Health Plan of Nevada, Inc. (HPN) Distinct Advantage POS Option 3

Transcription

1 Health Plan of Nevada, Inc. (HPN) Distinct Advantage POS Option 3 Attachment A Benefit Schedule This Plan includes a 12-month waiting period for maternity coverage. Lifetime Maximum Benefit: The combined lifetime maximum benefit for the Tier II Expanded Plan Provider and Tier III Non-Plan Provider plan services is $1,000,000 of EME. Tier I HMO Benefits apply when you obtain coverage or arrange for Covered Services through an HPN contracted Primary Care Physician. No claim forms are required, no deductible applies, and the Tier I HMO benefits provide a higher level of coverage with less out-of-pocket expenses than the Tier II Expanded Plan Provider or Tier III Non-Plan Provider benefits. Tier II Expanded Plan Provider Benefits apply when a Member obtains Covered Services from a Provider who is independently contracted by HPN, to provide services to Members enrolled in Distinct Advantage Option 3. The Member s out-of-pocket expenses will be higher than Tier I HMO benefits because the Member will be responsible for a Calendar Year deductible, coinsurance percentages and, in some instances, higher Copayments. Claim forms are not required when using contracted Tier II Expanded Plan Providers. Tier III Non-Plan Provider Benefits apply when a Member obtains Covered Services from a Tier III Non-Plan Provider. All benefits are subject to a Calendar Year deductible and coinsurance percentage, up to a Member s Calendar Year coinsurance maximum. Claim forms must be submitted for services received from Tier III Non-Plan Providers. Emergency Services: The Tier I HMO level of benefits will apply to Emergency Services provided at any duly licensed facility. Upon admission to a Tier III Non-Plan Hospital and stabilization of the emergency condition and safe for transfer as determined by the attending Physician, the Plan may require transfer to a Tier I HMO contracted facility in order to pay benefits at the Tier I HMO benefit level. Benefits for post-stabilization and follow-up care received at a Tier II Expanded Plan or Tier III Non-Plan Provider Hospital facility are subject to the applicable benefit tier. Calendar Year Deductible (CYD): Your CYD is $500 per Member and $1,500 per family. The CYD is a combined total of Eligible Medical Expenses (EME) for Tier II Expanded Plan Provider and Tier III Non-Plan Provider Covered Services. Coinsurance: After meeting your CYD, your coinsurance for most Tier II Expanded Plan Provider Covered Services is 20% of EME. Your coinsurance for most Tier III Non-Plan Provider Covered Services is 40% of EME. Coinsurance Maximum: After satisfying your CYD, your coinsurance is limited to a maximum of $2,000 of EME per Member per Calendar Year ($6,000 per family) if you use Tier II Expanded Plan Providers, and $4,000 of EME per Member per Calendar Year ($12,000 per family) if you use Tier III Non-Plan Providers. In no event will the total coinsurance you pay exceed $4,000 of EME per Member or $12,000 per family in any Calendar Year. Refer to the Distinct Advantage Point-of-Service Rider for amounts that do not accumulate to the Calendar Year coinsurance maximum. Note: You are responsible for all amounts exceeding the applicable benefit maximums, EME payments to Tier III Non-Plan Providers, and penalties for not complying with the Managed Care Program. Further, such amounts do not accumulate to your Calendar Year coinsurance maximum. Please read your HPN Agreement of Coverage and all other applicable Endorsements, Riders and Attachments, if any, to determine the governing contractual provisions for this Plan and to understand how EME payments to Providers are determined. Legal Documents Page 1

2 Medical Physician Services and Physician Consultations Office Visit/Consultation Primary Care Physician No $15 per visit $30 per visit After CYD, Member pays 40% Specialist Yes $30 per visit $45 per visit of EME. Prior Authorization is not required for Tier II and Tier III benefits. Inpatient Visit/Consultation Primary Care Physician Yes No charge No charge After CYD, Member pays 40% Specialist Yes No charge No charge of EME. Preventive Healthcare No $15 per visit Member pays 20% Member pays 40% Services of EME. of EME. a combined Tier II Not subject to CYD. Not subject to CYD. and Tier III maximum benefit of $500 per Calendar Year. Refer to your Agreement of Coverage for applicable age and frequency limitations. Laboratory Services Yes $15 per visit $15 per visit After CYD, Member Copayment is in addition to the pays 40% of EME. office visit Copayment and applies to services rendered in a Physician s office or at an independent lab. Routine Radiological and Yes $15 per visit $15 per visit After CYD, Member Non-Radiological Diagnostic pays 30% of EME. Imaging Services Copayment is in addition to the office visit Copayment and applies to services rendered in a Physician s office or at an independent radiological facility. Page 2

