Summary Plan Description

Transcription

1 Summary Plan Description UnitedHealthcare Choice Plus Plan Local 1 Security Officers, Security Specialists Sergeant Guards for New York University Group Number: Effective Date: January 1, 2013

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3 Table of Contents Introduction... 1 How to Use this Document... 1 Information about Defined Terms... 1 Your Contribution to the Benefit Costs... 1 Customer Service and Claims Submittal... 1 Section 1: What's Covered--Benefits... 3 Accessing Benefits... 3 Copayment... 3 Eligible Expenses... 3 Notification Requirements... 4 Special Note Regarding Mental Health and Substance Use Disorder Services... 4 Payment Information... 6 Annual Deductible... 6 Out-of-Pocket Maximum... 6 Maximum Plan Benefit... 6 Benefit Information Acupuncture Services Ambulance Services - Emergency only Dental Services - Accident only Dental Services - Non-Accident Durable Medical Equipment Emergency Health Services Eye Examinations Hearing Aids Home Health Care Hospice Care Hospital - Inpatient Stay Infertility Services Injections received in a Physician's Office Maternity Services Mental Health Services Morbid Obesity Neurobiological Disorders - Autism Spectrum Disorder Services Ostomy Supplies Outpatient Surgery, Diagnostic and Therapeutic Services Physician's Office Services Professional Fees for Surgical and Medical Services Prosthetic Devices Reconstructive Procedures Rehabilitation Services - Outpatient Therapy Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Spinal Treatment, Chiropractic and Osteopathic Manipulative Therapy Substance Use Disorder Services Transplantation Services Urgent Care Center Services iii (Table of Contents)

4 Section 2: What's Not Covered--Exclusions How We Use Headings in this Section We Do not Pay Benefits for Exclusions A. Alternative Treatments B. Comfort or Convenience C. Dental D. Drugs E. Experimental, Investigational or Unproven Services F. Foot Care G. Mental Health/Substance Use Disorder H. Nutrition I. Physical Appearance J. Providers K. Reproduction L. Services Provided under Another Plan M. Transplants N. Travel O. Vision and Hearing P. All Other Exclusions Section 3: Description of Network and Non-Network Benefits Network Benefits Non-Network Benefits Emergency Health Services Section 4: When Coverage Begins How to Enroll If You Are Hospitalized When Your Coverage Begins If You Are Eligible for Medicare Who is Eligible for Coverage Eligible Person Dependent When to Enroll and When Coverage Begins Initial Enrollment Period Open Enrollment Period New Eligible Persons Adding New Dependents Special Enrollment Period Section 5: How to File a Claim...60 If You Receive Covered Health Services from a Network Provider Filing a Claim for Benefits Section 6: Questions and Appeals...63 What to Do First How to Appeal a Claim Decision Appeal Process Appeals Determinations Urgent Claim Appeals that Require Immediate Action Concurrent Care Claims Federal External Review Program iv (Table of Contents)

5 Section 7: Coordination of Benefits Benefits When You Have Coverage under More than One Plan When Coordination of Benefits Applies Definitions Order of Benefit Determination Rules Effect on the Benefits of this Plan Right to Receive and Release Needed Information Payments Made Right of Recovery Section 8: When Coverage Ends General Information about When Coverage Ends Events Ending Your Coverage The Entire Plan Ends You Are No Longer Eligible The Plan Administrator Receives Notice to End Coverage Participant Retires or Is Pensioned Other Events Ending Your Coverage Fraud, Misrepresentation or False Information Threatening Behavior Coverage for a Disabled Child Extended Coverage for Total Disability Continuation of Coverage and Conversion Continuation Coverage under Federal Law (COBRA) Qualifying Events for Continuation Coverage under Federal Law (COBRA) Notification Requirements and Election Period for Continuation Coverage under Federal Law (COBRA) Terminating Events for Continuation Coverage under Federal Law (COBRA) Conversion Section 9: General Legal Provisions...80 Plan Document Relationship with Providers Your Relationship with Providers Incentives to Providers Incentives to You Interpretation of Benefits Administrative Services Amendments to the Plan Clerical Error Information and Records Examination of Covered Persons Workers' Compensation not Affected Medicare Eligibility Subrogation and Reimbursement Refund of Overpayments Limitation of Action Section 10: Glossary of Defined Terms...86 v (Table of Contents)

