgical and
Medical Services
'Include heading and row when
(''Designated
Designated Network Benefits apply
Network]
[Yes] [No)
[Yes] [No]
Include when enhanced benefits apply
[[50 - 100]%]
to specific Physician services.
[When you choose to seek care [as a
result of certain diagnoses or] from
Designated Network Physicians as
identified below, your Benefits will be
enhanced as described:
Specialties:
• [Cardiology.]
[Cardiac/Cardio-thoracic
Surgery.]
[Orthopedic Surgery.]
[Neurosurgery.]
SBN.CHP1,1.07.FL.KA Rev3 [34]
When Benefit limits apply, the limit refers to any combination of (Designated Network Benefits,)
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[Allergy.]
• [Nephrology.]
• [Neurology.]
• [Oncology.]
• [Pulmonology.]
[Rheumatology.]
• [Endocrinology.]
• [infectious Disease.]
• [Gastroenterology.]
• [Obstetrics/Gynecology.]
• [Reproductive Endocrinology.]
• [All specialties for which we
provide designation.]
Enhanced Benefits:
• [The Coinsurance you pay for
Physician's Fees from a
Designated Network Physician
will be reduced to [0 - 501% or
$[10 - 1,000] will be applied
toward any applicable Annual
Deductible if not already met, to
a maximum of $[10 - 1,0001.1
You can determine the specific
services for which enhanced Benefits
are available by going to
www.myuhc.com or by calling
Customer Care at the telephone
number on your ID card.]
Network
[50 - 1001%
[Yes] [No]
[Yes] [No]
Non -Network
[50 - 100]%
[Yes] [No]
[Yes] [No]
[22.] Physician's Office Services -
Sickness and Injury
_
SBN.CHP1.1.07.FL.KA Rev3 [35]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,)
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
'Include heading and row when
['Designated
Designated Network Benefits apply
Network]
[Yes] [No]
[Yes] [No]
Include when enhanced benefits apply
[[50-1001%]
to specific physician office services.
[100% after you pay
[When you choose to seek care [as a
a Copayment of $[5 -
result of certain diagnoses or] from
100] per visit]
Designated Network Physicians as
[100% after you pay
identified below, your Benefits will be
a Copayment of $[5 -
enhanced as described:
75] per visit for a
Specialties:
Primary Physician
office visit or $[5 -
• [Cardiology.]
100] per visit for a
• [Cardiac/Cardin-thoracic
Specialist Physician
Surgery.]
office visit]
• [Orthopedic Surgery.]
[100% after you pay
a Copayment of $[5 -
• [Neurosurgery.]
75] per visit for a
• [Allergy.)
Primary Physician
office visit; [50 -
• [Nephrology.]
100]% for a Specialist
Physician office visit]
• [Neurology.)
(100% for a Primary
® [Oncology.]
Physician office visit;
• [Pulrnonology.]
[50 - 100]% for a
Specialist Physician
• [Rheumatology.]
office visit]
• [Endocrinology.]
• [Infectious Disease.]
• [Gastroenterology.]
• [Obstetrics/Gynecology.]
• [Reproductive Endocrinology.]
• [All specialties for which we
provide designation.]
Enhanced Benefits:
• [The Copayment you pay for (the
initial office visit) [[1 - 100] office
visits)] provided by a
Designated Network Physician
will be reduced to $[0 - 1,0001.
The maximum reduction in
SBN.CHP1.IA7.FL.KA Rev3 [35]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Copayments is $[10 - 1,0001.11
• [The Coinsurance you pay for
[the initial office visit] [[1 - 100]
office visit(s)] provided by a
Designated Network Physician
will be reduced to [0 - 50]% or
$[10 - 1,000) will be applied
toward any applicable Annual
Deductible if not already met, to
a maximum of $[10 - 1,0001.1
You can determine the specific
specialties for which enhanced
Benefits are available by going to
www.myuhc,com or by calling
Customer Care at the telephone
number on your ID card.]
Include when covered health services
Network
performed in a physician's office are
[[50 - 1001%]
[Yes] [No]
[Yes] [No]
subject to the copaymentslcoinsurance
stated under other benefit categories,
[100% after you pay
in addition to the office visit copayment
a Copayment of $[5 -
stated in this section. (This will not
100] per visit]
apply when the office visit benefit is
[100% after you pay
subject to coinsurance only.)
a Copayment of $[5 -
[In addition to the office visit
75] per visit for a
Copayment stated in this section, the
Primary Physician
Copayments/Coinsurance for the
office visit or $[5 -
following services apply when the
100] per visit for a
Covered Health Service is performed in
Specialist Physician
a Physician's office:
office visit]
• [Lab, radiology/X-rays and other
[100% after you pay
diagnostic services described
a Copayment of $[5 -
under Lab, X-Ray and
75) per visit for a
Diagnostics - Outpatient.]
Primary Physician
• [Major diagnostic and nuclear
office visit; [50 -
100]% for a Specialist
medicine described under Lab.