3 Emergency Services Within Emergency Emergency the Service Area Services are Services are covered under the covered under the Urgent Care Facility Tier I HMO benefit. Tier I HMO benefit. Southwest Medical No $45 per visit Associates (SMA) Plan Provider Other Plan Provider No $50 per visit Non-Plan Provider No $60 per visit Physician s Services in Emergency Room Plan Provider No $25 per visit Non-Plan Provider No $75 per visit Emergency Room Plan Provider No $75 per visit Non-Plan Provider No $150 per visit Hospital Admission Emergency Stabilization No $150 per day not to Applies until stabilization and exceed $400 per safe for transfer as determined admission by the attending Physician. Legal Documents Lab and X-rays Plan Provider No $15 per visit Non-Plan Provider No $30 per visit The maximum benefit for Medically Necessary but non- Emergency Services received in an emergency room is 50% of EME. You are responsible for all amounts exceeding the Plan s applicable maximum Benefit and amounts exceeding The Plan s EME payment to Tier III Non-Plan Providers. Page 3

4 Emergency Services Outside Emergency Emergency the Service Area Services are Services are covered under the covered under the Urgent Care Facility No $60 per visit Tier I HMO benefit. Tier I HMO benefit. Physician s Services in Emergency Room No $75 per visit Emergency Room Facility No $150 per visit Hospital Admission Emergency Stabilization No $150 per day not to Applies until stabilization and exceed $400 per safe for transfer as determined admission. by the attending Physician. Lab and X-rays No $30 per visit The maximum benefit for Medically Necessary but non- Emergency Services received in an emergency room is 50% of EME. You are responsible for all amounts exceeding the Plan s applicable maximum Benefit and amounts exceeding the Plan s EME payment to Tier III Non-Plan Providers. Ambulance Services Emergency Emergency Ambulance Ambulance Emergency Ground Transport No $150 per trip Services are Services are covered under the covered under the Emergency Air Transport No 50% of EME per trip Tier I HMO benefit. Tier I HMO benefit. HPN Arranged Transfers Yes No charge Inpatient Hospital Facility Yes $150 per day not to After CYD, Member After CYD, Member Services exceed $400 per pays 20% of EME. pays 40% of EME. admission. Page 4

5 Outpatient Hospital Facility Yes $75 per admission After CYD, Member After CYD, Member and Ambulatory Surgical pays 20% of EME. pays 40% of EME. Facility Services, includes Sterilizations are Sterilizations are Sterilization covered under the covered under the Tier I HMO benefit. Tier I HMO benefit. Inpatient and Outpatient After CYD, Member After CYD, Member Physician Surgical Services pays 20% of EME. pays 40% of EME. Inpatient Hospital Facility Yes $100 per operative session Outpatient Hospital Facility Yes $75 per operative session Physician s Office Primary Care Physician Yes $15 per visit (inadditiontoofficevisit Copayment) Specialist (in addition to Yes $30 per visit office visit Copayment) Legal Documents Sterilizations in Physician s Yes $15 per surgery Sterilizations are Sterilizations are Office covered under the covered under the Tier I HMO benefit. Tier I HMO benefit. Assistant Surgical Services Yes $50 per operative After CYD, Member After CYD, Member session pays 20% of EME. pays 40% of EME. Anesthesia Services Yes $100 per operative After CYD, Member After CYD, Member session pays 20% of EME. pays 40% of EME. Gastric Restrictive Surgical Gastric Restrictive Gastric Restrictive Services Surgical Services Surgical Services are covered under are covered under Physician Surgical Services Yes 50% of EME. the Tier I HMO the Tier I HMO The maximum lifetime benefit benefit. benefit. for all Gastric Restrictive Surgical Services is $5,000 per Member. Page 5

6 Gastric Restrictive Surgical Gastric Restrictive Gastric Restrictive Services (continued) Surgical Services Surgical Services are covered under are covered under Complications Yes 50% of EME. the Tier I HMO the Tier I HMO The maximum lifetime benefit benefit. benefit. for all complications in connection with Gastric Restrictive Surgical Services is $5,000 per Member. Mastectomy Reconstructive Mastectomy Mastectomy Surgery Reconstructive Reconstructive Surgery is covered Surgery is covered Physician Surgical Services Yes $100 per operative under the Tier I under the Tier I session HMO benefit. HMO benefit. Prosthetic Device for Yes $750 per device Prosthetic Device Prosthetic Device Mastectomy Reconstruction for Mastectomy for Mastectomy Unlimited Reconstructive Reconstructive Surgery is covered Surgery is covered under the Tier I under the Tier I HMO benefit. HMO benefit. Oral Surgical Services After CYD, Member After CYD, Member pays 20% of EME. pays 40% of EME. Office Visit Yes $30 per visit Physician Surgical Services Inpatient Hospital Facility Yes $100 per operative session Outpatient Hospital Facility Yes $75 per operative session Organ and Tissue Transplant Organ Transplants/ Organ Transplants/ Surgical Services Retransplantations Retransplantations are covered under are covered under Inpatient Hospital Facility Yes $150 per day not to the Tier I HMO the Tier I HMO Services exceed $400 per benefit. benefit. admission. Subject to maximum benefit. Page 6

