Regulatory Update Notice

Regulatory Update Notice
On May 4, 2020, the Department of Labor published a temporary rule that extends the deadlines to complete various actions as described below.1
These deadlines are extended by disregarding the period from March 1, 2020 through sixty (60) days after the announced end of the COVID-19 National Emergency (“Outbreak Period”). If no end to the COVID-19 National Emergency is announced, the Outbreak Period ends no later than April 29, 2021. This notice will be updated if an end to the COVID-19 National Emergency is announced.
Specific changes under this notice include:
1. HIPAA Special Enrollment Period Extended – extends the 30-day and 60-day HIPAA special enrollment timeframes by disregarding the Outbreak Period;
2. COBRA Election Deadline Extended – extends the 60-day COBRA election period by disregarding any days in the Outbreak Period;
3. COBRA Premium Payment Period Extended – extends these 45- and 30-day COBRA premium payment timeframes, as applicable, by disregarding the Outbreak Period;
4. COBRA Qualifying Event Notice Deadlines Are Extended – extends these COBRA qualifying event timeframes by disregarding the Outbreak Period;
5. Deadline for Filing ERISA Benefit Claims Extended – extends this benefits claim deadline by disregarding the Outbreak Period;
6. Extension of Time for Filing ERISA Plan Appeals – the date within which claimants may file an appeal of a benefit claim denial has been extended by disregarding the Outbreak Period;
7. Timeframe Which Claimants May File a Request for an External Review Extended – the date within which ERISA group health plan claimants have to file a request for external review is extended by disregarding the Outbreak Period;
8. Timeframe Which Claimants May File Information to Perfect a Request for External Review Extended – extends the period that a claimant has to file information to perfect their request for external review by disregarding the Outbreak Period;
1 85 FR 26351-26355, May 4, 2020
City of Reno
Group Health Plan
1
The City of Reno Plan Document dated May 1, 2018 is hereby amended effective January 1, 2020, as
follows:
The following is added to the Schedule of Medical Benefits on page 10:
Bariatric Surgery
Benefits are available only when services are provided through the BARInet preferred provide network.
In-Network Out-of-Network
Not covered
professional consultations
copayments
40% after deductible
The following is added to page 25 in the Eligible Medical Expenses section:
D. BARIATRIC SURGERY
a) Covered Employees and Dependents over age 18.
b) Employee must have one year of service with the City of Reno.
c) Bariatric surgery services must be provided by a BARInet Specialty Network Provider.
2. Program Requirements
minimums, comorbidities, participation in educational programs, and others. Contact BARInet at 1-
866-868-1395 for detailed information about program requirements and instructions for starting the
approval process.
Item #14 in the Medical Limitations and Exclusions section, page 27 is amended as follows:
Additional cosmetic surgery or medical procedures exclusions include:
Complications resulting from excluded cosmetic surgery
Complications of medical procedures that result in conditions that affect the
appearance of the body without commensurate impairment of bodily function
Cosmetic treatment or service related complications, insertion, removal or revision of
breast implants (including complications) unless provided post mastectomy
Psychological and physical factors including but not limited to self-image, difficult
social or peer relations, embarrassment in social situations, inability to exercise or
participate in recreational activities comfortably, or impact on ability to perform one’s job duties
Charges which result from appetite control, food addictions, eating disorders (except
documented cases of bulimia or anorexia that meet standard diagnostic criteria as
City of Reno
Group Health Plan
2
determined by Hometown Health and present significant symptomatic medical
problems) or any treatment of obesity unless a Covered Employee meets the Bariatric Surgery benefit guidelines outlined in Item D. of the Eligible
Medical Expenses section.
Item #23 in the Medical Limitations and Exclusions section, page 27, is amended as follows:
Surgical or invasive treatment for obesity or morbid obesity including but not limited to Gastric Restrictive services; reversals and complications, unless the Covered Employee meets the
Bariatric Surgery benefit guidelines outlined in Item D. of the Eligible Medical Expenses section.
Add the following the Definitions section on page 61:
Bariatric Surgery -- under this Plan means Lab Gastric Bypass and Lap Sleeve Gastrectomy only.
City of Reno
Group Health Plan
Plan Amendment (effective February 1, 2019)
The City of Reno Plan Document, dated May 1, 2018, is hereby amended effective February 1, 2019, as follows:
1. Gender Reassignment listed in the ELIGIBLE MEDICAL EXPENSES on page 17 is amended as follows:
13 G~nder ReHsignment - Gender· reassignment surgery consisting of any combination of the following when
the following criterra is me ·
a. Requirements for mastectomy for femare:-to-rnar~ patients;
• Single Jette( of refetral from a. quafifre'¢1 rnenfal health professional: and • Persistent, wellt-documented gerrde dyspnfflia, and • Capacity fo make a fully nformed decision and to con.sen! for treatment and • Age of mafority (18 years DJ age or old'er); 8Jld • If slgni1lcanl medical or men!af lrlealth C!irlilcems are present. they must be reasonably Ylt*I 00111tro fed.
b. Requirements for gonadectomy ,ti.ysreteciomy ar:Td oophorectomy in female-to-mafe and orchiectomy in male-fo female):
• Two referral letters from quarified mental h:eallh professionals . one in a purely evaluative rofe (see AppencfrlG);
• Persistent, well-documented) gender dysphorta; and • Capacity to make a ·fully informed dedsioll and to consent for treatment; and • Age of majoriiy (18 years of age or ofder}: and • If significant medical or menial heallh concerns are present. they must be reasonably well controlled; and • Twelve months of continuous harm.one therapy as appropriate to the member's gender goals {unless (he
member has a medical contraindication or is otherwise unable or unwllling to take hormones).
c. Requirements for genital reconstructlve surgery (i.e. vaginectomy, urethroplasty, metoidioplasty. phalloplasly, scrotoplasty, and placement of a testicular prothesis and erectile prosthesis in female to male, penectomy. vaginoplasty, labiaplasty, and clitoroplasty ih male to female):
• Two referral letters from qualified mental health professionals, one in a purely evaluative role (see Appendix);
• Persistent, well-documented gender dysphoria; and • Capacity to make a fully informed decision and to consent for treatment; and • Age of majority ( 18 years of age or older); and • If significant medical or mental health concerns are present, they must be reasonably well controlled: and • Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the
member has a medical contraindication or is otherwise unable or unwilling to take hormones); and • Twelve months of living in a gender role that is congruent with their gender identity (real life experience).
11Pa ge Plan Amendment #1 (effective February 1, 2019)
NOTE: Behavioral Health and Hormone Therapy in relation to gender dysphoria is covered. Also, see Gender Reassignment under MEDICAL LIMITATIONS AND EXCLUSIONS for i,ervices and procedures that are not covered .
2. Gender Reassignment listed in the MEDICAL LIMITATION AND EXCLUSIONS on page 30 is amended as follows:
70. Gender Reassignment - Surgery, services and supplies when the criteria required under Gender Reassignment, listed in the Eligible Medical Expenses section, is not meL Procedures that me be performed as a component or a gender reassignment as cosmetic (not an all-inclusive list) will not be covered: abdomlnoplasty, blepharoplasty, brow lift, calf Implants, cheek/malar implants, chin/nose implants, collagen injections, construction of a clitoral hood, drugs for hair loss or growth, forehead lift, hair removal, hair transplantation, lip reduction, liposuction, mastopexy, neck tightening , pectoral implants, removal or redundant skin, rhinoplasty, voice therapy/voice lessons.
NOTE: See Gender Reassignment under ELIGIBLE MEDICAL EXPENSES on page 17 for services and procedures that are covered.
3. Mental health services listed in the ELIGIBLE MEDICAL EXPENSES on page 20 is amended as follows:
24. Mental health services - Covered benefits for general mental health (Including services related to the treatment of Attention Deficit Disorder (ADD & ADHD)) and severe mental illness will be provided under the same provisions as medical and surgical benefits, with no additional financial or treatment limitations.
NOTE: Behavioral health in relation to gender dysphoria is covered.
4. Hormone Therapy is added to the ELIGIBLE MEDICAL EXPENSES when in relation to gender dysphoria as follows:
Hormone Therapy - When in relation to gender dysphoria is covered .
NOTE: See Gender Reassignment under ELIGIBLE MEDICAL EXPENSES on page 17 for services and procedures that are covered.
