End of Coverage..............................................................................................................................................................................23
Extended Coverage for Total Disability ...................................................................................................................................24
Continuing Coverage Under USERRA ....................................................................................................................................24
Continuing Coverage under COBRA .......................................................................................................................................25
Plan Cancellation ............................................................................................................................................................................28
Certificates of Creditable Coverage ..........................................................................................................................................28
SECTION III - BENEFIT MANAGEMENT PROGRAM.................................................................................................30
Notice for Federal Newborns' and Mothers' Act...................................................................................................................30
Pre-admission Review....................................................................................................................................................................30
Participant Telephone Requirement ....................................................................................................................................30
Noncompliance Benefit Reduction........................................................................................................................................31
Plan Notification........................................................................................................................................................................31
Concurrent Review........................................................................................................................................................................31
Medical Case Management..........................................................................................................................................................32
Right to Appeal................................................................................................................................................................................32
SECTION IV - COVERED SERVICES ..................................................................................................................................33
Plan Benefit Schedules ..................................................................................................................................................................33
Schedule A Benefits...................................................................................................................................................................33
Schedule B Benefits ...................................................................................................................................................................33
Professional Health Care Providers ..........................................................................................................................................33
Participating Provider Network Program...............................................................................................................................34
Allowable Fees .................................................................................................................................................................................34
Preventive Care ...............................................................................................................................................................................34
Mammography Screening .......................................................................................................................................................34
Cervical Cytology/Pap Test....................................................................................................................................................34
Well Child Care .........................................................................................................................................................................34
Hospital Expense Benefits (Hospitals and other Facilities).................................................................................................35
Hospital ........................................................................................................................................................................................35
Inpatient Hospital Expenses..............................................................................................................................................35
Outpatient Hospital Expenses ..........................................................................................................................................37
Birth Center Facility.................................................................................................................................................................38
Mental Health Facility or Psychiatric Facility ..................................................................................................................38
Ambulatory Surgical Facility.................................................................................................................................................38
Urgent Care Facility Emergency Center .........................................................................................................................39
Skilled Nursing Facility /Convalescent Facility/Rehabilitation Facility (SNF) ........................................................39
Inpatient SNF Services .......................................................................................................................................................39
Outpatient SNF Services ....................................................................................................................................................39
Substance Abuse Facility or Center .....................................................................................................................................40
Inpatient Substance Abuse Rehabilitation....................................................................................................................40
Outpatient Substance Abuse Rehabilitation.................................................................................................................40
Home Health Care Agency.....................................................................................................................................................40
Hospice Care Agency................................................................................................................................................................41
Medical Expense Benefits .............................................................................................................................................................42
Surgical Care Expenses ...........................................................................................................................................................42
Surgeon Expenses.................................................................................................................................................................42
Maternity................................................................................................................................................................................42
Assistant Surgery .................................................................................................................................................................43
Anesthesia....................................................................................................................................................................................43
Second Surgical Opinion Consultation................................................................................................................................43
Inpatient Physician Services...................................................................................................................................................43
Medical/Surgical Care ........................................................................................................................................................43
Mental Illness Care..............................................................................................................................................................43
Specialist Consultations ...........................................................................................................................................................44
Physician Outpatient Services................................................................................................................................................44
Foot Care and Podiatry Services...........................................................................................................................................44