Physician office visit]
X-Ray and Major Diagnostics -
CT. PET, MRI, MRA and
[100% for a Primary
Nuclear Medicine - Outpatient.]
Physician office visit;
[50 - o for a
• [Diagnostic and therapeutic
[ g p
Specialist Physician
Specialist
scopic procedures described
office visit]
under Scopic Procedures -
Outpatient Dia nostic and
SBN.CHP1.1.07.FL.KA Rev3 [37]
When Benefit limits apply, the limit refers to any combination of[Designated Network BenefitsJ
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Therapeutic.]
• [Outpatient surgery procedures
described under Surgery -
Outpatient.]
• [Outpatient therapeutic
procedures described under
Therapeutic Treatments -
Outpatient.]
® [Rehabilitation therapy
procedures described under
Rehabilitation Services -
Outpatient Therapy and
Chiropractic Treatment]]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $t5 -
1001 per visit]
[100% after you pay
a Copayment of $[5 -
75] per visit for a
Primary Physician
office visit or $[5 -
100] per visit for a
Specialist Physician
office visit)
[100% after you pay
a Copayment of $[5 -
75] per visit for a
Primary Physician
office visit; [50 -
100]% for a Specialist
Physician office visit]
[100% for a Primary
Physician office visit;
[50 - 100]% for a
Specialist Physician
office visit]
SBN.CHP1I07.FL.KA Rev3 [38]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
App:toe
Must You Meet
Pay, based on
Outket
Annual
Covered Health Service
Eligible Expenses)
Max
Deductible?
'Always include Maternity Services
benefit except when small groups (14
or fewer employees) choose to
exclude. `lf Maternity Services are
excluded, Complications of Pregnancy
must always be included.
[23.] Pregnancy - ['Maternity
Services] [2Complications of
Pregnancy only]
'Include when benefits are provided for maternity services. 'Include applicable Benefit level.
['Pre -service Notification Requirement]
['For Non -Network Benefits you must notify us as soon as reasonably possible if the Inpatient Stay for the
mother and/or the newborn will be more than 48 hours for the mother and newborn child following a
normal vaginal delivery, or more than 96 hours for the mother and newborn child following a cesarean
section delivery. If you fail to notify us as required, Benefits will be reduced to [250 - 951% of Eligible
Expenses.]
'Include when benefits are provided for complications of pregnancy only. 4lnclude applicable Benefit level.
[''Pre -service Notification Requirement]
["For Non -Network Benefits you must notify us five business days before admission for scheduled
admissions or within one business day or the same day, or as soon as is reasonably possible for non-
scheduled admissions. If you fail to notify us as required, Benefits will be reduced to r5o - 95]% of
Eligible Expenses.]
It is important that you notify us regarding your Pregnancy. Your notification will open the
opportunity to become enrolled in prenatal programs that are designed to achieve the best
outcomes for you and your baby.
'Include when benefits are provided for maternity services.
t Network]
31nclude when an annual deductible applies to network benefits.
41nclude when Network services in the Physician's office are
subject to a Copayment.
['Benefits will be the same as those stated under each Covered
Health Service category in this Schedule OfBeneflts [''except
that an Annual Deductible will not apply for a newborn child
whose length of stay in the Hospital is the same as the mother's
length of stay].] ['For Covered Health Services provided in the
Physician's Office, a Copayment will apply only to the initial
office visit.]
[' Non -Network]
31nclude when an annual deductible applies to non -network
SBN.CHP1.1.07.FL.KA Rev3 [39]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefitsd
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
benefits.
41nCjUde when Non -Network services in the Physician's office
are subject to a Copayment.
['Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits [3except
that an Annual Deductible will not apply for a newborn child
whose length of stay in the Hospital is the same as the mother's
length of stay].) rFor Covered Health Services provided in the
Physician's Office, a Copayment will apply only to the initial
office visit.]
2 Include when benefits are provided for complications of
pregnancy only.
("Network]
[2 Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.]
f Non -Network]
rBenefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.]
[24.] Preventive Care Services
Physician office services
Network
Child Health Supervision Services are
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
not st.ibject to any Annual Deductible.
[100% after you pay
Benefits are limited to one visit,
a Copayment of $[5 -
payable to one provider, for all of the
75] per visit]
services provided at each visit.
[100% after you pay
a Copayment of $[5 -
75] per visit for a
Primary Physician
office visit or $[5 -
100] per visit for a
Specialist Physician
office visit]
[100% after you pay
a Copayment of $[5 -
75] per visit for a
Primary Physician
office visit; [50 -
100]% for a Specialist
Physician office visit]
SBN.CHP1.1.07.FL.KA Rev3 [40]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[100% for a Primary
Physician office visit;
[50 - 100]% for a
Specialist Physician
office visit]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
[Non -Network
[Non -Network
a Copayment of $[5 -
Benefits are not
Benefits are not
75] per visit]
available, except
available, except
[100% after you pay
for Child Health
for ChildHealth
a Copayment of $[5 -
Supervision
Supervision
75] per visit for a
.services, one
Services; one
Primary Physician
annual fem fle
annual female
office visit or $[5 -
physical,
physiuil, including
1001 per visit for a
including a pap
a pap smear ;.and a
Specialist Physician
smear and a
marnniograni.]
office visit]
niammogram.]