5. Hearing Aids listed in the MEDICAL LIMITATION AND EXCLUSIONS on page 28 is amended as follows:
REMOVE:
36. The fitting and cost of hearing aids including both surgical implanted bone conduction hearing aids and externally worn hearing aids regardless of the etiology of the deafness.
Hearing Aids is added to the ELIGIBLE MEDICAL EXPENSES as follows:
Hearing Aids - Hearing Aids and Related Examinations - Hearing examinations, hearing aids and the fitting and repair of hearing aids. Hearing exam is limited to one (1) every Calendar year. Hearing Aid is l imited to one (1) per ear every 36 months.
NOTE: Hearing aid batteries are not covered.
21Page Plan Amendment #1 (effective February 1, 2019)
ADO:
Hearing Aids and Related Examinations In-Network Out-of-Network
Hearing Exam CYD and 100% plan paid CYD and 100% of U&C
Hearing Aid CYD and 100% plan paid CYD and 100% of U&C
Hearing exam is limited to one (1) every calendar year. Hearing Aid is limited to one (1) per ear
every 36 months. NOTE: Hearing aid batteries are not covered.
6. Travel listed in the MEDICAL LIMITATION AND EXCLUSIONS on page 27 is amended as follows:
28. Travel, accommodations, and oxygen provided while traveling on an airline. Except when approved by Utilization Management as part of the, see Utah Travel Benefit.
7. Travel listed in the General Exclusions on page 36 is amended as follows:
Travel - Travel or accommodation charges, whether or not recommended by a Physician, except for ambulance charges or as otherwise expressly included. Except when approved by Utilization Management as part of the, see Utah Travel Benefit.
8. Utah Travel Benefit is added to Summary Plan Document, see Utah Travel Benefit following the MANAGED CARE/UTILIZATION MANAGEMENT PROGRAM section, page 6, Plan is amended as follows:
UTAH TRAVEL BENEFIT
The Utah Travel Benefit is established to offset the cost of travel for patients and/or their support person or family members when Utilization Management provides the physician and/or the Covered Person, as an option for Tertiary Care (evaluation and/or treatment), authorization to receive treatment at the University of Utah Medical Center. If the Covered Person is approved for the Utah travel benefit, the Plan will waive deductible and coinsurance requirements for the approved treatment at a University of Utah facility.
Tertiary Care: Highly specialized medical care usually over an extended period of time that involves advanced and complex procedures and treatments performed by medical specialists in state-of-the-art facilities. Examples of tertiary care are specialist cancer care , neurosurgery (brain surgery), burn care and plastic surgery.
To qualify for the Utah Travel Benefit, the following must apply:
1. Covered Person and/or their treating physician has requested a referral lo a specific facility/provider for Tertiary Care that is not in the primary PPO network and will require travel outside of Nevada.
2. Utilization Management has determined that the requested services are medically necessary and Tertiary Care cannot be provided in the primary PPO network.
3. Utilization Management has provided the physician and/or Covered Person, as an option, to receive Tertiary Care at the University of Utah Medi'cal Center.
4. Covered Person has agreed to be in Case Management, and followed by a Case Manager while in Tertiary Care.
5. Prior to travel to Utah for Tertiary Care, the Covered Person must advise the RN Case Manager of travel to receive the benefit.
, 3 I -, 0 g :-'
SinQle Episode of Care
Travel expenses per day, per trip $250 per patient, support person/caregiver or parenl as defined below
Travel exoenses maximum, oer trio $2,500 oer sinale eoisode of care
Travel exoenses calendar vear maximum $10,000
Covered Travel Expenses
1. For a covered child under the age of 19, travel expenses will be reimbursed at $250 per person for the patient and two parents or two legal guardians.
2. For a covered adult age 19 or older, travel expenses will be reimbursed for the person and one person/caregiver.
3. Coverage wlll include the day prior to a scheduled service and the day following the scheduled service not to exceed $2,500 per Episode of Care.
After approved travel to the University of Utah Medical Center for services, complete a Utah Travel Reimbursement Benefit Form, attach all receipts and submit to Medlcal Management at Hometown Health.
For more information on University of Utah health care, visit www.healthcare.utah.edu.
9. Provider Network listed under MEDICAL BENEFIT SUMMARY on page 9 is amended as follows:
The Plan's medical PPO is Hometown Health Network (within the service area), using all Renown Health facilities, including Renown Regional Medical Center and Renown South Meadows, for covered members and retirees residing in Nevada and the following California counties: Alpine, Amador, El Dorado, Inyo, Lassen, Modoc, Mono, Nevada, Placer, Plumas, Sierra and surrounding counties.
Out Of Area PPO Network
For covered members and retirees residing outside of the network service area, the covered members and retirees may gain access to a network of preferred providers. In order to gain access to the providers of the network (outside the service area), the covered members and retirees must contact the benefits department in human resources and provide the name and address of the covered members and retirees. If available, the out of area covered members and retirees will be assigned to the network and may use the providers in that network to obtain preferred benefits. The out of area covered members and retirees will be issued an ID card which provides the online link to find and use preferred providers in the network. If the covered members and retirees are not setup to access the Network outside of the service area. non-network services will be covered at the non-network benefit levels and are subject the usual, customary and reasonable (UCR) rates.
Network Access - outside the service area
Southern Nevada - https://www.hometownhealth.com/provider-directory-tiiter/ Select the southern Nevada link and Hometown Health PPO.
Outside of Nevada - https://www.hometownhealth.com/provider-directory-filter/ Select the Out-of-State Network.
Plan Amendment #1 (effective February 1, 2019)
10. Provider Network listed under MEDICAL BENEFIT SUMMARY on page 9 is amended as follows:
Unavailable Services - When a PPO cannot be used, Non-PPO providers will be paid at the PPO benefit level. A covered member may only use a non-PPO specialist and obtain this benefit when the specialty Is not represented by the PPO or is not reasonably accessible to the patient due to geographic constraints. Pre-certification must be obtained from UM, services will be paid as determined by the Administrator and are subject the usual, cust.omary and reasonable (UCR) rates.
All other Plan provisions remain unchanged so long as they are consistent with the Amendment.
City of Reno/ p;tY ~= Fire ~ uary 1, 2019
Signature: ~~C/J~~ Printed Name: "'1cx f'\I.., C. . G f e-3 e 1/"5 e ':'.'.'.)
Title: ~ 1 Q d'5 ~R Date: 'S--_ 14 -( ?
Plan Amendment #1 (effective February 1, 2019) SI Page
City of Reno- Introduction
Contract Administrator:
INTRODUCTION
This document is both the Summary Plan Description and the Plan Document for our Preferred Provider Organization (PPO) Group Health Plan. We recommend that you take the time to review the contents of this document. In particular, we call the following to your attention: • Most health claims of the Plan are handled by a Contract Administrator. The name, address and phone number
of that company is:
Hometown Health 10315 Professional Circle
Reno, Nevada 89521 (775) 982-3232
The Contract Administrator's office should also be contacted if you need additional information about Plan coverage for a specific drug, treatment, procedure, preventive service, etc. No charge will be made for the information.
• Some of the terms used in the document begin with a capital letter. These terms have a special meaning under the Plan and are included in the Definitions section. When reading the provisions of this Benefit Document, it will
be helpful to refer to this section. Becoming familiar with the terms defined there will give you a better understanding of the benefits and provisions.
• This Plan is a self-insured program. This means that coverage is not provided by an insurance company. Your and/or the City contributions are used to pay claims.
Please read this document carefully. If you do not understand a benefit, an exclusion or if you have a question, contact your Contract Administrator’s claims office. You can find the contact information on your Plan identification card. Failure to request and review the terms and conditions of the Plan prior to enrollment may not be utilized as a basis for contending lack of awareness of, or familiarity with, or knowledge of, or being bound by the provisions of the plan/
• Spanish Language Assistance. Si usted no entiende la información en este documento, por favor de ponerse en
• • • •
THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT
• • • •
THE WOMEN'S HEALTH AND CANCER RIGHTS ACT Under Federal law, the health benefits of most plans must include coverage for the following post-mastectomy services and supplies when provided in a manner determined in consultation between the attending physician and the patient: (1) reconstruction of the breast on which a mastectomy has been performed, (2) surgery and reconstruction of the other breast to produce symmetrical appearance, (3) breast prostheses, and (4) physical complications of all stages of mastectomy, including lymphedemas. Plan participants must be notified, upon enrollment and annually thereafter, of the availability of benefits required due to the Women’s Health and Cancer Rights Act (WHCRA).