7 Organ and Tissue Transplant Organ Transplants/ Organ Transplants/ Surgical Services (continued) Retransplantations Retransplantations are covered under are covered under Physician Surgical Services Yes $100 per operative the Tier I HMO the Tier I HMO session. benefit. benefit. Transportation, Lodging and Yes No charge. Subject Meals to maximum The maximum benefit per benefit. Member per Transplant Benefit Period for transportation, lodging and meals is $10,000. The maximum daily limit for lodging and meals is $200. Procurement Yes No charge. Subject The maximum benefit per to maximum Member per Transplant Benefit benefit. Period for Procurement of the organ/tissue is $15,000 of EME. Retransplantation Services Yes 50% of EME. The 50% of EME for Retransplantation Services does not apply towards the Copayment maximum. Legal Documents The maximum benefit that will be paid for a Member for all Covered Transplant Procedures combined is $100,000. Home Healthcare Services After CYD, Member After CYD, Member Refer to your outpatient pays 20% of EME. pays 40% of EME. Prescription Drug Benefit Rider, if applicable, for your outpatient self-injectable covered drug benefit. Physician House Calls Yes $30 per visit Home Care Services Yes $30 per visit Page 7

8 Home Healthcare Services After CYD, Member After CYD, Member (continued) pays 20% of EME. pays 40% of EME. Private Duty Nursing Yes $15 per visit a combined Tier II and Tier III maximum benefit of thirty (30) visits per Calendar Year or $5,000, whichever is less. Hospice Care Services Hospice Care Hospice Care Services are Services are Inpatient Hospice Services Yes $150 per day not to covered under the covered under the exceed $400 per Tier I HMO benefit. Tier I HMO benefit. admission. Outpatient Hospice Services Yes No charge Inpatient Respite Services Yes $150 per day not to Limited to $1,500 per Member exceed $400 per per Calendar Year. admission. Subject to maximum benefit. Outpatient Respite Services Yes $15 per visit. Limited to $1,000 per Member per Calendar Year. Bereavement Services Yes $15 per visit. Limited to five (5) group therapy sessions or a maximum of $500, whichever is less. Treatment must be completed within six (6) months. Skilled Nursing Facility Yes $150 per day not to After CYD, Member After CYD, Member Services exceed $400 per pays 20% of EME. pays 40% of EME. a combined Tier I, II admission. Subject and III maximum benefit of 100 to maximum days per Member per Calendar benefit. Year. Page 8

9 Manual Manipulation (except Yes $15 per visit $30 per visit. After CYD, Member for reduction of fractures Pays 40% of EME. or dislocation) a combined Tier II and Tier III maximum benefit of $1,000 per Member per Calendar Year and $5,000 maximum lifetime benefit. Short-Term Rehabilitation After CYD, Member After CYD, Member Services pays 20% of EME. pays 40% of EME. Inpatient Hospital Facility Yes $150 per day not to exceed $400 per admission. Subject to Outpatient Hospital Facility Yes $15 per visit. All Inpatient and outpatient Short-Term Rehabilitation Services are subject to a combined Tier I, II, and III lifetime maximum benefit of sixty (60) calendar days. Legal Documents Durable Medical Equipment Yes No charge. Subject After CYD, Member After CYD, Member For rental or purchase at HPN s to maximum pays 50% of EME. pays 50% of EME. option. Limited to a combined benefit. Tier I, II, and III lifetime maximum benefit of $4,000. Genetic Disease Testing Yes 50% of EME per Genetic Disease Genetic Disease Services test. Testing Services Testing Services Includes Inpatient, outpatient, are Covered under are Covered under and independent laboratory the Tier I HMO the Tier I HMO services. benefit. benefit. Page 9

10 Infertility Office Visit Yes $30 per visit After CYD, Member After CYD, Member Evaluation pays 20% of EME. pays 40% of EME. Please refer to Covered Services Copayments for any Infertility procedures performed. Medical Supplies Yes No charge After CYD, Member After CYD, Member pays 20% of EME. pays 40% of EME. Other Diagnostic and After CYD, Member After CYD, Member Therapeutic Services pays 20% of EME. pays 40% of EME. Copayment is in addition to the office visit Copayment and applies to services rendered in a Physician s office or at an independent facility. Allergy Testing and Serum Yes $30 per visit Amniocentesis Yes $30 per visit Anti-Cancer Drug Therapy, non- Yes $30 per visit cancer related intravenous injection therapy or other Medically Necessary intravenous therapeutic services. Dialysis Yes $30 per visit Other services such as: Yes $30 per test or complex diagnostic imaging procedure (i.e., CAT scan, MRI); complex neurological or psychiatric testing or therapeutic services; pulmonary diagnostic services; vascular diagnostic and therapeutic services. Page 10

11 Other Diagnostic and After CYD, Member After CYD, Member Therapeutic Services pays 20% of EME. pays 40% of EME. (continued) Otologic Evaluations Yes $30 per visit Positron Emission Tomography Yes $750 per procedure (PET Scan) Therapeutic Radiology Yes $30 per visit Prosthetic and Orthotic Yes $750 per device. After CYD, Member After CYD, Member Devices maximum pays 20% of EME. pays 40% of EME. Limited to a combined Tier I, II, benefit. and III lifetime maximum maximum Benefit. maximum Benefit. benefit,including repairs, of $10,000. Self-Management and Treatment of Diabetes After CYD, Member pays 40% of EME. Legal Documents Education and Training No $15 per visit $30 per visit Supplies (except for Insulin No $5 per therapeutic $5 per therapeutic Pump Supplies) supply supply Insulin Pump Supplies Yes $15 per therapeutic $15 per therapeutic supply supply Equipment (except for Insulin Yes $20 per device $20 per device Pumps) Insulin Pumps Yes $100 per device $100 per device Special Food Products and Yes No charge. See After CYD, Member After CYD, Member Enteral Formulas pays 20% of EME. pays 40% of EME. Special Food Products are See maximum See maximum Limited to a combined Tier I, II, benefit. benefit. Page 11