[100% after you pay
a Copayment of $[5 -
75] per visit for a
Primary Physician
office visit; [50 -
100]% for a Specialist
Physician office visit]
[100% for a Primary
Physician office visit;
[50 - 100]% for a
Specialist Physician
office visit]
[Non -Network
Benefits are not
available, except for
Child Health
Supervision Services,
one annual female
physical, including a
pap smear and a
mammogram.]
Lab, X-ray or other preventive tests:
Network
[[50-100]%]
[Yes] [No]
[Yes] [No]
100% after you pay
SBN.CHP1.1.07.FL.KA Rev3 [41]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We Apply to the Must You Meet
Pay, based on Out -of -Pocket Annual
Covered Health Service Eligible Expenses) Maximum? Deductible?
a Copayment of $[5 -
100] per service]
Non -Network
[[50 - 1001%]
[Yes] [No]
[Yes] [No]
[100% after you pay
[Non -Network
[Non -Network
a Copayment of $[5 -
Benefits are not
Benefits are not
100] per service]
available, except
available, except
for Child Health
for Child Health
[Non -Network
Supervision;
lion
Supervision
Benefits are not
Services, one
Services, one;
available, except for
annual female
annual female
Child Health
physical,
physical, including
Supervision Services,
including a pap
a pap smear an,-] a
one annual female
smear and a
man'imogram.]
physical, including a
martamog -am.]
pap smear and a
mammogram.]
Include when group purchases benefits
for prosthetic devices.
[25.1 [Prosthetic Devices]
SBN.CHP1.1.07.FL.KA Rev3 [42]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include if notification is required.
'Include when notification applies only to prosthetics that exceed a minimum dollar amount and insert
applicable dollar amount.
`Include applicable reduction in Benefits or no Benefits.
[Pre -service Notification Requirement)
[For Non -Network Benefits you must notify us before obtaining prosthetic devices ['that exceed $[1,000 -
5,000] in cost per device.] If you fail to notify us as required, [2Benefits will be reduced to [50 - 951% of
Eligible Expenses] [2you will be responsible for paying all charges and no Benefits will be paid].]
Include the limit selected by the group.
[Network]
'Include either option as standard.
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
['Limited to $[2,500 - 100,000] per
year. Benefits are limited to a single
purchase of each type of prosthetic
device every [year] [[two -five] years].]
['Limited per year as follows:
• A maximum of $[10,000 -
30,000] per body part for each
arm, leg, hand or foot.
• A maximum of $[5,000 - 15,000)
per body part for each eye, ear,
nose, face, breast, speech aid
prosthetics or tracheo-
esophageal voice prosthetics.
These limits include repair. Benefits for
replacement are limited to a single
purchase of each type of prosthetic
device every [year] [[two -five] years].
Always include statement below except
[Non -Network]
when prosthetics are not limited.
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[Once this limit is reached, Benefits
continue to be available for items
required by the Women's Health and
Cancer Rights Act of 1998.1
[26.] Reconstructive Procedures
'Include applicable Benefit level.
Pre -service Notification Requirement
For Non -Network Benefits you must notify us five business days before a scheduled reconstructive
SBN.CHR1.1.07.FL.KA Rev3 [43]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We Apply to the Must You Meet
Pay, based on Out -of -Pocket Annual
Covered Health Service Eligible Expenses) Maximum? Deductible?
procedure is performed or, for non-scheduled procedures, within one business day or as soon as is
reasonably possible. If you fail to notify us as required, Benefits will be reduced to ['50 - 951/o of Eligible
Expenses.
Include if pre -admission notification is required:
[in addition, for Non -Network Benefits you must contact us 24 hours before admission for scheduled
inpatient admissions or as soon as is reasonably possible for non-scheduled inpatient admissions
(including Emergency admissions).]
Network
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Include when group does not purchase benefits for prosthetic
devices.
'include when sold with a plan that has an annual deductible
and select either "are" or "are not."
'Include when sold with a plan that has an out-of-pocket
maximum and select either "applies" or "does not apply. "
[For breast prosthesis, mastectomy bras and lymphedema
stockings for the arms, the Benefit is [50 - 100]% of Eligible
Expenses ['and Benefits [are] [are not] subject to payment of
the Annual Deductible]. [CCoinsurance [applies] [does not apply]
to the Out -of -Pocket Maximum.]]
Non -Network
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Include when group does not purchase benefits for prosthetic
devices. The Benefit level inserted here must be the same as
the plan coinsurance level.