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7 Introduction We are pleased to provide you with this Summary Plan Description (SPD). This SPD describes your Benefits, as well as your rights and responsibilities, under the Plan. How to Use this Document We encourage you to read your SPD and any attached Riders and/or Amendments carefully. We especially encourage you to review the Benefit limitation of this SPD by reading (Section 1: What's Covered--Benefits) and (Section 2: What's Not Covered--Exclusions). You should also carefully read (Section 9: General Legal Provisions) to better understand how this SPD and your Benefits work. You should call the Claims Administrator if you have questions about the limits of the coverage available to you. Many of the sections of the SPD are related to other sections of the document. You may not have all of the information you need by reading just one section. We also encourage you to keep your SPD and any attachments in a safe place for your future reference. Please be aware that your Physician does not have a copy of your SPD and is not responsible for knowing or communicating your Benefits. Information about Defined Terms Because this SPD is a legal document, we want to give you information about the document that will help you understand it. Certain capitalized words have special meanings. We have defined these words in (Section 10: Glossary of Defined Terms). You can refer to Section 10 as you read this document to have a clearer understanding of your SPD. When we use the words "we," "us," and "our" in this document, we are referring to the Plan Sponsor. When we use the words "you" and "your" we are referring to people who are Covered Persons as the term is defined in (Section 10: Glossary of Defined Terms). Your Contribution to the Benefit Costs The Plan may require the Participant to contribute to the cost of coverage. Contact your benefits representative for information about any part of this cost you may be responsible for paying. Customer Service and Claims Submittal Please make note of the following information that contains Claims Administrator department names and telephone numbers. Customer Service Representative (questions regarding Coverage or procedures): As shown on your ID card. Prior Notification: As shown on your ID card. Mental Health/Substance Use Disorder Services Designee: As shown on your ID card. 1 (Introduction)

8 Claims Submittal Address: United HealthCare Service LLC P.O. Box Atlanta, Georgia Requests for Review of Denied Claims and Notice of Complaints: Name and Address For Submitting Requests: United HealthCare Service LLC P.O. Box Salt Lake City, Utah (Introduction)

9 Section 1: What's Covered--Benefits This section provides you with information about: Accessing Benefits. Copayments and Eligible Expenses. Annual Deductible, Out-of-Pocket Maximum and Maximum Plan Benefit. Covered Health Services. We pay Benefits for the Covered Health Services described in this section unless they are listed as not covered in (Section 2: What's Not Covered--Exclusions). Covered Health Services that require you or your provider to notify the Claims Administrator before you receive them. In general, Network providers are responsible for notifying the Claims Administrator before they provide certain health services to you. You are responsible for notifying the Claims Administrator before you receive certain health services from a non- Network provider. Accessing Benefits You can choose to receive either Network Benefits or Non-Network Benefits. In most cases, you must see a Network Physician to obtain Network Benefits. 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 the Plan. As a result, they may bill you for the entire cost of the services you receive. For details about when Network Benefits apply, see (Section 3: Description of Network and Non-Network Benefits). Benefits are available only if all of the following are true: Covered Health Services are received while the Plan is in effect. Covered Health Services are received prior to the date that any of the individual termination conditions listed in (Section 8: When Coverage Ends) occurs. The person who receives Covered Health Services is a Covered Person and meets all eligibility requirements specified in the Plan. Copayment Copayment is the amount you pay each time you receive certain Covered Health Services. For a complete definition of Copayment, see (Section 10: Glossary of Defined Terms). Copayment amounts are listed on the following pages next to the description for each Covered Health Service. Please note that when Copayments are calculated as a percentage (rather than as a set dollar amount) the percentage is based on Eligible Expenses. Eligible Expenses Eligible Expenses are the amount that we will pay for Benefits, as determined by us or by our designee. In almost all cases our designee is the Claims Administrator. For a complete definition of Eligible 3 (Section 1: What's Covered--Benefits)