GENETIC INFORMATION AND NON-DISCRIMINATION ACT GINA (Genetic Information and Non-Discrimination Act, effective 1/1/2010) prohibits group health plans from collecting genetic information and discriminating in enrollment and cost of coverage based on an individual’s genetic information – which includes family medical information.
MENTAL HEALTH PARITY
Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, this Plan applies its terms uniformly and enforces parity between covered health care benefits and covered mental health and substance disorder benefits relating to financial cost sharing restrictions and treatment duration limitations. For further details, please contact the Plan sponsor.
NON-GRANDFATHERED PLAN This Summary Plan Description (SPD) has been amended to comply with the requirements of the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010. We will provide coverage under your benefit plan in accordance with these laws and in compliance with applicable regulations and guidance as they are issued. We believe that this Policy is a “non-grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). Questions regarding which protections apply to a non-grandfathered health plan can be directed to City of Reno, the Plan sponsor, at 775-334-2285. The Plan participant may also contact the Employee Benefits Security administration U.S. Department of Labor at 1-866-444-3272 or www.dol.gove/ebsa.
COBRA NOTIFICATION PROCEDURES The following procedures will apply to Plan participants with regard to notifying the Plan of a COBRA-related event.
A. NOTICE RESPONSIBILITIES It is a Plan participant’s responsibility to provide the following Notices as they relate to COBRA Continuation Coverage:
Notice of Divorce or Separation - Notice of the occurrence of a Qualifying Event that is a divorce or legal separation of a covered Employee from his or her spouse.
Notice of Child’s Loss of Dependent Status - Notice of a Qualifying Event that is a child’s loss of Dependent status under the Plan (e.g., a Dependent child reaching the maximum age limit).
Notice of a Second Qualifying Event - Notice of the occurrence of a second Qualifying Event after a Qualified Beneficiary has become entitled to COBRA Continuation Coverage with a maximum duration of 18 (or 29) months.
Notice Regarding Disability - Notice that: (a) a Qualified Beneficiary entitled to receive COBRA Continuation Coverage with a maximum duration of 18 months has been determined by the Social Security Administration to be disabled at any time during the first 60 days of continuation coverage, or (b) a Qualified Beneficiary as described in “(a)” has subsequently been determined by the Social Security Administration to no longer be disabled.
Notice Regarding Address Changes - It is important that the Plan Sponsor be kept informed of the current addresses of all Plan participants or beneficiaries who are or may become Qualified Beneficiaries.
B. NOTIFICATION PROCEDURES Notification must be made in accordance with the following procedures. Any individual who is either the covered Employee, a Qualified Beneficiary with respect to the Qualifying Event, or any representative acting on behalf of the covered Employee or Qualified Beneficiary may provide the Notice. Notice by one individual shall satisfy any responsibility to provide Notice on behalf of all related Qualified Beneficiaries with respect to the Qualifying Event.
Form or Means of Notification - Notification of the Qualifying Event must be provided to the Employer’s Human Resources office. You may contact the Employer’s Human Resources office to fill out an enrollment form stating the qualifying event.
Content - Notification must include any official documentation showing evidence that a Qualifying Event has occurred such as a copy of a divorce decree, a child’s birth certificate, marriage certificate or a copy of the Social Security Administration’s disability determination, etc.
Delivery of Notification - Notification must be received by the Employer’s Human Resources Office.
Time Requirements for Notification - In the case of a divorce, legal separation or a child losing dependent status, Notice must be delivered within 60 days from the later of: (1) the date of the Qualifying Event, (2) the date health plan coverage is lost due to the event, or (3) the date the Qualified Beneficiary is notified of the obligation to provide Notice through the Summary Plan Description or the Plan Sponsor’s General COBRA Notice. If Notice is not received within the 60- day period, COBRA Continuation Coverage will not be available, except in the case of a loss of coverage due to
foreign competition where a second COBRA election period may be available – see “Effect of the Trade Act” in the COBRA Continuation Coverage section of the Plan’s Summary Plan Description or Benefit Document.
If an Employee or Qualified Beneficiary is determined to be disabled under the Social Security Act, Notice must be delivered within 60 days from the later of: (1) the date of the determination, (2) the date of the Qualifying event, (3) the date coverage is lost as a result of the Qualifying Event, or (4) the date the covered Employee or Qualified Beneficiary is advised of the Notice obligation through the SPD or the Plan Sponsor’s General COBRA Notice. Notice must be provided within the 18-month COBRA coverage period. Any such Qualified Beneficiary must also provide Notice within 30 days of the date he is subsequently determined by the Social Security Administration to no longer be disabled.
The Plan will not reject an incomplete Notice as long as the Notice identifies the Plan, the covered Employee and Qualified Beneficiary(ies), the Qualifying Event/disability determination and the date on which it occurred. However, the Plan is not prevented from rejecting an incomplete Notice if the Qualified Beneficiary does not comply with a request by the Plan for more complete information within a reasonable period of time following the request.
TABLE OF CONTENTS Page
MANAGED CARE / UTILIZATION MANAGEMENT PROGRAM................................................................ 6
MEDICAL BENEFIT SUMMARY .................................................................................................................. 9
ELIGIBLE MEDICAL EXPENSES .............................................................................................................. 14
PRESCRIPTION BENEFIT SUMMARY ..................................................................................................... 31
TERMINATION OF COVERAGE ............................................................................................................... 50
EXTENSIONS OF COVERAGE ................................................................................................................. 51
CLAIMS PROCEDURES ............................................................................................................................ 55
GENERAL PLAN INFORMATION ............................................................................................................. 77
COBRA CONTINUATION COVERAGE ..................................................................................................... 84
HIPAA PRIVACY & SECURITY ................................................................................................................. 90
City of Reno – Managed Care/Utilization Management Program - 6 -
MANAGED CARE/UTILIZATION MANAGEMENT PROGRAM The managed care/utilization management program uses set criteria and protocols to ensure that the most cost- effective preventive, acute, and tertiary care is provided to our Members consistent with the provision of quality care. You may be subject to a reduction in benefits if you do not comply with this utilization management program.
A. DELIVERY OF SERVICES
You are entitled to receive Medically Necessary medical care and services as specified in your plan-specific summary of benefits and this summary plan description. These include medical, surgical, diagnostic, therapeutic, and preventive services. These are services that are generally and customarily:
Provided in our Service Area,
Performed or ordered by a Participating Provider, and
Prior authorized by us according to our utilization management and quality assurance protocols, if applicable.
B. SCOPE OF PROGRAMS
Under the managed care/utilization management program, a prior-authorization is required for referrals to Physicians and Providers for certain services. Prior-authorization means our determination of medical necessity and benefit coverage using utilization management and quality assurance protocols prior to the services being rendered. All benefits listed in this summary plan description may be subject to prior-authorization requirements and concurrent review depending upon the circumstances associated with the services. Please refer to your plan-specific summary of benefits for services that require prior-authorization. The following services are subject to a prior-authorization:
All inpatient stays and services in any facility type, including Acute and skilled care, mental health care, drug or alcohol detoxification, or rehabilitation (including partial or day hospitalization services stays);
Inpatient, or same day surgical services;
Autism services;
Mental health and substance abuse services greater than 12 visits per calendar or plan year;
Home health care;
Healthcare services and supplies including but not limited to oxygen, oxygen-related equipment and all durable medical equipment with a cost greater than $100;
Prosthetic and orthopedic devices with a cost greater than $100;
Transplant services;
Services of all non-Participating Providers except that, in the case of an emergency or for urgent care, payment for services will be provided without a prior-authorization in accordance with the terms of your specific Policy;
All out-of-area services, except that out-of-area services will be provided without a prior-authorization in accordance with the terms of your specific Policy;
Anesthesiology and physiatry services including pain management;
Certain laboratory and diagnostic tests
Genetic counseling and testing;
We should be notified upon confirmation of pregnancy so we may better manage your benefits. You must comply and cooperate with the managed care/utilization management program. Services are subject to all of the terms of your specific Policy.