'Include when sold with a plan that has an annual deductible
and select either "are" or are not."
Include when sold with a plan that has an out-of-pocket
maximum and select either 'applies" or "does not apply. "
[For breast prosthesis, mastectomy bras and lymphedema
stockings for the arms, the Benefit is [50 - 100]% of Eligible
Expenses ['and Benefits [are] [are not] subject to payment of
the Annual Deductible]. [Coinsurance [applies] [does not apply]
to the Out -of -Pocket Maximum.]]
SBN.CHP1.1.07.FL.KA Rev3 [44]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Packet
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include entire section when
rehabilitation services benefit is sold.
[[27.] Rehabilitation Services -
Outpatient Therapy and Chiropractic
Treatment]
Include when notification is required for any rehabilitation service. 'Include Chiropractic Treatment only if
all services require notification.
`Include applicable Benefit level.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us five business days before receiving [physical therapy] [j
[and] [occupational therapy] [,][and] ['Chiropractic Treatment] [] [and] [speech therapy] [j [and]
[pulmonary rehabilitation therapy] [j [and] [cardiac rehabilitation therapy] [j [and] [post -cochlear implant
aural therapy] [j [and] [vision therapy] or as soon as is reasonably possible. If you fail to notify us as
required. Benefits will be reduced to [250 - 951% of Eligible Expenses.]
Include when per therapy limits apply.
[Network]
'Include when vision therapy benefits
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
are sold.
[100% after you pay
[Limited per year as follows:
a Copayment of $[5 -
• [10-100] visits of physical
75] per visit]
therapy.
• [10-100] visits of occupational
therapy.
• [10-100] visits of Chiropractic
Treatment.
• [10-100] visits of speech
therapy.
• [10-100] visits of pulmonary
rehabilitation therapy.
• [10-100] visits of cardiac
rehabilitation therapy.
• [10-100] visits of post -cochlear
implant aural therapy.
s [[10-100] visits of vision
therapy.]]
Include when combined therapy visit
[Non -Network]
limits apply.
50 - 100 /o
[[ ]° ]
Yes Na
[Yes] [ ]
[Yes] No
] [ ]
[Any combination of outpatient
SBN.CHP1.1.07.FL.KA Rev3 [45]
When Benefit limits apply, the limit refers to any combination of (Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
rehabilitation services is limited to [10 -
[100% after you pay
1601 visits per year.]
a Copayment of $[5 -
Include when combined therapy dollar
75] per visit]
limits apply.
[Any combination of outpatient
rehabilitation services is limited to
$[750 - 12,000] per year.]
Include when combined therapy visit
limits apply separately to network
benefits and to non -network benefits.
[Network Benefits for any combination
of outpatient rehabilitation services are
limited to [10 -160] visits per year.
Non -Network Benefits for any
combination of outpatient rehabilitation
services are limited to [10 -160] visits
per year.]
[28.] Scopic Procedures - Outpatient
Diagnostic and Therapeutic
include when notification is required for scopic procedures.
'Include applicable Benefit level.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us five business days before scheduled services are received
or, for non-scheduled services, within one business day or as soon as is reasonably possible. If you fail to
notify us as required, Benefits will be reduced to ['50 - 951% of Eligible Expenses.]
'include heading and row when
,('Designated
Designated Network Benefits apply.
Network]
[Yes] [No]
[Yes] [No]
[[50 - 100]%]
Network
[50 - 100]%
[Yes] [No]
[Yes] [No]
Non -Network
[50 - 100]%
[Yes] [No]
[Yes] [No]
[29.] Skilled Nursing
Facilitylinpatient Rehabilitation
Facility Services
'Include applicable Benefit level.
SBN.CHP1.1.07.FL.KA Rev3 [46]
When Benefit limits apply, the limit refers to any combination of (Designated Network Benefits,%
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Pre -service Notification Requirement
For Non -Network Benefits for a scheduled admission, you must notify us five business days before
admission, or as soon as is reasonably possible for non-scheduled admissions. If you fail to notify us as
required, Benefits will be reduced to [150 - 95]% of Eligible Expenses.
Include if pre -admission notification is required.
[in addition, for Non -Network Benefits you must contact us 24 hours before admission for scheduled
admissions or as soon as is reasonably possible for non-scheduled admissions (including Emergency
admissions).]
Include limit selected by group.
Network
[Limited to [40 - 1801 days per year.]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[Network Benefits are limited to [40 -
[100% after you pay
180] days per year. Non -Network
a Copayment of $[5 -
Benefits are limited to [40 - 180] days
100] per visit]
per year.]
[100% after you pay
a Copayment of $[50
- 1,000] per day]
Copayment option
below identified as #1
to be tied only to
either of the options
#1 below with an
Inpatient Stay
maximum.
[' 100% after you pay
a Copayment of $[50
- 2,0001 per Inpatient
Stay]
[' 100% after you pay
a Copayment of $[50
- 1,0001 per day to a
maximum
Copayment of $[50 -
5,000] per Inpatient
Stay]
Variable #1 can be
used only with
options numbered #1
above.