10 Expenses that describes how payment is determined, see (Section 10: Glossary of Defined Terms). We have delegated to the Claims Administrator the discretion and authority to determine on our behalf whether a treatment or supply is a Covered Health Service and how the Eligible Expense will be determined and otherwise covered under the Plan. When you receive Covered Health Services from Network providers, you are not responsible for any difference between the Eligible Expenses and the amount the provider bills. When you receive Covered Health Services from non-network providers, 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. Notification Requirements Prior notification is required before you receive certain Covered Health Services. In general, Network providers are responsible for notifying the Claims Administrator before they provide these services to you. There are some Network Benefits, however, for which you are responsible for notifying the Claims Administrator. When you choose to receive certain Covered Health Services from non-network providers, you are responsible for notifying us before you receive these Covered Health Services. Services for which you must provide prior notification appear in this section under the Must You Notify the Claims Administrator? column in the table labeled Benefit Information. To notify the Claims Administrator, call the telephone number on your ID card. 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, even if not indicated in the Must You Notify the Claims Administrator? column. 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 such as: The Cosmetic Procedures exclusion. Examples of procedures that may or may not be considered Cosmetic include: breast reduction and reconstruction (except for after cancer surgery when it is always considered a Covered Health Service); vein stripping, ligation and sclerotherapy, and upper lid blepharoplasty. The Experimental, Investigational or Unproven Services exclusion. Any other limitation or exclusion of the Plan. Special Note Regarding Mental Health and Substance Use Disorder Services You must provide pre-service notification as described below. When Benefits are provided for any of the services listed below, the following services require notification: Mental Health Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a Residential 4 (Section 1: What's Covered--Benefits)

11 Treatment Facility); intensive outpatient program treatment; outpatient electro-convulsive treatment; psychological testing; extended outpatient treatment visits beyond minutes in duration, with or without medication management; outpatient treatment provided in your home. Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders -inpatient services (including Partial Hospitalization/Day treatment and services at a Residential Treatment Facility); intensive outpatient program treatment; outpatient electro-convulsive treatment; psychological testing; extended outpatient treatment visits beyond minutes in duration, with or without medication management. Substance Use Disorder Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility); intensive outpatient program treatment; outpatient electro-convulsive treatment; psychological testing; extended outpatient treatment visits beyond minutes in duration, with or without medication management. For a scheduled admission, you must notify the Mental Health/Substance Use Disorder Administrator prior to the admission, or as soon as reasonably possible for non-scheduled admissions (including Emergency admissions). In addition, you must notify the Mental Health/Substance Use Disorder Administrator before the following services are received. Services requiring prior notification are: Intensive outpatient program treatment. Outpatient electro-convulsive treatment. Psychological testing. Outpatient treatment of opioid dependence. Extended outpatient treatment visits beyond minutes in duration, with or without medication management. Special Mental Health and Substance Use Disorder Programs and Services Special programs and services that are contracted under the Mental Health/Substance Use Disorder Administrator may become available to you as part of your Mental Health and Substance Use Disorder Services benefits. The Mental Health and Substance Use Disorder Services Benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of benefit use. Special programs or services provide access to services that are beneficial for the treatment of your Mental Illness or substance use disorder which may not otherwise be covered under this Plan. You must be referred to such programs through the Mental Health/Substance Use Disorder Administrator, who is responsible for coordinating your care or through other pathways as described in the program introductions. Any decision to participate in such program or service is at the discretion of the Covered Person and is not mandatory. Special Note Regarding Medicare If you are enrolled for Medicare on a primary basis (Medicare pays before we pay Benefits under the Plan), the notification requirements described in this SPD 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 the Claims Administrator before receiving Covered Health Services. 5 (Section 1: What's Covered--Benefits)

12 Payment Information Payment Term Description Amounts Annual Deductible The amount you pay for Covered Health Services before you are eligible to receive Benefits. For a complete definition of Annual Deductible, see (Section 10: Glossary of Defined Terms). Network* No Annual Deductible. Non-Network* $400 per Covered Person per calendar year, not to exceed $1,000 for all Covered Persons in a family. *Network and Non-Network Deductibles cross apply. Out-of- Pocket Maximum Maximum Plan Benefit The maximum you pay, out of your pocket, in a calendar year for Copayments. For a complete definition of Out-of-Pocket Maximum, see (Section 10: Glossary of Defined Terms). There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan. Network* $2,000 per Covered Person per calendar year, not to exceed $4,000 for all Covered Persons in a family. Non-Network* $6,000 per Covered Person per calendar year, not to exceed $12,000 for all Covered Persons in a family. The Out-of-Pocket Maximum does include the Annual Deductible. *Network and Non-Network Out of Pocket Maximums cross apply. Network and Non-Network No Maximum Plan Benefit. 6 (Section 1: What's Covered--Benefits)

13 Payment Term Description Amounts Generally the following are considered to be essential benefits under the Patient Protection and Affordable Care Act: Ambulatory patient services; emergency services, hospitalization; maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment); prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. 7 (Section 1: What's Covered--Benefits)