C. APPROVAL AND PRIOR-AUTHORIZATION PROCESS
In certain cases, as set forth below, in order for a benefit to be covered, we must approve and/or pre- authorize the service. If you do not obtain a required prior-authorization for a service you will not receive coverage for the service even if the service is Medically Necessary. We use nationally recognized criteria and internal medical policy guidelines, as reviewed periodically by our Utilization Management and Quality Improvement Committee, as the standard measurement tool to determine whether benefits are approved and/or authorized.
Hospital admissions.
You are responsible for notifying us of a Hospital stay at least five business days before elective admission to a Hospital to ensure that it is covered. Your Physician or other Provider may notify us but it is ultimately your responsibility to make sure we are notified. We will review the Provider’s recommendation to determine level of care and place of service. If we deny authorization for Hospital admission as not covered or we determine that the services does not meet our criteria and protocols, we will not pay Hospital or related charges for the care that is not Medically Necessary or does not meet our criteria or protocols.
Inpatient and outpatient surgery.
You are responsible for making sure we are notified at least five business days before elective inpatient or outpatient surgery is performed to ensure that it is covered. Your Physician or other Provider may notify us but it is ultimately your responsibility to make sure we are notified. We will review the Physician’s recommended course of treatment. We will pay benefits only for inpatient/outpatient surgery that we authorize. We will not pay for inpatient or outpatient surgery or related charges if we determine that such charges are not a Covered Service or do not meet our criteria and protocols.
Emergency and urgent Hospital admissions.
An emergency Hospital admission means an admission for Hospital confinement that results from a sudden and unexpected onset of a condition that requires medical or surgical care. In the absence of such care, you could reasonably be expected to suffer serious bodily Injury or death. Examples of emergency Hospital admissions include, but are not limited to, admissions for heart attacks, severe chest pain, burns, loss of consciousness, serious breathing difficulties, spinal Injuries, and other Acute conditions. An urgent Hospital admission means an admission for a medical condition resulting from Injury or serious Illness that is less severe than an emergency Hospital admission but requires care within a short time, including complications of pregnancy. For an emergency or urgent Hospital admission (including for all complications of pregnancy), you are responsible for making sure that we are notified within 24 hours, the next business day, or as soon as reasonable after admission. If you are incapacitated and you (or a friend or relative) cannot notify us within the above stated times, we must receive notification as soon as reasonably possible after the admission or you may be subject to reduced benefits as provided in you specific Policy.
Healthcare services and supplies review.
A Participating Provider, including your PCP, may notify us on your behalf to obtain prior-authorization for the services described in Part A above (“Scope of the Program.”). Non-Participating Providers may not know or attempt to notify us to obtain prior authorization for services. In such a case, you must confirm that we have pre-authorized a service in order to assure that the service is covered. We will pay for covered health care services and supplies only if authorized as outlined above. We will not pay for any healthcare services or supplies that are not Covered Services or do not meet our criteria and protocols.
D. CONCURRENT REVIEW AND CASE MANAGEMENT
After admission to a facility, we will continue to evaluate the patient’s progress to monitor appropriate level of care and services. If, after consulting with the Physician or a representative of your treatment team or the Hospital case management team, we determine a lower level of care is appropriate or a service does not meet our criteria standards, we will not extend continued authorization. We use nationally recognized criteria and internal medical policy guidelines as the standard measurement tool for this process for Acute care facilities. We
also use nationally recognized criteria as the standard assessment tool for skilled nursing facilities, rehabilitation facilities and mental health and substance abuse facilities and programs. Case management is a service provided by us to coordinate all services or alternate methods of medical care or treatment that may be used in replacement of or in combination with Hospital confinement. Our case managers will work in coordination with the attending Physician or other Professionals and community resources to develop a plan of treatment per the benefit level of this Policy. Discharge planning may be initiated at any stage of the process, and begins immediately upon identification of post discharge needs during prior-authorization or concurrent review.
E. RETROSPECTIVE REVIEW
We evaluate the medical records of those Members whose medical treatment or Hospital stay was not reviewed under authorization, prior-authorization, or concurrent review as described above. We will pay benefits only for those days or treatment that would have been authorized under the managed care/utilization management program.
F. SECOND OPINIONS
We will authorize a second opinion upon your request in accordance with the terms of your specific Policy. Examples of instances where a second opinion may be appropriate include:
Your Physician has recommended a procedure and you are unsure whether the procedure is necessary or reasonable;
You have questions about a diagnosis or plan of care for a condition that threatens substantial impairment or loss of life, limb, or bodily functions;
You are unclear about the clinical indications about your condition;
A diagnosis is in doubt due to conflicting test results;
Your Physician is unable to diagnose your condition; and
A treatment plan in progress is not improving your medical condition within a reasonable period of time.
City of Reno – Medical Benefit Summary - 9 -
MEDICAL BENEFIT SUMMARY
A. PROVIDER NETWORK
The Plan Sponsor has contracted with a Preferred Provider Organization (PPO) of health care providers. When obtaining health care services, a Covered Person has a choice of using providers who are participating in the PPO network or any other Covered Providers of his/her choice (Non-PPO providers). PPO providers have agreed to provide services to Covered Persons at negotiated discount fees to Plan participants. When a Covered Person uses a PPO provider his/her out-of-pocket costs may be reduced because he will not be billed for expenses in excess of those negotiated rates. PPO providers have agreed to accept the Plan’s benefit payment for eligible expenses, plus any applicable deductible, copayments or coinsurance you are responsible for paying, as payment in full. The Plan may also include other benefit incentives to encourage Covered Persons to use PPO providers whenever possible. Non-PPO providers have no agreements with the Plan and are generally free to set their own charges for services or supplies. The Non-PPO provider’s charge is subject to the Plan’s Usual and Customary (U&C) allowable. The U&C allowable for Non-PPO provider’s charges is the PPO negotiated rate. The Covered Person will be responsible for any amounts in excess of the U&C (called balance billing). You can avoid potential balance billing by using a PPO provider. The Plan’s medical PPO is Hometown Health Network, using all Renown Health facilities, including Renown Regional Medical Center and Renown South Meadows, for employees and retirees residing in Nevada and the following California counties: Alpine, Amador, El Dorado, Inyo, Lassen, Modoc, Mono, Nevada, Placer, Plumas, Sierra and surrounding counties. For employees and retirees residing outside of the service area or for emergency care outside of the service area, your PPO network is PHCS Network. PPO providers are added and dropped from the PPO networks periodically throughout the year and it is your responsibility to verify if the provider is in the PPO network BEFORE seeking services from a PPO provider. Listing of hospitals, physicians, ambulatory surgery centers, laboratory, radiology and other medical providers can be found at Hometown Health’s or PHCS Network’s website. You can search for providers and print the PPO directory from the website or you may call a customer service representative. Contract information is below.
HOMETOWN HEALTH PROVIDERS NETWORK
www.hometownhealth.com
www.multiplan.com
When a Non-PPO provider is used because of the below circumstances, then the Non-PPO’s billed charges will be subject to the Usual and Customary allowable defined in the Definitions. Emergency Care – In the event a Covered Person requires care for a Medical Emergency, as defined in the Definitions, and is transported to a Non-PPO provider, such Non-PPO billed charges will be subject to Usual and
Customary instead of the PPO allowable. Unavailable Services - If a Covered Person requires services from a Non-PPO provider because the necessary
specialty is not represented in the PPO network and Pre-certification has been obtained from UM, then the Non- PPO’s billed charges will be subject to Usual and Customary instead of the PPO allowable.
Ancillary Services - Services of a Non-PPO ancillary provider (i.e. emergency room Physician, urgent care
Physician, radiologist, pathologist, on-call Physician) will be covered at the PPO benefit levels if such services are received while a Covered Person is being treated in the emergency room of a PPO hospital, PPO Urgent Care Facility, PPO Ambulatory Surgery Center or confined in a PPO hospital facility.
B. SCHEDULE OF MEDICAL BENEFITS
The benefits outlined in the Benefit Summary Table are not a complete listing of the medical services covered under this benefit plan. Benefits for services not listed can be found throughout the plan document. Copayments and/or coinsurance for services not shown in the Benefit Summary Table are determined by the location in which services are provided (such as: emergency rooms, urgent care centers or physicians’ offices). The copayment and/or coinsurance amounts listed in the Benefits Summary Table are applicable for covered services received as described throughout the plan document. All charges associated with non-covered services or denied claims are the member’s responsibility.