12 Special Food Products and Enteral Formulas (continued) and III maximum benefit of $2,500 per Member per Calendar Year. Temporomandibular Yes 50% of EME. TMJ Treatment is TMJ Treatment is Joint Treatment (TMJ) covered under the covered under the Dental-related treatment is Tier I HMO benefit. Tier I HMO benefit. limited to $2,500 per Member per Calendar Year and $4,000 maximum lifetime benefit per Member. Mental Health Services Inpatient Hospital Facility Yes $150 per day not to After CYD, Member After CYD, Member Limited to a combined Tier I, II, exceed $400 per pays 20% of EME. pays 40% of EME. and III maximum benefit of thirty admission. Subject (30) days per Member per to maximum Calendar Year. benefit. Outpatient Treatment Group Therapy Yes $15 per visit After CYD, Member After CYD, Member Unlimited visits. pays 20% of EME. pays 40% of EME. Individual, Family and Partial Yes $20 per visit. After CYD, Member After CYD, Member Care Therapy** pays 20% of EME. pays 40% of EME. LimitedtoacombinedTier I, II, and III maximum benefit of twenty (20) visits per Member per Calendar Year. Benefit maximum does not apply to visits for medication management. Page 12

13 Mental Health Services (continued) **Partial care refers to a Coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. Severe Mental Illness After CYD, Member After CYD, Member Services pays 20% of EME. pays 40% of EME. maximum Benefit. maximum Benefit. Inpatient Hospital Facility Yes $150 per day not to Limited to a combined Tier I, II, exceed $400 per and III maximum benefit of forty admission. Subject (40) days per Member per to maximum Calendar Year. benefit. Legal Documents Outpatient Treatment Yes $15 per visit. Limited to a combined Tier I, II, and III maximum benefit of forty (40) visits per Member per Calendar Year. Two (2) visits for partial or respite care, or a combination thereof, may be substituted for each day of Inpatient hospitalization not used by the Member. Benefit maximum does not apply to visits for medication management. Page 13

14 Substance Abuse Services After CYD, Member After CYD, Member pays 20% of EME. pays 40% of EME. Inpatient Rehabilitation Yes $150 per day not to Limited to a combined Tier I, II, exceed $400 per and III maximum benefit of admission. Subject $9,000 per Member per to maximum Calendar Year. benefit. Outpatient Rehabilition Group Therapy Yes $15 per visit. Individual, Family and Partial Yes $20 per visit. Care Therapy** Rehabilitation counseling services for all group, individual, family and partial care therapy is limited to a combined Tier I, II, and III maximum benefit of $2,500 per Member per Calendar Year. Inpatient Detoxification Yes $150 per day not to (treatment for withdrawal) exceed $400 per admission. Outpatient Detoxification Yes $15 per visit. Unlimited visits **Partial care refers to a Coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. Page 14

15 Please note in addition to specified surgical Copayments and/or Coinsurance amounts, Member is also responsible for all other applicable facility and professional Copayments and/or Coinsurance as outlined in the Attachement A Benefit Schedule. Any and all amounts exceeding any stated maximum benefit amounts under the Plan do not accumulate to the calculation of the Calendar Year Copayment Maximum under Tier I. The Calendar Year Copayment Maximum for Tier I HMO basic health services is 200% of the total premium rate the Member would pay if he were enrolled under a Health Plan without Copayments. Contact HPN s Member Services Department at (702) or for the appropriate Calendar Year out-of-pocket maximum applicable to the Plan. *PAR (Prior Authorization Required) Except as otherwise noted, all Covered Services not provided by the Member s Primary Care Physician require Prior Authorization in the form of a written referral authorization from HPN. Please refer to your HPN Agreement of Coverage for additional information. (1) Tier I HMO benefits are provided by Health Plan of Nevada, Inc. (HPN), a Health Maintenance Organization (HMO). If Medically Necessary Covered Services are provided without Prior Authorization, for those services covered which require Prior Authorization and are available only under the Tier I HMO benefit, no benefits will be paid. (2) Tier II Expanded Plan Provider and Tier III Non-Plan Provider benefits are underwritten by HPN. If Medically Necessary Covered Services are provided without the required Prior Authorization, benefits are reduced to 50% of what the Member would have received with Prior Authorization. Legal Documents Page 15