14 Benefit Information Description of Covered Health Service 1. Acupuncture Services Acupuncture services for pain therapy when the following is true: The service is performed by a Medical Doctor or certified acupuncturist in the provider's office. Non-Network Benefits are limited to 14 visits per calendar year. Must You Notify the Claims Administrator? Network No Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Physician s Office: $15 per office visit $25 per Specialist office visit Other place of service: 10% Does Copayment Help Meet Outof-Pocket Maximum? No No Yes Do You Need to Meet Annual Deductible? N/A N/A N/A Non-Network No 30% Yes Yes 2. Ambulance Services - Emergency only Emergency ambulance transportation by a licensed ambulance service to the nearest Hospital where Emergency Health Services can be performed. Network No Ground Transportation: 10% Yes N/A Air Transportation: 10% Non-Network No Same as Network Same as Network Same as Network 8 (Section 1: What's Covered--Benefits)

15 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? 3. Dental Services - Accident only Dental services when all of the following are true: Network Yes 0% N/A N/A Treatment is necessary because of accidental damage. Dental services are received from a Doctor of Dental Surgery, "D.D.S." or Doctor of Medical Dentistry, "D.M.D.". The dental damage is severe enough that initial contact with a Physician or dentist occurred within 72 hours of the accident. Benefits are available only for treatment of a sound, natural tooth. The Physician or dentist must certify that the injured tooth was: A virgin or unrestored tooth, or A tooth that has no decay, no filling on more than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant and functions normally in chewing and speech. Non-Network Same as In Network Same as In Network Same as In Network Same as In Network Dental services for final treatment to repair the damage must be both of the following: Started within three months of the accident. Completed within 12 months of the accident. Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary use of the teeth is not considered an "accident". Benefits are not available for repairs to 9 (Section 1: What's Covered--Benefits)

16 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? teeth that are injured as a result of such activities. Covered services also include: dental work, surgery, and orthodontic treatment needed to remove, repair, replace, restore, or reposition sound and natural teeth which have been damaged, lost, or removed, or other body tissues of the mouth which have been fractured or cut due to injury, under the following conditions: Any affected teeth must either be free from decay or in good repair and firmly attached to the jaw bone at the time of the injury The treatment must be done in the calendar year of the accident or the next one. Crowns, dentures, bridgework, or in mouth appliances are installed due to such injury, covered medical expenses include only charges for : The first denture or fixed bridgework to replace lost teeth; The first crown needed to repair each damaged tooth; and An in mouth appliance used in the first course of orthodontic treatment after the injury Notify the Claims Administrator Please remember that you must notify the Claims Administrator as soon as possible, but at least five business days before follow-up (post-emergency) treatment begins. (You do not have to provide notification before the initial Emergency treatment.) If you don't 10 (Section 1: What's Covered--Benefits)

17 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? notify the Claims Administrator you will be charged a $400 penalty. 4. Dental Services - Non-Accident Some treatment of mouth, jaws, and teeth is covered and precertification is required. Covered expenses for treatment received from a physician or dentist for teeth, mouth, jaws, jaw joints, or supporting tissue (bones, muscles, and nerves) include surgery needed to: Network Yes 10% Yes N/A treat a fracture, dislocation, or wound cut out any of the following: Teeth partly or completely impacted in the bone of the jaw: Teeth that will not erupt through the gum Non-Network Yes 30% Yes Yes Other teeth that cannot be removed with cutting into the bone; The roots of a tooth without removing the entire tooth Cysts, tumors, or other diseased tissues cut into gums and tissues of the mouth alter the jaw, jaw joints, or bite relationships by a cutting procedure, when appliance therapy alone cannot result in functional improvement Non-surgical treatment of infections or diseases is covered. 11 (Section 1: What's Covered--Benefits)

18 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? However, this does not include those of or related to the teeth. Notify the Claims Administrator Please remember that for Non-Network Benefits you must notify the Claims Administrator five business days before receiving services. (You do not have to provide notification before the initial Emergency treatment.) If you don't notify the Claims Administrator you will be charged a $400 penalty. 4. Durable Medical Equipment Durable Medical Equipment that meets each of the following criteria: Ordered or provided by a Physician for outpatient use. Used for medical purposes. Not consumable or disposable. Not of use to a person in the absence of a disease or disability. Network No 10% Yes N/A Non-Network No 30% Yes Yes If more than one piece of Durable Medical Equipment can meet your functional needs, Benefits are available only for the most cost-effective piece of equipment. Examples of Durable Medical Equipment include: Equipment to assist mobility, such as a standard wheelchair. A standard Hospital-type bed. Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks). 12 (Section 1: What's Covered--Benefits)