NOTE: The Plan pays 20% of covered charges after the deductible for all retirees who are eligible for but not enrolled in Medicare Part A and Part B.
Benefit Summary Table Benefit Category In-Network Out-of-Network
Active Employees, Retirees Enrolled for Medicare and Retirees not Yet Medicare-Eligible
Maximum Plan Benefit unlimited
Maximum annual benefit unlimited
Prescription Drugs – Single / Family $3,850 / $7,700
During any calendar year, individuals are responsible for paying deductible, copayments and coinsurance up to the single, annual out-of-pocket maximum unless coverage is extended to qualified dependents and the family annual out-of-pocket maximum has been satisfied.
Deductibles –
Medical - Single / Family $300 / $600 $900 / $1800
Medical deductible applies to all medical services noted with CYD (calendar year deductible) under member responsibility... Medical deductible limits must be met every calendar year before benefits are payable for medical services other than Primary Care, Specialty Care or Wellness office visits. Individuals within a family must satisfy the single medical deductible limit every calendar year before medical benefits are payable for services other than Primary Care, Specialty Care or Wellness office visits. However, once the family as a whole has satisfied the family deductible within the calendar year, no further medical deductible limits need to be satisfied except for benefit-specific deductibles.
Physician Office Visits –
$20 / $50 copay / visit
$0 / $0 copay / visit
Not Covered
One wellness visit per year is covered for member older than two. All necessary wellness visits are covered for children less than two years of age.
Urgent Care and Emergency Services –
Urgent Care Center Services $50 copay / visit 40% after ded.
Emergency Room Services CYD and $250 copay / visit CYD and $250
copay / visit
Copayments for emergency room services are waived if the member is admitted to the hospital
Ambulance (ground) CYD and $200 copay / trip 40% after ded
Ambulance (air and water) CYD and $200 copay / trip 40% after ded
Imaging and Diagnostic Testing – Radiological/Cardiological/Neurological
Computer Tomography (CT) scan CYD and $200 copay / visit 40% after ded
Magnetic Resonance Imaging (MRI) CYD and $200 copay / visit 40% after ded
Positron Emission Tomography (PET) scan CYD and $200 copay / visit 40% after ded
All other X-ray services CYD and $30 copay / visit 40% after ded
Laboratory Services –
CYD and $30 copay 40% after ded
Benefit Summary Table (continued)
Benefit Category In-Network Out-of-Network
Wellness and Preventive Services–
(STI) HIV counseling and testing Breastfeeding support, supplies and counseling Screening for interpersonal and domestic
violence Contraceptives and Counseling for FDA
approved in office including injections, implants, and contraceptive devices not covered under pharmacy benefits
Screening for Gestational Diabetes High-risk human papillomavirus (HPV) testing in
women Certain other Preventive Services as defined by this Plan.
Primary / Specialty care physician
Hospital Inpatient Services –
CYD and $250 / admit
Outpatient observation CYD and $ 50 /
admit 40% after ded.
Skilled nursing facility Limited to 30- days per calendar year
CYD and $0/ admit
CYD and $0 / admit
Benefit Summary Table (continued) Benefit Category In-Network Out-of-Network
Outpatient Therapy and Rehabilitation Services –
Speech therapy Occupational therapy Physical therapy
Limited to 20 aggregate visits per therapy type per member per calendar year
$20 copay / visit 40% after ded
Wound therapy Chemotherapy Infusion therapy
Services provided in a physician office
$15 copay/visit 40% after ded
Chemotherapy Infusion therapy Radiation therapy
Services provided in an outpatient hospital setting
Cardiac and pulmonary rehabilitation
$15 copay/ visit 40% after ded
Cardiac and Pulmonary Rehabilitation services require prior authorization
Mental Health –
Inpatient Services for mental illnesses (including but not limited to semi- private room and meals)
CYD and $0 copay / per day
40% after ded
Partial hospitalization Services for mental illnesses CYD and $0 copay/ day 40% after ded
Outpatient visit-mental health
Services for mental health $20 copay / visit 40% after ded
Inpatient mental health, substance abuse and partial hospitalization require prior authorization. Outpatient mental health, substance abuse, and counseling visits for more than 12 visits per calendar year, require prior authorization for benefit coverage to be made available.
Surgical Services –
Performed in physician’s office
Primary / Specialty care physician $20 / $50 copay / visit 40% after ded
Performed in outpatient facility or same day surgery facility
Includes physician services and facility charges
CYD and $250 copay 40% after ded
Surgical removal of lipomas
Plus the PCP, Specialist office visit copay or surgery facility copayment as applicable
Medical Supplies –
Durable medical equipment (purchase and rental)
CYD and $0 copay per item CYD and $0 copay per item
/ per month
Ostomy care supplies (30-day supply)
CYD and $0 copay
CYD and $0 copay per 30
day supply 40% after ded.
Benefit Summary Table (continued) Benefit Category In-Network Out-of-Network
Alcohol and Substance-Abuse Treatment –
40% after ded.
by site of service) 40% after ded.
Outpatient treatment $20 copay / visit
Inpatient mental health, substance abuse and partial hospitalization require prior authorization. Outpatient mental health, substance abuse, and counseling visits for more than 12 visits per calendar year, require prior authorization for benefit coverage.
Prescription Drug Program –
$1,000 maximum benefit per calendar year
$30 copay / visit 40% after ded.
Spinal manipulation Maximum benefit: limited to 30 visits per member per calendar year
Home health care Maximum benefit: limited to 40 visits per member per calendar year.
Hospice
$0 copay 40% after ded.
Kidney dialysis and associated services
Infertility services Copayment varies by site of
service 40% after ded.
Genetic counseling and testing
Temporomandibular Joint Disorder (TMJ)
Immunosuppressive Medications
service 40% after ded.
Some medications, injections, and infusion drugs require prior authorization.
THIS IS A SUMMARY ONLY. SEE THE ELIGIBLE MEDICAL EXPENSES AND MEDICAL LIMITATIONS AND EXCLUSIONS SECTIONS FOR MORE INFORMATION.
City of Reno – Eligible Medical Expenses - 14 -
ELIGIBLE MEDICAL EXPENSES All medical care must be received from or ordered from a Covered Provider. Except as otherwise noted below or in the Medical Schedule of Benefits, eligible medical expenses are the charges for the items listed below and which are incurred by a Covered Person – subject to the Definitions, Limitations and Exclusions and all other provisions of the Plan. In general, services and supplies must be approved by a Physician or other appropriate Covered Provider and must be Medically Necessary for the care and treatment of a covered Illness, Injury, Pregnancy or other covered health care condition. For benefit purposes, medical expenses are deemed to be incurred on: the date delivery is made; or the actual date a service is rendered.
A. PROFESSIONAL SERVICES
1. Alcohol and substance abuse services (inpatient and outpatient)
Covered benefits for inpatient and outpatient alcohol and substance abuse services will be provided under the same provisions as medical and surgical benefits, with no additional financial or treatment limitations.
a. Covered services are limited to diagnosis, medical treatment, and medical aspects of rehabilitation. Non-medical ancillary services such as Narcotics Anonymous or Alcoholics Anonymous will not be covered. Covered services include:
i. Treatment for withdrawal from the physiological effects of Alcohol or Substance Abuse
ii. Inpatient treatment and
iii. Outpatient counseling, including group and family counseling
b. Benefits for covered services will be paid in the same manner as benefits for those services for any other illness covered by this SPD provided that the member is entitled to these benefits and treatment is received in:
i. A facility for the treatment of abuse of alcohol or drugs which is certified by the Health Division of the Department of Human Resources
ii. A hospital or other medical facility or facility which is licensed by the Health Division of the Department of Human Resources, accredited by the Joint Commission on Accreditation of Healthcare Organizations and provides a program for the treatment of abuse of alcohol or drugs as part of its accredited activities
2. Alternative medicine (see homeopathic and acupuncture care)
3. Ambulance services
a. Provided in an emergency
b. Provided in non-emergency setting when ordered by member's PCP and prior-authorized by Hometown Health
4. Autism Spectrum Disorder
Coverage is provided for Medically Necessary screening for and diagnosis of autism spectrum disorders, and for the Medically Necessary treatment of autism spectrum disorders to individuals under the age of 18 (or under the age of 22, for individuals enrolled in high school).
