SUMMARY OF COVERAGE ANTHEM BLUE SAVER 2000 PLAN ANTHEM BLUE CROSS AND BLUE SHIELD 700 Broadway Denver, CO 80273 (888) 231-5046 For Forms: NVSAVR0800 & NVIMSAVREND0104 Retain this for your records This disclosure statement provides a very brief description of some important features of your policy. However, the policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is therefore important that you READ YOUR POLICY CAREFULLY! COVERAGE Type of Policy: The policy provides basic hospital medical insurance. The benefits are based on a Covered Person s medical care expenses. That care must be due to an injury or illness. Please note that with this plan, only limited professional services are covered. Please refer to your policy for further details. Deductible: The amount of the deductible is $2,000. Benefit Percentage: Benefits provided by a Participating Physician or Hospital is paid at the rate of 70% of Covered Expenses. However, there are a few exceptions, as noted elsewhere in this disclosure. Benefits provided by a Non- Participating Physician or Hospital are paid at a rate of 50% of Covered Expenses. The Insured is responsible for any amount over the Covered Expense. For Non-Participating providers, Covered Expenses may be less than actual charges. Inpatient Hospital admissions require pre-authorization. You are responsible for an additional $500 Deductible per admission if pre-admission authorization is not obtained. Out of Pocket Maximum: Participating Providers Once an insured person accumulates a total of $3,500 in Out of Pocket Covered Expenses from Participating Providers in a Year, we will pay 100% of Covered Expenses. Non-Participating Providers Once the insured person accumulates a total of $ 7,000 in Out of Pocket expenses from Non-Participating Providers in a Year, the insured person will no longer have to pay any Copayment or Coinsurance for Covered Expenses for Non-Participating Providers for the remainder of the Year. However, you will always have to continue to pay any charges over what we allow for Non- Participating Providers. Maximum Benefit: Maximum Payment for inpatient treatment of mental illness Maximum Payment for alcoholism and drug dependency Maximum Payment for all Covered Expenses $100/day - $3,000/year $9,000/year for hospital $2,500/year for professional $5 million in each covered person s lifetime Be sure to refer to your policy for further details regarding coverage including coverage for clinical trials or studies for the treatment of cancer or chronic fatigue syndrome. NVSAVOUT0303A 05-00218 1 An independent licensee of the Blue Cross and Blue Shield Association. is the trade name of Rocky Mountain Hospital and Medical Service, Inc. Registered marks Blue Cross and Blue Shield Association
EXCLUSIONS AND LIMITATIONS The following is a partial listing of services that are excluded from coverage: Excess Amounts: Any amounts in excess of the maximum amounts stated in the Comprehensive Benefits Section of the Policy. Unlisted Services: Services not specifically listed in this Policy as Covered Services or amounts which exceed the Customary and Reasonable charge as determined by us. Not Medically Necessary: Any services or supplies that are: a) not Medically Necessary, b) not specifically described in this Policy and part of a treatment plan for non-covered services or which are required to treat medical conditions which are a direct and predictable complication or consequence of non-covered services. Experimental or Investigative: Medical, surgical, or other procedures, services, products, drugs, or devices (including implants) except as specifically stated under Clinical Trials in Part X, Comprehensive Benefits, which are either a) experimental or investigational or which are not recognized in accord with generally accepted professional medical standards as being safe and effective or use is in question, or b) outmoded or not efficacious, such as those defined by the Federal Medicare and State Medicaid programs or drugs or devices that are not approved by the Food and Drug Administration; c) services associated with a) and b) above. Expenses Before Coverage Begins: Services received before your Effective Date or during an inpatient stay that began before your Effective Date. End of Coverage: Services received after your coverage ends. Services for Which You are Not Legally Obligated to Pay: Services for which no charge is made to you in the absence of insurance coverage, except services received at a non-governmental charitable research Hospital. Such a Hospital must meet the following guidelines: 1. It must be internationally known as being devoted mainly to medical research, and 2. At least ten percent of its yearly budget must be spent on research not directly related to patient care, and 3. At least one-third of its gross income must come from donations or grants other than gifts or payments for patient care, and 4. It must accept patients who are unable to pay, and 5. Two-thirds of its patients must have conditions directly related to the Hospital s research. Worker s Compensation: Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employer s liability law or occupational disease law, even if you do not claim those benefits. War: Conditions caused by an act of war. Conditions caused by the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy. Government Services: Any services provided by a local, state or federal government agency. Non-Duplication of Medicare: Any services to the extent that Medicare benefits have been paid for those services. Any services for which payment may be obtained from any local, state or federal government agency. Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation. Services From Relatives: Professional services received from a person who lives in the Insured s home or who is related to the Insured by blood, marriage or adoption. Private Duty Nursing: Inpatient or outpatient services of a private duty nurse unless we determine in advance of such services that they are Medically Necessary. Custodial Care: Custodial care, domiciliary, or rest cures for which facilities, and/or services of a general acute hospital are not medically required. Custodial care is care that does not require the regular services of trained medical or health professionals, such as, but not limited to, help in walking, getting in and out of bed, bathing, dressing, preparation and feeding of special diets, and supervision of medications which are ordinarily selfadministered. Diagnostic Admissions: Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Mental, Emotional or Functional Nervous Disorders: Treatment of Mental, Emotional or Functional Nervous Disorders (including nicotine use) or psychological testing except as specifically stated under the benefit sections of this Policy Orthodontic Services: Braces, other orthodontic appliances, orthodontic services. Dental Services: Dentures, bridges, crowns, caps or other dental prostheses, dental services, extraction of teeth or treatment to the teeth or gums, except as specifically stated for Dental Care under the benefits section of this Policy. NVSAVOUT0104A 2
Dental Implants: (materials implanted into or on bone or soft tissue) or any associated procedure as part of the implantation or removal of implants. Hearing Aids Hearing aids and routine hearing tests.. Vision Care: Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams and routine eye refraction s, except as specifically stated under the benefit sections of this Policy. Outpatient Speech Therapy: All outpatient speech therapy. Cosmetic Surgery or other services for beautification, including, any complications arising from or the result of Cosmetic Surgery. Sex Changes: Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change. Infertility Services: All services related to the evaluation or treatment of infertility, including all tests, consultations, medications, surgical, medical or laboratory procedures. Weight Reduction: Services primarily for weight reduction or treatment of obesity or any care which involves weight reduction as a main method of treatment. Orthopedic Shoes: Orthopedic shoes (except when joined to braces) or shoe inserts. Maternity Care: No benefits are provided for pregnancy or any condition related to pregnancy, except for complications of pregnancy Outpatient Prescription Drugs: No benefits are provided for prescription or non-prescription drugs provided on an outpatient basis. Prior Anthem Coverage: If the Insured was covered by a prior Individual Coverage Anthem Policy which is replaced by this Policy, benefits used under the prior Policy will be charged against the benefits payable under this Policy. Personal Comfort Items: Items which are furnished primarily for your personal comfort or convenience. Air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators, and supplies for hygiene or beautification. Routine Physical Exams : Routine physical exams or tests which do not directly treat an actual illness, injury or condition, including those required by employment or government authority except as specifically stated in this Policy. Certain Eye Surgeries: Any eye surgery solely for the purpose of correcting refractive defects of the eye such as near sightedness (myopia) and astigmatism and/or farsightedness (presbyopia). Telephone Calls: Charges by a provider for telephone consultations. Acupuncture: Care or treatment provided through the use of acupuncture or acupressure. Durable Medical Equipment, including but not limited to orthopedic shoes or shoe inserts, air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators, supplies for comfort, hygiene or beautification, disposable sheaths and supplies, correction appliances or support appliances and supplies such as stockings. All durable medical equipment used in Infusion Therapy. Benefits for Medically Necessary prosthetic devices or supplies are provided as described in Part X, item E. (COVERED SERVICES). Educational