['If you are
transferred to a
Skilled Nursing
SBN.CHP1.1.07.FL.KA Rev3 [47]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,)
Network Benefits and Non -Network Benefits unless otherwise specifically stated
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Facility or Inpatient
Rehabilitation Facility
directly from an acute
facility, any
combination of
Copayments required
for the Inpatient Stay
in a Hospital and the
Inpatient Stay in a
Skilled Nursing
Facility or Inpatient
Rehabilitation Facility
will apply to the
stated maximum
Copayment per
Inpatient Stay.]
[No Copayment
applies if you are
transferred to a
Skilled Nursing
Facility or Inpatient
Rehabilitation Facility
directly from an acute
facility.]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[50
- 1,000] per day]
[100% after you pay
a Copayment of $[50
- 2,000] per Inpatient
Stay]
[100% after you pay
a Copayment of $[50
- 1,000] per day to a
maximum
Copayment of $[50 -
10,000] per Inpatient
Stay]
(30.) Surgery - Outpatient
SBN.CHP1 .1.07.FL.KA Rev3 [48]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include when notification is required.
'Include applicable Benefit level.
[Pre -service Notification Requirement]
[For Non -Network Benefits [for all outpatient surgeries] [for [blepharoplasty] [,] [and] [cardiac
catheterization] [,] [and] [cochlear implants] [,] [and] [uvulopalatopharyngoplastyj [,j [and] [pacemaker
insertion] [,] [and] [pain management procedures] [,] [and] [vein procedures] [] [and] [spine surgery] [,]
[and] [total joint replacements] [,] [and] [implantable cardioverter defibrillators]] you must notify us five
business days before scheduled services are received or, for non-scheduled services, within one
business day or as soon as is reasonably possible. If you fail to notify us as required, Benefits will be
reduced to [50 - 95]% of Eligible Expenses.]
'Include heading and row when
['Designated
Designated Network Benefits apply.
Network]
[Yes] [No]
[Yes] [No]
Include provision below when
[[50 - 100]%]
[Yes, after the Per
enhanced benefits apply to specific
[100% after you pay
Occurrence
outpatient surgical services.
a Copayment of $[10
Deductible is
`Include when Physician's fees are
- 1,000] per date of
satisfied]
paid under the facility charge.
service]
[When you choose to seek care from
Designated Network facilities for
certain surgical procedures. your
Benefits will be enhanced as follows:
• [The Copayment you pay for the
facility charge ['and Physician's
fees] for outpatient surgery
provided at a Designated
Network facility will be reduced
to [$0 - 1,00% [The maximum
reduction in Copayments is $[10
- 1,000].]]
• [The Coinsurance you pay for
the facility charge [Land
Physician's fees] for outpatient
surgery provided at a
Designated Network facility will
be reduced to [0 - 50]% or $[10 -
1,000] will be applied toward any
applicable Annual Deductible if
not already met, to a maximum
of $[10 - 1,000].]
You can determine the specific surgical
procedures for which enhanced
Benefits are available by goingto
SBN.CHP1.1.07.FL.KA Rev3 [49]
When Benefit limits apply, the limit refers to any combination of [Designated Network BenefitsJ
Network Benefits and Non -Network Benefits unless otherwise specifically stated,
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out-of-pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
www.myuhc.com or by calling
Customer Care at the telephone
number on Your ID card.]
Network
[[50 -100]%]
[Yes] [No]
[Yes] [No]
[[100% after you pay
[Yes, after the Per
a Copayment of $[10
Occurrence
- 1,000] per date of
Deductible is
service]
satisfied]
Non -Network
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[100% after You pay
[Yes, after the Per
a Copayment of $[10
Occurrence
- 1,000] per date of
Deductible is
service]
satisfied]
Include when group purchases TMJ
benefit.
[[31.] Temporomandibular Joint
Services]
When this benefit is purchased, pro -service notification will always be required.
'Include applicable Benefit level.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us five business days before temporomandibular joint services
are performed during an Inpatient Stay in a Hospital. if you fail to notify us as required, Benefits will be
reduced to ['50 - 95]% of Eligible Expenses.]
Include if pre -admission notification is required.
[in addition, for Non -Network Benefits you must contact us 24 hours before admission for scheduled
inpatient admissions.]
Include the limit selected by the group.
[Network]
[Limited to $[1,000 - 20,000] per year.]
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
[Non -Network]
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
SBN.CHP1.1.07.FL.KA Rev3 (50)
When Benefit limits apply, the limit refers to any combination of (Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
[32.] Therapeutic Treatments -
Outpatient
Include when notification is required.
'Include applicable Benefit level.