“Autism spectrum disorder” means a neurobiological medical condition including, without limitation, autistic disorder, Asperger’s Disorder, and Pervasive Developmental Autism Disorder Not Otherwise Specified. Treatment must be identified in a treatment plan prescribed by a licensed Physician, or psychologist and may be developed pursuant to a comprehensive evaluation in coordination with a licensed behavior analyst. Subject to the other requirements of this plan, treatment may include Medically Necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care, behavior therapy, or therapeutic care that is:
Prescribed for a person diagnosed with an autism spectrum disorder by a licensed Physician or licensed psychologist; and
Provided to a person diagnosed with an autism spectrum disorder by a licensed Physician, licensed psychologist, licensed behavior analyst, licensed assistant behavior analyst, certified autism behavior
interventionist or other provider that is supervised by the licensed Physician, psychologist, or behavior analyst.
Coverage is subject to a maximum benefit of 515 hours per calendar or plan year for applied behavioral analysis treatment. Services that are delivered subject to this specific benefit for services for Autism Spectrum Disorders do require prior authorization. Coverage is not provided for reimbursements to an early intervention agency or school for services delivered through early intervention or school services.
5. Blood services for surgery
6. Chemotherapy
The financial limits applicable to oral Chemotherapy will be no less favorable than the financial limits applicable to Chemotherapy administered by injection or intravenously
7. Clinical trials
The routine medical treatment costs, including all items and services that are otherwise generally available to Hometown Health members, received as part of a clinical trial or study is covered if:
a. The medical treatment is provided in a Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or chronic fatigue syndrome.
b. The clinical trial or study is approved by:
i. An agency of the National Institutes of Health
ii. A cooperative group, a network of facilities that collaborate on research projects and has established a peer review program approved by the National Institutes of Health
iii. The Food and Drug Administration (FDA) as an application for a new investigational drug
iv. The United States Department of Veterans Affairs
v. The United States Department of Defense
vi. The medical treatment is provided by a provider of health care and the facility and personnel have the experience and training to provide the treatment in a capable manner
vii. There is no medical treatment available which is considered a more appropriate alternative medical treatment than the medical treatment provided in the clinical trial or study
viii. There is a reasonable expectation based on clinical data that the medical treatment provided in the clinical trial or study will be at least as effective as any other medical treatment
ix. The clinical trial or study is conducted in Nevada, and
x. The member has signed, before his/her participation in the clinical trial or study, a statement of consent indicating that he/she has been informed of, without limitation:
The procedure to be undertaken;
Alternative methods of treatment; and
The risks associated with participation in the clinical trial or study, including, without limitation, the general nature and extent of such risks.
c. Medical treatment is limited to:
i. Coverage for any drug or device that is approved for sale by the Food and Drug Administration (FDA) without regard to whether the approved drug or device has been approved for use in the medical treatment of the member
ii. The cost of any reasonable necessary health care services that are required as a result of the medical treatment provided in the clinical trial or study or as a result of any complication arising out of the medical treatment provided in the clinical trial or study, to the extent that such health care services would otherwise be covered under Hometown Health
iii. The initial consultation to determine whether the member is eligible to participate in the clinical trial or study
iv. Health care services required for the clinically appropriate monitoring of the member during the clinical trial or study
d. In addition, if a member participates in an approved clinical trial with respect to the treatment of cancer or another life-threatening disease or condition, the Plan will not deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial and will not discriminate against the member on the basis of the individual’s participation in the trial. For these purposes, an “approved clinical trial” means a phase I, II, III or IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either (i) a federally funded or approved study or investigation, (ii) a study or investigation conducted under an investigational new drug application reviewed by the Food and Drug Administration, or (iii) a study or investigation that is a drug trial exempt from having such an investigational new drug application.
A member is eligible to participate in an approved clinical trial according to the trial protocol with respect to the treatment of cancer or another life-threatening disease or condition; if either: (1) the referring health care professional is a Participating Provider and has concluded that the individual’s participation in such trial would be appropriate; or (2) the member provides medical and scientific information establishing that the individual’s participation in such trial would be appropriate.
For questions about the coverage for clinical trials provision, including complaints regarding compliance with the statutory provision by health insurance issuers, contact the Nevada Division of Insurance at-1-888-872-3234 or the Centers for Medicare & Medicaid Services, Center for Consumer Information and Insurance Oversight at 1-888-393-2789.
8. Colorectal screening
9. Diabetic services for type 1, 2 and gestational diabetes
a. Management and treatment of diabetes including infusion pumps and related supplies, medication, equipment, supplies and appliances for the treatment of diabetes
b. Self-management of diabetes, including:
i. Training and education provided after a member is initially diagnosed with diabetes for the care and management of diabetes, including, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes
ii. Training and education which is necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition which requires modification of his/her program of self-management of diabetes, and
iii. Training and education which is necessary because of the development of new techniques and treatment for diabetes
10. Durable medical equipment (DME)
a. The purchase, rental, repair or maintenance of DME for other than kidney dialysis
b. DME includes, but not limited to:
i. Oxygen equipment (all oxygen and oxygen related equipment, except for oxygen while traveling on an airline)
ii. Wheelchairs
iii. Hospital beds
iv. Glucose monitors
v. Warning or monitoring devices for infants (defined as a child 24 months old or less) suffering from recurrent apnea (limited to 90 days)
Hometown Health’s coverage will be based on an amount equal to the generally accepted cost of DME that provides the necessary level of care at the lowest cost. In determining Hometown Health's liability, Hometown Health will be guided by nationally established standards of the rental or purchase of such equipment.
11. Family planning
12. Food products
Special food products for the treatment of inherited metabolic diseases characterized by deficient metabolism, or malabsorption originated from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate or fat.
13. Gender Reassignment – Gender reassignment surgery consisting of any combination of the following
when the following criteria is met:
a. Requirements for mastectomy for female-to-male patients:
Single letter of referral from a qualified mental health professional; and
Persistent, well-documented gender dysphoria (see Appendix); and
Capacity to make a fully informed decision and to consent for treatment; and
Age of majority (18 years of age or older); and
If significant medical or mental health concerns are present, they must be reasonably well controlled.
b. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female):
Two referral letters from qualified mental health professionals, one in a purely evaluative role (see Appendix);
If significant medical or mental health concerns are present, they must be reasonably well controlled; and
Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones).
c. Requirements for genital reconstructive surgery (i.e. vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prothesis and erectile prosthesis in female to male, penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male to female):
Two referral letters from qualified mental health professionals, one in a purely evaluative role (see Appendix);
If significant medical or mental health concerns are present, they must be reasonably well controlled; and
Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and
Twelve months of living in a gender role that is congruent with their gender identity (real life experience).
NOTE: See Gender Reassignment under MEDICAL LIMITATIONS AND EXCLUSIONS for
services and procedures that are not covered.
14. Genetic counseling/testing
a. Genetic Testing may only be done after consultation with an appropriately certified Genetic Counselor or as approved by Hometown Health medical director.
b. Genetic counseling will be covered in connection with pregnancy management in the following circumstances:
i. Parents of a child born with a genetic disorder, birth defect, inborn error of metabolism, or chromosome abnormality
ii. Parents of a child with mental retardation, autism, Down syndrome, trisomy conditions, or fragile X syndrome
iii. Pregnant women who, based on prenatal ultrasound tests or an abnormal multiple marker screening test, maternal serum alpha-fetoprotein (AFP) test, test for sickle cell anemia, or tests for other genetic abnormalities, have been told their pregnancy may be at increased risk for complications or birth defects
iv. Parents affected with an autosomal dominant disorder, contemplating pregnancy
v. Mother is a known or presumed carrier of an X-linked recessive disorder
15. Home health care
a. House Calls - provided by a member's PCP as the nature of the illness dictates
b. Home Care - provided by a home health agency. Such care will not be available if it is substantially or primarily for a member's convenience. Home care will be provided in the home only on a part-time and temporary basis. Certified Nurse’s Aides and Home Health Aides are not covered.
c. Home health care does not include over-the-counter medical equipment, over-the-counter supplies, or any prescription drugs. These benefits are only available to the extent that they are covered elsewhere in this SPD or Pharmacy Rider.