19 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? Delivery pumps for tube feedings (including tubing and connectors). Braces, including necessary adjustments to shoes to accommodate braces. Braces that stabilize an Injured body part are considered Durable Medical Equipment and are a Covered Health Service. Braces that straighten or change the shape of a body part are orthotic devices, and are excluded from coverage. Dental braces are also excluded from coverage. Mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters, and personal comfort items are excluded from coverage). We provide Benefits only for a single purchase (including repair/ replacement) of a type of Durable Medical Equipment once every three calendar years. We and the Claims Administrator will decide if the equipment should be purchased or rented. To receive Network Benefits, you must purchase or rent the Durable Medical Equipment from the vendor the Claims Administrator identifies. 5. Emergency Health Services Services that are required to stabilize or initiate treatment in an Emergency. Emergency Health Services must be received on an outpatient basis at a Hospital or Alternate Facility. You will find more information about Benefits for Emergency Network No Emergency: $50 per visit If admitted to the hospital Copayment is waived. No N/A 13 (Section 1: What's Covered--Benefits)

20 Description of Covered Health Service Health Services in (Section 3: Description of Network and Non-Network Benefits). Notify the Claims Administrator To ensure prompt and accurate payment of your claim as a Network Benefit, notify the Claims Administrator within two business days or as soon as possible after you receive outpatient Emergency Health Services at a non-network Hospital or Alternate Facility. Please remember that if you are admitted to a non-network Hospital as a result of an Emergency, you must notify the Claims Administrator within one business day or the same day of admission, or as soon as reasonably possible. If you don't notify the Claims Administrator you will be charged a $400 penalty. Benefits will not be reduced for the outpatient Emergency Health Services. 6. Eye Examinations Eye examinations received from a health care provider in the provider's office. Benefits include one routine vision exam, including refraction, to detect vision impairment by a Routine Vision Network Provider each calendar year. Benefits are not available for a routine vision exam, including refraction, that is not provided by a Routine Vision Network Provider. Must You Notify the Claims Administrator? Non-Network Yes, but only for an Inpatient Stay. Network No Non-Network No Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? Non-Emergency: 10% Yes N/A Same as Network Non-Emergency: 30% $15 per visit $25 per Specialist visit Same as Network Yes No No Yes Yes N/A N/A 30% Yes Yes 14 (Section 1: What's Covered--Benefits)

21 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? 7. Hearing Aids Hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive sound which may range from slight to complete deafness). Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver. Network No Non-Network No 10% 30% Yes Yes N/A Yes Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a Physician. Benefits are provided for the hearing aid and for charges for associated fitting and testing. Benefits under this section do not include bone anchored hearing aids. Bone anchored hearing aids are a Covered Health Service for which Benefits are available under the applicable medical/surgical Covered Health Services categories in the Certificate, only for Covered Persons who have either of the following: Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid. Hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid. Benefits are limited to $5,000 every 3 years.. 15 (Section 1: What's Covered--Benefits)

22 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? 8. Home Health Care Services received from a Home Health Agency that are both of the following: Network No 10% Yes N/A Ordered by a Physician. Provided by or supervised by a registered nurse in your home. Benefits are available only when the Home Health Agency services are provided on a part-time, intermittent schedule and when skilled care is required. Non-Network Yes 30% Yes Yes Skilled care is skilled nursing, skilled teaching, and skilled rehabilitation services when all of the following are true: It must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient. It is ordered by a Physician. It is not delivered for the purpose of assisting with activities of daily living, including but not limited to dressing, feeding, bathing or transferring from a bed to a chair. It requires clinical training in order to be delivered safely and effectively. It is not Custodial Care. We and the Claims Administrator will decide if skilled care is required by reviewing both the skilled nature of the service and the 16 (Section 1: What's Covered--Benefits)