[Pre -service Notification Requirement]
[For Non -Network Benefits you must notify us [for all outpatient therapeutic services] [for the following
outpatient therapeutic services] five business days before scheduled services are received or, for non-
scheduled services, within one business day or as soon as is reasonably possible. [Services that require
notification: [dialysis] [,j [and] chemotherapy] [j [and] [IV infusion] [,] [and] [radiation oncology] [,] [and]
[hyperbaric oxygen therapy].] If you fail to notify us as required, Benefits will be reduced to ['50 - 95]`% of
Eligible Expenses.]
'Include heading and row when
''Designated
Designated Network Benefits apply
Network]
[Yes] [No]
[Yes] [No]
[[50 - 100]%]
Network
[50 - 100]%
[Yes] [No]
[Yes] [No]
Non -Network
[50 - 1001%
[Yes] [No]
[Yes] [No]
[33.] Transplantation Services
Pre -service Notification Requirement
For Network Benefits you must notify us as soon as the possibility of a transplant arises (and before the
time a pre -transplantation evaluation is performed at a transplant center). If you don't notify us and if, as a
result, the services are not performed at a Designated Facility, Network Benefits will not be paid. Non -
Network Benefits will apply.
Include applicable benefit reduction penalty.
['For Non -Network Benefits you must notify us as soon as the possibility of a transplant arises (and
before the time a pre -transplantation evaluation is performed at a transplant center). If you fail to notify us
as required, Benefits will be reduced to [250 - 95]% of Eligible Expenses.]
Include if Non -Network Benefits are sold and pre -admission notification is required.
[In addition, for Non -Network Benefits you must contact us 24 hours before admission for scheduled
admissions or as soon as is reasonably possible for non-scheduled admissions (including Emergency
admissions)]
For Network Benefits, transplantation
Network
services must be received at a
[[50-100]%]
[Yes] [No]
[Yes] [No]
Designated Facility. We do not require
that cornea transplants be performed
[100% after you pa
[Yes, after the Per
SBN.CHP1.1.07.FL.KA Rev3 [51]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Benefits unless otherwise specifically stated
Network Benefits and Non -Network
Benefit
(The Amount We Apply to the
Must You Meet
Pay, based on out -of -Pocket
Eligible Expenses) Maximum?
Annual
Deductible?
Covered Health Service
at a Designated Facility in order for you a Copayment of
Occurrence
Deductible is
to receive Network Benefits. $floo - 1,0001 per
satisfied]
day]
[100% after you pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay)
[100% after you pay
a Copayment of
$floo - 1,0001 per
day to a maximum
Copayment of $[100 -
5,000] per Inpatient
Stay]
Non -Network
[[50 - 100]%] [Yes] [No]
[Yes] [No]
[100% after you pay
[Yes, after the Per
a Copayment of
occurrence
Deductible is
$tloo - 1,000] per
satisfied]
day]
[100% after You Pay
a Copayment of
$[100 - 2,000] per
Inpatient Stay]
[100% after you pay
a Copayment of
$[loo - 1,000] per
day to a maximum
Copayment of $[100 -
5,000] per Inpatient
Stay]
[34.) Urgent Care Center Services
SBN.CHPI.I.07.FL.KA Rev3 [52]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
Include when covered health services
Network
performed at an urgent care center are
[[50-100]%]
[Yes] [No]
[Yes] [No]
subject to the copayments/coinsurance
stated under other benefit categories,
[100% after you pay
in addition to the urgent care
a Copayment of $[5 -
copayment stated in this section. (This
1501 per visit]
will not apply when the urgent care
benefit is subject to coinsurance only.)
[In addition to the Copayment stated in
this section, the
Copayments/Coinsurance for the
following services apply when the
Covered t-lealth Service is performed
at an Urgent Care Center:
• [Lab, radiology/X-rays and other
diagnostic services described
under Lab. X-Ray and
Diagnostics - Outpatient.]
• [Major diagnostic and nuclear
medicine described under Lab,
X-Ray and Major Diagnostics -
CT, PET MRI, MRA and
Nuclear Medicine - Outpatient.]
• [Diagnostic and therapeutic
scopic procedures described
under Scopic Procedures -
Outpatient Diagnostic and
Therapeutic.]
• [Outpatient surgery procedures
described under Surgery -
Outpatient.]
• [Outpatient therapeutic
procedures described under
Therapeutic Treatments -
Outpatient.]
• [Rehabilitation therapy
procedures described under
Rehabilitation Services -
Outpatient Therapy and
Chiropractic. Treatment.]]
Non -Network
SBN.CHP1.1.07.FL.KA Rev3 [53]
When Benefit limits apply, the limit refers to any combination of (Designated Network Benefits, j
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Wealth Service
Eligible Expenses)
Maximum?
Deductible?
[[50 - 100]%)
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of $[5 -
150] per visit]
Include when group purchases benefits
for vision exams.