16 P.O. Box 15645, Las Vegas, Nevada Disclosure Summary for the Individual Distinct Advantage POS Option 3 This Plan includes a consecutive 12-month Maternity Waiting Period that must be satisfied before benefit coverage is provided for pregnancy. This Disclosure Summary outlines certain provisions of the Health Plan of Nevada, Inc. ( HPN ) Distinct Advantage - POS Option 3 Agreement of Coverage ( AOC ). Please read your AOC in its entirety for governing contractual provisions and refer to your Attachment A, Benefit Schedule for additional information on benefits. Carefully read the information contained in this Disclosure Summary to understand: 1. How some expenses are considered; 2. The meaning of certain words; and 3. Some specific requirements which will maximize your benefits. To understand exactly what coverage you have and what your responsibilities are, please read your HPN AOC, applicable Riders and Attachments. Distinct Advantage - POS Option 3 is a "Point of Service" plan that offers Members flexibility and freedom of choice to use either Tier I Health Maintenance Organization ("HMO") benefits, Tier II Expanded Plan Provider benefits or Tier III Non-Plan Provider benefits whenever healthcare services are needed. Benefits for certain Covered Services may only be payable when provided by the Tier I HMO Plan Provider. Certain Covered Services are subject to benefit maximums specific to the benefit level accessed which limit the amount of benefit payments you may receive. Please refer to the Attachment A Benefit Schedule for specific information on these benefit maximums. Tier I HMO Benefits apply when a Member obtains Covered Services or has them arranged by a Plan Provider from the Tier I HMO Plan Provider network and when the care has been Prior Authorized by HPN, if required. No claim forms are required for Tier I HMO benefits when Covered Services are received from Plan Providers. Tier I HMO benefits provide a higher level of coverage with less out-of-pocket expenses to the Member. Tier II - Expanded Plan Provider Benefits apply when a Member obtains Covered Services from a Plan Provider from the HPN Expanded Plan Provider network. Certain Covered Services require Prior Authorization from HPN s Managed Care Program in order for the Member to receive maximum benefits. The Member s out-of-pocket expenses will be higher than they would under the Tier I HMO benefits because the Member will be responsible for higher Copayments or a Calendar Year Deductible ( CYD ), and/or Coinsurance. Tier III - Non-Plan Provider Benefits apply when a Member obtains Covered Services from a Non-Plan Provider. Certain Covered Services require Prior Authorization from HPN s Managed Care Program in order for the Member to receive maximum benefits. All benefits are subject to a CYD and Coinsurance percentageup to a Member s Calendar Year Coinsurance Maximum, as set forth in the Attachment A Benefit Schedule. Emergency Services: Benefits and Copayments for Emergency Services received from Tier II and Tier III Providers are subject to varying Copayment amounts and limitations shown in the Attachment A Benefit Schedule and as set forth in the HPN AOC. The Tier I HMO level of benefits will apply to Emergency Services provided at any duly licensed Plan facility. When a Member is admitted to a Non-Plan Provider Hospital, upon stabilization of the emergency condition and establishment that Member is safe for transfer as determined by the attending Physician, the Plan may require transfer to a Tier I HMO contracted facility in order to pay benefits at the Tier I HMO benefit level. Benefits for poststabilization and follow-up care received at a Tier II or Tier III Provider Hospital facility are subject to the applicable benefit tier. NOTE: In addition to any required Copayments or CYD and Coinsurance, you are responsible Form No. HPN--DisSum- DAP Leg102\NV 2005\Individual\Form #

17 for expenses which exceed the Eligible Medical Expense ( EME ) payments to Tier III Non-Plan Providers, amounts that exceed applicable maximum benefit payments, and penalties for not complying with HPN s Managed Care program. Claim forms must be submitted for services received from Tier III Non-Plan Providers. Important Information Benefits for all Tier I HMO Covered Services not provided by the Member's Primary Care Provider ( PCP ) require Prior Authorization from the PCP and the Plan in the form of a written referral authorization. Covered Services requiring Prior Authorization and review through the Managed Care Program include, but are not limited to all hospitalizations, Inpatient and outpatient surgeries, diagnostic studies, Home Health Care services, Mental Health and Substance Abuse Services, prosthetics and all services provided by Tier III Non-Plan Providers. Failure to comply with the Prior Authorization requirement will result in the Member being responsible for the costs incurred for those medical services which required Prior Authorization but was not received. Emergency Covered Services do not require Prior Authorization. Please read your HPN AOC and Attachment A, Benefit Schedule to determine what Covered Services require Prior Authorization. Certain Tier II Expanded Plan Provider and Tier III Non-Plan Provider non-emergency Covered Services require Prior Authorization from HPN s Managed Care Program in order for the Member to receive maximum benefits. Failure to comply with the Prior Authorization requirements will result in a reduction of benefits. Benefits for Tier II Expanded Plan Provider benefits or Tier III Non-Plan Provider Covered Services which are not Prior Authorized by the Managed Care Program will be reduced to 50% of what the Member would have received if the services had been Prior Authorized. Benefits for Tier II Expanded Plan Provider benefits or Tier III Non-Plan Provider Covered Services which require Prior Authorization and review through HPN s Managed Care Program include: (a) All elective Inpatient admissions and extensions of stay beyond the original certified length of stay to a Hospital or Skilled Nursing Facility; (b) All outpatient surgery provided in any setting, including technical and professional services, if the charges exceed $200; (c) All outpatient tests, including technical and professional services, (except routine x- rays) if the charges for such tests exceed $200, including, for example, but not limited to, the following: angiograms; echocardiograms; EEGs; EMGs; and nerve conduction studies; Holter monitors (heart monitor-24 hours); myelograms; non-invasive vascular studies; psychological testing; pulmonary function tests; CAT scans, MRI scans, nuclear scans; sleep apnea studies; and treadmill stress tests (cardiac exercise tests); (see paragraph (d) below); and (d) All outpatient courses of treatment, including, for example, but not limited to, the following: allergy testing/treatment (e.g. skin, RAST); angioplasty; anti-cancer drug therapy; dialysis; Home Health Care; physiotherapy or manual manipulation; radiation therapy; and rehabilitation (physical, speech, occupational, other). Exclusions and Limitations This section tells you what services or supplies are excluded from coverage under this Agreement. Services or supplies for which coverage is not specifically provided in this AOC, complications resulting from non-covered Services, or services which are not Medically Necessary, whether or not recommended or provided by a Provider. Services not provided, directed, and/or Prior Authorized by a Member's PCP and the Managed Care Program, except for; 1) Emergency Services; or 2) Urgently Needed Services received outside the Service Area. Personal comfort, hygiene, or convenience items such as a Hospital television, telephone, or private room when not Medically Necessary. Housekeeping or meal services as part of Home Health Care. Modifications to a place of residence, including equipment to accommodate physical handicaps or disabilities. Services for a private room in excess of the average semi-private room and board rate. Dental or orthodontic splints or dental prostheses, or any treatment on or to teeth, gums, or jaws and other services customarily provided by a dentist. Charges for dental services in connection with temporomandibular joint dysfunction are also not covered unless they are determined to be Medically Necessary. Such dental-related services are subject to the limitations shown in the Benefit Schedule. Except for reconstructive surgery following a mastectomy, cosmetic procedures to Form No. HPN-DisSum-DAP Leg102\NV 2005\Individual\Form # 2