Services. Nutritional Counseling: Food Supplements. Physical and/or Occupational Therapy/Medicine or chiropractic services, except when provided during an inpatient Hospital confinement. Severe Mental Illness: Treatment of Severe Mental Illness except as specifically stated under the benefit sections of this Policy. All Infusion Therapy together with any associated supplies, drugs or professional services are excluded except as specifically provided under the benefit for Infusion Therapy described in this Policy. Non-prescription contraceptive Drugs, devices and supplies, and non-fda approved Prescription contraceptive Drugs, devices and supplies. FDA approved Prescription contraceptive Drugs or devices available through a licensed Pharmacy are covered under the Prescription Drug benefit of this Plan Important: Benefits are paid at different amounts based on whether or not the provider or hospital/facility is participating in the Anthem network. It is your responsibility to verify that any provider you use, or have been referred to, is participating in this plan. Likewise, it is your responsibility to verify that the hospital or facility that you use is participating in the network. NVSAVOUT0104A 3
PRE-EXISTING CONDITIONS Pre-existing Conditions: as defined in the Definitions section: 1. This Policy does not provide benefits for services related to a Pre-existing Condition if the services are received on or within twelve (12) months after your Effective Date. Exceptions: a. This limitation does not apply to a child born to or newly adopted by an enrolled Subscriber or spouse. 2. We will reduce this twelve (12) month period if, prior to the Insured s Effective Date, he or she had Qualifying Prior Coverage (as defined in the Definitions section) and the Subscriber becomes eligible and applies for coverage under this Policy within the period of time prescribed by law following termination of Qualifying Prior Coverage. RENEWABILITY CONDITIONS This is renewable and may be continued at the option of the Covered Person except in the case(s) of: 1. Non-Payment of required premiums; 2. Fraud or misrepresentation by the covered person; 3. Non-renewal by the insurer upon 180 days written notice with respect to all policyholders in the state, or 4. A determination by the Nevada Division of Insurance that the continuation of the coverage is not in the best interest of the policyholder or will impair the Insurer s ability to meet its contractual obligations. In such instances, the department must assist the individual in finding replacement coverage. GRIEVANCE PROCEDURES All complaints relating to coverage under this Policy will be reviewed by and resolved within Anthem s Customer Service Department. Complaints may be made by telephone (please call the number described on your Anthem member identification card) or submitted in writing to the address listed below: Customer Service Department P.O. Box 5747 Denver, CO 80217-5747 If the complaint cannot be resolved to the mutual satisfaction of the Member and Anthem, the complaint will be resolved in accordance with Anthem s appeals procedure. You must submit a written request to initiate the appeals procedure. Anthem will acknowledge receipt of the appeal in writing within 3 business days. Written appeals may be sent to the following address: Appeals Department P.O. Box 10330 Reno, NV 89520-0030 Upon review of the appeal Anthem will make a determination within 30 business days, unless additional information is required. You will be notified if additional information is required. Once the appeal review is complete, you will be notified within 5 business days. An expedited appeal involves an imminent and serious threat to the Member and Anthem will inform the Member immediately of his/her right to an expedited review of his/her appeal. If an expedited review is required, the review board will notify the Member in writing of its determination within 72 hours after the appeal is filed. NVSAVOUT0104A 4
If the resolution of the first appeal is not resolved to Your satisfaction, you may submit a written request for a second level appeal. The written appeal will be submitted to an appeal panel. The appeal panel may consist of persons not previously involved with the matter, persons not employed by Anthem and who do not have a financial interest in the appeal. If you are dissatisfied with the appeal determination, you may submit your grievance to the Nevada Division of Insurance for review. The Nevada Division of Insurance can be contacted by calling: The Department of Business and Industry, Division of Insurance 788 Fairview Drive Suite 300 Carson City, NV 89701-5491 Monday through Friday, 8:00 a.m. to 5:00 p.m. Pacific Time Toll Free within the State of Nevada (800) 992-0900 In Carson City (775) 687-4270 In Las Vegas (702) 486-4009 You may send a written grievance to the following address within sixty (60) days of the event: Quality Management Department 700 Broadway MC0532 Denver, CO 80273 NVSAVOUT0104A 5