[[35.] Vision Examinations]
[Limited to [1 exam] [[2-31 exams] per
[Network] _
year.]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[Limited to [1 exam] [[2-3] exams]
[100% after you pay
every [2 - 3] years.]
a Copayment of [$5 -
75] per visit]
[Non -Network]
[[50 - 1001%]
[Yes] [No]
[Yes] [No]
[100% after you pay
a Copayment of [$5 -
75] per visit]
Include when group purchases benefits
^
far wigs.
[[36.] Wigs]
Include the limit selected by the group.
(Network]
[Limited to $[100 - 1,0001 per year.]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
[Limited to $[100 - 5,0001 every [24 -
36] months.]
[Non -Network]
[[50 - 100]%]
[Yes] [No]
[Yes] [No]
Additional Benefits Required By Florida Law
[37.] Bones or Joints of the Jaw and
Facial Region
Notification Requirement
Depending upon where the Covered Health Service is provided, any applicable notification or
authorization requirements will be the same as those stated under each Covered Health Service category
in this .Schedule of Benetils.
SBN.CHP1.1.07.FL.KA Rev3 [54]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,]
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Pocket
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
'Include heading and row when
['Designated Network]
Designated Network Benefits apply
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
Network
Depending upon where the Covered Health Service is provided.
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Non -Network
Depending upon where the Covered Health Service is provided.
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
[38.] Cleft Lip/Cleft Palate Treatment
Notification Requirement
Depending upon where the Covered Health Service is provided, any applicable notification car
authorization requirements will be the same as those stated under each Covered Health Servi:;e caaiegory
in this Schedule of Benefits.
'Include heading and row when
['Designated Network]
Designated Network Benefits apply
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.)
Network
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Non -Network
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
[39.] Mental Services - Anesthesia
and Hospitalization
Notification Requirement
Depending upon where the Covered Health Service is provided, any applicable notification or
ar.,thorization requirements will be the sarne as those stated under each Covered Health Service category
in this Schedule of Benefits.
SBN.CHP1.1.07.FL.KA Rev3 [55]
When Benefit limits apply, the limit refers to any combination of [Designated Network Benefits,J
Network Benefits and Non -Network Benefits unless otherwise specifically stated.
Benefit
(The Amount We
Apply to the
Must You Meet
Pay, based on
Out -of -Packet
Annual
Covered Health Service
Eligible Expenses)
Maximum?
Deductible?
'Include heading and row when
['Designated Network]
Designated Network Benefits apply
[Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under each
Covered Health Service category in this Schedule of Benefits.]
Network
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Non -Network
Depending upon where the Covered Health Service is provided,
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits.
Include when group purchases.
[40.] [Enteral Formulas]
-
(Limited to $2,500 for food products
[Network]
modified to be low protein.]
[50 - 100%] [Yes] [No] (Yes] [No]
[Non -Network]
[50 - 100%] [Yes] [No] [Yes;] [No]
[41,] Osteoporosis Treatment
- Notification Requirement
Depending upon where the Covered Health Service is provided, any applicable notification or
those stated render each Covered Health Service category
authorization requirements will be the sarne as
in this Schedule of Benefits.
'Include heading and row when
['Designated
Designated Network Benefits apply
Network]
[Yes] [No]
[Yes] [No]
[50 - 100%]
Network
[50 - 100%]
[Yes] [No]
[Yes] [No]
Non -Network
[50 - 100%]
[Yes] [No]
[Yes] [No]
Eligible Expenses
'Include when Designated Network Benefits apply for any Covered Health Service.
SBN.CHP1.1.07.FL.KA Rev3 [55]
Eligible Expenses are the amount we determine that we will pay for Benefits. For ['Designated Network
Benefits and] Network Benefits, you are not responsible for any difference between Eligible Expenses
and the amount the provider bills. For Non -Network Benefits, you are responsible for paying, directly to
the non -Network provider, any difference between the amount the provider bills you and the amount we
will pay for Eligible Expenses. Eligible Expenses are determined solely in accordance with our
reimbursement policy guidelines, as described in the Certificate of Coverage.
Include paragraph below if pre -service benefit notification includes determining alternate levels of
benefits.
'Include when ,group purchases MH1SA benefits. 2Include when group does not purchase MH1SA
benefits.
[If one or more alternative health services that meets the definition of Covered Health Service in the
Certificate of Coverage under Section 9: Defined Terms are clinically appropriate and equally effective for
prevention, diagnosis or treatment of a Sickness, Injury, ['Mental Illness,] [2mental illness,] substance
abuse or their symptoms, we reserve the right to adjust Eligible Expenses for identified Covered Health
Services based on defined clinical protocols. Defined clinical protocols shall be based upon nationally
recognized scientific evidence and prevailing medical standards and analysis of cost-effectiveness.]
For ['Designated Network Benefits and] Network Benefits, Eligible Expenses are based on either of the
following:
• When Covered Health Services are received from a [Designated Network and] Network provider,
Eligible Expenses are our contracted fee(s) with that provider.
• When Covered Health Services are received from a non -Network provider as a result of an
Emergency or as otherwise arranged by us, Eligible Expenses are billed charges unless a lower
amount is negotiated [or authorized by state law].