23 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? need for Physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an available caregiver. Any combination of Network and Non-Network Benefits is limited to 200 visits per calendar year. One visit equals four hours of skilled care services. Notify the Claims Administrator Please remember that for Non-Network Benefits you must notify the Claims Administrator five business days before receiving services. If you don't notify the Claims Administrator you will be charged a $400 penalty. 9. Hospice Care Hospice care that is recommended by a Physician. Hospice care is an integrated program that provides comfort and support services for the terminally ill. Hospice care includes physical, psychological, social and spiritual care for the terminally ill person, and short-term grief counseling for immediate family members. Benefits are available when hospice care is received from a licensed hospice agency. Please contact the Claims Administrator for more information regarding guidelines for hospice care. You can contact the Claims Administrator at the telephone number on your ID card. Notify the Claims Administrator Please remember that for Non-Network Benefits you must notify the Claims Administrator five business days before receiving services. If you don't notify the Claims Administrator you will be Network No 10% Yes N/A Non-Network Yes 30% Yes Yes 17 (Section 1: What's Covered--Benefits)

24 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? charged a $400 penalty. 10. Hospital - Inpatient Stay Inpatient Stay in a Hospital. Benefits are available for: Services and supplies received during the Inpatient Stay. Room and board in a Semi-private Room (a room with two or more beds). Notify the Claims Administrator Please remember that for Non-Network Benefits you must notify the Claims Administrator as follows: Network No 10% Yes N/A Non-Network Yes 30% Yes Yes For elective admissions: five business days before admission. For non-elective admissions: within one business day or the same day of admission. For Emergency admissions: within one business day or the same day of admission, or as soon as is reasonably possible. If you don't notify the Claims Administrator you will be charged a $400 penalty. 11. Infertility Services Services for the diagnosis and treatment of underlying condition of infertility when provided by or under the direction of a Physician. Network No $15 per visit $25 per Specialist visit No N/A 18 (Section 1: What's Covered--Benefits)

25 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? Non-Network No 30% Yes Yes 12. Injections received in a Physician's Office Benefits are available for injections received in a Physician's office when no other health service is received, for example allergy immunotherapy. Network No $15 per visit $25 per Specialist visit No N/A Non-Network No 30% Yes Yes 13. Maternity Services Benefits for Pregnancy will be paid at the same level as Benefits for any other condition, Sickness or Injury. This includes all maternityrelated medical services for prenatal care, postnatal care, delivery (including home delivery), and any related complications. There are special prenatal programs to help during Pregnancy. They are completely voluntary and there is no extra cost for participating in the programs. To sign up, you should notify the Claims Administrator during the first trimester, but no later than one month prior to the anticipated childbirth. We will pay Benefits for an Inpatient Stay of at least: Network No 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 section. No Copayment applies to Physician office visits for prenatal care after the first visit. In place of the Copayments for Physician's 19 (Section 1: What's Covered--Benefits)

26 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? 48 hours for the mother and newborn child following a normal vaginal delivery. 96 hours for the mother and newborn child following a cesarean section delivery. If the mother agrees, the attending provider may discharge the mother and/or the newborn child earlier than these minimum time frames. Office Services and Professional Fees, a global maternity Copayment of $15 applies. Notify the Claims Administrator Please remember that for Non-Network Benefits you must notify the Claims Administrator as soon as reasonably possible if the Inpatient Stay for the mother and/or the newborn will be more than the time frames described. If you don't notify the Claims Administrator that the Inpatient Stay will be extended you will be charged a $400 penalty. Non-Network Yes if Inpatient Stay exceeds time frames. 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 section. 14. Mental Health Services The Mental Health Parity and Addiction Equity Act requires employers and Health Insurance plans to ensure that the financial requirements (Such as Co-pays, deductibles and treatment limitations (such as visit limits) applicable to mental health or substance abuse disorder be no more restrictive than the limits for all other medical/surgical benefits. NYU is fully compliant with the Mental Health Parity and Addiction Act. Network No Inpatient 10% Outpatient $15 Copay Yes No N/A No Mental Health Services include those received on an inpatient basis in a Hospital or an Alternate Facility, and those received on an 20 (Section 1: What's Covered--Benefits)

27 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? outpatient basis in a provider's office or at an Alternate Facility. Benefits include: diagnostic evaluations and assessment; treatment planning; referral services; medication management; individual, family, therapeutic group and provider-based case management services; and crisis intervention. Non-Network Yes 30% Yes Yes Benefits include the following services provided on an inpatient basis: Inpatient Hospitalization Partial Hospitalization/Day Treatment. Services at a Residential Treatment Facility. Benefits include the following services provided on an outpatient basis: Intensive Outpatient Treatment. The Mental Health/Substance Use Disorder Designee, who will authorize the services, will determine the appropriate setting for the treatment. If an Inpatient Stay is required, it is covered on a Semi-private Room basis. Referrals to a Mental Health Services provider are at the discretion of the Mental Health/Substance Use Disorder Designee, who is responsible for coordinating all of your care. 21 (Section 1: What's Covered--Benefits)