18 improve appearance without restoring a physical bodily function. Third-party physical exams for employment, licensing, insurance, school, camp, sports, or adoption purposes. Immunizations related to foreign travel. Expenses for medical reports, including presentation and preparation. Exams or treatment ordered by a court, or in connection with legal proceedings if not Medically Necessary or a Covered Service. The following infertility services and supplies are excluded, in addition to any other infertility services or supplies determined by HPN not to be Medically Necessary or not Prior Authorized by the Managed Care Program; 1. Advanced reproductive techniques such as embryo transplants, in vitro fertilization, GIFT and ZIFT procedures, assisted hatching, intracytoplasmic sperm injection, egg retrieval via laparoscope or needle aspiration, sperm preparation, specialized sperm retrieval techniques, sperm washing except prior to artificial insemination if required; 2. Home pregnancy or ovulation tests; 3. Sonohysterography; 4. Monitoring of ovarian response to stimulants; 5. CT or MRI of sella turcica unless elevated prolactin level; 6. Evaluation for sterilization reversal; 7. Laparoscopy; 8. Ovarian wedge resection; 9. Removal of fibroids, uterine septae and polyps; 10. Open or laparoscopic resection, fulguration, or removal of endometrial implants; 11. Surgical lysis of adhesions; 12. Surgical tube reconstruction. Services for the treatment of sexual dysfunction or inadequacies, including, but not limited to, impotence and implantation of a penile prosthesis. Reversal of surgically performed sterilization or subsequent resterilization. Elective abortions. Except as provided in the Covered Services Gastric Restrictive Surgery section, weight reduction procedures are excluded. Also excluded are any weight loss programs, whether or not recommended, provided or prescribed by a Physician or other medical Practitioner. Treatment of marital or family problems; occupational, religious, or other social maladjustments; chronic behavior disorders, codependency; impulse control disorders; organic disorders, learning disabilities or mental retardation or any Severe Mental Illness as defined in the AOC and otherwise covered under the Severe Mental Illness Covered Services section. For purposes of this exclusion, chronic means any condition existing for more than six (6) months. Institutional care which is determined to be for the primary purpose of controlling Member s environmental and Custodial Care, domiciliary care, convalescent care (other than Skilled Nursing Care) or rest cures. Vision exams to determine refractive errors of vision and eyeglasses or contacts. Coverage is provided for vision exams only when required to diagnose an Illness or Injury. Hearing exams to determine the need for or the appropriate type of hearing aid or similar. Coverage is provided for hearing exams only when required to diagnose an Illness or Injury. Ecological or environmental medicine. Use of chelation, orthomolecular substances; use of substances of animal, vegetable, chemical or mineral origin not specifically approved by the FDA as effective for treatment; electrodiagnosis; Hahnemannian dilution and succession; magnetically energized geometric patterns; replacement of metal dental fillings; laetrile, gerovital. Services for chronic, intractable pain by a pain control center or under a pain control program. Acupuncture or hypnosis. Treatment of an Illness or Injury caused by or arising out of a riot, declared or undeclared war or act of war, insurrection; rebellion; or armed invasion or aggression. Treatment of an occupational Injury or Illness which is any injury or Illness arising out of or in the course of employment for pay or profit. Travel and accommodations, whether or not recommended by prescribed by a Provider. Vitamins, herbal medicines, appetite suppressants, and other over-the-counter drugs. Drugs and medicines approved by the FDA for experimental or investigational use. Any services provided before the Effective Date or after the termination of coverage. Care for conditions that federal, state or local law requires to be treated in a public facility for which a charge is not normally made. Any equipment or supplies that condition the air, arch supports, support stockings, special shoe accessories or corrective shoes unless they are an integral part of a lower-body brace, heating pads, hot water bottles, wigs and their care and other primarily non-medical equipment. Special formulas, food supplements other Form No. HPN-DisSum- DAP Leg102\NV 2005\Individual\Form #