16. Hospice services
Hospice care services for members with a life expectancy of six (6) months or 185 days or less as certified by his or her PCP. (limited to a lifetime benefit maximum of 185 days).
a. Intermittent home health care
b. Outpatient counseling of the member and his or her immediate family. Counseling must be provided by:
i. A licensed psychiatrist;
ii. A licensed psychologist; or
iii. A licensed social worker.
c. Respite care provides nursing care for a maximum of three, 48-hour periods in the hospice benefit period. Inpatient respite care will be provided only when Hometown Health determines that home respite care is not appropriate or practical.
17. Homeopathic and acupuncture care
Office visits for homeopathic and acupuncture services, (limited to $1,000 per calendar year).
18. Infertility services
Medically Necessary services to diagnose problems of infertility are covered. The following services are not covered:
All other costs incurred for reproduction by artificial means or assisted reproductive technology (such as in-vitro fertilization, artificial insemination, or embryo transplants) including services, tests, supplies, devices, or drugs intended to produce a pregnancy;
The promotion of fertility including, but not limited to, fertility testing (except as otherwise covered and described above); serial ultrasounds; services to reverse voluntary surgically-induced infertility; reversal of surgical sterilization; any service, supply, or drug used in conjunction with or for the purpose of an artificially induced pregnancy, artificial insemination (including test-tube fertilization); the cost of donor sperm or eggs; in-vitro fertilization and embryo transfer or any artificial reproduction technology or the freezing of sperm or eggs or storage costs for frozen sperm, eggs, or embryos; maternity services related to a Member serving in the capacity of a surrogate mother or prescription (infertility) drugs; or GIFT or ZIFT procedures, low tubal transfers, or donor egg retrieval;
Any services related to a Member serving in the capacity of a surrogate mother, including, but not limited to, determining, evaluating, or enhancing the physical or psychological readiness for pregnancy, procedures to improve the Member’s ability to become pregnant or to carry a pregnancy to term, or maternity services; and
Any payment made by or on behalf of a Member who is contemplating or has entered into a contract for surrogacy to a Provider or individual related to any services potentially included in the scope of surrogacy services described above
19. Kidney dialysis services
Kidney dialysis services and related therapeutic services and supplies, (e.g., epogen) to the extent these are not covered by the Medicare program.
20. Lab and diagnostic services determined to be medically necessary
X-ray and laboratory procedures, services and materials, including, but not limited to:
Diagnostic X-rays (Radiological/Cardiology related/Neurological)
21. Mastectomy reconstructive surgery
Breast reconstructive surgery and the internal or external prosthetic devices for members who received mastectomy surgery as a covered benefit while a member of this group medical plan. External prosthesis are limited to the billed charges or the allowed charges set by the Centers for Medicare and Medicaid Services (CMS), whichever is less.
a. If reconstructive surgery is begun within 3 years after the mastectomy, coverage will be extended to the member or former member for all eligible charges for such reconstructive surgery as would have been provided at the time of the mastectomy. If a covered mastectomy is performed while a member of Hometown Health and the mastectomy is paid for by Hometown Health, subject to all the terms and conditions of this SPD, Hometown Health will also provide coverage for: (a) reconstruction of the breast on which the mastectomy has been performed; (b) surgery and reconstruction of the other breast to produce a symmetrical structure; and (c) prostheses; and (d) physical complications for all stages of mastectomy, including lymphedemas.
b. If reconstructive surgery is begun within 3 years after a mastectomy, the amount of the benefits for that surgery must equal the amounts provided for in the policy at the time of the mastectomy. If the surgery is begun more than 3 years after the mastectomy, the benefits provided are subject to all the terms, conditions and exclusions contained in the policy at the time of reconstructive surgery. No benefits will be paid for reconstructive surgery or any complications resulting from reconstructive surgery more than 3 years after the mastectomy if the patient is no longer a member of this plan.
22. Maternity care and care of newborns
Medically Necessary services for pregnant Members are covered, including prenatal and postpartum care, related delivery room an ancillary services and newborn care. Newborn care includes care and treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity and transportation costs of newborn to and from the nearest facility staffed and equipped to treat the newborn’s condition. Notwithstanding anything in this SPD to the contrary, for Non-Grandfathered Plans, a Member does not need prior authorization from us or from any other person in order to obtain access to obstetrical or gynecological care from a professional in our Network who specializes in obstetrics or gynecology. The Professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures from making referrals. For a list of participating Professionals who specialize in obstetrics or gynecology, go to www.hometownhealth.com or contact or customer services.
Notwithstanding anything in this SPD to the contrary, for Non-Grandfathered Plans, in the case of a person who has a child enrolled in coverage, we will permit such person to designate any pediatrician if such pediatrician
• Amniocentesis to extend that it is performed to determine the sex of the child
• Non-newborn circumcisions after eight weeks of age unless Medically necessary and prior- authorized by the Contract administrator.
23. Medical care and preventive services:
Office visits and consultations
Periodic physical examinations and routine immunizations in accordance with Hometown Health’s Medical Practice Guidelines
Routine gynecologic examination (1 per calendar year), including annual cytologic screening test (Pap smear) for women; pelvic examination; urinalysis and breast examination
Screening mammograms including an initial baseline mammogram for female members 35 - 39 and annually for women 40 years of age or older
Well-baby care, including immunizations in accordance with the American Academy of Pediatrics and other federal agencies
Allergy testing and serum
Influenza, Pneumovax, Haemophilus influenza B, Hepatitis A, Hepatitis B, Hepatitis C, Rubella and Tetanus immunizations.
Hearing and vision screening for children through age 17 to determine the need for hearing and vision correction
Services recommended and endorsed through the PPACA legislation and recommendations of the agencies named within
24. Mental health services
Covered benefits for general mental health (including services related to the treatment of Attention Deficit Disorder (ADD & ADHD)) and severe mental illness will be provided under the same provisions as medical and surgical benefits, with no additional financial or treatment limitations.
25. Oral surgery, dental services, and temporomandibular joint disorder (TMJ)
Oral surgery procedures will be provided (inpatient or outpatient) related to the following:
a. Accidental injury to the jaw bones or surrounding tissues when the injury occurs and the repair takes place while a member of the plan
Services must commence within 90 days after the accidental injury (services that commence after 90 days are not covered).
b. Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, and roof and floor of the mouth
c. Non-dental surgical procedures and hospitalization required for newly born and children placed for adoption or newly adopted to treat congenital defects, such as cleft lip and cleft palate
d. Medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including treatment of fractures
e. TMJ services are covered only when the required services are not recognized dental procedures.
f. Dental general anesthesia for a dependent child when services are rendered in a hospital or outpatient surgical facility, when enrolled dependent child is being referred because, in the opinion of the dentist, the child:
i. Is under 18 and has a physical, mental or medically compromising condition
ii. Is under 18 and has dental needs for which local anesthesia is ineffective because of an acute infection, an anatomic anomaly or an allergy, or
iii. Is under age 5
g. Prior-authorization is required for dental general anesthesia in a hospital or outpatient surgical facility. Dental anesthesiology services are covered only for procedures performed by a qualified specialist in pediatric dentistry, a dentist educationally qualified in a recognized dental specialty for which hospital privileges are granted or who is certified by virtue of completion of an accredited program of post-graduate hospital training to be granted hospital privileges.
26. Orthopedic devices and prosthetic devices
a. Orthopedic devices are limited to braces for problems requiring complete immobilization or for support, or if the braces are custom fitted or have rigid bar or flat steel supports and stays, splints, devices for congenital disorders, post and pre-operative devices.
b. Prosthetic devices, approved by Centers for Medicare & Medicaid, required to substitute for missing or non-functioning body parts or organs are limited to:
i. Devices provided in connection to an illness or injury, which occurred subsequent to a member’s effective date of coverage under this SPD
ii. Adjustment of initial prosthetic device
iii. Repair and replacement of prosthetic devices are not covered except in limited situations involving mastectomy reconstructive surgery
iv. The first pair of eyeglasses or contact lenses (up to the Medicare allowable) immediately following cataract surgery
27. Ostomy care supplies
Care and supplies provided to the member after colon, ileum and/or bladder surgery to carry on normal activities with a minimum of inconvenience.