For Non -Network Benefits, Eligible Expenses are based on either of the following:
Include the provisions that apply for determining Eligible Expenses for Non -Network Benefits.
• When Covered Health Services are received from a non -Network provider, Eligible Expenses are
determined, [at our discretion,] based on [ the lesser of]:
'When using PHCS to determine Eligible Expenses for Non -Network Benefits, include the following and
delete MNRP provisions.
■ ['For Covered Health Services other than Pharmaceutical Products, Eligible Expenses are
determined based on available data resources of competitive fees in that geographic area.
■ When Covered Health Services are Pharmaceutical Products, Eligible Expenses are
determined based on [�]% of the amount that the Centers for Medicare and Medicaid
Services (CMS) would have paid under the Medicare program for the drug determined by
either of the following:
Reference to available CMS schedules.
Methods similar to those used by CMS.
■ Fee(s) that are negotiated with the provider.
■ [50 - 100]% of the billed charge.
■ A fee schedule that we develop.]
2When using MNRP to determine Eligible Expenses for Non -Network Benefits, include the following and
delete PHCS provisions.
[2Fee(s) that are negotiated with the provider.
SBN.CHP1.1.07.FL.KA Rev3 [57]
■ [ �]°t° of the published rates allowed by the Centers for Medicare and Medicaid Services
(CMS) for Medicare for the same or similar service [within the geographic market].
■ [50 - 100]% of the billed charge.
■ A fee schedule that we develop.]
When Covered Health Services are received from a Network provider, Eligible Expenses are our
contracted fee(s) with that provider.
Provider Network
We arrange for health care providers to participate in a Network. Network providers are independent
practitioners. They are not our employees. it is your responsibility to select your provider.
Our credentialing process confirms public information about the providers' licenses and other credentials,
but does not assure the quality of the services provided.
Before obtaining services you should always verify the Network status of a provider. A provider's status
may change. You can verify the provider's status by calling Customer Care. A directory of providers is
available online at www.myuhc.com or by calling Customer Care at the telephone number on your ID card
to request a copy.
It is possible that you might not be able to obtain services from a particular Network provider. The network
of providers is subject to change. Or you might find that a particular Network provider may not be
accepting new patients. If a provider leaves the Network or is otherwise not available to you, you must
choose another Network provider to get Network Benefits.
If you are currently undergoing a course of treatment utilizing a non -Network Physician or health care
facility, you may be eligible to receive transition of care Benefits. This transition period is available for
specific medical services and for limited periods of time. If you have questions regarding this transition of
care reimbursement policy or would like help determining whether you are eligible for transition of care
Benefits, please contact Customer Care at the telephone number on your ID card.
Do not assume that a Network provider's agreement includes all Covered Health Services. Some Network
providers contract with us to provide only certain Covered Health Services, but not all Covered Health
Services. Some Network providers choose to be a Network provider for only some of our products. Refer
to your provider directory or contact us for assistance.
Designated Facilities and Other Providers
If you have a medical condition that we believe needs special services, we may direct you to a
Designated Facility or Designated Physician chosen by us. If you require certain complex Covered Health
Services for which expertise is limited, we may direct you to a Network facility or provider that is outside
your local geographic area. If you are required to travel to obtain such Covered Health Services from a
Designated Facility or Designated Physician, we may reimburse certain travel expenses at our discretion.
In both cases, Network Benefits will only be paid if your Covered Health Services for that condition are
provided by or arranged by the Designated Facility, Designated Physician or other provider chosen by us.
You or your Network Physician must notify us of special service needs (such as transplants or cancer
treatment) that might warrant referral to a Designated Facility or Designated Physician. If you do not notify
us in advance, and if you receive services from a non -Network facility (regardless of whether it is a
Designated Facility) or other non -Network provider, Network Benefits will not be paid. Non -Network
Benefits may be available if the special needs services you receive are Covered Health Services for
which Benefits are provided under the Policy.
SBN.CHP1.1.07.FL..KA Rev3 [53]
Health Services from Non -Network Providers Paid as Network
Benefits
If specific Covered Health Services are not available from a Network provider, you may be eligible for
Network Benefits when Covered Health Services are received from non -Network providers. In this
situation, your Network Physician will notify us and, if we confirm that care is not available from a Network
provider, we will work with you and your Network Physician to coordinate care through a non -Network
provider.
Limitations on Selection of Providers
If we determine that you are using health care services in a harmful or abusive manner, or with harmful
frequency, your selection of Network providers may be limited. If this happens, we may require you to
select a single Network Physician to provide and coordinate all future Covered Health Services.
If you don't make a selection within 31 days of the date we notify you, we will select a single Network
Physician for you.
If you fail to use the selected Network Physician, Covered Health Services will be paid as Non -Network
Benefits.
SBN.CHP1.1.07.FL.KA Rev3 [59]