19 than as specifically covered or special diets on an outpatient basis. (Except for the treatment of inherited metabolic disease) Services, supplies or accommodations provided without cost to the Member or which the Member is not legally required to pay. Milieu therapy, biofeedback, behavior modification, sensitivity training, hypnosis, hydrotherapy, electrohypsnoisis, electrosleep therapy, electronarcosis, narcosynthesis, rolffing, residential treatment, vocational rehabilitation and wilderness programs. Experimental or investigational treatment or devices. Sports medicine treatment plans intended to primarily improve athletic ability. Radial keratotomy or any surgical procedure for the improvement of vision when vision can be made adequate through the use of glasses or contact lenses. Any services given by a Provider to himself or to members of his family. Ambulance services when a Member could be safely transported by other means. Air ambulance services when a Member could be safely transported by ground Ambulance or other means. Late discharge billing and charges resulting from a canceled appointment or procedure. If you are eligible for Medicare, any services covered by Medicare under Parts A and B are excluded to the extent actually paid for by Medicare. Autologous blood donations. Any services or supplies provided in connection with pregnancy or childbirth except when provided in connection with Complications of Pregnancy until the date following the expiration date of the twelve (12) consecutive month Maternity Waiting Period. Durable Medical Equipment including administration, maintenance and operating costs of such equipment, if the equipment is not Medically Necessary or Prior Authorized. Durable Medical Equipment includes but is not limited to; outpatient oxygen, wheelchairs, crutches, walkers, hospital beds and traction equipment. Any services or supplies rendered in connection with Member acting as or utilizing the services of a surrogate mother. An attempt to commit or committing a felony by the Member. Covered Services received in connection with a clinical trial or study which includes the following: 1. Drugs and medicines approved by the FDA for experimental or investigational use except when prescribed for the treatment of cancer or chronic fatigue syndrome under a clinical trial or study approved by the Plan. 2. Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or medical industry; 3. Healthcare services that are specifically excluded from coverage under this Plan regardless of whether such services are provided under the clinical trial or study; 4. Healthcare services that are customarily provided by the sponsors of the clinical trial or study free of charge to the Member in the clinical trial or study; 5. Extraneous expenses related to participation in the clinical trial or study including, but not limited to, travel, housing and other expenses that a Member may incur; 6. Any expenses incurred by a person who accompanies the Member during the clinical trial or study; 7. Any item or service that is provided solely to satisfy a need or desire for data collection or analysis that is not directly related to the clinical management of the Member; and 8. Any cost for the management of research relating to the clinical trial or study. HPN will not be liable for any delay or failure to provide or arrange for Covered Services if the delay or failure is caused by the following: Natural disaster. War. Riot. Civil insurrection. Epidemic. Or any other emergency beyond HPN s control. In the event of one of these types of emergencies, HPN and its Plan Providers will provide the Covered Services shown in the AOC to the extent practical according to their best judgment. During the first twelve (12) consecutive months of coverage under the Agreement, no benefits will be payable for a Preexisting Condition or any complications thereof, with exception to Complications of Pregnancy. Form No. HPN-DisSum-DAP Leg102\NV 2005\Individual\Form # 4

20 Maternity Waiting Period No benefits will be paid for pregnancy or obstetrical delivery under this Plan, except when provided in connection with Complications of Pregnancy, until the expiration of the twelve (12) consecutive month Maternity Waiting Period commencing on the Effective Date of coverage. Please read your HPN AOC and Attachment A, Benefit Schedule for governing provisions, limitations and exclusions. Premiums HPN reserves the right to establish a revised schedule of premium payments provided it gives the Subscriber sixty (60) days prior written notice. The following factors may be considered in the premium rate determination: the age and gender of each individual, family composition, the geographical area, occupation and health status. The selection of variable Copayments will also affect the respective rates. Upon renewal, HPN will consider changes in case characteristics, including each individual's attained age, change in base premium rates and an adjustment factor for claims experience and health status. Renewability Coverage under the Plan is guaranteed renewable at the option of the Subscriber, except for the following reasons for which coverage may be terminated: 1) nonpayment of required premiums; 2) misrepresentation by the Subscriber of any information regarding the Subscriber or Dependent covered under the Plan or other information regarding eligibility for coverage under the Plan; 3) failure to comply with any applicable underwriting requirements; or 4) if HPN discontinues transacting healthcare coverage or insurance in the geographic area of this state where the Subscriber is located, provided HPN notifies the commissioner and all affected Subscribers at least one hundred eighty (180) days in advance. Glossary Coinsurance means the percentage of the charges billed or the percentage of Eligible Medical Expenses, whichever is less, that a Member must pay a Provider for Covered Services. Coinsurance amounts are to be paid by the Member directly to the Provider who bills for the Covered Services. (See Attachment A Benefit Schedule.) Coinsurance Maximum means the maximum amount to be paid by a Subscriber as Coinsurance for Covered Services per Calendar Year. Please refer to Attachment A, Benefit Schedule, for specific information on how the Coinsurance Maximum for your Plan is determined. The following are not included in the Calendar Year Coinsurance Maximum: Copayments; Deductibles; Any expenses for reductions in benefits resulting from Subscriber s failure to comply with HPN s Managed Care Program, including the inappropriate use of an emergency room facility for a condition which does not require Emergency Services; Any expenses for Covered Services in excess of the Eligible Medical Expenses; Amounts paid in connection with selfinjectable medication; Expenses for services not covered by the Plan; Expenses in excess of the Calendar Year, lifetime, or per illness maximum benefits shown in the Attachment A Benefit Schedule; or Mental Health and Substance Abuse Services. Creditable Coverage means certain types of coverage which are credited against and reduce the length of the Preexisting Condition limitation period. Coverage prior to a lapse in coverage of sixty-three (63) or more days is not credited toward any Preexisting Condition limitation period. Deductible means the portion of the covered expenses billed by Providers each Calendar Year that a Member must pay, either in the aggregate or for a particular service before the Plan will make any benefit payments for Covered Services under the Tier II Expanded Plan Provider benefits and Tier III Non-Plan Provider benefit levels. Eligible Medical Expenses or EME means charges up to the HPN Reimbursement Schedule amount incurred by a Member while he/she is covered under this Plan for Covered Services. Plan Providers have agreed to accept Form No. HPN-DisSum- DAP Leg102\NV 2005\Individual\Form #