28. Outpatient observation (in facility)
Services furnished on a hospital’s premises, including use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital. If the hospital intends to keep a patient in observation status for more than 24-48 hours, observation status will become an inpatient admission for administration of benefits.
29. Podiatry services
Podiatry services for the treatment of acute conditions of the foot such as infections, inflammation, or injury and other foot care, which is disease related.
30. Prescription Drugs
Medicines that are dispensed and administered to a Covered Person during an Inpatient confinement, during a Physician's office visit, or as part of a home health care or hospice care program. Other Outpatient drugs (i.e., pharmacy purchases) are covered through a separate program. See the Medical Benefit Summary for more information.
31. Preventive Services
Covered preventive services include but are not limited to: i. Periodic physical examinations and routine immunizations; ii. Routine gynecologic examination (one per calendar year), including annual cytologic
screening test (Pap smear) for women 18 years of age or older, pelvic examination, urinalysis, and breast examination;
iii. Screening mammograms including an initial baseline mammogram for female Members 35–39 and annually for women 40 years of age or older;
iv. Well-baby care, including immunizations in accordance with the American Academy of Pediatrics and other federal agencies;
v. Prostate and colorectal cancer screening in accordance with:
The guidelines concerning such screening that are published by the American Cancer Society or
Other guidelines or reports concerning such screening that are published by nationally recognized professional organizations and that include current or prevailing supporting scientific data.
vi. Influenza, pneumovax, haemophilus influenza B, hepatitis A, hepatitis B, hepatitis C, rubella, and tetanus immunizations; and
vii. Hearing and vision screening for children through age 17 to determine the need for hearing and vision correction.
Notwithstanding anything to the contrary in this EOC, Non-Grandfathered Plans will cover the following services without any Member cost-sharing requirements if such services are provided by a Participating Provider:
viii. 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, provided that, with regard to breast cancer screening, mammography, and prevention, the current recommendations of the United States Preventive Services Task Force will be the most current other than those issued in or around November 2009;
ix. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;
x. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services; and
xi. With respect to women, such additional preventive care and screenings not described under this section as provided for in comprehensive guidelines supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
32. Radiation therapy
33. Second opinions
34. Short-term rehabilitative therapy
a. Outpatient short-term speech, physical, and occupational rehabilitative therapy for acute conditions which are subject to significant clinical improvement over a three-month (90 day) period from the date outpatient therapy commences (limited to 20 visits each for speech, physical, and occupational therapy per calendar year)
b. Outpatient services for cardiac rehabilitation and pulmonary rehabilitation (limited to 40 visits/sessions per calendar year for each type of therapy)
c. Inpatient short term rehabilitative services are limited to treatment of conditions which are subject to significant clinical improvement over a continuous 30 day period from the date inpatient therapy commences in a distinct rehabilitation unit of a hospital, skilled nursing facility or other facility approved by Hometown Health. (limited to 30 days per calendar year)
35. Skin lesions
36. Spinal treatment (non-surgical)
Spinal manipulations and adjustments (limited to 30 visits per member per calendar year)
37. Transplant services
Organ transplants when the member is the organ recipient: cornea, artery or vein, kidney, joint, heart valve, implantable prosthetic lenses (in connection with cataracts), prosthetic bypass or replacement vessels, bone marrow, heart, lungs
a. Related services limited to: tests necessary to identify an organ donor, the reasonable expense of acquiring the donor organ, transportation of the donor organ (but not the donor), and life support where such support is for the sole purpose of removing the donor organ, follow-up care and immunosuppressive medications.
b. Immunosuppressive medications are covered after an organ transplant operation.
B. HOSPITAL, SKILLED NURSING AND SERVICES IN AN OUTPATIENT SURGICAL CENTER
1. Inpatient hospital services include, but are not limited to:
2. Semi-private room and board (private room when medically necessary)
3. General nursing care facilities, services, and supplies on an inpatient basis, including: meals and special diets when medically necessary, use of operating room and related facilities, use of intensive care or cardiac care units and related services, X-ray services, laboratory and other diagnostic tests, non-experimental and non-investigational prescription drugs, biologicals, anesthesia and oxygen services, blood and blood plasma and its administration, special duty nursing when medically necessary, radiation therapy, inhalation therapy, and chemotherapy (including chemotherapy drugs)
4. Inpatient care short-term rehabilitative services are limited to treatment of conditions which are subject to significant clinical improvement over a continuous 30 day period from the date inpatient therapy commences in a distinct rehabilitation unit of a hospital, skilled nursing facility or other facility approved by Hometown Health. (Inpatient short-term rehabilitative services are limited to 30 days per calendar year).
5. Surgical and obstetrical procedures, including the services of a surgeon or specialist, assistant, and anesthetist or anesthesiologist together with preoperative and postoperative care
6. Inpatient alcohol and substance abuse rehabilitation services in a hospital, hospital residential treatment facility, or day treatment program. Covered benefits for inpatient alcohol and substance abuse rehabilitation services in a hospital, hospital residential treatment facility, or day treatment program will be provided under the same provisions as medical and surgical benefits, with no additional financial or treatment limitations.
7. Inpatient severe mental health services
Covered benefits for severe mental illness will be provided under the same provisions as medical and surgical benefits, with no additional financial or treatment limitations.
8. Outpatient hospital or outpatient surgical center services
9. Hospital services such as radiation therapy, chemotherapy (including chemotherapy drugs) and outpatient surgery
10. Skilled nursing facility services (limited to 30 days per calendar year) for non-custodial care
Prior care in a hospital is not required before being eligible for care in a skilled nursing facility.
C. EMERGENCY SERVICES
Medically Necessary medical and/or Hospital services are covered in the case of an Emergency.
If you have an Emergency:
Get help as soon as possible. Call your PCP or 911 for help or go to the nearest emergency room,
Hospital, or other emergency facility. Call an ambulance if necessary.
As soon as possible, make sure that we are told about your emergency as set forth below. We need
to follow up on your emergency care.
Services must be provided at a Participating Provider unless the time requirement to reach a Participating Provider would result in a significant risk of permanent health damage. Unanticipated complications of pregnancy or premature delivery are covered outside our Service Area. Services furnished by a Physician, oral surgeon, or Hospital or emergency facility personnel for Covered Services are covered during the Emergency. Emergency medical and Hospital services (inside or outside our Service Area) are limited to situations that require immediate and unexpected treatment. You should notify your PCP and our customer services department as soon as possible following receiving Emergency services. If you are outside our Service Area at the time of your Emergency, you should notify your PCP and our customer services department as
soon as possible upon your return to our Service Area to avoid a denial of your claim. Notwithstanding anything in this EOC to the contrary, for Non-Grandfathered Plans, coverage for Emergency services will be provided:
Without the need for any prior-authorization determination whether the health care Provider furnishing such Emergency services is a Participating Provider with respect to such services;
Without regard to whether the Provider furnishing the Emergency services is a Participating Provider with respect to the services;
If the Emergency services are provided out of Network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to Emergency services received from Participating Providers;
If the Emergency services are provided out of Network, without the cost-sharing requirement expressed as a Copayment amount or Coinsurance rate imposed with respect to a participant or beneficiary for the services exceeding the cost-sharing requirements imposed if the services were provided in-Network; and
without regard to any other terms or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, as permitted by law, or applicable cost-sharing).
Medical care and notification.
Medically Necessary Emergency medical care is available through participating Physicians seven days a week, 24 hours a day. Medically Necessary Emergency services out of our Service Area will be covered. Out-of-area Emergency services are provided only if we are notified before the receipt of those services or as soon as possible after such Emergency services, but no more than 24 hours after onset of the Emergency, except as provided in this section.
Extended notification
If you are unable to contact us before you receive Emergency medical services or within 24 hours of the Emergency due to shock, unconsciousness, or otherwise, you must, at the earliest time reasonably possible, contact our customer services department to provide us with information about the event and relevant circumstances.
Follow-up care (outside our Service Area/non-contracted facility)
Continuing or follow-up treatment for an Emergency service outside of our Service Area or from a non- Network facility is limited to care required before you can, without harmful or injurious consequences, return to our Service Area and receive care from Participating Providers as determined by us. Benefits for continuing or follow-up treatment(s) are otherwise covered only in our Service Area from Participatin

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Regulatory Update Notice