28 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? Mental Health Services must be authorized and overseen by the Mental Health/Substance Use Disorder Designee. Contact the Mental Health/Substance Use Disorder Designee regarding Benefits for Mental Health Services. Inpatient Pre-Service Notification Requirement For Non-Network Benefits for a scheduled admission for Mental Health Services (including an admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility), you must notify us prior to the admission, or as soon as is reasonably possible for non-scheduled admissions (including Emergency admissions). If you fail to notify us as required, $400 penalty will apply. For Network Benefits notification is given by the provider. Outpatient Pre-Service Notification Requirement Notification is required before the following services are received: intensive outpatient program treatment; outpatient electroconvulsive treatment; psychological testing; extended outpatient treatment visits beyond minutes in duration, with or without medication management; outpatient treatment provided in your home. For Network Benefits notification is given by the provider. For Non-Network Benefits you must notify us before the services are received. 22 (Section 1: What's Covered--Benefits)

29 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? 17. Morbid Obesity Morbid Obesity Surgery Based on Care Coordination determination. Bariatric and Lap Band Surgery are covered. Abdominoplasty is covered when necessary due to significant weight loss. The procedure is covered when necessary for functional deficit, or physical impairment, such as skin rashes, paid as any other surgery. This is not covered if deemed cosmetic. Network No 10% Yes N/A Non-Network 15. Neurobiological Disorders - Autism Spectrum Disorder Services Psychiatric services for Autism Spectrum Disorders that are both of the following: Provided by or under the direction of an experienced psychiatrist and/or an experienced licensed psychiatric provider. Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others and property, and impairment in daily functioning. These Benefits describe only the psychiatric component of treatment for Autism Spectrum Disorders. Medical treatment of Autism No 30% Yes Yes Network No Inpatient 10% Outpatient $15 Copay Yes No N/A No 23 (Section 1: What's Covered--Benefits)

30 Description of Covered Health Service Spectrum Disorders is a Covered Health Service for which Benefits are available under the applicable medical Covered Health Services categories as described in this section. Benefits include the following services provided on either an outpatient or inpatient basis: Diagnostic evaluations and assessment. Treatment planning. Referral services. Medication management. Inpatient/24-hour supervisory care. Partial Hospitalization/Day Treatment. Intensive Outpatient Treatment. Services at a Residential Treatment Facility. Individual, family, therapeutic group, and provider-based case management services. Crisis intervention. Autism Spectrum Disorder services must be authorized and overseen by the Mental Health/Substance Use Disorder Designee. Contact the Mental Health/Substance Use Disorder Designee regarding Benefits for Neurobiological Disorders - Autism Spectrum Disorder Services. Inpatient Pre-Service Notification Requirement For Non-Network Benefits for a scheduled admission for Neurobiological Disorders - Autism Spectrum Disorder Services (including an admission for Partial Hospitalization/Day Treatment Must You Notify the Claims Administrator? Non-Network Yes Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? 30% Yes Yes 24 (Section 1: What's Covered--Benefits)

31 Description of Covered Health Service and services at a Residential Treatment Facility), you must notify us prior to the admission, or as soon as is reasonably possible for nonscheduled admissions (including Emergency admissions). If you fail to notify us as required, $400 penalty will apply. For Network Benefits notification is given by the provider. Outpatient Pre-Service Notification Requirement Notification is required before the following services are received: intensive outpatient program treatment; outpatient electroconvulsive treatment; psychological testing; extended outpatient treatment visits beyond minutes in duration, with or without medication management; outpatient treatment provided in your home. For Network Benefits, notification is given by the provider. For Non-Network Benefits you must notify us before the services are received. Mental Health Services for Biologically Based Mental Illness and for Children with Serious Emotional Disturbances- Inpatient and Intermediate Benefits for the treatment of certain Mental Illnesses are covered on the same basis as Benefits provided for the treatment of physical illnesses. Benefits are provided for the treatment of Biologically Based Mental Illness and for Children with serious Emotional Disturbances received on an inpatient or intermediate basis in a Hospital or an Must You Notify the Claims Administrator? Network No Non-Network Yes Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Same as Hospital Inpatient Stay Same as Hospital Inpatient Stay Do You Need to Meet Annual Deductible? 25 (Section 1: What's Covered--Benefits)