21 HPN s Reimbursement Schedule amount as payment in full for Covered Services, plus the Member s payment of any applicable Copayment, Deductible, or Coinsurance, whereas Non-Plan Providers have not. Members who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for charges in excess of HPN s Reimbursement Schedule for any Covered Services. HPN Reimbursement Schedule means the schedule showing the amount the Plan will pay for Eligible Medical Expenses. It is based upon: the amount usually paid to the Provider; or the amount paid to other Providers with the same or similar qualifications; or the relative value and worth of the service compared to other services which the Plan determines to be similar in complexity and nature with reference to other industry and governmental sources. Medically Necessary means a service or supply needed to improve a specific health condition or to preserve the Member s health and which, as determined by HPN is: Consistent with the diagnosis and treatment of the Member s Illness or Injury; The most appropriate level of service which can be safely provided to the Member; and Not solely for the convenience of the Member, the Provider(s) or Hospital. In determining whether a service or supply is Medically Necessary, HPN may give consideration to any or all of the following: The likelihood of a certain service or supply producing a significant positive outcome; Reports in peer-review literature; Evidence based reports and guidelines published by nationally recognized professional organizations that include supporting scientific data; Professional standards of safety and effectiveness that are generally recognized in the United States for diagnosis, care or treatment; The opinions of independent expert Physicians in the health specialty involved when such opinions are based on broad professional consensus; or Other relevant information obtained by HPN. When applied to Inpatient services, Medically Necessary further means that the Member s condition requires treatment in a Hospital rather than in any other setting. Services and accommodations will not automatically be considered Medically Necessary simply because they were prescribed by a Physician. Plan means the HPN Agreement of Coverage and any Attachments, Riders or Endorsements thereto, the Benefit Schedule, the Individual Enrollment Agreement, the individual application, the Subscriber s identification card, health statements, and all individual applications to HPN for healthcare benefits. Preexisting Condition means any Illness or Injury, or any related condition to an Illness or Injury for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the enrollment date of coverage under this Agreement. This term does not include genetic information in the absence of a diagnosis of the condition related to such information nor does it include Complications of Pregnancy, newborns, newly adopted children and coverage for enteral formulas and special food products. Primary Care Physician or PCP means a Plan Provider who has an independent contractor agreement with HPN to assume responsibility for arranging and coordinating the delivery of Covered Services to Members. A PCP s agreement with HPN may terminate. In the event that a Member s PCP agreement terminates, the Member will be required to select another PCP. Prior Authorization means a system that requires a Provider to get approval from the Plan before providing non-emergency healthcare services to a Member for those services to be considered Covered Services. Tier II Expanded Plan Provider Benefits means those benefits for services received from an HPN Plan Provider from HPN s expanded list of Providers, after satisfaction of a Calendar Year Deductible and subject to the Member s Coinsurance percentages, and/or Copayments, in some instances. Certain Covered Services require Prior Authorization from HPN s Managed Care Program in order for the Member to receive maximum benefits. Tier III Non-Plan Provider Benefits means those benefits for services received from a Tier III Non-Plan Provider after satisfaction of the Form No. HPN-DisSum-DAP Leg102\NV 2005\Individual\Form # 6

22 Calendar Year Deductible and subject to the Member s Coinsurance percentage. Certain Covered Services require Prior Authorization from HPN s Managed Care Program in order for the Member to receive maximum benefits. Member will be required to submit claim forms and itemized bills for services rendered. If you have any questions about your benefits or provider information, call the Member Services Department at (702) or Form No. HPN-DisSum- DAP Leg102\NV 2005\Individual\Form #