32 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? Alternate Facility. The Mental Health / Substance Abuse Designee, who will authorize the services, will determine the appropriate setting for the treatment. If an Inpatient Stay is required, it is covered on a Semi-private Room basis. At the discretion of the Mental Health/Substance Abuse Designee, two sessions of intermediate care (such as partial hospitalization) may be substituted for one inpatient day. Network Benefits for Mental Health Services for Biologically Based Mental Illness and for Children with serious Emotional Disturbances must be provided by or under the direction of the Mental Health / Substance Abuse Designee. For Network Benefits, referrals to a Mental Health provider are at the sole discretion of the Mental Health / Substance Abuse Designee, who is responsible for coordinating all of your care. Contact the Mental Health / Substance Abuse Designee regarding Benefits for inpatient / intermediate Mental Health Services for Biologically Based Mental Illness and Children with serious Emotional Disturbances. Notification Required Please remember that you must call to receive these Benefits in advance of any treatment through the Mental Health/Substance Abuse Designee. The Mental Health/Substance Abuse Designee phone number appears on your ID card. If you don't notify us, a $400 penalty will apply. 26 (Section 1: What's Covered--Benefits)

33 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? Biologically Based Mental Illness and Children with Serious Emotional Disturbances Outpatient Benefits for the treatment of certain Mental Illnesses are covered on the same basis as Benefits provided for the treatment of physical illnesses. Network No Outpatient $15 Copay No N/A Benefits are provided for the treatment of Biologically Based Mental Illness and Children with serious Emotional Disturbances received on an outpatient basis in a provider's office or at an Alternate Facility, including: Non-Network Yes 30% Yes Yes Biologically Based Mental Illness evaluations and assessment. Diagnosis. Treatment planning. Referral services. Medication management. Short-term individual, family and group therapeutic services (including intensive outpatient therapy). Crisis intervention. For Network Benefits, referrals to a Mental Health provider are at the sole discretion of the Mental Health / Substance Abuse Designee, who is responsible for coordinating all of your care. Contact the Mental Health / Substance Abuse Designee regarding Network Benefits for outpatient Mental Health Services for Biologically Based Mental Illness and Children with serious Emotional Disturbances. 27 (Section 1: What's Covered--Benefits)

34 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? 16. Ostomy Supplies Benefits for ostomy supplies include only the following: Network No 10% Yes N/A Pouches, face plates and belts. Irrigation sleeves, bags and catheters. Skin barriers. Benefits are not available for gauze, adhesive, adhesive remover, deodorant, pouch covers, or other items not listed above. 17. Outpatient Surgery, Diagnostic and Therapeutic Services Covered Health Services received on an outpatient basis at a Hospital or Alternate Facility including: Surgery and related services. Lab and radiology/x-ray. Mammography testing. Other diagnostic tests and therapeutic treatments (including cancer chemotherapy or intravenous infusion therapy). Non-Office based Preventive/Routine Care Services: In-Network Lab, X-Ray or Other Preventive/Routine Tests - 100% (Deductible does not apply). Non-Network No Network No 30% Yes Yes 10% for diagnostic and therapeutic services. Yes N/A 28 (Section 1: What's Covered--Benefits)

35 Description of Covered Health Service Must You Notify the Claims Administrator? Your Copayment Amount % Copayments are based on a percent of Eligible Expenses Does Copayment Help Meet Outof-Pocket Maximum? Do You Need to Meet Annual Deductible? Out of Network Lab, X-Ray or Other Preventive/Routine Tests - 60% after Deductible. Benefits under this section include only the facility charge and the charge for required services, supplies and equipment. Benefits for the professional fees related to outpatient surgery, diagnostic and therapeutic services are described under Professional Fees for Surgical and Medical Services below. Non-Network No 30% Yes Yes When these services are performed in a Physician's office, Benefits are described under Physician's Office Services below. 18. Physician's Office Services Covered Health Services for preventive medical care. Network No No Copayment No N/A Preventive care services provided on an outpatient basis at a Physician's office, an Alternate Facility or a Hospital encompass medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes and include the following as required under applicable law: Non-Network No 30% Yes Yes evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; 29 (Section 1: What's Covered--Benefits)